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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [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: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Larsson P, Englund B, Ekberg J, Felldin M, Broecker V, Mjörnstedt L, Baid-Agrawal S. Difficult-to-Treat Rejections in Kidney Transplant Recipients: Our Experience with Everolimus-Based Quadruple Maintenance Therapy. J Clin Med 2023; 12:6667. [PMID: 37892805 PMCID: PMC10607360 DOI: 10.3390/jcm12206667] [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: 10/04/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
All chronic and treatment-resistant acute rejections are "difficult-to-treat" and lead to progressive loss of graft function in kidney transplant recipients (KTR), as no effective treatment exists for such rejections to date. We review our experience with a novel strategy to treat such rejections by adding everolimus as a "rescue" to conventional triple maintenance therapy with prednisolone, mycophenolate mofetil and calcineurin inhibitor. We retrospectively analysed data in 28 KTR who received everolimus-based quadruple therapy at our institution for biopsy-proven chronic active T cell-mediated or antibody-mediated rejection (n = 19) or treatment-resistant acute rejections (n = 9) between 2011-2017. The primary outcome was 5-year death-censored graft survival. Main secondary outcomes were response to treatment defined by stable or improved graft function, 5-year patient survival and discontinuation rate of treatment. The Kaplan-Meier estimate for 5-year death-censored graft survival was 79% in all patients, 90% for patients with chronic active T cell-mediated rejections, 78% for chronic active antibody-mediated rejection and 67% for acute rejections. Response to treatment was achieved in 43% and 5-year patient survival was 94%. Treatment was stopped in 12 (43%) patients due to adverse events. Everolimus-based maintenance quadruple therapy, despite high rate of everolimus discontinuation due to adverse events, may be a valid approach in a subset of kidney transplant recipients with such difficult-to-treat rejections, which otherwise would lead to a high rate of graft loss.
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Affiliation(s)
- Pierre Larsson
- Transplantation Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden; (P.L.); (J.E.)
- Department of Pathology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Bodil Englund
- Department of Nephrology, Danderyd Hospital, Karolinska Institute, 18288 Stockholm, Sweden
| | - Jana Ekberg
- Transplantation Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden; (P.L.); (J.E.)
| | - Marie Felldin
- Transplantation Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden; (P.L.); (J.E.)
| | - Verena Broecker
- Department of Pathology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Lars Mjörnstedt
- Transplantation Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden; (P.L.); (J.E.)
| | - Seema Baid-Agrawal
- Transplantation Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden; (P.L.); (J.E.)
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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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Osmanodja B, Akifova A, Oellerich M, Beck J, Bornemann-Kolatzki K, Schütz E, Budde K. Donor-Derived Cell-Free DNA for Kidney Allograft Surveillance after Conversion to Belatacept: Prospective Pilot Study. J Clin Med 2023; 12:jcm12062437. [PMID: 36983437 PMCID: PMC10051604 DOI: 10.3390/jcm12062437] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Donor-derived cell-free DNA (dd-cfDNA) is used as a biomarker for detection of antibody-mediated rejection (ABMR) and other forms of graft injury. Another potential indication is guidance of immunosuppressive therapy when no therapeutic drug monitoring is available. In such situations, detection of patients with overt or subclinical graft injury is important to personalize immunosuppression. We prospectively measured dd-cfDNA in 22 kidney transplant recipients (KTR) over a period of 6 months after conversion to belatacept for clinical indication and assessed routine clinical parameters. Patient and graft survival was 100% after 6 months, and eGFR remained stable (28.7 vs. 31.1 mL/min/1.73 m2, p = 0.60). Out of 22 patients, 2 (9%) developed biopsy-proven rejection-one episode of low-grade TCMR IA and one episode of caABMR. While both episodes were detected by increase in creatinine, the caABMR episode led to increase in absolute dd-cfDNA (168 copies/mL) above the cut-off of 50 copies/mL, while the TCMR episode did show slightly increased relative dd-cfDNA (0.85%) despite normal absolute dd-cfDNA (22 copies/mL). Dd-cfDNA did not differ before and after conversion in a subgroup of 12 KTR with previous calcineurin inhibitor therapy and no rejection (12.5 vs. 25.3 copies/mL, p = 0.34). In this subgroup, 3/12 (25%) patients showed increase of absolute dd-cfDNA above the prespecified cut-off (50 copies/mL) despite improving eGFR. Increase in dd-cfDNA after conversion to belatacept is common and could point towards subclinical allograft injury. To detect subclinical TCMR changes without vascular lesions, additional biomarkers or urinary dd-cfDNA should complement plasma dd-cfDNA. Resolving CNI toxicity is unlikely to be detected by decreased dd-cfDNA levels. In summary, the sole determination of dd-cfDNA has limited utility in the guidance of patients after late conversion to belatacept. Further studies should focus on patients undergoing early conversion and include protocol biopsies at least for patients with increased dd-cfDNA.
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Affiliation(s)
- Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Aylin Akifova
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Julia Beck
- Chronix Biomedical GmbH, 37073 Göttingen, Germany
| | | | | | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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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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Moein M, Gao SX, Martin SJ, Farkouh KM, Li BW, Ball AS, Dvorai RH, Saidi RF. Conversion to Belatacept in kidney transplant recipients with chronic antibody-mediated rejection (CAMR). Transpl Immunol 2023; 76:101737. [PMID: 36379374 DOI: 10.1016/j.trim.2022.101737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/20/2022] [Accepted: 11/05/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The costimulatory inhibitor Belatacept (Bela) has been shown to be an effective alternative in several clinical situations, including chronic antibody-mediated rejection, calcineurin toxicity, and de novo alloantibody formation. To further explore the usefulness of Belatacept under various clinical scenarios, we performed a retrospective analysis of a prospective database of all recipients who had a BPAR diagnosis of CAMR and were converted to a Belatacept maintenance immunosuppression regimen after kidney transplantation. MATERIAL AND METHOD We conducted a retrospective analysis of a prospectively collected database of all kidney transplants adult patients at SUNY Upstate Medical Hospital from 1 January 2013 to 31 December 2021. Our inclusion criteria were the patients who have been diagnosed with CAMR according to their renal biopsy based on the 2013 Banff criteria. The primary objective was to compare the kidney viability and function using GFR between the two interest groups and finally compare the outcomes. RESULTS A total of 48 patients met our inclusion criteria based on the kidney biopsy result, which showed chronic antibody-mediated graft rejection (CAMR). Nineteen patients (39.6%) were converted to the Belatacept, and we continued the previous immunosuppression regimen in 29 patients (60.4%). The mean time from the transplant date to the diagnosis of CAMR was 1385 days in the Belatacept group and 914 days for the non-Belatacept group (P = 0.15). The mean GFR comparison at each time point between the groups did not show a significant difference, and Belatacept did not show superiority compared to the standard immunosuppression regimen in terms of kidney function preservation. 1 (5.2%) patient from the Belatacept group and 1 (3.4%) patient from the non-Belatacept group had a biopsy-proven acute rejection (BPAR) after CAMR confirmation, and it was comparable (P = 0.76). De novo synthesis of the DSA rate was 12.5% in the Belatacept group and 15% In the non-Belatacept group, which was comparable. (P = 0.90). The patient survival rate was 100% in both groups. CONCLUSIONS We conclude that compared to the standard Tacrolimus/MMF/Prednisone regimen, Belatacept did not significantly benefit in preserving the GFR in long-term follow-ups and stabilizing the DSA production, which is one of the main factors resulting in chronic graft failure.
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Affiliation(s)
- Mahmoudreza Moein
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Shuqi X Gao
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samuel J Martin
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Katie M Farkouh
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Benson W Li
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Angela S Ball
- 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
| | - Reza F Saidi
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA.
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Bredewold OW, Chan J, Svensson M, Bruchfeld A, de Fijter JW, Furuland H, Grinyo JM, Hartmann A, Holdaas H, Hellberg O, Jardine A, Mjörnstedt L, Skov K, Smerud KT, Soveri I, Sørensen SS, Zonneveld AJV, Fellström B. Cardiovascular Risk Following Conversion to Belatacept From a Calcineurin Inhibitor in Kidney Transplant Recipients: A Randomized Clinical Trial. Kidney Med 2022; 5:100574. [PMID: 36593877 PMCID: PMC9803830 DOI: 10.1016/j.xkme.2022.100574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rationale & Objective In kidney transplant recipients (KTRs), a belatacept-based immunosuppressive regimen is associated with beneficial effects on cardiovascular (CV) risk factors compared with calcineurin inhibitor (CNI)-based regimens. Our objective was to compare the calculated CV risk between belatacept and CNI (predominantly tacrolimus) treatments using a validated model developed for KTRs. Study Design Prospective, randomized, open-label, parallel-group, investigator-initiated, international multicenter trial. Setting & Participants KTRs aged 18-80 years with a stable graft function (estimated glomerular filtration rate > 20 mL/min/1.73 m2), 3-60 months after transplantation, treated with tacrolimus or cyclosporine A, were eligible for inclusion. Intervention Continuation with a CNI-based regimen or switch to belatacept for 12 months. Outcomes Comparison of the change in the estimated 7-year risk of major adverse CV events and all-cause mortality, changes in traditional markers of CV health, as well as measures of arterial stiffness. Results Among the 105 KTRs randomized, we found no differences between the treatment groups in the predicted risk for major adverse CV events or mortality. Diastolic blood pressure, measured both centrally by using a SphygmoCor device and peripherally, was lower after the belatacept treatment than after the CNI treatment. The mean changes in traditional cardiovascular (CV) risk factors, including kidney transplant function, were otherwise similar in both the treatment groups. The belatacept group had 4 acute rejection episodes; 2 were severe rejections, of which 1 led to graft loss. Limitations The heterogeneous baseline estimated glomerular filtration rate and time from transplantation to trial enrollment in the participants. A limited study duration of 1 year. Conclusions We found no effects on the calculated CV risk by switching to the belatacept treatment. Participants in the belatacept group had not only lower central and peripheral diastolic blood pressure but also a higher rejection rate. Funding The trial has received a financial grant from Bristol-Myers Squibb. Trial Registration EudraCT no. 2013-001178-20.
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Affiliation(s)
- Obbo W. Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands,Address for Correspondence: Obbo W. Bredewold, MD, Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Joe Chan
- Department of Renal Medicine, Akershus University Hospital, Lørenskog, Norway
| | - My Svensson
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Johan W. de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Furuland
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
| | - Josep M. Grinyo
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Hallvard Holdaas
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Olof Hellberg
- Department of Internal Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alan Jardine
- Department of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lars Mjörnstedt
- Division of Transplantation, Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Karin Skov
- Department of Renal Medicine, Aarhus University Hospital, Denmark
| | | | - Inga Soveri
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
| | - Søren S. Sørensen
- Department of Nephrology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Bengt Fellström
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
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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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9
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Campa-Carranza JN, Paez-Mayorga J, Chua CYX, Nichols JE, Grattoni A. Emerging local immunomodulatory strategies to circumvent systemic immunosuppression in cell transplantation. Expert Opin Drug Deliv 2022; 19:595-610. [PMID: 35588058 DOI: 10.1080/17425247.2022.2076834] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cell transplantation is a promising curative therapeutic strategy whereby impaired organ functions can be restored without the need for whole organ transplantation. A key challenge in allotransplantation is the requirement for life-long systemic immunosuppression to prevent rejection, which is associated with serious adverse effects such as increased risk of opportunistic infections and the development of neoplasms. This challenge underscores the urgent need for novel strategies to prevent graft rejection while abrogating toxicity-associated adverse events. AREAS COVERED We review recent advances in immunoengineering strategies for localized immunomodulation that aim to support allograft function and provide immune tolerance in a safe and effective manner. EXPERT OPINION Immunoengineering strategies are tailored approaches for achieving immunomodulation of the transplant microenvironment. Biomaterials can be adapted for localized and controlled release of immunomodulatory agents, decreasing the effective dose threshold and frequency of administration. The future of transplant rejection management lies in the shift from systemic to local immunomodulation with suppression of effector and activation of regulatory T cells, to promote immune tolerance.
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Affiliation(s)
- Jocelyn Nikita Campa-Carranza
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA.,School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, NL, Mexico
| | - Jesus Paez-Mayorga
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA.,School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, NL, Mexico
| | - Corrine Ying Xuan Chua
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Joan E Nichols
- Center for Tissue Engineering, Houston Methodist Research Institute, Houston, TX, USA.,Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Alessandro Grattoni
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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10
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Osmanodja B, Ronicke S, Budde K, Jens A, Hammett C, Koch N, Seelow E, Waiser J, Zukunft B, Bachmann F, Choi M, Weber U, Eberspächer B, Hofmann J, Grunow F, Mikhailov M, Liefeldt L, Eckardt KU, Halleck F, Schrezenmeier E. Serological Response to Three, Four and Five Doses of SARS-CoV-2 Vaccine in Kidney Transplant Recipients. J Clin Med 2022; 11:jcm11092565. [PMID: 35566691 PMCID: PMC9105533 DOI: 10.3390/jcm11092565] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/27/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Mortality from COVID-19 among kidney transplant recipients (KTR) is high, and their response to three vaccinations against SARS-CoV-2 is strongly impaired. We retrospectively analyzed the serological response of up to five doses of the SARS-CoV-2 vaccine in KTR from 27 December 2020 until 31 December 2021. Particularly, the influence of the different dose adjustment regimens for mycophenolic acid (MPA) on serological response to fourth vaccination was analyzed. In total, 4277 vaccinations against SARS-CoV-2 in 1478 patients were analyzed. Serological response was 19.5% after 1203 basic immunizations, and increased to 29.4%, 55.6%, and 57.5% in response to 603 third, 250 fourth, and 40 fifth vaccinations, resulting in a cumulative response rate of 88.7%. In patients with calcineurin inhibitor and MPA maintenance immunosuppression, pausing MPA and adding 5 mg prednisolone equivalent before the fourth vaccination increased the serological response rate to 75% in comparison to the no dose adjustment (52%) or dose reduction (46%). Belatacept-treated patients had a response rate of 8.7% (4/46) after three vaccinations and 12.5% (3/25) after four vaccinations. Except for belatacept-treated patients, repeated SARS-CoV-2 vaccination of up to five times effectively induces serological response in kidney transplant recipients. It can be enhanced by pausing MPA at the time of vaccination.
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Affiliation(s)
- Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
- Correspondence: ; Tel.: +49-30-450-614-368
| | - Simon Ronicke
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Annika Jens
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Charlotte Hammett
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Nadine Koch
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Evelyn Seelow
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Johannes Waiser
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Ulrike Weber
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | | | - Jörg Hofmann
- Labor Berlin—Charité Vivantes GmbH, 13353 Berlin, Germany; (B.E.); (J.H.)
| | - Fritz Grunow
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Michael Mikhailov
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Lutz Liefeldt
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (S.R.); (K.B.); (A.J.); (C.H.); (N.K.); (E.S.); (J.W.); (B.Z.); (F.B.); (M.C.); (U.W.); (F.G.); (M.M.); (L.L.); (K.-U.E.); (F.H.); (E.S.)
- Berlin Institute of Health, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
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11
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Serological Response to Three, Four and Five Doses of SARS-CoV-2 Vaccine in Kidney Transplant Recipients. J Clin Med 2022. [DOI: 10.3390/jcm11092565
expr 939359460 + 834636087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Mortality from COVID-19 among kidney transplant recipients (KTR) is high, and their response to three vaccinations against SARS-CoV-2 is strongly impaired. We retrospectively analyzed the serological response of up to five doses of the SARS-CoV-2 vaccine in KTR from 27 December 2020 until 31 December 2021. Particularly, the influence of the different dose adjustment regimens for mycophenolic acid (MPA) on serological response to fourth vaccination was analyzed. In total, 4277 vaccinations against SARS-CoV-2 in 1478 patients were analyzed. Serological response was 19.5% after 1203 basic immunizations, and increased to 29.4%, 55.6%, and 57.5% in response to 603 third, 250 fourth, and 40 fifth vaccinations, resulting in a cumulative response rate of 88.7%. In patients with calcineurin inhibitor and MPA maintenance immunosuppression, pausing MPA and adding 5 mg prednisolone equivalent before the fourth vaccination increased the serological response rate to 75% in comparison to the no dose adjustment (52%) or dose reduction (46%). Belatacept-treated patients had a response rate of 8.7% (4/46) after three vaccinations and 12.5% (3/25) after four vaccinations. Except for belatacept-treated patients, repeated SARS-CoV-2 vaccination of up to five times effectively induces serological response in kidney transplant recipients. It can be enhanced by pausing MPA at the time of vaccination.
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12
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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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13
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Influence of Belatacept- vs. CNI-Based Immunosuppression on Vascular Stiffness and Body Composition. J Clin Med 2022; 11:jcm11051219. [PMID: 35268310 PMCID: PMC8911184 DOI: 10.3390/jcm11051219] [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: 01/05/2022] [Revised: 02/12/2022] [Accepted: 02/19/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Arterial stiffness and phase angle (PhA) have gained importance as a diagnostic and prognostic parameter in the management of cardiovascular disease. There are few studies regarding the differences in arterial stiffness and body composition between renal transplant recipients (RTRs) receiving belatacept (BELA) vs. calcineurin inhibitors (CNI). Therefore, we investigated the differences in arterial stiffness and body composition between RTRs treated with different immunosuppressants, including BELA. Methods: In total, 325 RTRs were enrolled in the study (mean age 52.2 years, M −62.7%). Arterial stiffness was determined with an automated oscillometric device. All body composition parameters were assessed, based on bioelectrical impedance analysis (BIA), and laboratory parameters were obtained from the medical files of the patients. Results: We did not detect any significant difference in terms of arterial stiffness and PhA in RTRs undergoing different immunosuppressive regimens, based on CsA, Tac, or BELA. Age was an essential risk factor for greater arterial stiffness. The PhA was associated with age, BMI, time of dialysis before transplantation, and kidney graft function. Conclusion: No significant differences in arterial stiffness and PhA were observed in RTRs under different immunosuppressive regimens. While our data provide additional evidence for arterial stiffness and PhA in RTRs, more research is needed to fully explore these cardiovascular risk factors and the impact of different immunosuppressive regimens.
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14
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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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15
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Terrec F, Jouve T, Malvezzi P, Janbon B, Naciri Bennani H, Rostaing L, Noble J. Belatacept Use after Kidney Transplantation and Its Effects on Risk of Infection and COVID-19 Vaccine Response. J Clin Med 2021; 10:jcm10215159. [PMID: 34768680 PMCID: PMC8585113 DOI: 10.3390/jcm10215159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction: Belatacept is a common immunosuppressive therapy used after kidney transplantation (KT) to avoid calcineurin-inhibitor (CNI) use and its related toxicities. It is unclear whether its use exposes KT recipients (KTx) to a greater risk of infection or a poorer response to vaccines. Areas covered: We reviewed PubMed and the Cochrane database. We then summarized the mechanisms and impacts of belatacept use on the risk of infection, particularly opportunistic, in two settings, i.e., de novo KTx and conversion from CNIs. We also focused on COVID-19 infection risk and response to SARS-CoV-2 vaccination in patients whose maintenance immunosuppression relies on belatacept. Expert opinion: When belatacept is used de novo, or after drug conversion the safety profile regarding the risk of infection remains good. However, there is an increased risk of opportunistic infections, mainly CMV disease and Pneumocystis pneumonia, particularly in those with a low eGFR, in older people, in those receiving steroid-based therapy, or those that have an early conversion from CNI to belatacept (i.e., <six months post-transplantation). Thus, we recommend, if possible, delaying conversion from CNI to belatacept until at least six months post-transplantation. Optimal timing seems to be eight months post-transplantation. In addition, KTx receiving belatacept respond poorly to SARS-CoV-2 vaccination.
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Affiliation(s)
- Florian Terrec
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Hamza Naciri Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
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16
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Balani SS, Jensen CJ, Kouri AM, Kizilbash SJ. Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant 2021; 25:e14077. [PMID: 34216190 DOI: 10.1111/petr.14077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
Advances in immunosuppression have improved graft survival in pediatric kidney transplant recipients; however, treatment-related toxicities need to be balanced against the possibility of graft rejection. Several immunosuppressive agents are available for use in transplant recipients; however, the optimal combinations of agents remain unclear, resulting in variations in institutional protocols. Lymphocyte-depleting antibodies, specifically ATG, are the most common induction agent used for pediatric kidney transplantation in the US. Basiliximab may be used for induction in immunologically low-risk children; however, pediatric data are scarce. CNIs and antiproliferative agents (mostly Tac and mycophenolate in recent years) constitute the backbone of maintenance immunosuppression. Steroid-avoidance maintenance regimens remain controversial. Belatacept and mTOR inhibitors are used in children under specific circumstances such as non-adherence or CNI toxicity. This article reviews the indications, mechanism of action, efficacy, dosing, and side effect profiles of various immunosuppressive agents available for pediatric kidney transplantation.
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Affiliation(s)
- Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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17
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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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18
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Affiliation(s)
- Sundaram Hariharan
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
| | - Ajay K Israni
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
| | - Gabriel Danovitch
- From the University of Pittsburgh Medical Center, Pittsburgh (S.H.); Hennepin Healthcare, the University of Minnesota, and the Scientific Registry of Transplant Recipients - all in Minneapolis (A.K.I.); and the University of California, Los Angeles, Los Angeles (G.D.)
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19
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Chavarot N, Divard G, Scemla A, Amrouche L, Aubert O, Leruez-Ville M, Timsit MO, Tinel C, Zuber J, Legendre C, Anglicheau D, Sberro-Soussan R. Increased incidence and unusual presentations of CMV disease in kidney transplant recipients after conversion to belatacept. Am J Transplant 2021; 21:2448-2458. [PMID: 33283406 DOI: 10.1111/ajt.16430] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 01/25/2023]
Abstract
Belatacept may increase cytomegalovirus (CMV) disease risk after conversion from CNI-based therapy. We analyzed CMV disease characteristics after belatacept conversion. Propensity score matching was used to compare CMV disease incidence in belatacept- and CNI-treated kidney transplant recipients (KTRs). CMV disease characteristics and risk factors under belatacept were analyzed. In total, 223 KTRs (median age [IQR] 59.2 years [45.4-68.5]) were converted to belatacept (median of 11.5 months [2.5-37.0] post-transplantation); 40/223 (17.9%) developed CMV disease. Independent risk factors included increased age (p = .0164), D+/R- CMV serostatus (p = .0220), and low eGFR at conversion (p = .0355). Among 181 belatacept-treated patients matched to 181 controls, 32/181 (17.7%) experienced CMV disease (vs. 5/181 controls [2.8%]). CMV disease cumulative incidences were 6.33 and 0.91/100 person-years (p-y) in belatacept and control groups, respectively. CMV disease risk was particularly high in elderly patients (converted >70 years) and those with eGFR <30 ml/min; cumulative incidences were 18.4 and 5.2/100 p-y, respectively. CMV diseases under belatacept were atypical, with late-onset disease (24/40 patients [60%]), high CMV seropositivity (27/40, 67%), increased severe and tissue-invasive disease rates (gastrointestinal involvement in 32/40 [80%]) and life-threatening diseases (4/40 [10%]). These findings should stimulate further research to secure the use of belatacept as a valuable rescue therapy in KTRs.
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Affiliation(s)
- Nathalie Chavarot
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France.,Université de Paris, Paris, France
| | - Gillian Divard
- INSERM, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Anne Scemla
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France.,Université de Paris, Paris, France
| | - Lucile Amrouche
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France.,Université de Paris, Paris, France
| | - Olivier Aubert
- INSERM, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Marianne Leruez-Ville
- Département of Virology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc O Timsit
- Université de Paris, Paris, France.,Department of Urology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claire Tinel
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Julien Zuber
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France.,Université de Paris, Paris, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université de Paris, Paris, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France.,Université de Paris, Paris, France
| | - Rebecca Sberro-Soussan
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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20
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El Sakhawi K, Melica G, Scemla A, Bertrand D, Garrouste C, Malvezzi P, Rémy P, Moktefi A, Ingels A, Champy C, Lelièvre JD, Kheav D, Morel A, Mokrani D, Attias P, Grimbert P, Matignon M. Belatacept-based immunosuppressive regimen in HIV-positive kidney transplant recipients. Clin Kidney J 2020; 14:1908-1914. [PMID: 34345414 PMCID: PMC8323145 DOI: 10.1093/ckj/sfaa231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Indexed: 12/11/2022] Open
Abstract
Background Kidney allograft survival in human immunodeficiency virus (HIV)-positive patients is lower than that in the general population. Belatacept increases long-term patient and allograft survival rates when compared with calcineurin inhibitors (CNIs). Its use in HIV-positive recipients remains poorly documented. Methods We retrospectively report a French cohort of HIV-positive kidney allograft recipients who were switched from CNI to belatacept, between June 2012 and December 2018. Patient and allograft survival rates, HIV immunovirological and clinical outcomes, acute rejection, opportunistic infections (OIs) and HLA donor-specific antibodies (DSAs) were analysed at 3 and 12 months, and at the end of follow-up (last clinical visit attended after transplantation). Results were compared with HIV-positive recipients group treated with CNI. Results Twelve patients were switched to belatacept 10 (2–25) months after transplantation. One year after belatacept therapy, patient and allograft survival rates scored 92% for both, two (17%) HIV virological rebounds occurred due to antiretroviral therapy non-compliance, and CD4+ and CD8+ T-cell counts remained stable over time. Serious adverse events included two (17%) acute steroid-resistant T-cell-mediated rejections and three (25%) OIs. Kidney allograft function significantly increased over the 12 post-switch months (P = 0.009), and DSAs remained stable at 12 months after treatment. The control group showed similar results in terms of patient and kidney allograft survival rates, DSA characteristics and proteinuria Conclusions Switch from CNI to belatacept can be considered safe and may increase long-term kidney allograft survival in HIV-positive kidney allograft recipients. These results need to be confirmed in a larger cohort.
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Affiliation(s)
- Karim El Sakhawi
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Giovanna Melica
- Department of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Anne Scemla
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.,Immunology Department, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Dominique Bertrand
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | - Cyril Garrouste
- Department of Nephrology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Paolo Malvezzi
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France
| | - Philippe Rémy
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Anissa Moktefi
- Department of Pathology, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Alexandre Ingels
- Department of Urology, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Cécile Champy
- Department of Urology, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Jean-Daniel Lelièvre
- Department of Immunology, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Département Hospitalo-Universitaire (DHU), Virus-Immunité-Cancer (VIC), Université Paris-Est-Créteil (UPEC), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - David Kheav
- Assistance Publique-Hôpitaux de Paris (AP-HP), Laboratoire Régional d' Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Antoine Morel
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - David Mokrani
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Philippe Attias
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Philippe Grimbert
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Département Hospitalo-Universitaire (DHU), Université Paris-Est-Créteil (UPEC), Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Marie Matignon
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Département Hospitalo-Universitaire (DHU), Université Paris-Est-Créteil (UPEC), Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
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21
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Ville S, Gaborit B, Meyer J, Masset C, Tanguy L, Garandeau C. Nocardiosis in graft recipients of kidneys from extended-criteria donors following switch to belatacept complicated by acute rejection. Transpl Int 2020; 33:1565-1568. [PMID: 32866997 DOI: 10.1111/tri.13722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Simon Ville
- Centre de Recherche en Transplantation et Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Benjamin Gaborit
- Infectious Diseases Department, Centre Hospitalier Universitaire, Nantes, France
| | - Jeremy Meyer
- Radiology Department, Centre Hospitalier Universitaire, Nantes, France
| | - Christophe Masset
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Lescornet Tanguy
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Claire Garandeau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
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22
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Bertrand D, Terrec F, Etienne I, Chavarot N, Sberro R, Gatault P, Garrouste C, Bouvier N, Grall-Jezequel A, Jaureguy M, Caillard S, Thervet E, Colosio C, Golbin L, Rerolle JP, Thierry A, Sayegh J, Janbon B, Malvezzi P, Jouve T, Rostaing L, Noble J. Opportunistic Infections and Efficacy Following Conversion to Belatacept-Based Therapy after Kidney Transplantation: A French Multicenter Cohort. J Clin Med 2020; 9:jcm9113479. [PMID: 33126667 PMCID: PMC7693007 DOI: 10.3390/jcm9113479] [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: 10/02/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022] Open
Abstract
Conversion from calcineurin-inhibitors (CNIs) to belatacept can help kidney-transplant (KT) recipients avoid CNI-related nephrotoxicity. The risk of associated opportunistic infections (OPIs) is ill-defined. We conducted a multicentric cohort study across 15 French KT-centers in a real-life setting. Between 07-2010 and 07-2019, 453 KT recipients were converted from CNI- to belatacept-based therapy at 19 [0.13-431] months post-transplantation. Most patients, i.e., 332 (79.3%), were converted after 6-months post-transplantation. Follow-up time after conversion was 20.1 +/- 13 months. OPIs developed in 42(9.3%) patients after 14 +/- 12 months post-conversion. Eight patients (19%) had two OPI episodes during follow-up. Incidences of CMV DNAemia and CMV disease were significantly higher in patients converted before 6-months post-KT compared to those converted later (i.e., 31.6% vs. 11.5%; p < 0.001; and 11.6% vs. 2.4%, p < 0.001, respectively). Cumulative incidence of OPIs was 6.5 OPIs/100 person-years. Incidence of CMV disease was 2.8/100 person-years, of pneumocystis pneumonia 1.6/100 person-years, and of aspergillosis 0.2/100 person-years. Multivariate analyses showed that estimated glomerular filtration (eGFR) < 25 mL/min/1.73 m2 at conversion was independently associated with OPIs (HR = 4.7 (2.2 - 10.3), p < 0.001). The incidence of EBV DNAemia was 17.3 events /100 person-years. At 1-year post-conversion, mean eGFR had significantly increased from 32.0 +/- 18 mL/min/1.73 m2 to 42.2 +/- 18 mL/min/1.73 m2 (p < 0.0001). Conversion to belatacept is an effective strategy with a low infectious risk.
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Affiliation(s)
- Dominique Bertrand
- Department of Nephrology and Transplantation, Rouen University Hospital, 76000 Rouen, France; (D.B.); (I.E.)
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Isabelle Etienne
- Department of Nephrology and Transplantation, Rouen University Hospital, 76000 Rouen, France; (D.B.); (I.E.)
| | - Nathalie Chavarot
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Rebecca Sberro
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Philippe Gatault
- Department of Nephrology, Tours University Hospital, 37000 Tours, France;
| | - Cyril Garrouste
- Department of Nephrology, Clermont Ferrand University Hospital, 63000 Clermont Ferrand, France;
| | - Nicolas Bouvier
- Department of Nephrology, Caen University Hospital, 14000 Caen, France;
| | | | - Maïté Jaureguy
- Department of Nephrology, Amiens University Hospital, 80000 Amiens, France;
| | - Sophie Caillard
- Department of Nephrology, Strasbourg University Hospital, 67000 Strasbourg, France;
| | - Eric Thervet
- Department of Nephrology, European Georges Pompidou University Hospital, 75000 Paris, France;
| | - Charlotte Colosio
- Department of Nephrology, Reims University Hospital, 51100 Reims, France;
| | - Leonard Golbin
- Department of Nephrology, Rennes University Hospital, 35000 Rennes, France;
| | | | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, 86000 Poitiers, France;
| | - Johnny Sayegh
- Department of Nephrology, Angers University Hospital, 49000 Angers, France;
| | - Bénédicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
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Prevention of acute rejection after rescue with Belatacept by association of low-dose Tacrolimus maintenance in medically complex kidney transplant recipients with early or late graft dysfunction. PLoS One 2020; 15:e0240335. [PMID: 33057374 PMCID: PMC7561183 DOI: 10.1371/journal.pone.0240335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/24/2020] [Indexed: 01/23/2023] Open
Abstract
Background Increased acute rejection risk in rescue protocols with Belatacept may limit its use particularly in medically complex patients where preexisting increased risk of rejection couples with CNI toxicity. Methods Retrospective analysis was performed in 19 KTs shifted to a Belatacept-based immunosuppression with low-dose Tacrolimus (2–3 ng/mL) after evidence of allograft disfunction, including patients with primary non-function (PNF), chronic-active antibody-mediated rejection (cAMR), history of previous KTs and/or other concomitant transplants (liver, pancreas). Evaluation of CD28+ CD4+ effector memory T cell (TEM) before conversion was performed in 10/19. Results Kidney function significantly improved (median eGFR 16.5 ml/min/1.73m2 before vs 25 ml/min after; p = 0.001) at a median time after conversion of 12.5 months (9.1–17.8). Overall graft and patient survival were 89.5% and 100% respectively. Definitive weaning from dialysis in 5/5 KTs with PNF was observed, whereas 7/8 patients lost their graft within first year in a control group. eGFR significantly ameliorated in re-trasplants (p = 0.001) and stabilized in KTs with other organ transplants or cAMR. No acute rejection episodes occurred, despite the significant risk suggested by high frequency of CD28+ CD4+ TEM in most patients. Opportunistic infections were limited and most common in early vs late-converted. Conclusions Rescue association of Belatacept with low-dose Tacrolimus in medically complex KTs is a feasible option that allows prevention of acute rejection and amelioration of graft function.
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Bertrand D, Chavarot N, Gatault P, Garrouste C, Bouvier N, Grall-Jezequel A, Jaureguy M, Caillard S, Lemoine M, Colosio C, Golbin L, Rerolle JP, Thierry A, Sayegh J, Etienne I, Lebourg L, Sberro R, Guerrot D. Opportunistic infections after conversion to belatacept in kidney transplantation. Nephrol Dial Transplant 2020; 35:336-345. [PMID: 32030416 DOI: 10.1093/ndt/gfz255] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 10/29/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Belatacept (bela) rescue therapy seems to be a valuable option for calcineurin inhibitor chronic toxicity in kidney transplantation. Nevertheless, the risk of infection associated with bela is not well reported. METHODS We report the rate of opportunistic infections (OPI) after a switch to bela in a multicentric cohort of 280 kidney transplant patients. RESULTS Forty-two OPI occurred in 34 patients (12.1%), on average 10.8 ± 11.3 months after the switch. With a cumulative exposure of 5128 months of bela treatment, we found an incidence of 0.008 OPI/month of exposure, and 9.8 OPI/100 person-years. The most common OPI was cytomegalovirus (CMV) disease in 18/42 OPI (42.9%) and pneumocystis pneumonia in 12/42 OPI (28.6%). Two patients presented a progressive multifocal leucoencephalopathy and two patients developed a cerebral Epstein-Barr virus-induced post-transplant lymphoproliferative disease. OPI led to death in 9/34 patients (26.5%) and graft failure in 4/34 patients (11.8%). In multivariate analysis, estimated glomerular filtration rate <25/mL/min/1.73 m2 on the day of the switch and the use of immunosuppressive agents before transplantation were associated with the occurrence of OPI. We found a higher rate of infection-related hospitalization (24.1 versus 12.3/100 person-years, P = 0.0007) and also a higher rate of OPI (13.2 versus 6.7/100 person-years, P = 0.005) in the early conversion group (within 6 months). CONCLUSIONS The risk of OPI is significant post-conversion to bela and may require additional monitoring and prophylactic therapy, particularly regarding pneumocystis pneumonia and CMV disease. These data need to be confirmed in a larger case-control study.
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Affiliation(s)
| | - Nathalie Chavarot
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, Paris, France
| | - Philippe Gatault
- Department of Nephrology, Tours University Hospital, Tours, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont Ferrand University Hospital, Clermont Ferrand, France
| | - Nicolas Bouvier
- Department of Nephrology, Caen University Hospital, Caen, France
| | | | - Maïté Jaureguy
- Department of Nephrology, Amiens University Hospital, Amiens, France
| | - Sophie Caillard
- Department of Nephrology, Strasbourg University Hospital, Strasbourg, France
| | - Mathilde Lemoine
- Department of Nephrology, European Georges Pompidou University Hospital, Paris, France
| | | | - Léonard Golbin
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | | | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Johnny Sayegh
- Department of Nephrology, Angers University Hospital, Angers, France
| | - Isabelle Etienne
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Ludivine Lebourg
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Rebecca Sberro
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, Paris, France
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Gupta G, Raynaud M, Kumar D, Sanghi P, Chang J, Kimball P, Kang L, Levy M, Sharma A, Bhati CS, Kamal L, Yakubu I, Massey HD, Kidd C, King AL, Halloran PF. Impact of belatacept conversion on kidney transplant function, histology, and gene expression - a single-center study. Transpl Int 2020; 33:1458-1471. [PMID: 32790889 DOI: 10.1111/tri.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Pooja Sanghi
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
| | - Pam Kimball
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Marlon Levy
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amit Sharma
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Chandra S Bhati
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Hugh D Massey
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Chelsea Kidd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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Choi M, Bachmann F, Wu K, Lachmann N, Schmidt D, Brakemeier S, Duerr M, Kahl A, Eckardt KU, Budde K, Nickel P. Microvascular inflammation is a risk factor in kidney transplant recipients with very late conversion from calcineurin inhibitor-based regimens to belatacept. BMC Nephrol 2020; 21:354. [PMID: 32819287 PMCID: PMC7439694 DOI: 10.1186/s12882-020-01992-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/29/2020] [Indexed: 01/05/2023] Open
Abstract
Background In de novo kidney transplant recipients (KTR) treatment with belatacept has been established as a comparable option as maintenance immunosuppression, preferably as a strategy to convert from calcineurin inhibitor (CNI)- to belatacept-based immunosuppression. Switch to belatacept demonstrated improved renal function in patients with CNI-induced nephrotoxicity, but risk of transplant rejection and the development of donor-specific antibodies (DSA) are still a matter of debate. Only few data are available in patients at increased immunological risk and late after transplantation. Methods We analyzed 30 long-term KTR (including 2 combined pancreas-KTR) converted from CNI to belatacept > 60 months after transplantation with moderate to severe graft dysfunction (GFR ≤ 45 mL/min). Biopsies were classified according to the Banff 2015 criteria. Group differences were assessed in a univariate analysis using Mann Whitney U or Chi square test, respectively. Multivariate analysis of risk factors for treatment failure was performed using a binary logistic regression model including significant predictors from univariate analysis. Fifty-six KTR matched for donor and recipient characteristics were used as a control cohort remaining under CNI-treatment. Results Patient survival in belatacept cohort at 12/24 months was 96.7%/90%, overall graft survival was 76.7 and 60.0%, while graft survival censored for death was 79.3%/66.7%. In patients with functioning grafts, median GFR improved from 22.5 mL/min to 24.5 mL/min at 24 months. Positivity for DSA at conversion was 46.7%. From univariate analysis of risk factors for graft loss, GFR < 25 mL/min (p = 0.042) and Banff microvascular inflammation (MVI) sum score ≥ 2 (p = 0.023) at conversion were significant at 24 months. In the analysis of risk factors for treatment failure, a MVI sum score ≥ 2 was significant univariately (p = 0.023) and in a bivariate (p = 0.037) logistic regression at 12 months. DSA-positivity was neither associated with graft loss nor treatment failure. The control cohort had comparable graft survival outcomes at 24 months, albeit without increase of mean GFR in patients with functioning grafts (ΔGFR of − 3.6 ± 8.5 mL/min). Conclusion Rescue therapy with conversion to belatacept is feasible in patients with worsening renal function, even many years after transplantation. The benefit in patients with MVI and severe GFR impairment remains to be investigated.
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Affiliation(s)
- Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Lachmann
- Tissue Typing Laboratory, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Abstract
Costimulation between T cells and antigen-presenting cells is essential for the regulation of an effective alloimmune response and is not targeted with the conventional immunosuppressive therapy after kidney transplantation. Costimulation blockade therapy with biologicals allows precise targeting of the immune response but without non-immune adverse events. Multiple costimulation blockade approaches have been developed that inhibit the alloimmune response in kidney transplant recipients with varying degrees of success. Belatacept, an immunosuppressive drug that selectively targets the CD28-CD80/CD86 pathway, is the only costimulation blockade therapy that is currently approved for kidney transplant recipients. In the last decade, belatacept therapy has been shown to be a promising therapy in subgroups of kidney transplant recipients; however, the widespread use of belatacept has been tempered by an increased risk of acute kidney transplant rejection. The purpose of this review is to provide an overview of the costimulation blockade therapies that are currently in use or being developed for kidney transplant indications.
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28
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Santeusanio AD, Bhansali A, Weinberg A, Shapiro R, Delaney V, Florman S, De Boccardo G. Conversion to belatacept within 1‐year of renal transplantation in a diverse cohort including patients with donor‐specific antibodies. Clin Transplant 2020; 34:e13823. [DOI: 10.1111/ctr.13823] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew D. Santeusanio
- Recanati‐Miller Transplantation Institute Mount Sinai Hospital New York NY USA
- Department of Pharmacy Mount Sinai Hospital New York NY USA
| | - Arjun Bhansali
- Recanati‐Miller Transplantation Institute Mount Sinai Hospital New York NY USA
| | - Alan Weinberg
- Department of Population Health Science and Policy Mount Sinai Hospital New York NY USA
| | - Ron Shapiro
- Recanati‐Miller Transplantation Institute Mount Sinai Hospital New York NY USA
| | - Veronica Delaney
- Recanati‐Miller Transplantation Institute Mount Sinai Hospital New York NY USA
| | - Sander Florman
- Recanati‐Miller Transplantation Institute Mount Sinai Hospital New York NY USA
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Outcomes of Conversion From Calcineurin Inhibitor to Belatacept-based Immunosuppression in HLA-sensitized Kidney Transplant Recipients. Transplantation 2019; 104:1500-1507. [DOI: 10.1097/tp.0000000000002976] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Conversion to Belatacept in Maintenance Kidney Transplant Patients: A Retrospective Multicenter European Study. Transplantation 2019; 102:1545-1552. [PMID: 29570163 DOI: 10.1097/tp.0000000000002192] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of belatacept is not yet approved for maintenance in kidney transplant patients. This retrospective multicenter European study aimed to assess the efficacy and safety of conversion to belatacept in a large cohort of patients in a real-life setting and to identify the predictive factors for improved kidney function after the switch. METHODS Two hundred nineteen maintenance kidney transplant patients from 5 European kidney transplant centers were converted to belatacept at 21.2 months (0.1-337.1 months) posttransplantation, mainly because of impaired kidney function. Thirty-two patients were converted to belatacept within the first 3 months posttransplantation. The mean duration of follow-up was 21.9 ± 20.2 months. RESULTS The actuarial rate of patients still on belatacept-based therapy was 77.6%. Mean estimated glomerular filtration rate increased from 32 ± 16.4 at baseline to 38 ± 20 mL/min per 1.73 m (P < 0.0001) at last follow-up. Conversion to belatacept before 3 months posttransplantation was the main predictive factor for a significant increase in estimated glomerular filtration rate (of 5 and 10 mL/min per 1.73 m at 3 and 12 months after the switch, respectively). Eighteen patients (8.2%) presented with an acute rejection episode after conversion; 3 developed a donor-specific antibody. Overall efficacy and safety were good, including for the 35 patients that had a donor-specific antibody at conversion. CONCLUSIONS The conversion to belatacept was effective, especially when performed early after transplantation.
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Belatacept in Solid Organ Transplant: Review of Current Literature Across Transplant Types. Transplantation 2019; 102:1440-1452. [PMID: 29787522 DOI: 10.1097/tp.0000000000002291] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Calcineurin inhibitors (CNIs) have been the backbone immunosuppressant for solid organ transplant recipients for decades. Long-term use of CNIs unfortunately is associated with multiple toxicities, with the biggest concern being CNI-induced nephrotoxicity. Belatacept is a novel agent approved for maintenance immunosuppression in renal transplant recipients. In the kidney transplant literature, it has shown promise as being an alternative agent by preserving renal function and having a minimal adverse effect profile. There are emerging studies of its use in other organ groups, particularly liver transplantation, as well as using with other alternative immunosuppressive strategies. The purpose of this review is to analyze the current literature of belatacept use in solid organ transplantation and discuss its use in current practice.
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Pérez-Sáez MJ, Yu B, Uffing A, Murakami N, Borges TJ, Azzi J, El Haji S, Gabardi S, Riella LV. Conversion from tacrolimus to belatacept improves renal function in kidney transplant patients with chronic vascular lesions in allograft biopsy. Clin Kidney J 2018; 12:586-591. [PMID: 31384452 PMCID: PMC6671390 DOI: 10.1093/ckj/sfy115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Indexed: 01/05/2023] Open
Abstract
Background Conversion from tacrolimus to belatacept has been shown to be beneficial for an increasing number of kidney transplant (KT) patients. Predicting factors for favorable outcomes are still unknown. We aimed to investigate whether histological vascular lesions at the time of conversion might correlate with greater improvement in renal function post-conversion. Methods The study was conducted on a retrospective cohort of 34 KT patients converted from tacrolimus to belatacept. All patients underwent an allograft biopsy prior to conversion. We analyzed the evolution of the estimated glomerular filtration rate (eGFR) at 3 and 12 months after conversion. Results Median time to conversion was 6 (2–37.2) months post-transplant. About 52.9% of patients had moderate-to-severe chronic vascular lesions (cv2–3). We observed an increase in eGFR in the whole cohort from 35.4 to 41 mL/min/1.73 m2 at 3 months (P = 0.032) and 43.7 at 12 months (P = 0.013). Nine patients experienced acute rejection post-conversion, with one graft loss observed beyond the first year after conversion. Patients with cv2–3 had significant improvement in eGFR at 12 months (+8.6 mL/min/1.73 m2; 31.6 to 40.2 mL/min/1.73 m2; P = 0.047) compared with those without these lesions (+6.8 mL/min/1.73 m2; 40.9 to 47.7 mL/min/1.73 m2; P = 0.148). Conclusions Conversion from tacrolimus to belatacept has a beneficial effect in terms of renal function in KT patients. This benefit might be more significant in patients with cv in the biopsy.
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Affiliation(s)
- María José Pérez-Sáez
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Bryant Yu
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Audrey Uffing
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Naoka Murakami
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thiago J Borges
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jamil Azzi
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra El Haji
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steve Gabardi
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonardo V Riella
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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Chen JM, Canter CE, Hsu DT, Kindel SJ, Law YM, McKeever JE, Pahl E, Schumacher KR. Current Topics and Controversies in Pediatric Heart Transplantation: Proceedings of the Pediatric Heart Transplantation Summit 2017. World J Pediatr Congenit Heart Surg 2018; 9:575-581. [PMID: 30157743 DOI: 10.1177/2150135118782895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In October 2017, a pediatric heart transplant summit was held in Seattle-the first of its kind internationally-which focused solely upon controversies in pediatric end-stage heart failure management and pediatric heart transplantation. We selected five of the most popular and contentious topics and asked the speakers to provide a position paper. Worldwide, the vast majority of programs perform only a handful of pediatric heart transplants a year. Because of this, these "orphan" areas of investigation provide an opportunity for us as a community to aggregate our collective knowledge, which may represent the only viable way that we might sort through these complex and controversial issues in the field. We hope this represents the first of many such conferences and that this initial selection of papers encourages us to begin this collaborative process.
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Affiliation(s)
- Jonathan M Chen
- 1 Cardiothoracic Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | | | - Daphne T Hsu
- 3 Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Steven J Kindel
- 4 Herma Heart Institute, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yuk M Law
- 5 Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - James E McKeever
- 6 Clinical Psychology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Elfriede Pahl
- 7 Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kurt R Schumacher
- 8 C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Gupta S, Rosales I, Wojciechowski D. Pilot Analysis of Late Conversion to Belatacept in Kidney Transplant Recipients for Biopsy-Proven Chronic Tacrolimus Toxicity. J Transplant 2018; 2018:1968029. [PMID: 29854421 PMCID: PMC5954857 DOI: 10.1155/2018/1968029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/01/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Calcineurin inhibitors are associated with chronic nephrotoxicity, manifesting as interstitial fibrosis/tubular atrophy (IF/TA) and arteriolar hyalinosis. Conversion from tacrolimus to belatacept may be one strategy to preserve renal function. METHODS We conducted a retrospective review of renal transplant patients followed at our institution who were converted to belatacept and found to have chronic tacrolimus toxicity on biopsy. The primary outcome was eGFR at conversion as compared to eGFR at 3, 6, 12, and 24 months after conversion. We also assessed incidence of infection and rates of allograft survival at 1 year. RESULTS The average time between transplant and conversion was 11.9 years. There was no decrease in eGFR at any postconversion time point as compared with preconversion. The mean eGFR at time of preconversion was 32.9 mL/min, as compared with 35.6 mL/min at 3 months (p = 0.09), 34.1 mL/min at 6 months (p = 0.63), 34.9 mL/min at 12 months (p = 0.57), and 39.6 mL/min at 24 months after conversion (p = 0.92). Four of 7 patients had increases in their eGFR after conversion. All grafts were functioning at 1 year after conversion. CONCLUSION While this study was limited by a small number of patients, belatacept conversion stabilized eGFR at all time points in patients with late allograft function due to chronic tacrolimus toxicity, with a trend towards increased eGFR at 3 months.
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Affiliation(s)
| | - Ivy Rosales
- Massachusetts General Hospital, Boston, MA, USA
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Bertrand D, Cheddani L, Etienne I, François A, Hanoy M, Laurent C, Lebourg L, Le Roy F, Lelandais L, Loron MC, Godin M, Guerrot D. Belatacept Rescue Therapy in Kidney Transplant Recipients With Vascular Lesions: A Case Control Study. Am J Transplant 2017; 17:2937-2944. [PMID: 28707779 DOI: 10.1111/ajt.14427] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/02/2017] [Accepted: 07/06/2017] [Indexed: 02/07/2023]
Abstract
Immunosuppression in kidney transplant recipients with decreased graft function and severe histological vascular changes can be particularly challenging. Belatacept could be a valuable option, as a rescue therapy in this context. We report a retrospective case control study comparing a CNI to belatacept switch in 17 patients with vascular damage and low eGFR to a control group of 18 matched patients with CNI continuation. Belatacept switch was performed on average 51.5 months after kidney transplantation (6.2-198 months). There was no difference between the two groups regarding eGFR at inclusion, and 3 months before inclusion. In the "CNI to belatacept switch group," mean eGFR increased significantly from 23.5 ± 6.7 mL/min/1.73m2 on day 0, to 30.4 ± 9.1 mL/min/1.73 m2 on month 6 (p < 0.001) compared to the control group, in which no improvement was observed. These results were still significant on month 12. Two patients experienced biopsy-proven acute rejection. One was effectively treated without belatacept discontinuation. Two patients needed belatacept discontinuation for infection. In conclusion, the remplacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in eGFR.
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Affiliation(s)
- D Bertrand
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - L Cheddani
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - I Etienne
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - A François
- Department of Anatomy and Pathology, University Hospital, Rouen, France
| | - M Hanoy
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - C Laurent
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - L Lebourg
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - F Le Roy
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - L Lelandais
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - M C Loron
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - M Godin
- Department of Nephrology and Transplantation Centre, Rouen, France
| | - D Guerrot
- Department of Nephrology and Transplantation Centre, Rouen, France
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Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae –Related Urinary Tract Infection in Kidney Transplant Recipients: Risk Factors, Treatment, and Long-Term Outcome. Transplant Proc 2017; 49:1757-1765. [DOI: 10.1016/j.transproceed.2017.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/01/2017] [Indexed: 11/18/2022]
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Dürr M, Lachmann N, Zukunft B, Schmidt D, Budde K, Brakemeier S. Late Conversion to Belatacept After Kidney Transplantation: Outcome and Prognostic Factors. Transplant Proc 2017; 49:1747-1756.e1. [DOI: 10.1016/j.transproceed.2017.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 05/13/2017] [Indexed: 12/31/2022]
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Daloul R, Gupta S, Brennan DC. Biologics in Transplantation (Anti-thymocyte Globulin, Belatacept, Alemtuzumab): How Should We Use Them? CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schulte K, Vollmer C, Klasen V, Bräsen JH, Püchel J, Borzikowsky C, Kunzendorf U, Feldkamp T. Late conversion from tacrolimus to a belatacept-based immuno-suppression regime in kidney transplant recipients improves renal function, acid-base derangement and mineral-bone metabolism. J Nephrol 2017; 30:607-615. [PMID: 28540602 DOI: 10.1007/s40620-017-0411-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/12/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-induced nephrotoxicity and chronic graft dysfunction with deteriorating glomerular filtration rate (GFR) are common problems of kidney transplant recipients. The aim of this study was to analyze the role of belatacept as a rescue therapy in these patients. METHODS In this retrospective, observational study we investigated 20 patients (10 females, 10 males) who were switched from a CNI (tacrolimus) to a belatacept-based immunosuppression because of CNI intolerance or marginal transplant function. Patient follow-up was 12 months. RESULTS Patients were converted to belatacept in mean 28.8 months after transplantation. Reasons for conversion were CNI intolerance (14 patients) or marginal transplant function (6 patients). Mean estimated GFR (eGFR) before conversion was 22.2 ± 9.4 ml/min at baseline and improved significantly to 28.3 ± 10.1 ml/min at 4 weeks and to 32.1 ± 12.6 ml/min at 12 months after conversion. Serum bicarbonate significantly increased from 24.4 ± 3.2 mmol/l at baseline to 28.7 ± 2.6 mmol/l after 12 months. Conversion to belatacept decreased parathyroid hormone and phosphate concentrations significantly, whereas albumin levels significantly increased. In 6 cases an acute rejection preceded clinically relevant CNI toxicity; only two patients suffered from an acute rejection after conversion. Belatacept was well tolerated and there was no increase in infectious or malignant side effects. CONCLUSION A late conversion from a tacrolimus-based immunosuppression to belatacept is safe, effective and significantly improves renal function in kidney transplant recipients. Additionally, the conversion to belatacept has a beneficial impact on acid-base balance, mineral-bone and protein metabolism, independently of eGFR.
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Affiliation(s)
- Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany.
| | - Clara Vollmer
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Vera Klasen
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Jan Hinrich Bräsen
- Nephropathology, Institute for Pathology, Hannover Medical School, Hanover, Germany
| | - Jodok Püchel
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Christian-Albrechts University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
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Kumar D, LeCorchick S, Gupta G. Belatacept As an Alternative to Calcineurin Inhibitors in Patients with Solid Organ Transplants. Front Med (Lausanne) 2017; 4:60. [PMID: 28580358 PMCID: PMC5437176 DOI: 10.3389/fmed.2017.00060] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/01/2017] [Indexed: 12/28/2022] Open
Abstract
The goal of immunosuppression in transplantation has shifted to improving long-term outcomes, reducing drug-induced toxicities while preserving the already excellent short-term outcomes. Long-term gains in solid organ transplantation have been limited at least partly due to the nephrotoxicity and metabolic side effects of calcineurin inhibitors (CNIs). The alloimmune response requires activation of the costimulatory pathway for T cell proliferation and amplification. Belatacept is a molecule that selectively blocks T cell costimulation. In June 2011, the U.S. Food and Drug Administration approved it for maintenance immunosuppression in kidney transplantation based on two open-label, randomized, phase III trials. Since its introduction, belatacept has shown promise in both short- and long-term renal transplant outcomes in several other trials. It exhibits a superior side effect profile compared to CNIs with a comparable efficacy. Across all solid organ transplants, the burden of chronic kidney disease, its associated cardiovascular morbidity, mortality, and inferior patient/allograft survival is a well-documented problem. In this review, we aim to discuss the evidence behind the use of belatacept in solid organ transplants as an effective alternative to CNIs for renal rescue in patients with acute and/or chronic kidney injury.
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Affiliation(s)
- Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Spencer LeCorchick
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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Meneghini M, Gómez C, Mast R, Melilli E, Grinyó JM, Bestard O. Complete Regression of Psoriatic Arthritis After Belatacept Conversion in a Highly HLA-Sensitized Kidney Transplant Patient. Am J Transplant 2017; 17:1409-1413. [PMID: 27996207 DOI: 10.1111/ajt.14172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 01/25/2023]
Abstract
Costimulatory inhibitors (i.e. abatacept and belatacept) effectively abrogate T lymphocyte activation and proliferation and have been shown to be effective for disease control in certain autoimmune disorders as well as in preventing allograft rejection in kidney transplantation. Whether such immunomodulatory agents may be useful for the control of autoimmune flares and allograft acceptance, while avoiding the need of additional strong immunosuppressants, has not been shown. Here, we report the first case of a 47-year-old man affected by a serious debilitating form of psoriatic arthritis that presented during the course of a third, high immunological-risk kidney transplantation. Three years after transplantation, the patient benefited by switching from tacrolimus- to belatacept-based therapy, without additional immunosuppression, by showing complete regression of the arthritic symptoms as well as no progression of severe radiological lesions, which leaded to the recovery of disability and functional impairment. Remarkably, the treatment with belatacept in association with mycophenolate mofetil and steroids also provided a stable normal allograft function over time and abrogated the development of de novo circulating donor-specific alloantibodies after 4 years of follow-up.
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Affiliation(s)
- M Meneghini
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
| | - C Gómez
- Rheumatology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
| | - R Mast
- Radiology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
| | - E Melilli
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
| | - J M Grinyó
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
| | - O Bestard
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona University, IDIBELL, Barcelona, Spain
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Lerch C, Kanzelmeyer NK, Ahlenstiel-Grunow T, Froede K, Kreuzer M, Drube J, Verboom M, Pape L. Belatacept after kidney transplantation in adolescents: a retrospective study. Transpl Int 2017; 30:494-501. [PMID: 28166398 DOI: 10.1111/tri.12932] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/19/2017] [Accepted: 01/30/2017] [Indexed: 12/28/2022]
Abstract
Regardless of recipient age at kidney transplantation (KTx), patients are at greatest risk for graft loss in adolescence, partly due to nonadherence to an oral immunosuppressive regimen. Belatacept, a non-nephrotoxic, first-in-class immunosuppressant that inhibits costimulation of T cells requires intravenous application only every 4 weeks, potentially leading to better adherence. However, it is only approved for use in adults. We report here the findings of the first study of belatacept in adolescents, comprising all patients in our department switched to belatacept post-KTx. Six patients (median age 15.5 years) were switched after a median of 7.5 months (range 23 days to 12 years), treatment range 3-28 months (cumulative 83 months): Three patients switched early (<3 months after KTx) had increased estimated glomerular filtration rate (GFR); one patient switched 12 years post-KTx has stable GFR; two patients were switched following rapid decline of and with markedly impaired GFR, changing slope in one patient. One patient had one acute rejection. In addition of two patients who received belatacept for other conditions, the only relevant adverse event was neutropenia (after a cumulative 109 months). Belatacept as primary immunosuppression is an option in Epstein-Barr virus-seropositive nonadherent adolescents if administered sufficiently early before deterioration of graft function.
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Affiliation(s)
- Christian Lerch
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Nele K Kanzelmeyer
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | | | - Kerstin Froede
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Martin Kreuzer
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Jens Drube
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
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Affiliation(s)
- Timm H Westhoff
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University of Bochum, Herne, Germany
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