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Angkasekwinai N, Suputtamongkol Y, Tantibhedhyangkul W, Onlamoon N, Phoompoung P, Pithukpakorn M, Karuphong E, Pusuwan P, Angkasekwinai P. Efficacy of Bortezomib for Treating Anti-Interferon-Gamma Autoantibody-Associated Adult-Onset Immunodeficiency Syndrome. Clin Infect Dis 2024; 78:1033-1042. [PMID: 37947190 PMCID: PMC11006116 DOI: 10.1093/cid/ciad676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Currently, there is no effective treatment for adult-onset immunodeficiency (AOID) syndrome with anti-interferon-gamma autoantibodies (anti-IFN-γ-auto-Abs). This study aimed to investigate the effectiveness of bortezomib (BTZ) for decreasing anti-IFN-γ-auto-Abs. METHODS A pre- and post-intervention study was conducted from February 2017 through June 2019 at Siriraj Hospital (Bangkok, Thailand). Five patients were invited to receive once-weekly BTZ (1.3 mg/m2 body surface area) subcutaneously for 8 weeks followed by oral cyclophosphamide (1 mg/kg/d) for 4 months. The primary outcomes were the difference in antibody level at 8 and 48 weeks compared with baseline and the incidence of serious adverse events (AEs). The secondary outcome was the occurrence of opportunistic infections (OIs) during the 72 weeks after starting BTZ. RESULTS The median patient age was 46 years (range, 34-53). All patients had 3-5 OIs prior to enrollment. All patients were receiving antimycobacterial agents for treatment of nontuberculous mycobacterial infection at enrollment. There was no significant difference in the mean optical density of auto-Abs at 8 weeks (3.73 ± 0.72) or 48 weeks (3.74 ± 0.53) compared with baseline (3.84 ± 0.49; P = .336 and P = .555, respectively). However, after serum dilution, the antibody titer nonsignificantly decreased 8-16 weeks after BTZ initiation (P = .345). Ten OIs were observed 24-72 weeks after BTZ initiation. CONCLUSIONS Treatment with BTZ followed by cyclophosphamide yielded no significant decrease in antibody titer levels, and 10 OIs were observed during 24-72 weeks of BTZ treatment. No serious AEs were observed. Combining rituximab with BTZ is likely necessary to prevent generation of new autoantibody-producing plasma cells. Clinical Trials Registration. NCT03103555.
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Affiliation(s)
- Nasikarn Angkasekwinai
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yupin Suputtamongkol
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wiwit Tantibhedhyangkul
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawat Onlamoon
- Research Group in Immunobiology and Therapeutic Sciences, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pakpoom Phoompoung
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manop Pithukpakorn
- Division of Medical Genetics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ekkapun Karuphong
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pawana Pusuwan
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpimon Angkasekwinai
- Department of Medical Technology, Faculty of Allied Health Science, Thammasat University, Pathum Thani, Thailand
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Dhillon M, Kobashigawa JA, Kittleson M, Jain R, Patel N, Singer-Englar T, Zhang X, Hakimi M, Aintablian T, Vescio R, Dilibero D, Kransdorf E, Czer L, Nikolova AP, Patel JK. Does bortezomib influence pre-transplant desensitization therapy or benefit post-heart transplant outcomes for highly sensitized patients? Clin Transplant 2024; 38:e15165. [PMID: 37837612 DOI: 10.1111/ctr.15165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The use of bortezomib which is a proteasome inhibitor has been demonstrated to be efficacious in small number of patients as a desensitization strategy in heart transplant. We reviewed our single center's experience using Bortezomib along with plasmapheresis as desensitization therapy for highly sensitized patients to assess pre- and post-transplant outcomes. METHOD We assessed 43 highly sensitized patients awaiting HTx (defined as cPRA > 50%) between 2010 and 2021 who underwent desensitization therapy with bortezomib. Only those patients who subsequently underwent HTx were included in this study. Enrolled patients received up to four doses of bortezomib (1.3 mg/m2 ) over 2 weeks in conjunction with plasmapheresis. The efficacy of PP/BTZ was assessed by comparing the calculated panel reactive antibodies to HLA class I or class II antigens. Post-transplant outcomes including overall survival and incidence of rejection were compared to those of non-sensitized patients (PRA < 10%, n = 649) from the same center. RESULTS The average cPRA prior to PP/BTZ was 94.5%. Post-PP/BTZ there was no statistically significant decline in mean cPRA, class I cPRA, or class II cPRA, though the average percentage decrease in class I cPRA (8.7 ± 17.0%) was higher than the change in class II cPRA (4.4 ± 13.3%). Resulted were also replicated with C1q-binding antibodies showing more effect on I class compared to class II (15.0 ± 37.4% vs. 6.8 ± 33.6%) as well as with 1:8 dilutional assay (14.0 ± 23.0% vs. 9.1 ± 34.9%). Additionally, PP/BTZ treated patients and the control group of non-sensitized patients had similar overall 1 year survival (95.4 vs. 92.5%) but patients with PP/BTZ had increased incidence of AMR (79.1% vs. 97.1%, p = < .001), any treated rejection (62.8% vs. 86.7%, p = < .001) and de novo DSA development (81.4% vs. 92.5%, p = .007). Major side effects of PP/BTZ included thrombocytopenia (42%), infection requiring antibiotics (28%), and neuropathy (12%). CONCLUSION The use of bortezomib in highly sensitized patients does not significantly lower circulating antibodies prior to heart transplantation. However, its use may improve the chances of obtaining an immuno-compatible donor heart and contribute to acceptable post-transplant outcomes.
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Affiliation(s)
- Manvir Dhillon
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | | | - Rashmi Jain
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Nikhil Patel
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Xiaohai Zhang
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Matthew Hakimi
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Robert Vescio
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Evan Kransdorf
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Lawrence Czer
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
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Choi MC, Min EK, Yim SH, Kim DG, Lee JG, Joo DJ, Kim MS. High Number of Plasma Exchanges Increases the Risk of Bacterial Infection in ABO-incompatible Living Donor Liver Transplantation. Transplantation 2023:00007890-990000000-00615. [PMID: 38057966 DOI: 10.1097/tp.0000000000004883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Bacterial infections are major complications that cause significant mortality and morbidity in living donor liver transplantation (LDLT). The risk of bacterial infection has not been studied in ABO-incompatible (ABOi) recipients with a desensitization protocol in relation to the number of plasma exchanges (PEs). Therefore, we aimed to analyze the risk of bacterial infection in ABOi LDLT recipients with a high number of PEs compared with recipients with a low number of PEs. METHODS A retrospective study was performed with 681 adult LDLT recipients, of whom 171 ABOi LDLT recipients were categorized into the high (n = 52) or low (n = 119) PE groups based on a cutoff value of 6 PE sessions. We compared bacterial infections and postoperative bacteremia within 6 mo after liver transplantation with the ABO-compatible (ABOc) LDLT group (n = 510) as a control group. RESULTS The high PE group showed a bacterial infection rate of 49.9% and a postoperative bacteremia rate of 28.8%, which were significantly higher than those of the low PE group (31.1%, 17.8%) and the ABOc group (26.7%, 18.0%). In multivariate analysis, the high PE group was found to have a 2.4-fold higher risk of bacterial infection (P = 0.008). This group presented a lower 5-y survival rate of 58.6% compared with the other 2 groups (81.5% and 78.5%; P = 0.030 and 0.001). CONCLUSIONS A high number of preoperative PEs increases bacterial infection rate and postoperative bacteremia in ABOi LDLT.
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Affiliation(s)
- Mun Chae Choi
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun-Ki Min
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hyuk Yim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Deok-Gie Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Geun Lee
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Jin Joo
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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Eleutherakis Papaiakovou E, Terpos E, Kanellias N, Migkou M, Gavriatopoulou M, Ntanasis-Stathopoulos I, Fotiou D, Malandrakis P, Theodorakakou F, Spiliopoulou V, Kostopoulos IV, Tsitsiloni O, Tsirigotis P, Dimopoulos MA, Kastritis E. Impact of daratumumab on stem cell mobilization and collection, engraftment and early post-transplant complications among multiple myeloma patients undergoing autologous stem cell transplantation. Leuk Lymphoma 2023; 64:2140-2147. [PMID: 37655597 DOI: 10.1080/10428194.2023.2253479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
Autologous stem cell transplantation (ASCT) remains a standard therapy for multiple myeloma (MM) patients. Our study aimed to assess the impact of daratumumab-containing induction on stem cell (SC) mobilization, apheresis and hospitalization. We evaluated 200 newly diagnosed MM patients that were mobilized for SC collection and which received induction with (N = 40) or without daratumumab (N = 160). Dara group patients required more frequent use of plerixafor, larger collection volumes, and had lower SC yield. 87.5% (35/40) of dara group patients achieved the planned yield of ≥ 5 × 10^6 CD34+/kg for at least one transplant compared to 96.2% (154/160) of patients in the non-dara group. Dara group patients had delayed hematopoietic recovery (11 vs 10 days for PMN > 0.5 × 10E9/l), required more transfusions (4 vs 2 plts), prolonged hospitalization (20 vs 18 days), more febrile episodes and prolonged antibiotic administration. Despite daratumumab effect patients finally achieved a successful stem cell collection and proceeded to transplant.
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Affiliation(s)
- Evangelos Eleutherakis Papaiakovou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Despoina Fotiou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Ioannis V Kostopoulos
- Department of Biology, School of Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Ourania Tsitsiloni
- Department of Biology, School of Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Tsirigotis
- Second Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Attiko Hospital, Athens, Greece
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Abinti M, Favi E, Alfieri CM, Zanoni F, Armelloni S, Ferraresso M, Cantaluppi V, Castellano G. Update on current and potential application of extracellular vesicles in kidney transplantation. Am J Transplant 2023; 23:1673-1693. [PMID: 37517555 DOI: 10.1016/j.ajt.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
Kidney transplantation (KT) is the best treatment for end-stage kidney disease. However, early diagnosis of graft injury remains challenging, mainly because of the lack of accurate and noninvasive diagnostic techniques. Improving graft outcomes is equally demanding, as is the development of innovative therapies. Many research efforts are focusing on extracellular vesicles, cellular particles free in each body fluid that have shown promising results as precise markers of damage and potential therapeutic targets in many diseases, including the renal field. In fact, through their receptors and cargo, they act in damage response and immune modulation. In transplantation, they may be used to determine organ quality and aging, the presence of delayed graft function, rejection, and many other transplant-related pathologies. Moreover, their low immunogenicity and safe profile make them ideal for drug delivery and the development of therapies to improve KT outcomes. In this review, we summarize current evidence about extracellular vesicles in KT, starting with their characteristics and major laboratory techniques for isolation and characterization. Then, we discuss their use as potential markers of damage and as therapeutic targets, discussing their promising use in clinical practice as a form of liquid biopsy.
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Affiliation(s)
- Matteo Abinti
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evaldo Favi
- Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Carlo Maria Alfieri
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesca Zanoni
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Silvia Armelloni
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Mariano Ferraresso
- Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplant Unit, Department of Translational Medicine (DIMET), University of Piemonte Orientale (UPO), "Maggiore della Carita" University Hospital, Novara, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
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Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
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Wilson N, Reese S, Ptak L, Aziz F, Parajuli S, Jucaud V, Denham S, Mishra A, Cascalho M, Platt JL, Hematti P, Djamali A. Ixazomib for Desensitization (IXADES) in Highly Sensitized Kidney Transplant Candidates: A Phase II Clinical Trial. Kidney360 2023; 4:e796-e808. [PMID: 36951387 PMCID: PMC10371382 DOI: 10.34067/kid.0000000000000113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Key Points Ixazomib treatment resulted in decreases in B-cell subsets and bone marrow lymphocytes. Ixazomib treatment resulted in modest decreases in certain anti-HLA antibody specificities. Ixazomib treatment was tolerated, with modest adverse events. Background Ixazomib is a second-generation oral proteasome inhibitor approved for treatment of refractory multiple myeloma. We conducted an open-label phase II trial, IXAzomib for DESensitization (IXADES), testing the safety of ixazomib treatment as an approach to decreasing the level and diversity of specificities of anti-HLA antibodies in subjects awaiting kidney transplantation. The trial (NCT03213158 ) enrolled highly sensitized kidney transplant candidates, defined as subjects with calculated panel reactive antibodies (cPRA) >80%, awaiting kidney transplantation >24 months. The subjects were treated with 12 monthly cycles of ixazomib 3 mg+dexamethasone 20 mg. Efficacy was defined as a decrease of cPRA >20% or kidney transplantation. The safety end point was tolerability. Methods In ten enrolled subjects, no grade IV, five grade III, 11 grade II, and 43 grade I adverse events were noted. The adverse events included infection, transient paresthesia, nausea, vomiting, and diarrhea. The IXADES regimen was not associated with significant change in levels or diversity of anti-HLA antibodies (cPRA). Results Although the IXADES regimen did not exhibit a clear impact on levels and diversity of anti-HLA antibodies in this small cohort, the prolonged half-life of IgG could necessitate a longer duration of treatment for accurate evaluation of efficacy. Conclusions In conclusion, treatment with ixazomib/dexamethasone engendered mild-to-moderate toxicity. The impact on anti-HLA was modest and paradoxical in the case of anti-HLA-DR. Clinical trials combining ixazomib with other immunosuppressive agents may be more effective in addressing antibody-mediated processes in kidney transplantation.
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Affiliation(s)
- Nancy Wilson
- Department of Pathology and Laboratory Medicine, AVRL, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shannon Reese
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lucy Ptak
- Department of Administration, Division of Clinical Trials, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Fahad Aziz
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | | | | | - Ameet Mishra
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Marilia Cascalho
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey L. Platt
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Peiman Hematti
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, Maine
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Abstract
When first introduced, rituximab (RTX), a chimeric anti-CD20 monoclonal antibody, brought about an alternative therapeutic paradigm for primary membranous nephropathy (PMN). Rituximab was shown to be effective and safe in PMN patients with kidney dysfunction, with. patients receiving second-line rituximab therapy achieving remission as effectively as those patients who had not previously received immunotherapy. No safety issues were reported. The B cell-driven protocol seems to be as efficient as the 375 mg/m2 × 4 regimen or 1 g × 2 regimen in achieving B cell depletion and remission, but patients with high M-type phospholipase A2 receptor (PLA2R) antibody levels may benefit from a higher dose of rituximab. While rituximab added another therapeutic option to the treatment regimen, it does have limitations as 20 to 40% of patients do not respond. Not all patients respond to RTX therapy for lymphoproliferative disorders either, therefore further novel anti-CD20 monoclonal antibodies have been developed and these may provide alternative therapeutic options for PMN. Ofatumumab, a fully human monoclonal antibody, specifically recognizes an epitope encompassing both the small and large extracellular loops of the CD20 molecule, resulting in increased complement-dependent cytotoxic activity. Ocrelizumab binds an alternative but overlapping epitope region to rituximab and displays enhanced antibody-dependent cellular cytotoxic (ADCC) activities. Obinutuzumab is designed to have a modified elbow-hinge amino acid sequence, leading to increased direct cell death induction and ADCC activities. In PMN clinical studies, ocrelizumab and obinutuzumab showed promising results, while ofatumumab displayed mixed results. However, there is a lack of randomized controlled trials with large samples, especially direct head-to-head comparisons. Alternative molecular mechanisms have been suggested in this context to explore novel therapeutic strategies. B cell activator-targeted, plasma cell-targeted and complement-directed treatments may lead to novel therapy paradigms for PMN. Exploratory strategies for the use of drugs with different mechanisms, such as a combination of rituximab and cyclophosphamide and a steroid, a combination of rituximab and a calcineurin inhibitor, may provide more rapid and efficient remission, but the combination of standard immunosuppression with rituximab could increase infection risk.
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Affiliation(s)
- Le Deng
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, Jiangxi, China.
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Modica RF, Thatayatikom A, Bell-Brunson DH, Elder ME. Bortezomib is efficacious in the treatment of severe childhood-onset neuropsychiatric systemic lupus erythematosus with psychosis: a case series and mini-review of B-cell immunomodulation in antibody-mediated diseases. Clin Rheumatol 2023:10.1007/s10067-023-06559-y. [DOI: 10.1007/s10067-023-06559-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/29/2023]
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Abstract
By 2014, strategies to prevent antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) were established in Japan and expanded primarily to Asia, where LDLT is now the predominant form of LT owing to the scarcity of brain-dead donors. A desensitization protocol consisting of rituximab (375 mg/m 2 ), plasma pheresis, tacrolimus, and mycophenolate mofetil before LDLT, followed by standard immunosuppression, is currently the best option in terms of safety and efficacy. Rituximab administration is now known not to increase the risk of hepatocellular carcinoma recurrence, and the feasibility of rituximab for LDLT for acute liver failure and the need for desensitization before LDLT in children older than 1 y have been documented. Strategies are needed to distinguish patients at high risk of AMR from those at low risk and to adjust immunosuppression to prevent both AMR and infection. Specific single-nucleotide polymorphisms in genes encoding Fcγ receptors affecting the cytotoxicity of rituximab on B cells could be useful for adjusting immunosuppression levels to decrease infectious complications. Immunological accommodation after ABO-I transplantation could be provided by immune factors in both the grafts and recipients.
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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12
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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13
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Weinhard J, Noble J, Jouve T, Malvezzi P, Rostaing L. [Improving access to kidney transplantation for highly sensitized patients: What place for IL-6 pathway blockade in desensitization protocols?]. Nephrol Ther 2022; 18:577-583. [PMID: 36328901 DOI: 10.1016/j.nephro.2022.07.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 05/19/2022] [Accepted: 07/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Desensitization allows kidney transplantation for HLA highly sensitized subjects. Due to the central role of IL-6 in immunological response, tocilizumab (monoclonal antibody directed against IL-6 receptor) could probably improve desensitization efficacy. METHODS Pubmed systematic review by using MeSH terms: tocilizumab, clazakizumab, interleukin-6 blockade, kidney transplantation, kidney graft and desensitization. STUDIES IL-6 plays a role in humoral response (plasmocyte differentiation induced by lymphocyte T, IL-21 secretion) as well as in cellular response (differentiation of LT Th17 rather than T reg). In desensitization field, tocilizumab was first studied as second-line treatment after failing of standard-of-care (apheresis, rituximab ± IgIV). Recent study showed that tocilizumab as a monotherapy attenuated anti-HLA antibodies rates but was not sufficient to allow transplantation. However, lymphocyte immunophenotyping showed that tocilizumab hindered B cells maturation. Thereby, tocilizumab could improve long-term efficacy of desensitization, by limiting the anti-HLA rebound and so avoiding antibody-mediated rejection. This hypothesis is supported by a recent study which used clazakizumab (monoclonal antibody directed against IL-6) in association with standard-of-care. In that study, clazakizumab was continued after kidney transplantation. Results were encouraging because 9/10 patients were transplanted and there was no donor-specific antibody at 6 months post-transplantation. CONCLUSION IL-6 pathway blockade as a monotherapy fails to desensitize HLA highly sensitized kidney transplant candidates. In association with standard-of-care, it does not seem to significatively improve kidney allograft access (short-term efficacy) vs. standard-of-care only. However, it could improve long-term prognosis of HLA incompatible transplantation by orienting the response towards a tolerogenic profile, by hindering B-cell maturation and, thereby, avoiding DSA rebounds after transplantation. This hypothesis needs to be proven by further studies.
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Affiliation(s)
- Jules Weinhard
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Johan Noble
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Thomas Jouve
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France; Université Grenoble-Alpes, GrenobleFrance
| | - Paolo Malvezzi
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France; Université Grenoble-Alpes, GrenobleFrance.
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14
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Mujtahedi SS, Yigitbilek F, Benavides X, Merzkani MA, Ozdogan E, Abozied O, Moore NA, Park WD, Stegall MD. Bone marrow derived long-lived plasma cell phenotypes are heterogeneous and can change in culture. Transpl Immunol 2022; 75:101726. [PMID: 36183942 DOI: 10.1016/j.trim.2022.101726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/15/2022] [Accepted: 09/25/2022] [Indexed: 11/28/2022]
Abstract
Bone marrow derived long-lived plasma cells (LLPCs) are thought to be a major source of alloantibody in sensitized transplant patients. However, studies of LLPCs have been hampered not only by the fact that they are rare and difficult to isolate and culture but also due to the lack of consensus regarding a definitive cell-surface phenotype. The goal of the current study was to determine if LLPCs have a specific, stable cell-surface phenotype. PCs were isolated from high-volume (120 cc) bone marrow aspirates that were enriched first by negative selection then positive selection using anti-CD38 antibody-coated beads and purified by cell sorting. A typical isolation resulted in >100,000 PCs that were sorted into 4 populations with variable numbers of PCs: CD19+/CD138+/CD38Hi (64.1% of the PCs), CD19-/CD138+/CD38Hi (20.9%), CD19+/CD138-/CD38Hi (10.7%), and CD19-/CD138-/CD38Hi (4.3%). The purity of each subset was 96-99%. Each subset contained PCs secreting IgG and IgA. Measles- and tetanus-specific PCs (i.e. putative IgG secreting, antigen-specific LLPCs). LLPCs were identified in both the CD19+/CD138+/CD38Hi and CD19-/CD138+/CD38Hi subsets and in the smaller CD138- subsets (when pooled). Thus, all CD38Hi subsets contained LLPCs. Cultured PCs maintained viability (>50%) and function and could be retrieved for analyses. During 7 days of culture, cell surface expression changed from baseline in many PCs. For example, approximately 20% of CD19 + CD138+/CD38Hi cells (the largest PC subset) became CD19-. CFSE assays showed no division and only a small percentage of LLPCs were Ki-67 positive suggesting that the cells did not divide in culture and that the antibody detected was not from plasmablasts. We conclude that human bone marrow LLPCs have a heterogeneous expression of CD19 and CD138, which can change during cell culture. The fact that LLPCs were found in all four subsets raises the possibility that a large percentage of PCs in the bone marrow may be LLPCs.
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Affiliation(s)
- Syed S Mujtahedi
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Furkan Yigitbilek
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Xiomara Benavides
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA; Departments of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Massini A Merzkani
- John T. Milliken Department of Medicine, Division of Nephrology, Washington University, St. Louis, MO, USA
| | - Elif Ozdogan
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Omar Abozied
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | | | - Walter D Park
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Mark D Stegall
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA; Division of Transplant Surgery, Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN, USA.
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15
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van Vugt LK, Schagen MR, de Weerd A, Reinders ME, de Winter BC, Hesselink DA. Investigational drugs for the treatment of kidney transplant rejection. Expert Opin Investig Drugs 2022; 31:1087-1100. [PMID: 36175360 DOI: 10.1080/13543784.2022.2130751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Kidney transplant rejection remains an important clinical problem despite the development of effective immunosuppressive drug combination therapy. Two major types of rejection are recognized, namely T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), which have a different pathophysiology and are treated differently. Unfortunately, long-term outcomes of both TCMR and ABMR remain unsatisfactory despite current therapy. Hence, alternative therapeutic drugs are urgently needed. AREAS COVERED This review covers novel and investigational drugs for the pharmacological treatment of kidney transplant rejection. Potential therapeutic strategies and future directions are discussed. EXPERT OPINION The development of alternative pharmacologic treatment of rejection has focused mostly on ABMR, since this is the leading cause of kidney allograft loss and currently lacks an effective, evidence-based therapy. At present, there is insufficient high-quality evidence for any of the covered investigational drugs to support their use in ABMR. However, with the emergence of targeted therapies, this potential arises for individualized treatment strategies. In order to generate more high-quality evidence for such strategies and overcome the obstacles of classic, randomized, controlled trials, we advocate the implementation of adaptive trial designs and surrogate clinical endpoints. We believe such adaptive trial designs could help to understand the risks and benefits of promising drugs such as tocilizumab, clazakizumab, belimumab, and imlifidase.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maaike R Schagen
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annelies de Weerd
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies Ej Reinders
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda Cm de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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16
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Zhang X, Li J, Liu T, Zhao M, Liang B, Chen H, Zhang Z. Identification of Key Biomarkers and Immune Infiltration in Liver Tissue after Bariatric Surgery. Dis Markers 2022; 2022:4369329. [PMID: 35789605 PMCID: PMC9250435 DOI: 10.1155/2022/4369329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/17/2022]
Abstract
Background Few drugs are clearly available for nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH); nevertheless, mounting studies have provided sufficient evidence that bariatric surgery is efficient for multiple metabolic diseases, including NAFLD and NASH, while the molecular mechanisms are still poorly understood. Methods The mRNA expression profiling of GSE48452 and GSE83452 were retrieved and obtained from the Gene Expression Omnibus (GEO) database. The limma package was employed for identifying differentially expressed genes (DEGs), followed by clusterProfiler for performing Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses, and GSEA software for performing GSEA analyses. The PPI network analyses were constructed using Metascape online analyses. WGCNA was also utilized to identify and verify the hub genes. CIBERSORT tools contributed to the analysis of immune cell infiltration of liver diseases. Results We identify coexpressed differential genes including 10 upregulated and 55 downregulated genes in liver tissue after bariatric surgery. GO and KEGG enrichment analyses indicated that DEGs were remarkably involved in the immune response. GSEA demonstrated that DEGs were markedly enriched in the immune response before surgery, while most were enriched in metabolism after surgery. Seven genes were screened through the MCC algorithm and KME values, including SRGN, CD53, EVI2B, MPEG1, NCKAP1L, LCP1, and TYROBP. The mRNA levels of these genes were verified in the Attie Lab Diabetes Database, and only LCP1 was found to have significant differences and correlation with certain immune cells. Conclusion Our knowledge of the mechanisms by which bariatric surgery benefits the liver and the discovery of LCP1 is expected to serve as potential biomarkers or therapeutic targets for NAFLD and NASH.
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Affiliation(s)
- Xiaoyan Zhang
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Pediatrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jingxin Li
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Tiancai Liu
- School of Laboratory Medicine and Biotechnology, Institute of Antibody Engineering, Southern Medical University, Guangzhou, China
| | - Min Zhao
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Baozhu Liang
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Chen
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhen Zhang
- Department of Endocrinology and Metabolism, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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17
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Lee WC, Cheng CH, Lee CF, Hung HC, Lee JC, Wu TH, Wang YC, Wu TJ, Chou HS, Chan KM. Quick preparation of ABO-incompatible living donor liver transplantation for acute liver failure. Clin Transplant 2021; 36:e14555. [PMID: 34874071 DOI: 10.1111/ctr.14555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Acute liver failure is life-threatening and has to be treated by liver transplantation urgently. When deceased donors or ABO-compatible living donors are not available, ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) becomes the only choice. How to prepare ABO-I LDLT urgently is an unsolved issue. A quick preparation regimen was designed, which was consisted of bortezomib (3.5mg) injection to deplete plasma cells and plasma exchange to achieve isoagglutinin titer ≤ 1: 64 just prior to liver transplantation and followed by rituximab (375mg/m2 ) on post-operative day one to deplete B-cells. Eight patients received this quick preparation regimen to undergo ABO-I LDLT for acute liver failure from 2012 to 2019. They aged between 50 and 60 years. The median MELD score was 39 with a range from 35 to 48. It took 4.75 ± 1.58 days to prepare such an urgent ABO-I LDLT. All the patients had successful liver transplantations, but one patient died of antibody-mediated rejection at post-operative month 6. The 3-month, 6-month, and 1-year graft/patient survival were 100%, 87.5%, and 75%, respectively. In conclusion, this quick preparation regimen can reduce isoagglutinin titers quickly and make timely ABO-I LDLT feasible for acute liver failure. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Wei-Chen Lee
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Hsien Cheng
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chen-Fang Lee
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Hao-Chien Hung
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Jin-Chiao Lee
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsung-Han Wu
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Chao Wang
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Ting-Jung Wu
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Hong-Shiue Chou
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Kun-Ming Chan
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang-Gung Memorial Hospital, Linkou, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
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18
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Lee WC, Lee CF, Wu TH, Hung HC, Lee JC, Wang YC, Cheng CH, Wu TJ, Chou HS, Chan KM. Clinical Relevance of Isoagglutinin Rebound in Adult ABO-Incompatible Living Donor Liver Transplantation. J Pers Med 2021; 11:1300. [PMID: 34945772 DOI: 10.3390/jpm11121300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022] Open
Abstract
ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) can be performed successfully. However, anti-ABO isoagglutinin rebound may cause antibody-mediated rejection (AMR) and graft loss. The risk threshold of isoagglutinin rebound is still not defined. 76 ABO-I LDLT recipients were divided into group A (n = 56) with low isoagglutinin titers (<1:256), and group B (n = 20) with high isoagglutinin titers (≥1:256), at initial assessment for liver transplantation. The last 12 patients in group B received a modified desensitization regimen by adding bortezomib to deplete plasma cells. Six (10.7%) patients in group A and 10 (50.0%) patients in group B had postoperative isoagglutinin rebound (p < 0.001). Three patients (5.54%) in group A and two patients (10%) in group B developed clinical AMR (p = 0.602). The cutoff value of postoperative isoagglutinin rebound to cause clinical AMR was ≥1:1024. Among the 12 patients in group B with bortezomib administration, isoagglutinin rebounded up to 1:128 only, and no clinical AMR occurred. In conclusion, the patients with high isoagglutinin titers had a higher rate of postoperative isoagglutinin rebound. Isoagglutinin rebound ≥1:1024 is risky for developing clinical AMR. Adding bortezomib into the desensitization regimen may mitigate isoagglutinin rebound, and avoid clinical AMR.
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Benachi A, Rabant M, Martinovic J, Bouchghoul H, Vivanti AJ, Leon J, Grunenwald A, Roumenina L, Celton JL, Bessieres B, Taupin JL, Zuber J. Chronic histiocytic intervillositis: manifestation of placental alloantibody-mediated rejection. Am J Obstet Gynecol 2021; 225:662.e1-662.e11. [PMID: 34126086 DOI: 10.1016/j.ajog.2021.06.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic histiocytic intervillositis (chronic intervillositis) is defined by a diffuse infiltration of monocytes into the intervillous space, which often leads to poor obstetrical outcomes, including recurrent intrauterine growth restriction, miscarriage, and fetal death. The pathogenesis of chronic intervillositis is still poorly defined, and there is an unmet medical need for improved management. OBJECTIVE This study aimed to demonstrate the role of anti-human leukocyte antigen alloantibodies in the pathogenesis of chronic intervillositis through the application of criteria used in solid-organ transplantation for the diagnosis of antibody-mediated rejection. STUDY DESIGN A multidisciplinary research study based on thorough immunologic and pathologic investigations was carried out for 2 separate couples who experienced recurrent secondary fetal losses following a first normal pregnancy associated with histologic evidence of chronic intervillositis. RESULTS Very high levels of complement-fixing, fetus-specific antibodies targeting mismatched human leukocyte antigen alleles, harbored by the 2 paternal haplotypes, were identified in both cases. Polymorphic human leukocyte antigens were expressed on the surface of trophoblastic villi of the inflamed placenta but not in healthy placental tissue. The binding of alloantibodies to paternal human leukocyte antigens induced dramatic activation of the complement classical pathway in trophoblastic villi, leading to C4d deposition and formation of the terminal complex C5b-9. All requirements for the diagnosis of antibody-mediated placental rejection were fulfilled according to the criteria used in the Banff classification of allograft pathology. In silico analysis was performed using a human leukocyte antigen epitope viewer to reconstitute the human leukocyte antigen sensitization history. Reactivity against a single mismatched epitope present in the first-born healthy child accounted for a broad sensitization to human leukocyte antigens, including those harbored by the 2 paternal haplotypes. This finding explained the high rates of chronic intervillositis recurrence during subsequent pregnancies. CONCLUSION This study provides novel mechanistic insights into the pathogenesis of chronic intervillositis and provides new avenues for individualized counseling and therapeutic options.
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Affiliation(s)
- Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine-Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France; Université Paris-Saclay, Gif-sur-Yvette, France.
| | - Marion Rabant
- Département d'Anatomopathologie, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France; University of Paris, Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche (UMR) 1151, Paris, France
| | - Jelena Martinovic
- Département de Foetopathologie, Hôpital Antoine-Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Hanane Bouchghoul
- Université Paris-Saclay, Gif-sur-Yvette, France; Département d'Obstétrique et Gynécologie, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Alexandre J Vivanti
- Department of Obstetrics and Gynecology, Hôpital Antoine-Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France; Université Paris-Saclay, Gif-sur-Yvette, France
| | - Juliette Leon
- Département d'Anatomopathologie, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France; University of Paris, INSERM UMR 1163, Paris, France
| | - Anne Grunenwald
- Centre de Recherche des Cordeliers, INSERM, Sorbonne University, Université de Paris, Paris, France
| | - Lubka Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne University, Université de Paris, Paris, France
| | - Jean-Louis Celton
- Laboratoire d'Histocompatibilité, Hôpital de Nouméa, Nouméa, New Caledonia
| | - Bettina Bessieres
- Département d'Anatomopathologie, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, INSERM UMR 976, Institut de Recherche Saint Louis, Paris, France
| | - Julien Zuber
- University of Paris, INSERM UMR 1163, Paris, France; Département de Néphrologie et Transplantation Rénale, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.
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20
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Gołębiewska JE, Wardowska A, Pietrowska M, Wojakowska A, Dębska-Ślizień A. Small Extracellular Vesicles in Transplant Rejection. Cells 2021; 10:cells10112989. [PMID: 34831212 PMCID: PMC8616261 DOI: 10.3390/cells10112989] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/31/2021] [Accepted: 10/31/2021] [Indexed: 12/28/2022] Open
Abstract
Small extracellular vesicles (sEV), which are released to body fluids (e.g., serum, urine) by all types of human cells, may stimulate or inhibit the innate and adaptive immune response through multiple mechanisms. Exosomes or sEV have on their surface many key receptors of immune response, including major histocompatibility complex (MHC) components, identical to their cellular origin. They also exhibit an ability to carry antigen and target leukocytes either via interaction with cell surface receptors or intracellular delivery of inflammatory mediators, receptors, enzymes, mRNAs, and noncoding RNAs. By the transfer of donor MHC antigens to recipient antigen presenting cells sEV may also contribute to T cell allorecognition and alloresponse. Here, we review the influence of sEV on the development of rejection or tolerance in the setting of solid organ and tissue allotransplantation. We also summarize and discuss potential applications of plasma and urinary sEV as biomarkers in the context of transplantation. We focus on the attempts to use sEV as a noninvasive approach to detecting allograft rejection. Preliminary studies show that both sEV total levels and a set of specific molecules included in their cargo may be an evidence of ongoing allograft rejection.
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Affiliation(s)
- Justyna E. Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
- Correspondence:
| | - Anna Wardowska
- Department of Physiopathology, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Monika Pietrowska
- Centre for Translational Research and Molecular Biology of Cancer, Maria Skłodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland;
| | - Anna Wojakowska
- Institute of Bioorganic Chemistry Polish Academy of Sciences, 61-704 Poznań, Poland;
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
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21
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Mujtahedi SS, Yigitbilek F, Ozdogan E, Schinstock CA, Stegall MD. Antibody-Mediated Rejection: the Role of Plasma Cells and Memory B Cells. Curr Transpl Rep 2021. [DOI: 10.1007/s40472-021-00342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Weinhard J, Noble J, Jouve T, Malvezzi P, Rostaing L. Tocilizumab and Desensitization in Kidney Transplant Candidates: Personal Experience and Literature Review. J Clin Med 2021; 10:4359. [PMID: 34640377 PMCID: PMC8509506 DOI: 10.3390/jcm10194359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022] Open
Abstract
Desensitization (DES) allows kidney transplantation for highly HLA-sensitized subjects. Due to the central role of IL-6 in the immunological response, tocilizumab may improve DES efficacy. Thus, we conducted a PubMed systematic review using the MeSH terms tocilizumab, interleukin-6, kidney transplantation, and desensitization. Tocilizumab (TCZ) was first studied for DES as the second-line treatment after failure of a standard DES protocol (SP) (apheresis, rituximab +/- IVIg). Although TCZ (as a monotherapy) attenuated anti-HLA antibody rates, it did not permit transplantation. However, lymphocyte immuno-phenotyping has shown that TCZ hinders B-cell maturation and thus could improve the long-term efficacy of DES by limiting anti-HLA rebound and so avoid antibody-mediated rejection. This hypothesis is supported by a recent study where clazakizumab, a monoclonal antibody directed against IL-6, was continued after kidney transplantation in association with an SP. Nine out of ten patients were then eligible for transplantation, and there were no donor-specific antibodies at 6 months post-transplantation. In association with an SP, tocilizumab does not seem to significantly improve kidney-allograft access (short-term efficacy) vs. a SP only. However, it could improve the long-term prognosis of HLA-incompatible transplantation by hindering B-cell maturation and, thereby, avoiding donor-specific antibody rebounds post-transplantation.
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Affiliation(s)
- Jules Weinhard
- Service de Néphrologie, Hémodialyse, Aphérèses, et Transplantation Rénale, CHU Grenoble-Alpes, 38700 Grenoble, France; (J.W.); (J.N.); (T.J.); (P.M.)
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses, et Transplantation Rénale, CHU Grenoble-Alpes, 38700 Grenoble, France; (J.W.); (J.N.); (T.J.); (P.M.)
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses, et Transplantation Rénale, CHU Grenoble-Alpes, 38700 Grenoble, France; (J.W.); (J.N.); (T.J.); (P.M.)
- Faculté de Médecine, Université Grenoble-Alpes, 38700 Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses, et Transplantation Rénale, CHU Grenoble-Alpes, 38700 Grenoble, France; (J.W.); (J.N.); (T.J.); (P.M.)
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses, et Transplantation Rénale, CHU Grenoble-Alpes, 38700 Grenoble, France; (J.W.); (J.N.); (T.J.); (P.M.)
- Faculté de Médecine, Université Grenoble-Alpes, 38700 Grenoble, France
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23
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Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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24
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Abstract
Immunosuppressive drugs used in the transplantation period are generally defined as induction and maintenance therapy. The use of immunosuppressants, which are particularly useful and have fewer side effects, decreased both mortality and morbidity. Many drugs such as steroids, calcineurin inhibitors (cyclosporine-A, tacrolimus), antimetabolites (mycophenolate mofetil, azathioprine), and mTOR inhibitors (sirolimus, everolimus) are used as immunosuppressive agents. Although immunosuppressant drugs cause many side effects such as hypertension, infection, and hyperlipidemia, they are the agents that should be used to prevent organ rejection. This shows the importance of individualized drug use. The optimal immunosuppressive therapy post-transplant is not established. Therefore, discovering less toxic but more potent new agents is of great importance, and new experimental and clinical studies are needed in this regard.Our review discussed the mechanism of immunosuppressants, new agents' discovery, and current therapeutic protocols in the transplantation.
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Affiliation(s)
- Hakan Parlakpinar
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Mehmet Gunata
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
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25
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Vitkon R, Netanely D, Levi S, Ziv-Baran T, Ben-Yzak R, Katz BZ, Benyamini N, Trestman S, Mittelman M, Cohen Y, Avivi I. Daratumumab in combination with proteasome inhibitors, rapidly decreases polyclonal immunoglobulins and increases infection risk among relapsed multiple myeloma patients: a single center retrospective study. Ther Adv Hematol 2021; 12:20406207211035272. [PMID: 34377384 PMCID: PMC8323447 DOI: 10.1177/20406207211035272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background Daratumumab (Dara) is generally well tolerated, but is associated with increased risk of infection. Methods We investigated hypogammaglobinemia occurrence in different Dara-based regimens. Multiple myeloma (MM) patients were treated with ⩾2 cycles of Dara-based therapy during 2016-2020, mainly for relapsed/refractory disease. Data on patient characteristics, treatment regimens, polyclonal IgG (poly-IgG) and uninvolved free light chain (Un-FLC) levels during treatment, as well as predictors for hypogammaglobinemia and predictors for infections, were evaluated retrospectively. Results A total of 84 patients, median age 67.2 years, were included. Dara, mainly as ⩾2 line therapy (88.1%, n = 74), was combined with immunomodulating drugs (IMiDs) (53%), proteasome inhibitors (PIs) (15%), IMiDs-PIs (11%), or dexamethasone only (21%). Median treatment duration was 13 months. Median Poly-IgG levels at 0, 2, and 4 months were 7.1 g/l, 4.5 g/l, and 4 g/l, respectively, and remained low throughout treatment. Lower poly-IgG pre-Dara (p = 0.001) and Dara-PIs (±IMiDs) regimen were associated with lower poly-IgG levels at 4 months (p = 0.03). Only patients treated with Dara monotherapy had partial immune reconstitution, reflected by resumption of IgM levels. Most (85%) patients developed ⩾1 infections, mostly grade 1-2 respiratory (76%). A lower poly-IgG level post Dara (RR = 1.137 p = 0.026) predicted increased risk of any infection. Intravenous immunoglobulin (IVIG) was associated with a significant decrease in all infections. Conclusion Relapsed MM patients treated with Dara, often experience persistent hypogammaglobinemia, irrespective of responsiveness to treatment. Infections, especially respiratory, are frequent and apparently related to low Poly-IgG levels. IVIG should be considered for reducing infections in these patients.
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Affiliation(s)
- Roy Vitkon
- Department of Hematology, Tel Aviv Sourasky Medical Center, 6 Weizmann Street., Tel Aviv, 64239, Israel
| | - Dan Netanely
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shai Levi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Ben-Yzak
- The Hematology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ben-Zion Katz
- The Hematology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Noam Benyamini
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Svetlana Trestman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Moshe Mittelman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Cohen
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Irit Avivi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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26
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Wong D, Thomas W, Butler A, Sharkey L. Bortezomib for treatment-refractory autoimmune haemolytic anaemia following multivisceral transplantation. BMJ Case Rep 2021; 14:14/5/e241634. [PMID: 33980556 PMCID: PMC8118027 DOI: 10.1136/bcr-2021-241634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old man who received alemtuzumab as induction therapy for a multivisceral transplant experienced delayed onset of warm autoimmune haemolytic anaemia and neutropaenia. Serological testing and bone marrow biopsy excluded alternative causes. Haemolysis was refractory to standard therapies including corticosteroids, intravenous immunoglobulin and rituximab. The patient was successfully treated with bortezomib, a proteasome inhibitor, and has remained well as an outpatient without evidence of ongoing haemolysis.
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Affiliation(s)
- Darren Wong
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK .,Department of Gastroenterology, Austin Hospital, Heidelberg, Victoria, Australia
| | - William Thomas
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Butler
- Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Lisa Sharkey
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
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27
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Abstract
Major advancements in the development of HLA antibody detection techniques and our understanding of the outcomes of solid organ transplant in the context of HLA antibody have occurred since the relevance of sensitization was first recognized nearly 50 years ago. Additionally, kidney paired donation programs (KPD) have become widespread, deceased donor allocation policies have changed, and several new therapeutic options have become available with promise to reduce HLA antibody. In this overview we aim to provide thoughtful guidance about when desensitization in kidney transplantation should be considered taking into account the outcomes of HLA incompatible transplantation. Novel therapeutics, desensitization endpoints, and strategies for future study will also be discussed. While most of our understanding about desensitization comes from studying kidney transplant candidates and recipients, many of the concepts discussed can be easily applied to desensitization in all of solid organ transplantation.
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Affiliation(s)
- Carrie Schinstock
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Anat Tambur
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Mark Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
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28
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Rocco JM, Rosen LB, Hong GH, Treat J, Kreuzburg S, Holland SM, Zerbe CS. Bortezomib treatment for refractory nontuberculous mycobacterial infection in the setting of interferon gamma autoantibodies. J Transl Autoimmun 2021; 4:100102. [PMID: 34041472 PMCID: PMC8141761 DOI: 10.1016/j.jtauto.2021.100102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 11/28/2022] Open
Abstract
Interferon-γ autoantibodies increase the risk of disseminated nontuberculous mycobacterial infections. Addition of rituximab to antibiotics accelerates and improves outcomes, but refractory infections can occur due to persistent production of autoantibodies. We combined bortezomib with rituximab to reduce autoantibodies leading to clinical and radiographic improvement in infection. IFNγ autoantibodies increase the risk of disseminated infections with intracellular pathogens. Rituximab combined with antibiotics improves outcomes, but infections can become refractory. The addition of bortezomib is safe with close monitoring and can improve clinical outcomes.
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Affiliation(s)
- Joseph M Rocco
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lindsey B Rosen
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gloria H Hong
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Treat
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Samantha Kreuzburg
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Steven M Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Christa S Zerbe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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29
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Zhou Y, Zhang Y, Zhuang Z, Zhang Y. Successful Treatment of Acquired Hemophilia A with Bortezomib Plus Low Dose Rituximab in a Patient with Renal Failure and Severe Pneumonia. Indian J Hematol Blood Transfus 2021; 37:171-172. [PMID: 33707854 DOI: 10.1007/s12288-020-01296-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/26/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Beijing, China
| | - Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Beijing, China
| | - Zhe Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Beijing, China
| | - Yanbin Zhang
- Department of Hematology, Peking Union Medical College Hospital, Beijing, China
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30
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Lichvar AB, Tremblay S, Leino AD, Shields AR, Cardi MA, Abu Jawdeh BG, Govil A, Kremer J, Cuffy M, Paterno F, Diwan T, Brailey P, Girnita A, Alloway RR, Woodle ES. Reducing Donor-specific Antibody During Acute Rejection Diminishes Long-term Renal Allograft Loss: Comparison of Early and Late Rejection. Transplantation 2020; 104:2403-14. [PMID: 32000256 DOI: 10.1097/TP.0000000000003145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reduction in donor-specific antibody (DSA) has been associated with improved renal allograft survival after antibody-mediated rejection (AMR). These observations have not been separately analyzed for early and late AMR and mixed acute rejection (MAR). The purpose of this study was to evaluate long-term responses to proteasome inhibitor-based therapy for 4 rejection phenotypes and to determine factors that predict allograft survival. METHODS Retrospective cohort study evaluating renal transplant recipients with first AMR episodes treated with proteasome inhibitor-based therapy from January 2005 to July 2015. RESULTS A total of 108 patients were included in the analysis. Immunodominant DSA reduction at 14 days differed significantly (early AMR 79.6%, early MAR 54.7%, late AMR 23.4%, late MAR 21.1%, P < 0.001). Death-censored graft survival (DCGS) differed at 3 years postrejection (early AMR 88.3% versus early MAR 77.8% versus late AMR 56.7% versus late MAR 54.9%, P = 0.02). Multivariate analysis revealed that immunodominant DSA reduction > 50% at 14 days was associated with improved DCGS (odds ratio, 0.12, 95% CI, 0.02-0.52, P = 0.01). CONCLUSIONS In summary, significant differences exist across rejection phenotypes with respect to histological and DSA responses. The data suggest that DSA reduction may be associated with improved DCGS in both early and late AMR.
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31
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Alishetti S, Farr M, Jennings D, Serban G, Uriel N, Sayer G, Vasilescu R, Restaino S, Chong AS, Habal MV. Desensitizing highly sensitized heart transplant candidates with the combination of belatacept and proteasome inhibition. Am J Transplant 2020; 20:3620-3630. [PMID: 32506824 PMCID: PMC8366746 DOI: 10.1111/ajt.16113] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/12/2020] [Accepted: 05/26/2020] [Indexed: 01/25/2023]
Abstract
HLA antibodies pose a significant barrier to transplantation and current strategies to reduce allosensitization are limited. We hypothesized that augmenting proteasome inhibitor (PI) based desensitization with costimulation blockade (belatacept) to mitigate germinal center (GC) responses might increase efficacy and prevent rebound. Four highly sensitized (calculated panel reactive antibody [cPRA] class I and/or II >99%, complement-dependent cytotoxicity panel reactive antibody [CDC PRA+], C1q+) heart transplant candidates were treated with the combination of belatacept and PI therapy, which significantly reduced both class I and II HLA antibodies and increased the likelihood of identifying an acceptable donor. Three negative CDC crossmatches were achieved against 3, 6, and 8 donor-specific antibodies (DSA), including those that were historically C1q+ binding. Posttransplant, sustained suppression of 3 of 3, 4 of 6, and 8 of 8 DSA (cases 1-3) was achieved. Analysis of peripheral blood mononuclear cells before and after desensitization in one case revealed a decrease in naïve and memory B cells and a reduction in T follicular helper cells with a phenotype suggesting recent GC activity (CD38, PD1, and ICOS). Furthermore, a shift in the natural killer cell phenotype was observed with features suggestive of activation. Our findings support synergism between PI based desensitization and belatacept facilitating transplantation with a negative CDC crossmatch against historically strong, C1q binding antibodies.
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Affiliation(s)
- Shudhanshu Alishetti
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Douglas Jennings
- Department of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY
| | - Geo Serban
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Rodica Vasilescu
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Susan Restaino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Anita S. Chong
- Department of Surgery, University of Chicago, Chicago, IL
| | - Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
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32
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Hsu SC, Thorat A, Jeng LB, Li PC, Chen TH, Yang HR, Poon KS. ABO-Incompatible Living Donor Liver Transplantation with Reduced Rituximab Dose: A Retrospective Analysis of 65 Patients - Can We Fast-Track Liver Transplant Surgery and Improve Long-Term Survival? Ann Transplant 2020; 25:e923502. [PMID: 32943600 PMCID: PMC7526337 DOI: 10.12659/aot.923502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ABO-incompatible (ABO-i) living donor liver transplantation (LDLT) is a feasible alternative for donor liver allograft in emergency situations, especially in Asia, where deceased-donor organs remain scarce. The reported outcomes of ABO-i LDLT after optimal desensitization are comparable to those of ABO-compatible LDLT. In this retrospective study, we found improved outcomes after ABO-i LDLT with a low-dose rituximab in combination with double-filtration plasmapheresis (DFPP) and prophylactic antibiotic therapy. MATERIAL AND METHODS Between January 2006 and December 2018, a total of 65 recipients underwent ABO-i LDLT surgeries at our center. The study cohort consisted of 50 recipients (Era III) who underwent ABO-i LDLT using the recently updated desensitization protocol, which included rituximab 200 mg intravenous injection once a week prior to LDLT, 4 sessions of DFPP in all patients, and prophylactic antibiotics for 3 months. RESULTS The 3-year overall survival rate achieved in ABO-i LDLT patients was 72.7% (66.6% for Era I and 33.3% for Era II patients). In the study population, 11 patients developed complications due to infection. Five of these patients (10%) died due to overwhelming sepsis. Four patients (8%) were diagnosed with multiple strictures and diffusely scattered dilatation of intrahepatic bile ducts on computed tomography, without vascular complications. Three of them had evidence of antibody-mediated rejection (AMR). CONCLUSIONS Our experience shows that the ABO-i LDLT protocol of lowered rituximab combined with pre-transplant sessions of plasmapheresis and a quadruple immunosuppressive regimen can be effective in chronic liver failure patients with clinical urgency in the absence of an ABO-compatible donor. Fast-tracking the use of ABO-i LDLT is feasible in patients with an acute liver failure (ALF) and can safely increase the donor liver pool, with an acceptable outcome.
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Affiliation(s)
- Shih-Chao Hsu
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Ashok Thorat
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Long-Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University Hospital, Taiwan.,China Medical University, Taichung, Taiwan
| | - Ping-Chun Li
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan.,Department of Cardiovascular Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Te-Hung Chen
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Horng-Ren Yang
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
| | - Kin-Shing Poon
- China Medical University, Taichung, Taiwan.,Department of Anaesthesiology, China Medical University Hospital, Taichung, Taiwan
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33
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Abstract
Liver allograft rejection remains a significant cause of morbidity and graft failure in liver transplant recipients. Rejection is caused by the recognition of non-self donor alloantigens by recipient T-cells. Antigen recognition results in proliferation and activation of T-cells in lymphoid tissue before migration to the allograft. Activated T-cells have a variety of effector mechanisms including direct T-cell mediated damage to bile ducts, endothelium and hepatocytes and indirect effects through cytokine production and recruitment of tissue-destructive inflammatory cells. These effects explain the histological appearances of typical acute T-cell mediated rejection. In addition, donor specific antibodies, most typically against HLA antigens, may give rise to antibody-mediated rejection causing damage to the allograft primarily through endothelial injury. However, as an immune-privileged site there are several mechanisms in the liver capable of overcoming rejection and promoting tolerance to the graft, particularly in the context of recruitment of regulatory T-cells and promotors of an immunosuppressive environment. Indeed, around 20% of transplant recipients can be successfully weaned from immunosuppression. Hence, the host immunological response to the liver allograft is best regarded as a balance between rejection-promoting and tolerance-promoting factors. Understanding this balance provides insight into potential mechanisms for novel anti-rejection therapies.
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Affiliation(s)
- Vincenzo Ronca
- Division of Gastroenterology and Centre for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,National Institute of Health Research Liver Biomedical Research Unit Birmingham, Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Grace Wootton
- National Institute of Health Research Liver Biomedical Research Unit Birmingham, Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Chiara Milani
- Division of Gastroenterology and Centre for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Owen Cain
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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34
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Abstract
ABO incompatible living donor liver transplantation has the potential to expand the donor pool for patients with end stage liver diseases on the expense of challenges to overcome immunological barriers across blood type. There is a profound impact of age on incidence and severity of antibody mediated rejection (AMR). Even children older than 1 year have chances of AMR; children aged 8 years or older have risks of hepatic necrosis similar to adult liver recipients. The mechanism of AMR is based on circulatory disturbances secondary to inflammation and injury of the vascular endothelium caused by an antibody-antigen-complement reaction. The strategy to overcome ABO blood type barrier is based on both pre-transplant desensitization and adequate treatment of this phenomenon. Nowadays, rituximab is the standard means of desensitization but unfortunately an insufficient aid to treat AMR. Because of low incidence (less than 5% in the rituximab era), in practice of AMR only some case reports about the treatment of clinical AMR are available in the literature. Initial experiences revealed that the proteasome inhibitor, bortezomib might be a promising treatment based on its capacity to deplete plasma cell agents. Although ABO blood type barrier has been counteracted in 95% of patients by applying "rituximab-desensitization", many issues, such as prediction of high-risk patients of infection and AMR and secure treatment strategies for evoked AMR, remain to be resolved.
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Affiliation(s)
- Hiroto Egawa
- Department of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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35
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Kwun J, Knechtle S. Experimental modeling of desensitization: What have we learned about preventing AMR? Am J Transplant 2020; 20 Suppl 4:2-11. [PMID: 32538533 PMCID: PMC7522789 DOI: 10.1111/ajt.15873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 01/25/2023]
Abstract
During the past 5 decades, short-term outcomes in kidney transplant have significantly improved, in large part due to reduced rates and severity of acute rejection. Development of better immunosuppressive maintenance agents, as well as new induction therapies, helped make these advances. Nonhuman primate models provided a rigorous testing platform to evaluate candidate biologics during this process. However, antibody-mediated rejection remains a major cause of late failure of kidney allografts despite advances made in pharmacologic immunosuppression and strategies developed to facilitate improved donor-recipient matching. Our laboratory has been actively working to develop strategies to prevent and treat antibody-mediated rejection and immunologic sensitization in organ transplant, relying largely on a nonhuman primate model of kidney transplant. In this review, we will cover outcomes achieved by managing antibody-mediated rejection or sensitization in nonhuman primate models and discuss promises, limitations, and future directions for this model.
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Affiliation(s)
- Jean Kwun
- Address all correspondence and requests for reprints to: Jean Kwun, PhD, 207 Research Drive, Jones 362, DUMC Box 2645, Durham, NC 27710, USA Phone: 919-668-6792; Fax: 919-684-8716;
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36
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Lee KW. Mechanisms and clinical applications of immunosuppressive medications. J Korean Med Assoc 2020. [DOI: 10.5124/jkma.2020.63.5.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immunosuppressive medications and regimens have evolved with significant advancements in the understanding of the immunologic process after solid organ transplantation. Medications can block the communication between antigen-presenting cells and T-cells, the activation and proliferation of T-cells, antibody production by plasma cells, and the activation of the complement system by antibodies. T-cell depleting antibodies and interleukin-2 receptor blockers are commonly used during induction therapy. Calcineurin inhibitors, antimetabolites, antiproliferative agents, and corticosteroids are commonly used in maintenance therapy regimens. These medications decrease the rates of rejection episodes and markedly increase the survival rates of short-term grafts. However, in terms of the survival rate of long-term grafts, there is still room for improvement. Opportunistic infections, development of cancer, metabolic diseases, and calcineurin inhibitor toxicity are hurdles in the improvement in survival rates of long-term grafts. Therefore, many efforts are being taken to overcome these hurdles, such as the development of new drugs, individualization of immunosuppression, and induction of immune tolerance.
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Bahena Méndez J, López Y López LR, Sebastián Díaz MA, Trejo Curiel I, Galindo-Lopéz R, Baca Córdova A, Wasung de Lay M, Vázquez Dávila RA, Zarate Rodríguez PA, Carmona-Escamilla MA. Antibody-Mediated Rejection Treatment With Bortezomib in Renal Transplant Recipients: A Single-Center 24-Month Follow-up Case Report. Transplant Proc 2020; 52:1123-1126. [PMID: 32224016 DOI: 10.1016/j.transproceed.2020.01.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Antibody-mediated rejection (AMR) is related to a poor prognosis in graft survival, with 27% to 40% of patients experiencing graft loss within the first year. The mechanism of damage in AMR is mediated by donor-specific antibodies (DSA). No standard treatment for AMR exists, and conventional management includes high doses of steroids, plasmapheresis, intravenous immunoglobulin, and either rituximab or bortezomib. Because of the high cost of these medications and the lack of prospective studies to evaluate their efficacy and safety, their routine use is limited. In the following study, we describe the use of bortezomib for the treatment of AMR in 5 renal transplant recipients with a 24-month follow-up and compare this case with the reviewed literature. MATERIAL AND METHODS Five cases of AMR diagnosed by biopsy are reported, and these patients received bortezomib at a rate of 1.3 mg/m2 on days 1, 4, 8, and 11; plasmapheresis; and 1 patient received 30 g of intravenous immunoglobulin. RESULTS All patients received his or her first transplant; 4 were from a cadaveric donor, and 1 patient received thymoglobulin at a standard dose. All patients had maintenance therapy based on cyclosporine, mycophenolate mofetil, and prednisone, with an average baseline creatinine level of 1.3 mg/dL. The average days until rejection event were 952 days. DISCUSSION AND CONCLUSION AMR treatment with bortezomib was effective, showing stable renal function at 24 months. Patients had adequate tolerance for administration. So far, these results contrast with the literature reviewed, so additional studies and follow-up are required for a new evaluation.
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Affiliation(s)
- J Bahena Méndez
- Nephrology Fellowship Program, Universidad Nacional Autónoma de México Facultad de Medicina, México City, México
| | - L R López Y López
- Nephrology Fellowship Program, Universidad Nacional Autónoma de México Facultad de Medicina, México City, México
| | - M A Sebastián Díaz
- Nephrology, Hospital Central Sur Alta Especialidad "Picacho," Petróleos Mexicanos, México City, México
| | - I Trejo Curiel
- Nephrology Fellowship Program, Universidad Nacional Autónoma de México Facultad de Medicina, México City, México
| | - R Galindo-Lopéz
- Nephrology Fellowship Program, Universidad Nacional Autónoma de México Facultad de Medicina, México City, México
| | - A Baca Córdova
- Nephrology Fellowship Program, Universidad Nacional Autónoma de México Facultad de Medicina, México City, México
| | - M Wasung de Lay
- Nephrology, Hospital Central Sur Alta Especialidad "Picacho," Petróleos Mexicanos, México City, México
| | - R A Vázquez Dávila
- Transplant, Hospital Central Sur Alta Especialidad "Picacho," Petróleos Mexicanos, México City, México
| | - P A Zarate Rodríguez
- Central Laboratory, Hospital Central Sur Alta Especialidad "Picacho," Petróleos Mexicanos, México City, México
| | - M A Carmona-Escamilla
- Nephrology, Hospital Central Sur Alta Especialidad "Picacho," Petróleos Mexicanos, México City, México.
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Kolonko A, Słabiak-Błaż N, Karkoszka H, Więcek A, Piecha G. The Preliminary Results of Bortezomib Used as A Primary Treatment for An Early Acute Antibody-Mediated Rejection after Kidney Transplantation-A Single-Center Case Series. J Clin Med 2020; 9:jcm9020529. [PMID: 32075220 PMCID: PMC7074248 DOI: 10.3390/jcm9020529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/06/2020] [Accepted: 02/12/2020] [Indexed: 01/10/2023] Open
Abstract
Proteasome inhibitor bortezomib has been used in the treatment of refractory cases of acute and chronic antibody-mediated rejection (AMR) in kidney transplant recipients. However, its efficacy and safety as a primary treatment for early AMR has been scarcely investigated. We herein present our preliminary experience with bortezomib- and plasmapheresis-based primary treatment for early AMR. Thirteen patients transplanted between October 2015 and September 2019 were treated (starting at median 19th post-transplant day) with bortezomib/plasmapheresis protocol for early biopsy-proven AMR. Twelve out of thirteen patients received 4 doses and one patient recieved 3 doses of bortezomib (1.3 mg/m2 per dose). In 11/13 patients, 4–7 concomitant plasmapheresis sessions were performed, with or without intravenous immunoglobulin (IVIG). Of note, rituximab was not used in all study patients. The kidney graft and patient survival were 100%. The mean 3-month estimated glomerular filtration rate (eGFR) was 55.3 (95%CI: 44.9–65.8) mL/min/1.73m2, 8/13 patients completed 12-month follow-up with mean eGFR 60.4 (45.4–75.4) mL/min/1.73m2, and 6/13 patients completed a 24-month follow-up period with mean eGFR 73.9 (56.7–91.1) mL/min/1.73m2. Neutropenia < 1 G/L was observed in one patient, third or fourth grade thrombocytopenia in two patients, and eleven patients needed a blood transfusion (median: 2 units/patient). The mid-term results of a primary bortezomib-based treatment for kidney AMR showed its non-inferiority as compared to preceding regimens and acceptable safety. However, our data should be validated in a multicenter randomized trial.
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Abstract
Preformed donor-specific antibodies (DSAs) limit access to transplantation for thousands of renal transplant patients. While kidney paired donation offers the best strategy for patients with a living donor, for very highly sensitized patients and those without living donors, a strategy of desensitization offers the best hope of transplantation. Removal of DSAs with plasmapheresis, intravenous immunoglobulin and anti-CD20 antibodies can permit successful transplantation. While the clinical outcomes remain inferior to compatible transplant and the costs are significantly greater, when compared with long-term dialysis treatment, these strategies are offer improved survival and are cost-effective given nationally accepted benchmarks.
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Affiliation(s)
- Sarat Kuppachi
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, IA, USA
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Frandsen EL, Otero J, Rutledge JC, Kemna MS, Albers EL, Hong BJ, Law YM, Friedland-Little JM. A fatal case of bortezomib-induced lung toxicity in a young adult heart transplant recipient. Pediatr Transplant 2020; 24:e13628. [PMID: 31815325 DOI: 10.1111/petr.13628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/22/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
Abstract
Bortezomib is approved for the treatment of multiple myeloma but increasingly used in heart transplant (HTx) recipients with antibody-mediated rejection (AMR). Severe pulmonary toxicity is a rare complication in multiple myeloma patients treated with bortezomib, but has not been described in a solid organ transplant recipient. A 20-year-old man 7 years post-HTx presented with acute rejection with hemodynamic compromise. Endomyocardial biopsy showed mixed rejection (ISHLT grade 2R-3R acute cellular rejection (ACR) and pAMR 1 (I+) with diffuse C4d staining). Two new high MFI circulating MHC class-II donor-specific antibodies (DSA) were detected. Treatment included corticosteroids, antithymocyte globulin, plasmapheresis, IVIG, rituximab, and bortezomib (1.3 mg/m2 ). Due to rebound in DSA, a second course of bortezomib was started. Thrombocytopenia and peripheral neuropathy prompted a 50% dose reduction during the 2nd course. Shortly after the 3rd reduced dose, the patient developed hypoxemic respiratory failure. Bronchoscopy revealed pulmonary hemorrhage with negative infectious studies. Chest CT showed bilateral parenchymal disease with bronchiectasis and alveolar bleeding. Despite treatment with high-dose steroids, severe ARDS ensued with multisystem organ failure. The patient expired 23 days after the final dose of bortezomib. Post-mortem lung histology revealed diffuse alveolar damage, pulmonary fibrosis, and hemorrhage. Cardiac histology showed resolving/residual ACR 1R and pAMR 1 (I+). While rare, bortezomib-induced lung toxicity (BILT) can occur in HTx recipients and can carry a high risk of mortality. Drug reaction and immediate drug withdrawal should be considered in patients who develop respiratory symptoms, though optimal management of BILT is unclear.
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Affiliation(s)
| | - Jessica Otero
- Clinical Pharmacy Services, Seattle Children's Hospital, Seattle, WA, USA
| | - Joe C Rutledge
- Department of Pathology, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Erin L Albers
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Borah J Hong
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Heart Center, Seattle Children's Hospital, Seattle, WA, USA
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Woodle E, Tremblay S, Brailey P, Girnita A, Alloway R, Aronow B, Dasgupta N, Ebstein F, Kloetzel P, Lee M, Kim K, Singh H, Driscoll J. Proteasomal adaptations underlying carfilzomib-resistance in human bone marrow plasma cells. Am J Transplant 2020; 20:399-410. [PMID: 31595669 PMCID: PMC6984988 DOI: 10.1111/ajt.15634] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/15/2019] [Accepted: 09/15/2019] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSAs) have a deleterious effect on allografts and remain a major immunologic barrier in transplantation. Current therapies to eliminate DSAs are ineffective in highly HLA-sensitized patients. Proteasome inhibitors have been employed as a strategy to target bone marrow plasma cells (BMPCs), the source of long-term antibody production; however, their efficacy has been limited by poorly defined drug-resistance mechanisms. Here, we performed transcriptomic profiling of CD138+ BMPCs that survived in vivo desensitization therapy with the proteasome inhibitor carfilzomib to identify mechanisms of drug resistance. The results revealed a genomic signature that included increased expression of the immunoproteasome, a highly specialized proteasomal variant. Western blotting and functional studies demonstrated that catalytically active immunoproteasomes and the immunoproteasome activator PA28 were upregulated in carfilzomib-resistant BMPCs. Carfilzomib-resistant BMPCs displayed reduced sensitivity to the proteasome inhibitors carfilzomib, bortezomib, and ixazomib, but enhanced sensitivity to an immunoproteasome-specific inhibitor ONX-0914. Finally, in vitro carfilzomib treatment of BMPCs from HLA-sensitized patients increased levels of the immunoproteasome β5i (PSMB8) catalytic subunit suggesting that carfilzomib therapy directly induces an adaptive immunoproteasome response. Taken together, our results indicate that carfilzomib induces structural changes in proteasomes and immunoproteasome formation.
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Affiliation(s)
- E.S. Woodle
- Division of Transplantation, Department of Surgery, Cincinnati, OH, 45267, USA,Corresponding authors: E. Steve Woodle, MD; James J. Driscoll, MD, PhD; driscojs@ UCMAIL.UC.EDU
| | - S. Tremblay
- Division of Transplantation, Department of Surgery, Cincinnati, OH, 45267, USA,Department of Environmental Health, Division of Epidemiology, Cincinnati, OH, 45229, USA
| | - P. Brailey
- Hoxworth Blood Center, Transplant Immunology Division, Cincinnati, OH, 45229, USA
| | - A. Girnita
- Division of Transplantation, Department of Surgery, Cincinnati, OH, 45267, USA,Hoxworth Blood Center, Transplant Immunology Division, Cincinnati, OH, 45229, USA
| | - R.R. Alloway
- Division of Transplantation, Department of Surgery, Cincinnati, OH, 45267, USA
| | - B. Aronow
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - N. Dasgupta
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - F. Ebstein
- Institute for Biochemistry, Charité - University Medicine Berlin, Berlin, Germany
| | - P.M. Kloetzel
- Institute for Biochemistry, Charité - University Medicine Berlin, Berlin, Germany
| | - M.J. Lee
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - K.B. Kim
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - H. Singh
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - J.J. Driscoll
- Department of Internal Medicine, Division of Hematology and Oncology, Cincinnati, OH, 45267, USA,University of Cincinnati Cancer Institute, Cincinnati, OH, 45267, USA,Corresponding authors: E. Steve Woodle, MD; James J. Driscoll, MD, PhD; driscojs@ UCMAIL.UC.EDU
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Kincaide E, Hitchman K, Hall R, Yamaguchi I, Ding Y, Crowther B. Impact of active antibody-mediated rejection treatment on donor-specific antibodies in pediatric kidney transplant recipients. Pediatr Transplant 2019; 23:e13590. [PMID: 31617318 DOI: 10.1111/petr.13590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/17/2019] [Accepted: 09/01/2019] [Indexed: 01/06/2023]
Abstract
AMR is a major cause of graft loss after kidney transplantation. We evaluated a retrospective cohort of 13 pediatric kidney transplant patients diagnosed with active AMR. All 13 patients were treated with plasmapheresis (PP), IVIg, and rituximab. Anti-HLA DSAs were measured at the time of transplantation, AMR diagnosis, 30 days post-rejection treatment, 90 days post-rejection treatment, and 24 ± 12 months post-AMR. A total of 68 DSAs were identified from 13 patients at the time of active AMR diagnosis. The primary objective of this study was to differentiate treatment response rates between class I and class II anti-HLA DSA post-AMR treatment. Overall, DSAs were significantly reduced at 30 days, and the reduction was sustained at 90 days post-treatment, even for class II anti-HLA and strongly positive DSAs. A significant difference between class I and class II anti-HLA DSA was observed at 30 days; however, between class significance was lost at 90-day follow-up due to continued class II anti-HLA DSA treatment response. Low DSA strength was predictive of treatment response. eGFR demonstrated significant improvement 90 days after AMR diagnosis compared to the initial value at the time of AMR, and the effect was sustained for 12 months. These results suggest that the AMR treatment is effective in pediatric kidney transplant recipients with an early diagnosis of active AMR across both class I and class II anti-HLA DSAs.
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Affiliation(s)
- Elisabeth Kincaide
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,University Transplant Center, University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kelley Hitchman
- University Transplant Center, University Health System, San Antonio, TX, USA.,Histocompatibility and Immunogenetics Laboratory, University Health System, San Antonio, TX, USA.,Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Reed Hall
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,University Transplant Center, University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Ikuyo Yamaguchi
- University Transplant Center, University Health System, San Antonio, TX, USA.,Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Yanli Ding
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Health, Aurora, CO, USA.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
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Pham T, Lee L, Melcher ML. The Role of Desensitization in Kidney Paired Donation. Curr Transpl Rep 2019; 6:294-299. [DOI: 10.1007/s40472-019-00261-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Irure J, Sango C, San Segundo D, Fernández-Fresnedo G, Ruiz JC, Benito-Hernández A, Asensio E, López-Hoyos M, Rodrigo E. Late Plasma Cell Depletion After Thymoglobulin Induction in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2019; 17:732-738. [DOI: 10.6002/ect.2018.0261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The importance of B cell and antibody-mediated immune response in the acute and long-term persistence of transplanted solid organs has become increasingly evident in recent years. A variety of therapeutic innovations target antibodies directed toward HLA or blood groups (ABO) to allow better allocation and posttransplant longevity of organs. Antibodies originate from plasma cells (PCs), which are terminally differentiated B cells. Long-term production and persistence of these antibodies is partly due to fast reactivation of previously generated memory B cells; however, there is increasing evidence that some differentiated PCs can persist independently in the bone marrow for years or even decades, producing specific antibodies or even experiencing regeneration without proliferation without need to be replaced by newly differentiating B cells. This review outlines the currently presumed pathways of differentiation, antibody, and memory generation on both B-cell and PC levels. On this background, current therapeutic concepts for antibody reduction before and after solid organ transplantation are considered, to better understand their mechanisms, possible synergisms, and specific risks. Specific differences in regards to ABO versus HLA antibodies as well as practical relevance for generation of desensitization and posttransplant antibody-directed therapy protocols are discussed.
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Ezekian B, Schroder PM, Mulvihill MS, Barbas A, Collins B, Freischlag K, Yoon J, Yi JS, Smith F, Olaso D, Saccoccio FM, Permar S, Farris AB, Kwun J, Knechtle SJ. Pretransplant Desensitization with Costimulation Blockade and Proteasome Inhibitor Reduces DSA and Delays Antibody-Mediated Rejection in Highly Sensitized Nonhuman Primate Kidney Transplant Recipients. J Am Soc Nephrol 2019; 30:2399-2411. [PMID: 31658991 DOI: 10.1681/asn.2019030304] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/17/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with broad HLA sensitization have poor access to donor organs, high mortality while waiting for kidney transplant, and inferior graft survival. Although desensitization strategies permit transplantation via lowering of donor-specific antibodies, the B cell-response axis from germinal center activation to plasma cell differentiation remains intact. METHODS To investigate targeting the germinal center response and plasma cells as a desensitization strategy, we sensitized maximally MHC-mismatched rhesus pairs with two sequential skin transplants. We administered a proteasome inhibitor (carfilzomib) and costimulation blockade agent (belatacept) to six animals weekly for 1 month; four controls received no treatment. We analyzed blood, lymph node, bone marrow cells, and serum before desensitization, after desensitization, and after kidney transplantation. RESULTS The group receiving carfilzomib and belatacept exhibited significantly reduced levels of donor-specific antibodies (P=0.05) and bone marrow plasma cells (P=0.02) compared with controls, with a trend toward reduced lymph node T follicular helper cells (P=0.06). Compared with controls, carfilzomib- and belatacept-treated animals had significantly prolonged graft survival (P=0.02), and renal biopsy at 1 month showed significantly reduced antibody-mediated rejection scores (P=0.02). However, four of five animals with long-term graft survival showed gradual rebound of donor-specific antibodies and antibody-mediated rejection. CONCLUSIONS Desensitization using proteasome inhibition and costimulation blockade reduces bone marrow plasma cells, disorganizes germinal center responses, reduces donor-specific antibody levels, and prolongs allograft survival in highly sensitized nonhuman primates. Most animals experienced antibody-mediated rejection with humoral-response rebound, suggesting desensitization must be maintained after transplantation using ongoing suppression of the B cell response.
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Affiliation(s)
| | | | | | | | | | | | | | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina; and
| | | | - Danae Olaso
- Department of Surgery, Duke Transplant Center
| | - Frances M Saccoccio
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center,
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Abstract
Despite advancements in transplant immunosuppression and techniques for managing critically ill patients awaiting heart transplantation, children who are immunologically sensitized to human leukocyte antigen remain at increased risk for morbidity and mortality, both while awaiting and after heart transplant. In this review we will discuss the epidemiology of sensitization, review the immunologic basis and methods of human leukocyte antigen antibody detection, describe outcomes for sensitized pediatric transplant candidates, and consider both pre- and post-transplant management options for sensitized patients.
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Affiliation(s)
- Erik L Frandsen
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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48
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Abstract
The human major histocompatibility complex is a family of genes that encodes HLAs, which have a crucial role in defence against foreign pathogens and immune surveillance of tumours. In the context of transplantation, HLA molecules are polymorphic antigens that comprise an immunodominant alloreactive trigger for the immune response, resulting in rejection. Remarkable advances in knowledge and technology in the field of immunogenetics have considerably enhanced the safety of transplantation. However, access to transplantation among individuals who have become sensitized as a result of previous exposure to alloantigens is reduced proportional to the breadth of their sensitization. New approaches for crossing the HLA barrier in transplantation using plasmapheresis, intravenous immunoglobulin and kidney paired donation have been made possible by the relative ease with which even low levels of anti-HLA antibodies can now be detected and tracked. The development of novel protocols for the induction of tolerance and new approaches to immunomodulation was also facilitated by advances in HLA technology. Here, we review the progress made in understanding HLAs that has enabled organ transplantation to become a life-saving endeavour that is accessible even for sensitized patients. We also discuss novel approaches to desensitization, immunomodulation and tolerance induction that have the potential to further improve transplantation access and outcomes.
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49
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Su H, Zhang CY, Lin JH, Hammes HP, Zhang C. The Role of Long-Lived Plasma Cells in Antibody-Mediated Rejection of Kidney Transplantation: An Update. Kidney Dis (Basel) 2019; 5:211-219. [PMID: 31768378 DOI: 10.1159/000501460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/12/2019] [Indexed: 12/26/2022]
Abstract
Background Antibody-mediated rejection (ABMR) following kidney transplant is closely associated with poor prognosis of the recipients. Long-lived plasma cells (LLPCs) produce alloantibodies as long as life time and play a crucial role in ABMR. Summary LLPCs generate from germinal centers and reside in survival niches in the bone marrow as well as the inflamed tissues. They are the main and long-term source of the antibodies. LLPCs mediate ABMR via the generation of preformed antibodies in sensitized patients and de novo antibodies after transplantation. They have been acknowledged as the leading causes of ABMR; however, LLPCs are insensitive to traditional immunosuppressive therapy that removes B cells. Strategies targeting LLPCs, such as antithymocyte globulin, proteasome inhibitors as well as monoclonal antibodies, are promising methods to persistently and thoroughly clear the entire PC pool. Key Message LLPCs play an important role in ABMR by producing alloantibodies continually, and targeting LLPCs might be a novel and effective approach against ABMR.
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Affiliation(s)
- Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Yun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ji-Hong Lin
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hans-Peter Hammes
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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50
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Tasaki M, Saito K, Nakagawa Y, Ikeda M, Imai N, Ito Y, Sudo M, Ikezumi Y, Yamada T, Hasegawa H, Kobayashi T, Miura K, Narita I, Takahashi K, Tomita Y. Bortezomib Eliminates Plasma Cells From a Renal Graft in Plasma Cell-Rich Acute Rejection. Transplant Proc 2019; 51:1732-8. [PMID: 31301858 DOI: 10.1016/j.transproceed.2019.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/03/2019] [Indexed: 01/10/2023]
Abstract
Plasma cell-rich acute rejection (PCAR) and antibody-mediated rejection (ABMR), for which a standard treatment has not yet been established, are associated with poor graft survival after kidney transplantation. Here, we report a case series of 3 Japanese patients diagnosed with PCAR accompanied by ABMR. Steroid pulse therapy and rabbit antithymocyte globulin, plasma exchange, intravenous immunoglobulin, and rituximab therapies were sequentially performed in the first case. A graft biopsy after each treatment showed that plasma cell infiltration persisted. Five months after the initiation of rejection therapy, the patient was subjected to bortezomib therapy, which led to the partial elimination of plasma cells from the graft. However, the graft function gradually deteriorated, and hemodialysis treatment was warranted. In the other 2 cases, the patients received the same combination of therapy including bortezomib within a short period. Graft biopsies performed subsequently showed a marked decrease in the number of infiltrated plasma cells, and stabilization of renal graft function was achieved in both cases. Bortezomib, which targets plasma cells, is a potent drug that eliminates infiltrated plasma cells from the graft in PCAR. Thus, in addition to conventional therapy comprising plasma exchange, intravenous immunoglobulin, and rituximab against ABMR, bortezomib may be necessary to administer without any delay to control PCAR.
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