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Werbel WA, Bae S, Yu S, Al Ammary F, Segev DL, Durand CM. Early steroid withdrawal in HIV-infected kidney transplant recipients: Utilization and outcomes. Am J Transplant 2021; 21:717-726. [PMID: 32681603 PMCID: PMC7927911 DOI: 10.1111/ajt.16195] [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] [Received: 03/29/2020] [Revised: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant (KT) outcomes for HIV-infected (HIV+) persons are excellent, yet acute rejection (AR) is common and optimal immunosuppressive regimens remain unclear. Early steroid withdrawal (ESW) is associated with AR in other populations, but its utilization and impact are unknown in HIV+ KT. Using SRTR, we identified 1225 HIV+ KT recipients between January 1, 2000, and December 31, 2017, without AR, graft failure, or mortality during KT admission, and compared those with ESW with those with steroid continuation (SC). We quantified associations between ESW and AR using multivariable logistic regression and interval-censored survival analysis, as well as with graft failure and mortality using Cox regression, adjusting for donor, recipient, and immunologic factors. ESW utilization was 20.4%, with more zero HLA mismatch (8% vs 4%), living donors (26% vs 20%), and lymphodepleting induction (64% vs 46%) compared to the SC group. ESW utilization varied widely across 129 centers, with less use at high- versus moderate-volume centers (6% vs 21%, P < .001). AR was more common with ESW by 1 year (18.4% vs 12.3%; aOR: 1.08 1.612.41 , P = .04) and over the study period (aHR: 1.02 1.391.90 , P = .03), without difference in death-censored graft failure (aHR 0.60 0.911.36 , P = .33) or mortality (aHR: 0.75 1.151.77 , P = .45). To reduce AR after HIV+ KT, tailoring of ESW utilization is reasonable.
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Affiliation(s)
- William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunjae Bae
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Woodle ES, Kaufman DB, Shields AR, Leone J, Matas A, Wiseman A, West-Thielke P, Sa T, King EC, Alloway RR. Belatacept-based immunosuppression with simultaneous calcineurin inhibitor avoidance and early corticosteroid withdrawal: A prospective, randomized multicenter trial. Am J Transplant 2020; 20:1039-1055. [PMID: 31680394 DOI: 10.1111/ajt.15688] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 07/12/2019] [Revised: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous calcineurin inhibitor avoidance (CNIA) and early corticosteroid withdrawal (ESW) have not been achieved primarily due to excessive acute rejection. This trial compared 2 belatacept-based CNIA/ESW regimens with a tacrolimus-based ESW regimen. Kidney transplant recipients were randomized to receive alemtuzumab/belatacept, rabbit anti-thymocyte globulin (rATG)/belatacept, or rATG/tacrolimus. The combinatorial primary endpoint consisted of patient death, renal allograft loss, or a Modification of Diet in Renal Disease-calculated eGFR of <45 mL/min/1.73 m2 at 12 months. Results are reported by treatment group (alemtuzumab/belatacept, rATG/belatacept, and rATG/tacrolimus). Superiority was not observed at 1 year for the primary endpoint (9/107 [8.4%], 15/104 [14.4%], and 14/105 [13.3%], respectively; P = NS) for either belatacept-based regimen. Differences were not observed for secondary endpoints (death, death-censored graft loss, or estimated glomerular filtration rates < 45 mL/min/1.73 m2 ). Differences were observed in biopsy-proved acute cellular rejection (10.3%, 18.3%, and 1.9%, respectively) (P < .001), but not in antibody-mediated rejection, mixed acute rejection, or de novo donor-specific anti-HLA antibodies. Neurologic and electrolyte abnormality adverse events were less frequent under belatacept. Belatacept-based CNIA/ESW regimens did not prove to be superior for the primary or secondary endpoints. Belatacept-treated patients demonstrated an increase in biopsy-proved acute cellular rejection and reduced neurologic and metabolic adverse events. These results demonstrate that simultaneous CNIA/ESW is feasible without excessive acute rejection.
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Affiliation(s)
- E Steve Woodle
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Adele R Shields
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | | | - Ting Sa
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Eileen C King
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Rita R Alloway
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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Okano S, Abu-Elmagd K, Kish DD, Keslar K, Baldwin WM, Fairchild RL, Fujiki M, Khanna A, Osman M, Costa G, Fung J, Miller C, Kayashima H, Hashimoto K. Myeloid-derived suppressor cells increase and inhibit donor-reactive T cell responses to graft intestinal epithelium in intestinal transplant patients. Am J Transplant 2018; 18:2544-2558. [PMID: 29509288 PMCID: PMC6127002 DOI: 10.1111/ajt.14718] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 02/04/2018] [Accepted: 02/25/2018] [Indexed: 01/25/2023]
Abstract
Recent advances in immunosuppressive regimens have decreased acute cellular rejection (ACR) rates and improved intestinal and multivisceral transplant (ITx) recipient survival. We investigated the role of myeloid-derived suppressor cells (MDSCs) in ITx. We identified MDSCs as CD33+ CD11b+ lineage(CD3/CD56/CD19)- HLA-DR-/low cells with 3 subsets, CD14- CD15- (e-MDSCs), CD14+ CD15- (M-MDSCs), and CD14- CD15+ (PMN-MDSCs), in peripheral blood mononuclear cells (PBMCs) and mononuclear cells in the grafted intestinal mucosa. Total MDSC numbers increased in PBMCs after ITx; among MDSC subsets, M-MDSC numbers were maintained at a high level after 2 months post ITx. The MDSC numbers decreased in ITx recipients with ACR. MDSC numbers were positively correlated with serum interleukin (IL)-6 levels and the glucocorticoid administration index. IL-6 and methylprednisolone enhanced the differentiation of bone marrow cells to MDSCs in vitro. M-MDSCs and e-MDSCs expressed CCR1, -2, and -3; e-MDSCs and PMN-MDSCs expressed CXCR2; and intestinal grafts expressed the corresponding chemokine ligands after ITx. Of note, the percentage of MDSCs among intestinal mucosal CD45+ cells increased after ITx. A novel in vitro assay demonstrated that MDSCs suppressed donor-reactive T cell-mediated destruction of donor intestinal epithelial organoids. Taken together, our results suggest that MDSCs accumulate in the recipient PBMCs and the grafted intestinal mucosa in ITx, and may regulate ACR.
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Affiliation(s)
- Shinji Okano
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA,Dept. Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA,Address for correspondence: Shinji Okano M.D., Ph.D., Department of Immunology, Lerner Research Institutes, Cleveland Clinic, 2070 East 90th Street, NB3-30, Cleveland, Ohio 44195, USA. Fax number: +1 216 444 3146, Telephone number: +1 216 444 1230, or
| | - Kareem Abu-Elmagd
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Danielle D Kish
- Dept. Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Karen Keslar
- Dept. Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - William M. Baldwin
- Dept. Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Robert L. Fairchild
- Dept. Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Masato Fujiki
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Ajai Khanna
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Mohammed Osman
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Guilherme Costa
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - John Fung
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Charles Miller
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Hiroto Kayashima
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Koji Hashimoto
- Transplant Center, Dept. General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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