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Pierce DR, Gruessner A, Campara M, DiCocco P, Spaggiari M, Tzvetanov I, Tang I, Benedetti E, Lichvar AB. Impact of early corticosteroid withdrawal on simultaneous pancreas-kidney transplant long-term outcomes: Single center experience and comparison to the International Pancreas Transplant Registry. Clin Transplant 2023; 37:e15063. [PMID: 37392191 DOI: 10.1111/ctr.15063] [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: 10/24/2022] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND There remains a paucity of modern data comparing early steroid withdrawal (ESW) versus chronic corticosteroid (CCS) immunosuppression in simultaneous pancreas kidney (SPK) transplant recipients with long-term follow-up. Therefore, the purpose of this study is to assess the effectiveness and tolerability of ESW compared to CCS post-SPK. METHODS This was a retrospective single-center matched comparison with the International Pancreas Transplant Registry (IPTR). Patients from University of Illinois Hospital (UIH) represented the ESW group and were compared to those matched CCS patients from the IPTR. Included patients were adult recipients of a primary SPK transplant between 2003 and 2018 within the US receiving rabbit anti-thymocyte globulin induction. Patients were excluded if they had early technical failures, missing IPTR data, graft thrombosis, re-transplant, or positive crossmatch SPK. RESULTS A total of 156 patients were matched and included in the analysis. Patients were predominantly African American (46.15%) males (64.1%) with Type 1 diabetes etiology (92.31%). Overall pancreas allograft survival (hazard ratio [HR] = .89, 95% confidence interval [CI] .34-2.30, p = .81) and kidney allograft survival (HR = .80, 95%CI .32-2.03, p = .64) were similar between the two groups. Immunologic pancreas allograft loss was statistically similar at 1-year (ESW 1.3% vs. CCS 0%, p = .16), 5-year (ESW 1.3% vs. CCS 7.7%, p = .16), and 10-year (ESW 11.0% vs. CCS 7.7%, p = .99). The 1-year (ESW 2.6% vs. CCS 0%, p > .05), 5-year (ESW 8.3% vs. CCS 7.0%, p > .05), and 10-year (ESW 22.7% vs. CCS 9.9%, p = .2575) immunologic kidney allograft loss were also statistically similar. There was no difference in 10-year overall patient survival (ESW 76.2% vs. CCS 65.6%, p = .63). CONCLUSIONS No differences were found between allograft or patient survival post-SPK when comparing an ESW or CCS protocol. Future assessment is needed to determine differences in metabolic outcomes.
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Affiliation(s)
- Dana R Pierce
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois, USA
| | - Angelika Gruessner
- Department of Medicine/Nephrology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Maya Campara
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois, USA
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Pierpaolo DiCocco
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mario Spaggiari
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Ivo Tzvetanov
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Ignatius Tang
- Department of Nephrology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Alicia B Lichvar
- Center for Transplantation, University of California San Diego Health, La Jolla, California, USA
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2
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Von Stein L, Witkowsky O, Samidurai L, Doraiswamy M, Flores K, Pesavento TE, Singh P. Modification in induction immunosuppression regimens to safely perform kidney transplants amid the COVID-19 pandemic: A single-center retrospective study. Clin Transplant 2021; 35:e14365. [PMID: 34014588 DOI: 10.1111/ctr.14365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/05/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The COVID-19 pandemic has negatively impacted organ donation and transplantation across the globe. METHODS This study analyzed transplant outcomes during the pre-pandemic [PPE, 1/2019-2/2020] and pandemic era [PE, 3/2020-8/2020] based on changes in induction immunosuppression. During PPE, high immunological risk patients received 4-6 mg/kg, moderate risk 2-4 mg/kg, and low risk 1-2 mg/kg of ATG. During PE, ATG doses were reduced to 3-4 mg/kg for high risk, 1-2 mg/kg for moderate, and low changed to basiliximab. Primary outcomes are as follows: biopsy-proven rejection [BPAR], de-novo donor-specific antibody [DSA], delayed graft function [DGF], infection rates, graft loss, and all-cause of mortality. RESULTS During PPE, 224 kidney transplants [KTx] and 14 kidney/pancreas transplants [KP] were included, while 180 KTx and 5 KP were included for PE. Basiliximab use increased by 30% in the PE. The odds of DGF were statistically significant between PE vs PPE, OR 1.7 [1.05, 2.8, p-value = .042]. The odds of developing DSAs and BPAR during the PE vs. PPE were 0.34 [0.16, 0.71, p-value = .004] and OR 0.34 (0.1 to 1.1, p-value, .104)], respectively. Cytomegalovirus [19% in PE, 37% in PPE] and BK virus [5.4% PE vs. 16% PPE] incidence reduced during PE vs. PPE. COVID-19, graft loss, and mortality were comparable between groups. CONCLUSION KTx and KP transplants were performed safely during the COVID-19 pandemic with a reduction of induction immunosuppression.
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Affiliation(s)
- Lauren Von Stein
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Olya Witkowsky
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lakshmi Samidurai
- Department of Transplant Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - MohanKumar Doraiswamy
- Department of Transplant Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Karen Flores
- Department of Transplant Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Todd E Pesavento
- Department of Transplant Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Priyamvada Singh
- Department of Transplant Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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3
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Shihab F, Qazi Y, Mulgaonkar S, McCague K, Patel D, Peddi VR, Shaffer D. Association of Clinical Events With Everolimus Exposure in Kidney Transplant Patients Receiving Low Doses of Tacrolimus. Am J Transplant 2017; 17:2363-2371. [PMID: 28141897 PMCID: PMC5600116 DOI: 10.1111/ajt.14215] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 11/03/2016] [Revised: 01/04/2017] [Accepted: 01/24/2017] [Indexed: 01/25/2023]
Abstract
A key objective in the use of immunosuppression after kidney transplantation is to attain the optimal balance between efficacy and safety. In a phase 3b, multicenter, randomized, open-label, noninferiority study, the incidences of clinical events, renal dysfunction, and adverse events (AEs) were analyzed at 12 months in 309 de novo renal transplant recipients receiving everolimus (EVR), low-dose tacrolimus (LTac), and prednisone. Cox proportional hazard regression modeling was used to estimate the probability of clinical events at specified combinations of time-normalized EVR and Tac trough concentrations. At 12 months, the highest incidence of treated biopsy-proven acute rejection (tBPAR) and graft loss occurred most often in patients with EVR trough concentration <3 ng/mL (64.7% and 10.5%, respectively). At 1 month and 12 months, increasing EVR levels were associated with fewer tBPAR events (both p < 0.0001). Low estimated glomerular filtration rate (eGFR) and decreased eGFR occurred more often in patients with lower EVR and higher Tac levels. AEs were most often observed in patients with EVR levels <3 ng/mL. This study supports maintaining an EVR trough concentration of 3-8 ng/mL, when combined with LTac, to achieve balanced efficacy and safety in renal transplant recipients. TRIAL REGISTRATION NCT01025817.
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Affiliation(s)
| | - Y. Qazi
- University of Southern CaliforniaLos AngelesCA
| | | | - K. McCague
- Novartis Pharmaceuticals CorporationEast HanoverNJ
| | - D. Patel
- Novartis Pharmaceuticals CorporationEast HanoverNJ
| | - V. R. Peddi
- California Pacific Medical CenterSan FranciscoCA
| | - D. Shaffer
- Vanderbilt University Medical CenterNashvilleTN
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4
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Affiliation(s)
- V Carter
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Newcastle upon Tyne, UK
| | - W M Howell
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Newcastle upon Tyne, UK
| | - J A M Shaw
- Newcastle University Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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5
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Shanmugarajah K, Powell H, Leonard DA, Mallard C, Albritton A, Harrington E, Randolph MA, Farkash E, Sachs DH, Kurtz JM, Cetrulo CL. The Effect of MHC Antigen Matching Between Donors and Recipients on Skin Tolerance of Vascularized Composite Allografts. Am J Transplant 2017; 17:1729-1741. [PMID: 28035752 DOI: 10.1111/ajt.14189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 08/28/2016] [Revised: 12/16/2016] [Accepted: 12/22/2016] [Indexed: 01/25/2023]
Abstract
The emergence of skin-containing vascularized composite allografts (VCAs) has provided impetus to understand factors affecting rejection and tolerance of skin. VCA tolerance can be established in miniature swine across haploidentical MHC barriers using mixed chimerism. Because the deceased donor pool for VCAs does not permit MHC antigen matching, clinical VCAs are transplanted across varying MHC disparities. We investigated whether sharing of MHC class I or II antigens between donors and recipients influences VCA skin tolerance. Miniature swine were conditioned nonmyeloablatively and received hematopoietic stem cell transplants and VCAs across MHC class I (n = 3) or class II (n = 3) barriers. In vitro immune responsiveness was assessed, and VCA skin-resident leukocytes were characterized by flow cytometry. Stable mixed chimerism was established in all animals. MHC class II-mismatched chimeras were tolerant of VCAs. MHC class I-mismatched animals, however, rejected VCA skin, characterized by infiltration of recipient-type CD8+ lymphocytes. Systemic donor-specific nonresponsiveness was maintained, including after VCA rejection. This study shows that MHC antigen matching influences VCA skin rejection and suggests that local regulation of immune tolerance is critical in long-term acceptance of all VCA components. These results help elucidate novel mechanisms underlying skin tolerance and identify clinically relevant VCA tolerance strategies.
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Affiliation(s)
- K Shanmugarajah
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.,Department of Plastic Surgery, Massachusetts General Hospital, Boston, MA
| | - H Powell
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - D A Leonard
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.,Department of Plastic Surgery, Massachusetts General Hospital, Boston, MA
| | - C Mallard
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - A Albritton
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - E Harrington
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - M A Randolph
- Department of Plastic Surgery, Massachusetts General Hospital, Boston, MA
| | - E Farkash
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - D H Sachs
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA
| | - J M Kurtz
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.,Department of Biology, Emmanuel College, Boston, MA
| | - C L Cetrulo
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA.,Department of Plastic Surgery, Massachusetts General Hospital, Boston, MA
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6
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Kassar R, Chang J, Chan AW, Lilly LB, Al Habeeb A, Rotstein C. Leflunomide for the treatment of trichodysplasia spinulosa in a liver transplant recipient. Transpl Infect Dis 2017; 19. [PMID: 28326649 DOI: 10.1111/tid.12702] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 09/15/2016] [Revised: 11/30/2016] [Accepted: 01/08/2017] [Indexed: 11/27/2022]
Abstract
Trichodysplasia spinulosa (TS) is a rare dermatologic complication associated with the immunosuppressive therapy used in solid organ transplantation. The distinctive clinical manifestation of this condition is spiny follicular papules on the face, ears, extremities, and trunk. Histopathologically, abnormally maturing hair follicles with hyperkeratotic material are noted. The condition is produced by the trichodysplasia spinulosa-associated polyomavirus. Treatment of this condition in the past has entailed a reduction in immunosuppression, topical agents such as cidofovir or retinoids, or oral valganciclovir. Herein, we report a case of generalized TS treated successfully with leflunomide.
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Affiliation(s)
- Rawan Kassar
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Multi-organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Janis Chang
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Multi-organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - An-Wen Chan
- Multi-organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Leslie B Lilly
- Liver Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Ayman Al Habeeb
- Department of Pathology, University Health Network, Toronto, ON, Canada
| | - Coleman Rotstein
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Multi-organ Transplant Program, University Health Network, Toronto, ON, Canada
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7
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Qazi Y, Shaffer D, Kaplan B, Kim DY, Luan FL, Peddi VR, Shihab F, Tomlanovich S, Yilmaz S, McCague K, Patel D, Mulgaonkar S. Efficacy and Safety of Everolimus Plus Low-Dose Tacrolimus Versus Mycophenolate Mofetil Plus Standard-Dose Tacrolimus in De Novo Renal Transplant Recipients: 12-Month Data. Am J Transplant 2017; 17:1358-1369. [PMID: 27775865 DOI: 10.1111/ajt.14090] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [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: 05/20/2016] [Revised: 09/11/2016] [Accepted: 10/07/2016] [Indexed: 01/25/2023]
Abstract
In this 12-month, multicenter, randomized, open-label, noninferiority study, de novo renal transplant recipients (RTxRs) were randomized (1:1) to receive everolimus plus low-dose tacrolimus (EVR+LTac) or mycophenolate mofetil plus standard-dose Tac (MMF+STac) with induction therapy (basiliximab or rabbit anti-thymocyte globulin). Noninferiority of composite efficacy failure rate (treated biopsy-proven acute rejection [tBPAR]/graft loss/death/loss to follow-up) in EVR+LTac versus MMF+STac was missed by 1.4%, considering the noninferiority margin of 10% (24.6% vs. 20.4%; 4.2% [-3.0, 11.4]). Incidence of tBPAR (19.1% vs. 11.2%; p < 0.05) was significantly higher, while graft loss (1.3% vs. 3.9%; p < 0.05) and composite of graft loss/death/lost to follow-up (6.1% vs. 10.5%, p = 0.05) were significantly lower in EVR+LTac versus MMF+STac groups, respectively. Mean estimated glomerular filtration rate was similar between EVR+LTac and MMF+STac groups (63.1 [22.0] vs. 63.1 [19.5] mL/min/1.73 m2 ) and safety was comparable. In conclusion, EVR+LTac missed noninferiority versus MMF+STac based on the 10% noninferiority margin. Further studies evaluating optimal immunosuppression for improved efficacy will guide appropriate dosing and target levels of EVR and LTac in RTxRs.
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Affiliation(s)
- Y Qazi
- University of Southern California, Los Angeles, CA
| | - D Shaffer
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - B Kaplan
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - D Y Kim
- Henry Ford Hospital, Detroit, MI
| | - F L Luan
- Universtiy of Michigan, Ann Arbor, MI.,Barnabas Health, Livingston, NJ
| | - V R Peddi
- California Pacific Medical Center, San Francisco, CA
| | - F Shihab
- University of Utah School of Medicine, Salt Lake City, UT
| | | | - S Yilmaz
- University Calgary, Calgary, Alberta, Canada
| | - K McCague
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - D Patel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
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8
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Jindal R, Unadkat J, Zhang W, Zhang D, Ng TW, Wang Y, Jiang J, Lakkis F, Rubin P, Lee WPA, Gorantla VS, Zheng XX. Spontaneous resolution of acute rejection and tolerance induction with IL-2 fusion protein in vascularized composite allotransplantation. Am J Transplant 2015; 15:1231-40. [PMID: 25676865 DOI: 10.1111/ajt.13118] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 05/13/2014] [Revised: 11/23/2014] [Accepted: 11/23/2014] [Indexed: 01/25/2023]
Abstract
Vascularized composite allotransplantation (VCA) has emerged as a treatment option for treating nonlife-threatening conditions. Therefore, in order to make VCA a safe reconstruction option, there is a need to minimize immunosuppression, develop tolerance-inducing strategies and elucidate the mechanisms of VCA rejection and tolerance. In this study we explored the effects of hIL-2/Fc (a long-lasting human IL-2 fusion protein), in combination with antilymphocyte serum (ALS) and short-term cyclosporine A (CsA), on graft survival, regulatory T cell (Treg) proliferation and tolerance induction in a rat hind-limb transplant model. We demonstrate that hIL-2/Fc therapy tips the immune balance, increasing Treg proliferation and suppressing effector T cells, and permits VCA tolerance as demonstrated by long-term allograft survival and donor-antigen acceptance. Moreover, we observe two distinct types of acute rejection (AR), progressive and reversible, within hIL-2/Fc plus ALS and CsA treated recipients. Our study shows differential gene expression profiles of FoxP3 versus GzmB, Prf1 or interferon-γ in these two types of AR, with reversible rejection demonstrating higher Treg to Teff gene expression. This correlation of gene expression profile at the first clinical sign of AR with VCA outcomes can provide the basis for further inquiry into the mechanistic aspects of VCA rejection and future drug targets.
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Affiliation(s)
- R Jindal
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburg, PA
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9
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Poirier N, Dilek N, Mary C, Ville S, Coulon F, Branchereau J, Tillou X, Charpy V, Pengam S, Nerriere-Daguin V, Hervouet J, Minault D, Le Bas-Bernardet S, Renaudin K, Vanhove B, Blancho G. FR104, an antagonist anti-CD28 monovalent fab' antibody, prevents alloimmunization and allows calcineurin inhibitor minimization in nonhuman primate renal allograft. Am J Transplant 2015; 15:88-100. [PMID: 25488654 DOI: 10.1111/ajt.12964] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [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: 05/14/2014] [Revised: 08/01/2014] [Accepted: 08/04/2014] [Indexed: 01/25/2023]
Abstract
Selective targeting of CD28 might represent an effective immunomodulation strategy by preventing T cell costimulation, while favoring coinhibition since inhibitory signals transmitted through CTLA-4; PD-L1 and B7 would not be affected. We previously showed in vitro and in vivo that anti-CD28 antagonists suppress effector T cells while enhancing regulatory T cell (Treg) suppression and immune tolerance. Here, we evaluate FR104, a novel antagonist pegylated anti-CD28 Fab' antibody fragment, in nonhuman primate renal allotransplantation. FR104, in association with low doses of tacrolimus or with rapamycin in a steroid-free therapy, prevents acute rejection and alloantibody development and prolongs allograft survival. However, when FR104 was associated with mycophenolate mofetil and steroids, half of the recipients rejected their grafts prematurely. Finally, we observed an accumulation of Helios-negative Tregs in the blood and within the graft after FR104 therapy, confirmed by Treg-specific demethylated region DNA analysis. In conclusion, FR104 reinforces immunosuppression in calcineurin inhibitor (CNI)-low or CNI-free protocols, without the need of steroids. Accumulation of intragraft Tregs suggested the promotion of immunoregulatory mechanisms. Selective CD28 antagonists might become an alternative CNI-sparing strategy to B7 antagonists for kidney transplant recipients.
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Affiliation(s)
- N Poirier
- Institut National de la Santé Et de la Recherche Médicale Unité Mixte de Recherche 1064, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), Université de Nantes, Nantes, France; Effimune SAS, Nantes, France
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10
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Murakami N, Riella LV, Funakoshi T. Risk of metabolic complications in kidney transplantation after conversion to mTOR inhibitor: a systematic review and meta-analysis. Am J Transplant 2014; 14:2317-27. [PMID: 25146383 DOI: 10.1111/ajt.12852] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [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: 03/14/2014] [Revised: 05/14/2014] [Accepted: 05/28/2014] [Indexed: 01/25/2023]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors have been used in transplantation with the hope of minimizing calcineurin inhibitor (CNI)-induced nephrotoxicity. However, mTOR inhibitors are also associated with a range of side effects, including metabolic complications. We aimed to determine the risks of metabolic complications after the conversion from CNI to mTOR inhibitor postkidney transplant. A systematic search in PubMed up to September 2013 identified nine relevant trials (a total of 2323 patients). The primary end points were the relative risks (RRs) of new-onset diabetes after transplant (NODAT) and hypercholesterolemia. The overall RRs of NODAT and hypercholesterolemia associated with mTOR inhibitors were 1.32 (95% confidence interval [CI] 0.92-1.87) and 2.15 (95% CI 1.35-3.41), respectively, compared with CNI-based regimen. Subgroup analyses revealed no differences in the incidence of NODAT or hypercholesterolemia between sirolimus- versus everolimus-based regimen, or between early versus late conversion. Analyses of secondary outcomes revealed a higher risk of acute rejection, proteinuria and anemia, but no difference in the risk of opportunistic infections after mTOR inhibitor conversion. In conclusion, the conversion from CNI to mTOR inhibitor in low-to-moderate risk kidney transplant recipients was associated with nonsignificant trend toward increased risk of NODAT and significant increase in hypercholesterolemia, acute rejection, proteinuria and anemia.
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Affiliation(s)
- N Murakami
- Department of Medicine, Beth Israel Medical Center, New York, NY
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11
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Kirk AD, Guasch A, Xu H, Cheeseman J, Mead SI, Ghali A, Mehta AK, Wu D, Gebel H, Bray R, Horan J, Kean LS, Larsen CP, Pearson TC. Renal transplantation using belatacept without maintenance steroids or calcineurin inhibitors. Am J Transplant 2014; 14:1142-51. [PMID: 24684552 PMCID: PMC4642731 DOI: 10.1111/ajt.12712] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [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: 12/09/2013] [Revised: 01/27/2014] [Accepted: 02/12/2014] [Indexed: 01/25/2023]
Abstract
Kidney transplantation remains limited by toxicities of calcineurin inhibitors (CNIs) and steroids. Belatacept is a less toxic CNI alternative, but existing regimens rely on steroids and have higher rejection rates. Experimentally, donor bone marrow and sirolimus promote belatacept's efficacy. To investigate a belatacept-based regimen without CNIs or steroids, we transplanted recipients of live donor kidneys using alemtuzumab induction, monthly belatacept and daily sirolimus. Patients were randomized 1:1 to receive unfractionated donor bone marrow. After 1 year, patients were allowed to wean from sirolimus. Patients were followed clinically and with surveillance biopsies. Twenty patients were transplanted, all successfully. Mean creatinine (estimated GFR) was 1.10 ± 0.07 mg/dL (89 ± 3.56 mL/min) and 1.13 ± 0.07 mg/dL (and 88 ± 3.48 mL/min) at 12 and 36 months, respectively. Excellent results were achieved irrespective of bone marrow infusion. Ten patients elected oral immunosuppressant weaning, seven of whom were maintained rejection-free on monotherapy belatacept. Those failing to wean were successfully maintained on belatacept-based regimens supplemented by oral immunosuppression. Seven patients declined immunosuppressant weaning and three patients were denied weaning for associated medical conditions; all remained rejection-free. Belatacept and sirolimus effectively prevent kidney allograft rejection without CNIs or steroids when used following alemtuzumab induction. Selected, immunologically low-risk patients can be maintained solely on once monthly intravenous belatacept.
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Affiliation(s)
- A D Kirk
- Emory Transplant Center, Emory University, Atlanta, GA
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