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Ningoo M, Cruz-Encarnación P, Khilnani C, Heeger PS, Fribourg M. T-cell receptor sequencing reveals selected donor-reactive CD8 + T cell clones resist antithymocyte globulin depletion after kidney transplantation. Am J Transplant 2024; 24:755-764. [PMID: 38141722 PMCID: PMC11070313 DOI: 10.1016/j.ajt.2023.12.016] [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: 05/31/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 12/25/2023]
Abstract
High frequencies of donor-reactive memory T cells in the periphery of transplant candidates prior to transplantation are linked to the development of posttransplant acute rejection episodes and reduced allograft function. Rabbit antithymocyte globulin (rATG) effectively depletes naïve CD4+ and CD8+ T cells for >6 months posttransplant, but rATG's effects on human donor-reactive T cells have not been carefully determined. To address this, we performed T cell receptor β-chain sequencing on peripheral blood mononuclear cells aliquots collected pretransplant and serially posttransplant in 7 kidney transplant recipients who received rATG as induction therapy. We tracked the evolution of the donor-reactive CD4+ and CD8+ T cell repertoires and identified stimulated pretransplant, CTV-(surface dye)-labeled, peripheral blood mononuclear cells from each patient with donor cells or third-party cells. Our analyses showed that while rATG depleted CD4+ T cells in all tested subjects, a subset of donor-reactive CD8+ T cells that were present at high frequencies pretransplant, consistent with expanded memory cells, resisted rATG depletion, underwent posttransplant expansion and were functional. Together, our data support the conclusion that a subset of human memory CD8+ T cells specifically reactive to donor antigens expand in vivo despite induction therapy with rATG and thus have the potential to mediate allograft damage.
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Affiliation(s)
- Mehek Ningoo
- Translational Transplant Research Center, Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Immunology Institute Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Cruz-Encarnación
- Translational Transplant Research Center, Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Immunology Institute Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Calla Khilnani
- Translational Transplant Research Center, Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Immunology Institute Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter S Heeger
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Miguel Fribourg
- Translational Transplant Research Center, Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Immunology Institute Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Custodio LDFP, Martins SBS, Viana LA, Cristelli MP, Requião-Moura L, Chow CYZ, Camargo SFDN, Nakamura MR, Foresto RD, Tedesco-Silva H, Medina-Pestana J. Efficacy and safety of single-dose anti-thymocyte globulin versus basiliximab induction therapy in pediatric kidney transplant recipients: A retrospective comparative cohort study. Pediatr Transplant 2024; 28:e14713. [PMID: 38553819 DOI: 10.1111/petr.14713] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/11/2024] [Accepted: 01/28/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND This study aimed to compare the efficacy and safety of basiliximab (BAS) versus a single dose of anti-thymocyte globulin (r-ATG) induction therapy in pediatric kidney transplant recipients (KTRs). METHODS This single-center retrospective comparative cohort study included all pediatric KTRs from May 2013 to April 2018 and followed up to 12 months. In the first period, all recipients received BAS, while from May 2016, a single 3 mg/kg dose of r-ATG was instituted. Maintenance therapy consisted of a calcineurin inhibitor plus prednisone plus azathioprine or mycophenolate. RESULTS A total of 227 patients were included (BAS, n = 113; r-ATG, n = 114). The main combination of immunosuppressive drugs was tacrolimus, prednisone, and azathioprine in both groups (87% vs. 88%, p = .718). Patients receiving r-ATG showed superior survival-free of the composite endpoint (acute rejection, graft loss, or death; 76% vs. 61%, p = .003; HR 2.08, 1.29-3.34, p = .003) and lower incidence of biopsy-proven acute rejection (10% vs. 21%, p = .015). There was no difference in the overall incidence of CMV infection (33% vs. 37%, p = .457), PTLD (1% vs. 3%, p = .309), 30-day hospital readmissions (24% vs. 23%, p = .847), and kidney function at 12 months (86 ± 29 vs. 84 ± 30 mL/min/1.73m2, p = .614). CONCLUSIONS These data suggest that induction therapy with a single 3 mg/kg dose of r-ATG is associated with higher efficacy for preventing acute rejection and similar safety profile compared to BAS.
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Affiliation(s)
| | | | | | | | - Lucio Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Vnučák M, Graňák K, Beliančinová M, Kleinová P, Blichová T, Doboš V, Dedinská I. Effect of Different Induction Immunosuppression on the Incidence of Infectious Complications after Kidney Transplantation-Single Center Study. J Clin Med 2024; 13:2162. [PMID: 38673435 PMCID: PMC11050246 DOI: 10.3390/jcm13082162] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/29/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Potent immunosuppression lowers the incidence of acute graft rejection but increases the risk of infections. In order to decrease either infectious complications or acute rejection, it is necessary to identify risk groups of patients profiting from personalized induction immunosuppressive treatment. The aim of our analysis was to find whether there were higher incidences of infectious complications after kidney transplantation (KT) in groups with different induction immunosuppressive treatment and also to find independent risk factors for recurrent infections. Materials: We retrospectively evaluated all patients with induction treatment with basiliximab after kidney transplantation from 2014 to 2019 at our center relative to age- and sex-matched controls of patients with thymoglobulin induction immunosuppression. Results: Our study consisted of two groups: basiliximab (39) and thymoglobulin (39). In the thymoglobulin group we observed an increased incidence of recurrent infection in every observed interval; however, acute rejection was seen more often in the basiliximab group. A history of respiratory diseases and thrombocytopenia were identified as independent risk factors for recurrent bacterial infections from the first to sixth month after KT. Decreased eGFR from the first month, infections caused by multi-drug-resistant bacteria, and severe infections (reflected by the need for hospitalization) were identified as independent risk factors for recurrent bacterial infections from the first to the twelfth month after KT. Conclusions: We found that in the group of patients with thymoglobulin induction immunosuppressive treatment, infectious complications occurred significantly more often during the entire monitored period with decreased incidence of acute humoral and cellular rejection occurred more often.
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Affiliation(s)
- Matej Vnučák
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Karol Graňák
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Monika Beliančinová
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Patrícia Kleinová
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Tímea Blichová
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Vladimír Doboš
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Ivana Dedinská
- Transplant-Nephrology Centre, University Hospital Martin, Kollárova 2, 03601 Martin, Slovakia; (M.V.); (M.B.); (P.K.); (T.B.); (I.D.)
- 1st Department of Internal Diseases, University Hospital Martin and Jessenius Medical Faculty of Comenius University, Kollárova 2, 03601 Martin, Slovakia;
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Aydin-Ghormoz EA, Perlmutter J, Koizumi N, Ortiz J, Faddoul G. Outcomes of kidney transplantation in patients with IgA nephropathy based on induction: A UNOS data analysis. Clin Transplant 2024; 38:e15225. [PMID: 38127110 DOI: 10.1111/ctr.15225] [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: 06/06/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION IgA nephropathy (IgAN) can cause end-stage kidney disease (ESKD). This study assesses the impact of induction and maintenance immunosuppression on IgAN recurrence, graft survival, and mortality in living and deceased donor kidney transplants (LDKT and DDKT). METHODS Retrospective analysis of the UNOS database in adults with ESKD secondary to IgAN who received kidney transplants between January 2000 and June 30, 2022. Patients with thymoglobulin (ATG), alemtuzumab, or basiliximab/daclizumab induction with calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) with or without prednisone maintenance were analyzed. Multivariate logistic regression was performed to identify factors correlated with IgA recurrence. Multivariable Cox regression analyses were performed for clinically suspected risk factors. Kaplan Meir Analysis was utilized for overall graft survival. RESULTS Compared to ATG with steroid maintenance, alemtuzumab with steroid increased the odds of IgAN recurrence in DDKTs (OR 1.90, p < .010, 95% CI [1.169-3.101]). Alemtuzumab with and without steroid increased the odds of recurrence by 52% (p = .036) and 56% (p = .005), respectively, in LDKTs. ATG without steroids was associated with less risk of IgAN recurrence (HR .665, p = .044, 95% CI [.447-.989]), graft failure (HR .758, p = .002, 95% CI [.633-.907]), and death (HR .619, p < .001, 95% CI [.490-.783]) in DDKTs. Recurrence was strongly associated with risks of graft failure in DDKTs and LDKTs and death in LDKTs. CONCLUSION In patients with IgAN requiring a kidney transplant, Alemtuzumab induction correlates with increased IgAN recurrence. Relapse significantly affects graft survival and mortality. ATG without steroids is associated with the least graft loss and mortality.
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Affiliation(s)
| | | | - Naoru Koizumi
- Schar School of Policy & Government, George Mason University, Arlington, Virginia, USA
| | - Jorge Ortiz
- Department of Surgery, Erie County Medical Center, Buffalo, New York, USA
| | - Geovani Faddoul
- Department of Medicine, Albany Medical Center, New York, USA
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Al Jurdi A, Liu EC, Salinas T, Aull MJ, Lubetzky M, Drelick AL, Small CB, Kapur S, Hartono C, Muthukumar T. Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients. Front Nephrol 2022; 2:1047170. [PMID: 37675034 PMCID: PMC10479633 DOI: 10.3389/fneph.2022.1047170] [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] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 09/08/2023]
Abstract
Background Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking. Methods We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival. Results Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively. Conclusion rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.
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Affiliation(s)
- Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Esther C. Liu
- Department of Pharmacy, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Meredith J. Aull
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Michelle Lubetzky
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Alexander L. Drelick
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Catherine B. Small
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Sandip Kapur
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
- The Rogosin Institute, New York, NY, United States
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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Jha PK, Rana A, Kher A, Bansal SB, Sethi S, Nandwani A, Jain M, Bansal D, Yadav DK, Gadde A, Mahapatra AK, Sodhi P, Kher V. Grafalon® vs. Thymoglobulin® as an Induction Agent in Renal Transplantation - A Retrospective Study. Indian J Nephrol 2021; 31:336-340. [PMID: 34584347 PMCID: PMC8443089 DOI: 10.4103/ijn.ijn_205_20] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/16/2020] [Accepted: 07/28/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Antihuman thymocyte immunoglobulin, used as an induction agent in renal transplantation, is of two types - thymoglobulin and grafalon (formerly ATG-Fresenius). In this study, we compared outcomes with these two agents. Methods This was a single-center retrospective study of patients transplanted from January 2017 to October 2019, who received either grafalon or thymoglobulin induction. Grafalon or thymoglobulin was given at 6 and 3 mg/kg, respectively, followed by standard triple immunosuppression of tacrolimus, MMF, and prednisolone. Results Median follow up was 22 (3-36) months. Thymoglobulin was given to 255 patients, whereas 78 patients received grafalon. Baseline demographics were similar between the two groups although significantly more patients in the grafalon group received ABO incompatible transplant (15% vs. 4.3%; P = 0.002). Patient survival was similar between the two groups (99% in grafalon vs. 98.8% in thymoglobulin; P = 1.0). Death censored graft survival was also similar (99% in grafalon vs. 100% in thymoglobulin; P = 0.23). Biopsy proven acute rejection (BPAR) was significantly higher in the grafalon group (12.8% vs. 5.1%, P = 0.04). The significance persisted after multivariable regression analysis (P = 0.02). Other outcomes such as infection rate and estimated glomerular filtration rate on last follow up were comparable between the two groups. Conclusions Grafalon (6 mg/kg dose) when used as an induction agent was associated with significantly higher rate of BPARs as compared to thymoglobulin (3 mg/kg dose) although with comparable short-term patient and death censored graft survival, graft function, and infection rates.
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Affiliation(s)
- Pranaw Kumar Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Abhyudaysingh Rana
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ajay Kher
- Department of Nephrology, Max Super Specialty Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
| | - Shyam Bihari Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ashish Nandwani
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Manish Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Dinesh Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Dinesh Kumar Yadav
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Ashwini Gadde
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Amit Kumar Mahapatra
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Puneet Sodhi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
| | - Vijay Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Sector 38, Gurugram, Haryana, India
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Murata M, Teshima T. Treatment of Steroid-Refractory Acute Graft- Versus-Host Disease Using Commercial Mesenchymal Stem Cell Products. Front Immunol 2021; 12:724380. [PMID: 34489977 PMCID: PMC8417106 DOI: 10.3389/fimmu.2021.724380] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 06/13/2021] [Accepted: 07/29/2021] [Indexed: 01/09/2023] Open
Abstract
Acute graft-versus-host disease (GVHD) is a life-threatening complication that can develop after allogeneic hematopoietic stem cell transplantation. In particular, the prognosis of patients with steroid-refractory acute GVHD is extremely poor. Ryoncil™ (remestemcel-L), a human bone marrow-derived mesenchymal stem cell (MSC) product, failed to show superiority over placebo in patients with steroid-refractory acute GVHD, but it was approved for use in pediatric patients in Canada and New Zealand based on the results of a subgroup analysis. Temcell®, an equivalent manufactured MSC product to remestemcel-L, was approved in Japan based on small single-arm studies by using a regulation for regenerative medicine in 2016. The efficacy of Temcell was evaluated in 381 consecutive patients treated with Temcell during the initial 3 years after its approval. Interestingly, its real-world efficacy was found to be equivalent to that observed in a prospective study of remestemcel-L with strict eligibility criteria. In this article, the potential of MSC therapy in the treatment of acute GVHD is discussed. A meticulous comparison of studies of remestemcel-L and Temcell, remestemcel-L/Temcell and ruxolitinib, and remestemcel-L/Temcell and thymoglobulin showed that the precise position of remestemcel-L/Temcell therapy in the treatment of acute GVHD remains to be determined.
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Affiliation(s)
- Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
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Mohammadi K, Khajeh B, Dashti-Khavidaki S, Shab-Bidar S. Association between cumulative rATG induction doses and kidney graft outcomes and adverse effects in kidney transplant patients: a systematic review and meta-analysis. Expert Opin Biol Ther 2021; 21:1265-1279. [PMID: 34304664 DOI: 10.1080/14712598.2021.1960978] [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: 10/20/2022]
Abstract
BACKGROUND This systematic review and meta-analysis were performed to explore the association between rabbit thymoglobulin (rATG) doses and transplant-related efficacy and safety outcomes. METHODS We searched PubMed and Scopus databases from inception up to June 2020. The primary efficacy and safety endpoints in kidney transplant recipients were evaluated. RESULTS Data of 23 cohort studies (3457 patients) and three RCTs (154 patients) were extracted and analyzed. rATG doses of ≤4.5 m/kg was associated with lower rates of biopsy proven acute rejection, cytomegalovirus infection, BK virus infection, and malignancy with a comparable rate of delayed graft function, patients' mortality, and death-censored graft loss compared to rATG total doses of 4.5-6 mg/kg or more than 6 mg/kg. The rATG doses of 3-4.5 mg/kg was associated with better outcomes in dose-response analysis. EXPERT OPINION Cumulative rATG induction doses as much as 3-4.5 mg/kg is as effective as higher doses regarding to allograft and patient outcomes while minimizing potential adverse effects in kidney transplant recipients.
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Affiliation(s)
- Keyhan Mohammadi
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Behrouz Khajeh
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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Kerbauy MN, Ribeiro AAF, Arcuri LJ, Kerbauy LN, da Silva CC, Camargo LFA, Machado CM, Hamerschlak N. Clinical impact of multiple DNA virus infections in nondepleted haploidentical and unrelated allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2021; 23:e13626. [PMID: 33900012 DOI: 10.1111/tid.13626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/30/2020] [Revised: 03/26/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Few studies have compared the clinical impact of multiple DNA-virus infections in haploidentical hematopoietic stem cell transplantation (haplo-HSCT) with posttransplant cyclophosphamide (PTCy) and unrelated donor allogeneic hematopoietic stem cell transplantation (UD-HSCT) with thymoglobulin, so we retrospectively analyzed viral infections in the first 6 mo posttransplant in these scenarios. Fifty-nine patients underwent to haplo-HSCT, and 68 to UD-HSCT. The most frequent infection was cytomegalovirus (CMV) (76.3% in haplo-HSCT and 69.1% in UD-HSCT) (P = .878) and in the group of patients with CMV reactivation, maximal CMV viral load over 2500 UI/ml correlated with worse overall survival-hazard ratio (HR) 1.93 (95% confidence interval [CI] 1.04-3.59) P = .03. The cumulative incidence of multiple DNA virus within 180 d of posttransplant was 78.7% for one virus and 28.4% for two or more viruses with no difference regarding the type of transplant. Viral infections, age, and acute graft versus host disease (GVHD) grades II-IV were risk factors for worse overall survival in multivariate analyses: one virus HR 2.53 (95% CI 1.03-6.17) P = .04, two or more viruses HR 3.51 (95% CI 1.37-9) P < .01, age HR 1.03 (95% CI 1.02-1.05) P < .01 and acute GVHD II-IV HR 1.97 (95% CI 1.13-3.43) P = .01. Also, age over 50 y HR 4.25 (95% CI 2.01-8.97) P < .001, second CMV reactivation or having both CMV and BK polyomavirus (BKV) HR 2.65 (95% CI 1.26-5.56) P = .01 and acute GVHD grades II-IV HR 2.23 (95% CI 1.12-4.43) P = .022 were risk factors for nonrelapse mortality in the multivariate analyses. In conclusion, multiple DNA-virus infections are frequent in both haplo-HSCT and UD-HSCT and a risk factor for worse overall survival.
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Affiliation(s)
- Mariana N Kerbauy
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andreza A F Ribeiro
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Leonardo J Arcuri
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Lucila N Kerbauy
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Cinthya C da Silva
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luis Fernando A Camargo
- Instituto Israelita de Ensino e Pesquisa (IIEP), Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Infectious Diseases, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Infectious Diseases, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Clarisse M Machado
- Instituto Israelita de Ensino e Pesquisa (IIEP), Hospital Israelita Albert Einstein, São Paulo, Brazil.,Virology Laboratory, Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - Nelson Hamerschlak
- Department of Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil
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10
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de Paula MI, Bowring MG, Shaffer AA, Garonzik-Wang J, Bessa AB, Felipe CR, Cristelli MP, Massie AB, Medina-Pestana J, Segev DL, Tedesco-Silva H. Decreased incidence of acute rejection without increased incidence of cytomegalovirus (CMV) infection in kidney transplant recipients receiving rabbit anti-thymocyte globulin without CMV prophylaxis - a cohort single-center study. Transpl Int 2021; 34:339-352. [PMID: 33314321 PMCID: PMC8573716 DOI: 10.1111/tri.13800] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/28/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
Induction therapy with rabbit anti-thymocyte globulin (rATG) in low-risk kidney transplant recipients (KTR) remains controversial, given the associated increased risk of cytomegalovirus (CMV) infection. This natural experiment compared 12-month clinical outcomes in low-risk KTR without CMV prophylaxis (January/3/13-September/16/15) receiving no induction or a single 3 mg/kg dose of rATG. We used logistic regression to characterize delayed graft function (DGF), negative binomial to characterize length of hospital stay (LOS), and Cox regression to characterize acute rejection (AR), CMV infection, graft loss, death, and hospital readmissions. Recipients receiving 3 mg/kg rATG had an 81% lower risk of AR (aHR 0.14 0.190.25 , P < 0.001) but no increased rate of hospital readmissions because of infections (0.68 0.911.21 , P = 0.5). There was no association between 3 mg/kg rATG and CMV infection/disease (aHR 0.86 1.101.40 , P = 0.5), even when the analysis was stratified according to recipient CMV serostatus positive (aHR 0.94 1.251.65 , P = 0.1) and negative (aHR 0.28 0.571.16 , P = 0.1). There was no association between 3 mg/kg rATG and mortality (aHR 0.51 1.253.08 , P = 0.6), and graft loss (aHR 0.34 0.731.55 , P = 0.4). Among low-risk KTR receiving no CMV pharmacological prophylaxis, 3 mg/kg rATG induction was associated with a significant reduction in the incidence of AR without an increased risk of CMV infection, regardless of recipient pretransplant CMV serostatus.
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Affiliation(s)
- Mayara Ivani de Paula
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashton A. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Adrieli Barros Bessa
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Claudia Rosso Felipe
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Jose Medina-Pestana
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Helio Tedesco-Silva
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
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11
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Jeong R, Quinn RR, Lentine KL, Ravani P, Ye F, Campbell P, Wen K, Broscheit C, Gourishankar S, Lam NN. Incidence, Risk Factors, and Outcomes of Kidney Transplant Recipients Treated With Both Basiliximab and Antithymocyte Globulin. Can J Kidney Health Dis 2020; 7:2054358120964061. [PMID: 33117549 PMCID: PMC7573718 DOI: 10.1177/2054358120964061] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Kidney transplant recipients are given induction therapy to rapidly reduce the immune response and prevent rejection. Guidelines recommend that an interleukin-2 receptor antibody (basiliximab) be the first-line agent and that a lymphocyte-depleting agent (antithymocyte globulin [ATG]) be reserved for those at high immunologic risk. Objective: To determine the incidence, risk factors, and outcomes for patients who receive both basiliximab and ATG for induction compared to either agent alone. Design: Retrospective cohort study. Setting: We used the transplant electronic medical record at the University of Alberta Hospital in Edmonton, Canada. Patients/samples/participants: We included incident adult kidney transplant recipients from 2013 to 2018. Measurements: We measured baseline characteristics, type, and dose of induction therapy used, estimated glomerular filtration rate (eGFR) at 1-year posttransplant, and outcomes of all-cause graft failure, death-censored graft failure, all-cause mortality, and death with a functioning graft. Methods: Differences between induction groups were compared using chi-square test for categorical variables and Kruskal-Wallis tests for continuous variables. We performed multivariable logistic regression modeling with type of induction therapy as the dependent variable and the case-level factors as the predictors (adjusted odds ratio). We estimated the Kaplan-Meier failure functions and used log-rank tests to assess statistical significance of differences in unadjusted incidence across induction therapy types. We compared cumulative incidence functions using a Fine and Gray competing risk regression model. Results: In all, 430 kidney transplant recipients were followed for a mean of 3.9 years (standard deviation 1.5). Of these, 71% (n = 305) received basiliximab alone, 22% (n = 93) received ATG alone, and 7% (n = 32) received both basiliximab and ATG. After adjusting for age and sex, compared to the basiliximab alone group, patients were more likely to receive dual-induction therapy if they were sensitized (calculated panel reactive antibody ≥80%), had diabetes mellitus or peripheral vascular disease, or experienced delayed graft function. Compared to the ATG alone group, the dual-induction therapy group had worse graft function at 1 year (mean eGFR 42 vs. 59 mL/min/1.73 m2, P = .0008) and an increased risk of all-cause graft failure (31% vs. 13%, P = .02) and death-censored graft failure (16% vs. 4%, P = .03). Limitations: There is a risk of confounding by indication, as patients who received dual-induction therapy likely had worse outcomes due to the indication for dual-induction therapy (such as delayed graft function). Conclusions: In our study, 1 out of 10 recipients who were treated with basiliximab also received ATG for induction therapy. These patients experienced worse outcomes than those treated with ATG alone. Trial registration: Not applicable (cohort study).
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Affiliation(s)
- Rachel Jeong
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Robert R Quinn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, MO, USA
| | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Patricia Campbell
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Kevin Wen
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Chris Broscheit
- Department of Pharmacy, University of Alberta Hospital, Edmonton, Canada
| | - Sita Gourishankar
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Ngan N Lam
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
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12
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Abstract
The clinical and laboratory features of COVID-19 are reviewed with attention to the immunologic manifestations of the disease. Recent COVID-19 publications describe a variety of clinical presentations including an asymptomatic state, pneumonia, a hemophagocytic lymphohistiocytosis like syndrome, Multisystem Inflammatory Syndrome in Children (MIS-C) but, also called Pediatric Inflammatory Multisystem Syndrome-Toxic Shock (PIMS-TS), Kawasaki Disease, and myocarditis. A common theme amongst multiple reports suggests an overexuberant autoimmune component of the disease but a common pathophysiology to explain the variations in clinical presentation has been elusive. Review of the basic science of other viral induced autoimmune disorders may give clues as to why immunosuppressive and immunomodulating regimens now appear to have some efficacy in COVID-19. Review of the immunopathology also reveals other therapies that have yet to be explored. There is potential use of T cell depleting therapies and possibly anti-CD20 therapy for COVID-19 and clinical research using these medications is warranted.
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13
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Nedredal GI, Picon RV, Chedid MF, Foss A. Immunosuppression in Liver Transplantation: State of the Art and Future Perspectives. Curr Pharm Des 2020; 26:3389-3401. [PMID: 32520679 DOI: 10.2174/1381612826666200610183608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/24/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Novel drugs and combinations for immunosuppression (IS) after liver transplantation is one main reason for improved graft and patient survival seen in the last decades. The backbone of IS is still steroids and calcineurin inhibitors, although novel drugs are being introduced, such as the mammalian target of rapamycin inhibitors (mTOR inhibitor). The challenge today, along with increased patient survival, is the adverse effects of long-term use of immunosuppressive drugs, mainly nephrotoxicity and other serious adverse effects. Concepts: The ultimate outcome after liver transplantation would be achieving tolerance, a state where all IS can be withdrawn. In the meantime, different approaches to reduce and withdraw IS have been tested out in different clinical trials with the aim to reduce the adverse effects of steroids and calcineurin inhibitors. This has formed the basis of today's clinical practice. The different combinations of immunosuppressive drugs have included mTOR inhibitor such as everolimus and different induction drugs such as anti-interleukin 2 receptor antibodies. Regarding induction drugs, lymphocyte depleting (alemtuzumab and ATG) and non-depleting agents, such as basiliximab, have shown advantageous effects. SUMMARY Alongside steroid and calcineurin inhibitors reduction or elimination, current strategies for post-liver transplantation immunosuppression explore combinations of novel agents. The gauge (or yardstick) here is the fine balance between the adverse effects of IS drugs and the risk of rejection. Long-term maintenance IS regimens, development of tolerance and antibody-mediated rejection are also discussed in this review.
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Affiliation(s)
- Geir I Nedredal
- Department of Digestive Surgery, University Hospital Northern Norway, University of Tromso, Tromso, Norway
| | - Rafael V Picon
- Department of Gastroenterology, Universidade do Vale do Taquari - Univates -, Lajeado, Brazil
| | - Marcio F Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clinicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Aksel Foss
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Norway
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14
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Song T, Yin S, Li X, Jiang Y, Lin T. Thymoglobulin vs. ATG-Fresenius as Induction Therapy in Kidney Transplantation: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. Front Immunol 2020; 11:457. [PMID: 32318057 PMCID: PMC7146975 DOI: 10.3389/fimmu.2020.00457] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 10/20/2019] [Accepted: 02/27/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Thymoglobulin (THG) and antithymocyte globulin-Fresenius (ATG-F) have not been compared directly as induction therapies in kidney transplantation. Materials and Methods: We performed a Bayesian network meta-analysis to compare THG with ATG-F by pooling direct and indirect evidence. Surface under the cumulative ranking curve (SUCRA) values were used to compare the superiority of one method over the other. Results: A total of 27 randomized controlled trials (RCT) were eligible for the network meta-analysis. Efficacy endpoints, as well as safety indicators, were statistically comparable. For efficacy endpoints, THG seemed inferior to ATG-F in preventing delayed graft function [odds ratio (OR): 1.27; SUCRA: 78% vs. 58%], patient deaths (OR: 2.78; SUCRA: 83% vs. 34%), and graft loss (OR: 1.40; SUCRA: 83% vs. 59%), but superior to ATG-F in biopsy-proven acute rejection (BPAR; OR: 0.59; SUCRA: 78% vs. 39%) and steroid-resistant BPAR prevention (OR: 0.61; SUCRA: 76% vs. 49%) within the first year. For safety endpoints, THG was associated with higher risk of infection (OR: 1.49, SUCRA: 79% vs. 54%), cytomegalovirus infection (OR: 1.04; SUCRA: 40% vs. 37%), de novo diabetes (OR: 1.10; SUCRA: 90% vs. 30%), and malignancy (OR: 8.40; SUCRA: 89% vs. 6%) compared to ATG-F. A subgroup analysis of patients at high risk for immunologic complications revealed similar results, but THG performed better for graft loss (OR: 0.82; SUCRA: 68% vs. 54%). Conclusion: ATG-F seemed to be more effective than THG in improving the short-term kidney transplantation outcomes. Prospective head-to-head comparison of THG and ATG-F with larger sample sizes and longer follow-up is still required.
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Affiliation(s)
- Turun Song
- Department of Urology, Organ Transplantation Center, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Saifu Yin
- Department of Urology, Organ Transplantation Center, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Xingxing Li
- West China Medical School, Sichuan University, Chengdu, China
| | - Yamei Jiang
- Department of Urology, Organ Transplantation Center, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Lin
- Department of Urology, Organ Transplantation Center, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
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15
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Park SS, Cho SY, Han E, Min GJ, Park S, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Kim HJ, Min CK, Cho SG, Lee JW. Reactivation and dynamics of cytomegalovirus and Epstein-Barr virus after rabbit antithymocyte globulin and cyclosporine for aplastic anemia. Eur J Haematol 2019; 103:433-441. [PMID: 31381187 DOI: 10.1111/ejh.13308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 05/02/2019] [Revised: 07/25/2019] [Accepted: 07/27/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to identify the natural course of cytomegalovirus (CMV)/Epstein-Barr virus (EBV) after rabbit antithymocyte globulin and cyclosporine (rATG-CsA) for aplastic anemia (AA). METHODS In 113 prospectively observed AA patients treated with rATG-CsA, the CMV/EBV cohort was classified into two groups by baseline viremic status: no viremia (CMV-G1, n = 112; EBV-G1, n = 98) and the presence of viremia (CMV-G2, n = 1; EBV-G2, n = 13). RESULTS In CMV-G1, the mean CMV load increased up to 3 months but was completely resolved from 6 months. The mean EBV load of EBV-G1 showed a peak at 1 month and then gradually decreased over time but remained detectable throughout the observation period. EBV-G2 showed fluctuating EBV dynamics. With reactivation rates of 38.4% in CMV-G1 and 62.2% in EBV-G1, a longer time to rATG-CsA from diagnosis and a lower absolute lymphocyte count at 1 month from rATG-CsA were significantly associated with CMV and EBV reactivation, respectively. The mean peak CMV and EBV loads of patients with CMV-related (3.5%) and EBV-related (0.9%) diseases were evidently higher than those of the remaining patients without CMV and EBV diseases in the respective cohort. CONCLUSION Considering frequent reactivation and distinct courses of CMV/EBV, virologic surveillance is recommended after rATG-CsA for AA.
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Affiliation(s)
- Sung-Soo Park
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Yeon Cho
- Division of Infectious Disease, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eunhee Han
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gi June Min
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Silvia Park
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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16
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Fribourg M, Anderson L, Fischman C, Cantarelli C, Perin L, La Manna G, Rahman A, Burrell BE, Heeger PS, Cravedi P. T-cell exhaustion correlates with improved outcomes in kidney transplant recipients. Kidney Int 2019; 96:436-449. [PMID: 31040060 DOI: 10.1016/j.kint.2019.01.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [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: 09/19/2018] [Revised: 12/08/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
Continuous antigen stimulation during chronic infection or malignancy can promote functional T cell silencing, a phenomenon called T cell exhaustion. The prevalence and impact of T cell exhaustion following organ transplantation, another immune stimulus with persistently high antigen load, are unknown. Here, we characterized serially collected peripheral blood mononuclear cells from 26 kidney transplant recipients using time-of-flight mass cytometry (CyTOF) to define distinct subsets of circulating exhausted T cells and their relationship to induction therapy and allograft function. We observed an increase in specific subsets of CD4+ and CD8+ exhausted T cells from pre-transplant to 6-months post-transplant, with greater increases in participants given anti-thymocyte globulin induction than in participants who received no induction or non-depleting induction. The percentages of exhausted T cells at 6 months correlated inversely with adenosine triphosphate (ATP) production (a surrogate of T cell function) and with allograft interstitial fibrosis. Guided by the CyTOF data, we delineated a PD-1+CD57- phenotype for CD4+ and CD8+ exhausted T cells, and confirmed that these cells have limited capacity for cytokine secretion and ATP production. In an independent cohort of 50 kidney transplant recipients, we confirmed the predicted increase of PD-1+CD57- exhausted T cells after lymphocyte-depleting induction therapy and its direct correlation with better allograft function. Our findings suggest that monitoring T cell exhaustion can be useful for post-transplant risk assessment and support the need to develop and test strategies aimed at augmenting T cell exhaustion following kidney transplantation.
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Affiliation(s)
- Miguel Fribourg
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lisa Anderson
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Clara Fischman
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chiara Cantarelli
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Perin
- GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics in Urology, Children's Hospital Los Angeles, Division of Urology, Saban Research Institute, University of Southern California, Los Angeles, California, USA
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Adeeb Rahman
- Human Immune Monitoring Core, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Peter S Heeger
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paolo Cravedi
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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17
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Kako S, Gomyo A, Akahoshi Y, Harada N, Kameda K, Ugai T, Wada H, Ishihara Y, Kawamura K, Sakamoto K, Sato M, Terasako-Saito K, Kimura SI, Kikuchi M, Nakasone H, Kanda J, Kanda Y. Haploidentical transplantation using low-dose alemtuzumab: Comparison with haploidentical transplantation using low-dose thymoglobulin. Eur J Haematol 2019; 102:256-264. [PMID: 30578673 DOI: 10.1111/ejh.13204] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 10/25/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To establish the optimal strategy for haploidentical hematopoietic stem cell transplantation (HSCT). METHODS We performed a prospective study on haploidentical HSCT using low-dose alemtuzumab. Alemtuzumab was added at 0.25 mg/kg for 2 days. The primary outcome measure was the survival rate with the engraftment of donor cells and without grade III-IV acute graft-vs-host disease (GVHD) at 60 days after transplantation. RESULTS Fourteen adult patients with advanced hematological disease were enrolled. The primary outcome measure was achieved in 86% of the patients. Six patients experienced relapse/progression. Non-relapse death was observed in three patients, and all of them had a history of previous allogeneic HSCT. Overall survival and progression-free survival rates at 1 year were 51% and 43%, respectively. Four patients were suspected to have herpes simplex virus infection and three had aseptic meningitis under the use of acyclovir at 200 mg. There were no deaths due to viral infection. Compared to those who underwent haploidentical HSCT using thymoglobulin, patients with alemtuzumab showed a slower recovery of CD8+ T-cells and lower incidences of GVHD and EB virus reactivation. CONCLUSIONS Haploidentical HSCT using low-dose alemtuzumab can be performed safely. We need to overcome the high relapse/progression rate in non-remission patients.
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Affiliation(s)
- Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Ayumi Gomyo
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yu Akahoshi
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naonori Harada
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuaki Kameda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Tomotaka Ugai
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hidenori Wada
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Ishihara
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koji Kawamura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kana Sakamoto
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Miki Sato
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiriko Terasako-Saito
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Misato Kikuchi
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideki Nakasone
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Junya Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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18
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Macedo C, Hadi K, Walters J, Elinoff B, Marrari M, Zeevi A, Ramaswami B, Chalasani G, Landsittel D, Shields A, Alloway R, Lakkis FG, Woodle ES, Metes D. Impact of Induction Therapy on Circulating T Follicular Helper Cells and Subsequent Donor-Specific Antibody Formation After Kidney Transplant. Kidney Int Rep 2018; 4:455-469. [PMID: 30899873 PMCID: PMC6409398 DOI: 10.1016/j.ekir.2018.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 09/24/2018] [Revised: 10/24/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction The cellular events that contribute to generation of donor-specific anti-HLA antibodies (DSA) post-kidney transplantation (KTx) are not well understood. Characterization of such mechanisms could allow tailoring of immunosuppression to benefit sensitized patients. Methods We prospectively monitored circulating T follicular helper (cTFH) cells in KTx recipients who received T-cell depleting (thymoglobulin, n = 54) or T-cell nondepleting (basiliximab, n = 20) induction therapy from pre-KTx to 1 year post-KTx and assessed their phenotypic changes due to induction and DSA occurrence, in addition to healthy controls (n = 13), for a total of 307 blood samples. Results Before KTx, patients displayed comparable levels of resting, central memory cTFH cells with similar polarization to those of healthy controls. Unlike basiliximab induction, thymoglobulin induction significantly depleted cTFH cells, triggered lymphopenia-induced proliferation that skewed cTFH cells toward increased Th1 polarization, effector memory, and elevated programmed cell death protein 1 (PD-1)int/hi expression, resembling activated phenotypes. Regardless of induction, patients who developed DSA post-KTx, harbored pre-KTx donor-reactive memory interleukin (IL)-21+ cTFH cells and showed higher % cTFH and lower % of T regulatory (TREG) cells post-KTx resulting in elevated cTFH:TREG ratio at DSA occurrence. Conclusion Induction therapy distinctly shapes cTFH cell phenotype post-KTx. Monitoring cTFH cells before and after KTx may help detect those patients prone to DSA generation post-KTx.
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Affiliation(s)
- Camila Macedo
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin Hadi
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Walters
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Beth Elinoff
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marilyn Marrari
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adriana Zeevi
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bala Ramaswami
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Geetha Chalasani
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Douglas Landsittel
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adele Shields
- Division of Transplantation, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rita Alloway
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Fadi G Lakkis
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - E Steve Woodle
- Division of Transplantation, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diana Metes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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19
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Reusing JO, Feitosa EB, Agena F, Pierrotti LC, Azevedo LSF, Kotton CN, David-Neto E. Cytomegalovirus prophylaxis in seropositive renal transplant recipients receiving thymoglobulin induction therapy: Outcome and risk factors for late CMV disease. Transpl Infect Dis 2018; 20:e12929. [PMID: 29809309 DOI: 10.1111/tid.12929] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 02/01/2018] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-thymocyte globulin (ATG) therapy is a risk factor for cytomegalovirus (CMV) disease in renal transplant (RTx) recipients and therefore antiviral prophylaxis is commonly used. We evaluated the outcome of our current policy of 90 days of CMV prophylaxis in seropositive recipients given ATG and the risk factors for the occurrence of CMV disease after prophylaxis. METHODS We studied a retrospective cohort of 423 RTx (2010-2014) CMV-seropositive adults given ATG induction therapy. RESULTS 54 (13%) patients developed CMV disease at a median of 163 days after transplant, of which 29 (54%) had viral syndrome and 25 (46%) had invasive disease. Median prophylaxis time (94 days) and immunosuppressive drugs were similar between groups (CMV vs no-CMV). Those with CMV disease had more deceased donors and higher donor age, lower lymphocyte count, and lower median eGFR at day 90. Multivariable logistic regression analysis at day 90 and 180 found that eGFR ≤40 ml/min/1.73 m2 (but not acute rejection) was associated with late CMV disease. In a separate validation cohort of 124 patients with 8% late CMV disease, eGFR ≤45 and lymphocyte count ≤800 cells/mm3 at the end of prophylaxis remained predictive of late CMV disease occurrence. CONCLUSIONS These data indicate that antiviral prophylaxis adequately prevented CMV in seropositive recipients given ATG, but late disease still occurred. Low eGFR and low lymphocyte count at the end of prophylaxis may help identify patients at higher risk of CMV disease.
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Affiliation(s)
- Jose O Reusing
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Emanoela B Feitosa
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Fabiana Agena
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Lígia C Pierrotti
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Luiz S F Azevedo
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Harvard Medical School, Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA
| | - Elias David-Neto
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
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20
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Martín-Gandul C, Pérez-Romero P, Mena-Romo D, Molina-Ortega A, González-Roncero FM, Suñer M, Bernal G, Cordero E. Kinetic of the CMV-specific T-cell immune response and CMV infection in CMV-seropositive kidney transplant recipients receiving rabbit anti-thymocyte globulin induction therapy: A pilot study. Transpl Infect Dis 2018; 20:e12883. [PMID: 29570917 DOI: 10.1111/tid.12883] [Citation(s) in RCA: 8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/15/2018] [Accepted: 02/04/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Some studies have suggested that rATG treatment may be associated with an increased incidence of CMV infection and delayed CMV immune response. However, the evidences supporting this matter are scarce. This study aims to characterize the kinetic of the CMV-specific T-cell immune response before and after rATG induction therapy and the relationship with the development of CMV infection in CMV-seropositive kidney transplant recipients. METHODS An observational prospective study of CMV-seropositive kidney transplant patients that received rATG induction therapy was performed. A pretransplant sample was obtained before the surgery to determine the CMV-specific immunity. CMV viral load (by PCR) and CMV-specific T-cell immune response (by flow cytometry) were determined during the follow-up at 0.5, 1, 2, 3, 6, and 12 months post transplantation. RESULTS A total of 23 patients were included in the study. CMV prophylaxis was administrated for a media of 90 days after transplantation. At the end of follow-up, 18 (78.3%) patients had CMV-specific immunity with a median value of 0.31% CD8+ CD69+ INF-γ+ T cells at a median of 16 weeks post transplantation. Five patients never acquired CMV-specific immunity. No statistically significant association between CMV infection and CMV-specific T-cell immune response (P = .086) was observed. However, patients with positive pretransplant CMV-specific immunity developed earlier immunity and achieved higher levels of CD8+ CD69+ INF-γ+ T-cell post-transplantation than patients with negative pretransplant immunity. CONCLUSIONS CMV-specific immune monitoring in addition to CMV-serology may be useful to stratify patient's risk of CMV infection before transplantation.
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Affiliation(s)
- Cecilia Martín-Gandul
- Clinical Unit of Infectious Diseases, Microbiology and Medicine Preventive, Instituto de Biomedicina de Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD12/0015/0001; RD12/0015/0012; RD16/0016/0009), Instituto de Salud Carlos III, Madrid, Spain
| | - Pilar Pérez-Romero
- Clinical Unit of Infectious Diseases, Microbiology and Medicine Preventive, Instituto de Biomedicina de Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD12/0015/0001; RD12/0015/0012; RD16/0016/0009), Instituto de Salud Carlos III, Madrid, Spain
| | - Damián Mena-Romo
- Clinical Unit of Infectious Diseases, Microbiology and Medicine Preventive, Instituto de Biomedicina de Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD12/0015/0001; RD12/0015/0012; RD16/0016/0009), Instituto de Salud Carlos III, Madrid, Spain
| | - Alejandro Molina-Ortega
- Clinical Unit of Infectious Diseases, Microbiology and Medicine Preventive, Instituto de Biomedicina de Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD12/0015/0001; RD12/0015/0012; RD16/0016/0009), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Marta Suñer
- Clinical Unit of Nephro-Urology, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
| | - Gabriel Bernal
- Clinical Unit of Nephro-Urology, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain
| | - Elisa Cordero
- Clinical Unit of Infectious Diseases, Microbiology and Medicine Preventive, Instituto de Biomedicina de Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD12/0015/0001; RD12/0015/0012; RD16/0016/0009), Instituto de Salud Carlos III, Madrid, Spain
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21
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Kalra A, Roessner C, Jupp J, Williamson T, Tellier R, Chaudhry A, Khan F, Taparia M, Jimenez-Zepeda VH, Stewart DA, Daly A, Storek J. Epstein-barr virus DNAemia monitoring for the management of post-transplant lymphoproliferative disorder. Cytotherapy 2018; 20:706-714. [PMID: 29580864 DOI: 10.1016/j.jcyt.2018.02.367] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/12/2018] [Accepted: 02/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a potentially fatal complication of allogeneic hematopoietic cell transplantation (HCT). Epstein-Barr virus (EBV) reactivation (detectable DNAemia) predisposes to the development of PTLD. METHODS We retrospectively studied 306 patients monitored for EBV DNAemia after Thymoglobulin-conditioned HCT to determine the utility of the monitoring in the management of PTLD. DNAemia was monitored weekly for ≥12 weeks post-transplantation. RESULTS Reactivation was detected in 82% of patients. PTLD occurred in 14% of the total patients (17% of patients with reactivation). PTLD was treated with rituximab only when and if the diagnosis was established. This allowed us to evaluate potential DNAemia thresholds for pre-emptive therapy. We suggest 100,000-500,000 IU per mL whole blood as this would result in unnecessary rituximab administration to only 4-20% of patients and near zero mortality due to PTLD. After starting rituximab (for diagnosed PTLD), sustained regression of PTLD occurred in 25/25 (100%) patients in whom DNAemia became undetectable. PTLD progressed or relapsed in 12/17 (71%) patients in whom DNAemia was persistently detectable. DISCUSSION In conclusion, for pre-emptive therapy of PTLD, we suggest threshold DNAemia of 100,000-500,000 IU/mL. Persistently detectable DNAemia after PTLD treatment with rituximab appears to have 71% positive predictive value and 100% negative predictive value for PTLD progression/relapse.
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Affiliation(s)
- Amit Kalra
- University of Calgary, Calgary, Alberta, Canada.
| | | | - Jennifer Jupp
- Pharmacy Services, Alberta Health Services, Alberta, Canada
| | | | | | | | - Faisal Khan
- University of Calgary, Calgary, Alberta, Canada
| | | | | | - Douglas A Stewart
- University of Calgary, Calgary, Alberta, Canada; University of Alberta Edmonton, Alberta, Canada
| | - Andrew Daly
- University of Calgary, Calgary, Alberta, Canada
| | - Jan Storek
- University of Calgary, Calgary, Alberta, Canada
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22
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Abstract
OBJECTIVE Pyridoxine is 1 of 8 B vitamins that assist in a variety of essential functions including immune functions. The purpose of this study was to assess the risk factors associated with low pyridoxine levels in solid organ transplantation recipients. DESIGN The study cohort was divided into 2 groups: (a) patients with normal pyridoxine levels or (b) patients with low pyridoxine levels. Dietary evaluation and clinical characteristics of all patients, rejection episodes, and immunosuppression were collected. Simple descriptive statistics were used to analyze the overall cohort. RESULTS Of the 48 patients, 29 (60%) in the study cohort were identified to have low pyridoxine levels. The mean interval between transplantation and pyridoxine level check was 910 days (standard deviation [SD] 456). The mean weight at the time of dietary consultation was 80 kg (SD 20.7). More patients in the deficient group received thymoglobulin for rejection treatment (56% vs 0%; P = .01) and were thymoglobulin recipients (78% vs 10%; odds ratio [OR] = 31.5; 95% confidence interval [CI], 2.35-422.30; P < .01). A strong correlation was identified between thymoglobulin treatment for induction and a low level of pyridoxine (correlation coefficient R = 0.6, P = .004) and between thymoglobulin treatment for rejection and a low pyridoxine level (correlation coefficient R = 0.5, P = .05). Based on multivariate logistic regression analysis, only thymoglobulin treatment (induction or rejection treatment) was significantly associated with low pyridoxine levels (OR = 19.5, 95% CI, 1.01-375.24; P < .05). CONCLUSIONS Low levels of pyridoxine appear to be relatively common, and thymoglobulin treatments are associated with low pyridoxine levels. Prospective studies are needed to confirm and valuate the significance of these findings.
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Affiliation(s)
- Summer Van Arsdale
- 1 Department of Nutrition Services, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Sarah E Yost
- 2 Banner University Medical Center, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Chiu-Hsieh Hsu
- 3 Department of Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Mary Meer
- 1 Department of Nutrition Services, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Shari Schoentag
- 1 Department of Nutrition Services, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Shahid Habib
- 4 Division of Gastroenterology and Hepatology, Department of Medicine, Liver Institute, University of Arizona, Liver Institute, Tucson, AZ, USA
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Ali R, Ramdial J, Algaze S, Beitinjaneh A. The Role of Anti-Thymocyte Globulin or Alemtuzumab-Based Serotherapy in the Prophylaxis and Management of Graft-Versus-Host Disease. Biomedicines 2017; 5:biomedicines5040067. [PMID: 29186076 PMCID: PMC5744091 DOI: 10.3390/biomedicines5040067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 08/07/2017] [Revised: 11/01/2017] [Accepted: 11/20/2017] [Indexed: 12/02/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant is an established treatment modality for hematologic and non-hematologic diseases. However, it is associated with acute and long-term sequelae which can translate into mortality. Graft-versus-host disease (GVHD) remains a glaring obstacle, especially with the advent of reduced-intensity conditioning. Serotherapy capitalizes on antibodies which target T cells and other immune cells to mitigate this effect. This article focuses on the utility of two such agents: anti-thymocyte globulin (ATG) and alemtuzumab. ATG has demonstrated benefit in prophylaxis against GVHD, especially in the chronic presentation. However, there is limited impact of ATG on overall survival and it has little utility in the treatment context. There may be an initial improvement, particularly in skin manifestations, but no substantial benefit has been elicited. Alemtuzumab has shown benefit in both prophylaxis and treatment of GVHD, but at the consequence of a more profound immunosuppressive phase, mandating aggressive viral prophylaxis. There remains heterogeneity in the doses and regimens of the agents, with no standardized protocol in place. Furthermore, it seems that once steroid-refractory GVHD has been established, there is little that can be offered to offset the ultimately dismal outcome. Here we present a systematic overview of ATG- or alemtuzumab-based serotherapy in the prophylaxis and management of GVHD.
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Affiliation(s)
- Robert Ali
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeremy Ramdial
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Sandra Algaze
- Internal Medicine Residency Program, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Amer Beitinjaneh
- Associate Professor of Medicine, Stem Cell Transplant and Cellular Therapy Program, Sylvester Comprehensive Cancer Center, University of Miami/Miller School of Medicine; Miami, FL 33136, USA.
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24
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Caillard S, Cellot E, Dantal J, Thaunat O, Provot F, Janbon B, Buchler M, Anglicheau D, Merville P, Lang P, Frimat L, Colosio C, Alamartine E, Kamar N, Heng AE, Durrbach A, Moal V, Rivalan J, Etienne I, Peraldi MN, Moreau A, Moulin B. A French Cohort Study of Kidney Retransplantation after Post-Transplant Lymphoproliferative Disorders. Clin J Am Soc Nephrol 2017; 12:1663-1670. [PMID: 28818847 PMCID: PMC5628715 DOI: 10.2215/cjn.03790417] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 04/07/2017] [Accepted: 06/26/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Post-transplant lymphoproliferative disorders arising after kidney transplantation portend an increased risk of morbidity and mortality. Retransplantation of patients who had developed post-transplant lymphoproliferative disorder remains questionable owing to the potential risks of recurrence when immunosuppression is reintroduced. Here, we investigated the feasibility of kidney retransplantation after the development of post-transplant lymphoproliferative disorder. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We reviewed the data from all patients who underwent kidney retransplantation after post-transplant lymphoproliferative disorder in all adult kidney transplantation centers in France between 1998 and 2015. RESULTS We identified a total of 52 patients with kidney transplants who underwent 55 retransplantations after post-transplant lymphoproliferative disorder. The delay from post-transplant lymphoproliferative disorder to retransplantation was 100±44 months (28-224); 98% of patients were Epstein-Barr virus seropositive at the time of retransplantation. Induction therapy for retransplantation was used in 48 patients (i.e., 17 [31%] patients received thymoglobulin, and 31 [57%] patients received IL-2 receptor antagonists). Six patients were also treated with rituximab, and 53% of the patients received an antiviral drug. The association of calcineurin inhibitors, mycophenolate mofetil, and steroids was the most common maintenance immunosuppression regimen. Nine patients were switched from a calcineurin inhibitor to a mammalian target of rapamycin inhibitor. One patient developed post-transplant lymphoproliferative disorder recurrence at 24 months after retransplantation, whereas post-transplant lymphoproliferative disorder did not recur in 51 patients. CONCLUSIONS The recurrence of post-transplant lymphoproliferative disorder among patients who underwent retransplantation in France is a rare event.
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Affiliation(s)
- Sophie Caillard
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Abstract
Objective: This study assessed incidence, severity, and time to occurrence of drug-induced leukopenia/thrombocytopenia within 1st month after kidney transplantation. Methods: This cross-sectional study was conducted on newly kidney transplant recipients from two hospitals, Iran. Patients with thrombocytopenia due to acute antibody-mediated rejection were excluded from the study. Demographic, clinical, and laboratory data of patients within the 1st month after transplantation were collected. Findings: Of 213 patients, 14.1% and 66.2% experienced leukopenia and thrombocytopenia, respectively. Cytopenia happened more commonly among patients with thymoglobulin-containing regimen (for leukopenia: 24.6% vs. 0%, P < 0.001; for thrombocytopenia 84.4% vs. 41.8%, P < 0.001). Most leukopenia patients experienced Grades 1 and 2 of leukopenia (46.6% and 40% of patients). Most thrombocytopenic patients showed Grade 1 of thrombocytopenia (78.7%). Cumulative dose of thymoglobulin did not differ between patients with and without leukopenia (5.57 ± 1.13 vs. 5.9 ± 1.96 mg/kg; P = 0.613) or with and without thrombocytopenia (5.87 ± 1.86 vs. 5.56 ± 1.38 mg/kg; P = 0.29). Cytopenia were more common among recipients from deceased compared with from living donors (91.3% vs. 8.7% for leukopenia patients, P = 0.001; 69.9% vs. 33.1% for thrombocytopenia, P = 0.02). More patients with kidney from deceased donors received thymoglobulin in their immunosuppressive regimen (82% vs. 37%; P < 0.001). The median time to leukopenia and thrombocytopenia were 3 days and 1 day, respectively. Conclusion: Among immunosuppressive and prophylactic antimicrobial agents, thymoglobulin is more related to cytopenia; therefore, thymoglobulin dose reduction is recommended as the first intervention to manage cytopenia without need for reduction of its cumulative dose. The higher prevalence of cytopenia among recipients from deceased donors may be related to the higher use of thymoglobulin in these patients.
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Affiliation(s)
- Atefeh Jafari
- Department of Clinical Pharmacy, Guilan University of Medical Sciences, Rasht, Iran
| | - Parisa Najivash
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Khatami
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
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26
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Raida L, Rusinakova Z, Szotkowska R, Kuba A, Faber E, Rohon P, Szotkowski T, Hubacek J, Pikalova Z, Jarosova M, Divoka M, Indrak K, Langova K, Skoumalova I, Papajik T. Allogeneic stem cell transplantation after fludarabine, melphalan and thymoglobulin followed by early withdrawal of prophylactic immunosuppression could be an effective approach to patients with acute lymphoblastic leukemia. Neoplasma 2015; 62:805-11. [PMID: 26278139 DOI: 10.4149/neo_2015_097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Presented are results of allogeneic hematopoietic stem cell transplantations (HSCTs) in 13 patients with high-risk acute lymphoblastic leukemia (ALL) in the first complete remission after a reduced intensity conditioning combining fludarabine (150 mg/m2) and melphalan (140 mg/m2) with thymoglobulin (4.5 mg/kg). The immunosuppressive effect of T-cell depletion reducing the risk of graft-versus-host disease (GVHD) and non-relapse mortality was compensated by early initiation of reduction and withdrawal of prophylactic immunosuppression aimed at maintaining effective immunological antileukemic control. The median post-transplant follow-up was 23 (range, 10-65) months. Stable engraftment of donor's hematopoiesis was achieved in all patients. Acute GVHD was observed in two cases (15.4%); the chronic form was not noted. Two patients (15.4%) relapsed with ALL at 3 and 16 months after transplantation. During the above post-transplant follow-up, all 13 recipients were alive, with a probability of 2-year disease-free survival of 76.9% (95% CI 51-100%). Although the results were obtained with a small pilot study group it may be assumed that, given the prognostic risk of most patients and the nearly 2-year median post-transplant follow-up, the approach may be considered as an alternative to HSCTs after traditional myeloablative or reduced conditioning regimens with standard GVHD prophylaxis.
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27
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Affiliation(s)
- Alexander C Wiseman
- Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado, Denver, Colorado
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28
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Laftavi MR, Pankewycz O, Feng L, Said M, Patel S. Combined induction therapy with rabbit antithymocyte globulin and rituximab in highly sensitized renal recipients. Immunol Invest 2015; 44:373-84. [PMID: 25942348 DOI: 10.3109/08820139.2015.1014097] [Citation(s) in RCA: 6] [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] [Indexed: 12/11/2022]
Abstract
Compared to non-sensitized renal transplant recipients, patients with preformed alloantibodies are at greater risk of cellular and humoral rejection and premature graft failure. We explored the effects of adding B-cell depleting agent (rituximab) to standard rabbit anti-thymocyte globulin (rATG) induction regimen for patients with panel reactive antibody levels >50%. Following induction therapy, 14 recipients were given two doses of rituximab (375 mg/m(2)) within the first month post-transplantation. Their long-term outcomes were compared to a historical control group of 23 recipients who received rATG alone. Graft survival at 5 years was superior with combination therapy compared to induction therapy alone (92.9 versus 48.3%, respectively, p = 0.02). While 30% of the rATG alone group experienced cellular rejection and 26% humoral rejection, none of rituximab plus rATG renal transplant recipients group had rejection. Thus, addition of rituximab to rATG provided superior outcomes to rATG alone. This combination induction therapy should be considered for a high-risk population.
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Affiliation(s)
- Mark Reza Laftavi
- Department of Surgery, SUNY at Buffalo , Buffalo, New York , USA and
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Denny JT, Burr AT, Balzer F, Tse JT, Denny JE, Chyu D. Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Exp Ther Med 2015; 9:1915-1920. [PMID: 26136914 DOI: 10.3892/etm.2015.2349] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 05/28/2014] [Accepted: 03/03/2015] [Indexed: 12/29/2022] Open
Abstract
Rabbit anti-thymocyte globulin (rATG) is an infusion of polyclonal rabbit-derived antibodies against human thymocyte markers, which can be used to prevent and treat acute rejection following organ transplantation. However, the product monograph issued by the manufacturer (Sanofi Canada) reports that serious immune-mediated reactions have been observed following the use of rATG, consisting of anaphylaxis or severe cytokine release syndrome (CRS), which is a form of vasoplegic syndrome (VS), in which distributive shock occurs refractory to norepinephrine (NE) and vasopressin (VP). Severe infusion-associated reactions are consistent with CRS and can cause serious cardiac or respiratory problems, or in certain cases, mortality. CRS is a form of systemic inflammatory response syndrome (SIRS). In SIRS, the substantial activation of endothelial inducible nitric oxide synthase (iNOS) and smooth muscle guanylate cyclase (GC) is observed, which can produce severe hypotension that is unresponsive to conventional vasopressors. Methylene blue (MB) is a direct inhibitor of iNOS and GC and has been used as an effective treatment for VS following cardiothoracic surgery. In the present study, the successful use of MB as a rescue therapy for CRS in a patient receiving rATG following a renal transplant was reported. Following an uneventful cadaveric kidney transplant involving the intravenous (IV) administration of rATG for the induction of immunological tolerance, the patient became markedly hypotensive and tachycardic. The patient required high doses of VP and NE infusions. Following the protocol described for treating refractory VS in post-cardiac surgery patients, the decision was made to initiate the patient on an IV MB infusion. This treatment protocol was shown to improve the hemodynamic status of the patient, which enabled the withdrawal of vasopressors and suggests an important role for methylene blue in the management of refractory VS.
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Affiliation(s)
- John T Denny
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Andrew T Burr
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Fred Balzer
- Virtua Memorial Hospital, Department of Anesthesia, Mount Holly, NJ 08060, USA
| | - James T Tse
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Julia E Denny
- Department of Anesthesia, New York University Medical Center, New York, NY 10016, USA
| | - Darrick Chyu
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
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Whitson BA, Kilic A, Lehman A, Wehr A, Hasan A, Haas G, Hayes D, Sai-Sudhakar CB, Higgins RSD. Impact of induction immunosuppression on survival in heart transplant recipients: a contemporary analysis of agents. Clin Transplant 2014; 29:9-17. [PMID: 25284138 DOI: 10.1111/ctr.12469] [Citation(s) in RCA: 26] [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] [Accepted: 09/29/2014] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The impact of induction immunosuppression on long-term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data. METHODS We queried the United Network for Organ Sharing (UNOS) data registry for all heart transplants from 1987 to 2012. We restricted our analysis to adult (≥18 yr) recipients performed from 2001-2011 (to allow for the potential for a minimum of 12 months post-transplant follow-up) who received either: no antibody based induction (NONE) or the contemporary agents (INDUCED) of either: basiliximab/daclizumab (IL-2Rab), alemtuzumab, or ATG/ALG/thymoglobulin. Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models were utilized. RESULTS Of the 17 857 heart transplants that met the inclusion criteria, there were 4635 (26%) reported deaths during the follow-up period. There were 8216 (46%) patients who were INDUCED. Of the INDUCED agents, 55% were IL-2Rab, 4% alemtuzumab, and 40% ALG/ATG/thymoglobulin. Donor and recipient characteristics were evaluated. Overall, being INDUCED did not significantly affect survival in univariable (p = 0.522) and multivariable (p = 0.130) Cox models as well as a propensity score adjusted model (p = 0.733). Among those induced, ATG/ALG/thymoglobulin appeared to have superior survival as compared with IL-2Rab (log-rank p = 0.007, univariable hazard ratio [HR] = 0.886; 95% CI: 0.811-0.968; p = 0.522). However, in a multivariable Cox model that adjusted for recipient age, VAD, BMI, steroid use, CMV match, and ischemic time, the hazard ratio for ALG/ATG/thymoglobulin vs. IL-2Rab was no longer statistically significant (HR = 0.948; 95% CI: 0.850-1.058; p = 0.341). CONCLUSION In a contemporary analysis of heart transplant recipients, an overall analysis of induction agents does not appear to impact survival, as compared to no induction immunosuppression. While ALG/ATG/thymoglobulin appeared to have a beneficial effect on survival compared to IL-2Rab in the univariable model, this difference was no longer statistically significant once we adjusted for clinically relevant covariates.
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Affiliation(s)
- Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Nassif S, Kaufman S, Vahdat S, Yazigi N, Kallakury B, Island E, Ozdemirli M. Clinicopathologic features of post-transplant lymphoproliferative disorders arising after pediatric small bowel transplant. Pediatr Transplant 2013; 17:765-73. [PMID: 24118781 DOI: 10.1111/petr.12150] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [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] [Accepted: 08/14/2013] [Indexed: 01/31/2023]
Abstract
Few studies examined the clinicopathologic features of PTLD arising in pediatric SBT patients. Particularly, the association between ATG and PTLD in this population has not been described. Retrospective review of 81 pediatric patient charts with SBT--isolated or in combination with other organs--showed a PTLD incidence of 11%, occurring more frequently in females (median age of four yr) and with clinically advanced disease. Monomorphic PTLD was the most common histological subtype. There was a significant difference in the use of ATG between patients who developed PTLD and those who did not (p < 0.01); a similar difference was seen with the use of sirolimus (p < 0.001). These results suggested a link between the combination of ATG and sirolimus and development of more clinically and histologically advanced PTLD; however, the risk of ATG by itself was not clear. EBV viral loads were higher in patients with PTLD, and median time between detection of EBV to PTLD diagnosis was three months. However, viral loads at the time of PTLD diagnosis were most often lower than at EBV detection, thereby raising questions on the correlation between decreasing viral genomes and risk of PTLD.
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Affiliation(s)
- S Nassif
- Department of Pathology, Medstar Georgetown University Hospital, Washington, DC, USA
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Cherkassky L, Lanning M, Lalli PN, Czerr J, Siegel H, Danziger-Isakov L, Srinivas T, Valujskikh A, Shoskes DA, Baldwin W, Fairchild RL, Poggio ED. Evaluation of alloreactivity in kidney transplant recipients treated with antithymocyte globulin versus IL-2 receptor blocker. Am J Transplant 2011; 11:1388-96. [PMID: 21564525 PMCID: PMC3226763 DOI: 10.1111/j.1600-6143.2011.03540.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [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: 01/25/2023]
Abstract
Induction therapy is used in kidney transplantation to inhibit the activation of donor-reactive T cells which are detrimental to transplant outcomes. The choice of induction therapy is decided based on perceived immunological risk rather than by direct measurement of donor T-cell reactivity. We hypothesized that immune cellular alloreactivity pretransplantation can be quantified and that blocking versus depleting therapies have differential effects on the level of donor and third-party cellular alloreactivity. We studied 31 kidney transplant recipients treated with either antithymocyte globulin (ATG) or an IL-2 receptor blocker. We tested pre- and posttransplant peripheral blood cells by flow cytometry to characterize T-cell populations and by IFN-γ ELISPOT assays to assess the level of cellular alloreactivity. CD8(+) T cells were more resistant to depletion by ATG than CD4(+) T cells. Posttransplantation, frequencies of donor-reactive T cells were markedly decreased in the ATG-treated group but not in the IL-2 receptor blocker group, whereas the frequencies of third-party alloreactivity remained nearly equivalent. In conclusion, when ATG is used, marked and prolonged donor hyporesponsiveness with minimal effects on nondonor responses is observed. In contrast, induction with the IL-2 receptor blocker is less effective at diminishing donor T-cell reactivity.
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Affiliation(s)
- L. Cherkassky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - M. Lanning
- Department of Immunology, Lerner Research Institute, Cleveland Clinic
| | - P. N. Lalli
- Allogen Laboratories, Inc,Transplant Center, Cleveland Clinic
| | - J. Czerr
- Department of Nephrology and Hypertension, Cleveland Clinic
| | - H. Siegel
- Department of Immunology, Lerner Research Institute, Cleveland Clinic
| | - L. Danziger-Isakov
- Department of Infectious Diseases, Cleveland Clinic,Transplant Center, Cleveland Clinic
| | - T. Srinivas
- Department of Nephrology and Hypertension, Cleveland Clinic,Transplant Center, Cleveland Clinic,Glickman Urological and Kidney Institute, Cleveland Clinic
| | - A. Valujskikh
- Department of Immunology, Lerner Research Institute, Cleveland Clinic,Transplant Center, Cleveland Clinic,Glickman Urological and Kidney Institute, Cleveland Clinic
| | - D. A. Shoskes
- Department of Urology, Cleveland Clinic,Transplant Center, Cleveland Clinic,Glickman Urological and Kidney Institute, Cleveland Clinic
| | - W. Baldwin
- Department of Immunology, Lerner Research Institute, Cleveland Clinic,Transplant Center, Cleveland Clinic
| | - R. L. Fairchild
- Department of Immunology, Lerner Research Institute, Cleveland Clinic,Transplant Center, Cleveland Clinic,Glickman Urological and Kidney Institute, Cleveland Clinic
| | - E. D. Poggio
- Department of Immunology, Lerner Research Institute, Cleveland Clinic,Department of Nephrology and Hypertension, Cleveland Clinic,Transplant Center, Cleveland Clinic,Glickman Urological and Kidney Institute, Cleveland Clinic
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Waid TH, Thompson JS, Siemionow M, Brown SA. T10B9 monoclonal antibody: a short-acting nonstimulating monoclonal antibody that spares gammadelta T-cells and treats and prevents cellular rejection. Drug Des Devel Ther 2009; 3:205-12. [PMID: 19920935 PMCID: PMC2769243 DOI: 10.2147/dddt.s2750] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
T10B9.1A-31/MEDI-500 is a nonmitogenic immunoglobulin M kappa murine monoclonal antibody (mAb) directed against the alpha-beta (αβ) heterodimer of the T-lymphocyte receptor complex. The hybridoma was first produced by fusing spleen cells from BALB/C mice immunized with human peripheral blood T-lymphocytes with SP2/O-Ag14 mutant myeloma cells. The mAb is produced and purified using multistep ion exchange and molecular sieve chromatography protocols. T10B9 has been used successfully to treat acute cellular rejection in renal transplantation and as an immunosuppression induction agent in heart and simultaneous kidney-pancreas transplantation. Because T10B9 is nonmitogenic and causes minimal cytokine release, both treatment of rejection and induction of immunosuppression were accomplished with significantly fewer and milder untoward effects (cytokine release syndrome) than its comparator OKT3. Since T10B9 is directed against the αβ heterodimer of the CD3 epitope, it spares the gamma delta (γδ) region. These gamma delta (γδ) T cells have a unique role in the immune response controlling many serious human diseases and perhaps facilitating the development of immunologic tolerance. T10B9 has a relatively short duration of action, depleting T cells for only 10 to 14 days, unlike the protracted depletion seen with thymoglobulin and Campath-1H. There is no B-lymphocyte depletion with T10B9 as there is with both of the aforementioned reagents. The lack of prolonged lymphocyte depletion may account for less infection observed with T10B9 treatment.
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Affiliation(s)
- Thomas H Waid
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA.
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Willoughby LM, Schnitzler MA, Brennan DC, Pinsky BW, Dzebisashvili N, Buchanan PM, Neri L, Rocca-Rey LA, Abbott KC, Lentine KL. Early outcomes of thymoglobulin and basiliximab induction in kidney transplantation: application of statistical approaches to reduce bias in observational comparisons. Transplantation 2009; 87:1520-9. [PMID: 19461489 PMCID: PMC2833330 DOI: 10.1097/tp.0b013e3181a484d7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Retrospective comparison of treatment-related kidney transplant outcomes may be facilitated by multivariable statistical adjustments and case-matching. METHODS We studied Organ Procurement and Transplantation Network registry data for kidney transplants in 2001 to 2005 managed with thymoglobulin, basiliximab, or no antibody induction and discharge maintenance immunosuppression regimens of tacrolimus and mycophenolate mofetil. The primary outcome was the 6 month, Food and Drug Administration-approved composite endpoint of rejection, graft failure, or death. Outcomes according to induction exposure were compared using logistic regression analysis, exposure likelihood matching, and outcome risk score matching. RESULTS All statistical approaches demonstrated lower rates of the 6-month triple endpoint with thymoglobulin compared with basiliximab when steroids were present, with approximately 22% adjusted, relative reduction by logistic regression analysis and 3% absolute reductions by matching approaches. When steroids were absent, risk reduction among thymoglobulin versus basiliximab-treated patients was of larger magnitude but borderline statistical significance. Triple endpoint incidence was lower with both induction regimens compared with no induction across methods. Estimated sample sizes necessary to detect the observed differences between induction types in the presence of steroids in a prospective trial ranged from 1600 to nearly 7000 patients. CONCLUSIONS Consistency across statistical approaches suggests superiority of thymoglobulin compared with basiliximab or no antibody induction therapy for 6-month kidney transplant outcomes in the modern immunosuppression era. As the sample sizes necessary to power a prospective superiority trial are likely prohibitive, studies such as these provide clinically relevant information that may not be otherwise attainable.
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Affiliation(s)
- Lisa M. Willoughby
- Department of Research Methodology, Saint Louis University, St. Louis MO 63108
| | - Mark A. Schnitzler
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Daniel C. Brennan
- Division of Nephrology, Washington University School of Medicine, 6107 Queeny Tower, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110
| | - Brett W. Pinsky
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Nino Dzebisashvili
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Paula M. Buchanan
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Luca Neri
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Lisa A. Rocca-Rey
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
| | - Kevin C. Abbott
- Nephrology Service, Walter Reed Army Medical Center, Washington, DC, 20307-5001
| | - Krista L. Lentine
- Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, Salus Center 2nd Floor, St. Louis MO 63104
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, 63104
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Bellin MD, Kandaswamy R, Parkey J, Zhang HJ, Liu B, Ihm SH, Ansite JD, Witson J, Bansal-Pakala P, Balamurugan AN, Papas KK, Sutherland DER, Moran A, Hering BJ. Prolonged insulin independence after islet allotransplants in recipients with type 1 diabetes. Am J Transplant 2008; 8:2463-70. [PMID: 18808408 PMCID: PMC4312281 DOI: 10.1111/j.1600-6143.2008.02404.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [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] [Indexed: 01/25/2023]
Abstract
We sought to determine the long-term outcomes in type 1 diabetic recipients of intraportal alloislet transplants on a modified immunosuppressive protocol. Six recipients with hypoglycemia unawareness received one to two islet infusions. Induction therapy was with antithymocyte globulin (ATG) plus etanercept for tumor necrosis factor-alpha blockade. Recipients received cyclosporine and everolimus for maintenance immunosuppression for the first year posttransplant, with mycophenolic acid or mycophenolate mofetil subsequently substituted for everolimus. Recipients have been followed for 1173 +/- 270 days since their last infusion for islet graft function (insulin independence, hemoglobin A(1c) levels and C-peptide production) and for adverse events associated with the study protocol. Of the six recipients, five were insulin-independent at 1 year, and four continue to be insulin-independent at a mean of 3.4 +/- 0.4 years posttransplant. None of the six recipients experienced recurrence of severe hypoglycemia. Measured glomerular filtration rate decreased from 110.5 +/- 21.2 mL/min/1.73 m(2) pretransplant to 82.6 +/-19.1 mL/min/1.73 m(2) at 1 year posttransplant. In conclusion, islet transplants restored insulin independence for a mean of >3 years in four of six recipients treated with ATG and etanercept induction therapy and with cyclosporine and, initially, everolimus for maintenance. Our results suggest this immunosuppressive protocol may allow long-term graft survival.
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Affiliation(s)
- M D Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
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