Addition of induction therapy offsets the hazard of marked calcineurin minimization among renal transplant recipients treated with sirolimus.

AIMS: We sought to examine the improvement in renal function with preserved immunosuppression consequent to reducing de novo cyclosporine (CsA) doses combined with sirolimus and induction antibody treatment. MATERIALS AND METHODS: 408 renal recipients treated de novo with CsA-sirolimus included 91 patients who received high (> 5); 125, medium (2.5-5.0); or 192, low CsA doses (< 2.5 mg/kg/day) together with induction antibody among 5, 48 and 68% of subjects, respectively. At 2 years we excluded 21 (23), 30 (24) and 49 (25%) subjects who experienced the composite end-point, yielding 70 (71), 95 (76) and 143 (74%) cases, whose mean de novo CsA C2 values were 725, 400 and 306 ng/ml; for all cohorts, sirolimus C0 = 10-15 de novo and 8-12 ng/ml during maintenance treatment. The primary end-point--mean 4-year GFR by aMDRD--ascribed "0" to patients who experienced death or graft loss after 2 years. RESULTS: Although low-dose subjects were older (p = 0.008) and heavier (p < 0.001) with grafts exposed to longer cold ischemia times (p < 0.001), they displayed greater GFR: 64.8 versus 48.4 among the high and 54.1 ml/min/1.73 m(2) in the medium dose arms (p = 0.002). Polychotomous logistic regression revealed significant GFR predictors to be CsA dose (p = 0.015) and younger donor age (p < 0.001). Between 2 and 4 years, the incidences of the composite end-point were 17, 14 and 16%; including 13, 10 and 11% rejections. CONCLUSION: 80% reduction in de novo CsA exposure with antibody induction improved renal function at 4 years compared with 50 or 66% reductions.

Salt extraction of soluble HL-A antigens.

Extraction of cultured human lymphoid cells with hypertonic salt solutions (3 molar potassium chloride) resulted in high recoveries of membrane-associated histocompatibility (HL-A) antigens in soluble form with potent activity and marked immunologic specificity. The active principle was purified by preparative acrylamide-gel electrophoresis. Application of the hypertonic salt extraction method is now yielding sufficient HL-A antigen to begin the elucidation of the molecular basis of transplantation individuality.

Impact of rituximab therapy for treatment of acute humoral rejection.

INTRODUCTION: Antibody mediated rejection (AMR) is associated with a greater incidence of allograft loss because traditional approaches - pulse steroid or anti-lymphocyte antibodies are usually ineffective. This retrospective analysis documented the benefit of rituximab administration in addition to plasmapheresis (PP). METHODS: We retrospectively reviewed the data from 54 kidney transplant patients treated for AMR between 2001 and 2006, including 26 patients who received PP plus rituximab (Group A), versus 28 subjects who underwent PP without rituximab (Group B). Only patients whose serum IgG levels were below normal values received intravenous gamma globulin (IVIG). In addition to clinical and demographic variables we evaluated graft/patient survivals at two years post-diagnosis, Banff classification of rejections, serum creatinine and calculated GFR values at baseline, rejection, resolution as well as three, six, 12 and 24 months thereafter. RESULTS: The demographic features of the cohorts showed no significant differences. The two-year graft survival for patients treated with rituximab plus PP was 90%, significantly better than 60% in the PP cohort (p = 0.005). Upon multivariate analysis administration of rituximab was the most significant factor (>or= 0.009); whereas, IVIG also produced a useful effect (p = 0.05). Neither the mean (>or= 0.42) nor the slope (p = 0.25) of GFR values showed a significant difference among salvaged kidneys over 24 months after completion of AMR treatment. The rates and types of infectious complications at three and six months did not show significant differences or impact on graft survival. CONCLUSION: Addition of rituximab improved the outcomes of PP treatment of antibody mediated rejection episodes.

FTY720 and everolimus in de novo renal transplant patients at risk for delayed graft function: results of an exploratory one-yr multicenter study.

This exploratory, multicenter, open-label study evaluated the efficacy and safety of FTY720, as a part of an immunosuppressive regimen, in combination with everolimus and steroids in de novo renal transplant recipients at increased risk of delayed graft function (DGF). Patients received FTY720 (5 mg) and everolimus (4 mg) 2-12 h pre-transplantation, followed by 2.5 mg/d FTY720 and concentration-controlled everolimus (4-8 ng/mL) post-transplant for 12 months. Induction therapy was prohibited. After enrollment of 56 of the planned 200 patients between 2000 and 2002, the recruitment was terminated. The primary endpoint, rate of graft loss, or death at three months was 15.4% and the biopsy-confirmed acute rejection was 42.3%. Death or graft loss at 12 months in the DGF and non-DGF arms was 36.0% and 25.9%, respectively. The mean estimated creatinine clearance at three months was 63 and 55 mL/min in the non-DGF and DGF groups, respectively, while at 12 months it was 56 mL/min in both the groups. Although there was no comparator arm, the results from this exploratory study (compared with data from other phases II and III trials) indicated no apparent benefits of FTY720-based regimens for prevention of acute rejection and preservation of renal function in renal transplant recipients at high risk of DGF.

Living donor kidney transplantation without transmission of multiple sclerosis after 10 years.

We report the case of a successful renal transplant for over 10 years from a living donor with a history of multiple sclerosis.

The ruby anniversary: forty years of publication of Transplantation Proceedings - the first decade: the flowering of immunology and immunogenetics.

The fortieth-ruby-anniversary of publication of Transplantation Proceedings chronicles the major developments in this field of expanding scientific and clinical importance. The first decade of publication included seminal findings in immunogenetics of the major histocompatibility complex-HLA-A, -B, -C, and -D-and immunology of induction and expression of alloimmunity from single cell to mammalian organisms. Initial dissections of destructive versus acceptance mechanisms toward allografts revealed cytotoxic versus suppressive/enhancing cell-mediates and humoral vectors. Initial clinical successes revealed technical accomplishments that warranted broader application of this technology as described in the second decade of the Proceedings-the advent of cyclosporine.

Selective corticosteroid and calcineurin-inhibitor withdrawal after pancreas-kidney transplantation utilizing thymoglobulin induction and sirolimus maintenance therapy.

Of 25 simultaneous pancreas-kidney transplant (SPK) recipients treated with thymoglobulin induction, sirolimus and reduced-dose cyclosporine (CsA), 18 low-immune responders (non-African-Americans, PRA < 30%) were withdrawn from prednisone on post-transplant day 5, whereas seven high-immune responders continued on prednisone. Most high- and low-immune responder recipients were converted from CsA to mycophenolic acid (MPA) at six months post-transplantation. At a mean follow-up of 28 +/- 10 months, two pancreas grafts were lost to pancreatitis. There were no patient or kidney graft losses, but one acute rejection episode. At 28 +/- 11 months, all 18 low-responder recipients remain steroid-free. Twenty recipients (14 low and six high-immune responders) were converted from CsA to MPA. During conversion, immune response was monitored by Flow-PRA and T-cell stimulation (Cylex) assays. Nineteen of 20 recipients displayed a post-conversion PRA of 0%, whereas one highly sensitized patient expressed a post-conversion PRA of 67%. Fifty-eight percent of individual T-cell stimulation scores were in the hypo-responsive range. Twelve of 18 low-immune responders are both steroid and CsA-free at a mean follow-up of 17 +/- 13 months, whereas five of seven high-immune responders remain CsA-free at a mean follow-up of 11 +/- 10 months. These data suggest that thymoglobulin induction with combined sirolimus and CsA maintenance therapy permits immunosuppression minimization in selected SPK recipients.

Frontiers in immunosuppression.

Immunosuppressive therapy has relied on tailoring combinations of relatively nonselective drugs to individual patient tolerance. The next steps in the development of small molecule agents are to define and to develop selective inhibitors of cascades unique to T cells. This selectivity would minimize the inherent toxicity associated with drug therapy. Two targets identified at present are lymphoid cell kinase (lck; Signal 1) and Janus kinase 3 (Jak3; Signal 3). Although preliminary data support the immunosuppressive efficacy of putative antagonists, it is not clear that they are sufficiently selective for the target molecule as opposed to other kinases. Another novel approach to immunosuppression seeks to promote lymphoid cell sequestration in nodes through agonistic effects on sphingosine-1-phosphate receptors. Due to the availability of specific assays and high through put analysis of molecular candidates, the next decade should witness a panoply of new agents.

Fifteen years of clinical studies and clinical practice in renal transplantation: reviewing outcomes with de novo use of sirolimus in combination with cyclosporine.

Over the course of 15 years the use of sirolimus, a macrocyclic lactone, has evolved from an adjunct to calcineurin inhibitors (CNI) to the foundation of therapy due to the drug's unique properties: First, it displays synergistic pharmacodynamic interactions with CNI. Even among high immunologic risk patients, this regimen attenuates the risk of acute allograft rejection episodes when used in combination with cyclosporine or tacrolimus. Indeed >80% reduction in CNI exposure de novo yields better long-term renal function than full cyclosporine (CsA) doses, a useful tradeoff, despite the augmented occurrence of lymphoceles and impaired wound healing. Second, by inhibiting mammalian target of rapamycin (mTOR), it exerts profound anti-neoplastic effects reducing the incidence and mediating the regression of tumors displaying PTEN-deletions and/or Akt-activations in transplant and non-transplant patients. Third, it is relatively non-nephrotoxic although it may exacerbate that property of CNI agents. Fourth, it allows prompt withdrawal of steroid therapy. Fifth, it displays reduced rates of cytomegalovirus, and BK virus infections. The major adverse reactions can generally be controlled with countermeasure therapy. Myelosuppressive effects, which tend to be transient (unless sirolimus is combined with mycophenolic acid), are readily amenable to treatment with granulocyte colony stimulating factor for leukopenia, interleukin 11 for thrombocytopenia and erythropoietin for anemia. Combinations of statins and fibrates represent effective countermeasure therapy for hypercholesterolemia and hypertriglyceridemia, respectively. Idiosyncratic reactions include hypoxemic pulmonary toxicity, refractory edema and diarrhea. Thus, sirolimus represents the vanguard of a new class of maintenance agents for immunosuppression.

The impact of conversion from mycophenolate mofetil to mycophenolate sodium among renal transplant recipients on a sirolimus-based regimen.

OBJECTIVE: To examine the benefits of conversion from mycophenolate mofetil (MMF) to mycophenolic acid sodium (MPS) among renal transplant patients on sirolimus-based immunosuppression. METHODS: Alternate renal transplant recipients who were converted from MMF to MPS immediately (group A, n = 21) or 90 days thereafter (group B, n = 19) completed the Gastrointestinal Symptom Rating Scale and the Gastrointestinal Quality of Life Index (GIQLI) questionnaires at days 90 and 180. Similarly, at the completion of the study 20 members of groups A plus B (converted to MPS) and 19 patients who initially declined to participate (continuous MMF) completed the questionnaires. RESULTS: At 90 days after conversion, members of group A showed fewer responses to "feeling unwell" and to flatulence, which regressed in group B at 180 days, although more persons in the latter cohort complained of bloating. The average scores of cohort A on the GIQLI at day 180 were significantly better than those at day 90. Compared with a control cohort of continuous MMF treatment, members of cohorts A plus B showed lower incidences of diarrhea, dysphagia, and eructations but greater incidences of constipation and not feeling fit. CONCLUSION: Conversion from MMF to MPS offers subjective benefits for patients on maintenance therapy with mycophenolic acid in combination with sirolimus.

Case report: successful treatment of posttransplant lymphoproliferative disorder and quiescence of dermatomyositis with rituximab and sirolimus.

Posttransplant lymphoproliferative disorder (PTLD) remains one of the most important complications of intensive immunosuppressive therapy. A 65-year-old Caucasian woman received a primary en bloc kidney transplant from a deceased 2-year-old donor. After antithymocyte globulin induction she was treated with a maintenance regimen including cyclosporine and mycophenylate mofetil (MMF). She had a history of recurrent dermatomyositis, suggesting a flawed immune system. After a benign course for 9 months and after an increase in MMF from 2 to 3 g daily, she presented with pneumonia owing to Candida albicans, which was responsive to antibiotics, as was the PTLD. Persistent fever led to a diagnosis of PTLD. The immunosuppressive regimen was converted to sirolimus (SRL) and rituximab, with over 90% necrosis of the neoplasm at 1 month. However, owing to concern at exploration, the allografts were extirpated. This case documented the benefit of the rituximab-SRL combination to treat PTLD while maintaining dermatomyositis in remission.

Immunosuppressive therapy.

Although Cyclosporin A has improved transplant outcome, its use has serious limitations due to its narrow therapeutic window. New approaches to broaden this window exploit alternative drug formulations, pharmacokinetic profiling and new immunosuppressive agents, such as Rapamycin and Brequinar, which act in a synergistic fashion. There is no evidence to suggest that the pharmacological alternative to Cyclosporin A, FK-506, displays a broader therapeutic window, although it may be tenfold more potent. Similarly, despite the specificity of the IgG2a mouse anti-human CD3 monoclonal antibody, it displays a significant range of clinical side effects, delayed therapeutic action and frequently stimulates generation of human anti-mouse monoclonal antibodies. Recent advances in monoclonal antibody technology seek not only to produce antibodies against determinants involved in alloactivation, but also to 'humanize' the antibodies for reduced side effects. The availability of this array of potential agents highlights the need to develop guidelines for clinical trial methodologies to address the unique needs and demands of organ transplantation.

Statins benefit outcomes of renal transplant recipients on a sirolimus-cyclosporine regimen.

BACKGROUND: Statins offer a strategy to address dyslipidemia commonly experienced by immunosuppressed transplant recipients. METHODS: This single-center, retrospective study of 325 recipients (mean posttransplant follow-up of over 6 years; 75.0+/-26.0 months) correlated four adverse outcomes-biopsy-confirmed acute rejection episodes, biopsy-confirmed chronic rejection/allograft nephropathy, graft loss, or death-with demographic and posttreatment variables. Patients were treated with a combination of sirolimus (SRL), cyclosporine (CsA), and various durations of steroids. Statins were prescribed for 259/325 (79%) recipients whose serum cholesterol exceeded 240 mg/dL and discontinued when the creatine phosphokinase increased fivefold (3.4%) or the liver function, threefold (3.0%) above normal. RESULTS: Upon univariate (hazard ratio [HR] 0.16; P<.001) and multivariate analysis (HR 0.38; P=.02), statins were markedly protective against acute rejection episodes. They reduced occurrence of chronic nephropathy/chronic rejection (HR 0.60; P=.03 and HR 0.52; P=.01, respectively). Incidences of graft loss were diminished (HR 0.26; P<.001 and HR 0.49; P=.01, respectively). Finally, the mortality rate was decreased (HR 0.21, P=.001 and HR 0.26, P=.01, respectively). Upon multivariate analysis, a reduced incidence of acute rejection was correlated with greater exposure to SRL (HR 0.78, P=.016) and CsA (HR 0.39; P=.006). CONCLUSIONS: This study demonstrated compelling effects of statins against all adverse outcomes among patients treated with SRL-based, CsA-containing regimens. The profoundly dyslipidemic properties of SRL may explain these unique findings compared with previous studies on patients treated with CsA-based regimens.

Fibromuscular dysplasia recurrence after kidney transplantation: case report.

We report the extremely rare recurrence of intimal fibroplasia, a rare form of fibromuscular dysplasia, in a kidney recipient at 6 months after transplantation from a living-related donor. The patient was successfully treated and maintains good kidney function, however, the case raises the question of whether kidneys with fibromuscular dysplasia should be included in the expanded criteria for kidney transplantation.

Individualization of immunosuppressive therapy. II. Sirolimus as a less nephrotoxic alternative to calcineurin inhibitors.

The nephrotoxic effects of chronic administration of calcineurin inhibitors have created a demand for a potent immunosuppressive drug free of this side effect. Sirolimus (SRL) clearly displays fewer and a lesser degree of adverse effects on renal function by itself. However, in combination with calcineurin antagonists, it tends to augment the nephrotoxicity due, at least in part, to a pharmacokinetic interaction. The use of SRL for de novo immunosuppression (even with adjunctive mycophenolate mofetil) is probably not sufficient to avert alloimmune reactions. A useful combination with SRL can be achieved by reducing calcineurin inhibitor exposure by 80% for immediately functioning kidneys or by delaying its inception until renal graft recovery. SRL proffers additional benefits as an inhibitor of endothelial and smooth muscle cell proliferation, serving as the foundation of chronic immunosuppressive therapy.

Use of sirolimus to facilitate steroid withdrawal from a cyclosporine regimen.

OBJECTIVE: Chronic steroid therapy has been associated with many comorbidities of transplant immunosuppression. Because sirolimus blocks one of the sites affected by steroids, we sought to examine whether substituting this drug mitigated these toxicities. METHODS: We used intent-to-treat methodology to compare the clinical outcomes and laboratory results between 30 renal transplant recipients converted from steroids to sirolimus with a cohort of demographically matched subjects who were transplanted concurrently with the study group and maintained on steroids. All patients received ongoing cyclosporine-based immunosuppression. To compensate for pharmacokinetic interactions with sirolimus, the cyclosporine exposure was markedly reduced in the study group. Statistical comparisons utilized analysis of variance, chi-square tests, and log rank evaluation of Kaplan-Meier curves. RESULTS: Conversion from prednisone to sirolimus was accomplished without difficulty in 27 of 30 patients. Treatment failures among the converted patients were due to chronic allograft nephropathy (n = 1), recurrence of original disease (n = 1), or chronic rejection (n = 2). By intent-to-treat analysis, the outcomes were similar in the study versus concurrent control groups. Laboratory values showed triglyceridemia as an adverse reaction to sirolimus, and reduced leukocytes, to steroid withdrawal. The observed clinical benefits solely reflected the markedly reduced cyclosporine exposure. Based on responses to a questionnaire administered prior to versus 12 and 24 months after steroid withdrawal, several domains revealed improvements in subjective complaints. CONCLUSION: Conversion from prednisone to sirolimus in combination with cyclosporine was easily accomplished in most renal transplant recipients. Although a 2-year follow-up failed to reveal objective benefits of the maneuver (other than those consequent to reduced cyclosporine exposure), most patients reported a subjectively improved health status.

Individualization of immunosuppressive therapy. III. Sirolimus associated with a reduced incidence of malignancy.

OBJECTIVE: We examined the occurrence of neoplasms among 1008 renal transplant recipients treated with a sirolimus-cyclosporine (CsA) +/- prednisone (Pred) regimen. METHODS: A comprehensive database of demographic, laboratory, clinical, and histopathologic features of these patients all followed in our transplant center was analyzed using Student t test and Mann-Whitney U test for continuous and chi-square test for categorical variables. Comparisons were performed with information in the Israel Penn International Transplant Tumor Registry (IPITTR). RESULTS: During the mean patient follow-up of 62.3 +/- 26.1 months (range 27.1 to 131), 36 tumors occurred in 35 patients (3.6%) at 32.5 +/- 29.8 months. The most common neoplasms were skin tumors (2.4%), a value that was significantly lower than the 6% rate observed with CsA-azathioprine-Pred treatment. Also, the 0.4% incidence of posttransplant lymphoproliferative disorders and 0.2% incidence of renal cell carcinomas were less than half of those previously reported with a combination of tacrolimus and mycophenolate mofetil. The distribution of tumor types was similar to that reported to the IPITTR. The mean trough drug concentrations in affected recipients at the time of diagnosis were within the putative target ranges. CONCLUSION: Renal transplant recipients treated with the sirolimus-CsA +/- Pred combination showed a low incidence of tumors of similar types as those encountered with other regimens.

Extraction of a murine tumor-specific transplantation antigen with 1-butanol. I. Partial purification by isoelectric focusing.

Treatment of whole viable MCA-F murine sarcoma cells from syngeneic female C3H/HeJ mice with a single-phase solution of 2.5% (vol/vol) 1-butanol yielded a crude membrane protein extract without loss of cell viability. 1-Butanol-extracted cells were capable of in vitro proliferation. Variations in extraction conditions significantly influenced not only protein yield but also viability. The crude butanol extract (CBE) contained a tumor-specific transplantation antigen (TSTA) more potent than that obtained by 3-M KCl extraction of MCA-F cells: a specific activity of 40 TSTA U/mg protein in the former and 2 U/mg in the latter. The antigen was specific and protected host against challenge with MCA-F cells but not the antigenically different MCA-D cells. The growth of MCA-F cells was not reduced by pretreatment with equivalent doses of CBE obtained from MCA-D cells. Partial purification of the antigenic activity by preparative isoelectric focusing revealed that most activity focused in the pH 6.4 fraction, which increased the specific activity to 1,000 TSTA U/mg protein. Thus 1-butanol was an effective agent for the extraction of certain membrane polypeptides, including an immunogenic TSTA, from whole cells.

Immunotherapy of a carcinogen-induced murine sarcoma with soluble tumor-specific transplantation antigens.

Tumor-specific transplantation antigens (TSTA), extracted from the 3-methylcholanthrene-induced sarcoma MCA-F and partially purified by flat-bed isoelectric focusing, were used to treat syngeneic inbred C3H/HeJ mice bearing supralethal neoplastic challenges. Three weekly injections of 25 micrograms TSTA increased the survival times of hosts inoculated 1 day earlier with ten times the lethal dose of MCA-F cells. In another protocol TSTA injections decreased the incidence and outgrowth of a local metastasis in mice given sc supralethal inoculations and completely resected of established 1-cm tumors. In addition, weekly injections of 25 micrograms MCA-F TSTA decreased the tumor recurrence rate and increased the survival times of hosts with recurrent neoplastic disease by virtue of residual tumor cells following resection of 2-cm masses. The therapeutic effect of TSTA was immunologically specific: Animals cured of local MCA-F recurrences promptly died from primary challenge with the non-cross-reacting sarcoma MCA-D. The results suggest that active specific immunotherapy may represent a useful adjunct to treatment of hosts bearing modest tumor burdens.

Retardation of postsurgical metastases with the use of extracted tumor-specific transplantation antigens and cyclophosphamide.

In a 3-methylcholanthrene [(MCA) CAS: 56-49-5]-induced tumor model of C3H/HeJ mice excision of a growing primary tumor decreased concomitant immunity and facilitated experimental lung metastases. Administration of tumor-specific transplantation antigens extracted from viable MCA-F cells with the use of single-phase (2.5%) 1-butanol [crude butanol extract (CBE)] augmented immunity after resection of the primary MCA-F tumor. Two weeks after footpad inoculation of 2 X 10(5) MCA-F cells, the tumor-bearing limbs were amputated and the mice were challenged subsequently with 5 X 10(4) cells of clone-9-4, a metastatic variant of MCA-F, via the tail vein. Whereas treatment with either 50 micrograms CBE sc or 20 mg cyclophosphamide (CY)/kg ip failed to retard lung colonization, combination therapy with the two agents reduced the incidence of lung colonies by 69.8% (26.5 vs. 8; P less than .001) compared with the incidence in the surgery-alone group and by 55.5% (18 vs. 8; P less than .001) compared with the incidence in the group treated with surgery and CY. Furthermore, the combined effects of CBE and CY were immunologically specific: The combined therapy with the non-cross-reactive MCA-D-CBE did not protect against iv challenge with clone-9-4. Treatment with antigenic extracts induced a 21.4% (4.2 vs. 3.3%) decrease in the ratio of Lyt 1+:Lyt 2+ cells in the spleens of tumor-resected mice, which suggested restoration to normal levels. Therefore, in the combined regimen, antigen may induce specific activation of helper lymphocytes, while CY inhibits activation of suppressor cells.