Transcript Mayo Clinic Transplant Center Focus Groups
Disclosure Information: Mark D. Stegall, M.D.
I have the following financial relationship to disclose Research/Grant support from: Alexion and Millenium Pharmaceuticals I will discuss the following off label use and/or investigational use in my presentation: Eculizumab and Velcade
Acknowledgments
• • • • • • • • •
James Gloor Suresh Raghavaiah Tayyab Diwan Cindy Groettum Jennie Wilson Justin Burns Dana Perry Walter Park Lynn Cornell
• • • • • • •
Patrick Dean Steve DeGoey Manish Gandhi Jeff Winters Lynette Fix Kay Kosberg Surgeons, Nephrologists, Fellows and other staff
Actual Death-Censored 5 Year Graft Survival 70.7% vs 88.0%, p= 0.0006
Actual 5 Year Graft Survival T cell AHG
Actual 5 Year Outcomes After +XMKTx Rate of graft loss after 1 year Class I only 1.6%/yr Class II 7.0%/yr
What this talk is not about
Hyperacute Rejection
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Rare
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Very rare with a negative T cell AHG crossmatch
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Thus, PE or IVIG to achieve a –Tcell AHG pretransplant
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Very rare with anti-Class II alone
Combined Cellular and Antibody Mediated Rejection
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Most cases of AMR seen clinically in non-sensitized patients are a combination of cellular and antibody mediated rejection
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?Role of non-compliance
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DSA levels may be transient
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Time of occurrence may be months to years after transplantation
Bortezomib and AHR
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6 patients with combined cellular and humoral rejection (C4d+ and DSA by solid phase)
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Time of rejection episodes: POD 239, 95, 1766, 180, 2825,147
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All resolved
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3 of 6 had transplant glomerulopathy on follow-up
Two Talks Thursday
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Early Antibody Mediated Injury
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Acute Antibody Mediated (Humoral) Rejection Based on Experience with Sensitized Patients
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Late Antibody Mediated Injury
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Chronic AMR
Differences Between Early and Late Antibody Mediated Injury
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Early
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First 6 weeks after transplant, rarely later
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Incidence determined by DSA levels C4d+ Microthrombi, some cells Incidence higher with anti-Class I DSA Late
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Rare early, increases over years
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DSA levels usually low, C4d- common A cellular infiltrate termed “peritubular” capillaritis
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Incidence higher and outcome worse with anti-Class II DSA
Differences Between Early and Late Antibody Mediated Injury
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Early
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First 6 weeks after transplant, rarely later
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Incidence determined by DSA levels C4d+ Microthrombi, some cells Incidence higher with anti-Class I DSA Late
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Rare early, increases over years
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DSA levels usually low, C4d- common A cellular infiltrate termed “peritubular” capillaritis
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Incidence higher and outcome worse with anti-Class II DSA
Desensitization???
There is no evidence that any current therapy “desensitizes” patients — i.e. blocks alloantibody production permanently
Desensitization???
Alternate Explanations
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Remove DSA by plasma exchange or block with IVIG —prevents hyperacute rejection
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Kidney absorbs the antibody after transplant —DSA reduced
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Memory response may or may not occur — early AMR
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Chronic injury is common, but not detected
Pathways to Antibody Production 1 o Sensitization
Ag Naïve B Cell
CD20+, CD27 CD138-, CD38-
cytokines
CD20-, CD27 CD138-, CD38+
Plasmablast
Germinal Center Reaction
Low-affinity Abs Ү ү ү ү APC Ag T-helper cell Activated B Cell
CD20-, CD27 CD138+, CD38+ Memory Compartment
Proliferation Hypermutation Affinity maturation
CD20-, CD27+ CD138-, CD38 ?
Memory B Cell
Secondary Stimulation by Ag or CpG oligos,Bystander T cells
Stegall et al Am J Transplant 2009; 9:998-1005 .
Long-lived PC PC ?longevity
High-affinity Abs Ү ү ү ү High-affinity Abs Ү ү ү ү
Plasma cell
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Only “B” Cells actually secreting antibody
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Short and long-lived
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Pre-existing PCs source of DSA in sensitized patients
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Newly-emerging PCs post-transplant (converted from naïve and memory B cells)
1. Bone Marrow Aspiration in Sensitized Renal Allograft Candidate 60 ml Bone Marrow 6 x 10 8 Mononuclear cells 6 x 10 6 CD 138 + cells 2. Positive Selection of CD 138+ cells
ASCs
Cells in CD 138+ Fraction 25% 44% ASCs CD27-/20+ 19% CD27+/20+ T cells 2% 2% 8% CD27+/20 Other
PC ELISpot - Frequency of Tetanus and Allospecific PCs Tetanus Alloantibody Non-Sensitized Sensitized Non-Sensitized Sensitized Perry et al Am J Transplant 2008; 8:133-143
Methods
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Patients
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Very high alloantibody levels
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DSA that was deemed too high (BFXM > 450 or MFI>10,000) for our current desensitization protocols.
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Monotherapy
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Endpoint:
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Reduction in DSA-specific PC number
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Reduction on DSA/response to Plasma exchange Transplantation 2011; 91:536-541
Study Design.
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Bone marrow Bortezomib Bone marrow
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Bortezomib therapy (1.3 mg / m2). a) Phase 1 – 4 doses (n=4) b) Phase 2 – 16 doses (n=5) Transplantation 2011; 91:536-541
Results - ELISPOT
Effect of Bortezomib on PC *One patient’s baseline marrow clotted and hence was excluded from analysis.
Category (per ml marrow) Baseline (Mean + SD) Post Bortezomib (Mean + SD) (n=8) p value Paired T test Allo spots (X 10 2 ) 16.7 + 14.5
6.2 + 3.6
0.048
TT spots (X 10 2 ) 25.2 + 15.7
13.2 + 8.1
0.032
Total Cells (X 10 6 ) 14.3 + 5.1
11.6 + 3.9
0.27
PC no (X 10 3 ) 21.5 + 8.6
15.5 + 12.1
0.21
Transplantation 2011; 91:536-541
700 600 500 400 300 200 100 0 Baseline Effect Of PE.
PE only Bortezomib + PE Post PE Baseline Post PE
Effect of PE Category No of PE (Mean + SD) Baseline – Post PE BFXM (Mean + SD) % Change in BFXM CS (Mean + SD) Bortezomib + PE (n=5) (n=8) 11.4 + 2.7
11.6 + 3.9 272.6 + 92.1 49.1 + 14.9
95.4 + 72.2
17.7 + 12.5
p value 0.9
0.008
0.005
BFXM < 300 Post PE n (%) 3 (60) Transplantation 2011; 91:536-541 0 (0) 0.035
Conclusions
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Proteasome inhibition depletes normal human plasma cells in vivo.
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Depletion is significant, but not complete -- ? increases safety and tolerability, but may limit effectiveness
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New PCs replace old ones quickly
Conclusions: Clinical
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Improves efficacy of PE and increases the transplant rate in patients with extremely high levels of DSA
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Problems with bioavailability and irreversible binding
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May need more prolonged treatment or combine with other agents to increase efficacy
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Newer agents in development Transplantation 2011; 91:536-541
Bortezomib
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Weak impact with only 1 4 “cycles”
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Extend to 8 cycles now
Prevention of Early Antibody Mediated Rejection
Early Acute Antibody Mediated Rejection
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Common in +XMKTx (20-40%)
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Best correlated with DSA post transplantation (BFXM >360, MFI >8000) ~ 90% incidence
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Baseline DSA also somewhat predictive
Early AMR: May cause early graft loss Associated with shortened graft survival Expensive and increases morbidity Associated with high DSA levels post-transplant
Low baseline DSA levels (B-FXM) without AHR Low baseline DSA levels (B-FXM) with AHR Baseline Day 4 Day High baseline DSA levels (B-FXM) without AHR Day Baseline Day 4 Day High baseline DSA levels (B-FXM) with AHR Day Baseline Day 4 Day Burns et al Day Am J Transplant Baseline Day 4 Day 2008; 8:2684-2694 Day 28
Early AMR (Burns et al)
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Time to rejection 11.3+5.9 d (range 4 21)
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All except 1 C4d+ peritubular capillaries at time of diagnosis
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6 C4d+/-AHR
3 progressed to AHR
MCR: Actual 5 Year Outcomes after +XMKTx
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All +XMKTx 2000-2006 (n= 154)
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Retrospective LABscreen DSA (beads)
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52 excluded
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8 lost to f/u 11 no serum for DSA testing 12 CDC+ pre
failed desensitization 16 no DSA (+XM) 5 MFI <1000 100% 5 yr graft survival
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102 included in the study & compared to 204 –XMKTx matched by age/gender
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Specificity Class I alone Class I and II Class II alone DSA Specificity (MFI >1000) n CDC+ 36 20 46 55.6% 45.7% MFI-I II__ 9545 0 8849 7711 0% 0 8922
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Specificity Class I alone Class I and II Class II alone DSA Specificity (MFI >1000) n CDC+ 36 20 46 55.6% 45.7% MFI-I II__ 9545 0 8849 7711 0% 0 8922
• • •
Specificity Class I alone Class I and II Class II alone DSA Specificity (MFI >1000) n CDC+ 36 20 46 55.6% 45.7% MFI-I II__ 9545 0 8849 7711 0% 0 8922
Rates of Early AMR and DSA Type
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Anti-Class I only 38.9%
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Anti-Class I and II 45.7%
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Anti-Class II only 15% Explains why the T cell AHG crossmatch has worked well historically Problem with Class II is late injury
Prevention vs Treatment?
Acute Humoral Rejection
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Plasmapheresis
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IVIG
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Lefaucheur C, Nochy D, Andrade J, et al. Comparison of combination plasmapheresis/IVIg/anti-CD20 versus high-dose IVIg in the treatment of antibody mediated rejection. Am J Transplant. 2009;9:1099-1107.
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Splenectomy
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Rituximab
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Bortezomib (proteasome inhibitor)
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Eculizumab (C-5 inhibitor)
Hypothesis
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Almost all cases of AMR show evidence of complement activation — C4d+ peritubular capillaries
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Inhibition of terminal complement activation with anti-C5 antibody (eculizumab) will prevent AMR in +XM Kidney Transplantation
The Complement Cascade: Targeted Inhibition
Classical Pathway Antigen/Antibody Complexes Lectin Pathway Carbohydrate Structures C4+C2 Activated MBL Weak Anaphylatoxin Immune Complex Microbial Opsonization C3a C3 Activated C1 C3 Convertase C4b2a Alternative Pathway M/O and Mammalian Cell Membranes C3b C3bBb C3 Convertase Factor B+D C3H 2 0 Tickover Potent Anaphylatoxin Chemotaxis Cell Activation C5 Convertase C4b2a3b C5a Cell Activation Neisseria Clearance RBC Lysis C3b C5 X C5b C6 C7 C8 C9 C5b-9 C3bBb3b C5 Convertase Eculizumab Target
Am J Tx (2011) 11:2405-13
Pretransplant Management Same in Both Groups
Baseline T/B FXM
<300
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No PE Monitor DSA post transplant >300
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Pretransplant PE to achieve T and B FXM <300 Thymoglobulin induction, Prograf, Mycophenolate mofetil, Prednisone Am J Tx (2011) 11:2405-13
1 o Endpoint
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Incidence of AMR in first 90 days post-transplant
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Thrombotic microangiopathy Graft dysfunction ( ↑>0.3 mg/dl)
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Protocol biopsies at day 0, 4, 7, 10, 14, 21, 28
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Serum for SABs and T/B FXM
Study Design
BFXM 200 450 MFI 3000-12,000+
Historical Controls Anti-C5 Treated N=51
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1/1/05 —10/1/07
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PE-based “desensitization”
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Consecutive Patients N=26 6/1/08 —09/27/10
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Added to existing PE-based protocol 1 patient in each group had BFXM <450, but failed to reach <300 with PE
Is space does not allow keeping of both “anti-class xonly” and “andi-class x” I would keep “andi-class x” and drop “andi-class x only”. “andi-class x” better shows that the Eculizumab group has same or higher ab levels.
Patients Category Female Sex Age in years at time of transplantation (Mean + SD) Ethnicity * Caucasian White Hispanic Black Cause of Renal Failure Diabetes Polycystic disease Glomerulonephritis Hypertension Other Unknown Prior Kidney Transplant Donor-Specific Alloantibody Levels B flow crossmatch Baseline channel shift (mean + SD) Anti-Donor HLA Single Antigen Bead Assay Baseline mean fluorescence index (mean + SD) Antidonor Antibody Specificity Anti-Class 1 only Anti-Class 2 only Anti-Class 1 Anti-Class 2 Both Anti-Class 1 and 2 Pretransplant Plasma Exchange ** Number of patients receiving Number of PEs (mean + SD) Eculizumab Group (n=26) 21 (81%) 48.6 + 12.5
24 (92%) 2 (7.7%) 0 (0%) 1 (7.7%) 4 (15%) 4 (15%) 3 (12%) 11 (42%) 3 (12%) 13 (50%) 330 + 84 7188 + 3503 10 (38%) 7 (27%) 19 (73%) 16 (62%) 9 (35%) 18 (69%) 4.0 + 3.6
Control Group (n=51) 40 (78%) 48.4 + 11.4
44 (86%) 5 (9.8%) 2 (3.9%) 9 (18%) 7 (14%) 7 (14%) 2 (3.9%) 20 (39%) 6 (12%) 13 (25%) 327 + 73 6473 + 4946 30 (59%) 13 (25%) 38 (75%) 21 (41%) 8 (16%) 35 (69%) 3.7 + 3.4
p value 1.00
0.94
0.85
0.52
0.043
0.85
0.51
0.10 1.00
1.0
0.10
0.082
1.00
0.76
[WKK1] Please include the graft loss data in the dataset. Am J Tx (2011) 11:2405-13 Results Category Follow-up (mean months + SD, range) Graft Survival at 1 year (n, %) Antibody mediated rejection < 3months (n, %) Eculizumab Group (n=26) Control Group (n=51) p value 11.9 + 6.1
(3.0 – 27.5) 16/16 (100%) 2 (7.7%) Patients developing High DSA Levels < 3 months * High DSA Biopsies C4d+ (n, %) High DSA and C4d+ biopsies Showing AMR (n, %) 13 (50%) 13 (100%) 2 (15%) 48.8 + 14.1
(7.8 – 69.8) 49/51 (97%) 21 (41%) 22 (43%) 20 (90.9%) 20 (100%) 1.00
0.0031
0.63
0.52
<0.0001
Cellular Rejection <3 months (n, %) 1 (6.2%) 1 (2.0%) 0.42
AMR (n=2) BFXM MFI 250 371 7705 1133 No AMR (n=24) BFXM >200 N=2 N=7 N=6
AMR % with MFI
3001-6000 = 36.4%
>6000 = 51.3%
MFI <3000 >3000 >6000 >10,000
Low baseline DSA levels (B-FXM) without AHR Low baseline DSA levels (B-FXM) with AHR Baseline Day 4 Day High baseline DSA levels (B-FXM) without AHR Day Baseline Day 4 Day High baseline DSA levels (B-FXM) with AHR Day Baseline Day 4 Day Burns et al Day Am J Transplant Baseline Day 4 Day 2008; 8:2684-2694 Day 28
Am J Tx (2011) 11:2405-13 Results Category Follow-up (mean months + SD, range) Graft Survival at 1 year (n, %) Antibody mediated rejection < 3months (n, %) Eculizumab Group (n=26) Control Group (n=51) p value 11.9 + 6.1
(3.0 – 27.5) 16/16 (100%) 2 (7.7%) Patients developing High DSA Levels < 3 months * High DSA Biopsies C4d+ (n, %) High DSA and C4d+ biopsies Showing AMR (n, %) 13 (50%) 13 (100%) 2 (15%) 48.8 + 14.1
(7.8 – 69.8) 49/51 (97%) 21 (41%) 22 (43%) 20 (90.9%) 20 (100%) 1.00
0.0031
0.63
0.52
<0.0001
Cellular Rejection <3 months (n, %) 1 (6.2%) 1 (2.0%) 0.42
Histology with High DSA post-TX BFXM >359 post-transplant Control BFXM 550 =AMR Eculizumab BFXM 604 =Nl N=22 (43%) All AMR N=13 (50%) 2 AMR
Case: Early AMR with Eculizumab
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Elevated creatinine on POD #7 and 14
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Increased DSA
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Biopsy —thrombotic microangiopathy
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Eculizumab level therapeutic with no hemolytic activity
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Both treated with PE, resolved
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Cause unclear?
Day 7 - AMR
AMR and DSA IgM
16000 14000 12000 10000 8000 6000 4000 2000 0 0
AMR High response of DSA IgM
Day 14 - AMR 7 14
Days after transplant
27 A3_IgG A23_IgG B18_IgG DR7_IgG DR15_IgG DR51_IgG DR53_IgG A3_IgM A23_IgM B18_IgM DR7_IgM DR53_IgM
16000 14000 12000 10000 8000 6000 4000 2000 0 0
No DSA IgM High DSA IgG No AMR or TG High response of DSA IgG. No AMR and No DSA IgM response
7 14
Days from trans plant
28 DQ4_IgG DR15_IgG DR4_IgG DR51_IgG DR53_IgG
Plasma Exchange: Post Transplant
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Control group
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BFXM >300 at baseline, 7 d PE per protocol
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Any AMR
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Eculizumab group
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1 patient per protocol early 21 patients no PE per protocol 2 patient with AMR
Other Outcomes: Morbidity Category Eculizumab (n=26) Control Group (n=51) p value Post-Transplant PE Splenectomy in patients with AMR Graft Dysfunction Δ Cr (mg/dl)=Maximum - Nadir in first month 3 (12.5%) 0 39 (76.5%) 9 (17.7%) <0.0001
0.025
0.45 + 0.37
0.93 + 1.15 0.0087
Complications
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All patients receive pretransplant meningococcal vaccine
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No treatment related infections
DSA Levels after Transplant
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Levels change
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Specificities change
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Causes complex
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Absorption by the allograft Memory B cell response Anti idiotypic “blocking” Abs
16000 14000 12000 10000 8000 6000 4000 2000 0 BA SE LI N E PO D 4 PO D 7 PO D 1 4 PO D 2 8 3M O 6M O 1 Y R 16000 14000 12000 10000 8000 6000 4000 2000 0 BA SE LI N E PO D 4 PO D 7 PO D 1 4 PO D 2 8 3M O 6M O 1 Y R B35 B7 16000 14000 12000 10000 8000 6000 4000 2000 0 B A S E LI N E P O D 4 P O D 7 P O D 1 4 P O D 2 8 3M O 6M O 1 Y R A24a DR1a 16000 14000 12000 10000 8000 6000 4000 2000 0 BA SE LI N E PO D 4 PO D 7 PO D 1 4 PO D 2 8 3M O 6M O 1 Y R A30 DQ4 A24a B39a DQ7a
Late Results?
Stopping Eculizumab Goal BFXM <200
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No AMR after stopping eculizumab
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4 weeks: 8 patients stopped
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9 weeks: 6 stopped
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>9 weeks: 2 continued
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2 stopped at 1 year Am J Tx (2011) 11:2405-13
Evidence of CHR in C5 inhibitor treated patients?
Caveat: Trial not designed to test prevention of chronic humoral rejection Different post-transplant treatments (some received only 1 month C5 inhibitor, most had no post-transplant plasma exchange)
Eculizumab vs Historical Control 3 yr Death Censored Graft Survival
Chronic Injury: Transplant Glomerulopathy This is the lesion of chronic AMR
Late Events: Chronic Injury, Graft Loss and Death
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Transplant Glomerulopathy at 12 months Eculizumab 6.7% (1/15) Historical Controls 36% (15/42)
P=0.044
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Graft loss and Death 2 graft losses at 2 years due to TG in eculizumab group 1 death due to Burkitt’s lymphoma at 2.5 years
Pt #9 Continuous Eculizumab Eculiz Rx weeks 52 AMR No 3 mos cg/ci 1/1 6 mos cg/ci 1/1 1 yr cg/ci 1/2 Cr* BFXM* 3.1
121
16000 14000 12000 10000 8000 6000 4000 2000 0 BA SE LI N E PO D 4 PO D 7 PO D 1 4 PO D 2 8 3M O 6M O 1 Y R DQ4a DR15a DR4a DR51 DR53a
12000 10000 8000 6000 4000 2000 0 BA SE LI NE Pr eTx PO D 4 PO D 7 PO D 14 PO D 28 3M O 6M O 1 YR 700 600 500 400 300 200 100 0 BA SE LI NE Pr e Tx PO D 4 PO D 7 PO D 14 PO D 28 3M O 6M O 1 YR B44 DR52a A2 DQ6a DR13a
Conclusions: Terminal complement blockade with eculizumab
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Decreases the incidence of early AMR
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Prevents AMR and graft dysfunction with higher DSA levels post-transplant
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Decreases need for PE and splenectomy
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Decreased TG at 1 year?
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Chronic changes may require additional therapy
Multicenter Trial
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80 patients (1:1 randomization)
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Eculizumab vs Standard of Care (PE or IVIG)
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Central HLA Lab for entry criteria (BFXM >300) + DSA by flowbeads
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1 o Endpoint = AMR in first 90 d
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Eculizumab rescue for “refractory” rejection in standard of care arm
Future Studies
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Role of IgM in early AMR in eculizumab-treated patients?
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Role of more prolonged eculizumab therapy?
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Role of bortezomib vs eculizumab to treat new-onset AMR in patients not receiving eculizumab?
Thank You
Actual Death-Censored 5 Year Graft Survival 70.7% vs 88.0%, p= 0.0006
Actual 5 Year Outcomes After +XMKTx Rate of graft loss after 1 year Class I only 1.6%/yr Class II 7.0%/yr
-XM +XM I I/II Histology at 5 Years* 1/3 of grafts already lost 1 yr 5 yr cg 3.5
ptctis 7.7
cg 9 ptctis 7.8
8.4
37.8
20.9
44.4
50.0
58.3
*75-80% capture rate 47.% 63.7%