In this study, an IgG-degrading enzyme derived from
Streptococcus pyogenes
(IdeS) that cleaves human IgG into F(ab′)
2
and Fc fragments reduced or eliminated donor-specific antibodies and permitted ...HLA-incompatible renal transplantation.
Background Malignancies in the urinary tract and the kidney graft are quite common after kidney transplantation. In some selected cases tumours develop from donor-derived tissue. Objectives We ...hypothesised that there is a clinical value to investigate donor/recipient origin in urologic malignancies in renal transplant recipients. Methods In this retrospective study, including patients transplanted between the years 1969 and 2014 at Uppsala University Hospital, Sweden, 11 patients with malignancies in urinary tract and 4 patients with malignancies in kidney transplants were investigated. Donor/recipient origin of tumour tissue was analysed by polymerase chain reaction (PCR) of human leucocyte antigen (HLA) genotypes or by fluorescence in situ hybridization (FISH analysis) of sex chromosomes. HLA genotype and sex chromosomes of the tumour were compared to the known HLA genotype and sex chromosomes of recipient and donor. Results Three of ten cancers in the urinary tract and three of four cancers in the kidney transplants were donor-derived. Conclusions We suggest that urologic malignancies in renal transplant recipients can be investigated for transplant origin. In addition to conventional therapy the allograft immune response against these tumours can be valuable to treat donor-derived cancers.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Safety, immunogenicity, pharmacokinetics, and efficacy of the IgG‐degrading enzyme of Streptococcus pyogenes (IdeS imlifidase) were assessed in a single‐center, open‐label ascending‐dose study in ...highly sensitized patients with chronic kidney disease. Eight patients with cytotoxic PRAs (median cytotoxic PRAs of 64%) at enrollment received 1 or 2 intravenous infusions of IdeS on consecutive days (0.12 mg/kg body weight ×2 n = 3; 0.25 mg/kg ×1 n = 3, or 0.25 mg/kg ×2 n = 2). IgG degradation was observed in all subjects after IdeS treatment, with <1% plasma IgG remaining within 48 hours and remaining low up to 7 days. Mean fluorescence intensity values of HLA class I and II reactivity were substantially reduced in all patients, and C1q binding to anti‐HLA was abolished. IdeS also cleaved the IgG‐type B cell receptor on CD19+ memory B cells. Anti‐IdeS antibodies developed 1 week after treatment, peaking at 2 weeks. A few hours after the second IdeS infusion, 1 patient received a deceased donor kidney offer. At enrollment, the patient had a positive serum crossmatch (HLA‐B7), detected by complement‐dependent cytotoxicity, flow cytometry, and multiplex bead assays. After IdeS infusion (0.12 mg/kg ×2) and when the HLA‐incompatible donor (HLA‐B7+) kidney was offered, the HLA antibody profile was negative. The kidney was transplanted successfully.
In highly sensitized patients with chronic kidney disease, the immunoglobulin G–degrading enzyme of Streptococcus pyogenes (imlifidase) degrades plasma IgG efficiently, reduces HLA antibodies substantially, and abolishes C1q binding to anti‐HLA, thus enabling HLA‐incompatible kidney transplantation.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
BACKGROUND.When transplanted human pancreatic islets are exposed to blood during intraportal infusion, an innate immune response is triggered. This instant blood-mediated inflammatory reaction ...(IBMIR) activates the coagulation and complement cascades and leads to the destruction of 25% of all transplanted islets within minutes, contributing to the need, in most patients, for islets from more than 1 donor. Low molecular dextran sulfate (LMW-DS) has been shown in experimental settings to inhibit IBMIR.
METHODS.The Clinical Islet Transplantation consortium 01 study was a phase II, multicenter, open label, active control, randomized study. Twenty-four subjects were randomized to peritransplant intraportal and systemic treatment with either LMW-DS or heparin, targeting an activated partial thromboplastin time of 150 ± 10 seconds and 50 ± 5 seconds, respectively. C-peptide response was measured with a mixed meal tolerance test at 75 and 365 days after transplant.
RESULTS.Low molecular dextran sulfate was safe and well tolerated with similar observed adverse events (mostly attributed to immunosuppression) as in the heparin arm. There was no difference in the primary endpoint (stimulated C-peptide 75 ± 5 days after the first transplant) between the 2 arms (1.33 ± 1.10 versus 1.56 ± 1.36 ng/mL, P = 0.66). Insulin requirement, metabolic parameters, Clarke and HYPO score, quality of life, and safety were similar between the 2 treatments groups.
CONCLUSIONS.Even with low dosing, LMW-DS showed similar efficacy in preventing IBMIR to promote islet engraftment when compared to “state-of-the art” treatment with heparin. Furthermore, no substantial differences in the efficacy and safety endpoints were detected, providing important information for future studies with more optimal dosing of LMW-DS for the prevention of IBMIR in islet transplantation.
We performed a prospective, double blind, randomized, placebo-controlled multicenter study on the efficacy and safety of rituximab as induction therapy, together with tacrolimus, mycophenolate ...mofetil, and steroids. The primary endpoint was defined as acute rejection, graft loss, or death during the first 6 months. Secondary endpoints were creatinine clearance, incidence of infections, and incidence of rituximab-related adverse event.
We enrolled 140 patients (44 living donor and 96 deceased donor), and of those, 68 rituximab and 68 placebo patients fulfilled the study. In all the patients receiving rituximab, there was a complete depletion of CD19/CD20 cells, whereas there was no change in the number of CD19/CD20 cells in the placebo group. There were 10 treatment failures in the rituximab group versus 14 in the placebo group (P=0.348). There were eight rejection episodes in the rituximab group versus 12 in the placebo group (P=0.317) Creatinine clearance was 66+/-22 mL/min in the study group and 67+/-23 mL/min in the placebo group. There was no difference in the number of bacterial infections, cytomegalovirus infections, and BK virus infections or fungal infections.
We performed a placebo-controlled study of rituximab induction in renal transplantation. There was a tendency toward fewer and milder rejections during the first 6 months in the rituximab group. Although induction with one dose of rituximab induced a complete depletion B cells, there was no increase in the incidence of infectious complications or leukopenia and it seems safe, therefore, to conduct further studies on the use of rituximab in transplantation.
AdCD40L is a replication-deficient virus carrying the gene for CD40 ligand which has previously been evaluated in patients with urothelial cancer and malignant melanoma. Herein, we present the ...results of repeated intratumoral injections of AdCD40L in seven patients with metastatic solid cancer. One patient who developed urothelial cancer derived from a renal transplant was treated with repeated injections of AdCD40L alone. The remaining patients suffered from cholangiocarcinoma, kidney, breast, rectal, or ovarian cancer and received AdCD40L repeatedly (4x) in combination with cyclophosphamide. The treatment was safe and generally well-tolerated. Two patients had clinical benefit of the treatment and one of them was accepted for re-treatment. Circulating proinflammatory cytokines were commonly increased after treatment, but save for TNFα, significances were not reached which could be due to the low number of patients. Similar to earlier findings in AdCD40L-treated melanoma patients, IL8 plasma levels were high in the present study. In conclusion, gene therapy by repeated intratumoral AdCD40L injections alone, or in combination with cyclophosphamide, is feasible and safe in patients with solid cancers. The potential of intratumoral CD40L gene transfer as treatment of cancer was illustrated by the clinical improvement in two out of seven patients.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Islet Surface Heparinization Prevents the Instant Blood-Mediated Inflammatory Reaction in Islet Transplantation
Sanja Cabric 1 ,
Javier Sanchez 1 ,
Torbjörn Lundgren 2 ,
Aksel Foss 3 ,
Marie Felldin ...4 ,
Ragnar Källen 5 ,
Kaija Salmela 6 ,
Annika Tibell 2 ,
Gunnar Tufveson 7 ,
Rolf Larsson 1 8 ,
Olle Korsgren 1 and
Bo Nilsson 1 9
1 Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, The Rudbeck Laboratory, Uppsala
University, Uppsala, Sweden
2 Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
3 Department of Transplantation Surgery, Rikshospitalet, Oslo, Norway
4 Department of Transplantation, University Hospital, Gothenburg, Sweden
5 Department of Nephrology and Transplantation, University Hospital, Malmö, Sweden
6 Division of Transplantation, Surgical Hospital, Helsinki University, Helsinki, Finland
7 Division of Transplantation Surgery, Department of Surgical Sciences, University Hospital, Uppsala, Sweden
8 Corline System, Uppsala, Sweden
9 Rudbeck Laboratory, Uppsala, Sweden
Address correspondence and reprint requests to Bo Nillson, The Rudbeck Laboratory C5, Dag Hammarskölds väg 20, SE-751 85 Uppsala,
Sweden. E-mail: bo.nilsson{at}klinimm.uu.se
Abstract
OBJECTIVE —In clinical islet transplantation, the instant blood-mediated inflammatory reaction (IBMIR) is a major factor contributing
to the poor initial engraftment of the islets. This reaction is triggered by tissue factor and monocyte chemoattractant protein
(MCP)-1, expressed by the transplanted pancreatic islets when the islets come in contact with blood in the portal vein. All
currently identified systemic inhibitors of the IBMIR are associated with a significantly increased risk of bleeding or other
side effects. To avoid systemic treatment, the aim of the present study was to render the islet graft blood biocompatible
by applying a continuous heparin coating to the islet surface.
RESEARCH DESIGN AND METHODS —A biotin/avidin technique was used to conjugate preformed heparin complexes to the surface of pancreatic islets. This endothelial-like
coating was achieved by conjugating barely 40 IU heparin per full-size clinical islet transplant.
RESULTS —Both in an in vitro loop model and in an allogeneic porcine model of clinical islet transplantation, this heparin coating
provided protection against the IBMIR. Culturing heparinized islets for 24 h did not affect insulin release after glucose
challenge, and heparin-coated islets cured diabetic mice in a manner similar to untreated islets.
CONCLUSIONS —This novel pretreatment procedure prevents intraportal thrombosis and efficiently inhibits the IBMIR without increasing the
bleeding risk and, unlike other pretreatment procedures (e.g., gene therapy), without inducing acute or chronic toxicity in
the islets.
APC, activated protein C
IBMIR, instant blood-mediated inflammatory reaction
MCP, monocyte chemoattractant protein
TAT, thrombin antithrombin
Footnotes
Published ahead of print at http://diabetes.diabetesjournals.org on 31 May 2007. DOI: 10.2337/db07-0358.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore
be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
Accepted April 27, 2007.
Received March 19, 2007.
DIABETES
Tissue Factor Produced by the Endocrine Cells of the Islets of Langerhans Is Associated With a Negative Outcome of Clinical
Islet Transplantation
Helena Johansson 1 ,
Agneta Lukinius 2 ,
Lisa Moberg ...1 ,
Torbjörn Lundgren 3 ,
Christian Berne 4 ,
Aksel Foss 5 ,
Marie Felldin 6 ,
Ragnar Källen 7 ,
Kaija Salmela 8 ,
Annika Tibell 3 ,
Gunnar Tufveson 9 ,
Kristina Nilsson Ekdahl 1 10 ,
Graciela Elgue 1 ,
Olle Korsgren 1 and
Bo Nilsson 1
1 Department of Radiology, Oncology and Clinical Immunology, Division of Clinical Immunology, The Rudbeck Laboratory, University
Hospital, Uppsala, Sweden
2 Department of Genetics and Pathology, Division of Pathology, The Rudbeck Laboratory, University Hospital, Uppsala, Sweden
3 Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
4 Department of Medical Sciences, Division of Medicine, University Hospital, Uppsala, Sweden
5 Department of Transplantation Surgery, Rikshospitalet, Oslo, Norway
6 Department of Transplantation, University Hospital, Gothenburg, Sweden
7 Department of Nephrology and Transplantation, University Hospital, Malmö, Sweden
8 Division of Transplantation, Surgical Hospital, Helsinki University, Helsinki, Finland
9 Department of Surgical Sciences, Division of Transplantation Surgery, University Hospital, Uppsala, Sweden
10 Department of Chemistry and Biomedical Sciences, University of Kalmar, Kalmar, Sweden
Address correspondencereprint requests to Helena Johansson, The Rudbeck Laboratory, University Hospital, 751 85 Uppsala, Sweden.
E-mail: helena.johansson{at}klinimm.uu.se
Abstract
There are strong indications that only a small fraction of grafts successfully engraft in clinical islet transplantation.
One explanation may be the instant blood-mediated inflammatory reaction (IBMIR) elicited by tissue factor, which is produced
by the endocrine cells. In the present study, we show that islets intended for islet transplantation produce tissue factor
in both the transmembrane and the alternatively spliced form and that the membrane-bound form is released as microparticles
often associated with both insulin and glucagon granules. A low–molecular mass factor VIIa (FVIIa) inhibitor that indirectly
blocks both forms of tissue factor was shown in vitro to be a promising drug to eliminate the IBMIR. Thrombin-antithrombin
complex (TAT) and FVIIa-antithrombin complex (FVIIa-AT) were measured in nine patients who together received 20 infusions
of isolated human islets. Both the TAT and FVIIa-AT complexes increased rapidly within 15–60 min after infusion. When the
initial TAT and FVIIa-AT levels were plotted against the increase in C-peptide concentration after 7 days, patients with an
initially strong IBMIR showed no significant increase in insulin synthesis after 7 days. In conclusion, tissue factor present
in both the islets and the culture medium and elicits IBMIR, which affects the function of the transplanted islets.
FVIIa, factor VIIa, FVIIa-AT, FVIIa-antithrombin complex
IBMIR, instant blood-mediated inflammatory reaction
mAbs, monoclonal antibodies
TAT, thrombin-antithrombin complex
Footnotes
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore
be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
Accepted February 22, 2005.
Received May 4, 2004.
DIABETES
The procedure of human islet isolation needs further optimization and standardization. Here, we describe techniques to enhance enzymatic digestion and minimize mechanical forces during the digestion ...process. The isolation protocol has also been modified to meet current GMP (cGMP) standards. Moreover, the impact of donor- and process-related factors was correlated to the use of islets for clinical transplantation.
One hundred twelve standardized consecutive islet isolations were evaluated. Metyltioninklorid and indermil (topical tissue adhesive) were applied to detect leakage of collagenase injected and to repair the damaged pancreatic glands. The effects of dye and glue were evaluated in terms of islet yield, islet function using the perifusion assay, and success rate of the isolation. To analyze key factors for successful isolations, both univariate and multivariate regression analysis were performed.
Both Metyltioninklorid and Indermil were effective to prevent leakage of enzyme solutions from the pancreatic glands. Both islet yield and success rate were higher when these tools were applied (4,516.1+/-543.0 vs. 3,447.7+/-323.5, P=0.02; 50.0% vs. 21.3%, P=0.02, respectively). No adverse effects on islet function or collagenase activity were observed. Multivariate regression analysis identified the maximal recorded amylase >100 U/L (P=0.026), BMI (P=0.03), and the use of catecholamine (P=0.04) as crucial donor-related factors. In addition, cold ischemia time (P=0.005), the dissection procedure using whole glands with duodenum (P=0.02), and the local procurement team (P=0.03) were identified as crucial isolation-related variables.
A standardized technique of islet isolation is presented applying novel means to improve enzymatic digestion and to meet cGMP standards.
This study aimed to evaluate a 50:50 mix of perfluorohexyloctane/polydimethylsiloxane 5 (F6H8S5) preservation of pancreases in a clinical setting compared with standard solutions for 1) cold ischemia ...time (CIT) <10 h and 2) an extended CIT >20 h. Procured clinical-grade pancreases were shipped in either F6H8S5 or in standard preservation solutions, that is, University of Wisconsin (UW) or Custodiol. F6H5S5 was preoxygenated for at least 15 min. Included clinical-grade pancreases were procured in UW or Custodiol. Upon arrival at the islet isolation laboratory, the duodenum was removed followed by rough trimming while F6H8S5 was oxygenated for 15-20 min. Trimmed pancreases were immersed into oxygenated F6H8S5 and stored at 4°C overnight followed by subsequent islet isolation. Pancreas preservation using F6H8S5 proved as effective as UW and Custadiol when used within CIT up to 10 h, in terms of both isolation outcome and islet functionality. Preservation in F6H8S5 of pancreases with extended CIT gave results similar to controls with CIT <10 h for both isolated islet functionality and isolation outcome. This study of clinically obtained pancreases indicates a clear benefit of using F6H8S5 on pancreases with extended CIT as it seems to allow extended cold ischemic time without affecting islet function and islet numbers.
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