Cyclosporine Withdrawal Research Articles

ОСОБЕННОСТИ ТЕЧЕНИЯ КОРОНАВИРУСНОЙ ИНФЕКЦИИ У РЕЦИПИЕНТА ПОЧЕЧНОГО ТРАНСПЛАНТАТА

The new coronavirus infection poses a particular threat to patients receiving immunosuppressive therapy, including those with a history of organ transplantation. The article provides a clinical observation of coronavirus infection in a kidney transplant recipient. Patient M., 61 years old, was admitted to the infectious diseases department of the Kursk City Clinical Hospital No. 4 with complaints of high fever, cough, shortness of breath, severe weakness, loss of appetite. When examining a swab from the nose and throat by PCR for SARS-Cov-2 RNA, a positive result was obtained. Based on the clinical picture, computed tomography of the lungs, positive PCR result for SARS-Cov-2 RNA, the diagnosis was made: Coronavirus infection Covid-19 confirmed, moderate form. Bilateral polysegmental pneumonia of moderate severity. RF - 0-I degree (CT-1). Bilateral nephrosclerosis. Condition after kidney transplant (2006). On the fifth day, the patient's condition worsened, which was combined with the progression of lung damage according to CT of the chest to 45% (CT-2), the appearance of signs of acute respiratory distress syndrome. Taking into account the severity of the patient's condition, a consultation was held with a transplantologist and a decision was made to correct immunosuppressive therapy with temporary withdrawal of cyclosporine. Over the next two days, the patient's condition remained stably grave. Subsequently, against the background of complex therapy, including glucocorticosteroids, antibacterial drugs, monoclonal antibodies to the interleukin-6 receptor, positive dynamics was noted in the form of a decrease in shortness of breath, cough, normalization of body temperature, and an increase in SpO2 up to 95%. This was combined with the restoration of disturbed laboratory parameters and the positive dynamics of the inflammatory process in the lungs according to CT scans. The treatment of kidney transplant recipients with Covid-19 has a number of features due to a pronounced suppression of the immune system against the background of immunosuppressive therapy and, as a result, the development of a severe infection, often with impaired graft function. At the same time, despite the severity of the course of the infectious process, the complete abolition of immunosuppressive therapy is not carried out, but its correction is carried out in the form of the exclusion of one of the drugs and a decrease in the dose of other immunosuppressants. Coronavirus infection in patients with a history of organ transplantation justifies the need for timely hospitalization and correction of immunosuppressive therapy to prevent a severe course of the disease and adverse outcomes.

Feasibility of Cyclosporine Prophylaxis Withdrawal in Critically Ill Allogenic Hematopoietic Stem Cell Transplant Patients Admitted to the Intensive Care Unit With No GVHD

Twenty percent of allogenic hematopoietic stem cell transplantation (allo-HSCT) patients require intensive care unit (ICU) admission. Feasibility and long-term consequences of cyclosporine graft-versus-host disease (GVHD) prophylaxis withdrawal in the ICU are unknown. To assess the impact of cyclosporine prophylaxis withdrawal in critically ill allo-HSCT patients admitted to the ICU on GVHD incidence and to evaluate 6-month overall survival according to cyclosporine withdrawal and GVHD occurrence. From 2010 to 2020, 101 critically ill allo-HSCT patients admitted to the ICU in our institution were included. All received cyclosporine as GVHD prophylaxis. None of them had GVHD at ICU admission. Patients were admitted in the ICU after a median time of 11 days (5.5-18) after allo-HSCT. ICU, hospital mortality, and 6-month mortality were 43.6%, 56.4%, and 59.4%, respectively. Cyclosporine was withdrawn for 52 and continued for 49 patients in the ICU. A total of 38.6% (n=39) developed secondarily acute GVHD (aGVHD) after a median of 28 days (15-40) after cyclosporine was discontinued. In 74.4% (n=29) of cases, patients in the hematology ward developed aGVHD after ICU discharge. Cyclosporine dosages were similar in both groups. Factors independently associated with aGVHD occurrence in multivariate analysis were cyclosporine withdrawal in the ICU (subdistribution hazard ratios [sHR]=2.04, 95% confidence interval [CI]=1.02-4.1, P=.044), renal replacement therapy (RRT) (sHR=0.43, 95% CI=0.19-0.9, P=.03) and fungal prophylaxis (sHR=2.62, 95% CI=1.35-5.07, P=.004). Cyclosporine withdrawal in the ICU was associated with poorer 6-month overall survival (OS) (HR=1.96, 95% CI=1.16-3.33, P=.012), but after adjusting on severity (simplified acute physiology score, vasopressors, mechanical ventilation and RRT requirement), 6-month OS did not differ (HR=1.35, 95% CI=0.76-2.42, P=.30). GVHD occurrence after ICU stay was significantly associated with better 6-month OS in unadjusted (HR=0.53, 95% CI=0.31-0.90, P=.02) and severity-adjusted analysis (HR=0.54, 95% CI=0.31-0.93, P=.028). Cyclosporine prophylaxis withdrawal in critically ill allo-HSCT patients in the ICU appears to be feasible and did not impair long-term outcome.

Prospective Measures of Adherence by Questionnaire, Low Immunosuppression and Graft Outcome in Kidney Transplantation.

Background: Non-adherence with immunosuppressant medication (MNA) fosters development of de novo donor-specific antibodies (dnDSA), rejection, and graft failure (GF) in kidney transplant recipients (KTRs). However, there is no simple tool to assess MNA, prospectively. The goal was to monitor MNA and analyze its predictive value for dnDSA generation, acute rejection and GF. Methods: We enrolled 301 KTRs in a multicentric French study. MNA was assessed prospectively at 3, 6, 12, and 24 months (M) post-KT, using the Morisky scale. We investigated the association between MNA and occurrence of dnDSA at year 2 post transplantation, using logistic regression models and the association between MNA and rejection or graft failure, using Cox multivariable models. Results: The initial percentage of MNA patients was 17.7%, increasing to 34.6% at 24 months. Nineteen patients (8.4%) developed dnDSA 2 to 3 years after KT. After adjustment for recipient age, HLA sensitization, HLA mismatches, and maintenance treatment, MNA was associated neither with dnDSA occurrence, nor acute rejection. Only cyclosporine use and calcineurin inhibitor (CNI) withdrawal were strongly associated with dnDSA and rejection. With a median follow-up of 8.9 years, GF occurred in 87 patients (29.0%). After adjustment for recipient and donor age, CNI trough level, dnDSA, and rejection, MNA was not associated with GF. The only parameters associated with GF were dnDSA occurrence, and acute rejection. Conclusions: Prospective serial monitoring of MNA using the Morisky scale does not predict dnDSA occurrence, rejection or GF in KTRs. In contrast, cyclosporine and CNI withdrawal induce dnDSA and rejection, which lead to GF.

5-Year outcomes of the prospective and randomized CISTCERT study comparing steroid withdrawal to replacement of cyclosporine with everolimus in de novo kidney transplant patients.

Withdrawal of either steroids or calcineurin inhibitors are two strategies to reduce treatment-related side effects and improve long-term outcomes of kidney transplantation. The CISTCERT study compared the efficacy and safety of these two strategies. In this multicenter, randomized controlled trial, 151 incident kidney transplant recipients received cyclosporine (CsA), mycophenolic acid (MPA), and steroids during three months, followed by either steroid withdrawal (CsA/MPA) or replacement of cyclosporine with everolimus (EVL) (EVL/MPA/steroids). 5-year patient survival (89% vs. 86%; P=NS) and death-censored graft survival (95% vs. 96%; P=NS) were comparable in the CsA/MPA and EVL/MPA/steroids arm, respectively. 51 CrEDTA clearance was comparable in the intention-to-treat analysis, but in the on-treatment population, the EVL/MPA/steroids arm exhibited a superior 51 CrEDTA clearance at 1 and 5years after transplantation (61.6 vs. 52.4, P=0.05 and 59.1 vs. 46.2ml/min/1.73m2 , P=0.042). Numerically more and more severe rejections were observed in the EVL/MPA/steroids arm, which also experienced a higher incidence of posttransplant diabetes (26% vs. 6%, P=0.0016) and infections. No significant differences were observed in cardiovascular outcomes and malignancy. Both regimens provide an excellent long-term patient survival and graft survival. Regarding graft function, EVL/MPA/steroids is an attractive strategy for patients with good tolerability who remain free of rejection. (ClinicalTrials.gov number: NCT00903188; EudraCT Number 2007-005844-26).

Coronavirus Disease 2019 in Recipient of Allogeneic Hematopoietic Stem Cell Transplantation: Life-threating Features Within the Early Post-engraftment Phase.

Coronavirus Disease 2019 in Recipient of Allogeneic Hematopoietic Stem Cell Transplantation: Life-threating Features Within the Early Post-engraftment Phase.

Scientometric analysis of mTOR signaling pathway in liver disease.

The mTOR pathway is vital for homeostasis, metabolism, cancer transplantation and regeneration in the liver. The aim of this study is to use a bibliometric method to reveal current research hotspots and promising future trends in mTOR signaling in liver diseases. Publications were searched and downloaded from the Web of Science Core Collection (WOSCC) Database. CiteSpace, Carrot2, and VOSviewer programs were utilized to analyze the contribution of various countries/regions, institutes, and authors; and to reveal research hotspots and promising future trends in this research area. Until May 21, 2019, a total of 2,232 papers regarding mTOR signaling pathway in liver disease were included, and each paper was cited 23.21 times on average. The most active country was the USA. 5 landmark articles with centrality and burstiness were determined by co-citation analysis. Research hotspots included "liver transplantation" "hepatic stellate cell proliferation" "NAFLD" "therapy of HCC". Moreover, six key clusters were discovered during the procedure of "clustering", including "liver transplantation" "protein synthesis" "mTOR inhibitor" "following early cyclosporine withdrawal" "srebp-1 activation", and "hepatocellular cancer". Various scientific methods were applied to reveal scientific productivity, collaboration, and research hotspots in the mTOR signaling pathway in liver disease. Liver transplantation, hepatic stellate cell proliferation, non-alcoholic fatty liver disease (NAFLD), therapy of hepatocellular carcinoma (HCC), cell growth and autophagy, are research hotspots and are likely to be promising in the next few years. Further studies in this field are needed.

Recovery of T-cell function in healthy dogs following cessation of oral cyclosporine administration.

Cyclosporine is a potent immunosuppressive agent used to treat immune‐mediated disorders in dogs. Secondary infections sometimes necessitate withdrawal of cyclosporine, but it is not known how long it takes for the immune system to recover after cessation of cyclosporine. Our goal was to utilize a validated RT‐qPCR assay in dogs to assess recovery time of the T‐cell cytokines IL‐2 and IFN‐γ after discontinuation of cyclosporine. Six healthy dogs were given oral cyclosporine (10 mg/kg every 12 hr) for 1 week, with samples collected for measurement of cytokine gene expression prior to treatment, and on the last day of therapy. Cyclosporine was then discontinued, and samples were collected daily for an additional 7 days. Results revealed that there was a significant difference in cytokine expression when comparing pre‐treatment and immediate post‐treatment values, corresponding to marked suppression of T‐cell function. There was no significant difference between pre‐treatment values for either cytokine when compared with any day during the recovery period. Cytokine expression, evaluated as a percentage of pre‐treatment baseline samples, demonstrated progressing return of T‐cell function after drug cessation, with full recovery seen in all dogs by Day 4 of the recovery period.

Effects of late cyclosporine withdrawal on renal graft function and survival.

Attempts to discontinue calcineurin inhibitors (CNIs) early after renal transplantation without conversion to an alternative immunosuppressive have failed due to high rates of acute rejection. Data on "late" CNI withdrawal are lacking so far. We carried out a matched case-control study on the effects of CNI withdrawal on graft loss and mortality in 90 patients (1500 screened) with advanced graft dysfunction (serum creatinine > 3.5mg/dl) and a cyclosporine-based triple immunosuppressive regimen at the Charité University Hospital, Berlin. Cyclosporine was withdrawn at a mean of 54.0 ± 32.8months post-transplant in 45 subjects. Whereas estimated glomerular filtration rate (eGFR) did not significantly differ between the groups at this time (12.4 ± 2.7 vs. 14.7 ± 8.9 in the control group, p = 0.08), it was significantly higher in subjects undergoing withdrawal after 120months (Δ 4.1ml/min; p < 0.001). In a Cox regression analysis adjusted for age, gender and eGFR, patients with CNI withdrawal showed better survival rates for the combined endpoint death/graft loss (hazard ratio, HR [95% confidence interval]: 0.19 [0.12-0.33], p = 0.001) compared to matched controls. The survival benefit was significant for the endpoints death (p = 0.01) and graft loss (p = 0.001). CNI withdrawal was associated with improved survival rates in patients with advanced graft dysfunction in this retrospective analysis.

Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Heart Transplant Recipients.

Background Cardiac allograft vasculopathy (CAV) limits survival after heart transplantation, and the effect of different immunosuppressive regimens on CAV is not fully understood. The randomized SCHEDULE trial (Scandinavian Heart Transplant Everolimus De Novo Study With Early Calcineurin Inhibitors Avoidance) evaluated whether initiation of the proliferation signal inhibitor everolimus and early cyclosporine elimination can reduce CAV development. Methods and Results The SCHEDULE trial was a multicenter Scandinavian trial, where 115 de novo heart transplantation recipients were randomized to everolimus with complete cyclosporine withdrawal 7 to 11 weeks after heart transplantation or standard cyclosporine-based immunosuppression. Seventy-six (66%) patients had matched intravascular ultrasound examinations at baseline and 12 and 36 months. Intravascular ultrasound analysis evaluated maximal intimal thickness, percent atheroma volume, and total atheroma volume. Qualitative plaque analysis using virtual histology assessed fibrous, fibrofatty, and calcified tissue as well as necrotic core. Serum inflammatory markers were measured in parallel. The everolimus group (n=37) demonstrated significantly reduced CAV progression as compared with the cyclosporine group (n=39) at 36 months (Δ maximal intimal thickness, 0.09±0.05 versus 0.15±0.16 mm [ P=0.03]; Δ percent atheroma volume, 5.3±2.8% versus 7.6±5.9% [ P=0.03]; and Δ total atheroma volume, 33.9±71.2 versus 54.2±96.0 mm3 [ P=0.34], respectively]. At 36 months the number of everolimus patients with rejection graded ≥2R was 15 (41%) as compared with 5 (13%) in the cyclosporine group ( P=0.01). Everolimus did not affect CAV morphology or immune marker activity during the follow-up period. Conclusions The SCHEDULE trial demonstrates that everolimus initiation and early cyclosporine elimination significantly reduces CAV progression at 12 months, and this beneficial effect is clearly sustained at 36 months. Clinical trial registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01266148.

Rapamycin is highly effective in murine models of immune-mediated bone marrow failure.

Acquired aplastic anemia, the prototypical bone marrow failure disease, is characterized by pancytopenia and marrow hypoplasia. Most aplastic anemia patients respond to immunosuppressive therapy, usually with anti-thymocyte globulin and cyclosporine, but some relapse on cyclosporine withdrawal or require long-term administration of cyclosporine to maintain blood counts. In this study, we tested efficacy of rapamycin as a new or alternative treatment in mouse models of immune-mediated bone marrow failure. Rapamycin ameliorated pancytopenia, improved bone marrow cellularity, and extended animal survival in a manner comparable to the standard dose of cyclosporine. Rapamycin effectively reduced Th1 inflammatory cytokines interferon-γ and tumor necrosis factor-α, increased the Th2 cytokine interleukin-10, stimulated expansion of functional regulatory T cells, eliminated effector CD8+ T cells (notably T cells specific to target cells bearing minor histocompatibility antigen H60), and preserved hematopoietic stem and progenitor cells. Rapamycin, but not cyclosporine, reduced the proportion of memory and effector T cells and maintained a pool of naïve T cells. Cyclosporine increased cytoplasmic nuclear factor of activated T-cells-1 following T-cell receptor stimulation, whereas rapamycin suppressed phosphorylation of two key signaling molecules in the mammalian target of rapamycin pathway, S6 kinase and protein kinase B. In summary, rapamycin was an effective therapy in mouse models of immune-mediated bone marrow failure, acting through different mechanisms to cyclosporine. Its specific expansion of regulatory T cells and elimination of clonogenic CD8+ effectors support its potential clinical utility in the treatment of aplastic anemia.

Everolimus with cyclosporine withdrawal or low-exposure cyclosporine in kidney transplantation from Month 3: a multicentre, randomized trial.

Randomized trials have shown that early adoption of everolimus-based immunosuppressive regimens without a calcineurin inhibitor (CNI) improves long-term kidney graft function, but the optimal strategy for CNI minimization remains uncertain. In a prospective, randomized, multicentre, 12-month trial, 499 de novo kidney transplant patients were randomized at Month 3 to (i) remain on standard CNI (cyclosporine) therapy with mycophenolic acid, (ii) convert to everolimus with mycophenolic acid or (iii) start everolimus with reduced CNI and no mycophenolic acid (clinical trials registry: ClinicalTrials.gov-NCT00514514). The primary endpoint, change in estimated glomerular filtration rate (eGFR) (Nankivell) from randomization to Month 12, was significantly greater in the CNI-free arm versus standard CNI therapy: mean difference 5.6 mL/min/1.73 m 2 [95% confidence interval (CI) 2.8-8.3 mL/min/1.73 m 2 , P < 0.001]. The improvement in eGFR in the CNI-free arm was also higher than in the low-CNI group (mean difference 5.5 mL/min/1.73 m 2 , 95% CI 2.8-8.2 mL/min/1.73 m 2 , P < 0.001), while results were similar in the low-CNI and standard CNI arms. The post-randomization incidence of biopsy-proven acute rejection was 11.7%, 8.1% and 7.9% in the CNI-free, low-CNI and standard CNI groups, respectively (CNI-free versus standard CNI, P = 0.27; low-CNI versus standard CNI, P = 1.00). Adverse events led to study drug discontinuation in 28.7%, 15.5% and 15.2% of CNI-free, low-CNI and standard CNI patients, respectively. Everolimus initiation with CNI withdrawal at Month 3 after kidney transplantation achieves a significant improvement in renal function at 12 months, with a similar rate of acute rejection.

Long-term outcome after early cyclosporine withdrawal in kidney transplantation: ten years after.

Despite long-term side effects, calcineurin inhibitors (CNI) remain a cornerstone of immunosuppression in renal transplantation. Few trials assessed the long-term outcome after early CNI withdrawal. This intention-to-treat study assessed the 10-year outcome of 108 patients randomly converted from a cyclosporine (CsA)-mycophenolate mofetil (MMF)-prednisone regimen to a dual therapy (CsA-prednisone or MMF-prednisone) at 3months postgraft. At 10years, 3.7% in the CsA group and 35.2% in the MMF group remained on the protocol regimen (P<.001). eGFR was higher in the MMF group (64.4±21 vs 49.7±14.7 mL/min/1.73 m², P<.001), although acute rejection (12 vs 4 in the CsA group, P=.03) and Class II DSA incidences were increased. CNI-related toxicity (P=.019) and moderate-to-severe IF/TA (P=.004) were higher in the CsA group. Ten-year graft and patient survivals were not different. In multivariate analysis, acute rejection remained the strongest predictor of graft loss (HR=11.64, 95% CI [5.05-26.79], P<.0001). MMF withdrawal largely failed due to CNI toxicity, while CsA withdrawal led to increased graft failure due to uncontrolled acute rejection without increasing graft survival. From this study, it remains unclear which patients could benefit from limiting CNI exposure.

Failure of Calcineurin Inhibitor (Tacrolimus) Weaning Randomized Trial in Long-Term Stable Kidney Transplant Recipients.

Long-term renal transplant outcome is limited by side effects of immunosuppressive drugs, particularly calcineurin inhibitor (CNI). We assumed that some patients selected for a "low immunological risk of rejection" could be eligible and benefit from a CNI weaning strategy. We designed a prospective, randomized, multicenter, double-blind placebo-controlled clinical study (Eudract: 2010-019574-33) to analyze the benefit-risk ratio of tacrolimus weaning on highly selected patients (≥4 years of transplantation, normal histology, stable graft function, no anti-HLA immunization). The primary endpoint was improvement of renal function. Fifty-two patients were scheduled in each treatment arm, placebo compared to the CNI maintenance arm. Only 10 patients were eligible and randomized. Five patients were assigned to the placebo arm and five were assigned to the tacrolimus maintenance arm. In the tacrolimus maintenance arm, all patients maintained stable graft function and no immunological events occurred. Contrastingly, in the placebo arm, all five patients had to reintroduce a full dose of tacrolimus since three of them presented an acute rejection episode (one humoral, one mixed, and one borderline) and two displayed anti-HLA antibodies without histological lesion (one donor-specific antibodies [DSA] and one non-DSA). Clearly, tacrolimus withdrawal must be avoided even in long-term highly selective stable kidney recipients.

Effect of an Early Switch to Belatacept Among Calcineurin Inhibitor-Intolerant Graft Recipients of Kidneys From Extended-Criteria Donors.

Transplant recipients receiving a kidney from an extended-criteria donor (ECD) are exposed to calcineurin inhibitor (CNI) nephrotoxicity, as demonstrated by severe delayed graft function and/or a low GFR. Belatacept is a nonnephrotoxic drug that is indicated as an alternative to CNIs. We reported 25 cases of conversion from a CNI to belatacept due to CNI intolerance within the first 6 mo after transplantation. The mean age of the recipients was 59 years, and 24 of 25 patients received ECD kidneys. At the date of the medication switch, 12 of 25 patients displayed a calculated GFR (cGFR) <15 mL/min, six patients remained on dialysis, and the biopsies showed evidence of acute tubular damage associated with severe vascular or tubulointerstitial chronic lesions. Three patients did not recover renal function, and three patients died during the follow-up period. Among the remaining patients, renal function improved: The cGFR was 18.28 ± 12.3 mL/min before the medication switch compared with 34.9 ± 14.5 mL/min at 1 year after conversion to belatacept (p = 0.002). Tolerance of and compliance with belatacept were good, and only one patient experienced acute rejection. Belatacept is an effective therapy that preserves renal function in kidney transplant patients who are intolerant of CNIs.

Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Three-Year Results From the Randomized SCHEDULE Study.

In a randomized, open-label trial, de novo heart transplant recipients were randomized to everolimus (3-6 ng/mL) with reduced-exposure calcineurin inhibitor (CNI; cyclosporine) to weeks 7-11 after transplant, followed by increased everolimus exposure (target 6-10 ng/mL) with cyclosporine withdrawal or standard-exposure cyclosporine. All patients received mycophenolate mofetil and corticosteroids. A total of 110 of 115 patients completed the 12-month study, and 102 attended a follow-up visit at month 36. Mean measured GFR (mGFR) at month 36 was 77.4 mL/min (standard deviation [SD] 20.2 mL/min) versus 59.2 mL/min (SD 17.4 mL/min) in the everolimus and CNI groups, respectively, a difference of 18.3 mL/min (95% CI 11.1-25.6 mL/min; p < 0.001) in the intention to treat population. Multivariate analysis showed treatment to be an independent determinant of mGFR at month 36. Coronary intravascular ultrasound at 36 months revealed significantly reduced progression of allograft vasculopathy in the everolimus group compared with the CNI group. Biopsy-proven acute rejection grade ≥2R occurred in 10.2% and 5.9% of everolimus- and CNI-treated patients, respectively, during months 12-36. Serious adverse events occurred in 37.3% and 19.6% of everolimus- and CNI-treated patients, respectively (p = 0.078). These results suggest that early CNI withdrawal after heart transplantation supported by everolimus, mycophenolic acid and steroids with lymphocyte-depleting induction is safe at intermediate follow-up. This regimen, used selectively, may offer adequate immunosuppressive potency with a sustained renal advantage.

Sirolimus-Based Immunosuppressive Regimens in Renal Transplantation: A Systemic Review

Sirolimus (SRL)-based immunosuppressive regimens have been used for preventing rejection after kidney transplantation. This review analyzes their merits and demerits compared with other conventional regimes from the aspects of acute rejection rate, graft function, as well as patient/graft survival rates. In general, SRL is mostly recommended to be used as conversion therapy from calcineurin inhibitor (CNI) after kidney transplantation in most studies. Minimization or withdrawal of cyclosporine A (CsA) could also be considered when it was combined with SRL. SRL can replace mycophenolate mofetil (MMF), and the CNI dose should be reduced appropriately in this setting. Quadruple maintenance regimens containing SRL need future study to clarify their superiority. De novo use of low-dose CNI combined with SRL has no apparent merits and thus is not recommended. De novo use of standard-dose CNI combined with SRL followed by maintenance, de novo use of CNI-free regimens, as well as SRL use in delayed graft function (DGF) patients who spare antibody induction and postpone CNI administration should also be avoided. SRL supports steroids withdrawal after kidney transplantation, and SRL combined with tacrolimus is recommended in this setting. Loading dose is recommended when initiating SRL treatment and its trough blood level should be routinely monitored.

Rapamycin Is Highly Effective in a Mouse Model of Immune-Mediated Bone Marrow Failure By Mechanisms Distinct from Cyclosporine

Acquired aplastic anemia (AA) is bone marrow (BM) failure characterized by pancytopenia and marrow hypocellularity, in most patients due to immune attack by T cells that target hematopoietic stem and progenitor cells. Most patients respond to immunosuppressive therapy, but relapse, especially on withdrawal of cyclosporine A (CsA), occurs frequently (Scheinberg P, Am J Hematol., 2014). Rapamycin has been successful in some human autoimmune diseases and in mouse models of autoimmunity; rapamycin also appears to induce tolerance, as for example in the organ transplant setting. We have developed murine models of BM failure; animals can be salvaged by biologics and drugs that are effective in humans with AA. One purpose of these models is to test potential new therapies. We have compared rapamycin with customary immunosuppression by CsA. Infusion of lymph node cells from C57BL6 (B6) donor mice into CByB6F1 (F1) recipient mice (MHC-mismatched) induced massive BM destruction by activated T cells. Treatment with rapamycin (2 mg/kg/day, starting 1 hour post lymphocyte injection and continued for 2 weeks, n=9) effectively ameliorated pancytopenia and improved BM cellularity, better than did maximal dosing with CsA (50 mg/kg/day, starting 1 hour post lymphocyte injection, continued for 5 days, n=8) (Fig 1A). Rapamycin eliminated most BM-infiltrating CD8+ T cells, while CsA had less effect on CD8+ T cells than did rapamycin. Elimination of BM infiltrated T cells and restoration of megakaryocytes by rapamycin was visualized by confocal microscopy using whole-mounts of sternum, for which donor B6 lymph node cells were replaced with B6-DsRed lymph node cells. Plasma cytokines were measured by Luminex: IFNg, TNFa, IL-2, MIP1b, RANTES, sCD137 (all p < 0.001) were increased in BM failure mice compared with the control animals, indicating an inflammatory environment in AA. Rapamycin reduced these cytokines (p < 0.001) but increased Th2 cytokines such as IL-4 and IL-10 (p < 0.001) levels. CsA only decreased sCD137, reversely it even increased IFNg levels. Transcriptome analysis using pooled FACS-sorted CD4+ and CD8+ T cells from BM focusing on genes related to T cell functions revealed that rapamycin suppressed expression of Icam1, and Tnfsf14 in CD8+ T cells, and Cd27, Lgals3, Il10ra, Itga1, Tbx21, Gzmb, Tnfsf14 and Cd70 in CD4+ T cells, but increased Il-4, Il-2ra, and Tnfrsf8 expression in CD4+ T cells compared with AA mice. CsA suppressed Lgals3 in CD8+ T cells and Cd70 in CD4+ T cells, suggesting differential mechanisms of action by these two immunosuppressive drugs. All untreated AA mice (n=6) died within 3 weeks post lymphocyte infusion, while all mice treated with rapamycin for 2 weeks (n=8) survived until study termination at 7 weeks; similar results were obtained when we tested delayed treatment with rapamycin (starting 3 days post lymphocyte injection and continued for 10 days, n=8) in BM failure mice; but brief exposure to rapamycin, for only 5 days from 1 hour post lymphocyte infusion (n=8), could not rescue mice, suggesting a requirement for sustained administration. In contrast, all animals treated with CsA (n=6) died within 5 weeks (Fig 1B). We also tested the effect of rapamycin on antigen-specific T cells in another BM failure model induced by infusion of lymphocytes from B6 donor mice into C.B10-H2b /LilMcd recipient mice (MHC-matched but minor antigen-mismatched, n=10), in which BM destruction is mediated by H60-specific cytotoxic T cells (CTL) (Chen J, JI, 2007). Similar results were observed. Flow cytometry revealed massive expansion of H60-specific CTL in BM of untreated AA mice, rapamycin eliminated BM CD8+ T cell infiltration. CsA decreased BM CD8+ T cells, but had much weaker effect on H60 CTLs (Fig 1C). In summary, rapamycin is effective in treatment of AA murine models, which holds implications in the application in immune-mediated pathophysiologies in the laboratory and in the clinic. Compared with CsA, rapamycin suppressed expression of T cell activation genes more broadly, increased Th2 cytokines, eliminated antigen-specific T cells, and had better survival rate in animal BM failure model, supporting a clinical trial of rapamycin to prevent relapse and induce tolerance in patients with AA, many of whom are dependent on CsA administration for support of blood counts but at risk of CsA nephrotoxicity. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Fibrosis Progression According to Epithelial-Mesenchymal Transition Profile: A Randomized Trial of Everolimus Versus CsA

Markers of epithelial-mesenchymal transition (EMT) may identify patients at high risk of graft fibrogenesis who could benefit from early calcineurin inhibitor (CNI) withdrawal. In a randomized, open-label, 12-month trial, de novo kidney transplant patients received cyclosporine, enteric-coated mycophenolate sodium (EC-MPS) and steroids to month 3. Patients were stratified as EMT+ or EMT- based on month 3 biopsy, then randomized to start everolimus with half-dose EC-MPS (720 mg/day) and cyclosporine withdrawal (CNI-free) or continue cyclosporine with standard EC-MPS (CNI). The primary endpoint was progression of graft fibrosis (interstitial fibrosis/tubular atrophy [IF/TA] grade increase ≥1 between months 3-12) in EMT+ patients. 194 patients were randomized (96 CNI-free, 98 CNI); 153 (69 CNI-free, 84 CNI) were included in histological analyses. Fibrosis progression occurred in 46.2% (12/26) CNI-free EMT+ patients versus 51.6% (16/31) CNI EMT+ patients (p = 0.68). Biopsy-proven acute rejection (BPAR, including subclinical events) occurred in 25.0% and 5.1% of CNI-free and CNI patients, respectively (p < 0.001). In conclusion, early CNI withdrawal with everolimus initiation does not prevent interstitial fibrosis. Using this CNI-free protocol, in which everolimus exposure was relatively low and administered with half-dose EC-MPS, CNI-free patients were overwhelmingly under-immunosuppressed and experienced an increased risk of BPAR.

Pharmacology of Cyclosporine in an Ovine Model of Kidney Allograft Rejection.

Objective: We sought to develop a clinically relevant large animal model of kidney rejection that responds to the application and withdrawal of immunosuppressant drugs in a predictable manner. Methods: 2 year old sheep were MHC mismatched and underwent a kidney transplant and bilateral nephrectomy. The donor kidney was placed under a skin flap on the neck and anastomosed to the jugular and carotid artery while the ureter was externalized through the skin flap. The sheep was then dosed with cyclosporine for 7 days with the drug being withdrawn on day 8. Blood samples were taken daily and biopsies of the kidney performed every second day. Angiograms of the transplanted kidney were also carried out allowing for visualisation of the blood vessels. Results: Serum creatinine and urea stayed at an acceptable level for the first 7 days post transplantation, upon withdrawal of immunosuppression there was a rapid increase in both serum creatinine and urea consistent with a failing kidney. Likewise, Banff scores from the biopsies were stable for the first 7 days and saw a rapid spike upon withdrawal of cyclosporine as the kidney underwent rejection. Conclusions: The sheep kidney transplant model is a useful large animal model for kidney allograft rejection due to its ability to be MHC mismatched, the ability to use clinically relevant pharmaceutical intervention, and the predictable and pronounced rejection that is able to be easily monitored by renal allograft biopsy. Several imaging techniques, such as MRI to track cells, are also available to use in this model giving it a wide scope for future research.

(462) - Maintained Cardiac Reserve in Heart Transplant Patients During Early Calcineurin Inhibitor Avoidance: A Substudy of a Randomised Controlled Trial (SCHEDULE Trial)

Calcineurin inhibitors have been the cornerstone of immunosuppressive regime following heart transplantation. The transplanted heart is prone to increased hypertrophy and risk of developing graft vasculopathy. To what extent these negative effects are influenced by different immunosuppressive drugs, is largely unknown. We conducted a randomised, open-label, parallel group clinical trial to assess early introduction of everolimus (EVE) followed by withdrawal of cyclosporine (CYA) in de novo heart transplant recipients, compared to a standard protocol of cyclosporine-based immunosuppression.