Monitoring HLAspecific antibodies
In patients undergoing desensitization
Matthew J. Everly, PharmD, BCPS
One Lambda Inc.
Monitoring HLAspecific antibodies
In all transplant patients
Matthew J. Everly, PharmD, BCPS
One Lambda Inc.
Preformed anti-HLA DSA+ Patient
Screening De Novo anti-HLA DSA
In all transplant patients
Monitoring Removal of anti-HLA DSA
What we know about
donor specific anti-HLA
antibodies …
Donor Specific
Anti-HLA Antibodies
allograft rejection
=
allograft failure
in transplant patients
What we do
not know …
How to monitor anti-HLA DSA?
How to treat anti-HLA DSA?
DSA
Transplant
+ at Transplant
Patient
DSA - at Transplant
≥35%
15%
Up to
Acute
1- yearAntibody
Graft Failure
Mediated
Rejection
Rate (non-desensitized)
DSA + at Transplant
“Preformed DSA”
DSA - at Transplant
Lefacheur
Dunn et al.
et Am
al. Am
J Transplant
J Transplant
2011;11:2132
2008;8:324
De novo anti-HLA
<5%
DSA in the first year
Acute Antibody
And
beyond
Mediated Rejection
DSA + at Transplant
“Preformed DSA”
Smith et al. Am J Transplant 2011;11:312
Everly
al.Am
AmJJTransplant
Transplant2011;11:2132
2012; In submission
Dunn etetal.
DSA - at Transplant
Anti-HLA
Preformed DSA Patient
Major concern with preformed
anti-HLA DSA is the associated
AMR Risk
Preformed DSA Patient
DSA+ at Transplant
with AMR (n=37)
Amico et al. Transplantation 2009;87:1681
Preformed DSA Patient
DSA – (at transplant)
n=194
DSA + (no AMR), n=22
DSA+ AMR+, n=21
Lefaucheur et al. Am J Transplant 2008;8:324
DSA Associated AMR risk
not uniform
is
over the post-transplant period
Preformed DSA Patient
119
Positive Crossmatch
Gloor et al. Am J Transplant 2010;10:582
Preformed DSA Patient
DSA- (n=12)
DSA+ low MFI
Sum 0 - 5,000 MFI (n=23)
DSA+ low MFI
Sum 5,000-10,000 (n=16)
DSA+ high MFI
Sum >10,000 MFI (n=66)
Gloor et al. Am J Transplant 2010;10:582
Preformed DSA Patient
334
Negative CDC
Crossmatch
Aims:
What is the clinical relevance of preformed
DSA?
67 (20%)
What anti-HLA DSA characteristics are
predictive of DSA?
Anti-HLA DSA +
Pre-Transplant
Amico et al. Transplantation 2009;87:1681
Preformed DSA Patient
Amico et al. Transplantation 2009;87:1681
Preformed DSA Patient
237
Negative T- & B-Cell
CDC Crossmatch
194 (82%)
43 (18%)
Anti-HLA DSA Pre-Transplant
Anti-HLA DSA +
Pre-Transplant
Lefaucheur et al. Am J Transplant 2008;8:324
Preformed DSA Patient
DSA-
DSA+ low MFI
13/21 (62%) of AMR
DSA+ high MFI
in first 45 days posttransplant
Lefaucheur et al. Am J Transplant 2008;8:324
Preformed DSA Patient
587 patients
CDC XM- with single antigen bead
testing at transplant
Dunn et al. Am J Transplant 2011;11:2132
Preformed DSA Patient
DSA-
DSA+ low MFI
3rd party
HLA+ or
Neg.
DSA+ high MFI
DSA+
Dunn et al. Am J Transplant 2011;11:2132
Preformed DSA Patient
Median Time
to Acute Antibody Mediated Rejection
7.5
16
16.5
days
days
days
Gloor et al. (n=49)
Lefaucheur et al. (n=21)
Dunn et al. (n=46)
Can monitoring identify the
preformed anti-HLA DSA patients at
risk of AMR ?
Preformed DSA Patient
70
Positive Crossmatch
41
29
High anti-HLA DSA
(Flow Channel Shift >300)
Low anti-HLA DSA
(Flow Channel Shift <300)
Burns et al. Am J Transplant 2008;10:2684
Preformed DSA Patient
Low DSA, NO
AMR
Low DSA, AMR+
High DSA, NO
AMR
High DSA, AMR+
Burns et al. Am J Transplant 2008;8:2684
Preformed DSA Patient
116 Flow Negative Crossmatch, but DSA Positive
Clinical Transplants 2011. In Press
Preformed DSA Patient
Possible DSA
Monitoring Time Points
Pre-Transplant, Day of Transplant
1 week
2 weeks
4 weeks
8 weeks
Preformed DSA Patient
DSADSA-(n=12)
DSA+ low MFI
Sum 0 - 5,000 MFI (n=23)
DSA+ low MFI
DSA+ low MFI
Sum 5,000-10,000 (n=16)
DSA+ high MFI
DSA+ high MFI
Sum >10,000 MFI (n=66)
?
Gloor et al. Am J Transplant 2010;10:582
Transplant
Glomerulopathy Risk
47%
of XM+ AMR+ Patients
41%
of XM+ AMR- Patients
Gloor et al. Am J Transplant 2010;10:582
Preformed DSA Patient
69 patients
Flow Positive Crossmatch
11 excluded
no DSA, or not
clear group
33
15
Group 1
Convert to Flow XM -
Group 2
Remain Flow XM +
Kidney Int 2011;10:582
Preformed DSA Patient
Group 1
Group 2
Group 1
Group 2
Kimball et al. Kidney Int 2011;10:582
Pre-Transplant, Day of Transplant
1 week
2 weeks
4 weeks
8 weeks
6 months
12 months
After 12 months ?
With for cause biopsy
Preformed DSA Patient
Monitoring Time Points
* If patient’s DSA remain persistently positive –
treatment may be useful to improve outcomes.
Rationale to monitor DSA
Identify a patient
1. at risk of AMR
2. at risk of Chronic Antibody
Damage
3. who should receive treatment
for Antibodies
Preformed DSA
Pre-Transplant DSA - Patient
Screening for De Novo DSA
Early Acute Antibody Mediated Rejection
Preformed DSA
De Novo DSA
>35%
<5%
Screening for De Novo DSA
DSA-
DSA+ low MFI
DSA+ high MFI
Gill et al. Transplantation 2010;89:178
Rationale to monitor DSA
Identify a patient
1. at risk of AMR
2. at risk of Chronic Antibody
Damage
3. who should receive treatment
for Antibodies
De Novo DSA
East Carolina University (Rebellato et al.)
Everly et al. Am J Transplant. 2012; In Submission
Rebellato et al. Clinical Transplants 2011; In Press
De Novo
Anti-HLA
62 DSA +
27%
Everly et al. Am J Transplant. 2012; In Submission
Rebellato et al. Clinical Transplants 2011; In Press
De Novo DSA Incidence
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
10%3-4%
0
1
2
3
4
5
6
7
8
9 10 11 12
Year Post-transplant
Everly et al. Presented at American Transplant Congress 2011, Philadelphia
Everly et al. Am J Transplant 2012. In Submission
243
patients transplanted between 19952004 who had survived more than one
year
224
19
patients excluded
DSA positive at the time of
transplant
173
HLA Abs
51
patients with no HLA Abs
56
de novo
117
NDSA (52%)
DSA
(25%)
NDSA= non donor-specific antibody
Smith J et al. Am J Transplant. 2011;11:312-9
When do HEART TRANSPLANT
% DSA +ve patients
patients develop de-novo DSA?
45
40
35
30
25
20
15
10
5
0
72%
N=57
22
13
6
6
3
5
1
1
1 2 3 4 5 6 7 8 9 10 11
Year of DSA appearance
Smith J et al. Am J Transplant. 2011;11:312-9
Percent Allograft Survival
De novo anti-HLA DSA Positive (n=62)
100
90
80
15%
70
60
28%
50
42%
40
30
20
10
0
0
12
24
36
48
60
Months after DSA Appearance
Everly et al. Am J Transplant 2012. In Submission
Proportion Surviving
What is the risk for heart failure after
de novo anti-HLA DSA appears?
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
n=51
20%
probability
of failure
24%
37%
5 patients develop DSA after CAV:
4 CII Abs, 1 both classes of Abs
0
1
2
3
4
5
Year from DSA to CAV or Graft Loss (GL)
Smith J et al. Am J Transplant. 2011;11:312-9
Rationale to monitor DSA
Identify a patient
1. at risk of AMR
2. at risk of Chronic Antibody
Damage
3. who should receive treatment
for Antibodies
De Novo DSA
Pre-Transplant
1 week
2 weeks
4 weeks
8 weeks
6 months
12 months
Biannually after 1 year
With for cause biopsy
Screening for De Novo DSA
Monitoring Time Points
Removing
DSA
In Acute Antibody Mediated Rejection
Reduction of Donor Specific Antibody Levels
Prevents Renal Allograft Loss
Brody Medical School
at Eastern Carolina University, Greenville, NC
Everly, et al. Transplantation.
University of Cincinnati, Cincinnati, OH
Everly et al. Am J Transplant 2009;9:1-9
100
D S A R e d u c tio n > 5 0 %
(N = 6 ; N O A llo g ra fts L o st)
0 .9
0 .8
0 .7
Log Rank p=0.021
0 .6
0 .5
0 .4
0 .3
0 .2
D S A R e d u c tio n < 5 0 %
(N p
= =1 0.043
0 ; 7 A(Log-Rank)
llo g ra fts L o st)
0 .1
0 .0
0
6
Statistically significant
12 18 24 30 36 42 48at the
54 α60
66 level
72
= 0.05
T im e fro m T ra n sp la n ta tio n (M o n th s)
Antibody Reduction Responders
(n=7, NO Allograft Loss)
90
Percent Allograft Survival
P o rp o rtio n o f A llo g ra fts S u rvivin g
1 .0
80
70
Log-rank p=0.033
60
50
40
30
20
Antibody Reduction Non-Responders
(n=23, 12 Allografts Lost)
10
0
0
12
24
36
48
60
Months after Transplantation
72
84
96
Lefaucheur et al. Am J Transplant 2009;9:1099
Despite Histologic Improvements …
Antibody removal after AMR
improves outcomes
Removing
In patients with preformed DSA
DSA
Removing DSA
Impact of proteasome inhibitor
on anti-donor HLA antibody
production after kidney transplantation
Mayo Clinic Trial – Mark Stegall M.D.
2 cycles of bortezomib …
wait 2 months …
possible 2 more cycles of bortezomib
Removing DSA
IVIg + plasmapheresis 3 times per week
For 2 weeks
Kimball et al. Clinical Transplants 2011; In press
Removing DSA
Kimball et al. Clinical Transplants 2011; In press
In the patient with persistent
preformed anti-HLA DSA positive …
Antibody removal may
improve outcomes
Removing
DSA
In patients with stable allograft function
Removing DSA
61 lung transplant patients
Serial single antigen bead
testing after transplant
Hachem et al. J Heart Lung Transplant 2010;29:973
61
Patients in 2011
All DSA positive
All preemtive treatment
IVIg for at least 6 months
(+/- Rituximab)
Removing DSA
Hachem et al. J Heart Lung Transplant 2010;29:973
Removing DSA
Everly et al. Transplantation 2012; In Press.
26
Patients in 2011
All DSA positive
All preemtive treatment
All with no dysfunction at
DSA appearance
Both DSA Classes
27% (n=7)
DSA Class I Alone
23% (n=6)
DSA Class II Alone
50% (n=13)
- 65% of patients had ONLY a single DSA positive at the time of treatment
- 39% of class II were DQ DSA
Bortezomib
on days 1, 4, 8, 11
Plasmapheresis (n=14) on same days with bortezomib
Rituximab (n=9) single dose
Corticosteroid pulse – (all patients)
Male Gender
Age at Transplant
24 (92)
29.3 ± 9
# of HLA mismatch
2.9 ± 1.4
85 days
(median time to DSA – range from 6 - 536)
Txp
DSA
(MFI > 1000)
SCr - 1.17 ± 0.22
SCr - 1.26 ± 0.27
Reduction of DSAmax MFI by at least 50%
26 Patients
24 – Greater than 50%
reduction in DSAmax MFI
Median time to 50% reduction 37
days
2 – Less than 50%
reduction in DSAmax MFI
Removing DSA
Median
Serum Creatinine Change from Start of
Treatment to last follow-up
Remission (n=8)
Relapsed (n=10)
Partial/No Response (n=8)
(only a 50% reduction)
46%
Scr Increase
In the patient with persistent
de novo anti-HLA DSA …
Antibody removal may
improve outcomes
Removing
Improves
Outcomes
DSA
Problem with Treating antiHLA DSA
Remission
Refractory
Relapse
Removing DSA
“ A rapid partial response (50% reduction of DSAmax with 1 month of
treatment was associated with a complete response”
Post-Treatment Monitoring Time Points
Prior to start of treatment
1 month
Continued monitoring if
continued treatment
Remission
(possibly 2 months if not using plasmspheresis)
Refractory
When Removing DSA
DSA-
At 3 & 6 months then
every 6 months
Relapse ?
Summary
Nearly All transplant patients can
benefit for some degree of
monitoring …
Preformed DSA Patient
AMR Appears Early
Amico et al. Transplantation 2009;87:1681
Preformed DSA Patient
Monitoring Early Identifies
those AT RISK of AMR
Burns et al. Am J Transplant 2008;8:2684
Preformed DSA Patient
Monitoring Late Identifies
those AT RISK of Failure
Group 1
Group 2
Group 1
Group 2
Kimball et al. Kidney Int 2011;10:582
Pre-Transplant
1 week
2 weeks
4 weeks
8 weeks
6 months
12 months
After 12 months, annually
With for cause biopsy
Preformed DSA Patient
Monitoring Time Points
Screening for De Novo DSA
De novo anti-HLA DSA appears at
any time post transplant &
Identifies those AT RISK of Failure
Everly et al. Presented at American Transplant Congress 2011, Philadelphia
Everly et al. Am J Transplant 2012. In Submission
Monitoring Time Points
Pre-Transplant
6 months
12 months
Annually after 1 year
With for cause biopsy
Screening for De Novo DSA
DSA-
RemovingDSA
Improves Outcomes
Post-Treatment Monitoring Time Points
Prior to start of treatment
1 month
Continued monitoring if
continued treatment
Remission
(possibly 2 months if not using plasmspheresis)
Refractory
When Removing DSA
DSA-
At 3 & 6 months then
every 6 months
Relapse ?
Thank
meverly@terasakilab.org