International Renal Renal Meeting Meeting International and Mayo - PowerPoint PPT Presentation

International Renal Renal Meeting Meeting International and Mayo Mayo Clinic Day Clinic Day in in Sardinia Sardinia and Cagliari (Italy), April April 30 30- -May 3, 2011 May 3, 2011 Cagliari (Italy), Immunosuppressive Induction Induction Regimen Regimen Immunosuppressive in Renal Renal Transplantation Transplantation in Donato Donati Donato Donati Azienda Azienda Ospedaliera Ospedaliera- -Universitaria Universitaria, , Varese Varese - - Italy Italy

APC CD4+25+ Tolerance MHC FoxP3 B7-1/2 CD40 CD40L IL-2 T cell: CD28 TCR Commander in-chief Tcell orchestrating alloimmunity Th 2 IL-10 Th 1 Adapted from: Th17 Sayegh and Turka. IFN- γ IL-4 NEJM 1998;338:1813 IFN- γ IL-2 Tc Mo B IL-2, IFN-y IL-17, IL-21 TNF- α ,IL-6 Abs IL-1 � . Rejection

Anti -T Lymphocyte Antibodies selective to extracellular targets on T cells � Non Depletional Depletional Basiliximab ATGs Daclizumab Muromonab Belatacept Alemtuzumab Belatacept CD- CD -28 28 Muromonab

The IL-2/IL-2r interplay is crucial for T cell proliferation and response Basiliximab blocks � chain the � chain (CD25) (CD25) of the IL-2 receptor of the x The CD25 antigen is expressed on circulating CD4+ and on all subsets of activated T lymphocytes

Basiliximab Basiliximab by large large the best the best selling selling induction induction agent agent by in Italy in Italy Efficient in in preventing preventing acute acute rejection rejection Efficient (- - 10/15% vs. placebo) 10/15% vs. placebo) ( � Kahan Kahan BD, BD, et et al. al. Transplantation Transplantation 67:276, 1999 67:276, 1999 � � Ponticelli C, Ponticelli C, et et al. Transplantation 72: 126, 2001 al. Transplantation 72: 126, 2001 � � Lawen JG, et al. Transplantation 75:37,2003 Lawen JG, et al. Transplantation 75:37,2003 � � Adu D, et al. BMJ 326:789, 2003 ( Adu D, et al. BMJ 326:789, 2003 (metanalysis metanalysis) ) �

Expectations from Induction by means of anti-T Lymphocyte antibodies � Prevention of damages from I/R injury Prevention of damages from I/R injury � � Reduction of rate of acute rejection Reduction of rate of acute rejection � � Promotion of (sort of) tolerance Promotion of (sort of) tolerance � � Minimization of chronic Minimization of chronic immunosuppression immunosuppression �

Adhesion molecules ICAM-1 (leukocytes and endothelial cells) TGF- β 1 � PDGF Ox radicals, Free radicals NO MHC II I R Chemochines Endothelin TNF- α , IFN- γ, IL ox LDL MØ and T cell infiltration Tx vasculopathy= Graft Failure

T cell infiltration in I/R injury T cell infiltration in I/R injury CD4+ KO mice CD4+ KO mice NO Injury CD4+ T cell adoptive transfer Injury CD4+ T cell adoptive transfer

Model of Leucocyte Leucocyte/ /Endothelium Endothelium Model of Interaction Interaction Fluid Shear Sticking Rolling Activation Arrest Stress LPAM-1 VLA-4 LFA-1 CCR5 CXCR4 CCR7 � 4 � LPAM-1 VLA-4 CD49/CD29 � M � � 1 � 7 � 4 � CD195 CD184 CD197 Glycoprotein 2 (activated) CD49/CD29 (activated) 2 7 integrin or glycolipid PSGL-1 L-selectin sLe x sLe x sLe x sLe x Y Y Mediators of sLe x sLe x chemotaxis sLe x P-NAd MAdCAM-1 VCAM-1 ICAM-3 E-selectin P-selectin VCAM-1 ICAM-2 ICAM-1 MAdCAM-1 CD50 CD102 CD54

Cellular distribution of RATG target antigens CD3/TCR, NK cells Granulocytes Monocytes T cells CD2, CD4, CD5, CD6, CD7, CD8, CD25,CD28, CD30, CD45, CD80, CD86, CTLA-4, VLA-4, LFA-1, LPAM-1, CD2, CD45, CD4, LFA-1, HLA I CCR5, CCR7, CXCR4 CD56 CD45, CD86, CD126, ( chemochine receptors), VLA-4, LPAM-1 (integrins) HLA I, � 2-M B cells Plasmacells Endothelium CD19, CD20, CD25, CD138 CD27, CD30, CD32, ICAM-1, ICAM-2, ICAM-3 CD38, CD40, CD45, CD86, CD95, HLA-DR

Study of microcirculation in primates with Study of microcirculation in primates with ischemia/reperfusion injury of estremities estremities ischemia/reperfusion injury of effect of ATG ATG ( effect of (ATG ATG- -F and Thymoglobulin) F and Thymoglobulin) with ATGs: Blood speed Leukocytes rolling Leukocytes flow Adhesion of leukocytes to endothelial walls Chappell D, et al.Transplantation 2006; 81: 552-8

Kyllonen LE, et al. Transplantation 2007; 84:75 LE, et al. Transplantation 2007; 84:75- -82 82 Kyllonen DGF with DGF with ATG ATG- -F F vs vs Basiliximab Basiliximab % 3 groups of patients 3 groups of patients � ATG ATG- -F (53) F (53) � � Basiliximab Basiliximab (58) (58) � 20 � No induction (44) No induction (44) � 10

Brennan DC, et al. NEJM 2006; 355:1967- -1977 1977 Brennan DC, et al. NEJM 2006; 355:1967 Thymoglobulin (n= 141) (n= 141) vs vs Basiliximab Basiliximab (n= 137) (n= 137) Thymoglobulin 25.5 15.6 AR % AR % 8 SRAR SRAR 1 44 40 DGF % DGF %

Brennan DC, et al. NEJM 2006; 355:1967- -1977 1977 Brennan DC, et al. NEJM 2006; 355:1967 Thymoglobulin (n= 141) (n= 141) vs vs Basiliximab Basiliximab (n= 137) (n= 137) Thymoglobulin � Similar, but extremely high rate of Similar, but extremely high rate of DGF (40 DGF (40- -44%) but 44%) but � CIT longer than 24 hours � Reduced rate and and severity of acute rejection with Thymo Thymo � comparable GS and PS comparable GS and PS �

Lebranchu et al. Am J Transplant 2002; 2: 48 et al. Am J Transplant 2002; 2: 48- -58 58 Lebranchu vs Basiliximab Basiliximab Thymoglobulin vs Thymoglobulin Transplantation with CIT shorter than 24 hours Transplantation with DGF with Thymo 6% (vs 14%) SRAR with Thymo 8% (vs 14%)

Intra- -operative vs. Post operative vs. Post- -operative operative Intra Thymoglobulin induction Thymoglobulin induction Intra- -op op Post Post- -op op Intra Dose of Thymo (cumulative) of Thymo (cumulative) 4.6 mg/Kg 4.8 mg/Kg Dose 4.6 mg/Kg 4.8 mg/Kg DGF 4 4 11 DGF 11 Rejections 1 1 5 Rejections 5 W. Goggins et al, Transplantation 2003 W. Goggins et al, Transplantation 2003

Expectations from Induction by means of anti-T Lymphocyte antibodies � Prevention of damages from I/R injury Prevention of damages from I/R injury � � Reduction of rate of acute rejection Reduction of rate of acute rejection � � Promotion of (sort of) tolerance Promotion of (sort of) tolerance � � Minimization of chronic Minimization of chronic immunosuppression immunosuppression �

Meccanisms of Tolerance induction Clonal deletion total elimination of T and B cells i.e. lymphocyte depletion which has to be profound, both in the blood and in the lymphoid tissues Clonal suppression r egolatory T cells (CD4+CD25+) which suppress activation and response against antigen lymphocytes are present but don � Clonal anergy t act i.e. block of co-stimulation (signal 1 without signal 2)

Changes of number of peripheral lymphocytes with RATG (dose dependent) 3 1.2 2 CD3+ CD4+ CD8+ 1.5 Lymphocyte Counts (giga/L) 2 0.8 1 1 0.4 0.5 0 0 0 -1 1 3 5 7 9 11 13 15 17 19 -1 1 3 5 7 9 11 13 15 17 19 -1 1 3 5 7 9 11 13 15 17 19 2 CD2+ CD20+ 3 Control 1.5 LOD 2 1 HID 1 sVHID 0.5 lVHID 0 0 -1 1 3 5 7 9 11 13 15 17 19 -1 1 3 5 7 9 11 13 15 17 19 Days Days Préville X, et al. Transplantation. 2001;71:460-468

lymphocyte depletion in spleen with RATG 3 6 4 CD3+ CD4+ CD8+ Lymphocytes (no. × 10 8 /g of tissue) 3 4 2 2 2 1 1 nd nd nd 0 0 0 6 5 3 CD2+ CD20+ CD56+ 4 (NK) 4 2 3 2 1 2 1 nd nd nd 0 0 0 CNTRL LOD HID sVHID lVHID CNTRL LOD HID sVHID lVHID CNTRL LOD HID sVHID lVHID Préville X, et al. Transplantation. 2001;71:460-468

Lymphocyte depletion in lymph nodes with RATG (dose dependent) 1.5 1.5 CD3+ CD4+ CD8+ Lymphocytes (no. × 10 9 /g of tissue) 2 1 1 1 0.5 0.5 0 0 0 0.6 CD20+ CD56+ CD2+ 0.4 2 (NK) 0.4 0.2 1 0.2 0 0 0 CNTRL LOD HID sVHID lVHID CNTRL LOD HID sVHID lVHID CNTRL LOD HID sVHID lVHID Préville X, et al. Transplantation. 2001;71:460-468

T reg+ cells CD4 � -chain of IL-2 receptor, required for CD 25 generation, survival and development of T reg Transcription factor forkhead box p3 T reg FoxP3 Control gene of development and function of T reg constitutive, CTLA-4 not induced as it is on effector T cells IL-2 Crucial for generation and maintenance of T reg (CD4+CD25+ are severely impaired in IL-2 KO mice)

Expansion of CD4 + T cells expressing CD25 with Thymoglobulin 0 hrs 24 hrs 28% Thymo CD25+ 24% 4% CD25+ 49% 5% Rabbit Ig CD25+ CD4+ 50% Lopez M, et al . J Am Soc Nephrol. 2006 CD4+ In vitro data

Thymoglobulin-induced CD4 + CD25 + cells have a Treg Phenotype 30 P =0.008 P =0.001 24% Rabbit IgG 22% Thymoglobulin Percent 15 P <0.0001 P =0.001 8% 7% 2% 1% CD4 + CD25 HI GITR CTLA-4 Foxp3 Adapted from Lopez M, et al . J Am Soc Nephrol. 2006

Other T cell Depleting and Non Depleting agents Other T cell Depleting and Non Depleting agents + T cells do not cause expansion of CD4 + + CD25 CD25 + T cells do not cause expansion of CD4 Campath-1H Basiliximab Daclizumab Lopez M, et al . J Am Soc Nephrol. 2006;17(10) Epub Aug 16.