Monitoring HLAspecific antibodies In patients undergoing desensitization Matthew

Monitoring HLAspecific antibodies In patients undergoing desensitization Matthew J. Everly, Pharm. D, BCPS One Lambda Inc.

Monitoring HLAspecific antibodies In all transplant patients Matthew J. Everly, Pharm. D, 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 - year. Antibody 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 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 Am. JJTransplant 2011; 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 3 rd 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 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

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 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

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 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 Preformed DSA 1. at risk of AMR 2. at risk of Chronic Antibody Damage 3. who should receive treatment for Antibodies

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+ 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 51 patients with no HLA Abs 56 de novo 117 NDSA (52%) HLA Abs DSA (25%) NDSA= non donor-specific antibody Smith J et al. Am J Transplant. 2011; 11: 312 -9

When do HEART TRANSPLANT patients develop de-novo DSA? 72% N=57 22 13 6 6 3 5 1 1 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 Months after DSA Appearance 60 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% 24% probability of failure 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, OH Everly et al. Am J Transplant 2009; 9: 1 -9 100 Antibody Reduction Responders (n=7, NO Allograft Loss) Log Rank p=0. 021 Percent Allograft Survival 90 80 70 Log-rank p=0. 033 60 50 40 30 20 Antibody Reduction Non-Responders (n=23, 12 Allografts Lost) 10 p = 0. 043 (Log-Rank) Statistically significant at the α = 0. 05 level 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

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 26 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 # of HLA mismatch 24 (92) 29. 3 ± 9 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) 6. 5% Scr Increase 41% Scr Increase 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 anti. HLA 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- 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 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 Relapse Removing DSA 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- At 3 & 6 months then every 6 months Relapse ?

Thank You meverly@terasakilab. org