monitoring hla- specific antibodies matthew j. everly, pharmd, bcps one lambda inc. in patients...

Monitoring HLA-specific antibodies

Matthew J. Everly, PharmD, BCPSOne Lambda Inc.

In patients undergoing desensitization

Monitoring HLA-specific antibodies

Matthew J. Everly, PharmD, BCPSOne Lambda Inc.

In all transplant patients

In all transplant patients

Preformed anti-HLA DSA+ Patient

Screening De Novo anti-HLA DSA

Monitoring Removal of anti-HLA DSA

What we know about donor specific anti-HLA antibodies …

in transplant patients

Donor Specific

Anti-HLA Antibodies

allograft rejection

allograft failure=

What we do not know …

How to monitor anti-HLA DSA?

How to treat anti-HLA DSA?

Transplant PatientDSA + at Transplant DSA - at Transplant

DSA + at Transplant“Preformed DSA”

DSA - at Transplant

≥35% Acute Antibody Mediated Rejection

Dunn et al. Am J Transplant 2011;11:2132

Up to 15% 1- year Graft Failure Rate (non-desensitized)

Lefacheur et al. Am J Transplant 2008;8:324

DSA + at Transplant“Preformed DSA”

DSA - at Transplant

<5% Acute Antibody Mediated Rejection

Dunn et al. Am J Transplant 2011;11:2132

De novo anti-HLA DSA in the first yearAnd beyond

Everly et al. Am J Transplant 2012; In submissionSmith et al. Am J Transplant 2011;11:312

Preformed DSA PatientAnti-HLA

Major concern with preformed anti-HLA DSA is the associated AMR Risk

Pre

form

ed D

SA

Pat

ient

Amico et al. Transplantation 2009;87:1681

DSA+ at Transplant with AMR (n=37)

Pre

form

ed D

SA

Pat

ient

Lefaucheur et al. Am J Transplant 2008;8:324

DSA+ AMR+, n=21

DSA + (no AMR), n=22

DSA – (at transplant)

n=194

DSA Associated AMR riskis not uniform over the post-transplant period

Gloor et al. Am J Transplant 2010;10:582

119

Positive Crossmatch

Pre

form

ed D

SA

Pat

ient

Pre

form

ed D

SA

Pat

ient

DSA+ high MFISum >10,000 MFI (n=66)

DSA+ low MFI Sum 5,000-10,000 (n=16)

DSA- (n=12)

Gloor et al. Am J Transplant 2010;10:582

DSA+ low MFI Sum 0 - 5,000 MFI (n=23)

Amico et al. Transplantation 2009;87:1681

334 Negative CDC Crossmatch

67 (20%)Anti-HLA DSA +Pre-Transplant

Aims:

What is the clinical relevance of preformed DSA?

What anti-HLA DSA characteristics are predictive of DSA?

Pre

form

ed D

SA

Pati

ent

Pre

form

ed D

SA

Pati

ent

Amico et al. Transplantation 2009;87:1681

Lefaucheur et al. Am J Transplant 2008;8:324

237Negative T- & B-CellCDC Crossmatch

194 (82%)Anti-HLA DSA -Pre-Transplant

43 (18%)Anti-HLA DSA +Pre-Transplant

Pre

form

ed D

SA

Pati

ent

Pre

form

ed D

SA

Pat

ient

DSA+ high MFI

DSA+ low MFI

DSA-

Lefaucheur et al. Am J Transplant 2008;8:324

13/21 (62%) of AMR in first 45 days post-transplant

Dunn et al. Am J Transplant 2011;11:2132

587 patients CDC XM- with single antigen bead

testing at transplant

Pre

form

ed D

SA

Pati

ent

Pre

form

ed D

SA

Pati

ent

DSA+ high MFI

DSA+ low MFI

DSA-

Dunn et al. Am J Transplant 2011;11:2132

DSA+

3rd party HLA+ or Neg.

Pre

form

ed D

SA

Pat

ient

Gloor et al. (n=49) Lefaucheur et al. (n=21) Dunn et al. (n=46)

7.5 days

16.5 days

16days

Median Time to Acute Antibody Mediated Rejection

Can monitoring identify the preformed anti-HLA DSA patients at

risk of AMR ?

Burns et al. Am J Transplant 2008;10:2684

70Positive Crossmatch

Pre

form

ed D

SA

Pat

ient

41High anti-HLA DSA

(Flow Channel Shift >300)

29Low anti-HLA DSA

(Flow Channel Shift <300)

Pre

form

ed D

SA

Pat

ient

Low DSA, NO AMR

High DSA, NO AMR

Low DSA, AMR+

High DSA, AMR+

Burns et al. Am J Transplant 2008;8:2684

116 Flow Negative Crossmatch, but DSA Positive

Pre

form

ed D

SA

Pati

ent

Clinical Transplants 2011. In Press

Pre

form

ed D

SA

Pati

ent

Possible DSA Monitoring Time Points

Pre-Transplant, Day of Transplant

1 week

2 weeks

4 weeks

8 weeks

Pre

form

ed D

SA

Pat

ient

DSA+ high MFI

DSA+ low MFI

DSA-

Gloor et al. Am J Transplant 2010;10:582

DSA+ high MFISum >10,000 MFI (n=66)

DSA+ low MFI Sum 5,000-10,000 (n=16)

DSA- (n=12)

DSA+ low MFI Sum 0 - 5,000 MFI (n=23)

?

Transplant Glomerulopathy Risk

47% of XM+ AMR+ Patients

41% of XM+ AMR- Patients

Gloor et al. Am J Transplant 2010;10:582

Pre

form

ed D

SA

Pat

ient

Kidney Int 2011;10:582

69 patients Flow Positive Crossmatch

33Group 1

Convert to Flow XM -

15Group 2

Remain Flow XM +

11 excluded no DSA, or not clear group

Pre

form

ed D

SA

Pat

ient

Group 1 Group 2

Group 2

Group 1

Kimball et al. Kidney Int 2011;10:582

Pre

form

ed D

SA

Pat

ient Monitoring Time Points

Pre-Transplant, Day of Transplant

1 week

2 weeks

4 weeks

8 weeks

6 months

12 months

After 12 months ?

* If patient’s DSA remain persistently positive – treatment may be useful to improve outcomes.

Wit

h f

or

cause

bio

psy

Rationale to monitor DSA

Preformed DSA

Identify a patient

1. at risk of AMR2. at risk of Chronic Antibody

Damage3. 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

<5%>35%

DSA+ high MFI

DSA+ low MFI

DSA-

Scr

eeni

ng fo

r D

e N

ovo

DS

A

Gill et al. Transplantation 2010;89:178

Rationale to monitor DSA

De Novo DSA

Identify a patient

1. at risk of AMR2. at risk of Chronic Antibody

Damage3. who should receive treatment

for Antibodies

Everly et al. Am J Transplant. 2012; In SubmissionRebellato et al. Clinical Transplants 2011; In Press

East Carolina University (Rebellato et al.)

DSA +De N

ovo

An

ti-H

LA6227%

Everly et al. Am J Transplant. 2012; In SubmissionRebellato et al. Clinical Transplants 2011; In Press

0.000.100.200.300.400.500.600.700.800.901.00

0 1 2 3 4 5 6 7 8 9 10 11 12

Year Post-transplant

10%3-4%

De

Nov

o D

SA

Inci

denc

e

Everly et al. Presented at American Transplant Congress 2011, PhiladelphiaEverly et al. Am J Transplant 2012. In Submission

patients transplanted between 1995-2004 who had survived more than one year243

19224patients excludedDSA positive at the time of transplant

51173HLA Abs

patients with no HLA Abs

11756de novo DSA (25%)

NDSA (52%)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?

05

1015202530354045

1 2 3 4 5 6 7 8 9 10 11

% D

SA

+v

e p

ati

en

ts

Year of DSA appearance

22

6 63 1

51

72%

N=57

13

Smith J et al. Am J Transplant. 2011;11:312-9

0

10

20

30

40

50

60

70

80

90

100

Per

cent

Allo

graf

t Sur

viva

l

0 12 24 36 48 60

Months after DSA Appearance

De novo anti-HLA DSA Positive (n=62)

15%

28%

42%

Everly et al. Am J Transplant 2012. In Submission

0.000.100.200.300.400.500.600.700.800.901.00

0 1 2 3 4 5Year from DSA to CAV or Graft Loss (GL)

What is the risk for heart failure after de novo anti-HLA DSA appears?

24%

37%

20%probability

of failure

n=51

Pro

port

ion

Su

rviv

ing

5 patients develop DSA after CAV:4 CII Abs, 1 both classes of Abs

Smith J et al. Am J Transplant. 2011;11:312-9

Rationale to monitor DSA

De Novo DSA

Identify a patient

1. at risk of AMR2. at risk of Chronic Antibody

Damage3. who should receive treatment

for Antibodies

Scr

eeni

ng fo

r D

e N

ovo

DS

A

Monitoring Time Points

Pre-Transplant

1 week

2 weeks

4 weeks

8 weeks

6 months

12 months

Biannually after 1 year

Wit

h f

or

cause

bio

psy

Removing DSAIn Acute Antibody Mediated Rejection

Reduction of Donor Specific Antibody Levels Prevents Renal Allograft Loss

p = 0.043 (Log-Rank)

Statistically significant at the α = 0.05 level

Time from Transplantation (Months)

0 6 12 18 24 30 36 42 48 54 60 66 72

Por

por

tion

of A

llogr

afts

Su

rviv

ing

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0DSA Reduction > 50%(N = 6; NO Allografts Lost)

DSA Reduction < 50%(N = 10; 7 Allografts Lost)

University of Cincinnati, Cincinnati, OHEverly et al. Am J Transplant 2009;9:1-9

Log Rank p=0.021

Antibody Reduction Responders (n=7, NO Allograft Loss)

Antibody Reduction Non-Responders(n=23, 12 Allografts Lost)

Log-rank p=0.033

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nt

All

og

raft

Su

rviv

al

0 12 24 36 48 60 72 84 96

Months after Transplantation

Brody Medical School at Eastern Carolina University, Greenville, NCEverly, et al. Transplantation.

Lefaucheur et al. Am J Transplant 2009;9:1099

Despite Histologic Improvements …

Antibody removal after AMR improves outcomes

Removing DSAIn patients with preformed DSA

Impact of proteasome inhibitor on anti-donor HLA antibody production after kidney transplantation

Mayo Clinic Trial – Mark Stegall M.D.

Rem

ovin

g D

SA

2 cycles of bortezomib … wait 2 months … possible 2 more cycles of bortezomib

Rem

ovin

g D

SA

Kimball et al. Clinical Transplants 2011; In press

IVIg + plasmapheresis 3 times per weekFor 2 weeks

Rem

ovin

g D

SA

Kimball et al. Clinical Transplants 2011; In press

In the patient with persistent preformed anti-HLA DSA positive …

Antibody removal may improve outcomes

Removing DSAIn patients with stable allograft function

Hachem et al. J Heart Lung Transplant 2010;29:973

Rem

ovin

g D

SA

61 lung transplant patients Serial single antigen bead

testing after transplant

61

All DSA positive

All preemtive treatment

IVIg for at least 6 months(+/- Rituximab)

Patients in 2011

Hachem et al. J Heart Lung Transplant 2010;29:973

Rem

ovin

g D

SA

Everly et al. Transplantation 2012; In Press.

Rem

ovin

g D

SA

26

All DSA positive

All preemtive treatment

All with no dysfunction at DSA appearance

Patients in 2011

26 DSA Class II Alone

50% (n=13)

DSA Class I Alone

23% (n=6)

Both DSA Classes

27% (n=7)

- 65% of patients had ONLY a single DSA positive at the time of treatment

- 39% of class II were DQ DSA

Male Gender 24 (92)

Age at Transplant 29.3 ± 9

# of HLA mismatch 2.9 ± 1.4

Bortezomib on days 1, 4, 8, 11 Plasmapheresis (n=14) on same days with bortezomib

Rituximab (n=9) single doseCorticosteroid pulse – (all patients)

Bortezomib Alone(n=11)

Txp DSA(MFI > 1000)

85 days (median time to DSA – range from 6 - 536)

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

2 – Less than 50% reduction in DSAmax MFI

Median time to 50% reduction 37 days

Rem

ovin

g D

SA

Remission (n=8)

Relapsed (n=10)

Partial/No Response (n=8)(only a 50% reduction)

MedianSerum Creatinine Change from Start of

Treatment to last follow-up

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 DSA

Improves Outcomes

Problem with Treating anti-HLA DSA

RemissionRefractory

Relapse

Rem

ovin

g D

SA

“ A rapid partial response (50% reduction of DSAmax with 1 month of treatment was associated with a complete response”

DSA-

Whe

n R

emov

ing

DS

A

Post-Treatment Monitoring Time Points

Prior to start of treatment

1 month(possibly 2 months if not using plasmspheresis)

Refr

act

ory

Rem

issi

on

Continued monitoring if

continued treatment

At 3 & 6 months then every 6

months

Relapse ?

Summary

Nearly All transplant patients can benefit for some degree of monitoring …

Pre

form

ed D

SA

Pati

ent

Amico et al. Transplantation 2009;87:1681

AMR Appears Early

Pre

form

ed D

SA

Pat

ient

Burns et al. Am J Transplant 2008;8:2684

Monitoring Early Identifies those AT RISK of AMR

Pre

form

ed D

SA

Pat

ient

Group 1 Group 2

Group 2

Group 1

Kimball et al. Kidney Int 2011;10:582

Monitoring Late Identifies those AT RISK of Failure

Pre

form

ed D

SA

Pat

ient

Monitoring Time Points

Pre-Transplant

1 week

2 weeks

4 weeks

8 weeks

6 months

12 months

After 12 months, annually

Wit

h f

or

cause

bio

psy

Everly et al. Presented at American Transplant Congress 2011, PhiladelphiaEverly et al. Am J Transplant 2012. In Submission

De novo anti-HLA DSA appears at

any time post transplant & Identifies those AT RISK of Failure

Scr

eeni

ng fo

r D

e N

ovo

DS

A

DSA-

Scr

eeni

ng fo

r D

e N

ovo

DS

A

Monitoring Time Points

Pre-Transplant

6 months

12 months

Annually after 1 year Wit

h f

or

cause

bio

psy

RemovingDSA

Improves Outcomes

DSA Relapse

DSA Relapse

DSA-

Whe

n R

emov

ing

DS

A

Post-Treatment Monitoring Time Points

Prior to start of treatment

1 month(possibly 2 months if not using plasmspheresis)

Refr

act

ory

Rem

issi

on

Continued monitoring if

continued treatment

At 3 & 6 months then every 6

months

Relapse ?

Thank You

meverly@terasakilab.org