Immunosuppressive strategies for improved long-term outcomes in
renal transplantation
Jeremy Chapman Centre for Transplant and Renal Research
Millennium InstituteUniversity of SydneyWestmead Hospital
SYDNEY
Immunosuppressive strategies for improved long-term outcomes in
renal transplantation
Jeremy Chapman Centre for Transplant and Renal Research
Millennium InstituteUniversity of SydneyWestmead Hospital
SYDNEY
Mortality
Two Log orders of improvement needed
One Log order of improvement needed
We have to do something differently
We have to do something differently
The timeline for destruction of a kidney
Tx
Interstitial FibrosisInterstitial FibrosisTubularAtrophy TubularAtrophy
AcuteRejectionAcuteRejection
IschaemiaIschaemiaSubclinical Rejection/Chronic Humoral Rejection Subclinical Rejection/Chronic Humoral Rejection
ArteriosclerosisArteriosclerosis
Chronic Donor Disease
Acute Donor Disease
Chronic Donor Disease
Acute Donor Disease
Arteriolar HyalinosisArteriolar Hyalinosis
CNI ToxicityCNI Toxicity
Glomerular SclerosisGlomerular Sclerosis
GR
AF
T L
OS
S
Rising Creatinine
Chapman JR et al. J Am Soc Nephrol 2005; 16: 3015–3026.
0
0.5
1
1.5
2
Mean Banff score
0 2 4 6 8 10
Years after transplantation
tubular atrophy (ct)
chronic interstitial fibrosis (ci)
CNI Toxicity
Allograft Rejection
The Problem simplified
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
EARLY
Symphony Study designSymphony Study design1645 patients, 15 countries1645 patients, 15 countries
TxTx 6 mo6 mo 12 mo 12 mo
DaclizumabDaclizumabLow-dose CsALow-dose CsAMMFMMFSteroidsSteroids
50–100 ng/ml50–100 ng/ml
Low-dose sirolimusLow-dose sirolimusMMFMMFSteroidsSteroids
DaclizumabDaclizumab4-8 ng/ml4-8 ng/ml
Low-dose tacrolimusLow-dose tacrolimusMMFMMFSteroidsSteroids
DaclizumabDaclizumab3-7 ng/ml3-7 ng/ml
150-300 ng/ml for 3 months150-300 ng/ml for 3 months100-200 ng/ml thereafter 100-200 ng/ml thereafter
Standard-dose CsAStandard-dose CsAMMFMMFSteroidsSteroids
Standard-Standard-CsA CsA
Low-Low-CsACsA
Low-Low-TacTac
Low-Low-SRLSRL
Biopsy Proven Acute Rejection Biopsy Proven Acute Rejection at 1 yearat 1 year(ITT, Excluding Borderline)(ITT, Excluding Borderline)
26%26%24%24%
12%12%
37%37%
p<0.0001p<0.0001
p<0.0001p<0.0001
00
1010
2020
3030
4040
5050
12 months post-Tx12 months post-Tx
BP
AR
(%
of
pa
tien
ts)
BP
AR
(%
of
pa
tien
ts)
Standard-dose CsAStandard-dose CsA
Low-dose CsALow-dose CsA
Low-dose TACLow-dose TAC
Low-dose SRLLow-dose SRL
Cummulative Meta analysis of Il2r versus placebo
Biopsy proven
rejection
episodes
Relative Risk.4 .5 .6 .8 1 1.2 1.4
Yussim 2004
Fangmann 2004
Bernarde 2004
Ekberg 2004
Sheashaa 2003
Ahsan 2002
de Boccardo 2002
Ponticelli 2001
Pisani 2001
Folkmane 2001
Davies 2000
DDT 1999
Kahan 1999
DTT 1998
Nashan 1997
IL2Ra v placebo: Graft loss or death at 6 m
2003 Meta analysis: 7 Trials, 1081 Participants
2006 update: 13 Trials, 2516 Participants
How long has graft survival benefit been evident?
• Cumulative
meta-analysis
1.4
1.6
1.8
2
0 2 4 6 8 10
1.4
1.6
1.8
2
0 2 4 6 8 10
YEARS BEYOND MAIN STUDY
log survival
T 1/2: 11.1 ys
T 1/2: 19.2 ysT 1/2: 15.8 ys
T 1/2: 7.8 ys
log survival
Half-Life Estimates in Patients without and with Acute Rejection
TACROLIMUS CYCLOSPORIN
p<0.05
p<0.05
Long term Evaluation of the European Multicenter Trial Comparing Tacrolimus and Cyclosporin
Messages:
• Early - Low Risk Pts – IL2r, Tacro, Mycophenolate, Steroids
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
EARLY
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
Beyond 3 Months
CAESAR study: higher rejection rate (13%) after CsA withdrawal at month 3
0.90.80.7
0.60.50.40.30.20.1
0.0
Ev
ent-
fre
e p
rob
ab
ility
0 60 120 180 240 300 360 420 480 540 600
Time (days)
A: Low /no CsA
B: Low CsA
C: Norm CsA
H Ekberg et al Caesar Study Group AJT 2007
CsA withdrawal
A v B and A v C at 12 months p < 0.05
BPAR (excluding borderline, ITT population)
∆ 13%
CsA too low? (100ng/ml)
IL-2 Ab
Pilot study with MMF, Steroids and Daclizumab – high rejection rate
Vincenti F et al. Transplantation 2001; 71:1282–7.
n = 98
Cu
mu
lati
ve in
cid
enc
e (%
)
Kaplan-Meier estimates
0
10
20
30
40
50
60
70
80
Time from transplantation to event (months)
0 1 2 3 4 5 6 7 8 9 10 11 12
48% after 6 Months
53% after 12 Months
BPAR
310 - Study Design
Sirolimus*
3 months + 2 weeks
Sirolimus* (>5 ng/mL) CsA (75-200 ng/mL)
Steroids
CsA Stopped
(25% per week)
+CsA
Sirolimus* (20-30 ng/mL < 1 yr) (15-25 ng/mL > 1 yr)
Steroids
+ Steroids
n=525
SRL+ CsAn=215
SRL n=215
DiscontinuedBefore randomizationn=95
*Tablets
3m
Incidence of First Biopsy-Confirmed Acute Rejection*
* Intent-to-treat analysis.
Months0 6 12 18 24 30 36 42 48
Acu
te R
ejec
tio
n (
%)
0
5
10
15
20
25
30
0
5
10
15
20
25
30
SRL SRL + CsARandomization
*Log Rank Test = 0.205
*SRL+CsA vs SRL
Acute Rejection RateKaplan-Meier Estimates
TREATMENT REGIMENSTREATMENT REGIMENS
125-250ng/mL
SRL 8-12ng/mL
Induction Phase Maintenance Phase
CsA6-8mg/kg/d
(+/- Induction per local standard)
50-100ng/mL 50-75ng/mL
13 52Week 22
SRL + CsA Minimization + CCS*
Taper 25%/week to off by month 4
17
125-250ng/mL
SRL + CsA Elimination + CCS*
SRL LD 6mg SRL MD 2mg
CsA6-8mg/kg/d
12-20ng/mLSRL 8-12ng/mL 10-20ng/mL
*CCS per local standard
SRL LD 6mg SRL MD 2mg
30
35
40
45
50
55
60
65
70
Day 5 Month 1 Month 3 Month 6 Month 9 Month 12
Minimization
Elimination
RENAL FUNCTION: NANKIVELL GFR* RENAL FUNCTION: NANKIVELL GFR*
(ON THERAPY)(ON THERAPY)
*p = NS for all comparisons (t test). ITT analysis at 12 mo: 49.5 vs 51.6 mL/min, Minimization (n=105) vs Elimination (n=102), p=0.603; GFR=0 for missing values, graft loss, or death.
Minimization, n = 105 100 94 83 74 71
Elimination, n = 100 94 85 71 67 65
44.2
61.1
GFR
, mL/
min
55.8 56.4 61.559.5
39.9
50.1
56.0
63.4 62.4 65.2
RATES OF GRAFT AND PATIENT SURVIVAL RATES OF GRAFT AND PATIENT SURVIVAL AND DISCONTINUATIONS AT 12 MONTHSAND DISCONTINUATIONS AT 12 MONTHS
Minimization Elimination p-Value*
ITT Population, n (%)Graft survival* 92/105 (87.6) 90/102 (88.2) 1.000
Graft survival, death censored
103/105 (98.1) 96/102 (94.1) 0.166
Patient survival 94/105 (89.5) 94/102 (92.2) 0.632
Discontinuations, n (%)
- adverse event
- lack of efficacy/graft loss
34/105 (32.4)
13/105 (12.4)
5/105 (4.8)
37/102 (36.3)
13/102 (12.8)
15/102 (14.7)
0.562
1.000
0.018
*Includes death with a functioning graft
12.4 12.414.3
16.7
21.6 22.5
0
5
10
15
20
25
30
Month 3 Month 6 Month 12
% B
CA
R
Minimization, n=105
Elimination, n=102
BIOPSY-CONFIRMED ACUTE REJECTION*BIOPSY-CONFIRMED ACUTE REJECTION*
n = 13 17 13 22 15 23
p=0.433
p=0.096 p=0.152
*ITT analysis
CONCEPT studyTransplantation
n = 235
Sirolimus (SRL) Neoral (CsA)
DACLIZUMAB+
MMF+
NEORAL+
STEROIDS
Week 12randomisation
n=192
Group An=95
Group Bn=97
STEROIDS WITHDRAWN AT MONTH 8
Lebranchu Y Am J Transplant 2009
Before randomisati
on
After randomisation
MMF + SRL
(n = 95)
MMF + CsA (n = 97)
Graft loss 3 1 (1%)
Death 1
Graft and patient survival
One year results
Lebranchu Y Am J Transplant 2009
6%
72%
3%
68%
78%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
W35 W39 W52
MMF+SRL (n=95)
MMF+CsA (n=97)
MMF + SRL MMF + CsA Total
Mean duration of treatment prior to steroid withdrawal (months)
8.6 ± 2.4 8.8 ± 2.0 8.7 ± 2.2
One year results
Corticosteroid withdrawal (ITT)%
of
pati
en
ts
Lebranchu Y Am J Transplant 2009
61.8±16.8 59.3
±13.6
67.3±14.2
60.3±14.4
30
40
50
60
70
Randomisation W52
SRL CsAp=0.004
p=ns
ml/m
in
One year results:Iohexol clearance
n=59 n=75
Lebranchu Y. Transplantation Proceedings 2008;40:S57–S59.
MMF + SRL (n = 95)
MMF + CsA
(n = 97)
P-value
BPAR (grade ≥1) Banff classification Grade I Grade II Grade III
17 / 16 (17%)
1700
10 / 8 (8%)
541
0.07
Acute rejection after randomisation
One year results
Lebranchu Y Am J Transplant 2009
75.9%
87.0%
16.7%
8.7%
3.7%1.5% 3.7% 2.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
< 0.5g 0.5 - 1 g 1 - 2 g > 2 g
MMF+SRL MMF+CsA
Proteinuria at one year (g/day)
Lebranchu Y Am J Transplant 2009
Spare The Nephron Trial design
Spare The Nephron Trial design
MMF + tacrolimus
MMF + cyclosporine
MMF + tacrolimus
MMF + cyclosporine
MMF + sirolimus
MMF + sirolimus
Post-randomization
Patient screening and enrollment
1 year 2 years
30 – 180
DAYS
POST-TX
Pre-randomization
Sirolimus2 to 10 mg loading dose Maintain trough levels of 5 to 10 ng/mL
Key exclusion criteria
• Corticosteroid-resistant, biopsy-proven acute rejection or treated for acute rejection with antibody therapy within 90 days prior to randomization
• Corticosteroid-sensitive acute rejection 30 days prior to randomization
• >1 biopsy-proven acute rejection prior to study entry• SCr >2.5 mg/dL or CrCl <30 mL/min (Cockroft-Gault) at
study entry• Total cholesterol levels >300 mg/dL or triglycerides >350
mg/dL
Randomized N=298
MMF/CNIN=150
MMF/SRLN=148
TacrolimusWithdrawal
N=122
CyclosporineWithdrawal
N=26
CyclosporineN=31
*81% received tacrolimus and 19% received cyclosporine
Patient allocation (ITT)*
TacrolimusN=119
Patient demographics
MMF/CNI
MMF/SRL N=148
TotalN=150
MMF/TACN=119
Sex, n (%)*
Male Female
93 (63%)55 (37%)
95 (63%)55 (37%)
75 (63%)44 (37%)
Ethnicity, n (%)*
Caucasian 74 (50%) 74 (49%) 58 (49%)
African American 48 (32%) 50 (33%) 40 (34%)
Other 26 (18%) 26 (17%) 21 (18%)
Age (years)*
Mean SD 48.7 12.9 48.7 12.7 48.4 12.5
*P = NS for MMF/SRL vs MMF/CNI and for MMF/TAC vs MMF/CsA
Baseline characteristics MMF/CNI
MMF/SRL N=148
TotalN=150
MMF/TACN=119
Type of donor, n (%)*
Living related 41 (28%) 38 (25%) 29 (24%)
Living unrelated 19 (13%) 21 (14%) 19 (16%)
Deceased donor 88 (60%) 91 (61%) 71 (60%)
PRA level (highest assessment), n (%)*
0% 93 (63%) 91 (61%) 70 (59%)
1-19% 31 (21%) 27 (18%) 24 (20%)
>20% 21 (14%) 27 (18%) 22 (19%)
Not known/missing 3 (2%) 5 (3%) 3 (3%)
Time posttransplant to randomization*
Mean ± SD, Days 113 ± 54 116 ± 49
*P = NS for MMF/SRL vs MMF/CNI and for MMF/TAC vs MMF/CsA
Induction therapy, n (%)
MMF/CNI
MMF/SRLN=151
TotalN=150
MMF/TACN=119
Antithymocyte globulin 53 (35%) 53 (35%) 44 (37%)
Basiliximab 35 (23%) 44 (29%) 32 (27%)
Daclizumab 20 (13%) 13 (9%) 8 (7%)
MMF/SRL MMF/CNI
Mea
n do
se (
mg)
± S
D
BaselineN=140 N=139
Post-Randomization 1 MonthN=114 N=129
6 MonthsN=116 N=123
12 MonthsN=122 N=112
Mycophenolate mofetil dose
Sirolimus trough levelsM
ean
siro
limus
con
cent
ratio
nng
/mL
(± S
EM
)
Day 7N=123
1 MonthN=112
6 MonthsN=104
12 MonthsN=102
Post-Randomization
Treatment failure, n (%)MMF/CNI
MMF/SRLN=148
TotalN=150
MMF/TACN=119
Treatment failure* 44 (30%) 35 (23%) 30 (25%)
Reason for treatment failure
Death 0 (0%) 2 (1%) 1 (1%)
Withdrawal due to AE 23 (16%) 10 (7%) 8 (7%)
Need to resume CNI 5 (3%) 0 (0%) 0 (0%)
Need to withdraw therapy 5 (3%) 11 (7%) 11 (9%)
Lost to follow-up 10 (7%) 12 (8%) 10 (8%)
Withdrew consent 1 (1%) 0 (0%) 0 (0%)
*Events are mutually exclusive; only the first event counted per patient*P = NS for MMF/SRL vs. MMF/CNI
Adverse events post-randomization in >10% of patients, n (%)
MMF/SRLN=148
MMF/CNIN=153
Diarrhea 50 (34%) 47 (31%)
Peripheral edema 39 (26%) 20 (13%)
Hyperlipidemia 35 (24%) 13 (8%)
Leukopenia 33 (22%) 29 (19%)
Anemia 23 (16%) 18 (12%)
Hypertension 23 (16%) 12 (8%)
Mouth ulceration 21 (14%) 0 (0%)
Hypokalemia 20 (14%) 6 (4%)
Upper respiratory tract infection 19 (13%) 16 (10%)
Cough 16 (11%) 16 (10%)
Serum creatinine increased 13 (9%) 31 (20%)
Urinary tract infections 20 (14%) 30 (20%)
Opportunistic infections 16 (11%) 27 (18%)
Efficacy outcomes, n (%)
MMF/CNI
MMF/SRL*N=148
Total*N=150
MMF/TACN=119
Biopsy-proven acute rejection 10 (7%) 9 (6%) 7 (6%)
Death 0 (0%) 3 (2%) 2 (2%)
Graft loss 3 (2%) 4 (3%) 3 (3%)
*P = NS for MMF/SRL vs. MMF/CNI
Baseline to month 12
N = 118 N = 109
0
5
10
15
20
25
30
35
Mea
n P
erce
nt
Ch
ang
e ±
SE
MMMF/SRL
MMF/CNI
7.8
Baseline GFRmL/min/1.7 m2 SEM 59.5 2.0 58.7 2.2
-5
P=0.013
25.7
Mean % change in measured GFR
Messages:
• Early - Low Risk Pts – IL2r, Tacro, Mycophenolate, Steroids
• 3-12 months– TOR inhibitors have a place
• Proteinuria <1gm/d
• GFR >40ml/min
• No SubClinical Rejection
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
Beyond 3 Months
CNI Toxicity
Allograft Rejection
The Problem simplified
Manage Toxicity
Manage Immune Response
Years
Late
Measuring renal function
020406080
100120140160180200
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
years
crea
tini
ne
0102030405060708090100
GF
R
Creatinine GFR
Adapted from Chapman JR et al. J Am Soc Nephrol 2005; 16: 3015–3026.
020406080
100120140160180200
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
years
crea
tini
ne
0102030405060708090100
GF
R
Creatinine GFR
Adapted from Chapman JR et al. J Am Soc Nephrol 2005; 16: 3015–3026.
SCR – Aza changed to
Mycophenolate
Measuring renal function
Smak Gregoor PJH, JASN 2002, 13(5): 1365-1373
Dutch study:high rejection rate after CsA withdrawal
at 6 months
Acute Rejection: MMF/Pred MMF/CsA TripleAfter 3 mo 14 (22%) 3 (4%) 1 (1.4%) >Banff I 9 1 0
No difference in renal function, better blood pressure after steroids stopped
• Rejection 16% (8% in the 1st yr) vs. 1% (p<0.002)• 5.7ml/min difference in renal function (p=0.05)
4 year follow up after CNI withdrawal in stable patients at 12-30 months
Graft loss and acute rejection renal function
Abramowicz, D. et al. J Am Soc Nephrol 2005;16:2234-2240
• Prospective randomized study (187 patients)
Abramowicz D et al. Transplantation 2002; 74:1725-34;
CNI withdrawal in renal transplant patients with stable renal function at 12-30 monthsstable renal function at 12-30 months
Triple therapy
CsA withdrawn
Rejection risk after CNI withdrawal with MMF depends on the time post-transplant
Tx
Pre-adaptation Post-adaptation Stable12 30
risk of AR Vincenti 53%
CAESAR +13%Dutch +22%
Abramowicz + 8% (16%)
Weir 2.5%Dudley 0%Suwelack 0%
Zeit
Messages:
• Early - Low Risk Pts – IL2r, Tacro, Mycophenolate, Steroids
• 3-12 months– TOR inhibitors have a place
• Late (?Too Late)– MMF/Pred is not enough for most patients– Individualise depending upon
• baseline therapy• pathology• function and proteinuria
Mortality
Cancer and heart disease are the main causes of death in the transplant population in Australia
0
10
20
30
40
50
60
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cancer
Cardiac
InfectionVascularOther Social
ANZDATA Registry, 2006
0%
20%
40%
60%
80%
100%
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Years Post Transplant
0%
20%
40%
60%
80%
100% Any Cancer Skin Non Skin Age-Matched Gen. Pop
Cancer Occurs in 80% of transplanted patients by 30
yearsPatients at Risk (8,881) Australia and NZ
2436
370
118
Cancer in CKD – Individual Cancers
•What are the Risk Factors?
•What is the Prognosis?
•How should we treat these patients
•How should we screen for these cancers
•What are the Risk Factors?
•What is the Prognosis?
•How should we treat these patients
•How should we screen for these cancers
All cancersUnspecifiedLeukaemia
Non-Hodgkin lymphomaHodgkin disease
ThyroidBrain
EyeTestis
ProstatePenisOvary
Corpus uteriCervix uteri
VulvaBreast
Connective tissueKaposi sarcoma
MesotheliomaMelanoma
LungLarynx
PancreasGallbladder
LiverAnus
RectumColon
Small intestineStomach
OesophagusSalivary gland
MouthTongue
Lip
.01 .1 1 10 100 1000 .01 .1 1 10 100 1000 .01 .1 1 10 100 1000
Prior to RRT During dialysis After transplantation
Site
SIR
All cancersUnspecifiedLeukaemia
Non-Hodgkin lymphomaHodgkin disease
ThyroidBrain
EyeTestis
ProstatePenisOvary
Corpus uteriCervix uteri
VulvaBreast
Connective tissueKaposi sarcoma
MesotheliomaMelanoma
LungLarynx
PancreasGallbladder
LiverAnus
RectumColon
Small intestineStomach
OesophagusSalivary gland
MouthTongue
Lip
.01 .1 1 10 100 1000 .01 .1 1 10 100 1000 .01 .1 1 10 100 1000
Prior to RRT During dialysis After transplantation
Site
SIR
All cancersUnspecifiedLeukaemia
Non-Hodgkin lymphomaHodgkin disease
ThyroidBrain
EyeTestis
ProstatePenisOvary
Corpus uteriCervix uteri
VulvaBreast
Connective tissueKaposi sarcoma
MesotheliomaMelanoma
LungLarynx
PancreasGallbladder
LiverAnus
RectumColon
Small intestineStomach
OesophagusSalivary gland
MouthTongue
Lip
.01 .1 1 10 100 1000 .01 .1 1 10 100 1000 .01 .1 1 10 100 1000
Prior to RRT During dialysis After transplantation
Site
SIR
PRE Dx POST Dx POST Tx
Months0 6 12 18 24 30 36 42 48 54 60
Fir
st
No
n-s
kin
Ca
rcin
om
a(%
Pa
tie
nts
)
0
2
4
6
8
10
12
0
2
4
6
8
10
12
*Log-Rank Test, p = 0.094
*SRL-CsA-ST vs SRL-ST
SRL-CsA-ST
SRL-STRandomization
Protocol Extension to 60 Months
Amendment toDiscontinue
SRL-CsA-ST PatientsA
Months0 6 12 18 24 30 36 42 48 54 60
Fir
st
No
n-s
kin
Ca
rcin
om
a(%
Pa
tie
nts
)
0
2
4
6
8
10
12
0
2
4
6
8
10
12
*Log-Rank Test, p = 0.094
*SRL-CsA-ST vs SRL-ST
SRL-CsA-ST
SRL-STRandomization
Protocol Extension to 60 Months
Amendment toDiscontinue
SRL-CsA-ST PatientsA Non skin
Months0 6 12 18 24 30 36 42 48 54 60
Ski
n C
ance
rs (
Eve
nts
)
0
20
40
60
80
100
120
0
20
40
60
80
100
120
SRL-CsA-ST
SRL-STRandomization
BRelative Risk = 0.346
(p < 0.001)
Months0 6 12 18 24 30 36 42 48 54 60
Ski
n C
ance
rs (
Eve
nts
)
0
20
40
60
80
100
120
0
20
40
60
80
100
120
SRL-CsA-ST
SRL-STRandomization
BRelative Risk = 0.346
(p < 0.001)
SkinMonths
0 6 12 18 24 30 36 42 48 54 60
Fir
st C
ance
r (%
Pat
ien
ts)
0
5
10
15
20
0
5
10
15
20
*Log-Rank Test, p = 0.010
*SRL-CsA-ST vs SRL-ST
SRL-CsA-ST
SRL-STRandomization
Protocol Extension to 60 Months
Amendment toDiscontinue
SRL-CsA-ST PatientsA
Months0 6 12 18 24 30 36 42 48 54 60
Fir
st C
ance
r (%
Pat
ien
ts)
0
5
10
15
20
0
5
10
15
20
*Log-Rank Test, p = 0.010
*SRL-CsA-ST vs SRL-ST
SRL-CsA-ST
SRL-STRandomization
Protocol Extension to 60 Months
Amendment toDiscontinue
SRL-CsA-ST PatientsAll Cancers
Sirolimus
3 months + 2 weeks
+CsA+ Steroids
N=525
SRL-CsA-STSRL-CsA-STn=215n=215
SRL-STSRL-ST n=215n=215
CONVERT Study:Significantly Lower Malignancy Rates
0.20.40.9
1.4
2.2
0
3.3
5.1
0
5
10SRL CNI
Total Skin PTLD All Others
p = 0.004
p = 0.019
p = 1.000
(n=555) (n=274)
p = 0.006Rat
e,%
The timeline for destruction of a kidney
Tx
Interstitial FibrosisInterstitial FibrosisTubularAtrophy TubularAtrophy
AcuteRejectionAcuteRejection
IschaemiaIschaemiaSubclinical Rejection/Chronic Humoral Rejection Subclinical Rejection/Chronic Humoral Rejection
ArteriosclerosisArteriosclerosis
Chronic Donor Disease
Acute Donor Disease
Chronic Donor Disease
Acute Donor Disease
Arteriolar HyalinosisArteriolar Hyalinosis
CNI ToxicityCNI Toxicity
Glomerular SclerosisGlomerular Sclerosis
GR
AF
T L
OS
S
Rising Creatinine
Chapman JR et al. J Am Soc Nephrol 2005; 16: 3015–3026.
Predict
&
Prevent
0
20
40
60
80
100
120
140
160
180
200
Direct Pathway(donor-specific)
300
350
400
Direct Pathway(Third Party)
Indirect Pathway(donor-specific)
Indirect Pathway(Third Party)
Elispots / 300,000 PBMC
p = 0.001
61.2 9.6
20 21
82 85
14.3 20
59% pos 60% pos
Circulating alloreactive T cellsCirculating alloreactive T cells
Bestard et al.J Am Soc Nephrol, 2008; 19: 1419-29
Direct pathway 3 times higher Direct pathway 3 times higher than indirect responsesthan indirect responses
0 100 200 300
Direct Elispot / 300,000 PBMC
1
2
3
4
5
Serum Creatinine (mg/dL)
r = 0.551, p = 0.001
Direct T-cell alloreactivity is related to graft function
NO (n=22)
YES (n=12)
Late Acute Rejection
0
50
100
150
200
250
300
350
Direct Elispot / 300,000 PBMC
p = 0.016
*
Bestard et al.J Am Soc Nephrol, 2008; 19: 1419-29
NO (n=19) YES (n=15)
Proteinuria
20
40
60
80
Indirect Elispots / 300,000 PBMC*
p = 0.022
Indirect pathway T-cell alloresponse is related to proteinuria and time after transplantation
12 24 36 48 60 72 84 96 108 120 132
Time after transplantation (months)
0
10
20
40
60
Indirect Elispots / 300,000 PBMC
80
r = 0.351, p = 0.045
Bestard et al.J Am Soc Nephrol, 2008; 19: 1419-29
cDNA details
B raw
1 month gene expression 3 month gene expression
Name M Adj. P B Name M Adj. P B
hemoglobin. beta 4.34 5.94E-07 14.59 hemoglobin. beta 4.63 2.58E-10 21.85
hemoglobin. alpha 2 3.86 5.94E-07 13.96 hemoglobin. alpha 2 3.78 1.85E-09 19.43
dual specificity phosphatase 1 -1.71 2.50E-06 11.99 collagen. type I. alpha 2 3.21 1.02E-07 15.33
cysteine-rich. angiogenic inducer. 61 -1.78 2.50E-06 11.97transforming growth factor beta-stimulated
protein TSC-22 -0.97 1.93E-07 14.48
51F12;No Annotation 0.79 8.29E-06 10.65 dual specificity phosphatase 1 -1.75 2.46E-07 14.02
mannose receptor. C type 1 0.81 1.69E-05 9.79 prostaglandin E receptor 3 -1.09 1.04E-06 12.34
collagen. type I. alpha 2 2.86 1.83E-05 9.36 spondin 2. extracellular matrix protein 1.23 1.04E-06 12.28
collagen. type III. alpha 1 (Ehlers-Danlos syndrome type IV) 3.05 1.83E-05 9.35 cysteine-rich. angiogenic inducer. 61 -1.95 1.04E-06 12.19
sushi-repeat-containing protein. X chromosome 1.29 1.83E-05 9.06collagen. type III. alpha 1 (Ehlers-Danlos
syndrome type IV) 3.25 1.92E-06 11.44
ribonuclease. RNase A family. k6 0.74 2.22E-05 9.05 early growth response 1 -2.36 1.92E-06 11.42
solute carrier family 21 (organic anion transporter). member 9 1.12 2.22E-05 8.99 von Willebrand factor 1.18 2.08E-06 11.25
early growth response 1 -2.29 2.34E-05 8.85 procollagen C-endopeptidase enhancer 1.36 4.67E-06 10.30
p53 regulated PA26 nuclear protein 0.66 3.56E-05 8.31 dermatopontin 2.22 4.67E-06 10.29
bridging integrator 1 0.80 3.14E-05 8.18 secreted frizzled-related protein 4 2.44 4.67E-06 10.25
gene for serine/threonine protein kinase -0.99 4.07E-05 8.07 BTG family. member 3 -0.57 5.81E-06 9.97
glycoprotein 2 (zymogen granule membrane) -0.58 4.07E-05 8.06 collagen. type VI. alpha 2 0.93 8.78E-06 9.51
cartilage intermediate layer protein. nucleotide pyrophosphohydrolase 1.78 6.45E-05 7.53 Microfibril-associated glycoprotein-2 2.64 9.60E-06 9.34
zinc finger protein 145 (Kruppel-like) 1.13 6.90E-05 7.44chondroitin sulfate proteoglycan 2
(versican) 1.31 9.60E-06 9.25
sialyltransferase 1 (beta-galactoside alpha-2.6-sialytransferase) -1.10 6.90E-05 7.35 matrix metalloproteinase 23B 1.04 9.60E-06 9.21
Up
2-fold
Down
2-fold
1mth
CAN 3mth
Normal 3mth
1mth Gene expression 3mth “normal” gene expression
3mth “CAN” gene expression
6
2
245
232 genes 138 genes
65 genes
25
1
6
39
4
61
17
70
12
3
0
4
25
22
9
33
Up
2-fold
Down
2-fold
1mth
CAN 3mth
Normal 3mth
1mth Gene expression 3mth normal gene expression
3mth CAN gene expression
6
2
245
232 genes 138 genes
65 genes
25
1
6
39
4
61
17
70
12
3
0
4
25
22
9
33
Fingerprint?
PBTs predictive of Rejection
Cytotoxic T cell and Interferon PBT correlate with rejectionAnd associated with markers of Tubular Injury
Phil Halloran
PBTs for T-cell mediated, antibody mediated and mixed rejection were similar
ATAGCATAGC
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
i-Banff Banff t-score i-IFTA IFTA nodular
% c
on
trib
uti
on
not otherwise annotated
Endothel activation
B-cell / Ig associated
Injury and repair associated
Kidney parenchyma associated
Macrophage associated
Interferon-γ dependent
T-cell associated
IFTA correlates with different genes than i IFTA correlates with different genes than i and t scoresand t scores
484 probesets
249 probesets
172 probesets
34 probesets
202 probesets
*cut off: r>0.4, p<0.001
Vancouver 2010
Vancouver 2010