Pathophysiological role of B cells and the therapeutic potential of anti-CD20 in chronic renal allograft rejection

Lead Research Organisation: King's College London
Department Name: Immunology Infection and Inflam Diseases

Abstract

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Technical Summary

A significant cause of renal allograft failure is ‘chronic rejection‘ (CR), the pathophysiology of which is incompletely understood. Some patients (20-30%) develop anti-HLA antibodies before CR and it has been assumed that these antibodies cause the rejection. However, this assumption may not be correct. This project will clarify the relevance of anti-HLA antibodies after kidney transplantation, determine their relationship with CR, and undertake a pilot study of anti-CD20 therapy in these patients. Hypotheses: a) In CR, development of anti-HLA antibodies may indicate two types of damage, both linked by a role for B cells in pathophysiology; the antibody may be causing chronic humoral rejection or it may be a marker for a T cell-mediated process, with B cells playing a critical role in the presentation of graft antigens. b) However, anti-HLA antibodies may also be associated with transplant ‘accommodation‘ - this, rather than CR, is expected if patients develop low-titre anti-HLA antibodies and maintain effective mechanisms to regulate indirect T cell alloresponses. b) Targeting B cells using anti-CD20 therapy in patients with CR but not accommodation may help prevent graft loss. Aims and Methods: a) I will define, using FlowPRA , a subgroup of renal transplant patients who have anti-HLA atibodies and deteriorating graft function. Blood will be analysed to determine antibody specificity, and to assess whether B lymphocytes play a role as antigen presenting cells in indirect T cell alloresponses. A renal biopsy will be analysed for features of CR, C4d staining, B cell/plasma cell infiltration and T cell mediated rejection. b) A small number of patients with anti-HLA antibodies are expected to have stable graft function. Differences between these patients and those in group a) will be examined. In particular, the titres of antibodies and strength of indirect T cell responses will be analysed. A long-term follow-up study in these patients will be initiated. c) Patients with anti-HLA antibodies and deteriorating graft function will be offered anti-CD20 therapy. They will be followed up for 2 years, assessing for evidence of side-effects, changes in anti-HLA antibodies, stabilisation of transplant function and changes in strength of alloreactive T and B cell function. This study should lead to a greater understanding of the role of antibodies and B cells in CR and accommodation. This work is expected to eventually improve the prognosis of patients with failing grafts, thus having a significant impact on the lives of all renal transplant recipients.
 
Description KRUK
Amount £180,000 (GBP)
Organisation Kidney Research UK 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2011 
End 01/2014
 
Description MRC Extension and Supplement
Amount £56,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 02/2011 
End 02/2012
 
Description Optimized TracrolimuS and MMF for HLA Antibodies after Renal Transplantation (the OuTSMART study)
Amount £2,362,494 (GBP)
Funding ID EME/11/100/34 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 04/2013 
End 10/2019
 
Title Modified ELISPOT Assay 
Description This modified assay has been developed, and has been shown to be predictive of future graft outcome and may also indicate those who are responsive to therapy. 
Type Of Material Technology assay or reagent 
Provided To Others? No  
Impact Abstracts are being submitted for public dissemination early in 2012. This assay has been further tested in other groups of patients. The results have been communicated with clinicians and scientists, raising the level of debate on whether it is rational to target antibodies in chronic rejection. 
 
Description Novartis 
Organisation Novartis
Department Transplantation & Immunology
Country Switzerland 
Sector Private 
PI Contribution We used our stored peripheral blood samples, from healthy volunteers and renal transplant patients, to analyse using methods discussed and optimised with their assistance.
Collaborator Contribution They not only contributed financially with an unrestricted educational grant, but made suggestions for testing the samples, and have contributed with technical support and advice. We hope this will continue to be a productive collaboration in the future.
Impact The work that has been done, by a research assistant funded by their contribution is preliminary, but certainly indicates that the IFNgamma produced in response to donor antigens, appears to be predominantly made by CD4+ T cells, although there is also a minor contribution from B cells in some patients. In addition, IL10 production appears to occur in a number of samples. It will be used as a pilot for further work.
Start Year 2011
 
Description Roche Global/ Organ Transplant Research Fund 
Organisation F. Hoffmann-La Roche AG
Country Global 
Sector Private 
PI Contribution This funding is supporting the costs of additional laboratory science which were not covered by the consumables allowance provided by the MRC: it will support the costs of serial testing of anti-HLA testing in stable patients and those with de-novo antibodies who are not entered into the RituxiCAN-C4 trial, serial testing for non-HLA antibodies, and additional costs incurred in analysis of the role played by B cells and T reg cells in the in vitro T cell responses. It will also allow more detailed histological evaluations of renal transplant biopsies. This has extended the scope of my research, to be able to analyse the antibody status and evaluate the functional assay in more detail for individuals as well as in a broader range of patients.
Collaborator Contribution Roche are providing the Rituximab for the trial patients.
Impact Prior to an introduction of a clinically funded anti-HLA testing programme in post-transplant patients at the Hammersmith Hospital, this support has allowed us to begin testing patients from an early stage in the research project.
Start Year 2007
 
Description Roche Global/ Organ Transplant Research Fund 
Organisation Roche Organ Transplantation Research Foundation (ROTRF)
Country Switzerland 
Sector Charity/Non Profit 
PI Contribution This funding is supporting the costs of additional laboratory science which were not covered by the consumables allowance provided by the MRC: it will support the costs of serial testing of anti-HLA testing in stable patients and those with de-novo antibodies who are not entered into the RituxiCAN-C4 trial, serial testing for non-HLA antibodies, and additional costs incurred in analysis of the role played by B cells and T reg cells in the in vitro T cell responses. It will also allow more detailed histological evaluations of renal transplant biopsies. This has extended the scope of my research, to be able to analyse the antibody status and evaluate the functional assay in more detail for individuals as well as in a broader range of patients.
Collaborator Contribution Roche are providing the Rituximab for the trial patients.
Impact Prior to an introduction of a clinically funded anti-HLA testing programme in post-transplant patients at the Hammersmith Hospital, this support has allowed us to begin testing patients from an early stage in the research project.
Start Year 2007
 
Title OuTSMART - Optimized TacrolimuS and MMF for HLA Antibodies after Renal Transplantation 
Description This is a UK multicentre randomised controlled clinical trial to determine if a combined screening /treatment programme can prevent premature failure of renal transplants due to chronic rejection in patients with HLA antibodies. The aim is to identify and treat established kidney transplants that are at risk of developing problems and of failing more quickly than average. It builds upon the knowledge that a biomarker called 'HLA antibodies', which can be detected in the blood, identifies patients at risk of these problems, and tests the idea that optimising the doses of new immunosuppressive drugs can prevent these problems from developing and prevent transplants from failing. As part of this study we are also investigating the health impact and economic benefits of screening and diagnosis. The trial finished recruitment of >2100 patients in October 2016 and will finish follow-up in 2019. It arose directly from the work performed under this MRC award. It has been funded by an NIHR award. 
Type Therapeutic Intervention - Drug
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2012
Development Status Closed
Clinical Trial? Yes
Impact I am the Principal Investigator for the Royal Free Hospital, which after joining this study was instrumental in helping it achieve the number of required trial recruits. 
URL http://www.isrctn.com/ISRCTN46157828
 
Title RituxiCAN-C4 Trial 
Description This is a clinical trial, to evaluate the effectiveness of rituximab in C4d+ chronic allograft rejection, or C4d- chronic antibody-mediated rejection. Ref: EUDRACT 2006-002330-38 Primary objective; To determine whether anti-CD20 therapy can stabilize or improve renal function and/or proteinuria in patients with C4d+, chronic (humoral) rejection in whom standard therapeutic approaches have failed. 
Type Therapeutic Intervention - Drug
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2006
Development Status Closed
Clinical Trial? Yes
Impact This trial closed in April 2017 with 62 participants (less than the planned recruitment target). Publication of the results is planned. 
URL http://clinicaltrials.gov/show/NCT00476164
 
Description Frontiers In Transplantation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact 2 day meeting, with invited international speakers. Debate and discussion regarding development of research in transplantation.
Year(s) Of Engagement Activity 2013,2015
 
Description Frontiers in Transplantation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact My supervisor continues to be one of the organisers of this course, held at King's College London, but with a UK and European audience. 50-80 (numbers are rising) health professionals, including young medical trainees, nurses and doctors, as well as researchers attend this full 2 day course which recurs each year, In 2011 and 2012, this included a presentation by my supervisor - he presented the work done from this fellowship, which led to discussion of xeno- and allotransplantation. I attended, and also presented a poster at the meeting in 2011. In 2013, I was the invited speaker and presented "Mechanism of Chronic Rejection", including background and the research funded by this award.

Attendees have given excellent feedback, every year, and the audience numbers have grown year on year. Most have stated that they would recommend the course to others and would be interested in similar courses in future.
Year(s) Of Engagement Activity 2011,2012,2013
 
Description Miltenyi Biotec - Meeting in Stratford 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This was mainly attended by health professionals and researchers in the field of haematology / oncology / bone marrow transplantation. I presented my work, on behalf of my supervisor.

Several haematology/oncology consultants and researchers have expressed a particular interest in my research, after I presented.
Year(s) Of Engagement Activity 2011
 
Description Multicentre Trial Collaborator Meetings 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Type Of Presentation Workshop Facilitator
Geographic Reach National
Primary Audience Health professionals
Results and Impact Annual meetings (and sometimes additional mid-year meetings at external sites, as needed) to discuss with current and potential collaborators from UK transplant centres: information regarding the trial itself, the science behind the trial and preliminary data are presented.

A total of 12 centres are now recruiting to the multicentre RituxiCAN-C4 trial. We have expanded interest in the trial in this way, as well as developed interest and support for a further multi-centre clinical trial (OuTSMART), which has gained NIHR funding (see Funding section).
Year(s) Of Engagement Activity 2008,2009,2010,2011,2012,2013
 
Description Transplant Research Group Seminar 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Mainly hospital consultants and registrars interested in renal transplantation, but also laboratory scientists in tissue typing and pharmacists. 1 hour seminar.

This seminar led to the introduction of regular screening for anti-HLA antibodies post-renal transplant, at 3 monthly intervals for the first year, and then yearly.
Year(s) Of Engagement Activity 2008
 
Description Trial Newsletter 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact We have produced a Trial Newsletter, to disseminate information to the Clinicians responsible for the recruitment and management of patients with chronic rejection.

This has increased the number of participating trial centres to 8 (12 as of 2013), and has also aided the awareness of clinicians of the importance of chronic rejection, with more centres becoming interested in the research.
Year(s) Of Engagement Activity 2009,2010,2011,2012