Tuesday, January 26, 2010

B cell agents in Transplantation

A nice review in recent CJASN highlights the use of anti CD20 and other novel b cell agents in transplantation.
The paper actually reviews all of glomerular diseases and transplantation.
Few things about use of B cell agents in Transplantation
1. Use of Rituximab is increasing more and more with desensitizing protocols for ABOI and + DSA patients. Is it a combination of IVIG, Pheresis and Rituximab that really works or is one better than the other, no studies have confirmed that? Although IVIG alone has not been affective.  Hence, it might be an additive effect.
2. Use of anti CD20 in antibody mediated rejection has become an increasingly used agent.  This stems from a simple concept that antibodies are produced by B cells and hence depleting the B cells will deplete the production of antibodies.
3. Bortezomib, has been now used as well in refractory antibody mediated rejection and in biopsies that have enriched plasma cells.  Total IgG were unchanged in those patients treated, so we don't know if this is a one time effect and or long lasting and also there is potential increased risk for infectious complications.
I think we shall see more and more of these agents used for treating transplant patients in the future.
We have to be careful as there are Regulatory B cells and what we are doing to those B cell clones, we don't exactly know!

Clinical Transplantation: KDIGO Transplant Guidelines

The Feb 2010 issue of Kidney International has summarized the KDIGO clinical practice guidelines for kidney transplant recipients. Its a very brief and to the point summary to standardize transplant care all around the globe. Things we always talked about as transplant physicians and wondered were all discussed and laid down as what should be done and what is the grade of evidence behind it.
For induction, for instance, they recommend( Grade 1B) that an IL2 -RA be used as first line agent and antilymphocyte depleting agent to be used for all kidney transplant with immunologic risk( Grade 2B)
Also, interesting to note that there is Grade2B evidence and they suggest that in patients who are at low immunological risk and who receive induction therapy, corticosteroids could be discontinued during the first week after transplantation. Other concepts on BK treatment, Bone disease, CMV, Cancer and rejection. All are discussed. I think its a good start and an essential read for all of us.