Safety, immunogenicity, pharmacokinetics, and efficacy of degradation of anti-HLA antibodies by IdeS (imlifidase) in chronic kidney disease patients

Tomas Lorant, Mats Bengtsson, Torsten Eich, Britt-Marie Eriksson, Lena Winstedt, Sofia Järnum, Yvonne Stenberg, Anna-Karin Robertson, Kristina Mosén, Lars Björck, Lars Bäckman, Erik Larsson, Kathryn Wood, Gunnar Tufveson, Christian Kjellman, Tomas Lorant, Mats Bengtsson, Torsten Eich, Britt-Marie Eriksson, Lena Winstedt, Sofia Järnum, Yvonne Stenberg, Anna-Karin Robertson, Kristina Mosén, Lars Björck, Lars Bäckman, Erik Larsson, Kathryn Wood, Gunnar Tufveson, Christian Kjellman

Abstract

Safety, immunogenicity, pharmacokinetics, and efficacy of the IgG-degrading enzyme of Streptococcus pyogenes (IdeS [imlifidase]) were assessed in a single-center, open-label ascending-dose study in highly sensitized patients with chronic kidney disease. Eight patients with cytotoxic PRAs (median cytotoxic PRAs of 64%) at enrollment received 1 or 2 intravenous infusions of IdeS on consecutive days (0.12 mg/kg body weight ×2 [n = 3]; 0.25 mg/kg ×1 [n = 3], or 0.25 mg/kg ×2 [n = 2]). IgG degradation was observed in all subjects after IdeS treatment, with <1% plasma IgG remaining within 48 hours and remaining low up to 7 days. Mean fluorescence intensity values of HLA class I and II reactivity were substantially reduced in all patients, and C1q binding to anti-HLA was abolished. IdeS also cleaved the IgG-type B cell receptor on CD19+ memory B cells. Anti-IdeS antibodies developed 1 week after treatment, peaking at 2 weeks. A few hours after the second IdeS infusion, 1 patient received a deceased donor kidney offer. At enrollment, the patient had a positive serum crossmatch (HLA-B7), detected by complement-dependent cytotoxicity, flow cytometry, and multiplex bead assays. After IdeS infusion (0.12 mg/kg ×2) and when the HLA-incompatible donor (HLA-B7+ ) kidney was offered, the HLA antibody profile was negative. The kidney was transplanted successfully.

Trial registration: ClinicalTrials.gov NCT02224820.

Keywords: clinical research/practice; clinical trial; crossmatch; desensitization; histocompatibility; kidney transplantation/nephrology; kidney transplantation: living donor; pharmacokinetics/pharmacodynamics.

© 2018 The Authors. American Journal of Transplantation published by Wiley Periodicals, Inc. on behalf of The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

Figure 1
Figure 1
IdeS plasma concentration. Logarithm of mean IdeS plasma concentrations in patients given 2 doses of 0.12 mg/kg (n = 3), patients given a single dose of 0.25 mg/kg (n = 2), and patients given 2 doses of 0.25 mg/kg (n = 2). IdeS concentration measured using a validated assay after antibody dissociation (LLOQ: 0.1 μg/mL). Pharmacokinetics was evaluated using an open 2‐compartment model. Arithmetic mean values were reported for all parameters except for α and β half‐lives, where harmonic means were calculated. Cmax and Tmax were obtained directly from the experimental data. Nominal time is given on the x‐axis. Error bars = SD
Figure 2
Figure 2
IdeS effectively cleaves IgG. A, B. IgG in serum samples collected before and at consecutive time‐points after IdeS treatment. C. Nonreducing SDS‐PAGE analysis of serum from patient 205 who received 2 doses of 0.25 mg/kg BW IdeS showing protein banding patterns at the indicated time‐points. Right. IgG, scIgG, F(ab')2, and Fc bands are indicated
Figure 3
Figure 3
IdeS reduces CDC antibody reactivity. A. T‐cell non‐amplified CDC‐PRA 6‐24 hours after first treatment for patients dosed with 0.12 (patients 101, 102, and 103) or 0.25 (patients 201, 203, 204, and 205) mg/kg IdeS. B. B‐cell non‐amplified CDC‐PRA 6‐24 hours after first treatment. Paired t‐test
Figure 4
Figure 4
IdeS effectively cleaves anti‐HLA antibodies and eliminates C1q‐binding. Box‐plot of anti‐HLA antibodies having a pre‐dose MFI >1100 (cutoff in study) before and at consecutive time‐points following first and second IdeS treatment (0.12 or 0.25 mg/kg BW). A. Patient 205 LABScreen MFI. B. Patient 205 C1q‐Screen MFI. C. Patient 101 LABScreen MFI. D. Patient 101 C1q‐Screen MFI. Horizontal lines represent median MFI, boxes represent 25th and 75th percentile and vertical lines represent 10th and 90th percentile MFI. Dots are MFI of individual HLAs above or below the percentiles. The P‐values denote first significant difference between pre and post dose. N.S. is the time‐point when there is no longer any significance between pre and post dose. Statistics: Friedman test with Dunn multiple comparison test. The number (n) of HLAs having an MFI above the cutoff at 1100 is given in graph
Figure 5
Figure 5
IdeS effectively cleaves anti‐HLA and C1q‐binding antibodies. A, B. Average (+SD) anti‐HLA antibodies (LABScreen) before and at consecutive time‐points after IdeS treatment in patients treated with 2 doses of 0.12 mg/kg IdeS (patients 101, 102, and 103), 1 dose of 0.25 mg/kg IdeS (patients 201 and 204), or 2 doses of 0.25 mg/kg IdeS (patients 203 and 205). C, D. Average (+SD) C1q‐binding antibodies (C1qScreen) before and at consecutive time‐points after IdeS treatment. Antigens having a predose MFI >1100 were selected for analyses
Figure 6
Figure 6
IdeS degrades B cell receptor expressed by circulating CD19+ B cells. Flow cytometry analysis of CD19+/IgG+ cells at different time‐points after IdeS treatment as a mean of 6 patients. A. The patients showed a significant reduction in percentage of Fab‐positive CD19+ cells. B. The patients showed no significant reduction in percentage of Fc‐positive CD19+ cells. Data presented as mean (±SEM). The x‐axis shows time post first dosing. Data from patient 102 were not included due to too few CD19+ cells in the majority of the sampling points, and samples from patient 202 were not collected for BCR evaluation as this patient did not receive a full dose of IdeS
Figure 7
Figure 7
Anti‐IdeS IgG concentration in serum from all patients before and after IdeS treatment. The green lines represent group 1 (patients 101, 102, and 103) who received 2× 0.12 mg/kg BW IdeS, the red lines represent group 2 (patients 203 and 205) who received 2× 0.25 mg/kg BW IdeS, and the blue lines represent group 3 (patients 201 and 204) who received 1× 0.25 mg/kg BW IdeS. The dotted line is patient 202 who had dosing interrupted. Serum samples were analyzed using the IdeS‐ImmunoCAP (Thermo Fisher Scientific) on a Phadia 250 instrument. The cutoff (LLOQ) for IgG was 2 mg/L
Figure 8
Figure 8
Normal creatinine levels in patient 102 after transplant. Plasma creatinine levels at different time‐points in an IdeS‐treated recipient transplanted with an HLA‐incompatible kidney from a deceased donor

References

    1. Patel R, Terasaki PI. Significance of the positive crossmatch test in kidney transplantation. N Engl J Med. 1969;280(14):735‐739.
    1. Higgins RM, Bevan DJ, Carey BS, et al. Prevention of hyperacute rejection by removal of antibodies to HLA immediately before renal transplantation. The Lancet. 1996;348(9036):1208‐1211.
    1. Glotz D, Antoine C, Julia P, et al. Desensitization and subsequent kidney transplantation of patients using intravenous immunoglobulins (IVIg). Am J Transplant. 2002;2(8):758‐760.
    1. Montgomery RA, Lonze BE, King KE, et al. Desensitization in HLA‐Incompatible Kidney Recipients and Survival. N Engl J Med. 2011;365(4):318‐326.
    1. Stegall MD, Gloor J, Winters JL, Moore SB, DeGoey S. A comparison of plasmapheresis versus high‐dose IVIG desensitization in renal allograft recipients with high levels of donor specific alloantibody. Am J Transplant. 2006;6(2):346‐351.
    1. Vo AA, Lukovsky M, Toyoda M, et al. Rituximab and intravenous immune globulin for desensitization during renal transplantation. N Engl J Med. 2008;359(3):242‐251.
    1. Macklin PS, Morris PJ, Knight SR. A systematic review of the use of rituximab for desensitization in renal transplantation. Transplantation. 2014;98(8):794‐805.
    1. Orandi BJ, Luo X, Massie AB, et al. Survival benefit with kidney transplants from HLA‐incompatible live donors. N Engl J Med. 2016;374(10):940‐950.
    1. Riella LV, Safa K, Yagan J, et al. Long‐term outcomes of kidney transplantation across a positive complement‐dependent cytotoxicity crossmatch. Transplantation. 2014;97(12):1247‐1252.
    1. Montgomery RA, Warren DS, Segev DL, Zachary AA. HLA incompatible renal transplantation. Curr Opin Organ Transplant. 2012;17:386‐392.
    1. Vo AA, Jordan SC. Benefits, efficacy, cost‐effectiveness and infectious complications in transplant patients desensitized with intravenous immunoglobulin and anti‐CD20 therapy. Clin Exp Immunol. 2014;178:48‐51.
    1. von Pawel‐Rammingen U, Johansson BP, Björck L. IdeS, a novel streptococcal cysteine proteinase with unique specificity for immunoglobulin G. EMBO J. 2002;21(7):1607‐1615.
    1. von Pawel‐Rammingen U, Johansson BP, Tapper H, Bjorck L. Streptococcus pyogenes and phagocytic killing. Nat Med. 2002;8(10):1044‐1045.
    1. Vincents B, von Pawel‐Rammingen U, Björck L, Abrahamson M. Enzymatic characterization of the streptococcal endopeptidase, IdeS, reveals that it is a cysteine protease with strict specificity for IgG cleavage due to exosite binding. Biochemistry. 2004;43(49):15540‐15549.
    1. Wenig K, Chatwell L, von Pawel‐Rammingen U, Björck L, Huber R, Sondermann P. Structure of the streptococcal endopeptidase IdeS, a cysteine proteinase with strict specificity for IgG. Proc Natl Acad Sci USA. 2004;101(50):17371‐17376.
    1. Johansson BP, Shannon O, Björck L. IdeS: a bacterial proteolytic enzyme with therapeutic potential. PLoS ONE. 2008;3(2):e1692.
    1. Ryan MH, Petrone D, Nemeth JF, Barnathan E, Björck L, Jordan RE. Proteolysis of purified IgGs by human and bacterial enzymes in vitro and the detection of specific proteolytic fragments of endogenous IgG in rheumatoid synovial fluid. Mol Immunol. 2008;45(7):1837‐1846.
    1. Winstedt L, Järnum S, Nordahl EA, et al. Complete removal of extracellular IgG antibodies in a randomized dose‐escalation phase I study with the bacterial enzyme IdeS – a novel therapeutic opportunity. PLoS ONE. 2015;10(7):e0132011.
    1. Wahlberg J, Bengtsson M, Bergstrom C, et al. Impact of flow cytometry cross‐matching results on the outcome of cadaveric kidney transplantation. Transpl Proc. 1994;26:1752‐1753.
    1. Jordan SC, Lorant T, Choi J, et al. IgG endopeptidase in highly sensitized patients undergoing transplantation. N Engl J Med. 2017;377(5):442‐453.
    1. Järnum S, Bockermann R, Runström A, Winstedt L, Kjellman C. The bacterial enzyme IdeS cleaves the IgG‐type of B cell receptor (BCR), abolishes BCR‐mediated cell signaling, and inhibits memory B cell activation. J Immunol. 2015;195(12):5592‐5601.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren