Letter to the Editor
Role of photopheresis in the treatment of refractory cellular rejection in kidney transplantation
Papel de la fotoaféresis en el tratamiento del rechazo celular agudo refractario en trasplante renal
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=> true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Role of photopheresis in the treatment of refractory cellular rejection in kidney transplantation" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "327" "paginaFinal" => "328" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ernesto José Fernández, Celia López, Ana Ramírez, Rita Guerra, Lucía López, Fernando Fernández, Manuel Tapia, César García-Cantón" "autores" => array:8 [ 0 => array:3 [ "nombre" => "Ernesto José" "apellidos" => "Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Celia" "apellidos" => "López" "email" => array:1 [ 0 => "Celia.loap@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Ana" "apellidos" => "Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Rita" "apellidos" => "Guerra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Lucía" "apellidos" => "López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Fernando" "apellidos" => "Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Manuel" "apellidos" => "Tapia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "César" "apellidos" => "García-Cantón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Trasplante Renal, Servicio de Nefrología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Hematología y Hemoterapia, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel de la fotoaféresis en el tratamiento del rechazo celular agudo refractario en trasplante renal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal photopheresis is an immunomodulatory technique based on the apoptotic effects of 8-methoxypsoralen (8-MOP) and ultraviolet A (UVA) light on leukocytes. It is widely used in T-cell-mediated diseases such as cutaneous T-cell lymphoma, graft vs host disease, rheumatoid arthritis, and systemic lupus erythematosus.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Its use as prophylaxis for acute rejection (AR) in lung and heart transplants seems promising. However, there are few published articles on its use in the treatment of acute cellular rejection refractory to conventional treatment in renal transplant patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 56-year-old man, who received a cadaveric donor renal transplant in May 2013. Induction immunosuppression was with basiliximab, tacrolimus, mycophenolate mofetil, and steroids. Renal function was immediate and maintained until 16 days post-transplant, when it deteriorated. Percutaneous renal biopsy was performed, demonstrating Banff type Ib acute cellular rejection. Anti-HLA, anti-MICA, and antiendothelial antibodies were negative. The patient received salvage therapy with methylprednisolone (3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>mg) and thymoglobulin (1.25<span class="elsevierStyleHsp" style=""></span>mg/kg; total cumulative dose, 410<span class="elsevierStyleHsp" style=""></span>mg) without improvement. Seventeen days later a second renal biopsy was performed, reported as Banff type IIa acute cellular rejection, with mild intimal arteritis. Given the clinical course and refractoriness to treatment, with serum creatinine (SCr) of 2.97<span class="elsevierStyleHsp" style=""></span>mg/dL, photopheresis was prescribed (14 sessions, once per week, with Therakos<span class="elsevierStyleSup">®</span> UVAR XTS<span class="elsevierStyleSup">®</span> System) along with nonspecific human gammaglobulin (200<span class="elsevierStyleHsp" style=""></span>mg/kg; total dose, 80<span class="elsevierStyleHsp" style=""></span>g). Following this, a progressive improvement was seen in renal function, with SCr of 2.3<span class="elsevierStyleHsp" style=""></span>mg/dL on discharge. Renal function remained stable for 9 months, then deteriorated slightly, with a SCr of 2.62<span class="elsevierStyleHsp" style=""></span>mg/dL, so it was decided to start a new course of photopheresis (6 sessions, once weekly). There was a good response to treatment (7 months later, the current SCr of 1.9<span class="elsevierStyleHsp" style=""></span>mg/dL) and no treatment-related infectious complications were noted.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prophylactic treatment with photopheresis in renal transplant patients in addition to standard immunosuppression has shown improvement in renal function at 6 months and an increase in regulatory T-cells (Tregs).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Regarding its use in refractory AR, data from the literature are scarce, and, at times, contradictory. Horina et al. describe 3 patients treated with monthly photopheresis, who had no improvement in renal function, re-starting dialysis after a few months.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> However, in other publications, more frequent schedules have been associated with improvement of renal function.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Dall’Amico et al. describe 4 patients with different types of cellular rejection, who had previously received OKT3, with improvement in renal function after the first cycle of photopheresis treatment. Renal function remained stable one year later, allowing a reduction in immunosuppressive therapy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Weekly, fortnightly, and monthly schedules were used, up to a total of 19 sessions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The different mechanisms by which photopheresis exerts its beneficial effects are not completely understood. It seems to be related to triggering an immunomodulatory response of alloreactive T cells exposed to 8-MOP and to UVA light. It is likely that important roles are played by the synthesis of interleukins (especially TNF, IL-10, and IL-6) and the increase in regulatory T-cells (CD4+, CD25+ and FoxP3+), which increase progressively in number after each session. These mechanisms could explain why the benefits in cutaneous T-cell lymphoma are seen from the second or third month, while in AR they can be seen after a few days.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Currently, photopheresis could be useful as salvage therapy in cases of acute cellular rejection refractory to conventional treatment in renal transplants. More extensive investigation is needed to test its efficacy and safety.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández EJ, López C, Ramírez A, Guerra R, López L, Fernández F, et al. Papel de la fotoaféresis en el tratamiento del rechazo celular agudo refractario en trasplante renal. Nefrologia. 2016;36:327–328.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extracorporeal photopheresis for the treatment of autoinmune diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Adamski" 1 => "T. Kinard" 2 => "T. Ipe" 3 => "L. 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Kerl" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1995" "volumen" => "346" "paginaInicial" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7603178" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0210480612003294" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversal of acute renal allograft rejection by extracorporeal photopheresis: a case presentation and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.T. Wolfe" 1 => "J.E. Tomaszewski" 2 => "R.A. Grossman" 3 => "S.L. Gottlieb" 4 => "A. Naji" 5 => "K.L. Brayman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/(SICI)1098-1101(1996)11:1<36::AID-JCA8>3.0.CO;2-C" "Revista" => array:6 [ "tituloSerie" => "J Clin Apher" "fecha" => "1996" "volumen" => "11" "paginaInicial" => "36" "paginaFinal" => "41" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8722721" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Succesful treatment of recurrent rejection in renal transplant patients with photopheresis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Dall’Amico" 1 => "L. Murer" 2 => "G. Montini" 3 => "B. Andreetta" 4 => "G. Franco-Zanon" 5 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 47 | 43 | 90 |
| 2024 September | 48 | 36 | 84 |
| 2024 August | 56 | 59 | 115 |
| 2024 July | 47 | 37 | 84 |
| 2024 June | 57 | 38 | 95 |
| 2024 May | 76 | 29 | 105 |
| 2024 April | 46 | 28 | 74 |
| 2024 March | 46 | 26 | 72 |
| 2024 February | 58 | 36 | 94 |
| 2024 January | 50 | 23 | 73 |
| 2023 December | 40 | 31 | 71 |
| 2023 November | 50 | 36 | 86 |
| 2023 October | 111 | 31 | 142 |
| 2023 September | 42 | 26 | 68 |
| 2023 August | 45 | 28 | 73 |
| 2023 July | 43 | 31 | 74 |
| 2023 June | 80 | 19 | 99 |
| 2023 May | 99 | 34 | 133 |
| 2023 April | 38 | 14 | 52 |
| 2023 March | 51 | 21 | 72 |
| 2023 February | 31 | 23 | 54 |
| 2023 January | 37 | 22 | 59 |
| 2022 December | 45 | 31 | 76 |
| 2022 November | 48 | 29 | 77 |
| 2022 October | 40 | 41 | 81 |
| 2022 September | 55 | 39 | 94 |
| 2022 August | 52 | 49 | 101 |
| 2022 July | 34 | 50 | 84 |
| 2022 June | 30 | 37 | 67 |
| 2022 May | 33 | 38 | 71 |
| 2022 April | 42 | 42 | 84 |
| 2022 March | 61 | 65 | 126 |
| 2022 February | 65 | 50 | 115 |
| 2022 January | 59 | 30 | 89 |
| 2021 December | 51 | 31 | 82 |
| 2021 November | 37 | 44 | 81 |
| 2021 October | 48 | 28 | 76 |
| 2021 September | 49 | 35 | 84 |
| 2021 August | 40 | 43 | 83 |
| 2021 July | 89 | 32 | 121 |
| 2021 June | 53 | 29 | 82 |
| 2021 May | 69 | 51 | 120 |
| 2021 April | 128 | 85 | 213 |
| 2021 March | 87 | 42 | 129 |
| 2021 February | 51 | 40 | 91 |
| 2021 January | 78 | 23 | 101 |
| 2020 December | 51 | 16 | 67 |
| 2020 November | 48 | 27 | 75 |
| 2020 October | 39 | 24 | 63 |
| 2020 September | 42 | 26 | 68 |
| 2020 August | 48 | 21 | 69 |
| 2020 July | 44 | 21 | 65 |
| 2020 June | 41 | 28 | 69 |
| 2020 May | 62 | 11 | 73 |
| 2020 April | 33 | 16 | 49 |
| 2020 March | 55 | 25 | 80 |
| 2020 February | 40 | 21 | 61 |
| 2020 January | 54 | 36 | 90 |
| 2019 December | 51 | 30 | 81 |
| 2019 November | 47 | 25 | 72 |
| 2019 October | 32 | 18 | 50 |
| 2019 September | 36 | 17 | 53 |
| 2019 August | 28 | 24 | 52 |
| 2019 July | 24 | 23 | 47 |
| 2019 June | 40 | 26 | 66 |
| 2019 May | 28 | 26 | 54 |
| 2019 April | 56 | 44 | 100 |
| 2019 March | 51 | 23 | 74 |
| 2019 February | 35 | 21 | 56 |
| 2019 January | 31 | 22 | 53 |
| 2018 December | 120 | 40 | 160 |
| 2018 November | 228 | 27 | 255 |
| 2018 October | 212 | 24 | 236 |
| 2018 September | 130 | 14 | 144 |
| 2018 August | 63 | 17 | 80 |
| 2018 July | 62 | 12 | 74 |
| 2018 June | 79 | 18 | 97 |
| 2018 May | 78 | 14 | 92 |
| 2018 April | 115 | 10 | 125 |
| 2018 March | 96 | 10 | 106 |
| 2018 February | 88 | 7 | 95 |
| 2018 January | 92 | 8 | 100 |
| 2017 December | 82 | 8 | 90 |
| 2017 November | 67 | 11 | 78 |
| 2017 October | 50 | 6 | 56 |
| 2017 September | 38 | 10 | 48 |
| 2017 August | 36 | 7 | 43 |
| 2017 July | 31 | 11 | 42 |
| 2017 June | 55 | 10 | 65 |
| 2017 May | 52 | 15 | 67 |
| 2017 April | 35 | 12 | 47 |
| 2017 March | 28 | 6 | 34 |
| 2017 February | 34 | 11 | 45 |
| 2017 January | 24 | 19 | 43 |
| 2016 December | 39 | 9 | 48 |
| 2016 November | 47 | 20 | 67 |
| 2016 October | 61 | 13 | 74 |
| 2016 September | 111 | 12 | 123 |
| 2016 August | 94 | 3 | 97 |
| 2016 July | 109 | 4 | 113 |
| 2016 June | 94 | 0 | 94 |
| 2016 May | 125 | 0 | 125 |
| 2016 April | 102 | 0 | 102 |
| 2016 March | 66 | 0 | 66 |
| 2016 February | 69 | 0 | 69 |
| 2016 January | 57 | 0 | 57 |
| 2015 December | 21 | 0 | 21 |
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