Treatment of Chronic Antibody Mediated Rejection

Treatment of Chronic Antibody Mediated Rejection Robert A. Montgomery MD, DPhil Professor of Surgery Director of the NYU Langone Transplant Institute Disclosures: Served on Advisory Boards for Genentech Scientific/ROCHE, True North/iPierian, Alexion, Novartis, and Hansa Medical Received consulting fees from OrbidMed, GuidePoint Global, Sucampo, Astellas,and Shire Received research grants from Immune Tolerance Network, ViroPharma,Hansa, and Alexion. I have been involved in clinical trial design for some of the off label drugs I will be discussing. Objectives To understand the phenotypes and natural history of untreated chronic AMR and its effect on graft survival. To gain an appreciation for treatment modalities that have a mechanism of action that might prove effective for reversing chronic AMR or prolonging allograft half-life. 1

De Novo HLA DSA is Common and Leads to Graft Failure 1 Years post-transplant 1 Mao, et al. Am J Transplant. 2007 Apr;7(4):864-71. Development of De Novo HLA DSA is Associated With Allograft Loss 1 Graft survival of patients with de novo DSA versus those without 1 Wiebe C et al. Am J Transplant. 2012;12:1157-1167. AMR Is Associated With A Poor Outcome 1 1 Lefaucheur C et al. J Am Soc Nephrol. 2010.21:1398-1406. 2

Chronic AMR may result form De Novo DSA formation, incomplete elimination of DSA following Acute AMR, or persistence of preformed DSA after Desensitization Effectiveness of therapy may depend upon: Target Strength Timing Ability of DSA to Bind Complement Ability of DSA to Produce Microcirculation Inflammation Presence of Renal Dysfunction DSA Fate By Specificity After Plasmapheresis 1 Specific Eliminated Persistent ci 74% 26% cii (DR, DQ) 56% 44% DR51, 52, 53 20% 80% Isoagglutinins 0% 100% 1 Zachary, et al. Transplantation. 2003 Nov 27;76(10):1519-25. Allograft Survival Is Lower With Class II DSA 1 1 Bentall et al. AJT 2013; 13:76 3

The Significance of AMR Varies By The Antibody s Ability To Bind Complement: Outcomes of C4d+ vs. C4d-AMR 1 1 Orandi B et al. Am J Transplant. 2016; 16:213. However, Antibodies That Do Not Bind Complement Can Have Clinical Significance 1 Specificity/sensitivity/positive predictive and negative predictive values for C4d Sensitivity = 0.69 Specificity = 0.83 PPV = 0.93 NPV = 0.44 C4d+ (n = 90) KTRs with preformed DSA (n = 80) Protocol biopsies at 3-mo and 1-y post-transplant (n = 157) NPV: negative predictive value; PPV: positive predictive value. 1. Loupy A et al. Am J Transplant. 2011;11:652-660. C4d-(n = 67) Microvascular inflammation + (n = 84) Microvascular inflammation (n = 6) Microvascular inflammation + (n = 37) Microvascular inflammation (n = 30) Post Treatment DSA and C1q: Is There Both A Quantitative and Qualitative Difference in DSA 1 DSA+/C1q+ = Higher risk of graft loss 1 Loupy et al. NEJM 2013; 369:1215 4

SOC PP/IVIg Treatment Protocol Is Effective Therapy for Acute AMR but has Limited Success with Chronic AMR 1 Anti-CD20 Steroid bolus or α-thymocyte globulin PP: single plasma volume exchange IVIG: 100 mg/kg following each PP treatment (CMV hyperimmune globulin) PP/IVIg PP/IVIg PP/IVIg PP/IVIg PP/IVIg AMR diagnosis 2 4 6 8 1 Montgomery et al. Transplantation. 2000; 70(6):887-95. Rituximab as Add-On Therapy to SOC did not Show Improved Outcomes for Acute AMR Compared to SOC Alone in a Multi-Center Double-Blind Randomized trial 1 1 end pt: Day 12 < 30% Creatinine ABMR <1 year (Bx) (n=19) Placebo + IVIG + PE + Steroids 57.4% (n=19) Rituximab + IVIG + PE + Steroids 52.6% p = NS 1 Sautenet et al., Transplantation 2016; 100:391 Bortezomib Add-On to PP/IVIg Treatment Protocol Anti-CD20 Steroid bolus or α-thymocyte globulin PP: single plasma volume exchange IVIG: 100 mg/kg following each PP treatment (CMV hyperimmune globulin) Repeat cycle every 21 days PP/IVIg PP/IVIg PP/IVIg PP/IVIg PP/IVIg PP/IVIg AMR diagnosis 1 2 4 6 8 11 Bortezomib (1.5 mg/m 2 ) Bortezomib (1.5 mg/m 2 ) Bortezomib (1.5 mg/m 2 ) Bortezomib (1.5 mg/m 2 ) 5

Poor Responce to Bortezomib as Add-On to SOC for Chronic AMR 1 1 Alachkar et al. Transplantation; 97:1240. Bortezomib Differentially Effects Class I vs. Class II HLA Antibody 1 1 Philogene et al., Transplantation. 2014; 98:660. Tocilizumab (anti-il-6r mab) Treatment for Chronic AMR and TG: Failed SOC Patients 1 75 Patients with Chronic Active ABMR +/- Transplant Glomerulopathy (TG) 39 Patients Treated with IVIG + Rituximab +/- PLEX (SOC) 37 Patients who failed IVIG + Rituximab + PLEX Rx with Tocilizumab 8mg/kg monthly 6-18M 1 Vo AA et al. Transplantation. 99:2356. 6

Tocilizumab vs. SOC in Patients with Established Tg Classical Complement Pathway in Acute AMR in Sensitized KTRs 1 ECULIZUMAB a a FDA approved for PNH and ahus. AMR, antibody-mediated rejection; DAF, decay-accelerating factor; DSAs, donor-specific antibodies, HLA, human leukocyte antigen; Y-CVF, Yunnan-cobra venom factor.. 1 Stegall MD et al.nat Rev Nephrol.2012;8:670 678. AJT (2015) 5:1293-1302 Decreased ABMR 6.7% vs. 43.8% but no effect on TG at 2 years Transplant Glomerulopathy in Controls versus Eculizumab 3-4 months 1 year 2 years Eculizumab* 0% (0/28) Control 9.3% (4/43) 26.7% (8/30) 39.5% (15/38) 45.4% (10/22) 63.6% (21/33) P-value 0.15 0.31 0.27 *Residual DSA was not removed after the transplant 7

AMR: C1 Esterase Inhibitor Mechanistically Attractive Due To Proximal Complement Blockade 1 FDA approved for HAE: Hereditary Angioedema C1-INH: C1 esterase inhibitor; FDP: fibrin degradation product; HMWK: high molecular weight kininogen; IL: interleukin; KK: kallikrein; MASP: MBP-associated serine protease; MBP: mannosebinding protein; TNF: tumor necrosis factor; tpa: tissue plasminogen activator 1 Levy J, O Donnell P. Expert Opin Investig Drugs.2006;15:1077-1090. AMR: Randomized Placebo Controlled C1 INH Trial Cg on 6 mos. Biopsy 1 This study was sponsored by ViroPharma, Inc., a wholly owned subsidiary of Shire, PLC. CG CG CG mg/dl CG = chronic glomerulopathy 17 mg/dl = 1 U/mL 1 Montgomery et al. Am J Transplant 2016 Epub. mg/dl C1-INH (Berinert) as add on Therapy for Chronic AMR Unresponsive to SOC 1 1 Viglietti et al. Am J Transplant;16:1596 8

IdeS: IgG-degrading enzyme of Streptococcus pyogenes Highly specific for human IgG Glu-Leu-Leu-Gly236 Gly-Pro 2 hrs 4 hrs * *Single-cleaved IgG (scigg) IdeS Effect on Class II Antibody In A Sensitized Patient 25000 Placebo IdeS P02 20000 MFI (raw) 15000 10000 5000 0 DRB1*10:01,-,-,-,-,-,-,-,-,-,-,- -,-,DRB4*01:03,-,-,-,-,-,-,-,-,- DRB1*09:02,-,-,-,-,-,-,-,-,-,-,- -,-,DRB4*01:01,-,-,-,-,-,-,-,-,- DRB1*01:01,-,-,-,-,-,-,-,-,-,-,- DRB1*09:01,-,-,-,-,-,-,-,-,-,-,- DRB1*01:02,-,-,-,-,-,-,-,-,-,-,- DRB1*01:03,-,-,-,-,-,-,-,-,-,-,- DRB1*07:01,-,-,-,-,-,-,-,-,-,-,- -,-,DRB5*02:02,-,-,-,-,-,-,-,-,- DRB1*04:04,-,-,-,-,-,-,-,-,-,-,- DRB1*04:01,-,-,-,-,-,-,-,-,-,-,- -,-,DRB5*01:01,-,-,-,-,-,-,-,-,- DRB1*04:05,-,-,-,-,-,-,-,-,-,-,- DRB1*04:02,-,-,-,-,-,-,-,-,-,-,- DRB1*04:03,-,-,-,-,-,-,-,-,-,-,- DRB1*12:01,-,-,-,-,-,-,-,-,-,-,- -,-,DRB3*03:01,-,-,-,-,-,-,-,-,- DRB1*12:02,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,DQA1*01:03,-,DQB1*06:01,-,-,-,-,- -,-,DRB3*01:01,-,-,-,-,-,-,-,-,- -,-,-,-,DQA1*01:03,-,DQB1*06:03,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*09:01,- -,-,-,-,DQA1*02:01,-,DQB1*03:03,-,-,-,-,- -,-,-,-,DQA1*03:02,-,DQB1*03:03,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*17:01,- DRB1*14:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*03:01,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*06:01,- -,-,-,-,DQA1*03:02,-,DQB1*03:02,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*14:01,- -,-,-,-,-,-,-,-,DPA1*01:05,-,DPB1*03:01,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*03:01,- -,-,-,-,DQA1*01:02,-,DQB1*06:09,-,-,-,-,- DRB1*14:54,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,DQA1*01:02,-,DQB1*06:04,-,-,-,-,- -,-,-,-,DQA1*01:01,-,DQB1*06:02,-,-,-,-,- -,-,-,-,DQA1*01:02,-,DQB1*06:02,-,-,-,-,- -,-,-,-,DQA1*03:01,-,DQB1*03:03,-,-,-,-,- -,-,-,-,DQA1*03:01,-,DQB1*03:02,-,-,-,-,- DRB1*14:02,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,DQA1*01:01,-,DQB1*05:01,-,-,-,-,- -,-,-,-,DQA1*03:03,-,DQB1*04:01,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*03:02,-,-,-,-,- -,-,-,-,DQA1*01:01,-,DQB1*03:02,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*04:01,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*04:02,-,-,-,-,- -,-,-,-,DQA1*01:02,-,DQB1*05:02,-,-,-,-,- -,-,-,-,DQA1*04:01,-,DQB1*04:02,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*19:01,- DRB1*15:03,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*23:01,- -,-,-,-,-,-,-,-,DPA1*01:05,-,DPB1*11:01,- -,-,-,-,DQA1*06:01,-,DQB1*03:01,-,-,-,-,- DRB1*03:02,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*10:01,- DRB1*13:01,-,-,-,-,-,-,-,-,-,-,- DRB1*16:02,-,-,-,-,-,-,-,-,-,-,- DRB1*15:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*03:01,-,-,-,-,- DRB1*16:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*02:01,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*28:01,- -,-,-,-,-,-,-,-,DPA1*01:05,-,DPB1*13:01,- -,-,DRB3*02:02,-,-,-,-,-,-,-,-,- DRB1*15:02,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*11:01,- -,-,-,-,-,-,-,-,DPA1*01:05,-,DPB1*28:01,- DRB1*03:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*01:01,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*04:02,- -,-,-,-,DQA1*03:01,-,DQB1*03:01,-,-,-,-,- -,-,-,-,DQA1*05:05,-,DQB1*03:01,-,-,-,-,- -,-,-,-,DQA1*05:03,-,DQB1*03:01,-,-,-,-,- DRB1*11:04,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:05,-,DPB1*18:01,- DRB1*13:03,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*15:01,- -,-,-,-,-,-,-,-,DPA1*01:04,-,DPB1*18:01,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*01:01,- DRB1*08:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*05:01,- DRB1*11:01,-,-,-,-,-,-,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*01:03,-,DPB1*04:01,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*18:01,- -,-,-,-,DQA1*05:01,-,DQB1*02:01,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*02:02,-,-,-,-,- -,-,-,-,DQA1*04:01,-,DQB1*02:01,-,-,-,-,- -,-,-,-,-,-,-,-,DPA1*02:01,-,DPB1*13:01,- -,-,-,-,DQA1*03:01,-,DQB1*02:01,-,-,-,-,- -,-,-,-,DQA1*02:01,-,DQB1*02:01,-,-,-,-,- Individual HLA (DP, DQ, DR) Trouble in paradise: IgG rebounds by day 14 and patient cannot be given more than 2 doses because of antibody formation HLA Incompatible Donor IdeS Protocol IdeS.24 mg/kg Solumedrol 500mg/d IVIg 2 gm/kg SOC rescue If needed - XM 2 hrs Tx d 0 d 4 d 7 d 9 Positive Cytotoxic or Flow XM Campath SQ Anti-CD2 9

Which of the following best describes you? 1. I know there are no effective treatments for chronic AMR so I just let nature take its course and begin to plan for the next transplant. 2. When I identify a patient with chronic AMR I increase maintenance immunosuppression and observe. 3. I aggressively treat chronic AMR when found on a for cause biopsy. 4. I monitor at risk patients with protocol biopsies and treat chronic AMR until the microcirculation inflammation resolves on re-biopsy. Which of the following is false about the treatment of chronic AMR A. Therapies for Acute AMR tend to have limited efficacy for chronic AMR. B. Class I non-complement fixing antibodies are associated with the worst outcomes. C. DSA that binds C1q leads to a higher rate of graft loss. D. Transplant glomerulopathy can result form both acute and chronic AMR 10