Bortezomib (Velcade) to Deplete Plasma Cells and Remove HLA Antibodies

8/6/2019 Bortezomib (Velcade) to Deplete Plasma Cells and Remove HLA Antibodies

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3/17/200

Matthew J. Everly, PharmD, BCPSTerasaki Foundation Laboratory

March 2009

• Antibodies cause allograft loss. – McKenna RM, Takemoto SK, Terasaki PI. Transplantation. 2000; 69 : 319.

– Terasaki PI. Am J Transplant. 2003; 3 : 665

– Cai J, Terasaki PI. Hum Immunol. 2005; 66 : 334

– Terasaki PI, Cai J. Curr Opin Immunol. 2005; 17 : 541

– Terasaki P, Lachmann N, Cai J. Clin Transpl. 2006 : 455

– Terasaki PI, Cai J. Transplantation. 2008; 86 : 377

• Antibodies precede allograft dysfunction

Current Status of the Problem:



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Antibodies Precede Allograft Loss

0

1

2

3

4

5

6

78

0

5000

10000

15000

20000

25000

0 1 2 3 4 5 6 7 8

S C R ( m g / d

l )

M F I

ears post-Tx

Antibodies

F a

i l u r e

• Will a reduction/removal of antibodiesimprove allograft survival?

• What agent(s) will lead to a durableresponse in antibody removal?

Remaining Questions



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p = 0.043 (Log-Rank)

Statistically significant at the α = 0.05 level

Reduction of Donor Specific Antibody LevelsPrevents Renal Allograft LossUniversity of Cincinnati, Cincinnati, OH

Time from Transplantation (Months)

0 6 12 1 8 24 3 0 36 42 48 54 60 66 72

P o r p o r t i o n o

f A l l o g r a

f t s S u r v i v i n g

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0DSA Reduction > 50%(N = 6; NO Allografts Lost)

DSA Reduction < 50%(N = 10; 7 Allografts Lost)

Everly et al. Am J Transplant 2009;9:1-9

Log Rank p=0.021

Reduction of Donor Specific Antibody Levels

Prevents Renal Allograft LossBrody Medical School at Eastern Carolina University, Greenville, NC

Antibody Reduction Responders(n=7, NO Allograft Loss)

Antibody Reduction Non-Responders(n=23, 12 Allografts Lost)

Log-rank p=0.033

0

10

20

30

40

50

60

70

80

90

100

P e r c e n

t A l l o g r a

f t S u r v

i v a

l

0 12 24 36 48 60 72 84 96Months after Transplantation

MJ Everly, LM Rebellato, M Ozawa, KP Briley, PG Catrou, CE Haisch, and PI TerasakiTerasaki Foundation Laboratory and Brody School of Medicine at ECU



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Current Treatments to Reduce Antibodies

• Agents that neutralize/removeanti-HLA antibodies

• Plasmapheresis (PP)

• Immunoabsorption

• Intravenous Immune Globulin(IVIg)

• Agents that inhibit B-cellproliferation/differentiation

• Splenectomy

• Cyclophosphamide

• FK506 / MMF

• Rituximab

• Thymoglobulin

w/ Thymoglobulin

w/ Thymoglobulin

w/ Thymoglobulin

w/ Thymoglobulin

Current Treatments Unable to Deplete

Plasma Cells

Ramos et al. Am J Transplant 2007;7:402



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Further Evidence:Rituximab Fails to Reduce DSA

Zarkhin et al. Am J Transplant 2008;8:2607

Need to Deplete the Major Antibody Producing Cell:

The Plasma Cell

J I m m u n o

l 2 0 0 5 ; 1 7 5 : 4 0 3 4

S a r w a l M

. A T C 2 0 0 6 ; A

b s t r a c t 1 0 1 2

CD20+

CD38 + /-

CD138+



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What is Bortezomib?

• Bortezomib (Velcade)• Proteasome Inhibitor• FDA approved agent for the treatment of multiple myeloma

(plasma cell neoplasia)

• Mechanisms of Action - Pleotropic:• Blocks degradation of IκBα thereby inhibiting NF-κB gene transcription• Induce apoptosis on activated and mature T- and B- lymphocytes and

dendritic cells• Reduces class I MHC expression in lymphocytes and dendritic cells• Inhibit antigen processing• Targets plasma cells in the bone marrow compartment

PLASMACELL

SURVIVAL

Plasma Cell Survival in Hyper-Proliferative Response

PP

UbUb

UbUb

Ub

Iĸ Bα Degraded

26SProteasome

NF κ κκ κ B GeneTranscription

Enzymes & cellcycle regulators

Anti-apoptoticfactors

Cell adhesionmolecules

CytokinesReceptor signaling

I κ B kinase

Synthesizing1. large amounts of Ig2. Defective ribosomal

products ( DRiPs)

DRiPs

Ig

NF-ĸ B bound toinhibitor I ĸ Bα

Unfolded Protein ResponseActivation

Plasma cell

REGULATION



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PP

UbUb

UbUb

Ub

26SProteasome

GeneTranscription

Enzymes & cell cycleregulators

Anti-apoptoticfactors

Cell adhesionmolecules

CytokinesReceptor signaling

I κ B kinase

DRiPs

Ig

NF-ĸ B bound toinhibitor I ĸ Bα

Unfolded ProteinResponse Activation

Plasma Cells Deletion via Proteasome Inhibition

Plasma cell

PLASMACELL

APOPTOSIS

IN ENDOPLASMIC RECTICULUM

Accumulation ofUnfolded Proteins andDRiPs

Current Use of Plasma Cell Depleting Therapy with

Bortezomib in Solid Organ Transplant

• Bortezomib Provides Effective Therapy for Antibody – and Cell – Mediated Acute Rejection. Everly et al. Transplantation 2008;86:1754

• Proteasome Inhibition Causes Apoptosis of Normal Human PlasmaCells Preventing Alloantibody Production. Perry et al. Am J Transplant2009;9:201

• Proteasome Inhibition reduces donor- specific antibody levels. Everlyet al. Transplant Proc 2009: 105

• Abrogation of Anti-HLA Antibodies via Proteasome Inhibition. Trivediet al. Transplantation 2009; May 27: In press.

• Elimination of Post-Transplant Donor Specific HLA Antibodies withBortezomib. Idica et al. Clin Transplant 2008. In Press.



3/17/200

Treatment % ApoptoticCD138+ Cells

P-value

Untreated 26.8 ± 7.7

rATG 33.7 ± 9.4 0.0995

Rituximab 22.5 ± 3.5 0.2558

Bortezomib 64.8 ± 10.5 0.0001

Plasma Cell Apoptosis

Perry et al. Am J Transplant 2009;9:201

Proteasome Inhibition Inhibits Plasma CellsIn Transplant PatientsMayo Clinic, Rochester, MN

Everly et al. Transplantation 2008;86:1754Presented at the XXII International Congress of the Transplantation Society, Sydney, Australia

BortezomibUniversity of Cincinnati, Cincinnati, OH

• 8 Rejections episodes for 7 patients treated with Bortezomib• 1 st Patient was treated on July 24, 2007

• De novo donor specific antibodies present at the time ofrejection

• 6/7 patients had concomitant ACR and AMR (Mixedrejection) refractory to other therapy

• 1 patient with an isolated chronic rejection was also treated• Overall Follow-up from 1 st course of bortezomib

• 3 -12 months with mean of 140 days• 2 patients ≈ 11 month follow-up



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Bortezomib RegimenUniversity of Cincinnati, Cincinnati, OH

Bortezomib1.3 mg/m 2 IVP

1 CYCLE

EVERY 72 HOURS X 4

Plasmapheresis given 72 hours after last dose of bortezomib X 3 sessions

DSA samples were conducted at Day 0 (Prior to 1 st Bortezomib dose),

Day 7, 14, 30, 90, 180, and 360.

Everly et al. Transplantation 2008;86:1754Presented at the XXII International Congress of the Transplantation Society, Sydney, Australia

Days Following Treatment With Bortezomib

D A Y 1

D A Y 7

D A Y 1

4

D A Y 3

0

D A Y 6

0

D A Y 9

0

D A Y 1

2 0

D A Y 1

8 0

D A Y 3

6 0

I m m u n o

d o m

i n a n

t D S A M E S F

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1000000

1100000Recipient #1A (DQ7)Recipient #1B (DR53)Recipient #2A (A1)Recipient #3 (DQ6)Recipient #4 (DQ9)Recipient #5 (DR16)Patient #6 (DQ6)

Overall Follow-up from 1 st Course of bortezomib• 3-12 Months with mean of 140 days• 2 patients with 11 months follow-up

Bortezomib’s Effect on DSAUniversity of Cincinnati, Cincinnati, OH

Everly et al. Transplantation 2008;86:1754



3/17/200

Terasaki Foundation – IKDRC-ITSBortezomib Study

• Patients transplanted at the Institute of Kidney Diseasesand Research Centre Ahmedebad, India between January2008 andDecember 2008.

• All patients were consented to the use of bortezomib “off-label” for treatment of antibodies post transplant.

• 13 Patients Treated with Bortezomib / Plasmapheresis ±Rituximab

Trivedi et al. Transplantation 2009; May 27: In press.

Methods• Patients

– Patients were treated “off-label” for elevation in antibodies posttransplant

– IRB approval and patient consent was obtained for all patients.

• DSA Analysis – Antibody intensity was quantified by fluorescence intensity (MFI). – MFI >1000 was considered positive. – Serial measurements of HLA antibody were conducted weekly

before, during, & after treatment via single antigen bead onLuminex.

• Bortezomib dosing

– Given at 1.3 mg/m 2 x 4 doses with a 10 day wait between cycles• Endpoints

– Response = reduction of MFI of primary antibody (first to appear)below 1000 MFI.




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Patient Characteristics

• Mean patient age: 29.1 ± 9.3 years

• All patients were male

• All patient received living donor transplants

• All patients were non-sensitized based on crossmatchat time of transplant.

• All patients were treated under clonal deletionprotocol prior to antibody appearance.


DSA and Treatment Characteristics

DSA Responders(n=9), n (%)

DSA PartialResponders(n=4) , n (%)

p-value

Scr at DSA Appearance 1.3 +/- 0.2 1.2 +/- 0.2 NS

Class I 5 (56) 1 (25) NS

Class II 4 (44) 3 (75) NS

Use of > 1 cycle of Bortezomib 2 (22) 1 (25) NS

Time to DSAAppearance (days, median) 64 76 NS




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Days Post-Bortezomib

0 14 28 42 56 70 84 98 112 126 140 154 168 182 196

M e a n

F l u o r e s c e n

t I n t e n s i t y

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

12000A1 (Pt - CD15)B57 (Pt - CD2)DR7 (Pt-CD32)DQ7 (Pt - CD33)DQ6 (Pt - CD37)A24 (Pt - CD39)B8 (Pt - CD5)DR11 (Pt - CD79)A24 (Pt - CD86)

Results: Bortezomib’s Effect on DSA

Responders


Days Post-Bortezomib

0 14 28 42 56 70 84 98 112 126 140 154 168 182 196 210 224

M e a n

F l u o r e s e n c e

I n t e n s

i t y

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

12000

13000

14000

15000

Cw7 (Pt - CD35)DR51 (Pt - CD40)DQ2 (Pt - CD68)DQ5 (Pt - CD72)

Results: Bortezomib’s Effect on DSAPartial Responders




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Results: DSA Comparison

DSA Responders (n=9), n(%)

DSA Partial Responders(n=4) , n (%) p-value

Pre-Treatment MFI,Mean +/- SD 3961 +/- 2654 6450 +/- 3745 NS

Peak MFI during Treatment, Mean +/-SD 5700 +/- 3649 11825 +/- 1457 0.004

Last Follow-Up MFI,Mean +/- SD <1000 9150 +/- 870 <0.001

Percent DSA Reduction (mean) 76 % 55 % -

Time to DSA Removal(days, median (range)) 30 (14 -143) N/A -


Bortezomib’s ability to abrogate DSAA B Cw DRB1 DRB345 DQ Bw

Patient 3 26 8 35 4 7 17 8 52 - 3 - 6 -

Donor 1 3 57(17) 35 12 - 7 8 - - 3 - 4 6

BortezomibApheresis

Months Post Transplantation

S C r

(B57(17))

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,0001,000

0

(DR7)

(B57(17))

M F I

5

4

3

2

1

00 1 2 3 4 5




3/17/200

Monitoring with Bortezomib is Needed ToDetermine RIGHT TIME/ RIGHT DOSE

A B C DRB1 DQ DRB345 Bw

Patient 1 68 8 35 4 7 17 11 2 3 - 52 6 -Donor 2 68 57 5 4 12 17(3) - 1 2 - 52 4 -

BortezomibApheresis

Rituximab M F I S

C r

(DQ6(1))(DQ6(1))(DQ5(1))

(DQ5(1))

15,00014,00013,00012,00011,00010,000

9,0008,0007,0006,0005,0004,0003,000

2,0001,000

0 0 1 2 3 4 5

M F I


5

4

3

2

1

0


High Intensity DSA Responds well but 2 - 3

cycles of bortezomib may be neededA B C DRB1 DQ DRB345 Bw

Patient 24 68 7 35 4 12 14 15 1 - 51 52 6 -Donor 24 1 51 7 12 16 13 15 1 4 51 52 4 6

Bortezomib

Apheresis S C r

(A1)

5,000

4,000

3,000

2,000

1,000

0

M F I

5

4

3

2

1

00 1 2 3 4 5 6 7





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Bortezomib Summary:1. Bortezomib provides significant reductions/removal of DSA

2. Minimal Transient Toxicity with 1-2 cycles – (2 cases of generalized weakness, <5% Nausea/diarrhea,

transient drop in platelets.

3. Safe following or when given concurrently withThymoglobulin, Rituximab, Plasmapheresis,mycophenolate/tacrolimus

4. Higher MFI antibodies (>10,000) may require multiplecycles for removal

What is the Next Step…



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FIRST: MONITOR FOR ANTIBODIESLOW-RISK HIGH-RISK (XM-)

Pre-Transplant Pre-Transplant

P O S T - T

R A N S P L A N T

2 weeks

1 month

2 months

3 months 3 months

6 months 6 months

9 months 9 months

1 year 1 year

Beyond 1 year: Annually Beyond 1 year: Bi-Annually

More research is needed to confirm the clinicalsignificance of each testing time point

Study Design• Multicenter• 5 year study (with interim analysis annually)• 300 Patients (1:1 randomization)

• Pharmaceutical Support

THEN, TREAT THE ANTIBODY



3/17/200

Conclusions1. Current agents Are Ineffective at removing Alloantibodies

2. Bortezomib shows promise as the first agent capable of removing HLA antibodies

3. One cycle alone of bortezomib may not be enough for allpatients

4. Using HLA single antigen monitoring should provide theframework for improving survival through removal of antibodies.

Acknowledgements• Dr. Paul I. Terasaki

• Drs. E. Steve Woodle and Rita R. Alloway

• Terasaki Foundation Laboratory

• University of Cincinnati

• IKDRC-ITS

• Brody School of Medicine Eastern Carolina University



3/17/200

QuestionsEmail: [email protected]: 310-479-6101 ext 125

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Bortezomib (Velcade) to Deplete Plasma Cells and Remove HLA Antibodies

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