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Temperature requirements and kinetics of T cell signaling. Velocity of triggering correlates with functional effects of anti-CD3 mAb.

Antibody reactive with the CD3 complex on the surface of T lymphocytes can either: inhibit CTL lysis of target cells expressing Ag; or redirect CTL to lyse target cells expressing FcR in the absence of Ag expression. To investigate these phenomena we examined the effect of anti-CD3 mAb on two indicators of CTL activation, the release of esterase and target cell lysis. Esterase release by long term allo-reactive human CTL in response to target cells (JY or HLA transfected K562 cells) was found to be Ag specific and correlate with target cell lysis. Addition of anti-CD3 to either JY targets or K562 cells expressing FcR resulted in a high level of esterase release. Triggering of esterase release was found with both soluble intact and Fab fragment of anti-CD3 in the absence of cells expressing measurable FcR. This apparent FcR-independent triggering of esterase release occurred at 37 degrees C but not at 24 degrees C. In contrast esterase activity was released from CTL at both 24 and 37 degrees C in response to intact target cells, JY or K562 cells plus intact anti-CD3 mAb. Addition of anti-CD3 mAb, at a level capable of blocking target cell lysis by greater than 50%, resulted in an initial velocity of esterase release almost twice that found in response to JY target cells. With a low level of anti-CD3 mAb, able to block JY lysis by approximately 10%, the initial rate of esterase release was much slower than that found in response to target cells. In contrast when FcR+ cells, K562, were added along with a low level of anti-CD3 the initial velocity of esterase release was about twofold more than the velocity of esterase release triggered by soluble anti-CD3 alone. These results indicate that soluble antibody can trigger long term active CTL and the velocity of this triggering correlates with anti-CD3-mediated inhibition as well as redirected lysis.

Antibodies, Monoclonal↗

Long-term follow-up of heart transplant recipients treated with murine antihuman mature T cell monoclonal antibody (OKT3): the Loyola experience.

We describe the long-term follow-up of 25 patients treated with murine antihuman mature T cell (OKT3) monoclonal antibody at Loyola University Medical Center. After OKT3 rescue therapy, 12 patients were monitored for 16.5 +/- 6.5 months. Twenty-two moderate and three severe rejection episodes occurred 11 to 469 days (166.8 +/- 126.0) after OKT3 therapy in nine of 12 patients. During the follow-up period three patients died, and one required retransplantation because of recurrent rejection. The coronary arteries of three failed allografts had severe intimal thickening and infiltration with lymphocytes. Thirteen patients received OKT3 for prophylactic immunosuppression, and their course was compared to that of 13 patients who underwent transplantation during the same period but were given prophylactic horse antihuman thymocyte globulins (HATG). There were no differences between the two drugs with respect to long-term incidence and severity of rejection and infection, cardiac allograft function, and survival. Our results indicate that, despite successful reversal with OKT3, heart transplant recipients with refractory rejection remain plagued by recurrent rejection. Cardiac allografts in recipients who die as a result of recurrent rejection show evidence of immune-mediated vasculitis, which results in severe and diffuse coronary luminal narrowing. OKT3 and HATG appear to be equally effective for rejection prophylaxis.

Adult↗

OKT3 monoclonal antibody given for ten versus fourteen days as immunosuppressive prophylaxis in heart transplantation.

We have previously reported that murine antihuman monoclonal antibody OKT3 (Orthoclone OKT3) given for 14 days after heart transplantation is effective as immunosuppressive prophylaxis. The optimal protocol for OKT3 prophylaxis in heart transplantation is unknown, particularly the duration of OKT3 therapy. We conducted a consecutively allocated overlapping 6-month study with 68 heart transplant patients, comparing 14-day OKT3 (n = 34) to 10-day OKT3 treatment (n = 34). Both protocols included OKT3 given beginning 24 to 48 hours after operation, cyclosporine beginning on postoperative day 3, low-dosage steroids and azathioprine to prevent antibody production to OKT3, and a steroid pulse plus randomization to plus or minus vincristine after stopping OKT3. Pretransplant characteristics including age, sex, cause of congestive heart failure, and absence of positive pretransplant crossmatch were similar between the two groups. Although the infection rate was not significantly different between the two groups and mortality (one patient in each group) did not differ, 14-day prophylaxis decreased the number of treated rejection episodes per patient for the 6-month study (1.59 +/- 0.18 versus 2.24 +/- 0.19, p = 0.016). A 14-day course of OKT3 also decreased the risk of rejection during the 6-month follow-up period (p less than 0.05). In addition to having a decreased number of rejection episodes, patients in the 14-day protocol were also more likely to be withdrawn from maintenance steroids (79% versus 53%, p = 0.02). In conclusion, a measurable dose response efficacy can be demonstrated for 14-day versus 10-day OKT3 prophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies, Monoclonal↗

Using OKT3 to reverse cardiac allograft rejection.

Acute rejection is the major impediment to long-term patient survival after organ transplantation. Historically, the treatment of cardiac allograft rejection has been use of cytotoxic agents combined with high-dose steroids, resulting in an increased incidence of undesirable side effects. A new agent, OKT3, appears to be capable of reversing acute rejection episodes without significant morbidity. We report 10 cardiac transplant recipients in whom acute rejection was dramatically reversed and clinical symptoms resolved after treatment with OKT3. Side effects were minimal, including febrile episodes, innocuous diarrheal syndromes, mild opportunistic infections, and one hypotensive episode. Critical care nurses administering OKT3 must be cognizant of the risks and benefits of therapy in addition to recognizing potential drug side effects. A nursing care plan was devised to identify nursing diagnoses and intervention related to patient and family education as well as recognition and treatment of the reported adverse effects.

Acute Disease↗

Prophylactic OKT3 used as induction therapy for heart transplantation.

The benefit of an immunosuppressive agent should be demonstrated by less rejection, less toxicity, decreased hospital stay, and equal or superior patient survival. Since June 1987, a total of 61 patients have received prophylactic OKT3 for 14 days, beginning on postoperative day 1, in addition to cyclosporine, azathioprine, and prednisone (group 1). Group 1 was compared with our conventional-therapy group (group 2, n = 116) treated with cyclosporine, azathioprine, prednisone, and antithymocyte globulin. The hospital stay was reduced from 36 to 22 days (p less than 0.0001). The linearized rejection rate was reduced with OKT3 from 2.82 to 1.09 (p less than 0.0002), from 1.82 to 1.45 (p less than 0.02), and from 1.22 to 0.56 (p less than 0.04) during the first 3 months, respectively. Actuarial freedom from rejection at 12 months was 32% versus 12% (p less than 0.005). Antimurine antibodies developed in 12.7% of OKT3-treated patients.

Adult↗

Quadruple immunosuppression: comparison of OKT3 and Minnesota antilymphocyte globulin.

From May 1977 to June 1988, 110 patients receiving cadaveric kidney transplants were selected to receive Orthoclone (OKT3; Ortho Pharmaceutical Corporation, Raritan, NJ; 5 mg intravenous bolus) (n = 43) or Minnesota antilymphocyte globulin (MAG; 20 mg/kg/day) (n = 67) as the induction phase of a quadruple immunosuppressive protocol. The duration of treatment ranged from 5 to 16 days for OKT3 (mean, 8 days) and 7 to 14 days for MAG (mean, 9 days) as dictated by the postoperative recovery of renal function. All patients were followed-up for at least 3 months (maximum, 18 months; mean, 10 months). Of the 43 patients receiving OKT3, 11 (26%) had rejection episodes that were reversed and did not reoccur. Two patients had episodes that could not be reversed, resulting in graft loss. Of the 67 patients receiving MAG, 38 (57%) experienced a first rejection episode within the follow-up period; 16 of these had repeat rejections. Renal function was significantly better in the OKT3 group. Although both OKT3 and MAG were associated with excellent patient (98%) and graft (92%) survival, OKT3 was easier to administer with fewer rejection episodes. It was concluded that OKT3 is superior to MAG as perioperative cytoreductive therapy following cadaveric kidney transplantation.

Adult↗

Prophylactic use of OKT3 in immunologic high-risk cadaver renal transplant recipients.

Prophylactic OKT3 was administered to 27 immunologic high-risk cadaver renal transplant recipients (multiple transplant and/or panel reactive antibody greater than 50%) as part of a sequential immunosuppressive protocol consisting of OKT3, prednisone, azathioprine, and cyclosporine. The first dose of OKT3 was administered intraoperatively. Patient survival was 100% with a mean follow-up period of 13 months. Graft survival at 1 year was 70% (19 of 27). Eight grafts were lost during the first 6 weeks. Causes of graft loss were hyperacute rejection or primary nonfunction (4), irreversible rejection (2), and technical (2). After the first month, single rejection episodes occurred in four patients and multiple rejection episodes in three patients; all were successfully reversed, and no further graft losses were encountered. Mean serum creatinine level at 1 month posttransplant was 141 mumol/L (1.6 mg/dL), and the average serum creatinine has remained at that level during the follow-up period. No serious infections were encountered. Prophylactic OKT3 administration resulted in depletion of CD3+ lymphocytes from the peripheral circulation throughout therapy, as well as the development of therapeutic serum OKT3 levels. Five of the 27 (22%) patients developed antimurine antibodies during or after OKT3 therapy; four of these patients had low-titer antimurine antibody, and one had high-titer antimurine antibody. First-dose reactions were generally mild in this group of patients. Prophylactic use of OKT3 in this patient population resulted in superior graft survival when compared with a similar group of patients not receiving OKT3.

Adult↗

OKT3 prophylaxis in cadaveric kidney transplant recipients with delayed graft function.

Decreased 1-year allograft survival rates have frequently been observed in cadaveric renal allograft recipients with postoperative acute tubular necrosis (ATN), even in the cyclosporine era. Use of cyclosporine despite ATN may lead to a prolongation of ATN, while withholding cyclosporine may increase the chance of an early rejection episode. Prophylactic polyclonal antilymphocyte antibodies have been used postoperatively to prevent rejection while avoiding cyclosporine nephrotoxicity. Since January 1987, the authors have used OKT3 monoclonal antibody prophylaxis in all cadaver kidney recipients with ATN (n = 26). The posttransplant course of these patients was compared with that of cadaveric kidney recipients with ATN who received transplants in 1985-1986 and were treated with cyclosporine during ATN (n = 40). Allograft survival rates in these patients were also compared with those observed in cadaver kidney recipients with immediate graft function. The 1-year graft survival rate was significantly better in the ATN patients who received OKT3 prophylaxis (83%) than in those who were treated early with cyclosporine during the period of ATN (55%). The mean duration of OKT3 therapy was 11.1 +/- 2.5 days. There was no significant difference in 1-year graft survival rates between the ATN patients treated with OKT3 prophylaxis and patients who had immediate graft function (74%, 1985 through 1988 combined). Patient survival was unaffected by the occurrence of ATN or the postoperative immunosuppressive protocol. The duration of ATN was shortened (9.3 +/- 4.0 v 14.9 +/- 10.2 days), and the median time to first rejection was prolonged (23.5 v 11.0 days) by OKT3 prophylaxis compared with early cyclosporine.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Kidney Injury↗

Selective OKT3 induction therapy in adult cadaveric-donor renal transplant recipients.

Decreasing Medicare reimbursement for renal transplantation has placed a premium on early hospital discharge. On average, the diagnosis-related group reimbursement for renal transplantation is exhausted by the ninth hospital day at the authors' institution. Previously, the median length of hospital stay was 14 days for patients with initial graft dysfunction and 8 days for those with immediate function. In the present protocol, all patients received a single 10-mg dose of OKT3 during the transplant procedure. Those with good initial function received no further OKT3 and began receiving cyclosporine, 10 mg/kg/d, on the second posttransplant day. High-dose cyclosporine was avoided in those with poor initial function, whether they required dialysis or not. Instead, they received cyclosporine, 6 mg/kg/d and resumed OKT3, 5 mg/d, on the second day for up to a 14-day course to prevent rejection during recovery of renal function and permit early discharge. All patients received maintenance immunosuppression including cyclosporine, azathioprine, and prednisone. Of 39 adult cadaveric-donor renal transplant recipients entered in the protocol with 2 to 8 months follow-up, 13 (33%) had good graft function and received only the intraoperative dose of OKT3, 9 (23%) had poor initial function but did not require dialysis, and 17 (44%) had poor function receiving dialysis for a median duration of 15 days (range, 2-46 days). Side effects of OKT3 were well tolerated, and median hospital stays were 7 days (range, 6-11), 7 days (range, 5-14), and 9 days (range, 5-15), respectively, for the three groups. Overall patient survival was 100% and graft survival was 97% for the short follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

The reuse of OKT3 after previous rejection or induction therapy in cadaveric renal transplantation.

Twenty-three patients were retreated once and two patients were retreated two times with OKT3 after previous rejection or induction therapy in cadaveric renal transplantation. Retreatment was effective when the initial treatment was for rejection therapy or induction therapy protocols. Rejection reversal was 83% in the rejection group and 90% in the induction group. Long-term allograft function was 42% in the rejection group and 78% in the induction group. It is speculated that the immune response is more adequately controlled in the induction group. The antibody responses to retreatment were no antibody production (n = 9), antibody production on retreatment (n = 2), no change in antibody titer (n = 4), and increase in previously identified antibody titer (n = 3). Two patients with high titered antibodies had treatment failures caused by preformed antimouse antibodies. The only changes in antibody specificity occurred in patients with a change in preformed antibody. Retreatment of allograft rejection in patients previously treated with OKT3 has again been demonstrated to be effective. It is suggested that retreatment after OKT3 induction therapy may be the most effective.

Antibodies, Monoclonal↗

OKT3 prophylaxis versus conventional drug therapy: single-center perspective, part of a multicenter trial.

As part of a collaborative study, Orthoclone OKT3 (Ortho Pharmaceutical Corporation, Raritan, NJ) monoclonal anti-T-cell antibody was used prophylactically for 14 days following cadaveric renal transplantation. Patients were randomized before treatment and compared with a control group treated with triple-drug immunosuppressant therapy consisting of cyclosporine, azathioprine, and prednisone. The OKT3 group (also treated with prednisone and azathioprine) had significantly fewer patients with acute rejection during the first year (27% v 60%), significantly delayed onset of acute rejection (median number of days to rejection, 56 v 10), and shortened duration of delayed initial graft function (median number of days on nonfunction, 5.5 v 9.0). OKT3 was safely administered intraoperatively. The study group included diabetics and patients over the age of 50 years. There was an increased incidence of benign fungal infection in patients treated with OKT3. The outcome data of both the prophylactic and control groups in this single-center trial was different from the multicenter experience in that patient and graft survival was 100% in both groups. The only difference in the immunosuppressive protocol was the use of 2 g intravenous methylprednisolone intraoperatively. The combination of intraoperative OKT3 with 2 g methylprednisolone may merit further study. It was concluded that OKT3 prophylaxis reduces the incidence of rejection episodes, delays the occurrence of rejection, and may reduce the duration of delayed initial graft function. It is not associated with an increase in serious infection and can be administered safely to a variety of cadaver transplant recipients.

Antibodies, Monoclonal↗

[Orthoclone OKT3 (Muromonab CD3)--the indications for and manner of its use. Side effects and their prevention].

In the last decade renal transplantation has gained considerable development. This is due to the achievements of clinical immunology and refinement of the surgical technique. In spite of all this, the achievements of renal transplantation are variable. This primarily is due to T-lymphocyte mediation, causing hazards for graft rejection. At present, numerous therapeutic agents, blocking the immune response of the organism, are applied. They are most effective when block selectively the activity of the immune cells responsible for immune response. The first synthesized preparation is Orthoclone OKT3 (Muronab-CD3). It is a sterile solution of murine monoclonal antibody to T3 (CD3) antigen in human T-cells and functions as immunosuppressor. The first experimental data on its application have been published in 1975. In 1980 the preparation was applied for the first time for treatment of acute reaction for grafted kidney rejection. The authors set themselves the task to give a brief review of the nature of this preparation, mode of its storage, indications for use, side reactions and their prophylaxis.

Antibodies, Monoclonal↗

OKT3-associated adverse reactions: mechanistic basis and therapeutic options.

OKT3, a prototypic monoclonal antibody directed at the lineage-specific CD3 antigen expressed on mature T cells, is an effective immunosuppressant in organ graft recipients. Unfortunately, a variety of adverse reactions are observed following the first and second doses of OKT3. In a series of experiments designed to examine the signaling repertoire of OKT3, it was found that (1) OKT3 is an effective substitute for the alloantigen stimulus in the activation of antigen-specific memory T cells; (2) OKT3 is a potent inducer of cytolytic activity (secondary cytotoxic T-cell activity as well as natural killer-cell activity); (3) OKT3 is also an inducer of interleukin-2 and interferon gamma production; and (4) of the immunosuppressants currently in clinical use, cyclosporine greater than methylprednisolone greater than 6-mercaptopurine (an in vivo cleavage product of azathioprine) in curtailing T-cell activation with OKT3. Collectively, these observations suggest a potential mechanistic basis for the adverse reactions associated with OKT3 and provide experimental support for therapeutic strategies that include the use of cyclosporine and/or methylprednisolone before OKT3 administration.

Antibodies, Monoclonal↗