Diagnostic potential of tetramer-based monitoring of cytomegalovirus-specific CD8+ T lymphocytes in allogeneic stem cell transplantation

Patient risk stratification and tailored clinical management of post-transplant CMV-, EBV-, and BKV-infections by monitoring virus-specific T-cell immunity

Background

Despite routine post-transplant viral monitoring and pre-emptive therapy, viral infections remain a major cause of allogeneic hematopoietic cell transplantation-related morbidity and mortality.

Objective

We here aimed to prospectively assess the kinetics and the magnitude of cytomegalovirus-(CMV), Epstein Barr virus-(EBV), and BK virus-(BKV)-specific T cell responses post-transplant and evaluate their role in guiding therapeutic decisions by patient risk-stratification.

Study design

The tri-virus-specific immune recovery was assessed by Elispot, in 50 consecutively transplanted patients, on days +20, +30, +60, +100, +150, +200 post-transplant and in case of reactivation, weekly for 1 month.

Results

The great majority of the patients experienced at least one reactivation, while over 40% of them developed multiple reactivations from more than one of the tested viruses, especially those transplanted from matched or mismatched unrelated donors. The early reconstitution of virus-specific immunity (day +20), favorably correlated with transplant outcomes. Εxpanding levels of CMV-, EBV-, and BKV-specific T cells (VSTs) post-reactivation coincided with decreasing viral load and control of infection. Certain cut-offs of absolute VST numbers or net VST cell expansion post-reactivation were determined, above which, patients with CMV or BKV reactivation had >90% probability of complete response (CR).

Conclusion

Immune monitoring of virus-specific T-cell reconstitution post-transplant may allow risk-stratification of virus reactivating patients and enable patient-tailored treatment. The identification of individuals with high probability of CR will minimize unnecessary overtreatment and drug-associated toxicity while allowing candidates for pre-emptive intervention with adoptive transfer of VSTs to be appropriately selected.

Relationship between T-cell receptor beta chain sequences and human cytomegalovirus infection in allogeneic hematopoietic stem cell transplant recipients

In the present study, clonal amplifications of T-cell receptor β variable (TCR BV) linked to human cytomegalovirus (HCMV) infection were detected in recipients of allogeneic hematopoietic stem cell transplants (HSCT), and certain relationships between them were identified. Furthermore, the relationship between TCR BV sequences and HCMV infections was investigated. The results indicated that the 3 recipients of HSCT had monoclonal expansion of specific TCR BV clones following HSCT. Among these recipients, 2 suffered from pp65 and immediate early (IE) antigenemia. These patients demonstrated preferential expansion of TCR BV9 (QVRGGTDTQ) and TCR BV11 (VATDFQ). The remaining recipient did not express TCR BV9 and TCR BV11, nor did this individual have pp65 and IE antigenemia. These results suggest that expression of TCR BV9 and TCR BV11 may be associated with HCMV antigenemia, and may be involved in the immune response. The amino acid sequences 'QVRGGTDTQ' and 'VATDFQ' may be involved in HCMV reactivation in patients who have undergone HSCT. Assessment of the TCR BV families may provide valuable insight into HCMV pathogenesis and may aid in the diagnosis and therapy for HSCT recipients infected with HCMV.

Longitudinal analyses of leukemia-associated antigen-specific CD8+ T cells in patients after allogeneic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment approach for patients with acute myeloid leukemia (AML) and chronic lymphocytic leukemia (CLL). Graft versus leukemia (GVL) effects, which are exerted by donor T cells directed against leukemic-associated antigens (LAAs), are considered to play a crucial role in disease eradication. Although the expansion of cytotoxic T lymphocytes (CTLs) specific for cytomegalovirus (CMV) in response to an infection has been shown in multiple studies, data on CTLs mediating GVL effects are limited. To evaluate a potential increase or decrease of T lymphocytes specific for LAAs in the setting of allogeneic HSCT, we monitored leukemia-specific CD8⁺ T cells throughout the first year after HSCT in 18 patients using streptamer technology. A broad panel of promising LAAs was selected: Wilms tumor protein, proteinase 3, receptor for hyaluronan acid-mediated motility, apoptosis regulator Bcl-2, survivin, nucleophosmin, and fibromodulin. T cells specifically directed against AML- or CLL-associated antigens were found at very low frequencies in peripheral blood. Substantial frequencies of LAA-specific T cells could not be measured at any time point by flow cytometry. In contrast, abundant CMV-pp65-specific T cells were detected in CMV-seropositive patient-recipient pairs and an increase prompted by CMV infection could be demonstrated. In conclusion, T lymphocytes with specificities for the aforementioned LAAs can only be detected in minimal quantities in the early phase after allogeneic HSCT.

Development of two potential diagnostic monoclonal antibodies against human cytomegalovirus glycoprotein B

Human cytomegalovirus glycoprotein B (gB) represents a target for diagnosis and treatment in view of the role it plays in virus entry and spread. Nevertheless, to our knowledge, rare detection of a gB antigen has been reported in transplant patients and limited information is available about diagnostic gB monoclonal antibodies (mAbs). Our aim was to develop gB mAbs with diagnostic potential. Hydrophilic gB peptides (ST: amino acids 27-40, SH: amino acids 81-94) of favorable immunogenicity were synthesized and used to immunize BALB/c mice. Two mAbs, named ZJU-FH6 and ZJU-FE6, were generated by the hybridoma technique and limited serial dilution and then characterized by indirect ELISA, Western blotting, immunoprecipitation, and immunohistochemical staining. The mAbs displayed high titers of specific binding affinities for the ST and SH synthetic peptides at an mAb dilution of 1:60,000 and 1:240,000, respectively. Western blotting and immunoprecipitation indicated that these mAbs recognized both denatured and native gB of the Towne and AD169 strains. The mAbs, when used as the primary antibody, showed positive staining in cells infected with both Towne and AD169 strains. The mAbs were then tested on patients submitted to allogeneic hematopoietic stem cell transplantation. The gB antigen positivity rates of the patients tested using ZJU-FH6 and ZJU-FE6 were 62.0 and 63.0%, respectively. The gB antigen showed a significant correlation with the level of pp65 antigen in peripheral blood leukocytes. In conclusion, two potential diagnostic gB mAbs were developed and were shown to be capable of recognizing gB in peripheral blood leukocytes in a reliable manner.

Analytical performance of a standardized single-platform MHC tetramer assay for the identification and enumeration of CMV-specific CD8+ T lymphocytes

Major histocompatibility complex (MHC) multimers that identify antigen-specific T cells, coupled with flow cytometry, have made a major impact on immunological research. HLA Class I multimers detect T cells directed against viral, tumor, and transplantation antigens with exquisite sensitivity. This technique has become an important standard for the quantification of a T cell immune response. The utility of this method in multicenter studies, however, is dependant on reproducibility between laboratories. As part of a clinical study using a standardized two-tube three-color single-platform method, we monitored and characterized performance across multiple sites using tetramers against the T cell receptors (TCR) specific for MHC Class I, A*0101--VTEHDTLLY, A*0201--NLVPMVATV and B*0702--TPRVTGGGAM CMV peptides. We studied the analytical performance of this method, focusing on reducing background, maximizing signal intensity, and ensuring that sufficient cells are enumerated to provide meaningful statistics. Inter and intra-assay performance were assessed, which included inherent variability introduced by shipping, type of flow cytometer used, protocol adherence, and analytical interpretation across a range of multiple sample levels and specificities under routine laboratory testing conditions. Using the described protocol, it is possible to obtain intra- and interlab CV's of <20%, with a functional sensitivity for absolute tetramer counts of 1 cell/microL and 0.2% tetramer+ percent for A*0101, A*0201, and B*0702 alleles. The standardized single-platform MHC tetramer assay is simple, rapid, reproducible, and useful for assessing CMV-specific T cells, and will allow for reasonable comparisons of clinical evaluations across multiple centers at clinically relevant thresholds (2.0-10.0 cells/microL).

Ex vivo monitoring of human cytomegalovirus-specific CD8+ T-cell responses using QuantiFERON�-CMV

We have developed a novel diagnostic technology to monitor the human cytomegalovirus (HCMV)-specific CD8+ T-cell responses that is based on the detection of secreted interferon-gamma (IFN-gamma) in the whole blood (referred to as QuantiFERON -CMV). Evaluation of QuantiFERON -CMV in healthy individuals revealed that this technology was at least as sensitive and with some HCMV epitopes more sensitive than the ELISPOT for detecting ex vivo IFN-gamma. Results from QuantiFERON -CMV assays showed 97% (36/37 individuals) agreement with the anti-HCMV serology test in healthy individuals. Furthermore, we also show that this technology can be used to assess HCMV-specific T-cell responses in transplant patients. This study shows that QuantiFERON -CMV is a simple, reproducible, and reliable test for the detection of IFN-gamma in response to HCMV CD8+ T-cell epitopes, and may be a valuable diagnostic test for the detection of HCMV infection and a useful clinical tool for monitoring the immune response in immunosuppressed patients during therapy.

Improved preparation of class I HLA tetramers and their use in detecting CMV-specific CTL

Different methods were used to prepare HLA tetramers and the yields of each method were compared. Our results indicate that preliminary refolding of the heavy chain (Hc) and light chain (beta 2m) yields more monomer than the typical conventional method with urea-solubilized Hc and beta 2m. We then used the corresponding tetramers to detect cytomegalovirus (CMV)-specific cytotoxic T lymphocytes (CTL). Increasing data suggest that the adoptive transfer of CMV-specific CTL constitutes an effective strategy against CMV infections. We designed a method that efficiently induces CMV-specific CTL to a higher frequency in vitro than is currently achieved. This method increased the percentage of CMV-specific CTL from below 1% to 20% of PBL, accounting for more than 40% of CD8+ T cells. Successful HLA tetramer preparation provides the basis for the subsequent detection of CMV-specific CTL in clinical applications.

Choice of antibody immunotherapy influences cytomegalovirus viremia in simultaneous pancreas-kidney transplant recipients

OBJECTIVE

Simultaneous pancreas-kidney (SPK) transplantation in type 1 diabetic patients requires immunotherapy against allo- and autoreactive T-cells. Cytomegalovirus (CMV) infection is a major cause for morbidity after transplantation and is possibly related to recurrent autoimmunity. In this study, we assessed the pattern of CMV viremia in SPK transplant recipients receiving either antithymocyte globulin (ATG) or anti-CD25 (daclizumab) immunosuppressive induction therapy.

RESEARCH DESIGN AND METHODS

We evaluated 36 SPK transplant recipients from a randomized cohort that received either ATG or daclizumab as induction therapy. Patients at risk for CMV infection received oral prophylactic ganciclovir therapy. The CMV DNA level in plasma was measured for at least 180 days using a quantitative real-time PCR. Recipient peripheral blood mononuclear cells were cross-sectionally HLA tetramer-stained for CMV-specific CD8(+) T-cells.

RESULTS

Positive CMV serostatus in donors was correlated with a higher incidence of CMV viremia than negative serostatus. In patients at risk, daclizumab induction therapy significantly prolonged CMV-free survival. CMV viremia occurred earlier and was more severe in patients with rejection episodes than in patients without rejection episodes. CMV-specific CD8(+) T-cell counts were significantly lower in patients developing CMV viremia than in those who did not.

CONCLUSIONS

Despite their comparable immunosuppressive potential, daclizumab is safer than ATG regarding CMV infection risk in SPK transplantation. ATG-treated rejection episodes are associated with earlier and more severe infection. Furthermore, high CMV-specific tetramer counts reflect antiviral immunity rather than concurrent viremia because they imply low viremic activity. These findings may prove valuable in the discussion on both safety of induction therapy and recurrent autoimmunity in SPK and islet transplantation.

Evaluation of cytomegalovirus-specific cytotoxic T-lymphocytes in patients with the HLA-A*02 or HLA-A*24 phenotype undergoing hematopoietic stem cell transplantation

Cytomegalovirus-specific cytotoxic T-lymphocytes (CMV-CTL) are essential for the control of CMV reactivation. To monitor the quantity and function of CMV-CTL after hematopoietic stem cell transplantation (HSCT), two CMV epitopes that bind to HLA-A*0201 NLVPMVATV (A*02NLV) and HLA-A*2402 QYDPVAALF (A*24QYD) were evaluated for their immunological potential. Samples from patients with the HLA-A*02 or HLA-A*24 serotype were analyzed by tetramer, intracellular cytokine staining and enzyme-linked immunospot (ELISPOT) assay. There were significantly more A*02NLV-specific CMV-CTL than A*24QYD (23 x 10(6) vs 0.4 x 10(6)/l). The frequency of IFN-gamma-producing cells was also higher upon stimulation with A*02NLV than with A*24QYD (2.5 vs 0.1%/CD8). Furthermore, the magnitude of CMV-CTL expansion was two- to 50-fold when cells were cultured with A*02NLV, while only an insignificant increase was observed in culture with A*24QYD. Although the number of A*24QYD-specific CMV-CTL was very low in most of the HLA-A*24 patients, the incidence of CMV reactivation did not differ between those with HLA-A*02 and HLA-A*24 serotype alone. These results suggest that an epitope other than A*24QYD plays a major role in patients with HLA-A*24. Our study also showed that A*02NLV may be a useful epitope for monitoring CMV-CTL not only in patients with HLA-A*0201 but also in those with the A*0206 genotype.

Cytomegalovirus-specific CD4 T-cell and glycoprotein B specific antibody response in recipients of allogenic stem cell transplantation

BACKGROUND

The human cytomegalovirus (HCMV) causes severe complications in immunosuppressed patients, resulting in increased morbidity and mortality. The immunological components important for the control of HCMV are still not completely understood.

OBJECTIVE AND STUDY DESIGN

To evaluate the importance of cellular and humoral immunity in stem cell transplant (SCT) recipients, we analysed levels of HCMV specific IFN-gamma producing CD4+ cells and glycoprotein B (gB) specific antibodies in HCMV positive SCT patients with and without reactivation episodes after SCT.

RESULTS AND CONCLUSION

Patients without HCMV reactivation episodes showed a slow but steady increase in both parameters after SCT, indicating that initial high levels of gB specific antibodies or HCMV specific CD4+ IFN-gamma+ cells are not necessary to prevent reactivation of HCMV. In contrast, patients with reactivation episodes showed a steep, significant increase in HCMV specific CD4+ IFN-gamma+ counts just prior to HCMV reactivation, followed by a decline after the reactivation period. Patients who underwent only a single reactivation generated significant higher amounts of CD4+ IFN-gamma+ cells, than did patients with further reactivation episodes. The course of gB specific antibodies for reactivating patients was different, with significantly higher average values in the patients with HCMV reactivation. This indicates that patients with a HCMV reactivation exhibit a stronger humoral dominated immune response.

Procedure for preparing peptide-major histocompatibility complex tetramers for direct quantification of antigen-specific cytotoxic T lymphocytes

AIM

To establish a simplified method for generating peptide-major histocompatibility complex (MHC) class I tetramers.

METHODS

cDNAs encoding the extracellular domain of human lymphocyte antigen (HLA)-A*0201 heavy chain (A2) and beta(2)-microglobulin (beta(2)m) from total RNA extracted from leukocytes of HLA-A2(+) donors were cloned into separate expression vectors by reverse transcription-polymerase chain reaction. The recombinant A2 and beta(2)m proteins were expressed in Escherichia coli strain BL21(DE3) and recovered from the inclusion body fraction. Soluble A2 proteins loaded with specific antigen peptides were refolded by dilution from the heavy chain in the presence of light chain beta(2)m and HLA-A2-restricted peptide antigens. The refolded A2 monomers were biotinylated with a commercial biotinylation enzyme (BirA) and purified by low pressure anion exchange chromatography on a Q-Sepharose (fast flow) column. The tetramers were then formed by mixing A2 monomers with streptavidin-PE in a molar ratio of 4:1. Flow cytometry was used to confirm the expected tetramer staining of CD8(+) T cells.

RESULTS

Recombinant genes for HLA-A*0201 heavy chain (A2) fused to a BirA substrate peptide (A2-BSP) and mature beta(2)m from HLA-A2(+) donor leukocytes were successfully cloned and highly expressed in E. coli. Two soluble monomeric A2-peptide complexes were reconstituted from A2-BSP in the presence of beta(2)m and peptides loaded with either human cytomegalovirus pp65(495-503) peptide (NLVPMVATV, NLV; designated as A2-NLV) or influenza virus matrix protein Mp58-66 peptide (GILGFVFTL, GIL; designated as A2-GIL). Refolded A2-NLV or A2-GIL monomers were biotinylated and highly purified by single step anion exchange column chromatography. The tetramers were then formed by mixing the biotinylated A2-NLV or A2-GIL monomers with streptavidin-PE, leading to more than 80% multiplication as revealed by SDS-PAGE under non-reducing, unboiled conditions. Flow cytometry revealed that these tetramers could specifically bind to CD8(+) T cells from a HLA-A2(+) donor, but failed to bind to those from a HLA-A2- donor.

CONCLUSION

The procedure is simple and efficient for generating peptide-MHC tetramers.

Assessment of cellular immunity to human cytomegalovirus in recipients of allogeneic stem cell transplants

Effective reconstitution of cellular immunity following hematopoietic stem cell transplantation (HCT) is thought to be important for protection from the morbidity caused by cytomegalovirus (CMV) reactivation and disease. This review critically discusses current methods for assessment of CMV-specific cellular immune responses, with emphasis on flow cytometry-based methodologies such as MHC-I and MHC-II tetramer staining and intracellular cytokine assays. The advantages and weaknesses of these assays are considered in comparison to traditional immunologic techniques. Application of these newer methodologies has provided insight into the dynamics of the levels of CMV-specific CD4(+) and CD8(+) T-lymphocytes following HCT, and into the sources and diversity of these cells. Data from preliminary clinical studies suggest that CMV-specific CD8(+) T-lymphocyte levels greater than 1 x 10(7)/L of peripheral blood may correlate with protection from CMV disease. Studies on the functional phenotypes of CMV-specific CD8(+) T-lymphocytes such as cytokine production, degranulation, and cytotoxicity have indicated that these cells are heterogeneous with regard to these properties. Future research will focus on establishing whether any of these immunologic assays will serve as a correlate of protection and inform as to which patients are at high risk for CMV reactivation and disease. Identification of an informative assay may allow its incorporation into standard clinical practice for monitoring HCT patients.

Reconstitution of HLA-A*2402-restricted cytomegalovirus-specific T-cells following stem cell transplantation

Cytomegalovirus (CMV)-specific immune reconstitution early after stem cell transplantation (SCT) was evaluated prospectively by detecting CD8+ T-cells, which recognize the peptide QYDPVAALF in the context of HLA-A*2402. Fifteen allogeneic SCT recipients were included in the study. All recipients and donors were seropositive for CMV and had the HLA-A*2402 allele. CMV-specific T-cells were detected as early as 1 month after transplantation, and their numbers increased to peak levels 2 to 5 months after transplantation. The numbers of CMV-specific T-cells in patients who developed grade II to IV acute graft-versus-host disease (GVHD) and received corticosteroids for acute GVHD were low in the early period after allogeneic SCT. There was a trend toward earlier reconstitution of CMV-specific CD8+ T-cells in allogeneic peripheral blood SCT (PBSCT) patients than in allogeneic bone marrow transplantation patients. The contribution of T-cells in the graft to the recovery of CMV-specific immune responses was also suggested by the finding that the reconstitution of CMV-specific CD8+ T-cells was delayed in CD34-selected autologous PBSCT compared with unpurged autologous PBSCT. The reconstitution of CMV-specific CD8+ T-cells was delayed in patients with CMV disease or recurrent CMV reactivation. These observations suggest that the detection of CMV-specific T-cells with an HLA-peptide tetramer is useful to assess immune reconstitution against CMV and to identify patients at risk for CMV disease or recurrent CMV reactivation after SCT.

Interleukin-7 improves reconstitution of antiviral CD4 T cells

We evaluated whether long-term (2 months) administration of interleukin-7 (IL7) hastens immune recovery in baboons rendered severely lymphopenic by total body irradiation and antithymocyte globulin (ATG). Four baboons were treated with recombinant baboon IL7 and three baboons with placebo. Median CD4 T cell count at the end of IL7/placebo treatment was higher in the IL7-treated animals (2262 vs. 618/microl, P = 0.03). This appeared to be a result of peripheral expansion rather than de novo generation. Median cytomegalovirus (CMV)-specific IFNgamma-producing CD4 T cell count at the end of IL7/placebo treatment was higher in the IL7-treated animals (122 vs. 1/microl, P = 0.03). All animals were pretransplant cytomegalovirus-seropositive. One animal died at the end of IL7 treatment; necropsy showed extensive T cell infiltration of kidneys and lungs. In conclusion, IL7 stimulates the expansion of CD4 T cells, including functional antiviral cells. Clinical risk-benefit ratio needs to be evaluated.

Quantitation of MHC tetramer-positive cells from whole blood: Evaluation of a single-platform, six-parameter flow cytometric method

BACKGROUND

Quantitation of antigen-specific T cells provides an insight into the development and dynamics of T-cell responses in tumor immunology and infectious diseases. Soluble major histocompatibility class I tetramers are widely used to monitor immune responses; however, variations due to handling and analysis are likely to confound comparisons between different experiments and laboratories.

METHODS

Whole blood from healthy donors was stained with HLA-A*0201/tetramers specific for an epitope of phosphoprotein 65, the immunodominant antigen in cytomegalovirus infection. With the help of Trucount tubes, a single-platform, four-color flow cytometric assay was established to obtain absolute counts of tetramer-positive cells. Various staining and gating strategies were evaluated.

RESULTS

The no-wash method was a quick and straightforward procedure for the quantitation of tetramer-positive events from whole blood. The level for background staining was low. This information about the intra-assay-related variation and the physiologic variation will allow validation and interpretation of data in future studies.

CONCLUSIONS

The method is highly reliable and can be standardized for multiple experiments. It is therefore suitable for the direct ex vivo analysis of antigen-specific T cells in a variety of clinical settings such as infectious, autoimmune, or neoplastic diseases and can be implemented as a tool for multicenter studies.