Effect of Transgenic Expression of Human Decay—Accelerating Factor on the Inhibition of Hyperacute Rejection of Pig Organs

The complex functioning of the complement system in xenotransplantation

The role of complement in xenotransplantation is well-known and is a topic that has been reviewed previously. However, our understanding of the immense complexity of its interaction with other constituents of the innate immune response and of the coagulation, adaptive immune, and inflammatory responses to a xenograft is steadily increasing. In addition, the complement system plays a function in metabolism and homeostasis. New reviews at intervals are therefore clearly warranted. The pathways of complement activation, the function of the complement system, and the interaction between complement and coagulation, inflammation, and the adaptive immune system in relation to xenotransplantation are reviewed. Through several different mechanisms, complement activation is a major factor in contributing to xenograft failure. In the organ-source pig, the detrimental influence of the complement system is seen during organ harvest and preservation, for example, in ischemia-reperfusion injury. In the recipient, the effect of complement can be seen through its interaction with the immune, coagulation, and inflammatory responses. Genetic-engineering and other therapeutic methods by which the xenograft can be protected from the effects of complement activation are discussed. The review provides an updated source of reference to this increasingly complex subject.

IXA Honorary Member Lecture, 2017: The long and winding road to tolerance

The last 15 years or so have seen exciting progress in xenotransplantation, with porcine organ grafts surviving months or even years in non-human primates. These advances reflect the application of new scientific knowledge, improved immunosuppressive agents, and genetic engineering. The field has recently enjoyed a renaissance of interest and hope, largely due to the exponential increase in our capacity to genetically engineer porcine source animals. However, immune responses to xenografts are very powerful and widespread clinical application of xenotransplantation will depend on the ability to suppress these immune responses while preserving the capacity to protect both the recipient and the graft from infectious microorganisms. Our work over the last three decades has aimed to engineer the immune system of the recipient in a manner that achieves specific tolerance to the xenogeneic donor while preserving otherwise normal immune function. Important proofs of principle have been obtained, first in rodents, and later in human immune systems in "humanized mice" and finally in non-human primates, demonstrating the capacity and potential synergy of mixed xenogeneic chimerism and xenogeneic thymic transplantation in tolerizing multiple arms of the immune system. Considering the fact that clinical tolerance has recently been achieved for allografts and the even greater importance of avoiding excessive immunosuppression for xenografts, it is my belief that it is both possible and imperative that we likewise achieve xenograft tolerance. I expect this to be accomplished through the availability of targeted approaches to recipient immune conditioning, understanding of immunological mechanisms of tolerance, advanced knowledge of physiological incompatibilities, and the availability of inbred miniature swine with optimized use of genetic engineering.

Porcine to Human Heart Transplantation: Is Clinical Application Now Appropriate?

Cardiac xenotransplantation (CXTx) is a promising solution to the chronic shortage of donor hearts. Recent advancements in immune suppression have greatly improved the survival of heterotopic CXTx, now extended beyond 2 years, and life-supporting kidney XTx. Advances in donor genetic modification (B4GALNT2 and CMAH mutations) with proven Gal-deficient donors expressing human complement regulatory protein(s) have also accelerated, reducing donor pig organ antigenicity. These advances can now be combined and tested in life-supporting orthotopic preclinical studies in nonhuman primates and immunologically appropriate models confirming their efficacy and safety for a clinical CXTx program. Preclinical studies should also allow for organ rejection to develop xenospecific assays and therapies to reverse rejection. The complexity of future clinical CXTx presents a substantial and unique set of regulatory challenges which must be addressed to avoid delay; however, dependent on these prospective life-supporting preclinical studies in NHPs, it appears that the scientific path forward is well defined and the era of clinical CXTx is approaching.

The pathobiology of pig-to-primate xenotransplantation: a historical review

The immunologic barriers to successful xenotransplantation are related to the presence of natural anti-pig antibodies in humans and non-human primates that bind to antigens expressed on the transplanted pig organ (the most important of which is galactose-α1,3-galactose [Gal]), and activate the complement cascade, which results in rapid destruction of the graft, a process known as hyperacute rejection. High levels of elicited anti-pig IgG may develop if the adaptive immune response is not prevented by adequate immunosuppressive therapy, resulting in activation and injury of the vascular endothelium. The transplantation of organs and cells from pigs that do not express the important Gal antigen (α1,3-galactosyltransferase gene-knockout [GTKO] pigs) and express one or more human complement-regulatory proteins (hCRP, e.g., CD46, CD55), when combined with an effective costimulation blockade-based immunosuppressive regimen, prevents early antibody-mediated and cellular rejection. However, low levels of anti-non-Gal antibody and innate immune cells and/or platelets may initiate the development of a thrombotic microangiopathy in the graft that may be associated with a consumptive coagulopathy in the recipient. This pathogenic process is accentuated by the dysregulation of the coagulation-anticoagulation systems between pigs and primates. The expression in GTKO/hCRP pigs of a human coagulation-regulatory protein, for example, thrombomodulin, is increasingly being associated with prolonged pig graft survival in non-human primates. Initial clinical trials of islet and corneal xenotransplantation are already underway, and trials of pig kidney or heart transplantation are anticipated within the next few years.

The role of genetically engineered pigs in xenotransplantation research

There is a critical shortage in the number of deceased human organs that become available for the purposes of clinical transplantation. This problem might be resolved by the transplantation of organs from pigs genetically engineered to protect them from the human immune response. The pathobiological barriers to successful pig organ transplantation in primates include activation of the innate and adaptive immune systems, coagulation dysregulation and inflammation. Genetic engineering of the pig as an organ source has increased the survival of the transplanted pig heart, kidney, islet and corneal graft in non-human primates (NHPs) from minutes to months or occasionally years. Genetic engineering may also contribute to any physiological barriers that might be identified, as well as to reducing the risks of transfer of a potentially infectious micro-organism with the organ. There are now an estimated 40 or more genetic alterations that have been carried out in pigs, with some pigs expressing five or six manipulations. With the new technology now available, it will become increasingly common for a pig to express even more genetic manipulations, and these could be tested in the pig-to-NHP models to assess their efficacy and benefit. It is therefore likely that clinical trials of pig kidney, heart and islet transplantation will become feasible in the near future.

Genetic modification of xenografts

For nearly a century, xenotransplantation has been seen as a potential approach to replacing organs and tissues damaged by disease. Until recently, however, the application of xenotransplantation has seemed only a remote possibility. What has changed this perspective is the advent of genetic engineering of large animals; that is, the ability to add genes to and remove genes from lines of animals that could provide an enduring source of tissues and organs for clinical application. Genetic engineering could address the immunologic, physiologic and infectious barriers to xenotransplantation, and could allow xenotransplantation to provide a source of cells with defined and even controlled expression of exogenous genes. This communication will consider one perspective on the application of genetic engineering in xenotransplantation.

Delayed rejection of porcine cartilage is averted by transgenic expression of alpha1,2-fucosyltransferase

The use of xenogeneic cells or tissues for tissue engineering applications may lead to advances in biomedical research. Hyperacute and delayed rejection are immunologic hurdles that must be addressed to achieve xenograft survival in the pig-to-primate setting. Expression of human alpha1,2-fucosyltransferase (HT) in the donor cell or tissue protects from hyperacute rejection (HAR) by reducing expression of Galalpha1,3-Gal epitope, the major xenoantigen recognized by human natural antibodies. We hypothesized that Galalpha1,3-Gal antigen contributes to delayed tissue rejection. To test this hypothesis, we transplanted control or HT-transgenic engineered porcine cartilage s.c. into alpha1,3-galactosyltransferase knockout (Gal KO) mice. Control porcine cartilage grafted in Gal KO mice was not susceptible to HAR but was rejected in several wk by a prominent cellular immune infiltrate and elevated antibody titers. In contrast, Gal KO mice receiving the HT engineered cartilage showed a markedly reduced anti-pig antibody response and no anti-Galalpha1,3-Gal-elicited antibody response. The HT implants had a mild cellular infiltrate that was confined to the graft periphery. Our study demonstrates that a marked reduction of Galalpha1,3-Gal antigen in HT-transgenic porcine cartilage confers resistance to a process of delayed rejection. Further development of tissue engineering applications that use genetically modified porcine tissues is encouraged.

Human NK cell-mediated cytotoxicity triggered by CD86 and Gal alpha 1,3-Gal is inhibited in genetically modified porcine cells

Delayed xenograft rejection is a major hurdle that needs to be addressed to prolong graft survival in pig-to-primate xenotransplantation. NK cell activation has been implicated in delayed xenograft rejection. Both Ab-dependent and independent mechanisms are responsible for the high susceptibility of porcine cells to human NK cell-mediated cytotoxicity. Previous reports demonstrated a role of Galalpha1,3-Gal Ag in triggering the Ab-independent responses. We hypothesize that expression of CD80 and/or CD86 on porcine cells may also play a role in NK cell activation as human NK cells express a variant of CD28. Our initial analysis showed that porcine endothelial cells and fibroblasts express CD86, but not CD80. Genetic engineering of these cells to express hCD152-hCD59, a chimeric molecule designed to block CD86 in cis, was accompanied by a reduction in susceptibility to human NK cell-mediated cytotoxicity. The use of a specific anti-porcine CD86-blocking Ab and the NK92 and YTS cell lines further confirmed the involvement of CD86 in triggering NK cell-mediated lysis of porcine cells. Maximal protection was achieved when hCD152-hCD59 was expressed in H transferase-transgenic cells, which show reduced Galalpha1,3-Gal expression. In this work, we describe two mechanisms of human NK cell-mediated rejection of porcine cells and demonstrate that genetically modified cells resist Ab-independent NK cell-mediated cytotoxicity.

Xenotransplantation and other means of organ replacement

Exciting new technologies, such as cellular transplantation, organogenesis and xenotransplantation, are thought to be promising approaches for the treatment of human disease. The feasibility of applying these technologies, however, might be limited by biological and immunological hurdles. Here, we consider whether, and how, xenotransplantation and various other technologies might be applied in future efforts to replace or supplement the function of human organs and tissues.

The immunological hurdles to cardiac xenotransplantation

The main hurdle to clinical application of cardiac xenotransplantation is the immune response of the recipient against the graft. Although all xenografts arouse an intense immune response, the effect of that response depends very much on whether the graft consists of isolated cells or an intact organ, such as the heart. Intact organs, which are transplanted by primary vascular anastomosis, are subject to severe vascular injury owing to the reaction of immune elements with the endothelial lining of donor blood vessels. Vascular injury leads to hyperacute rejection, acute vascular rejection, and chronic rejection. The immunological basis for these types of rejection and potential therapies, which might be used to avert them, are discussed.

Therapeutic strategies for xenograft rejection

The increasing demand for transplantable organs over the past several decades has stimulated the idea of using animal organs in lieu of cadaveric organs in clinical transplantation. Pigs are now considered to be the most suitable source of organs for transplantation because of their abundant availability, their appropriate size, their relatively short gestation period, and the recent development in the technology to genetically manipulate them. In the past few years, some of the seemingly complex immunologic responses in pig-to-primate transplantation have been elucidated. This progress has allowed us to focus our efforts on devising specific therapeutic strategies to overcome or prevent some of the responses that contribute to rejection of the xenograft. In this article, we review the various approaches that might allow clinical xenotransplantation to come to fruition.

Physiologic and immunologic hurdles to xenotransplantation

The major problem in the field of renal transplantation is currently the shortage of available kidneys. However, the use of animals as a source of kidneys, i.e., xenotransplantation, is increasingly being viewed as a potential solution to this problem. One preeminent hurdle to xenotransplantation is the immune response of the recipient against the graft; other hurdles include the physiologic limitations of the transplant, infection, and ethical considerations. This review summarizes what is currently known regarding the obstacles to xenotransplantation and some potential solutions to those problems.

Report of the Xenotransplantation Advisory Committee of the International Society for Heart and Lung Transplantation: the present status of xenotransplantation and its potential role in the treatment of end-stage cardiac and pulmonary diseases

An urgent and steadily increasing need exists world-wide for a greater supply of donor thoracic organs. Xenotransplantation offers the possibility of an unlimited supply of hearts and lungs that could be available electively when required. However, anti-body- mediated mechanisms cause the rejection of pig organs transplanted into non-human primates, and these mechanisms provide major immunologic barriers that have not yet been overcome. Having reviewed the literature on xenotransplantation, we present a number of conclusions on its present status with regard to thoracic organs, and we make a number of recommendations relating to eventual clinical trials. Although pig hearts have functioned in heterotopic sites in non-human primates for periods of several weeks, median survival of orthotopically transplanted hearts is currently ,1 month. No transplanted pig lung has functioned for even 24 hours. Current experimental results indicate that a clinical trial would be premature. A potential risk exists, hitherto undetermined, of transferring infectious organisms along with the donor pig organ to the recipient, and possibly to other members of the community. A clinical trial of xeno-transplantation should not be undertaken until experts in microbiology and the relevant regulatory authorities consider this risk to be minimal. A clinical trial should be considered when approximately 60% survival of life-supporting pig organs in non-human primates has been achieved for a minimum of 3 months, with at least 10 animals surviving for this minimum period. Furthermore, evidence should suggest that longer survival (.6 months) can be achieved. These results should be achieved in the absence of life-threatening complications caused by the immunosuppressive regimen used. The relationship between the presence of anti-HLA antibody and anti-pig antibody and their cross-reactivity, and the outcome of pig-organ xenotransplantation in recipients previously sensitized to HLA antigens require further investigation. We recommend that the patients who initially enter into a clinical trial of cardiac xenotransplantation be unacceptable for allotransplantation, or acceptable for allotransplantation but unlikely to survive until a human cadaveric organ becomes available, and in whom mechanical assist-device bridging is not possible. National bodies that have wide-reaching government-backed control over all aspects of the trials should regulate the initial clinical trial and all subsequent clinical xenotransplantation procedures for the foreseeable future. We recommend coordination and monitoring of these trials through an international body, such as the International Society for Heart and Lung Transplantation, and setting up a registry to record and widely disperse the results of these trials. Xenotransplantation has the potential to solve the problem of donor-organ supply, and therefore research in this field should be actively encouraged and supported.

Xenotransplantation

BACKGROUND

The success of clinical transplantation has led to a large discrepancy between donor organ availability and demand; considerable pressure exists to develop an alternative source of organs. The use of animal organs for donation is a possible solution that is not yet clinically applicable.

METHODS AND RESULTS

A literature review was performed based on a Medline search to find articles on xenotransplantation. Keywords included hyperacute, acute vascular, xenograft rejection combined with concordant and discordant. Additional references cited in these articles from journals not included in Medline were obtained from the British Library. Limited information on unpublished, preliminary work has been included from sources known to the authors, based on their research work in the field. One hundred and forty-six references and four personal communications have been included in this review article.

CONCLUSION

A greater understanding of the pathogenesis of xenograft rejection is developing rapidly. Strategies to abrogate hyperacute rejection have proved successful, but control of antibody-driven acute vascular rejection has not yet been achieved. The safety and viability of xenotransplantation as a therapeutic modality are still unproven.

The target antigens of naturally occurring human anti-beta-galactose IgG are cryptic on porcine aortic endothelial cells

The identification of the xeno-antigens/xeno-antibodies combinations involved in pig-to-human xenograft rejection is an essential step for understanding this process and for the development of procedures to prevent it. Although it is widely accepted that the terminal disaccharide Galalpha1,3Gal-R is by far the major epitope recognized by human natural antibodies reactive with pig tissues, there is also evidence that other carbohydrate epitopes might be important in xenograft rejection. In an attempt to further improve our knowledge of the repertoire of human natural antibodies with anti-pig specificity we sought to determine whether naturally occurring human anti-beta-galactose IgG could interact with porcine aortic endothelial cells (PAEC). Histochemical analysis of porcine aorta sections revealed that the carbohydrate structures recognized by the anti-beta-galactose IgG are present on endothelial cells but in a cryptic form that can be unmasked by sialidase treatment. These structures were also found to be cryptic in cultured PAEC. In addition we demonstrated that PAEC may adsorb fetal calf serum (FCS) glycoproteins when cultured in FCS-supplemented medium, a process susceptible to generating artifactual observations in carbohydrate antigens analysis. In conclusion, despite their abundance, human anti-beta-galactose IgG do not represent a primary concern in pig-to-human xenotransplantation as the carbohydrate structures to which they bind are normally masked by sialic acid residues on porcine endothelial cells. However, whether these cryptic epitopes might be exposed on endothelial cells from genetically engineered animals should be further investigated because, if so, additional approaches will be needed to suppress their interaction with human anti-beta-galactose IgG.

Role of complement in xenotransplantation

1. Xenotransplantation, or transplantation across species, leads to rejection, which destroys the xenograft within hours to days of transplantation. 2. Complement is a major barrier to xenotransplantation of vascularized organs and is believed to play an important role in the rejection process. 3. The present paper reviews three aspects of complement in xenotransplantation. These include the mechanisms and regulation of complement activation as well as tissue injury mediated by complement activation.

Current status of xenotransplantation

1. The transplantation of organs and tissues from animals into humans (i.e. xenotransplantation) has been a long sought objective to allow xenotransplantation to achieve its full impact in the clinical practice of medicine. 2. The main hurdles to the application of xenotransplantation are the immunological reaction of the recipient against the transplant, the functional limitations of tissues and organs in biogenetically disparate recipients and the possibility of transferring infectious organisms from the graft into the recipient. 3. Advances in a variety of fields have shed new light on these hurdles and have given rise to potential solutions and prospects for the clinical application of xenotransplant and are summarized in the report that follows.

Expression of the human alpha1,2-fucosyltransferase in transgenic pigs modifies the cell surface carbohydrate phenotype and confers resistance to human serum-mediated cytolysis

Hyperacute rejection (HAR) is the first critical immunological hurdle that must be addressed in order to develop xenogeneic organs for human transplantation. In the area of cell-based xenotransplant therapies, natural antibodies (XNA) and complement have also been considered barriers to successful engraftment. Transgenic expression of human complement inhibitors in donor cells and organs has significantly prolonged the survival of xenografts. However, expression of complement inhibitors without eliminating xenogeneic natural antibody (XNA) reactivity may provide insufficient protection for clinical application. An approach designed to prevent XNA reactivity during HAR is the expression of human alpha1, 2-fucosyltransferase (H-transferase, HT). H-transferase expression modifies the cell surface carbohydrate phenotype of the xenogeneic cell, resulting in the expression of the universal donor O antigen and a concomitant reduction in the expression of the antigenic Galalpha1,3-Gal epitope. We have engineered various transgenic pig lines that express HT in different cells and tissues, including the vascular endothelium. We demonstrate that in two different HT transgenic lines containing two different HT promoter constructs, expression can be differentially regulated in a constitutive and cytokine-inducible manner. The transgenic expression of HT results in a significant reduction in the expression of the Galalpha1,3-Gal epitope, reduced XNA reactivity, and an increased resistance to human serum-mediated cytolysis. Transgenic pigs that express H-transferase promise to become key components for the development of xenogeneic cells and organs for human transplantation.

Prospects for xenotransplantation

The major limitation on the application of transplantation for the treatment of human disease is a severe shortage of human donor organs and tissues. One approach to overcoming this problem is xenotransplantation, that is the transplantation of animal organs into humans. The major hurdle to xenotransplantation is the immune response of the recipient against the graft. Recent years have brought new information concerning this hurdle and insights of strategies for overcoming it. Other hurdles include the physiological function of the graft in the foreign environment including the possibility of molecular incompatibilities between the donor and recipient and the possibility of transferring infectious diseases from the graft to the recipient. The current perspective on these issues will be presented in the review that follows.

The future promises of xenotransplantation

The use of animals as a source of organs and tissues for humans has been an enduring goal of transplantation. Xenotransplantation, as such, would overcome a shortage of human donors and allow for biochemical or genetic approaches to modification of transplants. The use of animal organs and tissue, however, is hindered by an intense immune response of the recipient against the graft. The molecular basis for this immune response has recently been elucidated, at least in part, and specific approaches to therapy, including the genetic engineering of source animals, have been developed. Other hurdles, including the physiologic limitations of the transplant and the possibility of transferring infectious agents from the transplant into the host, may also be important. The development of specific therapies and the application of genetic engineering to overcome these problems can now be envisioned. As the immunologic, physiologic, and infectious hurdles to xenotransplantation are addressed, new efforts will focus on the use of the transplant to impart novel functions to answer the therapeutic needs of the transplant recipient.

Cytochemical demonstration of sites of hydrogen peroxide generation and increased vascular permeability in isolated pig hearts after ischaemia and reperfusion

Isolated pig hearts, subsequently perfused with pig or human blood, were prepared for the cytochemical demonstration of sites of hydrogen peroxide generation and increased vascular permeability. Oxidant stress was associated with ultrastructural changes commonly seen following myocardial reperfusion. In addition, the precipitation of cerium perhydroxide following perfusion with physiological saline containing cerium chloride suggested the vascular endothelium and leukocytes as sources of oxidants. This was associated with rapid penetration of horseradish peroxidase through the intercellular clefts of the vascular endothelium into the interstitial space, suggesting increased vascular leakiness at these sites. The rapid penetration of horseradish peroxidase was observed at all monitored periods of reperfusion with pig or human blood. This indicates that the increased permeability occurred during the ischaemic period and continued during reperfusion. Morphological damage was greatest in pig hearts reperfused with whole human blood and this was attenuated if the blood was preabsorbed to remove antibodies prior to reperfusion. We conclude that oxidant stress was initiated during ischaemia and continued during reperfusion in this model.