Augmentation of chimerism with perioperative donor bone marrow infusion in organ transplant recipients: a 44 month follow-up

Characterization and Function of Cryopreserved Bone Marrow from Deceased Organ Donors: A Potential Viable Alternative Graft Source

Despite the readily available graft sources for allogeneic hematopoietic cell transplantation (alloHCT), a significant unmet need remains in the timely provision of suitable unrelated donor grafts. This shortage is related to the rarity of certain HLA alleles in the donor pool, nonclearance of donors owing to infectious disease or general health status, and prolonged graft procurement and processing times. An alternative hematopoietic progenitor cell (HPC) graft source obtained from the vertebral bodies (VBs) of deceased organ donors could alleviate many of the obstacles associated with using grafts from healthy living donors or umbilical cord blood (UCB). Deceased organ donor-derived bone marrow (BM) can be preemptively screened, cryogenically banked for on-demand use, and made available in adequate cell doses for HCT. We have developed a good manufacturing practice (GMP)-compliant process to recover and cryogenically bank VB-derived HPCs from deceased organ donor (OD) BM. Here we present results from an analysis of HPCs from BM obtained from 250 deceased donors to identify any substantial difference in composition or quality compared with HPCs from BM aspirated from the iliac crests of healthy living donors. BM from deceased donor VBs was processed in a central GMP facility and packaged for cryopreservation in 5% DMSO/2.5% human serum albumin. BM aspirated from living donor iliac crests was obtained and used for comparison. A portion of each specimen was analyzed before and after cryopreservation by flow cytometry and colony-forming unit potential. Bone marrow chimerism potential was assessed in irradiated immunocompromised NSG mice. Analysis of variance with Bonferroni correction for multiple comparisons was used to determine how cryopreservation affects BM cells and to evaluate indicators of successful engraftment of BM cells into irradiated murine models. The t test (with 95% confidence intervals [CIs]) was used to compare cells from deceased donors and living donors. A final dataset of complete clinical and matched laboratory data from 226 cryopreserved samples was used in linear regressions to predict outcomes of BM HPC processing. When compared before and after cryopreservation, OD-derived BM HPCs were found to be stable, with CD34+ cells maintaining high viability and function after thawing. The yield from a single donor is sufficient for transplantation of an average of 1.6 patients (range, 1.2 to 7.5). CD34+ cells from OD-derived HPCs from BM productively engrafted sublethally irradiated immunocompromised mouse BM (>44% and >67% chimerism at 8 and 16 weeks, respectively). Flow cytometry and secondary transplantation confirmed that OD HPCs from BM is composed of long-term engrafting CD34+CD38-CD45RA-CD90+CD49f+ HSCs. Linear regression identified no meaningful predictive associations between selected donor-related characteristics and OD BM HPC quality or yield. Collectively, these data demonstrate that cryopreserved BM HPCs from deceased organ donors is potent and functionally equivalent to living donor BM HPCs and is a viable on-demand graft source for clinical HCT. Prospective clinical trials will soon commence in collaboration with the Center for International Blood and Marrow Research to assess the feasibility, safety, and efficacy of Ossium HPCs from BM (ClinicalTrials.gov identifier NCT05068401).

Establishment of Chimerism and Organ Transplant Tolerance in Laboratory Animals: Safety and Efficacy of Adaptation to Humans

The definition of immune tolerance to allogeneic tissue and organ transplants in laboratory animals and humans continues to be the acceptance of the donor graft, rejection of third-party grafts, and specific unresponsiveness of recipient immune cells to the donor alloantigens in the absence of immunosuppressive treatments. Actively acquired tolerance was achieved in mice more than 60 years ago by the establishment of mixed chimerism in neonatal mice. Once established, mixed chimerism was self-perpetuating and allowed for acceptance of tissue transplants in adults. Successful establishment of tolerance in humans has now been reported in several clinical trials based on the development of chimerism after combined transplantation of hematopoietic cells and an organ from the same donor. This review examines the mechanisms of organ graft acceptance after establishment of mixed chimerism (allo-tolerance) or complete chimerism (self-tolerance), and compares the development of graft versus host disease (GVHD) and graft versus tumor (GVT) activity in complete and mixed chimerism. GVHD, GVT activity, and complete chimerism are also discussed in the context of bone marrow transplantation to treat hematologic malignancies. The roles of transient versus persistent mixed chimerism in the induction and maintenance of tolerance and organ graft acceptance in animal models and clinical studies are compared. Key differences in the stability of mixed chimeras and tolerance induction in MHC matched and mismatched rodents, large laboratory animals, and humans are examined to provide insights into the safety and efficacy of translation of results of animal models to clinical trials.

Development and validation of a procedure to isolate viable bone marrow cells from the vertebrae of cadaveric organ donors for composite organ grafting

BACKGROUND AIMS

Donor-derived vertebral bone marrow (BM) has been proposed to promote chimerism in solid organ transplantation with cadaveric organs. Reports of successful weaning from immunosuppression in patients receiving directed donor transplants in combination with donor BM or blood cells and novel peri-transplant immunosuppression has renewed interest in implementing similar protocols with cadaveric organs.

METHODS

We performed six pre-clinical full-scale separations to adapt vertebral BM preparations to a good manufacturing practice (GMP) environment. Vertebral bodies L4-T8 were transported to a class 10 000 clean room, cleaned of soft tissue, divided and crushed in a prototype bone grinder. Bone fragments were irrigated with medium containing saline, albumin, DNAse and gentamicin, and strained through stainless steel sieves. Additional cells were eluted after two rounds of agitation using a prototype BM tumbler.

RESULTS

The majority of recovered cells (70.9 ± 14.1%, mean ± SD) were eluted directly from the crushed bone, whereas 22.3% and 5.9% were eluted after the first and second rounds of tumbling, respectively. Cells were pooled and filtered (500, 200 μm) using a BM collection kit. Larger lumbar vertebrae yielded about 1.6 times the cells of thoracic vertebrae. The average product yielded 5.2 ± 1.2 × 10(10) total cells, 6.2 ± 2.2 × 10(8) of which were CD45(+) CD34(+). Viability was 96.6 ± 1.9% and 99.1 ± 0.8%, respectively. Multicolor flow cytometry revealed distinct populations of CD34(+) CD90(+) CD117(dim) hematopoietic stem cells (15.5 ± 7.5% of the CD34 (+) cells) and CD45(-) CD73(+) CD105(+) mesenchymal stromal cells (0.04 ± 0.04% of the total cells).

CONCLUSIONS

This procedure can be used to prepare clinical-grade cells suitable for use in human allotransplantation in a GMP environment.

Induction of allogeneic mixed chimerism by immature dendritic cells and bone marrow transplantation leads to prolonged tolerance to major histocompatibility complex disparate allografts

Mixed chimerism has been shown to lead to prolonged major histocompatibility complex (MHC) disparate allograft survival and immune-specific tolerance; however, traditional conditioning regimes often involve myeloablation, which may pose a significant safety risk. In this study we examined the use of donor C57BL/6 (H-2(b)) immature dendritic cells (imDCs) to tolerize the BALB/c (H-2(d)) recipient to bone marrow transplantation (BMT), allowing the induction of mixed chimerism without immunosuppression or myeloablation. We showed that successful mismatched bone marrow engraftment can be achieved using imDCs given up to 3 days prior to BMT and that mixed chimerism can be established and detected in excess of 100 days post-BMT without evidence of graft-versus-host disease. Furthermore, we showed that imDCs can suppress lymphocyte proliferation in response to mismatched MHC stimulation, leading to increased expression of interleukin (IL)-4 and IL-10 and decreased expression of IL-2 and interferon-gamma (IFN-gamma). The induction of stable chimeras through pre-conditioning of mice with donor imDCs followed by BMT led to tolerance, allowing the long-term survival (> 110 days) of mismatched cardiac allografts and the prolonged survival of mismatched skin allografts without the need for immunosuppression or myeloablation. Transplantation with third-party C3H allografts were rapidly rejected in this model, suggesting that immune-specific tolerance was achieved. The induction of immune-specific tolerance without the need for immunosuppression or myeloablation represents a significant advance in transplant immunology and may provide clinicians with a plausible alternative in combating organ rejection following transplantation.

Tolerance induction for solid organ grafts with donor-derived hematopoietic reconstitution

Tolerance of transplanted tissue has been a focus of immunologists for decades. Indeed, to some the birth of immunology and the search for tolerance of the non-self are synonymous. One of the most powerful and reproducible methods of tolerance induction to allogeneic tissue has involved infusion of donor-specific hematopoietic cells. Under certain conditions, such infusion can result in hematopoietic reconstitution that can be experimentally accomplished at a variety of different time-points in the life of an organism from the in utero period through adulthood, reconstitution at each time-point involving consideration of a different set of immunological and physiological parameters. When high levels of donor-derived hematopoietic reconstitution are achieved, tolerance induction to donor-specific antigens is reproducible and long-lasting. Unfortunately, however, clinical efforts to achieve such high levels of hematopoietic reconstitution have historically been unsuccessful or fraught with complications. Transplantation efforts have been plagued by failure of engraftment, graft-vs-host disease (GVHD), or severe immunoincompetence of the recipient. Laboratory and clinical efforts during the last decade have resulted in a variety of developments that may overcome these barriers: (1) methods have been devised in which cells that cause GVHD can be depleted from the hematopoietic graft while hematopoietic reconstitution potential is preserved, (2) methods of harvesting large numbers of cells with multilineage reconstitution potential have been devised (an accomplishment that seems to allow the immunological barrier to be overwhelmed), and (3) capitalizing on the above two principles, minimally toxic preconditioning regimens have been designed that allow allogeneic engraftment. This review will focus on some of the experimental and clinical data of the past and the experimental and clinical issues that loom ahead.

Current treatment practice in immunosuppression

New drugs have recently been added that may eventually replace the two-decade dominance of cyclosporin in solid organ transplantation. This cornerstone of immunosuppression was introduced by Borel [1] and Calne [2] in the mid-70s. In 1989, Starzl et al., after 2 years of preclinical experimentation, introduced tacrolimus (originally designated as FK506 by the Fujisawa Pharmaceutical Company of Japan) as a potent immunosuppressant for liver transplants [3]. Also, in recent years, a variety of novel purine and pyrimidine biosynthesis inhibitors have been tested for transplantation therapy. The leading agent which appears to be replacing the 35-year position occupied by azathioprine is the semi-synthetic morpholinoethyl ester of mycophenolic acid (MPA), mycophenolate mofetil (MMF), introduced by Allison [4] and Sollinger [5], and developed by the Syntex Corporation (now Roche Pharmaceuticals). Others, affecting different intra- or intercellular messages amplifying immunity, are in the pipeline.

Donor MHC class II antigen is essential for induction of transplantation tolerance by bone marrow cells

Posttransplant infusion of donor bone marrow cells (BMC) induces tolerance to allografts in adult mice, dogs, nonhuman primates, and probably humans. Here we used a mouse skin allograft model and an allogeneic radiation chimera model to examine the role of MHC Ags in tolerance induction. Infusion of MHC class II Ag-deficient (CIID) BMC failed to prolong C57BL/6 (B6) skin grafts in ALS- and rapamycin-treated B10.A mice, whereas wild-type B6 or MHC class I Ag-deficient BMC induced prolongation. Removal of class II Ag-bearing cells from donor BMC markedly reduced the tolerogenic effect compared with untreated BMC, although graft survival was significantly longer in mice given depleted BMC than that in control mice given no BMC. Infusion of CIID BMC into irradiated syngeneic B6 or allogeneic B10.A mice produced normal lymphoid cell reconstitution including CD4+ T cells except for the absence of class II Ag-positive cells. However, irradiated B10.A mice reconstituted with CIID BMC rejected all B6 and a majority of CIID skin grafts despite continued maintenance of high degree chimerism. B10.A mice reconstituted with B6 BMC maintained chimerism and accepted both B6 and CIID skin grafts. Thus, expression of MHC class II Ag on BMC is essential for allograft tolerance induction and peripheral chimerism with cells deficient in class II Ag does not guarantee allograft acceptance.

Immunologic Aspects of Transplant Management: Pharmacotherapy and Rejection

The intensivist caring for the critically ill transplant patient must be knowledgeable in the management of immunosuppression or have expert help. Critical illness often has a major impact on the absorption and metabolism of immunosuppressive drugs, increasing or decreasing net immunosuppression. Too little immunosuppression brings the risk of graft loss, while too much increases the morbidity and mortality of serious infection. Optimum management often requires the skillful manipulation of dosage and/or routes of drug delivery. In many cases of life-threatening infection, immunosuppression must be discontinued altogether and restarted prior to significant graft injury. The cost of miscalculation is very high. Loss of a renal, pancreas, or small bowel transplant is tragic, while loss of a heart, lung, or liver is usually fatal. Unfortunately the management of immunosuppression is becoming more complex. As the field of transplantation matures, new immunosuppressants are being introduced. Also, more experience and growing numbers of clinical trials are making the required knowledge base ever larger. Each type of transplant has its own set of evolving immunosuppression strategies. This review presents the basic mechanisms of the most widely used drugs and the dangers of immunosuppression. The drugs are then discussed in the context of liver, small bowel, kidney, pancreas, heart, and lung transplantation. Finally, a brief section on the practical pharmacokinetics of the drugs is presented.

Immunological importance of chimerism in transplantation: new conditioning protocol in BMT and the development of chimeric state

Chimerism is an exceptional immunogenetic state, characterized by the survival and collaboration of cell populations originated from two different individuals. The prerequisits to induce chimerism are immuno-suppression, myeloablation, or severe immunodeficiency of the recipients on the one side and donor originated immuno-hematopoietic cells in the graft on the other. The pathologic or special immunogenetic conditions to establish chimerism are combined with bone marrow transplantation, transfusion, and various kinds of solid organ grafting. Different types of chimerism are known including complete, mixed and mosaic, or split chimerism. There are various methods used to detect the type of chimera state, depending on the immunogenetic differences between the donor and recipient. The induction of complete or mixed chimerism is first determinated by the effect of myeloablative therapy. The chimera state seems to be one of the leading factors to influence the course of the post-transplant period, the frequency and severity of GVHD, and the rate of relapse. However, the most important contribution of the chimeric state is in development of graft versus leukemia effect. A new conditioning protocol (DBM/Ara-C/Cy) for allogeneic BMT in CML patients and its consequence on chimera state and GVL effect is demonstrated.

Antigen persistence and time of T-cell tolerization determine the efficacy of tolerization protocols for prevention of skin graft rejection

We studied antigen-specific T-cell tolerization therapy using skin transplantation across a defined minor histocompatibility antigen difference. Specific tolerization protocols using short-lived peptide or long-lived spleen cells presenting the peptide as antigen prevented graft rejection without immunosuppression when started before or as long as 10 days after transplantation. Peptide-induced T-cell tolerance was transient, and antigen presentation by the graft was not sufficient to maintain tolerance. In contrast, transfer of antigen-expressing lymphoid cells induced long-lasting tolerance correlating with donor cell chimerism. These findings show that antigen-specific tolerization can induce graft acceptance even when begun after transplantation and that long-term graft survival depends on persistence of the tolerizing antigen.

Lung transplantation for cystic fibrosis

Lung transplantation currently stands as the only therapeutic option that carries the potential to restore patients with advanced cystic fibrosis to a more normal state of health. Nonetheless, the procedure carries significant risk and median survival following transplantation is only 5 years. This article discusses the currently achievable outcomes and the common short-comings of transplantation. Strategies to optimize outcomes through appropriate patient selection, use of living donors, and novel research initiatives are discussed.

Abrogation of chronic rejection in a murine model of aortic allotransplantation by prior induction of donor-specific tolerance

Aortic allotransplantation in mice has been well established as a model of choice to study the evolvement of chronic rejection, the etiopathology of which is believed to be that of immune origin. This has prompted the postulation that prior induction of donor-specific tolerance would attenuate or abrogate the underlying events that culminate in posttransplant arteriosclerosis. To study the effects of donor-specific tolerance on chronic rejection, we performed orthotopic liver transplantation without immunosuppression in mice 30 days before aortic allotransplantation across C57Bl/ 10J (H2b)-->C3H (H2k) strain combinations (group III). Aortic allografting in syngeneic (group I; C3H-->C3H) and allogeneic (group II, C57Bl/10J-->C3H) animals served as controls. No morphological changes were evidenced in the transplanted aortas in group I animals. Contrarily, aortic allografts in group II animals underwent a self-limiting acute cellular rejection, which resolved completely and was succeeded by day 30 after transplantation by histopathological changes pathognomonic of chronic rejection. There was evidence for diffuse myointimal thickening, progressive concentric luminal narrowing, and patchy destruction of internal elastic membranes resulting in massive vascular obliteration by day 120 after transplantation. It was of interest that no arteriosclerotic changes were observed for the duration of follow-up (up to 120 days after transplantation) in transplanted aortas (liver donor-type) harvested from animals in group III. However, vasculopathy was prominent in third-party aortic grafts transplanted into tolerant recipients. Taken together, these data suggest that prior induction of tolerance abrogates the development of chronic rejection; this protection seems to be donor specific.