1
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Tran JQ, Muench MO, Gaillard B, Darst O, Tomayko MM, Jackman RP. Polyinosinic: polycytidylic acid induced inflammation enhances while lipopolysaccharide diminishes alloimmunity to platelet transfusion in mice. Front Immunol 2023; 14:1281130. [PMID: 38146372 PMCID: PMC10749330 DOI: 10.3389/fimmu.2023.1281130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/20/2023] [Indexed: 12/27/2023] Open
Abstract
Introduction Alloimmune responses against platelet antigens, which dominantly target the major histocompatibility complex (MHC), can cause adverse reactions to subsequent platelet transfusions, platelet refractoriness, or rejection of future transplants. Platelet transfusion recipients include individuals experiencing severe bacterial or viral infections, and how their underlying health modulates platelet alloimmunity is not well understood. Methods This study investigated the effect of underlying inflammation on platelet alloimmunization by modelling viral-like inflammation with polyinosinic-polycytidylic acid (poly(I:C)) or gram-negative bacterial infection with lipopolysaccharide (LPS), hypothesizing that underlying inflammation enhances alloimmunization. Mice were pretreated with poly(I:C), LPS, or nothing, then transfused with non-leukoreduced or leukoreduced platelets. Alloantibodies and allogeneic MHC-specific B cell (allo-B cell) responses were evaluated two weeks later. Rare populations of allo-B cells were identified using MHC tetramers. Results Relative to platelet transfusion alone, prior exposure to poly(I:C) increased the alloantibody response to allogeneic platelet transfusion whereas prior exposure to LPS diminished responses. Prior exposure to poly(I:C) had equivalent, if not moderately diminished, allo-B cell responses relative to platelet transfusion alone and exhibited more robust allo-B cell memory development. Conversely, prior exposure to LPS resulted in diminished allo-B cell frequency, activation, antigen experience, and germinal center formation and altered memory B cell responses. Discussion In conclusion, not all inflammatory environments enhance bystander responses and prior inflammation mediated by LPS on gram-negative bacteria may in fact curtail platelet alloimmunization.
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Affiliation(s)
- Johnson Q. Tran
- Vitalant Research Institute, San Francisco, CA, United States
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Marcus O. Muench
- Vitalant Research Institute, San Francisco, CA, United States
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Betty Gaillard
- Vitalant Research Institute, San Francisco, CA, United States
| | - Orsolya Darst
- Vitalant Research Institute, San Francisco, CA, United States
| | - Mary M. Tomayko
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, United States
- Department of Pathology, Yale University School of Medicine, New Haven, CT, United States
| | - Rachael P. Jackman
- Vitalant Research Institute, San Francisco, CA, United States
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
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2
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Zeng S, Crichton ES, Ford ML, Badell IR. Memory T follicular helper cells drive donor-specific antibodies independent of memory B cells and primary germinal center and alloantibody formation. Am J Transplant 2023; 23:1511-1525. [PMID: 37302575 PMCID: PMC11228286 DOI: 10.1016/j.ajt.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
Human leukocyte antigen antibodies are important immunologic mediators of renal allograft loss and are difficult to control. The inability to permanently eliminate donor-specific antibodies (DSA) is partly due to an incomplete understanding of the cellular mechanisms driving alloantibody formation, recurrence, and maintenance. Memory T follicular helper (mTfh) cells rapidly interact with memory B cells upon antigen re-exposure for anamnestic humoral responses, but little is known about Tfh memory in transplantation. We hypothesized that alloreactive mTfh cells form after transplantation and play a critical role in DSA formation following alloantigen re-encounter. To test this hypothesis, we utilized murine skin allograft models to identify and characterize Tfh memory and interrogate its ability to mediate alloantibody responses. We identified alloreactive Tfh memory as a mediator of accelerated humoral alloresponses independent of memory B cells and primary germinal center, or DSA, formation. Furthermore, we demonstrate that mTfh-driven alloantibody formation is susceptible to CD28 costimulation blockade. These findings provide novel insight into a pathologic role for memory Tfh in alloantibody responses and strongly support shifting therapeutic focus from the singular targeting of B cell lineage cells and alloantibodies themselves to multimodal strategies that include inhibition of mTfh cells to treat DSA.
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Affiliation(s)
- Shan Zeng
- Emory Transplant Center, Atlanta, Georgia, USA
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3
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Samson C, Thiolat A, Moktefi A, Cohen JL, Pilon C, Grimbert P. Belatacept inhibit human B cell germinal center development in immunodeficient mice. Sci Rep 2023; 13:13816. [PMID: 37620431 PMCID: PMC10449885 DOI: 10.1038/s41598-023-40700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
The humoral response mediated by alloantibodies directed against donor HLA molecules (DSAs) is one of the main causes of graft loss in kidney transplantation. Understanding the pathophysiology leading to humoral kidney rejection as the development of therapeutic tools is therefore a main objective in the field of solid organ transplantation and necessitate adapted experimental models. Among the immunosuppressive agents used in renal transplantation, belatacept, a fusion protein targeting T costimulatory molecules has shown its ability to prevent more efficiently the secretion of DSA by different mechanisms including a direct action on plasma cells but also on B lymphocytes and follicular helper T lymphocytes (Tfh) cooperation. This cellular cooperation occurs within germinal centers (GC), the seat of B lymphocytes differentiation. Here, we aimed to develop a dedicated mouse model in which human GC would be functional to study the effect of belatacept on GC formation and the ability of B lymphocytes to secrete immunoglobulin. We next demonstrate that belatacept inhibits the formation of these GCs, by inhibiting the frequency of Tfh and B lymphocytes. This alters the B maturation and therefore the generation of plasma cells and consequently, immunoglobulin secretion.
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Affiliation(s)
- Chloé Samson
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
| | - Allan Thiolat
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
| | - Anissa Moktefi
- Groupe Hospitalo-Universitaire Chenevier Mondor, Service d'Anatomopathologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - José L Cohen
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - Caroline Pilon
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - Philippe Grimbert
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France.
- Inserm, U955, 94000, Créteil, France.
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France.
- Groupe Hospitalo-Universitaire Chenevier Mondor, Service de Néphrologie-Transplantation, AP-HP, 94000, Créteil, France.
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4
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Iryaningrum MR, Cahyadi A, Damara FA, Bandiara R, Marbun MBH. Seroconversion rates in kidney transplant recipients following SARS-CoV-2 vaccination and its association with immunosuppressive agents: a systematic review and meta-analysis. Clin Exp Vaccine Res 2023; 12:13-24. [PMID: 36844682 PMCID: PMC9950232 DOI: 10.7774/cevr.2023.12.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 02/19/2023] Open
Abstract
This systematic and meta-analysis aims to evaluate humoral and cellular responses to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine among kidney transplant recipients (KTRs). We conducted a systematic literature search across databases to evaluate seroconversion and cellular response rates in KTRs receiving SARS-CoV-2 vaccines. We extracted studies that assessed seroconversion rates described as the presence of antibody de novo positivity in KTRs following SARS-CoV-2 vaccination published up to January 23rd, 2022. We also performed meta-regression based on immunosuppression therapy used. A total of 44 studies involving 5,892 KTRs were included in this meta-analysis. The overall seroconversion rate following complete dose of vaccines was 39.2% (95% confidence interval [CI], 33.3%-45.3%) and cellular response rate was 41.6% (95% CI, 30.0%-53.6%). Meta-regression revealed that low antibody response rate was significantly associated with the high prevalence of mycophenolate mofetil/mycophenolic acid (p=0.04), belatacept (p=0.02), and anti-CD25 induction therapy uses (p=0.04). Conversely, tacrolimus use was associated with higher antibody response (p=0.01). This meta-analysis suggests that postvaccination seroconversion and cellular response rates in KTRs are still low. And seroconversion rate was correlated with the type of immunosuppressive agent and induction therapy used. Additional doses of the SARS-CoV-2 vaccine for this population using a different type of vaccine are considered.
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Affiliation(s)
- Maria Riastuti Iryaningrum
- Department of Internal Medicine, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Alius Cahyadi
- Department of Internal Medicine, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Fachreza Aryo Damara
- Dr Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Ria Bandiara
- Department of Internal Medicine, Dr Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Maruhum Bonar Hasiholan Marbun
- Department of Internal Medicine, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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5
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Babel N, Hugo C, Westhoff TH. Vaccination in patients with kidney failure: lessons from COVID-19. Nat Rev Nephrol 2022; 18:708-723. [PMID: 35999285 PMCID: PMC9397175 DOI: 10.1038/s41581-022-00617-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/06/2023]
Abstract
Infection is the second leading cause of death in patients with chronic kidney disease (CKD). Adequate humoral (antibody) and cellular (T cell-driven) immunity are required to minimize pathogen entry and promote pathogen clearance to enable infection control. Vaccination can generate cellular and humoral immunity against specific pathogens and is used to prevent many life-threatening infectious diseases. However, vaccination efficacy is diminished in patients with CKD. Premature ageing of the immune system and chronic systemic low-grade inflammation are the main causes of immune alteration in these patients. In the case of SARS-CoV-2 infection, COVID-19 can have considerable detrimental effects in patients with CKD, especially in those with kidney failure. COVID-19 prevention through successful vaccination is therefore paramount in this vulnerable population. Although patients receiving dialysis have seroconversion rates comparable to those of patients with normal kidney function, most kidney transplant recipients could not generate humoral immunity after two doses of the COVID-19 vaccine. Importantly, some patients who were not able to produce antibodies still had a detectable vaccine-specific T cell response, which might be sufficient to prevent severe COVID-19. Correlates of protection against SARS-CoV-2 have not been established for patients with kidney failure, but they are urgently needed to enable personalized vaccination regimens.
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Affiliation(s)
- Nina Babel
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany.
- Center for Translational Medicine and Immune Diagnostics Laboratory, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany.
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Center for Advanced Therapies (BeCAT) and Berlin Institute of Health, Berlin, Germany.
| | - Christian Hugo
- Medizinische Klinik und Poliklinik III, Universitätsklinikum, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timm H Westhoff
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
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Chong AS, Habal MV. From bench to bedside: reversing established antibody responses and desensitization. Curr Opin Organ Transplant 2022; 27:376-384. [PMID: 35950890 PMCID: PMC9474614 DOI: 10.1097/mot.0000000000001009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Basic transplant immunology has primarily focused on the definition of mechanisms, but an often-stated aspirational goal is to translate basic mechanistic research into future therapy. Pretransplant donor-specific antibodies (DSA) mediate hyperacute as well as early antibody-mediated rejection (AMR), whereas DSA developing late posttransplantation may additionally mediate chronic rejection. Although contemporary immunosuppression effectively prevents early cellular rejection after transplant in nonsensitized patients, it is less effective at controlling preexisting HLA antibody responses or reversing DSA once established, thus underscoring a need for better therapies. RECENT FINDINGS We here review the development of a bench-to-bedside approach involving transient proteasome inhibition to deplete plasma cells, combined with maintenance co-stimulation blockade, with CTLA-4Ig or belatacept, to prevent the generation of new antibody-secreting cells (ASCs). SUMMARY This review discusses how this treatment regimen, which was rationally designed and validated to reverse established DSA responses in mouse models, translated into reversing active AMR in the clinic, as well as desensitizing highly sensitized patients on the transplant waitlist.
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Affiliation(s)
- Anita S. Chong
- Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - Marlena V. Habal
- Department of Medicine, Columbia University College of Medicine, New York, NY, USA
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7
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Anwar IJ, DeLaura IF, Gao Q, Ladowski J, Jackson AM, Kwun J, Knechtle SJ. Harnessing the B Cell Response in Kidney Transplantation - Current State and Future Directions. Front Immunol 2022; 13:903068. [PMID: 35757745 PMCID: PMC9223638 DOI: 10.3389/fimmu.2022.903068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 01/21/2023] Open
Abstract
Despite dramatic improvement in kidney transplantation outcomes over the last decades due to advent of modern immunosuppressive agents, long-term outcomes remain poor. Antibody-mediated rejection (ABMR), a B cell driven process, accounts for the majority of chronic graft failures. There are currently no FDA-approved regimens for ABMR; however, several clinical trials are currently on-going. In this review, we present current mechanisms of B cell response in kidney transplantation, the clinical impact of sensitization and ABMR, the B cell response under current immunosuppressive regimens, and ongoing clinical trials for ABMR and desensitization treatment.
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Affiliation(s)
| | | | | | | | | | | | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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8
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Chavarot N, Morel A, Leruez-Ville M, Vilain E, Divard G, Burger C, Serris A, Sberro-Soussan R, Martinez F, Amrouche L, Bererhi L, Lanternier F, Legendre C, Zuber J, Anglicheau D, Scemla A. Weak antibody response to three doses of mRNA vaccine in kidney transplant recipients treated with belatacept. Am J Transplant 2021; 21:4043-4051. [PMID: 34431207 PMCID: PMC9906354 DOI: 10.1111/ajt.16814] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/25/2023]
Abstract
Poor responses to mRNA COVID-19 vaccine have been reported after 2 vaccine injections in kidney transplant recipients (KTRs) treated with belatacept. We analyzed the humoral response in belatacept-treated KTRs without a history of SARS-CoV-2 infection who received three injections of BNT162b2-mRNA COVID-19 vaccine. We also investigated vaccine immunogenicity in belatacept-treated KTRs with prior COVID-19 and characterized symptomatic COVID-19 infections after the vaccine in belatacept-treated KTRs. Among the 62 belatacept-treated KTRs (36 [58%] males), the median age (63.5 years IQR [51-72]), without COVID-19 history, only four patients (6.4%) developed anti-SARS-CoV-2 IgG with low antibody titers (median 209, IQR [20-409] AU/ml). 71% were treated with mycophenolic acid and 100% with steroids in association with belatacept. In contrast, in all the 5 KTRs with prior COVID-19 history, mRNA vaccine induced a strong antibody response with high antibody titers (median 10 769 AU/ml, IQR [6410-20 069]) after two injections. Seroprevalence after three-vaccine doses in 35 non-belatacept-treated KTRs was 37.1%. Twelve KTRs developed symptomatic COVID-19 after vaccination, including severe forms (50% of mortality). Breakthrough COVID-19 occurred in 5% of fully vaccinated patients. Administration of a third dose of BNT162b2 mRNA COVID-19 vaccine did not improve immunogenicity in KTRs treated with belatacept without prior COVID-19. Other strategies aiming to improve patient protection are needed.
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Affiliation(s)
- Nathalie Chavarot
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Antoine Morel
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marianne Leruez-Ville
- Université de Paris, Paris, France
- Virology Laboratory, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Estelle Vilain
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gillian Divard
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Carole Burger
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Alexandra Serris
- Université de Paris, Paris, France
- Department of Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Rebecca Sberro-Soussan
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Frank Martinez
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Lucile Amrouche
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Lynda Bererhi
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fanny Lanternier
- Université de Paris, Paris, France
- Department of Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Julien Zuber
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Anne Scemla
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
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Terrec F, Jouve T, Malvezzi P, Janbon B, Naciri Bennani H, Rostaing L, Noble J. Belatacept Use after Kidney Transplantation and Its Effects on Risk of Infection and COVID-19 Vaccine Response. J Clin Med 2021; 10:jcm10215159. [PMID: 34768680 PMCID: PMC8585113 DOI: 10.3390/jcm10215159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction: Belatacept is a common immunosuppressive therapy used after kidney transplantation (KT) to avoid calcineurin-inhibitor (CNI) use and its related toxicities. It is unclear whether its use exposes KT recipients (KTx) to a greater risk of infection or a poorer response to vaccines. Areas covered: We reviewed PubMed and the Cochrane database. We then summarized the mechanisms and impacts of belatacept use on the risk of infection, particularly opportunistic, in two settings, i.e., de novo KTx and conversion from CNIs. We also focused on COVID-19 infection risk and response to SARS-CoV-2 vaccination in patients whose maintenance immunosuppression relies on belatacept. Expert opinion: When belatacept is used de novo, or after drug conversion the safety profile regarding the risk of infection remains good. However, there is an increased risk of opportunistic infections, mainly CMV disease and Pneumocystis pneumonia, particularly in those with a low eGFR, in older people, in those receiving steroid-based therapy, or those that have an early conversion from CNI to belatacept (i.e., <six months post-transplantation). Thus, we recommend, if possible, delaying conversion from CNI to belatacept until at least six months post-transplantation. Optimal timing seems to be eight months post-transplantation. In addition, KTx receiving belatacept respond poorly to SARS-CoV-2 vaccination.
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Affiliation(s)
- Florian Terrec
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Hamza Naciri Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
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10
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Louis K, Macedo C, Metes D. Targeting T Follicular Helper Cells to Control Humoral Allogeneic Immunity. Transplantation 2021; 105:e168-e180. [PMID: 33909968 PMCID: PMC8484368 DOI: 10.1097/tp.0000000000003776] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Humoral allogeneic immunity driven by anti-HLA donor-specific antibodies and antibody-mediated rejection (AMR) significantly impede prolonged survival of organ allografts after transplantation. Although the importance of T follicular helper (TFH) cells in controlling antibody responses has been long established, their role in directing donor-specific antibody generation leading to AMR was only recently appreciated in the clinical setting of organ transplantation. In this review, we provide a comprehensive summary of the current knowledge on the biology of human TFH cells as well as their circulating counterparts and describe their pivotal role in driving humoral alloimmunity. In addition, we discuss the intrinsic effects of current induction therapies and maintenance immunosuppressive drugs as well as of biotherapies on TFH cells and provide future directions and novel opportunities of biotherapeutic targeting of TFH cells that have the potential of bringing the prophylactic and curative treatments of AMR toward personalized and precision medicine.
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Affiliation(s)
- Kevin Louis
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Human Immunology and Immunopathology, Inserm UMR 976, Université de Paris, Paris, France
- Kidney Transplant Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Camila Macedo
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Diana Metes
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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11
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Suah AN, Tran DKV, Khiew SH, Andrade MS, Pollard JM, Jain D, Young JS, Yin D, Chalasani G, Alegre ML, Chong AS. Pregnancy-induced humoral sensitization overrides T cell tolerance to fetus-matched allografts in mice. J Clin Invest 2021; 131:140715. [PMID: 33393512 PMCID: PMC7773355 DOI: 10.1172/jci140715] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022] Open
Abstract
Immunological tolerance to semiallogeneic fetuses is necessary to achieving successful first pregnancy and permitting subsequent pregnancies with the same father. Paradoxically, pregnancy is an important cause of sensitization, resulting in the accelerated rejection of offspring-matched allografts. The underlying basis for divergent outcomes following reencounter of the same alloantigens on transplanted organs versus fetuses in postpartum females is incompletely understood. Using a mouse model that allows concurrent tracking of endogenous fetus-specific T and B cell responses in a single recipient, we show that semiallogeneic pregnancies simultaneously induce fetus-specific T cell tolerance and humoral sensitization. Pregnancy-induced antibodies, but not B cells, impeded transplantation tolerance elicited by costimulation blockade to offspring-matched cardiac grafts. Remarkably, in B cell-deficient mice, allogeneic pregnancy enabled the spontaneous acceptance of fetus-matched allografts. The presence of pregnancy-sensitized B cells that cannot secrete antibodies at the time of heart transplantation was sufficient to precipitate rejection and override pregnancy-established T cell tolerance. Thus, while induction of memory B cells and alloantibodies by pregnancies establishes formidable barriers to transplant success for multigravid women, our observations raise the possibility that humoral desensitization will not only improve transplantation outcomes, but also reveal an unexpected propensity of multiparous recipients to achieve tolerance to offspring-matched allografts.
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Affiliation(s)
- Ashley N Suah
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Dong-Kha V Tran
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Stella Hw Khiew
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Michael S Andrade
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jared M Pollard
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Dharmendra Jain
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - James S Young
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Dengping Yin
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Geetha Chalasani
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Anita S Chong
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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12
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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13
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Sakhi H, Chavarot N, Attias P, El Karoui K, Anglicheau D. [COVID-19 vaccination in dialysis and kidney transplant patients]. Nephrol Ther 2021; 17:208-213. [PMID: 34305020 PMCID: PMC8245347 DOI: 10.1016/j.nephro.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 01/04/2023]
Abstract
Au cours de la COVID-19, la dialyse et la transplantation rénale ont été identifiées comme d’importants facteurs de risque de développer une forme sévère de la maladie. La réponse immunitaire humorale post-infection est durable. Cependant, après vaccination, celle-ci apparaît plus limitée, tant en termes de taux de réponse (séropositivité post-vaccination) qu’en termes de taux quantitatif d’anticorps. Alors que les patients dialysés ont un taux de réponse de 80–95 % en fonction des études, la réponse est particulièrement faible chez les patients transplantés rénaux, avec des taux de séropositivité de 30–50 %, et notamment s’ils sont traités par bélatacept (environ 5 % de réponse). Ces éléments ont poussé à proposer des schémas vaccinaux alternatifs en France, avec notamment l’utilisation d’une 3e injection de vaccin ARNm. Malgré ces résultats, de nombreuses questions sur la vaccination des insuffisants rénaux restent en suspens, concernant notamment la qualité des réponses cellulaires (encore peu étudiées), la durabilité des réponses post-vaccinales, et surtout l’efficacité clinique des vaccins.
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Affiliation(s)
- Hamza Sakhi
- Service de néphrologie et transplantation, fédération hospitalo-universitaire « Innovative therapy for immune disorders », centre de référence maladie rare « syndrome néphrotique idiopathique », hôpitaux universitaires Henri-Mondor, Créteil, France; Équipe 21, institut national de la santé et de la recherche médicale (Inserm) U955, institut Mondor de recherche biomédicale (IMRB), université Paris-Est-Créteil, Créteil, France
| | - Nathalie Chavarot
- Service de néphrologie et transplantation, centre de référence Maladie rare MAREHA, hôpitaux universitaires Necker-Enfants malades, Paris, France
| | - Philippe Attias
- Department of nephrology and dialysis, hôpital privé Nord Parisien, Sarcelles, France
| | - Khalil El Karoui
- Service de néphrologie et transplantation, fédération hospitalo-universitaire « Innovative therapy for immune disorders », centre de référence maladie rare « syndrome néphrotique idiopathique », hôpitaux universitaires Henri-Mondor, Créteil, France; Équipe 21, institut national de la santé et de la recherche médicale (Inserm) U955, institut Mondor de recherche biomédicale (IMRB), université Paris-Est-Créteil, Créteil, France.
| | - Dany Anglicheau
- Service de néphrologie et transplantation, centre de référence Maladie rare MAREHA, hôpitaux universitaires Necker-Enfants malades, Paris, France
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14
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La Muraglia GM, Zeng S, Crichton ES, Wagener ME, Ford ML, Badell IR. Superior inhibition of alloantibody responses with selective CD28 blockade is CTLA-4 dependent and T follicular helper cell specific. Am J Transplant 2021; 21:73-86. [PMID: 32406182 PMCID: PMC7665991 DOI: 10.1111/ajt.16004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/15/2020] [Accepted: 05/07/2020] [Indexed: 01/25/2023]
Abstract
Anti-donor antibodies cause immunologic injury in transplantation. CD28 blockade with CTLA-4-Ig has the ability to reduce the incidence of these donor-specific antibodies (DSA), but its mechanism is suboptimal for the inhibition of alloimmunity in that CTLA-4-Ig blocks both CD28 costimulation and CTLA-4 coinhibition. Thus selective CD28 blockade that spares CTLA-4 has potential to result in improved inhibition of humoral alloimmunity. To test this possibility, we utilized a full allogeneic mismatch murine transplant model and T follicular helper (Tfh):B cell co-culture system. We observed that selective blockade with an anti-CD28 domain antibody (dAb) compared to CTLA-4-Ig led to superior inhibition of Tfh cell, germinal center, and DSA responses in vivo and better control of B cell responses in vitro. CTLA-4 blockade enhanced the humoral alloresponse and, in combination with anti-CD28 dAb, abrogated the effects of selective blockade. This CTLA-4-dependent inhibition was Tfh cell specific in that CTLA-4 expression by Tfh cells was necessary and sufficient for the improved humoral inhibition observed with selective CD28 blockade. As CD28 blockade attracts interest for control of alloantibodies in the clinic, these data support selective CD28 blockade as a superior strategy to address DSA via the sparing of CTLA-4 and more potent targeting of Tfh cells.
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Affiliation(s)
| | - Susan Zeng
- Emory Transplant Center, Atlanta, GA, USA
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15
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Alishetti S, Farr M, Jennings D, Serban G, Uriel N, Sayer G, Vasilescu R, Restaino S, Chong AS, Habal MV. Desensitizing highly sensitized heart transplant candidates with the combination of belatacept and proteasome inhibition. Am J Transplant 2020; 20:3620-3630. [PMID: 32506824 PMCID: PMC8366746 DOI: 10.1111/ajt.16113] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/12/2020] [Accepted: 05/26/2020] [Indexed: 01/25/2023]
Abstract
HLA antibodies pose a significant barrier to transplantation and current strategies to reduce allosensitization are limited. We hypothesized that augmenting proteasome inhibitor (PI) based desensitization with costimulation blockade (belatacept) to mitigate germinal center (GC) responses might increase efficacy and prevent rebound. Four highly sensitized (calculated panel reactive antibody [cPRA] class I and/or II >99%, complement-dependent cytotoxicity panel reactive antibody [CDC PRA+], C1q+) heart transplant candidates were treated with the combination of belatacept and PI therapy, which significantly reduced both class I and II HLA antibodies and increased the likelihood of identifying an acceptable donor. Three negative CDC crossmatches were achieved against 3, 6, and 8 donor-specific antibodies (DSA), including those that were historically C1q+ binding. Posttransplant, sustained suppression of 3 of 3, 4 of 6, and 8 of 8 DSA (cases 1-3) was achieved. Analysis of peripheral blood mononuclear cells before and after desensitization in one case revealed a decrease in naïve and memory B cells and a reduction in T follicular helper cells with a phenotype suggesting recent GC activity (CD38, PD1, and ICOS). Furthermore, a shift in the natural killer cell phenotype was observed with features suggestive of activation. Our findings support synergism between PI based desensitization and belatacept facilitating transplantation with a negative CDC crossmatch against historically strong, C1q binding antibodies.
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Affiliation(s)
- Shudhanshu Alishetti
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Douglas Jennings
- Department of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY
| | - Geo Serban
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Rodica Vasilescu
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Susan Restaino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Anita S. Chong
- Department of Surgery, University of Chicago, Chicago, IL
| | - Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY
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16
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Jain D, Rajab A, Young JS, Yin D, Nadasdy T, Chong AS, Pelletier RP. Reversing donor-specific antibody responses and antibody-mediated rejection with bortezomib and belatacept in mice and kidney transplant recipients. Am J Transplant 2020; 20:2675-2685. [PMID: 32243663 PMCID: PMC8232017 DOI: 10.1111/ajt.15881] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 01/25/2023]
Abstract
Active antibody-mediated rejection (AMR) is a potentially devastating complication and consistently effective treatment remains elusive. We hypothesized that the reversal of acute AMR requires rapid elimination of antibody-secreting plasma cells (PC) with a proteasome inhibitor, bortezomib, followed by the sustained inhibition of PC generation with CTLA4-Ig or belatacept (B/B). We show in mice that B/B therapy selectively depleted mature PC producing donor-specific antibodies (DSA) and reduced DSA, when administered after primary and secondary DSA responses had been established. A pilot investigation was initiated to treat six consecutive patients with active AMR with B/B. Compassionate use of this regimen was initiated for the first patient who developed early, severe acute AMR that did not respond to steroids, plasmapheresis, and intravenous immunoglobulin after his third kidney transplant. B/B treatment resulted in a rapid reversal of AMR, leading us to treat five additional patients who also resolved their acute AMR episode and had sustained disappearance of circulating DSA for ≤30 months. This study provides a proof-of-principle demonstration that mouse models can identify mechanistically rational therapies for the clinic. Follow-up investigations with a more stringent clinical design are warranted to test whether B/B improves on the standard of care for the treatment of acute AMR.
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Affiliation(s)
- Dharmendra Jain
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Amer Rajab
- Department of Surgery, The Ohio State University, Columbus, OH
| | - James S Young
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Dengping Yin
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Tibor Nadasdy
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Anita S Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
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17
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Abstract
Myasthenia gravis (MG) is an autoimmune, neuromuscular disorder that produces disabling weakness through a compromise of neuromuscular transmission. The disease fulfills strict criteria of an antibody-mediated disease. Close to 90% of patients have antibodies directed towards the nicotinic acetylcholine receptor (AChR) on the post-synaptic surface of skeletal muscle and another 5% to the muscle-specific kinase, which is involved in concentrating the AChR to the muscle surface of the neuromuscular junction. Conventional treatments of intravenous immunoglobulin and plasma exchange reduce autoantibody levels to produce their therapeutic effect, while prednisone and immunosuppressives do so by moderating autoantibody production. None of these treatments were specifically developed for MG and have a range of adverse effects. The extensive advances in monoclonal antibody technology allowing specific modulation of biological pathways has led to a tremendous increase in the potential treatment options. For MG, monoclonal antibody therapeutics target the effector mechanism of complement inhibition and the reduction of antibody levels by FcRn inhibition. Antibodies directed against CD20 and signaling pathways, which support lymphocyte activity, have been used to reduce autoantibody production. Thus far, only eculizumab, an antibody against C5, has reached the clinic. We review the present status of monoclonal antibody-based treatments for MG that have entered human testing and offer the promise to transform treatment of MG.
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Affiliation(s)
- Sawsan Alabbad
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Mohanad AlGaeed
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Patricia Sikorski
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Henry J Kaminski
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA.
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18
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Steines L, Poth H, Schuster A, Geissler EK, Amann K, Banas B, Bergler T. Anti-BAFF Treatment Interferes With Humoral Responses in a Model of Renal Transplantation in Rats. Transplantation 2020; 104:e16-e22. [PMID: 31609901 DOI: 10.1097/tp.0000000000002992] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND B-cell-activating factor (BAFF) is associated with donor-specific antibodies (DSA) and poorer outcomes after renal transplantation (RTx). We examined the effects of anti-BAFF treatment on B cells, expression of costimulatory molecules and cytokines, germinal centers (GCs), and DSA formation in an RTx model in rats. METHODS Anti-BAFF antibody was injected on days 3, 17, 31, and 45 after allogeneic RTx. Rats received reduced dose cyclosporine A for 28 or 56 days to allow chronic rejection and DSA formation. Leukocytes, B-cell subsets, and DSA were measured using flow cytometry; expression of cytokines and costimulatory molecules was measured by quantitative polymerase chain reaction, and GCs and T follicular helper were assessed using immunohistochemistry. Rejection was evaluated by a nephropathologist. RESULTS Anti-BAFF treatment reduced the frequency of B cells in allografts and spleen. Naive B cells were strongly reduced by anti-BAFF treatment in all compartments. Messenger RNA expression of interleukin-6 and the costimulatory molecules CD40 and inducible T cell costimulator ligand was significantly reduced in anti-BAFF-treated rats. GC area was smaller and plasmablasts/plasma cell numbers lower in anti-BAFF-treated rats, which was reflected by less DSA in certain IgG subclasses. CONCLUSIONS Anti-BAFF treatment interferes with humoral responses at multiple levels in this model of allogeneic RTx.
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Affiliation(s)
- Louisa Steines
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Helen Poth
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Antonia Schuster
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Edward K Geissler
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, Erlangen, Germany
| | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
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19
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Khiew SH, Jain D, Chen J, Yang J, Yin D, Young JS, Dent A, Sciammas R, Alegre ML, Chong AS. Transplantation tolerance modifies donor-specific B cell fate to suppress de novo alloreactive B cells. J Clin Invest 2020; 130:3453-3466. [PMID: 32452834 PMCID: PMC7329196 DOI: 10.1172/jci132814] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 03/11/2020] [Indexed: 12/22/2022] Open
Abstract
The absence of alloantibodies is a feature of transplantation tolerance. Although the lack of T cell help has been evoked to explain this absence, herein we provide evidence for B cell-intrinsic tolerance mechanisms. Using a murine model of heart tolerance, we showed that alloreactive B cells were not deleted but rapidly lost their ability to differentiate into germinal center B cells and secrete donor-specific antibodies. We inferred that tolerant alloreactive B cells retained their ability to sense alloantigen because they continued to drive T cell maturation into CXCR5+PD-1+ T follicular helper cells. Unexpectedly, dysfunctional alloreactive B cells acquired the ability to inhibit antibody production by new naive B cells in an antigen-specific manner. Thus, tolerant alloreactive B cells contribute to transplantation tolerance by foregoing germinal center responses while retaining their ability to function as antigen-presenting cells and by actively suppressing de novo alloreactive B cell responses.
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Affiliation(s)
- Stella H.W. Khiew
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Dharmendra Jain
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jianjun Chen
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jinghui Yang
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Dengping Yin
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - James S. Young
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Alexander Dent
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Roger Sciammas
- Center for Comparative Medicine, Schools of Medicine and Veterinary Medicine, UC Davis, Davis, California, USA
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Anita S. Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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20
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Chong AS. Mechanisms of organ transplant injury mediated by B cells and antibodies: Implications for antibody-mediated rejection. Am J Transplant 2020; 20 Suppl 4:23-32. [PMID: 32538534 PMCID: PMC7482418 DOI: 10.1111/ajt.15844] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/06/2020] [Accepted: 02/19/2020] [Indexed: 01/25/2023]
Abstract
Recent adjustments to the histological diagnosis and the introduction of molecular classification are providing renewed support for the paradigm that antibody-mediated rejection (ABMR) is an important clinical problem for which there is an urgent need for better therapies. Acute ABMR is observed when the graft is exposed to rapid increases in high-titer donor-specific antibodies (DSA) that are most often generated as anamnestic responses in sensitized recipients or de novo responses in nonsensitized patients who are nonadherent. Chronic ABMR is associated with slower increases in DSA, which may be high or low titer and transient or persistent. These DSA elicit cycles of injury and repair that manifest as multilamination of the peritubular capillary basement membrane or arteriopathy manifesting as intimal fibrosis. Mitigating the problem of AMBR requires the anamnestic and de novo DSA responses to be prevented and established DSA responses to be reversed. To this end, a better understanding of the immunobiology of DSA production is necessary and also the development of assays capable of detecting early humoral immune responses.Recent advances in understanding the immunobiology of B cells and areas requiring further investigation that might lead to new therapies or better diagnosis are discussed in this review.
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Affiliation(s)
- Anita S Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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21
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Chong AS. B cells as antigen-presenting cells in transplantation rejection and tolerance. Cell Immunol 2020; 349:104061. [PMID: 32059816 DOI: 10.1016/j.cellimm.2020.104061] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/21/2022]
Abstract
Transplantation of fully allogeneic organs into immunocompetent recipients invariably elicits T cell and B cell responses that lead to the production of donor-specific antibodies (DSA). When immunosuppression is inadequate donor-specific T cell and B cell responses escape, leading to T cell-mediated rejection (TCMR), antibody mediated (ABMR) rejection, or mixed rejection (MR) exhibiting features of both TCMR and ABMR. Current literature suggests that ABMR is a major cause of late graft loss, and that new therapies to curtail the donor-specific humoral response are necessary. The majority of research into B cell responses elicited by allogeneic allografts in both preclinical models and clinical studies, has focused on the function of B cells as antibody-secreting cells and the pathogenic effects of DSA as mediators of ABMR. However, it has long been recognized that the DSA response to allografts is T cell-dependent, and that B cells engage in cognate interactions with T cells that provide "help" and promote B cell differentiation into antibody-secreting cells (ASCs). This review focusses the function of B cells as antigen-presenting cells (APCs) to T cells in lymphoid organs, how they may be critical APCs to T cell in the allograft, and the functional consequences of these interactions.
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Affiliation(s)
- Anita S Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, United States.
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22
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Novel insights into the pathobiology of humoral alloimmune memory in kidney transplantation. Curr Opin Organ Transplant 2020; 25:15-21. [DOI: 10.1097/mot.0000000000000717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Hartigan CR, Sun H, Ford ML. Memory T‐cell exhaustion and tolerance in transplantation. Immunol Rev 2019; 292:225-242. [DOI: 10.1111/imr.12824] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - He Sun
- Emory Transplant Center and Department of Surgery Emory University Atlanta GA USA
- Department of Hepatobiliary Surgery and Transplantation The First Hospital of China Medical University Shenyang China
| | - Mandy L. Ford
- Emory Transplant Center and Department of Surgery Emory University Atlanta GA USA
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24
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Parsons RF, Larsen CP, Pearson TC, Badell IR. Belatacept and CD28 Costimulation Blockade: Preventing and Reducing Alloantibodies over the Long Term. CURRENT TRANSPLANTATION REPORTS 2019; 6:277-284. [PMID: 32158639 PMCID: PMC7063534 DOI: 10.1007/s40472-019-00260-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review Highlight developments in T and B cell biology that are helping elucidate the mechanisms underlying CD28 pathway blockade-mediated inhibition of alloantibodies in transplantation, and discuss recent clinical observations on the impact of belatacept on de novo and established HLA antibodies. Recent Findings The identification of T follicular helper cells as the CD4+ T cell subset required for optimal humoral immunity, along with newly identified roles for CD28 and the B7 molecules on B cell lineage cells has begun to pave the way for improved understanding and discovery of the mechanisms of CD28 costimulation blockade-mediated antibody inhibition. There has been resurgent clinical interest in the ability of belatacept to attenuate alloantibody responses. New reports have continued to document its ability to prevent de novo antibody responses, and more recent studies have surfaced exploring its potential to control nascent or pre-existing HLA antibodies. Summary A growing understanding of the mechanisms of anti-CD28-mediated alloantibody inhibition and continued clinical successes will guide the clinical optimization of belatacept and next generation CD28 blockers to prevent and reduce alloantibodies over the long-term.
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25
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Mardomi A, Mohammadi N, Khosroshahi HT, Abediankenari S. An update on potentials and promises of T cell co-signaling molecules in transplantation. J Cell Physiol 2019; 235:4183-4197. [PMID: 31696513 DOI: 10.1002/jcp.29369] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023]
Abstract
The promising outcomes of immune-checkpoint based immunotherapies in cancer have provided a proportional perspective ahead of exploiting similar approaches in allotransplantation. Belatacept (CTLA-4-Ig) is an example of costimulation blockers successfully exploited in renal transplantation. Due to the wide range of regulatory molecules characterized in the past decades, some of these molecules might be candidates as immunomodulators in the case of tolerance induction in transplantation. Although there are numerous attempts on the apprehension of the effects of co-signaling molecules on immune response, the necessity for a better understanding is evident. By increasing the knowledge on the biology of co-signaling pathways, some pitfalls are recognized and improved approaches are proposed. The blockage of CD80/CD28 axis is an instance of evolution toward more efficacy. It is now evident that anti-CD28 antibodies are more effective than CD80 blockers in animal models of transplantation. Other co-signaling axes such as PD-1/PD-L1, CD40/CD154, 2B4/CD48, and others discussed in the present review are examples of critical immunomodulatory molecules in allogeneic transplantation. We review here the outcomes of recent experiences with co-signaling molecules in preclinical studies of solid organ transplantation.
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Affiliation(s)
- Alireza Mardomi
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Immunogenetics Research Center, Mazandaran University of Medical Sciences, Sari, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Nabiallah Mohammadi
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Immunogenetics Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Saeid Abediankenari
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Immunogenetics Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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26
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Yu S, Su C, Luo X. Impact of infection on transplantation tolerance. Immunol Rev 2019; 292:243-263. [PMID: 31538351 PMCID: PMC6961566 DOI: 10.1111/imr.12803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
Allograft tolerance is the ultimate goal of organ transplantation. Current strategies for tolerance induction mainly focus on inhibiting alloreactive T cells while promoting regulatory immune cells. Pathogenic infections may have direct impact on both effector and regulatory cell populations, therefore can alter host susceptibility to transplantation tolerance induction as well as impair the quality and stability of tolerance once induced. In this review, we will discuss existing data demonstrating the effect of infections on transplantation tolerance, with particular emphasis on the role of the stage of infection (acute, chronic, or latent) and the stage of tolerance (induction or maintenance) in this infection-tolerance interaction. While the deleterious effect of acute infection on tolerance is mainly driven by proinflammatory cytokines induced shortly after the infection, chronic infection may generate exhausted T cells that could in fact facilitate transplantation tolerance. In addition to pathogenic infections, commensal intestinal microbiota also has numerous significant immunomodulatory effects that can shape the host alloimmunity following transplantation. A comprehensive understanding of these mechanisms is crucial for the development of therapeutic strategies for robustly inducing and stably maintaining transplantation tolerance while preserving host anti-pathogen immunity in clinically relevant scenarios.
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Affiliation(s)
- Shuangjin Yu
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, United States
- Division of Organ transplantation, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Chang Su
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, United States
| | - Xunrong Luo
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, United States
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, United States
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27
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Yoon I, Chung H, Kim H, Nam H, Shin J, Kim Y, Park C. Peri‐graft porcine‐specific CD4
+
FoxP3
+
regulatory T cells by CD40‐CD154 blockade prevented the rejection of porcine islet graft in diabetic mice. Xenotransplantation 2019; 26:e12533. [DOI: 10.1111/xen.12533] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Il‐Hee Yoon
- VHS Veterans Medical Research Institute VHS Medical Center Seoul Korea
| | - Hyunwoo Chung
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Department of Biomedical Sciences Seoul National University Graduate School Seoul Korea
| | - Hyun‐Je Kim
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Department of Biomedical Sciences Seoul National University Graduate School Seoul Korea
| | - Hye‐Young Nam
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
| | - Jun‐Seop Shin
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
- Institute of Endemic Diseases Seoul National University College of Medicine Seoul Korea
- Biomedical Research Institute Seoul National University Hospital Seoul Korea
| | - Yong‐Hee Kim
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Department of Biomedical Sciences Seoul National University Graduate School Seoul Korea
| | - Chung‐Gyu Park
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Department of Biomedical Sciences Seoul National University Graduate School Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
- Institute of Endemic Diseases Seoul National University College of Medicine Seoul Korea
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28
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Ho CM, Chen HL, Hu RH, Lee PH. Harnessing immunotherapy for liver recipients with hepatocellular carcinoma: a review from a transplant oncology perspective. Ther Adv Med Oncol 2019; 11:1758835919843463. [PMID: 31065295 PMCID: PMC6487770 DOI: 10.1177/1758835919843463] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
Without stringent criteria, liver transplantation for hepatocellular carcinoma (HCC) can lead to high cancer recurrence and poor prognosis in the current treatment context. Checkpoint inhibitors can lead to long survival by targeting coinhibitory pathways and promoting T-cell activity; thus, they have great potential for cancer immunotherapy. Therapeutic modulation of cosignaling pathways may shift paradigms from surgical prevention of recurrence to oncological intervention. Herein, we review the available evidence from a therapeutic perspective and focus on immune microenvironment perturbation by immunosuppressants and checkpoint inhibitors. Partial and reversible interleukin-2 signaling blockade is the mainstream strategy of immunosuppression for graft protection. Programmed cell death protein 1 (PD-1) is abundantly expressed on human liver allograft-infiltrating T-cells, which proliferate considerably after programmed death-ligand 1 (PD-L1) blockade. Clinically, checkpoint inhibitors are used in heart, liver, and kidney recipients with various cancers. Rejection can occur after checkpoint inhibitor administration through acute T-cell-mediated, antibody-mediated, or chronic allograft rejection mechanisms. Nevertheless, liver recipients may demonstrate favorable responses to treatment for HCC recurrence without rejection. Pharmacodynamically, substantial degrees of receptor occupancy can be achieved with lower doses, with favorable clinical outcomes. Manipulation of the immune microenvironment is a therapeutic niche that balances seemingly conflicting anticancer and graft protection needs. Additional translational and clinical studies emphasizing the comparative effectiveness of signaling networks within the immune microenvironment and conducting overall assessment of the immune microenvironment may aid in creating a therapeutic window and benefiting future liver recipients with HCC recurrence.
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Affiliation(s)
- Cheng-Maw Ho
- Department of Surgery, National Taiwan University Hospital and College of Medicine, 7 Chung-Shan South Road, Taipei 100, Taiwan
| | - Hui-Ling Chen
- Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Rey-Heng Hu
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Po-Huang Lee
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei College of Medicine, National Taiwan University, Taipei, Taiwan
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29
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Leibler C, Matignon M, Moktefi A, Samson C, Zarour A, Malard S, Boutin E, Pilon C, Salomon L, Natella PA, Durrbach A, Robert T, Canoui-Poitrine F, Grimbert P. Belatacept in renal transplant recipient with mild immunologic risk factor: A pilot prospective study (BELACOR). Am J Transplant 2019; 19:894-906. [PMID: 30582270 DOI: 10.1111/ajt.15229] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 11/21/2018] [Accepted: 12/06/2018] [Indexed: 01/25/2023]
Abstract
The benefit of belatacept on antibody-mediated rejection (ABMR) incidence after kidney transplant with preformed donor-specific antibodies (DSAs) has never been assessed. Between 2014 and 2016, we conducted a multicenter prospective clinical trial with 49 patients to determine kidney allograft outcome in recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000) treated with belatacept (BELACOR trial). Immunosuppressive strategy included antithymocyte globulin, belatacept, mycophenolate mofetil, and steroids. An ancillary control group was designed retrospectively, including patients fulfilling the same inclusion criteria treated with calcineurin inhibitors. In BELACOR group, no patient exhibited acute ABMR, patient and allograft survival at 1 year was 100% and 95.4%, respectively, and the estimated glomerular filtration rate was 53.2 mL/min/1.73 m2 . However, the 12-month incidence of acute T cell-mediated rejection was 25.4% (14.5% to 42.4%). Comparison with the control group showed significantly higher T cell-mediated rejection incidence only in the BELACOR group (P = .003). Considering the DSAs, the outcome was similar in the 2 groups except a significantly higher number of patients displayed a complete disappearance of class II DSAs in the BELACOR group (P = .001). Belatacept was not associated with an acute ABMR increased risk and may be considered as immunosuppressive strategy in transplant recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000). Prospective randomized trials are needed to confirm these results.
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Affiliation(s)
- Claire Leibler
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Marie Matignon
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Anissa Moktefi
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Pathology Department, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Chloé Samson
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Anissa Zarour
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Stéphanie Malard
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d' Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Emmanuelle Boutin
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Caroline Pilon
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Laurent Salomon
- Assistance Publique-Hôpitaux de Paris, Urology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Pierre-André Natella
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Antoine Durrbach
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Thomas Robert
- Department of Nephrology, Transplantation and Emergency, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Florence Canoui-Poitrine
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,Département Hospitalo-Universitaire A-TVB, Institut Mondor de Recherche Biomédicale - EA 7376 Clinical Epidemiology and Ageing Unit, Université Paris-Est-Créteil, Créteil, France
| | - Philippe Grimbert
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France.,Assistance Publique-Hôpitaux de Paris, CIC-BT 504, Créteil, France
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30
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Measuring Alloreactive B Cell Responses in Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Hasgur S, Valujskikh A. Measuring alloreactive B cell responses in transplant recipients. CURRENT TRANSPLANTATION REPORTS 2019; 6:99-105. [PMID: 31588407 PMCID: PMC6777871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Despite advanced immunosuppression, donor-specific antibodies (DSA) remain the leading cause of acute and chronic transplant tissue injury. Comprehensive evaluation of anti-donor humoral immune responses is critical for successful prevention, diagnosis and treatment of antibody-mediated rejection. This review summarizes the evolution of techniques used for this purpose in experimental and clinical transplantation. RECENT FINDINGS For decades, measuring DSA serum levels was the only way to assess recipient humoral immunity. Recently, the interest shifted from quantifying circulating DSA to the analyses of various B cell subsets and most importantly, of donor antigen-specific B cells. State-of-the-art approaches have been developed by studies of model antigens, infectious agents and autoimmunity. These methods are now being adopted by the transplantation field. SUMMARY The complexity of humoral immunity caused by organ transplantation necessitates complementary approaches assessing both DSA and various B cell subsets to successfully target antibody-mediated rejection.
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Affiliation(s)
- Suheyla Hasgur
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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32
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33
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Pivotal role for α V integrins in sustained Tfh support of the germinal center response for long-lived plasma cell generation. Proc Natl Acad Sci U S A 2019; 116:4462-4470. [PMID: 30770452 DOI: 10.1073/pnas.1809329116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
CD4+ follicular helper T cells (Tfh) are essential for germinal center (GC) reactions in the lymph node that generate high-affinity, long-lived plasma cells (LLPCs). Temporal GC analysis suggests B memory cells (Bmem) are generated early, while LLPCs are generated late in the GC reaction. Distinct roles for Tfh at these temporally different stages are not yet clear. Tfh entry into the GC is highly dynamic and the signals that maintain Tfh within the GC for support of late LLPC production are poorly understood. The GC is marked by inflammation-induced presentation of specific ECM components. To determine if T cell recognition of these ECM components played a role in Tfh support of the GC, we immunized mice with a T cell-restricted deletion of the ECM-binding integrin αV (αV-CD4 cKO). T cell integrin αV deletion led to a striking defect in the number and size of the GCs following immunization with OVA protein in complete Freund's adjuvant. The GC defect was not due to integrin αV deficiency impeding Tfh generation or follicle entry or the ability of αV-CD4 cKO Tfh to contact and support B cell activation. Instead, integrin αV was essential for T cell-intrinsic accumulation within the GC. Altered Tfh positioning resulted in lower-affinity antibodies and a dramatic loss of LLPCs. Influenza A infection revealed that αV integrin was not required for Tfh support of Bmem but was essential for Tfh support of LLPCs. We highlight an αV integrin-ECM-guided mechanism of Tfh GC accumulation that selectively impacts GC output of LLPCs but not Bmem.
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34
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Leibler C, Thiolat A, Elsner RA, El Karoui K, Samson C, Grimbert P. Costimulatory blockade molecules and B-cell-mediated immune response: current knowledge and perspectives. Kidney Int 2019; 95:774-786. [PMID: 30711200 DOI: 10.1016/j.kint.2018.10.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/17/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022]
Abstract
There is an urgent need for therapeutic agents that target humoral alloimmunity in solid organ transplantation. This includes sensitized patients with preformed donor-specific human leukocyte antigen antibodies and patients who develop de novo donor-specific antibodies, both of which are associated with acute and chronic antibody-mediated rejection and allograft loss. In the last decade, both experimental and clinical studies highlighted the major impact of costimulation molecules in the control of immune responses both in the field of transplantation and autoimmune disease. Although these molecules have been initially developed to control the early steps of T-cell activation, recent evidence also supports their influence at several steps of the humoral response. In this review, we aim to provide an overview of the current knowledge of the effects of costimulatory blockade agents on humoral responses in both autoimmune and allogeneic contexts. We first present the effects of costimulatory molecules on the different steps of alloantibody production. We then summarize mechanisms and clinical results observed using cytotoxic T lymphocyte antigen-4 (CTLA4)-Ig molecules both in transplantation and autoimmunity. Finally, we present the potential interest and implications of other costimulatory family members as therapeutic targets, with emphasis on combinatorial approaches, for the optimal control of the alloantigen-specific humoral response.
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Affiliation(s)
- Claire Leibler
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Allan Thiolat
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Rebecca A Elsner
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Chloe Samson
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France.
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35
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Chhabra M, Alsughayyir J, Qureshi MS, Mallik M, Ali JM, Gamper I, Moseley EL, Peacock S, Kosmoliaptsis V, Goddard MJ, Linterman MA, Motallebzadeh R, Pettigrew GJ. Germinal Center Alloantibody Responses Mediate Progression of Chronic Allograft Injury. Front Immunol 2019; 9:3038. [PMID: 30728823 PMCID: PMC6351502 DOI: 10.3389/fimmu.2018.03038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/07/2018] [Indexed: 02/02/2023] Open
Abstract
Different profiles of alloantibody responses are observed in the clinic, with those that persist, often despite targeted treatment, associated with poorer long-term transplant outcomes. Although such responses would suggest an underlying germinal center (GC) response, the relationship to cellular events within the allospecific B cell population is unclear. Here we examine the contribution of germinal center (GC) humoral alloimmunity to chronic antibody mediated rejection (AMR). A murine model of chronic AMR was developed in which T cell deficient (Tcrbd-/-) C57BL/6 recipients were challenged with MHC-mismatched BALB/c heart allografts and T cell help provided by reconstituting with 103 "TCR75" CD4 T cells that recognize self-restricted allopeptide derived from the H-2Kd MHC class I alloantigen. Reconstituted recipients developed Ig-switched anti-Kd alloantibody responses that were slow to develop, but long-lived, with confocal immunofluorescence and flow cytometric characterization of responding H-2Kd-allospecific B cells confirming persistent splenic GC activity. This was associated with T follicular helper (TFH) cell differentiation of the transferred TCR75 CD4 T cells. Heart grafts developed progressive allograft vasculopathy, and were rejected chronically (MST 50 days), with explanted allografts displaying features of humoral vascular rejection. Critically, late alloantibody responses were abolished, and heart grafts survived indefinitely, in recipients reconstituted with Sh2d1a-/- TCR75 CD4 T cells that were genetically incapable of providing TFH cell function. The GC response was associated with affinity maturation of the anti-Kd alloantibody response, and its contribution to progression of allograft vasculopathy related principally to secretion of alloantibody, rather than to enhanced alloreactive T cell priming, because grafts survived long-term when B cells could present alloantigen, but not secrete alloantibody. Similarly, sera sampled at late time points from chronically-rejecting recipients induced more vigorous donor endothelial responses in vitro than sera sampled earlier after transplantation. In summary, our results suggest that chronic AMR and progression of allograft vasculopathy is dependent upon allospecific GC activity, with critical help provided by TFH cells. Clinical strategies that target the TFH cell subset may hold therapeutic potential. This work is composed of two parts, of which this is Part II. Please read also Part I: Alsughayyir et al., 2019.
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Affiliation(s)
- Manu Chhabra
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jawaher Alsughayyir
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - M. Saeed Qureshi
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mekhola Mallik
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jason M. Ali
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ivonne Gamper
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ellen L. Moseley
- Department of Pathology, Papworth Hospital, Papworth Everard, United Kingdom
| | - Sarah Peacock
- Histocompatibility and Immunogenetics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Martin J. Goddard
- Department of Pathology, Papworth Hospital, Papworth Everard, United Kingdom
| | - Michelle A. Linterman
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Cambridge, United Kingdom
| | - Reza Motallebzadeh
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Centre for Transplantation, Department of Renal Medicine, University College London, London, United Kingdom
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
| | - Gavin J. Pettigrew
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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36
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Alsughayyir J, Chhabra M, Qureshi MS, Mallik M, Ali JM, Gamper I, Moseley EL, Peacock S, Kosmoliaptsis V, Goddard MJ, Linterman MA, Motallebzadeh R, Pettigrew GJ. Relative Frequencies of Alloantigen-Specific Helper CD4 T Cells and B Cells Determine Mode of Antibody-Mediated Allograft Rejection. Front Immunol 2019; 9:3039. [PMID: 30740108 PMCID: PMC6357941 DOI: 10.3389/fimmu.2018.03039] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/07/2018] [Indexed: 02/02/2023] Open
Abstract
Humoral alloimmunity is now recognized as a major determinant of transplant outcome. MHC glycoprotein is considered a typical T-dependent antigen, but the nature of the T cell alloresponse that underpins alloantibody generation remains poorly understood. Here, we examine how the relative frequencies of alloantigen-specific B cells and helper CD4 T cells influence the humoral alloimmune response and how this relates to antibody-mediated rejection (AMR). An MHC-mismatched murine model of cardiac AMR was developed, in which T cell help for alloantibody responses in T cell deficient (Tcrbd-/-) C57BL/6 recipients against donor H-2Kd MHC class I alloantigen was provided by adoptively transferred "TCR75" CD4 T cells that recognize processed H-2Kd allopeptide via the indirect-pathway. Transfer of large numbers (5 × 105) of TCR75 CD4 T cells was associated with rapid development of robust class-switched anti-H-2Kd humoral alloimmunity and BALB/c heart grafts were rejected promptly (MST 9 days). Grafts were not rejected in T and B cell deficient Rag2-/- recipients that were reconstituted with TCR75 CD4 T cells or in control (non-reconstituted) Tcrbd-/- recipients, suggesting that the transferred TCR75 CD4 T cells were mediating graft rejection principally by providing help for effector alloantibody responses. In support, acutely rejecting BALB/c heart grafts exhibited hallmark features of acute AMR, with widespread complement C4d deposition, whereas cellular rejection was not evident. In addition, passive transfer of immune serum from rejecting mice to Rag2-/- recipients resulted in eventual BALB/c heart allograft rejection (MST 20 days). Despite being long-lived, the alloantibody responses observed at rejection of the BALB/c heart grafts were predominantly generated by extrafollicular foci: splenic germinal center (GC) activity had not yet developed; IgG secreting cells were confined to the splenic red pulp and bridging channels; and, most convincingly, rapid graft rejection still occurred when recipients were reconstituted with similar numbers of Sh2d1a-/- TCR75 CD4 T cells that are genetically incapable of providing T follicular helper cell function for generating GC alloimmunity. Similarly, alloantibody responses generated in Tcrbd-/- recipients reconstituted with smaller number of wild-type TCR75 CD4 T cells (103), although long-lasting, did not have a discernible extrafollicular component, and grafts were rejected much more slowly (MST 50 days). By modeling antibody responses to Hen Egg Lysozyme protein, we confirm that a high ratio of antigen-specific helper T cells to B cells favors development of the extrafollicular response, whereas GC activity is favored by a relatively high ratio of B cells. In summary, a relative abundance of helper CD4 T cells favors development of strong extrafollicular alloantibody responses that mediate acute humoral rejection, without requirement for GC activity. This work is composed of two parts, of which this is Part I. Please read also Part II: Chhabra et al., 2019.
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Affiliation(s)
- Jawaher Alsughayyir
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manu Chhabra
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - M. Saeed Qureshi
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mekhola Mallik
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jason M. Ali
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ivonne Gamper
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ellen L. Moseley
- Department of Pathology, Papworth Hospital, Papworth Everard, United Kingdom
| | - Sarah Peacock
- Histocompatibility and Immunogenetics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Martin J. Goddard
- Department of Pathology, Papworth Hospital, Papworth Everard, United Kingdom
| | - Michelle A. Linterman
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Cambridge, United Kingdom
| | - Reza Motallebzadeh
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
- Centre for Transplantation, Department of Renal Medicine, University College London, London, United Kingdom
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
| | - Gavin J. Pettigrew
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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Chen M, Lin X, Olsen N, He X, Zheng SG. Advances in T follicular helper and T follicular regulatory cells in transplantation immunity. Transplant Rev (Orlando) 2018; 32:187-193. [PMID: 30139705 DOI: 10.1016/j.trre.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/08/2018] [Accepted: 07/20/2018] [Indexed: 12/14/2022]
Abstract
B cells play a crucial role in alloreactivity of organ transplant rejection and graft versus host diseases (GVHD). Over the past decade, it has been well recognized that B-cell infiltration in allografts and de novo donor-specific antibodies (DSA) were strongly associated with severe graft rejection and loss, as well as glucocorticoid resistance. Emerging evidence has demonstrated that Follicular T helper (Tfh) cells are key effectors to promote the proliferation and differentiation of B cells into antibody-producing plasmablasts and memory B cells. T-follicular regulatory (Tfr) cells are a recently recognized cell population that has a negative regulatory role on Tfh cells in the follicle, preventing incessant antibody production. It is still less clear how those humoral immunoreactive cells affect transplant rejection and allograft loss. This review focuses on the production and function of Tfr/Tfh cells in the transplant environment. Better understanding of the functions and mechanisms of Tfr/Tfh cells will help to design new strategies to prevent allograft rejection and prolong graft survival.
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Affiliation(s)
- Maogen Chen
- Organ transplant center, First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, PR China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, PR China
| | - Xiaohong Lin
- Division of general surgery, The Eastern Hospital of the First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China
| | - Nancy Olsen
- Division of Rheumatology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Xiaoshun He
- Organ transplant center, First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, PR China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, PR China
| | - Song Guo Zheng
- Division of Rheumatology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
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New insights into the development of B cell responses: Implications for solid organ transplantation. Hum Immunol 2018; 80:378-384. [PMID: 30240897 DOI: 10.1016/j.humimm.2018.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 12/23/2022]
Abstract
A resurgent interest in the role of B cells following solid organ transplantation is being driven by clinical data suggesting that antibody mediated rejection (AMR) is a major cause of dysfunction and organ transplant failure. These observations suggest that, in a subset of patients, current immunotherapies are failing to control the development of alloantibody responses, and/or failing to reverse the production or the effects of alloantibodies. Quantification of donor-specific antibodies (DSA) has proven to be an imperfect predictor of AMR, and efforts to improve DSA quantification anticipate that this will result in improved predictive power. At the same time, attempts to control of ABMR have focused on the non-specific elimination of B cells, plasma cells (PCs) or circulating antibodies. In the past decade, there has been an improvement in our understanding of the processes that drive B cell differentiation into germinal center (GC)-dependent or GC-independent memory B cells and antibody-secreting PC. These insights are suggesting new ways to more specifically target the DSA response, which may lead to better long-term allograft survival outcomes while preserving protective immunity. In this review, new insights into processes that lead to antibody production upon primary and secondary antigen encounter are discussed, and the potential implications to DSA production as well as future areas of investigation to control AMR are discussed.
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Wang S, Breskovska I, Gandhy S, Punga AR, Guptill JT, Kaminski HJ. Advances in autoimmune myasthenia gravis management. Expert Rev Neurother 2018; 18:573-588. [PMID: 29932785 PMCID: PMC6289049 DOI: 10.1080/14737175.2018.1491310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune neuromuscular disorder with no cure and conventional treatments limited by significant adverse effects and variable benefit. In the last decade, therapeutic development has expanded based on improved understanding of autoimmunity and financial incentives for drug development in rare disease. Clinical subtypes exist based on age, gender, thymic pathology, autoantibody profile, and other poorly defined factors, such as genetics, complicate development of specific therapies. Areas covered: Clinical presentation and pathology vary considerably among patients with some having weakness limited to the ocular muscles and others having profound generalized weakness leading to respiratory insufficiency. MG is an antibody-mediated disorder dependent on autoreactive B cells which require T-cell support. Treatments focus on elimination of circulating autoantibodies or inhibition of effector mechanisms by a broad spectrum of approaches from plasmapheresis to B-cell elimination to complement inhibition. Expert commentary: Standard therapies and those under development are disease modifying and not curative. As a rare disease, clinical trials are challenged in patient recruitment. The great interest in development of treatments specific for MG is welcome, but decisions will need to be made to focus on those that offer significant benefits to patients.
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Affiliation(s)
- Shuhui Wang
- Department of Neurology, George Washington University, Washington DC 20008
| | - Iva Breskovska
- Department of Neurology, George Washington University, Washington DC 20008
| | - Shreya Gandhy
- Department of Neurology, George Washington University, Washington DC 20008
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Jeffery T. Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington DC 20008
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Badell IR, La Muraglia GM, Liu D, Wagener ME, Ding G, Ford ML. Selective CD28 Blockade Results in Superior Inhibition of Donor-Specific T Follicular Helper Cell and Antibody Responses Relative to CTLA4-Ig. Am J Transplant 2018; 18:89-101. [PMID: 28637095 PMCID: PMC5740006 DOI: 10.1111/ajt.14400] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/02/2017] [Accepted: 06/13/2017] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSAs) are a barrier to improved long-term outcomes after kidney transplantation. Costimulation blockade with CTLA4-Ig has shown promise as a potential therapeutic strategy to control DSAs. T follicular helper (Tfh) cells, a subset of CD4+ T cells required for optimal antibody production, are reliant on the CD28 costimulatory pathway. We have previously shown that selective CD28 blockade leads to superior allograft survival through improved control of CD8+ T cells relative to CTLA4-Ig, but the impact of CD28-specific blockade on CD4+ Tfh cells is unknown. Thus, we identified and characterized donor-reactive Tfh cells in a murine skin transplant model and then used this model to evaluate the impact of selective CD28 blockade with an anti-CD28 domain antibody (dAb) on the donor-specific Tfh cell-mediated immune response. We observed that the anti-CD28 dAb led to superior inhibition of donor-reactive CXCR5+ PD-1high Tfh cells, CD95+ GL7+ germinal center B cells and DSA formation compared with CTLA4-Ig. Interestingly, donor-reactive Tfh cells differentially upregulated CTLA4 expression, suggesting an important role for CTLA4 in mediating the superior inhibition observed with the anti-CD28 dAb. Therefore, selective CD28 blockade as a novel approach to control Tfh cell responses and prevent DSA after kidney transplantation warrants further study.
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Affiliation(s)
- IR Badell
- Emory Transplant Center, Atlanta, GA, USA,Corresponding Author: I. Raul Badell, MD,
| | | | - D Liu
- Emory Transplant Center, Atlanta, GA, USA
| | - ME Wagener
- Emory Transplant Center, Atlanta, GA, USA
| | - G Ding
- Emory Transplant Center, Atlanta, GA, USA
| | - ML Ford
- Emory Transplant Center, Atlanta, GA, USA
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Fribourg M, Ni J, Papavasiliou FN, Yue Z, Heeger PS, Leventhal JS. Allospecific Memory B Cell Responses Are Dependent on Autophagy. Am J Transplant 2018; 18:102-112. [PMID: 28621910 PMCID: PMC5732898 DOI: 10.1111/ajt.14394] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 01/25/2023]
Abstract
Long-lived, donor-reactive memory B cells (Bmems) can produce alloantibodies that mediate transplant injury. Autophagy, an intrinsic mechanism of cell organelle/component recycling, is required for Bmem survival in infectious and model antigen systems, but whether autophagy affects alloreactive Bmem is unknown. We studied mice with an inducible yellow fluorescent protein (YFP) reporter expressed under the activation-induced cytidine deaminase (AID) promoter active in B cells undergoing germinal center reactions. Up to 12 months after allogeneic sensitization, splenic YFP+ B cells were predominantly IgD- IgM- IgG+ and expressed CD73, CD80, and PD-L2, consistent with Bmems. Labeled cells contained significantly more cells with autophagosomes and more autophagosomes per cell than unlabeled, naïve B cells. To test for a functional link, we quantified alloantibody formation in mice with B cells conditionally deficient in the requisite autophagy gene ATG7. These experiments revealed absent B cell ATG7 (1) prevented B cell autophagy, (2) inhibited secondary alloantibody responses without altering primary alloantibody formation, and (3) diminished frequencies of alloreactive Bmems. Pharmacological autophagy inhibition with 3-methyladenine had similar effects on wild-type mice. Together with new documentation of increased autophagosomes within human Bmems, our data indicate that targeting autophagy has potential for eliminating donor-reactive Bmems in transplant recipients.
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Affiliation(s)
- Miguel Fribourg
- Department of Neurology and Center for Translational Systems Biology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jie Ni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - F. Nina Papavasiliou
- Department of Immunology, Virology, and Microbiology, The Rockefeller University, New York, USA
| | - Zhenyu Yue
- Department of Neurology, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Peter S. Heeger
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA,Transplant Research Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jeremy S. Leventhal
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA,Transplant Research Institute, Icahn School of Medicine at Mount Sinai, New York, USA,Renal Division, James J Peters Bronx VA Medical Center, Bronx, New York, USA
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Evolving Approaches in the Identification of Allograft-Reactive T and B Cells in Mice and Humans. Transplantation 2017; 101:2671-2681. [PMID: 28604446 DOI: 10.1097/tp.0000000000001847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Whether a transplanted allograft is stably accepted, rejected, or achieves immunological tolerance is dependent on the frequency and function of alloreactive lymphocytes, making the identification and analysis of alloreactive T and B cells in transplant recipients critical for understanding mechanisms, and the prediction of allograft outcome. In animal models, tracking the fate of graft-reactive T and B cells allows investigators to uncover their biology and develop new therapeutic strategies to protect the graft. In the clinic, identification and quantification of graft-reactive T and B cells allows for the early diagnosis of immune reactivity and therapeutic intervention to prevent graft loss. In addition to rejection, probing of T and B cell fate in vivo provides insights into the underlying mechanisms of alloimmunity or tolerance that may lead to biomarkers predicting graft fate. In this review, we discuss existing and developing approaches to track and analyze alloreactive T and B cells in mice and humans and provide examples of discoveries made utilizing these techniques. These approaches include mixed lymphocyte reactions, trans-vivo delayed-type hypersensitivity, enzyme-linked immunospot assays, the use of antigen receptor transgenic lymphocytes, and utilization of peptide-major histocompatibility multimers, along with imaging techniques for static multiparameter analysis or dynamic in vivo tracking. Such approaches have already refined our understanding of the alloimmune response and are pointing to new ways to improve allograft outcomes in the clinic.
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Young JS, Khiew SHW, Yang J, Vannier A, Yin D, Sciammas R, Alegre ML, Chong AS. Successful Treatment of T Cell-Mediated Acute Rejection with Delayed CTLA4-Ig in Mice. Front Immunol 2017; 8:1169. [PMID: 28970838 PMCID: PMC5609110 DOI: 10.3389/fimmu.2017.01169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/04/2017] [Indexed: 12/25/2022] Open
Abstract
Clinical observations that kidney transplant recipients receiving belatacept who experienced T cell-mediated acute rejection can be successfully treated and subsequently maintained on belatacept-based immunosuppression suggest that belatacept is able to control memory T cells. We recently reported that treatment with CTLA4-Ig from day 6 posttransplantation successfully rescues allografts from acute rejection in a BALB/c to C57BL/6 heart transplant model, in part, by abolishing B cell germinal centers and reducing alloantibody titers. Here, we show that CTLA4-Ig is additionally able to inhibit established T cell responses independently of B cells. CTLA4-Ig inhibited the in vivo cytolytic activity of donor-specific CD8+ T cells, and the production of IFNγ by graft-infiltrating T cells. Delayed CTLA4-Ig treatment did not reduce the numbers of graft-infiltrating T cells nor prevented the accumulation of antigen-experienced donor-specific memory T cells in the spleen. Nevertheless, delayed CTLA4-Ig treatment successfully maintained long-term graft acceptance in the majority of recipients that had experienced a rejection crisis, and enabled the acceptance of secondary BALB/c heart grafts transplanted 30 days after the first transplantation. In summary, we conclude that delayed CTLA4-Ig treatment is able to partially halt ongoing T cell-mediated acute rejection. These findings extend the functional efficacy of CTLA4-Ig therapy to effector T cells and provide an explanation for why CTLA4-Ig-based immunosuppression in the clinic successfully maintains long-term graft survival after T cell-mediated rejection.
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Affiliation(s)
- James S Young
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Stella H-W Khiew
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Jinghui Yang
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States.,Department of Organ Transplantation, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Augustin Vannier
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Dengping Yin
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Roger Sciammas
- Center for Comparative Medicine, University of California, Davis, Davis, CA, United States
| | - Maria-Luisa Alegre
- Department of Medicine, Section of Rheumatology, The University of Chicago, Chicago, IL, United States
| | - Anita S Chong
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
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Tracing Donor-MHC Class II Reactive B cells in Mouse Cardiac Transplantation: Delayed CTLA4-Ig Treatment Prevents Memory Alloreactive B-Cell Generation. Transplantation 2017; 100:1683-91. [PMID: 27362308 DOI: 10.1097/tp.0000000000001253] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The dual role of B cells as drivers and suppressors of the immune responses have underscored the need to trace the fate of B cells recognizing donor major histocompatibility complex class I and class II after allograft transplantation. METHODS In this study, we used donor class II tetramers to trace the fate of I-E-specific B cells after immunization with BALB/c spleen cells or cardiac transplantation, in naive or sensitized C57BL/6 recipients. We combined this approach with genetic lineage tracing of memory B cells in activation-induced cytidine deaminase regulated Cre transgenic mice crossed to the ROSA26-enhanced yellow fluorescent protein reporter mice to track endogenous I-E-specific memory B cell generation. RESULTS Immunization with BALB/c splenocytes or heart transplantation induced an expansion and differentiation of I-E-specific B cells into germinal center B cells, whereas BALB/c heart transplantation into sensitized recipients induced the preferential differentiation into antibody-secreting cells. A 10.8-fold increase in the frequency of I-E-specific memory B cells was observed by day 42 postimmunization. Treatment with CTLA4-Ig starting on day 0 or day 7 postimmunization abrogated I-E-specific memory B cell generation and sensitized humoral responses, but not if treatment commenced on day 14. CONCLUSIONS The majority of donor-specific memory B cells are generated between days 7 and 14 postimmunization, thus revealing a flexible timeframe whereby delayed CTLA4-Ig administration can inhibit sensitization and the generation of memory graft-reactive B cells.
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Abstract
Crosstalk between B and T cells in transplantation is increasingly recognized as being important in the alloimmune response. T cell activation of B cells occurs by a 3-stage pathway, culminating with costimulation signals. We review the distinct T cell subtypes required for B-cell activation and discuss the formation of the germinal center (GC) after transplantation, with particular reference to the repopulation of the GC after depletional induction, and the subsequent effect of immunosuppressive manipulation of T cell-B cell interactions. In addition, ectopic GCs are seen in transplantation, but their role is not fully understood. Therapeutic options to target T cell-B cell interactions are of considerable interest, both as immunosuppressive tools, and to aid in the further understanding of these important alloimmune mechanisms.
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46
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Khiew SH, Yang J, Young JS, Chen J, Wang Q, Yin D, Vu V, Miller ML, Sciammas R, Alegre ML, Chong AS. CTLA4-Ig in combination with FTY720 promotes allograft survival in sensitized recipients. JCI Insight 2017; 2:92033. [PMID: 28469082 PMCID: PMC5414557 DOI: 10.1172/jci.insight.92033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/21/2017] [Indexed: 12/30/2022] Open
Abstract
Despite recent evidence of improved graft outcomes and safety, the high incidence of early acute cellular rejection with belatacept, a high-affinity CTLA4-Ig, has limited its use in clinical transplantation. Here we define how the incomplete control of endogenous donor-reactive memory T cells results in belatacept-resistant rejection in an experimental model of BALB/c.2W-OVA donor heart transplantation into C57BL/6 recipients presensitized to donor splenocytes. These sensitized mice harbored modestly elevated numbers of endogenous donor-specific memory T cells and alloantibodies compared with naive recipients. Continuous CTLA4-Ig treatment was unexpectedly efficacious at inhibiting endogenous graft-reactive T cell expansion but was unable to inhibit late CD4+ and CD8+ T cell infiltration into the allografts, and rejection was observed in 50% of recipients by day 35 after transplantation. When CTLA4-Ig was combined with the sphingosine 1-phosphate receptor-1 (S1PR1) functional antagonist FTY720, alloantibody production was inhibited and donor-specific IFN-γ-producing T cells were reduced to levels approaching nonsensitized tolerant recipients. Late T cell recruitment into the graft was also restrained, and graft survival improved with this combination therapy. These observations suggest that a rational strategy consisting of inhibiting memory T cell expansion and trafficking into the allograft with CTLA4-Ig and FTY720 can promote allograft survival in allosensitized recipients.
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Affiliation(s)
| | - Jinghui Yang
- Section of Transplantation, Department of Surgery
| | | | - Jianjun Chen
- Section of Transplantation, Department of Surgery
| | - Qiang Wang
- Section of Transplantation, Department of Surgery
| | - Dengping Yin
- Section of Transplantation, Department of Surgery
| | - Vinh Vu
- Section of Transplantation, Department of Surgery
| | - Michelle L. Miller
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Roger Sciammas
- Center for Comparative Medicine, University of California, Davis, California, USA
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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Miller ML, Chen J, Daniels MD, McKeague MG, Wang Y, Yin D, Vu V, Chong AS, Alegre ML. Adoptive Transfer of Tracer-Alloreactive CD4 + T Cell Receptor Transgenic T Cells Alters the Endogenous Immune Response to an Allograft. Am J Transplant 2016; 16:2842-2853. [PMID: 27063351 PMCID: PMC5065388 DOI: 10.1111/ajt.13821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 03/09/2016] [Accepted: 04/01/2016] [Indexed: 01/25/2023]
Abstract
T cell receptor transgenic (TCR-Tg) T cells are often used as tracer populations of antigen-specific responses to extrapolate findings to endogenous T cells. The extent to which TCR-Tg T cells behave purely as tracer cells or modify the endogenous immune response is not clear. To test the impact of TCR-Tg T cell transfer on endogenous alloimmunity, recipient mice were seeded with CD4+ or CD8+ TCR-Tg or polyclonal T cells at the time of cardiac allograft transplantation. Only CD4+ TCR-Tg T cells accelerated rejection and, unexpectedly, led to a dose-dependent decrease in both transferred and endogenous T cells infiltrating the graft. In contrast, recipients of CD4+ TCR-Tg T cells exhibited enhanced endogenous donor-specific CD8+ T cell activation in the spleen and accelerated alloantibody production. Introduction of CD4+ TCR-Tg T cells also perturbed the intragraft accumulation of innate cell populations. Transferred CD4+ TCR-Tg T cells alter many aspects of endogenous alloimmunity, suggesting that caution should be used when interpreting experiments using these adoptively transferred cells because the overall nature of allograft rejection may be altered. These results also may have implications for adoptive CD4+ T cell immunotherapy in tumor and infectious clinical settings because cell infusion may have additional effects on natural immune responses.
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Affiliation(s)
| | - Jianjun Chen
- Section of Transplantation, Department of Surgery, University of Chicago
| | - Melvin D. Daniels
- Section of Transplantation, Department of Surgery, University of Chicago
| | | | - Ying Wang
- Section of Rheumatology, Department of Medicine, University of Chicago
| | - Dengping Yin
- Section of Transplantation, Department of Surgery, University of Chicago
| | - Vinh Vu
- Section of Transplantation, Department of Surgery, University of Chicago
| | - Anita S. Chong
- Section of Transplantation, Department of Surgery, University of Chicago
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, University of Chicago,To whom correspondence should be addressed: Maria-Luisa Alegre, M.D., Ph.D., The University of Chicago, Department of Medicine, 924 E. 57 St., JFK-R312, Chicago, IL 60637; tel: 773-834-4317; fax: 773-702-4394;
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Oh B, Yoon J, Farris A, Kirk A, Knechtle S, Kwun J. Rapamycin Interferes With Postdepletion Regulatory T Cell Homeostasis and Enhances DSA Formation Corrected by CTLA4-Ig. Am J Transplant 2016; 16:2612-23. [PMID: 26990829 DOI: 10.1111/ajt.13789] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 03/01/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
Previously, we demonstrated that alemtuzumab induction with rapamycin as sole maintenance therapy is associated with an increased incidence of humoral rejection in human kidney transplant patients. To investigate the role of rapamycin in posttransplant humoral responses after T cell depletion, fully MHC mismatched hearts were transplanted into hCD52Tg mice, followed by alemtuzumab treatment with or without a short course of rapamycin. While untreated hCD52Tg recipients acutely rejected B6 hearts (n = 12), hCD52Tg recipients treated with alemtuzumab alone or in conjunction with rapamycin showed a lack of acute rejection (MST > 100). However, additional rapamycin showed a reduced beating quality over time and increased incidence of vasculopathy. Furthermore, rapamycin supplementation showed an increased serum donor-specific antibodies (DSA) level compared to alemtuzumab alone at postoperation days 50 and 100. Surprisingly, additional rapamycin treatment significantly reduced CD4(+) CD25(+) FoxP3(+) T reg cell numbers during treatment. On the contrary, ICOS(+) PD-1(+) CD4 follicular helper T cells in the lymph nodes were significantly increased. Interestingly, CTLA4-Ig supplementation in conjunction with rapamycin corrected rapamycin-induced accelerated posttransplant humoral response by directly modulating Tfh cells but not Treg cells. This suggests that rapamycin after T cell depletion could affect Treg cells leading to an increase of Tfh cells and DSA production that can be reversed by CTLA4-Ig.
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Affiliation(s)
- B Oh
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - J Yoon
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - A Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - A Kirk
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - S Knechtle
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - J Kwun
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC
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Kim I, Wu G, Chai NN, Klein AS, Jordan SC. Immunological characterization of de novo and recall alloantibody suppression by CTLA4Ig in a mouse model of allosensitization. Transpl Immunol 2016; 38:84-92. [PMID: 27507323 DOI: 10.1016/j.trim.2016.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/15/2016] [Accepted: 08/05/2016] [Indexed: 12/14/2022]
Abstract
It is well known that CTLA4Ig inhibits allogenic T-cell activation in transplantation. The immunological features and mechanisms associated with alloantibody suppression by CTLA4Ig, however, are poorly understood. Here, we used a mouse model of allosensitization to evaluate the efficacy of CTLA4Ig (abatacept) in suppression of donor-specific antibody (DSA) during de novo and recall alloantibody responses. We found that abatacept inhibited de novo DSA IgM and IgG responses to HLA-A2 expressing skin grafts. Abatacept administered during primary T cell priming also reduced recall IgG responses induced by re-immunization. Suppression of de novo DSA responses by abatacept is associated with a reduction in splenic expression of the germinal center activation marker GL7 and a reduction of CD4(+)PD1(+)CXCR5(+) follicular T helper (Tfh) subset in splenic lymphocytes detected by flow cytometry. The efficacy of abatacept on recall DSA suppression is moderate. In vitro experiments demonstrated that abatacept inhibited DSA IgG secretion by CD138(+) plasma cells isolated from allograft recipients. Additional experiments using an IgG1 secreting mouse hybridoma cell line showed that abatacept binds to CD80 expressed on these cells with subsequent inhibition of cell proliferation and reduction in IgG ELISpot formation. In conclusion, CTLA4Ig is a potent suppressor of de novo DSA responses and also affects recall responses. The data suggests modification of recall DSA responses is due to a direct suppressive effect on plasma cells.
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Affiliation(s)
- Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gordon Wu
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ning-Ning Chai
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew S Klein
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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