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Di Ianni M, Liberatore C, Santoro N, Ranalli P, Guardalupi F, Corradi G, Villanova I, Di Francesco B, Lattanzio S, Passeri C, Lanuti P, Accorsi P. Cellular Strategies for Separating GvHD from GvL in Haploidentical Transplantation. Cells 2024; 13:134. [PMID: 38247827 PMCID: PMC10814899 DOI: 10.3390/cells13020134] [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: 12/02/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
GvHD still remains, despite the continuous improvement of transplantation platforms, a fearful complication of transplantation from allogeneic donors. Being able to separate GvHD from GvL represents the greatest challenge in the allogeneic transplant setting. This may be possible through continuous improvement of cell therapy techniques. In this review, current cell therapies are taken into consideration, which are based on the use of TCR alpha/beta depletion, CD45RA depletion, T regulatory cell enrichment, NK-cell-based immunotherapies, and suicide gene therapies in order to prevent GvHD and maximally amplify the GvL effect in the setting of haploidentical transplantation.
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Affiliation(s)
- Mauro Di Ianni
- Hematology Unit, Pescara Hospital, 65124 Pescara, Italy; (C.L.); (N.S.); (P.R.)
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Carmine Liberatore
- Hematology Unit, Pescara Hospital, 65124 Pescara, Italy; (C.L.); (N.S.); (P.R.)
| | - Nicole Santoro
- Hematology Unit, Pescara Hospital, 65124 Pescara, Italy; (C.L.); (N.S.); (P.R.)
| | - Paola Ranalli
- Hematology Unit, Pescara Hospital, 65124 Pescara, Italy; (C.L.); (N.S.); (P.R.)
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giulia Corradi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Ida Villanova
- Blood Bank Unit, Pescara Hospital, 65124 Pescara, Italy; (I.V.); (B.D.F.); (C.P.); (P.A.)
| | - Barbara Di Francesco
- Blood Bank Unit, Pescara Hospital, 65124 Pescara, Italy; (I.V.); (B.D.F.); (C.P.); (P.A.)
| | - Stefano Lattanzio
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Cecilia Passeri
- Blood Bank Unit, Pescara Hospital, 65124 Pescara, Italy; (I.V.); (B.D.F.); (C.P.); (P.A.)
| | - Paola Lanuti
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, 66100 Chieti, Italy; (F.G.); (G.C.); (S.L.); (P.L.)
- Center for Advanced Studies and Technology (CAST), University of Chieti-Pescara, 66100 Chieti, Italy
| | - Patrizia Accorsi
- Blood Bank Unit, Pescara Hospital, 65124 Pescara, Italy; (I.V.); (B.D.F.); (C.P.); (P.A.)
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Laukova M, Glatman Zaretsky A. Regulatory T cells as a therapeutic approach for inflammatory bowel disease. Eur J Immunol 2023; 53:e2250007. [PMID: 36562391 PMCID: PMC10107179 DOI: 10.1002/eji.202250007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/20/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022]
Abstract
Foxp3+ T regulatory (Treg) cells suppress inflammation and are essential for maintaining tissue homeostasis. A growing appreciation of tissue-specific Treg functions has built interest in leveraging the endogenous suppressive mechanisms of these cells into cellular therapeutics in organ-specific diseases. Notably, Treg cells play a critical role in maintaining the intestinal environment. As a barrier site, the gut requires Treg cells to mediate interactions with the microbiota, support barrier integrity, and regulate the immune system. Without fully functional Treg cells, intestinal inflammation and microbial dysbiosis ensue. Thus, there is a particular interest in developing Treg cellular therapies for intestinal inflammatory disease, such as inflammatory bowel disease (IBD). This article reviews some of the critical pathways that are dysregulated in IBD, Treg cell mechanisms of suppression, and the efforts and approaches in the field to develop these cells as a cellular therapy for IBD.
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Joudi AM, Reyes Flores CP, Singer BD. Epigenetic Control of Regulatory T Cell Stability and Function: Implications for Translation. Front Immunol 2022; 13:861607. [PMID: 35309306 PMCID: PMC8924620 DOI: 10.3389/fimmu.2022.861607] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/14/2022] [Indexed: 12/13/2022] Open
Abstract
FoxP3+ regulatory T (Treg) cells maintain immune homeostasis, promote self-tolerance, and have an emerging role in resolving acute inflammation, providing tissue protection, and repairing tissue damage. Some data suggest that FoxP3+ T cells are plastic, exhibiting susceptibility to losing their function in inflammatory cytokine-rich microenvironments and paradoxically contributing to inflammatory pathology. As a result, plasticity may represent a barrier to Treg cell immunotherapy. Here, we discuss controversies surrounding Treg cell plasticity and explore determinants of Treg cell stability in inflammatory microenvironments, focusing on epigenetic mechanisms that clinical protocols could leverage to enhance efficacy and limit toxicity of Treg cell-based therapeutics.
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Affiliation(s)
- Anthony M. Joudi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Canning Thoracic Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Carla P. Reyes Flores
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Canning Thoracic Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Benjamin D. Singer
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Canning Thoracic Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Simpson Querrey Institute for Epigenetics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Kawai K, Uchiyama M, Hester J, Issa F. IL-33 drives the production of mouse regulatory T cells with enhanced in vivo suppressive activity in skin transplantation. Am J Transplant 2021; 21:978-992. [PMID: 33314772 PMCID: PMC7613121 DOI: 10.1111/ajt.16266] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/20/2020] [Accepted: 08/08/2020] [Indexed: 01/25/2023]
Abstract
Regulatory T cells (Tregs) are crucial mediators of immune homeostasis with the ability to modulate allogeneic response and control transplant rejection. Although Treg-based cell therapies have shown immense promise, methods to optimize current strategies are critical for successful implementation within the clinic. IL-33 is a cytokine with pleiotropic properties and effects on Treg function and development. In this study, we explored the unique properties of Treg populations activated through the IL-33/ST2 pathway, aiming to exploit their tolerogenic properties for cell therapy. We show that treatment with exogenous IL-33 results in a generalized downregulation of genes critical to T cell biology together with an upregulation of Treg-associated genes. Tregs that develop in response to IL-33 upregulate critical Treg-associated markers, yet without developing enhanced in vitro suppressive capacity. Conversely, these Tregs display potent regulatory activity in vivo, promoting long-term skin allograft survival in a stringent transplantation model. Detailed transcriptomic and immunophenotypic analyses of IL-33-expanded Tregs reveal an enhancement in graft-homing chemokine receptors, which may be partly responsible for their superior in vivo activity that is not reflected in vitro. IL-33 treatment is therefore an attractive adjunctive strategy for patients receiving Treg cell therapeutics.
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Affiliation(s)
- Kento Kawai
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Masateru Uchiyama
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK,Department of Surgery, Teikyo University, Tokyo, Japan
| | - Joanna Hester
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Fadi Issa
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Li M, Zhao L, Zhou X, Zhang K, Yin P, Liu S, Zou Y, Li Q. Detection of carcinoma in serous effusions: a review. Am J Cancer Res 2021; 11:43-60. [PMID: 33520359 PMCID: PMC7840719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023] Open
Abstract
A malignant serous effusion is one of the most common complications of advanced tumors, indicating a poor prognosis and having a profound impact on diagnosis, treatment, and prognosis. It is of great significance to identify benign and malignant effusions quickly and accurately. Both cellular and non-cellular components in the effusion can be employed for detection, diagnostic methods are necessary to obtain a definite diagnosis and more relevant information such as tumor classification. In this review, we focus on the comparison of several widespread cytological preparation methods, enrichment technology of exfoliated cells, and present tests for serous effusions, mainly including routine and special stains, immunocytochemistry, electron microscopy, enzyme-linked immunosorbent assay, flow cytometry, and molecular analysis.
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Affiliation(s)
- Min Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Lanbo Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Xue Zhou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Kailu Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Panyue Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Shuhua Liu
- College of Chemistry Engineering, Tianjin UniversityTianjin 300350, China
| | - Yuliang Zou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
| | - Qiling Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong UniversityXi’an 710061, China
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Ulbar F, Villanova I, Giancola R, Baldoni S, Guardalupi F, Fabi B, Olioso P, Capone A, Sola R, Ciardelli S, Del Papa B, Brattelli A, Ricciardi I, Taricani S, Sabbatinelli G, Iuliani O, Passeri C, Sportoletti P, Santarone S, Pierini A, Calabrese G, Falzetti F, Bonfini T, Accorsi P, Ruggeri L, Martelli MF, Velardi A, Di Ianni M. Clinical-Grade Expanded Regulatory T Cells Are Enriched with Highly Suppressive Cells Producing IL-10, Granzyme B, and IL-35. Biol Blood Marrow Transplant 2020; 26:2204-2210. [PMID: 32961369 DOI: 10.1016/j.bbmt.2020.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023]
Abstract
In the setting of T cell-depleted, full-haplotype mismatched transplantation, adoptive immunotherapy with regulatory T cells (Tregs) and conventional T cells (Tcons) can prevent graft-versus-host disease (GVHD) and improve post-transplantation immunologic reconstitution and is associated with a powerful graft-versus-leukemia effect. To improve the purity and the quantity of the infused Tregs, good manufacturing practices (GMP)-compatible expansion protocols are needed. Here we expanded Tregs using an automated, clinical-grade protocol. Cells were extensively characterized in vitro, and their efficiency was tested in vivo in a mouse model. Tregs were selected by CliniMacs (CD4+CD25+, 94.5 ± 6.3%; FoxP3+, 63.7 ± 11.5%; CD127+, 20 ± 3%; suppressive activity, 60 ± 7%), and an aliquot of 100 × 106 was expanded for 14 days using the CliniMACS Prodigy System, obtaining 684 ± 279 × 106 cells (CD4+CD25+, 99.6 ± 0.2%; FoxP3+, 82 ± 8%; CD127+, 1.1 ± 0.8%; suppressive activity, 75 ± 12%). CD39 and CTLA4 expression levels increased from 22.4 ± 12% to 58.1 ± 13.3% (P < .05) and from 20.4 ± 6.7% to 85.4 ± 9.8% (P < .01), respectively. TIM3 levels increased from .4 ± .05% to 29 ± 16% (P < .05). Memory Tregs were the prevalent population, whereas naive Tregs almost disappeared at the end of the culture. mRNA analysis displayed significant increases in CD39, IL-10, granzyme B, and IL-35 levels at the end of culture period (P < .05). Conversely, IFNγ expression decreased significantly by day +14. Expanded Tregs were sorted according to TIM3, CD39, and CD62L expression levels (purity >95%). When sorted populations were analyzed, TIM3+ cells showed significant increases in IL-10 and granzyme B (P < .01) .When expanded Tregs were infused in an NSG murine model, mice that received Tcons only died of GVHD, whereas mice that received both Tcons and Tregs survived without GVHD. GMP grade expanded cells that display phenotypic and functional Treg characteristics can be obtained using a fully automated system. Treg suppression is mediated by multiple overlapping mechanisms (eg, CTLA-4, CD39, IL-10, IL-35, TGF-β, granzyme B). TIM3+ cells emerge as a potentially highly suppressive population. © 2020 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Francesca Ulbar
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Ida Villanova
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | | | - Stefano Baldoni
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Bianca Fabi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Paola Olioso
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Anita Capone
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Rosaria Sola
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Sara Ciardelli
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Beatrice Del Papa
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | | | - Ilda Ricciardi
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Stefano Taricani
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Giulia Sabbatinelli
- Department of Neurosciences, Imaging and Clinical Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Ornella Iuliani
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Cecilia Passeri
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Paolo Sportoletti
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Stella Santarone
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Antonio Pierini
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Giuseppe Calabrese
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy; Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Pescara, Italy
| | - Franca Falzetti
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Tiziana Bonfini
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Patrizia Accorsi
- Department of Oncology Hematology, Pescara Hospital, Pescara, Italy
| | - Loredana Ruggeri
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Massimo Fabrizio Martelli
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Andrea Velardi
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Mauro Di Ianni
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Pescara, Italy; Department of Oncology Hematology, Pescara Hospital, Pescara, Italy.
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Aversa F, Pierini A, Ruggeri L, Martelli MF, Velardi A. The Evolution of T Cell Depleted Haploidentical Transplantation. Front Immunol 2019; 10:2769. [PMID: 31827475 PMCID: PMC6890606 DOI: 10.3389/fimmu.2019.02769] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
Work on bone marrow transplantation from haploidentical donor has been proceeding for over 20 years all over the world and new transplant procedures have been developed. To control both graft rejection and graft vs. host disease, some centers have preferred to enhance the intensity of the conditioning regimens and the post-transplant immune suppression in the absence of graft manipulation; others have concentrated on manipulating the graft in the absence of any additional post-transplant immune suppressive agent. Due to the current high engraftment rates, the low incidence of graft-vs.-host disease and regimen related mortality, transplantation from haploidentical donors have been progressively offered even to elderly patients. Overall, survivals compare favorably with reports on transplants from unrelated donors. Further improvements will come with successful implementation of strategies to enhance post-transplant immune reconstitution and to prevent leukemia relapse.
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Affiliation(s)
- Franco Aversa
- Hematology and Bone Marrow Transplantation Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonio Pierini
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Loredana Ruggeri
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Massimo Fabrizio Martelli
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Andrea Velardi
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
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Abstract
Regulatory T cells (Treg cells) represent a CD4+ T-cell lineage that plays a critical role in restraining immune responses to self and foreign antigens and associated inflammation. Due to the suppressive function of Treg cells, inhibition or ablation of these cells can be used to boost the immunity against malignant cells. On the other hand, augmenting the activity of Treg cells can be employed for the treatment of inflammatory or autoimmune diseases and allogeneic conflicts associated with transplantation. Graft-versus-host disease (GvHD) is a leading cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT). In this review, we describe basic biological properties of Treg cells and their role in GvHD. We focus on the application of adoptive transfer of Treg cells and the therapeutic modulation of their activity for the prevention and treatment of GvHD in pre-clinical models and in clinical settings. We also discuss the main obstacles to applying Treg cell-based therapies for GvHD in clinical practice.
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Affiliation(s)
- Shlomo Elias
- Howard Hughes Medical Institute and Immunology Program, Sloan-Kettering Institute, and Ludwig Center at Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Alexander Y. Rudensky
- Howard Hughes Medical Institute and Immunology Program, Sloan-Kettering Institute, and Ludwig Center at Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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The Clinical Significance of Programmed Death-1, Regulatory T Cells and Myeloid Derived Suppressor Cells in Patients with Nontuberculous Mycobacteria-Lung Disease. J Clin Med 2019; 8:jcm8050736. [PMID: 31126067 PMCID: PMC6572058 DOI: 10.3390/jcm8050736] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/15/2019] [Accepted: 05/18/2019] [Indexed: 01/05/2023] Open
Abstract
Background: Increasing expression of programmed death-1 (PD-1) in patients with nontuberculous mycobacteria lung disease (NTM-LD) has been reported, but its role in clinical characteristics and outcomes remains unclear. Methods: We enrolled 96 participants, including 46 with Mycobacterium avium complex (MAC)-LD, 23 with M. abscessus (MAB)-LD, and 27 controls. We measured expressions of PD-1, cytotoxic T-lymphocyte antigen-4 (CTLA-4) and regulatory T (Treg) cells on CD4+ lymphocytes and myeloid-derived suppressor cells (MDSCs) and analyzed their association with clinical features and radiographic outcomes. Results: The percentage of PD-1 on CD4+(PD-1+CD4+) lymphocytes and MDSCs were higher in the MAC-LD group than the controls. There were no intergroup differences regarding CTLA-4+CD4+ lymphocytes. Higher PD-1+CD4+ lymphocytes were found in M. intracellulare- and M. avium-LD than in other MAC-LD. Positive sputum acid-fast stains and fibrocavitary radiographic lesions were correlated with elevated PD-1+CD4+ lymphocytes and Treg cells. The percentage of PD-1+CD4+ lymphocytes at the initial and 2 months of follow-up significantly predicted subsequent radiographic progression. Conclusion: As markers of immune tolerance, PD-1+CD4+ lymphocytes and MDSCs were higher in MAC-LD patients. The levels of PD-1+CD4+ and Treg cells were correlated with high mycobacteria bacilli burden in NTM-LD. Monitoring the expressions of PD-1+CD4+ lymphocytes may predict radiographic progression.
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Romano M, Fanelli G, Tan N, Nova-Lamperti E, McGregor R, Lechler RI, Lombardi G, Scottà C. Expanded Regulatory T Cells Induce Alternatively Activated Monocytes With a Reduced Capacity to Expand T Helper-17 Cells. Front Immunol 2018; 9:1625. [PMID: 30079063 PMCID: PMC6062605 DOI: 10.3389/fimmu.2018.01625] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/02/2018] [Indexed: 12/29/2022] Open
Abstract
Regulatory T cells (Tregs) are essential in maintaining peripheral immunological tolerance by modulating several subsets of the immune system including monocytes. Under inflammatory conditions, monocytes migrate into the tissues, where they differentiate into dendritic cells or tissue-resident macrophages. As a result of their context-dependent plasticity, monocytes have been implicated in the development/progression of graft-vs-host disease (GvHD), autoimmune diseases and allograft rejection. In the last decade, Tregs have been exploited for their use in cell therapy with the aim to induce tolerance after solid organ transplantation and for the treatment of autoimmune diseases and GvHD. To date, safety and feasibility of Treg infusion has been demonstrated; however, many questions of how these cells induce tolerance have been raised and need to be answered. As monocytes constitute the major cellular component in inflamed tissues, we have developed an in vitro model to test how Tregs modulate their phenotype and function. We demonstrated that expanded Tregs can drive monocytes toward an alternatively activated state more efficiently than freshly isolated Tregs. The effect of expanded Tregs on monocytes led to a reduced production of pro-inflammatory cytokines (IL-6 and tumor necrosis factor-α) and NF-κB activation. Furthermore, monocytes co-cultured with expanded Tregs downregulated the expression of co-stimulatory and MHC-class II molecules with a concomitant upregulation of M2 macrophage specific markers, CD206, heme oxygenase-1, and increased interleukin-10 production. Importantly, monocytes co-cultured with expanded Tregs showed a reduced capacity to expand IL-17-producing T cells compared with monocyte cultured with freshly isolated Tregs and conventional T cells. The capacity to decrease the expansion of pro-inflammatory Th-17 was not cytokine mediated but the consequence of their lower expression of the co-stimulatory molecule CD86. Our data suggest that expanded Tregs have the capacity to induce phenotypical and functional changes in monocytes that might be crucial for tolerance induction in transplantation and the prevention/treatment of GvHD and autoimmune diseases.
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Affiliation(s)
- Marco Romano
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Giorgia Fanelli
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Nicole Tan
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Estefania Nova-Lamperti
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom.,Molecular and Translational Immunology Laboratory, Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepcion, Concepcion, Chile
| | - Reuben McGregor
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Robert I Lechler
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Giovanna Lombardi
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Cristiano Scottà
- Immunoregulation Laboratory, MRC Centre for Transplantation, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
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Kawai K, Uchiyama M, Hester J, Wood K, Issa F. Regulatory T cells for tolerance. Hum Immunol 2018; 79:294-303. [DOI: 10.1016/j.humimm.2017.12.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/16/2017] [Accepted: 12/26/2017] [Indexed: 12/29/2022]
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12
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Liu C. Microfluidic FACS becoming real. Cytometry A 2018; 93:589-591. [DOI: 10.1002/cyto.a.23376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/23/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Chengxun Liu
- Life Science Technology Department, Imec. Leuven 3001; Belgium
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13
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Anti-donor regulatory T cell therapy in liver transplantation. Hum Immunol 2017; 79:288-293. [PMID: 29292027 DOI: 10.1016/j.humimm.2017.12.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
Liver transplantation is accepted as the most reliable therapeutic option for patients with end-stage liver failure, but lifelong administration of immunosuppressive agents continues to be problematic due to various drug-induced morbidities and the risk of mortality. Complete cessation of immunosuppressive drugs while maintaining normal graft function and histology, called operational tolerance, has the potential to overcome these long-standing problems. Previously, we reported the results of a pilot study of anti- donor regulatory T cell therapy in 10 consecutive adult patients who underwent living donor liver transplantation (LDLT), of whom 7 patients successfully stopped immunosuppression for nearly 2 years. Described herein are the clinical follow-ups of these patients, a brief description of the protocol and its theoretical background, and a possible explanation for the immunological findings.
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14
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Ugor E, Simon D, Almanzar G, Pap R, Najbauer J, Németh P, Balogh P, Prelog M, Czirják L, Berki T. Increased proportions of functionally impaired regulatory T cell subsets in systemic sclerosis. Clin Immunol 2017; 184:54-62. [DOI: 10.1016/j.clim.2017.05.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 04/03/2017] [Accepted: 05/10/2017] [Indexed: 12/28/2022]
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15
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Mohr F, Fischer JC, Nikolaus M, Stemberger C, Dreher S, Verschoor A, Haas T, Poeck H, Busch DH. Minimally manipulated murine regulatory T cells purified by reversible Fab Multimers are potent suppressors for adoptive T-cell therapy. Eur J Immunol 2017; 47:2153-2162. [DOI: 10.1002/eji.201747137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/13/2017] [Accepted: 08/08/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Fabian Mohr
- Institute for Medical Microbiology; Immunology and Hygiene; Technische Universität München (TUM); Munich Germany
| | - Julius Clemens Fischer
- Klinik und Poliklinik für Innere Medizin III; Klinikum Rechts der Isar; TUM; Munich Germany
| | - Marc Nikolaus
- Institute for Medical Microbiology; Immunology and Hygiene; Technische Universität München (TUM); Munich Germany
| | - Christian Stemberger
- Focus Group “Clinical Cell Processing and Purification”; Institute for Advanced Study, TUM; Munich Germany
- Juno Cell Therapeutics; formerly Stage Cell Therapeutics; Munich Germany
| | - Stefan Dreher
- Focus Group “Clinical Cell Processing and Purification”; Institute for Advanced Study, TUM; Munich Germany
- Juno Cell Therapeutics; formerly Stage Cell Therapeutics; Munich Germany
| | - Admar Verschoor
- Institute for Medical Microbiology; Immunology and Hygiene; Technische Universität München (TUM); Munich Germany
- Institut für Systemische Entzündungsforschung; Universität zu Lübeck; Lübeck Germany
| | - Tobias Haas
- Institute for Medical Microbiology; Immunology and Hygiene; Technische Universität München (TUM); Munich Germany
- Klinik und Poliklinik für Innere Medizin III; Klinikum Rechts der Isar; TUM; Munich Germany
| | - Hendrik Poeck
- Klinik und Poliklinik für Innere Medizin III; Klinikum Rechts der Isar; TUM; Munich Germany
| | - Dirk H. Busch
- Institute for Medical Microbiology; Immunology and Hygiene; Technische Universität München (TUM); Munich Germany
- Focus Group “Clinical Cell Processing and Purification”; Institute for Advanced Study, TUM; Munich Germany
- National Center for Infection Research (DZIF); Munich Germany
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16
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Busca A, Aversa F. In-vivo or ex-vivo T cell depletion or both to prevent graft-versus-host disease after hematopoietic stem cell transplantation. Expert Opin Biol Ther 2017; 17:1401-1415. [PMID: 28846051 DOI: 10.1080/14712598.2017.1369949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) represents a widely accepted therapeutic strategy for the treatment of hematologic disorders which are otherwise considered incurable. Alloreactive T cells infused with the stem cell inoculum may generate graft-versus-host disease (GVHD) representing one the most relevant obstacles to the successful outcome of patients receiving allogeneic HSCT. Areas covered: In this review, the authors provide an overview of the most recent approaches of T-cell depletion (TCD) including ex-vivo αβ+ TCD and in-vivo TCD with anti-thymocyte globulin (ATG). Expert opinion: Ex vivo depletion of donor T-cells prevents both acute and chronic GVHD without the need for any additional posttransplant immunological prophylaxis either in haploidentical HSCT and HLA matched transplants. Three prospective trials evaluating the efficacy of ATG in matched unrelated donor transplant recipients demonstrated that ATG reduces the incidence of both acute and chronic GVHD without a significant increase of relapse rate, and similar results have been reported in the setting of blood stem cell grafts from matched sibling donors.
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Affiliation(s)
- Alessandro Busca
- a SSD Trapianto di Cellule Staminali , AOU Citta' della Salute e della Scienza , Torino , Italy
| | - Franco Aversa
- b Hematology and BMT Unit , University of Parma , Parma , Italy
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17
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Yang J, Yuan X, Lv C, Bai R, Zhang L, Ruang L, Zhang C, Quan XQ. Methylation of the FOXP3 upstream enhancer as a clinical indicator of defective regulatory T cells in patients with acute coronary syndrome. Am J Transl Res 2016; 8:5298-5308. [PMID: 28078003 PMCID: PMC5209483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
Atherosclerosis is an immune-mediated inflammatory process, which acts as the main cause of acute coronary syndrome (ACS). Regulatory CD4+CD25+FOXP3+T cells (Tregs) are thought to play a major role in inhibiting the formation and progression of atherosclerosis. However, the exact role played by Tregs in the pathogenesis of ACS is yet remained unclear. FOXP3 is a key regulator of Treg formation and function. Demethylation at the CpG-rich island of FOXP3 upstream enhancers can alter FOXP3 expression, and may affect Treg function during the development of ACS. This study investigated the immunosuppressive function and methylation status of a FOXP3 upstream enhancer in Tregs in ACS patients. Notably, Tregs from ACS patients exhibited a significantly lower immunosuppressive effect on Teffs. Furthermore, the methylation status of the FOXP3 upstream enhancer was significantly increased in ACS patients. Consistent with these observations, Tregs originated from ACS patients manifested significantly lower levels of FOXP3 mRNA. The immunosuppressive effect of Tregs on Teffs was compromised in ACS patients. Together, our data suggest that examination of the methylation status of the FOXP3 upstream enhancer might be a novel approach to diagnose ACS and to differentiate ACS subtypes.
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Affiliation(s)
- Jun Yang
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
- Department of Cardiology, Xinyang Center HospitalXinyang 464000, China
| | - Xiaoyang Yuan
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
| | - Caixia Lv
- Department of Geriatrics, Hebei Provincial People’s HospitalShijiazhuang 050000, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical UniversityBeijing 100029, China
| | - Le Zhang
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
| | - Lei Ruang
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
| | - Cuntai Zhang
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
| | - Xiao-Qing Quan
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan 430030, China
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18
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Immunity to Infections after Haploidentical Hematopoietic Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2016; 8:e2016057. [PMID: 27872737 PMCID: PMC5111540 DOI: 10.4084/mjhid.2016.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023] Open
Abstract
The advantage of using a Human Leukocyte Antigen (HLA)-mismatched related donor is that almost every patient who does not have an HLA-identical donor or who urgently needs hematopoietic stem cell transplantation (HSCT) has at least one family member with whom shares one haplotype (haploidentical) and who is promptly available as a donor. The major challenge of haplo-HSCT is intense bi-directional alloreactivity leading to high incidences of graft rejection and graft-versus-host disease (GVHD). Advances in graft processing and pharmacologic prophylaxis of GVHD have reduced these risks and have made haplo-HSCT a viable alternative for patients lacking a matched donor. Indeed, the haplo-HSCT has spread to centers worldwide even though some centers have preferred an approach based on T cell depletion of G-CSF-mobilized peripheral blood progenitor cells (PBPCs), others have focused on new strategies for GvHD prevention, such as G-CSF priming of bone marrow and robust post-transplant immune suppression or post-transplant cyclophosphamide (PTCY). Today, the graft can be a megadose of T-cell depleted PBPCs or a standard dose of unmanipulated bone marrow and/or PBPCs. Although haplo-HSCT modalities are based mainly on high intensity conditioning regimens, recently introduced reduced intensity regimens (RIC) showed promise in decreasing early transplant-related mortality (TRM), and extending the opportunity of HSCT to an elderly population with more comorbidities. Infections are still mostly responsible for toxicity and non-relapse mortality due to prolonged immunosuppression related, or not, to GVHD. Future challenges lie in determining the safest preparative conditioning regimen, minimizing GvHD and promoting rapid and more robust immune reconstitution.
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Combining Exosomes Derived from Immature DCs with Donor Antigen-Specific Treg Cells Induces Tolerance in a Rat Liver Allograft Model. Sci Rep 2016; 6:32971. [PMID: 27640806 PMCID: PMC5027549 DOI: 10.1038/srep32971] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022] Open
Abstract
Allograft tolerance is the ultimate goal in the field of transplantation immunology. Immature dendritic cells (imDCs) play an important role in establishing tolerance but have limitations, including potential for maturation, short lifespan in vivo and short storage times in vitro. However, exosomes (generally 30–100 nm) from imDCs (imDex) retain many source cell properties and may overcome these limitations. In previous reports, imDex prolonged the survival time of heart or intestine allografts. However, tolerance or long-term survival was not achieved unless immune suppressants were used. Regulatory T cells (Tregs) can protect allografts from immune rejection, and our previous study showed that the effects of imDex were significantly associated with Tregs. Therefore, we incorporated Tregs into the treatment protocol to further reduce or avoid suppressant use. We defined the optimal exosome dose as approximately 20 μg (per treatment before, during and after transplantation) in rat liver transplantation and the antigen-specific role of Tregs in protecting liver allografts. In the co-treatment group, recipients achieved long-term survival, and tolerance was induced. Moreover, imDex amplified Tregs, which required recipient DCs and were enhanced by IL-2. Fortunately, the expanded Tregs retained their regulatory ability and donor-specificity. Thus, imDex and donor-specific Tregs can collaboratively induce graft tolerance.
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21
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Montoro J, Sanz J, Sanz GF, Sanz MA. Advances in haploidentical stem cell transplantation for hematologic malignancies. Leuk Lymphoma 2016; 57:1766-75. [PMID: 27424663 DOI: 10.3109/10428194.2016.1167204] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
One of the most important advances in allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the use of alternative donors and cell sources, such as haploidentical transplants (haplo-HSCT) from family donors. Several approaches have been developed to overcome the challenging bidirectional alloreactivity. We discuss these approaches, including ex vivo T-cell-depleted grafts with megadose of CD34(+) cells, not requiring immunosuppression after allogeneic transplantation for graft-versus-host disease (GVHD) prophylaxis, and other strategies using unmanipulated T-cell-replete grafts with intensive immunosuppression or post-transplantation cyclophosphamide to minimize the GVHD. We also address the role of other strategies developed in the context of the haplo-HSCT platforms, such as ex vivo selective depletion of alloreactive donor T-cell subpopulations, infusion of antigen-specific T-cells against several pathogens, and infusion of regulatory T-cells, among other experimental approaches. Finally, some considerations about the selection of the most suitable donor, when more than one family member is available, are also addressed.
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Affiliation(s)
- Juan Montoro
- a Hematology Department , University Hospital La Fe and Department of Medicine, University of Valencia , Valencia , Spain
| | - Jaime Sanz
- a Hematology Department , University Hospital La Fe and Department of Medicine, University of Valencia , Valencia , Spain
| | - Guillermo F Sanz
- a Hematology Department , University Hospital La Fe and Department of Medicine, University of Valencia , Valencia , Spain
| | - Miguel A Sanz
- a Hematology Department , University Hospital La Fe and Department of Medicine, University of Valencia , Valencia , Spain
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22
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Zhang W, Smythe J, Frith E, Belfield H, Clarke S, Watt SM, Danby R, Benjamin S, Peniket A, Roberts DJ. An innovative method to generate a Good Manufacturing Practice-ready regulatory T-cell product from non-mobilized leukapheresis donors. Cytotherapy 2016; 17:1268-79. [PMID: 26276008 DOI: 10.1016/j.jcyt.2015.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/11/2015] [Accepted: 05/17/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND AIMS There is real and sustained interest in preparing T-regulatory cells from leukapheresis collections for cellular therapy through the use of simple, effective and reliable methods conforming to Good Manufacturing Practice (GMP). We describe a GMP-ready isolation procedure for CD25(+) products with the use of a sterile docking device, pigtail sampling, a laminar flow hood and the CliniMACS system that uses leukapheresis collections made by two apheresis machines. METHODS We used CD8/CD19 depletion followed by CD25-positive selection. The median number of CD4(+) cells recovered was 72.5 ± 32.6 × 10(6), of which 60.5% ± 17.8% were CD25(+)FOXP3(+) cells. Suppression of autologous CD25(-) cell proliferation by the cryopreserved CD25(+) products was 51.3% ± 4.4%, 49.0% ± 3.7% and 39.0% ± 3.6% at CD25(+):CD25(-) ratios of 1:1, 1:2 and 1:4 (n = 6), respectively, comparable to suppression by fresh CD25(+) products (53% ± 6.2%, 51% ± 3.3% and 39% ± 7.1%). RESULTS We found Leukapheresis collections by Cobe Spectra contained more lymphocytes and platelets than collections by Spectra Optia apheresis machine (median, 9.2 × 10(9) versus 6.7 × 10(9); P = 0.04) and platelets (median, 610 × 10(9) versus 170 × 10(9); P = 0.04). The frequency of CD4(+)CD25(+)FOXP3(+) was significantly higher in the leukapheresis (4.85%; 95% confidence interval, 1.95% to 5.38%) than in peripheral blood (3.9%; 95% confidence interval, 2.63% to 6.45%) (P = 0.02). The CD8- and CD19-negative depletion step was associated with significant loss of total CD4(+) T cells (P = 0.001). CONCLUSIONS Results suggest that functional CD25(+) products can be isolated with a GMP-ready method, and good recovery can be obtained with the use of an optimized cryopreservation protocol. These data and methods show the potential, possibilities and future work needed to isolate target cell populations in a reproducible, time-efficient and cost-efficient manner for clinical applications.
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Affiliation(s)
- Wei Zhang
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, Oxford, United Kingdom; NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom; Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Jon Smythe
- NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Emma Frith
- NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Helen Belfield
- NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Sophie Clarke
- NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Suzanne M Watt
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, Oxford, United Kingdom; NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Robert Danby
- Cancer and Haematology Centre, Churchill Hospital, Oxford, United Kingdom
| | - Sylvia Benjamin
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, Oxford, United Kingdom; NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom; Cancer and Haematology Centre, Churchill Hospital, Oxford, United Kingdom
| | - Andy Peniket
- Cancer and Haematology Centre, Churchill Hospital, Oxford, United Kingdom
| | - David J Roberts
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, Oxford, United Kingdom; NHS Blood and Transplant Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom; Cancer and Haematology Centre, Churchill Hospital, Oxford, United Kingdom
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23
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Li Pira G, Di Cecca S, Montanari M, Moretta L, Manca F. Specific removal of alloreactive T-cells to prevent GvHD in hemopoietic stem cell transplantation: rationale, strategies and perspectives. Blood Rev 2016; 30:297-307. [PMID: 27066851 DOI: 10.1016/j.blre.2016.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/06/2016] [Accepted: 03/08/2016] [Indexed: 01/05/2023]
Abstract
Hemopoietic stem cell transplantation (HSCT) is a standard procedure for treatment of malignant and non-malignant hematological diseases. HSCT donors include HLA-identical siblings, matched or mismatched unrelated donors and haploidentical related donors. Graft-versus-host disease (GvHD), mediated by donor alloreactive T-cells in the graft, can be triggered by minor histocompatibility antigens in HLA-identical pairs, by alleles at loci not considered for MUD-matching or by the mismatched haplotype in haplo-HSCT. Therefore, removal of donor T-cells, that contain the alloreactive precursors, is required, but T-cell depletion associates with opportunistic infections and with reduced graft-versus-leukemia effect. Selective T-cell depletion strategies have been introduced, like removal of αβ T-lymphocytes and of naive T-cells, two subsets including the alloreactive precursors, but the ultimate goal is specific removal of alloreactive T-cells. Here we review the different approaches to deplete alloreactive T-cells only and discuss pros and cons, specificity, efficiency and efficacy. Combinations of different methods and innovative approaches are also proposed for depleting specific alloreactive T-cells with high efficiency.
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Affiliation(s)
- Giuseppina Li Pira
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy; Unit of Immuno-hematology and Transfusion Medicine, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onoforio 4, 00165 Rome, Italy.
| | - Stefano Di Cecca
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy.
| | - Mauro Montanari
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy; Unit of Immuno-hematology and Transfusion Medicine, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onoforio 4, 00165 Rome, Italy.
| | - Lorenzo Moretta
- Immunology Area, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onoforio 4, 00165 Rome, Italy.
| | - Fabrizio Manca
- Immunology Area, IRCCS Bambino Gesù Children's Hospital, Piazza S. Onoforio 4, 00165 Rome, Italy.
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Haploidentical Hematopoietic Stem Cell Transplantation: Expanding the Horizon for Hematologic Disorders. Adv Hematol 2016; 2016:1423493. [PMID: 26949395 PMCID: PMC4754478 DOI: 10.1155/2016/1423493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/10/2016] [Indexed: 12/14/2022] Open
Abstract
Despite the advent of targeted therapies and novel agents, allogeneic hematopoietic stem cell transplantation remains the only curative modality in the management of hematologic disorders. The necessity to find an HLA-matched related donor is a major obstacle that compromises the widespread application and development of this field. Matched unrelated donors and umbilical cord blood have emerged as alternative sources of donor stem cells; however, the cost of maintaining donor registries and cord blood banks is very high and even impractical in developing countries. Almost every patient has an HLA haploidentical relative in the family, meaning that haploidentical donors are potential sources of stem cells, especially in situations where cord blood or matched unrelated donors are not easily available. Due to the high rates of graft failure and graft-versus-host disease, haploidentical transplant was not considered a feasible option up until the late 20th century, when strategies such as “megadose stem cell infusions” and posttransplantation immunosuppression with cyclophosphamide showed the ability to overcome the HLA disparity barrier and significantly improve the rates of engraftment and reduce the incidence and severity of graft-versus-host disease. Newer technologies of graft manipulation have also yielded the same effects in addition to preserving the antileukemic cells in the donor graft.
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25
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Patel P, Mahmud D, Park Y, Yoshinaga K, Mahmud N, Rondelli D. Clinical grade isolation of regulatory T cells from G-CSF mobilized peripheral blood improves with initial depletion of monocytes. AMERICAN JOURNAL OF BLOOD RESEARCH 2015; 5:79-85. [PMID: 27069755 PMCID: PMC4769349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
Clinical isolation of circulating CD4(+)CD25(+) regulatory T cells (Tregs) from peripheral blood mononuclear cells is usually performed by CD4(+) cell negative selection followed by CD25(+) cell positive selection. Although G-CSF mobilized peripheral blood (G-PBSC) contains a high number of Tregs, a high number of monocytes in G-PBSC limits Treg isolation. Using a small scale device (MidiMACS, Miltenyi) we initially demonstrated that an initial depletion of monocytes would be necessary to obtaina separation of CD4(+)CD25(+)FoxP3(+)CD127(-) cells from G-PBSC (G-Tregs) with a consistent purity >70% and inhibitory activity of T cell alloreactivity in-vitro. We then validated the same approach in a clinical scale setting by separating G-Tregs with clinically available antibodies to perform a CD8(+)CD19(+)CD14(+) cell depletion followed by CD25(+) cell selection (2-step process) or by adding an initial CD14(+) cell depletion (3-step process) using a CliniMACS column. The 3-step approach resulted in a better purity (81±12% vs. 35±33%) and yield (66% vs. 39%). Clinically isolated G-Tregs were also FoxP3(+)CD127(dim) and functionally suppressive in-vitro. Our findings suggest that a better and more consistent purity of Tregs can be achieved from G-PBSC by an initial single depletion of monocytes prior to selection of CD4(+)CD25(+) cells.
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Affiliation(s)
- Pritesh Patel
- Division of Hematology/Oncology, University of Illinois at ChicagoChicago, IL, USA
- Cancer Center, University of IllinoisChicago, IL, USA
| | - Dolores Mahmud
- Division of Hematology/Oncology, University of Illinois at ChicagoChicago, IL, USA
| | - Youngmin Park
- Hospital Stem Cell Laboratory, University of Illinois Hospital and Health Sciences SystemChicago, IL, USA
| | - Kazumi Yoshinaga
- Hospital Stem Cell Laboratory, University of Illinois Hospital and Health Sciences SystemChicago, IL, USA
| | - Nadim Mahmud
- Division of Hematology/Oncology, University of Illinois at ChicagoChicago, IL, USA
- Cancer Center, University of IllinoisChicago, IL, USA
- Hospital Stem Cell Laboratory, University of Illinois Hospital and Health Sciences SystemChicago, IL, USA
| | - Damiano Rondelli
- Division of Hematology/Oncology, University of Illinois at ChicagoChicago, IL, USA
- Cancer Center, University of IllinoisChicago, IL, USA
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26
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Theil A, Tuve S, Oelschlägel U, Maiwald A, Döhler D, Oßmann D, Zenkel A, Wilhelm C, Middeke JM, Shayegi N, Trautmann-Grill K, von Bonin M, Platzbecker U, Ehninger G, Bonifacio E, Bornhäuser M. Adoptive transfer of allogeneic regulatory T cells into patients with chronic graft-versus-host disease. Cytotherapy 2015; 17:473-86. [DOI: 10.1016/j.jcyt.2014.11.005] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 11/05/2014] [Accepted: 11/13/2014] [Indexed: 12/21/2022]
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27
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Janikashvili N, Trad M, Gautheron A, Samson M, Lamarthée B, Bonnefoy F, Lemaire-Ewing S, Ciudad M, Rekhviashvili K, Seaphanh F, Gaugler B, Perruche S, Bateman A, Martin L, Audia S, Saas P, Larmonier N, Bonnotte B. Human monocyte-derived suppressor cells control graft-versus-host disease by inducing regulatory forkhead box protein 3-positive CD8+ T lymphocytes. J Allergy Clin Immunol 2015; 135:1614-24.e4. [PMID: 25630940 DOI: 10.1016/j.jaci.2014.12.1868] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/17/2014] [Accepted: 12/09/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND Adoptive transfer of immunosuppressive cells has emerged as a promising strategy for the treatment of immune-mediated disorders. However, only a limited number of such cells can be isolated from in vivo specimens. Therefore efficient ex vivo differentiation and expansion procedures are critically needed to produce a clinically relevant amount of these suppressive cells. OBJECTIVE We sought to develop a novel, clinically relevant, and feasible approach to generate ex vivo a subpopulation of human suppressor cells of monocytic origin, referred to as human monocyte-derived suppressive cells (HuMoSCs), which can be used as an efficient therapeutic tool to treat inflammatory disorders. METHODS HuMoSCs were generated from human monocytes cultured for 7 days with GM-CSF and IL-6. The immune-regulatory properties of HuMoSCs were investigated in vitro and in vivo. The therapeutic efficacy of HuMoSCs was evaluated by using a graft-versus-host disease (GvHD) model of humanized mice (NOD/SCID/IL-2Rγc(-/-) [NSG] mice). RESULTS CD33+ HuMoSCs are highly potent at inhibiting the proliferation and activation of autologous and allogeneic effector T lymphocytes in vitro and in vivo. The suppressive activity of these cells depends on signal transducer and activator of transcription 3 activation. Of therapeutic relevance, HuMoSCs induce long-lasting memory forkhead box protein 3-positive CD8+ regulatory T lymphocytes and significantly reduce GvHD induced with human PBMCs in NSG mice. CONCLUSION Ex vivo-generated HuMoSCs inhibit effector T lymphocytes, promote the expansion of immunosuppressive forkhead box protein 3-positive CD8+ regulatory T cells, and can be used as an efficient therapeutic tool to prevent GvHD.
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Affiliation(s)
- Nona Janikashvili
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France.
| | - Malika Trad
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Alexandrine Gautheron
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Maxime Samson
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France; Department of Internal Medicine, University Hospital, Dijon, France
| | - Baptiste Lamarthée
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Francis Bonnefoy
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | | | - Marion Ciudad
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Khatuna Rekhviashvili
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Famky Seaphanh
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Béatrice Gaugler
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Sylvain Perruche
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France
| | - Andrew Bateman
- Cancer Sciences, University of Southampton, Southampton, United Kingdom
| | - Laurent Martin
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France; Department of Pathology and Cytology, University Hospital, Dijon, France
| | - Sylvain Audia
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France; Department of Internal Medicine, University Hospital, Dijon, France
| | - Philippe Saas
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France; CHU Besançon, CIC-BT506, FHU INCREASE, Besançon, France
| | - Nicolas Larmonier
- Department of Pediatrics, Steele Children's Research Center, Department of Immunobiology, BIO5 Institute and Arizona Cancer Center, University of Arizona, Tucson, Ariz
| | - Bernard Bonnotte
- INSERM UMR1098, University of Bourgogne Franche-Comté, EFS Bourgogne Franche-Comté, LabEX LipSTIC, ANR-11-LABX-0021, Besançon, France; Department of Internal Medicine, University Hospital, Dijon, France
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Chen SP, Huang Liu R, Lu TM, Wei JCC, Wu TC, Tsai WY, Tsai CH, Yang CC. Complementary usage of Rhodiola crenulata (L.) in chronic obstructive pulmonary disease patients: the effects on cytokines and T cells. Phytother Res 2014; 29:518-25. [PMID: 25403334 DOI: 10.1002/ptr.5259] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/11/2014] [Accepted: 10/20/2014] [Indexed: 12/17/2022]
Abstract
Although chronic obstructive pulmonary disease (COPD) is an inflammatory disease predominantly involving T cells, no study of Rhodiola as an immunomodulator in COPD patients has been reported. In this study, COPD patients took Rhodiola crenulata 500 mg (n = 38) or placebo (starch/phosphate buffered saline) (n = 19) daily for 12 weeks and were compared with untreated, age-matched, and sex-matched non-COPD control subjects. Our results showed that serum levels of IL-2, IL-10, and IFN-γ in COPD patients before treatment are significantly higher than levels in non-COPD controls (p < 0.05). A significant decrease in IFN-γ was seen in the Rhodiola treatment group (p < 0.05) but not in the placebo group (p > 0.05). The results suggested that Rhodiola treatment had beneficial antiinflammation effects, lower COPD assessment test score and decreased high-sensitivity C-reactive protein, on COPD patients (p < 0.05). The effects of Rhodiola treatment on COPD patients were shown to decrease the IFN-γ concentration and CD8(+) count but increase the expressions of CD4(+) CD25(+) FOXP3(+) and CD4(+) CD25(+) CD45(+) FOXP3(+) in the blood significantly (p < 0.05). This is the first trial using Rhodiola as a complementary therapy for COPD patients. T cells play an important role in the pathogenesis of COPD through the increased expression of CD8(+) T cells and IFN-γ and may be a viable target for potential therapy.
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Affiliation(s)
- Shih-Pin Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
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Cardenas PA, Huang Y, Ildstad ST. The role of pDC, recipient Treg, and donor Tregin HSC engraftment. CHIMERISM 2014. [DOI: 10.4161/chim.17588] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Today human leukocyte antigen-haploidentical transplantation is a feasible option for patients with high-risk acute leukemia who do not have matched donors. Whether it is T-cell replete or T-cell depleted, it is still, however, associated with issues of transplant-related mortality and posttransplant leukemia relapse. After reports that adoptive immunotherapy with T-regulatory cells controls the alloreactivity of conventional T lymphocytes in animal models, tomorrow’s world of haploidentical transplantation will focus on new “designed” grafts. They will contain an appropriate ratio of conventional T lymphocytes and T-regulatory cells, natural killer cells, γ δ T cells, and other accessory cells. Preliminary results of ongoing clinical trials show the approach is feasible. It is associated with better immune reconstitution and a quite powerful graft-versus-leukemia effect with a low incidence of graft-versus-host disease and no need for posttransplant pharmacological prophylaxis. Future strategies will focus on enhancing the clinical benefit of T-regulatory cells by increasing their number and strengthening their function.
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Cell therapy as a strategy to minimize maintenance immunosuppression in solid organ transplant recipients. Curr Opin Organ Transplant 2013; 18:408-15. [PMID: 23838645 DOI: 10.1097/mot.0b013e328363319d] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review presents a clinically focussed introduction to cell-based immunotherapy in solid organ transplantation. The potential benefits and risks of cell-based immunotherapeutics are critically discussed. RECENT FINDINGS The use of immunoregulatory cells as medicinal agents is very much in its infancy, but the field is expanding rapidly. In principle, this approach permits manipulation of specific immunological functions, opening new possibilities in the field of tolerance-promoting therapies. Several immunoregulatory cell types have reached the point of preclinical and clinical development that should allow them to be tested in early-phase clinical trials. Solid organ transplantation represents an important potential indication for the use of cell-based immunosuppressive agents because promoting immunological regulation towards allografts remains a promising strategy for preventing chronic rejection. SUMMARY Remarkable progress is being made in the implementation of novel cell-based immunotherapeutics in solid organ transplantation studies. It is hoped that these new immunoregulatory therapies will afford better long-term transplant outcomes by mitigating chronic graft injury.
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Bravery CA, Carmen J, Fong T, Oprea W, Hoogendoorn KH, Woda J, Burger SR, Rowley JA, Bonyhadi ML, Van't Hof W. Potency assay development for cellular therapy products: an ISCT review of the requirements and experiences in the industry. Cytotherapy 2013; 15:9-19. [PMID: 23260082 DOI: 10.1016/j.jcyt.2012.10.008] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022]
Abstract
The evaluation of potency plays a key role in defining the quality of cellular therapy products (CTPs). Potency can be defined as a quantitative measure of relevant biologic function based on the attributes that are linked to relevant biologic properties. To achieve an adequate assessment of CTP potency, appropriate in vitro or in vivo laboratory assays and properly controlled clinical data need to be created. The primary objective of a potency assay is to provide a mechanism by which the manufacturing process and the final product for batch release are scrutinized for quality, consistency and stability. A potency assay also provides the basis for comparability assessment after process changes, such as scale-up, site transfer and new starting materials (e.g., a new donor). Potency assays should be in place for early clinical development, and validated assays are required for pivotal clinical trials. Potency is based on the individual characteristics of each individual CTP, and the adequacy of potency assays will be evaluated on a case-by-case basis by regulatory agencies. We provide an overview of the expectations and challenges in development of potency assays specific for CTPs; several real-life experiences from the cellular therapy industry are presented as illustrations. The key observation and message is that aggressive early investment in a solid potency evaluation strategy can greatly enhance eventual CTP deployment because it can mitigate the risk of costly product failure in late-stage development.
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Safinia N, Leech J, Hernandez-Fuentes M, Lechler R, Lombardi G. Promoting transplantation tolerance; adoptive regulatory T cell therapy. Clin Exp Immunol 2013; 172:158-68. [PMID: 23574313 DOI: 10.1111/cei.12052] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2012] [Indexed: 01/09/2023] Open
Abstract
Transplantation is a successful treatment for end-stage organ failure. Despite improvements in short-term outcome, long-term survival remains suboptimal because of the morbidity and mortality associated with long-term use of immunosuppression. There is, therefore, a pressing need to devise protocols that induce tolerance in order to minimize or completely withdraw immunosuppression in transplant recipients. In this review we will discuss how regulatory T cells (T(regs)) came to be recognized as an attractive way to promote transplantation tolerance. We will summarize the preclinical data, supporting the importance of these cells in the induction and maintenance of immune tolerance and that provide the rationale for the isolation and expansion of these cells for cellular therapy. We will also describe the data from the first clinical trials, using T(regs) to inhibit graft-versus-host disease (GVHD) after haematopoietic stem cell transplantation and will address both the challenges and opportunities in human T(reg) cell therapy.
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Affiliation(s)
- N Safinia
- MRC Centre for Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Hannon M, Lechanteur C, Lucas S, Somja J, Seidel L, Belle L, Bruck F, Baudoux E, Giet O, Chantillon AM, Delvenne P, Drion P, Beguin Y, Humblet-Baron S, Baron F. Infusion of clinical-grade enriched regulatory T cells delays experimental xenogeneic graft-versus-host disease. Transfusion 2013; 54:353-63. [PMID: 23772685 DOI: 10.1111/trf.12279] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND We investigated the ability of clinical-grade enriched human regulatory T cells (Treg) to attenuate experimental xenogeneic graft-versus-host disease (GVHD) induced by peripheral blood mononuclear cells (PBMNCs; autologous to Treg) infusion in NSG mice, as well as verified their inability to induce xenogeneic GVHD when infused alone. STUDY DESIGN AND METHODS Human Treg were isolated from peripheral blood apheresis products with a cell separation system (CliniMACS, Miltenyi Biotec GmbH) using a two-step procedure (simultaneous CD8 and CD19 depletion followed by CD25-positive selection) in six independent experiments with six different healthy volunteer donors. Sublethally (2.5 Gy) irradiated NSG mice were given 2 × 10(6) cytapheresis (PBMNC) product cells intravenously (IV) without (PBMNC group) or with 1 × 10(6) Treg (PBMNC + Treg group), while other NSG mice received 2 × 10(6) enriched Treg alone (also in IV; Treg group). RESULTS The first five procedures were successful at obtaining a relatively pure Treg population (defined as >50%), while the sixth procedure, due to a technical problem, was not (Treg purity, 42%). Treg cotransfusion significantly delayed death from xenogeneic GVHD in the first five experiments, (p < 0.0001) but not in the sixth experiment. Importantly, none of the mice given enriched Treg alone (Treg group) experienced clinical signs of GVHD, while, interestingly, the CD4+ cells found in these mice 26 days after transplantation were mainly conventional T cells (median CD25+FoxP3+ cells among human CD4+ total cells were only 2.1, 3.1, and 12.2% in spleen, marrow, and blood, respectively). CONCLUSIONS Infusion of clinical-grade enriched Treg delayed the occurrence of xenogeneic GVHD without inducing toxicity in this murine model.
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Affiliation(s)
- Muriel Hannon
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Cell and Genetic Therapy, Department of Pathology, Department of Statistics, GIGA-R, Department of Medicine, Division of Hematology, University of Liège, Liège, Belgium; de Duve Institute, Université Catholique de Louvain, Brussels, Belgium; Red Cross Transfusion Center of Liege, Liège, Belgium; Autoimmune Genetics Laboratory, University of Leuven, Leuven, Belgium
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Abstract
PURPOSE OF REVIEW Transfer of human regulatory T cells (Tregs) has become an attractive therapeutic alternative to improve the long-term outcome in transplantation and thus reduce the side-effects of conventional immunosuppressive drugs. Here, we summarize the recent findings on human Treg subsets, their phenotype and in-vivo function. RECENT FINDINGS In the last 2 years, it has become apparent that several Treg subsets exist that specifically regulate Th1-driven, Th2-driven, or Th17-driven immune responses; these subsets are very unstable and rapidly change their phenotype, for example, there is loss of Foxp3 expression upon extensive ex-vivo expansion and only the administration of rapamycin has been shown to be able to interfere reproducibly. New humanized mouse models incorporating human solid-organ grafts have been developed, which have been used to test the human Treg in-vivo function, and the first human Treg-cell products have been tested for safety and efficacy in stem cell transplantation. SUMMARY With the recent findings, we have gained a better understanding of Treg heterogeneity, plasticity and function. Using the outcomes of clinical trials in stem cell transplantation, we have learned that adoptive therapy of Tregs is well tolerated and we are now awaiting the first result in solid-organ transplantation from the 'ONE Study'.
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Aversa F, Martelli MF, Velardi A. Haploidentical Hematopoietic Stem Cell Transplantation With a Megadose T-Cell–Depleted Graft: Harnessing Natural and Adaptive Immunity. Semin Oncol 2012. [DOI: 10.1053/j.seminoncol.2012.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Miao L, Run-ming J, Yi J. T-Bet Mediated Anti-Neoplastic Effects of Dendritic Cell-Cytokine Induced Killer Cells in vitro. IRANIAN JOURNAL OF PEDIATRICS 2012; 22:43-51. [PMID: 23056858 PMCID: PMC3448214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 05/25/2011] [Accepted: 08/25/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the molecular mechanism underlying T-bet mediated anti-neoplastic effects of cytokine induced killer (CIK) cells. METHODS Lymphocytes isolated from peripheral blood of leukemic children were induced with γ- interferon (IFN-γ), CD3McAb and interluki-2 (IL-2), and co-cultured with dendritic cells (DCs) to generate DC-CIK cells. The morphology and immunophenotype of these cells were determined by a light microscopy and flow cytometry, respectively. IL-2 and IFN-γ levels released by DC-CIK cells were quantified by ELISA. Cytotoxicity of DC-CIK cells against leukemia cell lines was measured by MTT assay. FCM was used to detect CD4(+)CD25(+)Treg cells, while RT-PCR and Western blot were used to determine mRNA and protein expressions of Foxp3 and GATA3 in DC-CIK cells treated with T-bet monoclonal antibody. FINDINGS Induced DC-CIK cells were regular, round and transparent with variable cell volume and cellular aggregation. The main effector cells in this population were CD3(+)CD8(+) cells and CD3(+)CD56(+) cells. We demonstrated a time dependent increase in IL-2 and IFN-γ levels after induction. DC-CIK cells were cytotoxic to B95 cells, Jhhan cells and M07e cells, with the highest cytotoxicity towards B95 cells. Treatment with mouse anti-human T-bet monoclonal antibody resulted in an increase in the proportion of CD4(+)CD25(+)Treg cells and elevation of Foxp3 and GATA3 mRNA and protein levels. CONCLUSION DC-CIK cells induced with cytokines were strongly cytotoxic towards a number of cancer cell lines. Foxp3 and GATA3 were implicated in the T-bet mediated anti-neoplastic effects of DC-CIK cells via activation of the Th1 pathway and suppression of the Th2 and Treg pathways.
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Affiliation(s)
- Liu Miao
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jin Run-ming
- Department of Pediatrics, Wuhan Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jiang Yi
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China,Corresponding Author:Address: Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430060, China. E-mail:
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Hamza E, Gerber V, Steinbach F, Marti E. Equine CD4(+) CD25(high) T cells exhibit regulatory activity by close contact and cytokine-dependent mechanisms in vitro. Immunology 2011; 134:292-304. [PMID: 21977999 DOI: 10.1111/j.1365-2567.2011.03489.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Horses are particularly prone to allergic and autoimmune diseases, but little information about equine regulatory T cells (Treg) is currently available. The aim of this study therefore was to investigate the existence of CD4(+) Treg cells in horses, determine their suppressive function as well as their mechanism of action. Freshly isolated peripheral blood mononuclear cells (PBMC) from healthy horses were examined for CD4, CD25 and forkhead box P3 (FoxP3) expression. We show that equine FoxP3 is expressed constitutively by a population of CD4(+) CD25(+) T cells, mainly in the CD4(+) CD25(high) subpopulation. Proliferation of CD4(+) CD25(-) sorted cells stimulated with irradiated allogenic PBMC was significantly suppressed in co-culture with CD4(+) CD25(high) sorted cells in a dose-dependent manner. The mechanism of suppression by the CD4(+) CD25(high) cell population is mediated by close contact as well as interleukin (IL)-10 and transforming growth factor-β1 (TGF-β1) and probably other factors. In addition, we studied the in vitro induction of CD4(+) Treg and their characteristics compared to those of freshly isolated CD4(+) Treg cells. Upon stimulation with a combination of concanavalin A, TGF-β1 and IL-2, CD4(+) CD25(+) T cells which express FoxP3 and have suppressive capability were induced from CD4(+) CD25(-) cells. The induced CD4(+) CD25(high) express higher levels of IL-10 and TGF-β1 mRNA compared to the freshly isolated ones. Thus, in horses as in man, the circulating CD4(+) CD25(high) subpopulation contains natural Treg cells and functional Treg can be induced in vitro upon appropriate stimulation. Our study provides the first evidence of the regulatory function of CD4(+) CD25(+) cells in horses and offers insights into ex vivo manipulation of Treg cells.
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Affiliation(s)
- Eman Hamza
- Department of Clinical Research and Veterinary Public Health, University of Bern, Bern, Switzerland.
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Ukena SN, Höpting M, Velaga S, Ivanyi P, Grosse J, Baron U, Ganser A, Franzke A. Isolation strategies of regulatory T cells for clinical trials: phenotype, function, stability, and expansion capacity. Exp Hematol 2011; 39:1152-60. [PMID: 21864487 DOI: 10.1016/j.exphem.2011.08.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 07/12/2011] [Accepted: 08/12/2011] [Indexed: 01/07/2023]
Abstract
Recent clinical results demonstrate the highly effective potency of regulatory T cells (Tregs) to control graft-versus-host disease (GvHD). In this presented study, we directly compared different Treg subpopulations in order to define the most promising Treg target cell population for cellular intervention studies with respect to their phenotype, functional properties, stability, and expansion capacity. Different Treg cell populations have been isolated from healthy donors and characterized by fluorescence activated cell sorting (FACS) analysis for their phenotypic marker and purity, functional properties by suppression assay, stability by Treg-specific demethylated region (TSDR) of the Foxp3 promoter and their in vitro expansion capacity. The direct comparison of the respective Treg target cell populations identified CD4(+)CD25(hi)CD127(-) and CD4(+)CD25(hi)ICOS(+) Tregs as the most promising Treg population for fresh cell infusions in clinical trials with respect to cell yield, phenotype, function, and stability. The CD4(+)CD25(hi) Tregs qualified as the best candidate for in vitro expansion combining a highly stable phenotype with strong suppressive potential and attractive cell yield after repetitive stimulation. The suppressive capacity of freshly isolated CD4(+)CD25(hi)CD45RA(+) and CD49d(-)CD127(-) Tregs is comparable to freshly isolated CD4(+)CD25(hi), but inferior to CD4(+)CD25(hi)CD127(-) and CD4(+)CD25(hi)ICOS(+) Tregs. In vitro expansion of CD4(+)CD25(hi)CD45RA(+) and CD49d(-)CD127(-) Tregs resulted in cell populations with less suppressive potency compared with CD4(+)CD25(hi) expanded Tregs correlating well with a higher TSDR demethylation level. In conclusion, future clinical trials should favor CD4(+)CD25(hi)CD127(-) and CD4(+)CD25(hi)ICOS(+) Tregs for direct Treg cell transfer, whereas CD4(+)CD25(hi) Tregs qualify as best candidate for in vitro expansion.
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Affiliation(s)
- Sya N Ukena
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
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Roncarolo MG, Gregori S, Lucarelli B, Ciceri F, Bacchetta R. Clinical tolerance in allogeneic hematopoietic stem cell transplantation. Immunol Rev 2011; 241:145-63. [PMID: 21488896 DOI: 10.1111/j.1600-065x.2011.01010.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been a curative therapeutic option for a wide range of immune hematologic malignant and non-malignant disorders including genetic diseases and inborn errors. Once in the host, allogeneic transplanted cells have not only to ensure myeloid repopulation and immunological reconstitution but also to acquire tolerance to host human leukocyte antigens via central or peripheral mechanisms. Peripheral tolerance after allogeneic HSCT depends on several regulatory mechanisms aimed at blocking alloimmune reactivity while preserving immune responses to pathogens and tumor antigens. Patients transplanted with HSCT represent an ideal model system in humans to identify and characterize the key cellular and molecular players underlying these mechanisms. The knowledge gained from these studies has allowed the development of novel therapeutic strategies aimed at inducing long-term peripheral tolerance, which can be applicable not only in allogeneic HSCT but also in autoimmune diseases and solid-organ transplantation. In the present review, we describe Type 1 regulatory T cells, initially discovered and characterized in chimeric patients transplanted with human leukocyte antigen-mismatched HSCT, and how their presence correlates to tolerance induction and maintenance. Furthermore, we summarize different cell therapy approaches with regulatory T cells, designed to facilitate tolerance induction, minimizing pharmaceutical interventions.
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Affiliation(s)
- Maria-Grazia Roncarolo
- San Raffaele Telethon Institute for Gene Therapy (HSR-TIGET), Division of Regenerative Medicine, Stem Cells, Gene Therapy, San Raffaele Scientific Institute, Milan, Italy.
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Cardenas PA, Huang Y, Ildstad ST. The role of pDC, recipient T(reg) and donor T(reg) in HSC engraftment: Mechanisms of facilitation. CHIMERISM 2011; 2:65-70. [PMID: 22163063 DOI: 10.4161/chim.2.3.17588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 06/20/2011] [Accepted: 08/01/2011] [Indexed: 11/19/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) has been utilized for treatment of many hematologic malignancies, genetic and metabolic disorders, and hemoglobinopathies such as sickle cell disease and thalassemia. It also induces donor-specific tolerance to organ and tissue transplants. The widespread success of HSCT is hampered by the toxicities of immunosuppression and development of graft-versus-host disease (GVHD). The mechanism of induction of transplantation tolerance (reciprocal donor/host) is still an elusive challenge in allogeneic HSCT. An understanding of the mechanisms for induction of tolerance and the critical cells involved in this process has resulted in novel cell-based therapies poised to be translated to clinical application. The focus of this review is those cells of interest.Bone marrow-derived plasmacytoid dendritic cells induce naïve T cells to differentiate to become antigen-specific regulatory T cells (T(reg)), creating a milieu for the induction of transplantation tolerance. Recently, CD8(+)/TCR(-) facilitating cells (FC), a novel cell population in mouse bone marrow, have been shown to potently enhance engraftment of allogeneic HSC without causing GVHD. The predominant subpopulation of FC resembles plasmacytoid precursor dendritic cells. FC induce antigen-specific T(reg) in vivo. Notably, FC address one major concern that has prevented the implementation of T(reg) cell therapy in the clinic: to expand T(reg) and have them remain tolerogenic in vivo. FC are novel in that they induce an antigen-specific regulatory milieu in vivo. The discovery of FC has opened new alternatives to expanded criteria in bone marrow transplantation that were previously restricted to human leukocyte antigen-matched recipients. The focus of this review is to cover what is currently known about the mechanism of FC action in inducing tolerance and preventing GVHD and hostversus-graft reactivity.
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Affiliation(s)
- Paul A Cardenas
- Institute for Cellular Therapeutics; University of Louisville; Louisville, KY USA
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Teshima T, Maeda Y, Ozaki K. Regulatory T cells and IL-17-producing cells in graft-versus-host disease. Immunotherapy 2011; 3:833-52. [DOI: 10.2217/imt.11.51] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Graft-versus-host disease (GvHD), a major complication following allogeneic hematopoietic stem cell transplantation, is mediated by donor-derived T cells. On activation with alloantigens expressed on host antigen-presenting cells, naive CD4+ T cells differentiate into T-helper cell subsets of effector T cells expressing distinct sets of transcriptional factors and cytokines. Classically, acute GvHD was suggested to be predominantly related to Th1 responses. However, we now face a completely different and complex scenario involving possible roles of newly identified Th17 cells as well as Tregs in GvHD. Accumulating data from experimental and clinical studies suggest that the fine balance between Th1, Th2, Th17 and Tregs after transplantation may be an important determinant of the severity, manifestation and tissue distribution of GvHD. Understanding the dynamic process of reciprocal differentiation of regulatory and T-helper cell subsets as well as their interactions will be important in establishing novel strategies for preventing and treating GvHD.
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Affiliation(s)
- Takanori Teshima
- Center for Cellular & Molecular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yoshinobu Maeda
- Biopathological Science, Okayama University Graduate School of Medicine & Dentistry, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Katsutoshi Ozaki
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329–0498, Japan
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Di Ianni M, Falzetti F, Carotti A, Terenzi A, Del Papa B, Perruccio K, Ruggeri L, Sportoletti P, Rosati E, Marconi P, Falini B, Reisner Y, Velardi A, Aversa F, Martelli MF. Immunoselection and clinical use of T regulatory cells in HLA-haploidentical stem cell transplantation. Best Pract Res Clin Haematol 2011; 24:459-66. [PMID: 21925099 DOI: 10.1016/j.beha.2011.05.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Haploidentical transplantation, with extensive T cell depletion to prevent GvHD, is associated with a high incidence of infection-related deaths. The key challenge is to improve immune recovery with allogeneic donor T cells without triggering GvHD. As T regulatory cells (Tregs) controlled GvHD in pre-clinical studies, the present study evaluated the impact of an infusion of donor CD4/CD25 + Tregs, followed by an inoculum of donor mature T cells (Tcons) and positively immunoselected CD34 + cells in the setting of haploidentical stem cell transplantation. PATIENTS AND METHODS Twenty-eight patients were enrolled in this study (22 AML; 5 ALL; 1 NHL). All received immunoselected Tregs (CliniMACS, Miltenyi Biotec) followed by positively immunoselected CD34 + cells together with Tcons 4 days later. No GvHD prophylaxis was administered. RESULTS 26/28 patients engrafted. No acute GvHD developed in 24/26 patients; 2 developed ≥ grade II acute GvHD. No patient has developed chronic GvHD. CD4 and CD8 counts rapidly increased after transplant. Episodes of CMV reactivation were significantly fewer than in controls. CONCLUSIONS In the setting of haploidentical transplantation infusion of Tregs makes administration of a high dose of T cells feasible. This strategy provides a long-term protection from GvHD and robust immune reconstitution.
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Affiliation(s)
- Mauro Di Ianni
- Hematology and Clinical Immunology Section, Department of Clinical and Experimental Medicine, University of Perugia, Italy.
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Abstract
Hastening posttransplantation immune reconstitution is a key challenge in human leukocyte antigen (HLA)-haploidentical hematopoietic stem-cell transplantation (HSCT). In experimental models of mismatched HSCT, T-regulatory cells (Tregs) when co-infused with conventional T cells (Tcons) favored posttransplantation immune reconstitution and prevented lethal graft-versus-host disease (GVHD). In the present study, we evaluated the impact of early infusion of Tregs, followed by Tcons, on GVHD prevention and immunologic reconstitution in 28 patients with high-risk hematologic malignancies who underwent HLA-haploidentical HSCT. We show for the first time in humans that adoptive transfer of Tregs prevented GVHD in the absence of any posttransplantation immunosuppression, promoted lymphoid reconstitution, improved immunity to opportunistic pathogens, and did not weaken the graft-versus-leukemia effect. This study provides evidence that Tregs are a conserved mechanism in humans.
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Mahmud D, Nicolini B, van den Dries L, Mahmud N, Arpinati M, Rondelli D. Human CD4+CD25+ Cells in Combination with CD34+ Cells and Thymoglobulin to Prevent Anti-hematopoietic Stem Cell T Cell Alloreactivity. Biol Blood Marrow Transplant 2011; 17:61-8. [DOI: 10.1016/j.bbmt.2010.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 08/04/2010] [Indexed: 12/29/2022]
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Pinheiro D, Singh Y, Grant CR, Appleton RC, Sacchini F, Walker KRL, Chadbourne AH, Palmer CA, Armitage-Chan E, Thompson I, Williamson L, Cunningham F, Garden OA. Phenotypic and functional characterization of a CD4(+) CD25(high) FOXP3(high) regulatory T-cell population in the dog. Immunology 2010; 132:111-22. [PMID: 20880379 DOI: 10.1111/j.1365-2567.2010.03346.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Relatively little is known about regulatory T (Treg) cells and their functional responses in dogs. We have used the cross-reactive anti-mouse/rat Foxp3 antibody clone FJK-16s to identify a population of canine CD4(+) FOXP3(high) T cells in both the peripheral blood (PB) and popliteal lymph node (LN). FOXP3(+) cells in both PB and LN yielded positive staining with the newly developed anti-murine/human Helios antibody clone 22F6, consistent with the notion that they were naturally occurring Treg cells. Stimulation of mononuclear cells of LN origin with concanavalin A (Con A) in vitro yielded increased proportions and median fluorescence intensity of FOXP3 expression by both CD4(+) and CD8(+) T cells. Removal of the Con A and continued culture disclosed a CD4(+) FOXP3(high) population, distinct from the CD4(+) FOXP3(intermediate) T cells; very few CD8(+) FOXP3(high) T cells were observed, though CD8(+) FOXP3(intermediate) cells were present in equal abundance to CD4(+) FOXP3(intermediate) cells. The CD4(+) FOXP3(high) T cells were thought to represent activated Treg cells, in contrast to the FOXP3(intermediate) cells, which were thought to be a more heterogeneous population comprising predominantly activated conventional T cells. Co-staining with interferon-γ (IFN-γ) supported this notion, because the FOXP3(high) T cells were almost exclusively IFN-γ(-) , whereas the FOXP3(intermediate) cells expressed a more heterogeneous IFN-γ phenotype. Following activation of mononuclear cells with Con A and interleukin-2, the 5% of CD4(+) T cells showing the highest CD25 expression (CD4(+) CD25(high) ) were enriched in cells expressing FOXP3. These cells were anergic in vitro, in contrast to the 20% of CD4(+) T cells with the lowest CD25 expression (CD4(+) CD25(-) ), which proliferated readily. The CD4(+) CD25(high) FOXP3(high) T cells were able to suppress the proliferation of responder CD4(+) T cells in vitro, in contrast to the CD4(+) CD25(-) cells, which showed no regulatory properties.
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Affiliation(s)
- Dammy Pinheiro
- Regulatory T Cell Laboratory, Department of Veterinary Clinical Sciences, The Royal Veterinary College, London, UK
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Ravindra K, Wu S, McKinney M, Xu H, Ildstad S. Composite Tissue Allotransplantation: Current Challenges. Transplant Proc 2009; 41:3519-28. [DOI: 10.1016/j.transproceed.2009.08.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 08/05/2009] [Indexed: 12/16/2022]
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