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Mathew JM, Sanders JM, Cirocco R, Miller J, Leventhal JR. Differentiation of regulatory myeloid and T-cells from adult human hematopoietic stem cells after allogeneic stimulation. Front Immunol 2024; 15:1366972. [PMID: 38455047 PMCID: PMC10918006 DOI: 10.3389/fimmu.2024.1366972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Donor hematopoietic stem cell (DHSC) infusions are increasingly being studied in transplant patients for tolerance induction. Methods To analyze the fate of infused DHSCs in patients, we developed an in vitro culture system utilizing CD34+DHSCs stimulated with irradiated allogeneic cells in cytokine supplemented medium long-term. Results Flow cytometric analyses revealed loss of the CD34 marker and an increase in CD33+ myeloid and CD3+ T-cell proportion by 10.4% and 72.7%, respectively, after 21 days in culture. T-cells primarily expressed TcR-αβ and were of both CD4+ and CD8+ subsets. Approximately 80% of CD3+ T cells lacked expression of the co-stimulatory receptor CD28. The CD4+ compartment was predominated by CD4+CD25+CD127-FOXP3+ Tregs (>50% CD4+CD127- compartment) with <1% of all leukocytes exhibiting a CD4+CD127+ phenotype. Molecular analyses for T-cell receptor excision circles showed recent and increased numbers of TcR rearrangements in generated T cells over time suggesting de novo differentiation from DHSCs. CD33+ myeloid cells mostly expressed HLA-DR, but lacked expression of co-stimulatory receptors CD80 and CD83. When studied as modulators in primary mixed lymphocyte reactions where the cells used to stimulate the DHSC were used as responders, the DHSC-lines and their purified CD8+, CD4+, CD33+ and linage negative subsets inhibited the responses in a dose-dependent and non-specific fashion. The CD8+ cell-mediated inhibition was due to direct lysis of responder cells. Discussion Extrapolation of these results into the clinical situation would suggest that DHSC infusions into transplant recipients may generate multiple subsets of donor "chimeric" cells and promote recipient Treg development that could regulate the anti-donor immune response in the periphery. These studies have also indicated that T cell maturation can occur in vitro in response to allogeneic stimulation without the pre-requisite of a thymic-like environment or NOTCH signaling stimulatory cell line.
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Affiliation(s)
- James M. Mathew
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jes M. Sanders
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Robert Cirocco
- HLA Laboratory, LeHigh Valley Health Network, Allentown, PA, United States
| | - Joshua Miller
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph R. Leventhal
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Mengrelis K, Muckenhuber M, Wekerle T. Chimerism-based Tolerance Induction in Clinical Transplantation: Its Foundations and Mechanisms. Transplantation 2023; 107:2473-2485. [PMID: 37046378 DOI: 10.1097/tp.0000000000004589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hematopoietic chimerism remains the most promising strategy to bring transplantation tolerance into clinical routine. The concept of chimerism-based tolerance aims to extend the recipient's mechanisms of self-tolerance (ie, clonal deletion, anergy, and regulation) to include the tolerization of donor antigens that are introduced through the cotransplantation of donor hematopoietic cells. For this to be successful, donor hematopoietic cells need to engraft in the recipient at least temporarily. Three pioneering clinical trials inducing chimerism-based tolerance in kidney transplantation have been published to date. Within this review, we discuss the mechanisms of tolerance that are associated with the specific therapeutic protocols of each trial. Recent data highlight the importance of regulation as a mechanism that maintains tolerance. Insufficient regulatory mechanisms are also a likely explanation for situations of tolerance failure despite persisting donor chimerism. After decades of preclinical development of chimerism protocols, mechanistic data from clinical trials have recently become increasingly important. Better understanding of the required mechanisms for tolerance to be induced in humans will be a key to design more reliable and less invasive chimerism protocols in the future.
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Affiliation(s)
- Konstantinos Mengrelis
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Sykes M. Leveraging the lymphohematopoietic graft-versus-host reaction (LGVHR) to achieve allograft tolerance and restore self tolerance with minimal toxicity. IMMUNOTHERAPY ADVANCES 2023; 3:ltad008. [PMID: 37426630 PMCID: PMC10327628 DOI: 10.1093/immadv/ltad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/12/2023] [Indexed: 07/11/2023] Open
Abstract
Mixed allogeneic chimerism has considerable potential to advance the achievement of immune tolerance to alloantigens for transplantation and the restoration of self-tolerance in patients with autoimmune disease. In this article, I review evidence that graft-versus-host (GVH) alloreactivity without graft-vs-host disease (GVHD), termed a lymphohematopoietic graft-vs-host reaction (LGVHR), can promote the induction of mixed chimerism with minimal toxicity. LGVHR was originally shown to occur in an animal model when non-tolerant donor lymphocytes were administered to mixed chimeras in the absence of inflammatory stimuli and was found to mediate powerful graft-vs-leukemia/lymphoma effects without GVHD. Recent large animal studies suggest a role for LGVHR in promoting durable mixed chimerism and the demonstration that LGVHR promotes chimerism in human intestinal allograft recipients has led to a pilot study aiming to achieve durable mixed chimerism.
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Affiliation(s)
- Megan Sykes
- Correspondence: Megan Sykes, Columbia Center for Translational Immunology, Columbia University College of Physicians and Surgeons, 650 West 168th Street, Suite 1512, New York, NY 10032, USA.
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Dykes K, Desale S, Javaid B, Miatlovich K, Kessler C. A New Reality for Multiple Myeloma Renal Failure: US Data Report on Kidney Transplant Outcomes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e314-e320. [PMID: 34872880 DOI: 10.1016/j.clml.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Describe graft and overall survival outcomes in multiple myeloma (MM) patients who underwent kidney transplant (KT) compared to the general KT population. PATIENTS AND METHODS The Organ Procurement and Transplantation Network/National United Network for Organ Sharing (OPTON/UNOS) database was analyzed from 1988 to 2019 with R 4.00 and the 2013-2017 United States Renal Data System (USRDS) was surveyed for incidence and mortality of MM ESRD. RESULTS USRDS analysis revealed 961 patients diagnosed with ESRD due to MM on average annually, accounting for 0.8% of the ESRD population. Without KT, 44.4% of MM patients died in the first year of renal replacement initiation. OPTON/UNOS analysis identified 218 MM KT patients, compared to 490,089 patients without MM. There was no difference in graft survival between MM KT and the general population (P-value = .13, HR = 1.19 [0.95, 1.49], 95% CI). Median graft survival in MM KT was 2683 days (7.4 years). KT patients with MM had a higher risk for death (P-value = <.0001, HR = 1.83 [1.41, 2.37], 95% CI), and median overall survival was 3076 days (8.4 years). Survival difference was lost when comparing patients ≥50 years (P-value = .42, HR = 1.14 [0.83, 1.56], 95% CI). CONCLUSION Patients with MM renal failure who underwent KT had equivalent graft and age-matched overall survival compared to the general KT population. Therefore select patients with MM renal failure have potential for excellent KT outcomes, should be considered for transplantation when feasible, and should not be excluded from KT based on a history of MM.
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Affiliation(s)
- Kaitlyn Dykes
- MedStar Georgetown University Hospital Internal Medicine, Washington, DC.
| | - Sameer Desale
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, MD
| | - Basit Javaid
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Krystsina Miatlovich
- Institute of Business and Management of Technologies, Belarusian State University, Minsk, Belarus
| | - Craig Kessler
- MedStar Georgetown Lombardi Comprehensive Cancer Center, Washington, DC
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Kundu S, Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Islam R, Sange I. Multiple Myeloma and Renal Failure: Mechanisms, Diagnosis, and Management. Cureus 2022; 14:e22585. [PMID: 35371791 PMCID: PMC8958144 DOI: 10.7759/cureus.22585] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/05/2022] Open
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Heybeli C, Bentall AJ, Alexander MP, Amer H, Buadi FK, Dispenzieri A, Dingli D, Gertz MA, Issa N, Kapoor P, Kukla A, Kumar S, Lorenz EC, Rajkumar SV, Schinstock CA, Leung N. Kidney Transplant Outcomes of Patients With Multiple Myeloma. Kidney Int Rep 2022; 7:752-762. [PMID: 35497786 PMCID: PMC9039485 DOI: 10.1016/j.ekir.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/04/2021] [Accepted: 01/03/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Data on kidney transplantation (KTx) outcomes of patients with multiple myeloma (MM) are very limited. Methods We investigated the outcomes of patients with MM who underwent KTx between 1994 and 2019. Results A total of 12 transplants from 11 patients were included. At the time of KTx, 6 were classified as having stringent complete response (CR), 2 as CR, 2 as very good partial response (VGPR), and 2 as partial response (PR). With a median follow-up of 40 (minimum–maximum, 5–92) months after KTx, hematologic progression occurred in 9 transplants (75%). There were 3 grafts (25%) that failed, and 5 patients (45.5%) experienced death with functioning allografts. Graft survival at 1 and 5 years was 82.5% and 66%, respectively. Progression-free survival (PFS) rates of the cohort at 1, 3, and 5 years were 83.3%, 55.6%, and 44.4%, respectively. The estimated median PFS of patients who received bortezomib at any time (pre-KTx and/or post-KTx) was not reached, whereas it was 24 months for those who never received bortezomib (P = 0.281). Overall survival (OS) rates of the cohort at 1, 3, and 5 years were 81.8%, 61.4%, and 61.4%, respectively. OS of patients who received bortezomib at any time was 87.5%, 72.9%, and 72.9%, and that for those who never received bortezomib was 66.7%, 33.3%, and 33.3% (P = 0.136). All deaths occurred owing to hematologic progression or treatment-related complications. Conclusion Kidney transplant outcomes of patients with myeloma who received bortezomib before or after KTx seem to be more favorable. Nevertheless, relapse after KTx in MM is still common. More studies are needed to better determine who benefits from a KTx.
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Shaw BI, Ord JR, Nobuhara C, Luo X. Cellular Therapies in Solid Organ Allotransplantation: Promise and Pitfalls. Front Immunol 2021; 12:714723. [PMID: 34526991 PMCID: PMC8435835 DOI: 10.3389/fimmu.2021.714723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022] Open
Abstract
Donor specific transfusions have been the basis of tolerance inducing protocols since Peter Medawar showed that it was experimentally feasible in the 1950s. Though trials of cellular therapies have become increasingly common in solid organ transplantation, they have not become standard practice. Additionally, whereas some protocols have focused on cellular therapies as a method for donor antigen delivery—thought to promote tolerance in and of itself in the correct immunologic context—other approaches have alternatively focused on the intrinsic immunosuppressive properties of the certain cell types with less emphasis on their origin, including mesenchymal stem cells, regulatory T cells, and regulatory dendritic cells. Regardless of intent, all cellular therapies must contend with the potential that introducing donor antigen in a new context will lead to sensitization. In this review, we focus on the variety of cellular therapies that have been applied in human trials and non-human primate models, describe their efficacy, highlight data regarding their potential for sensitization, and discuss opportunities for cellular therapies within our current understanding of the immune landscape.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC, United States
| | - Jeffrey R Ord
- School of Medicine, Duke University, Durham, NC, United States
| | - Chloe Nobuhara
- School of Medicine, Duke University, Durham, NC, United States
| | - Xunrong Luo
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC, United States
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Strobl J, Pandey RV, Krausgruber T, Bayer N, Kleissl L, Reininger B, Vieyra-Garcia P, Wolf P, Jentus MM, Mitterbauer M, Wohlfarth P, Rabitsch W, Stingl G, Bock C, Stary G. Long-term skin-resident memory T cells proliferate in situ and are involved in human graft-versus-host disease. Sci Transl Med 2020; 12:eabb7028. [PMID: 33208504 PMCID: PMC7615006 DOI: 10.1126/scitranslmed.abb7028] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/03/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022]
Abstract
The skin contains a population of tissue-resident memory T cells (Trm) that is thought to contribute to local tissue homeostasis and protection against environmental injuries. Although information about the regulation, survival program, and pathophysiological roles of Trm has been obtained from murine studies, little is known about the biology of human cutaneous Trm Here, we showed that host-derived CD69+ αβ memory T cell clones in the epidermis and dermis remain stable and functionally competent for at least 10 years in patients with allogeneic hematopoietic stem cell transplantation. Single-cell RNA sequencing revealed low expression of genes encoding tissue egress molecules by long-term persisting Trm in the skin, whereas tissue retention molecules and stem cell markers were displayed by Trm The transcription factor RUNX3 and the surface molecule galectin-3 were preferentially expressed by host T cells at the RNA and protein levels, suggesting two new markers for human skin Trm Furthermore, skin lesions from patients developing graft-versus-host disease (GVHD) showed a large number of cytokine-producing host-derived Trm, suggesting a contribution of these cells to the pathogenesis of GVHD. Together, our studies highlighted the relationship between the local human skin environment and long-term persisting Trm, which differs from murine skin. Our results also indicated that local tissue inflammation occurs through host-derived Trm after allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Johanna Strobl
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Ram Vinay Pandey
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Krausgruber
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, 1090 Vienna, Austria
| | - Nadine Bayer
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Lisa Kleissl
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, 1090 Vienna, Austria
| | - Bärbel Reininger
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Pablo Vieyra-Garcia
- Department of Dermatology and Venereology, Medical University of Graz, 8036 Graz, Austria
| | - Peter Wolf
- Department of Dermatology and Venereology, Medical University of Graz, 8036 Graz, Austria
| | - Maaia-Margo Jentus
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Margit Mitterbauer
- Department of Internal Medicine I, Hematopoietic Stem Cell Transplantation Unit, Medical University of Vienna, 1090 Vienna, Austria
| | - Philipp Wohlfarth
- Department of Internal Medicine I, Hematopoietic Stem Cell Transplantation Unit, Medical University of Vienna, 1090 Vienna, Austria
| | - Werner Rabitsch
- Department of Internal Medicine I, Hematopoietic Stem Cell Transplantation Unit, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Stingl
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, 1090 Vienna, Austria
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Stary
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria.
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, 1090 Vienna, Austria
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Twenty-year Follow-up of Histocompatibility Leukocyte Antigen-matched Kidney and Bone Marrow Cotransplantation for Multiple Myeloma With End-stage Renal Disease: Lessons Learned. Transplantation 2020; 103:2366-2372. [PMID: 30801529 DOI: 10.1097/tp.0000000000002669] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Specific immune tolerance of transplanted organs in association with either transient or sustained lymphohematopoietic chimerism has been demonstrated in several preclinical animal models and clinically in patients who are full donor chimeras after hematopoietic stem cell transplantation and subsequently received kidney transplants from the same donor. Most recently, tolerance induction has been extended to patients in whom chimerism was intentionally induced at the time of kidney transplantation. METHODS Twenty years ago, we reported the first successful histocompatibility leukocyte antigen-matched sibling donor bone marrow and kidney transplant following nonmyeloablative conditioning in a patient with multiple myeloma and end-stage renal disease (ESRD). After 2 decades, she has normal renal function in the absence of ongoing systemic immunosuppressive therapy. Nine patients have subsequently undergone similar treatment for multiple myeloma with ESRD. RESULTS In the initial patient, hematopoietic chimerism was detectable for only 105 days after the transplant. In subsequent patients, chimerism detection ranged from 49 days to >14 years. Nevertheless, a long remission of the myeloma and long-term immunosuppression-free survival of the kidney allograft were achieved in 7 of the 10 patients, 5 of whom currently survive. CONCLUSIONS This initial patient demonstrated the feasibility of performing combined histocompatibility leukocyte antigen-matched, sibling donor bone marrow and kidney transplantation for ESRD due to multiple myeloma. This experience paved the way for extending the initial trial to 9 additional patients with multiple myeloma and ESRD and, more recently, to tolerance induction strategies involving combined bone marrow and kidney transplantation for patients with and without an underlying malignancy.
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Mixed chimerism established by hematopoietic stem cell transplantation is maintained by host and donor T regulatory cells. Blood Adv 2020; 3:734-743. [PMID: 30824417 DOI: 10.1182/bloodadvances.2018025502] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/21/2019] [Indexed: 12/30/2022] Open
Abstract
Transplantation is an effective treatment of many clinical disorders, but the mechanisms that regulate immunological tolerance are uncertain and remain central to improving patient outcome. Hemopoietic stem cell transplantation (SCT) often establishes "mixed chimerism" in which immune cells from both the donor and patient coexist in vivo in a setting of immunological tolerance. We studied immune function in 69 patients within 2 months following SCT; 37 were fully donor and 32 displayed mixed chimerism. The proportion of T regulatory (Treg) cells was increased during mixed chimerism and comprised equal numbers of donor and host-derived regulatory cells. This was associated with a tolerogenic PD-L1+ profile on dendritic cells. Importantly, effector T cells from patients with mixed chimerism exhibited reduced cytotoxicity against host target cells in vitro, but this was restored following depletion of CD4+ Treg cells. These data show that Treg cells play a major role in sustaining immunological tolerance during mixed chimerism. These insights should help to guide novel interventions to improve clinical transplantation.
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Dangi A, Yu S, Lee FT, Burnette M, Wang JJ, Kanwar YS, Zhang ZJ, Abecassis M, Thorp EB, Luo X. Murine cytomegalovirus dissemination but not reactivation in donor-positive/recipient-negative allogeneic kidney transplantation can be effectively prevented by transplant immune tolerance. Kidney Int 2020; 98:147-158. [PMID: 32471635 PMCID: PMC7311252 DOI: 10.1016/j.kint.2020.01.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 12/17/2019] [Accepted: 01/24/2020] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) reactivation from latently infected donor organs post-transplantation and its dissemination cause significant comorbidities in transplant recipients. Transplant-induced inflammation combined with chronic immunosuppression has been thought to provoke CMV reactivation and dissemination, although sequential events in this process have not been studied. Here, we investigated this process in a high-risk donor CMV-positive to recipient CMV-negative allogeneic murine kidney transplantation model. Recipients were either treated with indefinite immunosuppression or tolerized in a donor-specific manner. Untreated recipients served as controls. Kidney allografts from both immunosuppressed and tolerized recipients showed minimal alloimmunity-mediated graft inflammation and normal function for up to day 60 post-transplantation. However, despite the absence of such inflammation in the immunosuppressed and tolerized groups, CMV reactivation in the donor positive kidney allograft was readily observed. Interestingly, subsequent CMV replication and dissemination to distant organs only occurred in immunosuppressed recipients in which CMV-specific CD8 T cells were functionally impaired; whereas in tolerized recipients, host anti-viral immunity was well-preserved and CMV dissemination was effectively prevented. Thus, our studies uncoupled CMV reactivation from its dissemination, and underscore the potential role of robust transplantation tolerance in preventing CMV diseases following allogeneic kidney transplantation.
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Affiliation(s)
- Anil Dangi
- Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Shuangjin Yu
- Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Division of Organ Transplantation, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Frances T Lee
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melanie Burnette
- Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jiao-Jing Wang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yashpal S Kanwar
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zheng J Zhang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Abecassis
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Edward B Thorp
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xunrong Luo
- Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Transplant Center, Duke University Medical Center, Durham, North Carolina, USA.
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12
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Nauman G, Borsotti C, Danzl N, Khosravi-Maharlooei M, Li HW, Chavez E, Stone S, Sykes M. Reduced positive selection of a human TCR in a swine thymus using a humanized mouse model for xenotolerance induction. Xenotransplantation 2020; 27:e12558. [PMID: 31565822 PMCID: PMC7007369 DOI: 10.1111/xen.12558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/27/2019] [Accepted: 09/13/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tolerance-inducing approaches to xenotransplantation would be optimal and may be necessary for long-term survival of transplanted pig organs in human patients. The ideal approach would generate donor-specific unresponsiveness to the pig organ without suppressing the patient's normal immune function. Porcine thymus transplantation has shown efficacy in promoting xenotolerance in humanized mice and large animal models. However, murine studies demonstrate that T cells selected in a swine thymus are positively selected only by swine thymic epithelial cells, and therefore, cells expressing human HLA-restricted TCRs may not be selected efficiently in a transplanted pig thymus. This may lead to suboptimal patient immune function. METHODS To assess human thymocyte selection in a pig thymus, we used a TCR transgenic humanized mouse model to study positive selection of cells expressing the MART1 TCR, a well-characterized human HLA-A2-restricted TCR, in a grafted pig thymus. RESULTS Positive selection of T cells expressing the MART1 TCR was inefficient in both a non-selecting human HLA-A2- or swine thymus compared with an HLA-A2+ thymus. Additionally, CD8 MART1 TCRbright T cells were detected in the spleens of mice transplanted with HLA-A2+ thymi but were significantly reduced in the spleens of mice transplanted with swine or HLA-A2- thymi. [Correction added on October 15, 2019, after first online publication: The missing superscript values +, -, and bright have been included in the Results section.] CONCLUSIONS: Positive selection of cells expressing a human-restricted TCR in a transplanted pig thymus is inefficient, suggesting that modifications to improve positive selection of cells expressing human-restricted TCRs in a pig thymus may be necessary to support development of a protective human T-cell pool in future patients.
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Affiliation(s)
- Grace Nauman
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
- Department of Microbiology and Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Chiara Borsotti
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Nichole Danzl
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Mohsen Khosravi-Maharlooei
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Hao-Wei Li
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Estefania Chavez
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Samantha Stone
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, USA
- Department of Microbiology and Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, USA
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Abstract
This review focuses on our recent studies involving nonmyeloablative bone marrow transplantation as an approach to inducing organ allograft tolerance across MHC barriers in nonhuman primates and in patients. The clinical studies are focused on mechanisms of tolerance involved in a protocol carried out at Massachusetts General Hospital in HLA-mismatched haploidentical combinations for the induction of renal allograft tolerance. These studies, in which chimerism was only transient and GVHD did not occur, suggest an early role for donor-specific regulatory T cells in tolerance induction, followed by partial and gradual deletion of donor-reactive T cells. We utilized high-throughput sequencing methodologies in a novel way to identify and track large numbers of alloreactive T cell receptors (TCRs). This method has been shown to identify biologically significant alloreactive TCRs in transplant patients and pointed to clonal deletion as a major mechanism of long-term tolerance in these patients. More recently, we adapted this sequencing method to optimally identify the donor-specific regulatory T cell (Treg) repertoire. Interrogation of the early posttransplant repertoire demonstrated expansion of donor-specific Tregs in association with tolerance. Our studies suggest a role for the kidney graft in tolerance by these mechanisms in patients who had only transient chimerism. Nonhuman primate studies indicate that other organs, including the heart, the lungs and the liver, are less readily tolerated following a period of transient mixed chimerism. Our efforts to extend the reach of mixed chimerism for tolerance induction beyond the kidney are therefore focused on the addition of recipient Tregs to the protocol. This approach has the potential to enhance chimerism while further reducing the risk of GVHD.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA.
- Department of Medicine, Columbia University Medical Center, New York, NY, USA.
- Department of Microbiology & Immunology, Columbia University Medical Center, New York, NY, USA.
- Department of Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Adam D Griesemer
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
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14
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Murine CMV induces type 1 IFN that impairs differentiation of MDSCs critical for transplantation tolerance. Blood Adv 2019; 2:669-680. [PMID: 29563123 DOI: 10.1182/bloodadvances.2017012187] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/01/2018] [Indexed: 01/03/2023] Open
Abstract
Clinical tolerance without immunosuppression has now been achieved for organ transplantation, and its scope will likely continue to expand. In this context, a previously understudied and now increasingly relevant area is how microbial infections might affect the efficacy of tolerance. A highly prevalent and clinically relevant posttransplant pathogen is cytomegalovirus (CMV). Its impact on transplantation tolerance and graft outcomes is not well defined. Employing a mouse model of CMV (MCMV) infection and allogeneic pancreatic islet transplantation in which donor-specific tolerance was induced by infusing donor splenocytes rendered apoptotic by treatment with ethylenecarbodiimide, we investigated the effect of CMV infection on transplantation tolerance induction. We found that acute MCMV infection abrogated tolerance induction and that this abrogation correlated with an alteration in the differentiation and function of myeloid-derived suppressor cells (MDSCs). These effects on MDSCs were mediated in part through MCMV induced type 1 interferon (IFN) production. During MCMV infection, the highly immunosuppressive Gr1HI-granulocytic MDSCs were markedly reduced in numbers, and the accumulating Ly6CHI-monocytic cells lost their MDSC-like function but instead acquired an immunostimulatory phenotype to cross-present alloantigens and prime alloreactive CD8 T cells. Consequently, the islet allograft exhibited an altered effector to regulatory T-cell ratio that correlated with the ultimate graft demise. Blocking type 1 IFN signaling during MCMV infection rescued MDSC populations and partially restored transplantation tolerance. Our mechanistic studies now provide a solid foundation for seeking effective therapies for promoting transplantation tolerance in settings of CMV infection.
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15
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Manzia TM, Gazia C, Baiocchi L, Lenci I, Milana M, Santopaolo F, Angelico R, Tisone G. Clinical Operational Tolerance and Immunosuppression Minimization in Kidney Transplantation: Where Do We Stand? Rev Recent Clin Trials 2019; 14:189-202. [PMID: 30868959 DOI: 10.2174/1574887114666190313170205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The 20th century represents a breakthrough in the transplantation era, since the first kidney transplantation between identical twins was performed. This was the first case of tolerance, since the recipient did not need immunosuppression. However, as transplantation became possible, an immunosuppression-free status became the ultimate goal, since the first tolerance case was a clear exception from the hard reality nowadays represented by rejection. METHODS A plethora of studies was described over the past decades to understand the molecular mechanisms responsible for rejection. This review focuses on the most relevant studies found in the literature where renal tolerance cases are claimed. Contrasting, and at the same time, encouraging outcomes are herein discussed and a glimpse on the main renal biomarkers analyzed in this field is provided. RESULTS The activation of the immune system has been shown to play a central role in organ failure, but also it seems to induce a tolerance status when an allograft is performed, despite tolerance is still rare to register. Although there are still overwhelming challenges to overcome and various immune pathways remain arcane; the immunosuppression minimization might be more attainable than previously believed. CONCLUSION . Multiple biomarkers and tolerance mechanisms suspected to be involved in renal transplantation have been investigated to understand their real role, with still no clear answers on the topic. Thus, the actual knowledge provided necessarily leads to more in-depth investigations, although many questions in the past have been answered, there are still many issues on renal tolerance that need to be addressed.
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Affiliation(s)
- Tommaso Maria Manzia
- Transplant and Hepatobiliary Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Gazia
- Transplant and Hepatobiliary Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
- Department of Surgery, Abdominal Organ Transplant Program, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
- Wake Forest Institute for Regenerative Medicine, Department of Surgery, Winston-Salem, NC, United States
| | - Leonardo Baiocchi
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Ilaria Lenci
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | | | - Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giuseppe Tisone
- Transplant and Hepatobiliary Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
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17
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Ezekian B, Schroder PM, Freischlag K, Yoon J, Kwun J, Knechtle SJ. Contemporary Strategies and Barriers to Transplantation Tolerance. Transplantation 2018; 102:1213-1222. [PMID: 29757903 PMCID: PMC6059978 DOI: 10.1097/tp.0000000000002242] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/30/2022]
Abstract
The purpose of this review is to discuss immunologic tolerance as it applies to solid organ transplantation and to identify barriers that hinder the achievement of this long-term goal. First, the definition of tolerance and an introduction of mechanisms by which tolerance exists or can be achieved will be discussed. Next, a review of contemporary attempts at achieving transplant tolerance will be described. Finally, a discussion of the humoral barriers to transplantation tolerance and potential ways to overcome these barriers will be presented.
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Affiliation(s)
- Brian Ezekian
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Paul M. Schroder
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Kyle Freischlag
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC
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18
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Espinel-Pinzón DA, Figueroa-Bohorquez D, Lozano-Márquez E. Inducción de tolerancia inmunológica: alotrasplantes compuestos vascularizados y trasplantes de órgano sólido. REVISTA DE LA FACULTAD DE MEDICINA 2018. [DOI: 10.15446/revfacmed.v66n3.61735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La inducción de tolerancia inmunológica solucionaría los problemas asociados con la inmunosupresión de por vida, necesaria para evitar el rechazo de aloinjertos.Objetivos. Revisar aspectos inmunológicos, modelos clínicos utilizados y resultados obtenidos en la tolerancia y comparar los resultados obtenidos con trasplante de órgano sólido y alotrasplante compuesto vascularizado.Materiales y métodos. Se realizó una búsqueda en la base de datos PubMed que arrojó 299 resultados; se revisaron las bibliografías de los artículos y se consultaron las referencias pertinentes. Al final se seleccionaron 83 artículos.Resultados. Existen mecanismos centrales y periféricos para mantener la tolerancia a antígenos propios; en la práctica clínica, la tolerancia central ha sido más utilizada, esto se ha hecho mediante estrategias que utilizan trasplante conjunto de medula ósea. Varios ensayos clínicos, la mayoría en pacientes con trasplante renal, han mostrado resultados prometedores pero inconsistentes.Conclusiones. En trasplantes renales fue posible suspender de forma exitosa la inmunosupresión, mientras que en trasplantes de mano se logró disminuirla considerablemente. El quimerismo inmunológico parece ser indispensable para el desarrollo de tolerancia a aloinjertos, por lo que es necesario desarrollar protocolos para inducir quimerismo mixto persistente.
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19
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Sykes M. Immune monitoring of transplant patients in transient mixed chimerism tolerance trials. Hum Immunol 2018; 79:334-342. [PMID: 29289741 PMCID: PMC5924718 DOI: 10.1016/j.humimm.2017.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/31/2022]
Abstract
This review focuses on mechanistic studies performed in recipients of non-myeloablative bone marrow transplant regimens developed at Massachusetts General Hospital in HLA-identical and HLA-mismatched haploidentical combinations, initially as a platform for treatment of hematologic malignancies with immunotherapy in the form of donor leukocyte infusions, and later in combination with donor kidney transplantation for the induction of allograft tolerance. In patients with permanent mixed chimerism, central deletion may be a major mechanism of long-term tolerance. In patients in whom donor chimerism is only transient, the kidney itself plays a significant role in maintaining long-term tolerance. A high throughput sequencing approach to identifying and tracking a significant portion of the alloreactive T cell receptor repertoire has demonstrated biological significance in transplant patients and has been useful in pointing to clonal deletion as a long-term tolerance mechanism in recipients of HLA-mismatched combined kidney and bone marrow transplants with only transient chimerism.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Columbia University Medical Center, NY, USA; Department of Medicine, Columbia University Medical Center, NY, USA; Department of Microbiology & Immunology, Columbia University Medical Center, NY, USA; Department of Surgery, Columbia University Medical Center, NY, USA.
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20
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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21
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Chan-On C, Liberto JM, Sarwal MM. Mechanisms and biomarkers of immune quiescence in kidney transplantation. Hum Immunol 2018; 79:356-361. [PMID: 29408630 DOI: 10.1016/j.humimm.2018.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 12/14/2022]
Abstract
This review discusses the current understanding of biomarkers of immune quiescence based on reviews of published literature in kidney transplant operational tolerance and mechanistic studies based on a better characterization of the stable, well-functioning renal allograft.
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Affiliation(s)
- Chitranon Chan-On
- Division of Nephrology, Faculty of Medicine, Department of Internal Medicine, Khon Kaen University, Khon Kaen, Thailand; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Juliane M Liberto
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Minnie M Sarwal
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States.
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22
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Abstract
PURPOSE OF REVIEW The attainment of tolerance remains a highly desirable goal in recipients of kidney transplants. Achievement of this goal would extend graft survival and eradicate toxicities related to long-term immunosuppression. Understanding mechanisms of tolerance and strategies to induce tolerance - their risk/benefit profiles - is essential for future success. RECENT FINDINGS Mechanistic studies of spontaneously tolerant kidney transplant recipients have uncovered potential roles for B or regulatory T cells, or both, in the maintenance of tolerance. Mixed hematopoietic chimerism has been the most commonly used approach to induce tolerance. Distinct protocols at three major transplant centers have led to successful withdrawal of immunosuppression in a subset of living donor kidney transplant recipients at the expense of complications such as infections and graft versus host disease. The addition of regulatory cell therapies to tolerance induction protocols could enhance success while minimizing complications. SUMMARY This review summarizes the features of spontaneous tolerance in kidney transplant recipients, the results of clinical trials of tolerance induction in the context of living donor kidney transplant, and potential measures to improve the safety and efficacy of tolerance induction strategies.
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23
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Chimerism: A Clinical Guide to Tolerance Induction. CHIMERISM 2018. [DOI: 10.1007/978-3-319-89866-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Gallon L, Mathew JM, Bontha SV, Dumur CI, Dalal P, Nadimpalli L, Maluf DG, Shetty AA, Ildstad ST, Leventhal JR, Mas VR. Intragraft Molecular Pathways Associated with Tolerance Induction in Renal Transplantation. J Am Soc Nephrol 2017; 29:423-433. [PMID: 29191961 DOI: 10.1681/asn.2017030348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 09/07/2017] [Indexed: 11/03/2022] Open
Abstract
The modern immunosuppression regimen has greatly improved short-term allograft outcomes but not long-term allograft survival. Complications associated with immunosuppression, specifically nephrotoxicity and infection risk, significantly affect graft and patient survival. Inducing and understanding pathways underlying clinical tolerance after transplantation are, therefore, necessary. We previously showed full donor chimerism and immunosuppression withdrawal in highly mismatched allograft recipients using a bioengineered stem cell product (FCRx). Here, we evaluated the gene expression and microRNA expression profiles in renal biopsy samples from tolerance-induced FCRx recipients, paired donor organs before implant, and subjects under standard immunosuppression (SIS) without rejection and with acute rejection. Unlike allograft samples showing acute rejection, samples from FCRx recipients did not show upregulation of T cell- and B cell-mediated rejection pathways. Gene expression pathways differed slightly between FCRx samples and the paired preimplantation donor organ samples, but most of the functional gene networks overlapped. Notably, compared with SIS samples, FCRx samples showed upregulation of genes involved in pathways, like B cell receptor signaling. Additionally, prediction analysis showed inhibition of proinflammatory regulators and activation of anti-inflammatory pathways in FCRx samples. Furthermore, integrative analyses (microRNA and gene expression profiling from the same biopsy sample) identified the induction of regulators with demonstrated roles in the downregulation of inflammatory pathways and maintenance of tissue homeostasis in tolerance-induced FCRx samples compared with SIS samples. This pilot study highlights the utility of molecular intragraft evaluation of pathways related to FCRx-induced tolerance and the use of integrative analyses for identifying upstream regulators of the affected downstream molecular pathways.
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Affiliation(s)
- Lorenzo Gallon
- Departments of Medicine-Nephrology, .,Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - James M Mathew
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois.,Surgery.,Microbiology-Immunology and
| | - Sai Vineela Bontha
- Translational Genomics Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Catherine I Dumur
- Molecular Diagnostics Laboratory, Department of Pathology, Virginia Commonwealth University, Richmond, Virginia; and
| | - Pranav Dalal
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois.,Surgery
| | - Lakshmi Nadimpalli
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois.,Surgery
| | - Daniel G Maluf
- Translational Genomics Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Aneesha A Shetty
- Departments of Medicine-Nephrology.,Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Suzanne T Ildstad
- Departments of Surgery.,Physiology, and.,Immunology, Institute for Cellular Therapeutics, University of Louisville, Louisville, Kentucky
| | - Joseph R Leventhal
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois.,Surgery
| | - Valeria R Mas
- Translational Genomics Transplant Laboratory, Department of Surgery, University of Virginia, Charlottesville, Virginia
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25
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Abstract
Renal transplantation has become the preferred treatment for end stage kidney failure. Although short-term graft survival has significantly improved as advances in immunosuppression have occurred, long-term patient and graft survival have not. Approximately only 50% of renal transplant recipients are alive at 10 years due to the toxicities of immunosuppression and alloimmunity. Emerging research on cell-based therapies is opening a new door for patients to receive the organs they need without sacrificing quality of life and longevity because of drug-based immunosuppression. Research has focused on inducing tolerance, a state in which the body accepts the transplant and graft function is stable. Cell-based therapies to facilitate chimerism and achieve tolerance in major histocompatibility disparate recipients have been developed in mouse, swine, canine, and nonhuman primate models. These findings are now being translated into the clinic in several trials currently underway. Protocols that use a combination of traditional therapeutic agents paired with cell populations including hematopoietic stem cells, regulatory T cells, and facilitating cells are being conducted with the objective to harness the donor immune system to protect the transplanted tissue. The benefits and feasibility of the clinical application of cell-based therapy has been demonstrated, and promising results have been achieved. Here we discuss the preclinical work that has led to the clinical application of the various approaches and a summary of the most current clinical data from groups throughout the world.
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26
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Pilat N, Granofszky N, Wekerle T. Combining Adoptive Treg Transfer with Bone Marrow Transplantation for Transplantation Tolerance. CURRENT TRANSPLANTATION REPORTS 2017; 4:253-261. [PMID: 29201599 PMCID: PMC5691126 DOI: 10.1007/s40472-017-0164-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The mixed chimerism approach is an exceptionally potent strategy for the induction of donor-specific tolerance in organ transplantation and so far the only one that was demonstrated to work in the clinical setting. Regulatory T cells (Tregs) have been shown to improve chimerism induction in experimental animal models. This review summarizes the development of innovative BMT protocols using therapeutic Treg transfer for tolerance induction. RECENT FINDINGS Treg cell therapy promotes BM engraftment in reduced conditioning protocols in both, mice and non-human primates. In mice, transfer of polyclonal recipient Tregs was sufficient to substitute cytotoxic recipient conditioning. Treg therapy prevented chronic rejection of skin and heart allografts related to tissue-specific antigen disparities, in part by promoting intragraft Treg accumulation. SUMMARY Adoptive Treg transfer is remarkably effective in facilitating BM engraftment in reduced-intensity protocols in mice and non-human primates. Furthermore, it promotes regulatory mechanisms that prevent chronic rejection.
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Affiliation(s)
- Nina Pilat
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Nicolas Granofszky
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Thomas Wekerle
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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27
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Zuber J, Sykes M. Mechanisms of Mixed Chimerism-Based Transplant Tolerance. Trends Immunol 2017; 38:829-843. [PMID: 28826941 PMCID: PMC5669809 DOI: 10.1016/j.it.2017.07.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/24/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023]
Abstract
Immune responses to allografts represent a major barrier in organ transplantation. Immune tolerance to avoid chronic immunosuppression is a critical goal in the field, recently achieved in the clinic by combining bone marrow transplantation (BMT) with kidney transplantation following non-myeloablative conditioning. At high levels of chimerism such protocols can permit central deletional tolerance, but with a significant risk of graft-versus-host (GVH) disease (GVHD). By contrast, transient chimerism-based tolerance is devoid of GVHD risk and appears to initially depend on regulatory T cells (Tregs) followed by gradual, presumably peripheral, clonal deletion of donor-reactive T cells. Here we review recent mechanistic insights into tolerance and the development of more robust and safer protocols for tolerance induction that will be guided by innovative immune monitoring tools.
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Affiliation(s)
- Julien Zuber
- Service de Transplantation Rénale, Hôpital Necker, Université Paris Descartes, Paris, France; INSERM UMRS_1163, IHU Imagine, Paris, France.
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY 10032, USA; Department of Surgery, Columbia University, New York, NY 10032, USA; Department of Microbiology and Immunology, Columbia University Center, New York, NY 10032, USA.
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28
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Abstract
The anti-tumor effects of allogeneic hematopoietic stem cell transplantation depend upon engraftment of donor cells followed by a graft-versus-tumor (GVT) effect. However, pre-clinical and clinical studies have established that under certain circumstances, anti-tumor responses can occur despite the absence of high levels of durable donor cell engraftment. Tumor response with little or no donor engraftment has been termed "microtransplantation." It has been hard to define conditions leading to tumor responses without donor cell persistence in humans because the degree of engraftment depends very heavily upon many patient-specific factors, including immune status and degree of prior therapy. Likewise, it is unknown to what degree donor chimerism in the blood or tissue is required for an anti-tumor effect under conditions of microtransplantation. In this review, we summarize some key studies supporting the concept of microtransplantation and emphasize the importance of recent large studies of microtransplantation in patients with acute myelogenous leukemia (AML). These AML studies provide the first evidence of the efficacy of microtransplantation as a therapeutic strategy and lay the foundation for additional pre-clinical studies and clinical trials that will refine the understanding of the mechanisms involved and guide its further development as a treatment modality.
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Affiliation(s)
- Kevin A David
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Dennis Cooper
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Roger Strair
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08901, USA.
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29
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Yolcu ES, Shirwan H, Askenasy N. Mechanisms of Tolerance Induction by Hematopoietic Chimerism: The Immune Perspective. Stem Cells Transl Med 2017; 6:700-712. [PMID: 28186688 PMCID: PMC5442770 DOI: 10.1002/sctm.16-0358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/02/2016] [Accepted: 10/10/2016] [Indexed: 01/05/2023] Open
Abstract
Hematopoietic chimerism is one of the effective approaches to induce tolerance to donor‐derived tissue and organ grafts without administration of life‐long immunosuppressive therapy. Although experimental efforts to develop such regimens have been ongoing for decades, substantial cumulative toxicity of combined hematopoietic and tissue transplants precludes wide clinical implementation. Tolerance is an active immunological process that includes both peripheral and central mechanisms of mutual education of coresident donor and host immune systems. The major stages include sequential suppression of early alloreactivity, establishment of hematopoietic chimerism and suppressor cells that sustain the state of tolerance, with significant mechanistic and temporal overlap along the tolerization process. Efforts to devise less toxic transplant strategies by reduction of preparatory conditioning focus on modulation rather than deletion of residual host immunity and early reinstitution of regulatory subsets at the central and peripheral levels. Stem Cells Translational Medicine2017;6:700–712
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Affiliation(s)
- Esma S Yolcu
- Institute for Cellular Therapeutics and Department of Microbiology and Immunology, University of Louisville, Louisville, Kentucky, USA
| | - Haval Shirwan
- Institute for Cellular Therapeutics and Department of Microbiology and Immunology, University of Louisville, Louisville, Kentucky, USA
| | - Nadir Askenasy
- Frankel Laboratory of Experimental Bone Marrow Transplantation, Petach Tikva, Israel
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30
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Picoraro JA, Ovchinsky N, Martinez M, Lobritto SJ, Satwani P, Ramphal R, Cairo MS, Kato T. First Attempt of Sequential Living Donor Liver and Hematopoietic Stem Cell Transplantation in a Child With Advanced Hepatocellular Carcinoma: Case Report. Transplant Proc 2016; 48:3174-3177. [PMID: 27932175 DOI: 10.1016/j.transproceed.2016.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/01/2016] [Indexed: 12/22/2022]
Abstract
Effective therapeutic options for advanced hepatocellular carcinoma are limited. Hematopoietic stem cell transplantation may offer a graft-versus-tumor effect. Combined liver and hematopoietic stem cell transplantation from the same donor with preparatory conditioning may promote tolerogenicity to the liver allograft and offers the potential for immunosuppression withdrawal. We report our experience with the use of this approach in a pediatric patient with invasive hepatocellular carcinoma and pulmonary metastases who underwent a living-donor liver transplantation followed by reduced-toxicity myeloablative conditioning and hematopoietic stem cell transplant from the same parental donor. Neutrophil engraftment and full donor chimerism was achieved without liver allograft dysfunction. Despite normal liver function and marrow engraftment, the patient succumbed to multisystem organ failure from disseminated toxoplasmosis. At autopsy, there was no histologic evidence of tumor recurrence. No pulmonary nodules were found. Regardless of the unfortunate overall result, this case demonstrates preliminary feasibility of sequential living-donor liver transplantation and hematopoietic stem cell transplantation for unresectable and metastasized hepatic tumors. Future studies in select pediatric patients require evaluation of the optimal conditioning regimen and prevention strategies for opportunistic infections to determine both graft-versus-tumor effect on hepatic tumors and durability of tolerogenicity and possible immunosuppression withdrawal.
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Affiliation(s)
- J A Picoraro
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York
| | - N Ovchinsky
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York (present address)
| | - M Martinez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York
| | - S J Lobritto
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Medical Center, New York, New York
| | - P Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, New York
| | - R Ramphal
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - M S Cairo
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, New York; Department of Pediatrics, New York Medical College, Valhalla, New York (present address)
| | - T Kato
- Department of Surgery, Columbia University Medical Center, New York, New York.
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Ikeda M, Tsukada N, Chikai H, Tasaki M, Saito K, Nakagawa Y, Takahashi K, Suzuki K. Successful Second Allogeneic Stem Cell Transplantation From a Sibling Donor for Relapse of Myelodysplastic Syndrome in a Recipient of a Renal Transplant From His Mother: Case Report. Transplant Proc 2016; 48:3085-3087. [PMID: 27932152 DOI: 10.1016/j.transproceed.2016.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/26/2016] [Accepted: 03/23/2016] [Indexed: 01/30/2023]
Abstract
There have been few reports on allogeneic stem cell transplantation in patients who have previously undergone solid organ transplantation. The clinical course of such patients is not yet well recognized. Therefore, appropriate immunosuppressive prophylaxis for the rejection of a solid organ graft or for graft-versus-host disease has not yet been established. We present the case of a successful allogeneic stem cell transplantation in a patient who relapsed after a first allogeneic stem cell transplantation for myelodysplastic syndrome and who had previously undergone renal transplantation. The prophylaxis in this case for graft-versus-host disease and rejection of the transplanted kidney was mycophenolate mofetil and tacrolimus. No hyperacute rejection of the transplanted kidney was observed. However, the patient's renal function deteriorated after the cessation of the mycophenolate mofetil and the reduction of the tacrolimus. This deterioration seemed to be due to rejection with humoral immunity of donor lymphocytes, and we were able to control it by resuming the mycophenolate mofetil and local graft irradiation.
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Affiliation(s)
- M Ikeda
- Division of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - N Tsukada
- Division of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan.
| | - H Chikai
- Division of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - M Tasaki
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Saito
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Y Nakagawa
- Division of Urology, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Takahashi
- Niigata Organ Transplant Foundation, Tokyo, Japan
| | - K Suzuki
- Division of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
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Bone marrow chimerism as a strategy to produce tolerance in solid organ allotransplantation. Curr Opin Organ Transplant 2016; 21:595-602. [PMID: 27805947 DOI: 10.1097/mot.0000000000000366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Clinical transplant tolerance has been most successfully achieved combining hematopoietic chimerism with kidney transplantation. This review outlines this strategy in animal models and human transplantation, and possible clinical challenges. RECENT FINDINGS Kidney transplant tolerance has been achieved through chimerism in several centers beginning with Massachusetts General Hospital's success with mixed chimerism in human leukocyte antigen (HLA)-mismatched patients and the Stanford group with HLA-matched patients, and the more recent success of the Northwestern protocol achieving full chimerism. This has challenged the original view that stable mixed chimerism is necessary for organ graft tolerance. However, among the HLA-mismatched kidney transplant-tolerant patients, loss of mixed chimerism does not lead to renal-graft rejection, and the development of host Foxp3+ regulatory T cells has been observed. Recent animal models suggest that graft tolerance through bone marrow chimerism occurs through both clonal deletion and regulatory immune cells. Further, Tregs have been shown to improve chimerism in animal models. SUMMARY Animal studies continue to suggest ways to improve our current clinical strategies. Advances in chimerism protocols suggest that tolerance may be clinically achievable with relative safety for HLA-mismatched kidney transplants.
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Elahimehr R, Scheinok AT, McKay DB. Hematopoietic stem cells and solid organ transplantation. Transplant Rev (Orlando) 2016; 30:227-34. [PMID: 27553809 DOI: 10.1016/j.trre.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
Solid organ transplantation provides lifesaving therapy for patients with end stage organ disease. In order for the transplanted organ to survive, the recipient must take a lifelong cocktail of immunosuppressive medications that increase the risk for infections, malignancies and drug toxicities. Data from many animal studies have shown that recipients can be made tolerant of their transplanted organ by infusing stem cells, particularly hematopoietic stem cells, prior to the transplant. The animal data have been translated into humans and now several clinical trials have demonstrated that infusion of hematopoietic stem cells, along with specialized conditioning regimens, can permit solid organ allograft survival without immunosuppressive medications. This important therapeutic advance has been made possible by understanding the immunologic mechanisms by which stem cells modify the host immune system, although it must be cautioned that the conditioning regimens are often severe and associated with significant morbidity. This review discusses the role of hematopoietic stem cells in solid organ transplantation, provides an understanding of how these stem cells modify the host immune system and describes how newer information about adaptive and innate immunity might lead to improvements in the use of hematopoietic stem cells to induce tolerance to transplanted organs.
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Affiliation(s)
- Reza Elahimehr
- Department of Medicine, Division of Nephrology/Hypertension, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Andrew T Scheinok
- Department of Medicine, Division of Nephrology/Hypertension, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Dianne B McKay
- Department of Medicine, Division of Nephrology/Hypertension, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
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Baraldi O, Grandinetti V, Donati G, Comai G, Battaglino G, Cuna V, Capelli I, Sala E, La Manna G. Hematopoietic Cell and Renal Transplantation in Plasma Cell Dyscrasia Patients. Cell Transplant 2016; 25:995-1005. [DOI: 10.3727/096368915x688560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gammopathies, multiple myeloma, and amyloidosis are plasma dyscrasias characterized by clonal proliferation and immunoglobulin overproduction. Renal impairment is the most common and serious complication with an incidence of 20–30% patients at the diagnosis. Kidney transplant has not been considered feasible in the presence of plasma dyscrasias because the immunosuppressive therapy may increase the risk of neoplasia progression, and paraproteins may affect the graft. However, recent advances in clinical management of multiple myeloma and other gammopathies allow considering kidney transplant as a possible alternative to dialysis. Numerous evidence indicates the direct relationship between hematological remission and renal function restoring. The combination of kidney and hematopoietic cell transplant has been reported as a promising approach to reestablish end-organ function and effectively treat the underlying disease. This review describes current protocols used to perform kidney transplantation in patients with plasma dyscrasias.
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Affiliation(s)
- Olga Baraldi
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Valeria Grandinetti
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gabriele Donati
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Battaglino
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Vania Cuna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Elisa Sala
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
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Siemionow M, Rampazzo A, Gharb BB, Cwykiel J, Klimczak A, Madajka M, Nasir S, Bozkurt M. The reversed paradigm of chimerism induction: Donor conditioning with recipient-derived bone marrow cells as a novel approach for tolerance induction in vascularized composite allotransplantation. Microsurgery 2016; 36:676-683. [DOI: 10.1002/micr.30041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/02/2016] [Accepted: 02/16/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Maria Siemionow
- Department of Orthopaedics; University of Illinois at Chicago, College of Medicine; Chicago IL
| | | | | | - Joanna Cwykiel
- Department of Orthopaedics; University of Illinois at Chicago, College of Medicine; Chicago IL
- Department of Plastic Surgery; Cleveland Clinic; Cleveland OH
| | | | - Maria Madajka
- Department of Plastic Surgery; Cleveland Clinic; Cleveland OH
| | - Serdar Nasir
- Department of Plastic Surgery; Cleveland Clinic; Cleveland OH
| | - Mehmet Bozkurt
- Department of Plastic Surgery; Cleveland Clinic; Cleveland OH
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Sykes M. Immune tolerance in recipients of combined haploidentical bone marrow and kidney transplantation. Bone Marrow Transplant 2016; 50 Suppl 2:S82-6. [PMID: 26039215 DOI: 10.1038/bmt.2015.102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The success of allogeneic hematopoietic cell transplantation (HCT) has been limited by transplant-associated toxicities related to the conditioning regimens used and to graft-vs-host disease (GVHD). The frequency and severity of GVHD observed when extensive HLA barriers are transgressed has greatly impeded the routine use of extensively HLA-mismatched HCT. Allogeneic HCT also has potential as an approach to organ allograft tolerance induction, but this potential has not been previously realized because of the toxicity associated with traditional conditioning. This paper reviews an approach to HCT involving reduced intensity conditioning that demonstrated sufficient safety in patients with hematologic malignancies, even in the HLA-mismatched transplant setting, to be applied for the induction of kidney allograft tolerance in humans with no other indication for HCT. These studies provided the first successful example of intentional organ allograft tolerance induction across HLA barriers in humans. Current data and hypotheses on the mechanisms of tolerance in these patients are reviewed.
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Affiliation(s)
- M Sykes
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
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Doney KC, Mielcarek M, Stewart FM, Appelbaum FR. Hematopoietic Cell Transplantation after Solid Organ Transplantation. Biol Blood Marrow Transplant 2015; 21:2123-2128. [DOI: 10.1016/j.bbmt.2015.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
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Morris H, DeWolf S, Robins H, Sprangers B, LoCascio SA, Shonts BA, Kawai T, Wong W, Yang S, Zuber J, Shen Y, Sykes M. Tracking donor-reactive T cells: Evidence for clonal deletion in tolerant kidney transplant patients. Sci Transl Med 2015; 7:272ra10. [PMID: 25632034 DOI: 10.1126/scitranslmed.3010760] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
T cell responses to allogeneic major histocompatibility complex antigens present a formidable barrier to organ transplantation, necessitating long-term immunosuppression to minimize rejection. Chronic rejection and drug-induced morbidities are major limitations that could be overcome by allograft tolerance induction. Tolerance was first intentionally induced in humans via combined kidney and bone marrow transplantation (CKBMT), but the mechanisms of tolerance in these patients are incompletely understood. We now establish an assay to identify donor-reactive T cells and test the role of deletion in tolerance after CKBMT. Using high-throughput sequencing of the T cell receptor B chain CDR3 region, we define a fingerprint of the donor-reactive T cell repertoire before transplantation and track those clones after transplant. We observed posttransplant reductions in donor-reactive T cell clones in three tolerant CKBMT patients; such reductions were not observed in a fourth, nontolerant, CKBMT patient or in two conventional kidney transplant recipients on standard immunosuppressive regimens. T cell repertoire turnover due to lymphocyte-depleting conditioning only partially accounted for the observed reductions in tolerant patients; in fact, conventional transplant recipients showed expansion of circulating donor-reactive clones, despite extensive repertoire turnover. Moreover, loss of donor-reactive T cell clones more closely associated with tolerance induction than in vitro functional assays. Our analysis supports clonal deletion as a mechanism of allograft tolerance in CKBMT patients. The results validate the contribution of donor-reactive T cell clones identified before transplant by our method, supporting further exploration as a potential biomarker of transplant outcomes.
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Affiliation(s)
- Heather Morris
- Columbia University Medical Center, New York, NY 10032, USA
| | - Susan DeWolf
- Columbia University Medical Center, New York, NY 10032, USA
| | - Harlan Robins
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Ben Sprangers
- Columbia University Medical Center, New York, NY 10032, USA
| | | | | | - Tatsuo Kawai
- Massachusetts General Hospital, Boston, MA 02114, USA
| | - Waichi Wong
- Columbia University Medical Center, New York, NY 10032, USA
| | - Suxiao Yang
- Columbia University Medical Center, New York, NY 10032, USA
| | - Julien Zuber
- Columbia University Medical Center, New York, NY 10032, USA
| | - Yufeng Shen
- Columbia University Medical Center, New York, NY 10032, USA.
| | - Megan Sykes
- Columbia University Medical Center, New York, NY 10032, USA.
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40
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Yilmaz VT, Koksoy S, Ulger BV, Salim O, Akbas H, Aliosmanoglu İ, Erbis H, Kocak H, Suleymanlar G. A Successful Renal Transplantation Case After Stem Cell Transplantation. Transplant Proc 2015; 47:2233-5. [PMID: 26361686 DOI: 10.1016/j.transproceed.2015.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/11/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
Abstract
Renal transplantation is the most effective treatment method for end-stage renal disease (ESRD). However, new treatment modalities are being investigated, such as immunotoleration, to avoid the acute and chronic side effects of immunosuppressant drugs. We report a case in which a man had undergone allogenic stem cell transplantation from his brother 16 years ago due to chronic myeloid leukemia, and who then developed ESRD due to arterial hypertension and underwent renal transplantation (Rtx) from the same brother. The patient was followed up without immunosuppression due to full chimerism.
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Affiliation(s)
- V T Yilmaz
- Division of Nephrology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey.
| | - S Koksoy
- Division of Immunology, Department of Microbiology, Akdeniz University Medical School, Antalya, Turkey
| | - B V Ulger
- Department of General Surgery, Dicle University Medical School, Diyarbakir, Turkey
| | - O Salim
- Division of Hematology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey
| | - H Akbas
- Department of Biochemistry, Akdeniz University Medical School, Antalya, Turkey
| | - İ Aliosmanoglu
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - H Erbis
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - H Kocak
- Division of Nephrology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey
| | - G Suleymanlar
- Division of Nephrology, Department of Internal Medicine, Akdeniz University Medical School, Antalya, Turkey
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41
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Hock K, Mahr B, Schwarz C, Wekerle T. Deletional and regulatory mechanisms coalesce to drive transplantation tolerance through mixed chimerism. Eur J Immunol 2015. [DOI: 10.1002/eji.201545494] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Karin Hock
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Benedikt Mahr
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Christoph Schwarz
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Thomas Wekerle
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
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Girmanova E, Hruba P, Viklicky O. Circulating biomarkers of tolerance. Transplant Rev (Orlando) 2015; 29:68-72. [PMID: 25636718 DOI: 10.1016/j.trre.2015.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 01/09/2015] [Accepted: 01/11/2015] [Indexed: 02/01/2023]
Abstract
On the basis of reviewed literature here we describe models of tolerance and summarize the evidence of circulating biomarkers suitable for the assessment of immunological risk in organ transplantation. We focused on results of evaluation of specific peripheral immune cell populations and transcripts in peripheral blood of operationally tolerant liver and kidney transplant recipients. Validation of described markers to define potentially tolerant patients before their use in clinical trials is critical.
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Affiliation(s)
- Eva Girmanova
- Transplant Laboratory, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Hruba
- Transplant Laboratory, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Laboratory, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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43
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Traitanon O, Gallon L. Chimerism and Tolerance Induction in Kidney Transplantation. Nephron Clin Pract 2014; 129:34-8. [DOI: 10.1159/000369311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/24/2014] [Indexed: 11/19/2022] Open
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Abstract
Advances in pharmacologic immunosuppression are responsible for the excellent outcomes experienced by recipients of liver transplants. However, long-term follow-up of these patients reveals an increasing burden of morbidity and mortality that is attributable to these drugs. The authors summarize the agents used in contemporary liver transplantation immunosuppression protocols and discuss the emerging trend within the community to minimize or eliminate these agents from use. The authors present recently published data that may provide the foundation for immunosuppression minimization or tolerance induction in the future and review studies that have focused on the utility of biomarkers in guiding immunosuppression management.
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46
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Kawai T, Sachs DH, Sprangers B, Spitzer TR, Saidman SL, Zorn E, Tolkoff-Rubin N, Preffer F, Crisalli K, Gao B, Wong W, Morris H, LoCascio SA, Sayre P, Shonts B, Williams WW, Smith RN, Colvin RB, Sykes M, Cosimi AB. Long-term results in recipients of combined HLA-mismatched kidney and bone marrow transplantation without maintenance immunosuppression. Am J Transplant 2014; 14:1599-611. [PMID: 24903438 PMCID: PMC4228952 DOI: 10.1111/ajt.12731] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/05/2014] [Accepted: 03/05/2014] [Indexed: 01/25/2023]
Abstract
We report here the long-term results of HLA-mismatched kidney transplantation without maintenance immunosuppression (IS) in 10 subjects following combined kidney and bone marrow transplantation. All subjects were treated with nonmyeloablative conditioning and an 8- to 14-month course of calcineurin inhibitor with or without rituximab. All 10 subjects developed transient chimerism, and in seven of these, IS was successfully discontinued for 4 or more years. Currently, four subjects remain IS free for periods of 4.5-11.4 years, while three required reinstitution of IS after 5-8 years due to recurrence of original disease or chronic antibody-mediated rejection. Of the 10 renal allografts, three failed due to thrombotic microangiopathy or rejection. When compared with 21 immunologically similar living donor kidney recipients treated with conventional IS, the long-term IS-free survivors developed significantly fewer posttransplant complications. Although most recipients treated with none or two doses of rituximab developed donor-specific antibody (DSA), no DSA was detected in recipients treated with four doses of rituximab. Although further revisions of the current conditioning regimen are planned in order to improve consistency of the results, this study shows that long-term stable kidney allograft survival without maintenance IS can be achieved following transient mixed chimerism induction.
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Affiliation(s)
- T. Kawai
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA,Corresponding author: Tatsuo Kawai,
| | - D. H. Sachs
- Transplantation Biology Research Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - B. Sprangers
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - T. R. Spitzer
- Bone Marrow Transplant Unit, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - S. L. Saidman
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - E. Zorn
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - N. Tolkoff-Rubin
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - F. Preffer
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - K. Crisalli
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - B. Gao
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - W. Wong
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - H. Morris
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - S. A. LoCascio
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - P. Sayre
- Immune Tolerance Network, San Francisco, CA
| | - B. Shonts
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - W. W. Williams
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - R.-N. Smith
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - R. B. Colvin
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - M. Sykes
- Columbia Center for Translational Immunology, Columbia University, New York, NY
| | - A. B. Cosimi
- Transplant Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA
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47
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Mechanistic and therapeutic role of regulatory T cells in tolerance through mixed chimerism. Curr Opin Organ Transplant 2014; 15:725-30. [PMID: 20881493 DOI: 10.1097/mot.0b013e3283401755] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Although substantial advances in transplantation medicine have improved short-term graft survival, long-term outcome after organ transplantation is unsatisfactory. The induction of donor-specific tolerance as a potential solution remains an unmet need. Mixed chimerism established through transplantation of donor bone marrow is an appealing tolerance strategy, but widespread clinical application is prevented by the toxicity of recipient conditioning, which is required for achieving bone marrow engraftment. Clonal deletion - both central and peripheral - has long been recognized as a cardinal mechanism in experimental mixed chimerism models. RECENT FINDINGS Several recent studies have delineated the importance of nondeletional, regulatory mechanisms for the induction of tolerance through mixed chimerism. Moreover, the therapeutic application of recipient regulatory T cells (Tregs) has been combined with the transplantation of donor bone marrow. Such a 'Treg-chimerism' protocol leads to engraftment of conventional doses of fully allogeneic bone marrow and to donor-specific tolerance without the need for any cytotoxic conditioning. SUMMARY Regulatory mechanisms play a major role in mixed chimerism protocols. Treg therapy is exceptionally effective in achieving bone marrow engraftment without cytotoxic recipient treatment, thereby eliminating a major toxic factor preventing widespread application of the mixed chimerism strategy.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Columbia University College of Physicians and Surgeons, 630 W. 168th Street, New York, NY 10032 USA, (212) 304-5696;
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Abstract
Tolerance induction and alloreactivity can be applied to the clinic for the transplantation of solid organs and in the treatment of human cancers respectively. Hematopoietic chimerism, the stable coexistence of host and donor blood cells, guarantees that a solid organ from the same donor will be tolerated without a requirement for maintenance immunosuppression, and it also serves as a platform for the adoptive immunotherapy of hematologic malignancies using donor lymphocyte infusions. This review focuses on clinically relevant methods for inducing hematopoietic chimerism and transplantation tolerance, with a special emphasis on reduced intensity transplantation conditioning and high dose, post-transplantation cyclophosphamide to prevent graft rejection and graft-versus-host disease (GVHD). Reduced intensity transplantation regimens permit a transient cooperation between donor and host immune systems to eradicate malignancy without producing GVHD. Their favorable toxicity profile also enables the application of allogeneic stem cell transplantation to treat non-malignant disorders of hematopoiesis and to induce tolerance for solid organ transplantation.
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Affiliation(s)
- Ephraim J. Fuchs
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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50
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Abstract
We are entering an exciting time in the study of immunologic tolerance. Several cellular and molecular strategies have been developed that show promise in nonhuman transplant models and these approaches are just now appearing in clinical trials. Tolerance strategies that prevent immune rejection and obviate the need for immunosuppressive medications (with inherent risk of cancer, infection, and organ toxicity) would improve both graft and patient survival. Each tolerance protocol brings its own set of associated risks. As the results of these trials become available, we must continue to evaluate their successes and failures. The balance of these outcomes will help us answer the question: "Tolerance-Is it worth it?"
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Affiliation(s)
- Erik B Finger
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455
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