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Peterson L, Yacoub MH, Ayares D, Yamada K, Eisenson D, Griffith BP, Mohiuddin MM, Eyestone W, Venter JC, Smolenski RT, Rothblatt M. Physiological basis for xenotransplantation from genetically modified pigs to humans. Physiol Rev 2024; 104:1409-1459. [PMID: 38517040 DOI: 10.1152/physrev.00041.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
The collective efforts of scientists over multiple decades have led to advancements in molecular and cellular biology-based technologies including genetic engineering and animal cloning that are now being harnessed to enhance the suitability of pig organs for xenotransplantation into humans. Using organs sourced from pigs with multiple gene deletions and human transgene insertions, investigators have overcome formidable immunological and physiological barriers in pig-to-nonhuman primate (NHP) xenotransplantation and achieved prolonged pig xenograft survival. These studies informed the design of Revivicor's (Revivicor Inc, Blacksburg, VA) genetically engineered pigs with 10 genetic modifications (10 GE) (including the inactivation of 4 endogenous porcine genes and insertion of 6 human transgenes), whose hearts and kidneys have now been studied in preclinical human xenotransplantation models with brain-dead recipients. Additionally, the first two clinical cases of pig-to-human heart xenotransplantation were recently performed with hearts from this 10 GE pig at the University of Maryland. Although this review focuses on xenotransplantation of hearts and kidneys, multiple organs, tissues, and cell types from genetically engineered pigs will provide much-needed therapeutic interventions in the future.
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Affiliation(s)
- Leigh Peterson
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | | | - David Ayares
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | - Kazuhiko Yamada
- Department of Surgery, Division of Transplantation, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Daniel Eisenson
- Department of Surgery, Division of Transplantation, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Bartley P Griffith
- University of Maryland Medical Center, Baltimore, Maryland, United States
| | | | - Willard Eyestone
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | - J Craig Venter
- J. Craig Venter Institute, Rockville, Maryland, United States
| | | | - Martine Rothblatt
- United Therapeutics Corporation, Silver Spring, Maryland, United States
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Manook M, Olaso D, Anwar I, DeLaura I, Yoon J, Bae Y, Barbas A, Shaw B, Moris D, Song M, Farris AB, Stiede K, Youd M, Knechtle S, Kwun J. Prolonged xenokidney graft survival in sensitized NHP recipients by expression of multiple human transgenes in a triple knockout pig. Sci Transl Med 2024; 16:eadk6152. [PMID: 38865482 DOI: 10.1126/scitranslmed.adk6152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 05/07/2024] [Indexed: 06/14/2024]
Abstract
Genetic modification of porcine donors, combined with optimized immunosuppression, has been shown to improve outcomes of experimental xenotransplant. However, little is known about outcomes in sensitized recipients, a population that could potentially benefit the most from the clinical implementation of xenotransplantation. Here, five highly allosensitized rhesus macaques received a porcine kidney from GGTA1 (α1,3-galactosyltransferase) knockout pigs expressing the human CD55 transgene (1KO.1TG) and were maintained on an anti-CD154 monoclonal antibody (mAb)-based immunosuppressive regimen. These recipients developed de novo xenoreactive antibodies and experienced xenograft rejection with evidence of thrombotic microangiopathy and antibody-mediated rejection (AMR). In comparison, three highly allosensitized rhesus macaques receiving a kidney from GGTA1, CMAH (cytidine monophospho-N-acetylneuraminic acid hydroxylase), and b4GNT2/b4GALNT2 (β-1,4-N-acetyl-galactosaminyltransferase 2) knockout pigs expressing seven human transgenes including human CD46, CD55, CD47, THBD (thrombomodulin), PROCR (protein C receptor), TNFAIP3 (tumor necrosis factor-α-induced protein 3), and HMOX1 (heme oxygenase 1) (3KO.7TG) experienced significantly prolonged graft survival and reduced AMR, associated with dampened post-transplant humoral responses, early monocyte and neutrophil activation, and T cell repopulation. After withdrawal of all immunosuppression, recipients who received kidneys from 3KO.7TG pigs rejected the xenografts via AMR. These data suggest that allosensitized recipients may be suitable candidates for xenografts from genetically modified porcine donors and could benefit from an optimized immunosuppression regimen designed to target the post-transplant humoral response, thereby avoiding AMR.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Imran Anwar
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Isabel DeLaura
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Andrew Barbas
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | | - Stuart Knechtle
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
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Vadori M, Cozzi E. Current challenges in xenotransplantation. Curr Opin Organ Transplant 2024; 29:205-211. [PMID: 38529696 PMCID: PMC11064916 DOI: 10.1097/mot.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW In recent years, the xenotransplantation science has advanced tremendously, with significant strides in both preclinical and clinical research. This review intends to describe the latest cutting-edge progress in knowledge and methodologies developed to overcome potential obstacles that may preclude the translation and successful application of clinical xenotransplantation. RECENT FINDINGS Preclinical studies have demonstrated that it is now possible to extend beyond two years survival of primate recipients of life saving xenografts. This has been accomplished thanks to the utilization of genetic engineering methodologies that have allowed the generation of specifically designed gene-edited pigs, a careful donor and recipient selection, and appropriate immunosuppressive strategies.In this light, the compassionate use of genetically modified pig hearts has been authorized in two human recipients and xenotransplants have also been achieved in human decedents. Although encouraging the preliminary results suggest that several challenges have yet to be fully addressed for a successful clinical translation of xenotransplantation. These challenges include immunologic, physiologic and biosafety aspects. SUMMARY Recent progress has paved the way for the initial compassionate use of pig organs in humans and sets the scene for a wider application of clinical xenotransplantation.
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Affiliation(s)
- Marta Vadori
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua
- Transplant Immunology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health Padua University Hospital, Padua, Italy
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Yuan Y, Cui Y, Zhao D, Yuan Y, Zhao Y, Li D, Jiang X, Zhao G. Complement networks in gene-edited pig xenotransplantation: enhancing transplant success and addressing organ shortage. J Transl Med 2024; 22:324. [PMID: 38566098 PMCID: PMC10986007 DOI: 10.1186/s12967-024-05136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
The shortage of organs for transplantation emphasizes the urgent need for alternative solutions. Xenotransplantation has emerged as a promising option due to the greater availability of donor organs. However, significant hurdles such as hyperacute rejection and organ ischemia-reperfusion injury pose major challenges, largely orchestrated by the complement system, and activated immune responses. The complement system, a pivotal component of innate immunity, acts as a natural barrier for xenotransplantation. To address the challenges of immune rejection, gene-edited pigs have become a focal point, aiming to shield donor organs from human immune responses and enhance the overall success of xenotransplantation. This comprehensive review aims to illuminate strategies for regulating complement networks to optimize the efficacy of gene-edited pig xenotransplantation. We begin by exploring the impact of the complement system on the effectiveness of xenotransplantation. Subsequently, we delve into the evaluation of key complement regulators specific to gene-edited pigs. To further understand the status of xenotransplantation, we discuss preclinical studies that utilize gene-edited pigs as a viable source of organs. These investigations provide valuable insights into the feasibility and potential success of xenotransplantation, offering a bridge between scientific advancements and clinical application.
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Affiliation(s)
- Yinglin Yuan
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuanyuan Cui
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dayue Zhao
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Yuan
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yanshuang Zhao
- Department of Pharmacy, The People's Hospital of Leshan, Leshan, China
| | - Danni Li
- Department of Pharmacy, Longquanyi District of Chengdu Maternity & Child Health Care Hospital, Chengdu, China
| | - Xiaomei Jiang
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Gaoping Zhao
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
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Li Z, Zhao M, Yang Y, Zou Z, Zhang L, Jiang F, Du D, Zhou P. Treatment of a MyD88 inhibitor alleviates rejection and inflammation in xenotransplantation by inhibiting dendritic cells activation and trained immunity in macrophages. Int Immunopharmacol 2024; 130:111664. [PMID: 38377850 DOI: 10.1016/j.intimp.2024.111664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Acute vascular rejection (AVR) and systemic inflammation in xenograft recipients (SIXR) negatively impact the xenografts survival, and novel immunosuppressants are required to improve survival outcomes. We previously reported that TJ-M2010-5, a myeloid differentiation factor 88 (MyD88) inhibitor, exerts excellent anti-rejection effects in allogeneic transplantation. The aim of the present study was to evaluate the efficacy of TJ-M2010-5 in preventing AVR and SIXR and to investigate whether combined treatment of TJ-M2010-5 with anti-CD154 antibody (MR1) could prolong xenograft survival furthermore. METHODS A model involving heart transplantation from Sprague-Dawley rats to BALB/c mice was established in vivo, and the xenografts developed typical AVR. Bone marrow-derived dendritic cells and macrophages were cultured to study the underlying mechanisms induced by rat cardiomyocyte lysate stimulation in vitro. RESULTS TJ-M2010-5 monotherapy prolonged xenograft survival, although combination treatment with MR1 further enhanced the anti-AVR and anti-SIXR effects with about 21 days graft survival, compared to monotherapy. TJ-M2010-5 reduced dendritic cell and macrophage activation induced by xenotransplantation, downregulated CD80/CD86 expression, suppressed B-cell activation and anti-donor antibody generation, reduced pro-inflammatory cytokine production and tissue factor expression, and attenuated epigenetic modifications underlying interleukin-6 and tumor necrosis factor-α production in macrophages by inhibiting nuclear factor kappa B nuclear translocation. CONCLUSIONS TJ-M2010-5 attenuated AVR and SIXR and contributed to xenograft survival by inhibiting dendritic cell and macrophage activation. A dual-system inhibition strategy combining TJ-M2010-5 with anti-CD154 antibody achieved better results in xenotransplantation.
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Affiliation(s)
- Zeyang Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Minghui Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yang Yang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhimiao Zou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Limin Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Fengchao Jiang
- Academy of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Dunfeng Du
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, China.
| | - Ping Zhou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, China.
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Abstract
Despite significant advances in the field of transplantation in the past two decades, current clinically available therapeutic options for immunomodulation remain fairly limited. The advent of calcineurin inhibitor-based immunosuppression has led to significant success in improving short-term graft survival; however, improvements in long-term graft survival have stalled. Solid organ transplantation provides a unique opportunity for immunomodulation of both the donor organ prior to implantation and the recipient post transplantation. Furthermore, therapies beyond targeting the adaptive immune system have the potential to ameliorate ischemic injury to the allograft and halt its aging process, augment its repair, and promote recipient immune tolerance. Other recent advances include expanding the donor pool by reducing organ discard, and bioengineering and genetically modifying organs from other species to generate transplantable organs. Therapies discussed here will likely be most impactful if individualized on the basis of specific donor and recipient considerations.
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Affiliation(s)
- Irma Husain
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA;
| | - Xunrong Luo
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA;
- Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina, USA
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7
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Xu H, He X. Developments in kidney xenotransplantation. Front Immunol 2024; 14:1242478. [PMID: 38274798 PMCID: PMC10808336 DOI: 10.3389/fimmu.2023.1242478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
The search for kidney xenografts that are appropriate for patients with end-stage renal disease has been ongoing since the beginning of the last century. The major cause of xenograft loss is hyperacute and acute rejection, and this has almost been overcome via scientific progress. The success of two pre-clinical trials of α1,3-galactosyltransferase gene-knockout porcine kidneys in brain-dead patients in 2021 triggered research enthusiasm for kidney xenotransplantation. This minireview summarizes key issues from an immunological perspective: the discovery of key xenoantigens, investigations into key co-stimulatory signal inhibition, gene-editing technology, and immune tolerance induction. Further developments in immunology, particularly immunometabolism, might help promote the long-term outcomes of kidney xenografts.
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Affiliation(s)
| | - Xiaozhou He
- Urology Department, Third Affiliated Hospital of Soochow University, Changzhou, China
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Lee S, Chung YS, Lee KW, Choi M, Sonn CH, Oh WJ, Hong HG, Shim J, Choi K, Kim SJ, Park JB, Kim TJ. Alteration of γδ T cell subsets in non-human primates transplanted with GGTA1 gene-deficient porcine blood vessels. Xenotransplantation 2024; 31:e12838. [PMID: 38112053 DOI: 10.1111/xen.12838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND αGal-deficient xenografts are protected from hyperacute rejection during xenotransplantation but are still rejected more rapidly than allografts. Despite studies showing the roles of non-Gal antibodies and αβ T cells in xenograft rejection, the involvement of γδ T cells in xenograft rejection has been limitedly investigated. METHODS Six male cynomolgus monkeys were transplanted with porcine vessel xenografts from wild-type (n = 3) or GGTA1 knockout (n = 3) pigs. We measured the proportions and T cell receptor (TCR) repertoires of blood γδ T cells before and after xenotransplant. Grafted porcine vessel-infiltrating immune cells were visualized at the end of experiments. RESULTS Blood γδ T cells expanded and infiltrated into the graft vessel adventitia following xenotransplantation of α-Gal-deficient pig blood vessels. Pre- and post-transplant analysis of γδ TCR repertoire revealed a transition in δ chain usage post-transplantation, with the expansion of several clonotypes of δ1, δ3, or δ7 chains. Furthermore, the distinctions between pre- and post-transplant δ chain usages were more prominent than those observed for γ chain usages. CONCLUSION γδ TCR repertoire was significantly altered by xenotransplantation, suggesting the role of γδ T cells in sustained xenoreactive immune responses.
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Affiliation(s)
- Sujin Lee
- Department of Immunology, Graduate School of Basic Medical Science, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Yun Shin Chung
- Department of Immunology, Graduate School of Basic Medical Science, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Miran Choi
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Chung Hee Sonn
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Won Jun Oh
- Department of Immunology, Graduate School of Basic Medical Science, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Hun Gi Hong
- Department of Immunology, Graduate School of Basic Medical Science, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Joohyun Shim
- Department of Transgenic Animal Research, Optipharm, Inc., Cheongju, Chungcheongbuk-do, Republic of Korea
| | - Kimyung Choi
- Department of Transgenic Animal Research, Optipharm, Inc., Cheongju, Chungcheongbuk-do, Republic of Korea
| | - Sung Joo Kim
- GenNBio Co., Ltd, Pyeongtaek, Gyeonggi-do, Republic of Korea
| | - Jae Berm Park
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Jin Kim
- Department of Immunology, Graduate School of Basic Medical Science, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
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Adams A, Cendales LC, Cooper DKC, Cozzi E, Gill J, Judd E, Katz E, Kirk AD, Fishman JA, Reese PP, Wall A, Markmann JF. American Society of Transplant Surgeons-American Society of Transplantation report of FDA meeting on regulatory expectations for xenotransplantation products. Am J Transplant 2023; 23:1290-1299. [PMID: 37217005 DOI: 10.1016/j.ajt.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023]
Abstract
In June 2022, the US Food and Drug Administration Center for Biologics Evaluation and Research held the 73rd meeting of the Cellular, Tissue, and Gene Therapies Advisory Committee for public discussion of regulatory expectations for xenotransplantation products. The members of a joint American Society of Transplant Surgeons/American Society of Transplantation committee on xenotransplantation compiled a meeting summary focusing on 7 topics believed to be key by the committee: (1) preclinical evidence supporting progression to a clinical trial, (2) porcine kidney function, (3) ethical aspects, (4) design of initial clinical trials, (5) infectious disease issues, (6) industry perspectives, and (7) regulatory oversight.
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Affiliation(s)
- Andrew Adams
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Linda C Cendales
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Cozzi
- Department of Cardiothoracic and Vascular Surgery, University of Padua, Padua, Italy
| | - John Gill
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Judd
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Allan D Kirk
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jay A Fishman
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA; Transplant Infectious Disease and Compromised Host Program and MGH Transplant Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter P Reese
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anji Wall
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - James F Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Anwar IJ, Berman DM, DeLaura I, Gao Q, Willman MA, Miller A, Gill A, Gill C, Perrin S, Ricordi C, Ruiz P, Song M, Ladowski JM, Kirk AD, Kenyon NS. The anti-CD40L monoclonal antibody AT-1501 promotes islet and kidney allograft survival and function in nonhuman primates. Sci Transl Med 2023; 15:eadf6376. [PMID: 37647390 PMCID: PMC10990482 DOI: 10.1126/scitranslmed.adf6376] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
Prior studies of anti-CD40 ligand (CD40L)-based immunosuppression demonstrated effective prevention of islet and kidney allograft rejection in nonhuman primate models; however, clinical development was halted because of thromboembolic complications. An anti-CD40L-specific monoclonal antibody, AT-1501 (Tegoprubart), was engineered to minimize risk of thromboembolic complications by reducing binding to Fcγ receptors expressed on platelets while preserving binding to CD40L. AT-1501 was tested in both a cynomolgus macaque model of intrahepatic islet allotransplantation and a rhesus macaque model of kidney allotransplantation. AT-1501 monotherapy led to long-term graft survival in both islet and kidney transplant models, confirming its immunosuppressive potential. Furthermore, AT-1501-based regimens after islet transplant resulted in higher C-peptide, greater appetite leading to weight gain, and reduced occurrence of cytomegalovirus reactivation compared with conventional immunosuppression. These data support AT-1501 as a safe and effective agent to promote both islet and kidney allograft survival and function in nonhuman primate models, warranting further testing in clinical trials.
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Affiliation(s)
- Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Dora M. Berman
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Qimeng Gao
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | | | - Allison Miller
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Alan Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | - Cindy Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | | | - Camillo Ricordi
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
- Department of Medicine, University of Miami; Miami, FL 33136, USA
| | - Philip Ruiz
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Joseph M Ladowski
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Allan D. Kirk
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
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11
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Lassiter G, Otsuka R, Hirose T, Rosales I, Karadagi A, Tomosugi T, Dehnadi A, Lee H, Colvin RB, Baardsnes J, Moraitis A, Smith EE, Ali Z, Berhe P, Mulder A, Meibohm B, Daugherty B, Fogarty S, Pierson RN, Lederman S, Kawai T. TNX-1500, a crystallizable fragment-modified anti-CD154 antibody, prolongs nonhuman primate renal allograft survival. Am J Transplant 2023; 23:1171-1181. [PMID: 37019335 PMCID: PMC10527606 DOI: 10.1016/j.ajt.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023]
Abstract
The blockade of the CD154-CD40 pathway with anti-CD154 monoclonal antibody has been a promising immunomodulatory approach to prevent allograft rejection. However, clinical trials of immunoglobulin G1 antibodies targeting this pathway revealed thrombogenic properties, which were subsequently shown to be mediated by crystallizable fragment (Fc)-gamma receptor IIa-dependent platelet activation. To prevent thromboembolic complications, an immunoglobulin G4 anti-CD154 monoclonal antibody, TNX-1500, which retains the fragment antigen binding region of ruplizumab (humanized 5c8, BG9588), was modified by protein engineering to decrease Fc binding to Fc-gamma receptor IIa while retaining certain other effector functions and pharmacokinetics comparable with natural antibodies. Here, we report that TNX-1500 treatment is not associated with platelet activation in vitro and consistently inhibits kidney allograft rejection in vivo without clinical or histologic evidence of prothrombotic phenomena. We conclude that TNX-1500 retains efficacy similar to that of 5c8 to prevent kidney allograft rejection while avoiding previously identified pathway-associated thromboembolic complications.
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Affiliation(s)
- Grace Lassiter
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryo Otsuka
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takayuki Hirose
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Karadagi
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Toshihide Tomosugi
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abbas Dehnadi
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hang Lee
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert B Colvin
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Anna Moraitis
- National Research Council, Montréal, Quebec H4P 2R2, Canada
| | - Emma E Smith
- National Research Council, Montréal, Quebec H4P 2R2, Canada
| | - Zahida Ali
- Charles River Laboratories, Skokie, Illinois, USA
| | - Phil Berhe
- Charles River Laboratories, Skokie, Illinois, USA
| | | | - Bernd Meibohm
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennesse, USA
| | | | | | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Seth Lederman
- Tonix Pharmaceuticals, Inc, Chatham, New Jersey, USA
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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12
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Swatek AM, Parekh KR. Lung Xenotransplantation. Thorac Surg Clin 2023; 33:291-297. [PMID: 37414485 DOI: 10.1016/j.thorsurg.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Although efforts have been made to expand the pool of donor lung allografts for human lung transplantation, a shortage remains. Lung xenotransplantation has been proposed as an alternative approach, but lung xenotransplantation in humans has not yet been reported. In addition, significant biological and ethical barriers will have to be addressed before clinical trials can be undertaken. However, significant progress has been made toward addressing biological incompatibilities that present a barrier, and recent advances in genetic engineering tools promise to accelerate further progress.
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Affiliation(s)
- Anthony M Swatek
- Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, SE500GH, Iowa City, IA 52242, USA
| | - Kalpaj R Parekh
- Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, SE500GH, Iowa City, IA 52242, USA.
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13
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Hara H, Yamamoto T, Wei HJ, Cooper DK. What Have We Learned From In Vitro Studies About Pig-to-primate Organ Transplantation? Transplantation 2023; 107:1265-1277. [PMID: 36536507 PMCID: PMC10205677 DOI: 10.1097/tp.0000000000004458] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Natural preformed and de novo antibodies against pig antigens are a major cause of pig xenograft rejection in nonhuman primates (NHPs). In vivo studies in pig-to-NHP models are time consuming. In vitro assays, for example, antibody binding to pig cells, complement-dependent cytotoxicity assays, provide valuable information quickly and inexpensively. Using in vitro assays for several years, it has been documented that (1) during the first year of life, humans and NHPs develop anti-wild-type pig antibodies, but humans develop no or minimal antibody to triple-knockout (TKO) pig cells. (2) Some adult humans have no or minimal antibodies to TKO pig cells and are therefore unlikely to rapidly reject a TKO organ, particularly if the organ also expresses human "protective" proteins. (3) There is good correlation between immunoglobulin (Ig)M (but no t IgG) binding and complement injury. (4) All Old World NHPs develop antibodies to TKO pig cells and are not optimal recipients of TKO organs. (5) galactosyltransferase gene-knockout/β4GalNT2KO pigs are preferred for Old World NHPs. (6) Humans develop anti-pig IgE and IgA antibodies against pig cells, but their role remains uncertain. (7) In a small percentage of allosensitized humans, antibodies that cross-react with swine leukocyte antigens may be detrimental to a pig organ xenograft. (8) Prior sensitization to pig antigens is unlikely to be detrimental to a subsequent allograft. (9) Deletion of expression of Gal and Neu5Gc is associated with a reduction in the T-cell response to pig cells. All of these valuable observations have largely predicted the results of in vivo studies.
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Affiliation(s)
- Hidetaka Hara
- College of Veterinary Medicine, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Takayuki Yamamoto
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Hong-Jiang Wei
- College of Veterinary Medicine, Yunnan Agricultural University, Kunming, Yunnan, China
- State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Yunnan Agricultural University, Kunming, Yunnan, China
| | - David K.C. Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA
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14
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Abstract
PURPOSE OF REVIEW The aim of this study was to highlight recent progress in xenotransplantation and discuss the remaining obstacles/steps before the FDA is likely to approve a clinical trial. RECENT FINDINGS Long-term survival of life-supporting xenografts in preclinical models has led to discussion of clinical trials of xenotransplantation. The reports of clinical cardiac xenotransplant based on compassionate use FDA approval and renal xenotransplants to brain-dead humans have led to further considerations of clinical trials. Discussions between the transplant community and the FDA have established critical next steps before a clinical trial of xenotransplants is likely to be approved. These steps include testing the clinical immunosuppression protocol and the organ from a genetically modified source animal in nonhuman primates with reproducible survival of at least 6 months. In addition, appropriate viral surveillance protocols and confirmation that the xenografts support appropriate human physiology are likely to be critical elements for FDA-approval. Finally, further studies in the human decedent model are likely to provide critical information about human immune and physiologic responses to xenografts. SUMMARY This review highlights the current progress in nonhuman primate models and recent reports of human xenotransplantation. It also describes the remaining hurdles and currently understood FDA requirements that remain to be achieved before a clinical trial of xenotransplantation can be approved.
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Affiliation(s)
- Daniel H Wolbrom
- Columbia Center for Translational Immunology, Columbia University College of Physicians and Surgeons
| | - Jacqueline I Kim
- NYU Langone Medical Center, Transplant Institute, New York, New York, USA
| | - Adam Griesemer
- Columbia Center for Translational Immunology, Columbia University College of Physicians and Surgeons
- NYU Langone Medical Center, Transplant Institute, New York, New York, USA
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15
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Hansen-Estruch C, Bikhet MH, Javed M, Katsurada A, Satou R, Shao W, Ayares D, Venkataramanan R, Cooper DKC, Judd E, Navar LG. Renin-angiotensin-aldosterone system function in the pig-to-baboon kidney xenotransplantation model. Am J Transplant 2023; 23:353-365. [PMID: 36695679 PMCID: PMC10124771 DOI: 10.1016/j.ajt.2022.11.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 10/31/2022] [Accepted: 11/22/2022] [Indexed: 01/07/2023]
Abstract
After pig-to-baboon kidney transplantation, episodes of hypovolemia and hypotension from an unexplained mechanism have been reported. This study evaluated the renin-angiotensin-aldosterone system post-kidney xenotransplantation. Kidneys from genetically-engineered pigs were transplanted into 5 immunosuppressed baboons after the excision of the native kidneys. Immunosuppressive therapy was based on the blockade of the CD40/CD154 costimulation pathway. Plasma renin, angiotensinogen (AGT), angiotensin II (Ang II), aldosterone levels, and urine osmolality and electrolytes were measured in healthy pigs, healthy nonimmunosuppressed baboons, and immunosuppressed baboons with life-supporting pig kidney grafts. After pig kidney transplantation, plasma renin and Ang II levels were not significantly different, although Ang II trended lower, even though plasma AGT and potassium were increased. Plasma aldosterone levels were unchanged. Urine osmolality and sodium concentration were decreased. Even in the presence of increasing AGT and potassium levels, lower plasma Ang II concentrations may be because of reduced, albeit not absent, the reactivity of pig renin to cleave baboon AGT, suggesting an impaired response of the renin-angiotensin-aldosterone system to hypovolemic and hypotensive episodes. The maintenance of aldosterone may be protective. The reduced urine osmolality and sodium concentration reflect the decreased ability of the pig kidney to concentrate urine. These considerations should not prohibit successful clinical pig kidney xenotransplantation.
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Affiliation(s)
- Christophe Hansen-Estruch
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mohamed H Bikhet
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mariyam Javed
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Akemi Katsurada
- Department of Physiology and Hypertension and Renal Center, Tulane University, New Orleans, Louisiana, USA
| | - Ryousuke Satou
- Department of Physiology and Hypertension and Renal Center, Tulane University, New Orleans, Louisiana, USA
| | - Weijian Shao
- Department of Physiology and Hypertension and Renal Center, Tulane University, New Orleans, Louisiana, USA
| | | | - Raman Venkataramanan
- Clinical Pharmacokinetics Laboratory, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - David K C Cooper
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric Judd
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Luis Gabriel Navar
- Department of Physiology and Hypertension and Renal Center, Tulane University, New Orleans, Louisiana, USA
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16
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Shi T, Burg AR, Caldwell JT, Roskin K, Castro-Rojas CM, Chukwuma PC, Gray GI, Foote SG, Alonso J, Cuda CM, Allman DA, Rush JS, Regnier CH, Wieczorek G, Alloway RR, Shields AR, Baker BM, Woodle ES, Hildeman DA. Single cell transcriptomic analysis of renal allograft rejection reveals novel insights into intragraft TCR clonality. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.08.524808. [PMID: 36798151 PMCID: PMC9934650 DOI: 10.1101/2023.02.08.524808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Bulk analysis of renal allograft biopsies (rBx) identified RNA transcripts associated with acute cellular rejection (ACR); however, these lacked cellular context critical to mechanistic understanding. We performed combined single cell RNA transcriptomic and TCRα/β sequencing on rBx from patients with ACR under differing immunosuppression (IS): tacrolimus, iscalimab, and belatacept. TCR analysis revealed a highly restricted CD8 + T cell clonal expansion (CD8 EXP ), independent of HLA mismatch or IS type. Subcloning of TCRα/β cDNAs from CD8 EXP into Jurkat76 cells (TCR -/- ) conferred alloreactivity by mixed lymphocyte reaction. scRNAseq analysis of CD8 EXP revealed effector, memory, and exhausted phenotypes that were influenced by IS type. Successful anti-rejection treatment decreased, but did not eliminate, CD8 EXP , while CD8 EXP were maintained during treatment-refractory rejection. Finally, most rBx-derived CD8 EXP were also observed in matching urine samples. Overall, our data define the clonal CD8 + T cell response to ACR, providing novel insights to improve detection, assessment, and treatment of rejection.
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17
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Tector AJ, Adams AB, Tector M. Current Status of Renal Xenotransplantation and Next Steps. KIDNEY360 2023; 4:278-284. [PMID: 36821619 PMCID: PMC10103350 DOI: 10.34067/kid.0007152021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/18/2022] [Indexed: 12/23/2022]
Abstract
Renal transplantation is the preferred treatment of ESKD, but the shortage of suitable donor kidneys from the cadaver pool means that many patients with ESKD will not receive a kidney transplant. Xenotransplantation has long represented a solution to the kidney shortage, but the occurrence of antibody-mediated rejection has precluded its clinical development. Developments in somatic cell nuclear transfer in pigs and gene editing tools have led to the creation of new donor pigs with greatly improved crossmatches to patients. In addition, improvements in preclinical kidney xenotransplant survival using new anti-CD40/CD154-based immunosuppression have pushed xenotransplantation to the point where it is reasonable to consider initiating a clinical trial to evaluate this potential therapy in patients.
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Affiliation(s)
- Alfred J. Tector
- Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Andrew B. Adams
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota
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18
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Cooper DKC, Habibabady Z, Kinoshita K, Hara H, Pierson RN. The respective relevance of sensitization to alloantigens and xenoantigens in pig organ xenotransplantation. Hum Immunol 2023; 84:18-26. [PMID: 35817653 PMCID: PMC10154072 DOI: 10.1016/j.humimm.2022.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Antibody-mediated rejection is a major cause of graft injury and contributes to failure of pig xenografts in nonhuman primates (NHPs). Most 'natural' or elicited antibodies found in humans and NHPs are directed against pig glycan antigens, but antibodies binding to swine leukocyte antigens (SLA) have also been detected. Of clinical importance is (i) whether the presence of high levels of antibodies directed towards human leukocyte antigens (HLA) (i.e., high panel-reactive antibodies) would be detrimental to the outcome of a pig organ xenograft; and (ii) whether, in the event of sensitization to pig antigens, a subsequent allotransplant would be at increased risk of graft failure due to elicited anti-pig antibodies that cross-react with human HLA or other antigens. SUMMARY A literature review of pig-to-primate studies indicates that relatively few highly-HLA-sensitized humans have antibodies that cross-react with pigs, predicting that most would not be at increased risk of rejecting an organ xenograft. Furthermore, the existing evidence indicates that sensitization to pig antigens will probably not elicit increased alloantibody titers; if so, 'bridging' with a pig organ could be carried out without increased risk of subsequent antibody-mediated allograft failure. KEY MESSAGE These issues have important implications for the design and conduct of clinical xenotransplantation trials.
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Affiliation(s)
- D K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
| | - Z Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - K Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - H Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - R N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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19
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Mohiuddin MM, Singh AK, Goerlich CE. Preclinical rationale and current pathways to support the first human clinical trials in cardiac xenotransplantation. Hum Immunol 2023; 84:34-42. [PMID: 35851182 PMCID: PMC10154071 DOI: 10.1016/j.humimm.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
Recent initiation of the first FDA-approved cardiac xenotransplantation suggests xenotransplantation could soon become a therapeutic option for patients unable to undergo allotransplantation. Until xenotransplantation is widely applied in clinical practice, consideration of benefit versus risk and approaches to management of clinical xenografts will based at least in part on observations made in experimental xenotransplantation in non-human primates. Indeed, the decision to proceed with clinical trials reflects significant progress in last few years in experimental solid organ and cellular xenotransplantation. Our laboratory at the NIH and now at University of Maryland contributed to this progress, with heterotopic cardiac xenografts surviving more than two years and life-supporting cardiac xenografts survival up to 9 months. Here we describe our contributions to the understanding of the mechanism of cardiac xenograft rejection and development of methods to overcome past hurdles, and finally we share our opinion on the remaining barriers to clinical translation. We also discuss how the first in human xenotransplants might be performed, recipients managed, and graft function monitored.
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20
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Lei T, Chen L, Wang K, Du S, Gonelle-Gispert C, Wang Y, Buhler LH. Genetic engineering of pigs for xenotransplantation to overcome immune rejection and physiological incompatibilities: The first clinical steps. Front Immunol 2022; 13:1031185. [PMID: 36561750 PMCID: PMC9766364 DOI: 10.3389/fimmu.2022.1031185] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Xenotransplantation has the potential to solve the shortfall of human organ donors. Genetically modified pigs have been considered as potential animal donors for human xenotransplantation and have been widely used in preclinical research. The genetic modifications aim to prevent the major species-specific barriers, which include humoral and cellular immune responses, and physiological incompatibilities such as complement and coagulation dysfunctions. Genetically modified pigs can be created by deleting several pig genes related to the synthesis of various pig specific antigens or by inserting human complement- and coagulation-regulatory transgenes. Finally, in order to reduce the risk of infection, genes related to porcine endogenous retroviruses can be knocked down. In this review, we focus on genetically modified pigs and comprehensively summarize the immunological mechanism of xenograft rejection and recent progress in preclinical and clinical studies. Overall, both genetically engineered pig-based xenografts and technological breakthroughs in the biomedical field provide a promising foundation for pig-to-human xenotransplantation in the future.
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Affiliation(s)
- Tiantian Lei
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Lin Chen
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Kejing Wang
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Suya Du
- Department of Clinical Pharmacy, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
| | - Yi Wang
- Department of Critical Care Medicine, Sichuan Academy of Medical Science and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
| | - Leo H. Buhler
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
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21
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Lucander ACK, Judd E, Cooper DKC. What is the clinical relevance of deviant serum calcium and phosphate levels after pig-to-primate kidney xenotransplantation? Xenotransplantation 2022; 29:e12785. [PMID: 36300760 PMCID: PMC10154070 DOI: 10.1111/xen.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 01/15/2023]
Abstract
Experience from human renal allotransplantation informs us that disturbances in serum calcium and phosphate levels are relatively common. Post-transplant hypercalcemia is associated with an increased risk of recipient mortality, but not of graft loss or nephropathy, and post-transplant hyperphosphatemia with an increased risk of both recipient mortality and death-censored graft failure, but neither post-transplant hypocalcemia nor hypophosphatemia is associated with adverse outcome. Studies after pig-to-nonhuman primate kidney xenotransplantation have demonstrated consistent supranormal serum calcium and subnormal serum phosphate levels. If these trends in serum electrolyte levels were to occur following pig-to-human kidney xenotransplantation, the data from allotransplant studies would indicate an increased risk of recipient mortality (associated with hypercalcemia) but not of graft loss or nephropathy, and no adverse outcome from hypophosphatemia. Furthermore, some nonhuman primates are now surviving in a healthy state for longer than a year after life-supporting pig kidney transplantation, suggesting that chronic hypercalcemia and/or hypophosphatemia are not detrimental to long-term survival, and should not prevent clinical trials of pig kidney transplantation from being undertaken.
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Affiliation(s)
- Aaron C K Lucander
- Medical Scientist Training Program, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Eric Judd
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Charlestown, Massachusetts, USA
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22
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Niemann H. Xenotransplantate vom Schwein – ist das Ende des Organmangels
in Sicht? TRANSFUSIONSMEDIZIN 2022. [DOI: 10.1055/a-1814-8440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungUnter „Xenotransplantation“ wird die Übertragung von
funktionsfähigen Zellen, Geweben oder Organen zwischen verschiedenen
Spezies verstanden, insbesondere von Schweinen auf den Menschen. In den meisten
Industrieländern klafft eine große Lücke zwischen der
Anzahl geeigneter Spenderorgane und der Anzahl benötigter Transplantate.
Weltweit können nur etwa 10% des Organbedarfs durch Spenden
gedeckt werden. Eine erfolgreiche Xenotransplantation könnte diesen
Mangel mildern oder sogar weitgehend vermeiden. Das Schwein wird aus
verschiedenen Erwägungen heraus als am besten geeignete Spenderspezies
angesehen. Bei einer Übertragung porziner Organe auf Primaten treten
verschiedene immunologisch bedingte Abstoßungsreaktionen auf, die das
übertragene Organ innerhalb kurzer Zeit zerstören
können, wie die HAR (hyperakute Abstoßung), die AVR (akute
vaskuläre Abstoßung) und die spätere zelluläre
Abstoßung. Diese Abstoßungsreaktionen müssen durch
genetische Modifikationen im Schwein und eine geeignete immunsuppressive
Behandlung des Empfängers kontrolliert werden. Dazu müssen Tiere
mit mehrfachen genetischen Veränderungen produziert und im Hinblick auf
ihre Eignung für eine erfolgreiche Xenotransplantation geprüft
werden. Inzwischen können die HAR und auch die AVR durch Knockouts von
antigenen Oberflächenepitopen (z. B. αGal
[Galaktose-α1,3-Galaktose]) und transgene Expression humaner Gene mit
antiinflammatorischer, antiapoptotischer oder antikoagulativer Wirkung
zuverlässig kontrolliert werden. Nach orthotopen Transplantationen in
nicht humane Primaten konnten inzwischen mit Schweineherzen
Überlebensraten von bis zu 264 Tagen und mit porzinen Nieren von 435
Tagen erzielt werden. Eine Übertragung pathogener Erreger auf den
Empfänger kann bei Einhaltung einschlägiger
Hygienemaßnahmen ausgeschlossen werden. PERV (porzine endogene
Retroviren) können durch RNA-(Ribonukleinsäure-)Interferenz oder
Gen-Knockout ausgeschaltet werden. Sie stellen damit kein
Übertragungsrisiko für den Empfänger mehr dar. Anfang
2022 wurde in Baltimore (USA) ein Schweineherz mit 10 genetischen Modifikationen
auf einen Patienten mit schwerem Herzleiden übertragen, mit dem der
Empfänger 2 Monate offenbar ohne größere Probleme lebte.
Es wird erwartet, dass Xenotransplantate vom Schwein in absehbarer Zeit zur
klinischen Anwendungsreife kommen werden. Dazu werden klinische Versuche zur
systematischen Erfassung aller Auswirkungen solcher Transplantate auf den
Patienten sowie geeignete rechtliche und finanzielle Rahmenbedingungen
benötigt.
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23
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Petitpas K, Habibabady Z, Ritchie V, Connolly MR, Burdorf L, Qin W, Kan Y, Layer JV, Crabtree JN, Youd ME, Westlin WF, Magnani DM, Pierson RN, Azimzadeh AM. Genetic modifications designed for xenotransplantation attenuate sialoadhesin-dependent binding of human erythrocytes to porcine macrophages. Xenotransplantation 2022; 29:e12780. [PMID: 36125388 PMCID: PMC10152518 DOI: 10.1111/xen.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/11/2022] [Accepted: 09/01/2022] [Indexed: 01/15/2023]
Abstract
The phenomenon of diminishing hematocrit after in vivo liver and lung xenotransplantation and during ex vivo liver xenoperfusion has largely been attributed to action by resident liver porcine macrophages, which bind and destroy human erythrocytes. Porcine sialoadhesin (siglec-1) was implicated previously in this interaction. This study examines the effect of porcine genetic modifications, including knockout of the CMAH gene responsible for expression of Neu5Gc sialic acid, on the adhesion of human red blood cells (RBCs) to porcine macrophages. Wild-type (WT) porcine macrophages and macrophages from several strains of genetically engineered pigs, including CMAH gene knockout and several human transgenes (TKO+hTg), were incubated with human RBCs and "rosettes" (≥3 erythrocytes bound to one macrophage) were quantified by microscopy. Our results show that TKO+hTg genetic modifications significantly reduced rosette formation. The monoclonal antibody 1F1, which blocks porcine sialoadhesin, significantly reduced rosette formation by WT and TKO+hTg macrophages compared with an isotype control antibody. Further, desialation of human RBCs with neuraminidase before addition to WT or TKO+hTg macrophages resulted in near-complete abrogation of rosette formation, to a level not significantly different from porcine RBC rosette formation on porcine macrophages. These observations are consistent with rosette formation being mediated by binding of sialic acid on human RBCs to sialoadhesin on porcine macrophages. In conclusion, the data predict that TKO+hTg genetic modifications, coupled with targeting of porcine sialoadhesin by the 1F1 mAb, will attenuate erythrocyte sequestration and anemia during ex vivo xenoperfusion and following in vivo liver, lung, and potentially other organ xenotransplantation.
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Affiliation(s)
- Kaitlyn Petitpas
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Zahra Habibabady
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Veronica Ritchie
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | | | - Lars Burdorf
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Wenning Qin
- eGenesis Inc., Cambridge, Massachusetts, USA
| | - Yinan Kan
- eGenesis Inc., Cambridge, Massachusetts, USA
| | | | | | | | | | | | - Richard N Pierson
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Agnes M Azimzadeh
- MGH, Center for Transplantation Sciences, Boston, Massachusetts, USA
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24
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Sykes M, Sachs DH. Progress in xenotransplantation: overcoming immune barriers. Nat Rev Nephrol 2022; 18:745-761. [PMID: 36198911 DOI: 10.1038/s41581-022-00624-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 11/09/2022]
Abstract
A major limitation of organ allotransplantation is the insufficient supply of donor organs. Consequently, thousands of patients die every year while waiting for a transplant. Progress in xenotransplantation that has permitted pig organ graft survivals of years in non-human primates has led to renewed excitement about the potential of this approach to alleviate the organ shortage. In 2022, the first pig-to-human heart transplant was performed on a compassionate use basis, and xenotransplantation experiments using pig kidneys in deceased human recipients provided encouraging data. Many advances in xenotransplantation have resulted from improvements in the ability to genetically modify pigs using CRISPR-Cas9 and other methodologies. Gene editing has the capacity to generate pig organs that more closely resemble those of humans and are hence more physiologically compatible and less prone to rejection. Despite such modifications, immune responses to xenografts remain powerful and multi-faceted, involving innate immune components that do not attack allografts. Thus, the induction of innate and adaptive immune tolerance to prevent rejection while preserving the capacity of the immune system to protect the recipient and the graft from infection is desirable to enable clinical xenotransplantation.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY, USA. .,Department of Surgery, Columbia University, New York, NY, USA. .,Department of Microbiology and Immunology, Columbia University, New York, NY, USA.
| | - David H Sachs
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY, USA. .,Department of Surgery, Columbia University, New York, NY, USA.
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25
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Cooper DK. Advancing Xenotransplantation to the Clinic: How Relevant Is the Pig-to-nonhuman Primate Kidney Transplantation Model Today? Transplantation 2022; 106:1717-1719. [PMID: 35323162 PMCID: PMC10124766 DOI: 10.1097/tp.0000000000004097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David K.C. Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
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26
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Hansen-Estruch C, Porrett PM, Kumar V, Locke JE. The science of xenotransplantation for nephrologists. Curr Opin Nephrol Hypertens 2022; 31:387-393. [PMID: 35703221 DOI: 10.1097/mnh.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW The field of xenotransplantation has seen remarkable progress since its inception with recent preclinical trials in human recipients pushing kidney xenotransplantation one-step closer to clinical reality. In this review, we update practicing clinicians on recent advances in kidney xenotransplantation given the proximity of clinical trials in humans. RECENT FINDINGS Early studies in the field established the physiologic basis of xenotransplantation and suggested that the pig kidney will support human physiology. Genetic engineering of source pigs has greatly reduced the immunogenicity of kidney grafts, and studies in nonhuman primates have demonstrated the viability of kidney xenotransplants for months after transplantation. Finally, a recent study in a novel preclinical human model demonstrated that key findings in NHP experiments are generalizable to humans, namely, the absence of hyperacute rejection. SUMMARY Overall, it appears that critical physiologic, immunologic and technical barriers to implementation of clinical trials in humans have been overcome.
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Affiliation(s)
| | - Paige M Porrett
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
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27
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Carrier AN, Verma A, Mohiuddin M, Pascual M, Muller YD, Longchamp A, Bhati C, Buhler LH, Maluf DG, Meier RPH. Xenotransplantation: A New Era. Front Immunol 2022; 13:900594. [PMID: 35757701 PMCID: PMC9218200 DOI: 10.3389/fimmu.2022.900594] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Organ allotransplantation has now reached an impassable ceiling inherent to the limited supply of human donor organs. In the United States, there are currently over 100,000 individuals on the national transplant waiting list awaiting a kidney, heart, and/or liver transplant. This is in contrast with only a fraction of them receiving a living or deceased donor allograft. Given the morbidity, mortality, costs, or absence of supportive treatments, xenotransplant has the potential to address the critical shortage in organ grafts. Last decade research efforts focused on creation of donor organs from pigs with various genes edited out using CRISPR technologies and utilizing non-human primates for trial. Three groups in the United States have recently moved forward with trials in human subjects and obtained initial successful results with pig-to-human heart and kidney xenotransplantation. This review serves as a brief discussion of the recent progress in xenotransplantation research, particularly as it concerns utilization of porcine heart, renal, and liver xenografts in clinical practice.
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Affiliation(s)
- Amber N Carrier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Anjali Verma
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Muhammad Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Manuel Pascual
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Yannick D Muller
- Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Chandra Bhati
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Leo H Buhler
- Faculty of Science and Medicine, Section of Medicine, University of Fribourg, Fribourg, Switzerland
| | - Daniel G Maluf
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Raphael P H Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
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28
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Zhang J, Xu Y, Zhang Y, Bossila EA, Shi M, Zhao Y. Bioinformatic analysis as a first step to predict the compatibility of hematopoiesis and immune system genes between humans and pigs. Xenotransplantation 2022; 29:e12764. [PMID: 35695327 DOI: 10.1111/xen.12764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
The shortage of allogeneic donor organs leaves its supply far short of clinical need. There are great expectations on xenotransplantation, especially with pigs' organs. With the genetic modification of donor pigs, the rejection and cross-species transmission issues have now been widely addressed. However, research on the compatibility of genes between humans and pigs was limited. We performed a systematic screening analysis of predicted incompatible genes between humans and pigs, judged by low protein sequence similarities or different predicted protein domain compositions. By combining with gene set enrichment analysis, we screened out several key genes of hematopoiesis and the immune system with possible incompatibilities, which might be important for establishing chimera and xenotransplantation between humans and pigs. There were seven chemokine genes, including CCL1, CCL5, CCL24, CCL25, CCL28, CXCL12, and CXCL16, that exhibited limited similarity between humans and pigs (similarity < 0.8). Among hematopoiesis process-related genes, 15 genes of adhesion molecules, Notch ligands, and cytokine receptors exhibited differences between humans and pigs. In complement and coagulation cascades, 19 genes showed low similarity and 77 genes had different domain compositions between humans and pigs. Our study provides a good reference for further genetic modification of pigs, which might be beneficial for xenotransplantation.
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Affiliation(s)
- Jiayu Zhang
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Yanan Xu
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Yingzi Zhang
- Biological and Environmental Sciences and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Elhusseny A Bossila
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China.,Biotechnology Department, Faculty of Agriculture Al-Azhar University, Cairo, Egypt
| | - Mingpu Shi
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Yong Zhao
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China.,Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
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29
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Ganchiku Y, Riella LV. Pig-to-human kidney transplantation using brain-dead donors as recipients: One giant leap, or only one small step for transplantkind? Xenotransplantation 2022; 29:e12748. [PMID: 35616243 DOI: 10.1111/xen.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/11/2022]
Abstract
Pig kidney xenotransplantation is increasingly regarded as a realistic solution to the current shortage of human organ donors for patients with end-stage organ failure. Recently, the news of three pig-to-human transplantation cases has awakened public interest. Notably, the case by the Alabama team reported detailed and important findings for the xenotransplantation field. Using a genetically modified pig, two porcine kidneys were transplanted into a brain-dead recipient. They applied several approaches established in the preclinical NHP study, including gene-edited pig kidney graft and preoperative laboratory inspection such as crossmatching and infection screening. The pig-to-human kidney xenotransplantation had no unexpected events during surgery or evidence of hyperacute rejection. Unfortunately, the grafts did not work appropriately, and the study had to be terminated due to the decompensation of the recipient. While this study demonstrated the outstanding achievement in this research area, it also revealed remaining gaps to move xenotransplantation to the clinic. While brain-dead human recipients could reinforce the compatibility achievements of gene-edited pigs in NHP, their pro-inflammatory and pro-coagulant environment, in combination with short-duration of experiments will limit the assessment of kidney function, infection and rejection risk post-transplant, in particular antibody-mediated rejection. The use of successful immunosuppressive protocols of non-human primates xenotransplant experiments including anti-CD154 antibody will be critical to maximize the success in the first in-human trials.
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Affiliation(s)
- Yoshikazu Ganchiku
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Lee H, Park EM, Ko N, Choi K, Oh KB, Kang HJ. Effect of Factor H on Complement Alternative Pathway Activation in Human Serum Remains on Porcine Cells Lacking N-Glycolylneuraminic Acid. Front Immunol 2022; 13:859261. [PMID: 35444661 PMCID: PMC9014258 DOI: 10.3389/fimmu.2022.859261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Triple knockout (TKO) donor pigs lacking alpha-1,3-galactose (Gal), N-glycolylneuraminic acid (Neu5Gc), and Sd(a) expressions were developed to improve the clinical success of xenotransplantation. Neu5Gc, a sialic acid expressed on cell surfaces, recruits factor H to protect cells from attack by the complement system. Lack of Neu5Gc expression may cause unwanted complement activation, abrogating the potential benefit of gene-modified donor pigs. To investigate whether TKO porcine cells display increased susceptibility to complement activation in human serum, pathway-specific complement activation, apoptosis, and human platelet aggregation by porcine cells were compared between alpha-1,3-galactosyltransferase gene-knockout (GTKO) and TKO porcine cells. Methods Primary porcine peripheral blood mononuclear cells (pPBMCs) and endothelial cells (pECs) from GTKO and TKO pigs were used. Cells were incubated in human serum diluted in gelatin veronal buffer (GVB++) or Mg++-EGTA GVB, and C3 deposition and apoptotic changes in these cells were measured by flow cytometry. C3 deposition levels were also measured after incubating these cells in 10% human serum supplemented with human factor H. Platelet aggregation in human platelet-rich plasma containing GTKO or TKO pECs was analyzed. Results The C3 deposition level in GTKO pPBMCs or pECs in GVB++ was significantly higher than that of TKO pPBMCs or pECs, respectively, but C3 deposition levels in Mg++-EGTA-GVB were comparable between them. The addition of factor H into the porcine cell suspension in 10% serum in Mg++ -EGTA-GVB inhibited C3 deposition in a dose-dependent manner, and the extent of inhibition by factor H was similar between GTKO and TKO porcine cells. The percentage of late apoptotic cells in porcine cell suspension in GVB++ increased with the addition of human serum, of which the net increase was significantly less in TKO pPBMCs than in GTKO pPBMCs. Finally, the lag time of platelet aggregation in recalcified human plasma was significantly prolonged in the presence of TKO pECs compared to that in the presence of GTKO pECs. Conclusion TKO genetic modification protects porcine cells from serum-induced complement activation and apoptotic changes, and delays recalcification-induced human platelet aggregation. It does not hamper factor H recruitment on cell surfaces, allowing the suppression of alternative complement pathway activation.
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Affiliation(s)
- Haneulnari Lee
- Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, South Korea
| | - Eun Mi Park
- Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, South Korea
| | - Nayoung Ko
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, South Korea
| | - Kimyung Choi
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, South Korea
| | - Keon Bong Oh
- Animal Biotechnology Division, National Institute of Animal Science, Rural Development Administration (RDA), Wanju, South Korea
| | - Hee Jung Kang
- Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, South Korea
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31
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Feng H, Li T, Du J, Xia Q, Wang L, Chen S, Zhu L, Pan D, Wang Y, Chen G. Both Natural and Induced Anti-Sda Antibodies Play Important Roles in GTKO Pig-to-Rhesus Monkey Xenotransplantation. Front Immunol 2022; 13:849711. [PMID: 35422817 PMCID: PMC9004458 DOI: 10.3389/fimmu.2022.849711] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/07/2022] [Indexed: 01/30/2023] Open
Abstract
Sda, produced by the B4GALNT2 enzyme, has been recognized as an important xenoantigen for pig-to-nonhuman primate xenotransplantation. However, little is known about Sda expression in pigs and its immunogenicity in xenotransplantation. In this study, peripheral blood mononuclear cells (PBMCs) were isolated from wildtype, GTKO (with high, moderate, and low Sda expression), GTKO/β4GalNT2KO, GTKO/CMAHKO, or GTKO/CMAHKO/β4GalNT2KO pigs. Anti-pig IgM/IgG binding and complement-dependent cytotoxicity (CDC) to pig PBMCs was measured by flow cytometry using pooled rhesus monkey sera (n=20) or human sera (n=20). As compared to wild-type pigs (n=12), GTKO pigs (n=17) had a significantly higher mean level of Sda expression on PBMCs and showed a greater individual difference in expression. Both the overall binding of monkey serum IgM/IgG antibody to GTKO pig PBMCs and CDC against these PBMCs decreased significantly with a progressive reduction in Sda expression, showing a clear dose-effect relationship. Both the monkey serum antibody binding and CDC decreased significantly after the additional deletion of Sda, whereas the binding of human serum antibody and CDC against the GTKO pig PBMCs were markedly reduced after the deletion of Neu5Gc in the pigs. In addition, anti-Sda antibody accounted for > 50% of the induced anti-non-Gal antibody at the time of rejection in two rhesus monkeys that received GTKO/hCD55 pig kidney xenotransplantation, and the anti-Sda antibody showed significant cytotoxic activity against GTKO pig cells. We conclude that both natural and induced anti-Sda antibodies play important roles in GTKO pig-to-rhesus monkey xenotransplantation, thus providing further evidence for GTKO/β4GalNT2KO pigs as the preferred organ source for rhesus monkeys as a preclinical model of xenotransplantation.
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Affiliation(s)
- Hao Feng
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Tao Li
- Department of Organ Transplantation, The Transplantation Institute of Hainan Medical University, The Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Jiaxiang Du
- Genetic Engineering Department, Chengdu Clonorgan Biotechnology Co., Ltd, Chengdu, China
| | - Qiangbing Xia
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Dengke Pan
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Yi Wang
- Department of Organ Transplantation, The Transplantation Institute of Hainan Medical University, The Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
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32
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Jagdale A, Nguyen H, Iwase H, Foote JB, Yamamoto T, Javed M, Ayares D, Anderson DJ, Eckhoff DE, Cooper DKC, Hara H. T and B lymphocyte dynamics after genetically-modified pig-to-baboon kidney xenotransplantation with an anti-CD40mAb-based immunosuppressive regimen. Transpl Immunol 2022; 71:101545. [PMID: 35114360 PMCID: PMC9395207 DOI: 10.1016/j.trim.2022.101545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim was to monitor recovery of T/B lymphocytes in baboons after depletion by anti-thymocyte globulin (ATG) and anti-CD20mAb (Rituximab), followed by pig kidney transplantation and maintenance therapy with an anti-CD40mAb-based regimen. METHODS In baboons (n = 14), induction was with ATG and anti-CD20mAb, and maintenance with (i) anti-CD40mAb, (ii) rapamycin, and (iii) methylprednisolone. Follow-up was for 6 months, or until rejection or other complication developed. Baboon blood was collected at intervals to measure T/B cells and subsets by flow cytometry. In a separate study in baboons receiving the same immunosuppressive regimen (n = 10), the populations of T/B lymphocytes in PBMCs, lymph nodes, and spleen were examined. RESULTS After induction therapy, the total lymphocyte count and the absolute numbers of CD3+, CD4+, and CD8+T cells fell by >80%, and no CD22+B cells remained (all p < 0.001). T cell numbers began to recover early, but no CD22+B cells were present in the blood for 2 months. Recovery of both T and B cells remained at <30% of baseline (p < 0.001), even if rejection developed. At 6 months, effector memory CD8+T cells had increased more than other T cell subsets, but a greater percentage of B cells were naïve. In contrast to blood and spleen, T and B cells were not depleted in lymph nodes. CONCLUSIONS ATG and anti-CD20mAb effectively decreased T and B lymphocytes in the blood and, in the presence of anti-CD40mAb maintenance therapy, recovery of these cells was inhibited. The recovery of effector memory CD8+T cells may be detrimental to long-term graft survival.
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Affiliation(s)
- Abhijit Jagdale
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Huy Nguyen
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hayato Iwase
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Mariyam Javed
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | | | | | - Devin E Eckhoff
- Department of Surgery, University of Alabama at Birmingham, AL, USA; Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hidetaka Hara
- Department of Surgery, University of Alabama at Birmingham, AL, USA.
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33
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Feng H, Li T, Du J, Xia Q, Wang L, Chen S, Zhu L, Pan D, Wang Y, Chen G. Both Natural and Induced Anti-Sda Antibodies Play Important Roles in GTKO Pig-to-Rhesus Monkey Xenotransplantation. Front Immunol 2022. [DOI: 10.3389/fimmu.2022.849711
expr 981672748 + 872648996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Sda, produced by the B4GALNT2 enzyme, has been recognized as an important xenoantigen for pig-to-nonhuman primate xenotransplantation. However, little is known about Sda expression in pigs and its immunogenicity in xenotransplantation. In this study, peripheral blood mononuclear cells (PBMCs) were isolated from wildtype, GTKO (with high, moderate, and low Sda expression), GTKO/β4GalNT2KO, GTKO/CMAHKO, or GTKO/CMAHKO/β4GalNT2KO pigs. Anti-pig IgM/IgG binding and complement-dependent cytotoxicity (CDC) to pig PBMCs was measured by flow cytometry using pooled rhesus monkey sera (n=20) or human sera (n=20). As compared to wild-type pigs (n=12), GTKO pigs (n=17) had a significantly higher mean level of Sda expression on PBMCs and showed a greater individual difference in expression. Both the overall binding of monkey serum IgM/IgG antibody to GTKO pig PBMCs and CDC against these PBMCs decreased significantly with a progressive reduction in Sda expression, showing a clear dose-effect relationship. Both the monkey serum antibody binding and CDC decreased significantly after the additional deletion of Sda, whereas the binding of human serum antibody and CDC against the GTKO pig PBMCs were markedly reduced after the deletion of Neu5Gc in the pigs. In addition, anti-Sda antibody accounted for > 50% of the induced anti-non-Gal antibody at the time of rejection in two rhesus monkeys that received GTKO/hCD55 pig kidney xenotransplantation, and the anti-Sda antibody showed significant cytotoxic activity against GTKO pig cells. We conclude that both natural and induced anti-Sda antibodies play important roles in GTKO pig-to-rhesus monkey xenotransplantation, thus providing further evidence for GTKO/β4GalNT2KO pigs as the preferred organ source for rhesus monkeys as a preclinical model of xenotransplantation.
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34
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Habibabady ZA, Sendil S, Ellett F, Pollok F, Elias GF, French BM, Sun W, Braileanu G, Burdorf L, Irimia D, Pierson RN, Azimzadeh AM. Human erythrocyte fragmentation during ex-vivo pig organ perfusion. Xenotransplantation 2022; 29:e12729. [PMID: 35112383 PMCID: PMC8995366 DOI: 10.1111/xen.12729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 01/25/2023]
Abstract
Platelet sequestration is a common process during organ reperfusion after transplantation. However, instead of lower platelet counts, when using traditional hemocytometers and light microscopy, we observed physiologically implausible platelet counts in the course of ex-vivo lung and liver xenograft organ perfusion studies. We employed conventional flow cytometry (FC) and imaging FC (AMINS ImageStream X) to investigate the findings and found platelet-sized fragments in the circulation that are mainly derived from red blood cell membranes. We speculate that this erythrocyte fragmentation contributes to anemia during in-vivo organ xenotransplant.
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Affiliation(s)
- Zahra A. Habibabady
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD,Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA
| | - Selin Sendil
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Felix Ellett
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard School of Medicine, and Shriners Burns Hospital, Boston, MA
| | - Franziska Pollok
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA,Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriela F. Elias
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA
| | - Beth M. French
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Gheorghe Braileanu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Lars Burdorf
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD,Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA
| | - Daniel Irimia
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard School of Medicine, and Shriners Burns Hospital, Boston, MA
| | - Richard N. Pierson
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD,Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA
| | - Agnes M. Azimzadeh
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD,Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, MA
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Cooper DKC. The 2021 IXA Keith Reemtsma Lecture: Moving xenotransplantation to the clinic. Xenotransplantation 2022; 29:e12723. [PMID: 34967057 PMCID: PMC8995333 DOI: 10.1111/xen.12723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 01/03/2023]
Abstract
Keith Reemtsma was a pioneer in xenotransplantation, the Honorary Founding President of the International Xenotransplantation Association (in 1998), and a wonderful personality. It is a privilege to be invited to give this lecture in his memory. If he were alive today, he would be delighted to see the progress that has been made in pig organ transplantation into nonhuman primate recipients. This progress has largely resulted from two major advances: (i) the increasing availability of pigs with multiple genetic manipulations aimed at protecting the cells of the organ from the primate immune response and (ii) the introduction of novel immunosuppressive agents that block the CD40/CD154 costimulation pathway. There is strong evidence from numerous in vitro studies that the transplantation of a triple-knockout pig organ, particularly if expressing several human protective proteins, into a patient is likely to be significantly more successful than if that same organ is transplanted into a nonhuman primate recipient. With this fact in mind, and in view of the advances currently being made, the time has surely come when we need to consider moving from the laboratory to the clinic. However, there are still questions we need to definitively resolve: (i) What exact genetic modifications do we need in the organ-source pig? (ii) What exact immunosuppressive regimen will we choose? (iii) How will we monitor the immune response and diagnose and treat rejection? and (iv) How do we plan to prevent or treat potential infectious complications? Furthermore, when these matters have been resolved, which patients will be offered a pig organ in the first trial? We have suggested that patients who are very unlikely to survive until a suitable deceased human donor kidney becomes available are those who should be considered for the initial trials. Assessing public attitudes to xenotransplantation is also important before embarking on a clinical trial. I suggest that progress is much more likely to be made from a small clinical trial than if we persist in carrying out experiments in an animal model that no longer mimics the clinical situation.
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Affiliation(s)
- David K. C. Cooper
- Center for Transplantation Sciences Department of Surgery Massachusetts General Hospital/Harvard Medical School Boston Massachusetts USA
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Li X, Wang Y, Yang H, Dai Y. Liver and Hepatocyte Transplantation: What Can Pigs Contribute? Front Immunol 2022; 12:802692. [PMID: 35095885 PMCID: PMC8795512 DOI: 10.3389/fimmu.2021.802692] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/30/2021] [Indexed: 12/25/2022] Open
Abstract
About one-fifth of the population suffers from liver diseases in China, meaning that liver disorders are prominent causative factors relating to the Chinese mortality rate. For patients with end-stage liver diseases such as hepatocellular carcinoma or acute liver diseases with life-threatening liver dysfunction, allogeneic liver transplantation is the only life-saving treatment. Hepatocyte transplantation is a promising alternative for patients with acute liver failure or those considered high risk for major surgery, particularly for the bridge-to-transplant period. However, the lack of donors has become a serious global problem. The clinical application of porcine xenogeneic livers and hepatocytes remains a potential solution to alleviate the donor shortage. Pig grafts of xenotransplantation play roles in providing liver support in recipients, together with the occurrence of rejection, thrombocytopenia, and blood coagulation dysfunction. In this review, we present an overview of the development, potential therapeutic impact, and remaining barriers in the clinical application of pig liver and hepatocyte xenotransplantation to humans and non-human primates. Donor pigs with optimized genetic modification combinations and highly effective immunosuppressive regimens should be further explored to improve the outcomes of xenogeneic liver and hepatocyte transplantation.
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Affiliation(s)
- Xiaoxue Li
- Jiangsu Key Laboratory of Xenotransplantation, Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Jiangsu Key Laboratory of Xenotransplantation, Nanjing Medical University, Nanjing, China.,Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China
| | - Haiyuan Yang
- Jiangsu Key Laboratory of Xenotransplantation, Nanjing Medical University, Nanjing, China.,Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China
| | - Yifan Dai
- Jiangsu Key Laboratory of Xenotransplantation, Nanjing Medical University, Nanjing, China.,Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China.,State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China.,Shenzhen Xenotransplantation Medical Engineering Research and Development Center, Institute of Translational Medicine, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
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Cooper DKC. Recent progress in the pig-to-nonhuman primate kidney transplantation model: Report of a symposium. Xenotransplantation 2022; 29:e12728. [PMID: 35001421 DOI: 10.1111/xen.12728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Abstract
Three excellent presentations at an industry-sponsored symposium at the (virtual) congress of the combined IXA/CTRMS (September 23-25, 2021) were directed to the value and limitations of the pig-to-nonhuman primate (NHP) kidney transplantation model. Daniel Firl and James Markmann provided a meta-analysis comparing the results of kidney allotransplantation and xenotransplantation in NHPs during the past 25 years. Remarkably, the authors had identified 73 published reports that included 910 individual experiments. Although recipient survival after allotransplantation was longer, the superiority over the survival of xenografts was less than anticipated. Given the excellent short- and medium-term results of clinical kidney allotransplantation today, these data provide hope that the results of clinical pig kidney xenotransplantation may prove significantly better than in NHPs. The authors identified several factors that were shown to statistically influence the success or failure of xenotransplantation. Jean Kwun provided valuable information relating to the longstanding question of whether the survival of a pig organ would be jeopardized if transplanted into an allosensitized recipient. He demonstrated that pig kidney transplantation in an HLA-sensitized patient may be at a disadvantage, although multiple genetic engineering of the organ-source pig significantly delayed rejection. In the initial clinical trials, therefore, it would seem wise to exclude any patient with evidence of anti-HLA antibodies. Andrew Adams reported longer survival (>1 year) of Rhesus monkeys with life-supporting pig kidney grafts than has been achieved previously. Although not consistently achieved, these excellent results were obtained with an anti-CD154mAb-based regimen after CD4+ T cell and partial CD20+ B cell depletion. Factors that might have contributed to this success, including the phenotype of the pig, the species of the recipient, the recipient's anti-pig antibody level, and the immunosuppressive regimen, were discussed. Importantly, pig kidney function appeared to be normal in long-term surviving monkeys. Each study contributed to our goal of introducing xenotransplantation into the clinic.
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Affiliation(s)
- David K C Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA
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Ma D, Hirose T, Lassiter G, Sasaki H, Rosales I, Coe TM, Rickert CG, Matheson R, Colvin RB, Qin W, Kan Y, Layer JV, Paragas VB, Stiede K, Hall KC, Youd ME, Queiroz LM, Westlin WF, Curtis M, Yang L, Markmann JF, Kawai T. Kidney transplantation from triple-knockout pigs expressing multiple human proteins in cynomolgus macaques. Am J Transplant 2022; 22:46-57. [PMID: 34331749 PMCID: PMC9291868 DOI: 10.1111/ajt.16780] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023]
Abstract
Porcine cells devoid of three major carbohydrate xenoantigens, αGal, Neu5GC, and SDa (TKO) exhibit markedly reduced binding of human natural antibodies. Therefore, it is anticipated that TKO pigs will be better donors for human xenotransplantation. However, previous studies on TKO pigs using old world monkeys (OWMs) have been disappointing because of higher anti-TKO pig antibodies in OWMs than humans. Here, we show that long-term survival of renal xenografts from TKO pigs that express additional human transgenes (hTGs) can be achieved in cynomolgus monkeys. Kidney xenografts from TKO-hTG pigs were transplanted into eight cynomolgus recipients without pre-screening for low anti-pig antibody titers. Two recipients of TKO-hTG xenografts with low expression of human complement regulatory proteins (CRPs) (TKO-A) survived for 2 and 61 days, whereas six recipients of TKO-hTG xenografts with high CRP expression (TKO-B) survived for 15, 20, 71, 135, 265, and 316 days. Prolonged CD4+ T cell depletion and low anti-pig antibody titers, which were previously reported important for long-term survival of αGal knock-out (GTKO) xenografts, were not always required for long-term survival of TKO-hTG renal xenografts. This study indicates that OWMs such as cynomolgus monkeys can be used as a relevant model for clinical application of xenotransplantation using TKO pigs.
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Affiliation(s)
- David Ma
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Takayuki Hirose
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Grace Lassiter
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Hajime Sasaki
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ivy Rosales
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Taylor M. Coe
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Charles G. Rickert
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Rudy Matheson
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Robert B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Yinan Kan
- eGenesis Inc.CambridgeMassachusettsUSA
| | | | | | | | | | | | | | | | | | | | - James F. Markmann
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
- eGenesis Inc.CambridgeMassachusettsUSA
| | - Tatsuo Kawai
- Center for Transplantation SciencesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Li T, Feng H, Du J, Xia Q, Cooper DKC, Jiang H, He S, Pan D, Chen G, Wang Y. Serum Antibody Binding and Cytotoxicity to Pig Cells in Chinese Subjects: Relevance to Clinical Renal Xenotransplantation. Front Immunol 2022; 13:844632. [PMID: 35418974 PMCID: PMC8996717 DOI: 10.3389/fimmu.2022.844632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/18/2022] [Indexed: 11/20/2022] Open
Abstract
Kidney xenotransplantation is expected to contribute to resolving the shortage of kidneys from deceased human donors. Although progress in experimental life-supporting pig renal xenotransplantation has been encouraging, there are still issues to be considered before a clinical trial can be initiated. We attempted to clarify some of these by an in vitro study. Blood was drawn from healthy volunteers (Volunteers, n=20), patients with end-stage renal disease (ESRD, n=20) pre-operation (Pre), and on Day 1 (POD 1) and Day 14 (POD 14) after renal allotransplantation, brain-dead organ donors (DBD, n=20), and renal allotransplant recipients who were currently experiencing T cell-mediated rejection (Allo-TCMR, n=20). Serum IgM/IgG binding to, and complement-dependent cytotoxicity (CDC) of, PBMCs and RBCs from (a) wild-type (WT), (b) α1,3-galactosyltransferase gene-knockout (GTKO), (c) GTKO/beta-1,4-N-acety1 galactosaminyltransferase 2-knockout (GTKO/β4GalNT2KO), (d) GTKO/cytidine monophosphate-N-acetylneuraminic acid hydroxylase-knockout (GTKO/CMAHKO), and (e) GTKO/β4GalNT2KO/CMAHKO/hCD55 (TKO/hCD55) pigs were measured by flow cytometry. We obtained the following results: (i) Serum IgM/IgG binding and CDC in Volunteers were significantly greater to WT, GTKO, and GTKO/β4GalNT2KO PBMCs or RBCs than to GTKO/CMAHKO and TKO/hCD55 cells; (ii) ESRD, DBD, and Allo-TCMR serum antibody binding and CDC to WT pig PBMCs were significantly greater than to GTKO, GTKO/β4GalNT2KO, GTKO/CMAHKO, and TKO/hCD55 cells; (iii) antibody binding to GTKO/CMAHKO pig cells was significantly lower in hemodialysis than peritoneal dialysis patients. (iv) Two of twenty allotransplantation recipients' serum IgG binding to GTKO pig PBMCs increased on POD14 compared with Pre, but IgG binding to GTKO pig RBCs did not; (v) In all sera, the lowest antibody binding and CDC were to GTKO/CMAHKO and TKO/CD55 pig cells. We conclude (i) CMAHKO in the pig may be critical to the success of clinical pig kidney xenotransplantation, and may be the most important after GTKO, at least in Chinese patients; (ii) subjects with ESRD, or who are immunosuppressed after kidney allotransplantation, and DBD, have lower levels of antibody binding and CDC to genetically-engineered pig cells than do volunteers; (iii) TKO pigs with selected human 'protective' transgenes, e.g., CD55, are likely to prove to be the optimal sources of kidneys for clinical xenotransplantation.
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Affiliation(s)
- Tao Li
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, The Transplantation Institute of Hainan Medical University, Haikou, China
| | - Hao Feng
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Jiaxiang Du
- Genetic Engineering Department, Chengdu Clonorgan Biotechnology Co., Ltd., Chengdu, China
| | - Qiangbing Xia
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Hongtao Jiang
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, The Transplantation Institute of Hainan Medical University, Haikou, China
| | - Songzhe He
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, The Transplantation Institute of Hainan Medical University, Haikou, China
| | - Dengke Pan
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- *Correspondence: Yi Wang, ; Gang Chen, ; Dengke Pan,
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
- *Correspondence: Yi Wang, ; Gang Chen, ; Dengke Pan,
| | - Yi Wang
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, The Transplantation Institute of Hainan Medical University, Haikou, China
- Department of Urology, Second Affiliated Hospital of University of South China, Hengyang, China
- *Correspondence: Yi Wang, ; Gang Chen, ; Dengke Pan,
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Feng H, Li T, Du J, Xia Q, Wang L, Chen S, Zhu L, Pan D, Wang Y, Chen G. Both Natural and Induced Anti-Sda Antibodies Play Important Roles in GTKO Pig-to-Rhesus Monkey Xenotransplantation. Front Immunol 2022. [PMID: 35422817 PMCID: PMC9004458 DOI: 10.3389/fimmu.2022.849711&set/a 866800723+810249609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Sda, produced by the B4GALNT2 enzyme, has been recognized as an important xenoantigen for pig-to-nonhuman primate xenotransplantation. However, little is known about Sda expression in pigs and its immunogenicity in xenotransplantation. In this study, peripheral blood mononuclear cells (PBMCs) were isolated from wildtype, GTKO (with high, moderate, and low Sda expression), GTKO/β4GalNT2KO, GTKO/CMAHKO, or GTKO/CMAHKO/β4GalNT2KO pigs. Anti-pig IgM/IgG binding and complement-dependent cytotoxicity (CDC) to pig PBMCs was measured by flow cytometry using pooled rhesus monkey sera (n=20) or human sera (n=20). As compared to wild-type pigs (n=12), GTKO pigs (n=17) had a significantly higher mean level of Sda expression on PBMCs and showed a greater individual difference in expression. Both the overall binding of monkey serum IgM/IgG antibody to GTKO pig PBMCs and CDC against these PBMCs decreased significantly with a progressive reduction in Sda expression, showing a clear dose-effect relationship. Both the monkey serum antibody binding and CDC decreased significantly after the additional deletion of Sda, whereas the binding of human serum antibody and CDC against the GTKO pig PBMCs were markedly reduced after the deletion of Neu5Gc in the pigs. In addition, anti-Sda antibody accounted for > 50% of the induced anti-non-Gal antibody at the time of rejection in two rhesus monkeys that received GTKO/hCD55 pig kidney xenotransplantation, and the anti-Sda antibody showed significant cytotoxic activity against GTKO pig cells. We conclude that both natural and induced anti-Sda antibodies play important roles in GTKO pig-to-rhesus monkey xenotransplantation, thus providing further evidence for GTKO/β4GalNT2KO pigs as the preferred organ source for rhesus monkeys as a preclinical model of xenotransplantation.
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Affiliation(s)
- Hao Feng
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Tao Li
- Department of Organ Transplantation, The Transplantation Institute of Hainan Medical University, The Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Jiaxiang Du
- Genetic Engineering Department, Chengdu Clonorgan Biotechnology Co., Ltd, Chengdu, China
| | - Qiangbing Xia
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
| | - Dengke Pan
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Yi Wang
- Department of Organ Transplantation, The Transplantation Institute of Hainan Medical University, The Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education and National Health Commission (NHC), Chinese Academy of Medical Sciences, Wuhan, China
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41
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Adams AB, Lovasik BP, Faber DA, Burlak C, Breeden C, Estrada JL, Reyes LM, Vianna RM, Tector MF, Tector AJ. Anti-C5 Antibody Tesidolumab Reduces Early Antibody-mediated Rejection and Prolongs Survival in Renal Xenotransplantation. Ann Surg 2021; 274:473-480. [PMID: 34238812 PMCID: PMC8915445 DOI: 10.1097/sla.0000000000004996] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Pig-to-primate renal xenotransplantation is plagued by early antibody-mediated graft loss which precludes clinical application of renal xenotransplantation. We evaluated whether temporary complement inhibition with anti-C5 antibody Tesidolumab could minimize the impact of early antibody-mediated rejection in rhesus monkeys receiving pig kidneys receiving costimulatory blockade-based immunosuppression. METHODS Double (Gal and Sda) and triple xenoantigen (Gal, Sda, and SLA I) pigs were created using CRISPR/Cas. Kidneys from DKO and TKO pigs were transplanted into rhesus monkeys that had the least reactive crossmatches. Recipients received anti-C5 antibody weekly for 70 days, and T cell depletion, anti-CD154, mycophenolic acid, and steroids as baseline immunosuppression (n = 7). Control recipients did not receive anti-C5 therapy (n = 10). RESULTS Temporary anti-C5 therapy reduced early graft loss secondary to antibody-mediated rejection and improved graft survival (P < 0.01). Deleting class I MHC (SLA I) in donor pigs did not ameliorate early antibody-mediated rejection (table). Anti-C5 therapy did not allow for the use of tacrolimus instead of anti-CD154 (table), prolonging survival to a maximum of 62 days. CONCLUSION Inhibition of the C5 complement subunit prolongs renal xenotransplant survival in a pig to non-human primate model.
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Affiliation(s)
- Andrew B Adams
- University of Minnesota School of Medicine, Minneapolis MN
| | | | | | | | | | | | - Luz M Reyes
- University of Miami School of Medicine, Miami, FL
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Jagdale A, Kumar V, Anderson DJ, Locke JE, Hanaway MJ, Eckhoff DE, Iwase H, Cooper DK. Suggested Patient Selection Criteria for Initial Clinical Trials of Pig Kidney Xenotransplantation in the United States. Transplantation 2021; 105:1904-1908. [PMID: 33481554 PMCID: PMC10124769 DOI: 10.1097/tp.0000000000003632] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a critical shortage of kidneys for transplantation into patients with kidney failure. Genetically-engineered pigs could provide an additional source. Increasing success is being reported of the transplantation of pig kidneys in nonhuman primates. Consideration is now being given to the selection of patients for the first clinical trial of pig kidney transplantation. In some US states, patients aged 55–65, particularly if of blood group O, may wait >5 years for a donor organ, by which time >50% are likely to have died or removed from the wait-list because they are no longer acceptable for transplantation. We suggest these patients, if otherwise healthy, might accept the opportunity of early pig kidney transplantation.
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Affiliation(s)
- Abhijit Jagdale
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Douglas J. Anderson
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E. Locke
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael J. Hanaway
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Devin E. Eckhoff
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K.C. Cooper
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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43
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Ladowski JM, Houp J, Hauptfeld-Dolejsek V, Javed M, Hara H, Cooper DKC. Aspects of histocompatibility testing in xenotransplantation. Transpl Immunol 2021; 67:101409. [PMID: 34015463 PMCID: PMC8197754 DOI: 10.1016/j.trim.2021.101409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 12/16/2022]
Abstract
Xenotransplantation, using genetically-modified pigs for clinical organ transplantation, is a solution to the organ shortage. The biggest barrier to clinical implementation is the antigenicity of pig cells. Humans possess preformed antibody to pig cells that initiate antibody-mediated rejection of pig organs in primates. Advances in genetic engineering have led to the development of a pig lacking the three known glycan xenoantigens (triple-knockout [TKO] pigs). A significant number of human sera demonstrate no antibody binding to TKO pig cells. As a result of the TKO pig's low antigen expression, survival of life-supporting pig organs in immunosuppressed nonhuman primates has significantly increased, and hope has been renewed for clinical trials of xenotransplantation. It is important to understand the context in which xenotransplantation's predecessor, allotransplantation, has been successful, and the steps needed for the success of xenotransplantation. Successful allotransplantation has been based on two main immunological approaches - (i) adequate immunosuppressive therapy, and (ii) careful histocompatibility matching. In vivo studies suggest that the available immunosuppressive regimens are adequate to suppress the human anti-pig cellular response. Methods to evaluate and screen patients for the first clinical xenotransplantation trial are the next challenge. The goal of this review is to summarize the history of histocompatibility testing, and the available tools that can be utilized to determine xenograft histocompatibility.
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Affiliation(s)
- Joseph M Ladowski
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Julie Houp
- Histocompatibility Laboratory, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Mariyam Javed
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Tomasi R, Tariq M, Hübner M, Strauss G, Längin M, Zeuzem-Lampert C, Vandewiele S, Kreth S, Abicht JM. T-Cell Response in a Cardiac Xenotransplant Model. EXP CLIN TRANSPLANT 2021; 19:708-716. [PMID: 34085920 DOI: 10.6002/ect.2020.0359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite the advances in preclinical cardiac xenotransplantation, the immune reactions caused by species differences are not fully understood. Hyperacute rejection can now be avoided using genetically engineered donor organs, but cellmediated rejection by the adaptive immune response has not been addressed successfully. Here we investigated the initial human pan-T-cell reaction using a pig-human blood working heart model. MATERIALS AND METHODS Porcine wild-type hearts (n = 7) were perfused with human blood in a biventricular working heart system for 3 hours. As control, blood from the same human donors was circulated without a pig heart. Pan-T cells were selectively extracted from blood taken before and at the end of the perfusion cycle. The relative mRNA expression of selected target genes (real-time quantitative polymerase chain reaction) and the expression of microRNAs were determined. RESULTS After xenogeneic organ perfusion, there was a moderate upregulation of several CD4+ marker cytokines (interleukin 2, interleukin 4, interferon γ) compared with control. We found a distinct increase in the mRNA expression of granzyme B and perforin, key markers of cytotoxic T cells. No differences in the marker genes of regulatory T cells were evident. Levels of the anti-inflammatory microRNAs miR-16 and miR-93 were significantly higher in the xenoperfused group than in the control group. CONCLUSIONS This study demonstrated that contact of human blood with pig endothelium activates cytotoxic T cells within the first few hours, indicating acute rejection processes. This is accompanied by upregulation of anti-inflammatory microRNAs, which may represent compensatory anti-inflammatory mechanisms.
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Affiliation(s)
- Roland Tomasi
- From the Department of Anesthesiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany.,From the Walter-Brendel Center of Experimental Medicine, Faculty of Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
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Lucander ACK, Nguyen H, Foote JB, Cooper DKC, Hara H. Immunological selection and monitoring of patients undergoing pig kidney transplantation. Xenotransplantation 2021; 28:e12686. [PMID: 33880816 DOI: 10.1111/xen.12686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/03/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023]
Abstract
Pig kidney xenotransplantation has the potential to alleviate the current shortage of deceased and living human organs and provide patients with end-stage renal disease with a greater opportunity for long-term survival and a better quality of life. In recent decades, advances in the genetic engineering of pigs and in immunosuppressive therapy have permitted the resolution of many historical obstacles to the success of pig kidney transplantation in nonhuman primates. Pig kidney xenotransplantation may soon be translated to the clinic. Given the potential risks of kidney xenotransplantation, particularly of immunologic rejection of the graft, potential patients must be carefully screened for inclusion in the initial clinical trials and immunologically monitored diligently post-transplantation. We provide an overview of the immunological methods we believe should be used to (i) screen potential patients for the first clinical trials to exclude those with a higher risk of rejection, and (ii) monitor patients with a pig kidney graft to determine their immunological response to the graft.
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Affiliation(s)
- Aaron C K Lucander
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Huy Nguyen
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Oligonucleotide-Based Therapies for Renal Diseases. Biomedicines 2021; 9:biomedicines9030303. [PMID: 33809425 PMCID: PMC8001091 DOI: 10.3390/biomedicines9030303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 02/07/2023] Open
Abstract
The global burden of chronic kidney disease (CKD) is increasing every year and represents a great cost for public healthcare systems, as the majority of these diseases are progressive. Therefore, there is an urgent need to develop new therapies. Oligonucleotide-based drugs are emerging as novel and promising alternatives to traditional drugs. Their expansion corresponds with new knowledge regarding the molecular basis underlying CKD, and they are already showing encouraging preclinical results, with two candidates being evaluated in clinical trials. However, despite recent technological advances, efficient kidney delivery remains challenging, and the presence of off-targets and side-effects precludes development and translation to the clinic. In this review, we provide an overview of the various oligotherapeutic strategies used preclinically, emphasizing the most recent findings in the field, together with the different strategies employed to achieve proper kidney delivery. The use of different nanotechnological platforms, including nanocarriers, nanoparticles, viral vectors or aptamers, and their potential for the development of more specific and effective treatments is also outlined.
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48
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Yu XH, Deng WY, Jiang HT, Li T, Wang Y. Kidney xenotransplantation: Recent progress in preclinical research. Clin Chim Acta 2020; 514:15-23. [PMID: 33301767 DOI: 10.1016/j.cca.2020.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 01/23/2023]
Abstract
Kidney transplantation is the most effective treatment for end-stage renal disease, but is limited by the increasing shortage of deceased and living human donor kidneys. Xenotransplantation using pig organs provides the possibility to resolve the issue of organ supply shortage and is regarded as the next great medical revolution. In the past five years, there have been sequential advances toward the prolongation of life-supporting pig kidney xenograft survival in non-human primates, with the longest survival being 499 days. This progress is due to the growing availability of pigs with multi-layered genetic modifications to overcome the pathobiological barriers and the application of a costimulation blockade-based immunosuppressive regimen. These encouraging results bring the hope to initiate the clinical trials of pig kidney transplantation in the near future. In this review, we summarized the latest advances regarding pig kidney xenotransplantation in preclinical models to provide a basis for future investigation and potential clinical translation.
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Affiliation(s)
- Xiao-Hua Yu
- Institute of Clinical Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; The Transplantation Institute of Hainan Medical University, Haikou, Hainan 460106, China
| | - Wen-Yi Deng
- Institute of Clinical Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; The Transplantation Institute of Hainan Medical University, Haikou, Hainan 460106, China
| | - Hong-Tao Jiang
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; The Transplantation Institute of Hainan Medical University, Haikou, Hainan 460106, China
| | - Tao Li
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; The Transplantation Institute of Hainan Medical University, Haikou, Hainan 460106, China
| | - Yi Wang
- Institute of Clinical Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 460106, China; The Transplantation Institute of Hainan Medical University, Haikou, Hainan 460106, China.
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Iwase H, Ball S, Adams K, Eyestone W, Walters A, Cooper DKC. Growth hormone receptor knockout: Relevance to xenotransplantation. Xenotransplantation 2020; 28:e12652. [PMID: 33058285 DOI: 10.1111/xen.12652] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/03/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
Xenotransplantation research has made considerable progress in recent years, largely through the increasing availability of pigs with multiple genetic modifications, effective immunosuppressive therapy, and anti-inflammatory therapy to protect pig tissues from the primate immune and inflammatory responses and correct molecular incompatibilities. Further study is required regarding identification and investigation of physiological incompatibilities. Although the exact cause remains uncertain, we and others have observed relatively rapid growth of kidney xenografts after transplantation into nonhuman primates (NHPs). There has also been some evidence of growth, or at least ventricular hypertrophy, of the pig heart after orthotopic transplantation into NHPs. Rapid growth could be problematic, particularly with regard to the heart within the relatively restricted confines of the chest. It has been suggested that the problem of rapid growth of the pig organ after transplantation could be resolved by growth hormone receptor (GHR) gene knockout in the pig. The GHR, although most well-known for regulating growth, has many other biological functions, including regulating metabolism and controlling physiological processes. Genetically modified GHRKO pigs have recently become available. We provide data on their growth compared to comparable pigs that do not include GHRKO, and we have reviewed the literature regarding the effect of GHRKO, and its relevance to xenotransplantation.
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Affiliation(s)
- Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Pierson RN, Burdorf L, Madsen JC, Lewis GD, D’Alessandro DA. Pig-to-human heart transplantation: Who goes first? Am J Transplant 2020; 20:2669-2674. [PMID: 32301262 PMCID: PMC9448330 DOI: 10.1111/ajt.15916] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 01/25/2023]
Abstract
Cardiac xenotransplantation has recently taken an important step towards clinical reality. In anticipation of the "first-in-human" heart xenotransplantation trial, we propose a set of patient characteristics that define potential candidates. Our premise is that, to be ethically justified, the risks posed by current state-of-the-art options must outweigh the anticipated risks of a pioneering xenotransplant procedure. Suitable candidates include patients who are at high immunologic risk because of sensitization to alloantigens, including those who have exhibited early onset or accelerated cardiac allograft vasculopathy. In addition, patients should be considered (1) for whom mechanical circulatory support would be prohibitively risky due to a hypercoagulable state, a contraindication to anticoagulation, or restrictive physiology; (2) with severe biventricular dysfunction predicting unsuccessful univentricular left heart support; and (3) adults with complex congenital heart disease. In conclusion, because the published preclinical benchmark for clinical translation of heart xenotransplantation appears within reach, carefully and deliberately defining appropriate trial participants is timely as the basis for ethical clinical trial design.
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Affiliation(s)
- Richard N. Pierson
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Lars Burdorf
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Joren C. Madsen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Gregory D. Lewis
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - David A. D’Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
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