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Annamalai C, Kute V, Sheridan C, Halawa A. Hematopoietic cell-based and non-hematopoietic cell-based strategies for immune tolerance induction in living-donor renal transplantation: A systematic review. Transplant Rev (Orlando) 2023; 37:100792. [PMID: 37709652 DOI: 10.1016/j.trre.2023.100792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/24/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Despite its use to prevent acute rejection, lifelong immunosuppression can adversely impact long-term patient and graft outcomes. In theory, immunosuppression withdrawal is the ultimate goal of kidney transplantation, and is made possible by the induction of immunological tolerance. The purpose of this paper is to review the safety and efficacy of immune tolerance induction strategies in living-donor kidney transplantation, both chimerism-based and non-chimerism-based. The impact of these strategies on transplant outcomes, including acute rejection, allograft function and survival, cost, and immune monitoring, will also be discussed. MATERIALS AND METHODS Databases such as PubMed, Scopus, and Web of Science, as well as additional online resources such as EBSCO, were exhaustively searched. Adult living-donor kidney transplant recipients who developed chimerism-based tolerance after concurrent bone marrow or hematopoietic stem cell transplantation or those who received non-chimerism-based, non-hematopoietic cell therapy using mesenchymal stromal cells, dendritic cells, or regulatory T cells were studied between 2000 and 2021. Individual sources of evidence were evaluated critically, and the strength of evidence and risk of bias for each outcome of the transplant tolerance study were assessed. RESULTS From 28,173 citations, 245 studies were retrieved after suitable exclusion and duplicate removal. Of these, 22 studies (2 RCTs, 11 cohort studies, 6 case-control studies, and 3 case reports) explicitly related to both interventions (chimerism- and non-chimerism-based immune tolerance) were used in the final review process and were critically appraised. According to the findings, chimerism-based strategies fostered immunotolerance, allowing for the safe withdrawal of immunosuppressive medications. Cell-based therapy, on the other hand, frequently did not induce tolerance except for minimising immunosuppression. As a result, the rejection rates, renal allograft function, and survival rates could not be directly compared between these two groups. While chimerism-based tolerance protocols posed safety concerns due to myelosuppression, including infections and graft-versus-host disease, cell-based strategies lacked these adverse effects and were largely safe. There was a lack of direct comparisons between HLA-identical and HLA-disparate recipients, and the cost implications were not examined in several of the retrieved studies. Most studies reported successful immunosuppressive weaning lasting at least 3 years (ranging up to 11.4 years in some studies), particularly with chimerism-based therapy, while only a few investigators used immune surveillance techniques. The studies reviewed were often limited by selection, classification, ascertainment, performance, and attrition bias. CONCLUSIONS This review demonstrates that chimerism-based hematopoietic strategies induce immune tolerance, and a substantial number of patients are successfully weaned off immunosuppression. Despite the risk of complications associated with myelosuppression. Non-chimerism-based, non-hematopoietic cell protocols, on the other hand, have been proven to facilitate immunosuppression minimization but seldom elicit immunological tolerance. However, the results of this review must be interpreted with caution because of the non-randomised study design, potential confounding, and small sample size of the included studies. Further validation and refinement of tolerogenic protocols in accordance with local practice preferences is also warranted, with an emphasis on patient selection, cost ramifications, and immunological surveillance based on reliable tolerance assays.
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Affiliation(s)
- Chandrashekar Annamalai
- Postgraduate School of Medicine, Institute of Teaching and Learning, Faculty of Health and Life Sciences, University of Liverpool, UK.
| | - Vivek Kute
- Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Carl Sheridan
- Department of Eye and Vision Science, Ocular Cell Transplantation, Faculty of Health and Life Sciences, University of Liverpool, UK
| | - Ahmed Halawa
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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2
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Mengrelis K, Muckenhuber M, Wekerle T. Chimerism-based Tolerance Induction in Clinical Transplantation: Its Foundations and Mechanisms. Transplantation 2023; 107:2473-2485. [PMID: 37046378 DOI: 10.1097/tp.0000000000004589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hematopoietic chimerism remains the most promising strategy to bring transplantation tolerance into clinical routine. The concept of chimerism-based tolerance aims to extend the recipient's mechanisms of self-tolerance (ie, clonal deletion, anergy, and regulation) to include the tolerization of donor antigens that are introduced through the cotransplantation of donor hematopoietic cells. For this to be successful, donor hematopoietic cells need to engraft in the recipient at least temporarily. Three pioneering clinical trials inducing chimerism-based tolerance in kidney transplantation have been published to date. Within this review, we discuss the mechanisms of tolerance that are associated with the specific therapeutic protocols of each trial. Recent data highlight the importance of regulation as a mechanism that maintains tolerance. Insufficient regulatory mechanisms are also a likely explanation for situations of tolerance failure despite persisting donor chimerism. After decades of preclinical development of chimerism protocols, mechanistic data from clinical trials have recently become increasingly important. Better understanding of the required mechanisms for tolerance to be induced in humans will be a key to design more reliable and less invasive chimerism protocols in the future.
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Affiliation(s)
- Konstantinos Mengrelis
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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3
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Sasaki H, Hirose T, Oura T, Otsuka R, Rosales I, Ma D, Lassiter G, Karadagi A, Tomosugi T, Dehnadi A, Matsunami M, Paul SR, Reeves PM, Hanekamp I, Schwartz S, Colvin RB, Lee H, Spitzer TR, Cosimi AB, Cippà PE, Fehr T, Kawai T. Selective Bcl-2 inhibition promotes hematopoietic chimerism and allograft tolerance without myelosuppression in nonhuman primates. Sci Transl Med 2023; 15:eadd5318. [PMID: 37018417 PMCID: PMC11022838 DOI: 10.1126/scitranslmed.add5318] [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: 06/16/2022] [Accepted: 03/02/2023] [Indexed: 04/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) has many potential applications beyond current standard indications, including treatment of autoimmune disease, gene therapy, and transplant tolerance induction. However, severe myelosuppression and other toxicities after myeloablative conditioning regimens have hampered wider clinical use. To achieve donor hematopoietic stem cell (HSC) engraftment, it appears essential to establish niches for the donor HSCs by depleting the host HSCs. To date, this has been achievable only by nonselective treatments such as irradiation or chemotherapeutic drugs. An approach that is capable of more selectively depleting host HSCs is needed to widen the clinical application of HSCT. Here, we show in a clinically relevant nonhuman primate model that selective inhibition of B cell lymphoma 2 (Bcl-2) promoted hematopoietic chimerism and renal allograft tolerance after partial deletion of HSCs and effective peripheral lymphocyte deletion while preserving myeloid cells and regulatory T cells. Although Bcl-2 inhibition alone was insufficient to induce hematopoietic chimerism, the addition of a Bcl-2 inhibitor resulted in promotion of hematopoietic chimerism and renal allograft tolerance despite using only half of the dose of total body irradiation previously required. Selective inhibition of Bcl-2 is therefore a promising approach to induce hematopoietic chimerism without myelosuppression and has the potential to render HSCT more feasible for a variety of clinical indications.
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Affiliation(s)
- Hajime Sasaki
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Takayuki Hirose
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Tetsu Oura
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Ryo Otsuka
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Ivy Rosales
- Massachusetts General Hospital, Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - David Ma
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Grace Lassiter
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Ahmad Karadagi
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Toshihide Tomosugi
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Abbas Dehnadi
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Masatoshi Matsunami
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Susan Raju Paul
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, M 02114, USA
| | - Patrick M. Reeves
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, M 02114, USA
| | - Isabel Hanekamp
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Samuel Schwartz
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Robert B. Colvin
- Massachusetts General Hospital, Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - Hang Lee
- Massachusetts General Hospital, Biostatistics Center, Boston, MA 02114, USA
| | - Thomas R. Spitzer
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, M 02114, USA
| | - A. Benedict Cosimi
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Pietro E. Cippà
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Cantonal Hospital Graubuenden, 7000 Chur, Switzerland
- Division of Nephrology, University Hospital, 8091 Zurich, Switzerland
| | - Tatsuo Kawai
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114, USA
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4
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Aviña AE, De Paz D, Huang SC, Chen KH, Chang YC, Lee CM, Lin CH, Wei FC, Wang AYL. IL-10 modified mRNA monotherapy prolongs survival after composite facial allografting through the induction of mixed chimerism. MOLECULAR THERAPY. NUCLEIC ACIDS 2023; 31:610-627. [PMID: 36910717 PMCID: PMC9996371 DOI: 10.1016/j.omtn.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/11/2023] [Indexed: 02/18/2023]
Abstract
Vascularized composite allotransplantation has great potential in face transplantation by supporting functional restoration following tissue grafting. However, the need for lifelong administration of immunosuppressive drugs still limits its wide use. Modified mRNA (modRNA) technology provides an efficient and safe method to directly produce protein in vivo. Nevertheless, the use of IL-10 modRNA-based protein replacement, which exhibits anti-inflammatory properties, has not been shown to prolong composite facial allograft survival. In this study, IL-10 modRNA was demonstrated to produce functional IL-10 protein in vitro, which inhibited pro-inflammatory cytokines and in vivo formation of an anti-inflammatory environments. We found that without any immunosuppression, C57BL/6J mice with fully major histocompatibility complex (MHC)-mismatched facial allografts and local injection of IL-10 modRNA had a significantly prolonged survival rate. Decreased lymphocyte infiltration and pro-inflammatory T helper 1 subsets and increased anti-inflammatory regulatory T cells (Tregs) were seen in IL-10 modRNA-treated mice. Moreover, IL-10 modRNA induced multilineage chimerism, especially the development of donor Treg chimerism, which protected allografts from destruction because of recipient alloimmunity. These results support the use of monotherapy based on immunomodulatory IL-10 cytokines encoded by modRNA, which inhibit acute rejection and prolong allograft survival through the induction of donor Treg chimerism.
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Affiliation(s)
- Ana Elena Aviña
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,Clinical Fellow, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; Chang Gung University and Medical College, Taoyuan 333, Taiwan
| | - Dante De Paz
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,Department of Head and Neck Surgery, National Police Hospital, Lima 15072, Peru
| | - Shu-Chun Huang
- Department of Physical Medicine and Rehabilitation, New Taipei Municipal Tucheng Hospital, Chang Gung Memorial Hospital, New Taipei 236, Taiwan.,Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Kuan-Hung Chen
- Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yun-Ching Chang
- Department of Health Industry Technology Management, Chung Shan Medical University, Taichung 402, Taiwan.,Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Chin-Ming Lee
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chia-Hsien Lin
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Fu-Chan Wei
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.,College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Aline Yen Ling Wang
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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5
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Iwahara N, Hotta K, Iwami D, Tanabe T, Tanaka Y, Ito YM, Otsuka T, Murai S, Takada Y, Higuchi H, Sasaki H, Hirose T, Harada H, Shinohara N. Analysis of T-cell alloantigen response via a direct pathway in kidney transplant recipients with donor-specific antibodies. Front Immunol 2023; 14:1164794. [PMID: 37207202 PMCID: PMC10189043 DOI: 10.3389/fimmu.2023.1164794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
Donor-specific antibodies (DSAs) are the main cause of graft loss over time. The direct pathway of alloantigen recognition is important in the pathogenesis of acute rejection. Recent studies have suggested that the direct pathway also contributes to the pathogenesis of chronic injury. Nevertheless, there are no reports on T-cell alloantigen response via the direct pathway in kidney recipients with DSAs. We analyzed the T-cell alloantigen response via the direct pathway in kidney recipients with DSAs (DSA+) or without DSAs (DSA-). A mixed lymphocyte reaction assay was implemented to assess the direct pathway response. DSA+ patients showed significantly higher CD8+ and CD4+ T cell responses to donor cells than DSA- patients. Furthermore, proliferating CD4+ T cells showed a marked increase in Th1 and Th17 responses in DSA+ patients than in DSA- patients. In a comparison between anti-donor and third-party responses, the anti-donor CD8+ and CD4+ T cell response was significantly lower than the anti-third-party response. In contrast, the donor-specific hyporesponsiveness was absent in DSA+ patients. Our study demonstrated that DSA+ recipients have a greater potential for developing immune responses against the donor tissues via the direct alloantigen recognition pathway. These data contribute to an understanding of DSAs pathogenicity during kidney transplantation.
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Affiliation(s)
- Naoya Iwahara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
- *Correspondence: Kiyohiko Hotta,
| | - Daiki Iwami
- Division of Renal Surgery and Transplantation, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tatsu Tanabe
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yuka Tanaka
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoichi M. Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Takuya Otsuka
- Department of surgical pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Sachiyo Murai
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Yusuke Takada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Haruka Higuchi
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hajime Sasaki
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Takayuki Hirose
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Harada
- Departments of Kidney Transplant Surgery, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
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6
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Hotta K, Hirose T, Kawai T. Clinical trials for renal allograft tolerance induction through combined hematopoietic stem cell transplantation: A narrative review. Int J Urol 2022; 29:1397-1404. [PMID: 36101964 DOI: 10.1111/iju.15035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022]
Abstract
During the last four decades, development of effective immunosuppressants has significantly improved short-term results of organ transplantation. However, long-term results have not been satisfactory due to chronic rejection or complications caused by immunosuppressive drugs. Therefore, induction of immunological tolerance of the transplanted organ is considered essential to improve the long-term results. Despite numerous tolerance strategies that have been successful in murine models, inducing hematopoietic chimerism through donor hematopoietic stem cell transplantation is the only method that reproducibly induces kidney allograft tolerance in nonhuman primates or humans. Combining kidney and hematopoietic stem cell transplantation to achieve allograft tolerance has now been attempted with different chimerism strategies. This review summarizes the status of current clinical trials on the induction of allograft tolerance. We also summarize recent studies to extend the chimerism approach to deceased donor transplant recipients.
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Affiliation(s)
- Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Takayuki Hirose
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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7
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Trevelin SC, Zampetaki A, Sawyer G, Ivetic A, Brewer AC, Smyth LA, Marelli-Berg F, Köchl R, Lechler RI, Shah AM, Lombardi G. Nox2-deficient Tregs improve heart transplant outcomes via their increased graft recruitment and enhanced potency. JCI Insight 2021; 6:e149301. [PMID: 34375309 PMCID: PMC8492330 DOI: 10.1172/jci.insight.149301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022] Open
Abstract
Nox2 is a ROS-generating enzyme, deficiency of which increases suppression by Tregs in vitro and in an in vivo model of cardiac remodeling. As Tregs have emerged as a candidate therapy in autoimmunity and transplantation, we hypothesized that Nox2 deficiency in Tregs in recipient mice may improve outcomes in a heart transplant model. We generated a potentially novel B6129 mouse model with Treg-targeted Nox2 deletion (Nox2fl/flFoxP3Cre+ mice) and transplanted with hearts from CB6F1 donors. As compared with those of littermate controls, Nox2fl/flFoxP3Cre+ mice had lower plasma levels of alloantibodies and troponin-I, reduced levels of IFN-γ in heart allograft homogenates, and diminished cardiomyocyte necrosis and allograft fibrosis. Single-cell analyses of allografts revealed higher absolute numbers of Tregs and lower CD8+ T cell infiltration in Nox2-deficient recipients compared with Nox2-replete mice. Mechanistically, in addition to a greater suppression of CD8+CD25- T effector cell proliferation and IFN-γ production, Nox2-deficient Tregs expressed higher levels of CCR4 and CCR8, driving cell migration to allografts; this was associated with increased expression of miR-214-3p. These data indicate that Nox2 deletion in Tregs enhances their suppressive ability and migration to heart allografts. Therefore, Nox2 inhibition in Tregs may be a useful approach to improve their therapeutic efficacy.
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Affiliation(s)
- Silvia C. Trevelin
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom.,King’s College London, School of Immunology and Microbial Sciences, London, United Kingdom
| | - Anna Zampetaki
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
| | - Greta Sawyer
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
| | - Aleksandar Ivetic
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
| | - Alison C. Brewer
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
| | - Lesley Ann Smyth
- University of East London, Health Sports Bioscience, London, United Kingdom
| | - Federica Marelli-Berg
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, United Kingdom
| | - Robert Köchl
- King’s College London, School of Immunology and Microbial Sciences, London, United Kingdom
| | - Robert I. Lechler
- King’s College London, School of Immunology and Microbial Sciences, London, United Kingdom
| | - Ajay M. Shah
- King’s College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
| | - Giovanna Lombardi
- King’s College London, School of Immunology and Microbial Sciences, London, United Kingdom
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8
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Hu M, Rogers NM, Li J, Zhang GY, Wang YM, Shaw K, O'Connell PJ, Alexander SI. Antigen Specific Regulatory T Cells in Kidney Transplantation and Other Tolerance Settings. Front Immunol 2021; 12:717594. [PMID: 34512640 PMCID: PMC8428972 DOI: 10.3389/fimmu.2021.717594] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 12/25/2022] Open
Abstract
Kidney transplantation is the most common solid organ transplant and the best current therapy for end-stage kidney failure. However, with standard immunosuppression, most transplants develop chronic dysfunction or fail, much of which is due to chronic immune injury. Tregs are a subset of T cells involved in limiting immune activation and preventing autoimmune disease. These cells offer the potential to provide tolerance or to allow reduction in immunosuppression in kidney transplants. The importance of Tregs in kidney transplantation has been shown in a number of seminal mouse and animal studies, including those with T cell receptors (TCRs) transgenic Tregs (TCR-Tregs) or Chimeric Antigen Receptor (CAR) Tregs (CAR-Tregs) showing that specificity increases the potency of Treg function. Here we outline the animal and human studies and clinical trials directed at using Tregs in kidney transplantation and other tolerance settings and the various modifications to enhance allo-specific Treg function in vivo and in vitro.
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Affiliation(s)
- Min Hu
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Natasha M Rogers
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Jennifer Li
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Geoff Y Zhang
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Yuan Min Wang
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Karli Shaw
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
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9
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Thomson AW, Sasaki K, Ezzelarab MB. Non-human Primate Regulatory T Cells and Their Assessment as Cellular Therapeutics in Preclinical Transplantation Models. Front Cell Dev Biol 2021; 9:666959. [PMID: 34211972 PMCID: PMC8239398 DOI: 10.3389/fcell.2021.666959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Non-human primates (NHP) are an important resource for addressing key issues regarding the immunobiology of regulatory T cells (Treg), their in vivo manipulation and the translation of adoptive Treg therapy to clinical application. In addition to their phenotypic and functional characterization, particularly in cynomolgus and rhesus macaques, NHP Treg have been isolated and expanded successfully ex vivo. Their numbers can be enhanced in vivo by administration of IL-2 and other cytokines. Both polyclonal and donor antigen (Ag) alloreactive NHP Treg have been expanded ex vivo and their potential to improve long-term outcomes in organ transplantation assessed following their adoptive transfer in combination with various cytoreductive, immunosuppressive and "Treg permissive" agents. In addition, important insights have been gained into the in vivo fate/biodistribution, functional stability, replicative capacity and longevity of adoptively-transferred Treg in monkeys. We discuss current knowledge of NHP Treg immunobiology, methods for their in vivo expansion and functional validation, and results obtained testing their safety and efficacy in organ and pancreatic islet transplantation models. We compare and contrast results obtained in NHP and mice and also consider prospects for future, clinically relevant studies in NHP aimed at improved understanding of Treg biology, and innovative approaches to promote and evaluate their therapeutic potential.
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Affiliation(s)
- Angus W Thomson
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kazuki Sasaki
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mohamed B Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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10
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Strategies for Liver Transplantation Tolerance. Int J Mol Sci 2021; 22:ijms22052253. [PMID: 33668238 PMCID: PMC7956766 DOI: 10.3390/ijms22052253] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/19/2021] [Accepted: 02/21/2021] [Indexed: 12/13/2022] Open
Abstract
Liver transplant (LT) recipients require life-long immunosuppression (IS) therapy to preserve allograft function. The risks of chronic IS include an increased frequency of malignancy, infection, renal impairment, and other systemic toxicities. Despite advances in IS, long-term LT outcomes have not been improved over the past three decades. Standard-of-care (SoC) therapy can, in rare cases, lead to development of operational tolerance that permits safe withdrawal of maintenance IS. However, successful IS withdrawal cannot be reliably predicted and, in current prospective studies, is attempted several years after the transplant procedure, after considerable exposure to the cumulative burden of maintenance therapy. A recent pilot clinical trial in liver tolerance induction demonstrated that peri-transplant immunomodulation, using a regulatory T-cell (Treg) approach, can reduce donor-specific alloreactivity and allow early IS withdrawal. Herein we review protocols for active tolerance induction in liver transplantation, with a focus on identifying tolerogenic cell populations, as well as barriers to tolerance. In addition, we propose the use of novel IS agents to promote immunomodulatory mechanisms favoring tolerance. With numerous IS withdrawal trials underway, improved monitoring and use of novel immunomodulatory strategies will help provide the necessary knowledge to establish an active liver tolerance induction protocol for widespread use.
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11
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Pilat N, Sprent J. Treg Therapies Revisited: Tolerance Beyond Deletion. Front Immunol 2021; 11:622810. [PMID: 33633742 PMCID: PMC7902070 DOI: 10.3389/fimmu.2020.622810] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023] Open
Abstract
Induction of immune tolerance is the Holy Grail in transplantation medicine and autoimmunity. Currently, patients are required to use immunosuppressive drugs for the rest of their lives, resulting in unwanted side effects and complication from global suppression of the immune response. It is well established that regulatory T cells (Tregs) are critical for the maintenance of immune tolerance towards self-antigens by several mechanisms of immune regulation, in parallel with intrathymic deletion of self-reactive T cells during ontogeny. Therefore, approaches for increasing Treg numbers or function in vivo could provide an all-purpose solution for tolerance induction. Currently, most state-of-the-art therapeutics for treating autoimmune diseases or preventing allograft rejection work either by general immunosuppression or blocking inflammatory reactions and are non-specific. Hence, these approaches cannot provide satisfactory long-term results, let alone a cure. However, in animal models the therapeutic potential of Treg expansion for inducing effective tolerance has now been demonstrated in various models of autoimmunity and allogeneic transplantation. Here, we focus on therapies for increasing the size of the Treg pool by expanding endogenous Treg numbers in vivo or by adoptive transfer of Tregs. In particular, we discuss IL-2 based approaches (low dose IL-2, IL-2 complexes) for inducing Treg expansion in vivo as well as cell-based approaches (polyclonal, antigen specific, or cell engineered) for adoptive Treg therapy. We also mention new questions arising from the first clinical studies on Treg therapy in the fields of transplantation and autoimmunity.
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Affiliation(s)
- Nina Pilat
- Section of Transplantation Immunology, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Jonathan Sprent
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia,St Vincent’s Clinical School, University of New South Wales, Sydney, NSW, Australia,*Correspondence: Jonathan Sprent,
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Inducing Transient Mixed Chimerism for Allograft Survival Without Maintenance Immunosuppression With Combined Kidney and Bone Marrow Transplantation: Protocol Optimization. Transplantation 2020; 104:1472-1482. [PMID: 31634324 DOI: 10.1097/tp.0000000000003006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tolerance induction is an important goal in the field of organ transplantation. We have sequentially modified our conditioning regimen for induction of donor-specific tolerance in recipients of major histocompatibility complex-mismatched combined kidney and bone marrow transplantation (CKBMT). METHODS From December 2011 to May 2017, 8 major histocompatibility complex-mismatched patients received CKBMT. The initial conditioning regimen (protocol 1) consisted of cyclophosphamide (CP), rituximab, rabbit antithymocyte globulin, and thymic irradiation. Tacrolimus and steroids were used for the maintenance of immunosuppression (IS). RESULTS This regimen was complicated by transient acute kidney injury, which has been the major clinical feature of engraftment syndrome and side effects of CP, although one of 2 subjects successfully discontinued his IS for 14 months. The conditioning regimen was modified by reducing the CP dose and adding fludarabine (protocol 2). The final modification was reducing the fludarabine and rabbit antithymocyte globulin doses (protocol 3). Mixed chimerism, detected by the short tandem repeat method, was achieved transiently in all subjects for 3-20 weeks. Among the 3 subjects treated with protocol 2, IS was successfully discontinued for >35 months in one subject, but the other 2 subjects suffered from severe BK virus-associated nephritis. All 3 subjects treated with protocol 3 tolerated the protocol well and have successfully discontinued IS for >4-41 months. Interestingly, de novo donor-specific antibody was not detected in any subject during all the follow-up periods. CONCLUSIONS Our clinical trial has shown that long-term renal allograft survival without maintenance IS can be achieved by induction of mixed chimerism following CKBMT.
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Chaudhry S, Kato Y, Weiner J, Alonso-Guallart P, Baker S, Woodland DC, Lefkowitch JH, Duran-Struuck R, Sondermeijer HP, Zitsman J, Sears ML, Wu A, Karolewski B, Houck PJ, Martinez M, Kato T, Sykes M, Griesemer AD. Transient-mixed Chimerism With Nonmyeloablative Conditioning Does Not Induce Liver Allograft Tolerance in Nonhuman Primates. Transplantation 2020; 104:1580-1590. [PMID: 32732835 PMCID: PMC7541736 DOI: 10.1097/tp.0000000000003263] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Although short-term outcomes for liver transplantation have improved, patient and graft survival are limited by infection, cancer, and other complications of immunosuppression. Rapid induction of tolerance after liver transplantation would decrease these complications, improving survival and quality of life. Tolerance to kidneys, but not thoracic organs or islets, has been achieved in nonhuman primates and humans through the induction of transient donor chimerism. Since the liver is considered to be tolerogenic, we tested the hypothesis that the renal transplant transient chimerism protocol would induce liver tolerance. METHODS Seven cynomolgus macaques received immune conditioning followed by simultaneous donor bone marrow and liver transplantation. The more extensive liver surgery required minor adaptations of the kidney protocol to decrease complications. All immunosuppression was discontinued on postoperative day (POD) 28. Peripheral blood chimerism, recipient immune reconstitution, liver function tests, and graft survival were determined. RESULTS The level and duration of chimerism in liver recipients were comparable to those previously reported in renal transplant recipients. However, unlike in the kidney model, the liver was rejected soon after immunosuppression withdrawal. Rejection was associated with proliferation of recipient CD8 T effector cells in the periphery and liver, increased serum interleukin (IL)-6 and IL-2, but peripheral regulatory T cell (Treg) numbers did not increase. Antidonor antibody was also detected. CONCLUSIONS These data show the transient chimerism protocol does not induce tolerance to livers, likely due to greater CD8 T cell responses than in the kidney model. Successful tolerance induction may depend on greater control or deletion of CD8 T cells in this model.
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Affiliation(s)
- Sulemon Chaudhry
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yojiro Kato
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Joshua Weiner
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paula Alonso-Guallart
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Sam Baker
- Institute of Comparative Medicine, Columbia University Irving Medical Center, New York, NY
- Veterinary Service Center, Stanford University, Stanford, CA
| | - David C Woodland
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Jay H Lefkowitch
- Department of Pathology, Columbia University Irving Medical Center, New York, NY
| | - Raimon Duran-Struuck
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA
| | - Hugo P Sondermeijer
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Jonah Zitsman
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Mallory L Sears
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Anette Wu
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Brian Karolewski
- Institute of Comparative Medicine, Columbia University Irving Medical Center, New York, NY
| | - Philipp J Houck
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Mercedes Martinez
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Tomoaki Kato
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Megan Sykes
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
- Department of Microbiology & Immunology, Columbia University Irving Medical Center, New York, NY
| | - Adam D Griesemer
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
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Twenty-year Follow-up of Histocompatibility Leukocyte Antigen-matched Kidney and Bone Marrow Cotransplantation for Multiple Myeloma With End-stage Renal Disease: Lessons Learned. Transplantation 2020; 103:2366-2372. [PMID: 30801529 DOI: 10.1097/tp.0000000000002669] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Specific immune tolerance of transplanted organs in association with either transient or sustained lymphohematopoietic chimerism has been demonstrated in several preclinical animal models and clinically in patients who are full donor chimeras after hematopoietic stem cell transplantation and subsequently received kidney transplants from the same donor. Most recently, tolerance induction has been extended to patients in whom chimerism was intentionally induced at the time of kidney transplantation. METHODS Twenty years ago, we reported the first successful histocompatibility leukocyte antigen-matched sibling donor bone marrow and kidney transplant following nonmyeloablative conditioning in a patient with multiple myeloma and end-stage renal disease (ESRD). After 2 decades, she has normal renal function in the absence of ongoing systemic immunosuppressive therapy. Nine patients have subsequently undergone similar treatment for multiple myeloma with ESRD. RESULTS In the initial patient, hematopoietic chimerism was detectable for only 105 days after the transplant. In subsequent patients, chimerism detection ranged from 49 days to >14 years. Nevertheless, a long remission of the myeloma and long-term immunosuppression-free survival of the kidney allograft were achieved in 7 of the 10 patients, 5 of whom currently survive. CONCLUSIONS This initial patient demonstrated the feasibility of performing combined histocompatibility leukocyte antigen-matched, sibling donor bone marrow and kidney transplantation for ESRD due to multiple myeloma. This experience paved the way for extending the initial trial to 9 additional patients with multiple myeloma and ESRD and, more recently, to tolerance induction strategies involving combined bone marrow and kidney transplantation for patients with and without an underlying malignancy.
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Abstract
The present review discusses current developments in tolerance induction for solid organ transplantation with a particular emphasis on chimerism-based approaches. It explains the basic mechanisms of chimerism-based tolerance and provides an update on ongoing clinical tolerance trials. The concept of "delayed tolerance" is presented, and ongoing preclinical studies in the nonhuman primate setting-including current limitations and hurdles regarding this approach-are illustrated. In addition, a brief overview and update on cell-based tolerogenic clinical trials is provided. In a critical approach, advantages, limitations, and potential implications for the future of these different regimens are discussed.
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Fukasaku Y, Goto R, Ganchiku Y, Emoto S, Zaitsu M, Watanabe M, Kawamura N, Fukai M, Shimamura T, Taketomi A. Novel immunological approach to asses donor reactivity of transplant recipients using a humanized mouse model. Hum Immunol 2020; 81:342-353. [PMID: 32345498 DOI: 10.1016/j.humimm.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/04/2020] [Accepted: 04/22/2020] [Indexed: 12/17/2022]
Abstract
In organ transplantation, a reproducible and robust immune-monitoring assay has not been established to determine individually tailored immunosuppressants (IS). We applied humanized mice reconstituted with human (hu-) peripheral blood mononuclear cells (PBMCs) obtained from living donor liver transplant recipients to evaluate their immune status. Engraftment of 2.5 × 106 hu-PBMCs from healthy volunteers and recipients in the NSG mice was achieved successfully. The reconstituted lymphocytes consisted mainly of hu-CD3+ lymphocytes with predominant CD45RA-CD62Llo TEM and CCR6-CXCR3+CD4+ Th1 cells in hu-PBMC-NSG mice. Interestingly, T cell allo-reactivity of hu-PBMC-NSG mice was amplified significantly compared with that of freshly isolated PBMCs (p < 0.05). Furthermore, magnified hu-T cell responses to donor antigens (Ag) were observed in 2/10 immunosuppressed recipients with multiple acute rejection (AR) experiences, suggesting that the immunological assay in hu-PBMC-NSG mice revealed hidden risks of allograft rejection by IS. Furthermore, donor Ag-specific hyporesponsiveness was maintained in recipients who had been completely weaned off IS (n = 4), despite homeostatic proliferation of hu-T cells in the hu-PBMC-NSG mice. The immunological assay in humanized mice provides a new tool to assess recipient immunity in the absence of IS and explore the underlying mechanisms to maintaining operational tolerance.
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Affiliation(s)
- Yasutomo Fukasaku
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Ryoichi Goto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan.
| | - Yoshikazu Ganchiku
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Shin Emoto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Masaaki Zaitsu
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Masaaki Watanabe
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan; Department of Transplant Surgery, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Norio Kawamura
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan; Department of Transplant Surgery, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Moto Fukai
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan
| | - Tsuyoshi Shimamura
- Division of Organ Transplantation, Hokkaido University Hospital, Sapporo 060-8648, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan.
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El-Ayachi I, Washburn WK, Schenk AD. Recent Progress in Treg Biology and Transplant Therapeutics. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00278-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Purpose of Review
Regulatory T cell (Treg) biology continues to evolve at a rapid pace. The role of Tregs in solid organ transplantation offers a unique window into Treg ontogeny and function as well as limitless possibilities for clinical application. Here we review recent significant discoveries and key translational work.
Recent Findings
Advances in transplantation deepen understanding of Treg differentiation, expansion, transcription, co-stimulation, and signaling. T cell receptor (TCR) sequencing and single-cell analytics allow unprecedented insight into Treg repertoire diversity and phenotypic heterogeneity. Efforts to replace conventional immunosuppression with Treg adoptive immunotherapy are underway and coalescing around strategies to increase efficiency through development of donor-reactive Tregs.
Summary
Adoptive immunotherapy with Tregs is a leading tolerogenic strategy. Early clinical trials suggest that Treg infusion is safe and reports on efficacy will soon follow.
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Predicting Outcomes of Rat Vascularized Composite Allotransplants through Quantitative Measurement of Chimerism with PCR-Amplified Short Tandem Repeat. J Immunol Res 2020; 2020:9243531. [PMID: 32090131 PMCID: PMC7024101 DOI: 10.1155/2020/9243531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/31/2019] [Accepted: 01/08/2020] [Indexed: 11/17/2022] Open
Abstract
Chimerism has been associated with the induction and maintenance of tolerance to vascularized composite allotransplants (VCA). Although most VCA studies have examined chimerism using flow cytometry, we proposed that precision in the measurement of chimerism may be better approximated when complimentary polymerase chain reaction (PCR) is applied to a specific short tandem repeat (STR). We identified a STR, D10Rat25, which exhibited a ~20 bp difference in length between two rat strains (BN and LEW) often utilized as the donor and recipient in many allotransplantation studies. D10Rat25 was PCR-amplified and quantified with capillary electrophoresis. With pure LEW and BN DNA, a standard curve was constructed to measure chimerism with good linearity. When applied to rat VCA, the relationship between systematic (in peripheral blood) or local (at specific organ/tissues) chimerism to allograft outcomes was noted. We found that peripheral chimerism was elevated by up to ~9% postoperative month 1 (POM 1) but then reduced regardless of the final VCA outcome. However, differences in VCA skin chimerism between early rejection and POM 1 (shown as ΔChimerismPOM1-ER) were notable with respect to VCA outcomes. ROC analysis identified the optimum cutoff value as 17.7%. In summary, we have developed a reliable method to quantify the percentage of BN cells/DNA in BN-LEW chimeras. The detection limit was characterized, and the acquired data were comparable with flow cytometry. This method can be applied to solid organ and composite tissue allotransplantation studies.
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Matsunami M, Rosales IA, Adam BA, Oura T, Mengel M, Smith RN, Lee H, Cosimi AB, Colvin RB, Kawai T. Long-term Kinetics of Intragraft Gene Signatures in Renal Allograft Tolerance Induced by Transient Mixed Chimerism. Transplantation 2019; 103:e334-e344. [PMID: 31397805 PMCID: PMC6814550 DOI: 10.1097/tp.0000000000002911] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Renal allograft tolerance (TOL) has been successfully induced in nonhuman primates (NHPs) and humans through the induction of transient mixed chimerism. To elucidate the mechanisms of TOL, we compared local immunologic responses in renal allografts with those in T-cell-mediated rejection (TCMR) and chronic antibody-mediated rejection (CAMR) in NHPs. METHODS Using the NanoString nCounter platform, we retrospectively studied 52 mRNAs in 256 kidney allograft samples taken from NHP kidney recipients of donor BMT. No immunosuppression was given after 1-month post-donor BMT. Recipients who achieved TOL (n = 13) survived for >1840 ± 1724 days with normal kidney function, while recipients with CAMR (n = 13) survived for 899 ± 550 days with compromised graft function, and recipients with TCMR (n = 15) achieved only short-term survival (132 ± 69 days). RESULTS The most prominent difference between the groups was FOXP3, which was significantly higher in TOL than in CAMR and TCMR, both early (<1 y, P < 0.01) and late (≥1 y, P < 0.05) after transplant. Other mRNAs related to regulatory T cells (Treg), such as IL10, TGFB, and GATA3, were also high in TOL. In contrast, transcripts of inflammatory cytokines were higher in TCMR, while activated endothelium-associated transcripts were higher in CAMR than in TOL. The receiver operating characteristic analyses revealed that intragraft FOXP3 and CAV1 can reliably distinguish TOL from CAMR. CONCLUSIONS High FOXP3 and other Treg-related mRNAs together with suppressed inflammatory responses and endothelial activation in renal allografts suggest that intragraft enrichment of Treg is a critical mechanism of renal allograft TOL induced by transient mixed chimerism.
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Affiliation(s)
- Masatoshi Matsunami
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ivy A. Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Benjamin A. Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Tetsu Oura
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Rex-Neal Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hang Lee
- Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Benedict Cosimi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robert B. Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tatsuo Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Importance of Hematopoietic Mixed Chimerism for Induction of Renal Allograft Tolerance in Nonhuman Primates. Transplantation 2019; 103:689-697. [PMID: 30300283 DOI: 10.1097/tp.0000000000002470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although induction of durable mixed chimerism is required for murine skin allograft tolerance (TOL), renal allograft TOL has been achieved after induction of only transient mixed chimerism in nonhuman primates (NHPs) and humans. To better define the level/duration of chimerism required for stable renal allograft TOL, we retrospectively analyzed these parameters and compared them with transplant outcomes in NHP combined kidney and bone marrow transplant recipients. METHODS Peripheral blood levels and duration of myeloid or lymphoid chimerism were retrospectively analyzed in 34 NHP combined kidney and bone marrow transplantation recipients which were divided into 3 groups: TOL, n = 10; chronic antibody-mediated rejection (CAMR), n = 12; and T cell-mediated rejection (TCMR), n = 12. RESULTS All 4 of the recipients that failed to develop any chimerism lost their allografts due to TCMR after discontinuation of immunosuppression (56 ± 3 d). Among 30 recipients who successfully developed multilineage chimerism, 10 achieved long-term immunosuppression-free survival without rejection (1258 ± 388 d), 12 eventually developed CAMR (932 ± 155 d), and 8 developed TCMR (82 ± 10 d). The maximum level but not duration of lymphoid chimerism was significantly higher in TOL recipients compared with both CAMR (P = 0.0159) and TCMR (P = 0.0074). On the other hand, the maximum myeloid chimerism was significantly higher in TOL than in TCMR (P = 0.0469), but not in CAMR. Receiver operating characteristic analyses revealed that lymphoid chimerism levels of 3.1% or greater could reliably predict long-term immunosuppression-free renal allograft survival (P < 0.0001). CONCLUSIONS This retrospective study confirmed that induction of chimerism is essential for long-term immunosuppression-free survival, which best correlates with lymphoid chimerism levels higher than 3.1%.
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Oura T, Hotta K, Rosales I, Dehnadi A, Kawai K, Lee H, Cosimi AB, Kawai T. Addition of Anti-CD40 Monoclonal Antibody to Nonmyeloablative Conditioning With Belatacept Abrogated Allograft Tolerance Despite Induction of Mixed Chimerism. Transplantation 2019; 103:168-176. [PMID: 30113996 PMCID: PMC6309923 DOI: 10.1097/tp.0000000000002417] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We recently reported anti-CD40 monoclonal antibody and rapamycin (aCD40/rapa) to be a reliable, nontoxic, immunosuppressive regimen for combined islet and kidney transplantation (CIKTx) in nonhuman primates. In the current study, we attempted to induce allograft tolerance through the mixed chimerism approach using a conditioning regimen with aCD40 and belatacept (Bela). METHODS Five CIKTx or kidney transplant alone recipients were treated with aCD40/rapa for 4 months. All recipients then received a conditioning regimen including horse antithymocyte globulin and aCD40/Bela. The results were compared with previous reports of recipients treated with Bela-based regimens. RESULTS All 3 CIKTx recipients developed mixed chimerism, which was significantly superior to that observed in the previous Bela-based studies. Nevertheless, all CIKTx recipients in this study lost their islet and renal allografts as a result of cellular and humoral rejection on days 140, 89, and 84. The 2 kidney transplant-alone recipients were treated with the same conditioning regimen and suffered rejection on days 127 and 116, despite the development of excellent chimerism. B lymphocyte reconstitution dominated by memory phenotypes was associated with early development of donor-specific antibodies in 4 of 5 recipients. In vitro assays showed no donor-specific regulatory T cell expansion, which has been consistently observed in tolerant recipients with our mixed chimerism approach. CONCLUSIONS Despite displaying excellent immunosuppressive efficacy, costimulatory blockade with anti-CD40 monoclonal antibody (2C10R4) may inhibit the induction of renal or islet allograft tolerance via a mixed chimerism approach.
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Affiliation(s)
- Tetsu Oura
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kiyohiko Hotta
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Abbas Dehnadi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kent Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hang Lee
- Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Benedict Cosimi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tatsuo Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Long-term Nonhuman Primate Renal Allograft Survival Without Ongoing Immunosuppression in Recipients of Delayed Donor Bone Marrow Transplantation. Transplantation 2018; 102:e128-e136. [PMID: 29300231 DOI: 10.1097/tp.0000000000002078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We have previously reported successful induction of renal allograft tolerance in nonhuman primates (NHP) after an initial posttransplant period of conventional immunosuppression (delayed tolerance) using a nonmyeloablative conditioning regimen consisting of anti-CD154 and anti-CD8 mAbs plus equine antithymocyte globulin (Atgam) and donor bone marrow transplantation (DBMT). Because these reagents are not currently clinically available, the protocol was revised to be applicable to human recipients of deceased donor allografts. METHOD Four cynomolgus monkeys received major histocompatibility complex-mismatched kidney allografts with conventional immunosuppression for 4 months. The recipients were then treated with a nonmyeloablative conditioning regimen consisting of thymoglobulin, belatacept, and DBMT. The results were compared with recipients treated with conditioning regimen consisting of Atgam and anti-CD154 mAb, with and without anti-CD8 mAb. RESULTS In 4 consecutive NHP recipients treated with the modified conditioning regimen, homeostatic recovery of CD8 TEM was delayed until after day 20 and multilineage chimerism was successfully induced. Three of the 4 recipients achieved long-term allograft survival (>728, >540, >449 days) without ongoing maintenance immunosuppression. Posttransplant MLR showed loss of antidonor CD8 T cell and CD4 IFNγ responses with expansion of CD4FOXP3 regulatory T cells. However, the late development of donor-specific antibody in NHP recipients confirms the need for additional anti-B-cell depletion with agents, such as rituximab, as has been shown in our clinical trials. CONCLUSIONS This study provides proof of principle that induction of mixed chimerism and long-term renal allograft survival without immunosuppression after delayed DBMT is possible with clinically available reagents.
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Sachs DH. Transplantation tolerance through mixed chimerism: From allo to xeno. Xenotransplantation 2018; 25:e12420. [PMID: 29913045 DOI: 10.1111/xen.12420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 05/03/2018] [Indexed: 12/21/2022]
Abstract
To date, the only successful means of achieving allogeneic transplantation tolerance in the clinic has involved induction of mixed lymphohematopoietic chimerism. Such chimerism was first achieved in mice and subsequently in large animals, including miniature swine, monkeys and most recently humans. The mechanism of tolerance has differed between models, involving both deletional and regulatory mechanisms, in varying proportions, depending on the model. Considerable progress has also been made toward induction of tolerance across the xenogeneic pig-to-primate barrier, although complete success has not yet been achieved. The two approaches toward xenograft tolerance currently being investigated both involve establishment of a mixture of host and donor cells in the thymus, in one case through administration of donor bone marrow to the recipient and in the other through vascularized donor thymus transplantation to a thymectomized recipient. Hopefully, a combination of these approaches may provide an effective means for achieving full tolerance and thereby bringing xenograft organ transplantation to the clinic.
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Affiliation(s)
- David H Sachs
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA.,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA
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25
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Nakamura T, Ushigome H. Myeloid-Derived Suppressor Cells as a Regulator of Immunity in Organ Transplantation. Int J Mol Sci 2018; 19:ijms19082357. [PMID: 30103447 PMCID: PMC6121658 DOI: 10.3390/ijms19082357] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/08/2018] [Indexed: 12/16/2022] Open
Abstract
Regulation of allo-immune responses is proposed as a topic for investigation in the current field of organ transplantation. As a regulator, regulatory T cells (Tregs) have received attention due to their ability to control allograft rejection. Concurrently, however, the independent action of Tregs is not enough to achieve tolerance status in many situations. Meanwhile, as a multi-functional regulator, myeloid-derived suppressor cells (MDSCs) can suppress effector T cells as well as induce Tregs or regulatory B cells (Bregs) in certain circumstances. Furthermore, the importance of a crosstalk between MDSCs and natural killer T cells to induce tolerance has been reported. Thus, orchestration between MDSCs, myeloid regulators, T/Bregs and other lymphoid/myeloid regulators can shed light on achieving allogeneic tolerance. Here, we review the current knowledge in terms of immunological regulatory function displayed by MDSCs in the context of organ transplantation. Ideal control of MDSCs would lead to a reduction of allograft rejection and subsequent long-term allograft acceptance.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan.
| | - Hidetaka Ushigome
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan.
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26
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Robinson KA, Orent W, Madsen JC, Benichou G. Maintaining T cell tolerance of alloantigens: Lessons from animal studies. Am J Transplant 2018; 18:1843-1856. [PMID: 29939471 PMCID: PMC6352985 DOI: 10.1111/ajt.14984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 01/25/2023]
Abstract
Achieving host immune tolerance of allogeneic transplants represents the ultimate challenge in clinical transplantation. It has become clear that different cells and mechanisms participate in acquisition versus maintenance of allograft tolerance. Indeed, manipulations which prevent tolerance induction often fail to abrogate tolerance once it has been established. Hence, elucidation of the immunological mechanisms underlying maintenance of T cell tolerance to alloantigens is essential for the development of novel interventions that preserve a robust and long lasting state of allograft tolerance that relies on T cell deletion in addition to intra-graft suppression of inflammatory immune responses. In this review, we discuss some essential elements of the mechanisms involved in the maintenance of naturally occurring or experimentally induced allograft tolerance, including the newly described role of antigen cross-dressing mediated by extracellular vesicles.
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Affiliation(s)
- Kortney A. Robinson
- Center for Transplant Sciences, Massachusetts General
Hospital and Harvard Medical School, Boston, MA
| | - William Orent
- Center for Transplant Sciences, Massachusetts General
Hospital and Harvard Medical School, Boston, MA
| | - Joren C. Madsen
- Center for Transplant Sciences, Massachusetts General
Hospital and Harvard Medical School, Boston, MA.,Division of Cardiac Surgery, Department of Surgery,
Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gilles Benichou
- Center for Transplant Sciences, Massachusetts General
Hospital and Harvard Medical School, Boston, MA
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27
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Sasaki H, Oura T, Spitzer TR, Chen YB, Madsen JC, Allan J, Sachs DH, Cosimi AB, Kawai T. Preclinical and clinical studies for transplant tolerance via the mixed chimerism approach. Hum Immunol 2018; 79:258-265. [PMID: 29175110 PMCID: PMC5963722 DOI: 10.1016/j.humimm.2017.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 01/22/2023]
Abstract
Based upon observations in murine models, we have developed protocols to induce renal allograft tolerance by combined kidney and bone marrow transplantation (CKBMT) in non-human primates (NHP) and in humans. Induction of persistent mixed chimerism has proved to be extremely difficult in major histocompatibility complex (MHC)-mismatched primates, with detectable chimerism typically disappearing within 30-60 days. Nevertheless, in MHC mismatched NHP, long-term immunosuppression-free renal allograft survival has been achieved reproducibly, using a non-myeloablative conditioning approach that has also been successfully extended to human kidney transplant recipients. CKBMT has also been applied to the patients with end stage renal disease with hematologic malignancies. Renal allograft tolerance and long-term remission of myeloma have been achieved by transient mixed or persistent full chimerism. This review summarizes the current status of preclinical and clinical studies for renal and non-renal allograft tolerance induction by CKBMT. Improving the consistency of tolerance induction with less morbidity, extending this approach to deceased donor transplantation and inducing tolerance of non-renal transplants, are critical next steps for bringing this strategy to a wider range of clinical applications.
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Affiliation(s)
- Hajime Sasaki
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tetsu Oura
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas R Spitzer
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi-Bin Chen
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joren C Madsen
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Allan
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David H Sachs
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A B Cosimi
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tatsuo Kawai
- Department of surgery, Center for transplant science, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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28
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Lin J, Chan WFN, Boon L, Anderson CC. Stability of Chimerism in Non-Obese Diabetic Mice Achieved By Rapid T Cell Depletion Is Associated With High Levels of Donor Cells Very Early After Transplant. Front Immunol 2018; 9:837. [PMID: 29740442 PMCID: PMC5928230 DOI: 10.3389/fimmu.2018.00837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/05/2018] [Indexed: 11/17/2022] Open
Abstract
Stable mixed hematopoietic chimerism is a robust method for inducing donor-specific tolerance with the potential to prevent rejection of donor islets in recipients with autoimmune type-1 diabetes. However, with reduced intensity conditioning, fully allogeneic chimerism in a tolerance resistant autoimmune-prone non-obese diabetic (NOD) recipient has rarely been successful. In this setting, successful multilineage chimerism has required either partial major histocompatability complex matching, mega doses of bone marrow, or conditioning approaches that are not currently clinically feasible. Irradiation free protocols with moderate bone marrow doses have not generated full tolerance; donor skin grafts were rejected. We tested whether more efficient recipient T cell depletion would generate a more robust tolerance. We show that a combination of donor-specific transfusion-cyclophosphamide and multiple T cell depleting antibodies could induce stable high levels of fully allogeneic chimerism in NOD recipients. Less effective T cell depletion was associated with instability of chimerism. Stable chimeras appeared fully donor-specific tolerant, with clonal deletion of allospecific T cells and acceptance of donor skin grafts, while recovering substantial immunocompetence. The loss of chimerism months after transplant was significantly associated with a lower level of chimerism and donor T cells within the first 2 weeks after transplant. Thus, rapid and robust recipient T cell depletion allows for stable high levels of fully allogeneic chimerism and robust donor-specific tolerance in the stringent NOD model while using a clinically feasible protocol. In addition, these findings open the possibility of identifying recipients whose chimerism will later fail, stratifying patients for early intervention.
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Affiliation(s)
- Jiaxin Lin
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
| | - William F N Chan
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
| | | | - Colin C Anderson
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
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29
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Kim H, Kim H, Lee SK, Jin XL, Kim TJ, Park C, Lee JI, Kim HS, Hong SK, Yoon KC, Ahn SW, Lee KB, Yi NJ, Yang J, Lee KW, Hawthorne WJ, Suh KS. Memory T cells are significantly increased in rejected liver allografts of rhesus monkeys. Liver Transpl 2018; 24:256-268. [PMID: 29150986 PMCID: PMC5817407 DOI: 10.1002/lt.24983] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/18/2017] [Accepted: 10/29/2017] [Indexed: 12/17/2022]
Abstract
The rhesus monkey (RM) is an excellent preclinical model in kidney, heart, and islet transplantation that has provided the basis for new immunosuppressive protocols for clinical studies. However, there remain relatively few liver transplantation (LT) models in nonhuman primates. In this study, we analyzed the immune cell populations of peripheral blood mononuclear cells (PBMCs) and secondary lymphoid organs along with livers of normal RMs and compared them with those of rejected LT recipients following withdrawal of immunosuppression. We undertook 5 allogeneic ABO compatible orthotopic LTs in monkeys using 5 normal donor monkey livers. We collected tissues including lymph nodes, spleens, blood, and recipient livers, and we performed flow cytometric analysis using isolated immune cells. We found that CD4 or CD8 naïve T cells were normally seen at low levels, and memory T cells were seen at high levels in the liver rather than lymphoid organs or PBMC. However, regulatory cells such as CD4+ forkhead box P3+ T cells and CD8+ CD28- cells remained in high numbers in the liver, but not in the lymph nodes or PBMC. The comparison of CD4/8 T subpopulations in normal and rejected livers and the various tissues showed that naïve cells were dramatically decreased in the spleen, lymph node, and PBMCs of rejected LT monkeys, but rather, the memory CD4/8 T cells were increased in all tissues and PBMC. The normal liver has large numbers of CD4 regulatory T cells, CD8+ CD28-, and myeloid-derived suppressor cells, which are known immunosuppressive cells occurring at much higher levels than those seen in lymph node or peripheral blood. Memory T cells are dramatically increased in rejected liver allografts of RMs compared with those seen in normal RM tissues. Liver Transplantation 24 256-268 2018 AASLD.
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Affiliation(s)
- Hwajung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sun-Kyung Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Xue-Li Jin
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae Jin Kim
- Division of Immunobiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Chanho Park
- Division of Immunobiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Jae-Il Lee
- Department of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyo-Sin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Chul Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sung Woo Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaeseok Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Transplantation Center, Seoul National University Hospital, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Wayne J Hawthorne
- Department of Surgery, University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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30
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Mahr B, Granofszky N, Muckenhuber M, Wekerle T. Transplantation Tolerance through Hematopoietic Chimerism: Progress and Challenges for Clinical Translation. Front Immunol 2017; 8:1762. [PMID: 29312303 PMCID: PMC5743750 DOI: 10.3389/fimmu.2017.01762] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
The perception that transplantation of hematopoietic stem cells can confer tolerance to any tissue or organ from the same donor is widely accepted but it has not yet become a treatment option in clinical routine. The reasons for this are multifaceted but can generally be classified into safety and efficacy concerns that also became evident from the results of the first clinical pilot trials. In comparison to standard immunosuppressive therapies, the infection risk associated with the cytotoxic pre-conditioning necessary to allow allogeneic bone marrow engraftment and the risk of developing graft-vs.-host disease (GVHD) constitute the most prohibitive hurdles. However, several approaches have recently been developed at the experimental level to reduce or even overcome the necessity for cytoreductive conditioning, such as costimulation blockade, pro-apoptotic drugs, or Treg therapy. But even in the absence of any hazardous pretreatment, the recipients are exposed to the risk of developing GVHD as long as non-tolerant donor T cells are present. Total lymphoid irradiation and enriching the stem cell graft with facilitating cells emerged as potential strategies to reduce this peril. On the other hand, the long-lasting survival of kidney allografts, seen with transient chimerism in some clinical series, questions the need for durable chimerism for robust tolerance. From a safety point of view, loss of chimerism would indeed be favorable as it eliminates the risk of GVHD, but also complicates the assessment of tolerance. Therefore, other biomarkers are warranted to monitor tolerance and to identify those patients who can safely be weaned off immunosuppression. In addition to these safety concerns, the limited efficacy of the current pilot trials with approximately 40-60% patients becoming tolerant remains an important issue that needs to be resolved. Overall, the road ahead to clinical routine may still be rocky but the first successful long-term patients and progress in pre-clinical research provide encouraging evidence that deliberately inducing tolerance through hematopoietic chimerism might eventually make it from dream to reality.
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Affiliation(s)
- Benedikt Mahr
- Department of Surgery, Section of Transplantation Immunology, Medical University of Vienna, Vienna, Austria
| | - Nicolas Granofszky
- Department of Surgery, Section of Transplantation Immunology, Medical University of Vienna, Vienna, Austria
| | - Moritz Muckenhuber
- Department of Surgery, Section of Transplantation Immunology, Medical University of Vienna, Vienna, Austria
| | - Thomas Wekerle
- Department of Surgery, Section of Transplantation Immunology, Medical University of Vienna, Vienna, Austria
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31
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Zuber J, Sykes M. Mechanisms of Mixed Chimerism-Based Transplant Tolerance. Trends Immunol 2017; 38:829-843. [PMID: 28826941 PMCID: PMC5669809 DOI: 10.1016/j.it.2017.07.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/24/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023]
Abstract
Immune responses to allografts represent a major barrier in organ transplantation. Immune tolerance to avoid chronic immunosuppression is a critical goal in the field, recently achieved in the clinic by combining bone marrow transplantation (BMT) with kidney transplantation following non-myeloablative conditioning. At high levels of chimerism such protocols can permit central deletional tolerance, but with a significant risk of graft-versus-host (GVH) disease (GVHD). By contrast, transient chimerism-based tolerance is devoid of GVHD risk and appears to initially depend on regulatory T cells (Tregs) followed by gradual, presumably peripheral, clonal deletion of donor-reactive T cells. Here we review recent mechanistic insights into tolerance and the development of more robust and safer protocols for tolerance induction that will be guided by innovative immune monitoring tools.
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Affiliation(s)
- Julien Zuber
- Service de Transplantation Rénale, Hôpital Necker, Université Paris Descartes, Paris, France; INSERM UMRS_1163, IHU Imagine, Paris, France.
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY 10032, USA; Department of Surgery, Columbia University, New York, NY 10032, USA; Department of Microbiology and Immunology, Columbia University Center, New York, NY 10032, USA.
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32
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Madsen JC. Advances in the immunology of heart transplantation. J Heart Lung Transplant 2017; 36:1299-1305. [PMID: 29173391 DOI: 10.1016/j.healun.2017.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/16/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Joren C Madsen
- Center for Transplantation Sciences and Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
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33
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Oura T, Cosimi AB, Kawai T. Chimerism-based tolerance in organ transplantation: preclinical and clinical studies. Clin Exp Immunol 2017; 189:190-196. [PMID: 28369830 DOI: 10.1111/cei.12969] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2017] [Indexed: 12/25/2022] Open
Abstract
Induction of allograft tolerance has been considered the ultimate goal in organ transplantation. Although numerous protocols to induce allograft tolerance have been reported in mice, a chimerism-based approach through donor haematopoietic stem cell transplantation has been the only approach to date that induced allograft tolerance reproducibly following kidney transplantation in man. Renal allograft tolerance has been achieved by induction of either transient mixed chimerism or persistent full donor chimerism. Although the risk of rejection may be low in tolerance achieved via durable full donor chimerism, the development of graft-versus-host disease (GVHD) has limited the wider clinical application of this approach. In contrast, tolerance induced by transient mixed chimerism has not been associated with GVHD, but the risk of allograft rejection is more difficult to predict after the disappearance of haematopoietic chimerism. Current efforts are directed towards the development of more clinically feasible and reliable approaches to induce more durable mixed chimerism in order to widen the clinical applicability of these treatment regimens.
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Affiliation(s)
- T Oura
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A B Cosimi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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