1
|
Contreras-Castillo E, García-Rasilla VY, García-Patiño MG, Licona-Limón P. Stability and plasticity of regulatory T cells in health and disease. J Leukoc Biol 2024; 116:33-53. [PMID: 38428948 DOI: 10.1093/jleuko/qiae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/09/2024] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
The mechanisms that negatively regulate inflammation upon a pathogenic stimulus are crucial for the maintenance of tissue integrity and organ function. T regulatory cells are one of the main drivers in controlling inflammation. The ability of T regulatory cells to adapt to different inflammatory cues and suppress inflammation is one of the relevant features of T regulatory cells. During this process, T regulatory cells express different transcription factors associated with their counterparts, Th helper cells, including Tbx21, GATA-3, Bcl6, and Rorc. The acquisition of this transcription factor helps the T regulatory cells to suppress and migrate to the different inflamed tissues. Additionally, the T regulatory cells have different mechanisms that preserve stability while acquiring a particular T regulatory cell subtype. This review focuses on describing T regulatory cell subtypes and the mechanisms that maintain their identity in health and diseases.
Collapse
Affiliation(s)
- Eugenio Contreras-Castillo
- Departamento de Biología Celular y del Desarrollo, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Circuito exterior s/n, CU Coyoacán, México City 04510, Mexico
| | - Verónica Yutsil García-Rasilla
- Departamento de Biología Celular y del Desarrollo, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Circuito exterior s/n, CU Coyoacán, México City 04510, Mexico
| | - María Guadalupe García-Patiño
- Departamento de Biología Celular y del Desarrollo, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Circuito exterior s/n, CU Coyoacán, México City 04510, Mexico
| | - Paula Licona-Limón
- Departamento de Biología Celular y del Desarrollo, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Circuito exterior s/n, CU Coyoacán, México City 04510, Mexico
| |
Collapse
|
2
|
Lu J, Chen Y, Zhou K, Ling Y, Qin Q, Lu W, Qin L, Mou C, Zhang J, Zheng X, Qin K. Immune characteristics of kidney transplant recipients with acute respiratory distress syndrome induced by COVID-19 at single-cell resolution. Respir Res 2024; 25:34. [PMID: 38238762 PMCID: PMC10795319 DOI: 10.1186/s12931-024-02682-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND COVID-19-induced acute respiratory distress syndrome (ARDS) can result in tissue damage and multiple organ dysfunction, especially in kidney transplant recipients (KTRs) receiving immunosuppressive drugs. Presently, single-cell research on COVID-19-induced ARDS is considerably advanced, yet knowledge about ARDS in KTRs is still constrained. METHODS Single-cell RNA sequencing (scRNA-seq) analysis was performed to construct a comprehensive single-cell immune landscape of the peripheral blood mononuclear cells (PBMCs) of eight patients with COVID-19-induced ARDS, five KTRs with COVID-19-induced ARDS, and five healthy individuals. Subsequently, we conducted a comprehensive bioinformatics analysis, including cell clustering, enrichment analysis, trajectory analysis, gene regulatory network analysis, and cell-cell interaction analysis, to investigate the heterogeneity of the immune microenvironment in KTRs with ARDS. RESULT Our study revealed that KTRs exhibit significant heterogeneity with COVID-19-induced ARDS compared with those of other individuals, with significant reductions in T cells, as well as an abnormal proliferation of B cells and monocytes. In the context of dual influences from immunosuppression and viral infection, KTRs exhibited more specific plasma cells, along with significant enrichment of dysfunctional GZMB and XAF1 double-positive effector T cells and IFI27-positive monocytes. Additionally, robust communication existed among T cells and monocytes in cytokine signaling. These effects impede the process of immune reconstitution in KTR patients. CONCLUSION Our findings suggest that KTRs with COVID-19-induced ARDS show elevated antibody levels, impaired T cell differentiation, and dysregulation of innate immunity. In summary, this study provides a theoretical foundation for a comprehensive understanding of COVID-19-induced ARDS in KTRs.
Collapse
Affiliation(s)
- Junyu Lu
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China.
- Guangxi Health Commission Key Laboratory of Emergency and Critical Medicine, Nanning, 530007, China.
| | - Yin Chen
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Kaihuan Zhou
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Yicong Ling
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Qianqian Qin
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Weisheng Lu
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Lian Qin
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Chenglin Mou
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
| | - Jianfeng Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China
- Guangxi Health Commission Key Laboratory of Emergency and Critical Medicine, Nanning, 530007, China
| | - Xiaowen Zheng
- Department of Emergency Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, China.
- Guangxi Health Commission Key Laboratory of Emergency and Critical Medicine, Nanning, 530007, China.
| | - Ke Qin
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, Guangxi, China.
- Department of Anesthesiology, Guilin People's Hospital, Guilin, 541002, China.
| |
Collapse
|
3
|
Short S, Lewik G, Issa F. An Immune Atlas of T Cells in Transplant Rejection: Pathways and Therapeutic Opportunities. Transplantation 2023; 107:2341-2352. [PMID: 37026708 PMCID: PMC10593150 DOI: 10.1097/tp.0000000000004572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 01/10/2023] [Accepted: 01/28/2023] [Indexed: 04/08/2023]
Abstract
Short-term outcomes in allotransplantation are excellent due to technical and pharmacological advances; however, improvement in long-term outcomes has been limited. Recurrent episodes of acute cellular rejection, a primarily T cell-mediated response to transplanted tissue, have been implicated in the development of chronic allograft dysfunction and loss. Although it is well established that acute cellular rejection is primarily a CD4 + and CD8 + T cell mediated response, significant heterogeneity exists within these cell compartments. During immune responses, naïve CD4 + T cells are activated and subsequently differentiate into specific T helper subsets under the influence of the local cytokine milieu. These subsets have distinct phenotypic and functional characteristics, with reported differences in their contribution to rejection responses specifically. Of particular relevance are the regulatory subsets and their potential to promote tolerance of allografts. Unraveling the specific contributions of these cell subsets in the context of transplantation is complex, but may reveal new avenues of therapeutic intervention for the prevention of rejection.
Collapse
Affiliation(s)
- Sarah Short
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Guido Lewik
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Fadi Issa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| |
Collapse
|
4
|
Swanson KJ, Bregman A, El-Rifai R, Jackson S, Kandaswamy R, Riad S. Second Kidney Transplant Outcomes in Dialysis Dependent Recipients by Induction Type in the United States. Transplant Proc 2023; 55:1535-1542. [PMID: 37419731 DOI: 10.1016/j.transproceed.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/18/2023] [Accepted: 04/14/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND We examined the association between induction type for a second kidney transplant in dialysis-dependent recipients and the long-term outcomes. METHODS Using the Scientific Registry of Transplant Recipients, we identified all second kidney transplant recipients who returned to dialysis before re-transplantation. Exclusion criteria included: missing, unusual, or no-induction regimens, maintenance regimens other than tacrolimus and mycophenolate, and positive crossmatch status. We grouped recipients by induction type into 3 groups: the anti-thymocyte group (N = 9899), the alemtuzumab group (N = 1982), and the interleukin 2 receptor antagonist group (N = 1904). We analyzed recipient and death-censored graft survival (DCGS) using the Kaplan-Meier survival function with follow-up censored at 10 years post-transplant. We used Cox proportional hazard models to examine the association between induction and the outcomes of interest. To account for the center-specific effect, we included the center as a random effect. We adjusted the models for the pertinent recipient and organ variables. RESULTS In the Kaplan-Meier analyses, induction type did not alter recipient survival (log-rank P = .419) or DCGS (log-rank P = .146). Similarly, in the adjusted models, induction type was not a predictor of recipient or graft survival. Live-donor kidneys were associated with better recipient survival (HR 0.73, 95% CI [0.65, 0.83], P < .001) and graft survival (HR 0.72, 95% CI [0.64, 0.82], P < .001). Publicly insured recipients had worse recipient and allograft outcomes. CONCLUSION In this large cohort of average immunologic-risk dialysis-dependent second kidney transplant recipients, who were discharged on tacrolimus and mycophenolate maintenance, induction type did not influence the long-term outcomes of recipient or graft survival. Live-donor kidneys improved recipient and graft survival.
Collapse
Affiliation(s)
- Kurtis J Swanson
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Adam Bregman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rasha El-Rifai
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Scott Jackson
- Complex Care Analytics, MHealth Fairview, Minneapolis, Minnesota
| | - Raja Kandaswamy
- Division of Transplant Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Samy Riad
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
5
|
Hassanzadeh Y, Yaghobi R, Pakzad P, Geramizadeh B. Decreased frequency of Th22 cells and IL-22 cytokine in kidney transplant patients with active cytomegalovirus infection. BMC Immunol 2023; 24:18. [PMID: 37403036 DOI: 10.1186/s12865-023-00555-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND The immunity of CD4+ T cell subsets against human cytomegalovirus (HCMV) is considerable due to their essential role in controlling the infection in transplant individuals. Previously explained CD4+ subsets such as T helper (Th) 1 have been proven to have a protective role against HCMV infection, while the role of the recently identified Th22 subset has not been described yet. Here, the frequency changes of Th22 cells and the IL-22 cytokine production were investigated in kidney transplant recipients with and without HCMV infection. METHODS Twenty kidney transplant patients and ten healthy controls were enrolled in this study. Patients were categorized into HCMV + and HCMV- groups based on the HCMV DNA real-time PCR results. After isolating CD4+ T cells from PBMCs, the phenotype (CCR6+CCR4+CCR10+) and cytokine profile (IFN-γ-IL-17-IL-22+) of Th22 cells were analyzed by flow cytometry. The gene expression of Aryl Hydrocarbon Receptor (AHR) transcription factor was analyzed by real-time PCR. RESULTS The phenotype frequency of these cells was lower in recipients with infection than in those without infection and healthy controls (1.88 ± 0.51 vs. 4.31 ± 1.05; P = 0.03 and 4.22 ± 0.72; P = 0.01, respectively). A lower Th22 cytokine profile was observed in patients with infection than in the two other groups (0.18 ± 0.03 vs. 0.20 ± 0.03; P = 0.96 and 0.33 ± 0.05; P = 0.04, respectively). AHR expression was also lower in patients with active infection. CONCLUSIONS Overall, this study for the first time suggests that the reduced levels of Th22 subset and IL-22 cytokine in patients with active HCMV infection might indicate the protective role of these cells against HCMV.
Collapse
Affiliation(s)
- Yashgin Hassanzadeh
- Department of Microbiology, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Ramin Yaghobi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Parviz Pakzad
- Department of Microbiology, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Bita Geramizadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
6
|
Cheung J, Zahorowska B, Suranyi M, Wong JKW, Diep J, Spicer ST, Verma ND, Hodgkinson SJ, Hall BM. CD4 +CD25 + T regulatory cells in renal transplantation. Front Immunol 2022; 13:1017683. [PMID: 36426347 PMCID: PMC9681496 DOI: 10.3389/fimmu.2022.1017683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/13/2022] [Indexed: 09/14/2023] Open
Abstract
The immune response to an allograft activates lymphocytes with the capacity to cause rejection. Activation of CD4+CD25+Foxp3+T regulatory cells (Treg) can down-regulate allograft rejection and can induce immune tolerance to the allograft. Treg represent <10% of peripheral CD4+T cells and do not markedly increase in tolerant hosts. CD4+CD25+Foxp3+T cells include both resting and activated Treg that can be distinguished by several markers, many of which are also expressed by effector T cells. More detailed characterization of Treg to identify increased activated antigen-specific Treg may allow reduction of non-specific immunosuppression. Natural thymus derived resting Treg (tTreg) are CD4+CD25+Foxp3+T cells and only partially inhibit alloantigen presenting cell activation of effector cells. Cytokines produced by activated effector cells activate these tTreg to more potent alloantigen-activated Treg that may promote a state of operational tolerance. Activated Treg can be distinguished by several molecules they are induced to express, or whose expression they have suppressed. These include CD45RA/RO, cytokine receptors, chemokine receptors that alter pathways of migration and transcription factors, cytokines and suppression mediating molecules. As the total Treg population does not increase in operational tolerance, it is the activated Treg which may be the most informative to monitor. Here we review the methods used to monitor peripheral Treg, the effect of immunosuppressive regimens on Treg, and correlations with clinical outcomes such as graft survival and rejection. Experimental therapies involving ex vivo Treg expansion and administration in renal transplantation are not reviewed.
Collapse
Affiliation(s)
- Jason Cheung
- Renal Unit, Liverpool Hospital, Sydney, NSW, Australia
| | | | - Michael Suranyi
- Renal Unit, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | | | - Jason Diep
- Renal Unit, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Stephen T. Spicer
- Renal Unit, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Nirupama D. Verma
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- Immune Tolerance Laboratory, Ingham Institute for Applied Medical Research, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Suzanne J. Hodgkinson
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- Immune Tolerance Laboratory, Ingham Institute for Applied Medical Research, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Bruce M. Hall
- Renal Unit, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- Immune Tolerance Laboratory, Ingham Institute for Applied Medical Research, University of New South Wales (UNSW), Sydney, NSW, Australia
| |
Collapse
|
7
|
Kim S, Shukla RK, Yu H, Baek A, Cressman SG, Golconda S, Lee GE, Choi H, Reneau JC, Wang Z, Huang CA, Liyanage NPM, Kim S. CD3e-immunotoxin spares CD62L lo Tregs and reshapes organ-specific T-cell composition by preferentially depleting CD3e hi T cells. Front Immunol 2022; 13:1011190. [PMID: 36389741 PMCID: PMC9643874 DOI: 10.3389/fimmu.2022.1011190] [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: 08/03/2022] [Accepted: 10/04/2022] [Indexed: 02/03/2023] Open
Abstract
CD3-epsilon(CD3e) immunotoxins (IT), a promising precision reagent for various clinical conditions requiring effective depletion of T cells, often shows limited treatment efficacy for largely unknown reasons. Tissue-resident T cells that persist in peripheral tissues have been shown to play pivotal roles in local and systemic immunity, as well as transplant rejection, autoimmunity and cancers. The impact of CD3e-IT treatment on these local cells, however, remains poorly understood. Here, using a new murine testing model, we demonstrate a substantial enrichment of tissue-resident Foxp3+ Tregs following CD3e-IT treatment. Differential surface expression of CD3e among T-cell subsets appears to be a main driver of Treg enrichment in CD3e-IT treatment. The surviving Tregs in CD3e-IT-treated mice were mostly the CD3edimCD62Llo effector phenotype, but the levels of this phenotype markedly varied among different lymphoid and nonlymphoid organs. We also found notable variations in surface CD3e levels among tissue-resident T cells of different organs, and these variations drive CD3e-IT to uniquely reshape T-cell compositions in local organs. The functions of organs and anatomic locations (lymph nodes) also affected the efficacy of CD3e-IT. The multi-organ pharmacodynamics of CD3e-IT and potential treatment resistance mechanisms identified in this study may generate new opportunities to further improve this promising treatment.
Collapse
Affiliation(s)
- Shihyoung Kim
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Rajni Kant Shukla
- Department of Microbial Immunity and Infection, The Ohio State University, Columbus, OH, United States
| | - Hannah Yu
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Alice Baek
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Sophie G. Cressman
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Sarah Golconda
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Ga-Eun Lee
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - Hyewon Choi
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States
| | - John C. Reneau
- Division of Hematology, The Ohio State University, Columbus, OH, United States
| | - Zhirui Wang
- Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Christene A. Huang
- Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Namal P. M. Liyanage
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States,Department of Microbial Immunity and Infection, The Ohio State University, Columbus, OH, United States,Infectious Disease Institute, The Ohio State University, Columbus, OH, United States,*Correspondence: Namal P. M. Liyanage, ; Sanggu Kim,
| | - Sanggu Kim
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, United States,Infectious Disease Institute, The Ohio State University, Columbus, OH, United States,*Correspondence: Namal P. M. Liyanage, ; Sanggu Kim,
| |
Collapse
|
8
|
Preemptive Second Kidney Transplant Outcomes by Induction Type in the United States. Transplant Proc 2022; 54:2125-2132. [PMID: 36210195 DOI: 10.1016/j.transproceed.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
|
9
|
Zhang H, Sage PT. Role of T follicular helper and T follicular regulatory cells in antibody-mediated rejection: new therapeutic targets? Curr Opin Organ Transplant 2022; 27:371-375. [PMID: 35959918 PMCID: PMC9474598 DOI: 10.1097/mot.0000000000001018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AbMR) after solid organ transplantation is tightly controlled by multiple cells of the immune system. Tfh and Tfr cells are essential controllers of antibody responses making them putative targets for therapeutics. However, the mechanisms of how Tfh and Tfr cells regulate B cell and antibody responses are not completely understood. Here, we summarize recent studies elucidating the functions of T follicular helper (Tfh) and T follicular regulatory (Tfr) cells as well as their possible roles in regulating AbMR in solid organ transplantation. RECENT FINDINGS New tools have been developed to study the roles of Tfh and Tfr cells in specific disease states, including AbMR after solid organ transplantation. These tools suggest complex roles for Tfh and Tfr cells in controlling antibody responses. Nevertheless, studies in solid organ transplant rejection suggest that Tfh and Tfr cells may be high value targets for therapeutics. However, specific strategies to target these cells are still being investigated. SUMMARY AbMR is still a substantial clinical problem that restricts long-term survival after solid organ transplantation. Growing evidence has demonstrated a pivotal role for Tfh and Tfr cells in controlling AbMR. In addition to providing an early indication of rejection as a biomarker, targeting Tfh and Tfr cells as a therapeutic strategy offers new hope for alleviating AbMR.
Collapse
Affiliation(s)
- Hengcheng Zhang
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
10
|
Yi SG, Gaber AO, Chen W. B-cell response in solid organ transplantation. Front Immunol 2022; 13:895157. [PMID: 36016958 PMCID: PMC9395675 DOI: 10.3389/fimmu.2022.895157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/11/2022] [Indexed: 11/21/2022] Open
Abstract
The transcriptional regulation of B-cell response to antigen stimulation is complex and involves an intricate network of dynamic signals from cytokines and transcription factors propagated from T-cell interaction. Long-term alloimmunity, in the setting of organ transplantation, is dependent on this B-cell response, which does not appear to be halted by current immunosuppressive regimens which are targeted at T cells. There is emerging evidence that shows that B cells have a diverse response to solid organ transplantation that extends beyond plasma cell antibody production. In this review, we discuss the mechanistic pathways of B-cell activation and differentiation as they relate to the transcriptional regulation of germinal center B cells, plasma cells, and memory B cells in the setting of solid organ transplantation.
Collapse
Affiliation(s)
- Stephanie G. Yi
- Division of Transplantation, Department of Surgery, Houston Methodist Hospital, Houston, TX, United States
- *Correspondence: Stephanie G. Yi,
| | - Ahmed Osama Gaber
- Division of Transplant Immunology, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Wenhao Chen
- Division of Transplantation, Department of Surgery, Houston Methodist Hospital, Houston, TX, United States
| |
Collapse
|
11
|
Mendoza Rojas A, Hesselink DA, van Besouw NM, Dieterich M, de Kuiper R, Baan CC, van Gelder T. High Tacrolimus Intrapatient Variability and Subtherapeutic Immunosuppression are Associated With Adverse Kidney Transplant Outcomes. Ther Drug Monit 2022; 44:369-376. [PMID: 35394988 PMCID: PMC9083489 DOI: 10.1097/ftd.0000000000000955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/12/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Kidney transplant recipients with high intrapatient variability (IPV) in tacrolimus (Tac) exposure experience more rejection and reduced graft survival. To understand the underlying pathophysiology of this association, the authors investigated whether patients with high tacrolimus IPV have a more activated immune system than patients with low IPV. In addition, exposure to tacrolimus and mycophenolic acid (MPA) was studied in relation to rejection and graft survival. METHODS At the time of patient inclusion (5-7 years post-transplantation), the frequency of donor-reactive cells was determined by enzyme-linked immunosorbent assay, and the development of donor-specific anti-Human Leukocyte Antigen antibodies (DSA) was measured by Luminex Single Antigen assay. Tacrolimus IPV was retrospectively calculated between 6 and 12 months and the exposure to tacrolimus and MPA was determined between 1 and 5 years post-transplantation. RESULTS A total of 371 kidney transplant recipients were included in this study, of whom 56 developed a rejection episode after 12 months and 60 experienced graft failure after 5-7 years. No correlations were found between tacrolimus IPV or immunosuppression exposure and the number of donor-reactive cells after 5 years of transplantation. DSA were detected more often in patients with low exposure to both tacrolimus and MMF [4/21 (19%) versus 17/350 (4.9%), P = 0.04]. In this cohort, neither tacrolimus IPV nor low overall immunosuppression exposure was associated with a higher incidence of rejection. However, regression analysis showed that a higher tacrolimus IPV was associated with an increased incidence of graft failure (odds ratio = 1.03, P = 0.02). CONCLUSIONS This study verifies the relationship between high tacrolimus IPV and impaired kidney allograft survival in long-term follow-up. DSA was also found to be more prevalent in patients with subtherapeutic concentrations of tacrolimus and MPA. An increased prevalence of donor-specific alloreactivity is yet to be demonstrated in patients with high IPV.
Collapse
Affiliation(s)
- Aleixandra Mendoza Rojas
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Dennis A. Hesselink
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Nicole M. van Besouw
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Marjolein Dieterich
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Ronella de Kuiper
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Carla C. Baan
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
12
|
Long-Term Outcomes of Kidney Transplant Recipients with Glomerulonephritides by Induction Type and Steroid Avoidance. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Kidney transplant programs have different approaches to induction immunosuppression, and conflicting data exist on the role of steroid maintenance in recipients with glomerulonephritis (GN). GN patients are unique because of a higher risk for immune system exhaustion due to prior exposure to immunosuppressants to treat their GN; this raises questions regarding the optimal immunosuppression needed for transplant success and reduction of complications. We sought to assess the effect of induction type and steroid maintenance on the recipient and kidney graft survival in those with IgA nephropathy (IgAN), systemic lupus erythematosus related GN (SLE), small-vessel vasculitis (SVV), and anti-glomerular basement membrane disease (anti-GBM). We analyzed the Scientific Registry of Transplant Recipients (SRTR) database for adult, primary kidney recipients with the above glomerulonephritides through September 2019. Kaplan–Meier curves were generated to examine kidney graft and recipient survival. We used multivariable Cox proportional hazard models to investigate the impact of induction type and steroid maintenance in each group separately. Our study included 9176 IgAN, 5355 SLE, 1189 SVV, and 660 anti-GBM recipients. Neither induction type nor steroid maintenance therapy influenced recipient or death-censored graft survival in this cohort of recipients. Our findings provide an opportunity for recipients with a history of one of the studied glomerulonephritides to receive a more tailored immunosuppression regimen, considering their previous exposure to immunosuppressants.
Collapse
|
13
|
Louis K, Macedo C, Metes D. Targeting T Follicular Helper Cells to Control Humoral Allogeneic Immunity. Transplantation 2021; 105:e168-e180. [PMID: 33909968 PMCID: PMC8484368 DOI: 10.1097/tp.0000000000003776] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Humoral allogeneic immunity driven by anti-HLA donor-specific antibodies and antibody-mediated rejection (AMR) significantly impede prolonged survival of organ allografts after transplantation. Although the importance of T follicular helper (TFH) cells in controlling antibody responses has been long established, their role in directing donor-specific antibody generation leading to AMR was only recently appreciated in the clinical setting of organ transplantation. In this review, we provide a comprehensive summary of the current knowledge on the biology of human TFH cells as well as their circulating counterparts and describe their pivotal role in driving humoral alloimmunity. In addition, we discuss the intrinsic effects of current induction therapies and maintenance immunosuppressive drugs as well as of biotherapies on TFH cells and provide future directions and novel opportunities of biotherapeutic targeting of TFH cells that have the potential of bringing the prophylactic and curative treatments of AMR toward personalized and precision medicine.
Collapse
Affiliation(s)
- Kevin Louis
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Human Immunology and Immunopathology, Inserm UMR 976, Université de Paris, Paris, France
- Kidney Transplant Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Camila Macedo
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Diana Metes
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
14
|
The role of circulating T follicular helper cells in kidney transplantation. Transpl Immunol 2021; 69:101459. [PMID: 34461243 DOI: 10.1016/j.trim.2021.101459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Humoral rejection plays a crucial role in the chronic deterioration of kidney allografts, but there is no effective therapeutic strategy to prevent or treat it. T follicular helper (Tfh) cells provide help to B cells, subsequently contributing to humoral rejection. Investigation of Tfh cells may be a useful strategy for assessing the risk and level of humoral rejection. However, it is difficult to investigate Tfh cells from patient-derived lymphoid tissue. Recent studies have shown that circulating Tfh (cTfh) cells, working in parallel to Tfh cells, have the capacity to promote antibody-secreting B cell differentiation and antibody secretion. Here, we review recent studies of cTfh cells in kidney transplantation and discuss the characteristics and functions of cTfh cells in kidney transplant recipients.
Collapse
|
15
|
Chong AS, Sage PT, Alegre ML. Regulation of Alloantibody Responses. Front Cell Dev Biol 2021; 9:706171. [PMID: 34307385 PMCID: PMC8297544 DOI: 10.3389/fcell.2021.706171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022] Open
Abstract
The control of alloimmunity is essential to the success of organ transplantation. Upon alloantigen encounter, naïve alloreactive T cells not only differentiate into effector cells that can reject the graft, but also into T follicular helper (Tfh) cells that promote the differentiation of alloreactive B cells that produce donor-specific antibodies (DSA). B cells can exacerbate the rejection process through antibody effector functions and/or B cell antigen-presenting functions. These responses can be limited by immune suppressive mechanisms mediated by T regulatory (Treg) cells, T follicular regulatory (Tfr) cells, B regulatory (Breg) cells and a newly described tolerance-induced B (TIB) cell population that has the ability to suppress de novo B cells in an antigen-specific manner. Transplantation tolerance following costimulation blockade has revealed mechanisms of tolerance that control alloreactive T cells through intrinsic and extrinsic mechanisms, but also inhibit alloreactive B cells. Thus, the control of both arms of adaptive immunity might result in more robust tolerance, one that may withstand more severe inflammatory challenges. Here, we review new findings on the control of B cells and alloantibody production in the context of transplant rejection and tolerance.
Collapse
Affiliation(s)
- Anita S. Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, United States
| | - Peter T. Sage
- Renal Division, Transplantation Research Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, United States
| |
Collapse
|
16
|
Pre-transplant donor-reactive IL-21 producing T cells as a tool to identify an increased risk for acute rejection. Sci Rep 2021; 11:12445. [PMID: 34127739 PMCID: PMC8203783 DOI: 10.1038/s41598-021-91967-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022] Open
Abstract
Pre-transplant screening focuses on the detection of anti-HLA alloantibodies. Previous studies have shown that IFN-γ and IL-21 producing T cells are associated with the development of acute rejection (AR). The aim of this study, was to assess whether pre-transplant donor-reactive T cells and/or B cells are associated with increased rejection risk. Samples from 114 kidney transplant recipients (transplanted between 2010 and 2013) were obtained pre-transplantation. The number of donor-reactive IFN-γ and IL-21 producing cells was analyzed by ELISPOT assay. The presence of donor specific antibodies (DSA) was also determined before transplantation. Numbers of donor-reactive IFN-γ producing cells were similar in patients with or without AR whereas those of IL-21 producing cells were higher in patients with AR (p = 0.03). Significantly more patients with AR [6/30(20%)] had detectable DSA compared to patients without AR [5/84(5.9%), p = 0.03]. Multivariate logistic regression showed that donor age (OR 1.06), pre-transplant DSA (OR 5.61) and positive IL-21 ELISPOT assay (OR 2.77) were independent predictors of an increased risk for the development of AR. Aside from an advanced donor-age and pre-transplant DSA, also pre-transplant donor-reactive IL-21 producing cells are associated with the development of AR after transplantation.
Collapse
|
17
|
Liu Y, Liu X, Zhou S, Xu R, Hu J, Liao G, Liao J, Guo Z, Li Y, Yang S, Li S, Chen H, Guo Y, Li M, Fan L, Li L, Zhao M, Liu D. Single-Cell Profiling of Kidney Transplant Recipients With Immunosuppressive Treatment Reveals the Dynamic Immune Characteristics. Front Immunol 2021; 12:639942. [PMID: 33959124 PMCID: PMC8093626 DOI: 10.3389/fimmu.2021.639942] [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: 12/10/2020] [Accepted: 03/31/2021] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is currently the first choice of treatment for various types of end-stage renal failure, but there are major limitations in the application of immunosuppressive protocols after kidney transplantation. When the dose of immunosuppressant is too low, graft rejection occurs easily, while a dose that is too high can lead to graft loss. Therefore, it is very important to explore the immune status of patients receiving immunosuppressive agents after kidney transplantation. To compare the immune status of the recipient’s whole peripheral blood before and after receipt of immunosuppressive agents, we used single-cell cytometry by time-of-flight (CyTOF) to detect the peripheral blood immune cells in five kidney transplant recipients (KTRs) from the Department of Organ Transplantation of Zhujiang Hospital of Southern Medical University before and after receiving immunosuppressive agents. Based on CyTOF analysis, we detected 363,342 live single immune cells. We found that the immune cell types of the KTRs before and after receipt of immunosuppressive agents were mainly divided into CD4+ T cells, CD8+ T cells, B cells, NK cells/γδ T cells, monocytes/macrophages, granulocytes, and dendritic cells (DCs). After further reclustering of the above cell types, it was found that the immune cell subclusters in the peripheral blood of patients underwent major changes after receipt of immunosuppressants. After receiving immunosuppressive therapy, the peripheral blood of KTRs had significantly increased levels of CD57+NK cells and significantly decreased levels of central memory CD4+ T cells, follicular helper CD4+ T cells, effector CD8+ T cells, effector memory CD8+ T cells and naive CD8+ T cells. This study used CyTOF to classify immune cells in the peripheral blood of KTRs before and after immunosuppressive treatment, further compared differences in the proportions of the main immune cell types and immune cell subgroups before and after receipt of immunosuppressants, and provided relatively accurate information for assessment and treatment strategies for KTRs.
Collapse
Affiliation(s)
- Yongguang Liu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoyou Liu
- Department of Organ Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Song Zhou
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ruiquan Xu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jianmin Hu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Guorong Liao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Liao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zefeng Guo
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzhu Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Siqiang Yang
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shichao Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hua Chen
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Guo
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Min Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Lipei Fan
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Liuyang Li
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Zhao
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ding Liu
- Department of Organ Transplantation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
18
|
Dudreuilh C, Basu S, Scottà C, Dorling A, Lombardi G. Potential Application of T-Follicular Regulatory Cell Therapy in Transplantation. Front Immunol 2021; 11:612848. [PMID: 33603742 PMCID: PMC7884443 DOI: 10.3389/fimmu.2020.612848] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/14/2020] [Indexed: 12/18/2022] Open
Abstract
Regulatory T cells (Tregs) constitute a small proportion of circulating CD4+ T cells that function to maintain homeostasis and prevent autoimmunity. In light of their powerful immunosuppressive and tolerance-promoting properties, Tregs have become an interesting potential candidate for therapeutic use in conditions such as solid organ transplant or to treat autoimmune and inflammatory conditions. Clinical studies have demonstrated the safety of polyclonally expanded Tregs in graft-versus-host disease, type 1 diabetes, and more recently in renal and liver transplantation. However, Tregs are heterogenous. Recent insights indicate that only a small proportion of Tregs, called T follicular regulatory cells (Tfr) regulate interactions between B cells and T follicular helper (Tfh) cells within the germinal center. Tfr have been mainly described in mouse models due to the challenges of sampling secondary lymphoid organs in humans. However, emerging human studies, characterize Tfr as being CD4+CD25+FOXP3+CXCR5+ cells with different levels of PD-1 and ICOS expression depending on their localization, in the blood or the germinal center. The exact role they play in transplantation remains to be elucidated. However, given the potential ability of these cells to modulate antibody responses to allo-antigens, there is great interest in exploring translational applications in situations where B cell responses need to be regulated. Here, we review the current knowledge of Tfr and the role they play focusing on human diseases and transplantation. We also discuss the potential future applications of Tfr therapy in transplantation and examine the evidence for a role of Tfr in antibody production, acute and chronic rejection and tertiary lymphoid organs. Furthermore, the potential impact of immunosuppression on Tfr will be explored. Based on preclinical research, we will analyse the rationale of Tfr therapy in solid organ transplantation and summarize the different challenges to be overcome before Tfr therapy can be implemented into clinical practice.
Collapse
Affiliation(s)
- Caroline Dudreuilh
- Department of Inflammation Biology, King's College London (KCL), Guy's Hospital, London, United Kingdom.,Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, London, United Kingdom
| | - Sumoyee Basu
- Department of Inflammation Biology, King's College London (KCL), Guy's Hospital, London, United Kingdom.,Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, London, United Kingdom
| | - Cristiano Scottà
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, London, United Kingdom.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Science, King's College London (KCL), Guy's Hospital, London, United Kingdom
| | - Anthony Dorling
- Department of Inflammation Biology, King's College London (KCL), Guy's Hospital, London, United Kingdom.,Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, London, United Kingdom
| | - Giovanna Lombardi
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, London, United Kingdom.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Science, King's College London (KCL), Guy's Hospital, London, United Kingdom
| |
Collapse
|