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Singh AK, Goerlich CE, Shah AM, Zhang T, Tatarov I, Ayares D, Horvath KA, Mohiuddin MM. Cardiac Xenotransplantation: Progress in Preclinical Models and Prospects for Clinical Translation. Transpl Int 2022; 35:10171. [PMID: 35401039 PMCID: PMC8985160 DOI: 10.3389/ti.2022.10171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/11/2022] [Indexed: 12/02/2022]
Abstract
Survival of pig cardiac xenografts in a non-human primate (NHP) model has improved significantly over the last 4 years with the introduction of costimulation blockade based immunosuppression (IS) and genetically engineered (GE) pig donors. The longest survival of a cardiac xenograft in the heterotopic (HHTx) position was almost 3 years and only rejected when IS was stopped. Recent reports of cardiac xenograft survival in a life-sustaining orthotopic (OHTx) position for 6 months is a significant step forward. Despite these achievements, there are still several barriers to the clinical success of xenotransplantation (XTx). This includes the possible transmission of porcine pathogens with pig donors and continued xenograft growth after XTx. Both these concerns, and issues with additional incompatibilities, have been addressed recently with the genetic modification of pigs. This review discusses the spectrum of issues related to cardiac xenotransplantation, recent progress in preclinical models, and its feasibility for clinical translation.
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Affiliation(s)
- Avneesh K. Singh
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Corbin E. Goerlich
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Aakash M. Shah
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Tianshu Zhang
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Ivan Tatarov
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | | | - Keith A. Horvath
- National Heart, Lung, and Blood Institute, National Institute of Health, Bethesda, MD, United States
| | - Muhammad M. Mohiuddin
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
- *Correspondence: Muhammad M. Mohiuddin,
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Burdorf L, Laird CT, Harris DG, Connolly MR, Habibabady Z, Redding E, O’Neill NA, Cimeno A, Parsell D, Phelps C, Ayares D, Azimzadeh AM, Pierson RN. Pig-to-baboon lung xenotransplantation: Extended survival with targeted genetic modifications and pharmacologic treatments. Am J Transplant 2022; 22:28-45. [PMID: 34424601 PMCID: PMC10292947 DOI: 10.1111/ajt.16809] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 01/25/2023]
Abstract
Galactosyl transferase knock-out pig lungs fail rapidly in baboons. Based on previously identified lung xenograft injury mechanisms, additional expression of human complement and coagulation pathway regulatory proteins, anti-inflammatory enzymes and self-recognition receptors, and knock-down of the β4Gal xenoantigen were tested in various combinations. Transient life-supporting GalTKO.hCD46 lung function was consistently observed in association with either hEPCR (n = 15), hTBM (n = 4), or hEPCR.hTFPI (n = 11), but the loss of vascular barrier function in the xenograft and systemic inflammation in the recipient typically occurred within 24 h. Co-expression of hEPCR and hTBM (n = 11) and additionally blocking multiple pro-inflammatory innate and adaptive immune mechanisms was more consistently associated with survival >1 day, with one recipient surviving for 31 days. Combining targeted genetic modifications to the lung xenograft with selective innate and adaptive immune suppression enables prolonged initial life-supporting lung function and extends lung xenograft recipient survival, and illustrates residual barriers and candidate treatment strategies that may enable the clinical application of other organ xenografts.
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Affiliation(s)
- Lars Burdorf
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Christopher T. Laird
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Donald G. Harris
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Margaret R. Connolly
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Zahra Habibabady
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Emily Redding
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Natalie A. O’Neill
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Arielle Cimeno
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Dawn Parsell
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | | | | | - Agnes M. Azimzadeh
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
| | - Richard N. Pierson
- Division of Cardiac Surgery, Department of Surgery, and
Center for Transplantation Sciences, Massachusetts General Hospital, Boston,
Massachusetts, USA
- Department of Surgery, University of Maryland School of
Medicine, Baltimore, Maryland, USA
- Baltimore Veterans Administration Medical Center,
Baltimore, Maryland, USA
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Singh AK, Chan JL, DiChiacchio L, Hardy NL, Corcoran PC, Lewis BGT, Thomas ML, Burke AP, Ayares D, Horvath KA, Mohiuddin MM. Cardiac xenografts show reduced survival in the absence of transgenic human thrombomodulin expression in donor pigs. Xenotransplantation 2018; 26:e12465. [PMID: 30290025 DOI: 10.1111/xen.12465] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/20/2018] [Accepted: 09/10/2018] [Indexed: 12/13/2022]
Abstract
A combination of genetic manipulations of donor organs and target-specific immunosuppression is instrumental in achieving long-term cardiac xenograft survival. Recently, results from our preclinical pig-to-baboon heterotopic cardiac xenotransplantation model suggest that a three-pronged approach is successful in extending xenograft survival: (a) α-1,3-galactosyl transferase (Gal) gene knockout in donor pigs (GTKO) to prevent Gal-specific antibody-mediated rejection; (b) transgenic expression of human complement regulatory proteins (hCRP; hCD46) and human thromboregulatory protein thrombomodulin (hTBM) to avoid complement activation and coagulation dysregulation; and (c) effective induction and maintenance of immunomodulation, particularly through co-stimulation blockade of CD40-CD40L pathways with anti-CD40 (2C10R4) monoclonal antibody (mAb). Using this combination of manipulations, we reported significant improvement in cardiac xenograft survival. In this study, we are reporting the survival of cardiac xenotransplantation recipients (n = 3) receiving xenografts from pigs without the expression of hTBM (GTKO.CD46). We observed that all grafts underwent rejection at an early time point (median 70 days) despite utilization of our previously reported successful immunosuppression regimen and effective control of non-Gal antibody response. These results support our hypothesis that transgenic expression of human thrombomodulin in donor pigs confers an independent protective effect for xenograft survival in the setting of a co-stimulation blockade-based immunomodulatory regimen.
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Affiliation(s)
- Avneesh K Singh
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Joshua L Chan
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Laura DiChiacchio
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Naomi L Hardy
- Department of Pathology at the University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
| | - Philip C Corcoran
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Billeta G T Lewis
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, Maryland
| | - Marvin L Thomas
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, Maryland
| | - Allen P Burke
- Department of Pathology at the University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
| | | | - Keith A Horvath
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Muhammad M Mohiuddin
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
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Burdorf L, Riner A, Rybak E, Salles II, De Meyer SF, Shah A, Quinn KJ, Harris D, Zhang T, Parsell D, Ali F, Schwartz E, Kang E, Cheng X, Sievert E, Zhao Y, Braileanu G, Phelps CJ, Ayares DL, Deckmyn H, Pierson RN, Azimzadeh AM, Dandro A, Karavi K. Platelet sequestration and activation during GalTKO.hCD46 pig lung perfusion by human blood is primarily mediated by GPIb, GPIIb/IIIa, and von Willebrand Factor. Xenotransplantation 2016; 23:222-236. [PMID: 27188532 DOI: 10.1111/xen.12236] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Here, we ask whether platelet GPIb and GPIIb/IIIa receptors modulate platelet sequestration and activation during GalTKO.hCD46 pig lung xenograft perfusion. METHODS GalTKO.hCD46 transgenic pig lungs were perfused with heparinized fresh human blood. Results from perfusions in which αGPIb Fab (6B4, 10 mg/l blood, n = 6), αGPIIb/IIIa Fab (ReoPro, 3.5 mg/l blood, n = 6), or both drugs (n = 4) were administered to the perfusate were compared to two additional groups in which the donor pig received 1-desamino-8-d-arginine vasopressin (DDAVP), 3 μg/kg (to pre-deplete von Willebrand Factor (pVWF), the main GPIb ligand), with or without αGPIb (n = 6 each). RESULTS Platelet sequestration was significantly delayed in αGPIb, αGPIb+DDAVP, and αGPIb+αGPIIb/IIIa groups. Median lung "survival" was significantly longer (>240 vs. 162 min reference, p = 0.016), and platelet activation (as CD62P and βTG) were significantly inhibited, when pigs were pre-treated with DDAVP, with or without αGPIb Fab treatment. Pulmonary vascular resistance rise was not significantly attenuated in any group, and was associated with residual thromboxane and histamine elaboration. CONCLUSIONS The GPIb-VWF and GPIIb/IIIa axes play important roles in platelet sequestration and coagulation cascade activation during GalTKO.hCD46 lung xenograft injury. GPIb blockade significantly reduces platelet activation and delays platelet sequestration in this xenolung rejection model, an effect amplified by adding αGPIIb/IIIa blockade or depletion of VWF from pig lung.
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Affiliation(s)
- L Burdorf
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - A Riner
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - E Rybak
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - I I Salles
- Laboratory for Thrombosis Research, IRF-Ls, Kulak KU Leuven, Belgium.,Centre for Hematology, Imperial College London, UK
| | - S F De Meyer
- Laboratory for Thrombosis Research, IRF-Ls, Kulak KU Leuven, Belgium
| | - A Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - K J Quinn
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - D Harris
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - T Zhang
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - D Parsell
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - F Ali
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - E Schwartz
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - E Kang
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - X Cheng
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - E Sievert
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - Y Zhao
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - G Braileanu
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - C J Phelps
- Revivicor, Inc., Blacksburg, VA, United States
| | - D L Ayares
- Revivicor, Inc., Blacksburg, VA, United States
| | - H Deckmyn
- Laboratory for Thrombosis Research, IRF-Ls, Kulak KU Leuven, Belgium
| | - R N Pierson
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
| | - A M Azimzadeh
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, and VA Maryland Health Care System, Baltimore, MD, United States
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5
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Azimzadeh AM, Kelishadi SS, Ezzelarab MB, Singh AK, Stoddard T, Iwase H, Zhang T, Burdorf L, Sievert E, Avon C, Cheng X, Ayares D, Horvath KA, Corcoran PC, Mohiuddin MM, Barth RN, Cooper DKC, Pierson RN. Early graft failure of GalTKO pig organs in baboons is reduced by expression of a human complement pathway-regulatory protein. Xenotransplantation 2015; 22:310-6. [PMID: 26174749 DOI: 10.1111/xen.12176] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/07/2015] [Indexed: 01/24/2023]
Abstract
We describe the incidence of early graft failure (EGF, defined as loss of function from any cause within 3 days after transplant) in a large cohort of GalTKO pig organs transplanted into baboons in three centers, and the effect of additional expression of a human complement pathway-regulatory protein, CD46 or CD55 (GalTKO.hCPRP). Baboon recipients of life-supporting GalTKO kidney (n = 7) or heterotopic heart (n = 14) grafts received either no immunosuppression (n = 4), or one of several partial or full immunosuppressive regimens (n = 17). Fourteen additional baboons received a GalTKO.hCPRP kidney (n = 5) or heart (n = 9) and similar treatment regimens. Immunologic, pathologic, and coagulation parameters were measured at frequent intervals. EGF of GalTKO organs occurred in 9/21 baboons (43%). hCPRP expression reduced the GalTKO EGF incidence to 7% (1/14; P < 0.01 vs. GalTKO alone). At 30 mins, complement deposits were more intense in organs in which EGF developed (P < 0.005). The intensity of peri-transplant platelet activation (as β-thromboglobulin release) correlated with EGF, as did the cumulative coagulation score (P < 0.01). We conclude that (i) the transgenic expression of a hCPRP on the vascular endothelium of a GalTKO pig reduces the incidence of EGF and reduces complement deposition, (ii) complement deposition and platelet activation correlate with early GalTKO organ failure, and (iii) the expression of a hCPRP reduces EGF but does not prevent systemic coagulation activation. Additional strategies will be required to control coagulation activation.
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Affiliation(s)
- Agnes M Azimzadeh
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Sean S Kelishadi
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Mohamed B Ezzelarab
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Avneesh K Singh
- Cardiothoracic Surgery Research Program, NHLBI/NIH, Bethesda, MD, USA
| | - Tiffany Stoddard
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Hayato Iwase
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tianshu Zhang
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Lars Burdorf
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Evelyn Sievert
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Chris Avon
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - Xiangfei Cheng
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | | | - Keith A Horvath
- Cardiothoracic Surgery Research Program, NHLBI/NIH, Bethesda, MD, USA
| | - Philip C Corcoran
- Cardiothoracic Surgery Research Program, NHLBI/NIH, Bethesda, MD, USA
| | | | - Rolf N Barth
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
| | - David K C Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard N Pierson
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD, USA
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