Tolerization of recent thymic emigrants is required to prevent RBC-specific autoimmunity

A retrospective analysis of autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation for transfusion-dependent β-thalassemia: focus on T and B lymphocyte reconstitution

BACKGROUND

Autoimmune hemolytic anemia (AIHA) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is often refractory and relapsing, leading to increased mortality post-HSCT.

METHODS

We retrospectively analyzed the cases of patients with transfusion-dependent β-thalassemia (TDT) who underwent allo-HSCT to study their clinical features, the occurrence of AIHA post-HSCT, and treatment response and to explore the possible pathogenesis of AIHA.

RESULT

A total of 113 patients were registered in the study, out of whom 14 developed AIHA following allo-HSCT, resulting in a cumulative incidence of 12.4%. The median age at HSCT was 5 (range: 2-14) years, and the median time of occurrence was 8 (range: 4-17) months after HSCT. Patients who are less than 4 years old at the time of HSCT (P = 0.032) exhibit a higher incidence of AIHA. Compared to patients without AIHA, AIHA patients demonstrate a lower percentage of B lymphocytes at the first 100 days (day + 100) post-HSCT(P = 0.002). There were no statistically significant differences in gender, unrelated donors, HLA incomplete mismatch, iron overload, ABO incompatibility, cytomegalovirus (CMV) reactivation, Epstein Barr virus (EBV) reactivation, acute and chronic graft-versus-host disease (GvHD). When AIHA occurred, the absolute value of regulatory T cells decreased without a clear reduction in the proportion of CD4 + cells, and there was no significant elevation of interleukin-17. Eventually, 78.6% (11/14) of patients achieved complete remission with corticosteroids and rituximab, and patients who failed were efficacious with the bortezomib in combination with corticosteroids. Four patients experienced relapse, with one of them relapsing twice. Two patients relapsed after bortezomib and subsequently achieved remission with retreatment using a combination of corticosteroids and rituximab. All AIHA patients were alive and without relapse at the follow-up cutoff.

CONCLUSIONS

Patients suffering from TDT are more prone to developing AIHA following allo-HSCT, potentially due to a disruption in the reconstitution balance of T and B lymphocytes. Despite the high incidence, the response to treatment was excellent. For relapsed/refractory patients, alternate therapy with bortezomib and rituximab may be considered.

Mitigation of checkpoint inhibitor-induced autoimmune hemolytic anemia through modulation of purinergic signaling

ABSTRACT

Immune checkpoint inhibitors (ICPis) have revolutionized cancer immunotherapy but also can induce autoimmune hemolytic anemia (AIHA), a severe disease with high mortality. However, the cellular and molecular mechanism(s) of AIHA secondary to ICPi therapy (ICPi-AIHA) are unclear, other than being initiated through decreased checkpoint inhibition. Herein, we report ICPi-AIHA in a novel mouse model that shows similar characteristics of known human ICPi-AIHA (eg, autoantibodies, hemolysis, and increased mortality). During ICPi-AIHA, there is the simultaneous reduction of 2 regulatory T-cell populations (FoxP3+ and Tr1 [type 1 regulatory cells]) and an increase in inflammatory T helper cell 17 (TH17). Moreover, a novel CD39+CD73-FoxP3-CD25- CD4+ T-cell subset (ie, CD39 single positive [CD39SP]) emerges, and early increases in CD39SP predict AIHA development; CD39 is an ectonuclease that breaks down adenosine triphosphate (ATP). Additionally, we found that boosting ATPase activity by injecting recombinant apyrase mitigates AIHA development and significant CD39SP reductions, both suggesting a functional role for CD39 and demonstrating a novel therapeutic approach. Importantly, CD39SP are detectable in multiple mouse models developing AIHA and in patients with AIHA, demonstrating applicability to idiopathic and secondary AIHA. Highlighting broader autoimmunity relevance, ICPi-treated NZB mice experienced accelerated onset and severity of lupus, including AIHA. Moreover, ICPi treatment of healthy B6 animals led to detectable CD39SP and development of autoantibodies against multiple autoantigens including those on red blood cells and platelets. Together, our findings provide further insight into the cellular and molecular mechanisms of ICPi-AIHA, leading to novel diagnostic and therapeutic approaches with translational potential for use in humans being treated with ICPi.

Prior immunization against an intracellular antigen enhances subsequent red blood cell alloimmunization in mice

Antibodies against red blood cell (RBC) alloantigens can increase morbidity and mortality among transfusion recipients. However, alloimmunization rates can vary dramatically, as some patients never generate alloantibodies after transfusion, whereas others not only become alloimmunized but may also be prone to generating additional alloantibodies after subsequent transfusion. Previous studies suggested that CD4 T-cell responses that drive alloantibody formation recognize the same alloantigen engaged by B cells. However, because RBCs express numerous antigens, both internally and externally, it is possible that CD4 T-cell responses directed against intracellular antigens may facilitate subsequent alloimmunization against a surface RBC antigen. Here, we show that B cells can acquire intracellular antigens from RBCs. Using a mouse model of donor RBCs expressing 2 distinct alloantigens, we demonstrate that immune priming to an intracellular antigen, which would not be detected by any currently used RBC compatibility assays, can directly influence alloantibody formation after exposure to a subsequent distinct surface RBC alloantigen. These findings suggest a previously underappreciated mechanism whereby transfusion recipient responders may exhibit an increased rate of alloimmunization because of prior immune priming toward intracellular antigens.

The Proportion of Recent Thymic Emigrant Lymphocytes in Breastfed and Formula Fed Term Neonates

Recent thymic emigrants (RTEs) represent a distinct T cell subset characterized by a tolerance-prone status. We have recently demonstrated that the proportion of regulatory T cells (Tregs) is nearly two-fold higher in exclusively breastfed compared with exclusively formula-fed neonates. However, it has been unknown whether the type of milk is also associated with the proportion of the RTE cell compartment. Cord blood (CB) and, at three weeks of age, peripheral venous blood samples were collected from 19 healthy-term neonates. A maternal blood sample was also taken. The proportion of RTEs, naïve CD4 cells, naïve RTEs, and Tregs was analyzed by flow cytometry in blood samples. RTE cell proportions were comparable between CB and 3 weeks. At both time points, there was no difference in the proportion of naïve CD4 cells, RTE CD4 cells, and naïve RTE CD4 cells between the feeding groups. The fold change of RTE cells between birth and three weeks of life was highest in mixed-fed babies. Since RTE counts were comparable across the feeding groups at birth, this most likely reflects a postnatal upregulation, to which the dual antigenic exposure to both non-inherited maternal antigens via breastmilk, as well as to other environmental antigens in formula milk, may contribute.

Distinct CD4+ T cell signature in ANA-positive young adult patients

Failure of immune tolerance can lead to autoantibody production resulting in autoimmune diseases, a broad spectrum of organ-specific or systemic disorders. Immune tolerance mechanisms regulate autoreactive T and B cells, yet some lymphocytes escape and promote autoantibody production. CD4+ T cell dysregulation, characterized by decreased or impaired regulatory cells (Tregs) and/or accumulation of memory and effector T cells such as TH17, plays a crucial role in the pathogenesis of these diseases. Antinuclear antibody (ANAs) testing is used as a first step for the diagnosis of autoimmune disorders, although most ANA-positive individuals do not have nor will develop an autoimmune disease. Studying the differences of T cell compartment among healthy blood donors, ANA-negative patients and ANA-positive patients, in which loss of tolerance have not led to autoimmunity, may improve our understanding on how tolerance mechanisms fail. Herein, we report that ANA-positive patients exhibit a distinct distribution of T cell subsets: significantly reduced frequencies of recent thymic emigrants (RTE) and naïve T cells, and significantly increased frequencies of central memory T cells, TH2 and TH17 cells; modulations within the T cell compartment are most profound within the 18-40 year age range. Moreover, CD4+ T cells in ANA-positive patients are metabolically active, as determined by a significant increase in mTORC1 and mTORC2 signals, compared to ANA-negative patients and healthy blood donors. No significant impairment of Treg numbers or pro-inflammatory cytokine production was observed. These results identify a unique T cell signature associated with autoantibody production in the absence of autoimmune disease.

A New Murine Model of Primary Autoimmune Hemolytic Anemia (AIHA)

Loss of humoral tolerance to red blood cells (RBCs) can lead to autoimmune hemolytic anemia (AIHA), a severe, and sometimes fatal disease. Patients with AIHA present with pallor, fatigue, decreased hematocrit, and splenomegaly. While secondary AIHA is associated with lymphoproliferative disorders, infections, and more recently, as an adverse event secondary to cancer immunotherapy, the etiology of primary AIHA is unknown. Several therapeutic strategies are available; however, there are currently no licensed treatments for AIHA and few therapeutics offer treatment-free durable remission. Moreover, supportive care with RBC transfusions can be challenging as most autoantibodies are directed against ubiquitous RBC antigens; thus, virtually all RBC donor units are incompatible. Given the severity of AIHA and the lack of treatment options, understanding the cellular and molecular mechanisms that facilitate the breakdown in tolerance would provide insight into new therapeutics. Herein, we report a new murine model of primary AIHA that reflects the biology observed in patients with primary AIHA. Production of anti-erythrocyte autoantibodies correlated with sex and age, and led to RBC antigen modulation, complement fixation, and anemia, as determined by decreased hematocrit and hemoglobin values and increased reticulocytes in peripheral blood. Moreover, autoantibody-producing animals developed splenomegaly, with altered splenic architecture characterized by expanded white pulp areas and nearly diminished red pulp areas. Additional analysis suggested that compensatory extramedullary erythropoiesis occurred as there were increased frequencies of RBC progenitors detectable in the spleen. No significant correlations between AIHA onset and inflammatory status or microbiome were observed. To our knowledge, this is the first report of a murine model that replicates observations made in humans with idiopathic AIHA. Thus, this is a tractable murine model of AIHA that can serve as a platform to identify key cellular and molecular pathways that are compromised, thereby leading to autoantibody formation, as well as testing new therapeutics and management strategies.