The failure of intrathymic transplantation of nonimmunogenic islet allografts to promote induction of donor-specific unresponsiveness

Resolving the conundrum of islet transplantation by linking metabolic dysregulation, inflammation, and immune regulation

Although type 1 diabetes cannot be prevented or reversed, replacement of insulin production by transplantation of the pancreas or pancreatic islets represents a definitive solution. At present, transplantation can restore euglycemia, but this restoration is short-lived, requires islets from multiple donors, and necessitates lifelong immunosuppression. An emerging paradigm in transplantation and autoimmunity indicates that systemic inflammation contributes to tissue injury while disrupting immune tolerance. We identify multiple barriers to successful islet transplantation, each of which either contributes to the inflammatory state or is augmented by it. To optimize islet transplantation for diabetes reversal, we suggest that targeting these interacting barriers and the accompanying inflammation may represent an improved approach to achieve successful clinical islet transplantation by enhancing islet survival, regeneration or neogenesis potential, and tolerance induction. Overall, we consider the proinflammatory effects of important technical, immunological, and metabolic barriers including: 1) islet isolation and transplantation, including selection of implantation site; 2) recurrent autoimmunity, alloimmune rejection, and unique features of the autoimmune-prone immune system; and 3) the deranged metabolism of the islet transplant recipient. Consideration of these themes reveals that each is interrelated to and exacerbated by the other and that this connection is mediated by a systemic inflammatory state. This inflammatory state may form the central barrier to successful islet transplantation. Overall, there remains substantial promise in islet transplantation with several avenues of ongoing promising research. This review focuses on interactions between the technical, immunological, and metabolic barriers that must be overcome to optimize the success of this important therapeutic approach.

Two developmentally distinct populations of dendritic cells inhabit the adult mouse thymus: demonstration by differential importation of hematogenous precursors under steady state conditions

Although a variety of lymphoid and myeloid precursors can generate thymic dendritic cells (DCs) under defined experimental conditions, the developmental origin(s) of DCs in the steady state thymus is unknown. Having previously used selective combinations of normal, parabiotic, and radioablated mice to demonstrate that blood-borne prothymocytes are imported in a gated and competitive manner, we used a similar approach in this study to investigate the importation of the hematogenous precursors of thymic DCs. The results indicate that two developmentally distinct populations of DC precursors normally enter the adult mouse thymus. The first population is indistinguishable from prothymocytes according to the following criteria: 1) inefficient (<20%) exchange between parabiotic partners; 2) gated importation by the thymus; 3) competitive antagonism for intrathymic niches; 4) temporally linked generation of thymocytes and CD8alpha(high) DCs; and 5) absence from prothymocyte-poor blood samples. The second population differs diametrically from prothymocytes in each of these properties, and appears to enter the thymus in at least a partially differentiated state. The resulting population of DCs has a CD8alpha(-/low) phenotype, and constitutes approximately 50% of total thymic DCs. The presence of two discrete populations of DCs in the steady state thymus implies functional heterogeneity consistent with evidence implicating lymphoid DCs in the negative selection of effector thymocytes and myeloid DCs in the positive selection of regulatory thymocytes.

A central role for peripheral dendritic cells in the induction of acquired thymic tolerance

Despite extensive negative selection in the thymus, numerous clones of self-reactive T cells are normally exported to the periphery. In most instances, autoimmunity is prevented by regulatory T (Tr) cells, many of which are also of recent thymic origin. We have demonstrated recently that natural killer (NK) Tr thymocytes (THYr) can be induced by the injection of antigen into the eye, an immunologically privileged site; and that the intravenous infusion of antigen-presenting cells (APCs) from such animals also induces NKT THYr. Furthermore, we have also observed that some of these APCs migrate to the thymus as CD11c(+) dendritic cells (DCs). Other authors have correlated the migration of DCs to the thymus with the generation of CD4(+)CD25(+) THYr. We therefore propose a novel tolerance induction pathway by which tolerogenic DCs routinely transport antigen (both self and nonself) from the periphery to the thymus, where they positively select THYr. We also propose that the ability of tolerogenic DCs to induce acquired thymic tolerance on demand might have important implications for the immunotherapy of autoimmunity and allotransplantation.

Induction of immunologic tolerance for transplantation

In the second half of the 20th century, the transplantation of replacement organs and tissues to cure disease has become a clinical reality. Success has been achieved as a direct result of progress in understanding the cellular and molecular biology of the immune system. This understanding has led to the development of immunosuppressive pharmaceuticals that are part of nearly every transplantation procedure. All such drugs are toxic to some degree, however, and their chronic use, mandatory in transplantation, predisposes the patient to the development of infection and cancer. In addition, many of them may have deleterious long-term effects on the function of grafts. New immunosuppressive agents are constantly under development, but organ transplantation remains a therapy that requires patients to choose between the risks of their primary illness and its treatment on the one hand, and the risks of life-long systemic immunosuppression on the other. Alternatives to immunosuppression include modulation of donor grafts to reduce immunogenicity, removal of passenger leukocytes, transplantation into immunologically privileged sites like the testis or thymus, encapsulation of tissue, and the induction of a state of immunologic tolerance. It is the last of these alternatives that has, perhaps, the most promise and most generic applicability as a future therapy. Recent reports documenting long-term graft survival in the absence of immunosuppression suggest that tolerance-based therapies may soon become a clinical reality. Of particular interest to our laboratory are transplantation strategies that focus on the induction of donor-specific T-cell unresponsiveness. The basic biology, protocols, experimental outcomes, and clinical implications of tolerance-based transplantation are the focus of this review.

Acquired transplant tolerance

Increasing the acceptance rate of organs is the central goal of transplantation research. Long-term survival of vascularized organs without chronic immunosuppressive therapy has been achieved in experimental animals. In humans, the possibility of achieving immunological tolerance and a drug-free state has been reported occasionally in patients who after withdrawal of immunosuppressants because of major toxicity still carry a functioning graft. It has been proposed that organ transplant implies a migratory flux of donor 'passenger' leukocytes out of the graft into the recipient tissue or organs, to establish a persistent condition of 'microchimerism'. Although there is evidence that the same migratory mechanisms apply to all organ grafts, migration of 'passenger' leukocytes is less in kidney and heart than in liver. To enhance the acceptance of organs less tolerogenic than liver, perioperative infusion of donor bone marrow has been attempted to increase the donor 'passenger' leukocyte load. It has been suggested that the established microchimerism is not only associated with long-term acceptance of the graft, but it also plays an active role in induction and maintenance of donor-specific unresponsiveness. However, the intimate mechanism(s) responsible for prolonged graft survival in this setting remain speculative. Experimental evidence is also available that the thymus plays a major role in the development of self-tolerance and is critical in the induction of acquired tolerance to exogenous antigens. It has been reported that after intrathymic injection of donor cells clonal deletion of maturing thymocytes occurs and is the major mechanism in the induction of donor-specific tolerance, since peripheral T-cell component would be devoid of alloreactive population. Studies are warranted in the near future to explore whether the thymus technique can be employed to prolong survival or induce tolerance to allograft in humans. An interesting novel strategy for transplant tolerance is also the oral administration of alloantigens, which has been recently applied to the cardiac transplant model in rat. All these approaches will have a major impact in the near future on transplant medicine, opening new perspectives to obtain indefinite graft survival.

Donor-specific tolerance by perioperative intrathymic injection of bone marrow cells in the rat cardiac allograft model: use of FK506 can shorten the necessary duration of pretransplant intrathymic conditioning

BACKGROUND

Many strategies of tolerance induction by intrathymic (IT) injection of donor alloantigens have been reported to date; however, the timing of IT injection is usually 1-3 weeks before transplantation.

METHODS

To apply IT injection to cadaveric organ transplantation, 1 x 10(8) fully allogeneic bone marrow cells (BMC) of Buffalo (BUF; RT1b) rats were intrathymically injected into Wistar Furth (WF; RT1u) rats at the time of BUF cardiac allografting with short-course therapy of antilymphocyte serum (ALS) and FK506 in our experimental model.

RESULTS

Allogeneic IT injection of BUF BMC with ALS and FK506 indefinitely prolonged graft survival (mean survival time > 210 days) in all WF rats. On day 130 after grafting, tolerant WF rats accepted donor BUF skin grafts (> 120 days) but not third-party Lewis skin grafts. In control groups, syngeneic IT injection of WF BMC or intravenous injection of donor BUF BMC in combination with ALS/FK506 therapy failed to induce tolerance. In vivo testing was performed during induction (1 month) or during maintenance (6 months of tolerance. In the mixed lymphocyte reaction (MLR), spleen T cells of tolerant rats at 1 month after grafting displayed hyporesponsiveness after stimulation with donor cells. The addition of interleukin (IL)-2 to MLR culture did not restore T-cell responsiveness. Tolerant rats had a significantly decreased frequency of T cytotoxic cell precursors (fTcp) of 1:4,926, and frequency of IL-2-producing T helper cell precursors (fThp) of 1:23,925, compared with naive rats (1: 2,158 and 1:4,266, respectively). By 6 months after grafting, however, the anti-donor MLR proliferative responses of tolerant rats had been restored to the levels of naive splenic T cells. These tolerant rats displayed restoration of the (fTcp) of 1:2,842 and of the (fThp) of 1:5,630, which were comparable frequencies of naive rats. Suppressor T cells did not contribute in this model. In cardiac grafts of tolerant rats induced by IT injection, expression of both Th1 (interferon-gamma and IL-2) and Th2 (IL-4 and IL-10) cytokines was detected in the early phase; thereafter, expression was completely inhibited, except for interferon-gamma in the chronic phase.

CONCLUSIONS

Perfect donor-specific tolerance was obtained by IT injection of donor BMC at the time of transplantation, while alloimmune responses were maintained at levels similar to those of naive rats.

The lost chord: microchimerism and allograft survival

Recent evidence suggests that passenger leukocytes migrate after organ transplantation and produce persistent chimerism, which is essential for sustained survival of the allografts. Here, Thomas Starzl and colleagues argure that this hematolymphopoietic chimerism provides an important framework for the interpretation of basic and therapeutically oriented transplantataion research.

Prevention of Transplant Rejection: Can Tolerance be Achieved with Immunosuppressive Treatment?

Successful solid organ transplantation is generally attributed to the increasingly precise ability of drugs to control rejection. However, it was recently shown that a few donor haematolymphoid cells can survive for decades in recipients of successful organ allografts, a phenomenon called microchimaerism. The association for decades of haematolymphoid chimaerism with allograft tolerance in experimental transplantation suggests that immunosuppressive drugs merely create a milieu that enables an allograft and its complement of passenger leucocytes to prime the recipient for graft acceptance.Exploitation of this concept requires a fundamental shift in the classical view of passenger leucocytes only as initiators of rejection. Microchimaerism has taught us that solid organ transplantation involves the transfer of two donor organ systems to the recipient: the allograft parenchyma and the donor haematolymphoid system in the form of donor stem cells contained within the passenger leucocyte compartment. Each has the potential to integrate with the corresponding recipient system and carry out normal physiological functions, such as immunological self definition. Resistance to initial integration by mature T cells requires some form of immunosuppression, but maintenance of donor immune system function will depend on renewable supply of cells, which can be provided by engrafted progenitors. Successful clinical application will depend on the development of low morbidity methods to enhance engraftment of donor haemopoietic stem cells.

Intrathymic transplantation of fresh and cryopreserved islets for the induction of a state of unresponsiveness in rats

The aim of this study was to assess the survival and function of cryopreserved islets in the thymus and to determine whether small numbers of allogeneic islets could induce a state of unresponsiveness to subsequent allogeneic islet grafts. Isografts of 1500 freshly isolated (n = 8) or 2500 frozen-thawed (n = 6) Wistar-Furth (RT1u/u) islets induced long-term normoglycemia after intrathymic transplantation (median survival time [MST] > 100 days in both groups), whereas isografts of 1500 frozen-thawed islets (n = 5) were inconsistent in restoring long-term normoglycemia. Transplantation of 1500 fresh (n = 6) or 2500 frozen-thawed (n = 6) Lewis (RT1l/l) islets induced long-term normoglycemia (MST > 100 days in both groups) when islets were transplanted in conjunction with a single injection of antilymphocyte serum. Intrathymic transplants of 500 freshly isolated Lewis islets induced a state of unresponsiveness to a second extrathymic allotransplant (MST > 100 days, n = 7). However, transplantation of 500 (n = 10) or 800 (n = 5) cryopreserved Lewis islets intrathymically did not prolong survival of a second extrathymic transplant (MST 19 and 21 days, P < 0.05 vs. fresh group, Mann-Whitney U test). These results demonstrate that cryopreserved intrathymic islets can normalize and maintain euglycemia providing the islet mass is augmented. Prolonged survival of cryopreserved islets in the thymus was observed; however, small numbers of allogeneic cryopreserved islets were unable to induced a state of unresponsiveness to a subsequent extrathymic islet graft.

Pancreatic islet allograft immunity and tolerance: the two-signal hypothesis revisited

The principle assumption of this discussion is that costimulation (CoS) forms the primary stimulus that compels T cells to mount a response to their specific antigen. However, this response can be either positive or negative, depending on the developmental stage of the T cell and the microenvironment in which the antigen and CoS are received. Thus, both immunity and tolerance may represent different outcomes of a two-signal process. We would emphasize that CoS is a functional term and not a strict molecular definition. While many molecular interactions have been described as providing CoS activity, notably those involving the B-7 family of cell surface molecules, it is not yet clear what combination(s) of non-antigen-specific signals may fulfil this function. This point is important because many studies have achieved tolerance through strategies designed to inhibit specific CoS molecules. However, it may be that differential signaling through distinct CoS molecules, rather than a global inhibition of CoS per se, plays a role in the generation of active tolerance in such studies (Bluestone 1995). A corollary of this notion is that antigen (signal 1) delivery to T cells is a null event and so is not an inherently paralysing signal. Of course, if signal 1 is not itself a tolerogenic signal, then other mechanisms are necessary to explain many empirical observations of tolerance to allogeneic or self antigens. This is best illustrated by those forms of functional tolerance to either alloantigens or self antigens that do not appear to be the result of clonal deletion/inactivation. It would be relatively simple to invoke a model of tolerance whereby the relevant tissue-destructive cell is eliminated or inactivated; such a model would preclude the necessity to suggest active regulatory mechanisms of tolerance. However, in several model systems, including our own observations concerning tolerance induction to APC-depleted islet allografts, tissue-destructive T cells can persist in recipients tolerant to allogeneic or self antigens. Furthermore, there are key examples in which tolerance demonstrates a dominant phenotype; that is, tolerant cells can regulate the activity of naive, non-tolerant cells. This latter observation points to the function of an active, regulatory form of tolerance. As such, we would emphasize that tolerance should not be defined as unresponsiveness since the tolerant state is the consequence of very active immune reactions.