Modification of humoral responses by the combination of leflunomide and cyclosporine in Lewis rats transplanted with hamster hearts

The Immunogenicity of Branded and Biosimilar Infliximab in Rheumatoid Arthritis According to Th9-Related Responses

Our objective was to evaluate the immunogenicity of branded and biosimilar infliximab by detecting changes in T-helper-9 (Th9) percentages induced by an in vitro stimulation test.

METHODS

Peripheral blood mononuclear cells collected from 55 consecutive rheumatoid arthritis (RA) outpatients (15 drug free, 20 successfully treated with branded infliximab, 20 branded infliximab inadequate responders) and 10 healthy controls were cultured, with or without 50 μg/mL of infliximab originator (Remicade^®) or 50 μg/mL of infliximab biosimilar (Remsima^®) for 18 h. Th9 lymphocytes were identified by means of flow cytometry as PU.1 and IRF4-expressing, IL-9-secreting CD4⁺ T cells. Furthermore, the markers CCR7 and CD45RA were used to distinguish naïve from memory IL-9 producer cells.

RESULTS

Under unstimulated conditions, the drug-free RA patients had the highest percentages of Th9 lymphocytes. Following stimulation with branded infliximab, the percentages of PU.1 and IRF4-expressing Th9 cells, CCR7⁺, CD45RA^- (central memory) and CCR7^-, CD45RA^- (effector memory) cells significantly increased in the group of inadequate responders, but no significant variation was observed after exposure to the biosimilar of infliximab.

CONCLUSIONS

Th9 cells seem to be involved in the immune response to the epitopes of branded, but not biosimilar, infliximab, and this may depend on the recall and stimulation of both central and effector memory cells.

Paradoxical Expansion of Th1 and Th17 Lymphocytes in Rheumatoid Arthritis Following Infliximab Treatment: a Possible Explanation for a Lack of Clinical Response

PURPOSE

The immunogenicity of anti-TNF-α drugs may affect their safety and efficacy. Infliximab (IFX), a chimeric monoclonal antibody, induces antibody formation in up to 60% of cases. Some studies have suggested the involvement of a Th1 response to TNFα blockers following immunization, but the triggering of Th17 responses has never been reported. The aim of this study is to investigate whether the immunogenicity of IFX affects the Th1, Th17 and Treg compartments in rheumatoid arthritis (RA) patients failing IFX therapy, and verify whether this may be responsible for treatment failure.

METHODS

The study involved 55 patients with RA (15 treatment-naïve patients; 20 IFX responders; 20 IFX non-responders) and 10 healthy controls. PBMCs were cultured in the presence/absence of IFX, and the variations in the percentage of Th1, Th17 and Treg lymphocytes following IFX treatment were analysed.

RESULTS

IFX-specific Th1 and Th17 responses and an increase in IL-21 production were observed in patients failing IFX (p < 0.01, p < 0.05, and p < 0.01 respectively). In contrast, IFX incubation reduced significantly Th1 and Th17 responses and IL-21 production (p < 0.05) in successfully-treated subjects, but did not affect these responses in healthy controls or treatment-naïve patients.

CONCLUSIONS

RA patients may have impaired peripheral tolerance, which could favour the development of an aberrant immunological response to biological drugs. The loss of therapeutic effectiveness of IFX and the onset of adverse events may be due to a paradoxical activation of Th17 or Th1 lymphocytes following sensitisation, thus worsening the patients' inflammatory status.

Accommodation and antibodies

Accommodation refers to the condition in which an organ transplant functions normally by acquiring resistance to immune-mediated injury (especially), despite the presence of anti-transplant antibodies in the recipient. This status is associated with several modifications in the recipient as well as in the graft, such as previous depletion of anti-graft antibodies and their slow return once the graft is placed; expression of several protective genes in the graft; a Th2 immune response in the recipient; and inhibition of the membrane attack complex of complement.

Effects of a Short Course of Leflunomide on T-Independent B-Lymphocyte Xenoreactivity and on Susceptibility of Xenografts to Acute or Chronic Rejection

BACKGROUND

Leflunomide is a novel immunosuppressive agent with promising activity for xenotransplantation. It is not clear yet which mechanisms of action of leflunomide are responsible for that.

METHODS

In a hamster-to-C57BL/6 nude mouse heart transplantation model, a 2-week course of leflunomide was used after transplantation or for pretreating donors. Nontolerant B lymphocytes were transferred to recipients after transplantation of first or second xenogeneic heart grafts that were transplanted with or without leflunomide treatment.

RESULTS

Hamster xenogeneic hearts transplanted into athymic C57BL/6 nude mice receiving leflunomide did not induce immunoglobulin (Ig) M xenoantibodies (XAb) and survived without signs of chronic rejection. Second xenogeneic hearts transplanted 4 weeks after withdrawal of leflunomide survived without induction of XAb but developed chronic vascular lesions. After injection of naive B lymphocytes at 6 weeks after grafting a first or second hamster heart, only in the latter case were XAb induced. These were deposited in, and provoked acute rejection of, only the second grafts. Pretreatment of donors with leflunomide decreased the ex vivo xenoantibody deposition on the xenogeneic heart endothelia.

CONCLUSIONS

A short posttransplant course of leflunomide induces T-independent B-lymphocyte xenotolerance. Leflunomide treatment also influences xenoantigen expression, as nontolerant B lymphocytes provoke IgM XAb formation and rejection of only second xenografts (transplanted without leflunomide) and not of first xenografts (transplanted with leflunomide treatment). The ex vivo experiments that show that XAb deposition is decreased in leflunomide-pretreated xenografts further confirm this. The latter may also explain the resistance of first and not second xenografts against chronic rejection.

Accommodation: preventing injury in transplantation and disease

Humoral immunity, as a cause of damage to blood vessels, poses a major barrier to successful transplantation of organs. Under some conditions, humoral immunity causes little or no damage to an organ graft. We have referred to this condition, in which a vascularized graft functions in the face of humoral immunity directed against it, as "accommodation." In this paper, we review changes in the graft and in the host that may account for accommodation, and we consider that what we call accommodation of organ grafts may occur widely in the context of immune responses, enabling immune responses to target infectious organisms without harming self-tissues.

Acute xenograft rejection, late xenograft rejection and long term survival xenografts in the hamster-to-rat heart transplantation model: histological characterisation under low-dose of FK506

BACKGROUND

Long-term survival studies have been conducted in hamster-to-rat cardiac models with a range of immunosuppressive treatments, but the histological pattern of Late Xenograft Rejection (LXR) has not been outlined. This study offers a detailed description of the histological changes in cardiac xenografts under three different immunological responses.

MATERIALS AND METHODS

Heterotopic hamster-to-Lewis rat cardiac transplant. Recipients were administered an antiproliferative drug (MMF, 25 mg/kg, or CyP, 10 mg/kg, from day -7 to +7 or from day 0 to +7, according to group) and FK506 (0.2 mg/kg; from day 0 to +30 or continuously). Unmodified recipients were used as controls. Conventional histology and indirect immunofluorescence of IgM, IgG and C3 deposits were performed.

RESULTS

In our study, xenografted rats that did not receive treatment developed a pattern of Acute Xenograft Rejection (AXR), with substantial tissue breakdown. Pretreated and treated animals until day 30 post-transplant developed LXR that may present two different histological patterns: one with vascular damage and predominant interstitial haemorrhage, and the other with extensive myocardial fibrosis. Long-term surviving rats (LTS) showed a morphology that was almost normal, with mild fibrosis and vascular endothelium preserved.

CONCLUSIONS

AXR, LXR and LTS in the hamster-to-rat heart transplantation model present a common humoral mechanism although their histopathological patterns are different depending on the length of immunosuppressive treatment but not on the type of antiproliferative drug administered. Pretreatment exerts an effect on fibrosis formation.

Induction of xenograft accommodation by modulation of elicited antibody responses1 2

BACKGROUND

We have established that the timing of splenectomy influences the magnitude of the xenoreactive antibody (XAb) response and thus hamster heart survival in cyclosporine (CyA)-treated rats. This model has been used to test our hypothesis that modulation of XAb responses without perturbation of complement may influence the development of graft accommodation.

METHODS

Pretransplantation splenectomy (day -1/day 0) fully abrogated anti-graft IgM response, whereas a delayed procedure (day 1/day 2) caused significantly delayed (3-4 days) and decreased levels (two- to threefold) of XAb. Both interventions resulted in long-term graft survival. After surviving for 7 or more days, xenografts in CyA-treated rats with post-, but not pre-, transplantation splenectomy were also resistant to exogenous anti-graft XAb. Such grafts meet the criteria for accommodation. Accommodating hearts displayed progressive and increasing expression of protective genes, such as heme oxygense (HO)-1 and A20, in endothelial cells and smooth muscle cells.

RESULTS

Our results suggest that XAb responses may influence the kinetics of accommodation development possibly by promoting protective gene expression. This hypothesis was directly tested in vitro. Pretreatment of porcine aortic endothelial cells with sublytic amounts of baboon anti-pig serum for 24 hr induced HO-1 expression; this was associated with cell resistance to lytic amounts of such serum. Overexpression of HO-1 by adenoviral-mediated gene transfer in porcine aortic endothelial cells resulted in similar protective effects.

CONCLUSIONS

Delayed and relatively low levels of XAb IgM promote expression of protective genes in the graft and thereby aid in the progress of accommodation. Expression of HO-1 protects xenoserum-mediated endothelial cell destruction.

Maturation of xenoantibody gene expression during the humoral immune response of rats to hamster xenografts

Immunoglobulin isotype switching represents an important component of antibody maturation in the development of humoral immune responses. We have recently conducted a series of studies in a nonimmunosuppressed rodent model to define the kinetics of xenoantibody production and seek evidence for the maturation of xenoantibody Ig gene expression by xenograft recipients. LEW rats were transplanted with hamster cardiac xenografts and the grafts were allowed to remain in situ for prolonged immune stimulation of the host. Anti-hamster antibodies were examined at days 4, 8, 21, 28 and 40 post-transplantation. cDNA libraries specific for rat mu or gamma heavy chains were constructed from B lymphocytes of the xenograft recipients at day 4 and day 21 post-transplantation. Selected cDNA clones encoding the Ig V(H)HAR family of genes from each group were sequenced and analyzed for the presence of somatic mutations. We found that the reactivity of xenoantibodies examined with flow cytometry underwent sequential changes in which IgM titers peaked at day 8 post-transplantation (PTx) and returned to low levels after 21 days. IgG titers started to increase at about one week PTx and peaked at 21-28 days. All the IgG isotypes (IgG1, 2a, 2b and 2c) were differentially involved in the IgG responses. Serum passive transfer experiments demonstrated that IgM antibody fractions separated from sera at day 4 post-transplantation were capable of causing hyperacute rejection (HAR) of hamster xenografts, whereas IgM fractions from days 21-40 failed to cause HAR (N = 7, MST = 4 days), a pattern that was consistent with a rise in total xenoreactive IgM levels at days 4-8 and a fall to low levels at 21 days post-transplantation. IgG-containing fractions separated from day 21-40 antisera caused HAR (N = 7, MST = 36 min) whereas IgG fractions from day 8 sera failed to induce graft rejection. Genetic analysis of the rearranged VH genes from 10 cDNA clones demonstrated that the Ig mu (n = 5) and gamma (n = 5) chain clones used the same family of VH genes (V(H)HAR family) to encode their antibody binding activity. The majority (80%) of the IgM clones were present in their original germline configuration. In contrast, the nucleotide sequences from IgG clones manifested an increase in the numbers of replacement mutations in the CDR region of the Ig heavy chain genes, providing evidence for a potential role for somatic mutation in the maturation of IgG xenoantibody responses as the humoral response matures with time post-transplantation.

Lewis rat pancreas, but not cardiac xenografts, are resistant to anti-gal antibody mediated hyperacute rejection

BACKGROUND

The objective of this study was to evaluate the role of anti-Gal Abs and non-anti-Gal Abs in hyperacute rejection (HAR) of concordant pancreas xenografts compared with heart xenografts. In addition, we tested whether rejection of Lewis rat pancreas grafts was T-cell dependent and could be prevented by anti-T-cell treatment.

METHODS

To determine the role of anti-Gal Abs in the induction of HAR, Lewis rat pancreas and heart xenografts were transplanted into alpha1,3Galactosyltransferase knockout (GT-Ko) mice treated with normal human serum (NHS) or hyperimmune serum, or into presensitized GT-Ko mice. To investigate whether rejection of pancreas xenograft was mediated by a T-cell dependent response, Lewis rat pancreas grafts were transplanted into streptozotocin (STZ)-induced diabetic GT-Ko mice treated with FK506, anti-CD4 mAbs (GK1.5), and thymectomy. Antidonor-specific IgM and IgG and anti-Gal Abs were analyzed by flow cytometry. Rejected and long-term surviving pancreas xenografts were assessed by functional (blood glucose) and histopathological examination.

RESULTS

HAR of Lewis rat pancreas xenografts could not be induced by NHS (0.4 ml), whereas NHS (0.2 ml) resulted in HAR of Lewis heart xenografts. Infusion of Lewis rat-specific hyperimmune serum (0.2 ml) resulted in HAR of Lewis rat pancreas xenografts. In addition, second Lewis rat pancreas grafts were hyperacutely rejected by presensitized GT-Ko mice. Immunohistochemical staining showed a low expression of Galalpha1,3Gal antigen in the endocrine tissue compared with that in the cardiac grafts. The levels of anti-Gal Abs in pancreas xenograft transplantation did not increase in GT-Ko mice after pancreas xenograft transplantation that was significantly increased after heart transplantation. FK506 treatment induced long-term survival of Lewis pancreas xenografts (mean survival time (MST) >90 days). Anti-CD4 treatment delayed rejection of Lewis rat pancreas xenografts with MST of 34.3 days, whereas anti-CD4, in combination with thymectomy, synergistically prolonged survival of pancreas xenograft (MST=70.4 days).

CONCLUSION

Pancreas xenograft is resistant to anti-Gal Abs-induced HAR but is susceptible to anti-donor specific Abs. Rejection of Lewis pancreas xenograft in STZ-induced, diabetic, GT-Ko mice is T-cell dependent.

Heart and liver xenotransplantation under low-dose tacrolimus: graft survival after withdrawal of immunosuppression

BACKGROUND

The hamster-to-rat xenotransplantation model is a useful model to investigate the features of extended host response to long-surviving xenografts. Early xenoantibody responses are T-cell independent and resistant to tacrolimus. Treatment with the combination of mofetil mycophenolate plus FK506 avoids acute xenograft rejection completely, but after withdrawal of immunosuppression hamster grafts are rejected by a process called late xenograft rejection (LXR).

METHODS

Hamster hearts and livers were transplanted into Lewis rats. Grafted rats were treated with mofetil mycophenolate (25 mg/kg/day) for 8 days and FK506 (0.2 mg/kg/day) for 31 days. Serum IgM and IgG levels were determined by flow cytometry and interferon-gamma levels by ELISA. IgM, IgG, and C3 deposits were measured in tissue by immunofluorescence, and leukocyte infiltration was measured by immunoperoxidase staining. Results. Survival of heart and liver xenografts in the rats was 48+/-4 days and 63+/-8 days, respectively. After cessation of all immunosuppression, hearts were rejected in 18+/-4 days and livers in 33+/-8 days. Production sequences of xenoantibodies in the two organs differed substantially, especially 7 days after transplantation and at the moment of rejection. Quantification of interferon-gamma levels indicated that there were no significant changes after transplantation. Histological and immunohistochemical studies showed signs of humoral mechanism of LXR in rats undergoing heart transplantation and cellular mechanism of LXR in those that received a liver transplant. Conclusions. These observations suggest that rejection in the hamster-to-rat heart xenotransplantation model is mediated by a T cell-independent B-cell response to which a T cell-dependent B-cell response is added in LXR. In the liver xenotransplantation model, our hypothesis is that LXR is mediated by a mixed cell mechanism, involving lymphocytes CD4+ CD45RC+, macrophages, and cytotoxic T lymphocytes. In summary, we have demonstrated and compared the peculiar features of LXR in two different organs.

Long-term survival of hamster hearts in presensitized rats

We transplanted hamster hearts into rats that had been sensitized to hamster cardiac grafts 5 days earlier as a model for discordant xenotransplantation. Sensitized rats had high serum levels of elicited anti-donor IgM and IgG that caused hyperacute rejection. Transient complement inhibition with cobra venom factor (CVF) plus daily and continuing cyclosporin A (CyA) prevented hyperacute rejection. However, grafts underwent delayed xenograft rejection (DXR). DXR involved IgG and associated Ab-dependent cell-mediated rejection, because depletion of IgG or Ab-dependent cell-mediated rejection-associated effector cells prolonged graft survival and the serum-mediated Ab-dependent cell-mediated cytotoxicity in vitro. Blood exchange in combination with CVF/CyA treatment dramatically decreased the level of preexisting Abs, but DXR still occurred in association with the return of Abs. Splenectomy and cyclophosphamide acted synergistically to delay Ab return, and when combined with blood exchange/CVF/CyA facilitated long-term survival of grafts. These grafts survived in the presence of anti-donor IgM, IgG, and complement that precipitated rejection of naive hearts, indicating that accommodation (survival in the presence of anti-graft Abs and complement) had occurred. We attribute the long-term survival to the removal of preexisting anti-donor Abs and therapy that attenuated the rate of Ab return. Under such conditions, the surviving hearts showed expression in endothelial cells and smooth muscle cells of protective genes and an intragraft Th2 immune response. Th2 responses and protective genes are associated with resistance to IgM- and IgG-mediated, complement-dependent and -independent forms of rejection.

Natural antibodies and the host immune responses to xenografts

Natural antibodies are present in the serum of individuals in the absence of known antigenic stimulation. These antibodies are primarily IgM, polyreactive, and encoded by immunoglobulin V genes in germline configuration. Natural antibodies are produced by B-1 lymphocytes, cells that form the primary cell of the fetal and newborn B cell repertoire and may represent the basic foundation upon which the adult repertoire of B cell antibodies is based. Natural antibodies react with a variety of endogenous and exogenous antigens, including xenoantigens expressed by tissues between unrelated species. These antibodies are capable of causing the immediate rejection of grafts exchanged across species barriers. One of the central issues related to our understanding of the immunopathologic mechanisms responsible for rejection of xenografts is whether pre-formed natural antibodies and new antibodies induced following xenotransplantation are produced by the same pathways of B cell antibody production. We have established in studies conducted in rodents and humans that the initial phases of antibody production xenogeneic tissues involves the use of a restricted population of Ig germline genes to encode xenoantibody binding. As the humoral xenoantibody response matures, the same closely-related groups of Ig V genes are used to encode antibody binding and there is evidence for an isotype switch to IgG antibody production and the appearance of somatic mutations consistent with antigen-driven affinity maturation. Our findings in both rodent and human studies form the basis for our proposal that the xenograft response reflects the use of B cell natural antibody repertoires originally intended to provide protection against infection. The host humoral response is inadvertently recruited to mount antibody responses against foreign grafts because they display carbohydrate antigens that are shared by common environmental microbes. This model of xenoantibody responses is being tested in our laboratory through the analysis of the binding of xenoantibodies in their original non-mutated configuration, and the examination of the effect of specific point mutations and gene shuffling have on xenoantibody binding activity. Establishment of the relationships between Ig structural changes and subsequent changes in binding affinity should provide important insights into the role that, natural antibodies and the cells that produce them play in the evolution of the host's humoral responses to xenografts.

Tolerance of T-independent xeno-antibody responses in the hamster-to-rat xenotransplantation model is species-restricted but not tissue-specific

Control of early acute xenograft rejection xenoreactions in the hamster-to-Lewis rat xenotransplantation model with cyclosporine (CsA) and leflunomide subdues early T-independent xenoreactivity and uncovers a late immune response that can be controlled by CsA alone. We had attributed this acquired responsiveness to CsA to the induction of tolerance of T-independent xeno-antibody responses in the recipient and recently reported that this tolerance is species-specific. Here we have further characterized the specificity and nature of this tolerant state. Lewis rats transplanted with either hearts, skin, kidney or spleen/pancreas from Golden Syrian hamsters were treated with leflunomide (5 mg/kg/day by gavage) for 14-21 days and CsA (20 mg/kg/day by gavage) continuously from the day of transplant. Some Lewis rats received a second graft of hearts or skin from Golden Syrian hamsters (day 21-30 after first transplant), and a third heart graft from Balb/c mice (day 60 after the first transplant). Serum was harvested and the titers of xenoreactive antibodies were quantified by flow cytometry. All grafts were harvested at the end of each experiment and examined by histological and immunohistochemical methods. The combination of CsA and leflunomide was able to completely inhibit the rejection of kidney, spleen and pancreas xenografts in this hamster-to-rat xenotransplantation model. In addition, only a transient treatment with leflunomide was necessary, and long-term graft survival could subsequently be maintained by CsA alone. Histological examination of these grafts at > 80 days post-transplantation indicated minimal signs of rejection. These immediately vascularized organs induced T-independent B-cell tolerance, so that second grafts of hamster hearts and skin could be maintained with CsA alone. Under the same immunosuppressive regimen, only four out of nine Lewis rats exhibited long-term hamster skin survival, probably reflecting the increased immunogenicity of the skin compared with other vascularized grafts. Nonetheless, all rats that did not reject the hamster skin graft also did not reject the hamster heart while on CsA alone. Finally, we demonstrate that the tolerant state could be maintained for up to 30 days in the absence of xenograft. The vigorous T-independent antibody response that mediates acute xenograft rejection in the hamster-to-rat model can be tolerized by the immunosuppressive regimen of CsA and leflunomide. The lack of organ specificity for the induction of this tolerance suggests that the xenoantigens inducing tolerance may be common endothelial cell antigens. Finally, the presence of the xenograft has been previously shown to be critical for the induction of T-independent B-cell tolerance, however, the tolerant state is relatively stable and persists after the removal of the xenograft.

Accommodated Xenografts Survive in the Presence of Anti-Donor Antibodies and Complement That Precipitate Rejection of Naive Xenografts

Hamster hearts transplanted into transiently complement-depleted and continuously cyclosporin A (CyA)-immunosuppressed rats survive long-term despite deposition of anti-donor IgM Abs and complement on the graft vascular endothelium. This phenomenon is referred to as “accommodation.” The hypothesis tested here is that accommodated xenografts are resistant to IgM Abs and complement that could result in rejection of naive xenografts. After first hamster hearts had been surviving in cobra venom factor (CVF) + CyA-treated rats for 10 days, a time when the anti-donor IgM Ab level was maximal and complement activity had returned to approximately 50% of pretreatment levels, naive hamster hearts or hamster hearts that had been accommodating in another rat for 14 days were transplanted into those rats carrying the surviving first graft. The naive hearts were all hyperacutely rejected. In contrast, a majority of regrafted accommodating hearts survived long-term. There was widespread Ab and activated complement deposition on the vascular endothelium of accommodating first hearts, second accommodating hearts, and rejected second naive hearts. However, only the rejected naive hearts showed extensive endothelial cell damage, myocardial necrosis, fibrin deposition, and other signs of inflammation. Accommodating first and second hearts but not rejected second naive hearts expressed high levels of the protective genes A20, heme oxygenase-1 (HO-1), bcl-2, and bcl-xL. These data demonstrate that accommodated xenografts become resistant to effects of anti-donor IgM Abs and complement that normally mediate rejection of xenografts. We hypothesize that this resistance involves expression by accommodated xenografts of protective genes.

In vivo activity of leflunomide: pharmacokinetic analyses and mechanism of immunosuppression

BACKGROUND

Leflunomide is an experimental drug with demonstrated ability to prevent and reverse acute allograft and xenograft rejection. The two biochemical activities reported for the active metabolite of leflunomide, A77 1726, are inhibition of tyrosine phosphorylation and inhibition of dihydroorotate dehydrogenase, an enzyme necessary for de novo pyrimidine synthesis. These activities can be distinctly separated in vitro by the use of uridine, which reverses the anti-proliferative effects of A77 1726 caused by inhibition of de novo pyrimidine synthesis. We report the effect of uridine on the in vivo immunosuppressive activities of leflunomide.

METHODS

We first quantified the serum levels of A77 1726, the active metabolite of leflunomide, after a single treatment of leflunomide (5, 15, and 35 mg/kg). Additionally, we quantified the levels of serum uridine and of nucleotide triphosphates in the liver, spleen, and lymph nodes of Lewis rats after the administration of a single dose of uridine (500 mg/kg; i.p.). Lewis rats heterotopically transplanted with brown Norway or Golden Syrian hamster hearts were treated for 50 or 75 days with leflunomide (5, 15, and 35 mg/kg/day; gavage) alone or in combination with uridine (500 mg/ kg/day; i.p.). Hematocrits were determined and the levels of alloreactive or xenoreactive immunoglobulin (Ig)M and IgG were determined by flow cytometric analysis. The allograft and xenografts, small bowel, liver, kidney, and spleen were subjected to pathological examination.

RESULTS

A linear relationship was observed between the serum A77 1726 concentrations in Lewis rats and the dose of leflunomide administered. Peak A77 1726 concentrations were 20.9, 71.8 and 129.3 mg/l (77.5, 266.1 and 478.8 microM) for the 5, 15, and 35 mg/kg doses of leflunomide, respectively. The concentration of uridine in the serum of normal Lewis rats is 6.5 microM; after i.p. administration of 500 mg/kg uridine, the serum uridine concentrations peaked at 384.1 microM in 15-30 min. The rapid elimination of uridine was not reflected in the lymphoid compartments, and the pharmacokinetics of pyrimidine nucleotides in the spleen resembled that of A77 1726. This dose of uridine, when administered daily (500 mg/kg/day, i.p.), weakly antagonized the immunosuppressive activities of leflunomide (5, 15, and 35 mg/kg/day) in the allotransplantation model. In contrast, in the xenotransplantation model, the same concentration of uridine completely antagonized the immunosuppressive activities of low-dose leflunomide (15 mg/kg/day) and partially antagonized the immunosuppressive activities of high-dose leflunomide (35 mg/kg/day). Toxicities associated with high-dose leflunomide (35 mg/kg/day) were anemia, diarrhea, and pathological changes in the small bowel and liver. These toxicities were significantly reduced by uridine co-administration.

CONCLUSION

These studies reveal that the blood levels of A77 1726 in Lewis rats satisfy in vitro requirements for both inhibition of de novo pyrimidine synthesis and protein tyrosine kinase activity. Our data also illustrate that the in vivo mechanism of immunosuppression by leflunomide is complex and is affected by at least the following four factors: type and vigor of the immune response, availability of uridine for salvage by proliferating lymphocytes, species being investigated, and concentration of serum A77 1726.

Histological characterization and pharmacological control of chronic rejection in xenogeneic and allogeneic heart transplantation

BACKGROUND

Chronic allograft rejection remains a major barrier to successful long-term allograft transplantation in humans. Chronic allograft rejection is characterized by the appearance of arterial lesions with concentric intimal thickening. This study investigates the development and control of chronic rejection in hamster cardiac xenografts transplanted into Lewis rats.

METHODS

Chronic rejection in the xenograft model involves transplantation of hamster hearts into Lewis rats treated with leflunomide (Lef) continuously at 15 mg/kg/day. The allograft model involves transplantation of Lewis hearts into Fisher-334 rats treated with cyclosporine (CsA) at 2.5 mg/kg for 5 days.

RESULTS

The average scores of arterial intimal thickening on day 45 after transplantation were 1.89+/-0.43 in the xenograft and 2.50+/-0.72 in the allograft. The basic pathology of both xenografts and allografts undergoing chronic rejection was arterial intimal thickening comprising smooth muscle cell proliferation, mononuclear cell infiltration, and fibrosis. The majority of cells infiltrating the arterial intima and myocardium were T cells and macrophages. Compared with the allograft, intimal edema, matrix deposition and fibrinoid necrosis were specifically presented in the xenografts and generally involved the larger arteries. The predominant isotype of antibody deposited was IgM in xenografts and IgG in allografts. When combined Lef and CsA therapy was initiated on day 45 after transplantation, the changes of chronic rejection were reversed in both xenografts and allografts by day 90. The scores of intimal thickening were significantly reduced to 0.97+/-0.45 and 1.48+/-0.56, respectively.

CONCLUSIONS

We conclude that chronic rejection can be induced in xenografts under conditions of inadequate immunosuppression. Chronic rejection in xenografts involves arterial lesions that bear some histological similarities to, as well as differences from, those observed in chronically rejected allografts. Finally, combination therapy with CsA and Lef reduced the incidence and severity of the intimal lesions in both chronically rejecting xenografts and allografts.

Induction of Species-Specific Host Accommodation in the Hamster-to-Rat Xenotransplantation Model

The combination of two immunosuppressants, leflunomide and cyclosporin A (CsA), completely inhibits immune xenoreactions in the hamster-to-Lewis rat xenotransplantation model. In addition, the control of acute xenograft rejection with this combination of immunosuppressants subdues early T-independent xenoreactivity and uncovers a late immune response that can be controlled by CsA alone. We attribute this acquired responsiveness to CsA to a modification in the recipient’s humoral response to the xenograft, and refer to this change as host accommodation. Host accommodation can be induced in Lewis rats receiving hamster hearts by the combination of leflunomide and CsA. A 7-day treatment with leflunomide and CsA was able to convert xenoreactivity from one that was resistant to CsA treatment into one that was controlled by CsA. The presence of the hamster xenograft was critical for the induction of host accommodation since the immunosuppressive regimen, either alone or in combination with a transfusion with donor-specific spleen cells, was unable to modify the anti-hamster reactivity in Lewis rats. When accommodation was induced in the presence of hamster hearts, these accommodated rats were able to acutely reject third-party mouse hearts while under CsA therapy, thus indicating that the host accommodation is species specific. Finally, we demonstrate that host accommodation is associated with a loss in the ability to produce species-specific, T-independent xenoantibodies. These novel observations suggest that xenoreactive T-independent humoral responses can be deleted selectively without significant loss of other innate, Ag-specific T-independent humoral responses.