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Lei YY, Chen XR, Jiang S, Guo M, Yu CL, Qiao JH, Cai B, Ai HS, Wang Y, Hu KX. Mechanisms of thymic repair of in vitro-induced precursor T cells as a haplo-identical HSCT regimen. Transplant Cell Ther 2023:S2666-6367(23)01174-0. [PMID: 36944387 DOI: 10.1016/j.jtct.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/06/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is currently an effective treatment for malignant hematological disease, but the immune deficiency and severe infection triggered by slow immune reconstitution are the main causes of high mortality and transplant failure. One of these outstanding problems is thymus damage, which is associated with graft-versus-host disease (GVHD), and preconditioning including irradiation and chemotherapy. Therefore, rapid repair of damaged thymus and rapid proliferation of thymus-derived donor T cells after transplantation are key to solving the problem. This study is designed to accelerate the recovery of thymus-derived T cells after transplantation. Wild-type mice with normal immunity were used as recipients in a haplo-HSCT mouse model to mimic clinical haplo-HSCT. A modified cell culture system using Notch ligand Delta4 and IL-7 was established that is capable of inducing and amplifying the differentiation and proliferation of hematopoietic stem cells into precursor T (preT) cells in vitro. Haplo-HSCT protocol included the preT and G-CSF mobilized donor splenic mononuclear cells (MNC) co-infusion or MNC alone. Thymic GVHD, thymic repair, and thymus-derived T cell development were compared in two groups by polychromatic immunofluorescence tracking, flow cytometry and detection of T cell receptor Vβ. The thymus homing and T-cell regeneration of allogenic preT cells were observed. The functions of preT cells in accelerating immune reconstitution, restoring thymic architecture, weakening GVH effects, and enhancing immuno-tolerance after transplantation were demonstrated. Further studies revealed that allogeneic preT cells induced by a culture system containing IL7 and Delta4 highly express ccr9 and RANKL. Interestingly, the RANK expression was promoted after preT cells' thymus homing. These results suggested that the RANK/RANKL pathway may play an important role in thymus homing. Our results provide a potential therapeutic option to optimize haplo-HSCT. It further opened up a new field of T cell therapy for artificial induction of allogeneic precursor T cells in vitro to repair the damaged thymus from irradiation and chemotherapy, and to compensate for the recovery of immune function in patients with immune deficiency caused by multiple reasons.
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Affiliation(s)
- Yang-Yang Lei
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China.
| | - Xin-Rui Chen
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Shan Jiang
- Anhui medical university, anhui province, China
| | - Mei Guo
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Chang-Lin Yu
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Jian-Hui Qiao
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Bo Cai
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Hui-Sheng Ai
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China
| | - Yi Wang
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China.
| | - Kai-Xun Hu
- Department of Hematology and Transplantation, the Fifth medical center, General Hospital of the People's Liberation Army, Beijing, China.
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2
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Shevyrev D, Tereshchenko V, Kozlov V. Immune Equilibrium Depends on the Interaction Between Recognition and Presentation Landscapes. Front Immunol 2021; 12:706136. [PMID: 34394106 PMCID: PMC8362327 DOI: 10.3389/fimmu.2021.706136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
In this review, we described the structure and organization of antigen-recognizing repertoires of B and T cells from the standpoint of modern immunology. We summarized the latest advances in bioinformatics analysis of sequencing data from T and B cell repertoires and also presented contemporary ideas about the mechanisms of clonal diversity formation at different stages of organism development. At the same time, we focused on the importance of the allelic variants of the HLA genes and spectra of presented antigens for the formation of T-cell receptors (TCR) landscapes. The main idea of this review is that immune equilibrium and proper functioning of immunity are highly dependent on the interaction between the recognition and the presentation landscapes of antigens. Certain changes in these landscapes can occur during life, which can affect the protective function of adaptive immunity. We described some mechanisms associated with these changes, for example, the conversion of effector cells into regulatory cells and vice versa due to the trans-differentiation or bystander effect, changes in the clonal organization of the general TCR repertoire due to homeostatic proliferation or aging, and the background for the altered presentation of some antigens due to SNP mutations of MHC, or the alteration of the presenting antigens due to post-translational modifications. The authors suggest that such alterations can lead to an increase in the risk of the development of oncological and autoimmune diseases and influence the sensitivity of the organism to different infectious agents.
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Affiliation(s)
- Daniil Shevyrev
- Laboratory of Clinical Immunopathology, Research Institute for Fundamental and Clinical Immunology, Novosibirsk, Russia
| | - Valeriy Tereshchenko
- Laboratory of Molecular Immunology, Research Institute for Fundamental and Clinical Immunology, Novosibirsk, Russia
| | - Vladimir Kozlov
- Laboratory of Clinical Immunopathology, Research Institute for Fundamental and Clinical Immunology, Novosibirsk, Russia
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National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. The 2020 Highly morbid forms report. Transplant Cell Ther 2021; 27:817-835. [PMID: 34217703 DOI: 10.1016/j.jtct.2021.06.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022]
Abstract
Chronic graft-versus-host disease (GVHD) can be associated with significant morbidity, in part because of nonreversible fibrosis, which impacts physical functioning (eye, skin, lung manifestations) and mortality (lung, gastrointestinal manifestations). Progress in preventing severe morbidity and mortality associated with chronic GVHD is limited by a complex and incompletely understood disease biology and a lack of prognostic biomarkers. Likewise, treatment advances for highly morbid manifestations remain hindered by the absence of effective organ-specific approaches targeting "irreversible" fibrotic sequelae and difficulties in conducting clinical trials in a heterogeneous disease with small patient numbers. The purpose of this document is to identify current gaps, to outline a roadmap of research goals for highly morbid forms of chronic GVHD including advanced skin sclerosis, fasciitis, lung, ocular and gastrointestinal involvement, and to propose strategies for effective trial design. The working group made the following recommendations: (1) Phenotype chronic GVHD clinically and biologically in future cohorts, to describe the incidence, prognostic factors, mechanisms of organ damage, and clinical evolution of highly morbid conditions including long-term effects in children; (2) Conduct longitudinal multicenter studies with common definitions and research sample collections; (3) Develop new approaches for early identification and treatment of highly morbid forms of chronic GVHD, especially biologically targeted treatments, with a special focus on fibrotic changes; and (4) Establish primary endpoints for clinical trials addressing each highly morbid manifestation in relationship to the time point of intervention (early versus late). Alternative endpoints, such as lack of progression and improvement in physical functioning or quality of life, may be suitable for clinical trials in patients with highly morbid manifestations. Finally, new approaches for objective response assessment and exploration of novel trial designs for small populations are required.
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4
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Meier JA, Haque M, Fawaz M, Abdeen H, Coffey D, Towlerton A, Abdeen A, Toor A, Warren E, Reed J, Kanakry CG, Keating A, Luznik L, Toor AA. T Cell Repertoire Evolution after Allogeneic Bone Marrow Transplantation: An Organizational Perspective. Biol Blood Marrow Transplant 2019; 25:868-882. [PMID: 30677510 DOI: 10.1016/j.bbmt.2019.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/11/2019] [Indexed: 12/31/2022]
Abstract
High-throughput sequencing (HTS) of human T cell receptors has revealed a high level of complexity in the T cell repertoire, which makes it difficult to correlate T cell reconstitution with clinical outcomes. The associations identified thus far are of a broadly statistical nature, precluding precise modeling of outcomes based on T cell repertoire development following bone marrow transplantation (BMT). Previous work has demonstrated an inherent, mathematically definable order observed in the T cells from a diverse group of donors, which is perturbed in recipients following BMT. In this study, T cell receptor (TCR)-β sequences from HLA-matched related donor and recipient pairs are analyzed to further develop this methodology. TCR-β sequencing from unsorted and sorted T cell subsets isolated from the peripheral blood samples of BMT donors and recipients show conservation and symmetry of VJ segment usage in the clonal frequencies, linked to the organization of the gene segments along the TCR locus. This TCR-β VJ segment translational symmetry is preserved post-transplantation and even in cases of acute graft-versus-host disease (aGVHD), suggesting that GVHD occurrence represents a polyclonal donor T cell response to recipient antigens. The complexity of the repertoire is significantly diminished after BMT, and the T cell clonal hierarchy is altered post-transplantation. Low-frequency donor clones tended to take on a higher rank in the recipients following BMT, especially in patients with aGVHD. Over time, the repertoire evolves to a more donor-like state in the recipients who did not develop GVHD as opposed to those who did. The results presented here support new methods of quantifying and characterizing post-transplantation T cell repertoire reconstitution.
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Affiliation(s)
- Jeremy A Meier
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Mahdee Haque
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Mohamed Fawaz
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Hamdi Abdeen
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - David Coffey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrea Towlerton
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ahmed Abdeen
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Abdullah Toor
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Edus Warren
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jason Reed
- Department of Physics, Virginia Commonwealth University, Richmond, Virginia
| | - Christopher G Kanakry
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Armand Keating
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Leo Luznik
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amir A Toor
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia.
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Papalexandri A, Karypidou M, Stalika E, Kotta K, Touloumenidou T, Zerva P, Paleta A, Mallouri D, Batsis I, Sakellari I, Kotsianidis I, Anagnostopoulos A, Hadzidimitriou A, Margaritis D, Stamatopoulos K. Skewing of the T-cell receptor repertoire in patients receiving rituximab after allogeneic hematopoietic cell transplantation: what lies beneath? Leuk Lymphoma 2019; 60:1685-1692. [PMID: 30652530 DOI: 10.1080/10428194.2018.1543881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Rituximab is known to affect T cell immune responses. We and others have reported expansions of T large granular lymphocytes (T-LGLs) in lymphoma patients after Rituximab. We report here the immunogenetic profiling of the T cell receptor (TR) gene repertoire in 14 patients who received Rituximab post allo-HCT and explore clinicobiological correlations. All experienced antigenic triggers, CMV, EBV re-activation and chronic GvHD and had been treated with Rituximab. Skewing of TRBV genes was observed: 3 TRBV genes accounted for half of the repertoire. Oligoclonal pattern with expanded clonotypes was common. Patients with oligoclonality exhibited frequently cGvHD. Longitudinal samples in one revealed distinct clonotypes, suggesting clonal drift. T-LGL leukemia of donor origin with mixed chimerism eventually developed. In conclusion, we report development of oligoclonal T-LGLs after Rituximab post allo-HCT, alluding to antigen selection. Persistence of this phenomenon likely reflects strong antigenic stimulation by viruses and/or cGVHD aggravated by Rituximab.
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Affiliation(s)
- Apostolia Papalexandri
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece.,b Hematology Department, School of Health Sciences , Democritus University of Thrace , Alexandropouli , Greece
| | - Maria Karypidou
- c Institute of Applied Biosciences, Centre for Research and Technology Hellas , Thessaloniki , Greece
| | - Evangelia Stalika
- c Institute of Applied Biosciences, Centre for Research and Technology Hellas , Thessaloniki , Greece
| | - Konstantina Kotta
- c Institute of Applied Biosciences, Centre for Research and Technology Hellas , Thessaloniki , Greece
| | - Tasoula Touloumenidou
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Panagiota Zerva
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Angeliki Paleta
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Despina Mallouri
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Ioannis Batsis
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Ioanna Sakellari
- a Haematology Department and BMT Unit , G.Papanikolaou Hospital , Thessaloniki , Greece
| | - Ioannis Kotsianidis
- b Hematology Department, School of Health Sciences , Democritus University of Thrace , Alexandropouli , Greece
| | | | - Anastasia Hadzidimitriou
- c Institute of Applied Biosciences, Centre for Research and Technology Hellas , Thessaloniki , Greece
| | - Dimitris Margaritis
- b Hematology Department, School of Health Sciences , Democritus University of Thrace , Alexandropouli , Greece
| | - Kostas Stamatopoulos
- c Institute of Applied Biosciences, Centre for Research and Technology Hellas , Thessaloniki , Greece
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6
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Iovino L, Mazziotta F, Buda G, Orciuolo E, Caracciolo F, Pelosini M, Morganti R, Galimberti S, Benedetti E, Petrini M. The Onset of Monoclonal and Oligoclonal Gammopathies Is a Good Prognostic Factor after Allogeneic Stem Cell Transplantation. Acta Haematol 2018; 141:7-11. [PMID: 30439709 DOI: 10.1159/000493416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/29/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Lorenzo Iovino
- Hematology Division, Pisa University Hospital, Pisa, Italy,
- Dudakov Lab, Program in Immunology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,
| | | | - Gabriele Buda
- Hematology Division, Pisa University Hospital, Pisa, Italy
| | | | | | | | - Riccardo Morganti
- Biostatistical Consulting, Pisa University Hospital, University of Pisa, Pisa, Italy
| | | | | | - Mario Petrini
- Hematology Division, Pisa University Hospital, Pisa, Italy
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7
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Leslie KA, Rasheed M, Sabo RT, Roberts CC, Toor AA, Reed J. Reconstituting donor T cells increase their biomass following hematopoietic stem cell transplantation. Analyst 2018; 143:2479-2485. [DOI: 10.1039/c8an00148k] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this study, we used a rapid, highly-sensitive, single-cell biomass measurement method, Live Cell Interferometry (LCI), to measure biomass in populations of CD3 + T cells isolated from hematopoietic stem cell transplant (SCT) patients at various times pre- and post-transplant (days 0–100).
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Affiliation(s)
- Kevin A. Leslie
- Department of Physics
- Virginia Commonwealth University
- Richmond
- USA
| | - Mahmood Rasheed
- Department of Internal Medicine
- Virginia Commonwealth University
- Richmond
- USA
- Department of Biostatistics
| | - Roy T. Sabo
- Department of Biostatistics
- Virginia Commonwealth University
- Richmond
- USA
| | - Catherine C. Roberts
- Department of Internal Medicine
- Virginia Commonwealth University
- Richmond
- USA
- Department of Biostatistics
| | - Amir A. Toor
- Department of Internal Medicine
- Virginia Commonwealth University
- Richmond
- USA
- Department of Biostatistics
| | - Jason Reed
- Department of Physics
- Virginia Commonwealth University
- Richmond
- USA
- Massey Cancer Center
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8
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Payne KK, Keim RC, Graham L, Idowu MO, Wan W, Wang XY, Toor AA, Bear HD, Manjili MH. Tumor-reactive immune cells protect against metastatic tumor and induce immunoediting of indolent but not quiescent tumor cells. J Leukoc Biol 2016; 100:625-35. [PMID: 26928306 PMCID: PMC4982610 DOI: 10.1189/jlb.5a1215-580r] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/08/2016] [Indexed: 11/24/2022] Open
Abstract
Quiescent, but not indolent, dormant tumor cells are resistant to immunoediting, and best targets for immunotherapy of cancer. Two major barriers to cancer immunotherapy include tumor-induced immune suppression mediated by myeloid-derived suppressor cells and poor immunogenicity of the tumor-expressing self-antigens. To overcome these barriers, we reprogrammed tumor-immune cell cross-talk by combined use of decitabine and adoptive immunotherapy, containing tumor-sensitized T cells and CD25+ NKT cells. Decitabine functioned to induce the expression of highly immunogenic cancer testis antigens in the tumor, while also reducing the frequency of myeloid-derived suppressor cells and the presence of CD25+ NKT cells rendered T cells, resistant to remaining myeloid-derived suppressor cells. This combinatorial therapy significantly prolonged survival of animals bearing metastatic tumor cells. Adoptive immunotherapy also induced tumor immunoediting, resulting in tumor escape and associated disease-related mortality. To identify a tumor target that is incapable of escape from the immune response, we used dormant tumor cells. We used Adriamycin chemotherapy or radiation therapy, which simultaneously induce tumor cell death and tumor dormancy. Resultant dormant cells became refractory to additional doses of Adriamycin or radiation therapy, but they remained sensitive to tumor-reactive immune cells. Importantly, we discovered that dormant tumor cells contained indolent cells that expressed low levels of Ki67 and quiescent cells that were Ki67 negative. Whereas the former were prone to tumor immunoediting and escape, the latter did not demonstrate immunoediting. Our results suggest that immunotherapy could be highly effective against quiescent dormant tumor cells. The challenge is to develop combinatorial therapies that could establish a quiescent type of tumor dormancy, which would be the best target for immunotherapy.
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Affiliation(s)
- Kyle K Payne
- Department of Microbiology and Immunology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Rebecca C Keim
- Department of Microbiology and Immunology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Laura Graham
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Michael O Idowu
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Pathology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Wen Wan
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Xiang-Yang Wang
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Human and Molecular Genetics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Amir A Toor
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; and
| | - Harry D Bear
- Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Masoud H Manjili
- Department of Microbiology and Immunology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA; Massey Cancer Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA;
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Abdul Razzaq B, Scalora A, Koparde VN, Meier J, Mahmood M, Salman S, Jameson-Lee M, Serrano MG, Sheth N, Voelkner M, Kobulnicky DJ, Roberts CH, Ferreira-Gonzalez A, Manjili MH, Buck GA, Neale MC, Toor AA. Dynamical System Modeling to Simulate Donor T Cell Response to Whole Exome Sequencing-Derived Recipient Peptides Demonstrates Different Alloreactivity Potential in HLA-Matched and -Mismatched Donor-Recipient Pairs. Biol Blood Marrow Transplant 2015; 22:850-61. [PMID: 26688192 DOI: 10.1016/j.bbmt.2015.11.1103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/29/2015] [Indexed: 12/11/2022]
Abstract
Immune reconstitution kinetics and subsequent clinical outcomes in HLA-matched recipients of allogeneic stem cell transplantation (SCT) are variable and difficult to predict. Considering SCT as a dynamical system may allow sequence differences across the exomes of the transplant donors and recipients to be used to simulate an alloreactive T cell response, which may allow better clinical outcome prediction. To accomplish this, whole exome sequencing was performed on 34 HLA-matched SCT donor-recipient pairs (DRPs) and the nucleotide sequence differences translated to peptides. The binding affinity of the peptides to the relevant HLA in each DRP was determined. The resulting array of peptide-HLA binding affinity values in each patient was considered as an operator modifying a hypothetical T cell repertoire vector, in which each T cell clone proliferates in accordance with the logistic equation of growth. Using an iterating system of matrices, each simulated T cell clone's growth was calculated with the steady-state population being proportional to the magnitude of the binding affinity of the driving HLA-peptide complex. Incorporating competition between T cell clones responding to different HLA-peptide complexes reproduces a number of features of clinically observed T cell clonal repertoire in the simulated repertoire, including sigmoidal growth kinetics of individual T cell clones and overall repertoire, Power Law clonal frequency distribution, increase in repertoire complexity over time with increasing clonal diversity, and alteration of clonal dominance when a different antigen array is encountered, such as in SCT. The simulated, alloreactive T cell repertoire was markedly different in HLA-matched DRPs. The patterns were differentiated by rate of growth and steady-state magnitude of the simulated T cell repertoire and demonstrate a possible correlation with survival. In conclusion, exome wide sequence differences in DRPs may allow simulation of donor alloreactive T cell response to recipient antigens and may provide a quantitative basis for refining donor selection and titration of immunosuppression after SCT.
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Affiliation(s)
- Badar Abdul Razzaq
- Virginia Commonwealth University School of Engineering, Virginia Commonwealth University, Richmond, VA 23298
| | - Allison Scalora
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298
| | - Vishal N Koparde
- Center for Biological Complexity, Virginia Commonwealth University, Richmond, VA 23298
| | - Jeremy Meier
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298
| | - Musa Mahmood
- Virginia Commonwealth University School of Engineering, Virginia Commonwealth University, Richmond, VA 23298
| | - Salman Salman
- Virginia Commonwealth University School of Engineering, Virginia Commonwealth University, Richmond, VA 23298
| | - Max Jameson-Lee
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298
| | - Myrna G Serrano
- Center for Biological Complexity, Virginia Commonwealth University, Richmond, VA 23298
| | - Nihar Sheth
- Center for Biological Complexity, Virginia Commonwealth University, Richmond, VA 23298
| | - Mark Voelkner
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298
| | - David J Kobulnicky
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298
| | - Catherine H Roberts
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298
| | | | - Masoud H Manjili
- Department of Microbiology and Immunology, Virginia Commonwealth University, Richmond, VA 23298
| | - Gregory A Buck
- Center for Biological Complexity, Virginia Commonwealth University, Richmond, VA 23298
| | - Michael C Neale
- Department of Psychiatry and Statistical Genomics, Virginia Commonwealth University, Richmond, VA 23298
| | - Amir A Toor
- Bone Marrow Transplant Program, Massey Cancer Center & Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298.
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10
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Dynamical System Modeling of Immune Reconstitution after Allogeneic Stem Cell Transplantation Identifies Patients at Risk for Adverse Outcomes. Biol Blood Marrow Transplant 2015; 21:1237-45. [PMID: 25849208 DOI: 10.1016/j.bbmt.2015.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/14/2015] [Indexed: 11/24/2022]
Abstract
Systems that evolve over time and follow mathematical laws as they evolve are called dynamical systems. Lymphocyte recovery and clinical outcomes in 41 allograft recipients conditioned using antithymocyte globulin (ATG) and 4.5-Gy total body irradiation were studied to determine if immune reconstitution could be described as a dynamical system. Survival, relapse, and graft-versus-host disease (GVHD) were not significantly different in 2 cohorts of patients receiving different doses of ATG. However, donor-derived CD3(+) cell reconstitution was superior in the lower ATG dose cohort, and there were fewer instances of donor lymphocyte infusion (DLI). Lymphoid recovery was plotted in each individual over time and demonstrated 1 of 3 sigmoid growth patterns: Pattern A (n = 15) had rapid growth with high lymphocyte counts, pattern B (n = 14) had slower growth with intermediate recovery, and pattern C (n = 10) had poor lymphocyte reconstitution. There was a significant association between lymphocyte recovery patterns and both the rate of change of donor-derived CD3(+) at day 30 after stem cell transplantation (SCT) and clinical outcomes. GVHD was observed more frequently with pattern A, relapse and DLI more so with pattern C, with a consequent survival advantage in patients with patterns A and B. We conclude that evaluating immune reconstitution after SCT as a dynamical system may differentiate patients at risk of adverse outcomes and allow early intervention to modulate that risk.
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11
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Toor AA, Kobulnicky JD, Salman S, Roberts CH, Jameson-Lee M, Meier J, Scalora A, Sheth N, Koparde V, Serrano M, Buck GA, Clark WB, McCarty JM, Chung HM, Manjili MH, Sabo RT, Neale MC. Stem cell transplantation as a dynamical system: are clinical outcomes deterministic? Front Immunol 2014; 5:613. [PMID: 25520720 PMCID: PMC4253954 DOI: 10.3389/fimmu.2014.00613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/14/2014] [Indexed: 12/22/2022] Open
Abstract
Outcomes in stem cell transplantation (SCT) are modeled using probability theory. However, the clinical course following SCT appears to demonstrate many characteristics of dynamical systems, especially when outcomes are considered in the context of immune reconstitution. Dynamical systems tend to evolve over time according to mathematically determined rules. Characteristically, the future states of the system are predicated on the states preceding them, and there is sensitivity to initial conditions. In SCT, the interaction between donor T cells and the recipient may be considered as such a system in which, graft source, conditioning, and early immunosuppression profoundly influence immune reconstitution over time. This eventually determines clinical outcomes, either the emergence of tolerance or the development of graft versus host disease. In this paper, parallels between SCT and dynamical systems are explored and a conceptual framework for developing mathematical models to understand disparate transplant outcomes is proposed.
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Affiliation(s)
- Amir A Toor
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Jared D Kobulnicky
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Salman Salman
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Catherine H Roberts
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Max Jameson-Lee
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Jeremy Meier
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Allison Scalora
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Nihar Sheth
- Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Vishal Koparde
- Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Myrna Serrano
- Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Gregory A Buck
- Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - William B Clark
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - John M McCarty
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Harold M Chung
- Stem Cell Transplant Program, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Masoud H Manjili
- Department of Microbiology and Immunology, Virginia Commonwealth University , Richmond, VA , USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University , Richmond, VA , USA
| | - Michael C Neale
- Department of Psychiatry and Statistical Genomics, Virginia Commonwealth University , Richmond, VA , USA
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12
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Jameson-Lee M, Koparde V, Griffith P, Scalora AF, Sampson JK, Khalid H, Sheth NU, Batalo M, Serrano MG, Roberts CH, Hess ML, Buck GA, Neale MC, Manjili MH, Toor AA. In silico Derivation of HLA-Specific Alloreactivity Potential from Whole Exome Sequencing of Stem-Cell Transplant Donors and Recipients: Understanding the Quantitative Immunobiology of Allogeneic Transplantation. Front Immunol 2014; 5:529. [PMID: 25414699 PMCID: PMC4222229 DOI: 10.3389/fimmu.2014.00529] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/07/2014] [Indexed: 12/18/2022] Open
Abstract
Donor T-cell mediated graft versus host (GVH) effects may result from the aggregate alloreactivity to minor histocompatibility antigens (mHA) presented by the human leukocyte antigen (HLA) molecules in each donor–recipient pair undergoing stem-cell transplantation (SCT). Whole exome sequencing has previously demonstrated a large number of non-synonymous single nucleotide polymorphisms (SNP) present in HLA-matched recipients of SCT donors (GVH direction). The nucleotide sequence flanking each of these SNPs was obtained and the amino acid sequence determined. All the possible nonameric peptides incorporating the variant amino acid resulting from these SNPs were interrogated in silico for their likelihood to be presented by the HLA class I molecules using the Immune Epitope Database stabilized matrix method (SMM) and NetMHCpan algorithms. The SMM algorithm predicted that a median of 18,396 peptides weakly bound HLA class I molecules in individual SCT recipients, and 2,254 peptides displayed strong binding. A similar library of presented peptides was identified when the data were interrogated using the NetMHCpan algorithm. The bioinformatic algorithm presented here demonstrates that there may be a high level of mHA variation in HLA-matched individuals, constituting a HLA-specific alloreactivity potential.
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Affiliation(s)
- Max Jameson-Lee
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Vishal Koparde
- The Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Phil Griffith
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Allison F Scalora
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Juliana K Sampson
- The Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Haniya Khalid
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Nihar U Sheth
- The Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Michael Batalo
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Myrna G Serrano
- The Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Catherine H Roberts
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
| | - Michael L Hess
- Department of Internal Medicine, Virginia Commonwealth University , Richmond, VA , USA
| | - Gregory A Buck
- The Center for the Study of Biological Complexity, Virginia Commonwealth University , Richmond, VA , USA
| | - Michael C Neale
- Department of Psychiatry and Statistical Genomics, Virginia Commonwealth University , Richmond, VA , USA
| | - Masoud H Manjili
- Department of Microbiology and Immunology, Virginia Commonwealth University , Richmond, VA , USA
| | - Amir Ahmed Toor
- Stem Cell Transplant Program, Massey Cancer Center, Virginia Commonwealth University , Richmond, VA , USA
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13
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Sulfamethoxazole induces a switch mechanism in T cell receptors containing TCRVβ20-1, altering pHLA recognition. PLoS One 2013; 8:e76211. [PMID: 24116097 PMCID: PMC3792127 DOI: 10.1371/journal.pone.0076211] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 08/21/2013] [Indexed: 11/19/2022] Open
Abstract
T cell receptors (TCR) containing Vβ20-1 have been implicated in a wide range of T cell mediated disease and allergic reactions, making it a target for understanding these. Mechanics of T cell receptors are largely unexplained by static structures available from x-ray crystallographic studies. A small number of molecular dynamic simulations have been conducted on TCR, however are currently lacking either portions of the receptor or explanations for differences between binding and non-binding TCR recognition of respective peptide-HLA. We performed molecular dynamic simulations of a TCR containing variable domain Vβ20-1, sequenced from drug responsive T cells. These were initially from a patient showing maculopapular eruptions in response to the sulfanilamide-antibiotic sulfamethoxazole (SMX). The CDR2β domain of this TCR was found to dock SMX with high affinity. Using this compound as a perturbation, overall mechanisms involved in responses mediated by this receptor were explored, showing a chemical action on the TCR free from HLA or peptide interaction. Our simulations show two completely separate modes of binding cognate peptide-HLA complexes, with an increased affinity induced by SMX bound to the Vβ20-1. Overall binding of the TCR is mediated through a primary recognition by either the variable β or α domain, and a switch in recognition within these across TCR loops contacting the peptide and HLA occurs when SMX is present in the CDR2β loop. Large binding affinity differences are induced by summed small amino acid changes primarily by SMX modifying only three critical CDR2β loop amino acid positions. These residues, TYRβ57, ASPβ64, and LYSβ65 initially hold hydrogen bonds from the CDR2β to adjacent CDR loops. Effects from SMX binding are amplified and traverse longer distances through internal TCR hydrogen bonding networks, controlling the overall TCR conformation. Thus, the CDR2β of Vβ20-1 acts as a ligand controlled switch affecting overall TCR binding affinity.
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14
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Sato M, Storb R, Loretz C, Stone D, Mielcarek M, Sale GE, Rezvani AR, Graves SS. Inducible costimulator (ICOS) up-regulation on activated T cells in chronic graft-versus-host disease after dog leukocyte antigen-nonidentical hematopoietic cell transplantation: a potential therapeutic target. Transplantation 2013; 96:34-41. [PMID: 23694952 PMCID: PMC3696413 DOI: 10.1097/tp.0b013e318295c025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inducible costimulator (ICOS), a member of the CD28 family of costimulatory molecules, is induced on CD4 and CD8 T cells after their activation. ICOS functions as an essential immune regulator and ICOS blockade is a potential approach to immune modulation in allogeneic transplantation. Here, we describe the expression profile of ICOS in dogs and determine whether ICOS expression is up-regulated during chronic graft-versus-host disease (GVHD) and host-versus-graft reactions in the canine hematopoietic cell transplantation model. METHODS Monoclonal antibodies (mAbs) against cell surface-expressed ICOS were produced and tested in vitro for suppression of canine mixed leukocyte reactions (MLR). Expression of ICOS on CD3 cells was evaluated by flow cytometry using peripheral blood, lymph nodes, and splenocytes obtained from dogs undergoing graft-versus-host and host-versus-graft reactions. RESULTS Canine ICOS was expressed in an inducible pattern on T cells activated by concanavalin A, anti-CD3 mAb in combination with anti-CD28 mAb, and alloantigen stimulation. Immunosuppressive effects of ICOS blockade were observed in MLR using peripheral blood mononuclear cells from dog leukocyte antigen-nonidentical dogs. Immunosuppressive effects of ICOS blockade were observed in MLR when anti-ICOS was combined with suboptimal concentrations of cytotoxic T-lymphocyte antigen 4-Ig or cyclosporine. ICOS expression was significantly up-regulated on T cells in dogs undergoing graft rejection or chronic GVHD after allogeneic hematopoietic cell transplantation. CONCLUSIONS These studies suggest that ICOS plays a role in graft rejection and GVHD in an outbred animal model, and ICOS blockade may be an approach to prevention and treatment of chronic GVHD.
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Affiliation(s)
- Masahiko Sato
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rainer Storb
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle Washington
| | - Carol Loretz
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Diane Stone
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Marco Mielcarek
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle Washington
| | - George E. Sale
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Pathology, University of Washington School of Medicine, Seattle Washington
| | - Andrew R. Rezvani
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Scott S. Graves
- Transplantation Biology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle Washington
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15
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A distinct evolution of the T-cell repertoire categorizes treatment refractory gastrointestinal acute graft-versus-host disease. Blood 2013; 121:4955-62. [PMID: 23652802 DOI: 10.1182/blood-2013-03-489757] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Steroid refractory gastrointestinal (GI) acute graft-versus-host disease (aGVHD) is a major cause of mortality in hematopoietic stem cell transplantation (HCT) without immune markers to establish a diagnosis or guide therapy. We found that T-cell receptor β (TCRβ) complementarity-determining region 3 repertoire sequencing reveals patterns that could eventually serve as a disease biomarker of T-cell alloreactivity in aGVHD. We identified T-cell clones in GI biopsies in a heterogeneous group of 15 allogeneic HCT patients with GI aGVHD symptoms. Seven steroid-refractory aGVHD patients showed a more conserved TCRβ clonal structure between different biopsy sites in the GI tract than 8 primary therapy-responsive patients. Tracking GI clones identified longitudinally at endoscopy in the blood also revealed an increased clonal expansion in patients with steroid-refractory disease. Immune repertoire sequencing-based methods could enable a novel personalized way to guide diagnosis and therapy in diseases where T-cell activity is a major determinant.
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16
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Meier J, Roberts C, Avent K, Hazlett A, Berrie J, Payne K, Hamm D, Desmarais C, Sanders C, Hogan KT, Archer KJ, Manjili MH, Toor AA. Fractal organization of the human T cell repertoire in health and after stem cell transplantation. Biol Blood Marrow Transplant 2013; 19:366-77. [PMID: 23313705 DOI: 10.1016/j.bbmt.2012.12.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 12/12/2012] [Indexed: 11/18/2022]
Abstract
T cell repertoire diversity is generated in part by recombination of variable (V), diversity (D), and joining (J) segments in the T cell receptor β (TCR) locus. T cell clonal frequency distribution determined by high-throughput sequencing of TCR β in 10 stem cell transplantation (SCT) donors revealed a fractal, self-similar frequency distribution of unique TCR bearing clones with respect to V, D, and J segment usage in the T cell repertoire of these individuals. Further, ranking of T cell clones by frequency of gene segment usage in the observed sequences revealed an ordered distribution of dominant clones conforming to a power law, with a fractal dimension of 1.6 and 1.8 in TCR β DJ and VDJ containing clones in healthy stem cell donors. This self-similar distribution was perturbed in the recipients after SCT, with patients demonstrating a lower level of complexity in their TCR repertoire at day 100 followed by a modest improvement by 1 year post-SCT. A large shift was observed in the frequency distribution of the dominant T cell clones compared to the donor, with fewer than one third of the VDJ-containing clones shared in the top 4 ranks. In conclusion, the normal T cell repertoire is highly ordered with a TCR gene segment usage that results in a fractal self-similar motif of pattern repetition across levels of organization. Fractal analysis of high-throughput TCR β sequencing data provides a comprehensive measure of immune reconstitution after SCT.
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MESH Headings
- Antilymphocyte Serum/pharmacology
- Antilymphocyte Serum/therapeutic use
- Clone Cells
- Fractals
- Hematologic Neoplasms/immunology
- Hematologic Neoplasms/pathology
- Hematologic Neoplasms/therapy
- High-Throughput Nucleotide Sequencing
- Humans
- Myeloablative Agonists/pharmacology
- Myeloablative Agonists/therapeutic use
- Receptors, Antigen, T-Cell, alpha-beta/chemistry
- Receptors, Antigen, T-Cell, alpha-beta/genetics
- Receptors, Antigen, T-Cell, alpha-beta/immunology
- Stem Cell Transplantation
- T-Lymphocytes/classification
- T-Lymphocytes/immunology
- T-Lymphocytes/pathology
- Transplantation Chimera/immunology
- Transplantation Conditioning
- Transplantation, Homologous
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Affiliation(s)
- Jeremy Meier
- Bone Marrow Transplant Program, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
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Current world literature. Curr Opin Organ Transplant 2013; 18:111-30. [PMID: 23299306 DOI: 10.1097/mot.0b013e32835daf68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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