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Peterson L, Yacoub MH, Ayares D, Yamada K, Eisenson D, Griffith BP, Mohiuddin MM, Eyestone W, Venter JC, Smolenski RT, Rothblatt M. Physiological basis for xenotransplantation from genetically modified pigs to humans. Physiol Rev 2024; 104:1409-1459. [PMID: 38517040 DOI: 10.1152/physrev.00041.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
The collective efforts of scientists over multiple decades have led to advancements in molecular and cellular biology-based technologies including genetic engineering and animal cloning that are now being harnessed to enhance the suitability of pig organs for xenotransplantation into humans. Using organs sourced from pigs with multiple gene deletions and human transgene insertions, investigators have overcome formidable immunological and physiological barriers in pig-to-nonhuman primate (NHP) xenotransplantation and achieved prolonged pig xenograft survival. These studies informed the design of Revivicor's (Revivicor Inc, Blacksburg, VA) genetically engineered pigs with 10 genetic modifications (10 GE) (including the inactivation of 4 endogenous porcine genes and insertion of 6 human transgenes), whose hearts and kidneys have now been studied in preclinical human xenotransplantation models with brain-dead recipients. Additionally, the first two clinical cases of pig-to-human heart xenotransplantation were recently performed with hearts from this 10 GE pig at the University of Maryland. Although this review focuses on xenotransplantation of hearts and kidneys, multiple organs, tissues, and cell types from genetically engineered pigs will provide much-needed therapeutic interventions in the future.
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Affiliation(s)
- Leigh Peterson
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | | | - David Ayares
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | - Kazuhiko Yamada
- Department of Surgery, Division of Transplantation, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Daniel Eisenson
- Department of Surgery, Division of Transplantation, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Bartley P Griffith
- University of Maryland Medical Center, Baltimore, Maryland, United States
| | | | - Willard Eyestone
- United Therapeutics Corporation, Silver Spring, Maryland, United States
| | - J Craig Venter
- J. Craig Venter Institute, Rockville, Maryland, United States
| | | | - Martine Rothblatt
- United Therapeutics Corporation, Silver Spring, Maryland, United States
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Saito S, Miyagawa S, Kawamura T, Yoshioka D, Kawamura M, Kawamura A, Misumi Y, Taguchi T, Yamauchi T, Miyagawa S. How should cardiac xenotransplantation be initiated in Japan? Surg Today 2024:10.1007/s00595-024-02861-7. [PMID: 38733536 DOI: 10.1007/s00595-024-02861-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024]
Abstract
The world's first clinical cardiac xenotransplantation, using a genetically engineered pig heart with 10 gene modifications, prolonged the life of a 57-year-old man with no other life-saving options, by 60 days. It is foreseeable that xenotransplantation will be introduced in clinical practice in the United States. However, little clinical or regulatory progress has been made in the field of xenotransplantation in Japan in recent years. Japan seems to be heading toward a "device lag", and the over-importation of medical devices and technology in the medical field is becoming problematic. In this review, we discuss the concept of pig-heart xenotransplantation, including the pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental heart overgrowth, as well as genetic modification strategies in pigs to prevent or minimize these problems. Moreover, we summarize the necessity for and current status of xenotransplantation worldwide, and future prospects in Japan, with the aim of initiating xenotransplantation in Japan using genetically modified pigs without a global delay. It is imperative that this study prompts the initiation of preclinical xenotransplantation research using non-human primates and leads to clinical studies.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Shuji Miyagawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Masashi Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yusuke Misumi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | | | - Takashi Yamauchi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Sun Q, Song SY, Ma J, Li D, Wang Y, Yang Z, Wang Y. Cutting edge of genetically modified pigs targeting complement activation for xenotransplantation. Front Immunol 2024; 15:1383936. [PMID: 38638432 PMCID: PMC11024274 DOI: 10.3389/fimmu.2024.1383936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
In the quest to address the critical shortage of donor organs for transplantation, xenotransplantation stands out as a promising solution, offering a more abundant supply of donor organs. Yet, its widespread clinical adoption remains hindered by significant challenges, chief among them being immunological rejection. Central to this issue is the role of the complement system, an essential component of innate immunity that frequently triggers acute and chronic rejection through hyperacute immune responses. Such responses can rapidly lead to transplant embolism, compromising the function of the transplanted organ and ultimately causing graft failure. This review delves into three key areas of xenotransplantation research. It begins by examining the mechanisms through which xenotransplantation activates both the classical and alternative complement pathways. It then assesses the current landscape of xenotransplantation from donor pigs, with a particular emphasis on the innovative strides made in genetically engineering pigs to evade complement system activation. These modifications are critical in mitigating the discordance between pig endogenous retroviruses and human immune molecules. Additionally, the review discusses pharmacological interventions designed to support transplantation. By exploring the intricate relationship between the complement system and xenotransplantation, this retrospective analysis not only underscores the scientific and clinical importance of this field but also sheds light on the potential pathways to overcoming one of the major barriers to the success of xenografts. As such, the insights offered here hold significant promise for advancing xenotransplantation from a research concept to a viable clinical reality.
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Affiliation(s)
- Qin Sun
- Department of Endocrinology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Si-Yuan Song
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
| | - Jiabao Ma
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, China
| | - Danni Li
- Department of Pharmacy, Longquanyi District of Chengdu Maternity & Child Health Care Hospital, Chengdu, China
| | - Yiping Wang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhengteng Yang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, China
| | - Yi Wang
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Center of Organ Transplantation, Sichuan Academy of Medical Science and Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
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Yuan Y, Cui Y, Zhao D, Yuan Y, Zhao Y, Li D, Jiang X, Zhao G. Complement networks in gene-edited pig xenotransplantation: enhancing transplant success and addressing organ shortage. J Transl Med 2024; 22:324. [PMID: 38566098 PMCID: PMC10986007 DOI: 10.1186/s12967-024-05136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
The shortage of organs for transplantation emphasizes the urgent need for alternative solutions. Xenotransplantation has emerged as a promising option due to the greater availability of donor organs. However, significant hurdles such as hyperacute rejection and organ ischemia-reperfusion injury pose major challenges, largely orchestrated by the complement system, and activated immune responses. The complement system, a pivotal component of innate immunity, acts as a natural barrier for xenotransplantation. To address the challenges of immune rejection, gene-edited pigs have become a focal point, aiming to shield donor organs from human immune responses and enhance the overall success of xenotransplantation. This comprehensive review aims to illuminate strategies for regulating complement networks to optimize the efficacy of gene-edited pig xenotransplantation. We begin by exploring the impact of the complement system on the effectiveness of xenotransplantation. Subsequently, we delve into the evaluation of key complement regulators specific to gene-edited pigs. To further understand the status of xenotransplantation, we discuss preclinical studies that utilize gene-edited pigs as a viable source of organs. These investigations provide valuable insights into the feasibility and potential success of xenotransplantation, offering a bridge between scientific advancements and clinical application.
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Affiliation(s)
- Yinglin Yuan
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuanyuan Cui
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dayue Zhao
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Yuan
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yanshuang Zhao
- Department of Pharmacy, The People's Hospital of Leshan, Leshan, China
| | - Danni Li
- Department of Pharmacy, Longquanyi District of Chengdu Maternity & Child Health Care Hospital, Chengdu, China
| | - Xiaomei Jiang
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Gaoping Zhao
- Department of Gastrointestinal Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
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Ghazi M, Saleh A, Abdallah M, El Masri D, El Masri J, El Ayoubi LM, Hawi J, Jurjus A. Barriers toward xenotransplantation in Arab World. Xenotransplantation 2024; 31:e12852. [PMID: 38526015 DOI: 10.1111/xen.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/26/2024]
Abstract
Organ transplant is a crucial therapeutic strategy offering a life-saving and transformative medical intervention. It provides an opportunity to improve their quality of life and increase their lifespan. The shortage of organs remains a critical global challenge, leading to a prolonged waiting times for organ receivers, which contributes to an increase in morbidity and mortality rates. Hence, xenotransplantation offered a promising solution to the global shortage of organs through the use of animal organs, leading to an increase in donor availability, reducing waiting times, minimizing organ trafficking, improving genetic engineering advancements, and driving scientific innovation. Even though xenotransplantation has many benefits in the clinical setting, it has many barriers that are hindering its achievements and constraining its occurrence. Some barriers to xenotransplant are general, such as the immunological barrier, while others are specific to certain regions due to local causes. The Arab region exhibits disparities in clinical settings compared to the global context, marked by the huge economic crisis and a shortage of trained healthcare professionals. Considering the huge resources and advancements needed in the field of xenotransplantation, this review aims to explore the specific barriers toward xenotransplantation in the Arab countries, highlighting the challenges to overcome these barriers.
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Affiliation(s)
- Maya Ghazi
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Aalaa Saleh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Malak Abdallah
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Diala El Masri
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Faculty of Medicine, University of Balamand, Koura, Lebanon
| | - Jad El Masri
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | | | - Jihad Hawi
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Abdo Jurjus
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Bender M, Panelli A, Reichart B, Radan J, Mokelke M, Neumann E, Buttgereit I, Michel S, Bauer A, Fresch AK, Mayr T, Werner F, Egerer S, Bähr A, Kessler B, Klymiuk N, Ayares D, Wolf E, Hagl C, Brenner P, Längin M, Abicht JM. Hemodynamics in pig-to-baboon heterotopic thoracic cardiac xenotransplantation: Recovery from perioperative cardiac xenograft dysfunction and impairment by cardiac overgrowth. Xenotransplantation 2024; 31:e12841. [PMID: 38864375 DOI: 10.1111/xen.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/04/2023] [Accepted: 12/19/2023] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Orthotopic cardiac xenotransplantation has seen notable improvement, leading to the first compassionate use in 2022. However, it remains challenging to define the clinical application of cardiac xenotransplantation, including the back-up strategy in case of xenograft failure. In this regard, the heterotopic thoracic technique could be an alternative to the orthotopic procedure. We present hemodynamic data of heterotopic thoracic pig-to-baboon transplantation experiments, focusing on perioperative xenograft dysfunction and xenograft overgrowth. METHODS We used 17 genetically modified piglets as donors for heterotopic thoracic xenogeneic cardiac transplantation into captive-bred baboons. In all animals, pressure probes were implanted in the graft's left ventricle and the recipient's ascending aorta and hemodynamic data (graft pressure, aortic pressure and recipient's heart rate) were recorded continuously. RESULTS Aortic pressures and heart rates of the recipients' hearts were postoperatively stable in all experiments. After reperfusion, three grafts presented with low left ventricular pressure indicating perioperative cardiac dysfunction (PCXD). These animals recovered from PCXD within 48 h under support of the recipient's heart and there was no difference in survival compared to the other 14 ones. After 48 h, graft pressure increased up to 200 mmHg in all 17 animals with two different time-patterns. This led to a progressive gradient between graft and aortic pressure. With increasing gradient, the grafts stopped contributing to cardiac output. Grafts showed a marked weight increase from implantation to explantation. CONCLUSION The heterotopic thoracic cardiac xenotransplantation technique is a possible method to overcome PCXD in early clinical trials and an experimental tool to get a better understanding of PCXD. The peculiar hemodynamic situation of increasing graft pressure but missing graft's output indicates outflow tract obstruction due to cardiac overgrowth. The heterotopic thoracic technique should be successful when using current strategies of immunosuppression, organ preservation and donor pigs with smaller body and organ size.
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Affiliation(s)
- Martin Bender
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Alessandro Panelli
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bruno Reichart
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Julia Radan
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Maren Mokelke
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Elisabeth Neumann
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Ines Buttgereit
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Michel
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Bauer
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Ann Kathrin Fresch
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Tanja Mayr
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Fabian Werner
- Transregional Collaborative Research Center 127, Walter Brendel Centre of Experimental Medicine, LMU Munich, Munich, Germany
| | - Stefanie Egerer
- Gene Center and Department of Veterinary Sciences, Institute of Molecular Animal Breeding and Biotechnology, LMU Munich, Munich, Germany
| | - Andrea Bähr
- Gene Center and Department of Veterinary Sciences, Institute of Molecular Animal Breeding and Biotechnology, LMU Munich, Munich, Germany
| | - Barbara Kessler
- Gene Center and Department of Veterinary Sciences, Institute of Molecular Animal Breeding and Biotechnology, LMU Munich, Munich, Germany
| | - Nikolai Klymiuk
- Gene Center and Department of Veterinary Sciences, Institute of Molecular Animal Breeding and Biotechnology, LMU Munich, Munich, Germany
| | | | - Eckhard Wolf
- Gene Center and Department of Veterinary Sciences, Institute of Molecular Animal Breeding and Biotechnology, LMU Munich, Munich, Germany
- Center for Innovative Medical Models (CiMM), LMU Munich, Munich, Germany
- Interfaculty Center for Endocrine and Cardiovascular Disease Network Modelling and Clinical Transfer (ICONLMU), LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Paolo Brenner
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Jan-Michael Abicht
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
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7
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Elalouf A, Elalouf H, Rosenfeld A. Modulatory immune responses in fungal infection associated with organ transplant - advancements, management, and challenges. Front Immunol 2023; 14:1292625. [PMID: 38143753 PMCID: PMC10748506 DOI: 10.3389/fimmu.2023.1292625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Organ transplantation stands as a pivotal achievement in modern medicine, offering hope to individuals with end-stage organ diseases. Advancements in immunology led to improved organ transplant survival through the development of immunosuppressants, but this heightened susceptibility to fungal infections with nonspecific symptoms in recipients. This review aims to establish an intricate balance between immune responses and fungal infections in organ transplant recipients. It explores the fundamental immune mechanisms, recent advances in immune response dynamics, and strategies for immune modulation, encompassing responses to fungal infections, immunomodulatory approaches, diagnostics, treatment challenges, and management. Early diagnosis of fungal infections in transplant patients is emphasized with the understanding that innate immune responses could potentially reduce immunosuppression and promise efficient and safe immuno-modulating treatments. Advances in fungal research and genetic influences on immune-fungal interactions are underscored, as well as the potential of single-cell technologies integrated with machine learning for biomarker discovery. This review provides a snapshot of the complex interplay between immune responses and fungal infections in organ transplantation and underscores key research directions.
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Affiliation(s)
- Amir Elalouf
- Department of Management, Bar-Ilan University, Ramat Gan, Israel
| | - Hadas Elalouf
- Information Science Department, Bar-Ilan University, Ramat Gan, Israel
| | - Ariel Rosenfeld
- Information Science Department, Bar-Ilan University, Ramat Gan, Israel
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8
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Burdorf L, Gao Z, Riner A, Sievert E, Harris DG, Kuravi KV, Morrill BH, Habibabady Z, Rybak E, Dahi S, Zhang T, Schwartz E, Kang E, Cheng X, Esmon CT, Phelps CJ, Ayares DL, Pierson RN, Azimzadeh AM. Expression of human thrombomodulin by GalTKO.hCD46 pigs modulates coagulation cascade activation by endothelial cells and during ex vivo lung perfusion with human blood. Xenotransplantation 2023; 30:e12828. [PMID: 37767640 PMCID: PMC10840969 DOI: 10.1111/xen.12828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
Thrombomodulin is important for the production of activated protein C (APC), a molecule with significant regulatory roles in coagulation and inflammation. To address known molecular incompatibilities between pig thrombomodulin and human thrombin that affect the conversion of protein C into APC, GalTKO.hCD46 pigs have been genetically modified to express human thrombomodulin (hTBM). The aim of this study was to evaluate the impact of transgenic hTBM expression on the coagulation dysregulation that is observed in association with lung xenograft injury in an established lung perfusion model, with and without additional blockade of nonphysiologic interactions between pig vWF and human GPIb axis. Expression of hTBM was variable between pigs at the transcriptional and protein level. hTBM increased the activation of human protein C and inhibited thrombosis in an in vitro flow perfusion assay, confirming that the expressed protein was functional. Decreased platelet activation was observed during ex vivo perfusion of GalTKO.hCD46 lungs expressing hTBM and, in conjunction with transgenic hTBM, blockade of the platelet GPIb receptor further inhibited platelets and increased survival time. Altogether, our data indicate that expression of transgenic hTBM partially addresses coagulation pathway dysregulation associated with pig lung xenograft injury and, in combination with vWF-GP1b-directed strategies, is a promising approach to improve the outcomes of lung xenotransplantation.
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Affiliation(s)
- Lars Burdorf
- Center for Transplantation Sciences, Department of Surgery,
Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Zhuo Gao
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
- Jiangsu Key Laboratory of Xenotransplantation, Nanjing
Medical University, Nanjing, China, USA
| | - Andrea Riner
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Evelyn Sievert
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Donald G. Harris
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | | | | | - Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery,
Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Elana Rybak
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Tianshu Zhang
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Evan Schwartz
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Elizabeth Kang
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Xiangfei Cheng
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Charles T. Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Department of Pathology, University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
| | | | | | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery,
Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
| | - Agnes M. Azimzadeh
- Center for Transplantation Sciences, Department of Surgery,
Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, University of Maryland School of
Medicine, and VA Maryland Health Care System, Baltimore, MD, USA
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9
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Mohiuddin MM, Singh AK, Scobie L, Goerlich CE, Grazioli A, Saharia K, Crossan C, Burke A, Drachenberg C, Oguz C, Zhang T, Lewis B, Hershfeld A, Sentz F, Tatarov I, Mudd S, Braileanu G, Rice K, Paolini JF, Bondensgaard K, Vaught T, Kuravi K, Sorrells L, Dandro A, Ayares D, Lau C, Griffith BP. Graft dysfunction in compassionate use of genetically engineered pig-to-human cardiac xenotransplantation: a case report. Lancet 2023; 402:397-410. [PMID: 37393920 PMCID: PMC10552929 DOI: 10.1016/s0140-6736(23)00775-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND A genetically engineered pig cardiac xenotransplantation was done on Jan 7, 2022, in a non-ambulatory male patient, aged 57 years, with end-stage heart failure, and on veno-arterial extracorporeal membrane oxygenation support, who was ineligible for an allograft. This report details our current understanding of factors important to the xenotransplantation outcome. METHODS Physiological and biochemical parameters critical for the care of all heart transplant recipients were collected in extensive clinical monitoring in an intensive care unit. To ascertain the cause of xenograft dysfunction, we did extensive immunological and histopathological studies, including electron microscopy and quantification of porcine cytomegalovirus or porcine roseolovirus (PCMV/PRV) in the xenograft, recipient cells, and tissue by DNA PCR and RNA transcription. We performed intravenous immunoglobulin (IVIG) binding to donor cells and single-cell RNA sequencing of peripheral blood mononuclear cells. FINDINGS After successful xenotransplantation, the graft functioned well on echocardiography and sustained cardiovascular and other organ systems functions until postoperative day 47 when diastolic heart failure occurred. At postoperative day 50, the endomyocardial biopsy revealed damaged capillaries with interstitial oedema, red cell extravasation, rare thrombotic microangiopathy, and complement deposition. Increased anti-pig xenoantibodies, mainly IgG, were detected after IVIG administration for hypogammaglobulinaemia and during the first plasma exchange. Endomyocardial biopsy on postoperative day 56 showed fibrotic changes consistent with progressive myocardial stiffness. Microbial cell-free DNA testing indicated increasing titres of PCMV/PRV cell-free DNA. Post-mortem single-cell RNA sequencing showed overlapping causes. INTERPRETATION Hyperacute rejection was avoided. We identified potential mediators of the observed endothelial injury. First, widespread endothelial injury indicates antibody-mediated rejection. Second, IVIG bound strongly to donor endothelium, possibly causing immune activation. Finally, reactivation and replication of latent PCMV/PRV in the xenograft possibly initiated a damaging inflammatory response. The findings point to specific measures to improve xenotransplant outcomes in the future. FUNDING The University of Maryland School of Medicine, and the University of Maryland Medical Center.
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Affiliation(s)
- Muhammad M Mohiuddin
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Avneesh K Singh
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda Scobie
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Corbin E Goerlich
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison Grazioli
- Cardiac Surgery Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kapil Saharia
- Institute of Human Virology, Division of Infectious Disease, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claire Crossan
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Allen Burke
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Cinthia Drachenberg
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Cihan Oguz
- Integrated Data Sciences Section, Research Technologies Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Tianshu Zhang
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Billeta Lewis
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alena Hershfeld
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Faith Sentz
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ivan Tatarov
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Mudd
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gheorghe Braileanu
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kathryn Rice
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Christine Lau
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Program in Cardiac Xenotransplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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10
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Chaban R, McGrath G, Habibabady Z, Rosales I, Burdorf L, Ayares DL, Rybak E, Zhang T, Harris DG, Dahi S, Ali F, Parsell DM, Braileanu G, Cheng X, Sievert E, Phelps C, Azimzadeh AM, Pierson RN. Increased human complement pathway regulatory protein gene dose is associated with increased endothelial expression and prolonged survival during ex-vivo perfusion of GTKO pig lungs with human blood. Xenotransplantation 2023; 30:e12812. [PMID: 37504492 DOI: 10.1111/xen.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/29/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Expression of human complement pathway regulatory proteins (hCPRP's) such as CD46 or CD55 has been associated with improved survival of pig organ xenografts in multiple different models. Here we evaluate the hypothesis that an increased human CD46 gene dose, through homozygosity or additional expression of a second hCPRP, is associated with increased protein expression and with improved protection from injury when GTKO lung xenografts are perfused with human blood. METHODS Twenty three GTKO lungs heterozygous for human CD46 (GTKO.heteroCD46), 10 lungs homozygous for hCD46 (GTKO.homoCD46), and six GTKO.homoCD46 lungs also heterozygous for hCD55 (GTKO.homoCD46.hCD55) were perfused with human blood for up to 4 h in an ex vivo circuit. RESULTS Relative to GTKO.heteroCD46 (152 min, range 5-240; 6/23 surviving at 4 h), survival was significantly improved for GTKO.homoCD46 (>240 min, range 45-240, p = .034; 7/10 surviving at 4 h) or GTKO.homoCD46.hCD55 lungs (>240 min, p = .001; 6/6 surviving at 4 h). Homozygosity was associated with increased capillary expression of hCD46 (p < .0001). Increased hCD46 expression was associated with significantly prolonged lung survival (p = .048),) but surprisingly not with reduction in measured complement factor C3a. Hematocrit, monocyte count, and pulmonary vascular resistance were not significantly altered in association with increased hCD46 gene dose or protein expression. CONCLUSION Genetic engineering approaches designed to augment hCPRP activity - increasing the expression of hCD46 through homozygosity or co-expressing hCD55 with hCD46 - were associated with prolonged GTKO lung xenograft survival. Increased expression of hCD46 was associated with reduced coagulation cascade activation, but did not further reduce complement activation relative to lungs with relatively low CD46 expression. We conclude that coagulation pathway dysregulation contributes to injury in GTKO pig lung xenografts perfused with human blood, and that the survival advantage for lungs with increased hCPRP expression is likely attributable to improved endothelial thromboregulation.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Cardiac and Vascular Surgery, University Hospital of Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gannon McGrath
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
| | - Zahra Habibabady
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ivy Rosales
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
| | - Lars Burdorf
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Revivicor, Inc., Blacksburg, Virginia, USA
| | | | - Elana Rybak
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tianshu Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Donald G Harris
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Siamak Dahi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Franchesca Ali
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Dawn M Parsell
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gheorghe Braileanu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Xiangfei Cheng
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Evelyn Sievert
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Agnes M Azimzadeh
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Richard N Pierson
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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11
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Singh AK, Goerlich CE, Zhang T, Lewis BG, Hershfeld A, Mohiuddin MM. CD40-CD40L Blockade: Update on Novel Investigational Therapeutics for Transplantation. Transplantation 2023; 107:1472-1481. [PMID: 36584382 PMCID: PMC10287837 DOI: 10.1097/tp.0000000000004469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Effective immune responses require antigen presentation by major histocompatibility complexes with cognate T-cell receptor and antigen-independent costimulatory signaling for T-cell activation, proliferation, and differentiation. Among several costimulatory signals, CD40-CD40L is of special interest to the transplantation community because it plays a vital role in controlling or regulating humoral and cellular immunity. Blockade of this pathway has demonstrated inhibition of donor-reactive T-cell responses and prolonged the survival of transplanted organs. Several anti-CD154 and anti-CD40 antibodies have been used in the transplantation model and demonstrated the potential of extending allograft and xenograft rejection-free survival. The wide use of anti-CD154 antibodies was hampered because of thromboembolic complications in transplant recipients. These antibodies have been modified to overcome the thromboembolic complications by altering the antibody binding fragment (Fab) and Fc (fragment, crystallizable) receptor region for therapeutic purposes. Here, we review recent preclinical advances to target the CD40-CD40L pair in transplantation.
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Affiliation(s)
| | | | - Tianshu Zhang
- University of Maryland School of Medicine, Baltimore, MD
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12
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Reichart B, Cooper DKC, Längin M, Tönjes RR, Pierson RN, Wolf E. Cardiac xenotransplantation: from concept to clinic. Cardiovasc Res 2023; 118:3499-3516. [PMID: 36461918 PMCID: PMC9897693 DOI: 10.1093/cvr/cvac180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
For many patients with terminal/advanced cardiac failure, heart transplantation is the most effective, durable treatment option, and offers the best prospects for a high quality of life. The number of potentially life-saving donated human organs is far fewer than the population who could benefit from a new heart, resulting in increasing numbers of patients awaiting replacement of their failing heart, high waitlist mortality, and frequent reliance on interim mechanical support for many of those deemed among the best candidates but who are deteriorating as they wait. Currently, mechanical assist devices supporting left ventricular or biventricular heart function are the only alternative to heart transplant that is in clinical use. Unfortunately, the complication rate with mechanical assistance remains high despite advances in device design and patient selection and management, and the quality of life of the patients even with good outcomes is only moderately improved. Cardiac xenotransplantation from genetically multi-modified (GM) organ-source pigs is an emerging new option as demonstrated by the consistent long-term success of heterotopic (non-life-supporting) abdominal and life-supporting orthotopic porcine heart transplantation in baboons, and by a recent 'compassionate use' transplant of the heart from a GM pig with 10 modifications into a terminally ill patient who survived for 2 months. In this review, we discuss pig heart xenotransplantation as a concept, including pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental overgrowth of the heart, as well as GM strategies in pigs to prevent or minimize these problems. Additional topics discussed include relevant results of heterotopic and orthotopic heart transplantation experiments in the pig-to-baboon model, microbiological and virologic safety concepts, and efficacy requirements for initiating formal clinical trials. An adequate regulatory and ethical framework as well as stringent criteria for the selection of patients will be critical for the safe clinical development of cardiac xenotransplantation, which we expect will be clinically tested during the next few years.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Centre for Experimental Medicine, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - Ralf R Tönjes
- Division of Medical Biotechnology, Paul-Ehrlich-Institute, Langen 63225, Germany
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Eckhard Wolf
- Gene Centre and Centre for Innovative Medical Models (CiMM), Ludwig-Maximilians-Universität München, Munich 81377, Germany
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13
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Arabi TZ, Sabbah BN, Lerman A, Zhu XY, Lerman LO. Xenotransplantation: Current Challenges and Emerging Solutions. Cell Transplant 2023; 32:9636897221148771. [PMID: 36644844 PMCID: PMC9846288 DOI: 10.1177/09636897221148771] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
To address the ongoing shortage of organs available for replacement, xenotransplantation of hearts, corneas, skin, and kidneys has been attempted. However, a major obstacle facing xenotransplants is rejection due to a cycle of immune reactions to the graft. Both adaptive and innate immune systems contribute to this cycle, in which natural killer cells, macrophages, and T-cells play a significant role. While advancements in the field of genetic editing can circumvent some of these obstacles, biomarkers to identify and predict xenograft rejection remain to be standardized. Several T-cell markers, such as CD3, CD4, and CD8, are useful in both the diagnosis and prediction of xenograft rejection. Furthermore, an increase in the levels of various circulating DNA markers and microRNAs is also predictive of xenograft rejection. In this review, we summarize recent findings on the advancements in xenotransplantation, with a focus on pig-to-human, the role of immunity in xenograft rejection, and its biomarkers.
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Affiliation(s)
- Tarek Ziad Arabi
- Division of Nephrology and
Hypertension, Mayo Clinic, Rochester, MN, USA,College of Medicine, Alfaisal
University, Riyadh, Saudi Arabia
| | - Belal Nedal Sabbah
- College of Medicine, Alfaisal
University, Riyadh, Saudi Arabia,Department of Urology, Mayo Clinic,
Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiology, Mayo Clinic,
Rochester, MN, USA
| | - Xiang-Yang Zhu
- Division of Nephrology and
Hypertension, Mayo Clinic, Rochester, MN, USA,Xiang-Yang Zhu, Division of Nephrology and
Hypertension, Mayo Clinic, 200 First Street SW., Rochester, MN 55905, USA.
| | - Lilach O. Lerman
- Division of Nephrology and
Hypertension, Mayo Clinic, Rochester, MN, USA
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14
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Accommodation in allogeneic and xenogeneic organ transplantation: Prevalence, impact, and implications for monitoring and for therapeutics. Hum Immunol 2023; 84:5-17. [PMID: 36244871 DOI: 10.1016/j.humimm.2022.08.001] [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: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
Accommodation refers to acquired resistance of organs or tissues to immune or inflammatory reactions that might otherwise cause severe injury or rejection. As first observed in ABO-incompatible kidney transplants and heterotopic cardiac xenografts, accommodation was identified when organ transplants continued to function despite the presence of anti-graft antibodies and/or other reactants in the blood of recipients. Recent evidence suggests many and perhaps most organ transplants have accommodation, as most recipients mount B cell responses specific for the graft. Wide interest in the impact of graft-specific antibodies on the outcomes of transplants prompts questions about which mechanisms confer protection against such antibodies, how accommodation might be detected and whether and how rejection could be superimposed on accommodation. Xenotransplantation offers a unique opportunity to address these questions because immune responses to xenografts are easily detected and the pathogenic impact of immune responses is so severe. Xenotransplantation also provides a compelling need to apply these and other insights to decrease the intensity and toxicity of immunosuppression that otherwise could limit clinical application.
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15
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Lei T, Chen L, Wang K, Du S, Gonelle-Gispert C, Wang Y, Buhler LH. Genetic engineering of pigs for xenotransplantation to overcome immune rejection and physiological incompatibilities: The first clinical steps. Front Immunol 2022; 13:1031185. [PMID: 36561750 PMCID: PMC9766364 DOI: 10.3389/fimmu.2022.1031185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Xenotransplantation has the potential to solve the shortfall of human organ donors. Genetically modified pigs have been considered as potential animal donors for human xenotransplantation and have been widely used in preclinical research. The genetic modifications aim to prevent the major species-specific barriers, which include humoral and cellular immune responses, and physiological incompatibilities such as complement and coagulation dysfunctions. Genetically modified pigs can be created by deleting several pig genes related to the synthesis of various pig specific antigens or by inserting human complement- and coagulation-regulatory transgenes. Finally, in order to reduce the risk of infection, genes related to porcine endogenous retroviruses can be knocked down. In this review, we focus on genetically modified pigs and comprehensively summarize the immunological mechanism of xenograft rejection and recent progress in preclinical and clinical studies. Overall, both genetically engineered pig-based xenografts and technological breakthroughs in the biomedical field provide a promising foundation for pig-to-human xenotransplantation in the future.
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Affiliation(s)
- Tiantian Lei
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Lin Chen
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Kejing Wang
- Department of Pharmacy, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Suya Du
- Department of Clinical Pharmacy, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
| | - Yi Wang
- Department of Critical Care Medicine, Sichuan Academy of Medical Science and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
| | - Leo H. Buhler
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland,*Correspondence: Carmen Gonelle-Gispert, ; Yi Wang, ; Leo H. Buhler,
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16
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Niemann H. Xenotransplantate vom Schwein – ist das Ende des Organmangels
in Sicht? TRANSFUSIONSMEDIZIN 2022. [DOI: 10.1055/a-1814-8440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungUnter „Xenotransplantation“ wird die Übertragung von
funktionsfähigen Zellen, Geweben oder Organen zwischen verschiedenen
Spezies verstanden, insbesondere von Schweinen auf den Menschen. In den meisten
Industrieländern klafft eine große Lücke zwischen der
Anzahl geeigneter Spenderorgane und der Anzahl benötigter Transplantate.
Weltweit können nur etwa 10% des Organbedarfs durch Spenden
gedeckt werden. Eine erfolgreiche Xenotransplantation könnte diesen
Mangel mildern oder sogar weitgehend vermeiden. Das Schwein wird aus
verschiedenen Erwägungen heraus als am besten geeignete Spenderspezies
angesehen. Bei einer Übertragung porziner Organe auf Primaten treten
verschiedene immunologisch bedingte Abstoßungsreaktionen auf, die das
übertragene Organ innerhalb kurzer Zeit zerstören
können, wie die HAR (hyperakute Abstoßung), die AVR (akute
vaskuläre Abstoßung) und die spätere zelluläre
Abstoßung. Diese Abstoßungsreaktionen müssen durch
genetische Modifikationen im Schwein und eine geeignete immunsuppressive
Behandlung des Empfängers kontrolliert werden. Dazu müssen Tiere
mit mehrfachen genetischen Veränderungen produziert und im Hinblick auf
ihre Eignung für eine erfolgreiche Xenotransplantation geprüft
werden. Inzwischen können die HAR und auch die AVR durch Knockouts von
antigenen Oberflächenepitopen (z. B. αGal
[Galaktose-α1,3-Galaktose]) und transgene Expression humaner Gene mit
antiinflammatorischer, antiapoptotischer oder antikoagulativer Wirkung
zuverlässig kontrolliert werden. Nach orthotopen Transplantationen in
nicht humane Primaten konnten inzwischen mit Schweineherzen
Überlebensraten von bis zu 264 Tagen und mit porzinen Nieren von 435
Tagen erzielt werden. Eine Übertragung pathogener Erreger auf den
Empfänger kann bei Einhaltung einschlägiger
Hygienemaßnahmen ausgeschlossen werden. PERV (porzine endogene
Retroviren) können durch RNA-(Ribonukleinsäure-)Interferenz oder
Gen-Knockout ausgeschaltet werden. Sie stellen damit kein
Übertragungsrisiko für den Empfänger mehr dar. Anfang
2022 wurde in Baltimore (USA) ein Schweineherz mit 10 genetischen Modifikationen
auf einen Patienten mit schwerem Herzleiden übertragen, mit dem der
Empfänger 2 Monate offenbar ohne größere Probleme lebte.
Es wird erwartet, dass Xenotransplantate vom Schwein in absehbarer Zeit zur
klinischen Anwendungsreife kommen werden. Dazu werden klinische Versuche zur
systematischen Erfassung aller Auswirkungen solcher Transplantate auf den
Patienten sowie geeignete rechtliche und finanzielle Rahmenbedingungen
benötigt.
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17
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An Efficacious Transgenic Strategy for Triple Knockout of Xeno-Reactive Antigen Genes GGTA1, CMAH, and B4GALNT2 from Jeju Native Pigs. Vaccines (Basel) 2022; 10:vaccines10091503. [PMID: 36146581 PMCID: PMC9505423 DOI: 10.3390/vaccines10091503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022] Open
Abstract
Pigs are promising donors of biological materials for xenotransplantation; however, cell surface carbohydrate antigens, including galactose-alpha-1,3-galactose (α-Gal), N-glycolylneuraminic acid (Neu5Gc), and Sd blood group antigens, play a significant role in porcine xenograft rejection. Inactivating swine endogenous genes, including GGTA1, CMAH, and B4GALNT2, decreases the binding ratio of human IgG/IgM in peripheral blood mononuclear cells and erythrocytes and impedes the effectiveness of α-Gal, Neu5Gc, and Sd, thereby successfully preventing hyperacute rejection. Therefore, in this study, an effective transgenic system was developed to target GGTA1, CMAH, and B4GALNT2 using CRISPR-CAS9 and develop triple-knockout pigs. The findings revealed that all three antigens (α-Gal, Neu5Gc, and Sd) were not expressed in the heart, lungs, or liver of the triple-knockout Jeju Native Pigs (JNPs), and poor expression of α-Gal and Neu5G was confirmed in the kidneys. Compared with the kidney, heart, and lung tissues from wild-type JNPs, those from GGTA1/CMAH/ B4GALNT2 knockout-recipient JNPs exhibited reduced human IgM and IgG binding and expression of each immunological rejection component. Hence, reducing the expression of swine xenogeneic antigens identifiable by human immunoglobulins can lessen the immunological rejection against xenotransplantation. The findings support the possibility of employing knockout JNP organs for xenogeneic transplantation to minimize or completely eradicate rejection using multiple gene-editing methods.
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18
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Singh AK, Griffith BP, Goerlich CE, Ayares D, Mohiuddin MM. The road to the first FDA-approved genetically engineered pig heart transplantation into human. Xenotransplantation 2022; 29:e12776. [PMID: 36125166 PMCID: PMC9547852 DOI: 10.1111/xen.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Abstract
We have been testing genetically engineered (GE) pig hearts and optimizing immunosuppression (IS) in non-human primates (NHPs) since 2005. We demonstrate how we translated this preclinical investigation into a US Food and Drug Administration (FDA)-approved clinical cardiac xenotransplantation. First, genetically engineered (GE) pig hearts were transplanted into the abdomen of NHP along with IS, which included anti-CD20 and anti-CD40-based co-stimulation blockade antibodies. We reported 945 days of survival of three gene GE pig hearts in NHPs. Building on this proof-of-concept, we tested 3-10 gene-modified GE pig hearts (in order to improve the immunocompatibility of the xenograft further) in a life-supporting orthotopic model, but had limited success due to perioperative cardiac xenograft dysfunction (PCXD). With novel non-ischemic continuous perfusion preservation (NICP), using the XVIVO Heart solution (XHS), life-supporting survival was extended to 9 months. We approached the FDA under an application for "Expanded Access" (EA), to transplant a GE pig heart in a patient with end-stage non-ischemic cardiomyopathy. He was without other therapeutic options and dependent on VA-ECMO. A team of FDA reviewers reviewed our preclinical research experience and data and allowed us to proceed. This clinical cardiac xenotransplantation was performed, and the patient survived for 60 days, demonstrating the translational preclinical investigation of cardiac xenotransplantation from bench to bedside. The ultimate etiology of graft failure is currently a topic of investigation and lessons learned will progress the field forward.
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Affiliation(s)
- Avneesh K Singh
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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19
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Kervella D, Le Bas-Bernardet S, Bruneau S, Blancho G. Protection of transplants against antibody-mediated injuries: from xenotransplantation to allogeneic transplantation, mechanisms and therapeutic insights. Front Immunol 2022; 13:932242. [PMID: 35990687 PMCID: PMC9389360 DOI: 10.3389/fimmu.2022.932242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term allograft survival in allotransplantation, especially in kidney and heart transplantation, is mainly limited by the occurrence of antibody-mediated rejection due to anti-Human Leukocyte Antigen antibodies. These types of rejection are difficult to handle and chronic endothelial damages are often irreversible. In the settings of ABO-incompatible transplantation and xenotransplantation, the presence of antibodies targeting graft antigens is not always associated with rejection. This resistance to antibodies toxicity seems to associate changes in endothelial cells phenotype and modification of the immune response. We describe here these mechanisms with a special focus on endothelial cells resistance to antibodies. Endothelial protection against anti-HLA antibodies has been described in vitro and in animal models, but do not seem to be a common feature in immunized allograft recipients. Complement regulation and anti-apoptotic molecules expression appear to be common features in all these settings. Lastly, pharmacological interventions that may promote endothelial cell protection against donor specific antibodies will be described.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Sarah Bruneau
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
- *Correspondence: Gilles Blancho,
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20
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Raza SS, Hara H, Cleveland DC, Cooper DKC. The potential of genetically engineered pig heart transplantation in infants with complex congenital heart disease. Pediatr Transplant 2022; 26:e14260. [PMID: 35233893 PMCID: PMC10124767 DOI: 10.1111/petr.14260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/16/2022]
Abstract
Despite advances in surgical and medical techniques, complex congenital heart disease in neonates and infants continues to be associated with significant mortality and morbidity. More than 500 infants in the USA are placed on the cardiac transplantation wait-list annually. However, there remains a critical shortage of deceased human donor organs for transplantation with a median wait-time of 4 months. Hence, infant mortality on the heart transplant wait-list in the USA is higher than for any other solid organ transplant group. Orthotopic transplantation of a pig heart as a bridge to allotransplantation might offer the best prospect of long-term survival of these patients. In recent years, there have been several advances in genetic engineering of pigs to mitigate the vigorous antibody-mediated rejection of a pig heart transplanted into a nonhuman primate. In this review, we briefly highlight (i) the history of clinical heart xenotransplantation, (ii) current advances and techniques of genetically engineering pigs, (iii) the current status of pig orthotopic cardiac graft survival in nonhuman primates, and (iv) progress toward pursuing clinical trials of cardiac xenotransplantation. Ultimately, we argue that pig heart xenotransplantation should initially be used as a bridge to cardiac allotransplantation in neonates and infants.
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Affiliation(s)
- Syed Sikandar Raza
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David C Cleveland
- Department of Cardiothoracic Surgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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21
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Goerlich CE, Singh AK, Griffith BP, Mohiuddin MM. The immunobiology and clinical use of genetically engineered porcine hearts for cardiac xenotransplantation. NATURE CARDIOVASCULAR RESEARCH 2022; 1:715-726. [PMID: 36895262 PMCID: PMC9994617 DOI: 10.1038/s44161-022-00112-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A summary of the scientific rationale of the advancements that led to the first genetically modified pig-to-human cardiac xenotransplantation is lacking in a complex and rapidly evolving field. Here, we aim to aid the general readership in the understanding of the gradual progression of cardiac (xeno)transplantation research, the immunobiology of cardiac xenotransplantation (including the latest immunosuppression, cardiac preservation and genetic engineering required for successful transplantation) and the regulatory landscape related to the clinical application of cardiac xenotransplantation for people with end-stage heart failure. Finally, we provide an overview of the outcomes and lessons learned from the first genetically modified pig-to-human cardiac heart xenotransplantation.
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Affiliation(s)
- Corbin E Goerlich
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Avneesh K Singh
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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22
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Wadiwala IJ, Garg P, Yazji JH, Alamouti-fard E, Alomari M, Hussain MWA, Elawady MS, Jacob S. Evolution of Xenotransplantation as an Alternative to Shortage of Donors in Heart Transplantation. Cureus 2022; 14:e26284. [PMID: 35754438 PMCID: PMC9230910 DOI: 10.7759/cureus.26284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
This review aims to show and illustrate the history, current, ethical considerations, and limitations concerning xenotransplantation. Due to the current shortage of available donor organs for transplantation, many alternative sources are being examined to solve the donor shortage. One of them is xenotransplantation which refers to the transplantation of organs from one species to another. Compared to other nonhuman primates (NHP), pigs are ideal species for organ harvesting as they rapidly grow to human size in a handful of months. There is much advancement in the genetic engineering of pigs, which have hearts structurally and functionally similar to the human heart. The role of genetic engineering is to overcome the immune barriers in xenotransplantation and can be used in hyperacute rejection and T cell-mediated rejection. It is technically difficult to use large animal models for orthotopic, life-sustaining heart transplantation. Despite the fact that some religious traditions, such as Jewish and Muslim, prohibit the ingestion of pork products, few religious leaders consider that donating porcine organs is ethical because it saves human life. Although recent technologies have lowered the risk of a xenograft producing a novel virus that causes an epidemic, the risk still exists. It has major implications for the informed consent procedure connected with clinical research on heart xenotransplantation.
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23
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Signaling cascades in the failing heart and emerging therapeutic strategies. Signal Transduct Target Ther 2022; 7:134. [PMID: 35461308 PMCID: PMC9035186 DOI: 10.1038/s41392-022-00972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic heart failure is the end stage of cardiac diseases. With a high prevalence and a high mortality rate worldwide, chronic heart failure is one of the heaviest health-related burdens. In addition to the standard neurohormonal blockade therapy, several medications have been developed for chronic heart failure treatment, but the population-wide improvement in chronic heart failure prognosis over time has been modest, and novel therapies are still needed. Mechanistic discovery and technical innovation are powerful driving forces for therapeutic development. On the one hand, the past decades have witnessed great progress in understanding the mechanism of chronic heart failure. It is now known that chronic heart failure is not only a matter involving cardiomyocytes. Instead, chronic heart failure involves numerous signaling pathways in noncardiomyocytes, including fibroblasts, immune cells, vascular cells, and lymphatic endothelial cells, and crosstalk among these cells. The complex regulatory network includes protein-protein, protein-RNA, and RNA-RNA interactions. These achievements in mechanistic studies provide novel insights for future therapeutic targets. On the other hand, with the development of modern biological techniques, targeting a protein pharmacologically is no longer the sole option for treating chronic heart failure. Gene therapy can directly manipulate the expression level of genes; gene editing techniques provide hope for curing hereditary cardiomyopathy; cell therapy aims to replace dysfunctional cardiomyocytes; and xenotransplantation may solve the problem of donor heart shortages. In this paper, we reviewed these two aspects in the field of failing heart signaling cascades and emerging therapeutic strategies based on modern biological techniques.
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24
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Jagdale A, Nguyen H, Iwase H, Foote JB, Yamamoto T, Javed M, Ayares D, Anderson DJ, Eckhoff DE, Cooper DKC, Hara H. T and B lymphocyte dynamics after genetically-modified pig-to-baboon kidney xenotransplantation with an anti-CD40mAb-based immunosuppressive regimen. Transpl Immunol 2022; 71:101545. [PMID: 35114360 PMCID: PMC9395207 DOI: 10.1016/j.trim.2022.101545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim was to monitor recovery of T/B lymphocytes in baboons after depletion by anti-thymocyte globulin (ATG) and anti-CD20mAb (Rituximab), followed by pig kidney transplantation and maintenance therapy with an anti-CD40mAb-based regimen. METHODS In baboons (n = 14), induction was with ATG and anti-CD20mAb, and maintenance with (i) anti-CD40mAb, (ii) rapamycin, and (iii) methylprednisolone. Follow-up was for 6 months, or until rejection or other complication developed. Baboon blood was collected at intervals to measure T/B cells and subsets by flow cytometry. In a separate study in baboons receiving the same immunosuppressive regimen (n = 10), the populations of T/B lymphocytes in PBMCs, lymph nodes, and spleen were examined. RESULTS After induction therapy, the total lymphocyte count and the absolute numbers of CD3+, CD4+, and CD8+T cells fell by >80%, and no CD22+B cells remained (all p < 0.001). T cell numbers began to recover early, but no CD22+B cells were present in the blood for 2 months. Recovery of both T and B cells remained at <30% of baseline (p < 0.001), even if rejection developed. At 6 months, effector memory CD8+T cells had increased more than other T cell subsets, but a greater percentage of B cells were naïve. In contrast to blood and spleen, T and B cells were not depleted in lymph nodes. CONCLUSIONS ATG and anti-CD20mAb effectively decreased T and B lymphocytes in the blood and, in the presence of anti-CD40mAb maintenance therapy, recovery of these cells was inhibited. The recovery of effector memory CD8+T cells may be detrimental to long-term graft survival.
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Affiliation(s)
- Abhijit Jagdale
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Huy Nguyen
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hayato Iwase
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Mariyam Javed
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | | | | | - Devin E Eckhoff
- Department of Surgery, University of Alabama at Birmingham, AL, USA; Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Hidetaka Hara
- Department of Surgery, University of Alabama at Birmingham, AL, USA.
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25
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Mohiuddin MM, Goerlich CE, Singh AK, Zhang T, Tatarov I, Lewis B, Sentz F, Hershfeld A, Braileanu G, Odonkor P, Strauss E, Williams B, Burke A, Hittman J, Bhutta A, Tabatabai A, Gupta A, Vaught T, Sorrells L, Kuravi K, Dandro A, Eyestone W, Kaczorowski DJ, Ayares D, Griffith BP. Progressive genetic modifications of porcine cardiac xenografts extend survival to 9 months. Xenotransplantation 2022; 29:e12744. [PMID: 35357044 DOI: 10.1111/xen.12744] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/02/2022] [Accepted: 03/10/2022] [Indexed: 01/04/2023]
Abstract
We report orthotopic (life-supporting) survival of genetically engineered porcine cardiac xenografts (with six gene modifications) for almost 9 months in baboon recipients. This work builds on our previously reported heterotopic cardiac xenograft (three gene modifications) survival up to 945 days with an anti-CD40 monoclonal antibody-based immunosuppression. In this current study, life-supporting xenografts containing multiple human complement regulatory, thromboregulatory, and anti-inflammatory proteins, in addition to growth hormone receptor knockout (KO) and carbohydrate antigen KOs, were transplanted in the baboons. Selective "multi-gene" xenografts demonstrate survival greater than 8 months without the requirement of adjunctive medications and without evidence of abnormal xenograft thickness or rejection. These data demonstrate that selective "multi-gene" modifications improve cardiac xenograft survival significantly and may be foundational for paving the way to bridge transplantation in humans.
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Affiliation(s)
- Muhammad M Mohiuddin
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Corbin E Goerlich
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Avneesh K Singh
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tianshu Zhang
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ivan Tatarov
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Billeta Lewis
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Faith Sentz
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alena Hershfeld
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gheorghe Braileanu
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Patrick Odonkor
- Department of Anesthesiology, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Erik Strauss
- Department of Anesthesiology, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brittney Williams
- Department of Anesthesiology, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Allen Burke
- Department of Pathology, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jamie Hittman
- Department of Pathology, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Adnan Bhutta
- Department of Pediatrics, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ali Tabatabai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anuj Gupta
- Department of Medicine, Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - Amy Dandro
- Revivicor, Inc., Blacksburg, Virginia, USA
| | | | - David J Kaczorowski
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Bartley P Griffith
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
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26
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Singh AK, Goerlich CE, Shah AM, Zhang T, Tatarov I, Ayares D, Horvath KA, Mohiuddin MM. Cardiac Xenotransplantation: Progress in Preclinical Models and Prospects for Clinical Translation. Transpl Int 2022; 35:10171. [PMID: 35401039 PMCID: PMC8985160 DOI: 10.3389/ti.2022.10171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/11/2022] [Indexed: 12/02/2022]
Abstract
Survival of pig cardiac xenografts in a non-human primate (NHP) model has improved significantly over the last 4 years with the introduction of costimulation blockade based immunosuppression (IS) and genetically engineered (GE) pig donors. The longest survival of a cardiac xenograft in the heterotopic (HHTx) position was almost 3 years and only rejected when IS was stopped. Recent reports of cardiac xenograft survival in a life-sustaining orthotopic (OHTx) position for 6 months is a significant step forward. Despite these achievements, there are still several barriers to the clinical success of xenotransplantation (XTx). This includes the possible transmission of porcine pathogens with pig donors and continued xenograft growth after XTx. Both these concerns, and issues with additional incompatibilities, have been addressed recently with the genetic modification of pigs. This review discusses the spectrum of issues related to cardiac xenotransplantation, recent progress in preclinical models, and its feasibility for clinical translation.
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Affiliation(s)
- Avneesh K. Singh
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Corbin E. Goerlich
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Aakash M. Shah
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Tianshu Zhang
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Ivan Tatarov
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
| | | | - Keith A. Horvath
- National Heart, Lung, and Blood Institute, National Institute of Health, Bethesda, MD, United States
| | - Muhammad M. Mohiuddin
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD, United States
- *Correspondence: Muhammad M. Mohiuddin,
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27
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Siems C, Huddleston S, John R. A Brief History of Xenotransplantation. Ann Thorac Surg 2022; 113:706-710. [DOI: 10.1016/j.athoracsur.2022.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
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28
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Gao M, Zhu X, Yang G, Bao J, Bu H. CRISPR/Cas9-Mediated Gene Editing in Porcine Models for Medical Research. DNA Cell Biol 2021; 40:1462-1475. [PMID: 34847741 DOI: 10.1089/dna.2020.6474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pigs have been extensively used as the research models for human disease pathogenesis and gene therapy. They are also the optimal source of cells, tissues, and organs for xenotransplantation due to anatomical and physiological similarities to humans. Several breakthroughs in gene-editing technologies, including the advent of clustered regularly interspaced short palindromic repeat (CRISPR)/CRISPR-associated 9 (Cas9), have greatly improved the efficiency of genetic manipulation and significantly broadened the application of gene-edited large animal models. In this review, we have not only outlined the important applications of the CRISPR/Cas9 system in pigs as a means to study human diseases but also discussed the potential challenges of the use of CRISPR/Cas9 in large animals.
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Affiliation(s)
- Mengyu Gao
- Department of Pathology, West China Hospital, Sichuan University, Chendu, P.R. China.,Key Laboratory of Transplant Engineering and Immunology, Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xinglong Zhu
- Key Laboratory of Transplant Engineering and Immunology, Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Guang Yang
- Experimental Animal Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Ji Bao
- Key Laboratory of Transplant Engineering and Immunology, Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Hong Bu
- Department of Pathology, West China Hospital, Sichuan University, Chendu, P.R. China.,Key Laboratory of Transplant Engineering and Immunology, Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
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29
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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30
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Zhang L, Zhu J, Wang H, Xia J, Liu P, Chen F, Jiang H, Miao Q, Wu W, Zhang L, Luo L, Jiang X, Bai Y, Sun C, Chen D, Zhang X. A high-resolution cell atlas of the domestic pig lung and an online platform for exploring lung single-cell data. J Genet Genomics 2021; 48:411-425. [PMID: 34144929 DOI: 10.1016/j.jgg.2021.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022]
Abstract
The genetically engineered pig is regarded as an optimal source of organ transplantation for humans and an excellent model for human disease research, given its comparable physiology to human beings. A myriad of single-cell RNA sequencing (scRNA-seq) data on humans has been reported, but such data on pigs are scarce. Here, we apply scRNA-seq technology to study the cellular heterogeneity of 3-month-old pig lungs, generating the single-cell atlas of 13,580 cells covering 16 major cell types. Based on these data, we systematically characterize the similarities and differences in the cellular cross-talk and expression patterns of respiratory virus receptors in each cell type of pig lungs compared with human lungs. Furthermore, we analyze pig lung xenotransplantation barriers and reported the cell-type expression patterns of 10 genes associated with pig-to-human immunobiological incompatibility and coagulation dysregulation. We also investigate the conserved transcription factors (TFs) and their candidate target genes and constructed five conserved TF regulatory networks in the main cell types shared by pig and human lungs. Finally, we present a comprehensive and openly accessible online platform, ScdbLung. Our scRNA-seq atlas of the domestic pig lung and ScdbLung database can guide pig lung research and clinical applicability.
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Affiliation(s)
- Lijing Zhang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; MGI, BGI-Shenzhen, Shenzhen 518083, China
| | - Jiacheng Zhu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; BGI-Shenzhen, Shenzhen 518083, China
| | - Haoyu Wang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; BGI-Shenzhen, Shenzhen 518083, China
| | - Jun Xia
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; MGI, BGI-Shenzhen, Shenzhen 518083, China
| | - Ping Liu
- MGI, BGI-Shenzhen, Shenzhen 518083, China
| | - Fang Chen
- MGI, BGI-Shenzhen, Shenzhen 518083, China; BGI-Shenzhen, Shenzhen 518083, China
| | - Hui Jiang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; MGI, BGI-Shenzhen, Shenzhen 518083, China
| | - Qiuling Miao
- Department of Pathology, Shenzhen Children's Hospital, Shenzhen 518038, China
| | - Weiying Wu
- Department of Neurobiology, NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brian Medicine, The MOE Frontier Science Center for Brain Research and Brain-Machine Integration, Zhejiang University School of Medicine, Hangzhou 310031, China
| | - Lingli Zhang
- Department of Pathophysiology, School of Basic Medicine, Guilin Medical University, Guilin 541199, China
| | - Lihua Luo
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; BGI-Shenzhen, Shenzhen 518083, China
| | - Xiaosen Jiang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; BGI-Shenzhen, Shenzhen 518083, China
| | - Yong Bai
- BGI-Shenzhen, Shenzhen 518083, China
| | - Chengcheng Sun
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China; BGI-Shenzhen, Shenzhen 518083, China
| | | | - Xingliang Zhang
- Institute of Pediatrics, Department of Pediatric Surgery, Shenzhen Children's Hospital, Shenzhen 518038, China; Department of Pediatrics, The Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, China.
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31
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Sakai H, Tanaka Y, Tanaka A, Ohdan H. TLR-MyD88 signaling blockades inhibit refractory B-1b cell immune responses to transplant-related glycan antigens. Am J Transplant 2021; 21:1427-1439. [PMID: 32865877 DOI: 10.1111/ajt.16288] [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: 03/26/2020] [Revised: 07/26/2020] [Accepted: 08/17/2020] [Indexed: 01/25/2023]
Abstract
Refractory B cell responses to T cell-independent (TI) carbohydrate antigens (Ags) are critical drivers of rejection reactions to ABO-incompatible allogeneic grafts and xenogeneic grafts from other species. To explore the biological significance of crosstalk between Toll-like receptors (TLRs) and B cell receptors (BCRs) in the TI B cell immunity, we here used MyD88-, TRIF-, and α-galactosyltransferase-deficient mice to study B cell phenotypes and functional properties during TI transplant-related glycan Ag exposure. BCR stimulation alone induced differentiation into CD5high (B-1a) cells, which were highly sensitive to a calcineurin inhibitor (CNI), while co-stimulation of TLRs and BCRs induced differentiation into CD5dim (B-1b) cells in MyD88-dependent and CNI-resistant manner. MyD88-dependent TLR stimulation in B-1b cells enhanced downstream factors in the BCR-calcineurin pathway, including a nuclear factor of activated T cells, cytoplasmic 1 (NFATc1). TLR inhibitor together with CNI abrogated refractory B-1b cell immune responses against the ABO-blood group Ags, while blocking both BCRs and TLR-MyD88 by using Bruton's tyrosine kinase inhibitor and histone deacetylase inhibitor abrogated refractory B-1b cell immune responses against Gal-glycan Ags. Thus, this study provides a rationale for a novel therapeutic approach to overcome refractory transplant-related anti-glycan Ab production by blocking both BCR and TLR-MyD88 signals.
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Affiliation(s)
- Hiroshi Sakai
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biochemical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Department of Medicine, Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biochemical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Asuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biochemical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biochemical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Hong SH, Kim HJ, Kang SJ, Park CG. Novel Immunomodulatory Approaches for Porcine Islet Xenotransplantation. Curr Diab Rep 2021; 21:3. [PMID: 33433735 DOI: 10.1007/s11892-020-01368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW Porcine islet xenotransplantation is a promising alternative to overcome the shortage of organ donors. For the successful application of islet xenotransplantation, robust immune/inflammatory responses against porcine islets should be thoroughly controlled. Over the last few decades, there have been numerous attempts to surmount xenogeneic immune barriers. In this review, we summarize the current progress in immunomodulatory therapy for the clinical application of porcine islet xenotransplantation. RECENT FINDINGS Long-term graft survival of porcine islets was achieved by using anti-CD154 Ab-based regimens in a preclinical non-human primate (NHP) model. However, owing to a serious complication of thromboembolism in clinical trials, the development of an anti-CD154 Ab-sparing immunosuppressant procedure is required. The efficacy of new immunosuppressive practices that employ anti-CD40 Abs or other immunosuppressive reagents has been tested in a NHP model to realize their utility in porcine islet xenotransplantation. The recent progress in the development of immunomodulatory approaches, including the immunosuppressive regimen, which enables long-term graft survival in a pig-to-non-human primate islet xenotransplantation model, with their potential clinical applicability was reviewed.
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Affiliation(s)
- So-Hee Hong
- Xenotransplantation Research Center, Seoul National University, College of Medicine, Seoul, South Korea
- Department of Microbiology and Immunology, Seoul National University, College of Medicine, Seoul, South Korea
- Institute of Endemic Diseases, Seoul National University, College of Medicine, Seoul, South Korea
- Cancer Research Institute, Seoul National University, College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hyun-Je Kim
- Xenotransplantation Research Center, Seoul National University, College of Medicine, Seoul, South Korea
- Department of Microbiology and Immunology, Seoul National University, College of Medicine, Seoul, South Korea
- Institute of Endemic Diseases, Seoul National University, College of Medicine, Seoul, South Korea
| | - Seong-Jun Kang
- Xenotransplantation Research Center, Seoul National University, College of Medicine, Seoul, South Korea
- Department of Microbiology and Immunology, Seoul National University, College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University, College of Medicine, Seoul, South Korea
| | - Chung-Gyu Park
- Xenotransplantation Research Center, Seoul National University, College of Medicine, Seoul, South Korea.
- Department of Microbiology and Immunology, Seoul National University, College of Medicine, Seoul, South Korea.
- Institute of Endemic Diseases, Seoul National University, College of Medicine, Seoul, South Korea.
- Cancer Research Institute, Seoul National University, College of Medicine, Seoul, South Korea.
- Department of Biomedical Sciences, Seoul National University, College of Medicine, Seoul, South Korea.
- Xenotransplantation Research Center, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Extensive germline genome engineering in pigs. Nat Biomed Eng 2020; 5:134-143. [PMID: 32958897 DOI: 10.1038/s41551-020-00613-9] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 08/22/2020] [Indexed: 12/30/2022]
Abstract
The clinical applicability of porcine xenotransplantation-a long-investigated alternative to the scarce availability of human organs for patients with organ failure-is limited by molecular incompatibilities between the immune systems of pigs and humans as well as by the risk of transmitting porcine endogenous retroviruses (PERVs). We recently showed the production of pigs with genomically inactivated PERVs. Here, using a combination of CRISPR-Cas9 and transposon technologies, we show that pigs with all PERVs inactivated can also be genetically engineered to eliminate three xenoantigens and to express nine human transgenes that enhance the pigs' immunological compatibility and blood-coagulation compatibility with humans. The engineered pigs exhibit normal physiology, fertility and germline transmission of the 13 genes and 42 alleles edited. Using in vitro assays, we show that cells from the engineered pigs are resistant to human humoral rejection, cell-mediated damage and pathogenesis associated with dysregulated coagulation. The extensive genome engineering of pigs for greater compatibility with the human immune system may eventually enable safe and effective porcine xenotransplantation.
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Heterotopic Porcine Cardiac Xenotransplantation in the Intra-Abdominal Position in a Non-Human Primate Model. Sci Rep 2020; 10:10709. [PMID: 32612124 PMCID: PMC7329828 DOI: 10.1038/s41598-020-66430-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/19/2020] [Indexed: 12/27/2022] Open
Abstract
Heterotopic cardiac transplantation in the intra-abdominal position in a large animal model has been essential in the progression of the field of cardiac transplantation. Our group has over 10 years of experience in cardiac xenotransplantation with pig to baboon models, the longest xenograft of which survived over 900 days, with rejection only after reducing immunosuppression. This article aims to clarify our approach to this model in order to allow others to share success in long-term survival. Here, we demonstrate the approach to implantation of a cardiac graft into the intra-abdominal position in a baboon recipient for the study of transplantation and briefly highlight our model's ability to provide insight into not only xenotransplantation but across disciplines. We include details that have provided us with consistent success in this model; performance of the anastomoses, de-airing of the graft, implantation of a long-term telemetry device for invasive graft monitoring, and ideal geometric positioning of the heart and telemetry device in the limited space of the recipient abdomen. We additionally detail surveillance techniques to assess long-term graft function.
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Shu S, Ren J, Song J. Cardiac xenotransplantation: a promising way to treat advanced heart failure. Heart Fail Rev 2020; 27:71-91. [DOI: 10.1007/s10741-020-09989-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Hryhorowicz M, Lipiński D, Hryhorowicz S, Nowak-Terpiłowska A, Ryczek N, Zeyland J. Application of Genetically Engineered Pigs in Biomedical Research. Genes (Basel) 2020; 11:genes11060670. [PMID: 32575461 PMCID: PMC7349405 DOI: 10.3390/genes11060670] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023] Open
Abstract
Progress in genetic engineering over the past few decades has made it possible to develop methods that have led to the production of transgenic animals. The development of transgenesis has created new directions in research and possibilities for its practical application. Generating transgenic animal species is not only aimed towards accelerating traditional breeding programs and improving animal health and the quality of animal products for consumption but can also be used in biomedicine. Animal studies are conducted to develop models used in gene function and regulation research and the genetic determinants of certain human diseases. Another direction of research, described in this review, focuses on the use of transgenic animals as a source of high-quality biopharmaceuticals, such as recombinant proteins. The further aspect discussed is the use of genetically modified animals as a source of cells, tissues, and organs for transplantation into human recipients, i.e., xenotransplantation. Numerous studies have shown that the pig (Sus scrofa domestica) is the most suitable species both as a research model for human diseases and as an optimal organ donor for xenotransplantation. Short pregnancy, short generation interval, and high litter size make the production of transgenic pigs less time-consuming in comparison with other livestock species This review describes genetically modified pigs used for biomedical research and the future challenges and perspectives for the use of the swine animal models.
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Affiliation(s)
- Magdalena Hryhorowicz
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-632 Poznań, Poland; (D.L.); (A.N.-T.); (N.R.); (J.Z.)
- Correspondence:
| | - Daniel Lipiński
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-632 Poznań, Poland; (D.L.); (A.N.-T.); (N.R.); (J.Z.)
| | - Szymon Hryhorowicz
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszyńska 32, 60-479 Poznań, Poland;
| | - Agnieszka Nowak-Terpiłowska
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-632 Poznań, Poland; (D.L.); (A.N.-T.); (N.R.); (J.Z.)
| | - Natalia Ryczek
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-632 Poznań, Poland; (D.L.); (A.N.-T.); (N.R.); (J.Z.)
| | - Joanna Zeyland
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-632 Poznań, Poland; (D.L.); (A.N.-T.); (N.R.); (J.Z.)
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The past, present, and future of costimulation blockade in organ transplantation. Curr Opin Organ Transplant 2020; 24:391-401. [PMID: 31157670 DOI: 10.1097/mot.0000000000000656] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Manipulating costimulatory signals has been shown to alter T cell responses and prolong graft survival in solid organ transplantation. Our understanding of and ability to target various costimulation pathways continues to evolve. RECENT FINDINGS Since the approval of belatacept in kidney transplantation, many additional biologics have been developed targeting clinically relevant costimulation signaling axes including CD40-CD40L, inducible costimulator-inducible costimulator ligand (ICOS-ICOSL), and OX40-OX40L. Currently, the effects of costimulation blockade on posttransplant humoral responses, tolerance induction, and xenotransplantation are under active investigation. Here, we will discuss these pathways as well as preclinical and clinical outcomes of biologics targeting these pathways in organ transplantation. SUMMARY Targeting costimultion is a promising approach for not only controlling T cell but also B cell responses. Consequently, costimulation blockade shows considerable potential for improving outcomes in antibody-mediated rejection and xenotransplantation.
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Lee H, Hwang IS, Vasamsetti BMK, Rallabandi HR, Park MR, Byun SJ, Yang H, Ock SA, Lee HC, Woo JS, Hwang S, Oh KB. Codon optimized membrane cofactor protein expression in α 1, 3 galactosyltransferase knockout pig cells improve protection against cytotoxicity of monkey serum. 3 Biotech 2020; 10:108. [PMID: 32095422 DOI: 10.1007/s13205-020-2091-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/23/2020] [Indexed: 01/16/2023] Open
Abstract
In this study, we attempted to upgrade GT -MCP/-MCP pig genetically to express MCP at a higher level and additionally thrombomodulin (TBM), which have respective roles as a complement regulatory protein and a coagulation inhibitor. We constructed a dicistronic cassette consisting of codon-optimized MCP (mMCP) and TBM (m-pI2), designed for ubiquitous expression of MCP and endothelium specific expression of TBM. The cassette was confirmed to allow extremely increased MCP expression compared with non-modified MCP, and an endothelial-specific TBM expression. We thus transfected m-pI2 into ear-skin fibroblasts isolated from a GT -MCP/-MCP pig. By twice selection using magnetically activated cell sorting (MACS), and single-cell culture, we were able to obtain clones over 90% expressing MCP. The cells of a clone were provided as a donor for nuclear transfer resulting in the generation of a GT -MCP/-MCP /mMCP/TBM pig, which was confirmed to be carrying cells expressing MCP and functioning as an inhibitor against the cytotoxic effect of normal monkey serum, comparable with donor cells. Collectively, these results demonstrated an effective approach for upgrading transgenic pig, and we assumed that upgraded pig would increase graft survival.
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Affiliation(s)
- Heasun Lee
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - In-Sul Hwang
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Bala Murali Krishna Vasamsetti
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Harikrishna Reddy Rallabandi
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Mi-Ryung Park
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Sung-June Byun
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Hyeon Yang
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Sun A Ock
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Hwi-Cheul Lee
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Jae-Seok Woo
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Seongsoo Hwang
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
| | - Keon Bong Oh
- Animal Biotechnology Division, National Institute of Animal Science, RDA, 1500, Kongwipatjwi-ro, Wanju-gun, Jeollabuk-do, 55365 Korea
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Lu T, Yang B, Wang R, Qin C. Xenotransplantation: Current Status in Preclinical Research. Front Immunol 2020; 10:3060. [PMID: 32038617 PMCID: PMC6989439 DOI: 10.3389/fimmu.2019.03060] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
The increasing life expectancy of humans has led to a growing numbers of patients with chronic diseases and end-stage organ failure. Transplantation is an effective approach for the treatment of end-stage organ failure; however, the imbalance between organ supply and the demand for human organs is a bottleneck for clinical transplantation. Therefore, xenotransplantation might be a promising alternative approach to bridge the gap between the supply and demand of organs, tissues, and cells; however, immunological barriers are limiting factors in clinical xenotransplantation. Thanks to advances in gene-editing tools and immunosuppressive therapy as well as the prolonged xenograft survival time in pig-to-non-human primate models, clinical xenotransplantation has become more viable. In this review, we focus on the evolution and current status of xenotransplantation research, including our current understanding of the immunological mechanisms involved in xenograft rejection, genetically modified pigs used for xenotransplantation, and progress that has been made in developing pig-to-pig-to-non-human primate models. Three main types of rejection can occur after xenotransplantation, which we discuss in detail: (1) hyperacute xenograft rejection, (2) acute humoral xenograft rejection, and (3) acute cellular rejection. Furthermore, in studies on immunological rejection, genetically modified pigs have been generated to bridge cross-species molecular incompatibilities; in the last decade, most advances made in the field of xenotransplantation have resulted from the production of genetically engineered pigs; accordingly, we summarize the genetically modified pigs that are currently available for xenotransplantation. Next, we summarize the longest survival time of solid organs in preclinical models in recent years, including heart, liver, kidney, and lung xenotransplantation. Overall, we conclude that recent achievements and the accumulation of experience in xenotransplantation mean that the first-in-human clinical trial could be possible in the near future. Furthermore, we hope that xenotransplantation and various approaches will be able to collectively solve the problem of human organ shortage.
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Affiliation(s)
- Tianyu Lu
- Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China.,NHC Key Laboratory of Human Disease Comparative Medicine, The Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Bochao Yang
- Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China.,NHC Key Laboratory of Human Disease Comparative Medicine, The Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Ruolin Wang
- Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China.,NHC Key Laboratory of Human Disease Comparative Medicine, The Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Chuan Qin
- Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China.,NHC Key Laboratory of Human Disease Comparative Medicine, The Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
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Lu Y, Zhou Y, Ju R, Chen J. Human-animal chimeras for autologous organ transplantation: technological advances and future perspectives. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:576. [PMID: 31807557 DOI: 10.21037/atm.2019.10.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Organ transplantation is the most promising curation for end-stage organ disease. However, the donor organ shortage has become a global problem that has limited the development of organ transplantation. Human-animal chimeras provide the ability to produce human organs in other species using autologous stem cells [e.g., induced pluripotent stem cells (iPSCs) or adult stem cells], which would be patient-specific and immune-matched for transplantation. Due to the potential application prospect of interspecies chimeras in basic and translational research, this technology has attracted much interest. This review focuses primarily on technological advances, including options of donor stem cell types and gene editing in donor cells and host animals, in addition to perspectives on human-animal chimeras in clinical and basic research.
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Affiliation(s)
- Yingfei Lu
- Central Laboratory, Translational Medicine Research Center, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China
| | - Yu Zhou
- Central Laboratory, Translational Medicine Research Center, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China.,Department of Obstetrics and Gynecology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China
| | - Rong Ju
- Department of Obstetrics and Gynecology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China
| | - Jianquan Chen
- Central Laboratory, Translational Medicine Research Center, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China.,Department of Obstetrics and Gynecology, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing 211100, China
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Chen P, Zhao Y, Gao H, Huang J, Lu Y, Song J, Lin L, Lin Z, Ou C, Sun H, Li Y, Zeng C, Cooper DKC, Zhan Y, Deng X, Mou L. Selective inhibition of cyclooxygenase‐2 protects porcine aortic endothelial cells from human antibody‐mediated complement‐dependent cytotoxicity. Xenotransplantation 2019; 26:e12536. [PMID: 31724835 DOI: 10.1111/xen.12536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 04/20/2019] [Accepted: 05/17/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Pengfei Chen
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center Institute of Translational Medicine Shenzhen University Health Science Center Shenzhen University School of Medicine First Affiliated Hospital of Shenzhen University Shenzhen Second People's Hospital Shenzhen China
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - Yanli Zhao
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - Hanchao Gao
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - Jiabao Huang
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center Institute of Translational Medicine Shenzhen University Health Science Center Shenzhen University School of Medicine First Affiliated Hospital of Shenzhen University Shenzhen Second People's Hospital Shenzhen China
| | - Ying Lu
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center Institute of Translational Medicine Shenzhen University Health Science Center Shenzhen University School of Medicine First Affiliated Hospital of Shenzhen University Shenzhen Second People's Hospital Shenzhen China
| | - Jinqi Song
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
| | - Lizhong Lin
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
| | - Zejin Lin
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
| | - Chunpei Ou
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
| | - Huimin Sun
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - Yajing Li
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - Changchun Zeng
- Department of Central Laboratory Shenzhen Longhua District Central Hospital Shenzhen China
| | - David K. C. Cooper
- Department of Surgery, Xenotransplantation Program University of Alabama at Birmingham Birmingham Alabama
| | - Yongqiang Zhan
- Department of Hepatopancreatobiliary Surgery Shenzhen University Health Science Center, Shenzhen University School of Medicine, First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital Shenzhen China
| | - Xuefeng Deng
- Department of Traumatic Orthopedics Shenzhen Longhua District Central Hospital Shenzhen China
| | - Lisha Mou
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center Institute of Translational Medicine Shenzhen University Health Science Center Shenzhen University School of Medicine First Affiliated Hospital of Shenzhen University Shenzhen Second People's Hospital Shenzhen China
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DiChiacchio L, Singh AK, Lewis B, Zhang T, Hardy N, Pasrija C, Morales D, Odonkor P, Strauss E, Williams B, Deatrick KB, Kaczorowski DJ, Ayares D, Griffith BP, Bartlett ST, Mohiuddin MM. Early Experience With Preclinical Perioperative Cardiac Xenograft Dysfunction in a Single Program. Ann Thorac Surg 2019; 109:1357-1361. [PMID: 31589847 DOI: 10.1016/j.athoracsur.2019.08.090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/16/2019] [Accepted: 08/28/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Perioperative cardiac xenograft dysfunction (PCXD) was described by McGregor and colleagues as a major barrier to the translation of heterotopic cardiac xenotransplantation into the orthotopic position. It is characterized by graft dysfunction in the absence of rejection within 24 to 48 hours of transplantation. We describe our experience with PCXD at a single program. METHODS Orthotopic transplantation of genetically engineered pig hearts was performed in 6 healthy baboons. The immunosuppression regimen included induction by anti-CD20 monoclonal antibodies (mAb), thymoglobulin, cobra venom factor, and anti-CD40 mAb, and maintenance with anti-CD40 mAb, mycophenolate mofetil, and tapering doses of steroids. Telemetry was used to assess graft function. Extracorporeal membrane oxygenation was used to support 1 recipient. A full human clinical transplantation team was involved in these experiments and the procedure was performed by skilled transplantation surgeons. RESULTS A maximal survival of 40 hours was achieved in these experiments. The surgical procedures were uneventful, and all hearts were weaned from cardiopulmonary bypass without issue. Support with inotropes and vasopressors was generally required after separation from cardiopulmonary bypass. The cardiac xenografts performed well immediately, but within the first several hours they required increasing support and ultimately resulted in arrest despite maximal interventions. All hearts were explanted immediately; histology showed no signs of rejection. CONCLUSIONS Despite excellent surgical technique, uneventful weaning from cardiopulmonary bypass, and adequate initial function, orthotopic cardiac xenografts slowly fail within 24 to 48 hours without evidence of rejection. Modification of preservation techniques and minimizing donor organ ischemic time may be able to ameliorate PCXD.
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Affiliation(s)
- Laura DiChiacchio
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Avneesh K Singh
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Billeta Lewis
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Tianshu Zhang
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Naomi Hardy
- Department of Pathology, University of Maryland Medical Center, Baltimore, Maryland
| | - Chetan Pasrija
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - David Morales
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Patrick Odonkor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Erik Strauss
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Brittney Williams
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - David J Kaczorowski
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Bartley P Griffith
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Stephen T Bartlett
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland.
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Yamamoto T, Hara H, Foote J, Wang L, Li Q, Klein EC, Schuurman HJ, Zhou H, Li J, Tector AJ, Zhang Z, Ezzelarab M, Lovingood R, Ayares D, Eckhoff DE, Cooper DKC, Iwase H. Life-supporting Kidney Xenotransplantation From Genetically Engineered Pigs in Baboons: A Comparison of Two Immunosuppressive Regimens. Transplantation 2019; 103:2090-2104. [PMID: 31283686 DOI: 10.1097/tp.0000000000002796] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aims of this study were to evaluate the efficacy of US Food and Drug Administration-approved drugs in genetically engineered pig-to-baboon kidney xenotransplantation and compare the results with those using an anti-CD40 monoclonal antibody (mAb)-based regimen. METHODS Ten life-supporting kidney transplants were carried out in baboons using α1,3-galactosyltransferase gene-knockout/CD46 pigs with various other genetic manipulations aimed at controlling coagulation dysregulation. Eight transplants resulted in informative data. Immunosuppressive therapy consisted of induction with antithymocyte globulin and anti-CD20mAb, and maintenance based on either (1) CTLA4-Ig and/or tacrolimus (+rapamycin or mycophenolate mofetil) (GroupA [US Food and Drug Administration-approved regimens], n = 4) or (2) anti-CD40mAb + rapamycin (GroupB, n = 4). All baboons received corticosteroids, interleukin-6R blockade, and tumor necrosis factor-α blockade. Baboons were followed by clinical and laboratory monitoring of kidney function, coagulation, and immune parameters. At euthanasia, morphological and immunohistochemical studies were performed on the kidney grafts. RESULTS The median survival in GroupB was 186 days (range 90-260), which was significantly longer than in GroupA; median 14 days (range 12-32) (P < 0.01). Only GroupA baboons developed consumptive coagulopathy and the histopathological features of thrombotic microangiopathic glomerulopathy and interstitial arterial vasculitis. CONCLUSIONS Recognizing that the pig donors in each group differed in some genetic modifications, these data indicate that maintenance immunosuppression including anti-CD40mAb may be important to prevent pig kidney graft failure.
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Affiliation(s)
- Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Liaoran Wang
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - Qi Li
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - Edwin C Klein
- Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, PA
| | | | - Hongmin Zhou
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- Department of Cardiothoracic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Li
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - A Joseph Tector
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Zhongqiang Zhang
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
- Department of General Surgery and Organ Transplantation, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Mohamed Ezzelarab
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Ray Lovingood
- Kirklin Clinic Pharmacy, University of Alabama at Birmingham, Birmingham, AL
| | | | - Devin E Eckhoff
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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DiChiacchio L, Singh AK, Chan JL, Shockcor NM, Zhang T, Lewis BG, Ayares D, Corcoran P, Horvath KA, Mohiuddin MM. Intra-Abdominal Heterotopic Cardiac Xenotransplantation: Pearls and Pitfalls. Front Cardiovasc Med 2019; 6:95. [PMID: 31404245 PMCID: PMC6669937 DOI: 10.3389/fcvm.2019.00095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/25/2019] [Indexed: 11/22/2022] Open
Abstract
Heterotopic cardiac xenotransplantation in the intra-abdominal position has been studied extensively in a pig-to-baboon model to define the optimal donor genetics and immunosuppressive regimen to prevent xenograft rejection. Extensive investigation using this model is a necessary stepping stone toward the development of a life-supporting animal model, with the ultimate goal of demonstrating suitability for clinical cardiac xenotransplantation trials. Aspects of surgical technique, pre- and post-operative care, graft monitoring, and minimization of infectious risk have all required refinement and optimization of heterotopic cardiac xenotransplantation over time. This review details non-immunologic obstacles relevant to this model described by our group and in the literature, as well as strategies that have been developed to address these specific challenges.
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Affiliation(s)
- Laura DiChiacchio
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Avneesh K. Singh
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Joshua L. Chan
- National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, United States
| | - Nicole M. Shockcor
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Tianshu Zhang
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Billeta G. Lewis
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | | | - Philip Corcoran
- National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, United States
| | - Keith A. Horvath
- National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, United States
| | - Muhammad M. Mohiuddin
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
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45
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Mohiuddin MM, DiChiacchio L, Singh AK, Griffith BP. Xenotransplantation: A Step Closer to Clinical Reality? Transplantation 2019; 103:453-454. [PMID: 30801425 DOI: 10.1097/tp.0000000000002608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Yamamoto T, Li Q, Hara H, Wang L, Zhou H, Li J, Eckhoff DE, Joseph Tector A, Klein EC, Lovingood R, Ezzelarab M, Ayares D, Wang Y, Cooper DKC, Iwase H. B cell phenotypes in baboons with pig artery patch grafts receiving conventional immunosuppressive therapy. Transpl Immunol 2018; 51:12-20. [PMID: 30092338 PMCID: PMC6249078 DOI: 10.1016/j.trim.2018.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/03/2018] [Accepted: 08/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the pig-to-baboon artery patch model with no immunosuppressive therapy, a graft from an α1,3-galactosyltransferase gene-knockout (GTKO) pig elicits a significant anti-nonGal IgG response, indicating sensitization to the graft. A costimulation blockade-based regimen, e.g., anti-CD154mAb or anti-CD40mAb, prevents sensitization. However, neither of these agents is currently FDA-approved. The aim of the present study was to determine the efficacy of FDA-approved agents on the T and B cell responses. METHODS Artery patch xenotransplantation in baboons was carried out using GTKO/CD46 pigs with (n = 2) or without (n = 1) the mutant transgene for CIITA-knockdown. Immunosuppressive therapy consisted of induction with ATG and anti-CD20mAb, and maintenance with different combinations of CTLA4-Ig, tacrolimus, and rapamycin. In addition, all 3 baboons received daily corticosteroids, the IL-6R blocker, tocilizumab, at regular intervals, and the TNF-α blocker, etanercept, for the first 2 weeks. Recipient blood was monitored for anti-nonGal antibody levels by flow cytometry (using GTKO/CD46 pig aortic endothelial cells), and mixed lymphocyte reaction (MLR). CD22+B cell profiles (naïve [IgD+/CD27-], non-switched memory [IgD+/CD27+], and switched memory [IgD-/CD27+] B cell subsets) were measured by flow cytometry. At 6 months, the baboons were euthanized and the grafts were examined histologically. RESULTS No elicited anti-pig antibodies developed in any baboon. The frequency of naïve memory B cells increased significantly (from 34% to 90%, p = 0.0015), but there was a significant decrease in switched memory B cells (from 17% to 0.5%, p = 0.015). MLR showed no increase in the proliferative T cell response in those baboons that had received CTLA4-Ig (n = 2). Histological examination showed few or no features of rejection in any graft. CONCLUSIONS The data suggest that immunosuppressive therapy with only FDA-approved agents may be adequate to prevent an adaptive immune response to a genetically-engineered pig graft, particularly if CTLA4-Ig is included in the regimen, in part because the development of donor-specific memory B cells is inhibited.
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Affiliation(s)
- Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Qi Li
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Liaoran Wang
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - Hongmin Zhou
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Li
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - Devin E Eckhoff
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A Joseph Tector
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Edwin C Klein
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ray Lovingood
- Kirklin Clinic Pharmacy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mohamed Ezzelarab
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Yi Wang
- Second Affiliated Hospital, University of South China, Hengyang City, Hunan, China
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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47
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Byrne GW. Does human leukocyte antigens sensitization matter for xenotransplantation? Xenotransplantation 2018; 25:e12411. [PMID: 29913037 DOI: 10.1111/xen.12411] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 01/09/2023]
Abstract
The major histocompatibility complex class I and class II human leukocyte antigens (HLA) play a central role in adaptive immunity but are also the dominant polymorphic proteins targeted in allograft rejection. Sensitized patients with high levels of panel-reactive anti-HLA antibody (PRA) are at risk of early allograft injury, rejection, reduced allograft survival and often experience prolonged waiting times prior to transplantation. Xenotransplantation, using genetically modified porcine organs, offers a unique source of donor organs for these highly sensitized patients if the anti-HLA antibody, which places the allograft at risk, does not also enhance anti-pig antibody reactivity responsible for xenograft rejection. Recent improvements in xenotransplantation efficacy have occurred due to improved immune suppression, identification of additional xenogeneic glycans, and continued improvements in donor pig genetic modification. Genetically engineered pig cells, devoid of the known xenogeneic glycans, minimize human antibody reactivity in 90% of human serum samples. For waitlisted patients, early comparisons of patient PRA and anti-pig antibody reactivity found no correlation suggesting that patients with high PRA levels were not at increased risk of xenograft rejection. Subsequent studies have found that some, but not all, highly sensitized patients express anti-HLA class I antibody which cross-reacts with swine leukocyte antigen (SLA) class I proteins. Recent detailed antigen-specific analysis suggests that porcine-specific anti-SLA antibody from sensitized patients binds cross-reactive groups present in a limited subset of HLA antigens. This suggests that using modern genetic methods, a program to eliminate specific SLA alleles through donor genetic engineering or stringent donor selection is possible to minimize recipient antibody reactivity even for highly sensitized individuals.
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Affiliation(s)
- Guerard W Byrne
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Surgery, University of Alabama, Birmingham, UK
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48
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Singh AK, Chan JL, DiChiacchio L, Hardy NL, Corcoran PC, Lewis BGT, Thomas ML, Burke AP, Ayares D, Horvath KA, Mohiuddin MM. Cardiac xenografts show reduced survival in the absence of transgenic human thrombomodulin expression in donor pigs. Xenotransplantation 2018; 26:e12465. [PMID: 30290025 DOI: 10.1111/xen.12465] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/20/2018] [Accepted: 09/10/2018] [Indexed: 12/13/2022]
Abstract
A combination of genetic manipulations of donor organs and target-specific immunosuppression is instrumental in achieving long-term cardiac xenograft survival. Recently, results from our preclinical pig-to-baboon heterotopic cardiac xenotransplantation model suggest that a three-pronged approach is successful in extending xenograft survival: (a) α-1,3-galactosyl transferase (Gal) gene knockout in donor pigs (GTKO) to prevent Gal-specific antibody-mediated rejection; (b) transgenic expression of human complement regulatory proteins (hCRP; hCD46) and human thromboregulatory protein thrombomodulin (hTBM) to avoid complement activation and coagulation dysregulation; and (c) effective induction and maintenance of immunomodulation, particularly through co-stimulation blockade of CD40-CD40L pathways with anti-CD40 (2C10R4) monoclonal antibody (mAb). Using this combination of manipulations, we reported significant improvement in cardiac xenograft survival. In this study, we are reporting the survival of cardiac xenotransplantation recipients (n = 3) receiving xenografts from pigs without the expression of hTBM (GTKO.CD46). We observed that all grafts underwent rejection at an early time point (median 70 days) despite utilization of our previously reported successful immunosuppression regimen and effective control of non-Gal antibody response. These results support our hypothesis that transgenic expression of human thrombomodulin in donor pigs confers an independent protective effect for xenograft survival in the setting of a co-stimulation blockade-based immunomodulatory regimen.
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Affiliation(s)
- Avneesh K Singh
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Joshua L Chan
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Laura DiChiacchio
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Naomi L Hardy
- Department of Pathology at the University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
| | - Philip C Corcoran
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Billeta G T Lewis
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, Maryland
| | - Marvin L Thomas
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, Maryland
| | - Allen P Burke
- Department of Pathology at the University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
| | | | - Keith A Horvath
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Muhammad M Mohiuddin
- Cardiothoracic Surgery Research Program/National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Department of Surgery, School of Medicine, University of Maryland, Baltimore, Maryland
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49
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Iwase H, Klein EC, Cooper DK. Physiologic Aspects of Pig Kidney Transplantation in Nonhuman Primates. Comp Med 2018; 68:332-340. [PMID: 30208986 DOI: 10.30802/aalas-cm-17-000117] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Xenotransplantation can provide a solution to the current shortage of human organs for patients with terminal renal failure. The increasing availability of genetically engineered pigs, effective immunosuppressive therapy, and antiinflammatory therapy help to protect pig tissues from the primate immune response and can correct molecular incompatibilities. Life-supporting pig kidney xenografts have survived in NHP for more than 6 mo in the absence of markers of consumptive coagulopathy. However, few reports have focused on the physiologic aspects of life-supporting pig kidney xenografts. We have reviewed the literature regarding pig kidney xenotransplantation in NHP. The available data indicate (1) normal serum creatinine, (2) normal serum electrolytes, except for a trend toward increased calcium levels and a transient rise in phosphate followed by a fall to slightly subnormal values, (3) minimal or modest proteinuria without hypoalbuminemia (suggesting that previous reports of proteinuria likely were due to a low-grade immune response rather than physiologic incompatibilities), (4) possible discrepancies between pig erythropoietin and the primate erythropoietin receptor, and (5) significant early increase in kidney graft size, which might result from persistent effects of pig growth hormone. Further study is required regarding identification and investigation of physiologic incompatibilities. However, current evidence suggests that, in the absence of an immune response, a transplanted pig kidney likely would satisfactorily support a human patient.
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Affiliation(s)
- Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham Alabama, USA.
| | - Edwin C Klein
- Department of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Kc Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham Alabama, USA
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50
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Wang R, Ruan M, Zhang R, Chen L, Li X, Fang B, Li C, Ren X, Liu J, Xiong Q, Zhang L, Jin Y, Li L, Li R, Wang Y, Yang H, Dai Y. Antigenicity of tissues and organs from GGTA1/CMAH/β4GalNT2 triple gene knockout pigs. J Biomed Res 2018; 33:235. [PMID: 30007952 PMCID: PMC6813527 DOI: 10.7555/jbr.32.20180018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/23/2018] [Indexed: 12/17/2022] Open
Abstract
Clinical xenotransplantations have been hampered by human preformed antibody-mediated damage of the xenografts. To overcome biological incompatibility between pigs and humans, one strategy is to remove the major antigens [Gal, Neu5Gc, and Sd(a)] present on pig cells and tissues. Triple gene (GGTA1, CMAH, and β 4GalNT2) knockout (TKO) pigs were produced in our laboratory by CRISPR-Cas9 targeting. To investigate the antigenicity reduction in the TKO pigs, the expression levels of these three xenoantigens in the cornea, heart, liver, spleen, lung, kidney, and pancreas tissues were examined. The level of human IgG/IgM binding to those tissues was also investigated, with wildtype pig tissues as control. The results showed that αGal, Neu5Gc, and Sd(a) were markedly positive in all the examined tissues in wildtype pigs but barely detected in TKO pigs. Compared to wildtype pigs, the liver, spleen, and pancreas of TKO pigs showed comparable levels of human IgG and IgM binding, whereas corneas, heart, lung, and kidney of TKO pigs exhibited significantly reduced human IgG and IgM binding. These results indicate that the antigenicity of TKO pig is significantly reduced and the remaining xenoantigens on porcine tissues can be eliminated via a gene targeting approach.
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Affiliation(s)
| | | | | | - Lei Chen
- Jiangsu Key Laboratory of Xenotransplantation
| | - Xiaoxue Li
- Jiangsu Key Laboratory of Xenotransplantation
| | - Bin Fang
- Jiangsu Key Laboratory of Xenotransplantation
| | - Chu Li
- Jiangsu Key Laboratory of Xenotransplantation
| | - Xueyang Ren
- Jiangsu Key Laboratory of Xenotransplantation
| | - Jiying Liu
- Jiangsu Key Laboratory of Xenotransplantation
| | - Qiang Xiong
- Jiangsu Key Laboratory of Xenotransplantation
| | | | - Yong Jin
- Jiangsu Key Laboratory of Xenotransplantation
| | - Lin Li
- Jiangsu Key Laboratory of Xenotransplantation
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine
| | - Rongfeng Li
- Jiangsu Key Laboratory of Xenotransplantation
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine
| | - Ying Wang
- Jiangsu Key Laboratory of Xenotransplantation
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine
| | - Haiyuan Yang
- Jiangsu Key Laboratory of Xenotransplantation
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine
| | - Yifan Dai
- Jiangsu Key Laboratory of Xenotransplantation
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu 211166, China
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center, Institute of Translational Medicine, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, China
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