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Annamalai C, Kute V, Sheridan C, Halawa A. Hematopoietic cell-based and non-hematopoietic cell-based strategies for immune tolerance induction in living-donor renal transplantation: A systematic review. Transplant Rev (Orlando) 2023; 37:100792. [PMID: 37709652 DOI: 10.1016/j.trre.2023.100792] [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: 12/30/2022] [Revised: 04/24/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Despite its use to prevent acute rejection, lifelong immunosuppression can adversely impact long-term patient and graft outcomes. In theory, immunosuppression withdrawal is the ultimate goal of kidney transplantation, and is made possible by the induction of immunological tolerance. The purpose of this paper is to review the safety and efficacy of immune tolerance induction strategies in living-donor kidney transplantation, both chimerism-based and non-chimerism-based. The impact of these strategies on transplant outcomes, including acute rejection, allograft function and survival, cost, and immune monitoring, will also be discussed. MATERIALS AND METHODS Databases such as PubMed, Scopus, and Web of Science, as well as additional online resources such as EBSCO, were exhaustively searched. Adult living-donor kidney transplant recipients who developed chimerism-based tolerance after concurrent bone marrow or hematopoietic stem cell transplantation or those who received non-chimerism-based, non-hematopoietic cell therapy using mesenchymal stromal cells, dendritic cells, or regulatory T cells were studied between 2000 and 2021. Individual sources of evidence were evaluated critically, and the strength of evidence and risk of bias for each outcome of the transplant tolerance study were assessed. RESULTS From 28,173 citations, 245 studies were retrieved after suitable exclusion and duplicate removal. Of these, 22 studies (2 RCTs, 11 cohort studies, 6 case-control studies, and 3 case reports) explicitly related to both interventions (chimerism- and non-chimerism-based immune tolerance) were used in the final review process and were critically appraised. According to the findings, chimerism-based strategies fostered immunotolerance, allowing for the safe withdrawal of immunosuppressive medications. Cell-based therapy, on the other hand, frequently did not induce tolerance except for minimising immunosuppression. As a result, the rejection rates, renal allograft function, and survival rates could not be directly compared between these two groups. While chimerism-based tolerance protocols posed safety concerns due to myelosuppression, including infections and graft-versus-host disease, cell-based strategies lacked these adverse effects and were largely safe. There was a lack of direct comparisons between HLA-identical and HLA-disparate recipients, and the cost implications were not examined in several of the retrieved studies. Most studies reported successful immunosuppressive weaning lasting at least 3 years (ranging up to 11.4 years in some studies), particularly with chimerism-based therapy, while only a few investigators used immune surveillance techniques. The studies reviewed were often limited by selection, classification, ascertainment, performance, and attrition bias. CONCLUSIONS This review demonstrates that chimerism-based hematopoietic strategies induce immune tolerance, and a substantial number of patients are successfully weaned off immunosuppression. Despite the risk of complications associated with myelosuppression. Non-chimerism-based, non-hematopoietic cell protocols, on the other hand, have been proven to facilitate immunosuppression minimization but seldom elicit immunological tolerance. However, the results of this review must be interpreted with caution because of the non-randomised study design, potential confounding, and small sample size of the included studies. Further validation and refinement of tolerogenic protocols in accordance with local practice preferences is also warranted, with an emphasis on patient selection, cost ramifications, and immunological surveillance based on reliable tolerance assays.
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Affiliation(s)
- Chandrashekar Annamalai
- Postgraduate School of Medicine, Institute of Teaching and Learning, Faculty of Health and Life Sciences, University of Liverpool, UK.
| | - Vivek Kute
- Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Carl Sheridan
- Department of Eye and Vision Science, Ocular Cell Transplantation, Faculty of Health and Life Sciences, University of Liverpool, UK
| | - Ahmed Halawa
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Mengrelis K, Muckenhuber M, Wekerle T. Chimerism-based Tolerance Induction in Clinical Transplantation: Its Foundations and Mechanisms. Transplantation 2023; 107:2473-2485. [PMID: 37046378 DOI: 10.1097/tp.0000000000004589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hematopoietic chimerism remains the most promising strategy to bring transplantation tolerance into clinical routine. The concept of chimerism-based tolerance aims to extend the recipient's mechanisms of self-tolerance (ie, clonal deletion, anergy, and regulation) to include the tolerization of donor antigens that are introduced through the cotransplantation of donor hematopoietic cells. For this to be successful, donor hematopoietic cells need to engraft in the recipient at least temporarily. Three pioneering clinical trials inducing chimerism-based tolerance in kidney transplantation have been published to date. Within this review, we discuss the mechanisms of tolerance that are associated with the specific therapeutic protocols of each trial. Recent data highlight the importance of regulation as a mechanism that maintains tolerance. Insufficient regulatory mechanisms are also a likely explanation for situations of tolerance failure despite persisting donor chimerism. After decades of preclinical development of chimerism protocols, mechanistic data from clinical trials have recently become increasingly important. Better understanding of the required mechanisms for tolerance to be induced in humans will be a key to design more reliable and less invasive chimerism protocols in the future.
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Affiliation(s)
- Konstantinos Mengrelis
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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3
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Zhang W, Wang Y, Zhong F, Wang X, Sucher R, Lin CH, Brandacher G, Solari MG, Gorantla VS, Zheng XX. Donor derived hematopoietic stem cell niche transplantation facilitates mixed chimerism mediated donor specific tolerance. Front Immunol 2023; 14:1093302. [PMID: 36875068 PMCID: PMC9978155 DOI: 10.3389/fimmu.2023.1093302] [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: 11/08/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
Compelling experimental evidence confirms that the robustness and longevity of mixed chimerism (MC) relies on the persistence and availability of donor-derived hematopoietic stem cell (HSC) niches in recipients. Based on our prior work in rodent vascularized composite allotransplantation (VCA) models, we hypothesize that the vascularized bone components in VCA bearing donor HSC niches, thus may provide a unique biologic opportunity to facilitate stable MC and transplant tolerance. In this study, by utilizing a series of rodent VCA models we demonstrated that donor HSC niches in the vascularized bone facilitate persistent multilineage hematopoietic chimerism in transplant recipients and promote donor-specific tolerance without harsh myeloablation. In addition, the transplanted donor HSC niches in VCA facilitated the donor HSC niches seeding to the recipient bone marrow compartment and contributed to the maintenance and homeostasis of stable MC. Moreover, this study provided evidences that chimeric thymus plays a role in MC-mediated transplant tolerance through a mechanism of thymic central deletion. Mechanistic insights from our study could lead to the use of vascularized donor bone with pre-engrafted HSC niches as a safe, complementary strategy to induce robust and stable MC-mediated tolerance in VCA or solid organ transplantation recipients.
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Affiliation(s)
- Wensheng Zhang
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Yong Wang
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Fushun Zhong
- Transplantation Medical Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xinghuan Wang
- Transplantation Medical Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Robert Sucher
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Cheng-Hung Lin
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mario G Solari
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Vijay S Gorantla
- Departments of Surgery, Ophthalmology and Bioengineering, Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Xin Xiao Zheng
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Transplantation Medical Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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4
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Podestà MA, Sykes M. Chimerism-Based Tolerance to Kidney Allografts in Humans: Novel Insights and Future Perspectives. Front Immunol 2022; 12:791725. [PMID: 35069574 PMCID: PMC8767096 DOI: 10.3389/fimmu.2021.791725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic rejection and immunosuppression-related toxicity severely affect long-term outcomes of kidney transplantation. The induction of transplantation tolerance – the lack of destructive immune responses to a transplanted organ in the absence of immunosuppression – could potentially overcome these limitations. Immune tolerance to kidney allografts from living donors has been successfully achieved in humans through clinical protocols based on chimerism induction with hematopoietic cell transplantation after non-myeloablative conditioning. Notably, two of these protocols have led to immune tolerance in a significant fraction of HLA-mismatched donor-recipient combinations, which represent the large majority of cases in clinical practice. Studies in mice and large animals have been critical in dissecting tolerance mechanisms and in selecting the most promising approaches for human translation. However, there are several key differences in tolerance induction between these models and humans, including the rate of success and stability of donor chimerism, as well as the relative contribution of different mechanisms in inducing donor-specific unresponsiveness. Kidney allograft tolerance achieved through durable full-donor chimerism may be due to central deletion of graft-reactive donor T cells, even though mechanistic data from patient series are lacking. On the other hand, immune tolerance attained with transient mixed chimerism-based protocols initially relies on Treg-mediated suppression, followed by peripheral deletion of donor-reactive recipient T-cell clones under antigenic pressure from the graft. These conclusions were supported by data deriving from novel high-throughput T-cell receptor sequencing approaches that allowed tracking of alloreactive repertoires over time. In this review, we summarize the most important mechanistic studies on tolerance induction with combined kidney-bone marrow transplantation in humans, discussing open issues that still need to be addressed and focusing on techniques developed in recent years to efficiently monitor the alloresponse in tolerance trials. These cutting-edge methods will be instrumental for the development of immune tolerance protocols with improved efficacy and to identify patients amenable to safe immunosuppression withdrawal.
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Affiliation(s)
- Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milano, Italy
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Department of Surgery, Department of Microbiology and Immunology, Columbia University, New York, NY, United States
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5
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Sánchez-Fueyo A, Dazzi F. On minor histocompatibility antigens, mixed chimerism, and transplantation tolerance. Am J Transplant 2021; 21:919-920. [PMID: 32810379 DOI: 10.1111/ajt.16276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/06/2020] [Accepted: 07/23/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Alberto Sánchez-Fueyo
- Institute of Liver Studies, King's College Hospital, Medical Research Council (MRC) Centre for Transplantation, King's College London University, London, UK
| | - Francesco Dazzi
- Division of Cancer Studies, King's College London University, London, UK
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6
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Indirectly Activated Treg Allow Dominant Tolerance to Murine Skin-grafts Across an MHC Class I Mismatch After a Single Donor-specific Transfusion. Transplantation 2020; 104:1385-1395. [PMID: 32053573 DOI: 10.1097/tp.0000000000003173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tolerance induced in stringent animal transplant models using donor-specific transfusions (DST) has previously required additional immunological manipulation. Here, we demonstrate a dominant skin-allograft tolerance model induced by a single DST across an major histocompatibility class I mismatch in an unmanipulated B6 host. METHODS C57BL/6 (H-2) (B6) mice were injected intravenously with splenocytes from B6.C.H-2 (H-2k) (bm1) or F1 (B6 × bm1) mice before skin transplantation. Mice were transplanted 7 days postinjection with donor (bm1 or F1) and third-party B10.BR (H-2) skin grafts. RESULTS B6 hosts acutely rejected skin grafts from B6.C.H-2 (bm1) and F1 (B6 × bm1) mice. A single transfusion of F1 splenocytes into B6 mice without any additional immune modulation led to permanent acceptance of F1 skin grafts. This graft acceptance was associated with persistence of donor cells long-term in vivo. The more rapid removal of DST bm1 cells than F1 cells was reduced by natural killer-cell depletion. Tolerant grafts survived an in vivo challenge with naive splenocytes. Both CD4CD25 and CD4CD25 T cells from F1 DST treated B6 mice suppressed alloproliferation in vitro. Tolerance was associated with expansion of peripheral Foxp3CD4CD25 regulatory T cells (Treg) and increased forkhead box P3 (Foxp3) expression in tolerant grafts. In tolerant mice, Foxp3 Treg arises from the proliferation of indirectly activated natural Foxp3 Treg (nTreg) and depletion of Foxp3 Treg abrogates skin-graft tolerance. CONCLUSIONS This study demonstrates that the persistence of transfused semiallogeneic donor cells mismatched at major histocompatibility class I can enhance tolerance to subsequent skin allografts through indirectly expanded nTreg leading to dominant tolerance without additional immunological manipulation.
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The intragraft vascularized bone marrow component plays a critical role in tolerance induction after reconstructive transplantation. Cell Mol Immunol 2019; 18:363-373. [PMID: 31754236 DOI: 10.1038/s41423-019-0325-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/20/2019] [Indexed: 11/08/2022] Open
Abstract
The role of the vascularized bone marrow component as a continuous source of donor-derived hematopoietic stem cells that facilitate tolerance induction of vascularized composite allografts is not completely understood. In this study, vascularized composite tissue allograft transplantation outcomes between recipients receiving either conventional bone marrow transplantation (CBMT) or vascularized bone marrow (VBM) transplantation from Balb/c (H2d) to C57BL/6 (H2b) mice were compared. Either high- or low-dose CBMT (1.5 × 108 or 3 × 107 bone marrow cells, respectively) was applied. In addition, recipients were treated with costimulation blockade (1 mg anti-CD154 and 0.5 mg CTLA4Ig on postoperative days 0 and 2, respectively) and short-term rapamycin (3 mg/kg/day for the first posttransplant week and then every other day for another 3 weeks). Similar to high-dose conventional bone marrow transplantation, 5/6 animals in the vascularized bone marrow group demonstrated long-term allograft survival (>120 days). In contrast, significantly shorter median survival was noted in the low-dose CBMT group (~64 days). Consistently high chimerism levels were observed in the VBM transplantation group. Notably, low levels of circulating CD4+ and CD8+ T cells and a higher ratio of Treg to Teff cells were maintained in VBM transplantation and high-dose CBMT recipients (>30 days) but not in low-dose VBM transplant recipients. Donor-specific hyporesponsiveness was shown in tolerant recipients in vitro. Removal of the vascularized bone marrow component after secondary donor-specific skin transplantation did not affect either primary allograft or secondary skin graft survival.
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8
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Sykes M. Immune monitoring of transplant patients in transient mixed chimerism tolerance trials. Hum Immunol 2018; 79:334-342. [PMID: 29289741 PMCID: PMC5924718 DOI: 10.1016/j.humimm.2017.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/31/2022]
Abstract
This review focuses on mechanistic studies performed in recipients of non-myeloablative bone marrow transplant regimens developed at Massachusetts General Hospital in HLA-identical and HLA-mismatched haploidentical combinations, initially as a platform for treatment of hematologic malignancies with immunotherapy in the form of donor leukocyte infusions, and later in combination with donor kidney transplantation for the induction of allograft tolerance. In patients with permanent mixed chimerism, central deletion may be a major mechanism of long-term tolerance. In patients in whom donor chimerism is only transient, the kidney itself plays a significant role in maintaining long-term tolerance. A high throughput sequencing approach to identifying and tracking a significant portion of the alloreactive T cell receptor repertoire has demonstrated biological significance in transplant patients and has been useful in pointing to clonal deletion as a long-term tolerance mechanism in recipients of HLA-mismatched combined kidney and bone marrow transplants with only transient chimerism.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Columbia University Medical Center, NY, USA; Department of Medicine, Columbia University Medical Center, NY, USA; Department of Microbiology & Immunology, Columbia University Medical Center, NY, USA; Department of Surgery, Columbia University Medical Center, NY, USA.
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9
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Chan-On C, Liberto JM, Sarwal MM. Mechanisms and biomarkers of immune quiescence in kidney transplantation. Hum Immunol 2018; 79:356-361. [PMID: 29408630 DOI: 10.1016/j.humimm.2018.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 12/14/2022]
Abstract
This review discusses the current understanding of biomarkers of immune quiescence based on reviews of published literature in kidney transplant operational tolerance and mechanistic studies based on a better characterization of the stable, well-functioning renal allograft.
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Affiliation(s)
- Chitranon Chan-On
- Division of Nephrology, Faculty of Medicine, Department of Internal Medicine, Khon Kaen University, Khon Kaen, Thailand; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Juliane M Liberto
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Minnie M Sarwal
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States.
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10
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Zuber J, Sykes M. Mechanisms of Mixed Chimerism-Based Transplant Tolerance. Trends Immunol 2017; 38:829-843. [PMID: 28826941 PMCID: PMC5669809 DOI: 10.1016/j.it.2017.07.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/24/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023]
Abstract
Immune responses to allografts represent a major barrier in organ transplantation. Immune tolerance to avoid chronic immunosuppression is a critical goal in the field, recently achieved in the clinic by combining bone marrow transplantation (BMT) with kidney transplantation following non-myeloablative conditioning. At high levels of chimerism such protocols can permit central deletional tolerance, but with a significant risk of graft-versus-host (GVH) disease (GVHD). By contrast, transient chimerism-based tolerance is devoid of GVHD risk and appears to initially depend on regulatory T cells (Tregs) followed by gradual, presumably peripheral, clonal deletion of donor-reactive T cells. Here we review recent mechanistic insights into tolerance and the development of more robust and safer protocols for tolerance induction that will be guided by innovative immune monitoring tools.
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Affiliation(s)
- Julien Zuber
- Service de Transplantation Rénale, Hôpital Necker, Université Paris Descartes, Paris, France; INSERM UMRS_1163, IHU Imagine, Paris, France.
| | - Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University, New York, NY 10032, USA; Department of Surgery, Columbia University, New York, NY 10032, USA; Department of Microbiology and Immunology, Columbia University Center, New York, NY 10032, USA.
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11
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Pilat N, Wekerle T. Combining Treg therapy with mixed chimerism: Getting the best of both worlds. CHIMERISM 2017; 1:26-9. [PMID: 21327149 DOI: 10.4161/chim.1.1.12964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 07/12/2010] [Indexed: 11/19/2022]
Abstract
Deliberate establishment of donor-specific immunologic tolerance is considered to be the "Holy Grail" in transplantation medicine, but clinical tolerance protocols for routine organ transplantation are still an unmet need. Mixed hematopoietic chimerism is an attractive tolerance strategy with considerable potential. Recent pilot trials provide proof-of-principle that mixed chimerism can induce tolerance in renal transplant recipients. Routine clinical translation, however, is impeded by the side effects of the cytotoxic recipient conditioning necessary for the transient engraftment of HLA-mismatched BM. In murine studies recently published in The American Journal of Transplantation, we demonstrated that the therapeutic application of polyclonal recipient regulatory T cells (Tregs) leads to engraftment of practicable doses of fully allogeneic BM and to donor-specific tolerance without any cytotoxic conditioning, thereby eliminating a major impediment for the clinical translation of the mixed chimerism strategy in the experimental setting. The background and the implications of these findings are discussed.
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Affiliation(s)
- Nina Pilat
- Division of Transplantation; Department of Surgery; Vienna General Hospital; Medical University of Vienna; Vienna, Austria
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12
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Yolcu ES, Shirwan H, Askenasy N. Mechanisms of Tolerance Induction by Hematopoietic Chimerism: The Immune Perspective. Stem Cells Transl Med 2017; 6:700-712. [PMID: 28186688 PMCID: PMC5442770 DOI: 10.1002/sctm.16-0358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/02/2016] [Accepted: 10/10/2016] [Indexed: 01/05/2023] Open
Abstract
Hematopoietic chimerism is one of the effective approaches to induce tolerance to donor‐derived tissue and organ grafts without administration of life‐long immunosuppressive therapy. Although experimental efforts to develop such regimens have been ongoing for decades, substantial cumulative toxicity of combined hematopoietic and tissue transplants precludes wide clinical implementation. Tolerance is an active immunological process that includes both peripheral and central mechanisms of mutual education of coresident donor and host immune systems. The major stages include sequential suppression of early alloreactivity, establishment of hematopoietic chimerism and suppressor cells that sustain the state of tolerance, with significant mechanistic and temporal overlap along the tolerization process. Efforts to devise less toxic transplant strategies by reduction of preparatory conditioning focus on modulation rather than deletion of residual host immunity and early reinstitution of regulatory subsets at the central and peripheral levels. Stem Cells Translational Medicine2017;6:700–712
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Affiliation(s)
- Esma S Yolcu
- Institute for Cellular Therapeutics and Department of Microbiology and Immunology, University of Louisville, Louisville, Kentucky, USA
| | - Haval Shirwan
- Institute for Cellular Therapeutics and Department of Microbiology and Immunology, University of Louisville, Louisville, Kentucky, USA
| | - Nadir Askenasy
- Frankel Laboratory of Experimental Bone Marrow Transplantation, Petach Tikva, Israel
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Bone marrow chimerism as a strategy to produce tolerance in solid organ allotransplantation. Curr Opin Organ Transplant 2016; 21:595-602. [PMID: 27805947 DOI: 10.1097/mot.0000000000000366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Clinical transplant tolerance has been most successfully achieved combining hematopoietic chimerism with kidney transplantation. This review outlines this strategy in animal models and human transplantation, and possible clinical challenges. RECENT FINDINGS Kidney transplant tolerance has been achieved through chimerism in several centers beginning with Massachusetts General Hospital's success with mixed chimerism in human leukocyte antigen (HLA)-mismatched patients and the Stanford group with HLA-matched patients, and the more recent success of the Northwestern protocol achieving full chimerism. This has challenged the original view that stable mixed chimerism is necessary for organ graft tolerance. However, among the HLA-mismatched kidney transplant-tolerant patients, loss of mixed chimerism does not lead to renal-graft rejection, and the development of host Foxp3+ regulatory T cells has been observed. Recent animal models suggest that graft tolerance through bone marrow chimerism occurs through both clonal deletion and regulatory immune cells. Further, Tregs have been shown to improve chimerism in animal models. SUMMARY Animal studies continue to suggest ways to improve our current clinical strategies. Advances in chimerism protocols suggest that tolerance may be clinically achievable with relative safety for HLA-mismatched kidney transplants.
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14
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Lin CH, Wang YL, Anggelia MR, Chuang WY, Cheng HY, Mao Q, Zelken JA, Lin CH, Zheng XX, Lee WPA, Brandacher G. Combined Anti-CD154/CTLA4Ig Costimulation Blockade-Based Therapy Induces Donor-Specific Tolerance to Vascularized Osteomyocutaneous Allografts. Am J Transplant 2016; 16:2030-41. [PMID: 26914847 DOI: 10.1111/ajt.13694] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/06/2015] [Accepted: 12/20/2015] [Indexed: 01/25/2023]
Abstract
Tolerance induction by means of costimulation blockade has been successfully applied in solid organ transplantation; however, its efficacy in vascularized composite allotransplantation, containing a vascularized bone marrow component and thus a constant source of donor-derived stem cells, remains poorly explored. In this study, osteomyocutaneous allografts (alloOMCs) from Balb/c (H2(d) ) mice were transplanted into C57BL/6 (H2(b) ) recipients. Immunosuppression consisted of 1 mg anti-CD154 on day 0, 0.5 mg CTLA4Ig on day 2 and rapamycin (RPM; 3 mg/kg per day from days 0-7, then every other day for 3 weeks). Long-term allograft survival, donor-specific tolerance and donor-recipient cell trafficking were evaluated. Treatment with costimulation blockade plus RPM resulted in long-term graft survival (>120 days) of alloOMC in 12 of 15 recipients compared with untreated controls (median survival time [MST] ≈10.2 ± 0.8 days), RPM alone (MST ≈33 ± 5.5 days) and costimulation blockade alone (MST ≈45.8 ± 7.1 days). Donor-specific hyporesponsiveness in recipients with viable grafts was demonstrated in vitro. Evidence of donor-specific tolerance was further assessed in vivo by secondary donor-specific skin graft survival and third-party graft rejection. A significant increase of Foxp3(+) regulatory T cells was evident in tolerant animals. Donor cells populated peripheral blood, thymus, and both donor and recipient bone marrow. Consequently, combined anti-CD154/CTLA4Ig costimulation blockade-based therapy induces donor-specific tolerance in a stringent murine alloOMC transplant model.
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Affiliation(s)
- C H Lin
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y L Wang
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - M R Anggelia
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - W Y Chuang
- Department of Pathology, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - H Y Cheng
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Q Mao
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J A Zelken
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C H Lin
- Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - X X Zheng
- Research Center of Translational Medicine, Shanghai East Hospital, Tongji University, Shanghai, China
| | - W P A Lee
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - G Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
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Pilat N, Mahr B, Unger L, Hock K, Schwarz C, Farkas AM, Baranyi U, Wrba F, Wekerle T. Incomplete clonal deletion as prerequisite for tissue-specific minor antigen tolerization. JCI Insight 2016; 1:e85911. [PMID: 27699263 PMCID: PMC5033814 DOI: 10.1172/jci.insight.85911] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/19/2016] [Indexed: 11/17/2022] Open
Abstract
Central clonal deletion has been considered the critical factor responsible for the robust state of tolerance achieved by chimerism-based experimental protocols, but split-tolerance models and the clinical experience are calling this assumption into question. Although clone-size reduction through deletion has been shown to be universally required for achieving allotolerance, it remains undetermined whether it is sufficient by itself. Therapeutic Treg treatment induces chimerism and tolerance in a stringent murine BM transplantation model devoid of myelosuppressive recipient treatment. In contrast to irradiation chimeras, chronic rejection (CR) of skin and heart allografts in Treg chimeras was permanently prevented, even in the absence of complete clonal deletion of donor MHC-reactive T cells. We show that minor histocompatibility antigen mismatches account for CR in irradiation chimeras without global T cell depletion. Furthermore, we show that Treg therapy-induced tolerance prevents CR in a linked suppression-like fashion, which is maintained by active regulatory mechanisms involving recruitment of thymus-derived Tregs to the graft. These data suggest that highly efficient intrathymic and peripheral deletion of donor-reactive T cells for specificities expressed on hematopoietic cells preclude the expansion of donor-specific Tregs and, hence, do not allow for spreading of tolerance to minor specificities that are not expressed by donor BM.
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Affiliation(s)
- Nina Pilat
- Section of Transplantation Immunology, Department of Surgery, and
| | - Benedikt Mahr
- Section of Transplantation Immunology, Department of Surgery, and
| | - Lukas Unger
- Section of Transplantation Immunology, Department of Surgery, and
| | - Karin Hock
- Section of Transplantation Immunology, Department of Surgery, and
| | | | | | - Ulrike Baranyi
- Section of Transplantation Immunology, Department of Surgery, and
| | - Fritz Wrba
- Institute of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Thomas Wekerle
- Section of Transplantation Immunology, Department of Surgery, and
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16
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Sykes M. Immune tolerance in recipients of combined haploidentical bone marrow and kidney transplantation. Bone Marrow Transplant 2016; 50 Suppl 2:S82-6. [PMID: 26039215 DOI: 10.1038/bmt.2015.102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The success of allogeneic hematopoietic cell transplantation (HCT) has been limited by transplant-associated toxicities related to the conditioning regimens used and to graft-vs-host disease (GVHD). The frequency and severity of GVHD observed when extensive HLA barriers are transgressed has greatly impeded the routine use of extensively HLA-mismatched HCT. Allogeneic HCT also has potential as an approach to organ allograft tolerance induction, but this potential has not been previously realized because of the toxicity associated with traditional conditioning. This paper reviews an approach to HCT involving reduced intensity conditioning that demonstrated sufficient safety in patients with hematologic malignancies, even in the HLA-mismatched transplant setting, to be applied for the induction of kidney allograft tolerance in humans with no other indication for HCT. These studies provided the first successful example of intentional organ allograft tolerance induction across HLA barriers in humans. Current data and hypotheses on the mechanisms of tolerance in these patients are reviewed.
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Affiliation(s)
- M Sykes
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
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17
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Ruiz P, Maldonado P, Hidalgo Y, Sauma D, Rosemblatt M, Bono MR. Alloreactive Regulatory T Cells Allow the Generation of Mixed Chimerism and Transplant Tolerance. Front Immunol 2015; 6:596. [PMID: 26635810 PMCID: PMC4655502 DOI: 10.3389/fimmu.2015.00596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/06/2015] [Indexed: 01/27/2023] Open
Abstract
The induction of donor-specific transplant tolerance is one of the main goals of modern immunology. Establishment of a mixed chimerism state in the transplant recipient has proven to be a suitable strategy for the induction of long-term allograft tolerance; however, current experimental recipient preconditioning protocols have many side effects, and are not feasible for use in future therapies. In order to improve the current mixed chimerism induction protocols, we developed a non-myeloablative bone-marrow transplant (NM-BMT) protocol using retinoic acid (RA)-induced alloantigen-specific Tregs, clinically available immunosuppressive drugs, and lower doses of irradiation. We demonstrate that RA-induced alloantigen-specific Tregs in addition to a NM-BMT protocol generates stable mixed chimerism and induces tolerance to allogeneic secondary skin allografts in mice. Therefore, the establishment of mixed chimerism through the use of donor-specific Tregs rather than non-specific immunosuppression could have a potential use in organ transplantation.
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Affiliation(s)
- Paulina Ruiz
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile ; Departamento de Tecnología Médica, Facultad de Medicina, Universidad de Chile , Santiago , Chile
| | - Paula Maldonado
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile
| | - Yessia Hidalgo
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile
| | - Daniela Sauma
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile
| | - Mario Rosemblatt
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile ; Fundación Ciencia y Vida , Santiago , Chile ; Facultad de Ciencias Biológicas, Universidad Andres Bello , Santiago , Chile
| | - Maria Rosa Bono
- Departmento de Biología, Facultad de Ciencias, Universidad de Chile , Santiago , Chile
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Hock K, Mahr B, Schwarz C, Wekerle T. Deletional and regulatory mechanisms coalesce to drive transplantation tolerance through mixed chimerism. Eur J Immunol 2015. [DOI: 10.1002/eji.201545494] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Karin Hock
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Benedikt Mahr
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Christoph Schwarz
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
| | - Thomas Wekerle
- Section of Transplantation Immunology; Department of Surgery; Medical University of Vienna; Austria
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19
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You S. Differential sensitivity of regulatory and effector T cells to cell death: a prerequisite for transplant tolerance. Front Immunol 2015; 6:242. [PMID: 26042125 PMCID: PMC4437185 DOI: 10.3389/fimmu.2015.00242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 05/06/2015] [Indexed: 12/13/2022] Open
Abstract
Despite significant progress achieved in transplantation, immunosuppressive therapies currently used to prevent graft rejection are still endowed with severe side effects impairing their efficiency over the long term. Thus, the development of graft-specific, non-toxic innovative therapeutic strategies has become a major challenge, the goal being to selectively target alloreactive effector T cells while sparing CD4+Foxp3+ regulatory T cells (Tregs) to promote operational tolerance. Various approaches, notably the one based on monoclonal antibodies or fusion proteins directed against the TCR/CD3 complex, TCR coreceptors, or costimulatory molecules, have been proposed to reduce the alloreactive T cell pool, which is an essential prerequisite to create a therapeutic window allowing Tregs to induce and maintain allograft tolerance. In this mini review, we focus on the differential sensitivity of Tregs and effector T cells to the depleting and inhibitory effect of these immunotherapies, with a particular emphasis on CD3-specific antibodies that beyond their immunosuppressive effect, also express potent tolerogenic capacities.
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Affiliation(s)
- Sylvaine You
- Université Paris Descartes, Sorbonne Paris Cité , Paris , France ; INSERM U1151, Institut Necker-Enfants Malades , Paris , France ; CNRS UMR 8253, Institut Necker-Enfants Malades , Paris , France
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20
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Application of allogeneic bone marrow cells in view of residual alloreactivity: sirolimus but not cyclosporine evolves tolerogenic properties. PLoS One 2015; 10:e0119950. [PMID: 25836261 PMCID: PMC4383565 DOI: 10.1371/journal.pone.0119950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/23/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Application of bone marrow cells (BMC) is a promising strategy for tolerance induction, but usually requires strong depletion of the host immune system. This study evaluates the ability of immunosuppressants to evolve tolerogenic properties of BMC in view of residual alloreactivity. METHODS The rat model used a major histocompatibility complex (MHC) class II disparate bone marrow transplantation (BMT) setting (LEW.1AR1 (RT1auu) → LEW.1AR2 (RT1aau)). Heart grafts (LEW.1WR1 (RT1uua)) were disparate for the complete MHC to recipients and for MHC class I to BMC donors. Limited conditioning was performed by total body irradiation of 6 Gy. Cyclosporine (CsA) or Sirolimus (Srl) were administered for 14 or 28 days. Transplantation of heart grafts (HTx) was performed at day 16 or at day 100 after BMT. Chimerism and changes in the T cell pool were detected by flow cytometry. RESULTS Mixed chimeras accepted HTx indefinitely, although the composition of the regenerated T cell pool was not changed to a basically donor MHC class II haplotype. Non-chimeric animals rejected HTx spontaneously. BMC recipients, who received HTx during T cell recovery at day 16, accepted HTx only after pre-treatment with Srl, although chimerism was lost. CsA pre-treatment led to accelerated HTx rejection as did isolated application of BMC. CONCLUSION Srl evolves tolerogenic properties of allogeneic BMC to achieve indefinite acceptance of partly MHC disparate HTx despite residual alloreactivity and in particular loss of chimerism.
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21
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Davis TA, Anam K, Lazdun Y, Gimble JM, Elster EA. Adipose-derived stromal cells promote allograft tolerance induction. Stem Cells Transl Med 2014; 3:1444-50. [PMID: 25411475 DOI: 10.5966/sctm.2014-0131] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Amputations and unsalvageable injuries with devastating tissue loss are common in the combat wounded. Reconstructive transplantation in the civilian setting using vascular composite allotransplants (VCAs) with multiple tissues (skin, muscle, nerve, bone) combined with long-term multidrug immunosuppression has been encouraging. However, skin rejection remains a critical complication. Adipose-derived stromal/stem cells (ASCs) are easily obtained from normal individuals in high numbers, precluding ex vivo expansion. The reparative function and paracrine immunomodulatory capacity of ASCs has gained considerable attention. The present study investigated whether ASCs facilitate long-term skin allograft survival. ASCs were isolated from fresh human subcutaneous adipose lipoaspirate. Full-thickness skin grafts from BALB/c mice were transplanted onto the dorsal flanks of C57BL/6 mice treated with five doses of anti-CD4/CD8 monoclonal antibodies (10 mg/kg) on days 0, +2, +5, +7, and +14 relative to skin grafting. A single nonmyeloablative low dose of busulfan (5 mg/kg) was given on day +5. Seven days after skin transplantation, ASCs (3×10(6)) were infused i.v. with or without donor bone marrow cells (BMCs; 5×10(5)). ASC+BMC coinfusion with minimal conditioning led to stable lymphoid and myeloid macrochimerism, deletion of alloreactive T cells, expansion of regulatory T cells, and long-term allograft survival (>200 days). ASCs constitutively produced high levels of anti-inflammatory/immunoregulatory factors such as prostaglandin E2, indoleamine 2,3-dioxygenase, APO-1/Fas (CD95), and programmed cell death-1 ligand-2. These findings serve as a foundation for developing a translational advanced VCA protocol, embodying both ASCs and low-dose donor BMCs, in nonhuman primates, with the goal of enhancing functional outcomes and eliminating the complications associated with long-term immunosuppression.
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Affiliation(s)
- Thomas A Davis
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Khairul Anam
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Yelena Lazdun
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Jeffrey M Gimble
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Eric A Elster
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
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22
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Shinoda K, Akiyoshi T, Chase CM, Farkash EA, Ndishabandi DK, Raczek CM, Sebastian DP, Pelle PD, Russell PS, Madsen JC, Colvin RB, Alessandrini A. Depletion of foxp3(+) T cells abrogates tolerance of skin and heart allografts in murine mixed chimeras without the loss of mixed chimerism. Am J Transplant 2014; 14:2263-2274. [PMID: 25155089 PMCID: PMC4523231 DOI: 10.1111/ajt.12851] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/27/2014] [Accepted: 05/27/2014] [Indexed: 01/25/2023]
Abstract
The relative contribution of central and peripheral mechanisms to the generation and maintenance of allograft tolerance is of considerable interest. Here, we present new evidence that regulatory T cells (Foxp3(+) ) maintain skin and heart allograft tolerance in mixed hematopoietic chimeric mice. Transient depletion of both donor- and recipient-derived Foxp3(+) cells was necessary and sufficient to induce decisive rejection of long-accepted skin and heart allografts. In contrast, stable hematopoietic chimerism remained, and there was no detectable induction of donor-specific reactivity to hematopoietic cells. Foxp3(+) cell depletion did not result in the rejection of skin grafts of only MHC-disparate donors (B6.C-H2(d) /bByJ), indicating that MHC antigens were not the target in the graft. We conclude that two different mechanisms of tolerance are present in mixed chimeras. Hematopoietic chimerism, resistant to Foxp3(+) depletion, is probably due to deletional tolerance to MHC antigens, as supported by previous studies. In contrast, regulatory tolerance mechanisms involving Foxp3(+) cells are required to control reactivity against non-MHC antigens not present on hematopoietic lineages.
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Affiliation(s)
- K. Shinoda
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - T. Akiyoshi
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - C. M. Chase
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - E. A. Farkash
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | | | - C. M. Raczek
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - D. P. Sebastian
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - P. Della Pelle
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - P. S. Russell
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - J. C. Madsen
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - R. B. Colvin
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Pathology, Massachusetts General Hospital, Boston, MA
- Department of Pathology, Harvard Medical School, Boston, MA
| | - A. Alessandrini
- Transplant Center, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
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23
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Mechanistic and therapeutic role of regulatory T cells in tolerance through mixed chimerism. Curr Opin Organ Transplant 2014; 15:725-30. [PMID: 20881493 DOI: 10.1097/mot.0b013e3283401755] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Although substantial advances in transplantation medicine have improved short-term graft survival, long-term outcome after organ transplantation is unsatisfactory. The induction of donor-specific tolerance as a potential solution remains an unmet need. Mixed chimerism established through transplantation of donor bone marrow is an appealing tolerance strategy, but widespread clinical application is prevented by the toxicity of recipient conditioning, which is required for achieving bone marrow engraftment. Clonal deletion - both central and peripheral - has long been recognized as a cardinal mechanism in experimental mixed chimerism models. RECENT FINDINGS Several recent studies have delineated the importance of nondeletional, regulatory mechanisms for the induction of tolerance through mixed chimerism. Moreover, the therapeutic application of recipient regulatory T cells (Tregs) has been combined with the transplantation of donor bone marrow. Such a 'Treg-chimerism' protocol leads to engraftment of conventional doses of fully allogeneic bone marrow and to donor-specific tolerance without the need for any cytotoxic conditioning. SUMMARY Regulatory mechanisms play a major role in mixed chimerism protocols. Treg therapy is exceptionally effective in achieving bone marrow engraftment without cytotoxic recipient treatment, thereby eliminating a major toxic factor preventing widespread application of the mixed chimerism strategy.
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Abstract
"Mixed chimerism" refers to a state in which the lymphohematopoietic system of the recipient of allogeneic hematopoietic stem cells comprises a mixture of host and donor cells. This state is usually attained through either bone marrow or mobilized peripheral blood stem cell transplantation. Although numerous treatment regimens have led to transplantation tolerance in mice, the induction of mixed chimerism is currently the only treatment modality that has been successfully extended to large animals and to the clinic. Here we describe and compare the use of mixed chimerism to establish transplantation tolerance in mice, pigs, monkeys, and in the clinic. We also attempt to correlate the mechanisms involved in achieving tolerance with the nature of the tolerance that has resulted in each case.
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Affiliation(s)
- David H Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02129
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25
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T-regulatory cell treatment prevents chronic rejection of heart allografts in a murine mixed chimerism model. J Heart Lung Transplant 2013; 33:429-37. [PMID: 24468120 PMCID: PMC3991417 DOI: 10.1016/j.healun.2013.11.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 11/04/2013] [Accepted: 11/12/2013] [Indexed: 12/14/2022] Open
Abstract
Background The mixed chimerism approach induces donor-specific tolerance in both pre-clinical models and clinical pilot trials. However, chronic rejection of heart allografts and acute rejection of skin allografts were observed in some chimeric animals despite persistent hematopoietic chimerism and tolerance toward donor antigens in vitro. We tested whether additional cell therapy with regulatory T cells (Tregs) is able to induce full immunologic tolerance and prevent chronic rejection. Methods We recently developed a murine “Treg bone marrow (BM) transplantation (BMT) protocol” that is devoid of cytoreductive recipient pre-treatment. The protocol consists of a moderate dose of fully mismatched allogeneic donor BM under costimulation blockade, together with polyclonal recipient Tregs and rapamycin. Control groups received BMT under non-myeloablative irradiation and costimulation blockade without Treg therapy. Multilineage chimerism was followed by flow cytometry, and tolerance was assessed by donor-specific skin and heart allografts. Results Durable multilineage chimerism and long-term donor skin and heart allograft survival were successfully achieved with both protocols. Notably, histologic examination of heart allografts at the end of follow-up revealed that chronic rejection is prevented only in chimeras induced with the Treg protocol. Conclusions In a mouse model of mixed chimerism, additional Treg treatment at the time of BMT prevents chronic rejection of heart allografts. As the Treg-chimerism protocol also obviates the need for cytoreductive recipient treatment it improves both efficacy and safety over previous non-myeloablative mixed chimerism regimens. These results may significantly impact the development of protocols for tolerance induction in cardiac transplantation.
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Anam K, Lazdun Y, Davis PM, Banas RA, Elster EA, Davis TA. Amnion-derived multipotent progenitor cells support allograft tolerance induction. Am J Transplant 2013; 13:1416-28. [PMID: 23651511 DOI: 10.1111/ajt.12252] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 02/11/2013] [Accepted: 03/10/2013] [Indexed: 01/25/2023]
Abstract
Donor-specific immunological tolerance using high doses of bone marrow cells (BMCs) has been demonstrated in mixed chimerism-based tolerance induction protocols; however, the development of graft versus host disease remains a risk. Here, we demonstrate that the co-infusion of limited numbers of donor unfractionated BMCs with human amnion-derived multipotent progenitor cells (AMPs) 7 days post-allograft transplantation facilitates macrochimerism induction and graft tolerance in a mouse skin transplantation model. AMPs + BMCs co-infusion with minimal conditioning led to stable, mixed, multilineage lymphoid and myeloid macrochimerism, deletion of donor-reactive T cells, expansion of CD4(+)CD25(+)Foxp3(+) regulatory T cells (T(regs)) and long-term allograft survival (>300 days). Based on these findings, we speculate that AMPs maybe a pro-tolerogenic cellular therapeutic that could have clinical efficacy for both solid organ and hematopoietic stem cell transplant applications.
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Affiliation(s)
- K Anam
- Department of Regenerative Medicine, Operational and Undersea Medicine Directorate at the Naval Medical Research Center, Silver Spring, MD, USA
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27
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Mixed chimerism through donor bone marrow transplantation: a tolerogenic cell therapy for application in organ transplantation. Curr Opin Organ Transplant 2013; 17:63-70. [PMID: 22186093 DOI: 10.1097/mot.0b013e32834ee68b] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Organ transplantation is the state-of-the-art treatment for end-stage organ failure; however, long-term graft survival is still unsatisfactory. Despite improved immunosuppressive drug therapy, patients are faced with substantial side effects and the risk of chronic rejection with subsequent graft loss. The transplantation of donor bone marrow for the induction of mixed chimerism has been recognized to induce donor-specific tolerance a long time ago, but safety concerns regarding toxicities of current bone marrow transplantation (BMT) protocols impede widespread application. RECENT FINDINGS Recent studies in nonhuman primates and kidney transplant patients have demonstrated successful induction of allograft tolerance even though--in contrast to murine models--only transient chimerism was achieved. Progress toward the development of nontoxic murine BMT protocols revealed that Treg therapy is a potent therapeutic adjunct eliminating the need for cytotoxic recipient conditioning. Furthermore, new insight into the mechanisms underlying tolerization of CD4 and CD8 T cells in mixed chimeras has been gained and has identified possible difficulties impeding clinical translation. SUMMARY This review will address the recent advances in murine models as well as findings from the first clinical trials for the induction of tolerance through mixed chimerism. Both the potential for more widespread clinical application and the remaining hurdles and challenges of this tolerance approach will be discussed.
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Al-Adra DP, Anderson CC. Mixed chimerism and split tolerance: mechanisms and clinical correlations. CHIMERISM 2013; 2:89-101. [PMID: 22509425 DOI: 10.4161/chim.2.4.19017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Establishing hematopoietic mixed chimerism can lead to donor-specific tolerance to transplanted organs and may eliminate the need for long-term immunosuppressive therapy, while also preventing chronic rejection. In this review, we discuss central and peripheral mechanisms of chimerism induced tolerance. However, even in the long-lasting presence of a donor organ or donor hematopoietic cells, some allogeneic tissues from the same donor can be rejected; a phenomenon known as split tolerance. With the current goal of creating mixed chimeras using clinically feasible amounts of donor bone marrow and with minimal conditioning, split tolerance may become more prevalent and its mechanisms need to be explored. Some predisposing factors that may increase the likelihood of split tolerance are immunogenicity of the graft, certain donor-recipient combinations, prior sensitization, location and type of graft and minimal conditioning chimerism induction protocols. Additionally, split tolerance may occur due to a differential susceptibility of various types of tissues to rejection. The mechanisms involved in a tissue's differential susceptibility to rejection include the presence of polymorphic tissue-specific antigens and variable sensitivity to indirect pathway effector mechanisms. Finally, we review the clinical attempts at allograft tolerance through the induction of chimerism; studies that are revealing the complex relationship between chimerism and tolerance. This relationship often displays split tolerance, and further research into its mechanisms is warranted.
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Affiliation(s)
- David P Al-Adra
- Department of Surgery, Alberta Diabetes Institute, University of Alberta, Edmonton, AB Canada
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29
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Tolerance induction strategies in vascularized composite allotransplantation: mixed chimerism and novel developments. Clin Dev Immunol 2012; 2012:863264. [PMID: 23320020 PMCID: PMC3540904 DOI: 10.1155/2012/863264] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 11/06/2012] [Accepted: 12/03/2012] [Indexed: 12/29/2022]
Abstract
Since the start of the clinical vascularized composite allotransplantation (VCA) era over a decade ago this field has witnessed significant developments in both basic and translational research. Transplant tolerance, defined as rejection-free acceptance of transplanted organs or tissues without long-term immunosuppression, holds the potential to revolutionize the field of VCA by removing the need for life-long immunosuppression. While tolerance of organ and vascularized composite transplants may be induced in small animal models by a variety of protocols, only mixed-chimerism-based protocols have successfully bridged the gap to preclinical study and to clinical trial in solid organ transplantation to date. In this paper we review the mixed-chimerism approach to tolerance induction, with specific reference to the field of VCA transplantation, and provide an overview of some novel cellular therapies as potential adjuvants to mixed chimerism in the development of tolerance induction protocols for clinical vascularized composite allotransplantation.
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30
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Combined treatment with regulatory T cells and vascularized bone marrow transplantation creates mixed chimerism and induces donor-specific tolerance to vascularized composite allografts without cytoreductive conditioning. J Surg Res 2012; 178:974-81. [DOI: 10.1016/j.jss.2012.06.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/18/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
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Issa F, Wood KJ. Translating tolerogenic therapies to the clinic - where do we stand? Front Immunol 2012; 3:254. [PMID: 22934094 PMCID: PMC3422982 DOI: 10.3389/fimmu.2012.00254] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/30/2012] [Indexed: 12/12/2022] Open
Abstract
Manipulation of the immune system to prevent the development of a specific immune response is an ideal strategy to improve outcomes after transplantation. A number of experimental techniques exploiting central and peripheral tolerance mechanisms have demonstrated success, leading to the first early phase clinical trials for tolerance induction. The first major strategy centers on the facilitation of donor-cell mixed chimerism in the transplant recipient with the use of bone marrow or hematopoietic stem cell transplantation. The second strategy, utilizing peripheral regulatory mechanisms, focuses on cellular therapy with regulatory T cells. This review examines the key studies and novel research directions in the field of immunological tolerance.
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Affiliation(s)
- Fadi Issa
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, Level 6, John Radcliffe Hospital, University of Oxford Oxford, UK
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Pasquet L, Joffre O, Santolaria T, van Meerwijk JPM. Hematopoietic chimerism and transplantation tolerance: a role for regulatory T cells. Front Immunol 2011; 2:80. [PMID: 22566869 PMCID: PMC3342389 DOI: 10.3389/fimmu.2011.00080] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 12/05/2011] [Indexed: 01/13/2023] Open
Abstract
The immunosuppressive regimens currently used in transplantation to prevent allograft destruction by the host's immune system have deleterious side effects and fail to control chronic rejection processes. Induction of donor-specific non-responsiveness (i.e., immunological tolerance) to transplants would solve these problems and would substantially ameliorate patients' quality of life. It has been proposed that bone marrow or hematopoietic stem-cell transplantation, and resulting (mixed) hematopoietic chimerism, lead to immunological tolerance to organs of the same donor. However, a careful analysis of the literature, performed here, clearly establishes that whereas hematopoietic chimerism substantially prolongs allograft survival, it does not systematically prevent chronic rejection. Moreover, the cytotoxic conditioning regimens used to achieve long-term persistence of chimerism are associated with severe side effects that appear incompatible with a routine use in the clinic. Several laboratories recently embarked on different studies to develop alternative strategies to overcome these issues. We discuss here recent advances obtained by combining regulatory T cell infusion with bone-marrow transplantation. In experimental settings, this attractive approach allows development of genuine immunological tolerance to donor tissues using clinically relevant conditioning regimens.
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Affiliation(s)
- Lise Pasquet
- INSERM U1043Toulouse, France
- CNRS U5282Toulouse, France
- Centre de Physiopathologie de Toulouse Purpan, Université Paul Sabatier, Université de ToulouseToulouse, France
| | - Olivier Joffre
- INSERM U1043Toulouse, France
- CNRS U5282Toulouse, France
- Centre de Physiopathologie de Toulouse Purpan, Université Paul Sabatier, Université de ToulouseToulouse, France
| | - Thibault Santolaria
- INSERM U1043Toulouse, France
- CNRS U5282Toulouse, France
- Centre de Physiopathologie de Toulouse Purpan, Université Paul Sabatier, Université de ToulouseToulouse, France
| | - Joost P. M. van Meerwijk
- INSERM U1043Toulouse, France
- CNRS U5282Toulouse, France
- Centre de Physiopathologie de Toulouse Purpan, Université Paul Sabatier, Université de ToulouseToulouse, France
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Liu G, Duan K, Ma H, Niu Z, Peng J, Zhao Y. An instructive role of donor macrophages in mixed chimeras in the induction of recipient CD4(+)Foxp3(+) Treg cells. Immunol Cell Biol 2011; 89:827-35. [PMID: 21844881 DOI: 10.1038/icb.2011.65] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The immune regulatory function of macrophages (Møs) in mixed chimeras has not been determined. In the present study, with a multi-lineage B6-to-BALB/c mixed chimeric model, we examined the ability of donor-derived splenic Møs in the induction of regulatory T cells (Treg). B6 splenic Møs from mixed chimeras induced significantly less cell proliferation, more IL-10 and TGF-β, and less IL-2 and IFN-γ productions of CD4(+) T cells from BALB/c mice than naive B6 Møs did, whereas they showed similar stimulatory activity to the third part C3H CD4(+) T cells. Importantly, highly purified donor F4/80(+)CD11c(-) Møs efficiently induced recipient CD4(+)Foxp3(+) Treg cells from CD4(+)CD25(-)Foxp3(-) T cells. Furthermore, donor Møs of mixed chimeras produced more IL-10 and less IFN-γ than those of naive mice when cultured with BALB/c but not the third party C3H CD4(+) T cells. Induction of recipient CD4(+) Treg cells by donor Møs was significantly blocked by anti-IL-10, but not by anti-TGF-β mAb. Therefore, donor Møs have the ability to induce recipient CD4(+)Foxp3(+) Treg cells in a donor antigen-specific manner, at least partially, via an IL-10-dependent pathway. This study for the first time showed that, in mixed allogeneic chimeras, donor Møs could be specifically tolerant to recipients and gained the ability to induce recipient but not the third party Foxp3(+) Treg cells. Whether this approach is involved in transplant immune tolerance needs to be determined.
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Affiliation(s)
- Guangwei Liu
- Transplantation Biology Research Division, State Key Laboratory of Biomembrane and Membrane Biotechnology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
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Abstract
Secondary, so-called costimulatory, signals are critically required for the process of T cell activation. Since landmark studies defined that T cells receiving a T cell receptor signal without a costimulatory signal, are tolerized in vitro, the investigation of T cell costimulation has attracted intense interest. Early studies demonstrated that interrupting T cell costimulation allows attenuation of the alloresponse, which is particularly difficult to modulate due to the clone size of alloreactive T cells. The understanding of costimulation has since evolved substantially and now encompasses not only positive signals involved in T cell activation but also negative signals inhibiting T cell activation and promoting T cell tolerance. Costimulation blockade has been used effectively for the induction of tolerance in rodent models of transplantation, but turned out to be less potent in large animals and humans. In this overview we will discuss the evolution of the concept of T cell costimulation, the potential of 'classical' and newly identified costimulation pathways as therapeutic targets for organ transplantation as well as progress towards clinical application of the first costimulation blocking compound.
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Affiliation(s)
- Nina Pilat
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Austria
| | - Mohamed H. Sayegh
- Brigham and Women's Hospital & Children's Hospital Boston, Harvard Medical School, Boston, USA
| | - Thomas Wekerle
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Austria
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Sachs DH, Sykes M, Kawai T, Cosimi AB. Immuno-intervention for the induction of transplantation tolerance through mixed chimerism. Semin Immunol 2011; 23:165-73. [PMID: 21839648 PMCID: PMC3178004 DOI: 10.1016/j.smim.2011.07.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 07/10/2011] [Indexed: 01/20/2023]
Abstract
The induction of transplantation tolerance could liberate organ transplant recipients from the complications of life-long chronic immunosuppression. The original description of tolerance induction through mixed hematopoietic chimerism in mice utilized lethal whole body irradiation as the preparative regimen for achieving mixed chimerism. While such a regimen might be acceptable for treatment of patients with malignancies, which might also respond to the therapeutic effects of radiation, its toxicity would be unacceptable for patients in need only of an organ transplant. Graft-vs.-host disease, which is frequently a complication of mismatched bone marrow transplantation, would likewise be unacceptable for ordinary clinical transplantation. Therefore, as we have extended the use of this modality for tolerance induction from mice to large animal models, we have attempted to design preparative regimens that avoid both of these complications. In this article, we review our studies of mixed chimerism in mice, miniature swine and monkeys, as well as the results of our recent clinical studies that have extended this treatment modality to a series of kidney transplant patients who have been successfully weaned from all immunosuppression while maintaining stable renal function for up to 8 years.
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Affiliation(s)
- David H Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Building 149, 13th Street, Boston, MA 02129, United States.
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El Essawy B, Putheti P, Gao W, Strom TB. Rapamycin generates graft-homing murine suppressor CD8(+) T cells that confer donor-specific graft protection. Cell Transplant 2011; 20:1759-69. [PMID: 21439133 DOI: 10.3727/096368911x566244] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
It has been reported that rapamycin (RPM) can induce de novo conversion of the conventional CD4(+)Foxp3(-) T cells into CD4(+)Foxp3(+) regulatory T cells (iTregs) in transplantation setting. It is not clear whether RPM can similarly generate suppressor CD8(+) T cells to facilitate graft acceptance. In this study, we investigated the ability of short-term RPM treatment in promoting long-term acceptance (LTA) of MHC-mismatched skin allografts by generating a CD8(+) suppressor T-cell population. We found that CD4 knockout (KO) mice (in C57BL/6 background, H-2(b)) can promptly reject DBA/2 (H-2(d)) skin allografts with mean survival time (MST) being 13 days (p < 0.01). However, a short course RPM treatment in these animals induced LTA with graft MST longer than 100 days. Adoptive transfer of CD8(+) T cells from LTA group into recombination-activating gene 1 (Rag-1)-deficient mice provided donor-specific protection of DBA/2 skin grafts against cotransferred conventional CD8(+) T cells. Functionally active immunoregulatory CD8(+) T cells also resided in donor skin allografts. Eighteen percent of CD8(+) suppressor T cells expressed CD28 as measured by flow cytometry, and produced reduced levels of IFN-γ, IL-2, and IL-10 in comparison to CD8(+) effector T cells as measured by ELISA. It is unlikely that CD8(+) suppressor T cells mediated graft protection via IL-10, as IL-10/Fc fusion protein impaired RPM-induced LTA in CD4 KO mice. Our data supported the notion that RPM-induced suppressor CD8(+) T cells home to the allograft and exert donor-specific graft protection.
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Affiliation(s)
- Basset El Essawy
- Department of Medicine, Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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SÁNCHEZ–FUEYO ALBERTO, STROM TERRYB. Immunologic basis of graft rejection and tolerance following transplantation of liver or other solid organs. Gastroenterology 2011; 140:51-64. [PMID: 21073873 PMCID: PMC3866688 DOI: 10.1053/j.gastro.2010.10.059] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 10/24/2010] [Accepted: 10/26/2010] [Indexed: 12/13/2022]
Abstract
Transplantation of organs between genetically different individuals of the same species causes a T cell-mediated immune response that, if left unchecked, results in rejection and graft destruction. The potency of the alloimmune response is determined by the antigenic disparity that usually exists between donors and recipients and by intragraft expression of proinflammatory cytokines in the early period after transplantation. Studies in animal models have identified many molecules that, when targeted, inhibit T-cell activation. In addition, some of these studies have shown that certain immunologic interventions induce transplantation tolerance, a state in which the allograft is specifically accepted without the need for chronic immunosuppression. Tolerance is an important aspect of liver transplantation, because livers have a unique microenvironment that promotes tolerance rather than immunity. In contrast to the progress achieved in inducing tolerance in animal models, patients who receive transplanted organs still require nonspecific immunosuppressant drugs. The development of calcineurin inhibitors has reduced the acute rejection rate and improved short-term, but not long-term, graft survival. However, long-term use of immunosuppressive drugs leads to nephrotoxicity and metabolic disorders, as well as manifestations of overimmunosuppression such as opportunistic infections and cancers. The status of pharmacologic immunosuppression in the clinic is therefore not ideal. We review recently developed therapeutic strategies to promote tolerance to transplanted livers and other organs and diagnostic tools that might be used to identify patients most likely to accept or reject allografts.
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Affiliation(s)
- ALBERTO SÁNCHEZ–FUEYO
- Liver Transplant Unit, Hospital Clinic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - TERRY B. STROM
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Anam K, Amare MF, Zins SR, Davis TA. Infusion of Lin- bone marrow cells results in multilineage macrochimerism and skin allograft tolerance in minimally conditioned recipient mice. Transpl Immunol 2010; 24:69-75. [PMID: 20950686 DOI: 10.1016/j.trim.2010.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 10/06/2010] [Indexed: 01/08/2023]
Abstract
Donor-specific immunological tolerance using high doses of donor bone marrow cells (BMC) has been demonstrated in mixed chimerism-based tolerance induction protocols; however, the development of graft versus host disease (GVHD) remains a risk. In the present study, we demonstrate that the infusion of low numbers of donor Lin(-) bone marrow cells (Lin(-) BMC) 7 days post allograft transplantation facilitates high level macrochimerism induction and graft tolerance. Full-thickness BALB/c skin allografts were transplanted onto C57BL/6 mice. Mice were treated with anti-CD4 and anti-CD8 mAbs on day 0, +2, +5, +7 and +14 along with low dose busulfan on day +5. A low dose of highly purified Lin(-) BMC from BALB/c donor mice was infused on day +7. Chimerism and clonal cell deletion were evaluated using flow cytometry. Donor-specific tolerance was tested by donor and third-party skin grafting and mixed leukocyte reaction (MLR). Lin(-) BMC infusion with minimal immunosuppression led to stable, mixed, multilineage macrochimerism and long-term allograft survival (>300 days). Mixed donor-recipient macrochimerism was observed. Donor-reactive T cells were clonally deleted and a 130% increase in CD4(+)CD25(+)Foxp3(+) regulatory T cells (Tregs) was observed in the spleen. Tolerant mice subsequently accepted second donor, but not third-party (C3H), skin grafts and recipient splenocytes failed to react with allogeneic donor cells indicating donor-specific immunological tolerance was achieved. We conclude that the infusion of donor Lin(-) BMC without cytoreductive recipient conditioning can induce indefinite survival of skin allografts via mechanisms involving the establishment of a multilineage macrochimeric state principally through clonal deletion of alloreactive T cells and peripherally induced CD4(+)Foxp3(+) Tregs.
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Affiliation(s)
- Khairul Anam
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate at the Naval Medical Research Center, Silver Spring, MD 20910-7500, USA
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40
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Tian C, Yuan X, Jindra PT, Bagley J, Sayegh MH, Iacomini J. Induction of transplantation tolerance to fully mismatched cardiac allografts by T cell mediated delivery of alloantigen. Clin Immunol 2010; 136:174-87. [PMID: 20452826 DOI: 10.1016/j.clim.2010.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 04/14/2010] [Accepted: 04/14/2010] [Indexed: 01/11/2023]
Abstract
Induction of transplantation tolerance has the potential to allow for allograft acceptance without the need for life-long immunosuppression. Here we describe a novel approach that uses delivery of alloantigen by mature T cells to induce tolerance to fully allogeneic cardiac grafts. Adoptive transfer of mature alloantigen-expressing T cells into myeloablatively conditioned mice results in long-term acceptance of fully allogeneic heart transplants without evidence of chronic rejection. Since myeloablative conditioning is clinically undesirable we further demonstrated that adoptive transfer of mature alloantigen-expressing T cells alone into mice receiving non-myeloablative conditioning resulted in long-term acceptance of fully allogeneic heart allografts with minimal evidence of chronic rejection. Mechanistically, tolerance induction involved both deletion of donor-reactive host T cells and the development of regulatory T cells. Thus, delivery of alloantigen by mature T cells induces tolerance to fully allogeneic organ allografts in non-myeloablatively conditioned recipients, representing a novel approach for tolerance induction in transplantation.
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Affiliation(s)
- Chaorui Tian
- Brigham and Women's Hospital and Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
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42
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Pilat N, Baranyi U, Klaus C, Jaeckel E, Mpofu N, Wrba F, Golshayan D, Muehlbacher F, Wekerle T. Treg-therapy allows mixed chimerism and transplantation tolerance without cytoreductive conditioning. Am J Transplant 2010; 10:751-762. [PMID: 20148810 PMCID: PMC2856406 DOI: 10.1111/j.1600-6143.2010.03018.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Establishment of mixed chimerism through transplantation of allogeneic donor bone marrow (BM) into sufficiently conditioned recipients is an effective experimental approach for the induction of transplantation tolerance. Clinical translation, however, is impeded by the lack of feasible protocols devoid of cytoreductive conditioning (i.e. irradiation and cytotoxic drugs/mAbs). The therapeutic application of regulatory T cells (Tregs) prolongs allograft survival in experimental models, but appears insufficient to induce robust tolerance on its own. We thus investigated whether mixed chimerism and tolerance could be realized without the need for cytoreductive treatment by combining Treg therapy with BM transplantation (BMT). Polyclonal recipient Tregs were cotransplanted with a moderate dose of fully mismatched allogeneic donor BM into recipients conditioned solely with short-course costimulation blockade and rapamycin. This combination treatment led to long-term multilineage chimerism and donor-specific skin graft tolerance. Chimeras also developed humoral and in vitro tolerance. Both deletional and nondeletional mechanisms contributed to maintenance of tolerance. All tested populations of polyclonal Tregs (FoxP3-transduced Tregs, natural Tregs and TGF-beta induced Tregs) were effective in this setting. Thus, Treg therapy achieves mixed chimerism and tolerance without cytoreductive recipient treatment, thereby eliminating a major toxic element impeding clinical translation of this approach.
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Affiliation(s)
- N Pilat
- Division of Transplantation, Department of Surgery, Medical University of ViennaAustria
| | - U Baranyi
- Division of Transplantation, Department of Surgery, Medical University of ViennaAustria
| | - C Klaus
- Division of Transplantation, Department of Surgery, Medical University of ViennaAustria
| | - E Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School (MHH)Hannover, Germany
| | - N Mpofu
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School (MHH)Hannover, Germany
| | - F Wrba
- Institute of Clinical Pathology, Medical University of ViennaAustria
| | - D Golshayan
- Transplantation Centre and Transplantation Immunopathology Laboratory, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne UniversityLausanne, Switzerland
| | - F Muehlbacher
- Division of Transplantation, Department of Surgery, Medical University of ViennaAustria
| | - T Wekerle
- Division of Transplantation, Department of Surgery, Medical University of ViennaAustria,* Corresponding author: Thomas Wekerle,
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Hematopoietic cell transplantation for tolerance induction: animal models to clinical trials. Transplantation 2009; 87:309-16. [PMID: 19202432 DOI: 10.1097/tp.0b013e31819535c2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The induction of donor-specific immune tolerance is the "holy grail" of transplantation, as it would avoid the toxicities of chronic immunosuppressive therapies while preventing acute and chronic graft rejection. A large number of approaches to tolerance induction have been described in the experimental literature, but only hematopoietic cell transplantation has shown preliminary success for intentional tolerance induction in pilot clinical trials. This review summarizes the conditions that allow progress to be made in moving strategies for tolerance induction from the bench to the bedside and discuss the mechanisms by which tolerance may be achieved through hematopoietic cell transplantation.
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Abstract
Although the inhibitory receptor CTLA-4 (CD152) has been implicated in peripheral CD4 T-cell tolerance, its mechanism of action remains poorly defined. We analyzed mechanisms of CD4 cell tolerance in a model of tolerance induction involving establishment of mixed hematopoietic chimerism in recipients of fully MHC-mismatched allogeneic bone marrow cells with anti-CD154 mAb. Animals lacking CD80 and CD86 failed to achieve chimerism. We detected no T cell-intrinsic requirement for CD28 for chimerism induction. However, a CD4 T cell-intrinsic signal through CTLA-4 was shown to be essential within the first 48 hours of exposure to alloantigen for the establishment of tolerance and mixed chimerism. This signal must be provided by a recipient CD80/86(+) non-T-cell population. Donor CD80/86 expression was insufficient to achieve tolerance. Together, our findings demonstrate a surprising role for interactions of CTLA-4 expressed by alloreactive peripheral CD4 T cells with CD80/86 on recipient antigen-presenting cells (APCs) in the induction of early tolerance, suggesting a 3-cell tolerance model involving directly alloreactive CD4 cells, donor antigen-expressing bone marrow cells, and recipient antigen-presenting cells. This tolerance is independent of regulatory T cells and culminates in the deletion of directly alloreactive CD4 T cells.
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Xu H, Huang Y, Chilton PM, Hussain LR, Tanner MK, Yan J, Ildstad ST. Strategic nonmyeloablative conditioning: CD154:CD40 costimulatory blockade at primary bone marrow transplantation promotes engraftment for secondary bone marrow transplantation after engraftment failure. THE JOURNAL OF IMMUNOLOGY 2009; 181:6616-24. [PMID: 18941252 DOI: 10.4049/jimmunol.181.9.6616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is an increased risk of failure of engraftment following nonmyeloablative conditioning. Sensitization resulting from failed bone marrow transplantation (BMT) remains a major challenge for secondary BMT. Approaches to allow successful retransplantation would have significant benefits for BMT candidates living with chronic diseases. We used a mouse model to investigate the effect of preparative regimens at primary BMT on outcome for secondary BMT. We found that conditioning with TBI or recipient T cell lymphodepletion at primary BMT did not promote successful secondary BMT. In striking contrast, successful secondary BMT could be achieved in mice conditioned with anti-CD154 costimulatory molecule blockade at first BMT. Blockade of CD154 alone or combined with T cell depletion inhibits generation of the humoral immune response after primary BMT, as evidenced by abrogation of production of anti-donor Abs. The humoral barrier is dominant in sensitization resulting from failed BMT, because almost all CFSE-labeled donor cells were killed at 0.5 and 3 h in sensitized recipients in in vivo cytotoxicity assay, reflecting Ab-mediated cytotoxicity. CD154:CD40 costimulatory blockade used at primary BMT promotes allogeneic engraftment in secondary BMT after engraftment failure at first BMT. The prevention of generation of anti-donor Abs at primary BMT is critical for successful secondary BMT.
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Affiliation(s)
- Hong Xu
- Institute for Cellular Therapeutics, University of Louisville, Louisville, KY 40202, USA
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Stapler D, Lee ED, Selvaraj SA, Evans AG, Kean LS, Speck SH, Larsen CP, Gangappa S. Expansion of effector memory TCR Vbeta4+ CD8+ T cells is associated with latent infection-mediated resistance to transplantation tolerance. THE JOURNAL OF IMMUNOLOGY 2008; 180:3190-200. [PMID: 18292543 DOI: 10.4049/jimmunol.180.5.3190] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Therapies that control largely T cell-dependent allograft rejection in humans also possess the undesirable effect of impairing T cell function, leaving transplant recipients susceptible to opportunistic viruses. Prime among these opportunists are the ubiquitous herpesviruses. To date, studies are lacking that address the effect of viruses that establish a true latent state on allograft tolerance or the effect of tolerance protocols on the immune control of latent viruses. By using a mixed chimerism-based tolerance-induction protocol, we found that mice undergoing latent infection with gammaHV68, a murine gamma-herpesvirus closely related to human gamma-herpesviruses such as EBV and Kaposi's sarcoma-associated herpesvirus, significantly resist tolerance to allografts. Limiting the degree of virus reactivation or innate immune response did not reconstitute chimerism in latently infected mice. However, gammaHV68-infected mice showed increased frequency of CD8+ T cell alloreactivity and, interestingly, expansion of virus-induced, alloreactive, "effector/effector memory" TCR Vbeta4+CD8+ T cells driven by the gammaHV68-M1 gene was associated with resistance to tolerance induction in studies using gammaHV68-M1 mutant virus. These results define the viral gene and immune cell types involved in latent infection-mediated resistance to allograft tolerance and underscore the influence of latent herpesviruses on allograft survival.
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Affiliation(s)
- Dale Stapler
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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Li W, Kuhr CS, Zheng XX, Carper K, Thomson AW, Reyes JD, Perkins JD. New insights into mechanisms of spontaneous liver transplant tolerance: the role of Foxp3-expressing CD25+CD4+ regulatory T cells. Am J Transplant 2008; 8:1639-51. [PMID: 18557727 DOI: 10.1111/j.1600-6143.2008.02300.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Liver allografts in mice are accepted across MHC barriers without requirement for immunosuppressive therapy. The mechanisms underlying this phenomenon remain largely undefined. In this study, we investigated the role of Foxp3-expressing CD25(+)CD4(+) regulatory T cells (Treg) in the induction of murine liver transplant tolerance. Foxp3(+)CD25(+)CD4(+) T cells were increased in liver grafts and recipient spleens from day 5 to day 100 posttransplantation, associated with enhanced CTLA4 and TGF-beta expression and IL-4 production. Depletion of recipient CD25(+)CD4(+) T cells using anti-CD25 mAb (250 microg/day) induced acute liver allograft rejection. This was associated with a decreased ratio of Foxp3(+) Treg: T effector cells, decreased IL-4 and elevated IL-10 and IL-2 production by graft-infiltrating T cells, and reduced apoptotic activity of graft-infiltrating CD4(+) and CD8(+) T cells in anti-CD25-mAb-treated recipients. Thus, the data suggest that Foxp3(+)CD25(+)CD4(+)Treg are involved in spontaneous acceptance of liver allografts in mice. The ratio of Treg to T effector cells appears to determine liver transplant outcome. CTLA4, IL-4, TGF-beta and apoptosis of graft-infiltrating T cells are also associated with liver transplant tolerance and may contribute, at least in part, to the mechanisms of Treg-mediated immune regulation in this model.
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Affiliation(s)
- W Li
- Division of Transplantation, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA.
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Gibbons C, Sykes M. Manipulating the immune system for anti-tumor responses and transplant tolerance via mixed hematopoietic chimerism. Immunol Rev 2008; 223:334-60. [PMID: 18613846 PMCID: PMC2680695 DOI: 10.1111/j.1600-065x.2008.00636.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
SUMMARY Stem cells (SCs) with varying potentiality have the capacity to repair injured tissues. While promising animal data have been obtained, allogeneic SCs and their progeny are subject to immune-mediated rejection. Here, we review the potential of hematopoietic stem cells (HSCs) to promote immune tolerance to allogeneic and xenogeneic organs and tissues, to reverse autoimmunity, and to be used optimally to cure hematologic malignancies. We also review the mechanisms by which hematopoietic cell transplantation (HCT) can promote anti-tumor responses and establish donor-specific transplantation tolerance. We discuss the barriers to clinical translation of animal studies and describe some recent studies indicating how they can be overcome. The recent achievements of durable mixed chimerism across human leukocyte antigen barriers without graft-versus-host disease and of organ allograft tolerance through combined kidney and bone marrow transplantation suggest that the potential of this approach for use in the treatment of many human diseases may ultimately be realized.
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Affiliation(s)
- Carrie Gibbons
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
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Abstract
In 1943, Gibson and Medawar opened the modern era of transplantation research with a paper on the problem of skin allograft rejection. Ten years later Billingham, Brent and Medawar demonstrated that it was possible to induce selective immune acceptance of skin grafts in mice, a state of tolerance. After over six decades, however, the precise mechanism of skin allograft rejection remains still ill-defined. Furthermore, it has not been possible to achieve reliably clinical tolerance allowing the widespread application of skin allotransplantation techniques. The first successful applications of skin allotransplantation have included the hand and face. However, complications from the chronic immunosuppression regimens limit the application of these techniques. Induction of tolerance to skin (and the other tissues in the allograft) would be the most effective way to overcome all these difficulties, but this is yet to be achieved reliably, stimulating some to look for other ways to surmount the current limitations. This paper summarizes alternatives to enlarge the scope of skin allotransplantation techniques, current understanding of mechanisms of skin rejection, and the utility and limitations of animal models used to study skin rejection and tolerance induction. Finally, manipulation strategies to achieve skin tolerance are outlined.
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Affiliation(s)
- Benjamin M Horner
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
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