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Moris D, Barfield R, Chan C, Chasse S, Stempora L, Xie J, Plichta JK, Thacker J, Harpole DH, Purves T, Lagoo-Deenadayalan S, Hwang ESS, Kirk AD. Immune Phenotype and Postoperative Complications After Elective Surgery. Ann Surg 2023; 278:873-882. [PMID: 37051915 DOI: 10.1097/sla.0000000000005864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To characterize and quantify accumulating immunologic alterations, pre and postoperatively in patients undergoing elective surgical procedures. BACKGROUND Elective surgery is an anticipatable, controlled human injury. Although the human response to injury is generally stereotyped, individual variability exists. This makes surgical outcomes less predictable, even after standardized procedures, and may provoke complications in patients unable to compensate for their injury. One potential source of variation is found in immune cell maturation, with phenotypic changes dependent on an individual's unique, lifelong response to environmental antigens. METHODS We enrolled 248 patients in a prospective trial facilitating comprehensive biospecimen and clinical data collection in patients scheduled to undergo elective surgery. Peripheral blood was collected preoperatively, and immediately on return to the postanesthesia care unit. Postoperative complications that occurred within 30 days after surgery were captured. RESULTS As this was an elective surgical cohort, outcomes were generally favorable. With a median follow-up of 6 months, the overall survival at 30 days was 100%. However, 20.5% of the cohort experienced a postoperative complication (infection, readmission, or system dysfunction). We identified substantial heterogeneity of immune senescence and terminal differentiation phenotypes in surgical patients. More importantly, phenotypes indicating increased T-cell maturation and senescence were associated with postoperative complications and were evident preoperatively. CONCLUSIONS The baseline immune repertoire may define an immune signature of resilience to surgical injury and help predict risk for surgical complications.
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Affiliation(s)
| | - Richard Barfield
- Department of Biostatistics and Bioinformatics, Duke University; Durham, NC
- Duke Center for Genomic and Computational Biology, Duke University; Durham, NC
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University; Durham, NC
- Duke Center for Genomic and Computational Biology, Duke University; Durham, NC
| | - Scott Chasse
- Department of Surgery, Duke University; Durham, NC
| | | | - Jichun Xie
- Department of Biostatistics and Bioinformatics, Duke University; Durham, NC
- Duke Center for Genomic and Computational Biology, Duke University; Durham, NC
| | | | | | | | - Todd Purves
- Department of Surgery, Duke University; Durham, NC
| | | | | | - Allan D Kirk
- Department of Surgery, Duke University; Durham, NC
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Gelbard RB, Hensman H, Schobel S, Stempora L, Gann E, Moris D, Dente CJ, Buchman T, Kirk A, Elster E. A Random Forest Model Using Flow Cytometry Data Identifies Pulmonary Infection after Thoracic Injury. J Trauma Acute Care Surg 2023:01586154-990000000-00334. [PMID: 37038251 DOI: 10.1097/ta.0000000000003937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Thoracic injury can cause impairment of lung function leading to respiratory complications such as pneumonia. There is increasing evidence that central memory T cells of the adaptive immune system play a key role in pulmonary immunity. We sought to explore whether assessment of cell phenotypes using flow cytometry (FCM) could be used to identify pulmonary infection after thoracic trauma. METHODS We prospectively studied trauma patients with thoracic injuries who survived >48 h at a Level 1 trauma center from 2014-2020. Clinical and FCM data from serum samples collected within 24 h of admission were considered as potential variables. Random forest (RF) and logistic regression (LR) models were developed to estimate the risk of hospital-acquired and ventilator-associated pneumonia (PNA). Variables were selected using backwards elimination and models were internally validated with leave-one-out. RESULTS Seventy patients with thoracic injuries were included (median age 35y (IQR: 25.25 - 51) 62.9% (44/70) male, 61.4% (42/70) blunt trauma). The most common injuries included rib fractures (52/70, 74.3%) and pulmonary contusions (26/70, 37%). The incidence of PNA was 14/70 (20%). Median ISS was similar for patients with and without PNA (30.5 (IQR 22.6 - 39.3) vs 26.5 (IQR 21.6 - 33.3). The final RF model selected three variables (APACHE score, highest pulse rate in first 24 h, and frequency of CD4+ central memory (CM) cells) that identified PNA with an AUC of 0.93, sensitivity of 0.91, and specificity of 0.88. A logistic regression with the same features had an AUC of 0.86, sensitivity of 0.76, and specificity of 0.85. CONCLUSION Clinical and FCM data have diagnostic utility in the early identification of patients at risk of nosocomial pneumonia following thoracic injury. Signs of physiologic stress and lower frequency of CM cells appear to be associated with higher rates of pneumonia after thoracic trauma. LEVEL OF EVIDENCE Diagnostic test/criteria, IV.
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Shaw BI, Lee HJ, Ettenger R, Grimm P, Reed EF, Sarwal M, Stempora L, Warshaw B, Zhao C, Martinez OM, MacIver NJ, Kirk AD, Chambers ET. Malnutrition and immune cell subsets in children undergoing kidney transplantation. Pediatr Transplant 2022; 26:e14371. [PMID: 35938682 PMCID: PMC9669171 DOI: 10.1111/petr.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malnutrition, including obesity and undernutrition, among children is increasing in prevalence and is common among children on renal replacement therapy. The effect of malnutrition on the pre-transplant immune system and how the pediatric immune system responds to the insult of both immunosuppression and allotransplantation is unknown. We examined the relationship of nutritional status with post-transplant outcomes and characterized the peripheral immune cell phenotypes of children from the Immune Development of Pediatric Transplant (IMPACT) study. METHODS Ninety-eight patients from the IMPACT study were classified as having obesity, undernutrition, or normal nutrition-based pre-transplant measurements. Incidence of infectious and alloimmune outcomes at 1-year post-transplantation was compared between nutritional groups using Gray's test and Fine-Gray subdistribution hazards model. Event-free survival was estimated by Kaplan-Meier method and compared between groups. Differences in immune cell subsets between nutritional groups over time were determined using generalized estimating equations accounting for the correlation between repeated measurements. RESULTS We did not observe that nutritional status was associated with infectious or alloimmune events or event-free survival post-transplant. We demonstrated that children with obesity had distinct T-and B-cell signatures relative to those with undernutrition and normal nutrition, even when controlling for immunosuppression. Children with obesity had a lower frequency of CD8 Tnaive cells 9-month post-transplant (p < .001), a higher frequency of CD4 CD57 + PD1- T cells, and lower frequencies of CD57-PD1+ CD8 and CD57-PD1- CD8 T cells at 12-month transplant (p < .05 for all). CONCLUSIONS Children with obesity have distinct immunophenotypes that may influence the tailoring of immunosuppression.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC, United States
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC United States
| | - Robert Ettenger
- Department of Pediatrics, University of California Los Angeles, CA, United States
| | - Paul Grimm
- Department of Pediatrics, Stanford University, CA, United States
| | - Elaine F Reed
- Department of Pathology, University of California, Los Angeles, CA, United States
| | - Minnie Sarwal
- Department of Surgery, University of California, San Francisco, CA, United States
| | - Linda Stempora
- Department of Surgery, Duke University, Durham, NC, United States
| | - Barry Warshaw
- Department of Pediatrics, Children’s Healthcare Atlanta, Atlanta, GA, United States
| | - Congwen Zhao
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC United States
| | - Olivia M Martinez
- Department of Surgery, Stanford University School of Medicine, CA, United States
| | - Nancie J MacIver
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, United States
- Department of Pediatrics, Duke University, CA, United States
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Moris D, Henao R, Hensman H, Stempora L, Chasse S, Schobel S, Dente CJ, Kirk AD, Elster E. Multidimensional machine learning models predicting outcomes after trauma. Surgery 2022; 172:1851-1859. [PMID: 36116976 DOI: 10.1016/j.surg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND An emerging body of literature supports the role of individualized prognostic tools to guide the management of patients after trauma. The aim of this study was to develop advanced modeling tools from multidimensional data sources, including immunological analytes and clinical and administrative data, to predict outcomes in trauma patients. METHODS This was a prospective study of trauma patients at Level 1 centers from 2015 to 2019. Clinical, flow cytometry, and serum cytokine data were collected within 48 hours of admission. Sparse logistic regression models were developed, jointly selecting predictors and estimating the risk of ventilator-associated pneumonia, acute kidney injury, complicated disposition (death, rehabilitation, or nursing facility), and return to the operating room. Model parameters (regularization controlling model sparsity) and performance estimation were obtained via nested leave-one-out cross-validation. RESULTS A total of 179 patients were included. The incidences of ventilator-associated pneumonia, acute kidney injury, complicated disposition, and return to the operating room were 17.7%, 28.8%, 22.5%, and 12.3%, respectively. Regarding extensive resource use, 30.7% of patients had prolonged intensive care unit stay, 73.2% had prolonged length of stay, and 23.5% had need for prolonged ventilatory support. The models were developed and cross-validated for ventilator-associated pneumonia, acute kidney injury, complicated dispositions, and return to the operating room, yielding predictive areas under the curve from 0.70 to 0.91. Each model derived its optimal predictive value by combining clinical, administrative, and immunological analyte data. CONCLUSION Clinical, immunological, and administrative data can be combined to predict post-traumatic outcomes and resource use. Multidimensional machine learning modeling can identify trauma patients with complicated clinical trajectories and high resource needs.
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Affiliation(s)
| | | | - Hannah Hensman
- DecisionQ, Arlington, VA; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Linda Stempora
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Scott Chasse
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Seth Schobel
- Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | | | - Allan D Kirk
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Eric Elster
- Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD; Walter Reed National Military Medical Center, Bethesda, MD
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Shaw BI, Espinosa JR, Stempora L, Miller A, Adams B, Kirk AD. Functional Characteristics and Phenotypic Plasticity of CD57 +PD1 - CD4 T Cells and Their Relationship with Transplant Immunosuppression. J Immunol 2021; 206:1668-1676. [PMID: 33597150 DOI: 10.4049/jimmunol.2000736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/20/2021] [Indexed: 12/28/2022]
Abstract
Costimulation blockade (CoB)-based immunosuppression offers the promise of improved transplantation outcomes with reduced drug toxicity. However, it is hampered by early acute rejections, mediated at least in part by differentiated, CoB-resistant T cells, such as CD57+PD1- CD4 T cells. In this study, we characterize these cells pretransplant, determine their fate posttransplant, and examine their proliferative capacity in vitro in humans. Our studies show that CD57+PD1- CD4 T cells are correlated with increasing age and CMV infection pretransplant, and persist for up to 1 y posttransplant. These cells are replication incompetent alone but proliferated in the presence of unsorted PBMCs in a contact-independent manner. When stimulated, cells sorted by CD57/PD1 status upregulate markers of activation with proliferation. Up to 85% of CD57+PD1- cells change expression of CD57/PD1 with stimulation, typically, upregulating PD1 and downregulating CD57. PD1 upregulation is accentuated in the presence of rapamycin but prevented by tacrolimus. These data support a general theory of CoB-resistant cells as Ag-experienced, costimulation-independent cells and suggest a mechanism for the synergy of belatacept and rapamycin, with increased expression of the activation marker PD1 potentiating exhaustion of CoB-resistant cells.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC 27710
| | | | - Linda Stempora
- Department of Surgery, Duke University, Durham, NC 27710
| | - Allison Miller
- Department of Surgery, Duke University, Durham, NC 27710
| | - Bartley Adams
- Department of Surgery, Duke University, Durham, NC 27710
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC 27710
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Moris D, Wang J, Selim MA, Song M, Stempora L, Parker W, Kirk AD, Cendales LC. Vascularized composite allotransplants as a mechanistic model for allograft rejection - an experimental study. Transpl Int 2021; 34:572-584. [PMID: 33453073 DOI: 10.1111/tri.13820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/09/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Abstract
Vascularized composite allotransplants (VCAs) seem to have several unique features of clinical and experimental importance, including uniquely definable lymphatic drainage that can be easily accessed at the level of ipsilateral regional node beds. Thus, VCA offers a unique opportunity to assess the relative contribution of peripheral and secondary lymphoid tissue to the process of rejection. We transplanted hind limb grafts from C3H donors to six different groups of C57BL/6 recipients: Spleen+ Map3k14-/- ; Spleen- Map3k14-/- ; Spleen+ Node- Map3k14-/- ; and Spleen- Node- Map3k14-/- . As positive controls, we used Map3k14+/- with or without spleen. Map3k14+/- mice demonstrated an average graft survival of 9.6 and 9.2 days for Spleen- and Spleen+ Map3k14+/- , respectively. Rejection in the Map3k14-/- group was considerably delayed (28.4 days, P = 0.002) in all recipients. The Spleen- Map3k14-/- mice rejected their hind limb allografts in an even more delayed fashion compared to Spleen+ Map3k14-/- (54.4 days, P = 0.02). Histological analysis of skin showed that acute rejection in both Map3k14+/- mice groups was graded as Banff III or Banff IV. In the Map3k14-/- groups, rejection was graded as Banff III. We demonstrated that in the absence of lymph nodes, grafts reject in a delayed fashion. Also, splenectomy in alymphoplastic mice further extends graft survival, but does not eliminate rejection all together.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jun Wang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Mingqing Song
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Linda Stempora
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - William Parker
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Allan D Kirk
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Linda C Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Shaw BI, Lee HJ, Chan C, Ettenger R, Grimm P, Pearl M, Reed EF, Robien MA, Sarwal M, Stempora L, Warshaw B, Zhao C, Martinez OM, Kirk AD, Chambers ET. Relationship between antithymocyte globulin, T cell phenotypes, and clinical outcomes in pediatric kidney transplantation. Am J Transplant 2021; 21:766-775. [PMID: 33480466 PMCID: PMC7952017 DOI: 10.1111/ajt.16263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 06/25/2020] [Accepted: 08/03/2020] [Indexed: 01/25/2023]
Abstract
Depletional induction using antithymocyte globulin (ATG) reduces rates of acute rejection in adult kidney transplant recipients, yet little is known about its effects in children. Using a longitudinal cohort of 103 patients in the Immune Development in Pediatric Transplant (IMPACT) study, we compared T cell phenotypes after ATG or non-ATG induction. We examined the effects of ATG on the early clinical outcomes of alloimmune events (development of de novo donor specific antibody and/or biopsy proven rejection) and infection events (viremia/viral infections). Long-term patient and graft outcomes were examined using the Scientific Registry of Transplant Recipients. After ATG induction, although absolute counts of CD4 and CD8 T cells were lower, patients had higher percentages of CD4 and CD8 memory T cells with a concomitant decrease in frequency of naïve T cells compared to non-ATG induction. In adjusted and unadjusted models, ATG induction was associated with increased early event-free survival, with no difference in long-term patient or allograft survival. Decreased CD4+ naïve and increased CD4+ effector memory T cell frequencies were associated with improved clinical outcomes. Though immunologic parameters are drastically altered with ATG induction, long-term clinical benefits remain unclear in pediatric patients.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC, United States
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC United States
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC United States
| | - Robert Ettenger
- Department of Pediatrics, University of California Los Angeles, CA, United States
| | - Paul Grimm
- Department of Pediatrics, Stanford University, CA, United States
| | - Meghan Pearl
- Department of Pediatrics, University of California Los Angeles, CA, United States
| | - Elaine F Reed
- Department of Pathology, University of California, Los Angeles, CA, United States
| | - Mark A Robien
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States
| | - Minnie Sarwal
- Department of Surgery, University of California, San Francisco, CA, United States
| | - Linda Stempora
- Department of Surgery, Duke University, Durham, NC, United States
| | - Barry Warshaw
- Department of Pediatrics, Children’s Healthcare Atlanta, Atlanta, GA, United States
| | - Congwen Zhao
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC United States
| | | | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, United States,Department of Pediatrics, Duke University, CA, United States
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Levitsky J, Burrell BE, Kanaparthi S, Turka LA, Kurian S, Sanchez-Fueyo A, Lozano JJ, Demetris A, Lesniak A, Kirk AD, Stempora L, Yang GY, Mathew JM. Immunosuppression Withdrawal in Liver Transplant Recipients on Sirolimus. Hepatology 2020; 72:569-583. [PMID: 31721246 PMCID: PMC7217743 DOI: 10.1002/hep.31036] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS As conversion from calcineurin inhibitor to sirolimus (SRL), a mechanistic target of rapamycin inhibitor (mTOR-I), has been shown to enhance immunoregulatory profiles in liver transplant (LT) recipients (LTRs), mTOR-I therapy might allow for increased success of immunosuppression (IS) withdrawal. Our aim was to determine if operational tolerance could be observed in LTRs withdrawn from SRL and if blood/graft tolerance biomarkers were predictive of successful withdrawal. APPROACH AND RESULTS We performed a prospective trial of SRL monotherapy withdrawal in nonimmune, nonviremic LTRs > 3 years post-LT. SRL was weaned over ~6 months, and biopsies were performed 12 months postweaning or at concern for acute rejection. Twenty-one LTRs consented; 6 were excluded due to subclinical acute rejection on baseline biopsy or other reasons, and 15 underwent weaning (age 61.3 ± 8.8 years; LT to SRL weaning 6.7 ± 3 years). Eight (53%) achieved operational tolerance (TOL). Of the 7 who were nontolerant (non-TOL), 6 had mild acute rejection on biopsy near the end of weaning or at study end; 1 was removed from the trial due to liver cancer recurrence. At baseline preweaning, there were statistically increased blood tolerogenic dendritic cells and cell phenotypes correlating with chronic antigen presentation in the TOL versus non-TOL groups. A previously identified biopsy gene signature accurately predicted TOL versus non-TOL in 12/14 LTRs before weaning. At study end, biopsy staining revealed statistically significant increases in antigen-presenting cell:leukocyte pairings, FOXP3+ /CD4+ T cells, Tbet+ /CD8+ T cells, and lobular dendritic cells in the non-TOL group. CONCLUSIONS This study evaluated IS withdrawal directly from mTOR-I therapy in LTRs and achieved > 50% operational tolerance. Preweaning gene expression and peripheral blood mononuclear cell profiling may be useful as predictors of successful mTOR-I therapy withdrawal. NCT02062944.
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Affiliation(s)
- Josh Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Laurence A. Turka
- Immune Tolerance Network, Bethesda, MD; Massachusetts General Hospital, Boston, MA
| | - Sunil Kurian
- Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States
| | | | - Juan J. Lozano
- Biomedical Research Center in Hepatic and Digestive Diseases, Carlos III Health Institute, Barcelona, Spain
| | | | | | | | | | - Guang-Yu Yang
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James M. Mathew
- Northwestern University Feinberg School of Medicine, Chicago, IL
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9
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Atia A, Moris D, McRae M, Song M, Stempora L, Leopardi F, Williams K, Kwun J, Parker W, Cardones AR, Kirk AD, Cendales LC. Th17 cell inhibition in a costimulation blockade-based regimen for vascularized composite allotransplantation using a nonhuman primate model. Transpl Int 2020; 33:1294-1301. [PMID: 32277724 DOI: 10.1111/tri.13612] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/11/2020] [Accepted: 03/31/2020] [Indexed: 12/23/2022]
Abstract
Vascularized composite allotransplantation (VCA) is challenged by the morbidity of immunosuppression required to prevent rejection. The use of highly specific biologics has not been well explored in VCA. Given that psoriasis is T-cell mediated, as is rejection of skin-containing VCAs, we sought to assess the role of ustekinumab and secukinumab, which are approved to treat psoriasis by inhibiting Th17 cells. We combined these agents with belatacept and steroids in a VCA nonhuman primate model. Group I consisted of belatacept and steroids, group II was belatacept, ustekinumab with steroid taper, and group III was belatacept, secukinumab with steroid taper. Three animals were transplanted in each group. In group I, the mean graft survival time until the first sign of rejection was 10 days whereas in group II and III it was 10.33 and 11 days, respectively. The immunohistochemistry analysis showed that the number of IL-17a+ cells and the intensity of IL-17a expression were significantly reduced in both dermis and hypodermis parts in groups II and III when compared to group I (P < 0.01). Ustekinumab and secukinumab led to less T-cell infiltration and IL-17a expression in the allograft but provided no benefit to belatacept and steroids in VCA survival.
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Affiliation(s)
- Andrew Atia
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - MacKenzie McRae
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mingqing Song
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Linda Stempora
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Francis Leopardi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kyha Williams
- Division of Laboratory Animal Resources, Duke University Medical Center, Durham, NC, USA
| | - Jean Kwun
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - William Parker
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Adela R Cardones
- Department of Dermatology, Duke University Medical Center, Durham, NC, USA
| | - Allan D Kirk
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Linda C Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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10
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Weinhold KJ, Bukowski JF, Brennan TV, Noveck RJ, Staats JS, Lin L, Stempora L, Hammond C, Wouters A, Mojcik CF, Cheng J, Collinge M, Jesson MI, Hazra A, Biswas P, Lan S, Clark JD, Hodge JA. Reversibility of peripheral blood leukocyte phenotypic and functional changes after exposure to and withdrawal from tofacitinib, a Janus kinase inhibitor, in healthy volunteers. Clin Immunol 2018. [PMID: 29518577 DOI: 10.1016/j.clim.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This study evaluated the short-term effects of tofacitinib treatment on peripheral blood leukocyte phenotype and function, and the reversibility of any such effects following treatment withdrawal in healthy volunteers. Cytomegalovirus (CMV)-seropositive subjects received oral tofacitinib 10 mg twice daily for 4 weeks and were followed for 4 weeks after drug withdrawal. There were slight increases in total lymphocyte and total T-cell counts during tofacitinib treatment, and B-cell counts increased by up to 26%. There were no significant changes in granulocyte or monocyte counts, or granulocyte function. Naïve and central memory T-cell counts increased during treatment, while all subsets of activated T cells were decreased by up to 69%. T-cell subsets other than effector memory cluster of differentiation (CD)4+, activated naïve CD4+ and effector CD8+ T-cell counts and B-cell counts, normalized 4 weeks after withdrawal. Following ex vivo activation, measures of CMV-specific T-cell responses, and antigen non-specific T-cell-mediated cytotoxicity and interferon (IFN)-γ production, decreased slightly. These T-cell functional changes were most pronounced at Day 15, partially normalized while still on tofacitinib and returned to baseline after drug withdrawal. Total natural killer (NK)-cell counts decreased by 33%, returning towards baseline after drug withdrawal. NK-cell function decreased during tofacitinib treatment, but without a consistent time course across measured parameters. However, markers of NK-cell-mediated cytotoxicity, antibody-dependent cellular cytotoxicity and IFN-γ production were decreased up to 42% 1 month after drug withdrawal. CMV DNA was not detectable in whole blood, and there were no cases of herpes zoster reactivation. No new safety concerns arose. In conclusion, the effect of short-term tofacitinib treatment on leukocyte composition and function in healthy CMV+ volunteers is modest and largely reversible 4 weeks after withdrawal.
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Affiliation(s)
- Kent J Weinhold
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | | | - Todd V Brennan
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | - Robert J Noveck
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | - Janet S Staats
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | - Liwen Lin
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | - Linda Stempora
- Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
| | | | - Ann Wouters
- Pfizer Inc, 235 E 42(nd) Street, New York, NY 10017, USA.
| | | | - John Cheng
- Pfizer Inc, 558 Eastern Point Road, Groton, CT 06340, USA.
| | - Mark Collinge
- Pfizer Inc, 558 Eastern Point Road, Groton, CT 06340, USA.
| | | | - Anasuya Hazra
- Pfizer Inc, 500 Arcola Road, Collegeville, PA 19426, USA
| | - Pinaki Biswas
- Pfizer Inc, 235 E 42(nd) Street, New York, NY 10017, USA.
| | - Shuping Lan
- Pfizer Inc, 558 Eastern Point Road, Groton, CT 06340, USA.
| | - James D Clark
- Pfizer Inc, 1 Portland Street, Cambridge, MA 02138, USA.
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11
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Osborne R, Joshi MB, Lockley J, Stempora L, Harpole D, Cheeseman J. Separation and Lysing Agents Effect Peripheral Blood Mononuclear Cell Recovery Pre-and Post-Cryopreservation. Cryobiology 2018. [DOI: 10.1016/j.cryobiol.2017.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Furlan SN, Watkins B, Tkachev V, Flynn R, Cooley S, Ramakrishnan S, Singh K, Giver C, Hamby K, Stempora L, Garrett A, Chen J, Betz KM, Ziegler CGK, Tharp GK, Bosinger SE, Promislow DEL, Miller JS, Waller EK, Blazar BR, Kean LS. Transcriptome analysis of GVHD reveals aurora kinase A as a targetable pathway for disease prevention. Sci Transl Med 2016; 7:315ra191. [PMID: 26606970 DOI: 10.1126/scitranslmed.aad3231] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplant (HCT). However, our understanding of the molecular pathways that cause this disease remains incomplete, leading to inadequate treatment strategies. To address this, we measured the gene expression profile of nonhuman primate (NHP) T cells during acute GVHD. Utilizing microarray technology, we measured the expression profiles of CD3(+) T cells from five cohorts: allogeneic transplant recipients receiving (i) no immunoprophylaxis (No Rx), (ii) sirolimus monotherapy (Siro), (iii) tacrolimus-methotrexate (Tac-Mtx), as well as (iv) autologous transplant recipients (Auto) and (v) healthy controls (HC). This comparison allowed us to identify transcriptomic signatures specific for alloreactive T cells and determine the impact of both mTOR (mechanistic target of rapamycin) and calcineurin inhibition on GVHD. We found that the transcriptional profile of unprophylaxed GVHD was characterized by significant perturbation of pathways regulating T cell proliferation, effector function, and cytokine synthesis. Within these pathways, we discovered potentially druggable targets not previously implicated in GVHD, prominently including aurora kinase A (AURKA). Utilizing a murine GVHD model, we demonstrated that pharmacologic inhibition of AURKA could improve survival. Moreover, we found enrichment of AURKA transcripts both in allo-proliferating T cells and in sorted T cells from patients with clinical GVHD. These data provide a comprehensive elucidation of the T cell transcriptome in primate acute GVHD and suggest that AURKA should be considered a target for preventing GVHD, which, given the many available AURKA inhibitors in clinical development, could be quickly deployed for the prevention of GVHD.
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Affiliation(s)
- Scott N Furlan
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | | | - Victor Tkachev
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | - Ryan Flynn
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Sarah Cooley
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | - Karnail Singh
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Cindy Giver
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Kelly Hamby
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Linda Stempora
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | - Jingyang Chen
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | - Kayla M Betz
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA
| | | | - Gregory K Tharp
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA
| | - Steven E Bosinger
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA
| | - Daniel E L Promislow
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jeffrey S Miller
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Leslie S Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, the University of Washington, and the Fred Hutchinson Cancer Research Center, Seattle WA 98101, USA.
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13
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George RP, Mehta AK, Perez SD, Winterberg P, Cheeseman J, Johnson B, Kwun J, Monday S, Stempora L, Warshaw B, Kirk AD. Premature T Cell Senescence in Pediatric CKD. J Am Soc Nephrol 2016; 28:359-367. [PMID: 27413076 DOI: 10.1681/asn.2016010053] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/07/2016] [Indexed: 12/29/2022] Open
Abstract
An individual's immune function, susceptibility to infection, and response to immunosuppressive therapy are influenced in part by his/her T cell maturation state. Although childhood is the most dynamic period of immune maturation, scant information regarding the variability of T cell maturation in children with renal disease is available. In this study, we compared the T cell phenotype in children with renal failure (n=80) with that in healthy children (n=20) using multiparameter flow cytometry to detect markers of T cell maturation, exhaustion, and senescence known to influence immune function. We correlated data with the degree of renal failure (dialysis or nondialysis), prior immunosuppression use, and markers of inflammation (C-reactive protein and inflammatory cytokines) to assess the influence of these factors on T cell phenotype. Children with renal disease had highly variable and often markedly skewed maturation phenotypes, including CD4/CD8 ratio reversal, increased terminal effector differentiation in CD8+ T cells, reduction in the proportion of naïve T cells, evidence of T cell exhaustion and senescence, and variable loss of T cell CD28 expression. These findings were most significant in patients who had experienced major immune insults, particularly prior immunosuppressive drug exposure. In conclusion, children with renal disease have exceptional heterogeneity in the T cell repertoire. Cognizance of this heterogeneity might inform risk stratification with regard to the balance between infectious risk and response to immunosuppressive therapy, such as that required for autoimmune disease and transplantation.
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Affiliation(s)
- Roshan P George
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia; .,Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | - Aneesh K Mehta
- Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | - Sebastian D Perez
- Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | - Pamela Winterberg
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | | | - Brandi Johnson
- Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | - Jean Kwun
- Division of Surgery, Duke University, Durham, North Carolina
| | | | - Linda Stempora
- Division of Surgery, Duke University, Durham, North Carolina
| | - Barry Warshaw
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and
| | - Allan D Kirk
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Nephrology, Department of Pediatrics, Emory Transplant Center, Emory University, Atlanta, Georgia; and.,Division of Surgery, Duke University, Durham, North Carolina
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14
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Espinosa J, Herr F, Tharp G, Bosinger S, Song M, Farris AB, George R, Cheeseman J, Stempora L, Townsend R, Durrbach A, Kirk AD. CD57(+) CD4 T Cells Underlie Belatacept-Resistant Allograft Rejection. Am J Transplant 2016; 16:1102-12. [PMID: 26603381 PMCID: PMC4867077 DOI: 10.1111/ajt.13613] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/16/2015] [Accepted: 10/18/2015] [Indexed: 01/25/2023]
Abstract
Belatacept is a B7-specific fusion protein used to prevent allograft rejection by blocking T cell costimulation. Generally efficacious, it fails to prevent acute rejection in a sizable minority of patients. In experimental models, memory T cells mediate costimulation blockade-resistant rejection (CoBRR), but this remains undefined in humans. To explore relationships between individual patients' immune cell phenotypes and CoBRR, we studied patients receiving belatacept or conventional calcineurin inhibitor-based immunosuppression. We identified a population of CD57(+) PD1(-) CD4 T cells present prior to transplantation that correlated with CoBRR. Contrary to data recognizing CD57 as a marker of senescence on CD8 T cells, we discovered a nonsenescent, cytolytic phenotype associated with CD57 on CD4 T cells. Moreover, CD57(+) CD4 T cells expressed high levels of adhesion molecules implicated in experimental CoBRR, were CD28(-) , expressed a transcriptional phenotype broadly defining allograft rejection and were shown to be present in rejecting human kidney allografts. These data implicate CD57(+) CD4 T cells in clinical CoBRR. If prospectively validated, this characteristic could identify patients at higher risk for acute rejection on belatacept-based therapy.
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Affiliation(s)
- Jaclyn Espinosa
- Department of Surgery, Emory University, Atlanta, Georgia, USA,Department of Surgery, Duke University, Durham, North Carolina, USA
| | | | - Gregory Tharp
- Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Steven Bosinger
- Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Mingqing Song
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Roshan George
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Jennifer Cheeseman
- Department of Surgery, Emory University, Atlanta, Georgia, USA,Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Linda Stempora
- Department of Surgery, Emory University, Atlanta, Georgia, USA,Department of Surgery, Duke University, Durham, North Carolina, USA
| | | | - Antoine Durrbach
- INSERM UMR1014, Villejuif, France,Department of Nephrology, IFRNT, University of Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - Allan D. Kirk
- Department of Surgery, Emory University, Atlanta, Georgia, USA,Department of Surgery, Duke University, Durham, North Carolina, USA
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15
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Xu H, Samy KP, Guasch A, Mead SI, Ghali A, Mehta A, Stempora L, Kirk AD. Postdepletion Lymphocyte Reconstitution During Belatacept and Rapamycin Treatment in Kidney Transplant Recipients. Am J Transplant 2016; 16:550-64. [PMID: 26436448 PMCID: PMC4822163 DOI: 10.1111/ajt.13469] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/09/2015] [Accepted: 07/17/2015] [Indexed: 01/25/2023]
Abstract
Belatacept is used to prevent allograft rejection but fails to do so in a sizable minority of patients due to inadequate control of costimulation-resistant T cells. In this study, we report control of costimulation-resistant rejection when belatacept was combined with perioperative alemtuzumab-mediated lymphocyte depletion and rapamycin. To assess the means by which the alemtuzumab, belatacept and rapamycin (ABR) regimen controls belatacept-resistant rejection, we studied 20 ABR-treated patients and characterized peripheral lymphocyte phenotype and functional responses to donor, third-party and viral antigens using flow cytometry, intracellular cytokine staining and carboxyfluorescein succinimidyl ester-based lymphocyte proliferation. Compared with conventional immunosuppression in 10 patients, lymphocyte depletion evoked substantial homeostatic lymphocyte activation balanced by regulatory T and B cell phenotypes. The reconstituted T cell repertoire was enriched for CD28(+) naïve cells, notably diminished in belatacept-resistant CD28(-) memory subsets and depleted of polyfunctional donor-specific T cells but able to respond to third-party and latent herpes viruses. B cell responses were similarly favorable, without alloantibody development and a reduction in memory subsets-changes not seen in conventionally treated patients. The ABR regimen uniquely altered the immune profile, producing a repertoire enriched for CD28(+) T cells, hyporesponsive to donor alloantigen and competent in its protective immune capabilities. The resulting repertoire was permissive for control of rejection with belatacept monotherapy.
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Affiliation(s)
- He Xu
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Kannan P. Samy
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | - Sue I. Mead
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Ada Ghali
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Aneesh Mehta
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Linda Stempora
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Allan D. Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC,Emory Transplant Center, Emory University, Atlanta, GA
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16
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Freitas AM, Samy KP, Farris AB, Leopardi FV, Song M, Stempora L, Strobert EA, Jenkins JA, Kirk AD, Cendales LC. Studies Introducing Costimulation Blockade for Vascularized Composite Allografts in Nonhuman Primates. Am J Transplant 2015; 15:2240-9. [PMID: 26139552 PMCID: PMC4918096 DOI: 10.1111/ajt.13379] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 01/25/2023]
Abstract
Vascularized composite allografts (VCAs) are technically feasible. Similar to other organ transplants, VCAs are hampered by the toxicity and incomplete efficacy associated with conventional immunosuppression. Complications attributable to calcineurin inhibitors remain prevalent in the clinical cases reported to date, and these loom particularly large given the nonlifesaving nature of VCAs. Additionally, acute rejection remains almost ubiquitous, albeit controllable with current agents. Costimulation blockade offers the potential to provide prophylaxis from rejection without the adverse consequences of calcineurin-based regimens. In this study, we used a nonhuman-primate model of VCA in conjunction with immunosuppressive regimens containing combinations of B7-specific costimulation blockade with and without adhesion blockade with LFA3-Ig to determine what adjunctive role these agents could play in VCA transplantation when combined with more conventional agents. Compared to tacrolimus, the addition of belatacept improved rejection free allograft survival. The combination with LFA3-Ig reduced CD2(hi) memory T cells, however did not provide additional protection against allograft rejection and hindered protective immunity. Histology paralleled clinical histopathology and Banff grading. These data provide the basis for the study of costimulation blockade in VCA in a relevant preclinical model.
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Affiliation(s)
- AM Freitas
- Emory Transplant Center, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322
| | - KP Samy
- Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
| | - AB Farris
- Department of Pathology & Laboratory Medicine, Emory University, 1364 Clifton Road NE, Atlanta, GA 30322
| | - FV Leopardi
- Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
| | - M Song
- Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
| | - L Stempora
- Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
| | - EA Strobert
- Yerkes National Primate Research Center, 954 Gatewood Road NE, Atlanta, GA 30329
| | - JA Jenkins
- Yerkes National Primate Research Center, 954 Gatewood Road NE, Atlanta, GA 30329
| | - AD Kirk
- Emory Transplant Center, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322
,Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
| | - LC Cendales
- Department of Surgery, Duke University Medical Center, 200 Trent Drive, Baker House #129, DUMC 3098, Durham, NC 27710
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17
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Mou D, Espinosa JE, Stempora L, Iwakoshi NN, Kirk AD. Viral-induced CD28 loss evokes costimulation independent alloimmunity. J Surg Res 2015; 196:241-6. [PMID: 25801976 DOI: 10.1016/j.jss.2015.02.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/21/2015] [Accepted: 02/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Belatacept, a B7-specific fusion protein, blocks CD28-B7 costimulation and prevents kidney allograft rejection. However, it is ineffective in a sizable minority of patients. Although T-cell receptor and CD28 engagement are known to initiate T-cell activation, many human antigen-experienced T-cells lose CD28, and can be activated independent of CD28 signals. We posit that these cells are central drivers of costimulation blockade resistant rejection (CoBRR) and propose that CoBRR might relate to an accumulation of CD28(-) T-cells resulting from viral antigen exposure. MATERIALS AND METHODS We infected C57BL/6 mice with polyomavirus (a BK virus analog), murine cytomegalovirus (a human cytomegalovirus analog), and gammaherpesvirus (HV68; an Epstein-Barr virus analog) and assessed for CD28 expression relative to mock infection controls. We then used mixed lymphocyte reaction (MLR) assays to assess the alloreactive response of these mice against major histocompatibility complex-mismatched cells. RESULTS We demonstrated that infection with polyomavirus, murine CMV, and HV68 can induce CD28 downregulation in mice. We showed that these analogs of clinically relevant human viruses enable lymphocytes from infected mice to launch an anamnestic, costimulation blockade resistant, alloreactive response against major histocompatibility complex-mismatched cells without prior alloantigen exposure. Further analysis revealed that gammherpesvirus-induced oligoclonal T-cell expansion is required for the increased alloreactivity. CONCLUSIONS Virus exposure results in reduced T-cell expression of CD28, the target of costimulation blockade therapy. These viruses also contribute to increased alloreactivity. Thus, CD28 downregulation after viral infection may play a seminal role in driving CoBRR.
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Affiliation(s)
- Danny Mou
- Department of Surgery, Emory University, Atlanta, Georgia.
| | | | - Linda Stempora
- Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Allan D Kirk
- Department of Surgery, Duke University, Durham, North Carolina
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18
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Singh K, Stempora L, R. Donald H, Kirk AD, Larsen CP, Blazar BR, Kean LS. Superiority of rapamycin over tacrolimus in preserving nonhuman primate Treg half-life and phenotype after adoptive transfer. Am J Transplant 2014; 14:2691-703. [PMID: 25359003 PMCID: PMC4236286 DOI: 10.1111/ajt.12934] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/22/2014] [Accepted: 06/05/2014] [Indexed: 01/25/2023]
Abstract
Many critical issues remain concerning how best to deploy adoptive regulatory T cell (Treg) immunotherapy to the clinic. These include a determination of their pharmacokinetic characteristics, their optimal dose, their phenotypic stability and the best therapies with which to pair Tregs. By performing a CFSE-labeled autologous Treg pulse experiment, we determined that the accessible peripheral blood Treg pool in rhesus macaques is quite large (75 ± 11 × 10(6) Tregs/kg). Pharmacokinetic analysis revealed that Tregs have two phases of elimination: an α phase, with a T1/2 in the peripheral blood of 32.4 ± 11.3 h and a β phase with a T1/2 of 120.4 ± 19.7 h. In addition to their short initial half-life, Tregs underwent rapid phenotypic shifts after infusion, with significant loss of both CD25 and FoxP3 by day +6. While tacrolimus stabilized CD25 expression, it did not improve T1/2 , nor mitigate the loss of FoxP3. In contrast, rapamycin significantly stabilized both CD25 and FoxP3, and supported an increased half-life, with an α phase of 67.7 ± 6.9 h and a β phase of 252.1 ± 54.9 h. These results suggest that rapamycin may be a necessary addition to Treg immunotherapy, and that tacrolimus may be deleterious to Treg integrity posttransfer.
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Affiliation(s)
- K Singh
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - L Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Harvey R. Donald
- Division of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta GA 30322
| | - AD Kirk
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - CP Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - BR Blazar
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN
| | - LS Kean
- Department of Pediatrics, Emory University School of Medicine, Atlanta GA,Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle, WA
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Xu H, Cheeseman J, Stempora L, Kirk A. Measurement of T Cell Homeostatic Activation and Proliferation Following T Cell Depletion With Alemtuzumab. Transplantation 2014. [DOI: 10.1097/00007890-201407151-01947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Kozyr N, Ziegler C, Ramakrishnan S, Polnett A, Hamby K, Deane T, Stempora L, Blazar BR, Kean LS. Defining the GvHD Transcriptome: Network Analysis Identifies the Key Pathways Responsible for Primate GvHD Pathogenesis and the Mechanisms of Partial GvHD Control with Sirolimus. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Kozyr N, Ramakrishnan S, Polnett A, Hamby K, Tiwari D, Watkins B, Deane T, Stempora L, Elder E, Esiashvili N, Jenkins J, Strobert E, Garcia A, Sharma P, Courtney C, Giver C, Waller EK, Mortari A, Blazar BR, Kean LS. Synergistic Control of Acute GvHD: Effectively Down-Regulating T Cell Proliferation and Cytotoxicity with Combined mTOR Inhibition and CD28:CD80/86 Costimulation Blockade. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Ramakrishnan SK, Page A, Farris AB, Singh K, Leopardi F, Hamby K, Sen S, Polnett A, Deane T, Song M, Stempora L, Strobert E, Kirk AD, Larsen CP, Kean LS. Evidence for kidney rejection after combined bone marrow and renal transplantation despite ongoing whole-blood chimerism in rhesus macaques. Am J Transplant 2012; 12:1755-64. [PMID: 22642491 PMCID: PMC3387328 DOI: 10.1111/j.1600-6143.2012.04045.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although there is evidence linking hematopoietic chimerism induction and solid organ transplant tolerance, the mechanistic requirements for chimerism-induced tolerance are not clearly elucidated. To address this, we used an MHC-defined primate model to determine the impact of impermanent, T cell-poor, mixed-chimerism on renal allograft survival. We compared two cohorts: one receiving a bone marrow and renal transplant ("BMT/renal") and one receiving only a renal transplant. Both cohorts received maintenance immunosuppression with CD28/CD40-directed costimulation blockade and sirolimus. As previously demonstrated, this transplant strategy consistently induced compartmentalized donor chimerism, (significant whole-blood chimerism, lacking T cell chimerism). This chimerism was not sufficient to prolong renal allograft acceptance: the BMT/renal mean survival time (MST, 76 days) was not significantly different than the renal transplant alone MST (85 days, p = 0.46), with histopathology documenting T cell mediated rejection. Flow cytometric analysis revealed significant enrichment for CD28-/CD95+ CD4+ and CD8+ Tem cells in the rejected kidney, suggesting a link between CD28-negative Tem and costimulation blockade-resistant rejection. These results suggest that in some settings, transient T cell-poor chimerism is not sufficient to induce tolerance to a concurrently placed renal allograft and that the presence of this chimerism per se is not an independent biomarker to identify tolerance.
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Affiliation(s)
- Swetha K Ramakrishnan
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Andrew Page
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Alton B. Farris
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Department of Pathology, Emory University School of Medicine, Atlanta GA 30322
| | - Karnail Singh
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Frank Leopardi
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Kelly Hamby
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Sharon Sen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | | | - Taylor Deane
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Mingqing Song
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Linda Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Elizabeth Strobert
- The Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322
| | - Allan D. Kirk
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Christian P. Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Leslie S. Kean
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Aflac Cancer Center and Blood Disorders Service, Department of Pediatrics and The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Corresponding Author Contact Information: Leslie S. Kean, 101 Woodruff Circle, NE, Room 5203, Emory University School of Medicine, Atlanta, GA 30322, Department Fax: 404-727-3660 Phone: 404-727-5265
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Singh K, Kozyr N, Stempora L, Kirk A, Larsen C, Blazar B, Kean L. Regulatory T cells exhibit decreased proliferation but enhanced suppression after pulsing with sirolimus. Am J Transplant 2012; 12:1441-57. [PMID: 22300641 PMCID: PMC3471086 DOI: 10.1111/j.1600-6143.2011.03963.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although regulatory T cells (Tregs) suppress allo-immunity, difficulties in their large-scale production and in maintaining their suppressive function after expansion have thus far limited their clinical applicability. Here we have used our nonhuman primate model to demonstrate that significant ex vivo Treg expansion with potent suppressive capacity can be achieved and that Treg suppressive capacity can be further enhanced by their exposure to a short pulse of sirolimus. Both unpulsed and sirolimus-pulsed Tregs (SPTs) are capable of inhibiting proliferation of multiple T cell subpopulations, including CD4(+) and CD8(+) T cells, as well as antigen-experienced CD28(+) CD95(+) memory and CD28(-) CD95(+) effector subpopulations. We further show that Tregs can be combined in vitro with CTLA4-Ig (belatacept) to lead to enhanced inhibition of allo-proliferation. SPTs undergo less proliferation in a mixed lymphocyte reaction (MLR) when compared with unpulsed Tregs, suggesting that Treg-mediated suppression may be inversely related to their proliferative capacity. SPTs also display increased expression of CD25 and CTLA4, implicating signaling through these molecules in their enhanced function. Our results suggest that the creation of SPTs may provide a novel avenue to enhance Treg-based suppression of allo-immunity, in a manner amenable to large-scale ex vivo expansion and combinatorial therapy with novel, costimulation blockade-based immunosuppression strategies.
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Affiliation(s)
- K. Singh
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - N. Kozyr
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - L. Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - A.D. Kirk
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - C.P. Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - B.R. Blazar
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN
| | - L.S. Kean
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA,Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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Page A, Srinivasan S, Singh K, Russell M, Hamby K, Deane T, Sen S, Stempora L, Leopardi F, Price AA, Strobert E, Reimann KA, Kirk AD, Larsen CP, Kean LS. CD40 blockade combines with CTLA4Ig and sirolimus to produce mixed chimerism in an MHC-defined rhesus macaque transplant model. Am J Transplant 2012; 12:115-25. [PMID: 21929643 PMCID: PMC3259212 DOI: 10.1111/j.1600-6143.2011.03737.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In murine models, T-cell costimulation blockade of the CD28:B7 and CD154:CD40 pathways synergistically promotes immune tolerance after transplantation. While CD28 blockade has been successfully translated to the clinic, translation of blockade of the CD154:CD40 pathway has been less successful, in large part due to thromboembolic complications associated with anti-CD154 antibodies. Translation of CD40 blockade has also been slow, in part due to the fact that synergy between CD40 blockade and CD28 blockade had not yet been demonstrated in either primate models or humans. Here we show that a novel, nondepleting CD40 monoclonal antibody, 3A8, can combine with combined CTLA4Ig and sirolimus in a well-established primate bone marrow chimerism-induction model. Prolonged engraftment required the presence of all three agents during maintenance therapy, and resulted in graft acceptance for the duration of immunosuppressive treatment, with rejection resulting upon immunosuppression withdrawal. Flow cytometric analysis revealed that upregulation of CD95 expression on both CD4+ and CD8+ T cells correlated with rejection, suggesting that CD95 may be a robust biomarker of graft loss. These results are the first to demonstrate prolonged chimerism in primates treated with CD28/mTOR blockade and nondepletional CD40 blockade, and support further investigation of combined costimulation blockade targeting the CD28 and CD40 pathways.
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Affiliation(s)
- Andrew Page
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Swetha Srinivasan
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Karnail Singh
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Maria Russell
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Kelly Hamby
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Taylor Deane
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Sharon Sen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Linda Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Frank Leopardi
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | | | - Elizabeth Strobert
- The Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322
| | | | - Allan D. Kirk
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Christian P. Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Leslie S. Kean
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Aflac Cancer Center and Blood Disorders Service, Department of Pediatrics and The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Corresponding Author Contact Information: Leslie S. Kean, 101 Woodruff Circle, NE, Room 5203, Emory University School of Medicine, Atlanta, GA 30322 Department Fax: 404-727-3660 Phone: 404-727-5265
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Floyd TL, Koehn BH, Kitchens WH, Robertson JM, Cheeseman JA, Stempora L, Larsen CP, Ford ML. Limiting the amount and duration of antigen exposure during priming increases memory T cell requirement for costimulation during recall. J Immunol 2011; 186:2033-41. [PMID: 21257960 DOI: 10.4049/jimmunol.1003015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Donor-reactive memory T cells (Tmem) can play an important role in mediating graft rejection after transplantation. Transplant recipients acquire donor-reactive Tmem not only through prior sensitization with alloantigens but also through previous exposure to environmental pathogens that are cross-reactive with allogeneic peptide-MHC complexes. Current dogma suggests that most, if not all, Tmem responses are independent of the requirement for CD28 and/or CD154/CD40-mediated costimulation to mount a recall response. However, heterogeneity among Tmem is increasingly being appreciated, and one important factor known to impact the function and phenotype of Ag-specific T cell responses is the amount/duration of Ag exposure. Importantly, the impact of Ag exposure on development of costimulation independence is currently unknown. In this study, we interrogated the effect of decreased Ag amount/duration during priming on the ability of donor-reactive Tmem to mediate costimulation blockade-resistant rejection during a recall response after transplantation in a murine model. Recipients possessing donor-reactive Tmem responses that were generated under conditions of reduced Ag exposure exhibited similar frequencies of Ag-specific T cells at day 30 postinfection, but, strikingly, failed to mediate costimulation blockade-resistant rejection after challenge with an OVA-expressing skin graft. Thus, these data demonstrate the amount/duration of Ag exposure is a critical factor in determining Tmem's relative requirement for costimulation during the recall response after transplantation.
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Affiliation(s)
- Tamara L Floyd
- Department of Surgery and Emory Transplant Center, Emory University, Atlanta, GA 30322, USA
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26
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Lo DJ, Weaver TA, Stempora L, Mehta AK, Ford ML, Larsen CP, Kirk AD. Selective targeting of human alloresponsive CD8+ effector memory T cells based on CD2 expression. Am J Transplant 2011; 11:22-33. [PMID: 21070604 PMCID: PMC3057516 DOI: 10.1111/j.1600-6143.2010.03317.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Costimulation blockade (CoB), specifically CD28/B7 inhibition with belatacept, is an emerging clinical replacement for calcineurin inhibitor-based immunosuppression in allotransplantation. However, there is accumulating evidence that belatacept incompletely controls alloreactive T cells that lose CD28 expression during terminal differentiation. We have recently shown that the CD2-specific fusion protein alefacept controls costimulation blockade-resistant allograft rejection in nonhuman primates. Here, we have investigated the relationship between human alloreactive T cells, costimulation blockade sensitivity and CD2 expression to determine whether these findings warrant potential clinical translation. Using polychromatic flow cytometry, we found that CD8(+) effector memory T cells are distinctly high CD2 and low CD28 expressors. Alloresponsive CD8(+) CD2(hi) CD28(-) T cells contained the highest proportion of cells with polyfunctional cytokine (IFNγ, TNF and IL-2) and cytotoxic effector molecule (CD107a and granzyme B) expression capability. Treatment with belatacept in vitro incompletely attenuated allospecific proliferation, but alefacept inhibited belatacept-resistant proliferation. These results suggest that highly alloreactive effector T cells exert their late stage functions without reliance on ongoing CD28/B7 costimulation. Their high CD2 expression increases their susceptibility to alefacept. These studies combined with in vivo nonhuman primate data provide a rationale for translation of an immunosuppression regimen pairing alefacept and belatacept to human renal transplantation.
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Affiliation(s)
- D J Lo
- Emory Transplant Center, Emory University, Atlanta, GA, USA
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Larsen CP, Page A, Linzie KH, Russell M, Deane T, Stempora L, Strobert E, Penedo MCT, Ward T, Wiseman R, O'Connor D, Miller W, Sen S, Singh K, Kean LS. An MHC-defined primate model reveals significant rejection of bone marrow after mixed chimerism induction despite full MHC matching. Am J Transplant 2010; 10:2396-409. [PMID: 20849552 PMCID: PMC2980834 DOI: 10.1111/j.1600-6143.2010.03272.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In murine models, mixed hematopoietic chimerism induction leads to robust immune tolerance. However, translation to primates and to patients has been difficult. In this study, we used a novel MHC-defined rhesus macaque model to examine the impact of MHC matching on the stability of costimulation blockade-/sirolimus-mediated chimerism, and to probe possible mechanisms of bone marrow rejection after nonmyeloablative transplant. Using busulfan-based pretransplant preparation and maintenance immunosuppression with sirolimus, as well as CD28 and CD154 blockade, all recipients demonstrated donor engraftment after transplant. However, the mixed chimerism that resulted was compartmentalized, with recipients demonstrating significantly higher whole blood chimerism compared to T cell chimerism. Thus, the vast majority of T cells presenting posttransplant were recipient-rather than donor-derived. Surprisingly, even in MHC-matched transplants, rejection of donor hematopoiesis predominated after immunosuppression withdrawal. Weaning of immunosuppression was associated with a surge of antigen-experienced T cells, and transplant rejection was associated with the acquisition of donor-directed T cell alloreactivity. These results suggest that a reservoir of alloreactive cells was present despite prior costimulation blockade and sirolimus, and that the post-immunosuppression lymphocytic rebound may have lead to a phenotypic shift in these recipient T cells towards an activated, antigen-experienced phenotype, and ultimately, to transplant rejection.
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Affiliation(s)
- Christian P. Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Andrew Page
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Kelly Hamby Linzie
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Maria Russell
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Taylor Deane
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Linda Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Elizabeth Strobert
- The Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322
| | | | - Thea Ward
- Veterinary Genetics Laboratory, University of California, Davis, Davis California, 95616
| | - Roger Wiseman
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison WI, 53715
| | - David O'Connor
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison WI, 53715
| | - Weston Miller
- Aflac Cancer Center and Blood Disorders Service, Department of Pediatrics and The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Sharon Sen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Karnail Singh
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Leslie S. Kean
- Aflac Cancer Center and Blood Disorders Service, Department of Pediatrics and The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322,Corresponding Author Contact Information: Leslie S. Kean, 101 Woodruff Circle, NE, Room 5203, Emory University School of Medicine, Atlanta, GA 30322 Department Fax: 404-727-3660 Phone: 404-727-5265
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28
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Weaver TA, Charafeddine AH, Agarwal A, Turner AP, Russell M, Leopardi FV, Kampen RL, Stempora L, Song M, Larsen CP, Kirk AD. Alefacept promotes co-stimulation blockade based allograft survival in nonhuman primates. Nat Med 2009; 15:746-9. [PMID: 19584865 PMCID: PMC2772128 DOI: 10.1038/nm.1993] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 06/03/2009] [Indexed: 12/12/2022]
Abstract
Memory T-cells promote allograft rejection particularly in costimulation blockade (CoB)-based immunosuppressive regimens. Here we show that the CD2-specific fusion protein alefacept (LFA3-Ig) selectively eliminates memory T-cells and when combined with a CoB-based regimen utilizing CTLA4-Ig, prevents renal allograft rejection and alloantibody formation in primates. These results support the development of an immediately translatable regimen for the prevention of allograft rejection without the use of calcineurin inhibitors, steroids, or pan-T-cell depletion.
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Affiliation(s)
- Tim A Weaver
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, US National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
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29
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Anderson A, Martens C, Hendrix R, Stempora L, Miller W, Hamby K, Russell M, Strobert E, Blazar BR, Pearson TC, Larsen CP, Kean LS. Expanded nonhuman primate tregs exhibit a unique gene expression signature and potently downregulate alloimmune responses. Am J Transplant 2008; 8:2252-64. [PMID: 18801023 PMCID: PMC2874242 DOI: 10.1111/j.1600-6143.2008.02376.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We have established two complementary strategies for purifying naturally occurring regulatory T cells (Tregs) from rhesus macaques in quantities that would be sufficient for use as an in vivo cellular therapeutic. The first strategy identified Tregs based on their being CD4+/CD25(bright). The second incorporated CD127, and purified Tregs based on their expression of CD4 and CD25 and their low expression of CD127. Using these purification strategies, we were able to purify as many as 1x10(6) Tregs from 120 cc of peripheral blood. Cultures of these cells with anti-CD3, anti-CD28 and IL-2 over 21 days yielded as much as a 450-fold expansion, ultimately producing as many as 4.7x10(8) Tregs. Expanded Treg cultures potently inhibited alloimmune proliferation as measured by a carboxyfluorescein succinimidyl ester- mixed lymphocyte reaction (CFSE-MLR) assay even at a 1:100 ratio with responder T cells. Furthermore, both responder-specific and third-party Tregs downregulated alloproliferation similarly. Both freshly isolated and cultured Tregs had gene expression signatures distinguishable from concurrently isolated bulk CD4+ T-cell populations, as measured by singleplex reverse transcriptase-polymerase chain reaction (RT-PCR) and gene array. Moreover, an overlapping yet distinct gene expression signature seen in freshly isolated compared to expanded Tregs identifies a subset of Treg genes likely to be functionally significant.
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Affiliation(s)
- Alan Anderson
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Christine Martens
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Rose Hendrix
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Linda Stempora
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Wes Miller
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
,The Aflac Cancer Center and Blood Disorders Clinic, Division of Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322
| | - Kelly Hamby
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Maria Russell
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Elizabeth Strobert
- Yerkes National Primate Research Center, Emory University School of Medicine, Atlanta, GA 30322
| | - Bruce R. Blazar
- Cancer Center and Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455
| | - Thomas C. Pearson
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Christian P. Larsen
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Leslie S. Kean
- The Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
,The Aflac Cancer Center and Blood Disorders Clinic, Division of Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322
,
corresponding author.
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30
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Kean LS, Anderson AR, Oliva VL, Stempora L, Rigby MR, Pearson TC, Larsen CP. Immune monitoring in nonhuman primate transplantation. A review of “Non-human primate transplantation tolerance models: Immune Assays and Analysis Workshop” held in Atlanta, Ga, September 2005. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2006.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kean LS, Hamby K, Koehn B, Lee E, Coley S, Stempora L, Adams AB, Heiss E, Pearson TC, Larsen CP. NK cells mediate costimulation blockade-resistant rejection of allogeneic stem cells during nonmyeloablative transplantation. Am J Transplant 2006; 6:292-304. [PMID: 16426313 DOI: 10.1111/j.1600-6143.2005.01172.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although T-cell CD28/CD40 costimulation blockade represents a powerful mechanism to promote immune tolerance during murine allotransplantation, it has not yet been successfully translated to clinical transplantation. We determined the impact of natural killer (NK) cells on costimulation blockade-resistant rejection of donor bone marrow. We found that NK cells represent a potent barrier to engraftment: host NK depletion led to increased donor stem cell survival, increased mixed hematopoietic chimerism and to engraftment of low doses of donor marrow (1 x 10(8)/kg) that were otherwise rejected. To understand the mechanisms of NK alloreactivity, we employed an in vivo NK-specific cytotoxicity assay. We found that an increased proportion of target cells were killed between days 2 and 8 after cell transfer, and that NK killing of parental targets was inducible: NK cells preprimed with allotargets were more efficient at their elimination upon reexposure. Finally, both transplant and in vivo NK-killing models were used to determine the contribution of LFA-1 to NK alloreactivity. Blockade of LFA-1 led to decreased NK-mediated killing, and increased alloengraftment. These results identify NK alloreactivity as an integral component to costimulation blockade-resistant rejection, and suggest that its inhibition may represent an important target in the clinical translation of tolerance-induction transplantation.
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Affiliation(s)
- L S Kean
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
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Abstract
The expression of lymphoid-associated antigens (LAA) on blasts in acute myeloid leukemia (AML) and myeloproliferative disorders in myeloid blast crisis (MPD/MBC) has often been used to establish a diagnosis of acute mixed lineage leukemia (AMLL). The purpose of this study was to determine the incidence of LAA expression in AML and MPD/MBC (Ly + AML); to assess lymphoid differentiation at the genomic level in Ly + AML; and to compare features of Ly + AML with AML and MPD/MBC lacking these antigens (Ly-AML). Seventy-four consecutive cases of AML and MPD/MBC were reviewed for blast morphology, TdT reactivity, and cytochemistry results. Blast immunophenotyping was performed by multiparameter flow cytometry. Acute myeloid leukemia was subtyped according to the FAB classification. Acute myeloid leukemia and MPD/MBC cases expressing one or more of the following antigens, CD2, CD3, CD5, CD7, CD19, or CD20, were considered to be Ly + AML. Immunoglobulin (Ig) and T-cell receptor (TCR) gene rearrangement studies were performed by Southern blot analysis using probes for JH, Jkappa, and JBI/BII. Sixteen of the 74 cases (22%) were identified as Ly + AML. Of these, the T-cell-associated markers CD7, CD2, and CD5 were expressed on 7(44%), 6(38%), and 4(25%) Ly + AML cases, respectively. The B-cell-associated markers CD19 and CD20 were expressed on two cases (13%) and one (6%) case, respectively. The FAB subtypes were similarly represented among Ly + AML and Ly-AML. Expression of LAA did not correlate with TdT positivity. In nine cases of Ly + AML (7 expressing T-cell-associated antigens and two expressing B-cell-associated antigens), Southern blot analysis revealed no Ig or TCR gene rearrangements. These results suggest that expression of CD2, CD5, and CD7 in otherwise straightforward AML should not be taken as evidence of lymphoid lineage commitment and does not warrant a diagnosis of AMLL.
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MESH Headings
- Acute Disease
- Adult
- Aged
- Antigens, CD/analysis
- Antigens, CD/biosynthesis
- Antigens, Neoplasm/immunology
- B-Lymphocytes/immunology
- Female
- Flow Cytometry
- Gene Rearrangement, T-Lymphocyte
- Histocytochemistry
- Humans
- Immunoglobulin Fab Fragments/immunology
- Immunophenotyping
- Leukemia, Biphenotypic, Acute/pathology
- Leukemia, Biphenotypic, Acute/physiopathology
- Leukemia, Myeloid/immunology
- Leukemia, Myeloid/pathology
- Male
- Middle Aged
- Retrospective Studies
- T-Lymphocytes/immunology
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Affiliation(s)
- T M Launder
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Chryssochoos JT, Weber CJ, Cohen C, Moore J, DeRose PB, Hagler M, Bray R, Stempora L, Mainiero M, McGarity WC. DNA index and ploidy distinguish normal human parathyroids from parathyroid adenomas and primary hyperplastic parathyroids. Surgery 1995; 118:1041-9; discussion 1049-50. [PMID: 7491521 DOI: 10.1016/s0039-6060(05)80112-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The goal of this study was to identify factors that might aid in diagnosis and intraoperative management of hyperparathyroidism. METHODS We analyzed biopsy specimens of 242 parathyroids from 159 patients by use of flow cytometry and image cytometry (ICM) for DNA index (DI), defined as the content of nuclear DNA compared with that expected for a DNA diploid standard, for proliferative index (PI), and for ploidy (diploid versus aneuploid or tetraploid). RESULTS True normal and normal parathyroids from patients with solitary adenomas were uniformly diploid. Abnormal ploidy (aneuploidy or tetraploidy) was identified frequently in adenomas and occasionally in hyperplasias with the exception that multiple endocrine neoplasia (MEN) biopsy specimens were uniformly diploid. DI for adenomas was similar to that for hyperplasias, and DI of both was higher than for normal glands. ICM-DI correlated positively with flow cytometry-DI and patient age and inversely with serum parathyroid hormone. PI was relatively low in all groups but was higher for hyperplasias versus normal parathyroids from patients with solitary adenomas and MEN versus non-MEN. PI correlated inversely with patient age. CONCLUSIONS DI by ICM differentiates normal from abnormal parathyroids. DI might influence extent of resection in two- and three-gland hyperplasia and selection of the most appropriate gland for autografting and cryopreservation in patients with four-gland hyperplasia.
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Affiliation(s)
- J T Chryssochoos
- Department of Surgery, Emory University School of Medicine, Atlanta, Ga 30308, USA
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