Predicting Immuno-Metabolic Complications After Allogeneic Hematopoietic Cell Transplant with the Cytokine Interleukin-33 (IL-33) and its Receptor Serum-Stimulation 2 (ST2)

Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for numerous acute and long-term complications from this procedure. Post-transplant diabetes mellitus (PTDM) is a common but under-recognized problem. Similar to graft-versus-host disease (GVHD), new-onset diabetes is characterized by immune dysregulation that can negatively impact transplant outcomes. This review will discuss the biology of IL-33/ST2 in acute GVHD and PTDM development, and how this cytokine axis could be leveraged for predicting and treating immuno-metabolic complications after transplant.

Nrf2 regulates CD4+ T cell-induced acute graft-versus-host disease in mice

Nuclear factor erythroid-derived 2-like 2 (Nrf2) is a ubiquitously expressed transcription factor that is well known for its role in regulating the cellular redox pathway. Although there is mounting evidence suggesting a critical role for Nrf2 in hematopoietic stem cells and innate leukocytes, little is known about its involvement in T-cell biology. In this study, we identified a novel role for Nrf2 in regulating alloreactive T-cell function during allogeneic hematopoietic cell transplantation (allo-HCT). We observed increased expression and nuclear translocation of Nrf2 upon T-cell activation in vitro, especially in CD4+ donor T cells after allo-HCT. Allo-HCT recipients of Nrf2 -/- donor T cells had significantly less acute graft-versus-host disease (GVHD)-induced mortality, morbidity, and pathology. This reduction in GVHD was associated with the persistence of Helios+ donor regulatory T cells in the allograft, as well as defective upregulation of the gut-homing receptor LPAM-1 on alloreactive CD8+ T cells. Additionally, Nrf2 -/- donor CD8+ T cells demonstrated intact cytotoxicity against allogeneic target cells. Tumor-bearing allo-HCT recipients of Nrf2 -/- donor T cells had overall improved survival as a result of preserved graft-versus-tumor activity and reduced GVHD activity. Our findings characterized a previously unrecognized role for Nrf2 in T-cell function, as well as revealed a novel therapeutic target to improve the outcomes of allo-HCT.

Oral mycoses and other opportunistic infections in HIV: therapy and emerging problems - a workshop report

Oral mycoses and other opportunistic infections are recognized features of HIV infection even after four decades of the epidemic. The therapeutic options, challenges of therapy, and evolving patterns of opportunistic infections were evaluated by the workshop. It was observed that high Candida counts and infection are still more prevalent in HIV-positive individuals even in the era of antiretroviral therapy. Furthermore, one or more non-Candida albicans are present in some HIV-positive individuals. While Candida species are more virulent in HIV infection, similar virulence may be present in other states of immunosuppression. Consequently, the interplay between host factors and virulence ultimately determines the clinical outcomes. Adverse clinical outcomes such as candidemia and other deep fungal infections are on the increase in HIV infection. Disseminated histoplasmosis and penicilliosis have been reported, especially with low CD4 counts. Even with advances in antifungal therapy, mortality and morbidity from deep fungal infections have not changed significantly. In addition, long-term exposure to common antifungal drugs such as fluconazole has led to the development of antifungal resistance in 6% to 36%. Development of new antifungal therapeutic agents and the use of alternative therapies may offer breakthrough. In addition, effective strategies to enhance the host immune status are being explored.

PLZF confers effector functions to donor T cells that preserve graft-versus-tumor effects while attenuating GVHD

Efforts to limit GVHD mediated by alloreactive donor T cells after allogeneic bone marrow transplantation are limited by a concomitant decrease in graft-versus-tumor (GVT) activity and increased possibilities of tumor relapse. Using a novel approach, we adoptively transferred conventional T cells expressing the transcription factor promyelocytic leukemia zinc finger (PLZF), which confers effector properties resembling invariant natural killer T cells, such as copious production of cytokines under suboptimal stimulation. PLZF expression in T-cell allografts attenuates expansion of alloreactive T cells, leading to lower GVHD. Intact alloreactivity-driven antitumor cytokine responses result in preserved GVT effects, leading to improved survival. Our findings suggest that therapy with PLZF-overexpressing T cells would result in overall improved outcomes due to less GVHD and intact GVT effects.

Adoptively transferred TRAIL+ T cells suppress GVHD and augment antitumor activity

Current strategies to suppress graft-versus-host disease (GVHD) also compromise graft-versus-tumor (GVT) responses. Furthermore, most experimental strategies to separate GVHD and GVT responses merely spare GVT function without actually enhancing it. We have previously shown that endogenously expressed TNF-related apoptosis-inducing ligand (TRAIL) is required for optimal GVT activity against certain malignancies in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT). In order to model a donor-derived cellular therapy, we genetically engineered T cells to overexpress TRAIL and adoptively transferred donor-type unsorted TRAIL+ T cells into mouse models of allo-HSCT. We found that murine TRAIL+ T cells induced apoptosis of alloreactive T cells, thereby reducing GVHD in a DR5-dependent manner. Furthermore, murine TRAIL+ T cells mediated enhanced in vitro and in vivo antilymphoma GVT response. Moreover, human TRAIL+ T cells mediated enhanced in vitro cytotoxicity against both human leukemia cell lines and against freshly isolated chronic lymphocytic leukemia (CLL) cells. Finally, as a model of off-the-shelf, donor-unrestricted antitumor cellular therapy, in vitro-generated TRAIL+ precursor T cells from third-party donors also mediated enhanced GVT response in the absence of GVHD. These data indicate that TRAIL-overexpressing donor T cells could potentially enhance the curative potential of allo-HSCT by increasing GVT response and suppressing GVHD.

Interleukin-22 protects intestinal stem cells from immune-mediated tissue damage and regulates sensitivity to graft versus host disease

Little is known about the maintenance of intestinal stem cells (ISCs) and progenitors during immune-mediated tissue damage or about the susceptibility of transplant recipients to tissue damage mediated by the donor immune system during graft versus host disease (GVHD). We demonstrate here that deficiency of recipient-derived IL-22 increased acute GVHD tissue damage and mortality, that ISCs were eliminated during GVHD, and that ISCs as well as their downstream progenitors expressed the IL-22 receptor. Intestinal IL-22 was produced after bone marrow transplant by IL-23-responsive innate lymphoid cells (ILCs) from the transplant recipients, and intestinal IL-22 increased in response to pretransplant conditioning. However, ILC frequency and IL-22 amounts were decreased by GVHD. Recipient IL-22 deficiency led to increased crypt apoptosis, depletion of ISCs, and loss of epithelial integrity. Our findings reveal IL-22 as a critical regulator of tissue sensitivity to GVHD and a protective factor for ISCs during inflammatory intestinal damage.

Ceacam1 separates graft-versus-host-disease from graft-versus-tumor activity after experimental allogeneic bone marrow transplantation

Background

Allogeneic bone marrow transplantation (allo-BMT) is a potentially curative therapy for a variety of hematologic diseases, but benefits, including graft-versus-tumor (GVT) activity are limited by graft-versus-host-disease (GVHD). Carcinoembryonic antigen related cell adhesion molecule 1 (Ceacam1) is a transmembrane glycoprotein found on epithelium, T cells, and many tumors. It regulates a variety of physiologic and pathological processes such as tumor biology, leukocyte activation, and energy homeostasis. Previous studies suggest that Ceacam1 negatively regulates inflammation in inflammatory bowel disease models.

Methods

We studied Ceacam1 as a regulator of GVHD and GVT after allogeneic bone marrow transplantation (allo-BMT) in mouse models. In vivo, Ceacam1^−/− T cells caused increased GVHD mortality and GVHD of the colon, and greater numbers of donor T cells were positive for activation markers (CD25^hi, CD62L^lo). Additionally, Ceacam1^−/− CD8 T cells had greater expression of the gut-trafficking integrin α₄β₇, though both CD4 and CD8 T cells were found increased numbers in the gut post-transplant. Ceacam1^−/− recipients also experienced increased GVHD mortality and GVHD of the colon, and alloreactive T cells displayed increased activation. Additionally, Ceacam1^−/− mice had increased mortality and decreased numbers of regenerating small intestinal crypts upon radiation exposure. Conversely, Ceacam1-overexpressing T cells caused attenuated target-organ and systemic GVHD, which correlated with decreased donor T cell numbers in target tissues, and mortality. Finally, graft-versus-tumor survival in a Ceacam1⁺ lymphoma model was improved in animals receiving Ceacam1^−/− vs. control T cells.

Conclusions

We conclude that Ceacam1 regulates T cell activation, GVHD target organ damage, and numbers of donor T cells in lymphoid organs and GVHD target tissues. In recipients of allo-BMT, Ceacam1 may also regulate tissue radiosensitivity. Because of its expression on both the donor graft and host tissues, this suggests that targeting Ceacam1 may represent a potent strategy for the regulation of GVHD and GVT after allogeneic transplantation.

Abstract 4743: Genetically engineered allogeneic T Cells for BMT immunotherapy: Expression of TRAIL and PLZF selectively enhances GVT and abrogates GVHD

Efforts to improve graft-versus-tumor (GVT) activity of alloreactive donor T cells are limited by a concomitant rise in graft-versus-host disease (GVHD). We employed experimental allogeneic bone marrow transplantation (allo-BMT) models to assess two novel strategies, in which T lineage cells were genetically engineered to enhance selective effector functions. In addition to the transgenic expression of these molecules on mature donor T cells, we also used genetically engineered precursor T cells as an “off the shelf” adoptive cell therapy.

One strategy relies on T cell cytolytic molecule TNF-Related Apoptosis Inducing Ligand (TRAIL), which induces apoptosis through death receptors (DR) 4 and 5 (only DR5 in mice). Certain tumor cells express high levels of DR5 making TRAIL an attractive candidate for engineering T cells to augment GVT. Mature T cells were transduced with a lentiviral TRAIL expression vector and adoptively transferred into lethally irradiated allogeneic bone marrow transplantation (allo-BMT) recipients, bearing LB27.4 tumors (B6 into CBF1+LB27.4). TRAIL+ T cells had enhanced antitumor effect compared to control-transduced T cells in vitro and upon transfer into tumor-bearing allo-BMT recipients (p<0.01). Interestingly, the recipients of TRAIL+ T cells had significantly less GVHD. We generated TRAIL+ precursor (pre)T cells using the OP9-DL1 co-culture system. Adoptive transfer of B6 TRAIL+ preT cells into syngeneic-transplanted BALB/c mice resulted in reconstitution with TRAIL+ T cells. When challenged with localized RENCA tumors, recipients of TRAIL+ preT cells had enhanced antitumor activity (p<0.05) compared to recipients of control-transduced preT cells.

The second strategy explores the effect of overexpressing the transcription factor promyelocytic leukemia zinc finger (PLZF) in T cells. PLZF transgenic (tg) T cells have an effector/memory phenotype with innate-like characteristics. Following transfer, they cells display an altered cytokine profile with increased expression of TNF-alpha and decreased IFN-gamma. Using adoptive transfer of CFSE-labeled donor T cells we observed that fast proliferating allo-responsive PLZF+ T cells died after only a few cell cycles. Using PLZF Tg mice, we found that PLZF+ T cells cause less GVHD with intact GVT activity (p<0.001) against A20 lymphoma. We then transduced T cells with PLZF expression vector and confirmed that donor PLZF+ T cells have less GVHD and intact GVT activity.

Our data suggest that adoptive therapy with genetically engineered TRAIL+ or PLZF+ T cells cause less GVHD while displaying intact or enhanced GVT activity. Furthermore, the “off the shelf” use of genetically enhanced preT cells represents a promising cell therapy strategy to enhance anti-tumor activity in both autologous and allo-BMT patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4743. doi:10.1158/1538-7445.AM2011-4743

Absence of P-selectin in recipients of allogeneic bone marrow transplantation ameliorates experimental graft-versus-host disease

Alloreactive T cells are crucial for graft-versus-host disease (GVHD) pathophysiology, and modulating their trafficking patterns has been efficacious in ameliorating experimental disease. We report in this paper that P-selectin, a glycoprotein found on resting and inflamed endothelium, is important for donor alloreactive T cells trafficking into GVHD target organs, such as the intestines and skin. Compared with wild-type (WT) recipients of allogeneic bone marrow transplantation, P-selectin(-/-) recipients exhibit decreased GVHD mortality and decreased GVHD of the skin, liver, and small bowels. This was associated with diminished infiltration of alloactivated T cells into the Peyer's patches and small bowels, coupled with increased numbers of donor T cells in the spleen and secondary lymphoid organs (SLOs). Surprisingly, however, donor T cells deficient for P-selectin glycoprotein ligand 1, the most well described P-selectin ligand, mediated GVHD similar to WT T cells and accumulated in SLO and target organs in similar numbers as WT T cells. This suggests that P-selectin may be required for trafficking into inflamed tissues but not SLO and that donor T cells may use multiple P-selectin ligands apart from P-selectin glycoprotein ligand 1 to interact with P-selectin and traffic into inflamed tissues during GVHD. We conclude that targeting P-selectin may be a viable strategy for GVHD prophylaxis or treatment.

Indian medical students' views on immigration for training and practice

PURPOSE

To assess the attitudes of medical students in India about participating in graduate medical education in the United States and other countries and in subsequent clinical practice in those countries.

METHOD

A total of 240 students who were attending their final year at two medical schools in Bangalore, India, were surveyed during 2004. Surveys were completed by 166 (69%) of the students.

RESULTS

Among the responding students, 98 (59%) thought of leaving India for further training abroad. Of those who wished to leave, 41 (42%) preferred the United States, 42 (43%) preferred the United Kingdom, and 9 (9%) preferred Canada, Australia or New Zealand. Only two students preferred the Middle East. Most who favored training in the United States indicated that they intended to remain after training, whereas fewer than 20% of those who favored training in the United Kingdom had such intentions. While more than 60% perceived greater professional opportunities in the United States than in India, approximately 75% were concerned that the United States had become less welcoming after the terrorist attacks of 9/11, and similar numbers were concerned about the examination administered by the Educational Commission on Foreign Medical Graduates. Conversely, the majority of respondents felt that opportunities for physicians in India were improving.

CONCLUSIONS

While optimism about future medical careers in India is increasing, the interest of Indian medical students in training and subsequently practicing in the United States remains high.

Indian medical students' views on immigration for training and practice

PURPOSE

To assess the attitudes of medical students in India about participating in graduate medical education in the United States and other countries and in subsequent clinical practice in those countries.

METHOD

A total of 240 students who were attending their final year at two medical schools in Bangalore, India, were surveyed during 2004. Surveys were completed by 166 (69%) of the students.

RESULTS

Among the responding students, 98 (59%) thought of leaving India for further training abroad. Of those who wished to leave, 41 (42%) preferred the United States, 42 (43%) preferred the United Kingdom, and 9 (9%) preferred Canada, Australia or New Zealand. Only two students preferred the Middle East. Most who favored training in the United States indicated that they intended to remain after training, whereas fewer than 20% of those who favored training in the United Kingdom had such intentions. While more than 60% perceived greater professional opportunities in the United States than in India, approximately 75% were concerned that the United States had become less welcoming after the terrorist attacks of 9/11, and similar numbers were concerned about the examination administered by the Educational Commission on Foreign Medical Graduates. Conversely, the majority of respondents felt that opportunities for physicians in India were improving.

CONCLUSIONS

While optimism about future medical careers in India is increasing, the interest of Indian medical students in training and subsequently practicing in the United States remains high.

Growth of Zambian children

A cross sectional study of 2,637 Zambian school children (1,220 boys and 1,417 girls) between the ages of six and eighteen years was carried out to observe growth patterns. Five anthropometric measurements were taken. It was noted that the growth spurt commenced at the age of nine years in girls. The accelerated growth continued until the age of fifteen years after which the rate of growth was very small. In boys, the growth spurt commenced a year later and continued until the age of seventeen years. Height was compared with that of the European and Ghanian children from London and Accra respectively. Although the growth patterns were similar, the Europeans were taller and the Ghanians were shorter than Zambians in this age group.

Puberty in Zambian children

A cross sectional study of 2,638 Zambian school children 1,220 boys and 1,418 girls has been done in Lusaka to study the puberty process. Public and axillary hair, breast development and menarche were studied. Pubic hair appeared for the first time in the group of 9 year-old girls and 10 year-old boys. Axillary hair appeared at about the same time. Stage two of the breast bud appeared for the first time in the group of 9 year-old girls. The earliest case of occurrence of menarche was in a girl of 9.4 years. The mean age at menarche in Zambian school girls was 13.7.

The sigmoid colon in Zambians

Four variables were measured in the sigmoid colon of 103 Zambians (73 men). The mean results were as follows:- Length 32.9cm (men), 29.5cm (women); height of mesentery 8.2cm in both sexes; length of attachment of the mesentery was 10.3cm (men), 10.8cm (women) and thickness 3.0mm in both sexes. The findings are inconclusive throwing no light on the aetiolocy of sigmoid volvulus.

The gall bladder in adult Zambians

The morphology of the gall bladder, the length and mode of termination of the cystic duct, and the origin and distribution of the cystic artery were studied in 88 adult Zambians (61 men, 27 women). The origin of the cystic artery was the right hepatic artery (53%), and the common hepatic artery (41%). Hartmann's pouch was observed in 44% of gall bladders. The cystic duct usually opened into the common hepatic duct (91%); its average length was 2 cm.