Current status and prospect of T cell costimulatory blockade in transplantation

Organ transplantation has been widely accepted as a routine medical treatment in Japan. The recent introduction of new immunosuppressive reagents may improve outcome after transplantation. However, further investigations are required to achieve the prevention of chronic rejection and the induction of donor-specific tolerance in clinical transplantation. The potential of costimulatory blockade in controlling allograft rejection is now extensively under investigation. Although costimulatory blockade can prevent rejection and induce tolerance experimentally, there are several issues that need to be clarified before its clinical application. Recently, several novel costimulatory pathways have also been reported. Each costimulatory pathway has distinct and unique immunological roles in T cell activation and down-regulation. Upon the perception of underlying mechanisms, the theoretical and effective use of costimulatory blockade in combination with conventional immunosuppression and/or novel molecular targeting therapies might make a major breakthrough in clinical transplantation.     

Integrin antagonists prevent costimulatory blockade-resistant transplant rejection by CD8(+) memory T cells

The success of belatacept in late-stage clinical trials inaugurates the arrival of a new class of immunosuppressants based on costimulatory blockade, an immunosuppression strategy that disrupts essential signals required for alloreactive T-cell activation. Despite having improved renal function, kidney transplant recipients treated with belatacept experienced increased rates of acute rejection. This finding has renewed focus on costimulatory blockade-resistant rejection and specifically the role of alloreactive memory T cells in mediating this resistance. To study the mechanisms of costimulatory blockade-resistant rejection and enhance the clinical efficacy of costimulatory blockade, we developed an experimental transplant system that models a donor-specific memory CD8(+) T-cell response. After confirming that graft-specific memory T cells mediate costimulatory blockade-resistant rejection, we characterized the role of integrins in this rejection. The resistance of memory T cells to costimulatory blockade was abrogated when costimulatory blockade was coupled with either anti-VLA-4 or anti-LFA-1. Mechanistic studies revealed that in the presence of costimulatory blockade, anti-VLA-4 impaired T-cell trafficking to the graft but not memory T-cell recall effector function, whereas anti-LFA-1 attenuated both trafficking and memory recall effector function. As antagonists against these integrins are clinically approved, these findings may have significant translational potential for future clinical transplant trials.     

Donor cardiac troponin T: a marker to predict heart transplant rejection

Background. Noninvasive methodologies have shown poor sensitivity in predicting rejection when compared to serial endomyocardial biopsies. We studied the potential role of donor blood troponin T (Tn-T) as a marker for predicting heart transplant rejection.

Methods. Blood cardiac Tn-T was measured from 16 heart donors. Transplant rejection and cardiac function in the recipients were monitored for 1 year.

Results. When data were analyzed based on donor blood Tn-T levels, 6 patients who received hearts from donors with low Tn-T (<0.45 ± 0.1 ng/mL) showed no rejection, and patients whose hearts came from donors with higher Tn-T (6.01 ± 0.81 ng/mL) developed episodes of high-grade rejection (3A) within 38.5 ± 2.1 days after transplantation. Eight patients who received hearts from donors with intermediate levels of Tn-T (3.57 ± 0.55 ng/mL) showed mild rejection (grade 1). All recipients had qualitatively normal left ventricular systolic function by serial echocardiography. The mean donor ischemic time was 169 ± 47 minutes.

Conclusions. The quality of the donor heart is an important prognostic factor in heart transplantation. It may be possible to identify severely damaged donor organs before transplantation and avoid their use or to develop more aggressive strategies for reducing recurrent acute rejection episodes in high-risk patients.     

Troponin T and I are not reliable markers of cardiac transplant rejection.

OBJECTIVE: Heart transplant recipients undergo a number of invasive endomyocardial biopsies to screen for rejection. Serum assays of troponin T and/or I may provide a less invasive alternative. The purpose of this study was to evaluate troponin T and I as markers of cardiac transplant rejection. METHODS: We conducted a prospective analysis comparing troponin T and I levels to biopsy results in heart transplant recipients. Plasma was assayed for troponin T and I preoperatively, on the first 3 postoperative days, and with each subsequent biopsy. RESULTS: Twenty-nine patients entered the study. A total of 173 biopsies were performed at a mean follow-up of 129+/-9 days (range: 12-564 days). There were two rejection episodes (> or = grade 3), one in each of two patients. There were no significant relationships between troponin T or I and biopsy-proven rejection (> or = grade 3; P=0.59 and 0.54, respectively). There were also no correlations between troponin T or I levels and biopsy grade (P=0.40 and 0.92, respectively). Troponin T and I levels peaked on postoperative day 1 and fell to baseline over long-term follow-up with no peak in serum markers associated with rejection episodes. Donor ischemic time was significantly correlated to troponin T on postoperative days 1-3 (r=0.58, P=0.005; r=0.61, P=0.004; and r=0.61, P=0.003, respectively). CONCLUSIONS: Troponin T and I are not useful indicators of cardiac rejection, but do correlate with donor heart ischemic injury.     

Primed allospecific T cells prevent the effects of costimulatory blockade on prolonged cardiac allograft survival in mice.

Costimulatory blockade can induce long‐term allograft survival in naïve animals, but may not be as effective in animals with previously primed immune repertoires. We attempted to induce long‐term graft survival in B10.D2 recipients of B10.A cardiac allografts using donor‐specific transfusion (DST) plus anti‐CD40 ligand antibody (αCD40L). Recipients were either naïve mice, or mice previously primed to B10.A or third party alloantigens through engraftment and rejection of skin transplants. Untreated naïve mice rejected cardiac transplants by day 15 and contained a high frequency of primed, donor‐reactive T cells. Donor‐specific transfusion/αCD40L treatment of naïve animals induced long‐term graft survival associated with low frequencies of donor‐reactive T cells. Previous priming of donor‐specific T cells through rejection of B10.A, but not third party, skin grafts prevented the effects of DST/αCD40L on prolonging survival of B10.A hearts. Moreover, adoptive transfer of CD3+, CD4+ or CD8+ T cells from B10.A skin‐graft‐primed animals prevented the effects of DST/αCD40L. The data demonstrate that animals with immune repertoires containing previously primed, donor‐reactive T cells are resistant to the effects of costimulatory blockade. The findings have important implications for ongoing, costimulatory blockade‐based trials in humans, whose T‐cell repertoires are known to contain memory alloreactive T cells.     

Secondary lymphoid tissue and costimulation‐blockade resistant rejection: A nonhuman primate renal transplant study

Naïve T cell activation requires antigen presentation combined with costimulation through CD28, both of which optimally occur in secondary lymphoid tissues such as lymph nodes and the spleen. Belatacept impairs CD28 costimulation by binding its ligands, CD80 and CD86, and in doing so, impairs de novo alloimmune responses. However, in most patients belatacept is ineffective in preventing allograft rejection when used as a monotherapy, and adjuvant therapy is required for control of costimulation‐blockade resistant rejection (CoBRR). In rodent models, impaired access to secondary lymphoid tissues has been demonstrated to reduce alloimmune responses to vascularized allografts. Here we show that surgical maneuvers, lymphatic ligation, and splenectomy, designed to anatomically limit access to secondary lymphoid tissues, control CoBRR and facilitate belatacept monotherapy in a nonhuman primate model of kidney transplantation without adjuvant immunotherapy. We further demonstrate that animals sustained on belatacept monotherapy progressively develop an increasingly naïve T and B cell repertoire, an effect that is accelerated by splenectomy and lost at the time of belatacept withdrawal and rejection. These pilot data inform the role of secondary lymphoid tissues on the development of CoBRR and the use of costimulation molecule–focused therapies.     

The biology of acute transplant rejection.

An intriguing and increasingly understood facet of immune responses is the ability of a recipient to destroy a foreign tissue or organ graft. The phenomenon of acute rejection of an allograft involves a series of complex and inter-related cellular and humoral events, culminating in graft death. Some of the current thinking surrounding this phenomenon is reviewed.     

Early markers of pancreas transplant rejection.

To compare the predictive value of urinary amylase (UA), urinary insulin (UI), and urinary prostaglandin (PGE2), whole pancreas isografts or allografts from (ACI rat donors, RT1a) with bladder drainage of exocrine secretions were performed in Lewis rats (RT1(1)) with streptozotocin-induced diabetes. UA, UI, PGE2 and plasma glucose levels were measured daily. Euglycemia was restored on Postoperative Day 1 in all the recipients of isografts (N = 6) and was maintained for over a year. UI concentrations and PGE2 outputs were stable, with low levels ranging between 0.3 +/- 0.2 to 7 +/- 2 ng/ml and 56 +/- 15 to 164 +/- 48 ng/24 hr, respectively, while UA levels were significantly elevated compared to normal controls (> 1,000 U/ml vs 29 +/- 16 U/ml). In the allograft group (N = 12), rejection occurred on Days 7 through 9, with a mean graft survival time of 8.1 +/- 0.1 days. UA dropped from a post-transplant peak of 2,422 +/- 353 U/ml on Postoperative Day 4 to below 1,380 +/- 256 U/ml 3 days before rejection (Day -3). UI increased to 83 +/- 16 ng/ml (P < 0.05) on Day -6 and reached a post-transplant peak of 140 +/- 24 ng/ml on Day -5, while PGE2 output rose from a pretransplant level of 18 +/- 2 to 92 +/- 25 ng/24 hr on Postoperative Day 1, followed by a significant elevation on Day 4 (-4).(ABSTRACT TRUNCATED AT 250 WORDS)     

Analysis of cloned T cell function. II. Differential blockade of various cloned T cell functions by cyclosporine

Cyclosporine has profound suppressive effects on selected in vitro functions of cloned T lymphocytes. Cyclosporine inhibits the antigen-induced proliferation of the helper T cell clone 12-11. The effective dose required to reduce this response by 50% (ED50) is 28 ng/ml. In contrast, the proliferation of clone 12-11 induced by exogenous growth factors in secondary mixed lymphocyte culture supernatant (2 degrees MLC SN), is relatively insensitive to cyclosporine (ED50 = 4600 ng/ml). Furthermore, cyclosporine abrogates both antigen-induced and mitogen-induced secretion of lymphokines by clone 12-11, indicating that cloned helper T cell function is sensitive to cyclosporine even when interactions between specific alloantigens and their cell surface receptors are bypassed with mitogen. The suppressive effect of cyclosporine is not limited to helper T cell clones. The cytolytic T lymphocyte (CTL) clone 5MD2-2 is also sensitive to cyclosporine. Again, cyclosporine (100 ng/ml) blocks the antigen-driven, but not the exogenous lymphokine-driven, component of clone 5MD2-2 proliferation. This suppression does not result from the occlusion of antigen receptors or from antigen deformation by cyclosporine, because clone 5MD2-2 remains capable of antigen-specific cytolysis in the presence of cyclosporine concentrations that can suppress its proliferation. Finally, the ability of clone 5MD2-2 to remove IL-2 activity from culture media, a function that is significantly enhanced by contact with specific alloantigen, is not influenced by suppressive cyclosporine concentrations.     

可诱导性共刺激分子单抗联合细胞毒T淋巴细胞4Ig在大鼠胰腺移植中的作用

目的 探讨可诱导性共刺激分子（ICOS）单抗、细胞毒T淋巴细胞4ig（CTLA41g）阻断共刺激通路对于异基因大鼠胰腺移植的作用及其机制。方法 建立胰腺移植模型，分A组（对照组），B组（CTLA4Ig组），C组（抗ICOS单抗组），D组（联合CTLA4Ig和抗ICOS单抗组）。术后1、4,7d监测血糖，第7天取胰腺做苏木素-伊红染色，脾脏做流式细胞检测CD3^＋CD8^＋T细胞、CD4^＋T细胞、CD4^＋CD25^＋T细胞。结果 与A组比较：B、C、D组排斥反应较A组明显减弱，显著延长了移植物的存活时间。CD3^＋CD8^＋T细胞计数B、C、D与A组比较均有减少，差异有统计学意义（P〈0．01）。CD4^＋T细胞B、D与A组的差异有统计学意义（P〈0．05）。CD4^＋CD25^＋T细胞各组间逐渐升高，差异有统计学意义（P〈0．01）。结论 抗ICOS单抗和CTLA4Ig能有效地抑制大鼠胰腺移植排斥反应，延长移植物存活时间，且联合应用比单一应用更有效。其可能机制为诱导了CD4^＋CD25^＋T细胞的产生。