Treg Reconstitution Research Articles

Distinct Patterns in Treg and T-helper Subset Reconstitution After Autologous Hematopoietic Stem Cell Transplantation in Juvenile-onset Systemic Sclerosis Patients

Systemic sclerosis (SSc) is a refractory autoimmune disease. In recent years, autologous hematopoietic stem cell transplantation (ASCT) has been performed to treat SSc. However, the reconstitution of immune components post-ASCT in SSc have not been fully described.We tested a total of 13 samples from 4 consenting SSc patients (median age: 18.5-years-old, 3F/1M) receiving IRB-approved immunoablation (TBI 600cGy) with lung/kidney shielding and Cytoxan (n = 3) or Thiotepa (n = 1) +/– Alemtuzumab followed by ASCT (CD34+ selected). Peripheral blood samples were collected at baseline, and 3, 6, 12, 24-months post-ASCT. By flow cytometry, we focused on the FOXP3+Treg and T-helper subset reconstitution.All 4 subjects experienced significant improvement in several clinical and quality of life parameters, especially in their skin disease evident within weeks after ASCT. T-cell recovery was evident by 6-months reaching pre-ASCT levels by 2-years post-ASCT (Fig. 1A). There was an increased percentage of FOXP3+Tregs in total CD4+T cells from 3- to 6-months post-ASCT (Fig. 1B), leading to an increase in the ratio of Treg/Tcon (Fig. 1B). The higher proportions of proliferating Tregs (Fig. 1C) likely led to their increased numbers. This trend was sustained until the last evaluation at 2-years post-ASCT (Fig. 1C). In contrast, CD4+Tcons showed a relatively lower proliferation rate, leading to a higher ratio of Ki67+Treg/Ki67+Tcon compared to pre-ASCT values (Fig. 1C). Notably, there was an increased proportion of Tregs expressing the skin-homing marker cutaneous lymphocyte-associated antigen (CLA) at 3-months lasting until the last test at 2-years post-ASCT (Fig. 1D), whereas CLA+/CD4+Tcons were less plentiful.The reconstitutions of T-helper (Th) subsets were also examined according to their chemokine receptor expression. Gradually decreased numbers of Th2, Th9, and Th17 were observed in the peripheral pool (Fig. 1E,1F). Nevertheless, the absolute number of Th1 and Th22 cells returned to levels seen pre-ASCT without any recurrence or flare of SSc symptoms.In summary, an increased number of circulating FOXP3+Tregs was observed leading to an elevated Treg/Tcon ratio in the peripheral pool. Skin-homing CLA+Treg subset was further enriched correlating with improved skin scores in all patients. The decrease of the Th2/Th9/Th17 subsets in the peripheral pool post-ASCT possibly contributes to the clinically less severe autoimmune phenotype. [Display omitted]

Donor Pretreatment with Agonistic Anti-DR3 Antibody Prevents Chronic GvHD in a Murine Sclerodermatous Model

Background: DR3 is a cell surface receptor of the TNF superfamily and is expressed preferentially by activated T cells. The agonistic antibody of DR3 (aDR3) can stimulate regulatory T cell (Treg) expansion and ameliorate acute GVHD in a major-mismatch murine model. However, it is still unclear whether the aDR3 is effective in other GVHD models. A murine sclerodermatous GVHD model features skin fibrosis and shares many clinical characteristics with human chronic GVHD, for which currently available therapies have demonstrated limited efficacy. Methods: The αDR3 or isotype control antibody (0.5 mg/kg) was intraperitoneally injected into B10.D2 mice four days before transplantation. To generate a sclerodermatous GVHD model, lethally irradiated BALB/c recipient mice were transplanted with T cell-depleted bone marrow cells from non-treated B10.D2 mice and splenocytes isolated from the αDR3 or isotype-treated B10.D2 mice. Some Balb/c mice were transplanted with only the T cell-depleted bone marrow cells (omitting splenocytes) and served as the non-GVHD control (the control recipients). Recipient mice were monitored for six weeks to assess body weight, GVHD score, and survival or sacrificed to harvest skin, spleen, and colon on 7, 14, and 42 days after transplantation. Bronchoalveolar lavage (BAL) was performed on days 7 and 14. Results: Recipients of the aDR3-treated splenocytes (the aDR3 recipients) experienced significantly less weight loss and showed decreased GVHD scores than recipients of isotype-treated splenocytes (the isotype recipients). The severity of cutaneous GVHD was considerably reduced in the aDR3 recipients than in the isotype recipients. Pathologic examinations such as the ratio of the dermis to subcutaneous tissue in the skin and histologic scores of the colon performed on days 7, 14, and 42 post-transplant confirmed the clinical results. Flow cytometric analysis suggested that the reconstitution of B and T cells in the spleen of isotype recipients was severely disrupted during the later phase of the transplant. Although the number of CD4 T cells and B cells in the control recipients and the aDR3 recipients had been increasing until day 42, those in the isotype recipients slightly increased on day 14 but markedly decreased on day 42. Therefore, the number of CD4 T cells in the isotype recipients was significantly lower than that of the other groups on day 42, and the number of B cells in the isotype showed a significant difference on days 14 and 42. In contrast, the reconstitution of CD11b monocytes was not disrupted in the spleen of the isotype recipients. The reconstitution of splenic Treg showed a similar pattern to CD4 T cells. Interestingly, the number of Treg in the aDR3 recipients was consistently higher than that of the other groups. These findings suggest that GVHD may disrupt lymphocyte reconstitution after hematopoietic cell transplantation but treating donors with αDR3 can prevent it. Next, we performed qPCR analysis to quantitate the mRNA levels of key cytokines and chemokines in the skin and colon. The expression level of TGF-β was remarkably higher in the skin than in the colon, and the reduction of TGF-β in the αDR3 recipients was more pronounced in the skin than in the colon, confirming its primary role in skin fibrosis. In addition, the αDR3 recipients had decreased levels of IFNg, IL-6, and IL-10 in the skin and the colon than the isotype recipients. Moreover, the αDR3 recipients had diminished expression of various chemokines (CCL1, CCL2, CCL3, CCL4, CCL8, CCL17, and CCL22) in the skin compared to the isotype recipients. Chemokine expression profile in the colon was almost identical to the skin except for CCL17 and CCL22. These two cytokines were similarly reduced in the colon of the αDR3 recipients and the isotype recipients. Next, we examined inflammatory cell content in the BAL fluid. The numbers of total cells and macrophages were significantly lower in the αDR3 recipients than in the isotype recipients on days 7 and 14, but the numbers of lymphocytes and neutrophils were different between these two groups only on day 14. The αDR3 recipients had significantly fewer CD4 T cells, B cells, and CD11b monocytes in BAL fluid than the isotype recipients. Conclusions: Treating donors with αDR3 before transplantation could alleviate sclerodermatous GVHD by preventing disruption of hematopoiesis, fostering immune reconstitution, and reducing skin fibrosis and lung inflammation.

Distinct Patterns in the Reconstitutions of Treg and T-Helper Subsets after Autologous Hematopoietic Stem Cell Transplantation in Juvenile-Onset Systemic Sclerosis Patients

Systemic sclerosis (SSc) is a refractory autoimmune disease characterized by diffuse fibrosis and vasculopathy affecting the skin, joints, and internal organs. Most immunosuppressive drugs have failed to show long-term benefit in randomized trials. In recent years, autologous hematopoietic stem cell transplantation (ASCT) has been performed to treat multiple sclerosis and SSc, however, the reconstitutions of immune components post-ASCT in SSc have not been fully described. Subjects and Methods: We tested a total of 13 samples from 4 consenting SSc patients (3 females, 1 male) receiving IRB-approved immunoablation (TBI 600cGy) with lung shielding and Cytoxan (n=3) or Thiotepa (n=1) +/- Alemtuzumab followed by autologous CD34+ selected, cryopreserved peripheral blood hematopoietic stem cells transplantation. Their median age was 18.5-years-old (range 15.2- to 21.4-years-old). Peripheral blood samples were collected at baseline pre-ASCT, and 3, 6, 12, 24-months post-ASCT. By flow cytometry, we examined lymphocyte and monocyte subset recovery with additional focus on the FOXP3+Treg and T-helper subset reconstitution. Results and Discussion: All 4 subjects experienced significant improvement in several clinical and quality of life parameters, especially in their skin disease evident within weeks after ASCT. T-cell lymphopenia was profound at 3-months; however, the recovery was evident by 6-months reaching pre-ASCT levels by 2-years post-ASCT (Fig 1A). Natural killer (NK) lymphocytes and monocytes attained the normal values by 3-months and after (Fig 1A). The FOXP3+Tregs that appeared post-ASCT displayed distinct features. There was an increased percentage of FOXP3+Tregs in total CD4+T cells during the early stage (3- to 6-months) post-ASCT (Fig 1B), leading to an increase in the ratio of Treg/Tcon (Fig 1B). The higher proportions of proliferating Tregs as measured by Ki67+FOXP3+CD4+/CD25+/CD127- T cells (Fig 1C) likely led to their increased numbers. This trend was sustained until the last evaluation at 2-years post-ASCT (Fig 1C). In contrast, CD4+Tcons showed a relatively lower proliferation rate, leading to a higher ratio of Ki67+Treg/Ki67+Tcon compared to pre-ASCT values (Fig 1C). Notably, there was an increased proportion of Tregs expressing the skin homing marker cutaneous lymphocyte-associated antigen (CLA) at 3-months lasting until the last test at 2-years post-ASCT (Fig 1D), whereas CLA+/CD4+Tcons were less plentiful. The reconstitutions of T-helper (Th) subsets were also examined. Due to lymphopenia at the early stage post-ASCT, Th subsets were identified according to their chemokine receptor expression (Mahnke et alCytometry 2013;83(5):439-440). Gradually decreased numbers of Th2, Th9, and Th17 were observed in the peripheral pool (Fig 1E) contributing to a decline of their proportions in total CD4+T (Fig 1F). Nevertheless, absolute number of Th1 and Th22 cells returned to levels seen pre-ASCT without any recurrence or flare of SSc symptoms. The CD45RO+ memory phenotype was dominant during the early stages post-ASCT in all subsets (data not shown). Summary: Successful reconstitution of lymphocytes and monocytes post-ASCT was observed in available SSc patients. Post-ASCT circulating FOXP3+Tregs displayed distinct features where the increased number led to an elevated Treg/Tcon ratio in the peripheral pool. Amongst Tregs, the skin homing CLA+ subset was further enriched correlating with improved skin scores in all patients. Improved peripheral proliferation and increased expression of CLA+ Tregs may provide protection from skin disease recurrence despite parallel Tcon reconstitution. The decrease of the Th2/Th9/Th17 subsets in the peripheral pool post-ASCT possibly contributes to the clinically less autoimmune phenotype. These results need to be validated in future patients. Acknowledgements: We thank all participating patients, nurses, physicians, and scientists in this study for their contributions. The study was supported by the "Idea Development Award" from the Department of Defense - Scleroderma Research Program (Award number W81XWH-21-1-0782 and W81XWH-21-1-0783). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Post-Transplantation Cyclophosphamide Uniquely Restrains Alloreactive CD4+ T-Cell Proliferation and Differentiation After Murine MHC-Haploidentical Hematopoietic Cell Transplantation.

Post-transplantation cyclophosphamide (PTCy) reduces the incidence and severity of graft-versus-host disease (GVHD), thereby improving the safety and accessibility of allogeneic hematopoietic cell transplantation (HCT). We have shown that PTCy works by inducing functional impairment and suppression of alloreactive T cells. We also have identified that reduced proliferation of alloreactive CD4+ T cells at day +7 and preferential recovery of CD4+CD25+Foxp3+ regulatory T cells (Tregs) at day +21 are potential biomarkers associated with optimal PTCy dosing and timing in our B6C3F1→B6D2F1 MHC-haploidentical murine HCT model. To understand whether the effects of PTCy are unique and also to understand better the biology of GVHD prevention by PTCy, here we tested the relative impact of cyclophosphamide compared with five other optimally dosed chemotherapeutics (methotrexate, bendamustine, paclitaxel, vincristine, and cytarabine) that vary in mechanisms of action and drug resistance. Only cyclophosphamide, methotrexate, and cytarabine were effective in preventing fatal GVHD, but cyclophosphamide was superior in ameliorating both clinical and histopathological GVHD. Flow cytometric analyses of blood and spleens revealed that these three chemotherapeutics were distinct in constraining conventional T-cell numerical recovery and facilitating preferential Treg recovery at day +21. However, cyclophosphamide was unique in consistently reducing proliferation and expression of the activation marker CD25 by alloreactive CD4+Foxp3- conventional T cells at day +7. Furthermore, cyclophosphamide restrained the differentiation of alloreactive CD4+Foxp3- conventional T cells at both days +7 and +21, whereas methotrexate and cytarabine only restrained differentiation at day +7. No chemotherapeutic selectively eliminated alloreactive T cells. These data suggest that constrained alloreactive CD4+Foxp3- conventional T-cell numerical recovery and associated preferential CD4+CD25+Foxp3+ Treg reconstitution at day +21 may be potential biomarkers of effective GVHD prevention. Additionally, these results reveal that PTCy uniquely restrains alloreactive CD4+Foxp3- conventional T-cell proliferation and differentiation, which may explain the superior effects of PTCy in preventing GVHD. Further study is needed to determine whether these findings also hold true in clinical HCT.

High Proliferating Regulatory T Cells Post-Transplantation Are Associated with Poor Survival in Lymphoma Patients Treated with Autologous Hematopoietic Stem Cell Transplantation

Autologous hematopoietic cell transplantation (AHCT) in lymphoma is well established and yields improved survival for patients with chemotherapy-sensitive disease. The patterns of immune cell reconstitution after AHCT have emerged as independent predictors of clinical outcomes. We sought to analyze the patterns of regulatory T cell (Treg) reconstitution after AHCT in non-Hodgkin lymphoma (NHL) and their correlations with clinical outcomes. In our prospective cohort study, we analyzed patterns of lymphocyte reconstitution and focused on T reg subsets for 41 patients who underwent AHCT for NHL between 2010 and 2016. Flow cytometry analysis was performed on blood samples collected prospectively at days +28, +60, and +100 post-AHCT. Patients' overall survival (OS) and progression-free survival (PFS) were correlated with Treg immune cell reconstitution. At day +28, Tregs comprised a median of 2.7% (range, 0.4% to 16.8%) of the total lymphocyte population. The proportion of proliferating Tregs (Ki67+ Tregs) varied widely from 6.3% to 59.2% (median, 16.1%) of total Tregs and has a significant effect on post-transplantation outcomes. AHCT recipients with low levels of proliferating Tregs (ie, <16.1%, Ki67+ Tregs) at 28 days had better 5-year OS compared to patients with high Ki67+ Treg levels (75% versus 42%; P=.01). Higher levels of proliferating Tregs at day +28 post-AHCT were associated with higher mortality, with the most frequent cause of death due to lymphoma progression. This association suggests that immunosuppressive cellular reconstitution adversely impacts survival in AHCT recipients with NHL.

Bone Marrow Regulatory T Cells Are a Unique Population, Supported by Niche-Specific Cytokines and Plasmacytoid Dendritic Cells, and Required for Chronic Graft-Versus-Host Disease Control.

Regulatory T cell (Treg) reconstitution is essential for reestablishing tolerance and maintaining homeostasis following stem-cell transplantation. We previously reported that bone marrow (BM) is highly enriched in autophagy-dependent Treg and autophagy disruption leads to a significant Treg loss, particularly BM-Treg. To correct the known Treg deficiency observed in chronic graft-versus-host disease (cGVHD) patients, low dose IL-2 infusion has been administered, substantially increasing peripheral Treg (pTreg) numbers. However, as clinical responses were only seen in ∼50% of patients, we postulated that pTreg augmentation was more robust than for BM-Treg. We show that BM-Treg and pTreg have distinct characteristics, indicated by differential transcriptome expression for chemokine receptors, transcription factors, cell cycle control of replication and genes linked to Treg function. Further, BM-Treg were more quiescent, expressed lower FoxP3, were highly enriched for co-inhibitory markers and more profoundly depleted than splenic Treg in cGVHD mice. In vivo our data are consistent with the BM and not splenic microenvironment is, at least in part, driving this BM-Treg signature, as adoptively transferred splenic Treg that entered the BM niche acquired a BM-Treg phenotype. Analyses identified upregulated expression of IL-9R, IL-33R, and IL-7R in BM-Treg. Administration of the T cell produced cytokine IL-2 was required by splenic Treg expansion but had no impact on BM-Treg, whereas the converse was true for IL-9 administration. Plasmacytoid dendritic cells (pDCs) within the BM also may contribute to BM-Treg maintenance. Using pDC-specific BDCA2-DTR mice in which diptheria toxin administration results in global pDC depletion, we demonstrate that pDC depletion hampers BM, but not splenic, Treg homeostasis. Together, these data provide evidence that BM-Treg and splenic Treg are phenotypically and functionally distinct and influenced by niche-specific mediators that selectively support their respective Treg populations. The unique properties of BM-Treg should be considered for new therapies to reconstitute Treg and reestablish tolerance following SCT.

Harnessing Treg Homeostasis to Optimize Posttransplant Immunity: Current Concepts and Future Perspectives.

CD4+CD25+Foxp3+ regulatory T cells (Tregs) are functionally distinct subsets of mature T cells with broad suppressive activity and have been shown to play an important role in the establishment of immune tolerance after allogeneic hematopoietic stem cell transplantation (HSCT). Tregs exhibit an activated phenotype from the stage of emigration from the thymus and maintain continuous proliferation in the periphery. The distinctive feature in homeostasis enables Tregs to respond sensitively to small environmental changes and exert necessary and sufficient immune suppression; however, on the other hand, it also predisposes Tregs to be susceptible to apoptosis in the inflammatory condition post-transplant. Our studies have attempted to define the intrinsic and extrinsic factors affecting Treg homeostasis from the acute to chronic phases after allogeneic HSCT. We have found that altered cytokine environment in the prolonged post-HSCT lymphopenia or peri-transplant use of immune checkpoint inhibitors could hamper Treg reconstitution, leading to refractory graft-versus-host disease. Using murine models and clinical trials, we have also demonstrated that proper intervention with low-dose interleukin-2 or post-transplant cyclophosphamide could restore Treg homeostasis and further amplify the suppressive function after HSCT. The purpose of this review is to reconsider the distinctive characteristics of post-transplant Treg homeostasis and discuss how to harness Treg homeostasis to optimize posttransplant immunity for developing a safe and efficient therapeutic strategy.

How to Identify Patients for Treg DLI - Treg Subsets in Gvhd As Biomarker for Successful Treg DLI

Introduction:Regulatory T cells (Treg) play a major role in controlling GvHD. Therefore many clinical studies focus on prophylactic or therapeutic Treg approaches. We focus on Treg reconstitution and their function in GvHD. Our aim is to identify patients with altered Treg function which may benefit from Treg DLI.Methods:We analysed peripheral blood samples of 38 patients with acute and 11 patients with chronic GVHD as well as 18 patients without GVHD after Alemtuzumab based conditioning, 10 patients with ATG for TCD and 10 healthy individuals. To identify Treg we stained for CD3, CD4, CD25, CD127, FoxP3. As activation markers GARP, TGF-beta, HLA-DR, CD45RA, CD39, CD44, CD62L, Granzyme A, CCR5, ILT3, CTLA4, CXCR3 and GITR were used. To investigate the influence of the CD52-AB Alemtuzumab, we also stained for CD52.Treg function was evaluated in CSFE suppression assays and TGF beta secretion. To investigate patient derived natural occurring Treg we sorted Treg from patients with GVHD or healthy controls with FACS and performed a CFSE proliferation assay with healthy PBMCs as effector T cells. To rule out the influence of systemic immunosuppression we analysed the effect of corticosteroids and CSA A on Treg marker expression and activation in healthy Treg. Treg were activated in vitro with IL2 (100U/ml AIM V+ human serum 10%) and OKT3 (30ng/ml).Results:Like in other publications in our cohort there were differences in absolute and relative Treg numbers in patients with acute, chronic or no GVHD compared with healthy controls: patients with aGVHD (mean 2,2%) had less Treg in comparison to patients with chronic (mean 4,5% p=0.0076) or no GVHD (mean 4,4% p=0.0045).CSA A or corticosteroids ex vivo (and in vivo) did not influence Treg marker expression significantly.Especially in patients after Alemtuzumab CD52 expression is the most prominent marker: Frequency of CD52pos Treg differed highly significant between patients with aGVHD (mean 15,94%) in comparison to patients with chronic (mean 75,85%) or no GVHD (mean 92,09%; p<0,0001). For all patients with acute or chronic GVHD FACS sorted Treg showed reduced capacity to suppress T cell proliferation in the proliferation assay.To determine the suppressive capacity of CD52neg Treg in comparison with CD52pos Treg of the same patient we divided Treg from one patient by FACS-Sort in CD52pos/neg subpopulations, which were used in a CFSE-proliferation assay again.We could show that CD52neg Tregwere less able to suppress effector T cell proliferation in comparison to CD52pos Treg (tested in 3 patients). Independent of the conditioning regimen Treg from GVHD patients were less able to suppress effector T cells in comparison with Treg from patients without GVHD or healthy individuals.We could not show any difference in activation markers ex vivo except GARP/TGFbeta. CD52neg Treg showed a reduced GARP/TGFbeta expression (mean 4,6% vs 1,65% p=0,012). After stimulation in vitro GARP/TGFbeta healthy controls showed the highest GARP/TGF-ß expression compared to patients with any GVHD, patients without GVHD exhibited higher amounts of GARP/TGFbeta compared to patients with aGVHD.We also analyzed patients after Alemtuzmab weekly during the first 200 days after HSCT to monitor the reconstitution of CD52neg Treg as a predictive marker for the development of aGVHD (n= 10). Patients who reconstituted with more than 50% of CD52pos Treg before d50 never developed any aGVHD. Patients with aGVHD and persistence of high amounts of CD52neg Treg showed a steroid refractory aGVHD with high mortality.Conclusion:Patients with acute GVHD showed different marker expression and decreased Treg function. Especially CD52neg Treg derived from patients after Alemtuzumab showed a reduced suppressive capacity and lower expression of activation markers. Higher GARP/TGFbeta expression seems to be associated with less development of acute GVHD. CD52 and GARP expression/TGFbeta secretion could be helpful biomarkers to identify a patient cohort with functional altered Treg and high risk of severe acute GVHD. In particular this patient cohort may benefit from Treg-DLI. DisclosuresNo relevant conflicts of interest to declare.

Final Analysis of the Phase I/II Study of CC-486 (Oral Azacitidine) Maintenance Therapy after Allogeneic Stem Cell Transplantation (Allo-SCT) in Patients with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndromes (MDS)

Final Analysis of the Phase I/II Study of CC-486 (Oral Azacitidine) Maintenance Therapy after Allogeneic Stem Cell Transplantation (Allo-SCT) in Patients with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndromes (MDS)

94 - Novel, Gene-Level Associations between the Microbiome and MAIT or Treg Reconstitution after Allogeneic HSCT

94 - Novel, Gene-Level Associations between the Microbiome and MAIT or Treg Reconstitution after Allogeneic HSCT

Rapid reconstitution of regulatory T-cell subsets is associated with reduced rates of acute graft-versus-host disease and absence of viremia after cord blood transplantation in children with reduced-intensity conditioning using alemtuzumab

Forkhead box P3 (FOXP3)+ regulatory T cell (Treg) reconstitution after unrelated donor umbilical cord blood transplantation in chemotherapy-naïve children is incompletely characterized. We studied 21 children with nonmalignant diseases receiving an identical alemtuzumab-containing regimen. We hypothesized that Treg recovery may be perturbed in patients not only by acute graft-versus-host disease (aGVHD) but also by viremia. Tregs and their memory and naïve subsets were serially monitored for proliferation and apoptosis along with conventional T cells (Tcon). A “reconstitution index” (RI) was calculated relative to pretransplantation values for each parameter. At 3 months post-UCBT, the RI of Tregs was faster compared with other immune components tested and was most rapid in patients free of aGVHD and viremia. There were significantly fewer Tregs in patients experiencing grade I–II aGVHD and/or viremia, leading to an imbalance between Tregs-Tcon ratios. Central and effector memory Tregs were most affected at this time point when they dominated in the circulation. Impaired Treg proliferation without increased apoptosis accounted for the reduced Treg-Tcon ratio. In patients affected with grade II aGVHD and viremia, the overall reduction in circulating Treg pool were associated with a more oligoclonal T-cell receptor β repertoire. Taken together, aGVHD and viremia can lead to defective Treg expansion homeostasis.

Advances in pathogenesis and treatment of chronic graft resistance to persistent diseases

Chronic graft-versus-host disease (cGVHD) is a major cause for late non-relapse-related death in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), and seriously affects their quality of life. cGVHD may involve many systems in the whole body and its clinical manifestations are similar to autoimmune diseases, and the main pathology is fibrosis. The therapeutic regimen based on glucocorticoids remains as the first-line treatment for cGVHD. Since long-term and high-dose application of glucocorticoids result in serious complications, along with the appearance of steroid-resistant and recurrence/refractory cGVHD, conventional immune suppressive agents have limited clinical efficacy. With the progress in understanding of the pathological mechanisms for cGVHD, many treatments, such as depletion of alloreactive T cells, B-cell depletion, preventing B cell differentiation, targeting the B-cell receptor signaling pathway, inhibition of cytokine receptor-mediated signaling, enhancement of Tregs in vivo, adoptive Tregs therapy, facilitating Tregs reconstitution, and anti-fibrosis therapy, have been supported by clinical and preclinical results.

Posttransplant Cyclophosphamide Promote Naïve-Subset Dominant B Cell Recovery Coordinated with Early Treg Expansion; Implication of Reduced Risk of Pathogenesis into Chronic Gvhd

Posttransplant cyclophosphamide (PTCy) is an effective prophylaxis for both acute and chronic graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). We recently studied the immune reconstitution dynamics of each lymphocyte subset after PTCy-based transplant using murine haploidentical BMT model and reported that PTCy strongly promoted Treg-dominant T-cell reconstitution and stem cell-derived mature B-cell generation with broad BCR-diversity. We also found that the early reconstitution of Treg could contribute to promote naïve B cell emergence from bone marrow, indicating the T and B cell recovery might be mutually coordinated after PTCy-based transplant (Iwamoto et al, ASH2017). However, the detailed process of immune reconstitution in patients after haploidentical HSCT with PTCy has not been well studied. To address this issue, we here investigated the early dynamics of donor-lymphocyte subset chimerisms in patient after clinical PTCy-based haploidentical HSCT with comparing those in patients after low-dose ATG-based haploidentical HSCT and patients after cord blood transplantation. Laboratory studies were undertaken in 13 adult patients who received HLA-mismatched allogeneic graft; unrelated cord blood (n=5), and haploidentical related peripheral blood after ATG-based conditioning (n=5) and haploidentical related peripheral blood after PTCy-based conditioning (n=5). Blood samples were obtained before and at 1, 2, 4, 6 and 8 weeks after HSCT. Peripheral blood mononuclear cells (PBMCs) were isolated from blood samples by density gradient centrifugation and cryopreserved before being analyzed. After thawing, to analyze the subset-specific chimerism, PBMCs were stained with anti-HLA monoclonal antibodies and other subset-specific antibodies as follows: Pacific Blue conjugated anti-CD4, eFluor450 conjugated anti-CD3, PE-Cy7 conjugated anti-CD25, anti-CD14, APC conjugated anti-CD127, anti-CD56, and APC-eFluor780 conjugated anti-CD8a, anti-CD19. Gated lymphotes (CD4+Tcons, CD4+Tregs, CD8+T cells, B cells, NK cells, Monocytes) were analyzed their chimerism by flowcytometry. To examine the detailed phenotype of B cells, the expression of CD27, CD24, CD38 and IgD were tested. Flowcytometry-based method enables us to analyze the lymphocyte subset chemerism in the very early phase after HSCT. At 2 weeks after HSCT, our analysis revealed that CD4+Tcons, CD4+Tregs and CD8+T cells had already achieved complete donor chimerisms (>95% in all subsets) in patients after ATG-based SCT and had been approaching complete donor chimerisms (85.8%, 75.4% and 87.2%, respectively) in patients after CBT. In contrast, percentage of donor chimerisms of CD4+Tcons, CD4+Tregs and CD8+T cells after PTCy-based haplo-SCT was 73.5%, 59.6% and 59.2%, respectively, and those remained to be in the lower levels than other 2 groups. However, at 4 weeks after HSCT, all examined patients achieved complete donor chimerism of T cells, NK cells and Monocytes (>90%). At 8 weeks after HSCT, the number of B cells in PTCy-based haplo-group was higher than in ATG-based haplo-group (3494 vs 1901/mm3). Of note, B cell population in PTCy-based haplo-group at 8 weeks contained the significantly higher percentage of CD24+CD27-IgD+CD38+ transitional/naïve subset and the significantly lower percentage of CD24+CD27+IgD-CD38neg/dim activated/switched-memory subset when compared to B cell population in ATG-based haplo-group (59.9% vs 10.2%, 2.6% vs 21.5%, P<0.02 respectively), suggesting PTCy treatment might be associated with the favorable B cell reconstitution with naïve-subset dominant composition. Moreover, in patients after PTCy-based haplo-group, the percentage of activated/switched-memory subsets in B cell population at 8 weeks was inversely correlated with percentage of Treg in CD4 T cells at 4 weeks (P<0.05, r2=0.77). Taken together, consistently with our murine study, the current data from clinical samples again suggest that PTCy-based immune-modulation lead to coordinated T and B cell recovery, especially promoting naïve-subset dominant B cell recovery with help of the early expansion of Treg, which might reduce the risk of subsequent chronic GVHD. These data provide the important information for understanding the immunological reconstitution after PTCy-based haploidentical HSCT. DisclosuresNo relevant conflicts of interest to declare.

Regulatory T Cells Restrict Permeability to Bacterial Antigen Translocation and Preserve Short‐Chain Fatty Acids in Experimental Cirrhosis

Intestinal permeability to translocation of bacterial products is increased in cirrhosis. Regulatory T cells (Tregs) remain central to the interplay between the host and microbial milieu. We propose that Tregs are involved in promoting gut barrier integrity and a balanced interaction with gut microbiota–derived short‐chain fatty acids (SCFAs). Carbon tetrachloride cirrhosis was induced in wild‐type and recombination activating gene 1 (Rag1)‐/‐ mice. Naive T cells and Treg cells were transferred into Rag1 ‐/‐ mice. Intestinal permeability was assessed in vivo after lipopolysaccharide (LPS) oral administration, and bacterial DNA presence was evaluated in mesenteric lymph nodes. Transcript and protein levels of tight‐junction (TJ) proteins were measured in colonic tissue. Intestinal T helper profile in response to Escherichia coli (E. coli) was determined by flow cytometry. SCFAs were measured by gas chromatography–mass spectrometry in colonic content before and after E. coli challenge. Rag1 ‐/‐ mice showed significantly increased permeability to LPS and bacterial DNA translocation rate compared with control mice. Naive T and Treg cotransfer significantly reduced gut permeability to bacterial antigen translocation and restored TJ protein expression in Rag1 ‐/‐ mice. Naive T and Treg replenishment in Rag1 ‐/‐ mice restrained proinflammatory differentiation of intestinal lymphocytes in response to E. coli. The main SCFA concentration resulted in significant reduction in Rag1 ‐/‐ mice after E. coli administration but remained unaltered after naive T and Tregs cotransfer. The reduced expression of SCFA receptors induced by E. coli was reestablished following naive T and Treg reconstitution in Rag1 ‐/‐ mice. Conclusion: The restriction of gut permeability, local inflammatory differentiation, and loss of bacteria‐derived SCFAs foster the value of Tregs in preventing bacterial translocation in cirrhosis.

CD28 blockade controls T cell activation to prevent graft-versus-host disease in primates.

Controlling graft-versus-host disease (GVHD) remains a major unmet need in stem cell transplantation, and new, targeted therapies are being actively developed. CD28-CD80/86 costimulation blockade represents a promising strategy, but targeting CD80/CD86 with CTLA4-Ig may be associated with undesired blockade of coinhibitory pathways. In contrast, targeted blockade of CD28 exclusively inhibits T cell costimulation and may more potently prevent GVHD. Here, we investigated FR104, an antagonistic CD28-specific pegylated-Fab', in the nonhuman primate (NHP) GVHD model and completed a multiparameter interrogation comparing it with CTLA4-Ig, with and without sirolimus, including clinical, histopathologic, flow cytometric, and transcriptomic analyses. We document that FR104 monoprophylaxis and combined prophylaxis with FR104/sirolimus led to enhanced control of effector T cell proliferation and activation compared with the use of CTLA4-Ig or CTLA4-Ig/sirolimus. Importantly, FR104/sirolimus did not lead to a beneficial impact on Treg reconstitution or homeostasis, consistent with control of conventional T cell activation and IL-2 production needed to support Tregs. While FR104/sirolimus had a salutary effect on GVHD-free survival, overall survival was not improved, due to death in the absence of GVHD in several FR104/sirolimus recipients in the setting of sepsis and a paralyzed INF-γ response. These results therefore suggest that effectively deploying CD28 in the clinic will require close scrutiny of both the benefits and risks of extensively abrogating conventional T cell activation after transplant.

Low-dose interleukin-2 as a modulator of Treg homeostasis after HSCT: current understanding and future perspectives.

CD4+CD25+Foxp3+ Treg is a functionally distinct subset of mature T cells with broad suppressive activity and has been shown to play an important role in the establishment of immune tolerance after HSCT. Altered cytokine environment in post-HSCT lymphopenia with a relative functional deficiency of IL-2 could hamper the reconstitution of Treg, leading to refractory GVHD. Based on the theory of low-dose IL-2 in which Treg can be selectively stimulated through the high-affinity IL-2 receptor, clinical studies have been conducted and demonstrated that low-dose IL-2 administration can restore Treg homeostasis and promote the expansion of this subset on the polymorphic processes of Treg reconstitution after HSCT. The new therapeutic indication of IL-2 for immune tolerance has launched in the field of HSCT and is spreading to the other fields including the treatment for autoimmune diseases. To further extend the indication of low-dose IL-2 to more patients with various immunological problems, the optimization of the timing and dosing of IL-2 intervention and the concomitant immune suppressive therapy according to each patient-based assessment are to be desired in the near future. Further prospective studies may facilitate the development of novel therapeutic algorithms for the effective and safe induction of immune tolerance after HSCT.

Distinct Biomarker Profiles in Ex Vivo T Cell Depletion Graft Manipulation Strategies: CD34+ Selection versus CD3+/19+ Depletion in Matched Sibling Allogeneic Peripheral Blood Stem Cell Transplantation

Various approaches have been developed for ex vivo T cell depletion in allogeneic stem cell transplantation to prevent graft-versus-host disease (GVHD). Direct comparisons of T cell depletion strategies have not been well studied, however. We evaluated cellular and plasma biomarkers in 2 different graft manipulation strategies, CD3+CD19+ cell depletion (CD3/19D) versus CD34+ selection (CD34S), and their associations with clinical outcomes. Identical conditions, including the myeloablative preparative regimen, HLA-identical sibling donor, GVHD prophylaxis, and graft source, were used in the 2 cohorts. Major clinical outcomes were similar in the 2 groups in terms of overall survival, nonrelapse mortality, and cumulative incidence of relapse; however, the cumulative incidence of acute GVHD trended to be higher in the CD3/19D cohort compared with the CD34S cohort. A distinct biomarker profile was noted in the CD3/19D cohort: higher levels of ST2, impaired Helios− FoxP3+Treg reconstitution, and rapid reconstitution of naïve, Th2, and Th17 CD4 cells in the early post-transplantation period. In vitro graft replication studies confirmed that CD3/19D disproportionately depleted Tregs and other CD4 subset repertoires in the graft. This study confirms the utility of biomarker monitoring, which can be directly correlated with biological consequences and possible future therapeutic indications.

Combined OX40L and mTOR blockade controls effector T cell activation while preserving Treg reconstitution after transplant.

A critical question facing the field of transplantation is how to control effector T cell (Teff) activation while preserving regulatory T cell (Treg) function. Standard calcineurin inhibitor-based strategies can partially control Teffs, but breakthrough activation still occurs, and these agents are antagonistic to Treg function. Conversely, mechanistic target of rapamycin (mTOR) inhibition with sirolimus is more Treg-compatible but is inadequate to fully control Teff activation. In contrast, blockade of OX40L signaling has the capacity to partially control Teff activation despite maintaining Treg function. We used the nonhuman primate graft-versus-host disease (GVHD) model to probe the efficacy of combinatorial immunomodulation with sirolimus and the OX40L-blocking antibody KY1005. Our results demonstrate significant biologic activity of KY1005 alone (prolonging median GVHD-free survival from 8 to 19.5 days), as well as marked, synergistic control of GVHD with KY1005 + sirolimus (median survival time, >100 days; P < 0.01 compared to all other regimens), which was associated with potent control of both TH/TC1 (T helper cell 1/cytotoxic T cell 1) and TH/TC17 activation. Combined administration also maintained Treg reconstitution [resulting in an enhanced Treg/Teff ratio (40% over baseline) in the KY1005/sirolimus cohort compared to a 2.9-fold decrease in the unprophylaxed GVHD cohort]. This unique immunologic signature resulted in transplant recipients that were able to control GVHD for the length of analysis and to down-regulate donor/recipient alloreactivity despite maintaining anti-third-party responses. These data indicate that combined OX40L blockade and sirolimus represents a promising strategy to induce immune balance after transplant and is an important candidate regimen for clinical translation.

Low-dose post-transplant cyclophosphamide can mitigate GVHD and enhance the G-CSF/ATG induced GVHD protective activity and improve haploidentical transplant outcomes

ABSTRACTUse of high-dose, post-transplant cyclophosphamide (PTCy) results in low rates of graft-versus-host-disease (GVHD) and favorable immune reconstitution, although with higher rates of relapse and somewhat high rates of graft failure. We hypothesized that permissible dose reduction of PTCy might be feasible. The current study attempts to establish a murine model and focus on regulatory T cells (Tregs) to clarify the immunological mechanisms for GVHD prevention by low-dose PTCy. In addition, a prospective, clinical cohort study in haploidentical, T-cell replete transplantation is initiated to support the rational. We found that acute GVHD could be alleviated by low-dose PTCy and could be further mitigated after the combined use of low-dose PTCy and antithymocyte globulin (ATG) in mice. Flow-cytometric analyses in mice showed that low-dose PTCy could increase the number of Tregs and the effect on Tregs is significantly prominent with the combined use of low-dose PTCy and ATG. In the clinical cohort study, the cumulative incidence of grades II-IV acute GVHD in combined treatment cohort with low-dose PTCy and ATG/granulocyte colony-stimulating factor (G-CSF) (17%; 95% CI, 5–29%) was significantly lower than both that in matched-pair cohort (33%; 95% CI, 25–41%; P = 0.04) and that in historical cohort (56%; 95% CI, 42–70%; P < 0.001). In-vivo immune reconstitution analysis showed that low-dose PTCy could facilitate suppressive Tregs reconstitution. In conclusion, low-dose PTCy is sufficient for GVHD abrogation under lymphopenic situation and can enhance the protective effect of ATG/G-CSF on GVHD. Intensified conditioning followed by low-dose PTCy might be a feasible option for patients undergoing haploidentical transplantation.

79 - CD56 Enriched Donor Cell Infusion Following Post-Transplantation Cyclophosphamide and Cyclosporine Alone for Haploidentical PBSCT in Myeloid Malignancies Is Associated with Prompt Reconstitution of Mature NK Cells and Tregs with Reduced Incidence of aGVHD

79 - CD56 Enriched Donor Cell Infusion Following Post-Transplantation Cyclophosphamide and Cyclosporine Alone for Haploidentical PBSCT in Myeloid Malignancies Is Associated with Prompt Reconstitution of Mature NK Cells and Tregs with Reduced Incidence of aGVHD