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Cellular Transplantation: From Laboratory to Clinic
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Commencer à lireLongueur: 2,115 pages24 heures
- Éditeur:
- Academic Press
- Sortie:
- Oct 10, 2011
- ISBN:
- 9780080469041
- Format:
- Livre
Description
There have been tremendous strides in cellular transplantation in recent years, leading to accepted practice for the treatment of certain diseases, and use for many others in trial phases. The long history of cellular transplantation, or the transfer of cells from one organism or region of the body to another, has been revolutionized by advances in stem cell research, as well as developments in gene therapy.
Cellular Transplants: From Lab to Clinic provides a thorough foundation of the basic science underpinning this exciting field, expert overviews of the state-of-the-art, and detailed description of clinical success stories to date, as well as insights into the road ahead. As highlighted by this timely and authoritative survey, scale-up technologies and whole organ transplantation are among the hurdles representing the next frontier.
The contents are organized into four main sections, with the first covering basic biology, including transplant immunology, the use of immunosuppressive drugs, stem cell biology, and the development of donor animals for transplantation. The next part looks at peripheral and reconstructive applications, followed by a section devoted to transplantation for diseases of the central nervous system. The last part presents efforts to address the key challenges ahead, such as identifying novel transplantable cells and integrating biomaterials and nanotechnology with cell matrices.
Provides detailed description of clinical trials in cell transplantation Review of current therapeutic approaches Coverage of the broad range of diseases addressed by cell therapeutics Discussion of stem cell biology and its role in transplantationInformations sur le livre
Cellular Transplantation: From Laboratory to Clinic
Longueur: 2,115 pages24 heures
Description
There have been tremendous strides in cellular transplantation in recent years, leading to accepted practice for the treatment of certain diseases, and use for many others in trial phases. The long history of cellular transplantation, or the transfer of cells from one organism or region of the body to another, has been revolutionized by advances in stem cell research, as well as developments in gene therapy.
Cellular Transplants: From Lab to Clinic provides a thorough foundation of the basic science underpinning this exciting field, expert overviews of the state-of-the-art, and detailed description of clinical success stories to date, as well as insights into the road ahead. As highlighted by this timely and authoritative survey, scale-up technologies and whole organ transplantation are among the hurdles representing the next frontier.
The contents are organized into four main sections, with the first covering basic biology, including transplant immunology, the use of immunosuppressive drugs, stem cell biology, and the development of donor animals for transplantation. The next part looks at peripheral and reconstructive applications, followed by a section devoted to transplantation for diseases of the central nervous system. The last part presents efforts to address the key challenges ahead, such as identifying novel transplantable cells and integrating biomaterials and nanotechnology with cell matrices.
Provides detailed description of clinical trials in cell transplantation Review of current therapeutic approaches Coverage of the broad range of diseases addressed by cell therapeutics Discussion of stem cell biology and its role in transplantation- Éditeur:
- Academic Press
- Sortie:
- Oct 10, 2011
- ISBN:
- 9780080469041
- Format:
- Livre
En rapport avec Cellular Transplantation
Aperçu du livre
Cellular Transplantation
Maryland
Preface
These are exciting times for everyone involved in and interested in cell transplantation. Great progress has been made using cellular transplants for the amelioration of diseases over the last three decades. Indeed, the field has grown to its current-day accepted practice for certain diseases. As you will read, however, this scientific and clinical field continues to mature and many hurdles remain that must be overcome for cell transplantation to be routinely accepted in clinical practice. Significant advances in cell sourcing (both stem cells and/or animal cell sources), gene therapy, and immunoprotectior/novel-immunosuppressants will be focal areas for the foreseeable future. In addition, the ability to scale up these technologies and package the cells is a difficult task for the eventual delivery of viable cells to the clinician. Finally, developing reproducible transplantation strategies that will ensure high-percentage outcomes without complications also has to be developed. These obstacles are embraced by the authors of the chapters in this text as challenges that will be overcome with a greater understanding of disease mechanisms and transplantation biology. These authors provide their insights into the accomplishments and challenges of cell transplantation in specific clinical applications.
Cell transplantation has passed through several revolutions in its surprisingly long history. One of the earliest recorded autograft transplants was performed to relieve cranial pressure in the Bronze age. A hole was bored in the skull, the bone removed, pressure relieved, and then the bone was grafted back into the skull. Modern organ transplantation relied on the development of anesthetics (earliest development in 1540 by Valerius Cordus discovering the effects of ether), the development of aseptic surgical techniques in the 1800s by Joseph Lister, and the discovery of cyclosporine in the 1970s by Jean-Francois Borel with the subsequent trials in transplant patients by Roy Calne. These were only some of the discoveries that have led to today’s successful whole-organ transplantation of kidneys, lungs, livers, pancreases, heart, and other peripheral organs.
Bone marrow transplantation of matched HLA donors became a successful procedure in the 1970s and 1980s. In the 1980s and into the 1990s, it was demonstrated that autologous bone marrow transplantation on irradiated patients could be used for cancer therapy. During this period, a subset population of cells (the stem cell) was identified and methods for expansion and further differentiation into the various myeloid lineages were developed. This therapy has revolutionized modern methods of treating several cancer phenotypes. Hence, the success of this cell therapy has led the impetus to develop other cell-based therapies.
The complexity of whole-organ transplantation for diseases such as diabetes and neuromuscular disorders has led to the final push in cell therapy. Over the past 20 years hundreds of clinical trials have been performed to evaluate the safety and efficacy of cell transplantation ranging from pancreatic islet transplantation for diabetes to dopamine-producing cells for Parkinson’s disease. Both successful and unsuccessful outcomes have been observed. It is the goal of this book to introduce the reader to many different potential applications of this therapy and to demonstrate not only the challenges but the clinical successes that have been achieved to date. Because the field of cell transplantation has become so broad, researchers and clinicians are finding it increasingly difficult to remain familiar with all of the different multidisciplinary aspects. Although several books exist on the topic, they tend to cover the field from a specialized perspective. A major impetus for this book was the belief that there is a need for a more inclusive approach that illuminates the rapid advances and developments that are pushing cell transplantation forward. We have organized the book into several parts to help ensure that as many aspects as possible could be covered by leading experts.
In Part I, some basic biology of cell transplantation is identified, including transplant immunology, the use of immunosuppressive drugs, stem cell biology, and the development of uniquely suitable donor animals for transplantation. In Part II, recent advances in cell transplantation for peripheral and reconstructive applications are identified, focusing on diabetes, kidney transplants, hemophilia, liver failure, autoimmune diseases, cardiac and orthopedic, and muscle transplantation. Part III describes the current state of central nervous system transplantation, describing the strategies under investigation for Parkinson’s, Alzheimer’s, and Huntington’s disease, as well as stroke and spinal cord trauma. Finally, Part IV attempts to be somewhat prescient describing future developments in the field, ranging from identifying novel transplantable cells to the combined use of biomaterials and nanotechnology with cell matrices.
We find ourselves in the midst of a new era in cell transplantation. The focus of cell transplantation is shifting from an intuitively appealing but speculative concept to clinical reality. With continued time and effort our hope is that one day off-the-shelf cell-based products will exist that will be able to treat hundreds of diseases and tissue malfunctions.
Craig R. Halberstadt, Dwaine F. Emerich
A.
The Basic Biology of Cell Therapy
Immunology of Cell and Tissue Xenotransplantation
Jeffrey L. Platt
Transplantation Biology and the Department of Surgery, Immunology, and Pediatrics, Mayo Clinic College of Medicine, Rochester, Minnesota
Introduction
Xenotransplantation refers to the transplanting of cells, tissues, or organs from individuals of one species into individuals of another species. Xenotransplantation has long been envisioned as a way of treating human diseases because animals are available in large numbers and at little expense. In contrast, when humans are used as a source of transplants for human recipients (allotransplants), the number of transplants that can be performed is limited by the availability of human donors (as low as 5% of the number needed) and the cost of these transplants can be very high [10].
The first serious efforts at xenotransplantation were made in the early years of the twentieth century. With the development of the surgical technique that could enable organ transplants to be performed (the vascular anastomosis), experimental surgeons sought a ready source of organs to treat subjects with organ failure, particularly kidney failure. Humans, living and recently deceased, were not viewed as a potential source of such organs because of such ethical questions as whether and under what conditions one could define death and whether and in what ways one could meddle with the deceased. Hence, the first attempts at clinical transplantation used animals as a source of organs [36]. The first animals used for xenotransplants were pigs and sheep (Table 1.1) [14]. The ethical hurdles to using humans as a source of organs for transplantation did not last very long. The year 1911 brought what may be the first recorded attempt to transplant an organ from one person to another [2].
TABLE 1.1 Some clinical attempts at xenotransplantation.
The early attempts at xenotransplantation failed, as did early attempts at human-to-human transplantation (allotransplantation). The reason for failure of xenografts and allografts was not understood until the 1940s, when the immune response of the recipient against the graft was found to be the principal biological barrier to transplantation [11]. With the advent of immunosuppressive drugs in the late 1950s, this barrier was overcome and the era of clinical allotransplantation began soon thereafter.
The application of organ transplantation for the treatment of disease was among the most exciting advances in medicine and surgery. However, as in the early years of the twentieth century the availability of human donors was quite limited. Hence, efforts were made once again to use animals, such as chimpanzees and baboons, as a source of organs [31, 34]. When the recipient was treated with immunosuppressive agents, primate-tohuman xenografts functioned for weeks to months, but ultimately failed. Human-to-human transplants, however, would sometimes function indefinitely. This experience suggested that although xenotransplantation was a potential solution to organ failure xenotransplantation was impaired by an immunological barrier more severe than the barrier hindering human-to-human transplantation. Recent years have brought a better understanding of the immunological barriers to xenotransplantation and allotransplantation, and the possibility of applying genetic engineering to better address that barrier, at least in part [6]. The material following reviews the immunological barriers to xenotransplantation and discusses the various approaches proposed for overcoming those barriers.
The Rationale for Xenotransplantation
Before the barriers to xenotransplantation are discussed, one may usefully consider why with the availability of allotransplantation we should pursue xenotransplantation today. The main rationale for xenotransplantation is that animals could potentially provide a limitless source of organs and tissues for transplantation. In addition, the cost of xenotransplantation might be very much lower than the cost of allotransplantation if the latter includes the costs of additional intensive care and clinical organ harvesting. Further, under some circumstances xenotransplantation may be preferred over allotransplantation. Where organ failure is caused by a viral infection (e.g., hepatitis), xenotransplantation might be preferred because the transplant would resist reinfection by the virus that caused organ failure [21, 25, 27]. Xenotransplantation might also be preferred as a way of delivering genes of therapeutic importance [7, 27]. For example, an animal source might be genetically engineered to express a gene at a high level or under regulated conditions.
An important consideration today is how to weigh xenotransplantation against other potential approaches to treating organ failure [5]. Although some new technologies (such as stem cells, tissue engineering, and cardiac assist devices) have received much attention, they have also received less scrutiny than xenotransplantation because they are so recent in their development. Most likely, these technologies will be applied in ways that fill therapeutic niches, such as repairing local defects or injury of tissues. Devices may eventually be used to replace the heart, but application for other organs is more remote. On the other hand, cell transplantation, stem cell transplantation, and tissue engineering seem less promising for replacement of the function of structurally complex organs such as the kidney, lungs, and heart. For replacement of these organs, organogenesis (the de novo formation of organs) or xenotransplantation may be necessary. Xenotransplantation may also find application in conjunction with organogenesis. For example, one might envision growing
human organs (perhaps derived from stem cells as a xenograft in an animal host) and then transplanting the organs to human patients [7, 24].
Source of Xenografts
Many species have been used as sources of tissues and organs for xenotransplantation. Xenografts from sources phylogenetically closer to the recipient would be expected to provoke less immunity and to be more physiologically compatible with the recipient. Consistent with that idea, experimental cardiac xenografts from monkeys to baboons have survived greater than a year, and renal xenografts from chimpanzees to humans have survived and functioned up to nine months (Table 1.1). However, some biological barriers to xenotransplantation derive from expression of one or very few genes in the donor or recipient. These barriers do not relate directly to overall genetic difference.
The genetic barrier of greatest current interest and importance is expression of α1-3 galactosyltransferase, a glycosyltransferase that catalyzes synthesis of Galα1-3Gal. Galα1-3Gal is a saccharide expressed by lower mammals and New World monkeys, but not by humans and old-world monkeys. Humans and old-world monkeys have natural
antibodies specific for this saccharide, and these antibodies trigger severe reactions when organs containing Galα1-3Gal are transplanted. Indeed, many of the efforts in genetic engineering and immunosuppression for xenotransplantation are directed respectively at eradicating expression of the sugar or suppressing immunity directed against it.
Today, most efforts in xenotransplantation focus on the pig as a potential source of tissues and organs. The most important reason for favoring the pig is that pigs are available in large numbers (it is estimated that more than one million would be needed for transplants each year on a worldwide basis). Another reason for favoring pigs as a source of xenografts is that pigs can be bred and genetically manipulated, as described in material following. Still another reason for favoring the pig is that the organs are large enough to fulfill the needs of full-sized humans, and some strains of pigs (such as the mini-pig) may at maturity approximate human size. Finally, the microorganisms harbored by pigs and potentially infectious for humans are well known, and measures for screening for these organisms are well established. In contrast, some viruses of nonhuman primates are poorly known and potentially lethal to humans.
Although the experience is limited, best present evidence would suggest that the heart, lung, and kidneys of the pig would function sufficiently to sustain the life of the human. Whether the liver would function sufficiently is a matter of controversy because of the metabolic complexity of that organ and because of the possibility that complex cascades, such as complementing coagulation, could be incompatible between pig and human.
The Immunological Barriers to Xenotransplantation: An Overview
Xenotransplantation excites nearly every immune and inflammatory pathway known. Among the inflammatory pathways are complement, coagulation, neutrophils, and natural killer cells. The immunological pathways include both innate and elicited responses by B-cells and T-cells. So intense is the response to xenotransplantation that no approach yet used has allowed the enduring survival of a xenogeneic organ transplant in a human subject, or in an animal for that matter. One might argue cynically that this failure of success drives even more daunting regulatory hurdles (put another way, one doubts that governments would impose such severe regulatory hurdles if xenotransplantation could clearly succeed). However, despite this discouraging picture there are reasons to think that the immunological barriers to xenotransplantation can be overcome.
One reason for this more encouraging view of the prospects for overcoming the immunological barriers to xenotransplantation is that in contrast to human-to-human transplantation genetic engineering might be applied to some of the barriers. For example, the author and co-workers suggested more than a decade ago that intrinsic susceptibility of a xenograft to the complement system of the recipient might be overcome by expressing human complement regulatory proteins in the graft [30]. This approach, the addressing of immunological hurdles by genetic engineering, is now considered routine in xenotransplantation.
Another reason for this more encouraging view of the prospects for overcoming the immunological barriers to xenotransplantation stems from the fact that the barrier to successful transplantation of xenogeneic cells may be much less daunting than the barrier to successful transplantation of xenogeneic organs.
The Type of Transplant and the Barrier to Xenotransplantation
No factor has a greater bearing on the barrier to xenotransplantation than the type of transplant: isolated cells or tissues on the one hand or intact organs on the other. All transplants can arouse immune responses, and by every measure the immune response to cell and tissue grafts may be quite comparable to the immune response to organ grafts. However, the impact of the immune response on cell and tissue grafts is profoundly different than the impact on organ grafts. This difference is summarized in Figure 1.1.
Figure 1.1 The biological outcome of xenografts: impact of mechanism of vascularization. Cell and tissue xenografts derive their blood supply through the in-growth of blood vessels of the recipient. Because the blood vessels of these grafts are constructed from cells of the recipient, antibodies of the recipient do not generally bind to the blood vessels and vascular diseases of organ grafts such as hyperacute and acute vascular rejection are not observed. Rather, the grafts are mainly subject to injury by T-cells that have the ability to migrate effectively through blood vessel walls. (a) Outcome of cell and tissue xenografts. Cell and tissue xenografts are subject to primary nonfunction and cellular rejection. Primary nonfunction, the immediate failure of the newly implanted cells or tissues, may be caused by various factors, including T-cells. (b) Outcome of organ xenografts. Like cell and tissue xenografts, organ xenografts are subject to cellular rejection, and to vascular types of rejection, including hyperacute, acute vascular, and chronic rejection. Vascular rejection, particularly hyperacute and acute vascular rejection, are caused by the binding of antibodies and activation of complement of the recipient on xenogeneic blood vessels. Having blood vessels originating with the recipient, cell and tissue xenografts are not subject to this type of problem.
The Immune Response to Cell and Tissue Transplants
Cell and tissue grafts provoke cell-mediated immune responses and humoral immune responses. Cellmediated immune responses give rise to cellular rejection and possibly to primary nonfunction. Humoral immune responses provide a reliable marker of immunity to the transplant, but as we shall see these responses have little or no impact on the fate of the graft. That is not to say that B-cells are unimportant in cell and tissue transplantation. As we shall discuss, B-cells have functions other than the production that may influence the fate of cell and tissue grafts.
Although any antigen carried by the graft and not by the recipient can elicit an immune response, responses to major histocompatibility complex (MHC) antigens are most pronounced and have the greatest impact on the fate of the graft [28]. A complete consideration of the immune response to MHC is quite beyond the scope of this chapter. Here it is pertinent to say that transplants generate cellular and humoral responses to MHC-encoded proteins. The cellular responses occur in nearly every instance and reliably and rapidly cause rejection. In fact, so reliable and rapid is rejection that the antigens were named major histocompatibility antigens [8]. The antibodies produced in response to MHC-encoded proteins were used to map the MHC locus. Other antigens (in contrast to MHC antigens) tend to trigger rejection less reliably and more slowly than MHC antigens, and hence these antigens are called minor histocompatibility antigens. However, in a given combination of donor and recipient strains some minor histocompatibility antigens cause rejection just as quickly and reliably as MHC antigens.
Responses to MHC antigens are quite vigorous for several reasons. One factor accounting for the importance of MHC antigens is that they are highly polymorphic. Thus, transplants between out-bred individuals are nearly certain to contain at least one MHC antigen not present in the recipient and are thus able to generate an immune response. Most other proteins are quite similar if not identical between different individuals, and hence any other given protein is unlikely to arouse a response. However, at least some protein allotypes will distinguish the donor and recipient, and therefore polymorphism alone (although necessary) does not account for the importance of MHC-encoded proteins as antigens.
A second reason MHC-encoded proteins are such potent antigens is that the polymorphic sequences are highly immunogenic. The factors that make an amino acid sequence more or less immunogenic are incompletely understood but include the presence of amino acids at key points that allow a peptide to be loaded onto MHC class I or class II complexes and probably the presence of consensus domains that allow the proteins to be cleaved in ways that will encourage such loading. Beyond these factors, however, is evidence that MHC-encoded proteins may have evolved in ways that make them better targets for T-cell receptors.
A third reason MHC-encoded proteins are such potent antigens is that when they are presented in grafts the proteins can be recognized in native form by T-cell receptors of the recipient [18]. All other antigens of the graft must be degraded and presented in association with MHC complexes of the recipient. This type of antigen presentation is known as direct antigen presentation,
and it is thought to be quite potent. Thus, up to 10% of the T-cells in a person’s blood can recognize foreign MHC by direct antigen presentation, whereas only a very much smaller fraction (perhaps less than 0.1% of a person’s T-cells) would recognize peptides from that MHC antigen presently in association with MHC on antigen-presenting cells of the responding individual. This second type of antigen presentation is referred to as indirect antigen presentation. It is the usual way in which foreign antigens are recognized [33].
Following cell and tissue transplantation, both direct and indirect pathways of MHC antigen presentation can be used in stimulating responses of the recipient. If the transplant contains cells expressing MHC class II (in mice, MHC class II is expressed mainly on dendritic cells and B-cells; in humans it is expressed on these cells and also on monocytes and endothelial cells), the cell may migrate to regional lymph nodes and there stimulate T-cells of the recipient directly. However, the T-cells activated through this pathway may find relatively few cells in the transplant expressing the allogeneic MHC class II. Of course, most or all parenchymal cells will express allogeneic MHC class I. However, the T-cells of the recipient are usually found near blood vessels and not parenchymal cells—at least during the early days after transplantation—and the blood vessels derive mainly from the recipient (by in-growth). Thus, in cell and tissue grafts the main pathway of antigen presentation leading to rejection may be the indirect pathway.
The pathway through which antigen presentation occurs is especially pertinent for xenografts. T-cells respond poorly to direct antigen presentation by xenogeneic antigen-presenting cells [1, 30]. The defective response is owed in part to species’ specificity of adhesion molecules that promote interaction of T-cells and antigen-presenting cells and in part to species specificity of cytokines. Thus, if rejection depended on the response of the direct pathway xenografts might be less susceptible to cellular rejection. Some have thought that these defects might allow xeonografts to be better accepted than allografts and that this susceptibility might be further improved by genetic engineering (to further dissuade interactions of recipient cells with the graft). Sadly, these hopes have not been realized. Cell and tissue xenografts are as susceptible as allografts to cellular rejection. Some differences between xenografts and allografts can still be exploited. Xenografts may depend to an even greater extent on the indirect pathway, and hence therapies that disrupt interaction of T-cells with MHC class II may be especially effective [26].
Still another consideration in the immune response to cell and tissue xenografts may be the possibility that cellular immune response will be generated to multiple proteins of the xenogeneic source. It was previously stated that most proteins of the donor will be the same (or at least not immunogenic) in an allogeneic recipient. The same cannot be said for xenotransplantation. Most or all proteins are immunogenic in xenogeneic species. Therefore, one might predict that the response to xenogeneic proteins would add significantly to the immune response to a xenograft. Consistent with this concept, some have found that T-cells will proliferate to these non-MHC-encoded proteins, whereas they do not proliferate to non-MHC alloantigens. The reason T-cells do not proliferate to non-MHC alloantigens is thought to be that the number of such antigens is so small that the fraction of the T-cell repertoire that can respond is too low to be detected.
The Impact of Immunity on Cell and Tissue Grafts
Cell and tissue grafts are subject mainly to primary nonfunction and cellular rejection. The mechanisms underlying cellular rejection have been considered elsewhere in detail [29] and will not be discussed here except as an index of the immune response.
PRIMARY NONFUNCTION
If a graft fails to show evidence of engraftment or function, it is considered to have primary nonfunction. Primary nonfunction may have a variety of causes, and these causes may differ depending on the type of graft and location in which it is placed. For example, engraftment of bone marrow and hepatocytes depends very much on the microenvironment in which the graft is placed. Bone marrow appears to require healthy stromal cells to support hematopoietic stem cells (hepatocytes engraft poorly in the microenvironment of the cirrhotic liver). When cellular grafts are administered into blood vessels such as the portal vein, the grafts may be subject to injury or destruction by antibodies and complement of the recipient. All of these factors may cause failure of engraftment or failure of function.
Cell and tissue grafts are also subject to allogeneic resistance caused by the action of natural killer cells of the recipient and manifest as failure of engraftment. Natural killer cells have killer inhibitory receptors that recognize self-MHC and upon doing so prevent natural killer cells from exerting cytotoxicity against cells expressing this MHC. For example, bone marrow from parental strain (homozygous for MHC) may not engraft in F1 (MHC heterozygotes) individuals because natural killer cells of the recipient lack killer inhibitory receptors that would suppress responses to the MHC class I missing in the parent. Resistance of this type would presumably be even more pronounced for xenografts because natural killer cells are stimulated by these grafts through multiple pathways [13].
Primary nonfunction may also be caused by T-cells [16]. How T-cells might cause primary nonfunction, however, is not entirely clear. Certainly T-cells respond vigorously and rapidly to allografts and xenografts. However, the kinetics of the best characterized response are seemingly too slow to account for primary nonfunction. The kinetics of the cellular immune response to allogeneic transplants have been thoroughly investigated. Typically, a cellular or tissue graft becomes vascularized over a period of three to five days and for a period of time functions normally. Only after a period of vascularization (often eight days to two weeks after engraftment) is cellular rejection and failure of function observed. This picture of function followed by failure differs from primary nonfunction, in which function is never observed.
Two recent observations may help explain how T-cells could cause primary nonfunction. First, contrary to the kinetics of T-cell activation in vitro or to the kinetics of rejection, T-cell activation in lymph nodes occurs within minutes of the introduction of antigen [35]. The T-cells activated most rapidly may be memory T-cells or some other population, the role of which may be more that of helping the activation of T-cells that will contribute to the effector response. However, these firstactivated cells can produce cytokines, and it may be these cytokines that account at least in part for primary nonfunction. Second, T-cells were recently found to act on grafts nonspecifically during the period of reperfusion and doing so to contribute to ischemia-reperfusion injury. Perhaps T-cells might cause primary nonfunction through this nonspecific action.
CELLULAR REJECTION
The most important type of rejection to afflict cell and tissue grafts is acute cellular rejection. Of course, cellular rejection depends on recognition of the graft and graft antigens by T-cells. To what extent and in which way(s) tissue damage depends on the function of T-cells are less clear. For allografts, the question is whether cytotoxicity mediated by CD8+ T-cells or a reaction such as delayed-type hypersensitivity initiated by CD4+ T-cells and mediated by macrophages predominates in rejection. Each of these mechanisms finds experimental support. For xenografts, the question of whether cytotoxicity or delayed-type hypersensitivity is of greater importance in causing tissue injury has not been addressed specifically. However, because xenografts usually contain a great many macrophages and seem especially to benefit from treatments aimed at CD4+ T-cells one might anticipate that delayed-type hypersensitivity might be more important than cytotoxicity as a mechanism of rejection. Consistent with this concept is the observation that CD8 binding to MHC class I may be especially impaired across species.
B-cells, Antibodies, and the Barrier to Cell and Tissue Transplantation
Although cell and tissue grafts stimulate a vigorous humoral immune response, antibodies appear to have a limited impact on the fate of cell and tissue grafts. For instance, studying porcine hepatocytes transplanted into rats [22], we found no evidence that humoral immune responses compromised graft function. Similar results have been observed in nonhuman primates.
How does humoral immunity have such a profound impact on organ grafts and such a limited impact on cell and tissue grafts? Organ grafts are vascularized by anastomosis of graft blood vessels with the blood vessels of the recipient. Hence, the vascular supply of the organ graft is that of the organ. As the graft is perfused with the blood of the recipient, antibodies in the blood specific for antigens of the graft can bind to endothelium, activate complement, and initiate vascular diseases such as hyperacute and acute vascular rejection and possibly chronic rejection [6, 25, 27]. These diseases of organ grafts—hyperacute and acute vascular rejection and chronic rejection—are diseases of blood vessels that are not observed in cell and tissue grafts. In fact, there exists no evidence that cell and tissue xenografts would benefit from genetic manipulations such as the expression of human complement regulatory proteins or the knocking out of the enzyme that catalyzes synthesis of Galα1-3Gal (the antigen targeted by natural antiswine) that has advanced the transplantation of organ grafts [20, 37].
The reasons vascular diseases (such as hyperacute and acute vascular rejection) are not observed, and expression of human complement regulatory proteins or abolished synthesis of Galα1-3Gal is not particularly beneficial in cell and tissue xenografts, are several. First, the diseases are caused by binding of antibodies of the recipient to donor blood vessels (cell and tissue grafts receive their blood supply by in-growth of blood vessels of the recipient). Second, cell and tissue grafts generally reside outside blood vessels, where the concentration of antibodies and complement are considerably lower than the concentrations in the blood.
Although antibodies and complement may not contribute importantly to rejection of cell and tissue grafts, B-cells may play an important role. B-cells can specifically capture, concentrate, and present foreign antigens. B-cells also help to generate the lymphoid tissues in which antigens are presented [19, 23]. Finally, B-cells promote diversification of the T-cell repertoire [15, 17]. Given these considerations, it may not be surprising that therapies directed at B-cells may have value for promoting survival of cell and tissue grafts.
Therapeutic Approaches to Cell and Tissue Transplantation
Although some important aspects of the cellular immune response to cell and tissue xenotransplantation are understood, the most important practical question—whether cell and tissue xenotransplants can be sustained by administration of available immunosuppressive drugs—is still not clear. Although in vitro studies may suggest that immune response to xenografts may be weaker than the immune response to allografts, cell and tissue xenografts are clearly subject to cellular rejection, and the kinetics of rejection of cell and tissue xenografts in untreated recipients are at least as rapid as the kinetics of rejection of allografts. Some have proposed that the cellular immune response to xenografts may be so strong that success may depend on the induction of immunological tolerance [32]. Unfortunately, the induction of an enduring state of tolerance between widely disparate species, particularly for swine transplants in primates, has not been accomplished. In part, the failure to achieve immunological tolerance between disparate species reflects the enormously difficult hurdle to achieving durable engraftment of hematopoietic stem cells [3, 4].
The difficulty in achieving tolerance between species, at least as it is pursued today, may reflect in part on mechanisms underlying primary nonfunction. Thus, if tolerance is sought by engraftment of hematopoietic stem cells success may be limited by incompatibility of xenogeneic stem cells with recipient bone marrow stroma and cytokines, and by the action of complement and of natural killer cells.
Despite the difficulties in inducing tolerance between species, however, cell and tissue xenografts have achieved at least some measure of success in recipients treated with conventional types of immunosuppression. As two examples, swine hepatocytes have been transplanted into rabbits [12] and into rats [22] with enduring function and survival observed in recipients treated with only cyclosporine or with no immunosuppression. Swine substantia nigra cells have survived for months in human subjects treated only with cyclosporine [9]. Soon to be published are accounts of engrafting of pancreatic islets and hepatocytes for many months in nonhuman primates. In neither case was genetic engineering, either expression of human complement regulatory protein or knocking out of α1,3-galactosyltransferase, needed. Thus, the hurdles to the transplantation of xenogeneic cells and tissues may be far less than might be thought based on the difficulties observed with intact organs. Indeed, from the perspective that can now be suggested the greatest hurdles to successful xenotransplantation of cells and tissues may be finding appropriate clinically advantageous applications and gaining regulatory approval.
Acknowledgments
Work in the author’s laboratory described in this chapter has been supported by grants from the National Institutes of Health (HL46810 and HL52297).
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Current Immunosuppressive Drugs and Clinical Use
Harrison S. Pollinger, D.O. [1], Justin M. Burns, M.D. [2], Vince P. Casingal, M.D. [2], Paul F. Gores, M.D. [2],
[1]Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota.
[2]Division of Transplantation Surgery, Carolinas Medical Center, Charlotte, North Carolina
The clinical application of cell transplantation is still in its infancy. However, the immunosuppressive drugs that make allotransplantation possible have been in use for over 50 years. During the latter half of the twentieth century, organ trasplantation evolved from an experimental technique performed in the animal laboratory to a mature clinical discipline affording improved health and a better quality of life for thousands of individuals. The fulcrum underpinning this successful transformation was the development of small molecule immunosuppressive agents which modulate the immune response in a non-antigen specific manner. Each of these molecules, aside from their immunosuppressive qualities, is associated with significant toxicities which precludes their use in high enough doses to provide effective prophylaxis as monotherapy against rejection. Fortunately, these drugs differ with respect to the way in which they interfere with the immune response. Thus it has been possible to implement combination therapies; minimizing drug specific side effects while taking advantage of synergies to potentiate suppression of the rejection response by the immune system. More recently biologic agents have been introduced which offer the promise of providing more specific immunomodulation. Refinement of these strategies will be essential for the continued development of cell transplantation which, in general, is a less invasive form of therapy than is solid organ transplantation.
The Alloimmune Response
An appreciation of the host response to donor antigen is essential for understanding the mechanism of action and rationale of combination therapies. Rejection of organ and tissue allografts is dependent on the generation of cytotoxic T-lymphocytes. Effective T-lymphocyte activation requires the delivery of two signals. The first signal is provided by engagement of the T-cell receptor with donor antigen presented in context with major histocompatibility molecules on antigen-presenting cells (APC) of either host or donor origin. The second (co-stimulatory) signal is delivered by the interaction of co-stimulatory ligands of the B7 family on the APC. B7-1 (CD80) and B7-2 (CD86) bind with CD28 expressed on T-cells. When two signals are delivered, activation triggers three signal transduction pathways: (1) the calcium-calcineurin pathway, (2) the RAS-mitogen-activated protein (MAP) kinase pathway, and (3) the nuclear factor-κβ pathway. Initiation of these pathways leads to the generation of numerous cytokines that in turn leads to activation of the target of rapamycin
and cell proliferation. Conversely, in the absence of this second signal the T-cell becomes anergic [59].
The spectrum of immunosuppressive agents currently utilized includes small-molecule drugs, glucocorticoids, depleting and nondepleting protein drugs (polyclonal and monoclonal antibodies), and fusion proteins [43]. These drugs deplete lymphocyte populations, divert or manipulate lymphocyte function, or block lymphocyte end products. Small-molecule immunosuppressive agents target intracellular proteins and include azathioprine, cyclosporine, tacrolimus, sirolimus, everolimus, and mycophenolate mofetil⁶ [43].
Azathioprine
Azathioprine (Imuran) is an antimetabolite derived from the imidazole derivative 6-mercaptopurine. This agent was responsible for the initial advancement of solid organ transplantation more than 30 years ago [31]. Gertrude Elion and George Hitchings are credited with its development, for which they were awarded the Nobel Prize in 1988. However, since the introduction of cyclosporine in the early 1990s azathioprine has been relegated to the role of an adjunctive second-line drug.
This purine analogue is incorporated into cellular deoxyribonucleic acid (DNA), where it functions to inhibit purine nucleotide synthesis and ultimately the synthesis of ribonucleic acid (RNA). This translates into the suppression of T-cell replication and activation. Unfortunately, azathioprine is not specific to T-cells. It is broadly myelosuppressive and is associated with a dose-related, generally reversible, depression of bone marrow function usually manifested as leukopenia and thrombocytopenia. It is an uncommon cause of anemia but can in rare cases lead to agranulocytosis, pancytopenia, and aplastic anemia.
Azathioprine can be administered either orally or intravenously. Half the orally administered dose is absorbed. Serum levels are not of importance clinically because its efficacy is not concentration dependent. The kidney does not excrete the drug. Neither is the drug dialyzable. The daily oral dose is 2 to 3 mg/kg when employed as a primary immunosuppressive agent and 1 to 2 mg/kg when used as an adjunctive agent in combination with a calcineurin inhibitor.
Azathioprine administration is associated with a major drug interaction. It is converted to its inactive form, 6-thiouric acid, by xanthine oxidase. Therefore, allopurinol (a powerful xanthine oxidase inhibitor) should be avoided or given with extreme care. The dose of azathioprine should be reduced by 50% and the white blood cell and platelet counts monitored more frequently when allopurinol is prescribed.
Cyclosporine
Cyclosporine belongs to a family of compounds known as calcineurin inhibitors, which currently serve as the backbone of solid organ immunosuppression. Cyclosporine is a small 11-amino-acid cyclic polypeptide derived from the fungus Tolypocladium inflatum [13], which binds to cyclophilin, an intracellular protein of the immunophilin family. The resulting complex targets the protein phosphatase calcineurin, which is required for the translocation of an activation factor (NF-ATc) from the cytosol to the nucleus [17]. In the presence of a calcineurin inhibitor, the cytosolic activation factor is unable to reach the nucleus and the transcription of interleukin-2 (IL-2) and other cytokines is strongly inhibited, resulting in a significant reduction in lymphocyte activation and proliferation.
The advantage of calcineurin inhibitors is the selective inhibition of the immune response. They do not hinder neutrophil function, as do corticosteroids, nor are they myelosuppressive. Patients receiving cyclosporine-based immunosuppression still possess adequate immune responsiveness to maintain host defense. This can be attributed to the fact that calcineurin inhibitors only inhibit approximately 50% of total calcineurin activity, thus enabling immune response to strong triggers of cytokine expression.
The original oil-based formulation of cyclosporine (Sandimmune) has been largely replaced by a microemulsion formulation (Neoral). The new microemulsion combines a lipophilic solvent, hydrophilic solvent, and surfactant, and is available in both liquid and gel cap forms [80]. The absorption of Neoral occurs in the proximal gastrointestinal (GI) tract at a constant rate, independent of drug concentration at the absorption site. Local metabolism of cyclosporine occurs immediately in the intestinal epithelium, via the cytochrome P450-IIIa system, reducing the amount of prodrug available for uptake [52]. The remaining compound is absorbed via the portal system, with very little drug transported through lymphatics [33]. The absorption of Sandimmune from the GI tract is bile dependent and is unreliable when compared to Neoral [33]. Peak concentration in the blood is achieved in 3 to 4 hours, with only 30% of the drug reaching systemic circulation. In contrast, the absorption of Neoral is more rapid, complete, and consistent due to the more homogenous dispersion of the uniform particles of the suspension [69]. The trough concentration of Neoral does not differ significantly from Sandimmune. However, the microemulsion possesses a maximum absorption of 60% and has an overall bioavailability 50% greater than the oil-based formulation [53]. Patients experiencing gastroparesis, cholestasis, biliary diversion, malabsorption, and diarrhea will all have variability with respect to the absorption of cyclosporine, especially the oil-based formulation [39, 58, 73].
Regardless of the cyclosporine formulation used, 50% is bound to erythrocytes, 10% to leukocytes, and 30 to 40% to plasma proteins. Only 1 to 5% exists in the free state [57]. Up to 46% of cyclosporine is associated with high-density lipoprotein, 35% with low-density lipoproteins, and 20% with very low-density lipoproteins in plasma. The close association of cyclosporine with the low-density lipoprotein receptor may account for the hyperlipidemia often experienced with its use [84]. Cyclosporine readily accumulates in fat, liver, pancreas, heart, lung, kidney, spleen, lymph nodes, and blood. Drug concentrations remain low in the cerebrospinal fluid and central nervous system, and very small amounts can be detected in the fetal circulation [72].
The liver and bowel epithelia are the primary sites for cyclosporine metabolism. This process is under the influence of the cytochrome P450-IIIA system via demethylation [54]. More than 25 active metabolites of cyclosporine have been isolated in human blood, bile, and urine. All of these retain the functional cyclic oligopeptide structure, and all are less immunosuppressive than the parent compound [48]. Cyclosporine is eliminated by biliary excretion, with a half-life of 6 to 8 hours. Clearance is significantly decreased in patients with hepatic impairment, thus mandating longer dosing intervals and/or reduction in the dose.
Any agent that alters cytochrome P450 enzyme activity will affect the metabolism and clearance of cyclosporine [103] (Table 2.1). Phenytoin and rifampin are two classic drugs that induce mixed-function oxidases of the cytochrome P450 system and cause a major fall in cyclosporine levels. This may lead to a rejection episode unless the interaction is recognized in a timely manner. Inhibitors of the cyctochrome P450 system will increase cyclosporine levels and may result in acute nephrotoxicity. Examples of cytochrome P450 inhibitors are erythromycin, ketoconazole, diltiazem, colchicine, and the fluoroquinolones [61].
TABLE 2.1 Drug interactions with cyclosporine.
The most significant and worrisome side effect of cyclosporine is nephrotoxicity. This is of critical importance with respect to renal transplant recipients because it can be difficult to distinguish cyclosporine nephrotoxicity from rejection. The toxic effects to the kidney can be seen early after transplantation, as the ischemic kidney is particularly susceptible to the deleterious effects of cyclosporine. There is an increased incidence of delayed renal allograft function when cyclosporine is used. After the kidney has recovered and baseline renal allograft function has been reached, high cyclosporine serum levels can lead to an increase in serum creatinine that needs to be distinguished from an acute allograft rejection episode. Often a percutaneous biopsy of the graft is required [3]. Microvascular thrombosis is another uncommon phenomenon associated with cyclosporine. These lesions mimic hemolytic-uremic syndrome and can be completely reversible if diagnosed early with the subsequent reduction in the cyclosporine level [82]. Chronic cyclosporine toxicity is associated with a slow decline of renal function and may be difficult to distinguish from chronic rejection. The major finding on biopsy is interstitial fibrosis. This chronic toxicity is not limited to renal allografts but is also seen in the native kidneys of recipients of a nonrenal organ [79].
The mechanism of cyclosporine nephrotoxicity has not been completely elucidated. It has been hypothesized that injury results from decreased renal blood flow with increased renal vascular resistance. The site of major insult is the afferent arteriole of the glomerular apparatus [83]. An alternative mechanism involves the decreased production of prostaglandins in the local environment of the kidney associated with cyclosporine use. This mechanism could also explain the functional and histological changes seen with the chronic use of cyclosporine [75].
Cyclosporine has been associated with a number of side effects as well. Hypertrichosis and gingival hyperplasia are cosmetically distressing to patients. These are both enhanced when cyclosporine is used in conjunction with calcium channel blockers. Cyclosporine is also linked with neurological, endocrine, and hepatic toxicity. Neurologic toxicities include fine motor tremor, headache, seizures, and a demyelinating neuropathic syndrome. Hepatic toxicities seem to correlate with elevated cyclosporine levels and are manifested by elevation of hepatic transaminase enzymes.
Hypertension is a major adverse effect associated with cyclosporine-based immunosuppression. Eightyfive percent of renal transplant recipients maintained on cyclosporine require antihypertension medication [22]. The mechanism appears to be multifactorial, but can be attributed to (1) increased intracellular calcium concentrations sensitizing resistance vessels, (2) increased sodium and water retention, and (3) increased sensitivity to adrenergic stimulation.
Tacrolimus
Tacrolimus (FK506) is a metabolite of the fungus Streptomyces tsukubaensis. It is a macrolide antibiotic with a mechanism of action very similar to that of cyclosporine, but tacrolimus inhibits cytokine production with a potency 100 times that of cyclosporine [90].
Tacrolimus is available in an intravenous formulation and as an enteric capsule. Gastrointestinal absorption is independent of bile metabolism and occurs primarily in the small intestine. Oral bioavailability approaches 25% and is relatively consistent. Subsequently, it is rarely necessary to administer tacrolimus parenterally. Onethird of absorbed tacrolimus is bound to lipoproteins, and the remainder of the drug is bound to erythrocytes in serum. Tacrolimus differs from cyclosporine in that it is not significantly bound to lipoproteins and thus has less of an adverse effect on cholesterol metabolism [92, 93]. Metabolites are excreted in bile, with virtually no renal excretion. Therefore, drug concentrations do not need to be modified in the face of renal dysfunction.
Tacrolimus resembles cyclosporine in that it is nephrotoxic and can induce hemolytic-uremic syndrome, but it is less likely to cause hyperlipidemia, hypertension, or cosmetic side effects. Tacrolimus has been associated with increased rates of posttransplantation diabetes and is more likely to induce BK-related polyomavirus nephropathy [64]. The common adverse effects of tacrolimus are listed in Table 2.2 and a side effect comparison of the calcineurin inhibitors is outlined in Table 2.3.
TABLE 2.2 Common adverse events with tacrolimus.
TABLE 2.3 Nonimmunologic side effect profile of tacrolimus versus cyclosporine.
New onset diabetes mellitus occurs significantly more often with tacrolimus than with cyclosporine, as demonstrated by both U.S. and European trials [2, 99]. These studies also demonstrated an increased incidence of neurologic sequelae (convulsions, confusion, psychosis, encephalopathy, and coma) with tacrolimus, but these events tended to be mild.
There have been many studies over the past decade designed to examine the effects of tacrolimus in renal transplant recipients. The European Tacrolimus Multicenter Renal Study Group trial reported that the graft survival for tacrolimus versus cyclosporine was the same. However, the incidence of histologically confirmed acute rejection was lower for the tacrolimus group (25.9% versus 45.7%, p<0.001) [63]. The complication rates encountered during the trial were similar, but each agent had a higher incidence of specific adverse events. Nephrotoxicity, tremor, diarrhea, hyperglycemia, and angina pectoris were higher in the tacrolimus group, whereas gingival hyperplasia, hirsutism, and arrhythmia were more common with cyclosporine [63]. The U.S. renal trial demonstrated a significantly higher number of patients requiring insulin therapy one year posttransplant if they were maintained on tacrolimus. However, 50% of those patients were reported as being off insulin therapy as of two years posttransplant [46]. The development of diabetes was dependent on the dose of tacrolimus and corticosteroids used to maintain graft function. Lower doses (0.18 mg/kg versus 0.3 mg/kg) were associated with a lower incidence of diabetes (10%) [30].
Sirolimus
Sirolimus (rapamycin) is a macrolide triene antibiotic produced by Streptomyces hygroscopicus. It is structurally related to tacrolimus, but differs because of its unique triene ring [32]. This compound was isolated from soil found on Rapa Nui (Easter Island) in 1968. The immunosuppressive properties of sirolimus were first discovered by Suren Sehgal and co-workers in 1972 [85]. Similar to cyclosporine and tacrolimus, sirolimus is also an immunophilin binding drug. Sirolimus differs from the calcineurin inhibitors in that it does not inhibit the phosphatase calcineurin nor does it inhibit cytokine transcription. Rather, sirolimus binds FK binding proteins, which form a unique ligand complex with an enzyme termed the target of rapamycin (TOR). TOR is a protein kinase vital to the regulation of cell growth factor receptors and cell proliferation. The cumulative effect of sirolimus is inhibition of these protein kinases, which then interfere with the progression of T-cells from the G1 to S phase of the cell cycle [68].
Sirolimus is rapidly absorbed from the GI tract, reaching peak serum concentration within 2 hours. Sirolimus has an extremely long half-life (mean 62 hours). Most of the drug is found within whole blood and tissue with less than 3% distributed within plasma [104]. It is largely metabolized by the hepatic cytochrome P450-IIIA4 system and does not require dose adjustment for renal impairment. Sirolimus and the calcineurin inhibitors are metabolized by the same enzyme systems and therefore significant drug interactions can be encountered. Cyclosporine can raise the blood level of sirolimus by as much as 80% when administered concomitantly. It is recommended that sirolimus be administered at least 4 hours after cyclosporine to limit this interaction.
The side effect profile of sirolimus has a spectrum best characterized by its metabolic, hematologic, and dermatologic derangements. Most adverse effects are directly related to the inhibition of growth factors [67]. Increased low-density lipoproteins and serum triglycerides are the principal metabolic side effect. All blood elements are also affected, with anemia, neutropenia, and thrombocytopenia being the most common. In a double-blind randomized trial thirty renal transplant patients were divided into three groups to better understand the side effect profile of sirolimus [70]. All patients had stable renal function maintained on a cyclosporine/steroid regimen and were randomized to low-dose (1 to 3 mg/m²/day), medium-dose (5 to 6 mg/m²/day), or high-dose (7 to 13 mg/m²/day) sirolimus therapy. The major toxic side effects were seen in the high-dose group and were predominantly hypertriglyceridemia and thrombocytopenia [70]. A deleterious effect unique to sirolimus therapy is delayed wound healing. Several reports in the literature correlate sirolimus usage with increased rates of wound complications, including fascial dehiscence [38]. Proposed mechanisms linking sirolimus to impaired wound healing include drastic reductions in the pro-inflammatory cytokines platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) [66]. Another postulated complication with sirolimus is an association with hepatic artery thrombosis, although this is controversial [28].
Several multicenter trials have been performed documenting the efficacy of sirolimus in combination with other agents in preventing acute rejection. Sirolimus, when used in combination with cyclosporine and prednisone, reduced rejection rates to 7% from nearly 40% when cyclosporine and prednisone were used alone [37]. The safety profile of sirolimus compared with cyclosporine was favorable, with a decreased incidence of tremor, hirsutism, and renal dysfunction but an increased incidence in aberrations of cholesterol metabolism [37]. There are several other trials currently underway designed to investigate the risks and benefits of sirolimus.
Mycophenolate Mofetil
Mycophenolate acid (MPA) is a fermentation product of Penicillium brevicompactum and related fungi. It was found to inhibit inosine 5′-monophosphate dehydrogenase (IMPDH) and to decrease the proliferation of some cancer cells. The mofetil moiety was added later to improve its bioavailability. Interest in its mechanism of action derived from research with inborn errors of metabolism and the finding that deficiency in enzymes involved with de novo purine synthesis resulted in profound immunodeficiency [7]. Allison and colleagues discovered that lymphocytes are especially dependent on de novo purine synthesis [8]. Essentially functioning as an antimetabolite, mycophenolate mofetil (MMF) exerts its immunosuppressant effects by selectively inhibiting the formation of guanosine and adenosine, two purine nucleosides. More specifically, the conversion of inosine monophosphate into guanosine monophosphate is blocked by MPA, which depletes lymphocytes of DNA. The ability of other cells to implement the salvage pathway for purine synthesis allows MMF to target the immune system specifically. MMF has also been shown to have several secondary characteristics that contribute to its immunosuppressive properties. By depleting nucleotide pools, MMF decreases the production of several adhesion molecules (integrins and selectins), which are crucial to the inflammatory response [9]. Although the major effects of MMF are on lymphocytes, it also significantly depletes guanosine triphosphate (GTP) levels in all mononuclear cells—effectively decreasing the levels of circulating cytokines, including IL-2 and tumor necrosis factor (TNF). Allison et al. have shown that MMF can also inhibit antibody production in vitro [6]. His group concluded that MMF can inhibit primary humoral responses in vivo, but does not effectively inhibit secondary antibody responses.
MMF is available for clinical use in both oral and intravenous formulations, and is generally well tolerated. The intravenous formulation is rarely needed. Oral formulations are available in both 250-mg and 500-mg capsules. The standard dose is 1 twice daily. The bioavailability of MMF is 90%, with a half-life of 12 hours. It is readily absorbed from the GI tract and hydrolyzed to MPA in the liver. The most common side effects associated with MMF involve the GI tract. Diarrhea has been reported in up to 1/3 of patients, with nausea, dyspepsia, vomiting, and dysphagia occurring in up to 20% of patients. Most of the GI-related adverse events resolve with reduction of the daily dose. Although the action of MMF is specific to lymphocytes, the incidence of anemia, leukopenia, and thrombocytopenia is similar to that of azathioprine. The incidence of posttransplant lymphoproliferative disorder (PTLD) and opportunistic infections is similar to that of other immunosuppressive agents. Epstein-Barr virus (EBV) infection (primary or reactivated) is a major risk factor associated with development of PTLD. The European MMF trial reported a slightly increased incidence of PTLD with patients treated in the MMF group compared to patients receiving azathioprine or placebo, with an overall frequency of less than 2%. In addition, there is a slight increase in the incidence of tissue invasive cytomegalovirus (CMV) infection in patients treated with MMF, especially in patients who receive more than 3 g/day. However, this observation could be related to more frequent endoscopic surveillance in patients who received higher doses of MMF [1].
Most adverse effects of MMF are self-limited or will resolve with a reduction in dose. Only 113 of 910 (12.4%) patients enrolled in renal transplant trials examining the effects of MMF discontinued the drug because of symptoms attributable to MMF [1, 50, 88, 89]. Unlike sirolimus and the calcineurin inhibitors, MMF is not metabolized by the cytochrome P450 system, resulting in fewer significant drug interactions. MMF should be administered with caution with sirolimus and tacrolimus because both of these medications have been shown to elevate the trough level of MMF [86].
The primary goal of adding MMF to maintenance immunosuppression regimens is to decrease the incidence of acute allograft rejection. A secondary objective is to minimize the need for more toxic agents, while not precipitating increased rates of rejection. Most of the data on MMF comes from experience in renal transplantation looking at combination therapy of MMF/cyclosporine versus azathioprine/cyclosporine. The U.S. and European trials had very defined end points: biopsy-proven rejection, incidence of graft loss, and patient death [1, 88, 89]. The incidence of graft loss was significantly reduced in the MMF group when compared to the azathioprine group (1.8% versus 8.6%) [88]. Biopsy-proven rejection occurred in 79 patients (47.6%) in the azathioprine group and in 52 patients (31.3%) in the MMF group
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