Protective effects of recombinant human antithrombin III in pig-to-primate renal xenotransplantation.

Delayed rejection of pig kidney xenografts by primates is associated with vascular injury that may be accompanied by a form of consumptive coagulopathy in recipients. Using a life-supporting pig-to-baboon renal xenotransplantation model, we have tested the hypothesis that treatment with recombinant human antithrombin III would prevent or at least delay the onset of rejection and coagulopathy. Non-immunosuppressed baboons were transplanted with transgenic pig kidneys expressing the human complement regulators CD55 and CD59. Recipients were treated with an intravenous infusion of antithrombin III eight hourly (250 units per kg body weight), with or without low molecular weight heparin. Antithrombin-treated recipients had preservation of normal renal function for 4-5 days, which was twice as long as untreated animals, and developed neither thrombocytopenia nor significant coagulopathy during this period. Thus, recombinant antithrombin III may be a useful therapeutic agent to ameliorate both early graft damage and the development of systemic coagulation disorders in pig-to-human xenotransplantation.

Hyperacute rejection of vascularized heart transplants in BALB/c Gal knockout mice.

Pig-to-primate vascularized xenografts undergo hyperacute rejection (HAR). This results from pre-formed xenoreactive antibodies directed against galactose-alpha1,3-galactose (alphaGal) in the donor organ and activation of the complement cascade. We describe an in vivo murine model of HAR using a BALB/c mice system devoid of histocompatibility or complement differences between donor and recipient to investigate in isolation, the effects of alphaGal epitope and anti-alphaGal antibody interactions in causing rejection of vascularized heart transplants. Gal KO mice were immunized with rabbit red blood cell membranes to induce high anti-alphaGal antibody titers that were predominantly IgM by ELISA (enzyme-linked immunosorbent assay). When alphaGal-expressing mice hearts were transplanted heterotopically into these recipients (n= 12), 67% of grafts rejected within 24 h, the majority within 16 h with histological features of HAR. In contrast, none of the grafts in the non-immunized Gal KO recipient control group (n=11) underwent HAR. Interestingly, approximately 50% of the remaining grafts in both the immunized and non-immunized Gal KO recipient group were rejected between 7 and 27 days by a rejection process characterized by a dense infiltrate of macrophage/monocytes, perivascular cuffing and tissue destruction similar to recent descriptions of delayed xenograft rejection (DXR). In addition, some grafts (21.5%) continued to survive in the immunized Gal KO recipients despite the presence of anti-alphaGal antibody and normal complement activity and these showed well-preserved myocardium when harvested whilst still functioning well at days 30 or 90. No rejection was seen when Gal KO donors were used in this system (n=4), nor when alphaGal-expressing BALB/c hearts were transplanted into alphaGal-expressing BALB/c recipients (n=5). This in vivo small animal model offers the opportunity to test a variety of strategies to overcome HAR prior to more resource intensive pig-to-primate studies, and may provide insights into the processes similar to DXR and accommodation.

Synthetic peptides which inhibit the interaction between C1q and immunoglobulin and prolong xenograft survival.

BACKGROUND: Acute vascular xenograft rejection (AVXR), also termed delayed xenograft rejection (DXR), occurs when hyperacute rejection (HAR) is prevented by strategies directed at xenoreactive natural antibodies and/or complement activation. We have hypothesized that AVXR/DXR is initiated in part by early components of the complement cascade, notably C1q. We have developed synthetic peptides (termed CBP2 and WY) that interfere with the interaction between C1q and antibody. METHODS: CBP2 and the WY-conjugates were used as inhibitors of immunoglobulin aggregate binding to solid phase C1q. Inhibition of complement activation by the peptides of the classical system was determined using lysis assays with sensitized sheep red blood cells or porcine aortic endothelial cells as targets and of the alternate complement pathway using guinea pig red blood cells as targets. Two transplant models were used to study the effects of administering peptides to recipients: rat heart transplant to presensitized mouse, and guinea heart transplant to PVG C6-deficient rats. RESULTS: CBP2 and WY-conjugates inhibited immunoglobulin aggregate binding to C1q. The peptides also inhibited human complement-mediated lysis of sensitized sheep red blood cells and porcine aortic endothelial cells in a dose-dependent manner and the WY-conjugates prevented activation of the alternate complement pathway as shown by inhibition of guinea pig red blood cells lysis with human serum. In addition, the use of the peptides and conjugates resulted in significant prolongation of xenograft survival. CONCLUSIONS: The CBP2 and WY peptides exhibit the functional activity of inhibition of complement activation. These peptides also prolong xenograft survival and thus provide reagents for the study of the importance of C1q and other complement components in transplant rejection mechanisms.

Renal xenografts from triple-transgenic pigs are not hyperacutely rejected but cause coagulopathy in non-immunosuppressed baboons.

BACKGROUND: The genetic modification of pigs is a powerful strategy that may ultimately enable successful xenotransplantation of porcine organs into humans. METHODS: Transgenic pigs were produced by microinjection of gene constructs for human complement regulatory proteins CD55 and CD59 and the enzyme alpha1,2-fucosyltransferase (H-transferase, HT), which reduces expression of the major xenoepitope galactose-alpha1,3-galactose (alphaGal). Kidneys from CD55/HT and CD55/CD59/HT transgenic pigs were transplanted into nephrectomised, nonimmunosuppressed adult baboons. RESULTS: In several lines of transgenic pigs, CD55 and CD59 were expressed strongly in all tissues examined, whereas HT expression was relatively weak and did not significantly reduce alphaGal. Control nontransgenic kidneys (n=4) grafted into baboons were hyperacutely rejected within 1 hr. In contrast, kidneys from CD55/HT pigs (n=2) were rejected after 30 hr, although kidneys from CD55/CD59/HT pigs (n=6) maintained function for up to 5 days. In the latter grafts, infiltration by macrophages, T cells, and B cells was observed at days 3 and 5 posttransplantation. The recipients developed thrombocytopenia and abnormalities in coagulation, manifested in increased clotting times and an elevation in the plasma level of the fibrin degradation product D-dimer, within 2 days of transplantation. Treatment with low molecular weight heparin prevented profound thrombocytopenia but not the other aspects of coagulopathy. CONCLUSIONS: Strong expression of CD55 and CD59 completely protected porcine kidneys from hyperacute rejection and allowed a detailed analysis of xenograft rejection in the absence of immunosuppression. Coagulopathy appears to be a common feature of pig-to-baboon renal transplantation and represents yet another major barrier to its clinical application.

Membrane-associated lymphotoxin on natural killer cells activates endothelial cells via an NF-kappaB-dependent pathway.

BACKGROUND: Inhibition of complement in small animal models of xenotransplantation has demonstrated graft infiltration with natural killer (NK) cells and monocytes associated with endothelial cell (EC) activation. We have previously demonstrated that human NK cells activate porcine EC in vitro, which results in adhesion molecule expression and cytokine secretion. In this study, we used the NK cell line NK92 to define the molecular and cellular basis of NK cell-mediated EC activation. METHODS: EC were transfected with either reporter constructs containing the luciferase gene driven either by E-selectin or interleukin (IL)-8 promoters or a synthetic NF-kappaB-dependent promoter. In addition, a dominant-negative mutant tumor necrosis factor receptor I (TNFRI) expression vector was co-transfected in inhibition studies. Forty-eight hours after transfection, EC were stimulated with NK cells or NK cell membrane extracts for 7 hr and activation was measured by a luciferase assay. RESULTS: Co-culture of NK cells with transfected EC enhanced E-selectin, IL-8, and NF-kappaB-dependent promoter activity. NK cell membrane extracts retained the capacity to activate EC and induced nuclear translocation of NF-kappaB (p50 and p65). Western blotting of NK cell and membrane extracts detected the presence of Lymphotoxin-alpha (LTalpha) but not tumor necrosis factor-alpha. Furthermore, LTalpha was secreted in NK:EC co-cultures. Co-transfection with dominant-negative mutant TNFRI inhibited EC activation by NK cell membrane extracts and by NK cells by 80% and 47%, respectively. The same pattern of inhibition was observed using anti-human LT sera. CONCLUSIONS: Human NK cell membrane-bound LT signals across species via TNFRI, leading to NF-kappaB nuclear translocation and transcription of E-selectin and IL-8, which results in EC activation. The discrepancy in the degree of inhibition by membrane extracts and NK cells with mutant TNFRI suggests that additional pathways are utilized by NK cells to activate EC.

Anti-Gal antibody-mediated allograft rejection in alpha1,3-galactosyltransferase gene knockout mice: a model of delayed xenograft rejection.

BACKGROUND: The key role of anti-galactose alpha1,3-galactose (anti-alphaGal) xenoantibodies in initiating hyperacute xenograft rejection has been clearly demonstrated using a variety of in vitro and in vivo approaches. However, the role of anti-alphaGal antibodies in mediating post-hyperacute rejection mechanisms, such as antibody-dependent cellular cytoxicity, remains to be determined, primarily because of the lack of a small animal model with which to study this phenomena. METHODS: Hearts from wild-type mice were transplanted heterotopically into alpha1,3-galactosyltransferase knockout (Gal KO) mice, which like humans develop antibodies to the disaccharide galactose alpha1,3-galactose (Gal). At the time of rejection, hearts were examined histologically to determine the mechanism of rejection. RESULTS: Hearts from wild-type mice transplanted into high-titer anti-alphaGal recipients were rejected in 8-13 days. Histological examination demonstrated a cellular infiltrate consisting of macrophages (80-90%), natural killer cells (5-10%), and T cells (1-5%). In contrast, wild-type hearts transplanted into low anti-Gal titer recipients demonstrated prolonged (>90 day) survival. However, a significant proportion (30-40%) of these underwent a minor rejection episode between 10 and 13 days, but then recovered ("accommodated"). CONCLUSIONS: The results of this study suggest that the Gal KO mouse is a useful small animal vascularized allograft model, in which the role of anti-alphaGal antibody in graft rejection can be studied in isolation from other rejection mechanisms. The titer of anti-alphaGal antibody was found to be the critical determinant of rejection. The histopathological features of rejection in this model are very similar to other models of delayed xenograft rejection, in both the timing and composition of the cellular infiltrate. The Gal KO mouse therefore provides a new rodent model, which will aid in the identification of the distinct components involved in the pathogenesis of delayed xenograft rejection.

Overcoming hyperacute xenograft rejection with transgenic animals.

Xenotransplantation offers an alternative source of organs to solve the current critical shortage of donor organs required for patients with end-stage kidney, heart and liver disease. For social, ethical and logistical purposes, pigs appear to be the most appropriate donor animal. The immunological barriers to xenotransplantation are greater than in allotransplantation because of the presence of preformed natural antibodies in the serum of the recipient. The rapid binding of antibody to donor endothelial cells is followed by complement activation, cell damage and vascular thrombosis. Antirejection therapies aimed at reducing the level of antibody, complement activity and cell-mediated immunity in the recipient may result in a significant increase in complications such as infections and malignancies compared with allotransplantation. Transgenic technology may permit modification of the donor organ, enabling it to evade the rapid antibody- and complement-mediated destruction. The main strategies to prevent xenotransplant rejection have been to reduce expression of 'Gal', the major target epitope for natural antibody, and to inhibit complement activation. Transgenic animals expressing membrane-bound inhibitors of the complement pathway and enzymes that compete for Gal synthesis have been generated. Both approaches provide limited protection, and preliminary experiments in vitro suggest that a combination approach may reduce antibody- and complement-mediated cellular damage.

Xenotransplantation: an update.

Over the past 20 years, the mortality and morbidity associated with cardiac allotransplantation has fallen significantly, providing a viable treatment for patients with terminal cardiac failure. Unfortunately, the increase in the number of patients who could benefit from cardiac transplantation has not been matched with an increase in the number of organs available for transplantation. Thus, many patients with cardiac failure die waiting for a suitable organ, unlike patients with renal failure, who can be maintained on dialysis while waiting for a kidney. Although the development of artificial hearts may provide a life-sustaining bridging therapy until a donor organ becomes available, the quality of life associated with cardiac prostheses is currently less than that following successful cardiac allotransplantation.

Simultaneous expression of germline gamma1 and epsilon immunoglobulin heavy chain transcripts in single murine splenic B-cells.

While successive isotype switching can occur from IgM to IgE via IgG1, little is known about the pattern of germline transcript expression in normal B cells committed to switching to multiple isotypes. In this study we define the relationship between germline transcript expression and immunoglobulin isotype expression and secretion in murine splenic B cells. Following 7 days stimulation with LPS and IL-4, 10% of single cells secrete IgE and of these only 1 in 10 secrete IgE alone. In contrast, when cells were stimulated with LPS and IL-4 for 48 hr prior to sorting into clonal cultures, 71% secreted IgE alone. In an attempt to isolate switch intermediates, IgG1+IgM- cells were sorted and upon re-culture secreted predominantly IgG1 alone or IgG1 and IgE. The frequency of cells expressing germline epsilon transcripts was 34% for surface IgG1+IgM- expressing cells and 14% for surface IgG1-IgM+ negative cells. Furthermore, analysis of single surface IgG1+IgM- cells demonstrated that these cells can co-express germline gamma1 and epsilon transcripts. Sorting of IgG1-IgM+ cells according to surface expression of the integral membrane proteoglycan, Syndecan, demonstrated that IgM+Syndecan+ cells had a lower frequency of germline transcript expression and a lower frequency of isotype switching (32%) compared to IgM+Syndecan cells (83%). Collectively, these finding show that murine B cells can switch successively from IgM to IgE via IgG1 and that IgG1 expressing intermediates express germline transcripts. Furthermore, Syndecan expression appears to be linked to germline CH transcription and isotype switch commitment.

Human monocytes activate porcine endothelial cells, resulting in increased E-selectin, interleukin-8, monocyte chemotactic protein-1, and plasminogen activator inhibitor-type-1 expression.

Monocytes (Mo) are thought to be important effector cells in early xenograft rejection. Effects of Mo-endothelial cell (EC) interactions on EC activation in vitro were studied by coculturing human Mo or human monocytoid cell lines, U937 and THP-1, with porcine EC. Without preactivation, U937 cells and Mo induced mRNA for the EC-specific adhesion receptor, E-selectin, expressed only on activated cells, after 2 hr. Surface protein was maximal when equal numbers of EC and Mo were cocultured. Increased mRNA expression of the chemokines, interleukin-8 and monocyte chemotactic protein-1, and the antifibrinolytic protein plasminogen activator inhibitor type-1, confirmed EC activation. Like E-selectin, plasminogen activator inhibitor type-1 mRNA was rapidly induced and returned to baseline after 24 hr, whereas chemokine gene expression was slower and more prolonged. Interleukin-1 receptor antagonist failed to modulate induction of E-selectin. Soluble tumor necrosis factor (TNF) alpha receptor inhibited E-selectin induced by TNF alpha, but not by U937 cells, and mRNA and protein on EC in Mo-EC mixtures cocultured at 1:1 ratios were not significantly reduced. The TNF alpha inhibitor did reduce E-selectin expression (30-40%), as well as induced chemokine gene expression (80%), at higher Mo-EC ratios. Despite this, minimal TNF alpha was detectable in supernatants. These results, along with the transwell experiments that confirmed a requirement for Mo-EC contact, suggest that membrane-bound TNF alpha may be involved. Thus, Mo-EC interactions in the porcine to human combination activated several EC functions, suggesting that initial Mo contact with the vessel wall of a xenogeneic graft may promote leukocyte recruitment, inflammation, and maintenance of thrombus, resulting in eventual organ destruction.

Adenoviral-mediated overexpression of I(kappa)B(alpha) in endothelial cells inhibits natural killer cell-mediated endothelial cell activation.

Activated natural killer (NK) cells have been found in rejecting discordant xenografts and may contribute to endothelial cell (EC) activation and damage. The transcription of genes associated with EC activation, such as E-selectin and interleukin (IL)-8, is regulated by the transcription factor NF-kappaB. In resting EC, NF-kappaB is complexed within the cytoplasm to I(kappa)B(alpha), and EC activation leads to dissociation of the I(kappa)B(alpha)-NF-kappaB complex and nuclear translocation of NF-kappaB. We investigated whether overexpression of I(kappa)B(alpha) in EC, using adenoviral gene transfer, could block NF-kappaB translocation, thereby inhibiting NK cell-mediated EC activation. Co-culture of human NK cells with porcine EC resulted in a threefold increase in E-selectin expression after 4 hr and secretion of greater than 650 pg/ml porcine IL-8 over 24 hr. Overexpression of I(kappa)B(alpha) inhibited the NK cell-mediated induction of E-selectin expression and IL-8 secretion, whereas overexpression of P-galactosidase did not. The inhibition of EC activation was not due to variation in NK-EC adhesion, as the level of adhesion was similar between adenovirally infected and noninfected EC over 4 hr. The level of NK cell-mediated EC cytotoxicity was not significantly different after 4 hr of co-culture, but after 24 hr, cytotoxicity was increased in virally infected cells. Cytotoxicity was more marked in cells overexpressing I(kappa)B(alpha) than cells overexpressing beta-galactosidase. SLA class I and the induction of SLA class II antigen in response to interferon-gamma treatment were reduced in cells infected with adeno-I(kappa)B(alpha) and empty adenovirus, demonstrating that viral infection alone can influence EC biology. Overexpression of I(kappa)B(alpha) using adenovirus provides a novel approach to inhibiting NK cell-mediated EC activation, but additional strategies will be required to inhibit NK cell-mediated cytotoxicity.

Direct activation of porcine endothelial cells by human natural killer cells.

Endothelial cell (EC) activation is a consistent feature of discordant xenograft rejection. Treatment of xenograft recipients with complement inhibitors and xenoreactive natural antibody depletion leads to delayed xenograft rejection associated with a cellular infiltrate comprising up to 20% natural killer (NK) cells. To determine the importance of NK cells in xenograft rejection, we studied EC activation and cytotoxicity in co-cultures containing human NK cells and porcine EC. The addition of freshly isolated NK cells to porcine EC resulted in EC cell activation, characterized by the induction of mRNA and protein for the adhesion molecule E-selectin and the chemotactic cytokine interleukin (IL)-8. The induction of E-selectin and IL-8 occurred with three separate sources of NK cells: purified CD56+ve cells, the NK cell clone B22, and the Fc receptor-deficient NK cell line NK92. Transwell cultures demonstrated that direct NK-EC contact was required for the EC induction of E-selectin and IL-8. These effects could not be inhibited with human recombinant tumor necrosis factor-alpha receptor, and the transfer of supernatants or cell lysates from activated EC to secondary cultures did not result in EC activation. The addition of human IgG enhanced the level of E-selectin expression and cellular cytotoxicity, and resulted in tumor necrosis factor-alpha and interferon-gamma secretion. Thus, human NK cells can lyse or activate EC by direct cell contact and the addition of IgG enhances EC activation and NK cell cytokine secretion. These findings implicate NK cells in EC activation and cell-mediated xenograft rejection.

Familial focal glomerulosclerosis: a genetic linkage to the HLA locus?

The aetiology and pathogenesis of focal glomerulosclerosis is poorly understood and many conflicting reports suggest HLA locus associations in both familial and non-familial glomerulosclerosis. We report a family in which 4 of 5 sisters developed proteinuria, 2 with hypertension and 1 progressing to end-stage renal failure (index case). Three underwent renal biopsy which displayed characteristic features of focal glomerulosclerosis and all shared the HLA alleles HLA-A1, B8, DR3, DR7. The index case received two cadaveric renal transplants from HLA-A1, B8, DR3 donors and developed chronic rejection with no histological evidence of recurrent glomerulonephritis in either kidney. The frequency of this haplotype in the Australian dialysis and transplant population with focal glomerulosclerosis was compared to that seen in the general Australian Caucasian population and was not significantly different suggesting that the presence of the HLA alleles HLA-A1, B8, DR3, DR7 may increase the predisposition to familial glomerulosclerosis but additional factors are required for disease development and progression.