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Human invariant natural killer T (iNKT) cells are a rare innate-like lymphocyte population that recognizes glycolipids presented on CD1d. Studies in mice have shown that these cells are heterogeneous and are capable of enacting diverse functions, and the composition of iNKT cell subsets can alter disease outcomes. In contrast, far less is known about how heterogeneity in human iNKT cells relates to disease. To address this, we used a high-dimensional, data-driven approach to devise a framework for parsing human iNKT heterogeneity. Our data revealed novel and previously described iNKT cell phenotypes with distinct functions. In particular, we found 2 phenotypes of interest: (1) a population with T helper 1 function that was increased with iNKT activation characterized by HLA-II+CD161– expression, and (2) a population with enhanced cytotoxic function characterized by CD4–CD94+ expression. These populations correlate with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation and with new onset type 1 diabetes, respectively. Our study identifies human iNKT cell phenotypes associated with human disease that could aid in the development of biomarkers or therapeutics targeting iNKT cells.

Based on preclinical studies, combined kidney and hematopoietic cell transplantation was performed on fully HLA matched and haplotype matched patients at the Stanford University Medical Center. The object of the studies was to induce mixed chimerism, immune tolerance, and complete immunosuppressive drug withdrawal. Tolerance, persistent mixed chimerism, and complete withdrawal was achieved in the majority of fully matched patients. Persistent mixed chimerism and partial withdrawal has been achieved in the haplotype matched patients at present.

Preclinical studies have shown that persistent mixed chimerism is linked to acceptance of organ allografts without immunosuppressive (IS) drugs. Mixed chimerism refers to continued mixing of donor and recipient hematopoietic cells in recipient tissues after transplantation of donor cells. To determine whether persistent mixed chimerism and tolerance can be established in patients undergoing living donor kidney transplantation, we infused allograft recipients with donor T cells and hematopoietic progenitors after posttransplant lymphoid irradiation. In 24 of 29 fully human leukocyte antigen (HLA)–matched patients who had persistent mixed chimerism for at least 6 months, complete IS drug withdrawal was achieved without subsequent evidence of rejection for at least 2 years. In 10 of 22 HLA haplotype–matched patients with persistent mixed chimerism for at least 12 months, reduction of IS drugs to tacrolimus monotherapy was achieved. Withdrawal of tacrolimus during the second year resulted in loss of detectable chimerism and subsequent rejection episodes, unless tacrolimus therapy was reinstituted. Posttransplant immune reconstitution of naïve B cells and B cell precursors was more rapid than the reconstitution of naïve T cells and thymic T cell precursors. Robust chimerism was observed only among naïve T and B cells but not among memory T cells. No evidence of rejection was observed in all surveillance graft biopsies obtained from mixed chimeric patients withdrawn from IS drugs, and none developed graft-versus-host disease. In conclusion, persistent mixed chimerism established in fully HLA- or haplotype-matched patients allowed for complete or partial IS drug withdrawal without rejection.

Murine models showed that CD8+CD44hi memory T (TM) cells could eradicate malignant cells without inducing graft-versus-host disease (GVHD). We evaluated the feasibility and safety of infusing freshly isolated and purified donor-derived phenotypic CD8+ TM cells into adults with disease relapse after allogeneic hematopoietic cell transplantation (HCT). Phenotypic CD8 TM cells were isolated after unmobilized donor apheresis using a tandem immunomagnetic selection strategy of CD45RA depletion followed by CD8+ enrichment. Fifteen patients received CD8+ TM cells at escalating doses (1 × 106, 5 × 106, or 10 × 106 cells per kg). Thirteen received cytoreduction before CD8+ TM cell infusion, and 9 had active disease at the time of infusion. Mean yield and purity of the CD8+ TM infusion were 38.1% and 92.8%, respectively; >90% had CD8+ T effector memory phenotype, cytokine expression, and secretion profile. No adverse infusional events or dose-limiting toxicities occurred; GVHD developed in 1 patient (grade 2 liver). Ten patients (67%) maintained or achieved response (7 complete response, 1 partial response, 2 stable disease) for at least 3 months after infusion; 4 of the responders had active disease at the time of infusion. With a median follow-up from infusion of 328 days (range, 118-1328 days), median event-free survival and overall survival were 4.9 months (95% confidence interval [CI], 1-19.3 months) and 19.6 months (95% CI, 5.6 months to not reached), respectively. Collection and enrichment of phenotypic CD8+ TM cells is feasible, well tolerated, and associated with a low incidence of GVHD when administered as a manipulated infusion of donor lymphocytes in patients who have relapsed after HCT. This trial was registered at www.clinicaltrials.gov as #NCT01523223.

The combination of total lymphoid irradiation and anti-T-cell antibodies safely induces immune tolerance to combined hematopoietic cell and organ allografts in humans. Our mouse model required host natural killer T (NKT) cells to induce tolerance. Because NKT cells normally depend on signals from CD8+ dendritic cells (DCs) for their activation, we used the mouse model to test the hypothesis that, after lymphoid irradiation, host CD8+ DCs play a requisite role in tolerance induction through interactions with NKT cells. Selective deficiency of either CD8+ DCs or NKT cells abrogated chimerism and organ graft acceptance. After radiation, the CD8+ DCs increased expression of surface molecules required for NKT and apoptotic cell interactions and developed suppressive immune functions, including production of indoleamine 2,3-deoxygenase. Injection of naive mice with apoptotic spleen cells generated by irradiation led to DC changes similar to those induced by lymphoid radiation, suggesting that apoptotic body ingestion by CD8+ DCs initiates tolerance induction. Tolerogenic CD8+ DCs induced the development of tolerogenic NKT cells with a marked T helper 2 cell bias that, in turn, regulated the differentiation of the DCs and suppressed rejection of the transplants. Thus, reciprocal interactions between CD8+ DCs and invariant NKT cells are required for tolerance induction in this system that was translated into a successful clinical protocol.

The goals of tolerance in patients with solid organ transplants are to eliminate the lifelong need for immunosuppressive (IS) drugs and to prevent graft loss due to rejection or drug toxicity. Tolerance with complete withdrawal of IS drugs has been achieved in recipients of HLA-matched and mismatched living donor kidney transplants in 3 medical centers using hematopoietic cell transplants to establish mixed or complete chimerism.

Conventional local tumor irradiation (LTI), delivered in small daily doses over several weeks, is used clinically as a palliative, rather than curative, treatment for chemotherapy-resistant diffuse large B-cell lymphoma (DLBCL) for patients who are ineligible for hematopoietic cell transplantation. Our goal was to test the hypothesis that accelerated, but not conventional, LTI would be more curative by inducing T cell–mediated durable remissions. We irradiated subcutaneous A20 and BL3750 lymphoma tumors in mice with a clinically relevant total radiation dose of 30 Gy LTI, delivered in 10 doses of 3 Gy over 4 days (accelerated irradiation) or as 10 doses of 3 Gy over 12 days (conventional irradiation). Compared with conventional LTI, accelerated LTI resulted in more complete and durable tumor remissions. The majority of these mice were resistant to rechallenge with lymphoma cells, demonstrating the induction of memory antitumor immunity. The increased efficacy of accelerated LTI correlated with higher levels of tumor cell necrosis vs apoptosis and expression of “immunogenic cell death” markers, including calreticulin, heat shock protein 70 (Hsp70), and Hsp90. Accelerated LTI–induced remissions were not seen in immunodeficient Rag-2−/− mice, CD8+ T-cell–depleted mice, or Batf-3−/− mice lacking CD8α+ and CD103+ dendritic cells. Accelerated, but not conventional, LTI in immunocompetent hosts induced marked increases in tumor-infiltrating CD4+ and CD8+ T cells and MHCII+CD103+CD11c+ dendritic cells and corresponding reductions in exhausted PD-1+Eomes+CD8+ T cells and CD4+CD25+FOXP3+ regulatory T cells. These findings raise the possibility that accelerated LTI can provide effective immune control of human DLBCL.

The Third International Workshop on Clinical Tolerance was held in Stanford, California, September 8-9, 2017. This is a summary of Workshop presentations of clinical trials designed to withdraw or minimize immunosuppressive (IS) drugs in kidney and liver transplant patients without subsequent evidence of rejection. All clinical protocols had in common the use of donor or recipient cell therapy combined with organ transplantation. Tolerance to HLA matched and mismatched living donor kidney transplants with complete withdrawal of IS drugs without subsequent rejection for up to 14 years of observation was achieved in more than 50 patients enrolled in trials in four medical centers after the establishment of transient or persistent chimerism. Complete IS drug withdrawal without chimerism was reported in a prospective trial of liver transplantation combined with injection of regulatory T cells. IS drug minimization without rejection was reported in recipients of living donor kidney transplants enrolled in the One Study consortium after injection of recipient regulatory T cells, or injection of donor regulatory monocytes or dendritic cells. In conclusion, considerable progress has been made in achieving IS drug withdrawal after cell therapy in recipients of organ transplants.

Current theory holds that macrochimerism is essential to the development of transplant tolerance. Hematopoietic cell transplantation from the solid organ donor is necessary to achieve macrochimerism. Over the last 10–20 years, trials of tolerance induction with combined kidney and hematopoietic cell transplantation have moved from the preclinical to the clinical arena. The achievement of macrochimerism in the clinical setting is challenging, and potentially toxic due to the conditioning regimen necessary to hematopoietic cell transplantation and due to the risk of graft-versus-host disease. There are differences in chimerism goals and methods of the three major clinical stage tolerance induction strategies in both HLA-matched and HLA-mismatched living donor kidney transplantation, with consequent differences in efficacy and safety. The Stanford protocol has proven efficacious in the induction of tolerance in HLA-matched kidney transplantation, allowing cessation of immunosuppressive drug therapy in 80% of study participants, with the safety profile of conventional transplantation. In HLA-mismatched transplantation, multi-lineage macrochimerism of over a year’s duration can now be consistently achieved with the Stanford protocol, with complete withdrawal of immunosuppressive drug therapy during the second post-transplant year as the next experimental step and test of tolerance.

Many patients lack a fully HLA-matched donor for hematopoietic cell transplantation (HCT), and HLA mismatch is typically associated with inferior outcomes. Total lymphoid irradiation and antithymocyte globulin (TLI-ATG) is a nonmyeloablative conditioning regimen that is protective against graft-versus-host disease (GVHD), and we hypothesized that the protective effect would extend beyond HLA-matched donors. We report outcomes for all consecutively transplanted patients at Stanford University from December 2001 through May 2015 who received TLI-ATG conditioning and HCTs from 8 to 9 out of 10 HLA-mismatched unrelated donors (MMUDs, N = 72) compared with 10 out of 10 HLA-matched unrelated donors (MUDs, N = 193). The median age of the patients was 60 years with a median follow-up of 2 years, and there was a similar distribution of lymphoid and myeloid malignancies in both cohorts. There were no significant differences between MMUD and MUD cohorts in overall survival (46% vs 46% at 5 years, P = .86), disease-free survival (38% vs 28% at 5 years, P = .25), nonrelapse mortality (17% vs 12% at 2 years, P = .34), acute GVHD grades III-IV (6% vs 3% at day +100, P = .61), or chronic GVHD (39% vs 35% at 5 years, P = .49). There was a trend toward less relapse in the MMUD cohort (45% vs 60% at 5 years, hazard ratio: 0.71, P = .094), which was significant for patients with lymphoid malignancies (29% vs 57% at 5 years, hazard ratio: 0.55, P = .044). Achieving full donor chimerism was strongly associated with lower relapse rates. TLI-ATG conditioning may overcome the traditionally poorer outcome associated with HLA-mismatched donors and may be particularly well suited for patients with lymphoid malignancies who lack HLA-matched donors.

Human invariant natural killer T cells (iNKT) are a rare population of lymphocytes that bridges innate and adaptive immune functions. These cells show diverse phenotypes and function, but the current population structure imposed on iNKT cells inadequately differentiates these diverse phenotypes and function. Using single-cell RNA-sequencing and subsequent functional assays and flow cytometric analysis, we present a novel population structure that characterizes human iNKT cell heterogeneity. Markers delineating primary iNKT cells for IL-4+, IFNg+TNFa+, and cytotoxicity functions were CD4, KLRG1, and CD94, respectively. In addition, iNKT cells follow a temporal evolution of function and associated markers - upon chronic activation, HLA-DR expression associated with increased Th1 skewing. Unsupervised clustering of our iNKT single-cell RNA-sequencing data from a graft-versus-host disease (GvHD) and a GvHD-free post-transplant patient showed a GvHD-enriched subset that is defined by expression of HLA-DR alleles. In a cohort of 38 patients, 19 of whom developed GvHD, flow cytometric analysis of iNKT cells revealed increased HLA-DR and decreased CD161 expression when compared to GvHD-free patients. CD94 expression was overall increased after allogeneic hematopoietic cell transplantation. Functional assessment of HLA-DRhiCD161− iNKT cells showed that this population produced significantly less IL-4 while maintaining IFNg production. Furthermore, high expression of HLA-DR could be detected before initial GvHD onset compared to in patients who did not develop GvHD. Together, our data suggests HLA-DR as a marker for delineating iNKT cells with a proinflammatory phenotype and is associated with GvHD. In sum, our approach for describing iNKT cell population structure revealed new markers that associate with different iNKT cell phenotypes. This new paradigm for describing iNKT cell heterogeneity can potentially be translated into the clinic as an immune monitoring tool for patients undergoing allogeneic hematopoietic cell transplantation.

Tolerance to combined kidney and hematopoietic cell transplant has been achieved in humans after establishment of mixed chimerism allowing for the withdrawal of immunosuppressive drugs. The seminal contributions of Ray Owen provided the scientific basis for the human protocol.

Sixteen patients conditioned with total lymphoid irradiation and anti-thymocyte globulin were given kidney transplants and an injection of CD34+ hematopoietic progenitor cells and T cells from HLA matched donors in a tolerance induction protocol. Blood cell monitoring included changes in chimerism, balance of T cell subsets, and responses to donor alloantigens. Fifteen patients developed multilineage chimerism without graft versus host disease (GVHD), and 8 with chimerism for at least 6 months were withdrawn from anti-rejection medications for 1 to 3 years (mean- 28 months) without subsequent rejection episodes. Four chimeric patients have just completed or are in the midst of drug withdrawal, and 4 patients were not withdrawn due to return of underlying disease or rejection episodes. Blood cells from all patients showed early high ratios of CD4+CD25+ regulatory T cells and NKT cells versus conventional naïve CD4+ T cells, and those off drugs showed specific unresponsiveness to donor alloantigens. In conclusion, total lymphoid irradiation and anti-thymocyte globulin promoted the development of persistent chimerism and tolerance in a cohort of patients given kidney transplants and hematopoietic donor cell infusions. All 16 patients had excellent graft function at the last observation point with or without maintenance drugs.

We used a model of combined bone marrow and heart transplantation, in which tolerance and stable chimerism is induced after conditioning with fractionated irradiation of the lymphoid tissues and anti–T-cell antibodies. Graft acceptance and chimerism required host CD4+CD25+ Treg production of IL-10 that was in-turn enhanced by host invariant natural killer (NK) T-cell production of IL-4. Up-regulation of PD-1 on host Tregs, CD4+CD25− conventional T (Tcon) cells, and CD8+ T cells was also enhanced by NKT cell production of IL-4. Up-regulated PD-1 expression on Tregs was linked to IL-10 secretion, on CD8+ T cells was linked to Tim-3 expression, and on CD4+ Tcon cells was associated with reduced IFNγ secretion. Changes in the expression of PD-1 were induced by the conditioning regimen, and declined after bone marrow transplantation. In conclusion, NKT cells in this model promoted changes in expression of negative costimulatory receptors and anti-inflammatory cytokines by Tregs and other T-cell subsets in an IL-4–dependent manner that resulted in tolerance to the bone marrow and organ grafts.

Our previous studies showed that treatment of mice with total body irradiation (TBI) or total lymphoid tissue irradiation markedly changes the balance of residual T cell subsets to favor CD4+CD44hi NKT cells because of the differential resistance of the latter subset to cell death. The object of the current study was to further elucidate the changed balance and mechanisms of differential radioresistance of T cell subsets after graded doses of TBI. The experimental results showed that CD4+ T cells were markedly more resistant than CD8+ T cells, and CD44hi T cells, including NKT cells and memory T cells, were markedly more resistant than CD44lo (naive) T cells. The memory T cells immunized to alloantigens persisted even after myeloablative (1000 cGy) TBI and were able to prevent engraftment of bone marrow transplants. Although T cell death after 1000 cGy was prevented in p53−/− mice, there was progressive T cell death in p53−/− mice at higher doses. Although p53-dependent T cell death changed the balance of subsets, p53-independent T cell death did not. In conclusion, resistance of CD44hi T cells to p53-dependent cell death results in the persistence of immunological memory after TBI and can explain the immune-mediated rejection of marrow transplants in sensitized recipients.

Background: Nonmyeloablative total lymphoid irradiation and antithymocyte globulin (TLI-ATG) conditioning is associated with a low risk of graft-versus-host disease (GVHD) and non-relapse mortality (NRM) while retaining graft-versus-tumor activity across a range of lymphoid and myeloid malignancies. Prior studies of TLI-ATG conditioning have been limited by the relatively small sample size and short duration of follow up. Herein we report mature data from a large, single-institution cohort of patients with lymphoid and myeloid malignancies who underwent allogeneic transplantation using TLI-ATG conditioning. Methods: Patients: We included all consecutively transplanted patients at Stanford University Hospital from December 2001 through December 2016 who underwent allogeneic hematopoietic cell transplantation (HCT) using TLI-ATG conditioning for lymphoid or myeloid malignancies. All patients received G-CSF-mobilized peripheral blood hematopoietic cells and cyclosporine and mycophenolate mofetil for GVHD prophylaxis. Statistical analysis: The data were analyzed as of December 31, 2017, allowing for a minimum follow up of 1 year for all patients. For time-to-event analyses, the Kaplan-Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and the cumulative incidence of acute and chronic GVHD and NRM. An exploratory analysis was done to identify factors associated with mortality and relapse. Log-rank tests were used to calculate differences between groups. Results: Patient characteristics: 613 patients underwent allogeneic HCT with TLI-ATG conditioning at a median age of 60 years (range 21-78 years) with a median follow up of 5.1 years (range 1.0-15.3 years). Diagnoses included acute myeloid leukemia (AML, N=194), myelodysplastic syndrome (MDS, N=93), myelofibrosis (N=10), chronic myeloid leukemia (N=12), acute lymphoblastic leukemia (N=11), chronic lymphocytic leukemia (CLL, N=83), non-Hodgkin lymphoma (NHL, N=175), and Hodgkin lymphoma (HL, N=35). 44% of patients had HLA-matched related, 41% had HLA-matched unrelated, and 15% had HLA-mismatched unrelated donors. 34% of patients had a comorbidity index ≥3, and 34% of patients had a disease risk index (DRI) of high or very high. 55% of lymphoma patients had failure of prior autologous HCT. Safety and tolerability: Patient outcomes are shown in Figure 1. Among all 613 patients, the cumulative incidences of acute GVHD grade 2-4 and grade 3-4 at day +100 were 11% and 4%, respectively, and the cumulative incidence of extensive chronic GVHD was 21% at 1 year. NRM was 7% at 1 year, and was consistently low across high-risk subgroups including older adults ≥65 years old (9% at 1 year), patients with a comorbidity index ≥3 (9% at 1 year), and patients lacking an HLA-matched related donor (10% at 1 year). 49% of patients remained outpatient without hospitalization during the first 100 days post-transplant. Long-term outcomes: For the five most common diagnoses, the 4-year OS and PFS estimates were 41% and 32% for AML, 31% and 23% for MDS, 66% and 42% for CLL, 67% and 46% for NHL, and 79% and 46% for HL, respectively. Factors associated with mortality included a high or very high DRI (HR 2.11, 95% CI 1.65-2.69, p Conclusions: TLI-ATG conditioning was well tolerated with a low risk of GVHD and NRM even among high-risk subgroups, including septuagenarians, patients with multiple comorbidities, and patients lacking an HLA-matched related donor. Nearly half of all patients remained outpatient during the first 100 days post-transplant. Long-term OS and PFS were seen across a range of hematologic malignancies, with particularly favorable outcomes for lymphoma patients, most of whom had failure of prior autologous HCT. Mixed chimerism correlates with the risk of relapse, and efforts are underway to augment donor chimerism and reduce relapse rates. Figure 1. Figure 1. Disclosures Miklos: Kite - Gilead: Consultancy, Research Funding; Pharmacyclics - Abbot: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Adaptive Biotechnologies: Consultancy, Research Funding; Genentech: Research Funding. Muffly:Adaptive Biotechnologies: Research Funding; Shire Pharmaceuticals: Research Funding.

Human invariant natural killer T cells (iNKT) are a rare population of lymphocytes that bridges innate and adaptive immune functions. iNKT cells have different potent effector functions and subsets, but this heterogeneity is mostly understood by a superimposed framework of classic T cell markers. This may help explain contradictory studies of iNKT cells in diseases for which they are thought to play a pathogenic role. In this study, we present data suggesting new markers to understand human iNKT cell heterogeneity and function, as well as monitoring this in the clinical context of allogeneic stem cell transplantation (ASCT) and graft-versus-host disease (GVHD). In both preclinical murine models and in correlative clinical studies, iNKT cells are associated with less GVHD and better immune reconstitution following ASCT. We performed bulk whole transcriptome sequencing on iNKT cells from patients at day +30 after ASCT, some who developed and some who did not develop GVHD. Gene expression signatures of the iNKT cells from each individual are grouped based on a transcriptome library of reference cell types (CIBERSORT). Using this approach, we distinguished patients who will develop GVHD as predominately having an activated cytotoxic cell gene signature, whereas patients without GVHD had a CD4+ T cell gene signature within purified peripheral blood iNKT cells. Using two different high throughput single-cell RNA sequencing (sc-seq) platforms to determine differential gene expression on the single cell level, we first examined the gene expression signatures of primary human iNKT cells from healthy donors. Activation with CD3/28 microbeads of primary iNKT cells promoted two main differential transcriptional profiles in iNKT cells. One profile resembles conventional CD4+ T cells and associated Th2 cytokine profile (IL2, IL4), whereas the other profile has genes associated with cytotoxicity and inflammation (TNF, IFNG, GZMB). Confirmation by flow cytometry showed that while CD8 surface expression did not well differentiate the pro-inflammatory and cytotoxic subsets, but both CD94 and KLRG1 better associate with Th1 and cytotoxic responses. CD94+ iNKT are restricted to CD4- cells and KLRG1 expressed in both CD4+ and CD4- populations. By comparison, the analysis of sc-seq of normal healthy subjects and post-transplant patients with and without GVHD resulted in the identification of three major iNKT populations. The population most associated with GVHD showed expression of a pro-inflammatory profile enriched for CXCR4,CD94, HLA-DRB1/A1 and decreased KLRB1. Whereas, post-transplant patients with healthy GVHD-free and relapse free immune reconstitution showed a more T cell like profile but with increased expression of CXCR4, CD94, KLRB1 and decreased HLA-DRB1/A1. Using flow cytometry of ex vivo expanded iNKT cells, we found the expansion of CXCR4+HLA-DR+ that can be CD4+ or CD4- and that these cells produce high levels of the cytokine TNF-a, IFN-g and IL-4. Importantly, iNKT cells that are CXC4+HLA-DR+KLRB1low make significantly less IL-4 and these are enriched in the GVHD setting. Using flow cytometry, we measured iNKT cell phenotypes in a pilot cohort of 48 individuals; 10 healthy controls, 10 patients with no complications or relapse after ASCT and 18 patients with GVHD of which 9 were steroid refractory. In addition, we evaluated 11 patients with new onset T1D. The frequency of the cytotoxic CD94+ iNKT cells were significantly increased in all patients following and in T1D compared to healthy controls. Whereas, patients with GVHD showed an increase in HLA-DR+CXCR4+KLRB1low iNKT cells. Increases in the late activation marker HLA-DR distinguished corticosteroid refractory (HLA-DR++) from steroid responsive patients at the time of initial GVHD diagnosis. For patients who responded to steroids or further therapy, we found that a reduction in HLA-DR associated with treatment response. In a second 24 patient cohort, we found that the presence HLA-DR+CXCR4+CD161low cells at day +30 was statistically greater in patients who would go on to develop GVHD as compared as those who did not (student T test, p To conclude, we have used different methods to discover and validate groups of iNKT cells with distinct functions, and the associated phenotype correlate with clinical inflammation both following ASCT and in T1D. Disclosures No relevant conflicts of interest to declare.

Although it is well known that in vivo radiation depletes immune cells via the Bcl-2 apoptotic pathway, a more nuanced analysis of the changes in the balance of immune-cell subsets is needed to understand the impact of radiation on immune function. We show the balance of T-cell subsets changes after increasing single doses of total body irradiation (TBI) or after fractionated irradiation of the lymphoid tissues (TLI) of mice due to differences in radioresistance and Bcl-2 expression of the NKT-cell and non-NKT subsets to favor CD4+Bcl-2hi NKT cells. Reduction of the Bcl-2lo mature T-cell subsets was at least 100-fold greater than that of the Bcl-2hi subsets. CD4+ NKT cells upregulated Bcl-2 after TBI and TLI and developed a Th2 bias after TLI, whereas non-NKT cells failed to do so. Our previous studies showed TLI protects against graft versus host disease in wild-type, but not in NKT-cell-deficient mice. The present study shows that NKT cells have a protective function even after TBI, and these cells are tenfold more abundant after an equal dose of TLI. In conclusion, differential expression of Bcl-2 contributes to the changes in T-cell subsets and immune function after irradiation.

We describe a recipient of combined kidney and hematopoietic-cell transplants from an HLA-matched donor. A post-transplantation conditioning regimen of total lymphoid irradiation and antithymocyte globulin allowed engraftment of the donor's hematopoietic cells. The patient had persistent mixed chimerism, and the function of the kidney allograft has been normal for more than 28 months since discontinuation of all immunosuppressive drugs. Adverse events requiring hospitalization were limited to a 2-day episode of fever with neutropenia. The patient has had neither rejection episodes nor clinical manifestations of graft-versus-host disease.

Lupus-prone NZB/W F1 mice develop glomerulonephritis after T helper cell-dependent isotype switching of autoantibody secretion from IgM to IgG at about 6 months of age. We compared innate immune natural killer (NK) T cells and conventional T cells for their capacity to help spontaneous in vitro immunoglobulin and autoantibody secretion of innate immune (B-1 and marginal zone) and conventional (follicular) B cell subsets from NZB/W F1 mice. We found that purified NKT cells not only increased spontaneous secretion of IgM and IgM anti-double-stranded (ds)DNA antibodies by B-1 and marginal zone B cells, but also facilitated secretion of IgG anti-dsDNA antibodies predominantly by B-1 B cells. Few IgM or IgG anti-dsDNA antibodies were secreted by follicular B cells, and conventional T cells failed to provide potent helper activity to any B cell subset. All combinations of T and B cell subsets from normal C57BL/6 mice failed to generate vigorous IgM and IgG secretion. NZB/W NKT cell helper activity was blocked by anti-CD1 and anti-CD40L mAb. In conclusion, direct interactions between innate immune T and B cells form a pathway for the development of IgM and IgG lupus autoantibody secretion in NZB/W mice.

Purpose: The goals of the study were to elucidate the immune mechanisms that contribute to desirable complete remissions of murine colon tumors treated with single radiation dose of 30 Gy. This dose is at the upper end of the ablative range used clinically to treat advanced or metastatic colorectal, liver, and non–small cell lung tumors. Experimental Design: Changes in the tumor immune microenvironment of single tumor nodules exposed to radiation were studied using 21-day (>1 cm in diameter) CT26 and MC38 colon tumors. These are well-characterized weakly immunogenic tumors. Results: We found that the high-dose radiation transformed the immunosuppressive tumor microenvironment resulting in an intense CD8+ T-cell tumor infiltrate, and a loss of myeloid-derived suppressor cells (MDSC). The change was dependent on antigen cross-presenting CD8+ dendritic cells, secretion of IFNγ, and CD4+T cells expressing CD40L. Antitumor CD8+ T cells entered tumors shortly after radiotherapy, reversed MDSC infiltration, and mediated durable remissions in an IFNγ-dependent manner. Interestingly, extended fractionated radiation regimen did not result in robust CD8+ T-cell infiltration. Conclusions: For immunologically sensitive tumors, these results indicate that remissions induced by a short course of high-dose radiotherapy depend on the development of antitumor immunity that is reflected by the nature and kinetics of changes induced in the tumor cell microenvironment. These results suggest that systematic examination of the tumor immune microenvironment may help in optimizing the radiation regimen used to treat tumors by adding a robust immune response. Clin Cancer Res; 21(16); 3727–39. ©2015 AACR.

We identified committed T cell progenitors (CTPs) in the mouse bone marrow that have not rearranged the TCRβ gene; express a variety of genes associated with commitment to the T cell lineage, including GATA-3, T cell-specific factor-1, Cβ, and Id2; and show a surface marker pattern (CD44+CD25−CD24+CD5−) that is similar to the earliest T cell progenitors in the thymus. More mature committed intermediate progenitors in the marrow have rearranged the TCR gene loci, express Vα and Vβ genes as well as CD3ε, but do not express surface TCR or CD3 receptors. CTPs, but not progenitors from the thymus, reconstituted the αβ T cells in the lymphoid tissues of athymic nu/nu mice. These reconstituted T cells vigorously secreted IFN-γ after stimulation in vitro, and protected the mice against lethal infection with murine CMV. In conclusion, CTPs in wild-type bone marrow can generate functional T cells via an extrathymic pathway in athymic nu/nu mice.

nu/nu mice fail to develop a thymus and mature T cells due to a defect in the whn gene encoding a transcription factor necessary for terminal epithelial cell differentiation. We investigated whether early T cell progenitor development in the nu/nu bone marrow is also defective. We demonstrated a maturation arrest of nu/nu marrow T cell progenitors associated with a lack of pTα gene expression and a failure to give rise to mature T cells in adoptive euthymic hosts. Wild-type hemopoietic stem cells rapidly matured into functional T cell progenitors in the marrow of euthymic or thymectomized but not nu/nu hosts. We show that defects in bone marrow prethymic T cell development can also contribute to T cell deficiency in nu/nu mice.

We searched for clonable committed T cell progenitors in the adult mouse bone marrow and isolated rare (≈0.05%) cells with the Thy-1hiCD2−CD16+CD44hiCD25−Lin−phenotype.In vivoexperiments showed that these cells were progenitors committed only to reconstituting the T cell lineage of irradiated Ly5 congenic hosts. Reconstitution of the thymus was minimal compared with that of the bone marrow, spleen, and lymph nodes. At limiting dilutions, donor T cell reconstitution of the spleen frequently occurred without detectable donor cells in the thymus. Progenitors were capable of rapidly reconstituting athymic hosts. In conclusion, the clonable bone marrow progenitors were capable of T cell reconstitution predominantly by means of an extrathymic pathway.

Our purpose was to evaluate the outcome and costs of high-dose chemotherapy and autologous peripheral blood progenitor cell (PBPC) transplantation in patients with the inability to mobilize sufficient numbers of PBPCs to allow rapid engraftment after PBPC transplantation. We treated 172 consecutive non-Hodgkin's lymphoma (NHL) patients with cyclophosphamide and granulocyte colony-stimulating factor followed by apheresis to collect PBPCs. The cells were separated on a Percoll gradient and purged with monoclonal antibodies and complement. The patients were categorized as "good" mobilizers if a collection of > or =2 x 10(6) CD34+ cells/kg was obtained (n = 138, 80%) or "poor" mobilizers if

Background. Previous studies showed that Lewis rats given posttransplant total lymphoid irradiation, antithymocyte globulin, and a single infusion of ACI peripheral blood or bone marrow cells develop tolerance to ACI heart allografts. Methods. To determine the effects of cyclosporine on these tolerance induction protocols, groups of Lewis hosts, given either ACI blood or marrow infusions, were given a 60-day course of daily cyclosporine immediately after the cell infusion. Results. Cyclosporine treatment was associated with uniform graft rejection in the groups given an ACI blood transfusion, and was associated with uniform graft acceptance in the groups given an ACI bone marrow infusion. Studies of donor-type T and B cell chimerism in the host blood showed that cyclosporine facilitated chimerism in the hosts given ACI bone marrow cells, and stable chimerism over a 300-day observation period was predicted by detectable chimerism by day 30. None of the hosts given ACI blood cells developed chimerism. Conclusion. Cyclosporine facilitated long-term graft acceptance in a tolerization protocol that induced mixed chimerism, but prevented long-term graft acceptance in a tolerization protocol that did not induce chimerism.

Background Previous studies showed that an intravenous infusion of donor blood cells facilitates tolerance to ACI heart allografts in Lewis rat hosts given posttransplant total lymphoid irradiation (TLI) and anti-thymocyte globulin (ATG). The object of the current study was to compare tolerance induction using donor cells that do or do not induce chimerism. Methods Normal peripheral blood mononuclear cells (PBMC), granulocyte colony-stimulating factor (G-CSF)-mobilized PBMC, and bone marrow (BM) cells from ACI donors were tested for their capacity to prolong ACI heart allograft survival in Lewis hosts. Chimerism, anti-donor cell reactivity, and cytokine gene expression in grafts were determined. Results Intravenous injections of equal numbers of all three donor cells markedly prolonged graft survival (median: >164 to >175 days) as compared to uninjected controls (median: 53 days). Chimerism among T and B cells in the blood was determined by immunofluorescent staining in hosts bearing long-term (> 150 days) grafts. Although no chimerism was detected in hosts given normal or G-CSF-mobilized PBMC, chimerism was detected at variable levels in all hosts given BM cells. Vigorous anti-donor reactivity in the mixed leukocyte reaction was present only in non-chimeric hosts. Long-term grafts from hosts given normal ACI PBMC developed chronic rejection, but those from hosts given ACI BM cells did not. The latter hosts showed the lowest levels of intragraft cytokine mRNA. Conclusions Chimeric tolerance is more robust than non-chimeric tolerance in the model of posttransplant TLI, ATG, and donor cell infusion, and is associated with less chronic rejection.

Sorted CD4(+) and CD8(+) T cells from the peripheral blood or bone marrow of donor C57BL/6 (H-2(b)) mice were tested for their capacity to induce graft-versus-host disease (GVHD) by injecting the cells, along with stringently T cell-depleted donor marrow cells, into lethally irradiated BALB/c (H-2(d)) host mice. The peripheral blood T cells were at least 30 times more potent than the marrow T cells in inducing lethal GVHD. As NK1.1(+) T cells represented1% of all T cells in the blood and approximately 30% of T cells in the marrow, the capacity of sorted marrow NK1.1(-) CD4(+) and CD8(+) T cells to induce GVHD was tested. The latter cells had markedly increased potency, and adding back marrow NK1.1(+) T cells suppressed GVHD. The marrow NK1.1(+) T cells secreted high levels of both interferon gamma (IFN-gamma) and interleukin 4 (IL-4), and the NK1.1(-) T cells secreted high levels of IFN-gamma with little IL-4. Marrow NK1.1(+) T cells obtained from IL-4(-/-) rather than wild-type C57BL/6 donors not only failed to prevent GVHD but actually increased its severity. Together, these results demonstrate that GVHD is reciprocally regulated by the NK1.1(-) and NK1.1(+) T cell subsets via their differential production of cytokines.

BACKGROUND Previous studies showed that a combination of posttransplant total lymphoid irradiation (TLI), rabbit antithymocyte globulin (ATG), and a single donor blood transfusion induced tolerance to ACI heart allografts in Lewis rats. All three modalities were required to achieve tolerance. The objective of the current study was to determine the subset(s) of cells in the donor blood that facilitated long-term allograft survival. METHODS Lewis hosts received TLI, ATG, and donor cell infusion after heart transplantation. Graft survival, mixed leukocyte reaction (MLR), and intragraft cytokine mRNA were studied. RESULTS The intravenous injection of 25 x 10(6) ACI peripheral blood mononuclear cells (PBMC) significantly prolonged graft survival as compared with that of Lewis hosts given TLI and ATG alone. Injection of highly enriched blood T cells or splenic B cells adjusted for the number contained in 25 x 10(6) PBMC failed to induce significant graft prolongation. Unexpectedly, depletion of monocytes (CD11b+ cells) from PBMC resulted in the loss of graft prolongation activity. Enriched populations of monocytes obtained by plastic adherence were more efficient in prolonging graft survival than PBMC on a per cell basis. Hosts with long-term grafts (>100-day survival) showed evidence of immune deviation, because the MLR to ACI stimulator cells was vigorous, but secretion of interferon-gamma in the MLR was markedly reduced. In situ hybridization studies of long-term grafts showed markedly reduced levels of interferon-gamma mRNA as compared with rejecting grafts. CONCLUSION Infusion of donor monocytes facilitated graft prolongation via immune deviation.

In the principal pathway of α/β T cell maturation, T cell precursors from the bone marrow migrate to the thymus and proceed through several well-characterized developmental stages into mature CD4+ and CD8+ T cells. This study demonstrates an alternative pathway in which the bone marrow microenvironment also supports the differentiation of T cell precursors into CD4+ and CD8+ T cells. The marrow pathway recapitulates developmental stages of thymic maturation including a CD4+CD8+ intermediary cell and positive and negative selection, and is strongly inhibited by the presence of mature T cells. The contribution of the marrow pathway in vivo requires further study in mice with normal and deficient thymic or immune function.

The feasibility of transplanting peripheral blood mononuclear cells (PBMC) from granulocyte colony-stimulating factor (G-CSF)–treated normal human donors to myeloablated allogeneic hosts has been demonstrated recently. The current work examined the ability of recombinant G-CSF to alter peripheral blood T-cell function and graft-versus-host disease (GVHD) in a murine model of allogeneic G-CSF–mobilized PBMC transplantation. Administration of recombinant G-CSF to C57BL/Ka mice markedly increased the capacity of PBMC to reconstitute lethally irradiated syngeneic hosts. T- and B-lineage lymphocytes were depleted about 10-fold in the bone marrow of the treated mice, and the T-cell yield in the blood was increased about fourfold. The ability of PBMC or purified CD4+ and CD8+ T cells to induce acute lethal GVHD in irradiated BALB/c mice was reduced after the administration of G-CSF. This was associated with decreased secretion of interferonγ and interleukin-2 (IL-2) and an increased secretion of IL-4. The donor cell inoculum, which was most successful in the rescue of irradiated allogeneic hosts, was the low-density fraction of PBMC from G-CSF–treated mice. These low-density cells were enriched for CD4−CD8−NK1.1+ T cells and secreted about 10-fold more IL-4 than the unfractionated cells from the G-CSF–treated donors.

The goal of the study was to elucidate the cellular and molecular mechanisms by which a clinically applicable immune tolerance regimen of combined bone marrow and heart transplants in mice results in mixed chimerism and graft acceptance. The conditioning regimen of lymphoid irradiation and anti-T cell antibodies changed the balance of cells in the lymphoid tissues to create a tolerogenic microenvironment favoring the increase of natural killer T (NKT) cells, CD4+ CD25+ regulatory T cells and Gr-1+ CD11b+ myeloid-derived suppressor cells (MDSCs), over conventional T cells (Tcons). The depletion of MDSCs abrogated chimerism and tolerance, and add back of these purified cells was restorative. The conditioning regimen activated the MDSCs as judged by the increased expression of arginase-1, IL-4Rα and programmed death ligand 1, and the activated cells gained the capacity to suppress the proliferation of Tcons to alloantigens in the mixed leukocyte reaction. MDSC activation was dependent on the presence of host invariant NKT cells. The conditioning regimen polarized the host invariant NKT cells toward IL-4 secretion, and MDSC activation was dependent on IL-4. In conclusion, there was a requirement for MDSCs for chimerism and tolerance, and their suppressive function was dependent on their interactions with NKT cells and IL-4.

Lupus is a systemic autoimmune disease characterized by anti-nuclear antibodies in humans and genetically susceptible NZB/W mice that can cause immune complex glomerulonephritis. T cells contribute to lupus pathogenesis by secreting pro-inflammatory cytokines such as IL-17, and by interacting with B cells and secreting helper factors such as IL-21 that promote production of IgG autoantibodies. In the current study, we determined whether purified NKT cells or far more numerous conventional non-NKT cells in the spleen of NZB/W female mice secrete IL-17 and/or IL-21 after TCR activation in vitro , and provide help for spontaneous IgG autoantibody production by purified splenic CD19 + B cells. Whereas invariant NKT cells secreted large amounts of IL-17 and IL-21, and helped B cells, non-NKT cells did not. The subset of IL-17 secreting NZB/W NKT cells expressed the Ly108 lo CD4 − NK1.1 − phenotype, whereas the IL-21 secreting subset expressed the Ly108 hi CD4 + NK1.1 − phenotype and helped B cells secrete a variety of IgG anti-nuclear antibodies. α-galactocylceramide enhanced the helper activity of NZB/W and B6.Sle1b NKT cells for IgG autoantibody secretion by syngeneic B cells. In conclusion, different subsets of i NKT cells from mice with genetic susceptibility to lupus can contribute to pathogenesis by secreting pro-inflammatory cytokines and helping autoantibody production.

Steroid refractory gastrointestinal (GI) acute graft-versus-host disease (aGVHD) is a major cause of mortality in hematopoietic stem cell transplantation (HCT) without immune markers to establish a diagnosis or guide therapy. We found that T-cell receptor β (TCRβ) complementarity-determining region 3 repertoire sequencing reveals patterns that could eventually serve as a disease biomarker of T-cell alloreactivity in aGVHD. We identified T-cell clones in GI biopsies in a heterogeneous group of 15 allogeneic HCT patients with GI aGVHD symptoms. Seven steroid-refractory aGVHD patients showed a more conserved TCRβ clonal structure between different biopsy sites in the GI tract than 8 primary therapy–responsive patients. Tracking GI clones identified longitudinally at endoscopy in the blood also revealed an increased clonal expansion in patients with steroid-refractory disease. Immune repertoire sequencing-based methods could enable a novel personalized way to guide diagnosis and therapy in diseases where T-cell activity is a major determinant.

OBJECTIVE To assess the effect on peripheral blood T lymphocytes of recombinant human growth hormone administered to healthy older women. DESIGN Prospective, open study. SETTING Veterans Administration clinical research unit and community surrounding Palo Alto, California. PARTICIPANTS Thirty-three women were recruited in two age groups: 20 to 40 years (n = 13) and 70 years or older (n = 24). Subjects were healthy, community-dwelling volunteers. INTERVENTIONS Recombinant human growth hormone at a dose of 0.025 mg/kg body weight/day was administered to the older subjects by daily subcutaneous injection over a 6-month study period. MAIN OUTCOME MEASURES Mean percentage and number of peripheral blood CD45RA+ (“naive”) T cells, mean counts per minute (CPM) of [3H]-thymidine incorporation following stimulation of peripheral blood mononuclear cells with phytohemaglutinin (T cell proliferation). RESULTS Before therapy, mean percentage and number of peripheral blood CD45RA+ T cells and T cell proliferative responses were significantly reduced in older compared with younger women. The fraction of older women with CD45RA+ T cell levels or T cell proliferative responses in the young range was significantly decreased in those who were receiving estrogen (1/10) compared with those who were not (9/14). After treatment with growth hormone, there were no significant changes in the mean CD45RA+ T cell levels or proliferative responses of the older women. CONCLUSIONS The results suggest that T cell changes associated with the age-related decline in secretion of growth hormone cannot be reversed by growth hormone therapy during the eighth decade.

Lewis rats were rendered tolerant to ACI heart allografts using a regimen of posttransplant total lymphoid irradiation (TLI), rabbit antithymocyte or antilymphocyte globulin (RATG or RALG), and a single donor blood transfusion. All three treatment modalities were required to induce tolerance. The mechanism of the maintenance of tolerance was investigated by comparing the secretion of cytokines in the MLR, and the expression of cytokine mRNA in the allografts of tolerant and nontolerant Lewis rats. Although, the 3H-thymidine incorporation and secretion of IL-2 was frequently comparable in the MLR from tolerant and nontolerant rats, the secretion of IFN-gamma was markedly reduced in the tolerant rats. This was reflected in a markedly reduced frequency of cells expressing IFN-gamma mRNA in the allografts of tolerant as compared with nontolerant hosts. The frequency of cells expressing IL-2 and IL-10 mRNA was also reduced, but no significant difference was observed for cells with IL-4 mRNA. Spleen cells from nontolerant rats rapidly rejected ACI allografts in irradiated adoptive hosts, but spleen cells from tolerant rats did not. Evaluation of the cytokine mRNA expression at early and late time points in the allografts of adoptive hosts showed a pattern similar to that of the primary hosts. Thus, the tolerant state was associated with a maintenance or elevation of IL-4 expression and a marked reduction of IFN-gamma expression. Previous reports have shown that TLI alone induced this shift in the early recovery phase after irradiation.

Background Relapse remains the primary cause of failure following allogeneic hematopoietic cell transplantation (HCT). Unmanipulateddonor lymphocyte infusion (DLI) may induce immune-mediated graft-versus-tumor (GVT) reactions, but often elicits significant graft-versus-host disease (GVHD). Murine models of transplantation showed that a purified CD8+CD44hi memory T cell subset containing both central and effector memory cells was capable of eradicating malignant cells without inducing GVHD. We now report on a Phase I safety and feasibility study in which escalating doses of phenotypic CD8+CD45RA- memory T cells derived from HLA-matched sibling donors were administered to recipients with hematologic malignancies who relapsed after allogeneic HCT. Methods Eligible patients were 18-75 years of age with a hematologic malignancy that relapsed after allogeneic HCT from an HLA-matched sibling donor. Phenotypic CD8+ memory T cells were isolated following two days of unmobilized donor apheresis using a tandem immunomagnetic selection strategy including CD45RA depletion followed by CD8+ enrichment on the CliniMACS Plus instrument. Cell recovery and purity were determined by flow cytometry analysis. The study followed a standard 3+3 dose escalation scheme, with three patients enrolled at escalating dose levels of 1x106 cells/kg, 5x106 cells/kg, and 10x106 cells/kg; six additional patients were enrolled at the maximum tolerated dose (MTD). Results Fifteen patients received CD8+ memory T cell infusion at three dose levels. Median age was 59 years (range, 29 to 70 years). Diagnoses included acute myeloid leukemia (n= 8), non-Hodgkin lymphoma (n= 3), chronic lymphocytic leukemia (n= 1), chronic myeloid leukemia (n=1), multiple myeloma (n=1), and acute lymphoblastic leukemia (n=1). Median times from allogeneic HCT to disease relapse, and disease relapse to CD8+ memory T cell infusion were 508 days (range, 59 to 3214 days), and 236 days (range, 7 to 3005 days), respectively. Thirteen patients (87%) received cytoreductive therapy prior to CD8+ memory T cell infusion; six (40%) had returned to complete remission (CR) at the time of infusion. CD8+ memory T cell recovery, purity, and dose infused for each dose level cohort is detailed in Table 1. All patients in dose levels 1 and 2 received the intended CD8+ memory T cell dose of 1x106/kg and 5x106/kg, respectively. Five of the patients treated at dose level 3 received the planned 10x106/kg CD8+ memory T cell dose; however, the intended dose could not be obtained in four patients, who received doses of 7.8x106/kg, 8.0x106/kg, 5.2x106/kg, and 7.7x106/kg. There were no adverse events during CD8+ memory T cell infusion, and no dose-limiting toxicities occurred. GVHD developed in only one patient, was limited to grade II involvement of the liver, and resolved following a course of steroids. The median follow-up from the time of CD8+ memory T cell infusion was 328 days (range, 118 to 1328 days). Ten patients (67%) maintained or achieved response (7 CR, 1 partial response, 2 stable disease) for at least three months following CD8+ memory T cell infusion; four of the responders had active disease at time of infusion. Five patients (33%) had disease progression after CD8+ memory T cell infusion; all five had active disease at time of infusion. Among the ten responders, seven have relapsed at the time of this report after a median 165 days (range, 90 to 973 days) to relapse. Eight patients are currently alive; three are alive in CR and five are alive with active disease. For the entire study cohort, the median event-free survival and overall survival following CD8+ memory T cell infusion were 4.9 months (95% CI, 1 month to 19.3 months) and 19.6 months (95% CI, 5.6 months to not reached), respectively. Conclusion Phenotypic CD8+ memory T cell DLI is well tolerated and associated with a low incidence of GVHD. The MTD was not reached even at the highest dose of 10x106/kg; however, we were unable to consistently obtain this yield using the current cell selection strategy. Some patients achieved prolonged CR in this small heterogeneous study population. Future work will focus on methods to increase CD8+ memory T cell yield and strategies to enhance GVT associated with these cells. 1.DuttS, et al., Blood 2011 Mar 17;117(11):3230-9 2. Armstrong R, et al., BBMT 2011; 17(2, S1):p.S220. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures Meyer: Stanford University: Patents & Royalties.

Introduction: Non-myeloablative conditioning with total lymphoid irradiation and antithymocyte globulin (TLI-ATG) is associated with a low risk of graft-versus-host disease (GVHD), attributed to skewing of residual host T-cell subsets to favor regulatory IL-4 producing natural killer T cells that polarize the infused donor T cells to a Th2 phenotype, while retaining graft-versus-tumor (GVT) reactions in lymphoid and myeloid malignancies. We hypothesized that the safety of TLI-ATG conditioning with its protection from GVHD would extend beyond matched donors, yet with mismatching there would be at least as potent GVT reactions as with matched donors. We therefore compared outcomes in patients who received TLI-ATG conditioning and allogeneic hematopoietic cell transplantation (HCT) from HLA-mismatched unrelated donors to those with HLA-matched unrelated donors. Methods: Patients: We included all consecutively transplanted patients at Stanford University Hospital from December 2001 through May 2015 who received TLI-ATG conditioning and allogeneic HCT from 10/10 HLA-matched unrelated donors (MUD, N=193) or HLA-mismatched unrelated donors (mmUD, N=72), including 70 patients matching in 9/10 alleles or antigens (55 mismatched at HLA-A, -B, -C or -DRB1 loci and 15 mismatched at HLA-DQB1) and 2 patients matched in 8/10 alleles. All patients received G-CSF-mobilized peripheral blood hematopoietic cells and cyclosporine and mycophenolate mofetil for GVHD prophylaxis. Statistical methods: For time-to-event analyses, Kaplan-Meier curves were used to estimate survival and cumulative incidence of acute and chronic GVHD, non-relapse mortality, and relapse. Log-rank tests were used to detect differences between groups. Results: Median age at the time of transplant was 60 years in both groups (range 21-76) with a median follow up of 677 days (range 53-3682) in the mmUD cohort and 762 days (range 37-4551) in the MUD cohort. There were no significant differences between the mmUD and MUD cohorts in underlying diagnosis (acute myeloid leukemia 32% vs 31%, non-Hodgkin lymphoma 22% vs 29%, chronic lymphocytic leukemia 17% vs 17%, myelodysplastic syndrome and myeloproliferative neoplasms 11% vs 14%, Hodgkin lymphoma 8% vs 5%; chronic myeloid leukemia 7% vs 2%, and acute lymphoblastic leukemia 3% vs 3%).The majority of patients in both mmUD and MUD cohorts had advanced stage lymphoid disease (75% vs 72%) and advanced stage myeloid disease (53% vs 54%), defined as disease status beyond second complete remission at the time of transplant, relapse following prior autologous or allogeneic transplant, high-risk cytogenetic abnormality and age over 55, myelodysplastic syndrome with progression to acute myeloid leukemia, or therapy-related myeloid neoplasm. Durable chimerism was achieved in 90% of patients in the mmUD group and 94% of patients in the MUD group. There were no significant differences between the mmUD and MUD cohorts in the cumulative incidence of acute GVHD at day +100 (grades II-IV: 21% vs 15%, p=0.78 and grades III-IV: 6% vs 3%, p=0.61). Non-relapse mortality (NRM) was not significantly different (14% at 1 year in mmUD group vs 6% in MUD group, p=0.34). There was no significant difference in the cumulative incidence of chronic GVHD (31% vs 27% at 2 years and 39% vs 35% at 5 years, p=0.49). There was a trend towards a lower rate of relapse in the mmUD group (40% vs 48% at 2 years, 45% vs 60% at 5 years, hazard ratio 0.71, p=0.094). There was no significant difference in overall survival (58% vs 60% at 2 years and 46% vs 46% at 5 years) or event-free survival (46% vs 44% at 2 years and 38% vs 28% at 5 years, p=0.25). In both groups, sustained remissions occurred among patients with active disease at the time of transplantation. Conclusions: TLI-ATG conditioning is associated with low rates of acute and chronic GVHD and NRM even in the setting of HLA-mismatched unrelated donor transplantation. There was a particularly low incidence of severe acute GVHD grades III-IV (3-6%) in this high-risk cohort. The trend towards lower relapse in recipients of HLA-mismatched grafts may reflect enhanced GVT reactions. TLI-ATG conditioning may overcome the traditionally poorer outcome and high NRM associated with HLA mismatch and should be considered in patients with advanced lymphoid and myeloid malignancies who cannot tolerate myeloablative preparatory regimens and who lack a fully HLA-matched donor. Figure 1 Figure 1. Disclosures Meyer: Stanford University: Patents & Royalties. Negrin:Stanford University: Patents & Royalties.

The ability of highly purified CD8+ T cells to mediate GVL activity and facilitate engraftment of allogeneic bone marrow cells was studied in the C57BL/Ka-->BALB/c mouse strain combination. Splenic CD8+ T cells were enriched by depletion of CD4+ T cells by "planning" or purified by positive selection by cell sorting. Although C57BL/Ka bone marrow cells reconstitute lethally irradiated BALB/c mice without severe GVHD, the addition of at least 1.0 x 10(6) donor spleen cells induced uniform acute lethal GVHD. Equivalent doses of spleen cells depleted of CD4+ T cells failed to induce lethal GVHD. Allogeneic bone marrow cells alone failed to mediate antitumor activity against the BCL1 B cell leukemia/lymphoma as compared with syngeneic bone marrow and spleen cell injections. Despite the inability to induce severe GVHD, CD4+ T cell-depleted allogeneic spleen cells prevented the progressive growth of the BCL1 tumor, and eliminated BCL1 idiotype-positive tumor cells in the blood. In order to determine whether CD8+ T cells can prevent tumor growth in the absence of other spleen cell subsets, such as NK cells, that are present in the CD4- populations, highly purified CD8+ T cells were obtained by positive selection using flow cytometry. The latter cells prevented the progressive growth of the tumor, and markedly reduced the level of tumor cells in the blood. Sorted CD8+ T cells facilitated the engraftment of allogeneic marrow cells in sublethally irradiated hosts. Thus, addition of highly purified CD8+ T cells to marrow cells provides GVL activity and facilitates engraftment without inducing severe GVHD in most recipients.

The rate of renewal of T lymphocytes in the bone marrow of euthymic C57BL/Ka and athymic nu/nu BALB/c mice was estimated by in vivo labeling with bromodeoxyuridine. T lymphocytes accounted for 16-18% of marrow cells in euthymic mice as judged by immunofluorescent staining with monoclonal antibodies for Thy-1, CD3, and alpha/beta T cell antigen receptor markers. About 70% of marrow cells expressed receptors (Mac-1, Gr-1, B220) for myeloid, macrophage, and B lineage cells. Approximately 13% of cells in the athymic bone marrow expressed alpha/beta T cell receptors. Sorted marrow T cells proliferated in response to stimulation with anti-alpha/beta antibodies in vitro and showed functional rearrangements of V beta and J beta genes. Sorted non-T cells did not respond to stimulation in vitro, and all V beta and J beta gene rearrangements identified were nonfunctional. In vivo labeling studies indicated that approximately 17 x 10(6) bone marrow T cells are renewed daily in euthymic mice and approximately 14 x 10(6) are renewed in athymic mice. Approximately 11 x 10(6) mature B cells (immunoglobulin M+) are renewed daily in the bone marrow of the latter mice. To determine whether marrow precursors can give rise to T cells directly, marrow cells from euthymic and athymic mice were depleted of T cells by cell sorting and incubated in vitro for 48 h in the absence of exogenous growth factors or thymic stromal cells. Examination of the cells after culture showed that 10-12% stained brightly for alpha/beta T cell receptors. Although functional rearrangements of V beta and J beta genes were not detected before culture, the majority of rearrangements were functional after culture. The emergence of the bright alpha/beta T cells in culture was dependent on depletion T cells from the marrow cells before culture. The results suggest that most marrow T cells are generated in the marrow itself.

This study examined whether posttransplant anti-T cell monoclonal or polyclonal antibody therapy could provide a window of treatment to allow posttransplant total lymphoid irradiation (TLI) to induce tolerance. These experiments were conducted in a high responder strain combination of an ACI cardiac allograft into a Lewis rat. In this situation, treatment with antibody or posttransplant TLI alone is insufficient to induce tolerance, while similar treatments alone have been shown to induce tolerance in low responder strains. The affects of three anti-T cell therapies were compared: anti-CD4 mAb therapy, anti-CD3 mAb, and rabbit antithymocyte globulin (RATG). None of these antibody therapies alone prolonged graft survival indefinitely. Combining anti-CD4 therapy with posttransplant TLI markedly delayed rejection but failed to induce long-term graft survival. Tolerance could be induced by a combination of anti-pan T cell antibody (anti-CD3) and TLI, and, all grafts survived beyond 100 days. RATG failed to prevent graft rejection when used alone or in combination with TLI. However, posttransplant therapy with a combination of RATG, TLI, and single-donor blood transfusion resulted in graft survival beyond 100 days. Recipients bearing long-term donor grafts rejected third-party (PVG) grafts within 2 weeks. Low density donor bone marrow cells used instead of a blood transfusion did not facilitate tolerance. The results indicate that monoclonal or polyclonal anti-pan T cell antibodies, TLI, and a donor blood cell infusion function synergistically in facilitating tolerance to allografts in the posttransplant period.

Bone marrow transplantation (BMT) is a potentially curative treatment for patients with leukemia and lymphoma. Tumor eradication is promoted by the anti-tumor activity of donor T cells contained in the transplant; however, donor T cells also mediate the serious side effect of graft-versus-host disease (GVHD). Separation of GVHD from graft anti-tumor activity is an important goal of research in improving transplant outcome. One approach is to take advantage of the immunomodulatory activity of regulatory NKT cells and CD4(+)CD25(+) Treg of host and/or donor origin. Both host and donor NKT cells and donor Treg are able to prevent GVHD in murine models. In this review, we summarize the mechanisms of NKT cell- and Treg-mediated protection against GVHD in mice while maintaining graft anti-tumor activity. In addition, we also examine the interactions between NKT cells and Treg in the context of BMT, and integrate the data from murine experimental models with the observations made in humans.

Posttransplant total lymphoid irradiation is a nonmyeloablative regimen that has been extensively studied in rodent models for the induction of tolerance to bone marrow and solid organ allografts. Previous studies of experimental models and clinical transplantation have used total lymphoid irradiation in combination with anti-lymphocyte-depleting reagents and donor cell infusion to promote graft acceptance. In a rat model of orthotopic liver transplantation, we demonstrated that total lymphoid irradiation alone induced long-term graft survival. Apoptotic T cells were detected in markedly higher numbers in the livers of the total lymphoid irradiation-treated group in comparison with the control group of liver allograft recipients. Intragraft CD4(+)CD25(+)FoxP3(+) cells were increased in the total lymphoid irradiation group in the first week post-transplant and remained elevated in the graft and in the spleen. Importantly, the adoptive transfer of splenocytes from recipients that received posttransplant total lymphoid irradiation prolonged the survival of donor heart grafts, but not third-party heart grafts, whereas the depletion of CD4(+)CD25(+) cells from transferred splenocytes abrogated this prolongation. We conclude that posttransplant total lymphoid irradiation significantly increases the apoptosis of T cells in the liver graft and allows the accumulation of CD4(+)CD25(+)FoxP3(+) T regulatory cells, which facilitate the generation of donor-specific tolerance.

The goal of the study was to determine how the changed balance of host naïve and regulatory T cells observed after conditioning with total lymphoid irradiation (TLI) and antithymocyte serum (ATS) promotes tolerance to combined organ and bone marrow transplants. Although previous studies showed that tolerance was dependent on host natural killer T (NKT) cells, this study shows that there is an additional dependence on host CD4(+)CD25(+) Treg cells. Depletion of the latter cells before conditioning resulted in rapid rejection of bone marrow and organ allografts. The balance of T-cell subsets changed after TLI and ATS with TLI favoring mainly NKT cells and ATS favoring mainly Treg cells. Combined modalities reduced the conventional naïve CD4(+) T cells 2800-fold. The host type Treg cells that persisted in the stable chimeras had the capacity to suppress alloreactivity to both donor and third party cells in the mixed leukocyte reaction. In conclusion, tolerance induction after conditioning in this model depends upon the ability of naturally occurring regulatory NKT and Treg cells to suppress the residual alloreactive T cells that are capable of rejecting grafts.

NZB/W female mice spontaneously develop systemic lupus, an autoantibody mediated disease associated with immune complex glomerulonephritis. Natural killer (NK) T cells augment anti-dsDNA antibody secretion by NZB/W B cells in vitro, and blocking NKT cell activation in vivo with anti-CD1 mAb ameliorates lupus disease activity. In the current study, we show that beta-galactosylceramide reduces the in vivo induction of serum IFN-gamma and/or IL-4 by the potent NKT cell agonist alpha-galactosylceramide and reduces NKT cell helper activity for IgG secretion. Treatment of NZB/W mice with the beta-galactosylceramide ameliorated lupus disease activity as judged by improvement in proteinuria, renal histopathology, IgG anti-dsDNA antibody formation, and survival. In conclusion, beta-galactosylceramide, a glycolipid that reduces the cytokine secretion induced by a potent NKT cell agonist ameliorates lupus in NZB/W mice.

Crude supernatants were obtained from cloned murine natural suppressor (NS) cells activated in vitro with phorbol-myristate-acetate (PMA) and calcium ionophore (A23187). Supernatants suppressed IL-2 production in the mixed leukocyte reaction (MLR) with BALB/c spleen cells, but no reduction was observed in the response to PHA, Con A, or anti-CD3 antibody. Suppressive activity was partially purified by DEAE ion exchange chromatography, and inhibited the antigenpresenting function of the macrophage line 1G18-LA in an assay system with the ovalbumin-specific T cell hybridoma, 3DO-18.3. In addition, the antigen-presenting function of the A20 B cell line was inhibited in an assay with a sperm whale myoglobin (SpWMb)-specific T cell hybridoma (8.2.1d.H1a). Results with blocking antibodies suggest that this factor appears to be a unique cytokine.

Four to six weeks after total lymphoid irradiation (TLI), there is a selective deficit in the CD4+ T cells which secrete IL-2, proliferate in the MLR, and induce GVHD (Th1-like functions). A similar deficit in CD4+ T cells which secrete IL-4 and help antibody responses (Th2-like functions) is not observed. In the present study, shielding of the thymus with lead during TLI increased the Th1-like functions of CD4+ cells. Mice without thymus shields showed a marked selective reduction in the medullary stromal cells identified with the monoclonal antibody, MD1, and the severe reduction was prevented with thymus shields. Thus, shielding the thymus prevents the depletion of thymic medullary stromal cells and allows for a rapid recovery of Th1-like functions in the mouse spleen after TLI. Th2-like functions recover rapidly after TLI whether or not the thymus is irradiated.