In vitro characterization of human AML-reactive CTL clones generated from the naive subset of healthy donors and adoptive transfer into leukemia-engrafted NSG mice

Acute myeloid leukemia (AML) is a very aggressive cancer of the hematopoietic system. Chemotherapy and immunotherapeutical approaches including hematopoietic stem cell transplantation (HSCT) and donor lymphocyte infusion (DLI) are the only curative options available. The beneficial graft-versus-leukemia (GVL) effect of cellular immunotherapy is mostly mediated by donor-derived CD8+ T lymphocytes that recognize minor histocompatibility antigens (mHags) and leukemia-associated antigens (LAAs) presented on the surface of AML blasts (Falkenburg et al. 2008; Kolb 2008). A main complication is graft-versus-host disease (GVHD) that can be induced when cytotoxic T lymphocytes (CTLs) recognize broadly expressed antigens. To reduce the risk of GVHD, specific allogeneic T-cell therapy inducing selective GVL responses could be an option (Barrett & Le Blanc 2010; Parmar et al. 2011; Smits et al. 2011). This requires efficient in vitro strategies to generate AML-reactive T cells with an early differentiation phenotype as well as vigorous effector functions and humanized mouse models to analyze the anti-leukemic potential of adoptively transferred T cells in vivo. In this study, AML-reactive CTL clones and oligoclonal T-cell lines could be reliably generated from the naive subset of healthy HLA-class I-identical donors by stimulation with primary AML blasts in mini-mixed-lymphocyte / leukemia cultures (MLLCs) in eight different patient / donor pairs. These CTLs were promising candidates for cellular immunotherapy because of their relatively early differentiation phenotype and strong proliferative and lytic capabilities. The addition of the common γ-chain cytokine IL-21 to the stimulation protocol enabled more precursors to develop into potent leukemia-reactive CTLs, presumably by its beneficial effects on cell survival and antigen-specific proliferation during the first weeks of cultures. It also strengthened the early-stage phenotype. Three long-term cultured CTLs exemplarily transferred into leukemia-engrafted immunodeficient NSG mice mediated a significant reduction of the leukemic burden after a single transfusion. These results demonstrate that CTL clones with reactivity to patient-derived AML blasts can be isolated from the naive compartment of healthy donors and show potent anti-leukemic effects in vivo. The herein described allo-MLLC approach with in vitro “programmed” naive CTL precursors independent of a HSCT setting is a valuable alternative to the conventional method of isolating in vivo primed donor CTLs out of patients after transplantation (Kloosterboer et al. 2004; Warren et al. 2010). This would make leukemia-reactive CTLs already available at the time point of HSCT, when residual leukemia disease is minimal and the chances for complete leukemia eradication are high. Furthermore, leukemia-reactive CTLs effectively expanded by this in vitro protocol can be used as screening populations to identify novel candidate LAAs and mHags for antigen-specific immunotherapy.

Untersuchungen zur Regulation von T-Effektorzellen im peripheren Blut von MS-Patienten und humanisierten Mäusen mit einer induzierten autoimmunen Enzephalitis

Die Multiple Sklerose (MS) ist eine Autoimmunkrankheit des zentralen Nervensystems, bei der sich autoreaktive T-Effektorzellen der Kontrolle durch regulatorische T-Zellen (Treg) entziehen. Innerhalb dieser Arbeit wurde gezeigt, dass T-Effektorzellen von MS-Patienten insensitiv gegenüber der Suppression durch Treg sind. Hervorgerufen wird diese Treg-Resistenz durch Interleukin-6 (IL-6). Die Inhibition des IL-6-Signalweges stellt die Treg-vermittelte Suppression der T-Effektorzellen wieder her. Es zeigte sich, dass die Bildung von IL-6 und die Expression des IL-6-Rezeptors in MS-Patienten in einer positiven Rückkopplungsschleife von IL-6 selbst induziert werden.rnZur Analyse humaner Immunantworten in vivo und deren Modulation durch humanspezifische Therapeutika wurden humanisierte Mausmodelle etabliert. Der adoptive Transfer humaner Immunzellen in immundefiziente Mäuse erlaubte die Untersuchung von T-Lymphozyten, die aus dem Blut von MS-Patienten isoliert wurden. Es zeigte sich, dass Treg-resistente T-Effektorzellen aus den MS-Patienten in den Tieren eine letale Graft-versus-Host-Erkrankung auslösten, die nicht durch aktivierte Treg therapiert werden konnte. Erst eine Behandlung mit dem humanspezifischen anti-IL-6-Antikörper Tocilizumab in vivo konnte die Erkrankung der Tiere deutlich abmildern.rnIm zweiten Modell wurden immundefiziente Mäuse mit humanen CD34+ Blutstammzellen immunologisch rekonstituiert. Diese Tiere entwickelten ein nahezu vollständig humanes Immunsystem. Die Immunisierung mit dem murinen Myelin-Oligodenrozyten-Glykoprotein löste in den humanisierten Mäusen eine MS-ähnliche Autoimmunität aus. Die Neuroinflammation wurde durch humane T- und B-Zellen vermittelt, korrelierte mit erhöhter IL-17-Produktion und führte zu einer IL-6-abhängigen Treg-Resistenz der T-Effektorzellen. Somit eignen sich die etablierten Modelle, um zukünftig die Wirksamkeit neuer Therapeutika zur Behandlung der MS präklinisch zu testen.rn

Generation and characterisation of acute myeloid leukaemia-reactive CD4 + T cells and their potential to eliminate human leukaemia blasts in NSG mice

Acute myeloid leukaemia (AML) is a cancer of the haematopoietic system, which can in many cases only be cured by haematopoietic stem cell transplantation (HSCT) and donor lymphocyte infusion (DLI) (Burnett et al., 2011). This therapy is associated with the beneficial graft-versus-leukaemia (GvL) effect mediated by transplanted donor T and NK cells that either recognise mismatch HLA molecules or polymorphic peptides, so-called minor histocompatibility antigens, leukaemia-associated or leukaemia-specific antigens in the patient and thus eliminate remaining leukaemic blasts. Nevertheless, the mature donor-derived cells often trigger graft-versus-host disease (GvHD), leading to severe damages in patients’ epithelial tissue, mainly skin, liver and intestine (Bleakley & Riddell, 2004). Therefore, approaches for the selective mediation of strong GvL effects are needed, also in order to prevent relapse after transplantation. One promising opportunity is the in vitro generation of AML-reactive CD4+ T cells for adoptive transfer. CD4+ T cells are advantageous compared to CD8+ T cells, as HLA class II molecules are under non-inflammatory conditions only expressed on haematopoietic cells; a fact that would minimise GvHD (Klein & Sato, 2000). In this study, naive CD4+ T cells were isolated from healthy donors and were successfully stimulated against primary AML blasts in mini-mixed lymphocyte/leukaemia cell cultures (mini-MLLC) in eight patient/donor pairs. After three to seven weekly restimulations, T cells were shown to produce TH1 type cytokines and to be partially of monoclonal origin according to their TCR Vβ chain usage. Furthermore, they exhibited lytic activity towards AML blasts, which was mediated by the release of granzymes A and B and perforin. The patient/donor pairs used in this study were fully HLA-class I matched, except for one pair, and also matched for HLA-DR and -DQ, whereas -DP was mismatched in one or both alleles, reflecting the actual donor selection procedure in the clinic (Begovich et al., 1992). Antibody blocking experiments suggested that the generated CD4+ T cells were directed against the HLA-DP mismatches, which could be confirmed by the recognition of donor-derived lymphoblastoid cell lines (LCLs) electroporated with the mismatched DP alleles. Under non-inflammatory conditions primary fibroblasts did not express HLA-DP and were thus not recognised, supporting the idea of a safer application of CD4+ T cells regarding induction of GvHD. For the assessment of the biological significance of these T cells, they were adoptively transferred into NSG mice engrafted with human AML blasts, where they migrated to the bone marrow and lymphoid tissue and succeeded in eliminating the leukaemic burden after only one week. Therefore, AML-reactive CD4+ T cells expanded from the naive compartment by in vitro stimulation with primary leukaemia blasts appear to be a potent tool for DLI in HSCT patients and promise to mediate specific GvL effects without causing GvHD.

Identifizierung und Charakterisierung von Zielantigenen alloreaktiver zytotoxischer T-Zellen mittels cDNA-Bank-Expressionsklonierung in akuten myeloischen Leukämien

Allogene hämatopoetische Stammzelltransplantationen (HSZTs) werden insbesondere zur Behandlung von Patienten mit Hochrisiko-Leukämien durchgeführt. Dabei bewirken T-Zellreaktionen gegen Minorhistokompatibilitätsantigene (mHAgs) sowohl den therapeutisch erwünschten graft-versus-leukemia (GvL)-Effekt als auch die schädigende graft-versus-host (GvH)-Erkrankung. Für die Identifizierung neuer mHAgs mittels des T-Zell-basierten cDNA-Expressionsscreenings waren leukämiereaktive T-Zellpopulationen durch Stimulation naïver CD8+-T-Lymphozyten gesunder HLA-Klasse I-identischer Buffy Coat-Spender mit Leukämiezellen von Patienten mit akuter myeloischer Leukämie (AML) generiert worden (Albrecht et al., Cancer Immunol. Immunother. 60:235, 2011). Im Rahmen der vorliegenden Arbeit wurde mit diesen im AML-Modell des Patienten MZ529 das mHAg CYBA-72Y identifiziert. Es resultiert aus einem bekannten Einzelnukleotidpolymorphismus (rs4673: CYBA-242T/C) des Gens CYBA (kodierend für Cytochrom b-245 α-Polypeptid; syn.: p22phox), der zu einem Austausch von Tyrosin (Y) zu Histidin (H) an Aminosäureposition 72 führt. Das mHAg wurde von T-Lymphozyten sowohl in Assoziation mit HLA-B*15:01 als auch mit HLA-B*15:07 erkannt. Eine allogene T-Zellantwort gegen CYBA-72Y wurde in einem weiteren AML-Modell (MZ987) beobachtet, die ebenso wie in dem AML-Modell MZ529 polyklonal war. Insgesamt konnte bei drei von fünf getesteten HLA-B*15:01-positiven Buffy Coat-Spendern, die homozygot für CYBA-72H (H/H) waren, eine CYBA-72Y-spezifische T-Zellantwort generiert werden. Das von den T-Lymphozyten übereinstimmend in niedrigster Konzentration erkannte Peptid umfasste die Aminosäuren 69 - 77, wobei das homologe Peptid aus CYBA-72H auch in hohen Konzentrationen keine Reaktivität auslöste. Eine reziproke Immunogenität des mHAg ist bislang nicht belegt. T-Lymphozyten gegen CYBA-72Y erkannten Leukämiezellen bei acht von zwölf HLA-B*15:01-positiven Patienten (FAB-Subtypen: M1, M2, M4, M5). Da das Gen CYBA für eine Komponente des mikrobiziden Oxidasesystems von phagozytierenden Zellen kodiert, ist es überwiegend in Zellen des hämatopoetischen Systems exprimiert. Von Leukozytensubtypen, aufgereinigt aus HLA-B*15:01-positiven Buffy Coat-Spendern mit CYBA-242T-Allel, wurden Monozyten und daraus abgeleitete dendritische Zellen durch CYBA-72Y-reaktive T-Lymphozyten sehr stark, untransformierte B-Zellen in weit geringerem Maße und Granulozyten sowie T-Lymphozyten nicht erkannt. Das für CYBA-72Y kodierende Allel CYBA-242T wurde bei 56% aller getesteten gesunden Spender und Malignompatienten (n=481) nachgewiesen. Unter Berücksichtigung der Häufigkeit des präsentierenden HLA-Allels ist davon auszugehen, dass etwa 4,5% der Kaukasier das mHAg CYBA-72Y zusammen mit HLA-B*15:01 tragen. Nach bisherigen Beobachtungen führt ein immunogener CYBA-72Y-Mismatch bei allogenen HSZTs nicht notwendigerweise zu einer schweren GvH-Erkrankung. Das hier beschriebene mHAg CYBA-72Y erscheint potenziell geeignet, im Rahmen einer allogenen HSZT die präferenzielle Elimination der Empfänger-Hämatopoese unter Einschluss von myeloischen Leukämiezellen zu bewirken. Jedoch sind weiterführende Untersuchungen erforderlich, um die therapeutische Relevanz des Antigens zu belegen.

Safety and therapeutic efficacy of adoptive p53-specific T cell antigen receptor (TCR) gene transfer

Immunotherapy with T cells genetically modified by retroviral transfer of tumor-associated antigen (TAA)-specific T cell receptors (TCR) is a promising approach in targeting cancer. Therefore, using a universal TAA to target different tumor entities by only one therapeutic approach was the main criteria for our TAA-specific TCR. Here, an optimized (opt) αβ-chain p53(264-272)-specific and an opt single chain (sc) p53(264-272)-specific TCR were designed, to reduce mispairing reactions of endogenous and introduced TCR α and TCR β-chains, which might lead to off-target autoimmune reactions, similar to Graft-versus-host disease (GvHD). rnIn this study we evaluated the safety issues, which rise by the risk of p53TCR gene transfer-associated on/off-target toxicities as well as the anti-tumor response in vivo in a syngeneic HLA-A*0201 transgenic mouse model. We could successfully demonstrate that opt sc p53-specific TCR-redirected T cells prevent TCR mispairing-mediated lethal off-target autoimmunity in contrast to the parental opt αβ-chain p53-specific TCR. Since the sc p53-specific TCR proofed to be safe, all further studies were performed using sc p53-specific TCR redirected T cells only. Infusion of p53-specific TCR-redirected T cells in Human p53 knock-in (Hupki) mice after lymphodepletion-preconditioning regimen with either sublethal body irradiation (5Gy) or chemotherapy (fludarabine and cyclophosphamide) in combination with vaccination (anti-CD40, CpG1668 and p53(257-282) peptide) did not result in a depletion of hematopoietic cells. Moreover, adoptive transfer of high numbers of p53-specific TCR-redirected T cells in combination with Interleukin 2 (IL-2) also did not lead to toxic on-target reactions. The absence of host tissue damage was confirmed by histology and flow cytometry analysis. Furthermore, p53-specific TCR-redirected T cells were able to lyse p53+A2.1+ tumor cells in vitro. However, in vivo studies revealed the potent suppressive effect of the tumor microenvironment (TME) mediated by tumor-infiltrating myeloid-derived suppressor cells (MDSC). Accordingly, we could improve an insufficient anti-tumor response in vivo after injection of the sc p53-specific TCR-redirected T cells by additional depletion of immunosuppressive cells of the myeloid lineage.rnTogether, these data suggest that the optimized sc p53(264-272)-specific TCR may represent a safe and efficient approach for TCR-based gene therapy. However, combinations of immunotherapeutic strategies are needed to enhance the efficacy of adoptive cell therapy (ACT)-mediated anti-tumor responses.

Einfluss des Treg-Aktivierungsmarkers GARP auf die Differenzierung und Funktion von T-Zellen

CD4+CD25+FoxP3+ regulatorische T-Zellen (Treg) spielen eine essentielle Rolle bei der Unterdrückung von schädlichen Immunreaktionen. Da aktivierte CD4+ T-Helferzellen auch CD25 und FoxP3 exprimieren, können diese nicht als spezifische Marker zur Identifikation von Treg verwendet werden. Die Analyse der Membranproteinexpression beider Populationen führte zur Identifikation von GARP (glycoprotein A repetitions predominant) als spezifischer Marker auf aktivierten Treg. GARP bindet LAP und TGF-beta, welches für die Unterdrückung von entzündlichen T-Zellantworten von Bedeutung ist. Um die Funktion von GARP unabhängig von Treg zu untersuchen, wurde ein lösliches GARP Protein (sGARP) synthetisiert und sein Effekt auf die Aktivierung und Differenzierung von humanen T-Zellen untersucht. Die Ergebnisse zeigen, dass sGARP die Proliferation von naiven CD4+ T-Zellen supprimiert und zu einer Phosphorylierung von SMAD2/3 sowie zu der Induktion von FoxP3 führt. Zusätzlich inhibiert sGARP die Produktion von Effektorzytokinen wie IL-2 und IFN-gamma. Die Stimulation von naiven CD4+ T-Zellen mit sGARP induziert die Differenzierung zu Treg, welche in Kokultur die Aktivierung von T-Effektorzellen supprimieren. Die Wirkung war vergleichbar in naiven CD4+ und ruhenden CD4+CD45RA+ T-Zellen, konnte aber in differenzierten CD4+CD45RO+ T-Zellen nicht nachgewiesen werden. Die Induktion von FoxP3 und die Phosphorylierung von SMAD2/3 konnte durch eine Blockade des TGF-beta-Signalweges inhibiert werden. Dies lässt vermuten, dass die Funktion von sGARP zumindest teilweise von TGF-beta abhängig ist. Zusätzlich zu seiner passiven Rolle als TGF-beta-Transporter, induzierte sGARP die TGF-beta-Produktion in naiven T-Zellen und trägt so zum Mechanismus der infektiösen Toleranz bei. Des Weiteren fördert die Stimulation von sGARP in Anwesenheit von IL-6 und IL-23 die Differenzierung zu Th17 Zellen. rnNeben dem Einfluss von sGARP auf die Differenzierung von CD4+ T-Zellen, supprimiert sGARP die Proliferation und Granzyme B-Expression in CD8+ T-Zellen. rnFür die Analyse der immunmodulatorischen Funktion von sGARP in vivo wurde ein Modell einer xenogenen GvHD (graft-versus-host disease) verwendet. Der Transfer von humanen PBMC in neugeborene, immundefiziente Rag2-/-gamma-chain-/--Mäuse führt zu einer letalen GvHD, welche durch die Applikation von humanen Treg dosisabhängig unterdrückt werden kann. In diesem Modell konnte die repetitive Gabe von sGARP, ohne zusätzliche Zugabe von Treg, ebenfalls die GvHD unterdrücken. Dies lässt auf einen synergistischen Effekt von sGARP und Treg bei der Suppression inflammatorischer T-Zellantworten schließen. rnZusammengefasst lassen die Ergebnisse auf eine entscheidende Rolle von GARP in der Modulation der peripheren Toleranz folgern und zeigen sGARP als potentes Biological für die Behandlung von unerwünschten inflammatorischen Immunantworten.

Survey of aspergillosis in non-neutropenic patients in Swiss teaching hospitals

Clin Microbiol Infect ABSTRACT: Invasive aspergillosis (IA) is a live-threatening opportunistic infection that is best described in haematological patients with prolonged neutropenia or graft-versus-host disease. Data on IA in non-neutropenic patients are limited. The aim of this study was to establish the incidence, disease manifestations and outcome of IA in non-neutropenic patients diagnosed in five Swiss university hospitals during a 2-year period. Case identification was based on a comprehensive screening of hospital records. All cases of proven and probable IA were retrospectively analysed. Sixty-seven patients were analysed (median age 60 years; 76% male). Sixty-three per cent of cases were invasive pulmonary aspergillosis (IPA), and 17% of these were disseminated aspergillosis. The incidence of IPA was 1.2/10?000 admissions. Six of ten cases of extrapulmonary IA affected the brain. There were six cases of invasive rhinosinusitis, six cases of chronic pulmonary aspergillosis, and cases three of subacute pulmonary aspergillosis. The most frequent underlying condition of IA was corticosteroid treatment (57%), followed by chronic lung disease (48%), and intensive-care unit stays (43%). In 38% of patients with IPA, the diagnosis was established at autopsy. Old age was the only risk factor for post-mortem diagnosis, whereas previous solid organ transplantation and chronic lung disease were associated with lower odds of post-mortem diagnosis. The mortality rate was 57%.

The Effect Of Osteoprotection On Immune Reconstitution Post Bone Marrow Transplant

Specialized microenvironments have been known to strongly influence stem cell fate in hematopoiesis. The interplay between osteolineage cells, specifically the mature osteoblast, and the hematopoietic stem cell (HSC) niche have been of particular note. Recently, preliminary unpublished data obtained in the Scadden laboratory suggests the critical role of the osteoblast in regulating T cells. The goal of this project was to initially determine whether stimulating the osteoblast in the HSC niche leads to increased immune reconstitution after hematopoietic stem cell transplant (HSCT). These results indicated that while bone manipulation pre-transplant may have a positive effect on T and B lymphocyte cell recovery, bone manipulation post-transplant seems to have a suppressing effect. Additionally, stimulation of the osteoblast may have an inhibitory effect on the regeneration of GR1+ myeloid cells. Based on these results, we then sought to determine how osteoprotection pre-HSCT modifies the kinetics of graft-versus-host disease (GVHD) and impacts the regeneration of immune cells. The data from this phase of my experiment suggests a possible immediate benefit in stimulation of the osteoblast in response to GVHD prior to HSCT. The overall results from my thesis project demonstrate a promising relationship between pre-HSCT stimulation of the osteoblast and lymphocyte recovery post-HSCT. ¿

ABO blood group incompatible haematopoietic stem cell transplantation and xenograft rejection

The current organ shortage in transplantation medicine stimulates the exploration of new strategies to expand the donor pool including the utilisation of living donors, ABO-incompatible grafts, and xenotransplantation. Preformed natural antibodies (Ab) such as anti-Gal or anti-A/B Ab mediate hyperacute graft rejection and thus represent a major hurdle to the employment of such strategies. In contrast to solid organ transplantation (SOT), ABO blood group incompatibilities are of minor importance in haematopoietic stem cell transplantation (HSCT). Thus, ABO incompatible HSCT may serve as an in vivo model to study carbohydrate antigen (Ag)-mismatched transplantations such as ABO-incompatible SOT or the effect of preformed Ab against Gal in xenotransplantation. This mini-review summarises our clinical and experimental studies performed with the support of the Swiss National Science Foundation program on Implants and Transplants (NFP-46). Part 1 describes data on the clinical outcome of ABO-incompatible HSCT, in particular the incidence of several immunohaematological complications, acute graft-versus-host-disease (GvHD), and the overall survival. Part 2 summarises the measurements of anti-A/B Ab in healthy blood donors and ABO-incompatible HSCT using a novel flow cytometry based method and the potential mechanisms responsible for the loss of anti-A/B Ab observed following minor ABO-incompatible HSCT, ie the occurrence of humoral tolerance. Part 3 analyses the potential of eliminating Gal expression as well as specific complement inhibitors such as dextran sulfate and synthetic tyrosine analogues to protect porcine endothelial cells from xenoreactive Ab-mediated damage in vitro and in a hamster-to-rat heart transplantation model. In conclusion, due to similarities of the immunological hurdles of ABO incompatible transplantations and xenotransplantation, the knowledge obtained from both fields might lead to new strategies to overcome humoral rejection in transplantation.

Infection prevention strategies in a stem cell transplant unit: impact of change of care in isolation practice and routine use of high dose intravenous immunoglobulins on infectious complications and transplant related mortality

OBJECTIVE: Nursing in 'live islands' and routine high dose intravenous immunoglobulins after allogeneic hematopoietic stem cell transplantation were abandoned by many teams in view of limited evidence and high costs. METHODS: This retrospective single-center study examines the impact of change from nursing in 'live islands' to care in single rooms (SR) and from high dose to targeted intravenous immunoglobulins (IVIG) on mortality and infection rate of adult patients receiving an allogeneic stem cell or bone marrow transplantation in two steps and three time cohorts (1993-1997, 1997-2000, 2000-2003). RESULTS: Two hundred forty-eight allogeneic hematopoetic stem cell transplantations were performed in 227 patients. Patient characteristics were comparable in the three cohorts for gender, median age, underlying disease, and disease stage, prophylaxis for graft versus host disease (GvHD) and cytomegalovirus constellation. The incidence of infections (78.4%) and infection rates remained stable (rates/1000 days of neutropenia for sepsis 17.61, for pneumonia 6.76). Cumulative incidence of GvHD and transplant-related mortality did not change over time. CONCLUSIONS: Change from nursing in 'live islands' to SR and reduction of high dose to targeted IVIG did not result in increased infection rates or mortality despite an increase in patient age. These results support the current practice.

Transfusion efficacy of apheresis platelet concentrates irradiated at the day of transfusion is significantly superior compared to platelets irradiated in advance.

BACKGROUND Gamma irradiation is currently the standard care to avoid transfusion-associated graft-versus-host disease. Guidelines on gamma irradiation of blood components state that platelets (PLTs) can be irradiated at any stage in their 5-day storage and can thereafter be stored up to their normal shelf life of 5 days after collection. In this study, we explored whether the timing of irradiation has an effect on transfusion efficacy of apheresis PLT concentrates (APCs). METHODS Based on the 1-hour percent PLT recovery (PPR1h), transfusion efficacy of 1,000 eligible APCs transfused to 144 children were evaluated retrospectively. PPR1h was compared in transfused APCs irradiated at the day of transfusion and APCs irradiated in advance. RESULTS In univariate analysis, transfusion efficacy of APCs irradiated in advance was significantly lower than that of APCs irradiated at the day of transfusion (mean PPR1h 27.7 vs. 35.0%; p = 0.007). This was confirmed in multivariate analysis (p = 0.030). Compared to non-irradiated APCs, transfusion efficacy of APCs irradiated at the day of transfusion was not significantly inferior (mean difference -2.8%; 95% CI -6.1 to 0.5%; p = 0.092), but APCs irradiated in advance were clearly less efficient (mean difference -8.1%; 95% CI -12.2 to -4.0%; p < 0.001). CONCLUSION Our data strongly support that APCs should not be irradiated in advance, 1.e., ≥24 h before transfusion.

Apoptotic enteropathy caused by antimetabolites and TNF-α antagonists.

AIMS To investigate whether drugs others than mycophenolic acid and ipilimumab might cause graft-versus-host-like apoptotic enteropathy, the clinicopathological findings in four patients were examined who had developed watery diarrhoea and apoptotic enteropathy (three cases from colon and one case from ileal pouch) after intake of antimetabolites (methotrexate and capecitabine) and/or tumour necrosis factor-α inhibitors (etanercept and infliximab). METHODS The clinical charts, endoscopy reports and intestinal biopsies from all endoscopies were reviewed for all patients. Biopsies were evaluated semiquantitatively for apoptosis of basal crypts, dilated damaged crypts, defined as cystically dilated crypts with flattened degenerated epithelium containing apoptotic debris and few neutrophils, and mucosal architecture. Further, the presence of intraepithelial lymphocytes, chronic inflammatory cells in the lamina propria and mucosal ulcerations was recorded and immunohistochemical analysis for human cytomegalovirus and herpes simplex virus was performed. RESULTS Endoscopic examination revealed normal mucosa in two patients, whereas the other two showed focal ulcerations. Histological changes included increased apoptosis of basal crypts, the presence of dilated damaged crypts and architecture distortion. In all cases, a temporal association between drug intake and/or dose increase, and onset of diarrhoea, was observed, and no convincing evidence of other potentially underlying causes of colitis/enteritis was found, including infections. CONCLUSIONS Pathologists should be aware of the expanding spectrum of drugs that can cause apoptotic enteropathy, including antimetabolites and tumour necrosis factor-α inhibitors.

Outcome of aplastic anaemia in children. A study by the severe aplastic anaemia and paediatric disease working parties of the European group blood and bone marrow transplant.

This study analysed the outcome of 563 Aplastic Anaemia (AA) children aged 0-12 years reported to the Severe Aplastic Anaemia Working Party database of the European Society for Blood and Marrow Transplantation, according to treatment received. Overall survival (OS) after upfront human leucocyte antigen-matched family donor (MFD) haematopoietic stem cell transplantation (HSCT) or immunosuppressive treatment (IST) was 91% vs. 87% (P 0·18). Event-free survival (EFS) after upfront MFD HSCT or IST was 87% vs. 33% (P 0·001). Ninety-one of 167 patients (55%) failed front-line IST and underwent rescue HSCT. The OS of this rescue group was 83% compared with 91% for upfront MFD HSCT patients and 97% for those who did not fail IST up-front (P 0·017). Rejection was 2% for MFD HSCT and HSCT post-IST failure (P 0·73). Acute graft-versus-host disease (GVHD) grade II-IV was 8% in MFD graft vs. 25% for HSCT post-IST failure (P < 0·0001). Chronic GVHD was 6% in MFD HSCT vs. 20% in HSCT post-IST failure (P < 0·0001). MFD HSCT is an excellent therapy for children with AA. IST has a high failure rate, but remains a reasonable first-line choice if MFD HSCT is not available because high OS enables access to HSCT, which is a very good rescue option.

Lymph node stromal cells negatively regulate antigen-specific CD4+ T cell responses

Lymph node (LN) stromal cells (LNSCs) form the functional structure of LNs and play an important role in lymphocyte survival and the maintenance of immune tolerance. Despite their broad spectrum of function, little is known about LNSC responses during microbial infection. In this study, we demonstrate that LNSC subsets display distinct kinetics following vaccinia virus infection. In particular, compared with the expansion of other LNSC subsets and the total LN cell population, the expansion of fibroblastic reticular cells (FRCs) was delayed and sustained by noncirculating progenitor cells. Notably, newly generated FRCs were preferentially located in perivascular areas. Viral clearance in reactive LNs preceded the onset of FRC expansion, raising the possibility that viral infection in LNs may have a negative impact on the differentiation of FRCs. We also found that MHC class II expression was upregulated in all LNSC subsets until day 10 postinfection. Genetic ablation of radioresistant stromal cell-mediated Ag presentation resulted in slower contraction of Ag-specific CD4(+) T cells. We propose that activated LNSCs acquire enhanced Ag-presentation capacity, serving as an extrinsic brake system for CD4(+) T cell responses. Disrupted function and homeostasis of LNSCs may contribute to immune deregulation in the context of chronic viral infection, autoimmunity, and graft-versus-host disease.

Drug Hypersensitivity: How Drugs Stimulate T Cells via Pharmacological Interaction with Immune Receptors.

Small chemicals like drugs tend to bind to proteins via noncovalent bonds, e.g. hydrogen bonds, salt bridges or electrostatic interactions. Some chemicals interact with other molecules than the actual target ligand, representing so-called 'off-target' activities of drugs. Such interactions are a main cause of adverse side effects to drugs and are normally classified as predictable type A reactions. Detailed analysis of drug-induced immune reactions revealed that off-target activities also affect immune receptors, such as highly polymorphic human leukocyte antigens (HLA) or T cell receptors (TCR). Such drug interactions with immune receptors may lead to T cell stimulation, resulting in clinical symptoms of delayed-type hypersensitivity. They are assigned the 'pharmacological interaction with immune receptors' (p-i) concept. Analysis of p-i has revealed that drugs bind preferentially or exclusively to distinct HLA molecules (p-i HLA) or to distinct TCR (p-i TCR). P-i reactions differ from 'conventional' off-target drug reactions as the outcome is not due to the effect on the drug-modified cells themselves, but is the consequence of reactive T cells. Hence, the complex and diverse clinical manifestations of delayed-type hypersensitivity are caused by the functional heterogeneity of T cells. In the abacavir model of p-i HLA, the drug binding to HLA may result in alteration of the presenting peptides. More importantly, the drug binding to HLA generates a drug-modified HLA, which stimulates T cells directly, like an allo-HLA. In the sulfamethoxazole model of p-i TCR, responsive T cells likely require costimulation for full T cell activation. These findings may explain the similarity of delayed-type hypersensitivity reactions to graft-versus-host disease, and how systemic viral infections increase the risk of delayed-type hypersensitivity reactions.