Arne Sattler

Depletion of autoreactive immunologic memory followed by autologous hematopoietic stem cell transplantation in patients with refractory SLE induces long-term remission through de novo generation of a juvenile and tolerant immune system

Clinical trials have indicated that immunoablation followed by autologous hematopoietic stem cell transplantation (ASCT) has the potential to induce clinical remission in patients with refractory systemic lupus erythematosus (SLE), but the mechanisms have remained unclear. We now report the results of a single-center prospective study of long-term immune reconstitution after ASCT in 7 patients with SLE. The clinical remissions observed in these patients are accompanied by the depletion of autoreactive immunologic memory, reflected by the disappearance of pathogenic anti-double-stranded DNA (dsDNA) antibodies and protective antibodies in serum and a fundamental resetting of the adaptive immune system. The latter comprises recurrence of CD31(+)CD45RA(+)CD4(+) T cells (recent thymic emigrants) with a doubling in absolute numbers compared with age-matched healthy controls at the 3-year follow-up (P = .016), the regeneration of thymic-derived FoxP3(+) regulatory T cells, and normalization of peripheral T-cell receptor (TCR) repertoire usage. Likewise, responders exhibited normalization of the previously disturbed B-cell homeostasis with numeric recovery of the naive B-cell compartment within 1 year after ASCT. These data are the first to demonstrate that both depletion of the autoreactive immunologic memory and a profound resetting of the adaptive immune system are required to reestablish self-tolerance in SLE.

Foxp3+ Helios+ regulatory T cells are expanded in active systemic lupus erythematosus

Objectives Recent data debate the suitability of Helios, an Ikaros family member, as a marker for thymic-derived regulatory T cells (Treg). Nevertheless, Foxp3+ Helios+ Treg may be of particular relevance in mediating immune tolerance in chronic autoimmunity, such as systemic lupus erythematosus (SLE), as they possess enhanced suppressive function, compared to Foxp3+ Helios− Treg. Methods Multicolour flow cytometry was performed to analyse Foxp3 and Helios expression in peripheral blood CD4 T cells from SLE patients, compared to healthy controls (HC) and systemic sclerosis (SSc) and rheumatoid arthritis (RA) patients. Cytokine production, chemokine receptor expression for CXCR3 and CCR4, basal signal transducer and activator of transcription 5 (STAT5)a phosphorylation levels and T-cell receptor (TCR) Vβ repertoire were analysed by flow cytometry, and the methylation status of the Foxp3 locus (Treg-specific demethylated region, TSDR) by real-time PCR. Results Frequencies of Foxp3+ Helios+ Treg, unlike Foxp3+ Helios− T cells, were significantly increased in SLE patients and positively correlated with disease activity, whereas they were unaltered in SSc and RA patients. Compared to HC, Foxp3+ Helios+ Treg in SLE predominantly displayed a CD45RA−/CD31−/FoxP3low memory phenotype with increased Ki-67 expression, enhanced basal pSTAT5a levels and a restricted TCR repertoire. Nonetheless, similar to HC, Foxp3+ Helios+ Treg in SLE lacked effector cytokine production, possessed a highly demethylated TSDR and expressed comparable levels of CXCR3 and CCR4. Conclusions Our data suggest that Helios-expressing Foxp3+ Treg with functional suppressive capacity and migratory potential into inflamed tissues are expanded in active SLE, presumably through γ-chain signalling cytokines and TCR stimulation, to compensate for autoreactive effector responses.

Cytokine-induced human IFN-γ–secreting effector-memory Th cells in chronic autoimmune inflammation

T-helper (Th) cells activated by cytokines in the absence of T-cell receptor ligation are suspected to participate in inflammatory processes by production of interferon-gamma (IFN-gamma). Still, the relevance of such a mechanism has not been addressed in humans. Here we demonstrate that a subset of human effector-memory Th cells expressing functional interleukin-12R (IL-12R), IL-18Ralpha, and CCR5 ex vivo can be induced to secrete IFN-gamma by cytokines signaling via the IL-2R common gamma-chain in combination with IL-12 and IL-18. Cytokine-driven IFN-gamma production depends on JAK3- and p38 mitogen-activated kinase signals and is sensitive to suppression by CD25(++) regulatory T cells. Contrary to IFN-gamma(+) Th cells induced upon antigen-specific stimulation, their cytokine-activated counterparts characteristically lack expression of costimulator 4-1BB (CD137). Strikingly, the majority of Th cells infiltrating inflamed joints of rheumatoid arthritis patients is equipped with receptors prerequisite for cytokine-induced IFN-gamma secretion. Among these cells, we detected a substantial fraction that secretes IFN-gamma directly ex vivo but lacks 4-1BB expression, indicating that cytokine-induced IFN-gamma(+) Th cells operate in autoimmune inflammation. Our data provide a rationale for how human effector-memory Thcells can participate in perpetuating inflammatory processes in autoimmunity even in the absence of T-cell receptor ligation.

Plasma Cell-Like Morphology of Th1-Cytokine-Producing Cells Associated with the Loss of CD3 Expression

Here we clarified the morphology and phenotype of interleukin (IL)-17- and interferon (IFN)-gamma-producing cells in both in vitro and in vivo situations. Oligoclonal activation of normal peripheral blood mononuclear cells with the superantigen Staphylococcus aureus enterotoxin B and polyclonal activation with phorbol myristate acetate/phytohemagglutinin were used as in vitro models. This study was extended to various in vivo situations such as rheumatoid arthritis, dermatomyositis, and normal activated lymph nodes. The phenotype of IL-17- and IFN-gamma-producing cells was evaluated by immunohistochemistry using the CD3 and CD4 T-cell markers, the CD20, CD38, kappa and lambda light chain B-cell lineage markers. The expression of two chemokine receptors, CCR6 and CCR7, involved with their associated ligands CCL20 and CCL19/CCL21 in the migration of T lymphocytes, was evaluated in tissue sections. After both polyclonal and oligoclonal activation, IL-17+ and IFN-gamma+ cells acquired a plasma cell-like morphology associated with a high secretory activity, the reduced expression of CD3, and no change of CD4 expression. In rheumatoid arthritis, dermatomyositis, and activated lymph nodes, both IL-17- and IFN-gamma-producing cells had the same morphology. These Th1 cytokine-producing cells were CD4(+)-, CD3-, and B-cell lineage marker-negative. In both in vitro and in vivo situations, expression of CCR6 or CCR7 was not associated with a particular subset. In conclusion, activated T-helper CD4(+) T cells, by their release of cytokines, seem to have functional similarities with plasma cells secreting immunoglobulins.

IL-15 dependent induction of IL-18 secretion as a feedback mechanism controlling human MAIT-cell effector functions

Mucosal‐associated invariant T (MAIT) cells are characterized by an invariant TCRVα7.2 chain recognizing microbial vitamin B metabolites presented by the MHC‐Ib molecule MR1. They are mainly detectable in the CD8+ and CD8−CD4− “double negative” T‐cell compartments of mammals and exhibit both Th1‐ and Th17‐associated features. As MAIT cells show a tissue‐homing phenotype and operate at mucosal surfaces with myriads of pathogenic encounters, we wondered how IL‐15, a multifaceted cytokine being part of the intestinal mucosal barrier, impacts on their functions. We demonstrate that in the absence of TCR cross‐linking, human MAIT cells secrete IFN‐γ, increase perforin expression and switch on granzyme B production in response to IL‐15. As this mechanism was dependent on the presence of CD14+ cells and sensitive to IL‐18 blockade, we identified IL‐15 induced IL‐18 production by monocytes as an inflammatory, STAT5‐dependent feedback mechanism predominantly activating the MAIT‐cell population. IL‐15 equally affects TCR‐mediated MAIT‐cell functions since it dramatically amplifies bacteria‐induced IFN‐γ secretion, granzyme production, and cytolytic activity at early time points, an effect being most pronounced under suboptimal TCR stimulation conditions. Our data reveal a new quality of IL‐15 as player in an inflammatory cytokine network impacting on multiple MAIT‐cell functions.

Novel approach for improved assessment of phenotypic and functional characteristics of BKV-specific T-cell immunity.

Background. BKV-associated nephropathy represents a serious complication of the posttransplant period in kidney transplant recipients. Monitoring BKV-specific immunity is of a special importance for estimation of clinical course in patients with BKV reactivation. Our recent data demonstrated that all five BKV antigens are immunogenic and elicit T-cell responses varying within patients. Therefore, all five BKV proteins should be evaluated for the assessment of BKV-specific immunity. However, analysis of five proteins performed separately is time- and cost-intensive and requires large amount of blood. Methods. Using novel approach of a mixture of overlapping peptide pools encompassing all five BKV antigens (viral protein [VP] 1, VP2, VP3, large tumor antigen, and small tumor antigen) and multiparameter flow cytometry, we evaluate BKV-specific T cells in patients with a previous/present severe long-lasting or transient BKV reactivation. Patients without BKV reactivation were used as control. Results. In this study, we show that using mixture of overlapping peptide pool results in the magnitude of CD4- and CD8-positive BKV-specific T-cell response, which is significantly higher compared with any frequencies detected by previously used single BKV antigen stimulation. Of interest, patients with a history of rapid BKV clearance had significantly higher frequency of multifunctional interferon gamma-&ggr;/interleukin (IL)-2/tumor necrosis factor-&agr; and IL-2/tumor necrosis factor-&agr; CD4-positive T cells, suggesting protective potential of polyfunctional T cells. Furthermore, we did not find IL-17-producing BKV-specific memory T cells in patients recovered from BKV reactivation. Conclusions. Here, we established a fast and sensitive approach allowing the most comprehensive assessment of the total BKV immunity performed to date and offer a new platform for further prospective studies.

Clonotype Analysis of Cytomegalovirus-Specific Cytotoxic T Lymphocytes

Cytotoxic T lymphocytes (CTL) control the replication of human cytomegalovirus (CMV). Previous studies assessed the clonotypic composition of CTL specific for individual immunodominant peptides within a certain HLA context. Such an approach has inherent limitations and may not assess the true clonal CTL response in vivo. Here, the clonotypic composition of CMV-specific CTL was determined in HLA-A2, CMV-seropositive kidney transplant recipients and healthy blood donors after stimulation of peripheral blood mononuclear cells with either a pp65 whole-peptide pool or a single immunodominant peptide. Even after stimulation with the whole peptide pool, CMV-specific CTL remained monoclonal or oligoclonal. Regarding intraindividual variation, the CDR3 motifs of the dominant clones were identical to those observed in CTL generated by the single immunodominant peptide. Sequencing of the CDR3 regions demonstrated significant interindividual variation; however, structural homology was observed for immunodominant clonotypes in three individuals. In conclusion, the highly focused T cell receptor repertoire found after stimulation with either a single immunodominant peptide or a peptide pool demonstrates a pivotal role for immunodominant epitopes in the generation of a clonal repertoire. These results provide new insights into the regulation of CMV clonal dominance and may contribute to the design and monitoring of adoptive immunotherapy.

The role of CD4+ T cells in BKV-specific T cell immunity

Abstract Reactivation of polyomavirus BK (BKV) infection represents a severe complication in kidney transplant (KTX) patients. We previously reported an association between a declining BK viral load and the reconstitution of CD4+ T cell BKV-specific immunity in patients following kidney transplantation. However, the specific contribution of CD4+ T cells in the regulation of BKV-replication is unknown. Nevertheless, in vitro enrichment of BKV-specific T cells and subsequent adoptive T cell transfer may improve the restoration of immune competence in KTX patients with BKV infection. To date, strategies to capture human BKV-specific T cells with the ensuing expansion to clinically useful numbers are lacking. Here, we demonstrated a comprehensive flow cytometric analysis of the BKV-specific T cell response that permits access to the majority of T cells specific for immunodominant BKV antigens. A full-spectrum evaluation of the BKV-specific T cell response was performed by stimulating peripheral blood mononuclear cells (PBMC) with a mixture of BKV immunodominant peptide pools at varying concentrations and measuring activation marker expression and cytokine secretion. We also examined the effects of co-stimulation and PBMC resting time prior to activation. We defined the narrow range of stimulation conditions that permit the capture and expansion of functional BKV-specific T cell lines. The generated BKV-specific T cell lines showed the highest specificity and functionality when the T cells were captured according to IFNγ-secretion. This study highlights the multifunctional and cytolytic BKV-specific CD4+ T cells as a dominant population within the generated T cell product. This method offers a novel approach for the generation of BKV-specific T cell lines for adoptive immunotherapy and underscores the critical role of CD4+ T cells in the clearance of BKV.

Comparing Humoral and Cellular Immune Response Against HBV Vaccine in Kidney Transplant Patients.

Host protection upon vaccination usually results from the complex interplay of humoral and cellular components of the immune system. Exploring hepatitis B surface antigen (HBsAg)‐specific T cell responses and their correlation with humoral responses under immunosuppression, we analyzed 51 renal transplant recipients, differing in HBV vaccine–specific antibody titers (non [NRs]‐, low [LRs]‐, and high responders [HRs]) and in 22 healthy controls (HCs) in a cross‐sectional study. HBsAg‐specific T cells were analyzed by flow cytometry according to expression of activation markers CD40L and/or CD69, and the cytokines IFNγ, IL‐2, TNFα, and IL‐17. No significant differences in responder rate and magnitude of HBsAg‐specific T cell responses were found between HCs and HRs. Interestingly, HBsAg‐specific Th‐cells were also observed in 50% of humoral NRs. Frequencies of HBsAg‐specific CD40L+ Th‐cells were significantly higher in HRs compared to LRs (p = 0.009) and in LRs in comparison to NRs (p = 0.043). All but NRs showed a predominance of multi‐potent HBsAg‐specific TNFα+IL‐2+ Th‐cells. As expected, HBsAg‐specific CD8+ T cells were rarely found. In conclusion, mounting of hepatitis B vaccine‐specific T cell responses is possible in kidney transplant recipients despite immunosuppression. Detection of HBV‐specific Th‐cells in a significant proportion of humoral NRs contributes to the current discussion on conferring immune protection by cellular memory in such patients.

MODIFICATION OF IMMUNOSUPPRESSION CAN ENHANCE THE RECONSTITUTION OF BKV-SPECIFIC IMMUNITY PREVENTING GRAFT FAILURE DUE TO BKV-ASSOCIATED NEPHROPATHY IN RENAL TRANSPLANT PATIENTS: 1889

Introduction: Due to the lack of an effective specific treatment for active BKV infection/BKVAN, early detection of BKV reactivation and reduction/modification of immunosuppressive regimen is the only proven option preventing graft loss. However, the optimal immunosuppressive regimen for this pre-emptive approach has not been identified so far. Cellular immune system is known to play a very important role in the control of BK viral replication. Some previous data on viral load and a recent in vitro study on BKVspecific cellular immunity suggest that immunosuppressive therapy with low-dose ciclosporin leads to more favorable outcome in BKV infection/BKVAN. Methods: Therefore, we performed a retrospective/ prospective study on 21 renal transplant patients with sustained BK viremia treated by a modification of immunosuppressive regimen (switch FK to CsA +/switsch MMF to AZA). 14 and 7 transplant patients were analyzed in retrospective and prospective manner, respectively. Monitoring of BK load in serum by real-time PCR was performed monthly for all study patients. In parallel, BKV-specific T cells were analyzed by multicolor flow cytometry/elispot in 7 patients. Results: following modification of immunosuppressive regimen, 10 out of 21 patients showed normalization of viral load/renal function within 4-10 weeks. None of the patients developed BKVAN or acute rejection. In 11 other patients, low-dose cidofovir therapy was added, since now therapeutic response was achieved within 10 weeks (two patients were treated additionally with IVIG or leflunomide due to non-response to cidofovir). Complete therapeutic response measured by normalization of BKV load and stabilization of graft function in these 11 patients was achieved within 14 to 48 weeks. Interestingly, analysis of BKV-specific T cells and BKV load revealed a clear correlation between viral load and BKV-immunity showing decrease/ normalization of BKV load immediately upon reconstitution of BKV-T cell responses, independently from additionally applied therapeutic regimen. Conclusion: Our data demonstrate that modification of immunosuppression used in our study represents an effective and safe approach preventing graft failure due to BKVAN. In addition, normalization of BK load was associated with reconstitution of functional activity of BKV-specific T cells independently of the applied adjuvants. Since normalization of BKV immunity can be considered as a result of diminished T cell inhibition achieved by switching to lowdose ciclosporin-based immunsosuppressive regimen, we suggest that the positive outcome demonstrated in our study can be mainly addressed to the applied immunosuppressive modifications. Further prospective studies are required in order to prove our observations.