Francisca A. Neethling

Delayed xenograft rejection of pig-to-baboon cardiac transplants after cobra venom factor therapy

BACKGROUND This study sought to (i) investigate the efficacy of cobra venom factor (CVF) in preventing hyperacute rejection (HAR) after pig-to-baboon heart transplantation, (ii) examine the effect of additional splenectomy (Spx) and pharmacologic immunosuppression (IS), and (iii) study delayed graft rejection when HAR is avoided by complement depletion. METHODS Eleven recipient baboons received heterotopic pig heart transplants. Three received either no therapy or IS (cyclosporine + methylprednisolone +/- cyclophosphamide +/- methotrexate) at clinically well-tolerated doses, with graft survival for only 40, 32, and 15 min, respectively. Two received CVF+/-Spx, which extended survival to 5 and 6 days, respectively. Six underwent Spx + CVF therapy + IS; graft survival was 3 hr (technical complication), 6 days (death from sepsis), 10, 12, and 22 days (vascular rejection), and <25 days (euthanized for viral pneumonia with a functioning graft that showed histopathologic features of vascular rejection). RESULTS Dense deposition of IgM and, to a lesser extent, IgG and IgA were seen on the endothelial cells within 1 hr of transplantation, but only trace levels of complement deposition were present in CVF-treated recipients. Within approximately 5-12 days, cardiac xenografts showed progressive infiltration by mononuclear cells, consisting primarily of activated macrophages producing tumor necrosis factor-alpha and small numbers of natural killer cells; T and B cells were absent. CONCLUSIONS We conclude that (i) CVF prevents HAR, (ii) the addition of Spx + IS delays rejection, but (iii) the early deposition of antibody leads to progressive graft injury, resulting in (iv) delayed vascular rejection. Our findings indicate that the features of delayed xenograft rejection described in small animal models also occur in the pig-to-baboon model, and that rejection may occur in a complement-independent manner from the effects of antibody and/or host macrophages.

EVIDENCE THAT INTRAVENOUSLY ADMINISTERED α-GALACTOSYL CARBOHYDRATES REDUCE BABOON SERUM CYTOTOXICITY TO PIG KIDNEY CELLS (PK15) AND TRANSPLANTED PIG HEARTS

Methods of inhibiting the hyperacute antibody-mediated rejection that occurs when pig organs are transplanted into primates have been investigated using the baboon as a potential recipient. Baboons were treated with different regimens that included combinations of (1) splenectomy, (2) pharmacologic immunosuppression (CsA, cyclophosphamide, corticosteroids +/- methotrexate), and (3) intravenous infusion of oligosaccharides. The cytotoxicity of the serum was then assessed on cultures of pig kidney cells (PK15). Unmodified serum caused approximate 65-100% pig cell destruction. Splenectomy and/or pharmacologic immunosuppression, and infusions of dextran, dextrose or mannitol, did not result in any reduction of cytotoxicity. Infusions of melibiose and/or arabinogalactan, both of which have terminal non-reducing alpha-galactose, however, decreased relative PK15 cell damage significantly in a dose-dependent manner. At high concentrations (< or = 50 g/hr), complete inhibition of cytotoxicity was achieved in 4 of 15 baboons. The extracorporeal immunoadsorption of baboon serum utilizing immunoaffinity columns of melibiose also resulted in a significant reduction (of approximately 80%) in cytotoxic effect. In 1 baboon, melibiose and arabinogalactan infusion delayed vascular rejection of a pig cardiac xenograft from 10 min to about 12 hr, at which time the baboon died from the toxic effects of the carbohydrate infusion. These observations (1) add further support to the role that anti-alpha-galactosyl antibodies play in the hyperacute rejection of pig tissues transplanted into primates, and (2) demonstrate that serum cytotoxicity can be reduced by the intravenous infusion of alpha-galactosyl oligosaccharides or by extracorporeal immunoadsorption using these carbohydrates.

In vivo immunoadsorption of antipig antibodies in baboons using a specific Gal(alpha)1-3Gal column.

The major role of anti-alphaGal antibodies in the hyperacute rejection of pig organs by humans and baboons has been clearly demonstrated. Spacered alpha-galactose disaccharide (Gal(alpha1)-3Gal) hapten was produced by chemical synthesis and covalently attached to a flexible, hydrophilic polymer (PAA), which in turn was covalently coupled to macroporous glass beads, forming an immunoadsorbent that is mechanically and chemically stable and can be sterilized. The extracorporeal immunoadsorption (EIA) of anti-alphaGal antibodies using this column has been investigated in vivo in 3 baboons. In Baboon 1 (which had hyperacutely rejected a pig heart transplant 4 months previously, was not splenectomized, and did not receive any pharmacologic immunosuppression) the levels of anti-alphaGal antibody and antipig IgM and IgG, as well as serum cytotoxicity, fell significantly after each of 3 EIAs but were not eliminated. Serum cytotoxicity, antipig immunoglobulin and anti-alphaGal antibody rose steeply within 24 hr of the final EIA, suggesting that the return of cytotoxicity was associated with anti-alphaGa1 antibody. In Baboons 2 and 3 (which were immunologically naive and splenectomized, and received triple drug immunosuppressive therapy) serum cytotoxicity was totally eliminated and anti-alphaGal antibody and antipig IgM and IgG levels were greatly reduced by courses of EIA. In Baboon 2, cytotoxicity and all antibody levels remained negligible for approximately one week after the final (fourth) daily EIA. In Baboon 3, cytotoxicity and antibody levels were maintained low by intermittent EIA (over a period of 13 days) for almost 3 weeks, although antipig IgM began to rebound 4 days after the final EIA. We conclude that, in an immunosuppressed, splenectomized baboon, repeated EIA using a specific alphaGal disaccharide column will reduce antipig and anti-alphaGal antibody levels and serum cytotoxicity significantly for several days. This reduction in cytotoxicity will almost certainly be sufficient to delay the hyperacute rejection of a transplanted pig organ, but further studies are required to investigate whether it will be sufficient to allow accommodation to develop.

Intravenous infusion of Galα1-3Gal oligosaccharides in baboons delays hyperacute rejection of porcine heart xenografts

BACKGROUND Hyperacute rejection (HAR) of pig-to-primate discordant xenografts is caused by the deposition of preexisting natural antibodies that recognize Galalpha1-3Gal (alphaGal)-terminating oligosaccharides on glycoproteins and glycolipids, followed by complement-mediated lysis of the grafts endothelium. In vitro, these natural xenoantibodies can be blocked by alphaGal-containing oligosaccharides. We undertook in vivo pig-to-baboon cardiac xenotransplantation experiments to evaluate free oligosaccharides as inhibitors of HAR. METHODS Initial 15-min intravenous infusions of alphaGal-oligosaccharides into baboons were used to measure pharmacokinetic parameters, and to assess the extent of neutralization of anti-alphaGal antibody activity. AlphaGal trisaccharide (Galalpha1-3Galbeta1-4GlcNAc) or pentasaccharide (Galalpha1-3Galbeta1-4GlcNAcbeta1-3Galbeta1-4Glc ) was administered at 0.5 mmol/kg into baboons. Next, two baboons that received porcine heterotopic heart xenografts were continuously infused with alphaGal pentasaccharide for 4-5 hr, maintaining the serum oligosaccharide concentration in the millimolar range. RESULTS Pharmacokinetic analysis indicated that the oligosaccharides were rapidly cleared from the blood, with a serum half-life of 50 min. In the period during which blood oligosaccharide concentration was above 1 mM, as determined by high-pressure liquid chromatography, the serum cytotoxic activity against porcine cells was completely abolished. HAR of the xenograft was inhibited during the infusions, although there was some histological and immunohistological evidence of antibody-mediated injury on biopsies taken at the end of this period. CONCLUSIONS Intravenous alphaGal oligosaccharides, by inhibiting anti-alphaGal antibody activity, delay but do not abolish the onset of HAR.

Protection of pig kidney (PK15) cells from the cytotoxic effect of anti-pig antibodies by alpha-galactosyl oligosaccharides.

Anti-pig antibodies in human and baboon serum are believed to be directed against α-galactosyl (αGal) epitopes expressed on various pig cells, including vascular endothelia. We have investigated the effect of human sera on the PK15 pig kidney cell line, which abundantly expresses αGal epitopes. To quantitate cell viability, we have used a staining method that differentiates live cells from dead ones. Various carbohydrates (n=28) were added individually to serum at concentrations of 0.125–50 mg/ml. Unmodified serum caused approximate 100% PK15 cell death within 60 min. Carbohydrates that were not αGal based did not significantly protect PK15 cells. Of the αGal-based carbohydrates, only B disaccharide protected PK15 cells from both human and baboon serum (76% and 93% protection, respectively, at 1 mg/ml). Three αGal oligosaccharides provided approximately 80–90% protection against both human and baboon sera at a concentration of 10 mg/ml. Three other closely related structures protected only against baboon serum (> 80%) at high concentration (50 mg/ml), suggesting a difference in anti-pig antibody affinity between baboon and man. Specific anti-αGal antibody-depleted serum caused < 10% pig cell death, whereas the antibodies eluted from the αGal columns caused > 70% pig cell death. In conclusion, this study provides further evidence that (1) αGal structures are the targets for human and baboon anti-pig antibodies, and (2) there may be a therapeutic role for the infusion of specific αGal carbohydrates, or for antibody removal using αGal immunoaffinity columns, in order to prevent hyperacute rejection of pig organs in man.

Detection, immunoabsorption, and inhibition of cytotoxic activity of anti‐αGal antibodies using newly developed substances with synthetic Gal α1–3Gal disaccharide epitopes

Abstract: The presence of naturally occurring anti‐Galα1–3Gal (anti‐αGal) antibodies in human serum is believed to be a major factor in the hyperacute rejection of discordant organ xenografts such as the pig‐to‐human combination. Galα1–3Gal epitopes are expressed on pig tissues and the binding of anti‐αGal leads to endothelial cell activation and complement‐mediated, hyperacute graft rejection. One possible method to overcome this problem is to absorb anti‐αGal antibodies from the plasma of the xenograft recipient using a suitable immunoabsorbent or to interfere with their binding to tissues and thus prevent their cytotoxic activity by the intravenous injection of soluble antigen. We describe here the use of new synthetic antigens containing the Galα1–3Gal disaccharide (Bdi) epitope. Soluble conjugates of the Bdi with polyacrylamide (PAA‐Bdi) were used as coating antigens for an anti‐αGal ELISA as well as for in vitro inhibition of the cytotoxicity of anti‐αGal. An immunoabsorbent consisting of PAA‐Bdi coupled to macroporous glass (Sorbent Bdi) was tested for absorption of anti‐αGal from human serum.

Pharmacologic immunosuppressive therapy and extracorporeal immunoadsorption in the suppression of anti-αGal antibody in the baboon

Abstract: The aim of this study was to deplete baboons of anti‐αgalactosyl (αGal] antibody and attempt to maintain depletion by pharmacologic immunosuppressive therapy (PI). In 12 experiments, involving nine baboons, repeated extracorporeal immunoadsorption (EIA) was carried out by plasma perfusion through immunoaffinity columns of synthetic αGal trisaccharide type 6. Five of the baboons were immunologically naive and four had undergone various procedures at least 6 months previously. All, however, had recovered lymphohematopoietic function and (with one exception) had levels of anti‐αGal antibody within the normal range. Eleven protocols included continuous i.v. cyclosporine (to maintain whole blood levels of approximately 1,600 ng/ml). In addition, in ten protocols, the baboon received one or more of the following drugs: cyclophosphamide (1–20 mg/kg/day), mycophenolate mofetil (70–700 mg/kg/day), brequinar sodium (1–12 mg/kg/day), prednisolone (1 mg/kg/day), melphalan (0.15–0.6 mg/kg/day), methylprednisolone (125 mg/day ×3), and antilymphocyte globulin (ATG) (50 mg/kg/day ×3). EIA was carried out on 1–9 occasions in each study and was temporarily successful in removing all antibody. When no PI was administered, antibody returned close to pre‐EIA levels within 48 hr. Cyclosporine alone delayed the rate of antibody return only slightly. While EIA was continuing on a daily or alternate day schedule, antibody levels (both IgM and IgG) were maintained at 20–45% of pre‐EIA levels. Once EIA was discontinued but PI maintained, IgM rose to 40–90% and IgG to 30–60% of pre‐EIA levels. In vitro testing demonstrated significant cytotoxicity to pig cells at these antibody levels. We conclude that i) EIA utilizing columns of αGal trisaccharide is successful in temporarily depleting baboons of anti‐αGal antibody, but ii) none of the PI regimens tested suppressed antibody production to levels which would be expected to prevent antibody‐mediated rejection of pig xenografts. Additional strategies will therefore be required if xenotransplantation is to become a clinical reality.

Variability of anti‐αGal antibodies in human serum and their relation to serum cytotoxicity against pig cells

Abstract: One of the major obstacles in pig‐to‐human xenografting is hyperacute rejection (HAR) of pig cells caused by preformed anti‐pig antibodies and complement. In 1991 we suggested that anti‐αGal antibodies play a major role in the HAR of pig cells. Anti‐αGal antibodies recognize terminal α‐galactose‐containing epitopes on glycoproteins and glycolipids. They are present in humans, apes, and Old World monkeys, but not in lower mammals such as pigs. However, pigs, unlike humans, express terminal α‐galactose epitopes on vascular endothelium which represent targets for human anti‐αGal antibodies. Despite increasing recognition that anti‐αGal antibodies are an important factor, many questions related to their precise role in HAR remain to be answered.

TRANSFER OF SWINE MAJOR HISTOCOMPATIBILITY COMPLEX CLASS II GENES INTO AUTOLOGOUS BONE MARROW CELLS OF BABOONS FOR THE INDUCTION OF TOLERANCE ACROSS XENOGENEIC BARRIERS

BACKGROUND The present study examined the potential role of gene therapy in the induction of tolerance to anti-porcine major histocompatibility complex (SLA) class II-mediated responses after porcine renal or skin xenografts. METHODS Baboons were treated with a non-myeloablative or a myeloablative preparative regimen before bone marrow transplantation with autologous bone marrow cells retrovirally transduced to express both SLA class II DR and neomycin phosphotransferase (NeoR) genes, or the NeoR gene alone. Four months or more after bone marrow transplantation, the immunological response to a porcine kidney or skin xenograft was examined. Both the renal and skin xenografts were SLA DR-matched to the transgene, and recipients were conditioned by combinations of complement inhibitors, adsorption of natural antibodies, immunosuppressive therapy, and splenectomy. RESULTS Although the long-term presence of the SLA transgene was detected in the peripheral blood and/or bone marrow cells of all baboons, the transcription of the transgene was transient. Autopsy tissues were available from one animal and demonstrated expression of the SLA DR transgene in lymphohematopoietic tissues. After kidney and skin transplantation, xenografts were rejected after 8-22 days. Long-term follow-up of control animals demonstrated that high levels of induced IgG antibodies to new non-alphaGal epitopes developed after organ rejection. In contrast, induced non-alphaGal IgG antibody responses were minimal in the SLA DR-transduced baboons. CONCLUSIONS Transfer and expression of xenogeneic class II DR transgenes can be achieved in baboons. This therapy may prevent late T cell-dependent responses to porcine xenografts, which include induced non-alphaGal IgG antibody responses.

Anti-Gal IgG antibodies in sera of newborn humans and baboons and its significance in pig xenotransplantation

We have previously demonstrated that hyperacute rejection does not occur in a pig-to-newborn baboon heart transplant model, presumably because of low levels of cytotoxic antipig antibodies present in the serum of newborn baboons. Cytotoxic antipig antibodies are primarily directed to alpha-1,3-galactosyl (alpha Gal) residues on endothelial cell surface structures Twenty-one full-term humans and 5 full-term baboons were tested for complement mediated lysis (CML) of pig kidney (PK-15) cells and anti-alpha Gal activity with an ELISA using BSA-conjugated alpha Gal residues as target. To evaluate the significance of the anti-alpha Gal titers in vivo 5 newborn baboons underwent heterotopic pig cardiac xenotransplantation. Six of 21 human samples and 1 of 5 baboon samples demonstrated significant cytotoxicity to PK-15 cells. Twelve of 21 newborn humans had anti-alpha Gal IgG antibodies at titers of 1:80 or greater. None of the samples had anti-alpha Gal IgM. In newborn baboons, 1 of 5 sera had anti-alpha Gal IgG antibodies at titers greater than 1:80 and none of these samples had anti-alpha Gal IgM. Xenografts survived for an average of 3.6 days, even in the baboon with high anti-alpha Gal IgG titers. Analysis of the explanted grafts showed minimal evidence of complement-mediated hyperacute rejection (HAR), but prominent mononuclear cell infiltrates. In serum tested posttransplant there was an induced anti-alpha Gal response with cytotoxicity against PK-15 cells. These results show that anti-alpha Gal IgM is absent in newborn human and baboon sera, allowing pig grafts to avoid HAR. However, the presence of anti-alpha Gal IgG may be associated with mononuclear cell infiltration of the xenograft and its subsequent rejection.