Can We Predict or Induce It Are Any Approaches Ready for Prime Time A SánchezFueyo Institute of Liver Studies MRC Transplant Centre Kings College London UK Liver Biopsy Liver Biopsy ID: 544859
Download Presentation The PPT/PDF document "TOLERANCE:" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
TOLERANCE:
Can We Predict or Induce It? Are Any Approaches Ready for Prime Time?
A Sánchez-FueyoInstitute of Liver Studies, MRC Transplant Centre,King’s College London, UKSlide2
Liver Biopsy
Liver Biopsy
2
years,
etc
Stable liver function
(
Tolerant
)
Immunosuppression withdrawal
6-9 months
12 month follow-up
Withdrawal Failure
Rejection
(
Non-Tolerant
)
Stable liver function
(
Tolerant
)
Liver Biopsy
Intentional immunosuppression discontinuation in
STABLE
liver transplant recipients
Safety
Logistics & applicability
Mechanistic researchSlide3
Gene expression in liver biopsies
D
rug withdrawal
in stable recipients elicits
a transient intra-graft inflammatory response
CD4
+
FOXP3+
Treg density
Treg/CD8+ Teff ratio
Taubert
R et al. Am J Transplant 2016Slide4
European Multi-Centre Drug Withdrawal Trial in Adult Liver Transplant Recipients
102 patients enrolled
235 patients excluded Medical contraindications (139 patients) Other reasons (96 patients)497 patients screened
41 patients TOLERANT
57 patients REJECTED
4
Patients withdrawn
during weaning
160
patients
transplanted for
<3 years and excluded337 patientstransplanted
for ≥ 3 years
Benítez C, et al. Hepatology
. 2013;58(5):1824-1835.Slide5
Time
since transplantation
≤ 6 years
6-11 years
>11 years
Age
at transplantation
≤ 50 years
>50 years
13%
38%
80%
0%
38%
LOW
INTERMEDIATE
HIGH
Probability of successful immunosuppression withdrawal following adult liver transplantation
Succcessful
withdrawal
(%)
0
20
40
60
80
100
0
5
10
15
20
Time since transplantation (years)
Benitez C et al.
Am J Transplant
2010
0
% <1 year post-
Tx
Shaked
A et al.
Am J Transplant
2016; 16(
suppl
3)
13% 2 years post-
Tx
Garcia
de la Garza, et al.
Liver
Transplant
2013
63
%
9
years post-
TxSlide6
Time
≤ 6 years
6-11 years
>11 years
Age
≤ 50 years
>50 years
13%
38%
80%
0%
38%
LOW
INTERMEDIATE
HIGH
Probability of successful immunosuppression withdrawal following adult liver transplantation
Biomarker-guided immunosuppression withdrawal
Induction of
toleranceSlide7
Clinical trials at King’s College London aiming at facilitating immunosuppression withdrawal in liver transplantation
Intervention
Time after Tx
Status
ThRIL
Ex vivo
expanded polyclonal
Tregs
3
months
(6-12 months
)In progress(3 patients dosed)
Ex vivo expanded antigen-specific Tregs1 year In preparationLow
dose IL-22-6
years (age <50 years)
Scheduled
for 2017LIFTBiomarker-guided drug withdrawal
>3
years (age >50 years)>6 years (age <50 years)In
progress(38 patients
enrolled)Slide8
Biomarkers
Healthy
individuals
Stable
liver
function
Operational
toleranceStable
recipients under immunosuppression
Withdrawal
of
immunosuppressive
therapy
Failure
T
olerance
Induction of
tolerance
Spontaneous tolerance elicited by immunosuppression
withdrawal
Can we identify tolerance or predict the outcome of drug withdrawal?
Markers of immunological effectSlide9
CD3
δ1
CD3
δ2
Altered
distribution
of
circulating
γδ
T
cell
subsets
P
eripheral
blood
signatures of operational
tolerance in liver
transplantation
– γδ T cell subsetsLi et al. Am J Transplant 2004
Martínez-Llordella et al.
Am J Transplant 2007
p
=0.03
0
5
10
15
Vdelta-2 TCR+
TOL
Non-TOL
Bohne
et
al.
J
Clin
Invest
2012Slide10
Increased
NK/NKT-
related
transcriptional
markers
Martinez
-Llordella
et al.
J Clin Invest 2008Puig-Pey et al. Transplant Int 2010Shi et al. Am J Transplant 2015
Peripheral blood signatures
of operational tolerance in liver
transplantation – γδ
T
cell subsets
Shi
et al. Am J Transplant 2015Slide11
SN 82%, 53% SP, PPV 67%, NPV 73%
Bohne F. et al. Sci Transl
Med 2014Stratification of liver recipients for drug withdrawal using γδ T cell
subset
ratio
HCV-
infected
liver
recipients -- Blood Vd1/Vd2 T cell ratio Slide12
Martinez
-Llordella M et al. J Clin Invest 2008
Transcriptional signatures of tolerance in blood
Increased
NK/NKT-
related
transcriptional
markers
in bloodGene signature
Error rate training setError rate validation set
KLRF1, SLAMF 7
0.064
0.13
KLRF1, NKG7, ILR2B, KLRB1, FANCG, GNPTAB
0.032
0.17
SLAMF7, KLRF1, CLIC3, PSMD14, ALG8, CX3CR1, RGS3
0.064
0.13
Gene signatures
Li &
Sarwal
. Am J Transplant 2012Slide13
Non-TOL
TOL
Bonhe F, Martinez-Llordella M et al.
J Clin Invest
2012
Transcriptional s
ignatures
of tolerance
liver
tissue samples
Barcelona
Rome & Leuven
AUC
SN
SP PPV NPVER SN SP
PPV
NPVERCDHR2, MIF, PEBP1, SOCS1, TFRC0.8589
8680
92
13
80100100859.5Slide14
Bohne
F et al.
J Clin Invest 2012
Barcelona
Rome & Leuven
AUC
SN
SP
PPV
NPVER SN
SP PPVNPVERCDHR2, MIF, PEBP1, SOCS1, TFRC0.85
8986
80
92
1380100100859.5
Liver tissue (CDHR2, MIF, PEBP1, SOCS1, TFRC
)
PBMC
(
NCR1, PDGFRB, PSMD14)
PBMC
(SLAMF7, KLRF1, CLIC3, PSMD14, ALG8, CX3CR1, RGS3)
Sensitivity
1.0 0.8 0.6 0.4 0.2 0.0
0.0 0.2 0.4 0.6 0.8 1.0
Specificity
Prediction of drug withdrawal outcome using transcriptional signatures in blood or liver tissue
Liver tissue transcriptional signature of operational toleranceSlide15
CDHR2
, MIF, PEBP1, SOCS1,
TFRC
Liver tissue transcriptional signature of tolerance
Delta CT
Barcelona 2011
delta CT
King
’
s 2013
r=0.91
Left
lobe
Right
lobe
SOCS1
Left
lobe
Right
lobe
CDHR2
Left
lobe
Right
lobe
MIF
Left
lobe
Right
lobe
PEBP1
Left
lobe
Right
lobe
TFRCSlide16
Stratification of liver recipients for drug withdrawal using transcriptional biomarkers
King’s
Royal Free
Cambridge
Leeds
Newcastle
Edinburgh
Birmingham
Leuven
Hospital
Clinic
BarcelonaHannoverBerlinMulti-centre randomized controlled biomarker-based
clinical trial‘LIFT’ Liver Immunosuppression Free Trial
148 adult
liver recipients
>3
years post-transplant (>6 years if <50 years old)Slide17
A
WEANING
(N=74)
All patients satisfying clinical criteria will be weaned off IS irrespective of biomarker result
B
BIOMARKER
BASED WEANING
STRATEGY
N = 74Randomisation
1:1N =134+14
B+WEANING ((N~37)Patients with a positive biomarker will be weaned off IS.B- MAINTENANCE IMMUNOSUPPRESSION (N~37)
Patients with a negative biomarker test result will be informed of the result and will remain on IS.Clinical Eligibility ScreeningN = 592AWEANING ALL
STRATEGYN = 74
Diagnosis of Biomarker
~50%
Expected Biomarker +~50% Expected
Biomarker −
Stratification of liver recipients for drug withdrawal using transcriptional biomarkers
Multi
-centre
randomized controlled biomarker-based clinical trialSlide18
‘LIFT’
Liver
Immunosuppression
Free Trial
Detailed
immunophenotypic
analysis employing mass
cytometry
(
CyTOF
).Gut microbiome analysis and metabolic profiling.B cell function and alloantibody production.Extracellular vesicles as a mechanism to maintain immune tolerance. Slide19
Signatures of tolerance in liver tissue samples from HCV-infected recipients:
Type-1 IFN signaling and CD8+ T cell exhaustion
TOL
vs
Non-TOL
TOL
vs
HC
Non-TOL
vs
HC
Interferon alpha/beta signaling (
Reactome) ER phagosome pathway (Reactome)Interferon signaling (Reactome)
Autoimmune thyroid disease (KEGG)Lysosome (KEGG)Immunoregulatory interactions (Reactome)Activation of ATR in Replication Stress (
Reactome)Natural Killer Cell Mediated Cytotoxicity (KEGG)M-G1 transition (
Reactome)
Adaptive immune system (Reactome)HIV infection (Reactome)Interferon-gamma signaling (Reactome)Cell cycle checkpoints (Reactome)Graft versus host disease (KEGG)Antigen processing and presentation (KEGG)Allograft rejection (KEGG)Host interactions of HIV factors (Reactome)Antigen Processing & Cross-presentation (Reactome)Cytokine signaling in immune system (Reactome)Generation of 2nd messengers (Reactome)Toll receptor cascades (Reactome)
RNA-pol III transcription (Reactome
)TCR signaling (Reactome)Extension of Telomeres (Reactome)MHC-II Antigen Presentation(Reactome)DNA strand elongation (Reactome)Synthesis of DNA (Reactome)T Cell Signal Transduction (ST)DNA replication (KEGG)DNA replication (Reactome)Cell Cycle Mitotic (Reactome)
Liver tissue microarray gene expression
Bohne F et al.
Science Transl Med
, 2014
Type
1 interferon stimulated genes (ISG)
TOL
No- TOL
/Slide20
Bohne F et al.
Science Transl Med, 2014
TOLERANT
NON-TOLERANT
PD1
p<0.023
PDL1
p<0.023
IL10
p<0.039
BATF
p<0.032
Foxp3
p<0.038
Liver tissue
qPCR
gene expression
Signatures of tolerance in liver tissue samples from HCV-infected recipients:
Type-1 IFN
signaling
and CD8+ T cell exhaustionSlide21
‘OPTIMAL’
Evaluation of Donor Specific Immune Senescence and Exhaustion as Biomarkers of Operational Tolerance Following Liver Transplantation in Adults
Multi-centre cohort
drug
withdrawal
trial
60
adult liver recipientsChief Investigator: Jim
MarkmanSlide22
Rejection
Baseline
E
arly identification of allograft damage during weaning of immunosuppression
Bonaccorsi-Riani
et al.
Am J
Transplant
2016LIVER TISSUE
BLOOD
CXCL10 mRNATimeWeaning
Rejection
Sequential gene expression profiling in blood samples during
drug withdrawal predicts
the development of rejection in liver transplantationSlide23
Does the presence of anti
-HLA antibodies
influence the outcome of drug withdrawal?Cross-sectional retrospective studiesOhe et al. Transplantation
2014
81 patients with successful or failed weaning and mild or severe fibrosis.
39% of patients with mild fibrosis had anti-class II Abs
64% of patients with advanced fibrosis had anti-class II Abs
Wozniak et al.
Transplantation
2015Non-tolerant patients: anti-class II Abs in 61%Stable immunosuppressed: 20%Tolerant: 29%Slide24
Does the presence of anti
-HLA antibodies
influence the outcome of drug withdrawal?Prospective studiesBenitez C. et al. Hepatology 2013
31% of tolerant patients had anti-class II Abs at baseline
20% of non-tolerant patients
Feng
S. et al.
JAMA
2012
20 children LDLT recipients: no differences in anti-HLA Abs at baselineFeng S. et al. I-WITH study88 children – 29 met laboratory and histological criteria of operational tolerance: no differences in anti-HLA Abs at baseline 157 screened recipients – anti-class II was associated with the presence of interface hepatitis. Slide25
SUMMARY AND CONCLUSIONS
Both rejection and tolerance are associated with distinct
blood and liver tissue cellular
and transcriptional
signatures.
Tolerance signatures can change over time and are influenced by the underlying inflammatory status of the graft.
There is still limited information on the capacit
y of these markers to predict the outcome of drug withdrawal
.
Mechanistic insight: T cell exhaustion and iron status as permissive factors for the development of tolerance. Slide26
Marc Martinez-
Llordella
Gavin WhitehouseSotiris MastoriadisEliano RianiElisavet
Kodela
Lindsey Edwards
Elliot
Merritt
A.Sanchez
-Fueyo lab
Collaborators
A.Rimola
, H. Clinic Barcelona
M.Navasa
, H. Clinic Barcelona
MC
Londoño, H. Clinic BarcelonaE.Jaeckel, HannoverM.Berenguer, ValenciaH-D Volk, Charite BerlinP.Reinke, Charite Berlin
J.Marmann, MGH Boston
S.Feng, UCSFAJ Demetris, PittsurghJuanjo Lozano (Ciberehd, bioinformatics)Rosa Miquel (King’s liver pathology)LIFT clinical investigators
Robert
Lechler
Dominic
BoardmanHenrieta FraserQi PengKulachelvy RatnasothyPervinder SagooCristiano ScottaLesley SmythTrishan VaikunthanathanNiloufar SafiniaLaura FryKatie Lowe
Sarah Thirkell
Giovanna Lombardi lab