Regulatory T cells for minimising immune suppression in kidney transplantation: phase I/IIa clinical trial
Andy Roemhild, Natalie Maureen Otto, Guido Moll, Mohamed Abou-El-Enein, Daniel Kaiser, Gantuja Bold, Thomas Schachtner, Mira Choi, Robert Oellinger, Sybille Landwehr-Kenzel, Karsten Juerchott, Birgit Sawitzki, Cordula Giesler, Anett Sefrin, Carola Beier, Dimitrios Laurin Wagner, Stephan Schlickeiser, Mathias Streitz, Michael Schmueck-Henneresse, Leila Amini, Ulrik Stervbo, Nina Babel, Hans-Dieter Volk, Petra Reinke, Andy Roemhild, Natalie Maureen Otto, Guido Moll, Mohamed Abou-El-Enein, Daniel Kaiser, Gantuja Bold, Thomas Schachtner, Mira Choi, Robert Oellinger, Sybille Landwehr-Kenzel, Karsten Juerchott, Birgit Sawitzki, Cordula Giesler, Anett Sefrin, Carola Beier, Dimitrios Laurin Wagner, Stephan Schlickeiser, Mathias Streitz, Michael Schmueck-Henneresse, Leila Amini, Ulrik Stervbo, Nina Babel, Hans-Dieter Volk, Petra Reinke
Abstract
Objective: To assess whether reshaping of the immune balance by infusion of autologous natural regulatory T cells (nTregs) in patients after kidney transplantation is safe, feasible, and enables the tapering of lifelong high dose immunosuppression, with its limited efficacy, adverse effects, and high direct and indirect costs, along with addressing several key challenges of nTreg treatment, such as easy and robust manufacturing, danger of over immunosuppression, interaction with standard care drugs, and functional stability in an inflammatory environment in a useful proof-of-concept disease model.
Design: Investigator initiated, monocentre, nTreg dose escalation, phase I/IIa clinical trial (ONEnTreg13).
Setting: Charité-University Hospital, Berlin, Germany, within the ONE study consortium (funded by the European Union).
Participants: Recipients of living donor kidney transplant (ONEnTreg13, n=11) and corresponding reference group trial (ONErgt11-CHA, n=9).
Interventions: CD4+ CD25+ FoxP3+ nTreg products were given seven days after kidney transplantation as one intravenous dose of 0.5, 1.0, or 2.5-3.0×106 cells/kg body weight, with subsequent stepwise tapering of triple immunosuppression to low dose tacrolimus monotherapy until week 48.
Main outcome measures: The primary clinical and safety endpoints were assessed by a composite endpoint at week 60 with further three year follow-up. The assessment included incidence of biopsy confirmed acute rejection, assessment of nTreg infusion related adverse effects, and signs of over immunosuppression. Secondary endpoints addressed allograft functions. Accompanying research included a comprehensive exploratory biomarker portfolio.
Results: For all patients, nTreg products with sufficient yield, purity, and functionality could be generated from 40-50 mL of peripheral blood taken two weeks before kidney transplantation. None of the three nTreg dose escalation groups had dose limiting toxicity. The nTreg and reference groups had 100% three year allograft survival and similar clinical and safety profiles. Stable monotherapy immunosuppression was achieved in eight of 11 (73%) patients receiving nTregs, while the reference group remained on standard dual or triple drug immunosuppression (P=0.002). Mechanistically, the activation of conventional T cells was reduced and nTregs shifted in vivo from a polyclonal to an oligoclonal T cell receptor repertoire.
Conclusions: The application of autologous nTregs was safe and feasible even in patients who had a kidney transplant and were immunosuppressed. These results warrant further evaluation of Treg efficacy and serve as the basis for the development of next generation nTreg approaches in transplantation and any immunopathologies.
Trial registration: NCT02371434 (ONEnTreg13) and EudraCT:2011-004301-24 (ONErgt11).
Conflict of interest statement
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the European Union 7th EU Framework Programme and Horizon 2020 programme and the BMBF under grant agreement BCRT and the BIH for the submitted work; no direct funding or donations from private parties, including the pharmaceutical industry; PR, HDV, and SLK also received unrestricted research funding from the public sources for the project (see funding).
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Figures
References
- Bluestone JA, Tang Q. Treg cells-the next frontier of cell therapy. Science 2018;362:154-5. 10.1126/science.aau2688.
- Raffin C, Vo LT, Bluestone JA. Treg cell-based therapies: challenges and perspectives. Nat Rev Immunol 2020;20:158-72. 10.1038/s41577-019-0232-6.
- Halloran PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med 2004;351:2715-29. 10.1056/NEJMra033540.
- Ekberg H, Tedesco-Silva H, Demirbas A, et al. ELITE-Symphony Study Reduced exposure to calcineurin inhibitors in renal transplantation. N Engl J Med 2007;357:2562-75. 10.1056/NEJMoa067411.
- Pascual M, Theruvath T, Kawai T, Tolkoff-Rubin N, Cosimi AB. Strategies to improve long-term outcomes after renal transplantation. N Engl J Med 2002;346:580-90. 10.1056/NEJMra011295.
- Sayegh MH, Carpenter CB. Transplantation 50 years later--progress, challenges, and promises. N Engl J Med 2004;351:2761-6. 10.1056/NEJMon043418.
- Naesens M, Kuypers DR, Sarwal M. Calcineurin inhibitor nephrotoxicity. Clin J Am Soc Nephrol 2009;4:481-508. 10.2215/CJN.04800908.
- Rama I, Grinyó JM. Malignancy after renal transplantation: the role of immunosuppression. Nat Rev Nephrol 2010;6:511-9. 10.1038/nrneph.2010.102.
- Golshayan D, Pascual M. Minimization of calcineurin inhibitors to improve long-term outcomes in kidney transplantation. Transpl Immunol 2008;20:21-8. 10.1016/j.trim.2008.08.006.
- Ponticelli C, Scolari MP. Calcineurin inhibitors in renal transplantation still needed but in reduced doses: a review. Transplant Proc 2010;42:2205-8. 10.1016/j.transproceed.2010.05.036.
- Leventhal JR, Mathew JM. Outstanding questions in transplantation: Tolerance. Am J Transplant 2020;20:348-54. 10.1111/ajt.15680.
- Siepert A, Ahrlich S, Vogt K, et al. Permanent CNI treatment for prevention of renal allograft rejection in sensitized hosts can be replaced by regulatory T cells. Am J Transplant 2012;12:2384-94. 10.1111/j.1600-6143.2012.04143.x.
- Wood KJ, Bushell A, Hester J. Regulatory immune cells in transplantation. Nat Rev Immunol 2012;12:417-30. 10.1038/nri3227.
- Sakaguchi S, Yamaguchi T, Nomura T, Ono M. Regulatory T cells and immune tolerance. Cell 2008;133:775-87. 10.1016/j.cell.2008.05.009.
- Safinia N, Grageda N, Scottà C, et al. Cell therapy in organ transplantation: our experience on the clinical translation of regulatory T cells. Front Immunol 2018;9:354. 10.3389/fimmu.2018.00354.
- Romano M, Fanelli G, Albany CJ, Giganti G, Lombardi G. Past, present, and future of regulatory T cell therapy in transplantation and autoimmunity. Front Immunol 2019;10:43. 10.3389/fimmu.2019.00043.
- Atif M, Conti F, Gorochov G, Oo YH, Miyara M. Regulatory T cells in solid organ transplantation. Clin Transl Immunology 2020;9:e01099. 10.1002/cti2.1099.
- Gladstone DE, Kim BS, Mooney K, Karaba AH, D’Alessio FR. Regulatory T cells for treating patients with covid-19 and acute respiratory distress syndrome: two case reports. Ann Intern Med 2020. 10.7326/L20-0681.
- Sawitzki B, Harden PN, Reinke P, et al. Regulatory cell therapy in kidney transplantation (The ONE Study): a harmonised design and analysis of seven non-randomised, single-arm, phase 1/2A trials. Lancet 2020;395:1627-39. 10.1016/S0140-6736(20)30167-7.
- Streitz M, Miloud T, Kapinsky M, et al. Standardization of whole blood immune phenotype monitoring for clinical trials: panels and methods from the ONE study. Transplant Res 2013;2:17. 10.1186/2047-1440-2-17.
- Abou-El-Enein M, Römhild A, Kaiser D, et al. Good Manufacturing Practices (GMP) manufacturing of advanced therapy medicinal products: a novel tailored model for optimizing performance and estimating costs. Cytotherapy 2013;15:362-83. 10.1016/j.jcyt.2012.09.006.
- Landwehr-Kenzel S, Issa F, Luu SH, et al. Novel GMP-compatible protocol employing an allogeneic B cell bank for clonal expansion of allospecific natural regulatory T cells. Am J Transplant 2014;14:594-606. 10.1111/ajt.12629.
- Döcke WD, Höflich C, Davis KA, et al. Monitoring temporary immunodepression by flow cytometric measurement of monocytic HLA-DR expression: a multicenter standardized study. Clin Chem 2005;51:2341-7. 10.1373/clinchem.2005.052639.
- Kverneland AH, Streitz M, Geissler E, et al. Age and gender leucocytes variances and references values generated using the standardized ONE-Study protocol. Cytometry A 2016;89:543-64. 10.1002/cyto.a.22855.
- Bestard O, Crespo E, Stein M, et al. Cross-validation of IFN-γ Elispot assay for measuring alloreactive memory/effector T cell responses in renal transplant recipients. Am J Transplant 2013;13:1880-90. 10.1111/ajt.12285.
- Dziubianau M, Hecht J, Kuchenbecker L, et al. TCR repertoire analysis by next generation sequencing allows complex differential diagnosis of T cell-related pathology. Am J Transplant 2013;13:2842-54. 10.1111/ajt.12431.
- Lei H, Kuchenbecker L, Streitz M, et al. Human CD45RA(-) FoxP3(hi) memory-type regulatory T cells show distinct TCR repertoires with conventional T cells and play an important role in controlling early immune activation. Am J Transplant 2015;15:2625-35. 10.1111/ajt.13315.
- Bacher P, Heinrich F, Stervbo U, et al. Regulatory T cell specificity directs tolerance versus allergy against aeroantigens in humans. Cell 2016;167:1067-78.e16. 10.1016/j.cell.2016.09.050
- Bacher P, Hohnstein T, Beerbaum E, et al. Human anti-fungal Th17 immunity and pathology rely on cross-reactivity against Candida albicans . Cell 2019;176:1340-55.e15. 10.1016/j.cell.2019.01.041.
- Sagoo P, Perucha E, Sawitzki B, et al. Development of a cross-platform biomarker signature to detect renal transplant tolerance in humans. J Clin Invest 2010;120:1848-61. 10.1172/JCI39922.
- Brunner E, Domhof S, Langer F. Nonparametric analysis of longitudinal data in factorial experiments. Wiley, 2002.
- Noguchi K, Gel YR, Brunner E, et al. nparLD: an R software package for the nonparametric analysis of longitudinal data in factorial experiments. J Stat Softw 2012;50:23 10.18637/jss.v050.i12
- Bluestone JA, Liu W, Yabu JM, et al. The effect of costimulatory and interleukin 2 receptor blockade on regulatory T cells in renal transplantation. Am J Transplant 2008;8:2086-96. 10.1111/j.1600-6143.2008.02377.x.
- Abou-El-Enein M, Elsanhoury A, Reinke P. Overcoming challenges facing advanced therapies in the EU market. Cell Stem Cell 2016;19:293-7. 10.1016/j.stem.2016.08.012.
- Fritsche E, Volk HD, Reinke P, Abou-El-Enein M. Toward an optimized process for clinical manufacturing of CAR-Treg cell therapy. Trends Biotechnol 2020;38:1099-112. 10.1016/j.tibtech.2019.12.009.
- Elsallab M, Levine BL, Wayne AS, Abou-El-Enein M. CAR T-cell product performance in haematological malignancies before and after marketing authorisation. Lancet Oncol 2020;21:e104-16. 10.1016/S1470-2045(19)30729-6.
- Safinia N, Vaikunthanathan T, Fraser H, et al. Successful expansion of functional and stable regulatory T cells for immunotherapy in liver transplantation. Oncotarget 2016;7:7563-77. 10.18632/oncotarget.6927.
- Fraser H, Safinia N, Grageda N, et al. A rapamycin-based GMP-compatible process for the isolation and expansion of regulatory T cells for clinical trials. Mol Ther Methods Clin Dev 2018;8:198-209. 10.1016/j.omtm.2018.01.006.
- Bluestone JA, Buckner JH, Fitch M, et al. Type 1 diabetes immunotherapy using polyclonal regulatory T cells. Sci Transl Med 2015;7:315ra189. 10.1126/scitranslmed.aad4134.
- Mathew JM, H-Voss J, LeFever A, et al. A phase I clinical trial with ex vivo expanded recipient regulatory T cells in living donor kidney transplants. Sci Rep 2018;8:7428. 10.1038/s41598-018-25574-7.
- Zhang Q, Lu W, Liang CL, et al. Chimeric antigen receptor (CAR) Treg: a promising approach to inducing immunological tolerance. Front Immunol 2018;9:2359. 10.3389/fimmu.2018.02359.
- Moroni G, Belingheri M, Frontini G, Tamborini F, Messa P. Immunoglobulin A nephropathy. recurrence after renal transplantation. Front Immunol 2019;10:1332. 10.3389/fimmu.2019.01332.
- Wyld ML, Chadban SJ. Recurrent IgA nephropathy after kidney transplantation. Transplantation 2016;100:1827-32. 10.1097/TP.0000000000001093.
- Oberbauer R. Calcineurin inhibitor withdrawal from sirolimus-based therapy in kidney transplantation: a systematic review of randomized trials. Am J Transplant 2005;5:3023. 10.1111/j.1600-6143.2005.01100.x.
- Larson TS, Dean PG, Stegall MD, et al. Complete avoidance of calcineurin inhibitors in renal transplantation: a randomized trial comparing sirolimus and tacrolimus. Am J Transplant 2006;6:514-22. 10.1111/j.1600-6143.2005.01177.x.
- Tan HP, Donaldson J, Basu A, et al. Two hundred living donor kidney transplantations under alemtuzumab induction and tacrolimus monotherapy: 3-year follow-up. Am J Transplant 2009;9:355-66. 10.1111/j.1600-6143.2008.02492.x.
- Chan K, Taube D, Roufosse C, et al. Kidney transplantation with minimized maintenance: alemtuzumab induction with tacrolimus monotherapy--an open label, randomized trial. Transplantation 2011;92:774-80. 10.1097/TP.0b013e31822ca7ca.
- van der Zwan M, Baan CC, van Gelder T, Hesselink DA. Review of the clinical pharmacokinetics and pharmacodynamics of alemtuzumab and its use in kidney transplantation. Clin Pharmacokinet 2018;57:191-207. 10.1007/s40262-017-0573-x.
- Chandran S, Tang Q, Sarwal M, et al. Polyclonal regulatory T cell therapy for control of inflammation in kidney transplants. Am J Transplant 2017;17:2945-54. 10.1111/ajt.14415.
- Cathomen T, Schüle S, Schüßler-Lenz M, Abou-El-Enein M. The human genome editing race: loosening regulatory standards for commercial advantage? Trends Biotechnol 2019;37:120-3. 10.1016/j.tibtech.2018.06.005.
- Wagner DL, Amini L, Wendering DJ, et al. High prevalence of Streptococcus pyogenes Cas9-reactive T cells within the adult human population. Nat Med 2019;25:242-8. 10.1038/s41591-018-0204-6.
Source: PubMed