American Journal of Transplantation 2016; 16: 1949–1950
Wiley Periodicals Inc.
Editorial
Regulating T Cell Behavior
S. J. Knechtle1,* and R. L. Fairchild2
1
Department of Surgery, Duke University, Durham, NC
2
Department of Immunology, The Cleveland Clinic,
Cleveland, OH
*Corresponding author: Stuart J. Knechtle,
stuart.knechtle@duke.edu
Received 28 December 2015 and accepted for publi-
cation 14 January 2016
A critical feature of the immune system is the presence
of multiple mechanisms that regulate the magnitude and
duration of innate and adaptive responses. Populations of
CD4+ T cells that develop to inhibit the activation of
autoantigen-reactive T cells are essential to prevent the
occurrence of autoimmune disease. The absence of
FoxP3+CD4+ T regulatory cells (Tregs) or their suboptimal
function underlies the development of colitis and many
other autoimmune- and autoinflammatory-mediated
pathologies. The potent immunoregulatory functions of
Tregs have prompted the design of strategies to isolate
Tregs from patients with autoimmune disease, expand
the cells to large numbers in vitro, and then infuse the
Tregs back into the patient. A recent phase 1 trial testing
the safety of Treg infusions into patients with recent-
onset type 1 diabetes reported that the infusions were
well tolerated and the transferred Tregs were retained
for >1 year (1). The impact of the Treg infusion on the
course of the type 1 diabetes in these patients remains
to be determined during longer follow-up.
The potential use of regulatory immune cells expanded
in vitro and then administered to transplant recipients
in vivo has attracted considerable attention as a potential
strategy to attenuate the host alloimmune response to
transplanted organs and perhaps promote the develop-
ment of donor nonresponsiveness in the absence of
immunosuppression (i.e. tolerance). Applications of this
strategy to transplantation in rodent and nonhuman
primate (NHP) models have prolonged allograft survival
(2–5). Based on these promising preclinical results, proto-
cols for expanding Tregs for infusion into kidney and liver
transplant patients are under way in the United States
and in Europe.
In this issue of the journal, a recent study of adoptive
Treg therapy in NHP recipients of heterotopically trans-
planted heart allografts raises a red flag with this strategy
© Copyright 2016 The American Society of Transplantation
and the American Society of Transplant Surgeons
doi: 10.1111/ajt.13724
(6). A single infusion of Tregs did not extend allograft sur-
vival compared with noninfused controls in recipients
conditioned with antithymocyte globulin and treated with
tacrolimus and anti–interleukin-6 receptor antibody. More-
over, administration of multiple Treg infusions actually
shortened allograft survival. The Treg infusions were
accompanied by increased recovery of effector T cells,
particularly effector memory CD8 T cells, B cells, and the
accelerated and high-level production of donor-reactive
antibodies. These results raise questions that are at the
moment unanswered but include the following: (1) What
is the impact of the recipient conditioning and/or
immunosuppressive treatment on the infused Tregs?
(2) Do the Tregs retain their regulatory properties in vivo,
or do they differentiate in a different cytokine microenvi-
ronment to adopt effector cell properties? (3) Does the
presence of the infused Tregs facilitate host cells deviat-
ing to a more aggressive effector phenotype directed
against the donor tissue? (4) Is the Treg strategy going
to be more efficacious for kidney versus heart allografts?
The unexpected results reported by Thomson’s group
raise concerns about the Treg cell transfer studies
because similar protocols for Treg preparation are being
planned and conducted in human transplant recipients in
the United States and Europe. At this point, there are no
reported results in humans that either raise similar con-
cerns or adequately address such concerns of autoim-
mune disease or graft rejection exacerbation by Treg
infusion strategies. It is also important to note that three
other NHP studies have demonstrated an outcome bene-
fit of adoptive Treg transfer (2–4).
The methods used to raise Tregs differ widely according
to the center developing them. Therefore, what happens
in Pittsburgh may not happen elsewhere, so it would be
premature to generalize concern about the current NHP
report. Nevertheless, the results beg explanation. Con-
cerns about the strategy of ex vivo growth of Tregs for
in vivo administration include (1) stability of biological activ-
ity of the cells after in vivo administration, (2) adequate
potency of the cells, (3) deviation of the cells from their
intended purpose in an altered environment, (4) impact of
dilution of the Tregs after infusion into their host, (5) hom-
ing of the Tregs to unknown location(s) in the host, and
(6) sensitization of the recipient.
An aspect of the NHP study that may have influenced the
outcome is the use of T cell depletion (Thymoglobulin)
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Knechtle and Fairchild
with Treg administration soon after depletion and before
effector T cell repopulation occurred. Perhaps the Thy-
moglobulin also depleted the administered Tregs, negat-
ing a potential benefit, although Treg:effector T cell ratios
are high for prolonged periods after Treg infusion. The
stability of FOXP3 expression by the Tregs was not moni-
tored in the current study, although it was monitored in a
previously reported study by the same group in NHP and
found to gradually decrease over time (5). Given the differ-
ent timing, frequency, and dosing of Tregs in the current
study and the unique immunosuppressive regimen that
included interleukin-6 receptor blockade and rapamycin,
there may be several potential explanations for the unex-
pected shortening of graft survival. It would be helpful and
well worth understanding the impact of recipient treat-
ment on the lack of efficacy of the Treg infusions in this
study. More importantly, it will be essential for under-
standing mechanisms underlying the increased and more
aggressive recovery of the recipient donor-reactive effec-
tor T and B cell response. Provision of these insights will
be important to improve the efficacy of adoptive Treg ther-
apies in transplantation and to avoid the adverse effect
reported by this group.
The One Study funded mainly by the European Commis-
sion is seeking phase 1/2 data in renal transplantation
regarding the use of regulatory T cells (four sites), den-
dritic cells (one site), or monocytes (one site) produced
by six separate study sites using a common renal trans-
plant protocol and using a common control group per-
formed as a reference trial. The study is enrolling well
and without a concerning safety signal to date (7,8).
Therefore, one might say at this point that the NHP study
from Pittsburgh departs from the more common observa-
tion in animal models regarding regulatory T cells and
that the early rejections reported suggest a model-speci-
fic issue with regard to the concerns given here. NHP
models are best used for proof-of-principle rather than
direct extrapolation to humans, but we appreciate the
publication of the unfavorable results using Tregs as evi-
dence of an unexpected outcome that must be seriously
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considered by the participants of studies testing this
strategy in human transplant patients.
Disclosure
The authors of this manuscript have no conflicts of inter-
est to disclose as described by the American Journal of
Transplantation.
References
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Correction made after online publication March 17, 2016: Reference
5 has been updated.
American Journal of Transplantation 2016; 16: 1949–1950