Modulatory role for B and T cells in ischemic reperfusion injury

1
Modulatory role for B (and T) cells in ischemic
reperfusion injury

• Hamid Rabb MD
• Physician Director, Kidney Transplant Program
• The Johns Hopkins Hospital

2
Acknowledgements

• Lorraine Racusen
• Wink Baldwin
• Robert Colvin
• Dolores Ascon
• Shannon Bevans
• Roshni Molls
• Manchang Liu

• Mark Haas
• Melissa Burne-Taney
• Naoko Yokota
• Vladimir Savransky
• Carmelo Mendiola
• Gilbert Postler
• Niamh Kieran

3
Outline

• Importance of ischemia reperfusion injury (IRI)
  in transplantation
• Cellular inflammation during IRI
• Role of T lymphocytes in kidney IRI
• Role of B lymphocytes in kidney IRI
• Role of B lymphocytes in intestinal IRI

4
High incidence of kidney ischemia reperfusion
injury

• Delayed graft function occurs in 30 of deceased
  donor (cadaver) kidney transplants (50 at
  Hopkins-ECD population), which predisposes to
  acute rejection and chronic allograft nephropathy
  (NEJM 1995)
• All deceased donors have some degree of
  significant IRI
• No specific therapy

5
Ischemia/hypoxia is a major pathophysiologic
process during antibody mediated rejection
NIH antibody rejection workshop AJT 2004
6
Pathophysiologic processes in ATN
Tubules Loss of Polarity Apoptosis Necrosis Detach
ment Back-leak Obstruction
Vasculature Vasoconstriction Vasodilation Thrombos
is Coagulation Inflammation Plugging No Reflow
7
Wound
Kidney Int 2002
Skin barrier
NK cells
Bacteria
Cytokines and Chemokines
Activation of serum complement
Phagocytosis and destruction of bacteria by
macrophages and neutrophils
Dendritic cells
Macrophages
Neutrophils
Blood vessel
8
Leukocyte adhesion in renal IRI

• CD11/CD18 - ICAM-1
• PNAS 94, Am J Physiol 94, BBRC 95, JCI 96, KI
  97...
• Selectin
• JASN 94, Am J Physiol 96, JCI 97, FASEB 2000,
• KI 2001 (selectin ligand), J Immunol
  2002(selectin ligand fucose groups)
• Assumption working solely via neutrophils

9
Role of CD11/CD18 and neutropenia on ischemic
ARF. Mendiola Rabb, J Am Soc Nephrol 4741 1993

• Neutropenia induced to gt98 depletion
• No benefit on course of ARF with 60 min
  unilateral ischemia
• CD11/CD18-ICAM-1 pathway blockade protective in
  same experiment

10
Human ischemic acute renal failure

• 58 year old one week post cadaveric renal
  transplant and long ischemia time with no
  evidence of rejection or calcineurin-inhibitor
  toxicity. Small arrow erythrocytes rouloux and
  sludging in peri-tubular capillaries. Large
  arrowmarginating leukocytes, mostly mononuclear
  cells.

Kidney Int 2004
11
T cell staining in human ischemicacute renal
failure

• Immunoperoxidase stain from the same kidney
  showing that some, but not all of the leukocytes
  stain positive for CD3.

Kidney Int 2004
12

• Is there data to support the hypothesis that
  lymphocytes play an important role in renal IRI?
• Sparse lymphocytes are found in the postischemic
  kidney (Solez)
• CTLA-4 Ig (against T cell costimulation)
  decreases cold ischemic injury (Takada J Clin
  Invest 1997, Chandraker Kidney Int 1997, B7-1
  pathway important in rat model of ARF (DeGreef,
  Ysebart, De Broe Kidney Int 2001)
• Lymphocyte related cytokines are upregulated in
  the postischemic kidney (Goes/Halloran et al
  Transplantation 1995, Lemay et al
  Transplantation 2000)
• T lymphocytes mediate murine liver IRI (Zwacka et
  al J Clin Invest 1997)

13
ICAM-1 and CD11/CD18 (LFA-1) also mediate T cell
adhesion and function
14
CD4/CD8 (-/-) have an improved course of ischemic
ARF
Am J Physiol Renal 2000
15
Nu/nu mice are protected from renal IRI
J Clin Invest 2001
16
Adoptive transfer of T Cells into nu/nu mice
reconstitutes injury phenotype
? Control C57BL/6 ? nu/nu ? Transfer nu/nu

J Clin Invest 2001
17
Nu/nu mice have reduced tubular necrosis
following renal IRI
J Clin Invest 2001
18
Effects of T cell depletion on renal IRI
Transplantation 2002
19
Blood pressure during murine cardiac arrest and
CPR
Am J Physiol 2003
20
T cell deficient mice have significant protection
from acute renal failure after cardiac arrest and
CPR
? wild type CPR ? T cell deficient CPR ? wild
type sham arrest ? T cell deficient sham arrest


Am J Physiol 2003
21
Evidence for T cell modulation of IRI in lung and
liver

• Am J Transp 2002 FTY 720 liver
• Hepatology 2003 Stat 4 Stat 6 liver
• Am J Path 2003 Fibronectin-VLA-4 liver
• Mol Ther 2004 CD40Ig liver
• J Immunol 2003 rat lung tx model

22
B cell deficient mice are protected from renal
injury following IRI
J Immunol 2003
23
Normal wild-type
Wild-type
B cell-deficient
J Immunol 2003
24
J Immunol 2003
25
Renal complement (C3d) deposition is similar post
ischemia in wild type and B cell
deficient mice
WT
WT C3d
B-/- C3d
J Immunol 2003
26
Serum transfer, but not B cell transfer,
partially restores injury response in B cell
deficiency
J Immunol 2003
27
RAG-1 (T and B cell deficient) mice are not
protected postischemia in both C57BL/6 and BALB/c
background strains

• RAG-1 deficient mice
• Wild type mice
• ? T cell deficient (nude mice)

Am J Transplant 2005
28
Am J Transplant 2005
29
Am J Transplant 2005
30
B or T cell transferred RAG-1 deficient mice were
protected from renal IRI compared to RAG-1
deficient mice that did not receive a transfer of
cells
? RAG-1 deficient ? B cell transferred RAG-1
deficient ? T cell transferred RAG-1
deficient ? wt mice
Am J Transplant 2005
31
Am J Transplant 2005

32
Specific IgM mediates intestinal IRI in mice
Proc Natl Acad Sc 2004
33
LOCAL
DISTANT
Endothelial cells
Thymus
B Cell
T Cell
Neutrophils
Lymph nodes
Macrophages
Platelets
BLOOD VESSEL
Collagen
Cytokines and chemokines
Spleen
INTERSTITIUM
Bone Marrow
T Cell
EPITHELIUM
Kidney
T Cell
Kidney Int 2002
34
Summary

• IRI is a major cause of delayed graft function,
  increases graft immunogenicity, and decreases
  long term function
• Ischemic injury is a final mediator of antibody
  mediated rejection
• T cells are a newly identified mediator of IRI
• B cells are a newly identified mediator of IRI
• T and B cells may interact for full expression of
  IRI
• Role of T and B cells in IRI has similarities and
  differences between kidney and intestine
• B and T cells are a novel therapeutic target for
  IRI
• The mechanisms underlying the role for
  lymphocytes in IRI is largely unknown.