A combination of six antibodies can successfully prepare mice to accept blood and immune stem cells from an immunologically mismatched donor, according to a study by researchers at the Stanford University School of Medicine.
The recipient animals can then accept an organ or tissue transplant matching that of the donor stem cells without requiring ongoing immune suppression.
If the findings are replicated in humans, the work could transform the treatment of people with immune or blood disorders while also vastly increasing the pool of available organs for those who need transplants.
The work builds on a series of recent studies conducted at Stanford that may pave the way for this type of stem cell transplant, known as a hematopoietic stem cell transplant, to safely treat a variety of disorders.
The technique is now primarily used to treat cancers of the blood and immune system.
“Radiation and chemotherapy are the current standard for preparing patients for a bone marrow transplant,” said Irving Weissman, MD, professor of pathology and developmental biology at Stanford.
“For the past decade, we have been working to step-by-step replace these nonselective and dangerous treatments with targeted antibodies.
This study is an important milestone that began with our isolation of purified blood stem cells 30 years ago.”
Weissman, the director of Stanford’s Institute for Stem Cell Biology and Regenerative Medicine and of the Ludwig Center for Cancer Stem Cell Research and Medicine at Stanford, is the senior author of the study, which will be published online June 13 in Cell Stem Cell. Graduate student Benson George is the lead author.
“This study indicates that it’s possible to perform these transplants in mice in a much gentler way without requiring a complete match between the donor and the recipient stem cells,” George said.
“It also opens the door to increasing the availability of solid organs for transplant.”
Harsh process
Hematopoietic stem cells are a rare type of stem cell in the bone marrow that give rise to the progenitors of all blood and immune cells throughout our lives.
It’s been known for some time that people with genetic blood disorders such as sickle cell anemia or thalassemia, or those with autoimmune diseases or immune deficiencies, can be cured by a transplant of healthy hematopoietic stem cells.
But in order for the transplanted cells to settle in to the recipient’s bone marrow – a process known as engrafting – it’s first necessary to eliminate key components of the recipient’s own blood and immune system.
Traditionally this has been accomplished with toxic doses of chemotherapy or radiation, or both.
But this pretreatment, known as conditioning, is so harsh that clinicians have been hesitant to resort to hematopoietic stem cell transplantation unless the patient’s life is threatened by their disease.
For this reason, most transplant recipients have been people with cancers such as leukemia or lymphoma.
Hematopoietic stem cells for transplant are typically obtained by collecting them from either circulating blood (although the cells usually live in the bone marrow they can be induced by specific drugs to enter the blood) or from the bone marrow itself, which is why the procedure is often referred to as a bone marrow transplant.
In either case, the recipient receives a mixture of cells from the donor, only some of which are hematopoietic stem cells.
Unfortunately, some of those passenger cells include a type of immune cell called a T cell, which Weissman and others have shown is responsible for a life-threatening transplant complication called graft-versus-host disease.
This occurs when the donor’s cells recognize the recipient’s tissues as foreign and begin to attack it.
Clinicians try to reduce the likelihood of graft-versus-host disease by using donor stem cells that immunologically match the recipient as closely as possible.
But those matches can be difficult to find, particularly for some ethnic minorities.
Although it’s possible to do transplants with less-than-perfect matches – a situation known as a haploidentical transplant – the recipient then requires ongoing treatment with strong immunosuppressive drugs to prevent rejection or graft-versus-host disease.
Over 50 years ago, it was first demonstrated that total body irradiation (TBI) along with transplantation of genetically identical (syngeneic) bone marrow could induce remission in a minority of patients with end-stage leukaemia [1].
Whilst transplantation was initially limited to bone marrow obtained from an identical twin, later identification of HLA types made the process of allogeneic transplantation possible that is from nonidentical HLA-matched donors such as siblings [2].
Subsequently, allogeneic transplantation was shown to be curative in a small percentage of patients with acute leukaemia who, at that time, were deemed incurable [3].
This was an especially significant outcome, despite frequent setbacks such as aggressive leukaemia progression and posttransplant complications like infection and graft-versus-host disease (GVHD) [4].
Further efforts were therefore focused on exploring how the procedure could become more successful in a greater number of patients.
It was later established that transplants were more effective during the first remission of leukaemia, when transplantation could achieve a cure in more than 50 percent of patients [3, 5]. It was also found that patients who suffered subsequent GVHD had a better leukaemia-free survival in the long term [6].
This has now been determined to be part of a graft-versus-tumour effect (graft-versus-leukaemia or GVL effect) in which allogeneic immune cells eliminate occult tumour cells which may have survived the initial conditioning [7, 8].
Even more recently, advances in transplantation techniques have led to improved survival rates and reduced incidence of complications such as GVHD, thus lowering rates of transplant-related morbidity and mortality [9].
These include improved preparative regimens such as reduced intensity conditioning (RIC), which causes less severe side effects whilst still ensuring transplant engraftment [10].
RIC has also enabled transplantation in older, more comorbid populations, where myeloablative (MA) conditioning would have led to more substantive harm.
Other techniques used involve better informed measures to prevent or limit GVHD and techniques to reduce the risk of posttransplantation opportunistic infections [4].
Transplantation has now been extended successfully to include HLA-matched unrelated donors with the development of national bone marrow registries in over 50 countries worldwide [4].
Studies have shown that, in some cases, fully matched unrelated donor (MUD) transplants can be comparable with matched related donors (MRD) in terms of disease-free survival and overall survival [11, 12].
Umbilical cord blood has also been identified as a source of haematopoietic stem cells (HSCs) for transplantation [7].
Haematopoietic stem cell transplantation (HSCT) is now a well-established treatment option for conditions such as acute myeloid leukaemia (AML) and myelodysplastic syndromes (MDS), as well as a number of other blood disorders [13].
In European centres alone, close to 15,000 allogeneic transplants were performed in 2013 and this number is increasing annually [14].Go to:
Limitations of HLA-Matched Transplants
Unfortunately, as few as 30 to 35 percent of patients will have an HLA-identical matched sibling donor available for HSC donation [7].
Furthermore, despite an estimated 25 million HLA-typed potential volunteer donors on the worldwide register [15], it remains difficult for some patients to find timely unrelated donors.
This problem is most significant for persons of ethnic backgrounds that vary from the donor pool and persons of mixed heritage.
It has been estimated that the chance of success in finding a matched donor ranges from 79% of patients with Caucasian background to less than 20% for some ethnic groups [16].
This is due to a variety of factors, including greater HLA polymorphism among persons of ethnic minorities, a smaller pool of potential donors, and higher rates of attrition from donor registries [17, 18].
Additional difficulties arise when a transplant is needed urgently, for example, in the case of particularly aggressive or rapidly progressing disease.
The search for a transplant can often be a lengthy process involving identification, typing, and collection of cells from the stem cell donor.
The entire process has been estimated to take a median of 4 months [9]. Shockingly, retrospective data have shown that even after a matched donor is found, only 53% of transplants actually proceed with delays and resultant disease progression being a major factor preventing follow-through [19].
Umbilical cord donations can solve many of these issues, mainly through reduced search times and greater mismatch tolerance [7].
Unfortunately, cord blood produces very few HSCs and therefore double cords may be necessary to provide adequate HSCs in adult patient [20].
The availability of cords from accredited banks is also a significant limiting factor.
Engraftment time may be prolonged compared to regular HSCT, leading to prolonged neutropenia and subsequent susceptibility to infection in the posttransplant period.
UCBT therefore results in higher rates of posttransplant complications and higher overall transplant-related mortality [9, 21].
Although pure hematopoietic stem cell transplants avoid this outcome, they are more difficult to obtain in sufficient quantities, and they engraft less readily than whole bone marrow.
“We wanted to eliminate three major barriers: the toxicity of the conditioning procedure, the need to have an immunologically matched donor and the difficulties in transplanting purified hematopoietic stem cells,” George said.
Hopes for first-line therapy
The researchers found that treating mice with a combination of six specific antibodies safely and efficiently eliminated several types of immune cells in the animals’ bone marrow and allowed haploidentical pure hematopoietic stem cells to engraft and begin producing blood and immune cells without the need for continued immunosuppression.
The degree of difference in a haploidentical transplant is similar to what naturally occurs between parent and child, or between about half of siblings.
“This finding suggests that, if these results are replicated in humans, we could have a child with sickle cell anemia in the clinic and, rather than considering stem cell transplant as a last resort and contingent on finding a perfectly matching donor, we could instead turn to transplant with stem cells from one of the child’s parents as a first-line therapy,” George said.
Additional experiments showed that the mice treated with the six antibodies could also accept completely mismatched purified hematopoietic stem cells, such as those that might be obtained from an embryonic stem cell line.
After transplantation with the mismatched stem cells, the recipient mice developed blood and immune systems that contained cells from both the donor and the recipient.
This allowed them to subsequently accept transplants of heart tissue from animals genetically identical to the donor animals.
“The immune systems exist together in a kind of a symbiosis,” George said, “and they view both the donor and recipient tissue as ‘self.’
This suggests that it may be possible to make haploidentical stem transplants both safe and achievable in human patients without the need for either conditioning with radiation or chemotherapy or subsequent immunosuppression.”
The researchers are next planning to conduct similar antibody-mediated conditioning followed by transplant with mismatched hematopoietic stem cells in large animal models.
If the technique one day clears the hurdles necessary to prove it is safe and effective in humans, the researchers envision a time when people who need transplanted organs could first undergo a safe, gentle transplant with hematopoietic stem cells derived in the laboratory from embryonic stem cells.
The same embryonic stem cells could also then be used to generate an organ that would be fully accepted by the recipient without requiring the need for long-term treatment with drugs to suppress the immune system.
In particular, Hiromitsu Nakauchi, MD, Ph.D., a professor of genetics at Stanford, is studying how to generate human organs in large animals from laboratory-grown stem cells.
“With support by the California Institute for Regenerative Medicine, we’ve been able to make important advances in human embryonic stem cell research,” Weissman said.
“In the past, these stem cell transplants have required a complete match to avoid rejection and reduce the chance of graft versus host disease.
But in a family with four siblings the odds of having a sibling who matches the patient this closely are only one in four. Now we’ve shown in mice that a ‘half match,’ which occurs between parents and children or in two of every four siblings, works without the need for radiation, chemotherapy or ongoing immunosuppression.
This may open up the possibility of transplant for nearly everyone who needs it.
Additionally, the immune tolerance we’re able to induce should in the future allow the co-transplantation of hematopoietic stem cells and tissues, such as insulin-producing cells or even organs generated from the same embryonic stem cell line.”
Weissman is the Virginia & D.K. Ludwig Professor for Clinical Investigation in Cancer Research. He is a member of Stanford Bio-X, the Stanford Cardiovascular Institute and the Stanford Cancer Institute.
Journal information: Cell Stem Cell
Provided by Stanford University Medical Center
