Belatacept and sirolimus prolong nonhuman primate renal allograft survival without a requirement for memory T cell depletion.

Belatacept is an inhibitor of CD28/B7 costimulation that is clinically indicated as a calcineurin inhibitor (CNI) alternative in combination with mycophenolate mofetil and steroids after renal transplantation. We sought to develop a clinically translatable, nonlymphocyte depleting, belatacept-based regimen that could obviate the need for both CNIs and steroids. Thus, based on murine data showing synergy between costimulation blockade and mTOR inhibition, we studied rhesus monkeys undergoing MHC-mismatched renal allotransplants treated with belatacept and the mTOR inhibitor, sirolimus. To extend prior work on costimulation blockade-resistant rejection, some animals also received CD2 blockade with alefacept (LFA3-Ig). Belatacept and sirolimus therapy successfully prevented rejection in all animals. Tolerance was not induced, as animals rejected after withdrawal of therapy. The regimen did not deplete T cells. Alefecept did not add a survival benefit to the optimized belatacept and sirolimus regimen, despite causing an intended depletion of memory T cells, and caused a marked reduction in regulatory T cells. Furthermore, alefacept-treated animals had a significantly increased incidence of CMV reactivation, suggesting that this combination overly compromised protective immunity. These data support belatacept and sirolimus as a clinically translatable, nondepleting, CNI-free, steroid-sparing immunomodulatory regimen that promotes sustained rejection-free allograft survival after renal transplantation.

Platelet-derived CD154: ultrastructural localization and clinical correlation in organ transplantation.

CD154 is an immunostimulatory ligand for CD40 that markedly influences alloimmunity. Its presence in platelets suggests that its release and subsequent immune effects are driven by trauma and thus could be relevant following organ transplantation. However, the release of platelet derived CD154 and its consequences have not been investigated in a clinical transplant setting. To better characterize the relationship between platelet activation and CD154 release, we investigated CD154 release by platelets obtained from normal individuals, and patients with two genetic defects that influence platelet granule development. Using these unique patient populations and immune-electron microscopy, we confirmed that CD154 was an alpha granule and not a cell surface protein, and thereafter optimized the methods for its in vivo measurement in humans. We then investigated plasma CD154 levels in kidney and liver transplant recipients and found no evidence that CD154 levels fluctuated systemically as a result of kidney or liver transplant procedures. Paradoxically, we found that kidney transplant patients had significantly lower systemic CD154 levels during episodes of rejection. These data suggest that the immune effects of CD154 are likely mediated through local and not systemic mechanisms, and discourage the use of CD154 as a peripheral biomarker in organ transplantation.

Selective targeting of human alloresponsive CD8+ effector memory T cells based on CD2 expression.

Costimulation blockade (CoB), specifically CD28/B7 inhibition with belatacept, is an emerging clinical replacement for calcineurin inhibitor-based immunosuppression in allotransplantation. However, there is accumulating evidence that belatacept incompletely controls alloreactive T cells that lose CD28 expression during terminal differentiation. We have recently shown that the CD2-specific fusion protein alefacept controls costimulation blockade-resistant allograft rejection in nonhuman primates. Here, we have investigated the relationship between human alloreactive T cells, costimulation blockade sensitivity and CD2 expression to determine whether these findings warrant potential clinical translation. Using polychromatic flow cytometry, we found that CD8(+) effector memory T cells are distinctly high CD2 and low CD28 expressors. Alloresponsive CD8(+) CD2(hi) CD28(-) T cells contained the highest proportion of cells with polyfunctional cytokine (IFNγ, TNF and IL-2) and cytotoxic effector molecule (CD107a and granzyme B) expression capability. Treatment with belatacept in vitro incompletely attenuated allospecific proliferation, but alefacept inhibited belatacept-resistant proliferation. These results suggest that highly alloreactive effector T cells exert their late stage functions without reliance on ongoing CD28/B7 costimulation. Their high CD2 expression increases their susceptibility to alefacept. These studies combined with in vivo nonhuman primate data provide a rationale for translation of an immunosuppression regimen pairing alefacept and belatacept to human renal transplantation.

Portal venous donor-specific transfusion in conjunction with sirolimus prolongs renal allograft survival in nonhuman primates.

Pretransplant exposure to donor antigen is known to modulate recipient alloimmunity, and frequently results in sensitization. However, donor-specific transfusion (DST) can have a protolerant effect that is dependent on route, dose and coadministered immunosuppression. Rodent studies have shown in some strain combinations that portal venous (PV) DST alone can induce tolerance, and uncontrolled clinical use of PVDST has been reported. In order to determine if pretransplant PVDST has a clinically relevant salutary effect, we studied it and the influence of concomitant immunosuppression in rhesus monkeys undergoing renal allotransplantation. Animals received PVDST with unfractionated bone marrow and/or tacrolimus or sirolimus 1 week prior to transplantation. Graft survival was assessed without any posttransplant immunosuppression. PVDST alone or in combination with tacrolimus was ineffective. However, PVDST in combination with sirolimus significantly prolonged renal allograft survival to a mean of 24 days. Preoperative sirolimus alone had no effect, and peripheral DST with sirolimus prolonged graft survival in 2/4 animals, but resulted in accelerated rejection in 2/4 animals. These data demonstrate that PVDST in combination with sirolimus delays rejection in a modest but measurable way in a rigorous model. It may thus be a preferable method for donor antigen administration.

Translational readthrough in the hdc mRNA generates a novel branching inhibitor in the drosophila trachea.

A central question in the development of many branched tubular organs, including the Drosophila trachea, concerns the mechanisms and molecules that control the number and pattern of new branches arising from preexisting vessels. We report on a branching inhibitor, Fusion-6 (Fus-6) produced by specialized tracheal cells to prevent neighboring cells from branching. In Fus-6 mutants, cells that are normally quiescent acquire the branching fate and form an increased number of sprouts emanating from the primary branches. Fus-6 is identified as the headcase (hdc) gene and is expressed in a subset of the cells that extend fusion sprouts to interconnect the tracheal network. hdc expression is regulated by the transcription factor escargot (esg) because it is not expressed in the fusion cells of esg mutants and is ectopically activated in the trachea in response to esg misexpression. We show that the hdc mRNA encodes two overlapping protein products by an unusual suppression of translational termination mechanism. Translational readthrough is necessary for hdc function because rescue of the tracheal mutant phenotype requires the full-length hdc mRNA. In ectopic expression experiments with full-length and truncated hdc constructs, only the full-length cDNA encoding both proteins could inhibit terminal branching. We propose that hdc acts non-autonomously in an inhibitory signaling mechanism to determine the number of cells that will form unicellular sprouts in the trachea.

headcase, an imaginal specific gene required for adult morphogenesis in Drosophila melanogaster.

The majority of adult organs of a holometabolic insect like Drosophila melanogaster are derived from specific imaginal cells. These cells differ from their larval equivalents in many important cellular characteristics, ranging from the nature of the cell cycle to the timing and pattern of cellular differentiation. Here we describe the cellular, molecular and genetic characterization of a gene, headcase (hdc), which is required for imaginal cell development. hdc is the first gene to be described which is specifically expressed in all imaginal cells; this has allowed us to identify many imaginal primordia in the embryo and larval development. The Hdc protein is an extremely basic (pI 9.6) cytoplasmic protein with no obvious sequence similarities or conserved motifs. Interestingly, the spatial-temporal pattern of hdc expression prefigures imaginal cell re-entry into the mitotic cell cycle and persists until the final cell divisions. hdc null alleles have been isolated and found to cause pupal lethality, with dead pharate adults exhibiting defects in the differentiation of many adult tissues, most notably in head development. Ectopic expression of hdc, provided by a hdc-minigene, rescues the pupal lethality. Imaginal disc morphology in null mutants appears normal, therefore loss of hdc expression does not affect imaginal cell growth, but instead interferes with the ability of the imaginal primordia to differentiate properly during pupal development, suggesting that hdc may be involved in hormonal responsiveness during metamorphosis.

A computer-controlled conformal radiotherapy system. I: Overview.

PURPOSE: Equipment developed for use with computer-controlled conformal radiotherapy (CCRT) treatment techniques, including multileaf collimators and/or computer-control systems for treatment machines, are now available. The purpose of this work is to develop a system that will allow the safe, efficient, and accurate delivery of CCRT treatments as routine clinical treatments, and permit modifications of the system so that the delivery process can be optimized. METHODS AND MATERIALS: The needs and requirements for a system that can fully support modern computer-controlled treatment machines equipped with multileaf collimators and segmental or dynamic conformal therapy capabilities have been analyzed and evaluated. This analysis has been used to design and then implement a complete approach to the delivery of CCRT treatments. RESULTS: The computer-controlled conformal radiotherapy system (CCRS) described here consists of a process for the delivery of CCRT treatments, and a complex software system that implements the treatment process. The CCRS system described here includes systems for plan transfer, treatment delivery planning, sequencing of the actual treatment delivery process, graphical simulation and verification tools, as well as an electronic chart that is an integral part of the system. The CCRS system has been implemented for use with a number of different treatment machines. The system has been used clinically for more than 2 years to perform CCRT treatments for more than 200 patients. CONCLUSIONS: A comprehensive system for the implementation and delivery of computer-controlled conformal radiation therapy (CCRT) plans has been designed and implemented for routine clinical use with multisegment, computer-controlled, multileaf-collimated conformal therapy. The CCRS system has been successfully implemented to perform these complex treatments, and is considered quite important to the clinical use of modern computer-controlled treatment techniques.

A computer-controlled conformal radiotherapy system. II: Sequence processor.

PURPOSE: A sequence processor (SP) is described as part of a larger computer-controlled conformal radiotherapy system (CCRS). The SP provides the means to accept and then translate highly sophisticated radiation therapy treatment plans into vendor specific instructions to control treatment delivery on a computer-controlled treatment machine. METHODS AND MATERIALS: The sequence processor (SP) is a small workstation computer that interfaces to the control computer of computer-controlled treatment machines, and to other parts of the larger CCRS system. The system reported here has been interfaced to a computer-controlled racetrack microtron with two treatment gantries, and also to other linear accelerator treatment machines equipped with multileaf collimators. An extensive design process has been used in defining the role of the SP within the context of the larger CCRS project. Flexibility and integration with various components of the project, including databases, treatment planning system, graphical simulator, were key factors in the development. In conjunction with the planned set of treatment fields, a procedural scripting language is used to define the sequence of treatment events that are performed, including operator interactions, communications to other systems such as dosimetry and portal imaging devices, and database management. RESULTS: A flexible system has been developed to allow investigation into procedural steps required for simulating and delivering complex radiation treatments. The system has been used to automate portions of the acceptance testing for the control system of the microtron, and is used for routine daily quality assurance testing. The sequence processor system described here has been used to deliver all clinical treatments performed on the microtron system in 2 years of clinical treatment (more than 200 patients treated to a variety of treatment sites). CONCLUSIONS: The sequence processor system has enabled the delivery of complex treatment using computer-controlled treatment machines. The flexibility of the system allows integration with secondary devices and modification of procedural steps, making it possible to develop effective techniques for insuring safe and efficient computer-controlled conformal radiation therapy treatments.

A computer-controlled conformal radiotherapy system. IV: Electronic chart.

PURPOSE: The design and implementation of a system for electronically tracking relevant plan, prescription, and treatment data for computer-controlled conformal radiation therapy is described. METHODS AND MATERIALS: The electronic charting system is implemented on a computer cluster coupled by high-speed networks to computer-controlled therapy machines. A methodical approach to the specification and design of an integrated solution has been used in developing the system. The electronic chart system is designed to allow identification and access of patient-specific data including treatment-planning data, treatment prescription information, and charting of doses. An in-house developed database system is used to provide an integrated approach to the database requirements of the design. A hierarchy of databases is used for both centralization and distribution of the treatment data for specific treatment machines. RESULTS: The basic electronic database system has been implemented and has been in use since July 1993. The system has been used to download and manage treatment data on all patients treated on our first fully computer-controlled treatment machine. To date, electronic dose charting functions have not been fully implemented clinically, requiring the continued use of paper charting for dose tracking. CONCLUSIONS: The routine clinical application of complex computer-controlled conformal treatment procedures requires the management of large quantities of information for describing and tracking treatments. An integrated and comprehensive approach to this problem has led to a full electronic chart for conformal radiation therapy treatments.

Mechanical and dosimetric quality control for computer controlled radiotherapy treatment equipment.

Modern computer controlled radiotherapy treatment equipment offers the possibility of delivering complex, multiple field treatments with minimal operator intervention, thus making multiple field conformal therapy practical. Conventional quality control programs are inadequate for this new technology, so new quality control procedures are needed. A reasonably fast, sensitive, and complete daily quality control program has been developed in our clinic that includes nearly automated mechanical as well as dosimetric tests. Automated delivery of these quality control fields is performed by the control system of the MM50 racetrack microtron, directed by the CCRS sequence processor [D. L. McShan and B. A. Fraass, Proceedings of the XIth International Conference on the use of computers in Radiation Therapy, 20-24 March 1994, Manchester, U.K. (North Western Medical Physics Department, Manchester, U.K., 1994), pp. 210-211], which controls the treatment process. The mechanical tests involve multiple irradiations of a single film to check the accuracy and reproducibility of the computer controlled setup of gantry and collimator angles, table orientation, collimator jaws, and multileaf collimator shape. The dosimetric tests, which involve multiple irradiations of an array of ionization chambers in a commercial dose detector (Keithly model 90100 Tracker System) rigidly attached to the head of the treatment gantry, check the output and symmetry of the treatment unit as a function of gantry and collimator angle and other parameters. For each of the dosimetric tests, readings from the five ionization chambers are automatically read out, stored, and analyzed by the computer, along with the geometric parameters of the treatment unit for that beam.(ABSTRACT TRUNCATED AT 250 WORDS)

Genetic alterations in chronic venous insufficiency.

We have previously reported on the possible role of mitochondrial myopathy with altered respiratory chain function in patients with chronic venous insufficiency. The lymphocytes of twelve individuals, eight with venous insufficiency and four controls were evaluated. The patients were all failures of vein valve transplant, had angiographic grade IV venous insufficiency and biopsy proven type II muscle atrophy in both the upper and lower extremities. All lymphocyte samples underwent mitochondrial DNA (mDNA) restriction enzyme analysis with either Kpn I, Eco RI, Ban HI, and/or Pst I. The analysis of the digested mDNA was performed utilizing Tris/Acetate agarose submarine gel electrophoresis. The patient group demonstrated a 100 to 200 base pair deletion in the mDNA. This preliminary study identifies a possible chromosomal deletion in the human genome which may be responsible for the pathogenesis of chronic venous insufficiency.

Targets of homeotic gene regulation in Drosophila.

We have used a chromatin immunopurification approach to identify target genes regulated by the homeotic gene Ultrabithorax. A monoclonal antibody against the Ultrabithorax gene product is used to immunopurify in vivo Ultrabithorax protein binding sites in embryonic chromatin. The procedure gives an enrichment of sequences with matches to a consensus homeodomain binding site. In one case we have shown that an immunopurified sequence lies within a 4 kb fragment that acts in vivo as a homeotic response element. We anticipate that this approach will enable us to identify further targets, allowing the analysis of their regulation and function. The chromatin immunopurification strategy may be of general application for the identification of direct in vivo targets of DNA-binding proteins.

N myristoylation of the spleen necrosis virus matrix protein is required for correct association of the Gag polyprotein with intracellular membranes and for particle formation.

To determine whether myristoylation is required for spleen necrosis virus replication, we constructed a substitution mutation in the gag gene that alters the putative myristate acceptor glycine residue. This single amino acid change was lethal for virus replication, resulted in aberrant proteolytic processing, and interrupted virion assembly and the release of virus from cells. Immunofluorescence analysis indicated that the amount of Gag polyprotein at the cell periphery and in Golgi-associated vesicles is severely reduced in the myristoylation mutant, indicating that correct intracellular targeting is affected by a lack of myristoylation. Coexpression of wild-type Gag polyprotein did not complement and rescue the replication-defective phenotype of the myristoylation mutant. Thus, it appears that the nonmyristoylated polyproteins are incapable of interacting with their myristoylated counterparts to form biologically active particles.

Spleen necrosis virus gag polyprotein is necessary for particle assembly and release but not for proteolytic processing.

The nature of spleen necrosis virus pol gene expression and the role of gag and gag-pol polyproteins in virion assembly was investigated. The DNA sequence of the gag-pol junction revealed that the two genes occupy the same open reading frame but are separated by an in-frame amber stop codon. Biochemical analysis of gag-pol translational readthrough in vitro and in Escherichia coli suggests that, in a manner similar to that in other mammalian type C retroviruses, amber stop codon suppression is required for pol gene expression. Removal of the gag stop codon had little or no effect on synthesis or cleavage of the polyprotein but interrupted particle assembly. This block could be overcome by complementation with wild-type gag protein.

Scleral flap surgery for modification of corneal astigmatism.

We performed resections and recessions of scleral flaps on human cadaver eyes in order to measure the induced change in keratometric astigmatism. We prepared 3-mm scleral flaps that were 3, 5, 7, or 10 mm long and resected or recessed these flaps up to 1 mm in 0.25-mm increments. Scleral flap resection resulted in up to 10.1 D of net corneal steepening along the meridian of the incision. Scleral flap recessions resulted in up to 7.7 D of net corneal flattening along the meridian of the incision; the effect increased with increasing flap length in the recessed eyes. There was a tendency toward mean corneal flattening with resections and mean corneal steepening with recessions.