Prevention of Acute GvHD during Haplo-BMT: Evaluating the Efficacy of T-Cell Costimulation Blockade Using a Novel Rhesus Macaque Transplant Model
Authors: Miller Weston , Wheeler Caleb E. , Mortari Angela Panoskaltsis- , Kirk Allan , Larsen Christian P , Blazar Bruce R , Kean Leslie 
Published: October 2019

Abstract
Introduction: While bone marrow transplantation (BMT) offers curative therapy for many malignant and non-malignant hematologic diseases, it remains plagued by high morbidity and mortality, most prominently through the complications of graft-versus-host disease (GvHD). The field of GvHD research has been limited by a small number of clinically relevant model systems, which, until now, have focused on murine and canine models. However, many new human therapeutics, including those directed at T cell costimulation pathways, do not cross-react with targets in these model systems, limiting their utility to fully evaluate the new generation biologic anti-GvHD therapies.
Methods: We have developed a fully pedigreed and MHC-typed rhesus macaque bone marrow transplant system, with which to model GvHD and its prevention. This model relies upon microsatellite typing of both autosomal chromosomes to create genetically-verified family trees and microsatellite-and allele-specific PCR-based MHC typing, with which to identify MHC haplotypes within each family group. By this methodology, full and half-sibling pairs can be identified with either full MHC matching, one MHC haplotype matching or full MHC disparity. This represents a significant advance compared to previous primate haplo-studies, which relied upon parent-offspring transplants, as it optimizes animal availability and colony stability as well as permiting the rigorous evaluation of the degree of MHC disparity on the non-shared chromosome 6. For the current study, we have concentrated on MHC haplo-identical BMT. Our preparative regimen consists of TBI (8.00 Gy with lung shielding to 6.00 Gy), which is performed on the day of transplant with hematopoietic stem cells. After transplant, donor engraftment is measured by microsatellite analysis, from both whole blood and from flow cytometrically sorted T and B cell populations. GvHD is graded using standard clinical grading scales. The immune phenotype after transplant is also measured by cell- and serum-based flow cytometric analyses.
Results: Three animals have so far been studied. The first animal served as a control for TBI-based preparation. This animal exhibited both neutropenia (nadir = 0.015 × 103/uL at 12 days) and thrombocytopenia (nadir = 2 × 103/uL at 12 days) and prolonged anemia (hgb=5.8 g/dL on the day of sacrifice). This animal was sacrificed at day 29 due to prolonged pancytopenia. The second animal was transplanted with haploidentical hematopoietic stem cells (4.47 × 108 total nucleated cells/kg and 1.10 × 108 CD3+ T cells/kg) and was treated with only rapamycin for immunosuppression. He exhibited profuse diarrhea and necrotic skin changes within 8 days of transplant, coincident with early engraftment and was sacrificed at day 14. A full histologic analysis to determine the cause of these lesions (and the histopathologic extent of GvHD) is currently underway. The third animal was transplanted with haploidentical donor bone marrow (1.1 × 109 total nucleated cells/kg and 6.9 × 107 CD3+ T cells/kg), but was given T cell costimulation blockade with abatacept (targeting the CD28/B7 pathway) and an anti-CD40 antibody (targeting the CD40/CD154 pathway) in addition to rapamycin. Abatacept is currently clinically approved for treatment of rheumatoid arthritis, but has not been added to clinical GvHD regimens, largely due to the paucity of translational efficacy data. This animal is currently >43 days post-transplant, with full donor chimerism (including 100% T and B cell chimerism), without signs of GvHD: he has no rash, no diarrhea and is stable clinically. Additional animals are now being added to the study, to confirm these initial results.
Conclusions:
We have established a robust non-human primate model of GvHD using pedigreed and MHC-typed rhesus macaques. We have used this model to begin to test the efficacy of a novel agent combination, capable of preventing the onset and complications of acute GvHD. Preliminary results suggest that CD28- and CD40-directed costimulation blockade may be active agents for the prevention of GvHD. A large scale analysis of their efficacy and immune consequences is currently underway.