Role of complement regulatory protein expression and CD154 blockade in Gal‐independent xenograft rejection
Authors: Azimzadeh A. M. , Kelishadi S. S. , Stoddard T. , Zhang T. , Ezzelarab M. , Welty E. , Avon C. , Nguyen B‐N. , Laaris A. , Cheng X. , Ayares D. , Cooper D. K. C. , Barth Rolf N. , Pierson III R. N. 
Published: April 2010

IntroductionHyperacute (HAR) and delayed xenograft (DXR) rejection are well defined barriers following discordant transplantation of porcine organs into primate recipients. Significant progress has been made in recent years to overcome these immunological barriers, based on the development of pigs genetically modified to reduce immunogenicity: [1,2] A major step has been the generation of pigs lacking expression of Gala1,3Gal (GalTKO), the principal carbohydrate target of human anti‐pig antibody. [3,4] However, both in vitro and in vivo studies demonstrated that non‐gal antibodies have the ability to activate endothelial cells, and thus, amplify procoagulant molecular incompatibilities between pig and primate.[5,6] Based on our prior work with pigs expressing the Gal epitope, we tested the hypothesis that over‐expression of human complement regulatory proteins (hCRP) and/or blockade of the CD154/CD40 costimulation pathway will result in reduced graft injury, anti‐pig responses and coagulation dysregulation. Briefly, twenty two organs (13 hearts, 9 kidneys) from GalT‐KO pigs (9 expressing hCRP) were transplanted into baboons that received no immunosuppressive therapy, or a therapeutic regimen based on costimulation blockade. The incidence of HAR was decreased in GalTKO organs expressing hCRP as compared to GalTKO. Pre‐transplant anti‐non‐Gal antibody titers were inconsistently associated with early GalT‐KO xenograft failure. In contrast, coagulation cascade activation and platelet activation correlated closely with incidence of HAR of GalTKO organs. Strong elicited anti‐non‐gal antibody responses were detected after transplantation of a GalTKO organ. Delayed xenograft rejection was associated with coagulation dysregulation and elicited anti‐non‐gal antibody production. Future work in xenotransplantation should place emphasis on further targeting of anti‐non gal humoral immune responses and inhibiting coagulation activation.References1. Pierson RN III. JAMA 2009; Current status of xenotransplantation. 30: 967–969.2. Cooper DK, Dorling A, Pierson RN III, et al. Alpha1,3‐galactosyltransferase gene‐knockout pigs for xenotransplantation: where do we go from here? Transplantation 2007; 84: 1–7.3. Yamada K, Yazawa K, Shimizu A, et al. Marked prolongation of porcine renal xenograft survival in baboons through the use of alpha1,3‐galactosyltransferase gene‐knockout donors and the cotransplantation of vascularized thymic tissue. Nat Med 2005; 11: 32–34.4. Kuwaki K, Tseng YL, Dor FJ, et al. Heart transplantation in baboons using alpha1,3‐galactosyltransferase gene‐knockout pigs as donors: initial experience. Nat Med 2005; 11: 29–31.5 Saethre M, Baumann BC, Fung M, Seebach JD, Mollnes TE. Characterization of natural human anti‐non‐gal antibodies and their effect on activation of porcine gal‐deficient endothelial cells. Transplantation. 2007; 84: 244–250.6. Hisashi Y, Yamada K, Kuwaki K, et al. Rejection of cardiac xenografts transplanted from alpha1,3‐galactosyltransferase gene‐knockout (GalT‐KO) pigs to baboons. Am J Transplant. 2008; 8: 2516–2526.