BACKGROUND: Natural antibodies directed against cell surface carbohydrates are thought to be vital to host defense and to initiate the rejection of xenografts and ABO-incompatible allografts. The biophysical properties underlying the association and dissociation of these antibodies from cell surfaces is incompletely understood. We investigated those properties for the binding of Galalpha1-3Gal antibodies to porcine endothelial cell surfaces, because such interactions might be relevant to the clinical application of xenotransplantation. RESULTS AND CONCLUSIONS: The initial rate of binding of anti-Galalpha1-3Gal antibodies to endothelial cells was found to depend on antibody concentration, antibody diffusion, and antigen concentration. The presence of an intact glycocalyx had a greater impact on antibody binding than mobility of antigen in cell membranes. Disruption of glycocalyx increased the amount of antibody bound at equilibrium by more than 50%. Although the binding of anti-Galalpha1-3Gal antibodies to cell surfaces could be inhibited by soluble Galalpha1-3Gal, once bound, some anti-Galalpha1-3Gal could not be dissociated by competitive inhibitors of binding or by denaturation of the bound Ig with chaotropic reagents, but could be dissociated by reduction of disulfide bonds, suggesting that attachment to cell surfaces was, at least in part, by means other than specific reaction with the epitope.

BACKGROUND: Acute vascular rejection (AVR) is an important immunological barrier to xenotransplantation. Thought to be initiated by xenoreactive antibodies, acute vascular rejection might, in principle, be avoided by engineering animals to express low levels of antigen. The extent to which antigen expression would have to be decreased to achieve such a goal is unknown. METHODS: We estimated the decrease in expression of a xenogeneic antigen, Galalpha1-3Gal, which might be needed to avert acute vascular rejection of xenotransplants based on the decrease in antibody binding to endothelium that would prevent tissue damage. RESULTS: The level of decrease needed in Galalpha1-3Gal expression needed to avoid acute vascular rejection was estimated to exceed 96% of baseline. The extent of the decrease needed reflected, in part, a substantial "excess" of Galalpha1-3Gal on porcine endothelial cell surfaces. CONCLUSIONS: Although the change in antigen expression required to avoid acute vascular rejection might be conditioned by various factors, the very large magnitude of this change necessitates application of highly efficient approaches to antigen modification.

BACKGROUND: A major impediment to the transplanting of porcine organs into humans is the susceptibility of porcine organs to acute vascular rejection, which can destroy a vascularized xenograft over a period of hours to days. Acute vascular rejection of porcine-to-primate xenografts is thought to be triggered by binding of xenoreactive antibodies to the graft. We tested whether antibodies, binding to Galalpha1-3Gal epitopes in porcine tissue, initiate this phenomenon. METHODS AND RESULTS: Specific depletion of anti-Galalpha1-3Gal antibodies from the blood of baboons, using extracorporeal perfusion of separated plasma through columns of Sepharose beads covalently linked to the antigenic trisaccharide, Galalpha1-3Galbeta1-4GlcAc, averted the development of acute vascular rejection in porcine organs transgenic for human decay-accelerating factor and CD59. More importantly, after immunodepletion was stopped and Gala1-3Gal antibodies were allowed to return, these same organs continued to function and remained pathologically normal and thus seemed to achieve a state of accommodation. CONCLUSION: These results demonstrate that anti-Galalpha1-3Gal antibodies cause acute vascular rejection and suggest that depletion of these antibodies leads to accommodation of the donor cardiac xenograft and could supply an important model for additional study.

OBJECTIVE: Pulmonary transplantation has become the preferred treatment for end-stage lung disease, but application of the procedure is limited because of a paucity of donors. One way to solve donor limitations is to use animal organs as a donor source or xenotransplantation. The current barrier to pulmonary xenotransplantation is the rapid failure of the pulmonary xenograft. Although antibodies are known to play a role in heart and kidney xenograft rejection, their involvement in lung dysfunction is less defined. This project was designed to define the role of antibodies in pulmonary graft rejection in a pig-to-baboon model. METHODS: Orthotopic transgenic swine left lung transplants were performed in baboons depleted of antibodies by one of three techniques before transplantation:(1) ex vivo swine kidney perfusion,(2) total immunoglobulin-depleting column perfusion, and (3) ex vivo swine lung perfusion. Results were compared with those of transgenic swine lung transplants in unmodified baboons. RESULTS: All three techniques of antibody removal resulted in depletion of xenoreactive antibodies. Only pretransplantation lung perfusion improved pulmonary xenograft function compared with lung transplantation in unmodified baboons. CONCLUSIONS: The pathogenesis of pulmonary injury in a swine-to-primate transplant model is different from that in renal and cardiac xenografts. Depletion of antibodies alone does not have a beneficial effect and may actually be detrimental.

Antibodies produced by an individual without a known history of sensitization to the relevant antigen are called "natural" antibodies. Some natural antibodies, called xenoreactive antibodies, react with the cells of foreign species. Most xenoreactive antibodies in humans and higher primates bind to a nonreducing terminal galactose expressed by pigs and other lower mammals. Although human natural antibodies which bind to one or more of a variety of terminal alpha-galactosyl structures have been identified previously, the antigen recognized by anti-alpha-galactosyl antibodies on the cells of foreign species is thought to be exclusively Galalpha1-3Gal. Thus, anti-alpha-galactosyl antibodies which do not react with Galalpha1-3Gal are thought to be nonxenoreactive. Here, we identify natural antibodies in human serum which bind to Galalpha1-6Hexosepyrranosides but not Galalpha1-3Gal, indicating that these antibodies are not xenoreactive. Various lower mammals were found to have natural anti-Galalpha1-2Gal antibodies in their sera, suggesting that at least some anti-Galalpha1-2Gal antibodies might not be xenoreactive and indicating, surprisingly, that anti-alpha-galactosyl antibodies are much more phylogenetically disperse than previously known. Also surprising was the finding that some natural antibodies which bind to Galalpha1-3Gal in vitro do not bind to porcine xenografts. These studies show that naturally occurring anti-alpha-galactosyl antibodies in mammalian serum include antibodies with a greater variety of reactivities than previously thought, only some of which would bind to a porcine xenograft. Further, these studies show that the methods used to detect anti-alpha-galactosyl antibodies of relevance in xenotransplantation must be carefully evaluated to avoid detection of anti-alpha-galactosyl antibodies which would not bind to a porcine organ and which therefore are not involved in xenograft rejection.

The binding of proteins to cell surface carbohydrates contributes to cell-cell interactions in development, immunity, and various physiologic processes. Such interactions are presumably dictated not only by the chemical structure of the carbohydrate but also reflect the properties of the protein and the microenvironment in which the protein-carbohydrate interaction occurs. To explore the factors influencing the recognition of cell surface carbohydrates by proteins, the extent to which three classes of proteins--anti-Gal alpha 1-3Gal IgM found in higher primates, Griffonia simplicifolia type I lectin, isolectin B4 (GS-IB4), and alpha-galactosidase--interact with Gal alpha 1-3Gal on porcine cell surfaces was tested. Although the Gal alpha 1-3Gal residues expressed on porcine endothelial cells and recognized by anti-Gal alpha 1-3Gal IgM and GS-IB4 were both sensitive to cleavage by alpha-galactosidase, the sites recognized by GS-IB4 were more sensitive to cleavage than sites recognized by anti-Gal alpha 1-3Gal IgM. Cross-blocking studies on porcine cell surfaces revealed that a significant proportion of anti-Gal alpha 1-3Gal IgM bound to sites not recognized by GS-IB4; however, anti-Gal alpha 1-3Gal IgM and GS-IB4 recognized the same sites on solubilized membrane proteins and model compounds. These results suggest that features of the cell surface such as the three-dimensional arrangement of Gal alpha 1-3Gal and characteristics of the protein such as size and valency play critical roles in specific interactions on cell surfaces.

Long-term success in xenotransplantation is currently hampered by acute vascular rejection. The inciting cause of acute vascular rejection is not yet known; however, a variety of observations suggest that the humoral immune response of the recipient against the donor may be involved in the pathogenesis of this process. Using a pig-to-baboon heterotopic cardiac transplant model, we examined the role of antibodies in the development of acute vascular rejection. After transplantation into baboons, hearts from transgenic pigs expressing human decay-accelerating factor and CD59 underwent acute vascular rejection leading to graft failure within 5 d; the histology was characterized by endothelial injury and fibrin thrombi. Hearts from the transgenic pigs transplanted into baboons whose circulating antibodies were depleted using antiimmunoglobulin columns (Therasorb, Unterschleisshein, Germany) did not undergo acute vascular rejection in five of six cases. Biopsies from the xenotransplants in Ig-depleted baboons revealed little or no IgM or IgG, and no histologic evidence of acute vascular rejection in the five cases. Complement activity in the baboons was within the normal range during the period of xenograft survival. In one case, acute vascular rejection of a xenotransplant occurred in a baboon in which the level of antidonor antibody rose after Ig depletion was discontinued. This study provides evidence that antibodies play a significant role in the pathogenesis of acute vascular rejection, and suggests that acute vascular rejection might be prevented or treated by therapies aimed at the humoral immune response to porcine antigens.

Organs transplanted between phylogenetically-disparate species, such as from the pig into the primate, are subject to hyperacute and acute vascular rejection. Hyperacute rejection of a porcine organ by a primate is thought to be initiated by the binding of xenoreactive natural antibodies to Galalpha1-3Gal expressed on the endothelial lining of blood vessels in the xenograft. The factor(s) which initiates acute vascular rejection is uncertain; however, there is some evidence implicating xenoreactive antibodies. The nature of the humoral response which might contribute to acute vascular rejection of a porcine organ was investigated in baboons which received a porcine cardiac xenograft plus immunosuppression with methylprednisolone, azathioprine, and cyclosporine. Following rejection and surgical removal of the xenografts, the serum concentration of xenoreactive antibodies increased in untreated animals but in immunosuppressed animals was similar to the concentration in preimmune serum. The antibodies in the sensitized recipients were specific for Galalpha1-3Gal (70-95%) and other determinants (5-30%). However, cross-blocking studies showed that, following xenotransplantation, the immunosuppressed baboons had no detectable IgM or IgG directed against "new" endothelial antigens. These results indicate that antibodies made by immunosuppressed individuals in response to xenotransplantation are much like xenoreactive natural antibodies and suggest that acute vascular rejection might in some cases be addressed by therapeutic strategies aimed at those antibodies.

Xenoreactive natural antibodies in humans and higher primates are directed predominantly at Gal alpha 1-3Gal. These antibodies are thought to initiate hyperacute rejection of porcine organ xenografts. The contribution of anti-Gal alpha 1-3Gal antibodies to the xenoractive natural antibody repertoire and to the initiation of hyperacute rejection was tested in a pig-to-baboon cardiac xenograft model. Anti-Gal alpha 1-3Gal antibodies were depleted from baboons by extracorporeal absorption of anti-Gal alpha 1-3Gal antibodies from plasma using columns with a matrix bearing Gal alpha 1-3Galb1-4GlcNAc. Specific removal of anti-Gal alpha 1-3Gal antibodies was achieved prior to transplantation as demonstrated by immunoassay. Porcine hearts were then transplanted into these baboons and the outcome of the transplants was analysed. Immunofluorescence revealed little deposition of baboon antibodies in the grafts. The porcine hearts did not undergo hyperacute rejection even though complement activity was approximately 90% of baseline at the time of transplantation. These findings demonstrate that anti-Gal alpha 1-3Gal antibodies constitute a major fraction of xenoreactive natural antibodies in primate blood and that these antibodies contribute significantly to the pathogenesis of hyperacute xenograft rejection.

Just as anti-blood group A and anti-blood group B antibodies pose a strong humoral barrier to the transplantation of allogeneic organs or blood, xenoreactive natural antibodies directed against Gal alpha 1-3Gal pose a barrier to the transplantation of xenogeneic organs or blood. We tested the idea that, although "natural" iso-hemagglutinins and xenoreactive natural antibodies recognize distinct structures, they have a similar origin and function. Anti-A antibodies, anti-B antibodies, and xenoreactive natural antibodies were present in serum at similar concentrations and varied with age, gender, and the concentration of total IgM in serum in a similar manner. Anti-A antibodies, anti-B antibodies, and xenoreactive natural antibodies, unlike some elicited antibodies, had a high degree of thermal lability and bound more avidly at lower temperatures. The natural antibodies manifest remarkable homogeneity and high functional avidity for determinants on a cell surface but only a weak affinity for monovalent ligands. These findings suggest that anti-A antibodies, anti-B antibodies, and xenoreactive natural antibodies specific for Gal alpha 1-3Gal have a common origin and function and, given similar antigen density on target cells, provide similar humoral barriers to transplantation or transfusion and that these antibodies may be members of a common "family" of antibodies.

The major immunological barrier that prevents the use of wild-type pig xenografts as an alternative source of organs for human xenotransplantation is antibody-mediated rejection. In this study, we identify the immunoglobulin variable region heavy (IgV(H)) chain genes encoding xenoantibodies to porcine heart and fetal porcine islet xenografts in non-immunosuppressed rhesus monkeys. We sought to compare the IgV(H) genes encoding xenoantibodies to porcine islets and solid organ xenografts. The immunoglobulin M (IgM) and IgG xenoantibody response was analysed by enzyme-linked immunosorbent assay and cDNA libraries from peripheral blood lymphocytes were prepared and sequenced. The relative frequency of IgV(H) gene usage was established by colony filter hybridization. Induced xenoantibodies were encoded by the IGHV3-11 germline progenitor, the same germline gene that encodes xenoantibodies in humans mounting active xenoantibody responses. The immune response to pig xenografts presented as solid organs or isolated cells is mediated by identical IgV(H) genes in rhesus monkeys. These animals represent a clinically relevant model to identify the immunological basis of pig-to-human xenograft rejection.

BACKGROUND: Hyperacute rejection of vascularized discordant xenografts can now be effectively managed. However, acute vascular rejection (AVR) then ensues, resulting in graft destruction, coagulopathy, or both within weeks. The aim of this study was to determine associations between humoral responses to the xenograft and the induction of AVR, coagulopathy, or both. METHODS: In vitro, heat-inactivated, naive or sensitized baboon sera containing xenoreactive natural or elicited antibodies were used to activate porcine aortic endothelial cells (PAEC) in vitro. Tissue factor expression on PAEC was determined as an index of heightened procoagulant activity. In vivo, porcine renal xenografts were transplanted into immunosuppressed baboons, and at the time of rejection or the development of a consumptive coagulopathy, biopsy specimens were obtained for studies of xenoreactive antibody binding and tissue factor expression. RESULTS: In vitro, incubation of PAEC with naive baboon sera containing natural anti-Galalpha1,3Gal (Gal) antibodies resulted in minimal tissue factor induction; the addition of complement boosted procoagulant responses. Elicited xenoreactive antibodies, and to non-Gal epitopes alone, induced high amounts of procoagulant activity on PAEC; the addition of complement resulted in overt cytotoxicity. In vivo, AVR was associated with xenoreactive antibody deposition in the graft. When vascular endothelial binding of xenoreactive antibody was combined with the expression of tissue factor, consumptive coagulopathy developed irrespective of histopathologic features of AVR. CONCLUSIONS: Our in vitro results indicate that elicited antibodies, potentially to non-Gal epitopes, induce endothelial cell activation and tissue factor expression; in vivo, a consumptive coagulopathy occurred when there was xenoreactive antibody deposition and increase of tissue factor.

Transfusion of group O single-donor apheresis PLTs (SDP) to group A recipients has resulted in intravascular hemolysis and mortality. Owing to low availability of type-specific SDPs, transfusion services sometimes issue ABO-mismatched PLTs. After observing two cases of acute hemolysis following infusion of O SDPs to group A patients, where both recipient eluates revealed anti-A specificity, a prospective study to determine the prevalence of "high-titer" anti-A/A,B in group O SDPs was commenced. One hundred group O SDP samples were tested. Titers of at least 64 and/or 256 from either buffered (generally reflective of IgM antibodies) or anti-IgG gel cards, respectively, were considered critically high. Twenty-eight and 39 percent of samples revealed critically high anti-A/A,B IgM and IgG titers, respectively. IgM titers were at 1:64 (18%), 128 (6%), and 256 (4%), whereas IgG titers were at 1:256 (28%), 512 (7%), 1024 (2%), and 2048 (2%). The prevalence of critical anti-A/A,B titers in group O SDPs is relatively high. Thus, the risk of minor side ABO mismatch and potential intravascular hemolysis during group O SDP transfusion to group A recipients may be significant. Based on these data, a policy was instituted to test anti-A/A,B titers in O SDPs prior to "out-of-group" transfusion.

A patient with blood group type O accidentally received a blood group B cardiac allograft. He died almost 5 years after transplantation because of transplant vasculopathy. We monitored the expression of ABO-type antigens on the vascular endothelial cells of the cardiac allograft for 44 months, using monoclonal antibodies for immunohistology. The antigenic profile of the graft endothelial cells changed progressively from B to O. This change was first detectable 14 months after transplantation and it was most prominent at the end of the observation period. Thus, we have shown that the allograft blood type of the endothelium of this patient's heart began to change from type B to his own, 1 year after transplantation. By 44 months post-transplantation, it had changed to O type.

Summary:Delayed donor red cell engraftment and prolonged red cell aplasia (PRCA) are well-recognized complications of major ABO-incompatible myeloablative and nonmyelo-ablative hematopoietic stem cell transplantation (HSCT). There is an intense debate about the impact on outcome, severity of hemolysis, association with graft-versus-host disease and survival after blood group-incompatible stem cell transplantation. Therefore, therapeutic strategies should be considered to avoid these possible complications. We present five patients, who received allogeneic HSCT from human leukocyte antigen-identical donors for hematological malignancies, which were treated with Ig-Therasorb((R)) immunoadsorption (five treatments/week) to remove persisting incompatible isohemagglutinins. After a median of 17 treatments (range 9-25), all the patients became transfusion independent with the presentation of donor's blood group. No side effects occurred during treatment. Ig-Therasorb((R)) immunoadsorption seems to be a promising therapeutic method for rapid, efficient and safe elimination for persisting isohemagglutinins for patients with PRCA after allogeneic hematological stem cell transplantation.Bone Marrow Transplantation (2003) 32, 1015-1019. doi:10.1038/sj.bmt.1704264

Human antibodies (Abs) against blood group A or B carbohydrate determinant are a major barrier to ABO-incompatible organ transplantation; however, the phenotype and other properties of B cell types responding to A or B carbohydrate epitopes have not been defined. Studies here, which use fluorescein-labeled synthetic A determinant (GalNAcalpha1-3Fucalpha1-2Gal), demonstrate that B cells bearing surface IgM (sIgM) receptors recognizing blood group A carbohydrate determinant are found exclusively in a small B cell subpopulation, i.e. sIgM+ CD11b+ CD5+ B1 cells, in blood group O human peripheral blood mononuclear cells (PBMC). In order to test anti-A Abs producing capacity of the human PBMC, nonobese diabetic (NOD)/severe combined immune-deficient (SCID) mice that have been treated with rabbit anti-asialo GM1 serum to deplete natural killer cells and with 3 Gy of whole body irradiation were engrafted with blood group O or A human PBMC, followed by sensitization of human blood group A red blood cells. Anti-A-specific human Abs were detected in the sera of the mice that received blood group O human PBMC, whereas they were not detected in the sera of the mice that received blood group A human PBMC, indicating profound tolerance of auto-reactive B cells. The human PBMC-NOD/SCID chimera developed by injection of blood group O human PBMC might be a useful in vivo model to test effects of immunosuppressants or other approaches on human B cells that respond to blood group A antigens.

ABSTRACT. Xenotransplantation is increasingly viewed as a promising way to alleviate the problem of patients who have alloreactive lymphocytotoxic antibodies and therefore tend to accumulate on the waiting list for renal transplantation. One barrier to xenotransplantation in these patients could be the hyperacute or acute vascular rejection as a result of preexisting anti-HLA antibodies that recognize swine leukocyte antigens. The cross-reactivity of sera from 98 patients with pig lymphocytes was studied by flow cytometry. After absorption of xenoreactive natural antibodies (XNA), isotype, class, and antibody specificity causing a positive cross-match (XM) were determined. For nonsensitized patients, all of the antibody binding to pig lymphocytes was due to XNA, which were removed by pig red blood cells absorption. In contrast, in sensitized patients, after removal of XNA, pig lymphocyte XM remained positive. There was no correlation between antibody binding to pig lymphocytes and Ig isotype (IgG or IgM) or HLA class-specific antibodies. For testing evidence that class II-specific antibodies were responsible for antibody binding to pig lymphocytes, HLA class I-specific antibodies were absorbed with pooled human platelets. It was confirmed that HLA class II-specific antibodies were responsible for the positive pig XM, but the strength of the positive XM was weaker than the strength caused by HLA class I-specific antibodies. Sera with multiple specificities (plurispecific sera) displayed a greater frequency of cross-reactivity with swine leukocyte antigens (P < 0.05). Seven of 11 highly immunized patients without cross-reactivity IgG with porcine lymphocytes showed positive XM before an IgM was used. The results demonstrate the cross-reactive nature of HLA antibodies and therefore point out the need to perform a prospective XM after absorption of XNA in presensitized individuals. E-mail: idv@udc.es