Mobilization of healthy donors with plerixafor affects the cellular composition of T-cell receptor (TCR)-αβ/CD19-depleted haploidentical stem cell grafts
- Sergio Rutella1, 5Email author,
- Perla Filippini1,
- Valentina Bertaina1,
- Giuseppina Li Pira1,
- Lidia Altomare1,
- Stefano Ceccarelli1,
- Letizia P Brescia1,
- Barbarella Lucarelli1,
- Elia Girolami1,
- Gianpiero Conflitti1,
- Maria Giuseppina Cefalo1,
- Alice Bertaina1,
- Tiziana Corsetti2,
- Lorenzo Moretta3, 4 and
- Franco Locatelli1, 4
© Rutella et al.; licensee BioMed Central Ltd. 2014
Received: 16 July 2014
Accepted: 23 August 2014
Published: 2 September 2014
HLA-haploidentical hematopoietic stem cell transplantation (HSCT) is suitable for patients lacking related or unrelated HLA-matched donors. Herein, we investigated whether plerixafor (MZ), as an adjunct to G-CSF, facilitated the collection of mega-doses of hematopoietic stem cells (HSC) for TCR-αβ/CD19-depleted haploidentical HSCT, and how this agent affects the cellular graft composition.
Ninety healthy donors were evaluated. Single-dose MZ was given to 30 ‘poor mobilizers’ (PM) failing to attain ≥40 CD34+ HSCs/μL after 4 daily G-CSF doses and/or with predicted apheresis yields ≤12.0x106 CD34+ cells/kg recipient’s body weight.
MZ significantly increased CD34+ counts in PM. Naïve/memory T and B cells, as well as natural killer (NK) cells, myeloid/plasmacytoid dendritic cells (DCs), were unchanged compared with baseline. MZ did not further promote the G-CSF-induced mobilization of CD16+ monocytes and the down-regulation of IFN-γ production by T cells. HSC grafts harvested after G-CSF + MZ were enriched in myeloid and plasmacytoid DCs, but contained low numbers of pro-inflammatory 6-sulfo-LacNAc+ (Slan)-DCs. Finally, children transplanted with G-CSF + MZ-mobilized grafts received greater numbers of monocytes, myeloid and plasmacytoid DCs, but lower numbers of NK cells, NK-like T cells and Slan-DCs.
MZ facilitates the collection of mega-doses of CD34+ HSCs for haploidentical HSCT, while affecting graft composition.
HLA-haploidentical hematopoietic stem cell transplantation (HSCT) is an effective therapeutic option for patients with high-risk leukemia, and without human leukocyte antigen (HLA)-matched donors . Historically, clinical success, i.e., full donor-type engraftment in 95% of patients with acute leukemia and negligible incidence of acute and chronic graft-versus-host disease (GVHD), has been achieved with T-cell depleted (TCD) grafts containing a mega-dose of positively selected CD34+ cells, without the use of any post-transplant immunosuppression .
Granulocyte colony-stimulating factor (G-CSF) is widely employed as mobilizing agent in healthy donors and cancer patients. However, G-CSF-based regimens are associated with a 5-30% failure rate . The bicyclam AMD3100, also known as plerixafor, was approved in 2008 for use in combination with G-CSF to mobilize hematopoietic stem cells (HSC) for autologous HSCT . Plerixafor (Mozobil®, MZ) specifically and reversibly blocks the binding of C-X-C chemokine receptor 4 (CXCR4) to its natural ligand, stromal cell-derived factor 1 (SDF1), a CXC chemokine and key regulator of HSC homing and retention in the bone marrow (BM). We previously showed that G-CSF-mobilized peripheral blood CD34+ cells retain surface CXCR4 , implying that BM microenvironment might easily accommodate immigrating progenitor cells that express high levels of CXCR4 following G-CSF mobilization or stress conditions. MZ synergizes with G-CSF through its different mechanism of action, as suggested by randomized phase III studies, where plerixafor and G-CSF were shown to be superior to G-CSF alone for CD34+ HSC mobilization and collection ,.
Dendritic cells (DCs) are professional antigen-presenting cells triggering primary adaptive immune responses through the activation of naïve CD4+ and CD8+ T cells . Initially, human DCs were categorized into type 1 (DC1) and type 2 DCs (DC2), which are functionally distinguished by pattern of cytokine production and T-cell driving capacity. Recently, 3 cell types assigned to the DC lineage have been characterized in human blood, i.e., type 1 myeloid DCs (MDC1), type 2 myeloid DCs (MDC2) and plasmacytoid DCs -. Blood CD1c+ MDC1 efficiently cross-present soluble antigens and prime cytotoxic T cells . Human BDCA-3+ MDC2 share some characteristics with murine CD8α+ DCs, such as production of high amounts of IL-12p70 and interferon (IFN)-λ ,. By contrast, human plasmacytoid DCs secrete IFN-α and activate natural killer (NK) cells, macrophages and myeloid DCs to mount immune responses against microbial products.
There is growing evidence that the biological activities of G-CSF are not limited only to the myeloid lineage, but extend to other cell types mediating, amongst the others, inflammation, immunity and angiogenesis ,. Initial studies in mice supported a role for G-CSF in immune skewing towards T helper type 2 (Th2) cytokine production . In humans, G-CSF increases IL-4 release and decreases IFN-γ secretion , and promotes the differentiation of transforming growth factor-β1/IL-10-producing type 1 regulatory T cells (Treg), which are endowed with the ability to suppress T-cell proliferation in a cytokine-dependent manner ,. Finally, G-CSF indirectly modulates DC function, by inducing hepatocyte growth factor, IL-10 and IFN-α, and mobilizes DC2 -.
Currently, the use of MZ in healthy donors is off-label, with anecdotal reports describing its ‘just-in-time’ application either as single agent or after mobilization failure with G-CSF -. The few available data on immunological effects of MZ are mostly limited to cancer patients and show that CD8+ T-cell release of IFN-γ and TNF-α may be higher in autologous grafts collected after G-CSF and MZ, compared with G-CSF alone .
We recently developed a novel graft manipulation strategy aimed at extensively removing T-cell receptor (TCR)-αβ+ T cells and CD19+ B cells from haploidentical HSCs, prior to their infusion into children with non-malignant disorders . TCR-αβ and B-cell depletion is intended to prevent GVHD and post-transplantation lymphoproliferative disorders, respectively. The present study was designed and conducted to investigate whether and to what extent the administration of MZ, an ‘immediate salvage’ strategy in donors with suboptimal CD34-cell counts after standard-dose G-CSF, affects the cellular composition of the graft in the setting of TCR-αβ/CD19-depleted haploidentical HSCT for children with hematological disorders.
Donor eligibility and treatment plan
Antibodies and reagents
Antibody panel used for graft characterization
Events analyzed (#)
>100 CD34+ events
Enumeration of CD34+ cells
CD34+ HSCs in donor PB, leukapheresis products and manipulated grafts were counted using the ISHAGE protocol .
TCR-αβ/CD19 immunomagnetic depletion
Leukapheresis collections containing <60.0x109 nucleated cells were washed by centrifugation at 300 g for 15 minutes with PBS-EDTA-0.5% human serum albumin (Clini-MACS® washing buffer; Miltenyi Biotec) and were treated with γ-globulins to minimize the non-specific antibody binding to Fc receptors, before the addition of the biotin-conjugated, anti-TCR-αβ antibody. Cells were then incubated with magnetic beads conjugated to anti-biotin and to anti-CD19 antibodies, were re-suspended at <300.0x106/mL and were applied to the fully automated Clini-MACS® device .
Enumeration of B-cell and T-cell subsets
The following B-cell subsets were monitored in HSC donors: naïve B cells (CD19+CD27-IgD+), switched memory B cells (CD19+CD27+IgD-), non-switched memory B cells (CD19+CD27+IgD+) and double-negative memory B cells (CD19+CD27-IgD-).  Based on CD45RO and CD62L expression, T cells were allotted to either of the following subpopulations: naïve T cells (TN; CD45RO-CD62L+), effector memory T cells (TEM; CD45RO+CD62L-), central memory T cells (TCM; CD45RO+CD62L+) and terminally differentiated effector T cells (TEFF; CD45RO-CD62L-) .
Enumeration of NK cells
Three NK-cell subsets were identified and counted. Based on their reciprocal expression of CD16 and CD56, CD3- cells within the lymphoid gate were subdivided into fully mature NK cells (CD56+CD16+), tissue-resident NK cells (CD56+CD16-) and immature NK cells (CD56-CD16+) .
Enumeration of monocyte and DC subsets
Three monocyte subsets were analyzed based on CD14 and CD16 expression: classical (CD14++CD16-), intermediate (CD14++CD16+) and non-classical monocytes (CD14+CD16++) . Intermediate and non-classical monocytes were collectively referred to as CD16+ monocytes. To monitor DC mobilization, cells were stained with the ‘Lineage Cocktail-1’ and with mAbs directed against CD1c, CD303, CD141, or CD304 . After gating on Lineage- events, DCs were enumerated and their frequency was expressed as a percentage of total leukocytes ,. 6-sulfo-LacNAc+ (Slan)-DCs were counted with the anti-M-DC8 antibody recognizing an O-linked carbohydrate modification of P-selectin glycoprotein ligand-1 .
Intracellular cytokine staining
Cytokine production at the single-cell level was assessed with mAbs directed against IFN-γ, IL-17 and IL-4. CD4+ cells were activated for 4-6 hours with 50 ng/mL PMA and 1 μg/mL ionomycin, in the presence of inhibitors of protein transport. Following fixation and permeabilization, cells were labeled with cytokine-specific mAbs for 30 minutes at 4°C and then analyzed by flow cytometry.
After staining for surface antigens with mAbs at 4°C for 30 minutes, cells were incubated with 0.9% ammonium chloride for 5 minutes to lyse residual red blood cells. Cells were then extensively washed with PBS - 1% BSA and were run on a FACS Canto II® flow cytometer (BD Biosciences) with standard equipment. A minimum of 50,000 events was collected and acquired in list mode using the FACS Diva® software package (BD Biosciences).
The approximation of data distribution to normality was tested preliminarily using statistics for kurtosis and symmetry. Data were presented as median and range, and comparisons were performed with the Mann-Whitney U test for paired or unpaired data, or with the Kruskal-Wallis test with Bonferroni’s correction for multiple comparisons, as appropriate. P values ≤ 0.05 denoted statistical significance.
MZ in adjunct to G-CSF potently mobilizes CD34+ HSCs in healthy donors
In GMs and PMs, the frequency (Figure 2A) and number (Figure 2B) of circulating CD34+ HSCs were 0.10% (range 0.02-0.25) and 0.05% (0.01-0.09; p < 0.0001), and 36.5 cells/μL (5-110) and 16.0 cells/μL (2-36; p < 0.0001), respectively, on day +4 of G-CSF administration. Figure 2B also illustrates that CD34+-cell counts further increased on day +5 in GMs given G-CSF alone, when compared with those recorded on day +4. PMs consistently achieved >40 CD34+ cells/μL of blood after single-dose MZ, and their CD34+ counts on day +5 were even higher when compared with those measured in GMs given G-CSF alone [135.0 cells/μL (40-277) vs. 99.0 cells/μL (29-232); p = 0.0089]. Interestingly, PMs given single-dose MZ had higher day-5 monocyte and lymphocyte counts compared with GMs receiving G-CSF alone (Figure 2C-D). The role of MZ in mobilizing monocytes and lymphocytes was further reinforced by the observation that PMs and GMs had similar monocyte and lymphocyte counts on day +4, before receiving single-dose MZ (Figure 2C-D).
Number of CD34 + HSCs harvested and infused according to the mobilization regimen
G-CSF + MZ
Harvested CD34+ HSCs
Infused CD34+ HSCs
Effects of MZ on circulating immune cells
Finally, no changes were recorded in the frequency of MDC1, MDC2 or plasmacytoid CD303+ or CD304+ DCs when comparing baseline and post-mobilization samples, irrespective of the mobilization regimen (Additional file 3) and in keeping with previous reports showing no changes in the frequency of BDCA-2+ DCs in donors given G-CSF . Collectively, these experiments suggest that single-dose MZ exerts no major effects on circulating B-cell and T-cell subsets and on monocyte/DC subpopulations, although it may reduce the frequency of blood NK cells and NK-like T cells, when compared with G-CSF alone.
Effects of MZ on graft composition
In 70 randomly selected HSC donors (43 GMs given G-CSF only and 27 PMs receiving G-CSF plus MZ) undergoing a standard large-volume (15-20 L) leukapheresis, the graft was extensively characterized in terms of immune effector cells with particular relevance to the setting of haploidentical HSCT, such as NK cells, CD3+CD56+ NK-like T cells, monocytes and DCs. - For the purpose of comparison, we also enumerated immune effectors in 10 BM samples from healthy HLA-identical sibling donors. TCR-αβ/CD19-depleted grafts obtained after either mobilization regimen were highly enriched with NK cells compared with normal BM samples (Figure 5D). However, the frequency and absolute numbers of NK cells were comparable in grafts collected after the administration of either G-CSF alone or G-CSF and MZ (Figure 5D-E). Although grafts from donors assigned to the GM group had a higher frequency of NK-like CD56+ T cells compared with those from the PM group (Figure 5F), the overall number of CD56+ NK-like T cells harvested was similar (Figure 5G).
Number of nucleated cells, NK cells, monocytes and DCs infused (per kg of recipient’s body weight) according to the mobilization regimen
G-CSF + MZ
NK-like T cells
From a clinical standpoint, neither the HSC mobilization regimen (G-CSF alone vs. G-CSF and MZ) nor the number of monocytes and DCs infused correlated with either the occurrence of acute GVHD or the reactivation of viral infections (data not shown). By contrast, patients who developed chronic GVHD had received lower numbers of conventional CD14+CD16- monocytes (3.76×106/kg, 1.7-10.1) compared with children without chronic GVHD (11.45×106/kg, 0.6-144.2; p = 0.016].
Herein, we show that the addition of ‘immediate salvage’ MZ to a standard, G-CSF-based mobilization regimen augments HSC yield in HLA-haploidentical donors showing less-than-optimal CD34-cell mobilization, and that MZ administration affects the graft cell composition. Thirty-two percent of our donors were operationally defined as PMs and were given MZ to increase HSC mobilization. More than 95% of the donors collected the required mega-dose of HSCs with a single apheresis session.
Currently, anecdotal reports describe the ‘just-in-time’ application of MZ to healthy donors, either as single agent or after mobilization failure with G-CSF -. In our donor cohort, single-dose MZ given on day +5 increased the count of CD34+ HSCs by 8.2-fold (range 1.4-29.2), compared with that measured after 4 days of G-CSF treatment. This is remarkably similar to the 8-fold increase of CD34+ HSCs reported in donors given MZ only .
The few available data on immunological effects of MZ are mostly limited to cancer patients and show that CD8+ T-cell release of IFN-γ and TNF-α may be higher in autologous grafts collected after G-CSF and MZ, compared with G-CSF alone . We previously showed that G-CSF polarizes human T-cell and DC function towards a tolerogenic profile, implying that G-CSF-mobilized cell therapy products may be intrinsically less capable of inducing uncontrollable GVHD ,,. This is reinforced by intriguing observations in major histocompatibility complex (MHC)-matched HSCT, where mice given G-CSF-mobilized splenocytes experienced lower rates of skin GVHD compared with recipients of MZ-mobilized splenocytes . In our healthy donors treated with G-CSF, the down-regulation of CD4+ T-cell production of IFN-γ was not potentiated by single-dose MZ. Furthermore, IL-17 and IL-4 release by CD4+ T cells were not affected by G-CSF and/or MZ administration. These observations are in line with pre-clinical data showing that MZ alone, in contrast to G-CSF, is unable to alter the phenotype and cytokine polarization of T cells, as well as T-cell’s ability to induce acute GVHD . It must be emphasized that, in our study, neither G-CSF nor MZ significantly impaired IFN-γ production by CD8+ T cells. Notably, studies in mice suggest that G-CSF may separate GVHD and graft-versus-leukemia (GVL) responses by exerting suppressive effects on CD4+ T cells, that are implicated in GVHD, while preserving the cytolytic pathways of CD8+ T cells that are critical for effective GVL . At variance with a recent report on the immunological effects of single-dose MZ in healthy donors , we were unable to detect any difference in the frequency of naïve B cells after MZ administration. Conceivably, any MZ effect on the recirculation of B-cell subsets may have been obscured by treatment with G-CSF during the 4 days preceding MZ administration. However, neither that study  nor our own report identified any modification of CD4 and CD8 T-cell frequencies that could be directly attributable to MZ.
In our cohort of 90 donors, HSC mobilization with G-CSF translated into lowered frequencies of both NK cells and NK-like CD56+ T cells, a phenomenon that was mainly accounted for by a reduction of fully mature CD56+CD16+ and tissue-resident CD56+CD16- NK cells, with preserved frequencies of immature CD56-CD16+ NK cells. Interestingly, the frequency of both NK cells and NK-like CD56+ T cells was reduced in the PM group receiving single-dose MZ. Although the number of NK cells collected was not significantly different when comparing donors given G-CSF alone with those receiving G-CSF in combination with MZ, higher numbers of both NK cells and NK-like CD56+ T cells were infused in children transplanted with G-CSF-mobilized HSC products. A potential clinical implication of this finding pertains to the field of graft engineering, insofar donor mobilization with G-CSF alone might offer an advantage over the use of G-CSF + MZ for patients with NK-susceptible hematological malignancies .
As previously published, G-CSF-mobilized monocytes are functionally defective . In our study, treatment with G-CSF and MZ potently mobilized donor monocytes, especially the CD16+ subset of intermediate/non-conventional monocytes. Although the frequency of both conventional and CD16+ monocytes was higher in TCR-αβ/CD19-depleted HSC grafts compared with normal BM samples, the overall number of conventional and CD16+ monocytes infused in our haploidentical HSCT recipients was not correlated with the mobilization regimen used in the donor. It has been demonstrated that macrophages generated from CD16+ monocytes manifest higher phagocytic activity compared with macrophages derived from classical monocytes . In addition, CD14dimCD16+ monocytes are endowed with a unique patrolling function, as they detect virally infected and damaged cells and produce pro-inflammatory cytokines . In light of these findings, it is conceivable that CD16+ monocytes infused with the TCR-αβ/CD19-depleted haploidentical grafts may protect the recipient from infectious episodes, while contributing to prevention of GVHD .
There is also evidence that G-CSF mobilizes IL-12/TNF-α-producing, pro-inflammatory Slan-DCs . Thus, Slan-DCs may incite GVHD on the one side, while preserving GVL reactivity on the other side. In our study, the addition of MZ to G-CSF did not affect the mobilization of Slan-DCs. In addition, the frequency of Slan-DCs was lower in HSC grafts collected after the combined treatment with G-CSF and MZ. Because G-CSF administration is associated with in vivo cleavage of the N-terminus of CXCR4 on BM-resident HSCs , it is tempting to speculate that Slan-DCs, at variance with CD34+ HSCs and monocytes ,, may not entirely depend upon the CXCR4/SDF-1α axis for re-circulation and homing into lymphoid organs and/or tissues. Our contention is backed by experiments with CD184-12G5 antibodies showing that CXCR4 levels are preserved on the surface of Slan-DCs, but not other leukocyte subsets, analyzed after the in vivo administration of G-CSF, when compared to G-CSF plus MZ, this likely favoring Slan-DC retention into tissues. The CD184-12G5 mAbs recognize an epitope involving the first and second extracellular domains of CXCR4, and inhibit MZ binding to CXCR4. A different anti-CXCR4 mAb, termed 1D9, binds to the N terminus of CXCR4 and is not affected by MZ . In a phase 1/2 study of chemo-sensitization with MZ in relapsed or refractory acute myeloid leukemia, a decrease in CD184-12G5 binding was observed from pre-treatment to 6 hours, followed by an increase from 6 to 24 hours, indicating CXCR4 blockade by MZ in vivo. By contrast, labeling with CD184-1D9 after MZ treatment revealed an increased expression of CXCR4 between pretreatment and 6 hours, that remained elevated at 24 hours.
Finally, the frequency of CD1c+ MDC1, CD141+ MDC2 and plasmacytoid DCs  was unchanged in PB of donors treated with G-CSF, either alone or in combination with MZ. This is in agreement with previous reports showing no changes in the frequency of BDCA-2+ DCs in donors given G-CSF compared with baseline . The TCR-αβ/CD19-depleted haploidentical grafts collected after the administration of G-CSF and MZ were highly enriched with MDC1, MDC2 and plasmacytoid DCs, when compared with normal BM samples. The role played by DCs in the regulation of human GVHD and GVL responses is the subject of intense investigation. Studies of BM transplantation have shown that high numbers of plasmacytoid DCs in the graft correlate with decreased chronic GVHD, at the expense of an increased incidence of leukemia relapse . Conversely, the number of DCs in PB allografts may not predict DC reconstitution kinetics after transplantation or clinical outcome . Importantly, low DC counts at time of engraftment have been associated with worse survival, increased incidence of relapse and higher incidence of grade II-IV acute GVHD .
Thus far, we have transplanted 23 children with non-malignant disorders using TCR-αβ/CD19-depleted HSC grafts . Primary graft failure occurred in 4 patients, with 3 patients developing skin-only grade 1 to 2 acute GVHD and no patient suffering from chronic GVHD. The cumulative incidence of transplantation-related mortality was 9.3%. With a median follow-up of 18 months, 21 of 23 children are alive and disease-free, the 2-year probability of disease-free survival being 91.1% . It remains to be determined whether and to what extent the DC content of our TCR-αβ/CD19-depleted HSC grafts and, in particular, the remarkably high numbers of MDC1, MDC2 and plasmacytoid DCs infused correlate with infection control, GVHD and/or leukemia recurrence.
Collectively, our study shows that MZ is highly effective at mobilizing mega-doses of CD34+ HSCs to be transplanted into haploidentical recipients. Furthermore, our data shed some light into the optimal clinical use of MZ, insofar differences in graft cellular composition after mobilization with G-CSF and MZ are expected to quantitatively and/or qualitatively influence the immune processes that occur after allogeneic HSCT.
These studies were supported by research funds to F.L. (PRIN-2010, ‘5 × Mille’ Special Grant - AIRC, Ricerca Corrente 2014 - IRCCS Bambino Gesù Children’s Hospital, Rome) and S.R. (PRIN-2012, grant #2012NA9E9Y_004; Nuove Linee di Cellule Staminali Adulte - FILAS, Rome; Ricerca Corrente 2014 - IRCCS Bambino Gesù Children’s Hospital, Rome).
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