Protective conditioning against GVHD and graft rejection after combined organ and hematopoietic cell transplantation.

We have performed combined organ and hematopoietic cell transplantation using a similar conditioning regimen in mice and humans. In the mouse model of MHC-mismatched combined heart and marrow transplantation, we compared conditioning of BALB/c hosts with total lymphoid irradiation (TLI: 10 doses of 240 cGy each) targeted to the spleen, lymph nodes and thymus to conditioning with a single dose of sublethal total body irradiation (TBI; 450 cGy). Conditioning also included three injections of anti-thymocyte serum (ATS), in both groups. C57BL/6 heart grafts, marrow cells and blood mononuclear cells were transplanted 24 h after the completion of irradiation. Blood mononuclear cells were added to the marrow cells to engender severe graft versus host disease (GVHD) that is present after combined organ and hematopoietic cell transplantation in humans given non-myeloablative conditioning. Both TLI and TBI conditioned groups accepted the organ grafts and became stable chimeras. However, the TBI group all died of GVHD during the 100-day observation period. The TLI group survived during the same period without clinical signs of GVHD. These hosts were tolerized to the donor organ grafts, since third party grafts were rejected rapidly when transplanted after 100 days. When NK T-cell-deficient CD1d(-/-) BALB/c hosts were used instead of wild-type hosts in the TLI/ATS conditioned group, then all hosts survived but all rejected the organ grafts and almost all failed to develop stable chimerism. None developed GVHD. Since host NK T cells were required for graft acceptance and NK T cells are activated after recognition of CD1d on antigen presenting cells, we compared heart and marrow graft survival from wild-type versus CD1d(-/-) donors after transplantation to TLI and ATS conditioned wild-type hosts. Whereas marrow and heart grafts from wild-type donors were accepted, almost all grafts from CD1d donors were rejected. Grafts from control Jalpha18(-/-) donors that were NK T cell deficient but expressed CD1d were all accepted. The results indicate that host NK T cells facilitate graft acceptance by recognizing CD1d on donor cells. We applied the TLI conditioning regimen using 10 doses of 80 cGy each and 5 doses of rabbit ATG to human recipients of HLA-matched G-CSF "mobilized" blood mononuclear cell transplants for the treatment of leukemia and lymphoma [R. Lowsky, T. Takahashi, Y.P. Liu, et al., Protective conditioning for acute graft-versus-host disease. N. Engl. J. Med. 353 (2005) 1321-1331.]. Currently more than 100 transplants have been performed, and the incidence of acute GVHD has been about 4% when both MRD and MUD transplants are combined. Almost all recipients became complete chimeras after receiving grafts that contained 2-3x10(8) CD3(+) T cells/kg. In further studies, we applied the same TLI and ATG conditioning regimen to combined kidney and G-CSF "mobilized" blood stem cell transplantation from HLA-matched sibling donors. The hematopoietic grafts in the latter protocol were selected CD34(+) cells with 1x10(6) CD3(+) T cells/kg added back to the hematopoietic cells. Preliminary results indicate that stable mixed chimerism can be achieved using this protocol allowing for complete immunosuppressive drug withdrawal without GVHD or subsequent rejection episodes. Thus, conditioning with TLI based regimens can simultaneously protect against organ graft rejection and GVHD. Levels of chimerism are dependent upon the content of donor T cells in the hematopoietic graft.