The effect of combination cyclosporine and CTLA4-Ig therapy on cardiac allograft survival.

Transplant rejection requires not only T cell receptor/CD3 complex activation by foreign MHC, but also additional costimulatory signals, as T cell receptor activation alone is insufficient for induction of the immune response. The CD28 receptor on helper T cells, interacting with its ligand B7 on activated B cells or macrophages, provides this costimulus to support T cell activity. CTLA4Ig (a soluble CD28 receptor analog), binds B7 and inhibits CD28 activation. As cyclosporine (CsA) has many side effects and CTLA4Ig alone has a significant benefit upon cardiac allograft survival, we theorized that allograft survival could be improved by using CTLA4Ig with lowered dose CsA. In vitro, high-dose CTLA4Ig inhibited the mixed lymphocyte culture reaction (MLR) between MHC-incompatible rat strains. Furthermore, there was synergistic suppression of MLR by low-dose CTLA4Ig combined with low-dose CsA. In vivo studies used a cervical heterotopic transplant model. Control recipients received no immunotherapy. Experimental recipients received low-dose CsA (1.5 mg/kg/day im) x 14 days after transplant or CTLA4Ig (10, 50, or 150 micrograms IP x 7 days). Combination animals received both CTLA4Ig and CsA. These studies showed that low doses of CsA and CTLA4Ig were additive in vivo, although no additional benefit was seen when CsA was combined with high-dose CTLA4Ig. These data suggest that the combination of low-dose CsA plus CTLA4Ig may prove useful in clinical transplantation to maximize immunosuppression and minimize side effects.