Das grundlegende Problem in der Transplantationsimmunologie ist es, die Langzeitakzeptanz eines fremden (allogen) Organs zu erreichen, ohne die sonstige Immunkompetenz des Empfängers zu beeinträchtigen. Die Induktion einer solchen spenderspezifischen Toleranz würde eine Alternative zum Langzeiteinsatz von Immunsuppressiva darstellen. Deswegen versucht man, während der Transplantation die Aktivierung der für die Abstoßung entscheidenden T-Helferzellen zu unterdrücken, bis eine Akzeptanz des Spenderorgans etabliert ist. Wichtig für eine Aktivierung der T-Zellen ist das für alle T-Helferzellen typische Zelloberflächenmolekül CD4. Antikörper gegen CD4 können in Tiermodellen eine Transplantattoleranz induzieren. Ein besonderes Interesse gilt der Charakterisierung der genauen Mechanismen dieser induzierten Transplantatakzeptanz, da diese noch wenig verstanden sind. Der von uns verwendete nicht-depletierende Maus-anti-Ratten-CD4mAk (RIB5/2) besitzt im allogenen Nierentransplantationsmodell der Ratte eine hohe toleranzinduzierende Wirkung und erzielt eine permanente Transplantatakzeptanz bei >80% der Empfängertiere. In dieser Arbeit wurde versucht, die Effekte dieses monoklonalen Antikörpers auf die T-Zellaktivierung näher zu untersuchen. Ausdruck der blockierten T-Zellaktivierung ist eine verminderte T-Zell-Proliferation und die Reduzierung der Synthese von TH-1-Effektorzytokinen, welche eine zelluläre Immunantwort fördern. Zu diesen für die Abstoßung gefährlichen Th-1-Effektorzytokinen gehören Interleukin 2 (=IL-2, Hauptwachstumsfaktor aktivierter T-Zellen) und Interferon gamma (=IFNgamma, wichtiger Aktivator von APC''s). Während die IL-2 Produktion vollständig verhindert wird, ist die Alloantigen-induzierte IFNgamma mRNA Expression nicht reduziert. Allerdings kommt es unter dem Einfluss des Antikörpers nicht zur IFNgamma Proteinsekretion. Wird jedoch das fehlende IL-2 ersetzt, kann sowohl die defekte Proliferation als auch die posttranskriptionelle Blockade der IFNgamma Produktion wieder aufgehoben werden. Das spiegelt sich auch in vivo wieder, da rekombinantes IL-2 auch hier den Toleranzstatus brechen kann. In dieser Arbeit konnte ein Kandidat dieser IFNgamma Translationskontrolle ermittelt werden. Zusätzlich wurde das Kochaperon p23, Teil eines Hsp90-Komplexes, in unsere Untersuchungen miteinbezogen, da es als ein differentiell reguliertes Gen in allogenen und anti-CD4mAk-behandelten T-Zellen identifiziert wurde. Hsp90 stabilisiert z.B. Kinasen, die wichtige Mediatoren der Signaltransduktion sind. p23 könnte aufgrund seiner Funktion als Kofaktor von Hsp90 an der Regulierung dieser Kinasen beteiligt sein, ist jedoch bisher kaum im Zusammenhang mit T-Zellaktivierung analysiert worden. Meine Untersuchungen ergaben, dass die p23 Expression ebenfalls durch den anti-CD4mAk reduziert wird. Da die Proliferation/p23 und die IFNgamma Synthese IL-2-abhängig reguliert werden, wurden IL-2-induzierte Signalwege auf ihre Relevanz für Proliferation und IFNgamma Regulation hin untersucht. Die Aufklärung der molekularen Mechanismen der anti-CD4mAk-Behandlung auf die T-Zellaktivierung soll mit dazu beitragen, Grundlagen für ein besseres Verständnis des Abstoßungsprozesses und damit Transplantatfunktions-Monitoring zu schaffen. / The major problem in transplantation immunology is the development of long-term donor-specific nonresponsiveness without reduction of the normal recipient immunocompetence. A tolerant state would obviate the need for continuing immunosuppressive therapy. One level of immunosuppression for inducing graft acceptance involves antibodies specific for T-cells of the recipient leading to donorspecific tolerance (e.g. by using of anti-CD4 monoclonal antibodies = aCD4mAb). CD4+ T cells play a predominant role in the cascade of immune processes following transplantation of foreign tissues. The anti-rat CD4 mAb RIB5/2 is very potent in inducing allo-specific tolerance to renal and heart allografts in rat recipients. Here I investigated the molecular mechanisms underlying anti-CD4 antibody mediated inhibition of allo-specific T cell activation and how this is antagonised by exogenous IL-2. IL-2 acts as growth factor for antigen-activated T cells by inducing the expression of cell cycle proteins and also enhances the expression of cytokines, e.g. IFNgamma in T cells. IFNgamma profoundly affects a variety of immune responses, including activation of antigen presenting cells. Anti-CD4 treatment, in vivo and in vitro, completely abrogated IL-2 production by alloreactive T cells. In contrast, anti-CD4 treated allo-activated T cells showed similar IFNgamma mRNA expression as untreated allo-activated T cells, but did not secrete any protein. Thus, the anti-CD4 antibody cannot prevent IFNgamma mRNA expression but is interfering with posttranscriptional mechanisms controlling IFNgamma production during allo-activation of T cells. The investigations revealed a candidate of these IFNgamma translation control. Additionally I investigated the heat shock protein 90 (Hsp90)-associated cochaperone p23. p23 upregulation during T cell activation is also abrogated by anti-CD4 treatment. Hsp90 chaperoning is critical for proper folding, stabilization and trafficking of a number of cellular signaling proteins as e.g. kinases. Hsp90-kinase complexes play an important role in T-cell signal transduction and little is known about the importance or even regulation of Hsp90-cochaperones like p23 during T-cell activation. I analysed the regulation of p23 and downstream effects on different kinases involved in T-cell signaling. These findings are supposed to contribute to a better understanding of the mechanisms underlying tolerance induction.

Suite à une transplantation, les patients présentent un affaiblissement de leur système immunitaire laissant ainsi place libre aux infections opportunistes et principalement au CMV. L’implication de ce virus dans l’accélération de la mise en place du rejet chronique du greffon reste controversée et largement incomprise. Nos objectifs ont été d’une part de déterminer l’impact de l’infection à CMV du donneur sur la survie du greffon rénal et d’autre part d’identifier certains facteurs liés à la réponse immunitaire de l’hôte pouvant moduler ce risque. Selon nos résultats, l’infection à CMV du donneur est un facteur de risque indépendant de la perte des greffons rénaux, d’autant plus si le receveur est aussi infecté. Le SNP PD-1.3 est un facteur de risque génétique fort de la perte du greffon rénal associé au CMV du donneur et ce résultat est confirmé grâce à une cohorte de validation de patients transplantés pulmonaires. Ce travail suggère un lien fort entre ce SNP et l’épuisement de la réponse immunitaire anti-CMV et met en avant l’importance de la physiopathologie liée au CMV sur l’association clinique observée. / Following a solid organ transplant, and to prevent the risk of rejection, patients take immunosuppressive treatments that weaken their immune system and promote tumors and infections, including cytomegalovirus (CMV). This virus is the cause of clinical infectious syndromes but also many "indirect" effects which are not yet clearly understood. Our objectives were firstly to determine the impact of the CMV donor infection on the renal graft survival and secondly to identify factors related to the immune response of the host which can modulate the risk. We showed that the CMV donor is an independent risk factor for kidney graft loss, especially if the recipient is infected. The SNP PD-1.3 is a strong genetic risk factor for renal graft loss associated with CMV donor and this result is confirmed by a validation cohort of lung transplant patients. This work suggests a strong link between this SNP and the exhaustion of the immune response specific anti -CMV and highlights the importance of the pathophysiology associated with CMV on the observed clinical association.

Einleitung: CTLA-4Ig blockiert CD28-vermittelte co-stimulatorische Signale und inhibiert kompetitiv in vitro und in vivo immunologische Reaktionen. Der signifikante immunsuppressive Effekt von CTLA4-IG konnte in verschiedenen tierexperimentellen Untersuchungen zur Entwicklung von Toleranz nach Organtransplantation aufgezeigt werden. Allerdings waren die Ergebnisse nach CTLA-4Ig Therapie in den nachfolgenden Untersuchungen variable und ein Großteil der transplantierten Organe wurde letztendlich abgestoßen. Neuere Studien zeigen das die Effizienz der CTLA-4Ig Therapie von dem Zeitpunkt der Gabe abhängen. Weiterhin gibt es Anhalte dafür, daß dieser Effekt durch spenderabgeleitete Transfusionen noch verstärkt werden kann. Für uns stellte sich daher die Frage ob durch die Kombination von CTLA-4IG und Applikation spenderabgeleiteter Splenozyten ein additiver immunsuppressiver Effekt zu erreichen ist und untersuchten dies im Modell der Rattenlebertransplantation (ORLT). Methodik: Wir führten Rattenlebertransplantationen (ORLT) im arterialisierten, voll allogenen Modell Da (RT1a) auf Lew (RT1l) in Standardtechnik durch. Die Ratten erhielten in verschiedenen Gruppen vor/nach der Transplantation CTLA-4Ig oder die Kombination von CTLA-4Ig mit spenderabgeleiteten oder unspezifischen Milzzellen. Ergebnisse: Bei der Vorbehandlung der Empfänger, entweder mit spenderabgeleiteten Zellen oder CTLA-4Ig, ließ sich eine Verbesserung des Transplantatüberlebens, aber keine Langzeitakzeptanz des Transplantates erreichen. Erst die Kombinationstherapie vor der Transplantation gewährleistete ein langfristiges Organüberleben ohne Zeichen für chronische Rejektionen nach mehr als 150 Tagen. Die Therapie mit spenderabgeleiteten Zellen am Tag der Transplantation oder verzögert nach 4 Tagen nach Transplantation veränderte die Überlebenszahlen nicht. Die verzögerte postoperative Therapie mit CTLA-4Ig, wie sie auch von anderen Gruppen durchgeführt wurde, resultierte in unseren Versuchen in einem verlängertem Überleben, führte aber nur bei 2/7 Tieren zur langfristigen Transplantatakzeptanz. Die zusätzliche Applikation nicht abgeleiteter Milzzellen verbesserte die Ergebnisse nicht signifikant. Transplantatakzeptanz bei allen Tieren ließ sich wiederum nur durch die Kombination spenderabgeleiteter Zellen und CTLA-4Ig erreichen. Spenderabgeleiteter Mikrochimärismus trat bei allen Tieren, also auch bei Kontrolltieren trotz ablaufender Abstoßung am 6. POD nach ORLT auf. Am 12. POD zeigten tolerante Gruppen noch spenderabgeleitete Zellen, wohingegen diese bei abstoßenden Gruppen nicht mehr nachweisbar waren. Im Langzeitverlauf waren diese spenderabgeleiteten Zellen auch in toleranten Tieren nur noch vereinzelt nachzuweisen. Eine Verschiebung der Zytokinantwort von TH1- Richtung TH2-Zytokinen konnte bei langfristig überlebenden Tieren nicht aufgezeigt werden. Im Gegenteil, die TH1-Antwort mit INF-g und IL-12b war bei toleranten, kombiniert mit CTLA-4Ig und adoptivem Zelltransfer behandelten Ratten früher und stärker ausgeprägt, aber schneller wieder rückläufig als bei unbehandelten Kontrollen. Dies galt nicht für IL-2, das in allen Gruppen, die mit CTLA-4Ig behandelt wurden, stark unterdrückt war. Langfristig überlebende Tiere zeigten mehr als 150 Tage nach ORLT nahezu keine Expression dieser TH1-Zytokine mehr, wohingegen IL-4 deutlich exprimiert wurde. Dies spricht gegen eine ausschließliche Verschiebung der Zytokinantwort nach TH2 und betont die Bedeutung von TH1-Zytokinen in der initialen Phase der Toleranzentwicklung. In toleranten Tieren mit adoptivem Zelltransfer zeigte sich im Vergleich zu abstoßenden Tieren eine stärkere Ausprägung von Apoptose in den Transplantaten, die zeitlich parallel zu der mRNA-Expression der TH1-Zytokine verlief. Dies läßt darauf schließen, daß Apoptose aktivierter T-Zellen der Mechanismus ist, der die additiven Effekte der CTLA-4Ig-Behandlung und des adoptiven Zelltransfers vermittelt. Die CTLA4-Ig Behandlung verhindert effektiv Abstoßungsepisoden nach ORLT. Die Effizienz der Behandlung kann durch die Applikation von spenderabgeleiteten Zellen noch signifikant verbessert werden. Hierbei spielt die Herunterregulation von IL-2 und Hochregulierung von INF-g eine maßgebliche Rolle, wohingegen der spenderabgeleitete Chimärismus von nachgeordneter Rolle zu sein scheint. Parallel zu dem Nachweis von IFN-g finden sich mehr apoptotische Zellen am Tag 6 in den Transplantaten der später toleranten Ratten, verglichen mit den abstoßenden Kontrolltieren. Dies weist in diesem Modell, im Gegensatz zu anderen Theorien, auf einen immunaktivierten Mechanismus mit nachfolgender Apoptose aktivierter Lymphozyten hin / Blockage of co-stimulatory CD28-mediated signals by CTLA4-Ig inhibits in vitro and in vivo immune responses. However, in recent trials monotherapy with CTLA4-Ig failed to introduce long-term survival in several animal transplant models. The study was conducted to investigate the effectiveness of CTLA-4Ig treatment with additional application of donor splenocytes in preventing rejection and improving graft function in rat liver allografts. DA rats (RT1a) were used as donors and Lew (RT1l) rats as recipients in an orthotopic liver transplantation model (ORLT). Recipients were divided in 3 groups depending on the start of treatment: The first group was treated prior to transplantation with CTLA-4Ig (0.5 mg i.p.) alone or in combination with donor derived or donor unspecific 2.5 x 108 splenocytes. The second group was treated simultaneously at transplantation with CTLA-4Ig or received no further treatment and served as controls. The third group received an ORLT and was treated postoperatively on day 3 and 4 with CTLA4-Ig alone or in combination with donor derived or unspecific spleen cells. Only the combination of CTLA-4Ig and donor derived cells pre- or postoperatively led to a 100% graft survival in the long-term. The treatment with CTLA-4Ig alone at each time point led to prolonged graft survival but not to a long-term graft survival. The additional administration of donor unspecific cells could improve these results, however, the differences were not significantly different between these groups. All rats without any treatment died within 12 days after ORLT. When treating the rats with donor derived spleen cells prior to transplantation the survival was significantly prolonged. The application of donor unspecific cells alone pre- and postoperatively had no effect on the survival rates. Microscopic and macroscopic studies of the liver demonstrated no signs of ongoing rejection after 150 days in rats treated with the combination of CTLA4-Ig and donor derived cells. All other long term survivors demonstrated signs of chronic rejection with bile duct loss. Immunohistological staining for DA specific surface antigen demonstrated donor specific chimerism with no predominance in any group. In the early postoperative course, the expression of IL-2 in liver specimen was significantly reduced in all groups receiving CTLA-4Ig. In contrast to this the tolerant rats surviving long-term showed a marked expression of IFN-g in the early course after ORLT. Additionally, these rats showed on day 6 after ORLT more apoptosis in the liver graft specimens compared to rejecting controls. CTLA4-Ig treatment is highly effective in rat liver transplantation and ensure long term survival. Pretransplant or delayed treatment with CTLA4-Ig alone prolongs survival but does not introduce long term tolerance. The effectiveness of the treatment can be markedly improved by the additional application of donor derived cells. The downregulation of IL-2 is mainly involved in the development of tolerance whereas detection of donor specific chimerism is not correlated to the development of tolerance in our study. Additionally an activation induced cell death via IFN-g may be involved in the tolerance induction. Although the mechanisms are still not completely understood immunomodulation by adaptive cell transfer and costimulatory blockage is an interesting and promising option for the future of clinical liver transplantation.

Zusammenfassung der Habilitationsschrift: Untersuchungen zum Einfluss von Mycophenolat Mofetil auf die Transplantat-Vaskulopathie nach allogener Aorten-Transplantation im Primaten-Modell Ein Hauptmerkmal der chronischen Rejektion nach allogener Organtransplantation ist die Transplantat-Vaskulopathie. Durch eine konzentrische Intimahyperplasie in den Arterien und Arteriolen des Transplantates, hervorgerufen durch eine Proliferation von glatten Muskelzellen und Fibroblasten, kommt es zu einer Minderperfusion des Organs und letztendlich zu einem chronisch fortschreitenden Transplantatversagen. Mycophenolat Mofetil (MMF) zeigt neben seiner Eigenschaft akute Rejektionen zu verhindern, auch eine antiproliferative Wirksamkeit auf glatte Muskelzellen, die eine Schlüsselrolle in der Entwicklung der chronischen Rejektion spielen. In mehreren Tierexperimenten konnte im Rattenmodell gezeigt werden, dass MMF die Entwicklung der Intimaproliferation hemmen kann. In der hier vorgestellten Studie wurde nun der Effekt von MMF auf eine fortgeschrittene, bereits etablierte Transplantat-Vaskulopathie im Primatenmodell geprüft. Nachdem in mehreren Vorstudien die Dosis, das Dosierungsintervall und der Applikationsweg getestet wurde, konnte MMF in einer maximal tolerierten Dosis Cynomolgus Affen verabreicht werden. Diese Tiere dienten jeweils als Spender und Empfänger eines 3 cm langen, infrarenalen Aortensegmentes. Um sicher zu stellen, dass sich eine Transplantat-Vaskulopathie etablieren konnte, erhielten die Tiere in den ersten 6 Wochen nach Transplantation keinerlei Immunsuppression. Erst ab Tag 45 wurde mit der MMF Therapie begonnen. Die Entwicklung der Intimahyperplasie wurde mit intravaskulären Ultraschalluntersuchungen dokumentiert und mit einer unbehandelten Kontrollgruppe verglichen. Während sich in der Kontrollgruppe die Intimahyperplasie ungebremst entwickelte, kam es in der Therapiegruppe zu einer Verlangsamung des Intimawachstums. Auch wenn der Unterschied zwischen den Gruppen am Versuchsende nicht signifikant war, so zeigte sich eine hohe Korrelation zwischen der verabreichten MMF Dosis und der sich entwickelten Transplantat-Vaskulopathie: Tiere, welche die MMF Therapie gut tolerierten, zeigten eine signifikant geringer Intimahyperplasie als Tiere der Kontrollgruppe. Bei den Tieren, bei denen die MMF Dosis aufgrund von Nebenwirkungen reduziert werden musste, entwickelte sich die Intimaproliferation ungehindert. Ferner konnte gezeigt werden, dass pharmakodynamische Messungen, welche die unterschiedlichen Medikamenten-Sensibilität der Tiere widerspiegelten, ebenfalls mit der Transplantat-Vaskulopathie korrelierten. / Evaluation of the influence of mycophenolate mofetil on graft vascular disease after allogenic aortic transplantation in non-human primates Graft vascular disease is pathognomonic for chronic rejection after solid organ transplantation. By inhibiting smooth muscle cell proliferation Mycophenolate Mofetil (MMF) has theoretically a beneficial effect on graft vascular disease and in rodent models MMF was able to halt graft vascular disease progress. To evaluate the efficacy of MMF on advanced graft vascular disease, a study was performed in non-human primates. Aortic allografts were exchanged between MLR mismatched, blood group compatible cynomolgus monkeys. 6 control animals received no immunosuppression, 6 animals were treated with MMF from day 45 after transplantation on in an individual maximal tolerated dose, which was determined in elaborative pre-studies in rodents and non-human primates. Until day 45 the animals did not receive any immunosuppressive treatment. The progression of graft vascular disease was quantified by intravascular ultrasound as changes in intimal area in the midsegments of all grafts every 3 weeks until day 105 when the animals were euthanized and the grafts have been harvested for histopathological analysis. Pharmacokinetik and pharmacodynamic monitoring was used to optimize the immunosuppressive efficacy. While in grafts from the control animals intimal hyperplasia developed unhindered, the increase of intimal areas over time was attenuated in the treatment group. Although this effect was not statistically significant, there was a high correlation between the daily MMF dose administered and the intimal proliferation in the treated animals. Animals which tolerated high doses of MMF showed significant lower graft vascular disease than animals of the control group. In two animals with MMF toxicity and dose reduction, high intimal hyperplasia was observed. In this demanding model evaluating advanced graft vascular disease in non-human primates MMF was able to halt GVD when given in a high maximal tolerated dose. In case of toxicity and individual necessary dose reduction, progress of GVD was not altered.

Die Hyperlipidämie wird als Risikofaktor für die Nierentransplantatfunktionsverschlechterung und den -verlust diskutiert. Wir untersuchten den Zusammenhang zwischen Lipidstoffwechsel und Nierentransplantatfunktion und ihre Beziehungen zu Immunsuppression, Rejektionen, Transplantatalter und Dialysedauer. Im 1. Quartal 1996 wurde allen nierentransplantierten Patienten der Ambulanz die Bestimmung eines umfassenden Lipidstatus (Cholesterine (HDL, LDL, VLDL), Triglyzeride, Apolipoproteine A1, A2, B, Lp(a) und Apo E-Genotyp) angeboten. Die ermittelten Laborwerte wurden zum klinischen Verlauf der Patienten in Beziehung gesetzt. Es wurden 201 Patienten in die Studie eingeschlossen, deren mittleres Alter bei 46,2 ± 11,4 Jahren lag. Die Transplantation lag bei den 146 Männer (72,6 %) und 55 Frauen (27,4 %) 7,7 ± 4,9 Jahre zurück. Eine auf Cyclosporin A basierende Immunsuppression erfolgte bei 143 Patienten (71,1 %), 87 Patienten (43,3 %) erhielten eine lipidsenkende Therapie. Kreatinin 122 ± 86,9 µmol/l; Cholesterin 253,6 ± 52,9 mg/dl; atherogene Risikoratio (Chol/HDL) 5,3 ± 2,3. Das Kreatinin korreliert signifikant mit dem Cholesterin (p < 0,001) und der atherogenen Risikoratio (p < 0,001) - auch in der Untergruppe ohne lipidsenkende Therapie (p = 0,001 bzw. p < 0,001), ebenso LDL, Triglyzeride, VLDL und Apo B. Die Rejektionshäufigkeit war bei Patienten mit und ohne Fettstoffwechselstörung nahezu gleich. Der Apo E-Genotyp scheint keinen Einfluss auf den Lipid- und Nierenstoffwechsel zu haben. Die Lipidparameter unserer Patienten korrelieren in der Querschnittsuntersuchung signifikant mit der Nierentransplantatfunktion, scheinen aber keinen Einfluss auf die Rejektionshäufigkeit zu haben / Hyperlipidemia is discussed as a risk factor for deterioration of the renal transplant function and the graft loss. We examined the relations between the lipid metabolism and renal transplant function and their connections to factors like immunsuppression, rejections, transplant age und time of dialysis. In the first months of 1996 all patients having a renal transplant were offered an extensive blood control including cholesterol, HDL, LDL, VLDL, triglycerides, apolipoproteins A1, A2, B, Lp(a) und Apo E-Genotype. Afterwards the lipid parameters were put into relation to the clinical course of each patient. We included 201 patients in our study, they were 46,2 ± 11,4 years old. The renal transplantation was in 146 men (72,6 %) und 55 women (27,4 %) 7,7 ± 4,9 years ago. 143 patients got a Cyclosporin A based immunsuppression (71,1 %), 87 patients (43,3 %) were set on lipid lowering therapie. Creatinin 122 ± 86,9 µmol/l; cholesterol 253,6 ± 52,9 mg/dl; Chol/HDL-quotient 5,3 ± 2,3. Creatinin correlates significantly with cholesterol (p < 0,001) and the Chol/HDL-quotient (p < 0,001) - even in the group of patients without lipid lowering therapie (p = 0,001 and p < 0,001) - and LDL, Triglyzeride, VLDL and Apo B. The frequency of rejections did not differ between patients with and without hyperlipidemia. The Apo E-Genotype seems to have no influence on the lipid- and renal metabolism. The lipid parameters our patients correlate in our study significantly with the renal transplant function, but seem to have no influence on the frequency of rejections.

In den letzten zwei Jahrzehnten wurden T-Lymphozyten verstärkt als Zielzellen für genetische Modifikationen eingesetzt, mit der Absicht vererbbare oder erworbene Krankheiten zu behandeln. Vor kurzem konnte unsere Arbeitsgruppe zeigen, dass alloantigen-spezifische, genmodifizierte T-Lymphozyten ein enormes Potential besitzen, als Transport- Systeme für therapeutische Gene in allogene Transplantate zu dienen. Diese T-Lymphozyten migrieren und akkumulieren spezifisch in das allogene Transplantat, in welchem es zu einer lokalen und starken T-Zell aktivierungsabhängigen Expression des Transgens kommt. In der vorliegenden Arbeit wurde das Potential von viralem IL-10 als therapeutisches Transgen untersucht. Dazu wurde zunächst in der gemischten Lymphozyten-Kultur (MLR) eine Lewis T-Zelllinie spezifisch für Ratten-DA Alloantigene generiert. Während der MLR wurden die Lymphozyten retroviral transduziert, so dass sie vIL-10 stabil exprimieren. Der Zytokin-Level der TvIL-10-Lymphozyten liegt 48h nach der T-Zellaktivierung zwischen 1-2ng/m. Die vIL-10 transgenen T-Lymphozyten zeigen einen CD4+CD25+ Phänotyp und sezernieren neben vIL-10 auch Ratten IL-10 und IFN-g aber kein IL-4, ähnlich wie T-regulatorische Zellen Typ 1 (Treg1). Zunächst wurden die vIL-10 transgenen T-Lymphozyten hinsichtlich ihres Potentials untersucht, die alloantigen-spezifische Immunantwort in vitro zu modulieren. Dazu wurden 5% vIL-10 transgener T-Lymphozyten zu einer MLR hinzugegeben. Zuvor wurden die naiven Lewis T-Lymphozyten mit einem Membranfarbstoff markiert, um die Proliferation und die Zytokin-Expression dieser Zellen zu untersuchen. Im Vergleich zu Kontroll-MLRs ohne transgene oder mit EGFP-transgenen Lymphozyten konnte eine signifikante Inhibierung der Proliferation als auch der INF-g Expression von naiven T-Lymphozyten detektiert werden. Trotz dieses großen Potentials in vitro, führte der adoptive Transfer der vIL-10 transgenen Zellen allein oder in Kombination mit Cyclosporin (0,5mg/kg/Tag) nicht zu einer Verlängerung der Transplantatüberlebenszeit im allogenen Herztransplantationsmodell. Diese Daten zeigen, dass die Überexpression von vIL-10 im Transplantat eines starken Abstoßungsmodells nicht zur Verlängerung der Transplantatüberlebenszeit führt. Außerdem kann das in vitro gezeigte regulatorische Potential dieser T-Zellen nicht zwangsläufig auf ihr in vivo Potential übertragen werden. / During last two decades T lymphocytes have become key targets for genetic modification in order to treat inherited or acquired human diseases. Recently, we demonstrated the capacity of allospecific gene-engineered T lymphocytes as a transport shuttle for therapeutic transgenes into allografts. These lymphocytes migrate and accumulate specifically in allografts where alloantigen-driven T cell activation strongly enhances local expression of the gene of interest. In this study, the influence of viral IL-10 as a therapeutic transgene was addressed. Lewis T cell lines specific for DA rat alloantigens were generated in a modified mixed lymphocyte reaction protocol (MLR). During MLR, lymphocytes were genetically modified to express vIL-10 using a retroviral gene expression system. The cytokine level in the supernatant of TvIL-10-lymphocytes varied between 1-2 ng/ml 48h after T-cell activation. Like T regulatory 1 (Treg1) cells, vIL-10 transgenic T lymphocytes express the phenotype CD4+25+ and secrete, in addition to vIL-10, rat IL-10 and IFN-g but no IL-4. First we evaluated the potential of vIL-10 transgenic T cell lines to modulate alloantigen-specific immune responses in vitro. Small numbers of TvIL-10-lymphocytes were added to MLR (less than 5%). Naive cells were stained with membrane dyes to trace proliferation and to analyze cytokine expression. In comparison to control MLR with no transgenic cells or equal numbers of TEGFP-lymphocytes, the proliferation as well as the production of IFN-g of naive responder cells were significantly diminished. Despite this regulatory capacity in vitro, the vIL-10 transgenic T lymphocytes were not able, either alone or in combination with suboptimal cyclosporine (0,5mg/kg/day), to prolong the survival of DA rat cardiac allografts in LEW recipients. These data demonstrate that intragraft IL-10 overexpression is not sufficient to prolong allograft survival in a high-responder strain combination and that the regulatory capacity of T cells in vitro does not predict their in vivo efficiency.

O transplante de células-tronco hematopoéticas tem surgido como alternativa ao tratamento de doenças autoimunes como artrite reumatóide, lúpus eritematoso sistêmico, esclerose múltipla e diabetes mellitus tipo 1. No diabetes mellitus tipo 1, uma síndrome de etiologia múltipla, o transplante de células-tronco hematopoéticas, na sua modalidade autóloga, tem sido utilizado como alternativa ao tratamento convencional (insulinoterapia), já que este retarda, mas não elimina as consequências da doença como disfunção e falência de vários órgãos, especialmente rins, olhos, nervos, coração e vasos sanguíneos. Apesar disso, o transplante é um procedimento altamente invasivo que acarreta repercussões intensas na qualidade de vida desses pacientes exigindo dos mesmos uma readaptação à essas repercussões. O presente estudo teve por objetivo avaliar a qualidade de vida e o ajustamento psicossocial de participantes com diabetes mellitus tipo 1. Participaram do estudo 22 pacientes que foram submetidos consecutivamente ao transplante de células-tronco hematopoéticas na Unidade de Transplante de Medula Óssea do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, no período de 2006 a 2008. Os instrumentos aplicados para a coleta de dados: Questionário Genérico de Avaliação de Qualidade de Vida Medical Outcomes Study 36 Item Short-Form Health Survey (SF-36), Escala de Ansiedade e Depressão Hospitalar - Hospital Anxiety and Depression Scale (HAD) e Inventário de Sintomas de Stress para Adultos de Lipp (ISSL). As avaliações ocorreram em três momentos distintos: na admissão do paciente, um ano após a realização do procedimento e dois anos após o transplante no retorno ambulatorial. A análise dos instrumentos aconteceu de acordo com as recomendações específicas preconizadas pela literatura. Os resultados obtidos mostraram, que para a maioria dos participantes deste estudo, após um ano do procedimento, os índices de qualidade de vida melhoraram significativamente principalmente os domínios Aspectos Físicos (p=0,0003), Estado Geral de Saúde (p=0,0142), Aspectos Sociais (p=0,0018) e Aspectos Emocionais (p=0,0316). Decorrido dois anos, o transplante teve um impacto também positivo sobre a qualidade de vida principalmente nos domínios Aspectos Físicos (p<0,0001), Aspectos Sociais (p=0,0235) e Aspectos Emocionais (p=0,0270). Em relação ao ajustamento psicossocial os resultados mostraram redução dos sintomas de ansiedade após o primeiro ano de transplante (p<0,01) e depressão nos dois momentos após o transplante (p<0,01). Observou-se ainda a diminuição dos sintomas de estresse nos momentos avaliados (p<0,01). Tais resultados podem representar uma possibilidade de retomada da vida e dos planos futuros que foram interrompidos por uma doença crônica que impunha inevitáveis dificuldades e limitações para esses participantes. Os resultados deste estudo oferecem subsídios para a equipe multidisciplinar de saúde refletir sobre as implicações dessa terapêutica inovadora em aspectos essenciais da vida do participante que vão além da dimensão biomédica, considerando as repercussões sobre sua qualidade de vida e ajustamento psicossocial. / Transplantation of hematopoietic stem cells has emerged as an alternative to the treatment of autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis and type 1 diabetes mellitus. In the latter, a syndrome of multiple etiology, the hematopoietic stem cell transplantation, in its autologous method, has been used as an alternative to conventional treatment (therapy with insulin), once it slows, but does not eliminate the consequences of the disease such as dysfunction and failure of various organs, especially kidneys, eyes, nerves, heart and blood vessels. Nevertheless, transplantation is a highly invasive procedure that carries severe repercussions on the quality of life of these patients, requiring from them a readjustment to these repercussions. The present study aimed to evaluate the quality of life and psychosocial adjustment of participants with type 1 diabetes mellitus. The study included 22 patients who underwent consecutive hematopoietic stem cell transplantation in the Bone Marrow Transplantation Ward of the Hospital das Clinicas of the University of Sao Paulo at Ribeirao Preto Medical School, between 2006 and 2008. The following instruments were used for data collection: Medical Outcomes Study 36 Item Short-Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HAD) and Lipp Stress Symptoms Inventory for Adults (LSSI). Assessments were performed at three different moments: at patient admission, one year after the performance of the procedure and two years after transplantation at the post-transplant outpatient clinic. Analysis of the instruments was done according to specific recommendations proposed in the literature. Results showed that, for most participants of the study, one year after the procedure, the indices of quality of life improved significantly, mainly the domains Physical Functioning (p=0.0003), General Health (p=0.0142), Social Functioning (p=0.0018) and Role-Emotional (p=0.0316). After two years, the transplant also had a positive impact on the quality of life, especially in the domains Physical Functioning (p<0.0001), Social Functioning (p=0.0235) and Role-Emotional (p=0.0270). In relation to psychosocial adjustment, results showed a reduction in symptoms of anxiety after the first year of transplantation (p<0.01) and depression at the two moments after transplantation (p<0.01). A decrease in symptoms of stress at the studied moments (p <0.01) was also observed. These results may represent a possibility of renewed life and future plans that were interrupted by a chronic illness that imposed inevitable difficulties and limitations to these participants. Results of this study provide support to the multidisciplinary health team reflect on the implications of this innovative therapy in essential aspects of participants life that go beyond the biomedical dimension, considering the repercussions on their quality of life and psychosocial adjustment.

Ce travail s’efforce d’élaborer une philosophie clinique des greffes, particulièrement des greffes de mains et de visage ; c’est-à-dire une philosophie qui repart toujours de l’expérience du soin et des patients. L’histoire de la constitution des greffes comme soin efficace, du début du vingtième siècle aux années 1960, y est examinée : elle permet de percevoir les obstacles inattendus qu’il a fallu apprendre à surmonter, et combien ces procédures reposent sur des conditions précises et contraignantes. Cette épistémologie critique permet ensuite d’aborder les questions éthiques soulevées par les greffes de tissus composites. Celles-ci ont suscité d’importants débats, auxquels la clinique a en partie apporté des réponses. Mais des questions éthiques subsistent, qui sont abordées en décrivant les conditions délicates du choix de la procédure et en interrogeant les normes qui légitiment de recourir à ce soin risqué pour le traitement de handicaps graves. / This work aims at building a clinical philosophy of transplantations, especially in regards to hand and face allografts; this means a philosophy rooted in the experience of care and that of the patients. The history of the establishment of transplantation as an efficient procedure, from the beginning of the twentieth century to the 1960s, is examined: it helps understand the unexpected challenges that had to be met, and how these procedures are subject to precise and restrictive conditions. This critical epistemology then allows to approach the ethical questions raised by composite tissue allografts. These procedures have given birth to intense debate, to which the clinic has already partially brought answers. But other ethical problems remain, which are considered by describing the delicate conditions for choosing the procedure and by interrogating the norms legitimating this risky procedure as a cure for severe handicaps.

皮膚是人體最大的器官，具有多種功能，其中最重要的功能之一就是作為身體內部和外界環境之間的的保護屏障。完整地修復這一保護屏障是創傷癒合和組織再生領域的一個重要內容。本論文探討了人類臍帶被覆上皮細胞 (cord lining epithelial cells, CLECs)作為一種幹細胞來源，可用于表皮重建的潛能. / 本論文的第二章對CLECs的體外分離和增殖進行了詳細地描述。這一類細胞具有較長的染色體端粒，較高的增殖潛能和傳代能力。同時，它們表達上皮幹細胞和多能性幹細胞的標誌性表面抗原。它們還具有多種分化潛能，包括成脂、成骨和成軟骨。然而當皮下異種移植後，它們並不會形成畸胎瘤。 / 本論文的第三章對CLECs的免疫特性進行了評估。結果顯示CLECs不但具有低免疫原性，還具有免疫調節功能。它們表達典型性的一型主要組織相容性複合體(MHC class I)，即人白細胞ABC抗原(HLA-ABC)，但不表達典型性的二型主要組織相容性複合體(MHC class II)，即人白細胞DR抗原(HLA-DR)。它們同時還表達非典型性的MHC class I, 包括人白細胞G抗原和人白細胞E 抗原(HLA-G和HLA-E), 但不表達共激分子(CD40, CD80和CD86)。此外，體外檢測還發現它們表達適度的促炎/抗炎細胞因子和大量的生長因子. / 本論文的第四章對CLECs在表皮重建應用中的潛能進行了考察。結果顯示無論在體外器官培養還是異種移植動物模型中，CLECs都能形成分層的上皮結構，與用表皮細胞構建的分層上皮結構相類似。而且在CLECs構建的皮膚替代物中證實了有表皮分化標誌性抗原的表達。 / 結論：本論文證明了CLECs具有幹細胞樣特性但無致瘤性，具有低免疫原性和表皮分化的可塑性。研究結果支持CLECs在創傷癒合和皮膚再生領域的臨床應用可行性. / The skin is the largest organ in the body and has multiple functions. One of the most important functions is to serve as a protective barrier between the internal and external environments of the body. Restoration of the integrity of this protective barrier is an essential aspect of wound healing and tissue regeneration. In this thesis, the potential of human umbilical cord lining epithelial cells (CLECs) as a source of stem cells with appropriate differentiation capacity for epidermal reconstitution has been explored. / The isolation and propagation of CLECs from human umbilical cord lining epithelium were described in Chapter II. The cells presented a long telomere length and had high proliferative potential and passaging capability. They were also shown to display both epithelial and pluripotent stem cell markers. They were capable of multipotent differentiation, including adipogenesis, osteogenesis and chondrogenesis. However, they didn’t form teratoma after subcutaneous xenotransplantation until 12 weeks. / The immune properties of CLECs in vitro were assessed in Chapter III. The cells were shown to have low immunogenicity but high immunosuppressive function. They expressed classical major histocompatibility complex (MHC) class I antigens (HLA-ABC), but not MHC class II antigen (HLA-DR). They also expressed non-classical MHC class I antigens (HLA-G and HLA-E), but lacked the expression of the co-stimulatory molecules (CD40, CD80 and CD86). Moreover, they expressed moderate pro/anti-inflammatory cytokines and multiple growth factors both in cell supernatants and cell lysates. / The potential of CLECs for epidermal reconstitution was investigated in Chapter IV. In both organotypic culture and xenotransplantation model, CLECs were capable of generating a stratified epithelial structure, which is similar to that constructed by using keratinocytes. Furthermore, the expression of epidermal differentiation markers was verified in CLEC-constructed skin substitutes. / In conclusion, the stem cell-like properties of CLECs have been demonstrated in the present study. In addition to the lack of tumorigenicity, CLECs also have low immunogenicity and significant plasticity in epidermal differentiation. The findings support the potential clinical application of CLECs in wound healing and skin regeneration. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Cai, Yijun. / "October 2012." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 114-129). / Abstract also in Chinese. / Abstrac --- p.i / Table of Contents --- p.v / Abbreviations --- p.vii / List of Figures --- p.viii / List of Tables --- p.x / Chapter Chapter I --- Introduction --- p.1 / Skin --- p.3 / Wound healing --- p.6 / Wound regeneration and repair --- p.6 / Recent history of wound treatment --- p.9 / Skin substitutes --- p.11 / Stem cells for wound treatment --- p.14 / Stem cells overview --- p.15 / Adult stem cells --- p.16 / Fetal stem cells --- p.18 / Amniotic membrane derived stem cells --- p.19 / Umbilical cord stem cells --- p.22 / Hypothesis and Specific aims --- p.24 / Chapter Chapter II --- The Isolation and Characterization of the Stem Cell-like Properties of Human Umbilical Cord Lining Epithelial Cells --- p.28 / Introduction --- p.28 / Materials and methods --- p.30 / Results --- p.47 / Discussion --- p.62 / Conclusion --- p.67 / Chapter Chapter III --- The assessment of the Immune Properties of Human Umbilical Cord Lining Epithelial Cells --- p.69 / Introduction --- p.69 / Materials and methods --- p.72 / Results --- p.75 / Discussion --- p.83 / Conclusion --- p.88 / Chapter Chapter IV --- The Investigation of the Potential of Human Umbilical Cord Lining Epithelial Cells for the Epidermal Reconstitution --- p.89 / Introduction --- p.89 / Materials and methods --- p.91 / Results --- p.94 / Discussion --- p.101 / Conclusion --- p.104 / Chapter Chapter V --- Summary and Future Plan --- p.105 / Summary --- p.105 / Future plan --- p.108 / Acknowledgements --- p.113 / References --- p.114 / Appendix --- p.130

A esclerose múltipla (EM) é uma doença autoimune desmielinizante progressiva imunomediada por linfócitos T auto-reativos, que provocam uma cascata imunológica, amplificando a inflamação local. No Diabetes mellitus tipo 1 (DM1), existem linfócitos T auto reativos destroem as células beta do pâncreas, causando deficiência na produção de insulina. O desenvolvimento de terapêuticas específicas fica limitado pela etiologia indefinida destas doenças, apesar de avanços na terapêutica antiinflamatória e imunossupressora. Uma alternativa de tratamento atual para tais doenças é o transplante autólogo de células tronco hematopoéticas (TACTH). O presente estudo, observacional do tipo transversal, com a coleta de dados de caráter retrospectivo, tem como objetivo identificar as reações adversas manifestadas pelos pacientes diabéticos ou de esclerose múltipla, submetidos ao TACTH no período de 2004 a dezembro de 2010. Para a coleta de dados elaborou-se dois instrumentos que foram submetidos à validação aparente e de conteúdo por três juízes. A amostra final do estudo foi constituída pela obtenção dos dados de 72 prontuários, sendo 23 de pacientes diabéticos e 49 de pacientes com EM. Em relação aos pacientes diabéticos 16 pertenciam ao sexo masculino e a idade média foi 18,26 anos. Todos possuíam positividade para o anticorpo anti-carboxilase do ácido glutâmico (antiGAD65). Quanto aos pacientes com EM, trinta e três pertenciam ao sexo feminino e idade média foi de 37,2 anos. O subtipo da doença mais frequente foi o surto-remissivo em 21 (42,9%) pacientes. A escala expandida do estado de incapacidade (EDSS) variou entre 3,0 e 6,5. Em relação às reações adversas manifestadas pelos pacientes diabéticos foram mais frequentes os calafrios, febre, cefaléia, náusea e vômito e nos pacientes com esclerose múltipla foram retenção hídrica e cefaléia. As principais intervenções de enfermagem identificadas para os pacientes diabéticos e com EM foram monitorização dos sinais vitais, coleta de hemocultura, otimização da administração de medicamentos antieméticos, controle da infusão da globulina antitimocitária, orientações sobre alimentação e para reduzir o risco de queda. Os pacientes com DM1 apresentam reações mais agudas e necessitam de monitorização contínua. Já os pacientes com EM são mais dependentes dos cuidados de enfermagem, exigindo maior tempo de cuidados prestados pelo profissional. Embora o DM1 e a EM sejam doenças distintas, percebe-se que na prática clínica, exigem do enfermeiro uma excelência no cuidado, quer pelas particularidades do tratamento realizado ou pelas singularidades de cada uma delas. / Multiple sclerosis (MS) is a progressive demyelinating autoimmune disease, immune- mediated by auto-reactive T lymphocytes, which provoke an immunological cascade, enhancing the local inflammation. In type 1 diabetes mellitus (DM1), self-reactive T lymphocytes exist that destroy ? cells in the pancreas, causing insulin production deficiency. The development of specific therapeutics is limited by these diseases\' undefined etiology, despite advances in anti-inflammatory and immunosuppressive therapy. A current treatment alternative for these diseases is autologous hematopoietic stem cell transplantations (AHSCT). The aim of this observational and cross-sectional study with retrospective data collection is to identify the adverse reactions manifested by diabetic or MS patients who were submitted to AHSCT between 2004 and December 2010. For data collection, two instruments were elaborated, submitted to face and content validation with the help of three experts. The final study sample comprised data from 72 patient files, 23 from diabetic and 49 from MS patients. As for the diabetic patients, 16 were male and the mean age was 18.26 years. All were positive for the anti-glutamic acid decarboxylase (antiGAD65) antibody. Concerning MS patients, 33 were female and the mean age was 37.2 years. The most frequent disease subtype was relapsing-remitting in 21 (42.9%) patients. The expanded disability status scale (EDSS) score ranged between 3.0 and 6.5. As for the adverse reactions the diabetic patients manifested, shivers, fever, migraine, nausea and vomiting were the most frequent, while fluid retention and migraine were the most frequent among multiple sclerosis patients. The main nursing interventions identified for the diabetic and MS patients were vital sign monitoring, blood culture collection, optimization of anti-emetic drug administration, control of anti- thymocyte globulin infusion, dietary orientations and advice to reduce the risk of falls. DM1 patients present more acute reactions and need continuous monitoring. MS patients are more dependent on nursing care, demanding lower professional care time. Although DM1 and MS are distinct conditions, in clinical practice, they demand excellent care from nurses, whether due to the particularities of the treatment or the singularities of each disease.