The main functions of natural killer (NK) cells are early protection against viruses or tumor cells and production of cytokines that regulate immune functions. The present study assessed the role of different NK subsets in exerting graft-versus-leukemia effects in recipients of human leukocyte antigen (HLA) haploidentical hematopoietic transplants and monitored for the first time CD3–/CD56– lymphocyte expansion. CD3–/CD56– cells expressed NK cell-associated molecules, such as CD16, NKp46, NKp30, CD244 (2B4), CD161, and killer cell immunoglobulin-like receptors. CD3–/CD56– cells further exhibited the classical functional characteristics of NK cells: cytolysis of target cells lacking HLA class I, antibody-dependent cellular cytotoxicity and cytokine production. These results demonstrate that CD56– NK cells are functional, recognize missing self and, like their CD56+ counterparts, may contribute to graft-versus-leukemia reactions.

Inhibitory-cell killer immunoglobulin-like receptors (KIR) negatively regulate natural killer (NK) cell-mediated killing of HLA class I-expressing tumors. Lack of KIR-HLA class I interactions has been associated with potent NK-mediated antitumor efficacy and increased survival in acute myeloid leukemia (AML) patients upon haploidentical stem cell transplantation from KIR-mismatched donors. To exploit this pathway pharmacologically, we generated a fully human monoclonal antibody, 1-7F9, which cross-reacts with KIR2DL1, -2, and -3 receptors, and prevents their inhibitory signaling. The 1-7F9 monoclonal antibody augmented NK cell-mediated lysis of HLA-C-expressing tumor cells, including autologous AML blasts, but did not induce killing of normal peripheral blood mononuclear cells, suggesting a therapeutic window for preferential enhancement of NK-cell cytotoxicity against malignant target cells. Administration of 1-7F9 to KIR2DL3-transgenic mice resulted in dose-dependent rejection of HLA-Cw3-positive target cells. In an immunodeficient mouse model in which inoculation of human NK cells alone was unable to protect against lethal, autologous AML, preadministration of 1-7F9 resulted in long-term survival. These data show that 1-7F9 confers specific, stable blockade of KIR, boosting NK-mediated killing of HLA-matched AML blasts in vitro and in vivo, providing a preclinical basis for initiating phase 1 clinical trials with this candidate therapeutic antibody.

Allogeneic hematopoietic transplantation relies on T-cell alloreactions for engraftment and the GvL effect. In HLA haplotype-mismatched transplants, extensive T-cell depletion of the graft is essential to prevent GvHD. This raises the question of whether mismatched transplants exert any GvL effect, and whether it will ever be possible to reduce the intensity of preparative regimens. Natural killer (NK) cells are negatively regulated by MHC Class I-specific inhibitory receptors. Mismatched transplants may therefore trigger NK-cell alloreactivity.The effects of NK-cell alloreactivity were evaluated in clinical transplantation and in murine transplant models.In clinical hematopoietic stem-cell transplants, HLA Class I disparities driving NK-cell alloreactions in the GvH direction eliminate AML relapse and graft rejection, while protecting patients from GvHD. In murine MHC mismatched transplant models, the pre-transplant infusion of donor-versus-recipient alloreactive NK cells conditioned the recipients to BMT, and reduced GvHD.NK-cell alloreactivity may thus provide a novel, powerful tool for enhancing the efficacy and safety of allogeneic hematopoietic transplantation.

Abstract Abstract 511 Donor-versus-recipient NK cell alloreactivity has been established as a key therapeutic element in HLA haplotype mismatched hematopoietic transplants in adult AML (Ruggeri et al. Blood 1999; Science 2002; Blood 2007; Stern et al., Blood 2008) and paediatric ALL (Pende et al. Blood 2009). It is effected by donor NK cells which express inhibitory KIRs for self class I KIR ligands (HLA-C1, C2, Bw4). In KIR ligand mismatched recipients, they sense missing expression of donor KIR ligand(s) and mediate alloreactions. Recent studies have proposed refinements to this mechanism and have emphasized the role of donor activating KIR variants in the control of leukemia relapse after haploidentical (Pende et al. Blood 2008) and unrelated (Cooley et al. Blood 2009) hematopoietic cell transplantation. ∼25% of Caucasians are homozygous for A haplotypes which contain inhibitory KIR genes and the KIR2DS4 activating KIR (non-functional in 2/3 of individuals). 75% of Caucasians are either heterozygous or homozygous for B haplotypes which carry not only inhibitory KIRs but also various combinations of activating KIRs (KIR2DS1-2-3-5 and KIR3DS1). Our extensive functional assessments of donor NK clone repertoires from representative sets of A (homozygous) or B (homozygous and heterozygous) haplotype donors, involving functional analyses of >5,000 NK clones from 70 donors, revealed that frequencies of alloreactive NK cell clones did not differ significantly in A vs B haplotype donors, that NK alloreactive repertoires in B haplotype positive individuals were largely composed of clones which did not express activating KIR(s) and, finally, that activating KIR-negative clones killed as efficiently as the positive. In contrast, dramatic differences emerged when inflammatory cytokine production was assessed in alloreactive NK clones with possessed or did not possess activating KIR variants. Upon incubation with KIR ligand-mismatched LPS or Aspergillus or CMV antigen-treated DCs, NK clones expressing activating KIR receptors produced several-fold more IFN-gamma and TNF-alfa than NK clones not expressing activating KIRs. The clinical role of donor activating KIR genetics was evaluated in 86 haploidentical transplants for AML. 49 recipients were transplanted from NK alloreactive (KIR ligand-mismatched) donors (12 with group A KIR gene haplotypes vs 37 with B haplotypes) and 37 recipients from non-NK alloreactive (KIR ligand-matched) donors (8 with group A KIR gene haplotypes vs 29 with B haplotypes). The remarkable GvL effect of NK alloreactive transplants (Ruggeri et al. Blood 2007) was unaffected by donor A vs B KIR gene haplotypes. In contrast, in transplants from NK alloreactive donors, presence of group B haplotype KIR genes in the donors was associated with reduced incidence of TRM (largely infection-related) (B vs A haplotypes: 20% vs 67% TRM, p<0.01). In multivariate analyses it was the only significant variable predicting protection from TRM (RR: 0.24; 95% CI:0.14-0.42; p<0.01). When the number of activating KIR genes in the donor was taken into account, donors carrying ≥ 3 activating KIR genes provided significant protection from TRM and significantly better EFS compared with A haplotype donors (TRM: 12% vs 67%, p<0.003) (EFS: 71% vs 33%, p=0.02). In multivariate analysis, transplantation from alloreactive donors carrying ≥3 group B haplotype activating KIR genes was the only variable predicting protection from TRM (RR: 0.36; 95% CI: 0.25-0.54; p<0.01) and tended to improve EFS (RR: 0.64; 95% CI: 0.38-1.07; p<0.1). We conclude that NK alloreactive, KIR ligand-mismatched donors who possess activating KIRs may confer protection against infections through their enhanced NK cell cytokine secretion upon interaction with recipient pathogen-infected DCs. Disclosures: No relevant conflicts of interest to declare.

NK cells use a variety of receptors to detect abnormal cells, including tumors and their metastases. However, in the case of melanoma, it remains to be determined what specific molecular interactions are involved and whether NK cells control metastatic progression and/or the route of dissemination. Here we show that human melanoma cell lines derived from LN metastases express ligands for natural cytotoxicity receptors (NCRs) and DNAX accessory molecule-1 (DNAM-1), two emerging NK cell receptors key for cancer cell recognition, but not NK group 2 member D (NKG2D). Compared with cell lines derived from metastases taken from other anatomical sites, LN metastases were more susceptible to NK cell lysis and preferentially targeted by adoptively transferred NK cells in a xenogeneic model of cell therapy. In mice, DNAM-1 and NCR ligands were also found on spontaneous melanomas and melanoma cell lines. Interference with DNAM-1 and NCRs by antibody blockade or genetic disruption reduced killing of melanoma cells. Taken together, these results show that DNAM-1 and NCRs are critical for NK cell-mediated innate immunity to melanoma cells and provide a background to design NK cell-based immunotherapeutic strategies against melanoma and possibly other tumors.

Inhibitory killer cell immunoglobulin receptors (KIR) bind to major histocompatibility complex antigens. Concise knowledge of KIR ligands allows prediction of natural killer (NK)-cell alloreactivity after hematopoietic stem cell transplantation. KIR3DL1 binds to the Bw4 epitope on HLA-B antigens. Although the same epitope is also found on 4 HLA-A antigens (HLA-A23/24/25/32), these are not currently regarded as KIR3DL1 ligands. We show that expression of HLA A*2301, A*2402, or A*3201 but not HLA A*2501 protects target cells from lysis by KIR3DL1(+) NK cells. KIR3DL1(+) NK cells from donors expressing the Bw4 epitope on an HLA-A antigen only are fully functional and capable of lysing Bw4(-) target cells. HLA A25 differs at amino acid 90, close to the serologic Bw4 epitope, from A23/24/32 and from Bw4(+) HLA-B antigens. These data suggest that HLA-A antigens should be taken into consideration when assessing the potential for NK alloreactivity after hematopoietic stem cell transplantation.

NK cell alloreactivity mediated by donor NK cells is a fundamental therapeutic tool in HLA haplotype mismatched hematopoietic transplantation in adult acute myeloid leukemia and pediatric acute lymphoblastic leukemias. NK cell is mediated by donor NK cells recovering very early after transplant. The self donor KIR ligands educates the donor NK repertoire and arms functional NK cells which express inhibitory killer cell immunoglobulin-like receptor(s) (KIRs) for self-class I ligand(s), They sense missing expression of donor KIR ligand(s) in the recipient and mediate alloreactivity. Donor-versus-recipient NK cell alloreactivity is evaluated by KIR genotyping and phenotyping and functional assay.

Objectives: Exposure to cardiovascular risk factors causes the release of pro-atherogenic microparticles from vascular cells and reduces the number of the atheroprotective endothelial progenitor cells (EPCs). We investigated whether microparticles shedding from EPCs are detectable in cultures of EPCs and in the circulation of subjects with various degrees of cardiovascular risk. We also investigated the relationship of EPCs-derived microparticles to cardiovascular risk factors and aortic stiffness, a marker of cardiovascular risk and impaired vascular repair by EPCs.Methods and Results: We estimated the 10-year Framingham risk score in 105 individuals with various degrees of cardiovascular risk and measured the number of circulating EPCs, EPCs-derived microparticles (CD34+/KDR+) and aortic stiffness. Release of CD34+/KDR+ microparticles was tested in cultures of EPCs exposed to hydrogen-peroxide. CD34+/KDR+ microparticles were found in EPCs cultures incubated with hydrogen-peroxide. Framingham risk was associated with EPCs (r = -0.47, p < 0.00 1) and CD34+/KDR+ microparticles (r= 0.56, p < 0.001). Low EPCs (r= -0.59, p < 0.001) and high CD34+/KDR+ microparticle (r= 0.57, p < 0.001) levels were predictors of aortic stiffness, independent of the Framingham risk.Conclusions: EPCs undergo fragmentation into microparticles when exposed to a pro-apoptotic milieu. Increased microparticle shedding from EPCs may reduce circulating EPCs levels and may thus contribute to increase aortic stiffness beside traditional risk factors. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

In patients with acute myeloid leukemia (AML), haplo-identical stem cell transplantation (SCT) can lead to expansion and activation of Killer Immunoglobulin-like Receptor (KIR)-HLA class I mismatched NK cells, resulting in reduced rates of leukemia relapse and no graft-versus-host disease (Ruggeri et al. Science 2002). However, this SCT is not available to the majority of AML patients who are elderly. To explore the feasibility of achieving similar NK-mediated anti-leukemia activity by a pharmacological approach, we generated fully human anti-KIR mAbs that block the interactions of inhibitory KIR2DL receptors with their HLA-C ligands, thereby enhancing NK activity. Here we describe one such therapeutic candidate anti-KIR mAb, designated 1-7F9. As distinct HLA-C allotypes are recognized by KIR2DL1 or −2/3, only mAbs that cross-react with these KIRs would be expected to work in the entire population. Hence, 1-7F9 was initially selected based on its ability to bind soluble, recombinant KIR2L1, −2 and −3. By Biacore analysis, the bivalent affinities for KIR2DL1 and −3 were 0.43 × 10−9 M and 0.025 × 10−9 M, respectively. In experimental systems and in normal human blood, 1-7F9 bound KIR2DL1, −2 and −3, and −2DS1 and −2, but not to KIR2DS3 or −4. 1-7F9 dose-dependently inhibited the binding of soluble KIR2DL1-Fc to cell surface HLA-Cw4. 1-7F9 augmented the lysis of 721.221-Cw4 B-EBV cells by an NK cell line transfected with KIR2DL1 (YTS-2DL1) from 5% lysis in absence of mAb to a maximal 55% lysis at 5 ug/ml of mAb, but did not affect lysis by KIR-negative NK cells. Lysis of PHA-stimulated blasts and primary AML blasts by autologous IL-2 activated NK cells (E:T=6:1) was 10 and 15%, respectively, in absence of mAb vs 80% and 55% in presence of 1-7F9. Incubation of IL-2 activated blood mononuclear cells with 1-7F9 resulted in expression of the activation marker CD107 on about 10% of KIR2D-positive NK cells, which increased to 20% upon addition of HLA-C-positive B-EBV targets, suggesting that 1-7F9 preferentially induces activation of NK cells in presence of transformed cells. The isotype of 1-7F9 is IgG4; accordingly, it did not cause depletion of KIR positive cells in vitro or in vivo in KIR-transgenic mice despite long-lived KIR-occupancy. As KIR are not found in mice, in vivo activity was tested in a NOD-SCID mouse model where inoculation of in vitro-expanded NK cells (80% of NK cells KIR2D-positive) and autologous human B-EBV cells (E:T=1:3) resulted in death of all mice by day 26. A single injection of 1-7F9 (125 ug/mouse) resulted in long-term survival, with 100% of treated mice alive beyond day 60; in contrast, 60 ug/mouse of the mAb was ineffective. Similarly, ex vivo pre-incubation of NK cells with 1-7F9 (37,3 ug/106 NK cells) prior to inoculation in mice resulted in elimination of the autologous transformed B cells in vivo and survival of 100% of the treated animals. These data show that 1-7F9 augments NK-mediated tumor killing in vitro and in vivo, and that it exhibits long-lived KIR binding in vivo, providing a preclinical basis for initiating phase 1 clinical trials with the mAb.

We analyzed 112 patients with high-risk acute myeloid leukemia (61 in complete remission [CR]; 51 in relapse), who received human leukocyte-antigen (HLA)-haploidentical transplants from natural killer (NK) alloreactive (n = 51) or non-NK alloreactive donors (n = 61). NK alloreactive donors possessed HLA class I, killer-cell immunoglobulin-like receptor (KIR) ligand(s) which were missing in the recipients, KIR gene(s) for missing self recognition on recipient targets, and alloreactive NK clones against recipient targets. Transplantation from NK-alloreactive donors was associated with a significantly lower relapse rate in patients transplanted in CR (3% versus 47%) (P > .003), better event-free survival in patients transplanted in relapse (34% versus 6%, P = .04) and in remission (67% versus 18%, P = .02), and reduced risk of relapse or death (relative risk versus non-NK-alloreactive donor, 0.48; 95% CI, 0.29-0.78; P > .001). In all patients we tested the "missing ligand" model which pools KIR ligand mismatched transplants and KIR ligand-matched transplants from donors possessing KIR(s) for which neither donor nor recipient have HLA ligand(s). Only transplantation from NK-alloreactive donors is associated with a survival advantage.

Objectives— Atherosclerosis may be caused by increased endothelial damage and by a consumptive loss of endothelial repair capacity by endothelial progenitors. Arterial stiffness is a reliable marker of atherosclerosis and a positive correlate of endothelial damage. We investigated whether an increased ratio of CD31 + /CD42 − microparticles to endothelial progenitors, a possible indicator of endothelial damage and impaired endothelium reparation, may contribute to aortic stiffness in hypercholesterolemia. We also studied the in vitro effect of microparticles from hypercholesterolemic patients on endothelial progenitor survival. Methods and Results— Circulating CD31 + /CD42 − microparticles, endothelial progenitors, and aortic pulse wave velocity (aPWV), a measure of aortic stiffness, were measured in 50 patients with never-treated hypercholesterolemia and 50 normocholesterolemic controls. Hypercholesterolemic patients had more circulating CD31 + /CD42 − microparticles, less endothelial progenitors, and a stiffer aorta than controls. aPWV was associated with CD31 + /CD42 − microparticles ( r =0.61; P <0.001), endothelial progenitors ( r =−0.45, P <0.001), and with cholesterol levels ( r =0.51; P <0.001). High plasma cholesterol and a high ratio of CD31 + /CD42 − microparticles to endothelial progenitors independently predicted an increased aPWV. Microparticles from hypercholesterolemic patients caused a significant endothelial progenitor loss in vitro. Conclusions— Hypercholesterolemia-related aortic stiffness is promoted by plasma cholesterol directly, increased endothelial damage, and reduced endothelium repair capacity by endothelial progenitors.

In haploidentical transplants that are KIR ligand mismatched in the GvH direction, functional donor NK-cells that express as their sole inhibitory receptor for self, a KIR for the HLA-class-I group which is absent in the recipient, sense the missing expression of the self class-I ligand on allogeneic targets and mediate alloreactions. In a limited series of transplants donor-vs-recipient NK-cell alloreactivity reduced the risk of AML relapse and markedly improved EFS (Ruggeri L, Science 2002). Here, we analyzed 112 AML patients transplanted from NK-alloreactive (n=51) or non-NK-alloreactive (n=61) haploidentical donors. NK-alloreactive donors possessed: HLA-class-I KIR ligand(s) which were missing in the recipients, KIR gene(s) for missing self recognition on recipient targets, and alloreactive NK-clones against recipient targets. Transplantation from NK-alloreactive donors was associated with: significantly lower relapse rate in patients transplanted in CR (3% vs 47%) (P<0.003); decrease infectious mortality which was more evident in patients transplanted in relapse (P=0.1); better EFS in patients transplanted in relapse (34% vs 6%, P=0.04) and in remission (67% vs 18%, P=0.02); reduced risk of relapse or death (relative risk vs non-NK-alloreactive donor: 0.48 [95% CI 0.29–0.78], P<0.001). Recently, an additional algorithm, termed the “missing ligand” model, has been proposed for predicting favorable outcomes not only in haploidentical (Leung W, JI 2004; JI 2005) but also in matched sibling (Hsu KC, Blood 2005) and in unrelated donor transplants (Hsu KC, BBMT 2006). The “missing-ligand” model includes all donor-recipient pairs in whom there is a mismatch between KIR(s) in the donor and HLA molecule(s) in the recipient. Consequently, the model includes all KIR ligand-mismatched transplants because they are all associated with a missing KIR ligand in the recipient, and KIR ligand-matched transplants from donors possessing “extra” KIR(s) for which neither donor nor recipient have HLA ligand(s). Therefore, in the same series of patients we tested the “missing ligand” model. The first step was to divide our 61 non-NK alloreactive (KIR ligand-matched) donor-recipient pairs according to the number of KIR ligands in donor and recipient, i.e., three KIR ligands (29 patients; 15 in remission, 14 in relapse at transplant) vs fewer than three (32 patients; 16 in remission, 16 in relapse at transplant). EFS did not differ in each sub-group. Both curves indicated worse survival than after transplantation from NK-alloreactive donors. The second step was to group the above 32 “missing ligand” transplants and all 51 KIR ligand-mismatched transplants (which corresponded to all our NK-alloreactive transplants). We analyzed EFS in this pool of 83 patients (46 in remission, 37 in relapse at transplant) against EFS in 29 patients with no missing ligand (15 in remission, 14 in relapse at transplant). No significant difference emerged. EFS in the “missing ligand” cohort was worse than after transplantation from NK-alloreactive donors. Therefore, the present analysis leaves no doubt that KIR ligand mismatches, i.e., donor NK cell recognition of “missing self” on recipient targets, are essential for triggering powerful NK cell alloreactions that impact beneficially on transplantation outcomes.

Transplantation of peripheral blood hematopoietic cells from HLA haplotype-mismatched family members is a therapeutic strategy for patients with high-risk acute leukemia who need transplantation and do not have matched donors. As T cell alloreactions cause lethal GvHD in mismatched transplants, only T cell-depleted hematopoietic grafts can be used. In adults, because of declining thymic function, immune-recovery originates from expansion of the mature T cells infused with the graft. In T cell depleted mismatched transplant immune recovery is hindered by the paucity of the starting T-cell population. Slow recovery of functional T cell immunity to pathogens is responsible for 35% infection-related mortality which remains the most pressing clinical issue. In murine MHC-haploidentical bone marrow transplant models we demonstrated donor-versus-recipient alloreactive NK cells ablate recipient-type lympho-hematopietic cells such as leukemic cells, the T cells that cause rejection and the antigen-presenting cells which trigger GvHD.

Aspergillus and cytomegalovirus are major causes of morbidity/mortality after haploidentical hematopoietic transplantation. The high degree of mismatching makes cell immunotherapy impossible as it would result in lethal graft-versus-host disease (GvHD). We generated large numbers of donor T-cell clones specific for Aspergillus or cytomegalovirus antigens. We identified clones potentially responsible for causing GvHD by screening them for cross-reactivity against recipient mononuclear cells. Non-recipient reactive, pathogen-specific clones were infused soon after transplantation. They were CD4+ and produced high levels of interferon-gamma and low levels of interleukin-10. In 46 control transplant recipients who did not receive adoptive therapy, spontaneous pathogen-specific T cells occurred in low frequency 9 to 12 months after transplantation and displayed a non-protective low interferon-gamma/high interleukin-10 production phenotype. In the 35 recipients who received adoptive therapy, one single infusion of donor alloantigen-deleted, pathogen-specific clones in the dose range of 10(5) to 10(6) cells/kg body weight did not cause GvHD and induced high-frequency T-cell responses to pathogens, which exhibited a protective high interferon-gamma/low interleukin-10 production phenotype within 3 weeks of infusion. Frequencies of pathogen-specific T cells remained stable over time, and were associated with control of Aspergillus and cytomegalovirus antigenemia and infectious mortality. This study opens new perspectives for reducing infectious mortality after haploidentical transplantations.

NK cells are primed to kill by several activating receptors. Killing of autologous cells is prevented as NK cells co-express inhibitory receptors for self-MHC class I molecules. Human NK cells discriminate between different allelic forms of MHC molecules via killer cell immunoglobulin-like receptors (KIRs), which are clonally distributed, and each cell in the repertoire bears at least one receptor that is specific for self-MHC class I molecules. Consequently, when faced with mismatched allogeneic targets, NK cells in the repertoire will sense the missing expression of self-MHC class I alleles and will mediate alloreactions. Recent studies in murine transplant models and data from mismatched haematopoietic transplant trials demonstrate MHC class I mismatches, which generate an alloreactive NK-cell response in the graft-versus-host direction, eradicate leukaemia, improve engraftment and protect against T-cell-mediated graft-versus-host disease.

Natural killer (NK) cells are primed to kill by several activating receptors. NK cell killing of autologous cells is prevented because NK cells coexpress inhibitory receptors (killer cell immunoglobulin-like receptors [KIR]) that recognize groups of (self) major histocompatibility complex class I alleles. Because KIRs are clonally distributed, the NK cell population in any individual are constituted of a repertoire with a variety of class I specificities. NK cells in the repertoire mediate alloreactions when the allogeneic targets do not express the class I alleles that block them. After haploidentical hematopoietic transplantation, NK cell-mediated donor-versus-recipient alloresponses reduce the risk of relapse in acute myeloid leukemia patients while improving engraftment and protecting against graft-versus-host disease. High-resolution molecular HLA typing of recipient and donor, positive identification of donor KIR genes, and, in some cases, functional assessment of donor NK clones identify haploidentical donors who are able to mount donor-versus-recipient NK alloreactions.

Although natural killer (NK) cells are triggered to kill by many activating receptors, lysis of autologous cells is blocked by inhibitory receptors (called Killer cell Ig-like receptors or KIRs) which recognize epitopes shared by certain major histocompatibility complex (MHC) class I allele groups (called KIR ligands). As these inhibitory receptors are clonally distributed, they constituted a repertoire containing different allospecificities. Thus, the NK cells in the repertoire are lytic against allogeneic targets that do not express their inhibitory KIR ligands. In hematopoietic human-leukocyte-antigen (HLA)-haplotype mismatched transplantation, donor-vs-recipient alloreactive NK cells improve engraftment, decrease the incidence of leukemia relapse and do not cause Graft-vs-Host disease (GvHD). Pre-transplant molecular high-resolution HLA of recipient and donor, KIR genotyping of the donor and direct assessment of the donor NK repertoire identify donors with the potential for donor-vs-recipient NK cell alloreactivity.