Alloreactivity after transplantation is associated with profound immune suppression, and consequent opportunistic infection results in high morbidity and mortality. This immune suppression is most profound during GVHD after bone marrow transplantation where an inflammatory cytokine storm dominates. Contrary to current dogma, which avers that this is a T-cell defect, we demonstrate that the impairment lies within conventional dendritic cells (cDCs). Significantly, exogenous antigens can only be presented by the CD8 ؊ cDC subset after bone marrow transplantation, and inflammation during GVHD specifically renders the MHC class II presentation pathway in this population incompetent. In contrast, both classic and cross-presentation within MHC class I remain largely intact. Importantly, this defect in antigen processing can be partially reversed by TNF inhibition or the adoptive transfer of donor cDCs generated in the absence of inflammation. (Blood. 2012;119(24): 5918-5930)
IntroductionBone marrow transplantation (BMT) is well established as curative therapy for hematologic malignancies, including leukemia. BMTrelated mortality remains high, however, with death occurring in up to 50% of recipients because of leukemic relapse, GVHD, and infection. Despite advances in the use of prophylactic antibiotic and antifungal therapies in patients with GVHD, infection remains a major cause of nonrelapse mortality. GVHD pathogenesis itself is characterized by 3 key elements: (1) the initial damage of host tissue by pretransplant conditioning, which leads to the release of proinflammatory cytokines and translocation of toll-like receptor (TLR) ligands from the gastrointestinal tract into the systemic circulation; (2) the activation of donor-derived T cells by contact with host and donor antigen-presenting cells (APCs); and (3) the subsequent expansion of effector T cells and production of further proinflammatory cytokines. 1 Importantly, the hallmark pathologic feature of acute GVHD is extensive host tissue apoptosis.Suppression of immune function is well recognized as one of the consequences of GVHD after BMT, with reports of suppressed immune function in humans and mice with GVHD appearing in the literature as early as the 1960s. [2][3][4][5][6] Importantly, although immunosuppressive pharmacologic agents are administered to patients to prevent and treat GVHD, the observed level of immune suppression far exceeds that which may be expected because of their effects. The basis of this immunologic defect remains unclear, although it has primarily been attributed to defects within the T-cell compartment induced by the inflammatory cytokine milieu during GVHD. 3 Defects in both cytotoxic T lymphocytes and T-helper cell function have been reported in GVHD, although these studies do not address the mechanism underlying the reported T-cell insufficiency.Myeloid suppressor cells have also been recognized as potential contributors to post-BMT immune suppression, through both the production of regulatory cytokines and contact-dependent mec...