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Definitions

• liver transplantation has become widely popular as the ultimate treatment for patients with end-stage liver failure.
• the world's first clinical liver transplant was performed in 1963, and to date, more than 300,000 cases have been performed.
• the development of liver transplantation has been due to advances in surgical techniques, organ preservation, pre- and post-operative management, and among others, improvements in immunosuppressants used to suppress post-transplant rejection have made a major contribution.
• the 1- and 5-year patient survival rates of azathioprine (1960s-70s), cyclosporine (1980s), and tacrolimus (1990s and later), which have been used to date, are approximately 35%, 20%, 70%, and 20%, respectively. 60%, and about 80% and 70%.
• the technology of the present disclosure avoids treatment with immunosuppressants, which are always exposed to the risks of drug-induced side effects such as infection, carcinogenesis, and exacerbation of metabolic diseases, and prevents grafting even if immunosuppressants are discontinued. Provides induction of normally functioning immune tolerance.
• the present inventors have discovered cells and their suppressive molecules that induce donor antigen-selective immune tolerance through anti-CD80 and anti-CD86 antibody treatment to attenuate immune rejection in organ transplant patients.
• the mechanism it provides the best technology for practical use in the clinic, including a suitable manufacturing method in human patients.
• Inducible suppressive T cell preparations are induced by co-culturing patient peripheral blood mononuclear cells with irradiated donor peripheral blood mononuclear cells in the presence of anti-CD80 and anti-CD86 antibodies. It contains induced suppressive T cells.
• the components of the induced suppressive T cells contained in the preparation of the present disclosure are mononuclear cells, mainly T lymphocytes, and mainly CD4 + T cells and CD8 + T cells.
• the active ingredients of the formulations of the present disclosure are CD4 + CD25 + Foxp3 + T cells (regulatory CD4 + T cells) and CD8 + CD45RA ⁇ T cells (suppressive CD8 + T cells).
• effector CD4 + T cells and effector CD8 + T cells that have reacted with HLA class I and class II antigens expressed in the donor organ is inhibited, resulting in new regulatory control.
• CD4 + T cells and suppressive CD8 + T cells are induced.
• the immune rejection reaction specific to the donor HLA antigen is continuously attenuated, making it possible to reduce the amount of immunosuppressant used or to withdraw it.
• the present disclosure provides: (Item 1) A method for evaluating the quality of a drug for achieving immune tolerance administered to a patient receiving a living donor liver transplant, the method comprising: (a) a step of mixedly culturing peripheral blood lymphocytes collected from the patient before the living liver transplant and peripheral blood lymphocytes collected from the donor of the living liver transplant; (b) mixing peripheral blood lymphocytes collected from the patient before said living liver transplant, peripheral blood lymphocytes collected from the donor of said living liver transplant, and a drug for achieving immune tolerance in said patient; A step of culturing; (c) measuring the cytokine production in steps (a) and (b), and if the cytokine production in step (b) is altered compared to step (a), the agent is How to consider it as a therapeutic drug.
• the drug is an inhibitory factor that inhibits the interaction between CD80 and/or CD86 expressed on the cell surface of a certain cell and CD28 expressed on the cell surface of another cell.
• the method of. The drug is an induced suppressive T cell preparation, and the induced suppressive T cell preparation induces peripheral blood lymphocytes from the living donor liver transplant patient and donor in the presence of a CD80 antibody and/or a CD86 antibody.
• step 5 The method according to any one of the above items, characterized in that the immunotolerance therapy for the patient is changed if the cytokine production in step (b) is altered compared to step (a). .
• step 6 (i) increasing the amount of immunosuppressant administered to said patient if pro-inflammatory cytokine production in step (b) is increased compared to step (a); and/or immunizing said patient; discontinuing tolerance therapy and/or (ii) increasing the amount of immunosuppressant administered to said patient if anti-inflammatory cytokine production is reduced in step (b) compared to step (a);
• a method for achieving immune tolerance in a patient comprising: collecting lymphocytes from the donor by apheresis; collecting lymphocytes from the patient by apheresis; transplanting the donor-derived liver or a portion thereof to the patient; After the living donor liver transplant, the patient: sequential administration of a corticosteroid, an antimetabolite, and a first immunosuppressant; performing immune monitoring for rejection of the living donor liver transplant and/or periodic liver biopsy; After the living donor liver transplantation, administering a second immunosuppressant to the patient; After administering the second immunosuppressive agent, administering to the patient an agent for achieving immune tolerance in the patient; stepwise reducing the dosage of the corticosteroid, the antimetabolite, and the first immunosuppressant.
• a final decision to discontinue administration of the first immunosuppressant is made based on liver biopsy at the end of the period, Furthermore, if the patient continues to have stable liver function values and a liver biopsy in which no pathologically treatable rejection is confirmed for a predetermined period of time after discontinuing administration of the first immunosuppressant, , Operational tolerance is determined to have been achieved.
• a method for achieving immune tolerance in a patient comprising: Collecting lymphocytes from the donor by apheresis 14 to 3 days before transplantation; collecting lymphocytes from the patient by apheresis one day before transplantation; transplanting the donor-derived liver or a portion thereof to the patient; After the living donor liver transplant, the patient: continuous administration of corticosteroids, antimetabolites, and calcineurin inhibitors; performing immune monitoring for rejection of the living donor liver transplant and/or periodic liver biopsy; 4 to 6 days after liver transplantation, administering 20 to 50 mg/kg of cyclophosphamide to the patient; administering to the patient, at any point between 9 and 11 days after liver transplantation, a drug for achieving immune tolerance in the patient; reducing the dose of the calcineurin inhibitor at least 13 weeks post-transplant; including; Immune monitoring for said rejection and/or periodic liver biopsies to confirm the achievement of immune tolerance or to determine transition to conventional immunosuppressive therapy; Monitor the patient
• a final decision to discontinue administration of the calcineurin inhibitor is made based on liver biopsy; Furthermore, if the patient has stable liver function values and a liver biopsy in which no pathologically treatable rejection has been confirmed for 52 weeks or more after discontinuing administration of the calcineurin inhibitor, the patient will have to undergo operational tolerance.
• a method characterized in that it is determined to have been accomplished. (Item A4) The method of any one of the preceding items, wherein administration of the corticosteroid and antimetabolite to the patient is discontinued at least within 4 weeks after the living donor liver transplant. (Item A5) The method of any one of the preceding items, wherein administration of the corticosteroid and antimetabolite to the patient is discontinued at least within 26 weeks after the living donor liver transplant.
• the drug is an inhibitory factor that inhibits the interaction between CD80 and/or CD86 expressed on the cell surface of a certain cell and CD28 expressed on the cell surface of another cell.
• the drug is an induced suppressive T cell preparation, and the induced suppressive T cell preparation induces peripheral blood lymphocytes from the living donor liver transplant patient and donor in the presence of a CD80 antibody and/or a CD86 antibody.
• (Item B1) A method for reducing the dose of an immunosuppressant in immunotolerance therapy, the method comprising: (1) Regarding corticosteroids, the step of administering them according to the schedule below; Administration during reperfusion After liver transplantation, reduce the dose and complete the administration within the prescribed period. If administration cannot be completed within the prescribed period, administer using any method of reducing the dose. (2) For antimetabolites, administering according to the schedule below; Administration after liver transplantation Discontinue administration within the specified period after liver transplantation. If administration cannot be completed within the specified period after liver transplantation, use any dose reduction method to terminate administration. As necessary.
• the dosage can be increased with a target of 1 week after liver transplantation, and in that case, the dosage is reduced in stages, (3) administering the first immunosuppressant according to the following schedule; (3-1) Predetermined period after liver transplantation (dose adjustment period) Administration was started on the day of liver transplantation or 1 day after liver transplantation, and the following blood trough concentrations: A predetermined blood trough concentration in the first predetermined period from the start of administration to the first predetermined period after liver transplantation A predetermined blood trough concentration in the second predetermined period after the first predetermined period after liver transplantation, respectively.
• first immunosuppressant dose reduction period After 26 weeks after liver transplantation (first immunosuppressant dose reduction period) During the first predetermined period after liver transplantation (reduction 1), the dosage and administration are adjusted to maintain the predetermined blood trough concentration.After the second predetermined period after liver transplantation (reduction 2), 1) Maintain the dose and gradually reduce the number of doses according to the reduction schedule. (3-3) If necessary, the period for reducing the dose of the first immunosuppressant is extended, each reduction is carried out if it is confirmed that there is no rejection reaction; Method.
• (Item B2) A method for reducing the dose of an immunosuppressant in immunotolerance therapy, the method comprising: (1) Regarding corticosteroids, the step of administering them according to the schedule below; Administer 1000 mg during reperfusion Administer 20 mg/day from 1 day after liver transplantation for 1 week Reduce the dose by 5 mg/day every week and finish administration within 4 weeks after liver transplantation 4 weeks after liver transplantation If administration cannot be completed within this period, use any reduction method to complete administration by 26 weeks after liver transplantation. (2) For antimetabolites, administer according to the schedule below; Administer a total of 500 mg/day in two divided doses starting from the 1st day after liver transplantation. Discontinue administration within 4 weeks after liver transplantation.
• the dose can be increased to 1000 to 2000 mg/day with a goal of 1 week after liver transplantation, in which case the gradual reduction is to 500 mg/day.
• a method for confirming the presence or absence of rejection by periodic liver biopsy in immunotolerance therapy comprising: A step of performing histological diagnosis on a control liver tissue sample collected from the transplanted liver on the day of liver transplantation and a sample obtained from regular liver biopsy after liver transplantation, and the results of the histological diagnosis. If the overall evaluation of acute rejection results in one of the predetermined discontinuation criteria, it is determined that there is a ⁇ pathological rejection reaction that requires treatment,'' and treatment for the rejection reaction is immediately started to establish immune tolerance.
• a method comprising the steps of discontinuing therapy.
• (Item C2) A method for confirming the presence or absence of rejection by periodic liver biopsy in immunotolerance therapy, comprising: Control liver tissue was collected from the transplanted liver on the day of liver transplantation, and samples obtained from routine liver biopsies 26 weeks after liver transplantation, 4 weeks after weight loss 5, and 52 weeks after liver transplantation.
• a step of performing a tissue diagnosis according to the scoring of Banff criteria (2016) and Venturi (2012), and the overall assessment of acute rejection is "moderate or higher” as a result of the tissue diagnosis
• the step of performing a tissue diagnosis according to the scoring of Banff criteria (2016) and Venturi (2012) and the overall evaluation of acute rejection is "moderate or higher” as a result of the tissue diagnosis, If the overall evaluation is ⁇ Yes'' and the liver fibrosis score is ⁇ 2 or more'', it is determined that there is a ⁇ pathological rejection reaction that should be treated'', and treatment for the rejection reaction is immediately performed.
• a method comprising the steps of initiating and discontinuing immune tolerance therapy.
• (Item D1) A method for achieving immune tolerance in a living donor liver transplant patient using a quality-evaluated agent for achieving immune tolerance, the method comprising: (a) a step of mixedly culturing peripheral blood lymphocytes collected from the patient before the living liver transplant and peripheral blood lymphocytes collected from the donor of the living liver transplant; (b) mixing peripheral blood lymphocytes collected from the patient before said living liver transplant, peripheral blood lymphocytes collected from the donor of said living liver transplant, and a drug for achieving immune tolerance in said patient; A step of culturing; (c) measuring cytokine production in steps (a) and (b); (d) After said living donor liver transplant, for said patient: sequential administration of a corticosteroid, an antimetabolite, and a first immunosuppressant; performing immune monitoring for rejection of the living donor liver transplant and/or periodic liver biopsy; (e) administering a single dose of a second immunosuppressant to the patient after the living donor liver transplant; (f) after administering the second immunosup
• the drug is an inhibitory factor that inhibits the interaction between CD80 and/or CD86 expressed on the cell surface of a certain cell and CD28 expressed on the cell surface of another cell.
• the drug is an induced suppressive T cell preparation, and the induced suppressive T cell preparation induces peripheral blood lymphocytes from the living donor liver transplant patient and donor in the presence of a CD80 antibody and/or a CD86 antibody.
• (Item D5) The method according to any one of the above items, characterized in that the immunotolerance therapy for the patient is changed if the cytokine production in step (b) is altered compared to step (a). .
• (Item D6) (i) increasing the amount of immunosuppressant administered to said patient if pro-inflammatory cytokine production in step (b) is increased compared to step (a); and/or immunizing said patient; discontinuing tolerance therapy and/or (ii) increasing the amount of immunosuppressant administered to said patient if anti-inflammatory cytokine production is reduced in step (b) compared to step (a);
• (Item D7) The method according to any of the preceding items, wherein the peripheral blood lymphocytes are stained with CFSE.
• (Item D8) The process according to any one of the above items, characterized in that in steps (a) and (b), B cells collected from the donor are used instead of peripheral blood lymphocytes collected from the donor.
• Method. (Item D9) The method of any of the preceding items, wherein the method is performed within at least about 3 days to about 6 days after the living donor liver transplant. (Item D10) The method according to any one of the above items, wherein the cytokine comprises IFN ⁇ , TNF, IL-2, IL-12, IL-15, IL-17, IL-18, IL-10, and/or TGF ⁇ . .
• (Item E1) A drug for achieving immune tolerance that is administered to a patient who has undergone living donor liver transplantation, the quality of which has been evaluated by the method described in any one of the above items.
• (Item F1) A method for reducing the dose of immunosuppressive drugs in immunotolerance therapy in patients undergoing living donor liver transplantation using quality-evaluated drugs for achieving immune tolerance, the method comprising: A method comprising the steps of the method according to item 1.
• FIG. 1A shows evaluation of immune reaction suppression ability of cell products by MLR.
• the same number of patient-derived cells and irradiated donor-derived cells, and the number of patient-derived cells in the cell artifact: Cell artifact 1:1/2, 1:1/4, 1:1/8, or 1:1/16
• Figures 1A-C show the results of three independent runs.
• FIG. 1B shows evaluation of immune reaction suppression ability of cell products by MLR.
• FIG. 1C shows evaluation of immune reaction suppression ability of cell products by MLR.
• FIG. 2 is a schematic diagram illustrating an overview of achieving a reduction in immunosuppressive drug use in a patient after living donor liver transplantation using an inducible suppressive T cell preparation according to an embodiment of the present disclosure.
• FIG. 3A shows the process from living donor liver transplantation to immunosuppressive drug reduction when the inducible suppressive T cell preparation according to an embodiment of the present disclosure is used to reduce the immunosuppressive drug in a patient after living donor liver transplantation.
• JB-101 indicates the induced suppressive T cell preparation of the present disclosure
• JB-CPA indicates endoxan for injection.
• the legends in the figures are as follows and are common to FIGS. 3A and 3B. *: It is not possible to perform the infusion on the same day as the inducible suppressive T cell preparation of the present disclosure.
• ⁇ Perform before and after peripheral blood mononuclear cell collection. However, it is not necessary to measure the body weight after collection.
• test data from the previous day can be used.
• ⁇ Performed before liver transplantation, administration of endoxan for injection, or infusion of the inducible suppressive T cell preparation of the present disclosure. If immunosuppressive therapy is to be started on the same day as the liver transplantation, it should, in principle, be administered after the liver transplantation and before the start of administration of immunosuppressants other than steroids.
• ⁇ Dosage etc. will be determined by the judgment of a physician, etc.
• ⁇ Performed at the time of donor liver graft collection (possible at back table). ⁇ : If possible, perform at the doctor's discretion.
• test data is available within 8 weeks before liver transplantation, that test data can be used with the patient's consent. However, if histocompatibility tests, virus tests 1, virus tests 2, fungal tests, hepatitis B or C tests, and anti-HLA antibodies are performed as eligibility tests for living liver transplantation, they must be performed before liver transplantation. The test data will be available for use beyond 8 weeks.
• *b The timing of weight loss can be extended for a total of 13 weeks, but the next weight loss should be done at least 13 weeks after the most recent weight loss.
• *c In addition to observing the patient's general condition, blood biochemical tests and liver biopsy will be performed to confirm withdrawal from immunosuppressants.
• *d Indicates the test items when discontinuing after administration of endoxan for injection. *e: If the inspection date overlaps with the prescribed observation date, the test results from the prescribed observation date will be used, and duplicate items may be omitted. If conducted over multiple days, in principle it should be conducted within one week. *f: Excluding the start date of immunosuppressive therapy, collect blood just before administering the prescribed calcineurin inhibitor and measure blood trough concentration (take blood at least 12 hours after the previous administration. *g: If rejection is suspected. Liver biopsy and histological diagnosis can be performed at each medical institution. FIG.
• FIG. 3B shows the process from living donor liver transplantation to immunosuppressive drug reduction when the inducible suppressive T cell preparation according to an embodiment of the present disclosure is used to reduce the immunosuppressive drug in a patient after living donor liver transplantation. This is an example of a patient's schedule.
• FIG. 3C shows the process from living donor liver transplantation to immunosuppressive drug reduction in a case where the inducible suppressive T cell preparation according to an embodiment of the present disclosure is used to reduce the immunosuppressive drug in a patient after living donor liver transplantation. This is an example of a donor schedule.
• the legend in the figure is as follows. ⁇ : Perform before the start of apheresis and after completion of apheresis. However, it is not necessary to measure body weight after completion.
• FIG. 4 shows an immunosuppressant administration/reduction schedule (immunosuppressant dose adjustment/reduction period) when using an inducible suppressive T cell preparation according to an embodiment of the present disclosure.
• immune tolerance refers to a state in which a specific immune response to a specific antigen is not exhibited or the specific immune response is suppressed.
• Immune tolerance is a state in which immune cells (especially T cells) do not show a specific immune response to a specific antigen, or a state in which the specific immune response is suppressed, and a state in which a person does not show a specific immune response to a specific antigen. , may mean either or both of the states in which the specific immune response is suppressed. It is attracting attention because the induction of immune tolerance makes it possible to treat immune rejection and to treat allergies.
• induced suppressive cells or “anergy cells” refer to cells in which immune tolerance has developed (immune unresponsiveness), and "induced suppressive T cells” or “anergic T cells” T cells are T cells that have developed immune tolerance (immune unresponsiveness), and include T cells that are not activated and are unresponsive when faced with the same antigen again.
• PBMCs or T cells in which immune tolerance has been induced
• induced suppressive T cells and “anergic PBMCs (or T cells)” have the same meaning.
• subject (sometimes expressed as “subject” in English) or “patient” refers to domestic animals (e.g., cows, sheep, cats, dogs, horses), primates, etc. (eg, humans and non-human primates such as monkeys), rabbits, and rodents (eg, mice and rats).
• the subject or patient is a human.
• the disease targeted by the formulation of the present disclosure is immune rejection of donor organs in patients who have undergone inter-vivo allogeneic organ transplantation.
• a subject In the recipient, even after the cells in which anergy has been induced disappear from the subject, a state of immune tolerance to the specific antigen remains for at least a certain period of time (e.g., several months, one year, or three years or more). maintained and permanent immune tolerance (infectious immune tolerance) can be acquired.
• a certain period of time e.g., several months, one year, or three years or more.
• infectious immune tolerance infectious immune tolerance
• drug drug
• agent agent
• factor agent in English
• substances include, for example, proteins, polypeptides, oligopeptides, peptides, polynucleotides, oligonucleotides, nucleotides, nucleic acids (including, for example, DNA such as cDNA and genomic DNA, and RNA such as mRNA), Saccharides, oligosaccharides, lipids, small organic molecules (e.g.
• hormones e.g., hormones, ligands, information transmitters, other small organic compounds, molecules synthesized by combinatorial chemistry, small molecules that can be used as pharmaceuticals (e.g. small molecule ligands, etc.) ), complex molecules thereof, but are not limited to them.
• inhibitor refers to all kinds of small molecules, proteins, nucleic acids, lipids, sugars, etc. that can inhibit a given action (for example, interaction, signal transduction, etc.).
• the present disclosure provides anergic stimulation of T cells by blocking the interaction of CD28 with CD80 and/or CD86 on the cell surface and inhibiting CD28 costimulatory signals. induce.
• the inhibitor used to block the interaction of CD80 and/or CD86 with CD28 is selected from the group consisting of small molecules, proteins, nucleic acids, lipids, sugars, and combinations thereof.
• the protein is an antibody or variant thereof, or a cell surface molecule or variant thereof.
• the variant of the antibody is an antigen-binding fragment.
• the variant of the cell surface molecule is a fusion protein.
• the inhibitory agent is an anti-CD80 antibody, an anti-CD86 antibody, a bispecific antibody to CD80 and CD86, an anti-CD28 antibody or an antigen-binding fragment thereof, a CTLA4-Ig fusion protein, a CD28-Ig fusion protein. selected from the group.
• the CTLA4-Ig fusion protein is abatacept or belatacept. It is also envisioned that a factor that indirectly inhibits the above interaction (eg, an inhibitor of upstream or downstream signals of signal transduction) may be used in combination.
• Antibody in the broad sense herein refers to a molecule or a population thereof that can specifically bind to a particular epitope on an antigen.
• An “antibody” in the broad sense herein may be a full-length antibody (ie, an antibody having an Fc portion) or an antibody lacking an Fc portion.
• Antibodies lacking an Fc portion only need to be able to bind to the target antigen; examples of such antibodies include Fab antibodies, F(ab') 2 antibodies, Fab' antibodies, Fv antibodies, scFv antibodies, etc. These include, but are not limited to:
• the antibody may be any type of antibody, ie, an immunoglobulin known in the art.
• the antibody is of the isotype IgA, IgD, IgE, IgG, or IgM class.
• the antibodies described herein include one or more alpha, delta, epsilon, gamma, and/or mu heavy chains.
• the antibodies described herein include one or more kappa or light chains.
• the antibody is an IgG antibody and is one of the four human subclasses: IgG1, IgG2, IgG3 and IgG4.
• Antibodies envisioned for use in the present disclosure include camelid-derived antibodies (e.g., VHH antibodies), shark-derived antibodies (e.g., single-chain antibodies), peptibodies, and nanobodies. mono-domain antibodies), minibodies, multispecific antibodies (e.g., bispecific antibodies, diabodies, triabodies, tetrabodies, tandem di-scFV, tandem tri-scFv ), which are known in the art. For example, Kortt et al., Biomol Eng. 2001 18:95-108, (2001) and Todorovska et al., J Immunol Methods. 248: 47-66, (2001). Antibodies also include modified antibodies or unmodified antibodies.
• camelid-derived antibodies e.g., VHH antibodies
• shark-derived antibodies e.g., single-chain antibodies
• peptibodies e.g., single-chain antibodies
• nanobodies e.g., single-chain antibodies
• minibodies
• the antibody may be bound to various molecules such as polyethylene glycol.
• Modified antibodies can be obtained by chemically modifying antibodies using known techniques. For information on artificially produced antibodies and various methods for modifying/altering antibodies, see also Seikagaku (2016), Vol. 88, No. 3, pp. 380-385.
• an antibody in the narrow sense refers to an immunoglobulin or a group thereof that can specifically bind to a specific epitope on an antigen, and a variant thereof is referred to as a "variant antibody.”
• An “antibody” in the narrow sense herein may be a full-length antibody (i.e., an antibody having an Fc portion), and a “variant of an antibody” herein refers to a variant of the above antibody that lacks the Fc portion. could be. Therefore, an antibody in the narrow sense herein can also be referred to as a full-length antibody, and a variant of an antibody can also be referred to as a variant of a full-length antibody.
• Variants lacking the Fc portion only need to be able to bind to the target antigen; examples of such variants include Fab antibodies, F(ab') 2 antibodies, Fab' antibodies, Fv antibodies, scFv Examples include, but are not limited to, antibodies.
• Variants of antibodies also include modified antibodies and unmodified antibodies. In the antibody modification product, the antibody may be bound to various molecules such as polyethylene glycol. Modified antibodies can be obtained by chemically modifying antibodies using known techniques.
• polyclonal antibody refers to, for example, in order to induce the production of polyclonal antibodies specific to an antigen, a target animal is given to mammals (e.g., rats, mice, rabbits, cows, monkeys, etc.), birds, etc. It can be generated by administering an immunogen containing the antigen. Administration of the immunogen may be accompanied by injection of one or more immunizing agents and, if desired, an adjuvant. Adjuvants may also be used to increase the immune response and may include Freund's adjuvant (complete or incomplete), mineral gels (such as aluminum hydroxide), or surfactants (such as lysolecithin), etc. . Immunization protocols are known in the art and may be carried out by any method that elicits an immune response, depending on the host organism of choice (Protein Experiment Handbook, Yodosha (2003): 86-91 ).
• a "monoclonal antibody” refers to an antibody in which the individual antibodies that make up a population are essentially identical antibodies that respond to a single epitope, except for antibodies that have mutations that may occur naturally. Including some cases. Alternatively, the individual antibodies that make up the population may be substantially identical, except for antibodies that have mutations that may occur in small amounts naturally. Monoclonal antibodies are highly specific and are different from regular polyclonal antibodies, which typically contain different antibodies corresponding to different epitopes and/or which typically contain different antibodies corresponding to the same epitope. different. In addition to their specificity, monoclonal antibodies are useful in that they can be synthesized from hybridoma cultures that are uncontaminated by other immunoglobulins.
• monoclonal may indicate the characteristic that the antibody is obtained from a substantially homogeneous population of antibodies, but does not imply that the antibody must be produced by any particular method.
• monoclonal antibodies may be produced by a method similar to the hybridoma method as described in "Kohler G, Milstein C., Nature. 1975 Aug 7;256(5517):495-497.”
• monoclonal antibodies may be produced by recombinant methods similar to those described in US Pat. No. 4,816,567.
• the monoclonal antibody is "Clackson et al., Nature. 1991 AUG 15; 352 (6336): 624-628.”, Or "Marks et al., J Mol Biol. 1991 Dec 5; 222 (3): 581 -597.'' may be used to isolate from phage antibody libraries.
• it may be produced by the method described in "Protein Experiment Handbook, Yodosha (2003): 92-96.”
• a "chimeric antibody” is one in which the variable region of an antibody between different species and the constant region of an antibody are linked, and can be constructed by genetic recombination technology.
• Mouse-human chimeric antibodies can be produced, for example, by the method described in "Roguska et al., Proc Natl Acad Sci USA. 1994 Feb 1;91(3):969-973.”
• the basic method for making mouse-human chimeric antibodies is, for example, to combine mouse leader and variable region sequences present in a cloned cDNA encoding human antibody constant regions already present in a mammalian cell expression vector. concatenate to the array.
• the mouse leader sequence and variable region sequence present in the cloned cDNA may be ligated to a sequence encoding a human antibody constant region, and then ligated to a mammalian cell expression vector.
• a fragment of a human antibody constant region can be of any human antibody heavy chain constant region and human antibody light chain constant region, such as C ⁇ 1, C ⁇ 2, C ⁇ 3 or C ⁇ 4 for a human heavy chain; Regarding the light chain, C ⁇ or C ⁇ can be mentioned, respectively.
• a "humanized antibody” has, for example, one or more CDRs from a non-human species and framework regions (FRs) from a human immunoglobulin, as well as constant regions from a human immunoglobulin. It is an antibody that binds to the desired antigen. Humanization of antibodies can be performed using a variety of techniques known in the art (Almagro et al., Front Biosci. 2008 Jan 1;13:1619-1633.).
• CDR grafting (Ozaki et al., Blood.1999 Jun1;93(11):3922-3930.), Re-surfacing (Roguska et al., Proc Natl Acad Sci US A.1994 Feb 1;91( 3 ):969-973.), or FR shuffle (Damschroder et al., Mol Immunol. 2007 Apr;44(11):3049-3060. Epub 2007 Jan 22.).
• amino acid residues in the human FR region may be substituted with corresponding residues from the CDR donor antibody. This FR substitution can be performed by methods well known in the art (Riechmann et al., Nature. 1988 Mar 24;332(6162):323-327.).
• FR residues important for antigen binding may be identified by modeling interactions between CDRs and FR residues.
• unusual FR residues at particular positions may be identified by sequence comparison.
• a "human antibody” refers to, for example, a region including a heavy chain variable region and constant region, and a light chain variable region and constant region constituting the antibody, derived from a gene encoding human immunoglobulin. It is an antibody that
• the main production methods include the transgenic mouse method for producing human antibodies and the phage display method.
• the transgenic mouse method for producing human antibodies if a functional human Ig gene is introduced into a mouse in which endogenous Ig has been knocked out, human antibodies with diverse antigen-binding abilities are produced in place of mouse antibodies. Furthermore, by immunizing this mouse, it is possible to obtain human monoclonal antibodies using conventional hybridoma methods.
• a foreign gene is typically fused to the N-terminal side of the coat protein (g3p, g10p, etc.) of a filamentous phage, such as M13 or T7, which are Escherichia coli viruses, so as not to lose the infectivity of the phage.
• a filamentous phage such as M13 or T7, which are Escherichia coli viruses, so as not to lose the infectivity of the phage.
• M13 or T7 which are Escherichia coli viruses
• the formulations of the present disclosure when manufacturing the formulation of the present disclosure, cells obtained from a subject (patient) to whom the composition or formulation of the present disclosure is administered or cells derived from the subject are used. Cells can be used.
• the formulations of the present disclosure contain antigens produced by the subject themselves that produce an immune response, such as antigens produced by the subject themselves that cause an autoimmune disease in a subject with an autoimmune disease. It can also be produced using an antigen derived from a subject.
• formulations of the present disclosure can also be manufactured using antigens that are not derived from the subject, which are foreign antigens that can generate an immune response.
• a formulation of the present disclosure uses a non-subject-containing antigen-containing material that is any substance or collection of substances that contains an antigen that is not derived from a subject. Examples include cells, cell populations, tissues, etc. that express antigens not derived from the subject.
• compositions or formulations of the present disclosure can induce immune tolerance in such cases as well.
• the present disclosure provides an inducible suppressive T cell preparation, its usage, dosage, etc., and a drug for achieving immune tolerance administered using the same to a patient receiving a living donor liver transplant.
• a drug for achieving immune tolerance administered using the same to a patient receiving a living donor liver transplant.
• the induced suppressive T cells of the present disclosure are obtained by co-culturing patient peripheral blood mononuclear cells with irradiated donor peripheral blood mononuclear cells in the presence of anti-CD80 and anti-CD86 antibodies. Obtained by being guided.
• the components of the induced suppressive T cells of the present disclosure are mononuclear cells, mainly T lymphocytes, and mainly CD4 + T cells and CD8 + T cells.
• the active ingredients of the induced suppressive T cells of the present disclosure include CD4 + CD25 + FoxP3 + T cells (regulatory CD4 + T cells) and CD8 + CD45RA ⁇ T cells (suppressive CD8 + T cells). It is.
• effector CD4 + T cells and effector CD8 + cells in response to HLA class I and class II antigens expressed in the donor organ are generated.
• T cells are inhibited from their activation and induced to become new regulatory CD4 + T cells and suppressive CD8 + T cells.
• the immune rejection reaction specific to the donor HLA antigen will be continuously attenuated, making it possible to reduce the amount of immunosuppressants used or withdraw them.
• the induced suppressive T cells of the present disclosure can be produced at the Juntendo University graduate School of Medicine Research Infrastructure Center Cell Processing Room, which is a cell culture processing facility.
• the inducible suppressor T cells of the present disclosure may contain, for example, about 5.0 ⁇ 10 5 nucleated cells comprising autologous inducible suppressor T cells in one bag (100 mL) of the primary packaging
• the liquid preparation may contain at least about 5.0 ⁇ 10 6 , about 5.0 ⁇ 10 7 or more, about 5.0 ⁇ 10 8 or more, or about 5.0 ⁇ 10 9 or more.
• the induced suppressive T cells of the present disclosure are induced by co-culturing subject peripheral blood mononuclear cells with irradiated donor peripheral blood mononuclear cells in the presence of anti-CD80 and anti-CD86 antibodies. It can be assumed that
• the induced suppressive T cells of the present disclosure may be stored at about 8 ⁇ 3°C, for example, although there are no particular limitations on the storage method or shelf life as long as the effect of inducing immune tolerance is achieved. It can be about 7 ⁇ 3°C, about 6 ⁇ 3°C, about 5 ⁇ 3°C, or about 4 ⁇ 3°C.
• the validity period can be, for example, within about 36 hours, about 30 hours, about 24 hours, about 18 hours, about 12 hours, or about 6 hours after completion of the primary packaging.
• the primary packaged bags for storage of induced suppressive T cells of the present disclosure are stored in a secondary packaging container at 1 bag/bag, and further stored at 1 bag/bag in a final packaging container together with a water-absorbing sheet.
• the primary packaging can be affixed with a label stating that it is for therapeutic use, the serial number, the product name, the number of cells it contains, the expiration date, storage conditions, etc. .
• a drug for achieving immune tolerance "inhibiting the interaction between CD80 and/or CD86 expressed on the cell surface of a certain cell and CD28 expressed on the cell surface of another cell” is used.
• These include anti-CD80 antibodies, anti-CD86 antibodies, double antibodies thereof, as well as inhibitors against CD80 and/or CD86 (e.g. abatacept or belatacept, or Examples include, but are not limited to, inducible suppressive T cells (described).
• anti-CD80 antibody and anti-CD86 antibody refer to anti-CD80 antibodies and anti-CD86 Each antibody can be used.
• a chimeric anti-CD80 antibody and a chimeric anti-CD86 antibody may be used, respectively.
• anti-CD80 antibody and anti-CD86 antibody human anti-CD80 antibody and human anti-CD86 antibody may be used, respectively.
• the anti-human CD80 antibody may be of subclass IgG1.
• the anti-human CD86 antibody may also be of subclass IgG1.
• Plasmids encoding anti-CD80 antibodies and anti-CD86 antibodies may be produced by oneself or outsourced to an external company (for example, TPG Biologics, Inc. Taiwan) to express them from CHO cells to produce and purify the antibodies. can be used.
• Antibodies other than the anti-CD80 antibody and anti-CD86 antibody specifically described in WO2019/245037 (PCT/JP2019/024752), WO2014/186193 (PCT/US2014/037195), etc. may also be used.
• anti-CD80 antibody and anti-CD86 antibody can be replaced with any inhibitory factor that can inhibit the interaction between CD80 and/or CD86 and CD28.
• inhibitors include anti-CD80 antibodies, anti-CD86 antibodies, bispecific antibodies against CD80 and CD86, anti-CD28 antibodies or antigen-binding fragments thereof, CTLA4-Ig fusion proteins (e.g., abatacept or belatacept). , CD28-Ig fusion protein.
• Belatacept is available, for example, from Bristol-Myers Squibb, New York, NY (final concentration 10 ⁇ g/ml to 40 ⁇ g/ml).
• endoxan can be administered as a pretreatment for induced suppressive T cell infusion therapy to acquire immune tolerance after liver transplantation.
• endoxane the following can be used, for example.
• cyclophosphamide hydrate a cyclophosphamide hydrate in a vial.
• Vials containing 534.5 mg of cyclophosphamide hydrate are stored in a white box at 1 vial/box. Attach a label to the inner package (vial) and outer box (white box) that indicates that it is for therapeutic use, the serial number, the identification code, the expiration date, and the storage conditions. be able to.
• a method for evaluating the quality of a drug for achieving immune tolerance administered to a patient receiving a living donor liver transplant comprising: (a) a step of mixedly culturing peripheral blood lymphocytes collected from the patient before the living liver transplant and peripheral blood lymphocytes collected from the donor of the living liver transplant; (b) mixing peripheral blood lymphocytes collected from the patient before said living liver transplant, peripheral blood lymphocytes collected from the donor of said living liver transplant, and a drug for achieving immune tolerance in said patient; A step of culturing; (c) measuring the cytokine production in steps (a) and (b), and if the cytokine production in step (b) is altered compared to step (a), the agent is Methods are provided for considering therapeutic agents.
• the patient in the method of the present disclosure may or may not have received prior administration of an immunosuppressant.
• the agent of the present disclosure can be an inhibitor that inhibits the interaction between CD80 and/or CD86 expressed on the cell surface of a certain cell and CD28 expressed on the cell surface of another cell.
• such agents can include belatacept, abatacept, and the inducible suppressive T cell preparations described below.
• an agent of the present disclosure can be an inducible suppressive T cell preparation, where the inducible suppressive T cell preparation stimulates peripheral blood lymphocytes from living liver transplant patients and donors. It can be obtained by co-culturing in the presence of CD80 antibody and/or CD86 antibody.
• the induced suppressive T cells that can be used in the quality assessment method of the present disclosure can include the induced suppressive T cells described elsewhere in this disclosure.
• the immunotolerance therapy for the patient may be modified if cytokine production in step (b) is altered compared to step (a), such as (i) If pro-inflammatory cytokine production in step (b) is increased compared to step (a), increasing the amount of immunosuppressant administered to said patient and/or administering immunotolerance therapy to said patient can be canceled or canceled.
• an increase or decrease in cytokine production can include a detectable difference when comparing step (a) and step (b).
• peripheral blood lymphocytes may be stained with CFSE.
• B cells collected from the donor can be used instead of peripheral blood lymphocytes collected from the donor.
• the immunosuppressant is not particularly limited, but for example, a calcineurin inhibitor can be used, and examples of the calcineurin inhibitor include tacrolimus or cyclosporine.
• the quality assessment method of the present disclosure is for achieving immune tolerance in a patient who has received a living liver transplant, and can be performed at any time, e.g. It can be performed within at least about 2 days, about 4 days, about 6 days, about 8 days after liver transplantation, or before living donor liver transplantation. Also, in one embodiment, the methods of the present disclosure can be performed multiple times.
• the cytokine may include IFN ⁇ , TNF, IL-2, IL-12, IL-15, IL-17, IL-18, IL-10, TGF ⁇ , etc., of which inflammatory Examples of cytokines include IL-17 and IL-18, and examples of anti-inflammatory cytokines include IL-10 and TGF ⁇ .
• the measurement of cytokine production used in the method of evaluating the quality of drugs for achieving immune tolerance administered to patients who have received living liver transplantation can be carried out as follows, using, for example, an ELISA method. I can do it.
• Calibrator Diluent RD5P is diluted five times with distilled water to prepare Calibrator Diluent RD5P (dilution ratio 1:5).
• Preparation of diluted sample Dilute the sample with Calibrator Diluent RD5P (1:5 dilution ratio). The homogeneously mixed sample is placed in a centrifuge and centrifuged at 460 G for 5 minutes at 4°C, and the supernatant is used for dilution.
• Assay 1 Primary reaction a. Create a plate layout. b. Set the required amount of Microplate Strips on the Plate Frame (hereinafter referred to as Assay plate). c. Add 100 ⁇ L/well of Assay Diluent RD1-63 to the Assay plate. d. a. According to the plate layout, add 100 ⁇ L/well of Calibrator Diluent RD5P (dilution ratio 1:5) as a standard dilution series, sample, and blank. Note that this operation is completed within 15 minutes after adding Assay Diluent RD1-63. e. Cover the Assay plate with a plate seal, place it in a constant temperature shaking incubator (room temperature) set at 25°C, and incubate for 2 hours.
• room temperature room temperature
• Measurement a Measure the OD of each well within 30 minutes using a microplate reader set at 450 nm/570 nm.
• b After the measurement is completed, a calibration curve is created on the software, confirm that the IFN- ⁇ amount of each sample has been calculated, and then overwrite and save.
• c Print measurement results and export data.
• the quality evaluation method of the present disclosure can be performed using, for example, mixed lymphocyte reaction (MLR), and MLR can be performed as follows, for example.
• MLR mixed lymphocyte reaction
• Donor frozen cells and recipient frozen cells Record information on cryopreserved donor cells and recipient cells.
• the cell concentration can be adjusted to an arbitrary cell concentration using a culture medium based on the cell information of the MLR sample (cell process product) provided by the CPC.
• the total cell concentration is 2.0 ⁇ 10 5 cells/mL, 4.0 ⁇ 10 5 cells/mL, 2.0 ⁇ 10 6 cells/mL, 4.0 ⁇ 10 6 cells/mL, 2
• the concentration can be adjusted to .0 ⁇ 10 7 cells/mL, 4.0 ⁇ 10 7 cells/mL, etc.
• Recipient cells and donor cells can be adjusted to any viable cell concentration using a culture medium based on the results of cell counting.
• the viable cell concentration is 2.0 ⁇ 10 5 cells/mL, 4.0 ⁇ 10 5 cells/mL, 2.0 ⁇ 10 6 cells/mL, 4.0 ⁇ 10 6 cells/mL, 2
• the concentration can be adjusted to .0 ⁇ 10 7 cells/mL, 4.0 ⁇ 10 7 cells/mL, etc.
• each cell suspension and culture medium whose concentration was adjusted to 2.0 ⁇ 10 6 cells/mL are used to prepare a cell mixture at the ratio shown in Table 2 (Plate No. 1). The preparation is carried out under the following conditions. 2) In one embodiment, a cell mixture is prepared by mixing each cell suspension and culture medium at a concentration of 4.0 ⁇ 10 6 cells/mL at the ratio shown in Table 2 (Plate No. 2). . The preparation is carried out under the following conditions. A sample name is given to each mixture ratio, and subsequent samples are identified by the sample name. The mixing order may be any order. For example, in one embodiment, the sequence can be recipient cell ⁇ cell artifact ⁇ medium ⁇ donor cell, etc. Each cell suspension is individually seeded into 3 wells of a 96-well round bottom plate at 250 ⁇ L/well. 3) Start culturing in a CO2 incubator.
• MLR as described above is a method for evaluating the reactivity of lymphocytes to non-self, it is useful for evaluating the quality of the induced suppressive T cells of the present disclosure that induce immune tolerance. For example, by conducting this test, it is possible to predict to what extent a patient's immune response to a transplanted organ can be suppressed after administration of the induced suppressive T cells of the present disclosure. Furthermore, in one embodiment, a portion of the patient- and donor-derived lymphocytes used in the MLR test can be selected from those obtained in the process of producing the induced suppressive T cells of the present disclosure. , can be carried out without placing any additional burden on the patient or donor for specimen collection.
• the ELISA method described above can be carried out according to the flow of conventionally known methods and kit instructions, and the MLR method can also be carried out in addition to the matters described herein. Some or all of the flow features of conventionally known methods and kit instructions can be used as appropriate.
• the ability to induce immune tolerance (efficacy) after infusion of the inducible suppressive T cells of the present disclosure in living donor liver transplant patients may be evaluated using whether or not operational tolerance has been achieved as an index. can.
• a method for achieving immune tolerance in a patient comprises the steps of: collecting lymphocytes from a donor by apheresis; collecting lymphocytes from a patient by apheresis; transplanting the liver or part thereof to the patient, and after the living liver transplantation, the patient: continuous administration of a corticosteroid, an antimetabolite, and a first immunosuppressant, immune monitoring for rejection of the living liver transplant and/or periodic liver biopsy; and later, administering to the patient a second immunosuppressant, and after administering the second immunosuppressant, administering to the patient a drug for achieving immune tolerance in the patient; and stepwise reducing the dosage of the corticosteroid, the antimetabolite, and the first immunosuppressant.
• the immune monitoring for rejection and/or periodic liver biopsies confirms the achievement of immune tolerance or determines transition to conventional immunosuppressive therapy. can be done.
• the patient's general condition and/or blood biochemical test values are observed over time for a predetermined period after the administration of the first immunosuppressant is discontinued, and the first immunosuppressant is A final decision to discontinue administration of the first immunosuppressant can also be made by performing a liver biopsy at a predetermined time point after discontinuation of administration of the first immunosuppressant.
• stable liver function values and a state in which no pathologically treatable rejection reaction can be confirmed by liver biopsy continue for a predetermined period or longer after discontinuing administration of the first immunosuppressant. If so, it may be determined that the patient has achieved operational tolerance.
• a method for achieving immune tolerance in a patient includes the steps of: collecting lymphocytes from a donor by apheresis 14 to 3 days before transplant; collecting the liver or a portion thereof from the donor to the patient; and after the living liver transplantation, performing the following steps on the patient: Continuous administration of corticosteroids, antimetabolites, and calcineurin inhibitors, immune monitoring for rejection of the living liver transplant and/or periodic liver biopsy, and 4 to 6 days after liver transplantation.
• a final decision to discontinue administration of the calcineurin inhibitor is made by liver biopsy at least 52 weeks after discontinuation of administration of the calcineurin inhibitor, and The patient is considered to have achieved operational tolerance if hepatic function values and a liver biopsy in which no pathologically treatable rejection reaction continues for 52 weeks or more after discontinuing administration of the calcineurin inhibitor.
• the corticosteroid is not particularly limited, and for example, methylprednisolone can be used.
• the antimetabolite is not particularly limited, and for example, mycophenolate mofetil can be used.
• the first immunosuppressant is not particularly limited, and for example, a calcineurin inhibitor can be used, and examples of the calcineurin inhibitor include tacrolimus or cyclosporine. I can do it.
• the second immunosuppressant is not particularly limited, but can include, for example, cyclophosphamide.
• administration of corticosteroids and antimetabolites to the patient can be discontinued at least within 4 weeks after living donor liver transplantation. In another embodiment, administration of corticosteroids and antimetabolites to the patient can be discontinued at least within 26 weeks after living donor liver transplantation.
• administration of the calcineurin inhibitor to the patient can be discontinued at least within 78 weeks after living donor liver transplantation.
• achieving operational tolerance is achieved by weaning from immunosuppressants by 78 weeks (up to 91 weeks) after liver transplantation, followed by stable liver function values and pathological treatment with liver biopsy. It can be defined as a state in which a rejection reaction cannot be confirmed for 52 weeks or more after withdrawal from immunosuppressants.
• immune tolerance by the induced suppressive T cell preparation of the present disclosure can be targeted to end-stage liver failure patients undergoing living donor liver transplantation, during the pre-liver transplantation observation period, and during the administration of immunosuppressive drugs. It consists of a period of dose adjustment/reduction, and a period of confirmation of withdrawal from immunosuppressants.
• Peripheral blood mononuclear cells can be collected.
• the collected peripheral blood mononuclear cells from the subject were cultured for 10 days with donor peripheral blood mononuclear cells (antigen) inactivated by radiation irradiation and anti-CD80/anti-CD86 monoclonal antibodies, and the induced suppressive T cells of the present disclosure were cultured. can be induced.
• the immunosuppressant 40 mg/kg of cyclophosphamide (reduced to 20 mg/kg as necessary) is administered after liver transplantation to temporarily reduce lymphocytes in the body. It can be administered on the 5th day. Thereafter, the inducible suppressive T cells of the present disclosure are infused into the subject 10 days after liver transplantation, and the ability of the inducible suppressive T cells of the present disclosure to induce immune tolerance up to 78 weeks (up to 91 weeks) after liver transplantation. and safety can be evaluated. In one embodiment, the subject can be managed in the hospital for at least 4 weeks after liver transplantation.
• the immunosuppressant used in the method of the present disclosure is not particularly limited, but for example, drugs similar to those used after liver transplantation (corticosteroids, antimetabolites, calcineurin inhibitors, etc.) may be used.
• the dose can be reduced according to the immunosuppressant dose reduction/withdrawal method of the present disclosure.
• the subject's general condition, blood biochemical test values, etc. are observed over time for 52 weeks after withdrawal from immunosuppressants, and the subject is withdrawn from immunosuppressants. At 52 weeks, it is possible to confirm whether operational tolerance has been achieved by performing a liver biopsy or the like.
• the donor's liver graft harvesting procedure, the subject's liver transplantation procedure, and the postoperative management method of the donor and the subject are in accordance with the standard liver transplantation procedure and postoperative management method performed at each medical institution. I can do it.
• the day of living liver transplantation is set as Day 0, and subsequent tests and evaluations are performed.
• endoxan can be used as a pretreatment to deplete lymphocytes in a subject prior to inducible suppressive T cell preparation infusion.
• physicians should consider whether to administer endoxan based on the subject's general condition, etc., and if deemed eligible, administer endoxan intravenously to the subject over 23 hours on Day 5 after liver transplantation. I can do it.
• the standard dose of endoxan can be about 40 mg/kg, but since this drug is a drug for liver metabolism, the standard dose of endoxan can be about 20 mg/kg to about 20 mg/kg, while monitoring the transition of liver function after liver transplantation.
• Doses can also be adjusted within the range of 40 mg/kg. There have been reports of cases in which the myelosuppressive effect of leukopenia and neutropenia appeared significantly after administration of endoxan, so in other embodiments, doctors etc. can also adjust the dose with reference to past cases.
• the following measures can also be taken as a response to the side effects of endoxan.
• endoxan administer 9.9 mg of dexamethasone (equivalent to 50 mg of methylprednisolone) and 125 mg of aprepitant (or 150 mg of fosaprepitant) on the first day (before administration of endoxan).
• a 5-HT 3 receptor antagonist can be administered at 8 mg (equivalent to 40 mg of methylprednisolone) on day 24.
• Aprepitant (or fosaprepitant) is a CYP3A4 substrate and has mild to moderate CYP3A4 inhibition (dose-dependent) and induction effects, so avoid administering it as it may affect the blood concentration of tacrolimus. is preferable.
• uromitexan for suppressing the occurrence of urinary system disorders (hemorrhagic cystitis, urinary disorder, etc.) and other preventive supportive treatments (prophylactic administration of antibiotics, etc.) can also be carried out.
• a G-CSF formulation can also be used if the neutrophil count falls below 1000/mm 3 after administration of Endoxan. If an induced suppressive T cell preparation cannot be administered after administration of endoxan, even if the neutrophil count is not less than 1000/ mm3 , it is predicted that it will tend to decrease and become less than 1000/ mm3 . In some cases, administration of G-CSF formulations can be performed. However, if the neutrophil count increases to 5000/mm 3 or more, it is preferable to reduce the dose or discontinue administration depending on the symptoms.
• ⁇ Infusion of inducible suppressive T cell preparation ⁇ Infusion of inducible suppressive T cell preparation>
• the physician, etc. considers whether or not to infuse the inducible suppressive T cell preparation based on the general condition of the subject, and if it is determined that the inducible suppressive T cell preparation is suitable, injects the inducible suppressive T cell preparation into the subject. Can be transfused.
• a blood transfusion filter can be used for transfusion of the induced suppressive T cell preparation, and it is preferable not to use a blood transfusion filter since the constituent cells of the induced suppressive T cell preparation are removed by a leukocyte removal filter.
• the infusion can be started at a low rate, and the rate of administration can be increased while checking the subject's condition, and administration of the inducible suppressive T cell preparation can be completed in about 30 minutes.
• Physicians, etc. should constantly monitor the condition of the subject during administration of induced suppressive T cell preparations, and if symptoms such as a drop in blood pressure that is difficult to control appear, they should immediately interrupt administration and consider whether to restart the administration. can. Once restarted, further administration can be discontinued if a situation requiring discontinuation occurs again.
• a method for reducing the dose of an immunosuppressant in immunotolerance therapy comprising: (1) administering corticosteroids according to the following schedule; Administration during reperfusion After liver transplantation, reduce the dose and complete the administration within the prescribed period. If administration cannot be completed within the prescribed period, administer using any method of reducing the dose.
• administering according to the schedule below; Administration after liver transplantation Discontinue administration within the specified period after liver transplantation.
• the dosage can be increased with a target of 1 week after liver transplantation, and in that case, the dose is reduced in stages; (3) the step of administering the first immunosuppressant according to the following schedule; and, (3-1) Predetermined period after liver transplantation (dose adjustment period) Administration was started on the day of liver transplantation or 1 day after liver transplantation, and the following blood trough concentrations: A predetermined blood trough concentration in the first predetermined period from the start of administration to the first predetermined period after liver transplantation A predetermined blood trough concentration in the second predetermined period after the first predetermined period after liver transplantation, respectively.
• first immunosuppressant dose reduction period After 26 weeks after liver transplantation (first immunosuppressant dose reduction period) During the first predetermined period after liver transplantation (reduction 1), the dosage and administration are adjusted to maintain the predetermined blood trough concentration.After the second predetermined period after liver transplantation (reduction 2), 1) Maintain the dose and gradually reduce the number of doses according to the reduction schedule. (3-3) If necessary, the period for reducing the dose of the first immunosuppressant is extended, A method is provided, wherein each dose reduction is performed when the absence of a rejection reaction is confirmed.
• a method for reducing the dose of an immunosuppressant in immunotolerance therapy comprising: (1) administering corticosteroids according to the following schedule; Administer 1000 mg during reperfusion Administer 20 mg/day from 1 day after liver transplantation for 1 week Reduce the dose by 5 mg/day every week and finish administration within 4 weeks after liver transplantation 4 weeks after liver transplantation If administration cannot be completed within this period, use any reduction method to complete administration by 26 weeks after liver transplantation.
• administer according to the schedule below Administer a total of 500 mg/day in two divided doses starting from the 1st day after liver transplantation. Discontinue administration within 4 weeks after liver transplantation.
• the dose can be increased to 1000 to 2000 mg/day with a goal of 1 week after liver transplantation, in which case the gradual reduction is to 500 mg/day.
• dose reduction 2 From 39 weeks post-transplant (dose reduction 2) onwards, maintain the dose at 26 weeks post-transplant (dose reduction 1) and change the frequency of administration to the calcineurin inhibitor dose reduction schedule (dose reduction 2: 3 times a week, reduction 3: twice a week). , Weight loss 4: Once a week: Weight loss 5: Withdrawal), gradually reduce weight. (3-3) If necessary, the calcineurin inhibitor dose reduction period will be extended for a total of 13 weeks. A method is provided, wherein each dose reduction is performed when the absence of a rejection reaction is confirmed.
• FIG. 4 shows the administration/reduction schedule of the immunosuppressant during the dose adjustment/reduction period of the epidemic suppressant in an embodiment of the present disclosure.
• the following immunosuppressive therapy can be performed after liver transplantation. Physicians, etc. can decide to reduce the dose or withdraw from each immunosuppressant after confirming that no rejection reaction is observed when considering dose reduction or withdrawal. In addition, if side effects occur due to immunosuppressants, the dose can be reduced as necessary.
• Corticosteroids methylprednisolone, etc.
• the drug be administered from the day of liver transplantation according to the judgment of a doctor or the like depending on the condition of the subject, and that administration be discontinued by 4 weeks after liver transplantation. If administration cannot be completed within 4 weeks after liver transplantation, it can be tapered and stopped by 26 weeks after liver transplantation.
• the approximate dosing/reduction schedule is shown below.
• methylprednisolone 1000 mg is administered during reperfusion, and 20 mg/day of methylprednisolone is administered for 1 week from the day after liver transplantation (Day 1).
• the dose of corticosteroids should be reduced by 5 mg/day every week, and administration should be discontinued within 4 weeks after liver transplantation.
• the drug in principle, it is preferable that the drug be administered from the day after liver transplantation according to the judgment of a doctor depending on the condition of the subject, and that administration be discontinued by 4 weeks after liver transplantation. If administration cannot be completed within 4 weeks after liver transplantation, it can be tapered and stopped by 26 weeks after liver transplantation. The approximate dosing/reduction schedule is shown below.
• mycophenolate mofetil 500 mg/day (divided into two doses per day) will be administered.
• the dose is increased to 1000 to 2000 mg/day for about 1 week with the goal of Day 7, and then the dose is gradually reduced in 500 mg/day increments, and administration is discontinued with a goal of 4 weeks after liver transplantation.
• the calcineurin inhibitor is preferably tacrolimus as the first choice, and if tacrolimus cannot be used due to side effects or the like, cyclosporine is preferably used as the second choice. However, if a doctor determines that temporary discontinuation of calcineurin inhibitors is necessary due to an infection, etc., calcineurin inhibitors may be discontinued for an appropriate period of time.
• the method for reducing the dose of calcineurin inhibitors can be determined by referring to the usage and dosage of cyclosporin capsules in bone marrow transplantation. Blood trough concentration can be measured by collecting blood immediately before administration of the prescribed calcineurin inhibitor (blood sampling and measurement at least 12 hours after the previous administration). Further, the conversion value when switching from tacrolimus to cyclosporine can be determined by a doctor or the like in a comprehensive manner, taking into account the number of days that have passed since surgery and the general condition of the subject.
• Calcineurin inhibitor dose adjustment period from day 0 to week 26 after liver transplantation In one embodiment, administration is started orally or by continuous intravenous injection from Day 0 or Day 1 after liver transplantation, and the blood trough concentration [target concentration: 8 to 12 ng/mL] is maintained until 13 weeks after liver transplantation. (Tacrolimus or 200 to 300 ng/mL (cyclosporine) can be maintained. Until 26 weeks after liver transplantation, the blood trough concentration should be gradually reduced to a target of 5 to 8 ng/mL of tacrolimus or 125 to 200 ng/mL of cyclosporine. If continuous intravenous injection is selected, oral administration (twice a day) can be switched from the moment oral administration becomes possible.
• tacrolimus is being administered as a calcineurin inhibitor
• physicians, etc. can, in principle, change the dosage form to a sustained-release formulation and administer it (once a day) approximately one week before discharge.
• a regular formulation can be administered.
• the blood trough concentration [target concentration: 35 ng/mL (tacrolimus or 75125 ng/mL (cyclosporine)] can be maintained. Also, the dose adjustment period for calcineurin inhibitors If tacrolimus cannot be changed to an extended-release formulation during treatment, it is preferable to continue adjusting the dosage and administration as appropriate to maintain the target blood trough concentration, and switch tacrolimus to an extended-release formulation as soon as possible. .
• dose reduction 2 From 39 weeks post-liver transplantation (dose reduction 2) onwards, maintain the dose at 26 weeks post-liver transplantation (dose reduction 1) and increase the frequency of administration, for example, 3 times a week from 39 weeks post-liver transplantation (dose reduction 2);
• the dose can be reduced in stages, such as twice a week at 52 weeks (reduction 3), once a week at 65 weeks after liver transplantation (reduction 4), and withdrawal at 78 weeks after liver transplantation (reduction 5).
• the dosage When administering cyclosporine or tacrolimus, the dosage can be gradually reduced by adjusting the usage and dosage appropriately using the blood trough concentration as an indicator.
• the dose of the calcineurin inhibitor if a physician or the like determines that the dose of the calcineurin inhibitor needs to be reduced due to side effects of the calcineurin inhibitor, the dose can be changed. Even in this case, the next visit schedule may remain unchanged.
• withdrawal from the immunosuppressant may be performed before reaching 78 weeks (dose reduction 5) after liver transplantation at the discretion of a physician or the like.
• Provisions for extending the timing of reducing the dose of calcineurin inhibitor In one embodiment, if the doctor, etc. determines that the dose of the calcineurin inhibitor cannot be reduced due to the subject's general condition or that it is necessary to change the drug (from tacrolimus to cyclosporine), the dose may be reduced.
• the timing can be extended by a total of 13 weeks. There is no limit to the number of extensions of dose reduction, but if the total extension period exceeds 13 weeks, at that point the dose reduction for the purpose of weaning off the immunosuppressant may be discontinued and the subject may receive the necessary treatment. .
• a method for confirming the presence or absence of a rejection reaction by periodic liver biopsy in immunotolerance therapy the control liver tissue being a specimen collected from a transplanted liver on the day of liver transplantation. and performing a histological diagnosis on specimens obtained from routine liver biopsies after liver transplantation, and determining whether the results of the histological diagnosis indicate that the overall assessment of acute rejection meets any of the predetermined discontinuation criteria.
• a method is provided that includes the steps of determining that there is a "pathological rejection reaction that should be treated," immediately starting treatment for the rejection reaction, and discontinuing immune tolerance therapy.
• a method for confirming the presence or absence of rejection by periodic liver biopsy in immunotolerance therapy comprising: collecting control liver tissue from the transplanted liver on the day of liver transplantation; Banff criteria (2016) and Venturi (2012) scores for specimens obtained from routine liver biopsies 26 weeks after liver transplantation, 4 weeks after debulking, and 52 weeks after weight loss5.
• liver fibrosis or chronic rejection may occur even if liver function tests are normal. Therefore, the presence or absence of rejection can be confirmed by periodic liver biopsy.
• liver biopsy can be performed in the hospital (for one night) in consideration of the safety of the subject after liver biopsy.
• routine liver biopsies can be performed 26 weeks after liver transplantation, 4 weeks after weight loss 5, and 52 weeks.
• control liver tissue can be collected from the transplanted liver on the day of liver transplantation.
• one specimen of liver tissue is collected using a 16G liver biopsy needle, and tissue diagnosis of rejection can be performed.
• the tissue diagnosis of a tissue specimen collected by liver biopsy can be performed according to the Banff criteria (2016) and Venturi (2012) scoring, and the following evaluation can be performed.
• the histological diagnosis results indicate that the overall evaluation of acute rejection is “moderate or higher,” the overall evaluation of chronic rejection is “present,” and the liver fibrosis score is “2 or higher.” If this is the case, it is determined that there is a rejection reaction that should be treated pathologically, and treatment for the rejection reaction can be started immediately.
• Example 1 MLR and IFN- ⁇ quantitative ELISA
• the cryopreserved donor-derived cells were thawed and adjusted to 2.0x10 6 cells/ml with a medium.
• frozen patient-derived cells were thawed and adjusted to 2.0x10 6 cells/ml with a medium.
• the cell product was adjusted to 2.0 cells/ml with a medium, and the cells were mixed at the following ratio. 1. Only patient-derived cells2.
• Patient-derived cells: donor-derived cells 1:1 3.
• Patient-derived cells: Donor-derived cells: Cell processing material 1:1:1/2 4.
• Patient-derived cells: Donor-derived cells: Cell processing material 1:1:1/4 5.
• Patient-derived cells: Donor-derived cells: Cell processing material 1:1:1/8 6.
• Patient-derived cells: Donor-derived cells: Cell processing material 1:1:1/16
• the cells were cultured at 37°C for 5 days, and the culture supernatant was collected.
• the culture supernatant was diluted 5 times, and the amount of IFNg was measured by ELISA. Based on the IFNg concentration, the above 2. The percentage was calculated taking the group as 100%.
• the results are shown in Figures 1A-C.
• Figures 1A, B, and C show the results of three independent production runs.
• the graph on the left side of each figure is the IFNg concentration measured by ELISA, and the graph on the right side is the percentage when the IFNg concentration in the culture supernatant of the mixed culture group (Allo) of only patient-derived cells and donor-derived cells is taken as 100%. shows.
• FIG. 2 shows an overview of using the inducible suppressive T cell preparation of the present disclosure to achieve reduced doses of immunosuppressants in patients after living donor liver transplantation.
• Lymphocytes are collected from a donor and a patient (recipient), respectively, and co-cultured with CD80 and CD86 antibodies to obtain the induced suppressive T cell preparation of the present disclosure.
• CD80 and CD86 antibodies antibodies disclosed in WO2019/245037 are used. Thereafter, the induced suppressive T cell preparation of the present disclosure is administered to a patient after living liver transplantation, and the dose of the immunosuppressant is reduced.
• the schedule from living donor liver transplantation to the dose reduction of immunosuppressants is performed as shown in Figures 3A to C.
• the patient schedule is shown in Figures 3A and B, and the donor schedule is shown in Figure 3C.
• Example 3 Immune tolerance prediction
• Approximately 40 mL of blood is collected from each patient and donor before transplantation, and blood cells are separated. Some of the blood cells are frozen and used for later MLR testing.
• the induced suppressive T cells of the present disclosure are obtained by co-culturing patient-derived blood cells and irradiated donor-derived blood cells with CD80 and CD86 antibodies.
• CD80 and CD86 antibodies antibodies disclosed in WO2019/245037 are used.
• the suppressive ability of the obtained induced suppressive T cells is evaluated by MLR.
• Example 4 Living donor liver transplantation and immunosuppression
• the patient received induced suppressive T cells 10 days after living donor liver transplantation and did not develop any serious adverse events associated with administration.
• the immunosuppressants were reduced from steroids, calcineurin inhibitors (tacrolimus), and antimetabolites (Celcept) to one type of tacrolimus extended-release preparation within one month after transplantation, and the patient was discharged from the hospital on the 36th day after transplantation. It became.
• the present disclosure provides a method for evaluating the quality of induced suppressive T cell preparations and provides various techniques related to immune tolerance therapy.

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