9/30/2016 Disclosures F Vincenti University of California San - - PowerPoint PPT Presentation

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Flavio Vincenti

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Disclosures

F Vincenti University of California San Francisco, San Francisco, United States

– I have received grants and/or research support from:

• Astellas
• Alexion
• Immucor
• Bristol-Myers Squibb
• Genentech
• Novartis

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Two Important Initiatives in Kidney Transplantation at UCSF

Apply Precision Medicine to transplantation Use cellular therapies to control alloimmune response

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Personalized/Individualized Medicine vs Precision Medicine

Personalized medicine has been practiced in transplantation (i.e. low risk vs high risk) Precision medicine requires new diagnostics

• r

biomarkers to select or modify immunosuppression regimens preferable with novel therapies

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Can we apply genomic and biomarker information in selecting therapy that improves clinical care and

• utcomes in transplantation?

The need: biomarkers that are accurate, reliable and are associated with events and endpoints that may lead to better patient outcome

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THE NEED FOR PRECISION MEDICINE

Deceased SCD Living Donor

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Patients aged ≥18 years at transplant; adjusted by age, gender, and race

Adjusted Rate of Allograft Failure in the USA

United States Renal Data System; 2013 Annual Data Report. Available at: www.usrds.org/2013/slides/vol2_chap07_13.zip

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Without New Biomarkers it will be Difficult to Develop Novel Therapies for Precision Medicine in Transplantation

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Rear View Mirror Strategies Do Not Work

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Methods

The Clinical Trials in Organ Transplantation-09 CTOT Trial was a randomized, prospective study of non sensitized primary recipients of living donor kidney

• transplants. Subjects received rabbit anti-lymphocyte

globulin, tacrolimus, mycophenolate mofetil, and prednisone. Six months post-transplantation, subjects without de novo donor-specific antibodies (DSAs), AR,

• r

inflammation at protocol biopsy were randomized to wean off or remain on tacrolimus.

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Results

The study was terminated prematurely because of unacceptable rates of AR (4 of 14) and/or de novo DSAs (5 of 14) in the tacrolimus withdrawal arm.

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Conclusions

….past performance does not predict future results in manupulating immunosuppresion regimens.Safe and effective application

• f

novel regimens

• r

drug elimination require reliable biomarkers.

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Lack of Biomarkers Has Halted Development

• f Several Promising Drugs

Sotrastaurin – a CNI alternative targeting PKC Alefacept – targeting memory cells ASKP1240 – inhibits the CD40-CD154 pathway

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Biomarkers and Belatacept

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Belatacept potently and selectively blocks T-cell activation

• No cell division
• No cytokine

production

• Anergy
• Apoptosis.

Selective co-stimulation blocker

Belatacept

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219 226 221 212 220 208 208 218 206 206 216 202 204 213 199 202 209 197 199 204 186 153 165 137 151 161 123 149 159 117 146 152 112 142 151 107 135 142 102 131 139 100 128 137 92 Belatacept MI Belatacept LI CsA N at risk

1.00 0.30

Belatacept MI Belatacept LI CsA

6 12 18 24 30 36 42 48 54 60 66 72 78 84 Months 0.40 0.60 0.80 0.90 0.70 0.50

Time to Death or Graft Loss From Randomization to Month 84

Bela=belatacept; CI=confidence interval; CsA=cyclosporine A; HR=hazard ratio; LI=less intensive; MI=more intensive. Month 60 P-value HR (95% CI) Bela MI vs. CsA 0.0100 0.521 (0.306, 0.889) Bela LI vs. CsA 0.0045 0.477 (0.277, 0.819) Month 84 P-value HR (95% CI) Bela MI vs. CsA 0.0225 0.573 (0.348, 0.946) Bela LI vs. CsA 0.0210 0.570 (0.348, 0.935)

Survival Probability

BENEFIT

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Estimated Mean GFR Over 84 Months: MEM With Imputation*

*GFR values that were missing due to death or graft loss were imputed as 0. CsA=cyclosporine A; GFR=glomerular filtration rate; LI=less intensive; MEM=mixed effects modeling; MI=more intensive. Estimated mean GFR, mL/min/1.73m2 (95% CI)

10 20 30 40 50 60 70 80 90 6 12 18 24 30 36 42 48 54 60 66 72 78 84 Month Belatacept MI Belatacept LI CsA

P<0.001 for overall treatment effect

Belatacept MI Belatacept LI CsA GFR Difference vs. CsA GFR Difference vs. CsA GFR Month 12 64.3 14.5 63.8 14.0 49.8 Month 36 64.8 20.5 65.2 20.9 44.3 Month 60 63.9 24.8 65.2 26.1 39.1 Month 84 62.0 25.4 63.3 26.7 36.6 20

Kaplan-Meier Analysis of Cumulative De Novo DSA Over Time

50 Cumulative Event Rate %

Belatacept MI Belatacept LI CsA

P-value HR (95% CI) Bela MI vs. CsA <0.0001 0.097 (0.029, 0.320) Bela LI vs. CsA <0.0001 0.245 (0.111, 0.539) 6 12 18 24 30 36 42 48 54 60 66 72 78 84 Months

219 226 215 182 187 186 174 183 171 168 180 159 163 178 150 158 169 143 156 165 136 148 158 124 147 154 115 144 152 108 141 145 103 136 143 97 130 138 92 127 133 90 124 130 85 Belatacept MI Belatacept LI CsA N at risk

10 20 30 40

BENEFIT

Bela=belatacept; CI=confidence interval; CsA=cyclosporine A; DSA=donor-specific antibody; HR=hazard ratio; LI=less intensive; MI=more intensive.

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Acute Rejection

Bela=belatacept; CI=confidence interval; CsA=cyclosporine A; HR=hazard ratio; LI=less intensive; MI=more intensive.

100 Probability of Acute Rejection, %

Belatacept MI Belatacept LI CsA P-value HR (95% CI) Bela MI vs. CsA 0.0001 2.649 (1.596, 4.397) Bela LI vs. CsA 0.0302 1.905 (1.124, 3.232)

6 12 18 24 30 36 42 48 54 60 66 72 78 84 Months

219 226 221 154 168 180 147 164 167 144 162 156 140 160 147 137 157 141 136 155 135 128 149 123 127 144 115 125 142 110 122 137 106 117 135 101 111 130 96 108 125 94 105 122 89 Belatacept MI Belatacept LI CsA N at risk

20 40 60 80

For patients with an event, the time to event was defined as minimum of event date and date of last dose (transplant date for non-treated patients) plus 56 days. For patients without an event, the time to event was defined as last follow-up date for on-treatment patients, date of last dose plus 56 days for off-treatment patients, and transplant date plus 56 days for non-treated patients. Between Month 36 and Month 84, 0 belatacept MI-treated, 1 (grade IIA) belatacept LI-treated, and 2 (grade IA [n=1], grade IIA [n=1]) CsA-treated patients experienced acute rejection. *Three patients (n=1 [grade IIA], belatacept MI; n=2, CsA [n=1, grade IA; n=1, grade IIA]) experienced acute rejection more than 56 days after treatment discontinuation.

Belatacept MI (N=219) Belatacept LI (N=226) CsA (N=221) Banff grade of acute rejection*, n Mild acute (IA) Mild acute (IB) Moderate acute (IIA) Moderate acute (IIB) Severe acute (III) 7 (3.2) 3 (1.4) 18 (8.2) 22 (10.0) 3 (1.4) 4 (1.8) 8 (3.5) 17 (7.5) 10 (4.4) 1 (0.4) 6 (2.7) 7 (3.2) 7 (3.2) 3 (1.4) 0 (0.0)

BENEFIT

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Can we apply precision medicine to belatacept therapy?

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Representative images from a Belatacept (a) and CNI (b) patient with acute cellular rejection featuring CD57 (brown) and CD4 (red) positive cells in the cellular infiltrate. Semiquantitative analysis showed a higher density of CD57 positive cells in the Belatacept patients.

UCSF Histology

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Select patients for belatacept who lack CD57+ PD1- CD4+ cells by flow and post transplant monitoring with kSORT

APPLYING PRECISION MEDICINE Personalizing Costimulation Blockade Efficacy in Renal Transplantation (PACER)

CD45RA CCR7 PD-1

9.75%

19.2% CD4 gate TEMRA CD4 TEMRA gate CD57

Total=105 TEMRA- TEMRA+

27 *low %CD57+PD1- in CD4 TEMRA *moderate %CD57+PD1- in CD4 TEMRA *very high %CD57+PD1- in CD4 TEMRA

Example of 3 Patients with Different Risk Profiles for Belatacept

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Application of the kSORT blood assay for the non-invasive prediction of histological rejection kSORT (Kidney Solid Organ Response Test)

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N=558 biopsy matched blood samples profiled by QPCR 8 programs; US, EU, Mexico , ADULT and PEDS

kSORT validated in pediatric and adult populations, LD and DD recipients; independent of Rx

N=367 biopsy matched blood samples profiled by QPCR 12 programs; US,, PEDS

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Kidney- Solid Organ Response Test (kSORT)

CFLAR, DUSP1, IFNGR1, ITGAX, MAPK9, NAMPT, NKTR, PSEN1,CEACAM4, EPOR, GZMK, RARA, RHEB, RXRA, SLC25A37, RNF130, RYBP

Roedder et al, Plos Medicine, 2014; Li et al, AJT, 2012

17 gene PCR test measuring graft immune activation by RNA isolated from whole blood 17 gene PCR test measuring graft immune activation by RNA isolated from whole blood The answer in a drop of blood…..

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QPCR Validation: SNSO1 NIH Trial

N=367 blood samples matched with renal allograft biopsies, central read (R. Sibley, Stanford); NIH SNSO1 clinical trial BLINDED ANALYSIS BY Rho/NIH

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QPCR Cross- Validation; ARRT Study

UCSF, Barcelona, Mexico, Pittsburg, Emory, UCLA, CPMC, Stanford

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kSORT for prediction of preAR

68% 92% 93% 47% 56% 0% 50% 100%

• 3 to -6

(N=16) 0 to -3 (N=11) (N=40) 0 to 3 (N=12) 3 to 6 (N=18) Probability of acute rejection AR pre-AR post-AR ** threshold ** p < 0.001 ** ** Stable graft function Time(months) prior and post acute rejection

B

Samples(N=97) from patients with acute rejection 7% 4% 5% 4% 0% 50% 100% 0 to 3 (N=16) 3 to 6 (N=28) 6 to 12 (N=13) >12 (N=13) Probability of acute rejection threshold Stable graft function Time(months) after transplantation

A

Samples(N=70) from stable patients without acute rejection

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Precision Medicine for De Novo Belatacept Therapy at UCSF

First Phase: Validation in 25 patients Second Phase: Select for Belatacept therapy only patients that have low levels of CD57+PD1- cells

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Precision Medicine Offers Belatacept Monotherapy (PROBE) An initiative to both simplify and reduce costs of immunosuppression with belatacept

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Study Centers

The study will be conducted at 4 centers in the USA, Spain, France and Mexico

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Investigative Team

Flavio Vincenti, M.D.

• UCSF, San Francisco, USA

Minnie Sarwal, MD, PhD

• UCSF, San Francisco, USA

Oriol Bestard, MD, PhD; J Grinyo, MD

• Bellvitge University Hospital, Barcelona, Spain

Antoine Durrbach, M.D.

• Centre Hospitalier Universitaire de Bicetre, France

Josefina Alberu, M.D.

• National Institute of Medical Science and Nutrition Salvadore

Zubiran, Mexico City, Mexico

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Study Design

Patients on belatacept who fulfill the entry criteria will be screened to determine if they have a quiescent molecular immunologic profile with kSORT and uCRM. Patients who screen negative on both tests will undergo stepwise withdrawal first of steroids then of MMF or mTor inhibitors. Prior to each withdrawal the 2 screening molecular tests will be performed and advancement to the next withdrawal phase will be performed if both are negative.

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Background: Study Design

• Phase 2, 1-year, open-label, randomized study of adult kidney transplant patients (first
• r subsequent transplant)

1 month 3 months 6 months

All patients received basiliximab induction, MMF (2 g daily) and steroids. Steroids were dosed IV on days 1 (500 mg) and 2 (250 mg) and administered orally thereafter (tapered from a dose of 100 mg daily to no less than 5 mg daily). LI=less intensive; MI=more intensive; MMF=mycophenolate mofetil.

Belatacept 1 year

Belatacept 4-week (5 mg/kg) MI regimen (10 mg/kg)

15 29 43 57 71 85 113 141 169 DAY 1 5 Second randomizatio n

Belatacept 8-week (5 mg/kg) LI regimen (10 mg/kg)

15 29 57 85 DAY 1 Second randomizatio n

Belatacept 4-week (5 mg/kg) Belatacept 8-week (5 mg/kg)

CsA

(7± ± ± ±3 mg/kg daily)

150–400 mg/mL 150–300 mg/mL

Assigned dosing continued in LTE The 4- and 8-week dosing schedules were unique to this study LI dosing in this study differs from the approved belatacept dosing regimen

DAY 29

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Biopsy-Proven Acute Rejection From Second Randomization to Year 10

CI=confidence interval; CsA=cyclosporine A; HR=hazard ratio; LI=less intensive; MI=more intensive. Years from Second Randomization BMS Highly Confidential Kaplan-Meier cumulative event rate at year 10, % Belatacept 4-week 11.1 Belatacept 8-week 21.9 CsA 13.9

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Estimated Mean GFR Over 10 Years in the Population at Second Randomization

Estimated mean GFR, mL/min/1.73m2 (95% CI)

10 20 30 40 50 60 70 80 90 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120 Month Belatacept 4-week Belatacept 8-week CsA Belatacept 4-week Belatacept 8-week CsA GFR Difference vs. CsA GFR Difference vs. CsA GFR Year 1 70.8 9.4 69.2 7.8 61.4 Year 3 74.2 13.3 71.1 10.2 60.9 Year 5 69.7 18.4 71.1 19.8 51.3 Year 7 63.9 16.9 67.8 20.8 47.0 Year 10 67.0 24.3 68.7 26.0 42.7

P<0.0001 for overall treatment effect

CI=confidence interval; CsA=cyclosporine A; GFR=glomerular filtration rate.

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Summary

Precision Medicine has greatly improved the use of novel agents in oncology and may have similar impact in organ transplantation The UCSF initiative is a step towards that goal

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Modulation of the Immune System with Cellular Therapies

Tolerance vs Improved Outcomes

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Why UCSF is Not Currently Participating in Stem Cell-BM Tolerance Trials

Stanford: TLI, good results in HLA identical patients, results in mismatched patients unclear MGH: Protocol has been problematic, engraftment syndrome and AMR Northwestern: Use BM + Facilitator Cell infusions High % of patients develop full chimerism Good early results but…… Major concerns: conditioning regimens, requirements for chimerism , the risk of GVHD and the risk of rejection with drug withdrawal

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Modulation of the Immune System

Cellular Therapy (T regulatory cells) A nuanced and more precise and selective strategy to control adverse alloimmune responses

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What are Tregs?

Tregs are a small subset of T cells, ~ 5% of CD4+ T

• cells. They can be distinguished from other T cells by

the expression of CD4, CD25, low CD127 and FOXP3 .Natural and Induced T regs , also polyclonal or antigen specific . The main function of Tregs is to suppress immune responses by

• preventing

unwarranted immune activation

• resolving immune responses to limit collateral tissue

damage Loss of Tregs due to FOXP3 mutation leads to lethal autoimmunity in early life if untreated

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Types of Tregs

Natural Tregs (nTregs) Induced Tregs (iTregs)

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How do Tregs function?

Tang and Bluestone, Nat Immunol 2008, 9(3):239

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Background: Treg Therapy

Effective at preventing rejection

• f allografts in animal

models

– Does not appear to inhibit responses to viral pathogens or vaccines in mouse models

Effective at preventing GVHD in humans Well-tolerated in recent phase I clinical trial of type 1 diabetes

51 Ex vivo expanded human Treg protect a human islet allograft from rejection. Wu DC, et al. Transplantation 2013; Bluestone JA, et al. Sc Transl Med 2015

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The Era of T Reg Therapies in Transplantation is Here

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TASKp DART deLTa Artemis TASK

PI Vincenti Kang Feng/Kang Feng Vincenti Indication Kidney @6

• Mo. post Tx

Living donor kidney @Tx Adult liver @3m post Tx Liver IS withdrawal Kidney @6

• Mo. post Tx

Treg type Poly Donor- reactive Donor- reactive Donor- reactive Both # of patients 3 8 15 8 30 Target start date Completed Spring, 2015 Summer, 2015 Spring, 2015 Fall, 2016

Ongoing Treg transplant trials at UCSF

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Theme of CTOT 21-TASK Trial

Subclinical inflammation in renal allografts as a target for testing novel therapies in organ transplantation to improve outcomes

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Fibrosis with Inflammation at One Year Predicts Transplant Functional Decline

Walter D. Park, Matthew D. Griffin, Lynn D. Cornell, Fernando G. Cosio, and Mark D. Segall

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Methods

This study tested whether fibrosis with inflammation at 1 year associates with decline of renal function in a low-risk cohort and characterized the nature of the

• inflammation. The authors studied 151 living-donor,

tacrolimus/mycophenolate-treated recipients without

• vert risk factors for reduced graft survival.

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A Kaplan-Meier plot is shown for death-censored graft survival after T12 surveillance

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Group mean values for GFRu, measured by Cioth and expressed as a percent baseline value at 1 month (1m) are shown for 1, 12, 24, 36, and 48 months after transplantation

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Subclinical inflammation in 6m protocol biopsy

• Re-biopsy in

14d

• Infused Tregs in

circulation

• Biomarkers

Standard-of-care control n=15 PolyTreg 400+/-100 million n=15 darTreg 400+/-100 million n=15

Clinical sites: UCSF, UAB, Cleveland Clinic, University of Michigan, Cedars-Sinai

TASK

Treg Adoptive therapy for Subclinical Inflammation in Kidney transplantation

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Treg Adoptive therapy in Subclinical inflammation in Kidney transplantation (TASK). A randomized controlled trial to compare the safety and preliminary efficacy of autologous ex vivo expanded polyclonal Tregs (polyTregs) and donor alloantigen reactive Tregs (darTregs) to control graft inflammation and borderline rejection. Hypotheses to be tested: 1. PolyTreg and darTreg infusions are safe. They will increase Tregs in circulation and in the in inflamed kidney allograft. 2. darTregs will accumulate more effectively in the graft than polyTregs. 3. Treg infusion will suppress inflammation in the graft and reduce markers of inflammation in the graft and urine.

CTOT-21

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10 10 10 5 4 3 10 5 10 4 10 3

CD127 CD25 94 FOXP3 Polyclonal primary expansion with anti- CD3/28 beads 9 days Isolate CD4+127-/lo25+ Tregs Polyclonal secondary expansion using anti- CD3/28 beads 5 days Harvest and QC infusion

Polyclonal expansion of human Tregs

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Treg manufacturing: darTreg

The darTreg expansion process uses CD40L- activated donor B cells to first selectively expand donor alloantigen-reactive Tregs. The Tregs are then restimulated with anti-CD3 and anti-CD28-coated beads on day 11 to increase cell

• yield. Tregs expand 100-4200 fold in 16 days. The

expanded Tregs are highly alloantigen reactive and express the phenotype of stable Tregs.

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Antigen-specific primary expansion with donor B cells 11 days Polyclonal secondary expansion using anti- CD3/28 beads 5 days Harvest & Release assays 10-12 hrs

10 10 10 5 4 3 10 5 10 4 10 3

CD127 CD25 Donor B cell activation 10 days Irradiated GMP K562-hCD40L cells

Putnam et al Am J Transpl 2013

Donor-reactive Treg expansion

Large scale Treg expansion

2 4 6 8 10 12 14 16 1 4 16 64 256 1024 Days in Culture Fold Expansion

200-1600 fold

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Polyclonal Treg Adoptive Therapy for Control of Subclinical Kidney Transplant Inflammation

TASK Pilot Trial

June 14, 2016

Sindhu Chandran, Qizhi Tang, Minnie Sarwal, Zoltan Laszik, Amy Putnam, Tara Sigdel, Erica Tavares, Jeffrey Bluestone, Flavio Vincenti

Results: Graft Pathology

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6 months post-transplant 2 weeks post-Treg 12 months post-transplant

i1 t1 ti2 at1 i0 t0 ti0 at0 i0 t0 ti1 at1

• Subject 1

Infused T regs remain detectable in circulation

Treg% Days after infusion

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Conclusions

The transplant pipeline of immunosuppression drugs is currently depleted because of a failure to adopt Precision Medicine and Biomarkers in the clinical trials of novel drugs Cellular therapies, stem cells, facilitator cells, mesenchymal cells and Treg cells are yet to fulfill their promise in inducing tolerance and/or improved

• utcomes