Depletion of alloreactive B cells by chimeric alloantigen receptor T cells with drug resistance to prevent antibody-mediated rejection in solid organ transplantation

In the present study, we developed a novel cell therapy approach to selectively combat antibody-mediated rejection (AMR), a major and unresolved complication after solid organ transplantation (SOT) caused by donor-HLA-specific, alloreactive B cells. Current treatment options including B-cell depletion protocols are inefficient and result in complete loss of humoral immunity. To selectively eliminate alloreactive B cells characterized by corresponding anti-donor-HLA B-cell receptors (BCRs), we engineered T cells with a novel chimeric receptor comprising a truncated HLA molecule fused to intracellular 4-1BB/CD3ξ signaling domains to generate T cells overcoming rejection by antibodies (CORA-Ts). As proof-of-concept, CORA receptors based on HLA-A*02 were shown to bind anti-HLA-A*02 antibodies from the serum of kidney transplant recipients, indicating their suitability to also target the respective membrane-bound anti-HLA-A*02 BCRs on alloreactive B cells. In co-cultures with B-cell lines expressing and releasing anti-HLA-A*02 antibodies, CORA-Ts were specifically activated, released pro-inflammatory cytokines (e.g. IFN-γ, granzyme B), and exhibited strong cytotoxicity resulting in an effective reduction of anti-HLA-A*02 antibody release. A modification of the HLA-A*02 α3-domain within the CORA receptor effectively abrogated T-cell sensitization. Additionally, using CRISPR/Cas9-mediated knockout of a selected binding protein, CORA-Ts were able to resist immunosuppressive treatment to ensure high efficiency in transplant patients. Our results demonstrate that CORA-Ts are able to specifically recognize and eliminate alloreactive B cells, and thus selectively prevent formation of anti-HLA antibodies even under immunosuppressive conditions. This suggests CORA-Ts as potent novel approach to specifically combat AMR and improve long-term graft survival in SOT patients while preserving their overall B-cell immunity.