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The Fetal-Maternal Immune Interface in Uterus Transplantation.

Authors: Jasper Iske|||Abdallah Elkhal|||Stefan G Tullius

Journal: Trends in immunology

Publication Type: Journal Article

Date: 2020

DOI: NIHMS1660950

ID: 32109373

Affiliations:

Affiliations

    Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany.|||Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.|||Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: stullius@bwh.harvard.edu.

Abstract

Uterus transplants (UTxs) have been performed worldwide. Overall frequencies have been low, but globally initiated UTx programs are expected to increase clinical implementation. The uterus constitutes a unique immunological environment with specific features of tissue renewal and a receptive endometrium. Decidual immune cells facilitate embryo implantation and placenta development. Although UTx adds to the complexity of immunity during pregnancy and transplantation, the procedure provides a unique clinical and experimental model. We posit that understanding the distinct immunological properties at the interface of the transplanted uterus, the fetus and maternal circulation might provide valuable novel insights while improving outcomes for UTx. Here, we discuss immunological challenges and opportunities of UTx affecting mother, pregnancy and healthy livebirths.


Reference List

    Johannesson L et al. (2015) Uterus transplantation trial: 1-year outcome. Fertil Steril 103 (1), 199–204.|||Watanabe T et al. (2017) Ischemia Reperfusion Injury Augments Acute and Chronic Rejection and Alloimmune-Dependent Intrapulmonary Lymphoid Neogenesis in a Mouse Orthotopic Lung Transplant Model. The Journal of Heart and Lung Transplantation 36 (4), S191–S192.|||Uehara M et al. (2018) Ischemia augments alloimmune injury through IL-6-driven CD4(+) alloreactivity. Sci Rep 8 (1), 2461.|||Perez Valdivia MA et al. (2011) Impact of cold ischemia time on initial graft function and survival rates in renal transplants from deceased donors performed in Andalusia. Transplant Proc 43 (6), 2174–6.|||Wu MY et al. (2018) Current Mechanistic Concepts in Ischemia and Reperfusion Injury. Cell Physiol Biochem 46 (4), 1650–1667.|||Tugmen C et al. (2016) Delayed Graft Function in Kidney Transplantation: Risk Factors and Impact on Early Graft Function. Prog Transplant 26 (2), 172–7.|||Akhi SN et al. (2013) Uterine rejection after allogeneic uterus transplantation in the rat is effectively suppressed by tacrolimus. Fertil Steril 99 (3), 862–70.|||Donnahoo KK et al. (2000) Early renal ischemia, with or without reperfusion, activates NFkappaB and increases TNF-alpha bioactivity in the kidney. J Urol 163 (4), 1328–32.|||Kisu I et al. (2017) Allowable warm ischemic time and morphological and biochemical changes in uterine ischemia/reperfusion injury in cynomolgus macaque: a basic study for uterus transplantation. Hum Reprod 32 (10), 2026–2035.|||Enskog A et al. (2010) Uterus transplantation in the baboon: methodology and long-term function after auto-transplantation. Hum Reprod 25 (8), 1980–7.|||Tricard J et al. (2017) Uterus tolerance to extended cold ischemic storage after auto-transplantation in ewes. Eur J Obstet Gynecol Reprod Biol 214, 162–167.|||Padma AM et al. (2019) The development of an extended normothermic ex vivo reperfusion model of the sheep uterus to evaluate organ quality after cold ischemia in relation to uterus transplantation. Acta Obstet Gynecol Scand.|||Tardieu A et al. (2019) Changes in the metabolic composition of storage solution with prolonged cold ischemia of the uterus. J Assist Reprod Genet.|||Oberbarnscheidt MH et al. (2014) Non-self recognition by monocytes initiates allograft rejection. J Clin Invest 124 (8), 3579–89.|||Molne J et al. (2017) Monitoring of Human Uterus Transplantation With Cervical Biopsies: A Provisional Scoring System for Rejection. Am J Transplant 17 (6), 1628–1636.|||Jones BP et al. (2019) Human uterine transplantation: a review of outcomes from the first 45 cases. BJOG 126 (11), 1310–1319.|||Wranning CA et al. (2005) Short-term ischaemic storage of human uterine myometrium--basic studies towards uterine transplantation. Hum Reprod 20 (10), 2736–44.|||Chmel R et al. (2019) Revaluation and lessons learned from the first 9 cases of a Czech uterus transplantation trial: Four deceased donor and 5 living donor uterus transplantations. Am J Transplant 19 (3), 855–864.|||Ejzenberg D et al. (2018) Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility. Lancet.|||El-Akouri RR et al. (2006) Rejection patterns in allogeneic uterus transplantation in the mouse. Hum Reprod 21 (2), 436–42.|||Becker J and Grasso RJ (1985) Suppression of phagocytosis by dexamethasone in macrophage cultures: inability of arachidonic acid, indomethacin, and nordihydroguaiaretic acid to reverse the inhibitory response mediated by a steroid-inducible factor. Int J Immunopharmacol 7 (6), 839–47.|||Olivares-Morales MJ et al. (2018) Glucocorticoids Impair Phagocytosis and Inflammatory Response Against Crohn’s Disease-Associated Adherent-Invasive Escherichia coli. Front Immunol 9, 1026.|||Matyszak MK et al. (2000) Differential effects of corticosteroids during different stages of dendritic cell maturation. Eur J Immunol 30 (4), 1233–42.|||Meehan AC et al. (2013) Impact of commonly used transplant immunosuppressive drugs on human NK cell function is dependent upon stimulation condition. PLoS One 8 (3), e60144.|||Ashkar AA et al. (2000) Interferon gamma contributes to initiation of uterine vascular modification, decidual integrity, and uterine natural killer cell maturation during normal murine pregnancy. J Exp Med 192 (2), 259–70.|||Fu B et al. (2013) Natural killer cells promote immune tolerance by regulating inflammatory TH17 cells at the human maternal-fetal interface. Proc Natl Acad Sci U S A 110 (3), E231–40.|||Fu B et al. (2017) Natural Killer Cells Promote Fetal Development through the Secretion of Growth-Promoting Factors. Immunity 47 (6), 1100–1113.e6.|||Bittmann I et al. (2001) Cellular chimerism of the lung after transplantation. An interphase cytogenetic study. Am J Clin Pathol 115 (4), 525–33.|||Hanna J et al. (2003) CXCL12 expression by invasive trophoblasts induces the specific migration of CD16− human natural killer cells. Blood 102 (5), 1569–77.|||Li YH et al. (2016) The Galectin-9/Tim-3 pathway is involved in the regulation of NK cell function at the maternal-fetal interface in early pregnancy. Cell Mol Immunol 13 (1), 73–81.|||Southcombe JH et al. (2017) An altered endometrial CD8 tissue resident memory T cell population in recurrent miscarriage. Sci Rep 7, 41335.|||Plaks V et al. (2008) Uterine DCs are crucial for decidua formation during embryo implantation in mice. J Clin Invest 118 (12), 3954–65.|||Lash GE et al. (2016) Decidual macrophages: key regulators of vascular remodeling in human pregnancy. J Leukoc Biol 100 (2), 315–25.|||Yao Y et al. (2019) Macrophage Polarization in Physiological and Pathological Pregnancy. Front Immunol 10, 792.|||Abumaree MH et al. (2012) Trophoblast debris modulates the expression of immune proteins in macrophages: a key to maternal tolerance of the fetal allograft? J Reprod Immunol 94 (2), 131–41.|||Lee CL et al. (2015) Soluble human leukocyte antigen G5 polarizes differentiation of macrophages toward a decidual macrophage-like phenotype. Hum Reprod 30 (10), 2263–74.|||Szondy Z et al. (2014) Impaired clearance of apoptotic cells in chronic inflammatory diseases: therapeutic implications. Front Immunol 5, 354.|||Moura R et al. (2008) Thrombospondin-1 deficiency accelerates atherosclerotic plaque maturation in ApoE−/− mice. Circ Res 103 (10), 1181–9.|||Thorp E et al. (2008) Mertk receptor mutation reduces efferocytosis efficiency and promotes apoptotic cell accumulation and plaque necrosis in atherosclerotic lesions of apoe−/− mice. Arterioscler Thromb Vasc Biol 28 (8), 1421–8.|||Hanayama R et al. (2004) Autoimmune disease and impaired uptake of apoptotic cells in MFG-E8-deficient mice. Science 304 (5674), 1147–50.|||Levy R et al. (2002) Trophoblast apoptosis from pregnancies complicated by fetal growth restriction is associated with enhanced p53 expression. Am J Obstet Gynecol 186 (5), 1056–61.|||Coscia LA et al. (2010) Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl, 65–85.|||Durst JK and Rampersad RM (2015) Pregnancy in Women With Solid-Organ Transplants: A Review. Obstet Gynecol Surv 70 (6), 408–18.|||Humphreys RA et al. (2012) Pregnancy outcomes among solid organ transplant recipients in British Columbia. J Obstet Gynaecol Can 34 (5), 416–424.|||Johannesson L et al. (2019) Rethinking the time interval to embryo transfer after uterus transplantation - DUETS (Dallas UtErus Transplant Study). Bjog 126 (11), 1305–1309.|||Wei L et al. (2013) Modified uterine allotransplantation and immunosuppression procedure in the sheep model. PLoS One 8 (11), e81300.|||Bulmer JN et al. (1991) Granulated lymphocytes in human endometrium: histochemical and immunohistochemical studies. Hum Reprod 6 (6), 791–8.|||Gnainsky Y et al. (2015) Biopsy-induced inflammatory conditions improve endometrial receptivity: the mechanism of action. Reproduction 149 (1), 75–85.|||Pavlov O et al. (2008) Characterization of cytokine production by human term placenta macrophages in vitro. Am J Reprod Immunol 60 (6), 556–67.|||Huang WC et al. (2012) Classical macrophage activation up-regulates several matrix metalloproteinases through mitogen activated protein kinases and nuclear factor-kappaB. PLoS One 7 (8), e42507.|||Groth K et al. (2009) Rejection of allogenic uterus transplant in the mouse: time-dependent and site-specific infiltration of leukocyte subtypes. Hum Reprod 24 (11), 2746–54.|||Tornblom SA et al. (2005) Non-infected preterm parturition is related to increased concentrations of IL-6, IL-8 and MCP-1 in human cervix. Reprod Biol Endocrinol 3, 39.|||Gonzalez JM et al. (2011) Complement activation triggers metalloproteinases release inducing cervical remodeling and preterm birth in mice. Am J Pathol 179 (2), 838–49.|||Brannstrom M et al. (2015) Livebirth after uterus transplantation. Lancet 385 (9968), 607–616.|||Testa G et al. (2018) First live birth after uterus transplantation in the United States. Am J Transplant 18 (5), 1270–1274.|||Nakashima A et al. (2010) Circulating and decidual Th17 cell levels in healthy pregnancy. Am J Reprod Immunol 63 (2), 104–9.|||Wu HX et al. (2014) Decidual stromal cells recruit Th17 cells into decidua to promote proliferation and invasion of human trophoblast cells by secreting IL-17. Cell Mol Immunol 11 (3), 253–62.|||Santner-Nanan B et al. (2009) Systemic increase in the ratio between Foxp3+ and IL-17-producing CD4+ T cells in healthy pregnancy but not in preeclampsia. J Immunol 183 (11), 7023–30.|||Ito M et al. (2010) A role for IL-17 in induction of an inflammation at the fetomaternal interface in preterm labour. J Reprod Immunol 84 (1), 75–85.|||Wang WJ et al. (2010) Increased prevalence of T helper 17 (Th17) cells in peripheral blood and decidua in unexplained recurrent spontaneous abortion patients. J Reprod Immunol 84 (2), 164–70.|||Syrjala SO et al. (2010) Increased Th17 rather than Th1 alloimmune response is associated with cardiac allograft vasculopathy after hypothermic preservation in the rat. J Heart Lung Transplant 29 (9), 1047–57.|||Itoh S et al. (2011) Interleukin-17 accelerates allograft rejection by suppressing regulatory T cell expansion. Circulation 124 (11 Suppl), S187–96.|||Guleria I et al. (2005) A critical role for the programmed death ligand 1 in fetomaternal tolerance. J Exp Med 202 (2), 231–7.|||Blois SM et al. (2007) A pivotal role for galectin-1 in fetomaternal tolerance. Nat Med 13 (12), 1450–7.|||Munn DH et al. (1998) Prevention of allogeneic fetal rejection by tryptophan catabolism. Science 281 (5380), 1191–3.|||Baban B et al. (2004) Indoleamine 2,3-dioxygenase expression is restricted to fetal trophoblast giant cells during murine gestation and is maternal genome specific. J Reprod Immunol 61 (2), 67–77.|||Moreau A et al. (2012) Absence of Galectin-1 accelerates CD8(+) T cell-mediated graft rejection. Eur J Immunol 42 (11), 2881–8.|||Ma D et al. (2016) PD-L1 Deficiency within Islets Reduces Allograft Survival in Mice. PLoS One 11 (3), e0152087.|||Hunt JS et al. (1997) Fas ligand is positioned in mouse uterus and placenta to prevent trafficking of activated leukocytes between the mother and the conceptus. J Immunol 158 (9), 4122–8.|||Qiu Q et al. (2005) Fas ligand expression by maternal decidual cells is negatively correlated with the abundance of leukocytes present at the maternal-fetal interface. J Reprod Immunol 65 (2), 121–32.|||Min WP et al. (2000) Dendritic cells genetically engineered to express Fas ligand induce donor-specific hyporesponsiveness and prolong allograft survival. J Immunol 164 (1), 161–7.|||Alegre ML et al. (2016) Antigen Presentation in Transplantation. Trends Immunol 37 (12), 831–843.|||Collins MK et al. (2009) Dendritic cell entrapment within the pregnant uterus inhibits immune surveillance of the maternal/fetal interface in mice. J Clin Invest 119 (7), 2062–73.|||Nancy P et al. (2012) Chemokine gene silencing in decidual stromal cells limits T cell access to the maternal-fetal interface. Science 336 (6086), 1317–21.|||van Golen RF et al. (2019) The damage-associated molecular pattern HMGB1 is released early after clinical hepatic ischemia/reperfusion. Biochim Biophys Acta Mol Basis Dis 1865 (6), 1192–1200.|||Ferhat M et al. (2018) Endogenous IL-33 Contributes to Kidney Ischemia-Reperfusion Injury as an Alarmin. J Am Soc Nephrol 29 (4), 1272–1288.|||Heikkinen J et al. (2004) Phenotypic characterization of regulatory T cells in the human decidua. Clin Exp Immunol 136 (2), 373–8.|||Somerset DA et al. (2004) Normal human pregnancy is associated with an elevation in the immune suppressive CD25+ CD4+ regulatory T-cell subset. Immunology 112 (1), 38–43.|||Erlebacher A (2013) Mechanisms of T cell tolerance towards the allogeneic fetus. Nat Rev Immunol 13 (1), 23–33.|||Cederbom L et al. (2000) CD4+CD25+ regulatory T cells down-regulate co-stimulatory molecules on antigen-presenting cells. Eur J Immunol 30 (6), 1538–43.|||Fallarino F et al. (2003) Modulation of tryptophan catabolism by regulatory T cells. Nat Immunol 4 (12), 1206–12.|||Fallarino F et al. (2004) CTLA-4-Ig activates forkhead transcription factors and protects dendritic cells from oxidative stress in nonobese diabetic mice. J Exp Med 200 (8), 1051–62.|||Maynard CL et al. (2007) Regulatory T cells expressing interleukin 10 develop from Foxp3+ and Foxp3− precursor cells in the absence of interleukin 10. Nat Immunol 8 (9), 931–41.|||Sundstedt A et al. (2003) Role for IL-10 in suppression mediated by peptide-induced regulatory T cells in vivo. J Immunol 170 (3), 1240–8.|||Oishi H et al. (2018) A novel combined ex vivo and in vivo lentiviral interleukin-10 gene delivery strategy at the time of transplantation decreases chronic lung allograft rejection in mice. J Thorac Cardiovasc Surg 156 (3), 1305–1315.|||Niu J et al. (2014) Prevention of acute liver allograft rejection by IL-10-engineered mesenchymal stem cells. Clin Exp Immunol 176 (3), 473–84.|||Oberhuber R et al. (2015) CD11c+ Dendritic Cells Accelerate the Rejection of Older Cardiac Transplants via Interleukin-17A. Circulation 132 (2), 122–31.|||Tullius SG and Milford E (2011) Kidney allocation and the aging immune response. N Engl J Med 364 (14), 1369–70.|||Brannstrom M et al. (2014) First clinical uterus transplantation trial: a six-month report. Fertil Steril 101 (5), 1228–36.|||Testa G et al. (2017) Living Donor Uterus Transplantation: A Single Center’s Observations and Lessons Learned From Early Setbacks to Technical Success. Am J Transplant 17 (11), 2901–2910.|||Brannstrom M (2018) Current status and future direction of uterus transplantation. Curr Opin Organ Transplant 23 (5), 592–597.|||Fowler KB et al. (1992) The outcome of congenital cytomegalovirus infection in relation to maternal antibody status. N Engl J Med 326 (10), 663–7.|||Picone O et al. (2014) Detailed in utero ultrasound description of 30 cases of congenital cytomegalovirus infection. Prenat Diagn 34 (6), 518–24.|||Ariga H et al. (2001) Kinetics of fetal cellular and cell-free DNA in the maternal circulation during and after pregnancy: implications for noninvasive prenatal diagnosis. Transfusion 41 (12), 1524–30.|||Lo YM et al. (2000) Quantitative analysis of the bidirectional fetomaternal transfer of nucleated cells and plasma DNA. Clin Chem 46 (9), 1301–9.|||Maloney S et al. (1999) Microchimerism of maternal origin persists into adult life. J Clin Invest 104 (1), 41–7.|||Bianchi DW et al. (1996) Male fetal progenitor cells persist in maternal blood for as long as 27 years postpartum. Proc Natl Acad Sci U S A 93 (2), 705–8.|||Wang XQ et al. (2012) Hematopoietic chimerism in liver transplantation patients and hematopoietic stem/progenitor cells in adult human liver. Hepatology 56 (4), 1557–66.|||Bartmann C et al. (2014) Quantification of the predominant immune cell populations in decidua throughout human pregnancy. Am J Reprod Immunol 71 (2), 109–19.|||Kwan M et al. (2014) Dynamic changes in maternal decidual leukocyte populations from first to second trimester gestation. Placenta 35 (12), 1027–34.|||Stevens AM et al. (2003) Myocardial-tissue-specific phenotype of maternal microchimerism in neonatal lupus congenital heart block. Lancet 362 (9396), 1617–23.|||Stevens AM (2016) Maternal microchimerism in health and disease. Best Pract Res Clin Obstet Gynaecol 31, 121–30.|||Shulman HM et al. (1980) Chronic graft-versus-host syndrome in man. A long-term clinicopathologic study of 20 Seattle patients. Am J Med 69 (2), 204–17.|||Fedoseyeva EV et al. (1996) Induction of T cell responses to a self-antigen following allotransplantation. Transplantation 61 (5), 679–83.|||Adams Waldorf KM and Nelson JL (2008) Autoimmune disease during pregnancy and the microchimerism legacy of pregnancy. Immunol Invest 37 (5), 631–44.|||Fageeh W et al. (2002) Transplantation of the human uterus. Int J Gynaecol Obstet 76 (3), 245–51.|||Chmel R et al. (2019) Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives. J Obstet Gynaecol Res 45 (8), 1458–1465.|||Scott JR et al. (1971) Transplantation of the primate uterus. Surg Gynecol Obstet 133 (3), 414–8.|||Ramirez ER et al. (2008) Modified uterine transplant procedure in the sheep model. J Minim Invasive Gynecol 15 (3), 311–4.|||Jiga LP et al. (2003) Experimental model of heterotopic uterus transplantation in the laboratory rat. Microsurgery 23 (3), 246–50.