|Values are valid only on day of printing.|
Determining over immunosuppression within the CD8 T-cell compartment, when used on transplant recipients and patients with autoimmune disorders receiving therapy with immunosuppressant agents
CD8 T cells play an important role in the immune response to viral or intracellular infectious agents, as well as antitumor immunity and immune surveillance.
Upon activation, CD8 T cells mediate a variety of effector functions, including cytokine secretion and cytotoxicity. Interferon-gamma (IFN-gamma) is 1 of the early cytokines produced by CD8 T cells; it is released within a few hours of activation.(1) The cytotoxic function is mediated by the contents of the cytolytic granules.(1) Cell-surface mobilization of the cytolytic granule components, CD107a and CD107b, also known as lysosome-associated membrane proteins LAMP-1 and LAMP-2, occurs when CD8 T cells mediate their cytolytic function and degranulate.(2)
CD8 T-cell activation occurs either through the T-cell receptor (TCR)-peptide-major histocompatibility complex (MHC) or by use of a mitogen (eg, phorbol myristate acetate and the calcium ionophore ionomycin). Mitogen-mediated activation is antigen nonspecific.
Impairment of global CD8 T-cell activation (due to inherent cellular immunodeficiency or as a consequence of over-immunosuppression by therapeutic agents) results in reduced production of IFN-gamma and other cytokines, reduced cytotoxic function, and increased risk for developing infectious complications. Agents associated with over-immunosuppression include the calcineurin inhibitors (eg, cyclosporine A, FK506 [Prograf/tacrolimus], and rapamycin [sirolimus]), antimetabolites (eg, mycophenolate mofetil), and Thymoglobulin.
Immunosuppression is most commonly used for allograft maintenance in solid organ transplant recipients, to prevent graft-versus-host disease (GVHD) in allogeneic hematopoietic stem cell transplant patients and to treat patients with autoimmune diseases. In these settings, reducing the risk for developing infectious complications as a result of over-immunosuppression is a clinical challenge.
Therapeutic drug monitoring (TDM) is routinely used in the transplant practice to avoid overtreatment and to determine patient compliance. But, the levels of drugs measured in blood do not directly correlate with the administered dose due to individual pharmacokinetic differences.(3) Furthermore, drug levels may not necessarily correlate with biological activity of the drug. Consequently, it may be beneficial to consider modification of the immunosuppression regimen based on the patient's level of functional immune competence.
This assay provides a means to evaluate over-immunosuppression within the CD8 T-cell compartment (global CD8 T-cell function). Intracellular IFN-gamma expression is a marker for CD8 T-cell activation. Surface CD107a and CD107b are markers for cytotoxic function. This test may be most useful when ordered at the end of induction immunosuppression and 2 to 3 months after maintenance immunosuppression to ensure that global CD8 T-cell function is not compromised. The test may also provide value when immunosuppression is increased to halt or prevent graft rejection, to provide information on a balance between over-immunosuppression with subsequent infectious comorbidities and under-immunosuppression with resultant graft rejection.
The absolute counts of lymphocyte subsets are known to be influenced by a variety of biological factors, including hormones, the environment, and temperature. The studies on diurnal (circadian) variation in lymphocyte counts have demonstrated progressive increase in CD4 T cell count throughout the day, while CD8 T cells and CD19+ B cells increase between 8:30 a.m. and noon with no change between noon and afternoon. Natural Killer (NK) cell counts, on the other hand, are constant throughout the day.(4) Circadian variations in circulating T-cell counts have been shown to be negatively correlated with plasma cortisol concentration.(5,6,7) In fact, cortisol and catecholamine concentrations control distribution and therefore, numbers of naive versus effector CD4 and CD8 T cells.(5) It is generally accepted that lower CD4 T cell counts are seen in the morning compared to the evening(8) and during summer compared to winter.(9) These data therefore indicate that timing and consistency in timing of blood collection is critical when serially monitoring patients for lymphocyte subsets.
Interferon-gamma (IFN-gamma) expression (as % CD8 T cells): 10.3-56.0%
CD107a/b expression (as % CD8 T cells): 8.5-49.1%
Reference values have not been established for patients who are <19 years of age.
Interferon-gamma (IFN-gamma) and CD107a and CD107b expression below the defined reference range are consistent with a global impairment in CD8 T-cell function, most likely due to overimmunosuppression.
IFN-gamma and CD107a and CD107b levels greater than the defined reference range are unlikely to have any clinical significance.
This assay is specific only for CD8 T cells; it does not provide information for overall T-cell competence.
Further studies are needed to determine if, within the reference range, certain levels of Interferon-gamma and CD107a and b expression confer greater or lesser degrees of risk for infectious disease.
Timing and consistency in timing of blood collection is critical when serially monitoring patients for lymphocyte subsets. See data under Clinical Information.
The 95% confidence interval reference values were determined from 102 healthy adult donors.
1. Betts MR, Casaza JP, Patterson BA, et al: Putative immunodominant human immunodeficiency virus-specific CD8 T-cell responses cannot be predicted by MHC class I haplotype. J Virol. 2000 Oct;74(19):9144-9151
2. Peters PJ, Borst J, Oorschot V, et al: Cytotoxic T-lymphocyte granules are secretory lysosomes, containing both perforin and granzymes. J Exp Med. 1991 May 1;173(5):1099-1109
3. Venkataramanan R, Shaw LM, Sarkozi L, et al: Clinical utility of monitoring tacrolimus blood concentrations in liver transplant patients. J Clin Pharmacol 2001 May;41(5):542-551
4. Carmichael KF, Abayomi A: Analysis of diurnal variation of lymphocyte subsets in healthy subjects and its implication in HIV monitoring and treatment. 15th Intl Conference on AIDS, Bangkok, Thailand, 2004, Abstract # B11052
5. Dimitrov S, Benedict C, Heutling D, et al: Cortisol and epinephrine control opposing circadian rhythms in T-cell subsets. Blood 2009;113:5134-5143
6. Dimitrov S, Lange T, Nohroudi K, Born J: Number and function of circulating antigen presenting cells regulated by sleep. Sleep 2007;30:401-411
7. Kronfol Z, Nair M, Zhang Q, et al: Circadian immune measures in healthy volunteers: relationship to hypothalamic-pituitary-adrenal axis hormones and sympathetic neurotransmitters. Pyschosom Med 1997;59:42-50
8. Malone JL, Simms TE, Gray GC, et al: Sources of variability in repeated T-helper lymphocyte counts from HIV 1-infected patients: total lymphocyte count fluctuations and diurnal cycle are important. J AIDS 1990;3:144-151
9. Paglieroni TG, Holland PV: Circannual variation in lymphocyte subsets, revisited. Transfusion 1994;34:512-516