The Ratio of Circulating Regulatory T Cells (Tregs)/Th17 Cells Is Associated with Acute Allograft Rejection in Liver Transplantation
et al. (2014) The Ratio of Circulating Regulatory T Cells (Tregs)/Th17 Cells Is Associated with Acute Allograft
Rejection in Liver Transplantation. PLoS ONE 9(11): e112135. doi:10.1371/journal.pone.0112135
The Ratio of Circulating Regulatory T Cells (Tregs)/Th17 Cells Is Associated with Acute Allograft Rejection in Liver Transplantation
Ying Wang 0
Min Zhang 0
Zhen-Wen Liu 0
Wei-Guo Ren 0
Yan-Chao Shi 0
Yan-Ling Sun 0
Hong- Bo Wang 0
Lei Jin 0
Fu-Sheng Wang 0
Ming Shi 0
Valquiria Bueno, UNIFESP Federal University of Sao Paulo, Brazil
0 1 Research Center for Liver Transplantation, Beijing 302 Hospital, Peking University Health Science Center , Beijing , China , 2 Research Centre for Liver Transplantation, Beijing 302 Hospital , Beijing , China , 3 The Third Xiangya Hospital of Central South University , Changsha , China , 4 Research Center for Biological Therapy, Beijing 302 Hospital , Beijing , China
CD4+CD25+FoxP3+ regulatory T cells (Tregs) and Th17 cells are known to be involved in the alloreactive responses in organ transplantation, but little is known about the relationship between Tregs and Th17 cells in the context of liver alloresponse. Here, we investigated whether the circulating Tregs/Th17 ratio is associated with acute allograft rejection in liver transplantation. In present study, thirty-eight patients who received liver transplant were enrolled. The patients were divided into two groups: acute allograft rejection group (Gr-AR) (n = 16) and stable allograft liver function group (Gr-SF) (n = 22). The frequencies of circulating Tregs and circulating Th17 cells, as well as Tregs/Th17 ratio were determined using flow cytometry. The association between Tregs/Th17 ratio and acute allograft rejection was then analyzed. Our results showed that the frequency of circulating Tregs was significantly decreased, whereas the frequency of circulating Th17 cells was significantly increased in liver allograft recipients who developed acute rejection. Tregs/Th17 ratio had a negative correlation with liver damage indices and the score of rejection activity index (RAI) after liver transplantation. In addition, the percentages of CTLA-4+, HLA-DR+, Ki67+, and IL-10+ Tregs were higher in Gr-SF group than in Gr-AR group. Our results suggested that the ratio of circulating Tregs/Th17 cells is associated with acute allograft rejection, thus the ratio may serve as an alternative marker for the diagnosis of acute rejection.
Funding: This work was supported by Project of Research on The Application of Capital, Clinical Characteristics (Z111107058811069); The Key Project of Medical
Science and Technology of PLA (BWS11J075) of China. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of
Competing Interests: The authors have declared that no competing interests exist.
. These authors contributed equally to this work.
Despite the use of potent immunosuppressive agents, acute
rejection (AR) remains a major cause of early allograft loss and an
obstacle for long-term allograft survival. The hallmarks of acute
rejection include infiltration of T lymphocytes, monocytes, and
other inflammatory cells [1,2]. Laboratory and clinical
investigations have indicated that CD4+CD25+FoxP3+ regulatory T cells
(Tregs) are one of the major cell types responsible for the immune
responses to alloantigens. Tregs activation is involved in the
prevention of rejection, the induction and maintenance of
peripheral tolerance of the allograft , and the support of
allograft survival . Several other studies indicated that Tregs
are an essential element of the immunoregulatory pathway which
induces peripheral allograft tolerance [7,8], that the frequency of
circulating Tregs is significantly decreased during acute rejection
, and that the transfer of Tregs pre-stimulated in vitro can
protect skin and cardiac allografts from acute and chronic
rejection [10,11]. In clinical transplantation, T cells with the
phenotypic characteristics of regulatory cells are detected in both
the peripheral blood and within the graft itself [3,12,13]. In renal
transplant recipients, grafts infiltrated with more Tregs display
much longer survival [7,14]. Pediatric patients who acquired
operational tolerance after liver transplantation showed increased
levels of circulating Tregs compared with patients who received
immunosuppression . Allograft tolerance in liver transplant
recipients may be partly attributable to a higher frequency of
circulating Tregs . Therefore, an increased level of circulating
Tregs may be beneficial for allograft survival.
Th17 cells are a subset of T helper cells which is characterized
by the production of IL-17. Th17 cells have been suggested to play
a role in allograft rejection in the context of organ transplantation
. A study reported that cardiac allografts infiltrated with
Th17 cells underwent accelerated vascular rejection in Tbet2/2
mice model . IL-17, a potent proinflammatory cytokine, has
been demonstrated to participate in allograft rejection . It
promotes cardiac allograft rejection by inducing the maturation,
antigen presentation, and co-stimulatory capabilities of dendritic
cells in mice . In a corneal transplant model, mice with
deficient IL-17 experienced delayed graft rejection compared to
wild-type mice . Blocking IL-17 promoted the maturation of
dendritic cells, inhibited the proliferation of alloreactive T cells
in vitro, and prolonged the survival time of vascularized cardiac
allografts in vivo [19,20]. IL-17 neutralization inhibits acute, but
not chronic, vascular rejection in mice [17,25]. Clinical evidence
showed that the level of IL-17 in the blood is positively correlated
with acute allograft rejection in the renal [21,26] and the liver 
transplant recipients. Graft infiltrated with Th17 cells is associated
with a faster destruction of allograft in renal transplant patients
The aforementioned evidence suggests that Tregs cells have a
protective effect against graft rejection, whereas Th17 cells play an
essential role in promoting graft rejection. The differentiation
pathways of Tregs and Th17 cells are known to be antagonistic
[29,30], and Tregs can be converted into Th17 cells under
inflammatory conditions . However, the relationship between
Tregs and Th17 cells is yet to be fully understood in the context of
transplant alloresponse. Further validation is necessary to
determine whether the balance between circulating Tregs and Th17
cells may be used as a predictor for the outcome of transplantation.
This study is aimed to investigate the dynamics of Tregs/Th17
ratio in liver transplant recipients with or without post-operative
rejection, and to assess whether Tregs/Th17 ratio may serve as an
alternative marker for the diagnosis of acute rejection.
Materials and Methods
The study protocol was approved by the institutional review
board of Beijing 302 hospital. All participants provided written
informed consent to participate in this study. Thirty-eight patients
were enrolled in our hospital for this study. All participants
received a first cadaveric liver transplantation with an identical or
compatible blood-group graft. Based on clinical and biochemical
indicators as well as pathologic diagnosis, the patients were divided
into two groups: acute allograft rejection group (Gr-AR, n = 16)
and stable allograft liver function group (Gr-SF, n = 22). The
histopathologic diagnosis of acute allograft rejection was defined
according to Banff criteria . Acute rejection and stable
allograft liver function were defined as previously described .
All patients received conventional immunosuppressive agents after
liver transplantation, such as tacrolimus, steroids (prednisolone)
and mycophenolate mofetil (MMF). The dose of tacrolimus was
adjusted when acute rejection was diagnosed. Patients with HBV
infection received prophylactic therapies with hepatitis B immune
globulin (HBIG) plus nucleos(t)ide analogues (NAs). The blood
samples were obtained from all patients prior to transplant and at
the following timepoints after transplantation: 1, 2, 3, 4, 8, 12
weeks. In addition, the blood samples and allograft biopsy tissues
were obtained at the time of presenting worsening liver function
test results and/or symptoms suggestive of acute rejection after
liver transplantation. The clinical characteristics of these subjects
were listed in Table 1.
Flow cytometric analysis
The phycoerythrin (PE)-conjugated anti-IL-17A and fluorescein
isothiocyanate (FITC)-conjugated anti-FoxP3 were purchased
from eBioscience (San Diego, CA), and all other antibodies used
in flow cytometry were from BD Biosciences (San Jose, CA). For
immunostaining of intracellular IL-17A, two samples of freshly
heparinized peripheral blood (200 mL each) were incubated for 6
hours with phorbol-12-myristate-13-acetate (PMA, 300 ng/mL,
Sigma-Aldrich, St. Louis, MO) and ionomycin (1 mL/mL,
SigmaAldrich) in 800 mL of RPMI 1640 medium supplemented with
10% fetal calf serum. Monensin (0.4 mM, BD PharMingen) was
added during the first hour of incubation. Then cytofix/cytoperm
kit (BD PharMingen), anti-CD3, anti-CD8, anti-IL17, and
antiIFN-c antibody (mAb) were used in one sample, whereas
antiCD4, anti-CD25, and anti- FoxP3 mAb were used in the other
sample according to the manufacturers protocols. For Tregs
analysis, anti-CD4, anti-CD25, and anti-HLA-DR mAb were
added to 200 mL freshly heparinized blood sample, and then the
sample was permeabilized and fixed using fix/perm kit
(eBioscience) according to the manufacturers instructions. After
permeabilization, cells were incubated with anti-FoxP3,
antiCTLA-4, and anti-Ki67 mAb. The stained cells were acquired on
a FACSCalibur (BD Biosciences) and analyzed using FlowJo
software (Tritar, USA).
Biopsy specimens from 16 patients with acute rejection were
collected and used in immunochemical staining with antiFoxP3
(eBioscience) and anti-IL-17 (R&D Systems). Formalin-fixed,
paraffin-embedded liver tissues were cut into 5 mm sections and
placed on polylysine-coated slides. Antigen retrieval was achieved
via pressure cooking for 10 min in citrate buffer (pH 6.0).
Endogenous peroxidase activity was blocked with 0.3% H2O2.
The sections were then incubated with anti-FoxP3 or anti-IL-17
antibodies for overnight at 4uC. 3-amino-9-ethyl-carbazole (red
color) was used as a substrate, and hematoxylin was used in the
SPSS 16.0 software (SPSS, Chicago, IL, USA) was used for all
statistical analyses. The data were presented as means 6 SD.
Mann-Whitney nonparametric U-test was applied to comparisons
between 2 groups. Spearmans rank test was used to analyze the
association between the severity of allograft tissue injury and Tregs
frequency, Th17 cell frequency, or Tregs/Th17 ratio.
Chi-squaretest was used to assess the difference among clinical data. A value
of P,0.05 was considered to be statistically significant.
The patterns of Tregs and Th17 cell frequencies and
Tregs/Th17 ratio in transplant recipients with acute
We investigated Tregs and Th17 cell frequencies and Tregs/
Th17 ratio in all participants after liver transplantation. We
collected the values of Tregs, Th17 cells and Tregs/Th17 ratio in
Gr-SF and Gr-AR in the period prior to a rejection or at the onset
of acute rejection after liver transplantation, and compared the
values in Gr-SF group to those in Gr-AR group. Flow cytometry
was used to analyze Tregs and Th17 frequencies in peripheral
blood in all patients after liver transplantation. The results showed
that during the period preceding rejection, the frequencies of
Tregs, Th17 cells, and the Tregs/Th17 ratio have not significant
differences between two groups. At the period onset of acute
rejection, however, the frequency of Tregs was significantly higher
in Gr-SF than in Gr-AR (P,0.01), but the frequency of Th17 was
significantly lower in Gr-SF than in Gr-AR (P,0.01), yielding a
significantly higher Tregs/Th17 ratio in Gr-SF than in Gr-AR
(P,0.01). In addition, the frequency of IL-17/IFN-c producing
CD4+ T cells (IL-17+IFN-c+) was higher in Gr-AR than that in
Gr-SF (P,0.05) (Fig. 1A, B).
To investigate the distribution patterns of Tregs and Th17 cells
in acute rejection allografts, we next examined the infiltration of
Tregs and Th17 cells in biopsy samples obtained from allografts in
patients with acute rejection. Immunohistochemical staining was
performed using anti-FoxP3+ and anti-IL-17 antibodies on
paraffin embedded sections. Our results demonstrated an
extensive infiltration of Tregs and Th17 cells in the acute reject allograft
liver tissue (Fig. 1C). These findings, along with previously
published data , suggested that Tregs may be involved in
the regulation of alloreactive response in liver allograft tissue, but
might be deficient in some patients. One representative patient
with acute allograft rejection was followed up for 12 months after
liver transplantation. The dynamics of Tregs and Th17 cell
frequencies during the follow-up period was depicted in
Figure 1D. The Th17 cell frequency exhibited a trend opposite to
that of Tregs or Tregs/Th17 ratio. At the onset of acute rejection,
Tregs frequency and Tregs/Th17 ratio were sharply decreased,
whereas Th17 cell frequency was dramatically increased.
Interestingly, as the rejection subsided, the frequencies of Tregs and
Th17 cells were both restored to levels close to those before
The correlation between Tregs/Th17 ratio and the
biochemical indices of liver damage
Little is known about the association between the balance of
Tregs/Th17 and the liver damage in liver transplant recipients.
Therefore, we analyzed the correlation of Tregs/Th17 ratio and
the biochemical indices of liver damage, such as alanine amino
transferase (ALT), aspartate amino transferase (AST), alkaline
phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT), in
the 16 patients during the acute allograft rejection episode.
Negative correlations were observed between Tregs/Th17 ratio
and the levels of ALT (r = 20.668, P = 0.005), AST (r = 20.541,
P = 0.031), ALP (r = 20.518, P = 0.039), and GGT (r = 20.764,
P = 0.001) (Fig. 2). These results indicated that Tregs/Th17 ratio
may be used as an alternative indicator for the diagnosis of liver
damage in liver transplant recipients.
Tregs frequency, Th17 cell frequency, and Tregs/Th17
ratio is correlated with rejection activity index (RAI)
To confirm whether Tregs and Th17 cells were associated with
liver allograft rejection, we analyzed the correlation between the
rejection activity index (RAI) and the frequencies of circulating
Tregs and Th17 cells. We found that Tregs/Th17 ratio (r = 2
0.859, P,0.001) and the level of Tregs (r = 20.867, P,0.001)
had a negative correlation with RAI, whereas the level of Th17
n = 16
n = 22
cells showed a positive correlation with RAI (r = 0.890, P,0.001)
(Fig. 3). These results suggested that Tregs/Th17 ratio may serve
as a biomarker for the diagnosis of acute rejection.
The phenotypes of CTLA-4+, HLA-DR+, Ki67+ Tregs in liver
To better understand the mechanism by which Tregs function
in liver transplant recipients, some important molecules that
regulate Tregs were analyzed. CTLA-4 is expressed by human
Tregs and is also upregulated in T cells upon activation. We
characterized the patterns of CTLA-4 expression in Tregs in all
patients. The percentage of CTLA-4+ Tregs was calculated as the
percentage in total Tregs. The results showed that the frequency of
CTLA-4+ Tregs was higher in Gr-SF group (35.5618.9%) than in
Gr-AR group (23.7612.8%) (P,0.05). We also evaluated the
activated (HLA-DR+) and proliferating (Ki67+) Tregs in peripheral
blood in all patients. We found that the percentages of HLA-DR+
Tregs and Ki67+ Tregs were higher in Gr-SF (26.8617.2%,
30.6615.8%, respectively) than in Gr-AR (17.2611.6%,
20.3610.9%, respectively) (P,0.05) (Fig. 4). Such data suggested
that more Tregs were in active and proliferating state in Gr-SF
than in Gr-AR, and may facilitate the suppression of alloreactive
responses in liver transplant recipients.
Many studies have demonstrated that CD4+CD25+FoxP3+
Tregs and Th17 cells are involved in the tolerance or rejection
response in organ transplantation [17,3437]. The current study is
designed to investigate the relationship between Tregs and Th17
cells in the context of alloresponse in liver transplant patients. The
major finding of our study is that Tregs/Th17 ratio is associated
with alloresponse after liver transplantation. Our data confirm that
the frequency of circulating Tregs is significantly decreased,
whereas the frequency of Th17 cells is significantly increased in
liver allograft recipients with acute rejection, and that Tregs/Th17
ratio has a negative correlation with liver damage. To our
knowledge, this is the first study to demonstrate an association
between Tregs/Th17 imbalance and allografts rejection. These
findings suggest that the ratio of circulating Tregs/Th17 may serve
as an alternative marker for the diagnosis of acute rejection and for
the evaluation of the immune status in liver transplant recipients.
Tregs are a unique subset of CD4+ T helper cells in that they
control the responses of effector T-cells to prevent autoimmune
reactions. Several studies show that Tregs can prevent rejection
and promote the long-term survival of skin grafts in a mouse
model [6,38]. In clinical, Tregs have been reported to be
Figure 1. The distribution of Tregs and Th17 cells in the peripheral blood and in the grafts of patients with acute allograft rejection.
(A) Representative profiles of Tregs and Th17 cells in peripheral blood collected using fluorescence-activated cell sorter (FACS). (B) The frequency of
Tregs and Tregs/Th17 ratio were significantly higher in Gr-SF than in Gr-AR. On the contrary, the frequency of Th17 cells was significantly lower in
GrSF than in Gr-AR. In addition, the frequency of IL-17+IFN-c+ cells was lower in Gr-SF than in Gr-AR. (C) To evaluate the distribution pattern of Tregs and
Th17 cells in allografts with acute rejection, we examined the infiltration of Tregs and Th17 cells using immunohistochemical staining. Anti-FoxP3+
and anti-IL-17 antibodies were used on paraffin embedded biopsy samples which were obtained from allograft with acute rejection. The results
showed extensive infiltration of Tregs (red) and Th17 cells (red). Original magnification, 6400. (D) One representative patient with acute allograft
rejection was followed-up for 12 months after liver transplantation. The dynamics of Tregs and Th17 cell frequencies were depicted during the
followup period (the black line represents Th17 cells frequency; the blue line the Tregs frequency; and the red line Tregs/Th17 ratio). ARS: Acute rejection
Figure 2. Tregs/Th17 ratio is correlated with the serum levels of ALT, AST, ALP and GGT. We analyzed the correlation between the ratio of
circulating Tregs/Th17 and the biochemical indices for liver damage, ALT, AST, ALP and GGT, in the 16 patients with acute allograft rejection. Negative
correlations were found between the ratio of circulating Tregs/Th17 and the levels of ALT, AST, ALP, and GGT (P,0.05).
associated with allograft tolerance in liver transplant recipients
[9,12]. The Th17 subset is involved in mediating autoimmune
responses and regulating allograft rejection both in rat renal
transplant models and human renal transplantation [39,40]. In
lung and heart transplantation, IL-17 has also been reported to be
involved in allograft acute rejection [41,42]. A recent study
reported that the levels of circulating CD4+IL217+ T cells are
substantially higher in rejection group than in non-rejection group
in liver transplant recipients, and the frequency of CD4+IL217+
cells in peripheral blood is positively correlated with the rejection
activity index . Recent researches reported that a new
subpopulation of CD161+ Treg is able to produce IL-17 and has
both inflammatory and suppressive potentials [44,45]. The
functional and phenotypic characteristics of this subset in
alloreactive response are worth further study.
The frequency of Tregs in Gr-AR is significantly lower; on the
contrary, the frequency of Th17 cells in Gr-AR is significantly
higher than that in Gr-SF. In addition, the frequency of circulating
Tregs has a negative correlation with RAI, whereas the frequency
of circulating Th17 cells has a positive correlation with RAI. These
data indicate that the decreased levels of Tregs and increased
levels of Th17 cells may be involved in the acute rejection episodes
in liver transplantation. Histopathological results demonstrate that
the allograft tissue with acute rejection is extensively infiltrated
with Tregs and Th17 cells. These findings are consistent with that
from Stenards study, which revealed increased intragraft Tregs
during acute rejection . Such data suggest that Tregs are
mobilized to the site of immune activation and may participate in
the regulation of alloreactive responses. However, the observation
that acute allograft rejection can occur, even in the presence of
Tregs, indicates that at least under some circumstances the
mobilization of Tregs to the site is insufficient to effectively
downmodulate the alloreactivity.
Next, we suggest the mechanism by which Tregs are involved in
the rejection episodes. CTLA-4 is an inhibitory receptor expressed
by both activated T cells and Tregs, and may be crucial for their
activity. HLA-DR is a marker for T cell activation. Ki67 is a
marker of T cell proliferation. In our results, the percentages of
CTLA-4 and HLA-DR+ Tregs are significantly higher in Gr-SF
than in Gr-AR. In addition, the level of Ki67+ Tregs is
significantly higher in Gr-SF than in Gr-AR. In general, the
increase in the frequencies of CTLA-4+ Tregs, HLA-DR+ Tregs,
and Ki67+ Tregs following the alloreactive immunosuppression
may facilitate Tregs to exert their suppressive function, and may
reflect the restoration of their functions because these changes
occurred in parallel with stable liver functions. However, we have
not assessed the suppressive function of Tregs in stable versus
acutely rejecting subjects, so cannot draw any conclusions about
the functional relevance of these cells in preventing/ameliorating
rejection and impacting transplant outcomes.
In conclusion, maintaining an appropriate balance between
Tregs and Th17 cells is indispensable for the maintenance of stable
liver function in transplant recipients. Tilting Tregs-Th17
equilibrium toward Tregs dominance may promote transplant
tolerance. However, we carried out a small-scale observation study
that is underpowered to draw firm conclusions about cause and
Figure 3. The frequency of Tregs, the frequency of Th17 cells, and Tregs/Th17 ratio are correlated with RAI. To confirm whether Tregs,
Th17 cells and Tregs/Th17 were associated with the liver allograft rejection, we analyzed the correlation between RAI and the frequency of circulating
Tregs, the frequency of circulating Th17 cells, and Tregs/Th17 ratio. We found that the Tregs level and Tregs/Th17 ratio had a negative correlation
with RAI, whereas the Th17 cell level showed a positive correlation with RAI (P,0.01).
effect between Treg/Th17 ratio and acute rejection. These
findings should be the subject of further inquiry through a
carefully conducted, larger, prospective study to determine
whether Tregs/Th17 ratio can be used as a diagnosis marker
and whether it may serve as a potential therapeutic target to
manage the acute rejection of liver allografts.
Figure 4. The phenotypes of CTLA-4+, HLA-DR+, Ki67+ Tregs in liver transplant patients. The activated and proliferative molecules on
Tregs were detected in liver transplant patients. The results showed that the frequencies of CTLA-4+, HLA-DR+, and Ki67+ Tregs were higher in Gr-SF
than in Gr-AR (all P,0.05). The above data suggested more Tregs were active and proliferating in Gr-SF than in Gr-AR in liver transplant recipients.
Conceived and designed the experiments: YW MZ ZWL FSW MS.
Performed the experiments: YW WGR YCS YLS HBW LJ MS. Analyzed
the data: YW MZ MS. Contributed reagents/materials/analysis tools: MZ
ZWL FSW MS. Contributed to the writing of the manuscript: MS.
1. O'Leary JG , Lepe R , Davis GL ( 2008 ) Indications for liver transplantation . Gastroenterology 134 : 1764 - 1776 .
2. Blocher S , Wilker S , Sucke J , Pfeil U , Dietrich H , et al. ( 2007 ) Acute rejection of experimental lung allografts: characterization of intravascular mononuclear leukocytes . Clin Immunol 124 : 98 - 108 .
3. Wood KJ ( 2011 ) Regulatory T Cells in Transplantation. Transpl Proc 43 : 2135 - 2136 .
4. Keller MR , Burlingham WJ ( 2011 ) Loss of tolerance to self after transplant . Semin Immunopathol 33 : 105 - 110 .
5. Long E , Wood KJ ( 2009 ) Regulatory T cells in transplantation: transferring mouse studies to the clinic . Transplantation 88 : 1050 - 1056 .
6. Issa F , Hester J , Goto R , Nadig SN , Goodacre TE , et al. ( 2010 ) Ex VivoExpanded Human Regulatory T Cells Prevent the Rejection of Skin Allografts in a Humanized Mouse Model . Transplantation 90 : 1321 - 1327 .
7. Sakaguchi S , Yamaguchi T , Nomura T , Ono M ( 2008 ) Regulatory T cells and immune tolerance . Cell 133 : 775 - 787 .
8. Gorantla VS , Schneeberger S , Brandacher G , Sucher R , Zhang D , et al. ( 2010 ) T Regulatory Cells and Transplantation Tolerance . Transplant Rev 24 : 147 - 159 .
9. He Q , Fan H , Li JQ , Qi HZ ( 2011 ) Decreased Circulating CD4+CD25 highFoxp3+ T Cells During Acute Rejection in Liver Transplant Patients . Transpl Proc 43 : 1696 - 1700 .
10. Joffre O , Santolaria T , Calise D , Saati TA , Hudrisier D , et al. ( 2008 ) Prevention of acute and chronic allograft rejection with CD4+CD25+Foxp3+ regulatory T lymphocytes . Nat Med 14 : 88 - 92 .
11. Zhang X , Li M , Lian D , Zheng X , Zhang ZX , et al. ( 2008 ) Generation of therapeutic dendritic cells and regulatory T cells for preventing allogeneic cardiac graft rejection . Clin Immunol 127 : 313 - 321 .
12. Li Y , Koshiba T , Yoshizawa A , Yonekawa Y , Masuda K , et al. ( 2004 ) Analyses of peripheral blood mononuclear cells in operational tolerance after pediatric living donor liver transplantation . Am J Transplant 4 : 2118 - 2125 .
13. Li Y , Zhao X , Cheng D , Haga H , Tsuruyama T , et al. ( 2008 ) The presence of Foxp3 expressing T cells within grafts of tolerant human liver transplant recipients . Transplantation 86 : 1837 - 1843 .
14. Zuber J , Brodin-Sartorius A , Lapidus N , Patey N , Tosolini M , et al. ( 2009 ) FOXP3-enriched infiltrates associated with better outcome in renal allografts with inflamed fibrosis . Nephrol Dial Transplant 24 : 3847 - 3854 .
15. Heidt S , Segundo DS , Chadha R , Wood KJ ( 2010 ) The impact of TH17 cells on transplant rejection and the induction of tolerance . Curr Opin Organ Transplant 15 : 456 - 461 .
16. Hammerich L , Heymann F , Tacke F ( 2011 ) Role of IL-17 and Th17 cells in liver diseases . Clin Dev Immunol 2011 : 1 - 12 .
17. Burrell BE , Bishop DK ( 2010 ) Th17 cells and transplant acceptance . Transplantation 90 : 945 - 948 .
18. Kim HY , Cho ML , Jhun JY , Byun JK , Kim EK , et al. ( 2013 ) The imbalance of T helper 17/regulatory T cells and memory B cells during the early posttransplantation period in peripheral blood of living donor liver transplantation recipients under calcineurin inhibitor-based immunosuppression . Immunology 138 : 124 - 133 .
19. Yuan X , Paez-Cortez J , Schmitt-Knosalla I , D'Addio F , Mfarrej B , et al. ( 2008 ) A novel role of CD4 Th17 cells in mediating cardiac allograft rejection and vasculopathy . J Exp Med 205 : 3133 - 3144 .
20. Antonysamy MA , Fanslow WC , Fu F , Li W , Qian S , et al. ( 1999 ) Evidence for a role of IL-17 in organ allograft rejection: IL-17 promotes the functional differentiation of dendritic cell progenitors . J Immunol 162 : 577 - 584 .
21. Loong CC , Hsieh HG , Lui WY , Chen A , Lin CY ( 2002 ) Evidence for the early involvement of interleukin 17 in human and experimental renal allograft rejection . J Pathol 197 : 322 - 332 .
22. Fabrega E , Lopez-Hoyos M , San Segundo D , Casafont F , Pons-Romero F ( 2009 ) Changes in the serum levels of interleukin-17/interleukin-23 during acute rejection in liver transplantation . Liver Transpl 15 : 629 - 633 .
23. Vanaudenaerde BM , Dupont LJ , Wuyts WA , Verbeken EK , Meyts I , et al. ( 2006 ) The role of interleukin-17 during acute rejection after lung transplantation, . Eur Respir J 27 : 779 - 787 .
24. Chen H , Wang W , Xie H , Xu X , Wu J , et al. ( 2009 ) A pathogenic role of IL-17 at the early stage of corneal allograft rejection . Transpl Immunol 21 : 155 - 161 .
25. Tang JL , Subbotin VM , Antonysamy MA , Troutt AB , Rao AS , et al. ( 2001 ) Interleukin-17 antagonism inhibits acute but not chronic vascular rejection . Transplantation 72 : 348 - 350 .
26. Crispim JC , Grespan R , Martelli-Palomino G , Rassi DM , Costa RS , et al. ( 2009 ) Interleukin-17 and kidney allograft outcome . Transplant Proc 41 : 1562 - 1564 .
27. Abadja F , Atemkeng S , Alamartine E , Berthoux F , Mariat C ( 2011 ) Impact of Mycophenolic Acid and Tacrolimus on Th17-Related Immune Response . Transplantation 92 : 396 - 403 .
28. Deteix C , Attuil-Audenis V , Duthey A , Patey N , McGregor B , et al. ( 2010 ) Intragraft Th17 infiltrate promotes lymphoid neogenesis and hastens clinical chronic rejection . J Immunol 184 : 5344 - 5351 .
29. Korn T , Bettelli E , Oukka M , Kuchroo VK ( 2009 ) IL-17 and Th17 Cells . Annu Rev Immunol 27 : 485 - 517 .
30. Bettelli E , Carrier Y , Gao W , Korn T , Strom TB , et al. ( 2006 ) Reciprocal developmental pathways for the generation of pathogenic effector TH17 and regulatory T cells . Nature 441 : 235 - 238 .
31. Deknuydt F , Bioley G , Valmori D , Ayyoub M ( 2009 ) IL-1beta and IL-2 convert human Treg into T(H)17 cells . Clin Immunol 131 : 298 - 307 .
32. ( 1997 ) Banff schema for grading liver allograft rejection: an international consensus document . Hepatology 25 : 658 - 663 .
33. Yu X , Liu ZW , Wang Y , Wang HB , Zhang M , et al. ( 2013 ) Characteristics of Vd1+ and Vd2+ cd T cell subsets in acute liver allograft rejection . Transpl Immunol 29 : 118 - 122 .
34. Stenard F , Nguyen C , Cox K , Kambham N , Umetsu DT , et al. ( 2009 ) Decreases in circulating CD4+CD25hiFOXP3+ cells and increases in intragraft FOXP3+ cells accompany allograft rejection in pediatric liver allograft recipients . Pediatr Transplant 13 : 70 - 80 .
35. Koshiba T , Li Y , Takemura M , Wu Y , Sakaguchi S , et al. ( 2007 ) Clinical, immunological, and pathological aspects of operational tolerance after pediatric living-donor liver transplantation . Transpl Immunol 17 : 94 - 97 .
36. Li J , Lai X , Liao W , He Y , Liu Y , et al. ( 2011 ) The dynamic changes of Th17/ Treg cytokines in rat liver transplant rejection and tolerance . Int Immunopharmacol 11 : 962 - 967 .
37. Hanidziar D , Koulmanda M ( 2010 ) Inflammation and the balance of Treg and Th17 cells in transplant rejection and tolerance . Curr Opin Organ Transplant 15 : 411 - 415 .
38. Feng G , Wood KJ , Bushell A ( 2008 ) Interferon-gamma conditioning ex vivo generates CD25+CD62L+Foxp3+ regulatory T cells that prevent allograft rejection: Potential avenues for cellular therapy . Transplantation 86 : 578 - 589 .
39. Afzali B , Lombardi G , Lechler RI , Lord GM ( 2007 ) The role of T helper 17 (Th17) and regulatory T cells (Treg) in human organ transplantation and autoimmune disease . Clin Exp Immunol 148 : 32 - 46 .
40. Loong CC , Hsieh HG , Lui WY , Chen A , Lin CY ( 2002 ) Evidence for the early involvement of interleukin 17 in human and experimental renal allograft rejection . J Pathol 197 : 322 - 332 .
41. Yoshida S , Haque A , Mizobuchi T , Iwata T , Chiyo M , et al. ( 2006 ) Anti-type V collagen lymphocytes that express IL-17 and IL-23 induce rejection pathology in fresh and well-healed lung transplants . Am J Transplant 6 : 724 - 735 .
42. Li J , Simeoni E , Fleury S , Dudler J , Fiorini E , et al. ( 2006 ) Gene transfer of soluble interleukin-17 receptor prolongs cardiac allograft survival in a rat model . Eur J Cardiothorac Surg 29 : 779 - 783 .
43. Fan H , Li LX , Han DD , Kou JT , Li P , et al. ( 2012 ) Increase of peripheral Th17 lymphocytes during acute cellular rejection in liver transplant recipients . Hepatobiliary Pancreat Dis Int 11 : 606 - 611 .
44. Afzali B , Mitchell PJ , Edozie FC , Povoleri GAM , Dowson SE , et al. ( 2013 ) CD161 expression characterizes a subpopulation of human regulatory T cells that produces IL-17 in a STAT3-dependent manner . Eur J Immunol 43 : 2043 - 2054 .
45. Pesenacker AM , Bending David , Ursu S , Wu Qi , Nistala K , et al. ( 2013 ) CD161 defines the subset of FoxP31 T cells capable of producing proinflammatory cytokines . Blood 121 : 2647 - 2658 .