Recovery of immune reactivity after T-cell–depleted bone marrow transplantation depends on thymic activity

To evaluate the importance of the thymus for the reconstitution of immunity in recipients of a T-cell–depleted bone marrow, we measured the appearance of CD4+CD45RA+RO−naive T cells (thymic rebound), restoration of the diversity of the T-cell–receptor (TCR) repertoire and the response to vaccinations with tetanus toxoid (TT). Repopulation by CD4+CD45RA+RO− thymic emigrants varied among patients, starting at approximately 6 months after transplantation. Young patients reconstituted swiftly, whereas in older patients, the recovery of normal numbers of naive CD4+ T cells could take several years. Restoration of TCR diversity was correlated with the number of naive CD4+CD45RA+RO− T cells. Moreover, the extent of the thymic rebound correlated with the patient's capacity to respond to vaccinations. Patients without a significant thymic rebound at the moment of vaccination (CD4+CD45RA+RO− T cells less than 30 μL) did not respond, or responded only marginally even after 3 boosts with TT. We conclude that during the first year after transplantation, the absence of an immune response is due mainly to the loss of an adequate T-cell repertoire. Restoration of the repertoire can come only from a thymic rebound that can be monitored by measuring the increase of CD4+CD45RA+RO−naive T cells. This will allow postponing revaccinations to a moment when the patient will be able to respond more effectively. This may be particularly useful in the elderly patient who, owing to low thymic activity, might not yet be able to respond 1 year after transplant when revaccinations are usually scheduled.