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Immune checkpoint

Immune checkpoints are a class of inhibitory receptors primarily expressed on T cells and other immune cells that function to dampen immune responses, thereby maintaining self-tolerance, preventing autoimmunity, and modulating the amplitude and duration of immune activation to avoid excessive tissue damage.^[1] These molecules act as molecular "brakes" on the immune system, evolved alongside stimulatory receptors to balance activation and suppression during physiological responses to pathogens or self-antigens.^[2] The most prominent immune checkpoints include CTLA-4 (cytotoxic T-lymphocyte-associated protein 4), which competes with the co-stimulatory receptor CD28 for binding to B7 ligands (CD80/CD86) on antigen-presenting cells during early T cell priming in lymph nodes, thereby inhibiting initial T cell activation; and PD-1 (programmed cell death protein 1), which interacts with its ligands PD-L1 and PD-L2 in peripheral tissues and tumor microenvironments to suppress T cell effector functions, proliferation, and cytokine production.^[1] Other notable checkpoints encompass LAG-3 (lymphocyte-activation gene 3), which binds to MHC class II molecules to further dampen T cell responses; TIM-3 (T-cell immunoglobulin and mucin-domain containing-3), involved in T cell exhaustion; and TIGIT (T cell immunoreceptor with Ig and ITIM domains), which inhibits natural killer and T cell activity.^[2] These pathways collectively ensure immune homeostasis but can lead to T cell anergy, apoptosis, or exhaustion when dysregulated.^[3] In cancer, tumor cells exploit immune checkpoints by upregulating ligands such as PD-L1 on their surface or in the microenvironment, inducing adaptive immune resistance that suppresses antitumor T cell activity and enables immune evasion.^[1] This exploitation contributes to tumor progression across various malignancies, including melanoma, lung cancer, and renal cell carcinoma.^[2] The therapeutic blockade of these checkpoints using monoclonal antibodies—known as immune checkpoint inhibitors (ICIs)—reactivates exhausted T cells, enhancing antitumor immunity and achieving durable responses in a subset of patients, with objective response rates of 10–40% depending on the cancer type and combination strategies.^[1] Key FDA-approved ICIs include ipilimumab (anti-CTLA-4, approved in 2011 for melanoma), pembrolizumab and nivolumab (anti-PD-1, approved in 2014 for multiple indications), and atezolizumab (anti-PD-L1, approved in 2016).^[1] Emerging inhibitors target additional checkpoints like LAG-3 (e.g., relatlimab, approved in 2022 in combination with nivolumab for melanoma), reflecting ongoing expansion of this therapeutic paradigm.^[1] The foundational discoveries in checkpoint biology and blockade, led by researchers James P. Allison and Tasuku Honjo, were honored with the 2018 Nobel Prize in Physiology or Medicine for their impact on cancer immunotherapy.^[1] Despite successes, challenges persist, including immune-related adverse events from hyperactivation and primary resistance in certain tumors, underscoring the need for predictive biomarkers and combination therapies.^[2]

Overview

Definition

Immune checkpoints are regulatory proteins expressed on the surface of T cells and other immune cells that function as molecular switches to control the magnitude and duration of immune responses. These proteins integrate signals from antigen recognition to either promote or suppress T cell activation, thereby preventing excessive immune activity that could lead to tissue damage or autoimmunity.^[3] By modulating the balance between activation and inhibition, immune checkpoints play a crucial role in maintaining self-tolerance, allowing the immune system to distinguish between self-antigens and foreign threats such as pathogens. This regulatory function ensures that immune responses are appropriately calibrated, avoiding chronic inflammation while enabling effective defense against infections. Disruptions in these checkpoints can contribute to immune-related disorders, highlighting their importance in physiological homeostasis.^[4]^[5] Immune checkpoints can be broadly categorized into co-stimulatory molecules, which provide activating signals necessary for full T cell engagement and proliferation, and co-inhibitory molecules, which deliver suppressive signals to dampen responses once the threat is neutralized. Both categories are essential for the two-signal model of T cell activation, where the first signal comes from antigen presentation and the second from these checkpoint interactions. This dual system underscores the precision required for adaptive immunity.^[3]^[4] The concept and terminology of immune checkpoints emerged in the early 2000s amid advancing research in immunotherapy, building on foundational studies of T cell regulation from the late 20th century. This period marked a shift toward understanding these molecules as therapeutic targets to fine-tune immune function.^[6]

Role in Immune System

Immune checkpoints serve as critical regulators in the immune system, maintaining homeostasis by balancing activation and inhibition of immune responses to prevent excessive inflammation or autoimmune damage. These molecules modulate the intensity and duration of immune activity, acting as brakes to terminate responses once threats are neutralized, thereby protecting host tissues from collateral harm. This regulatory function ensures that immune activation does not escalate into chronic inflammation, which could lead to tissue destruction, or autoimmunity, where self-reactive responses persist unchecked.^[7]^[8] In T cell biology, immune checkpoints play a pivotal role during priming, where they help calibrate initial activation to avoid overzealous responses, and in exhaustion states during chronic infections, where sustained antigen exposure upregulates inhibitory signals to dampen persistent T cell activity and preserve energy homeostasis. This involvement prevents T cells from becoming dysfunctional yet limits their effector functions to avert prolonged inflammation in settings of ongoing pathogen challenge. Such dynamics are essential for adaptive immunity, allowing T cells to respond effectively without compromising long-term immune fitness.^[9]^[10] Immune checkpoints also facilitate tolerance in specialized contexts, such as pregnancy, where they promote maternal acceptance of the semi-allogeneic fetus by suppressing potentially harmful immune reactions at the maternal-fetal interface, and in transplant settings, where they contribute to graft tolerance by restraining alloreactive T cell responses. In these scenarios, checkpoints ensure immune quiescence toward non-threatening antigens, supporting physiological processes without eliciting rejection or inflammatory cascades.^[11]^[12] From an evolutionary perspective, immune checkpoints have developed to safeguard against the perils of unchecked immune activation, which could otherwise cause widespread tissue damage during infections or stress. They integrate with core adaptive immunity pathways, including antigen presentation by antigen-presenting cells and cytokine signaling, to fine-tune T cell differentiation and effector functions, thereby optimizing responses for survival while minimizing self-harm. This interplay underscores their foundational role in orchestrating balanced, context-dependent immunity.^[3]^[13]

Types

Stimulatory Molecules

Stimulatory molecules, also referred to as costimulatory receptors, deliver positive signals that amplify T cell responses and are crucial for initiating robust adaptive immune defenses against pathogens.^[1] These molecules belong to the immunoglobulin superfamily and function by providing secondary activation signals to T cells upon antigen recognition by the T cell receptor (TCR).^[14] Prominent examples include CD28 and the inducible costimulator (ICOS), which enhance T cell proliferation, cytokine secretion, and survival to ensure effective immune activation.^[15] CD28 is constitutively expressed on the surface of naive and central memory T cells and serves as the primary costimulatory receptor by binding to B7-1 (CD80) and B7-2 (CD86) ligands on antigen-presenting cells (APCs).^[14] This interaction provides the essential second signal for T cell activation, preventing anergy and promoting full effector function.^[14] Mechanistically, CD28 ligation recruits PI3K and other adaptors via its cytoplasmic YMNM and PYAP motifs, leading to upregulation of interleukin-2 (IL-2) production through NF-κB and AP-1 pathways, as well as enhanced T cell proliferation and survival via Bcl-xL expression.^[14] Structurally, CD28 forms a disulfide-linked homodimer with an extracellular domain containing a single V-set immunoglobulin-like fold, facilitating ligand binding and immunological synapse formation.^[14] By driving these processes, CD28 plays a pivotal role in initiating adaptive responses, enabling clonal expansion of antigen-specific T cells to combat infections.^[14] ICOS (CD278), a related member of the CD28 family, is inducibly expressed on activated T cells following initial TCR and CD28 signaling, and binds to its ligand ICOSL (B7-H2) on APCs and inflamed non-hematopoietic cells.^[15] It primarily enhances T helper cell responses, supporting differentiation and function of Th1, Th2, Th17, and follicular helper T (Tfh) subsets, which are essential for coordinated humoral and cellular immunity.^[15] ICOS signaling, mediated by its cytoplasmic motifs (including YMFM and proline-rich regions), activates PI3K and JNK pathways to boost cytokine production (such as IL-4, IL-10, and IFN-γ), T cell proliferation, and survival, thereby amplifying effector responses during ongoing immune challenges.^[15] Structurally, ICOS is a homodimeric glycoprotein with a V-type immunoglobulin extracellular domain that engages ICOSL in a 1:1 complex, stabilized by a conserved FDPPPF motif critical for costimulation.^[15] Through these actions, ICOS sustains adaptive immune initiation, particularly in germinal center reactions and pathogen clearance.^[15] These stimulatory pathways operate in concert with inhibitory signals to maintain immune homeostasis.^[1]

Inhibitory Molecules

Inhibitory molecules, also known as immune checkpoint receptors, are cell surface proteins that negatively regulate immune responses to prevent excessive activation and maintain self-tolerance. These molecules primarily act on T cells, countering stimulatory signals to limit proliferation, cytokine production, and effector functions during immune activation. By dampening T cell activity, they play a crucial role in avoiding autoimmunity and controlling inflammation in peripheral tissues.^[16] Key examples of inhibitory molecules include cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed death-1 (PD-1). CTLA-4, a member of the CD28 immunoglobulin superfamily, competes with the stimulatory receptor CD28 for binding to B7-1 (CD80) and B7-2 (CD86) ligands on antigen-presenting cells, but with higher affinity than CD28 (approximately 10-fold higher for CD80),^[17] thereby outcompeting CD28 and attenuating T cell priming in lymphoid organs.^[16]^[2] This competition reduces CD28-mediated costimulation, downregulating T cell proliferation and interleukin-2 (IL-2) secretion, as demonstrated in seminal studies showing enhanced antitumor immunity upon CTLA-4 blockade. PD-1, another immunoglobulin superfamily member, binds to programmed death-ligand 1 (PD-L1) and PD-L2, primarily expressed on peripheral tissues and tumor cells, inducing T cell exhaustion characterized by impaired proliferation, reduced cytokine secretion (e.g., IFN-γ, TNF-α), and diminished effector functions like cytotoxicity.^[16]^[2] This inhibitory effect was first elucidated in functional studies revealing PD-1's role in negative regulation of lymphocyte activation. Expression of these molecules is dynamically regulated and upregulated in contexts of chronic immune stimulation. CTLA-4 is constitutively expressed at low levels intracellularly in resting T cells but rapidly translocates to the surface upon T cell receptor (TCR) engagement, peaking 2-3 days post-activation, and is particularly enriched on regulatory T cells (Tregs) in tumor microenvironments.^[16]^[2] PD-1 expression is induced on activated or exhausted CD4+ and CD8+ T cells, B cells, and other immune cells during chronic infections (e.g., HIV, hepatitis) or in tumors, where it correlates with T cell dysfunction and is driven by inflammatory signals like IFN-γ.^[16]^[2] Structurally, these molecules feature motifs that facilitate inhibitory signaling through phosphatase recruitment. PD-1 contains immunoreceptor tyrosine-based inhibitory motifs (ITIM) and switch motifs (ITSM) in its cytoplasmic tail; upon ligand binding, tyrosine phosphorylation of these motifs (particularly ITSM) recruits Src homology 2 domain-containing phosphatases (SHP-1 and SHP-2), which dephosphorylate key signaling molecules in TCR and CD28 pathways, thereby suppressing downstream activation of PI3K-AKT and Ras-MAPK.^[16]^[2] CTLA-4, lacking classical ITIM/ITSM, instead uses a YVKM motif in its short cytoplasmic domain to bind clathrin adaptor protein AP-2 and PP2A phosphatase, promoting ligand sequestration and TCR signal attenuation, with N-glycosylation sites enhancing its surface stability and inhibitory potency.^[2] These structural elements underscore their roles in fine-tuning immune responses to prevent immunopathology.^[16]

Mechanisms

Signal Transduction

Upon engagement, inhibitory immune checkpoints recruit protein tyrosine phosphatases, such as SHP-1 and SHP-2, to their immunoreceptor tyrosine-based inhibitory motifs (ITIMs) and switch motifs (ITSMs), which dephosphorylate critical elements of the T cell receptor (TCR) complex, including the CD3 zeta chain.^[18] This dephosphorylation inhibits the activation of proximal kinases like ZAP-70, thereby dampening downstream signaling cascades, particularly the PI3K/AKT pathway that promotes cell survival and proliferation, and the MAPK/ERK pathway that drives cytokine production and differentiation.^[19] For instance, in PD-1 signaling, SHP-2-mediated dephosphorylation of CD28 further suppresses PI3K recruitment, leading to reduced AKT phosphorylation and overall attenuation of T cell effector responses.^[20] In contrast, stimulatory immune checkpoints, such as CD28, initiate signaling by phosphorylating tyrosine residues in their cytoplasmic tail, recruiting the p85 regulatory subunit of PI3K via the YMNM motif and generating phosphatidylinositol-3,4,5-trisphosphate (PIP3).^[21] PIP3 then facilitates the membrane recruitment and activation of PDK1 and AKT, which in turn activate PKCθ; this kinase promotes the nuclear translocation of transcription factors NF-κB and AP-1 through IKK and JNK pathways, respectively, culminating in enhanced IL-2 promoter activity and T cell proliferation.^[22] Adaptor proteins like GRB2 and GADS further amplify this by linking CD28 to Ras and Vav1, sustaining AP-1 formation essential for IL-2 expression.^[23] T cell activation adheres to a two-signal threshold model, wherein TCR engagement provides signal 1 but requires a co-stimulatory signal 2 from stimulatory checkpoints to exceed the activation threshold and prevent anergy; inhibitory checkpoints elevate this threshold by counteracting co-stimulation, ensuring immune tolerance.^[24] This quantitative balance of signals determines the intensity of the response, with insufficient co-stimulation leading to T cell unresponsiveness.^[25] Immune checkpoint pathways cross-talk with the JAK/STAT cascade to modulate cytokine responses, as seen when STAT3 activation downstream of certain cytokines upregulates PD-L1 expression via IFN-γ signaling, thereby enhancing inhibitory checkpoint activity and suppressing pro-inflammatory cytokine production like IL-2.^[26] Conversely, JAK/STAT dysregulation, such as SOCS1 loss, amplifies IFN-mediated PD-L1 induction, linking checkpoint inhibition to altered cytokine signaling in immune regulation.^[27]

Ligand Interactions

Immune checkpoint ligand interactions primarily occur at the extracellular domain, where inhibitory receptors on T cells bind to their cognate ligands on antigen-presenting cells (APCs) or tumor cells, modulating immune responses through precise binding dynamics. These interactions are spatially organized within the immunological synapse, a specialized interface formed between interacting immune cells that facilitates receptor-ligand clustering and signal integration. The synapse's bull's-eye structure positions costimulatory and inhibitory molecules in distinct zones, allowing ligands such as PD-L1 and B7 family members to engage receptors like PD-1 and CTLA-4 at specific membrane domains, thereby regulating T cell activation thresholds.^[16]^[28] A key example is the interaction between programmed death-1 (PD-1) and its primary ligand, programmed death-ligand 1 (PD-L1). Binding of PD-L1 to PD-1 induces a conformational change in the PD-1 extracellular domain, repositioning its immunoglobulin-like fold to expose intracellular inhibitory signaling motifs for subsequent recruitment. This interaction is particularly relevant in the tumor microenvironment, where PD-L1 is frequently upregulated on cancer cells in response to interferon-gamma secreted by activated T cells, enabling tumors to evade immune surveillance by engaging PD-1 on infiltrating lymphocytes.30090-6)^[29]^[30] In contrast, cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) engages B7 ligands (CD80 and CD86) on APCs through a distinct mechanism involving trans-endocytosis. Upon binding within the immunological synapse, CTLA-4 captures CD80 and CD86 from the APC surface via a trogocytosis-like process, internalizing and degrading the ligands in lysosomal compartments of the T cell, thereby depleting available B7 molecules and limiting costimulatory signals to other T cells. This ligand removal is facilitated by CTLA-4's markedly higher binding affinity for B7-1 (CD80) and B7-2 (CD86), with dissociation constants approximately 20- to 100-fold lower than those of the stimulatory receptor CD28, enabling CTLA-4 to outcompete CD28 for ligand access during early synaptic formation.^[31]^[32]^[33]

History

Key Discoveries

The discovery of cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) in 1987 marked a pivotal moment in understanding immune regulation, when researchers in Pierre Goldstein's laboratory cloned the gene from activated cytotoxic T cells, identifying it as a novel member of the immunoglobulin superfamily with structural similarity to CD28. Subsequent work by James P. Allison's group in the early 1990s further characterized CTLA-4 as a homolog of CD28, revealing its potential role in modulating T-cell activation through shared ligand interactions. This finding laid the groundwork for recognizing inhibitory signals in T-cell responses, contrasting with CD28's stimulatory function. The inhibitory function of CTLA-4 was confirmed in 1995 through studies showing that CTLA-4-deficient mice developed lymphoproliferative disease and autoimmunity, and in 1996, Allison demonstrated that antibody blockade of CTLA-4 enhanced T-cell responses in vivo.^[34]^[35] In 1992, Tasuku Honjo's laboratory at Kyoto University identified programmed death-1 (PD-1) through a search for genes involved in programmed cell death, cloning it from apoptotic T-cell hybridomas and noting its induction upon T-cell activation as a member of the immunoglobulin superfamily. The protein, named for its association with cell death pathways, was expressed on activated T cells, B cells, and myeloid cells, suggesting a role in downregulating immune responses to prevent excessive activation.^[36] Honjo's team hypothesized that PD-1 signaling might contribute to apoptosis in immune cells, a concept that evolved to encompass broader tolerance mechanisms. In the late 1990s, PD-1 ligands were identified, with PD-L1 (B7-H1) cloned in 1999 by Lieping Chen's group, establishing its role in inhibiting T-cell activation upon interaction with PD-1.^[37] Throughout the 1990s, immune checkpoints gained recognition as critical regulators in models of T-cell anergy and peripheral tolerance, where incomplete activation signals led to T-cell unresponsiveness without deletion. Studies demonstrated that CTLA-4 engagement inhibited T-cell proliferation and cytokine production, promoting anergy in self-reactive clones and maintaining immune homeostasis, as evidenced by experiments showing CTLA-4 blockade enhanced T-cell responses in vitro. By the early 2000s, the roles of these checkpoints were further clarified, including PD-1 knockout studies in mice revealing spontaneous autoimmunity such as lupus-like glomerulonephritis and dilated cardiomyopathy, highlighting PD-1's essential function in preventing pathological immune activation.^[38] Connections between immune checkpoints and tumor immunology also emerged, particularly with the observation that PD-1 ligand 1 (PD-L1, also known as B7-H1) was aberrantly expressed on various human cancer cells, enabling tumors to induce T-cell apoptosis and evade immune detection. Lieping Chen's group reported in 2002 that PD-L1 upregulation on tumor surfaces, often induced by inflammatory cytokines, correlated with poor T-cell infiltration and survival, establishing a mechanism of adaptive immune resistance in solid tumors like ovarian and breast cancers. This discovery shifted focus toward checkpoints as exploitable targets in cancer, bridging basic tolerance research with oncology.

Inhibitor Development

The development of immune checkpoint inhibitors began with the targeting of CTLA-4, following its identification as a key regulatory molecule in T-cell activation. In 2010, a pivotal phase III clinical trial demonstrated that ipilimumab, a monoclonal antibody against CTLA-4, significantly improved overall survival in patients with previously treated metastatic melanoma compared to a peptide vaccine alone. This trial, involving 676 patients, reported a median overall survival of 10.1 months with ipilimumab versus 6.4 months with the vaccine, providing the evidence base for regulatory approval. The U.S. Food and Drug Administration (FDA) subsequently approved ipilimumab in March 2011 as the first immune checkpoint inhibitor for the treatment of unresectable or metastatic melanoma, marking a breakthrough in cancer immunotherapy. Subsequent efforts focused on the PD-1 pathway, another critical inhibitory checkpoint. In September 2014, the FDA granted accelerated approval to pembrolizumab, the first anti-PD-1 monoclonal antibody, for patients with unresectable or metastatic melanoma whose disease had progressed following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. Just months later, in December 2014, nivolumab received FDA accelerated approval for the same indication, based on objective response rates of 40% in clinical trials. These approvals rapidly expanded the therapeutic arsenal beyond CTLA-4 blockade, leveraging PD-1 inhibition to enhance T-cell antitumor activity. By 2015, the field evolved toward combination strategies to potentiate efficacy, with the FDA approving the first dual checkpoint inhibitor regimen of nivolumab plus ipilimumab for advanced melanoma on September 30. This combination demonstrated superior response rates compared to monotherapy in phase III trials, setting the stage for broader integration with other modalities. As of 2025, the FDA has approved over 50 distinct indications for 11 immune checkpoint inhibitors across multiple cancer types, reflecting accelerated clinical development and expanded applications.

Clinical Applications

Cancer Therapy

Immune checkpoint inhibitors, particularly those targeting the PD-1/PD-L1 axis and CTLA-4, have revolutionized cancer therapy by blocking inhibitory signals that tumors exploit to evade immune detection, thereby reinvigorating exhausted T cells within the tumor microenvironment. These monoclonal antibodies disrupt the interaction between programmed death-1 (PD-1) on T cells and its ligand PD-L1 on tumor cells, or between cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) on T cells and B7 molecules on antigen-presenting cells, restoring T cell proliferation, cytokine production, and cytotoxic activity against malignant cells. This approach shifts the balance from immune suppression to activation, enabling the adaptive immune system to mount a robust anti-tumor response. By 2025, the U.S. Food and Drug Administration (FDA) has approved immune checkpoint inhibitors for numerous oncology indications, including melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma, often as monotherapy or in combinations such as nivolumab (anti-PD-1) plus ipilimumab (anti-CTLA-4). Recent 2025 approvals include subcutaneous pembrolizumab (Keytruda Qlex) on September 19 for multiple solid tumors, pembrolizumab for resectable locally advanced head and neck cancer on June 13, and nivolumab plus ipilimumab for MSI-H/dMMR colorectal cancer on May 2.^[39] For instance, pembrolizumab (anti-PD-1) is indicated for advanced melanoma based on improved overall survival compared to ipilimumab alone, while atezolizumab (anti-PD-L1) is approved for NSCLC in patients with high PD-L1 expression. Combination therapies like nivolumab plus ipilimumab have demonstrated superior progression-free survival in melanoma and renal cell carcinoma, expanding their use across solid tumors. Clinical efficacy of these inhibitors varies by cancer type, with objective response rates typically ranging from 20% to 40% in advanced solid tumors, particularly those with immunogenic features. Biomarkers such as PD-L1 expression levels on tumor cells (assessed via immunohistochemistry) and microsatellite instability-high (MSI-H) status predict higher response likelihood; for example, in MSI-H colorectal cancer, pembrolizumab achieves response rates exceeding 40%. These therapies have led to durable responses in responders, with some patients experiencing long-term remission, underscoring their role in transforming palliative care into potentially curative strategies for subsets of patients. The preventive mechanism against tumor escape involves enhanced infiltration and activation of cytotoxic CD8+ T cells into the tumor bed, promoting apoptosis of cancer cells through perforin and granzyme release, while also fostering a pro-inflammatory milieu that sustains immune vigilance. This T cell reinvigoration counters the immunosuppressive tumor microenvironment, reducing regulatory T cell dominance and myeloid-derived suppressor cell activity, thereby amplifying the overall anti-tumor immune cascade.

Other Diseases

In autoimmune diseases, immune checkpoint modulation aims to enhance inhibitory signaling to restore immune tolerance and mitigate excessive T cell activation. For instance, PD-1 agonists have been investigated to amplify PD-1 pathway inhibition in conditions like rheumatoid arthritis (RA), where chronic inflammation drives joint damage. A phase 2a clinical trial of the PD-1 agonist peresolimab demonstrated significant efficacy in patients with active RA who had inadequate responses to conventional therapies, achieving American College of Rheumatology 20/50/70 response rates of 55%/40%/26% at week 12, compared to 16%/5%/0% with placebo, with a favorable safety profile.^[40] Similarly, the PD-1 agonist JNJ-67484703 showed biologic activity and clinical improvement in a small phase 1 trial for active RA, supporting further development of agonists to suppress autoreactive T cells without broad immunosuppression.^[41] These approaches contrast with checkpoint blockade used in cancer, focusing instead on agonism to dampen pathogenic responses. In chronic infections such as HIV and hepatitis B virus (HBV), immune checkpoint blockade targets T cell exhaustion to reinvigorate antiviral immunity. During persistent HIV infection, upregulated PD-1 expression on CD8+ T cells contributes to functional impairment, reducing cytokine production and proliferation; blocking PD-1/PD-L1 restores HIV-specific T cell responses in preclinical models and early human studies, potentially aiding viral control when combined with antiretroviral therapy.^[42] For chronic HBV, PD-1 blockade with nivolumab in virally suppressed patients led to significant HBsAg decline in a subset, indicating reversal of exhaustion in HBV-specific T cells without HBV reactivation, though larger trials are needed to confirm therapeutic potential.^[43] These strategies leverage the PD-1 pathway's role in exhaustion, similar to its function in tumor microenvironments, but prioritize infection-specific T cell revival. For transplant rejection, targeting inhibitory checkpoints promotes allograft tolerance by suppressing alloreactive T cell responses. CTLA4-Ig, a fusion protein mimicking CTLA-4 to block CD28 costimulation, induces long-term tolerance in murine cardiac allograft models by preventing acute rejection and enabling regulatory T cell expansion, with clinical applications in renal transplantation showing reduced rejection rates when combined with other agents.^[44] The PD-1/PD-L1 pathway also maintains peripheral tolerance post-transplantation; PD-1-deficient models exhibit accelerated graft rejection, while PD-L1 upregulation on graft endothelium protects against T cell infiltration, suggesting potential for PD-1 agonists or enhancers to foster tolerance in solid organ transplants.^[45] Emerging applications in 2025 extend checkpoint modulation to neurodegenerative diseases like multiple sclerosis (MS), where dysregulated T cell responses contribute to central nervous system inflammation and demyelination. Inducing inhibitory checkpoints such as PD-1 agonists shows promise for restoring tolerance by suppressing autoreactive T cells, with preclinical data indicating reduced neuroinflammation and lesion formation in MS models.^[46] Recent biomarker studies highlight PD-1/PD-L1 expression on T cells as predictors of therapeutic response to disease-modifying therapies in MS patients, supporting targeted modulation to enhance inhibitory signaling and potentially halt progression.^[47] Clinical trials exploring these approaches remain in early phases, emphasizing antigen-specific tolerance induction over systemic suppression.

Challenges

Resistance

Resistance to immune checkpoint inhibitors (ICIs) primarily arises through tumor-intrinsic and adaptive (tumor-extrinsic) mechanisms that enable cancer cells to evade T-cell-mediated cytotoxicity. Tumor-intrinsic resistance often involves the loss of neoantigens, where tumors with low tumor mutational burden (TMB) generate fewer immunogenic neoantigens, reducing T-cell recognition and ICI efficacy, as observed in non-small cell lung cancer (NSCLC) cohorts.^[48] Similarly, downregulation of major histocompatibility complex (MHC) class I molecules, frequently due to beta-2-microglobulin (B2M) mutations, impairs antigen presentation on tumor cells, leading to primary or acquired resistance in melanoma and other solid tumors.^[49] Upregulation of alternative checkpoints, such as lymphocyte activation gene-3 (LAG-3) and T-cell immunoglobulin and mucin domain-3 (TIM-3), further compensates for PD-1/PD-L1 blockade by exhausting T cells and promoting an immunosuppressive microenvironment.^[48] Adaptive resistance mechanisms enhance the tumor's immunosuppressive environment post-ICI initiation. Increased transforming growth factor-β (TGF-β) signaling, often secreted by regulatory T cells (Tregs), inhibits T-cell infiltration and promotes fibrosis, contributing to resistance in pancreatic and breast cancers. Myeloid-derived suppressor cells (MDSCs) accumulate in the tumor microenvironment, suppressing CD8+ T-cell function through arginase and reactive oxygen species, and their high infiltration correlates with poor outcomes in ICI-treated patients. Biomarkers like low TMB (<10 mutations per megabase) predict reduced neoantigen load and ICI non-response across tumor types, while B2M mutations, occurring in up to 28% of microsatellite instability-high tumors, specifically disrupt MHC stability and are associated with therapeutic failure.^[50]^[51] Emerging biomarkers, including PD-L1 expression levels and gut microbiome composition, also influence response prediction as of 2025.^[52] Strategies to overcome resistance have advanced significantly by 2025, incorporating bispecific antibodies and combination therapies to restore immunogenicity and counteract evasion. Bispecific antibodies targeting dual checkpoints, such as PD-1/TGF-β or PD-L1/VEGF (e.g., ivonescimab), enhance T-cell activation and inhibit angiogenesis, demonstrating superior progression-free survival (11.1 months vs. 5.8 months) compared to PD-1 monotherapy in PD-L1-positive NSCLC.^[53] Combinations with targeted therapies, including lenvatinib plus pembrolizumab, address adaptive resistance by blocking VEGF and PD-1 pathways, yielding improved response rates in renal cell carcinoma and endometrial cancers. Emerging 2025 approaches, such as triplet ICI regimens (nivolumab, relatlimab, ipilimumab) targeting LAG-3, achieve 58.7% overall response rates in advanced melanoma, while epigenetic modulators like EZH2 inhibitors (tazemetostat) combined with ICIs reprogram low-TMB tumors to boost neoantigen expression.

Adverse Effects

Immune checkpoint inhibitors (ICIs) can trigger immune-related adverse events (irAEs) through the unleashing of autoreactive T cells, leading to autoimmune-like inflammation across various organs.^[54] Common irAEs include dermatitis, manifesting as pruritic rashes or maculopapular eruptions; colitis, characterized by diarrhea and abdominal pain; pneumonitis, presenting with dyspnea and cough; and endocrinopathies such as thyroiditis or hypophysitis, resulting in hormonal imbalances.^[54] These events arise from the disruption of immune self-tolerance, where blockade of checkpoints like PD-1/PD-L1 or CTLA-4 allows excessive T-cell activation against self-antigens.^[54] The incidence of severe irAEs (grade 3 or higher) typically ranges from 10% to 20% with PD-1/PD-L1 monotherapy, increasing to 20%–40% with combination therapies involving CTLA-4 inhibitors.^[52] Factors such as combination regimens and patient comorbidities contribute to higher rates, with gastrointestinal and pulmonary toxicities often requiring hospitalization.^[55] Management of irAEs follows standardized protocols, emphasizing early recognition and immunosuppression. Corticosteroids at doses of 0.5–2 mg/kg/day are the cornerstone for grade 2 or higher events, with rapid tapering once symptoms improve; for refractory cases like severe colitis or pneumonitis, tumor necrosis factor inhibitors such as infliximab are recommended after 48–72 hours without response.^[55] Monitoring guidelines, updated by the American Society of Clinical Oncology (ASCO) in 2021 and aligned with ongoing practices as of 2025, advocate for baseline assessments, symptom tracking via patient education tools, and multidisciplinary consultation for organ-specific toxicities.^[55] Long-term risks persist in a subset of patients, with endocrinopathies like hypothyroidism affecting up to 10% and often requiring lifelong hormone replacement, as approximately 83% of endocrine irAEs become chronic.^[56] Cardiac events, including myocarditis and arrhythmias, occur in 1%–6% of treated individuals, posing risks of myocardial infarction or heart failure that necessitate vigilant surveillance beyond treatment cessation.^[57]

References

[1]
Mechanisms of immune checkpoint inhibitors - Nature
Jan 4, 2024 · Immune checkpoints are a type of immunosuppressive molecules expressed on immune cells, which can regulate the degree of immune activation and ...
[2]
Immune checkpoint signaling and cancer immunotherapy - Nature
May 28, 2020 · Upon ligand engagement, different checkpoints show distinct signaling mechanisms to suppress antitumor immunity. Here we review these ...
[3]
The blockade of immune checkpoints in cancer immunotherapy - PMC
Immune checkpoints refer to a plethora of inhibitory pathways hardwired into the immune system that are crucial for maintaining self-tolerance and modulating ...
[4]
The history and advances in cancer immunotherapy - Nature
Jul 1, 2020 · Several types of immunotherapy, including adoptive cell transfer (ACT) and immune checkpoint inhibitors (ICIs), have obtained durable clinical ...
[5]
Mechanisms of immune checkpoint inhibitors: insights into the ... - NIH
Jan 4, 2024 · Immune checkpoints are a type of immunosuppressive molecules expressed on immune cells, which can regulate the degree of immune activation and ...Missing: general | Show results with:general
[6]
[PDF] Discovery of cancer therapy by inhibition of negative immune ...
Sep 30, 2018 · Monoclonal antibodies with similar capacity to unleash responses against tumors are nowadays often referred to as immune checkpoint inhibitors ( ...
[7]
Targeting the ubiquitination/deubiquitination process to regulate ...
Jan 22, 2021 · To balance the immune responses and maintain immune homeostasis, there are immune checkpoints to terminate overwhelmed immune responses.
[8]
The role of immune checkpoints in antitumor response - NIH
Immune checkpoint molecules can modulate the response of T cells to self-proteins, chronic infections, or tumor antigens.1. Introduction · 2.1. 1. Anti-Ctla-4... · 2.7. Cd137 (4-1bb)Missing: definition general<|control11|><|separator|>
[9]
Immunological exhaustion: How to make a disparate concept ...
Sep 23, 2021 · PD-1 has been the most extensively studied marker of exhaustion. It is considered as characterizing exhausted T cells in both chronic infection ...
[10]
The role of CD4+ T cells in tumor and chronic viral immune responses
Oct 10, 2023 · Owing to continued antigen stimulation, CD8+ T cells become exhausted in tumors and chronic viral infections. Similar to the CD8+ T cells, CD4+ ...
[11]
Expression of Immune Checkpoint Receptors in Placentae ... - NIH
Jul 30, 2021 · Together, these studies indicate a critical role for immune checkpoint receptors in mediating maternal immune tolerance to the allogenic fetus.
[12]
The Functional Adaptability of Hyporesponsive T Cells and its ... - NIH
May 31, 2023 · Checkpoint inhibitor therapy reinvigorates alloreactive T cells, increasing the risk of transplant rejection. Angeletti et al. have recently ...
[13]
Principles and therapeutic applications of adaptive immunity - PMC
T cell activation largely relies on signals 1–3 (antigen, co-stimulation, and cytokines). ... Importantly, the interplay between signals 1–3 orchestrates adaptive ...
[14]
https://www.cell.com/immunity/fulltext/S1074-7613(16)30149-2
[15]
Structural characterization of the ICOS/ICOS-L immune complex ...
Oct 8, 2020 · The inducible co-stimulator (ICOS) is a member of the CD28/B7 superfamily, and delivers a positive co-stimulatory signal to activated T ...
[16]
Fundamental Mechanisms of Immune Checkpoint Blockade Therapy
This review provides an overview of immune checkpoint blockade therapy from a basic biology and immunologic perspective for the cancer research community.Introduction · Mechanisms Of Ctla4-Mediated... · Mechanisms Of Pd-1--Mediated...
[17]
https://pmc.ncbi.nlm.nih.gov/articles/PMC2196039/
[18]
Immune Checkpoint Receptors Signaling in T Cells - PubMed Central
Mar 24, 2022 · The joined inhibitory action of PD-1 on both the PI3K/AKT pathway and the MAPK pathway results in transcriptional modulation of cell cycle ...
[19]
https://pmc.ncbi.nlm.nih.gov/articles/PMC8999077/
[20]
https://doi.org/10.1016/j.celrep.2019.05.041
[21]
https://doi.org/10.1016/j.immuni.2016.04.020
[22]
https://doi.org/10.1126/science.1846244
[23]
A Threshold Model for T-Cell Activation in the Era of Checkpoint ...
Mar 18, 2019 · We apply the threshold model to better understand how to overcome these regulatory mechanisms and induce effective anti-tumor immune responses ...
[24]
https://pmc.ncbi.nlm.nih.gov/articles/PMC6431643/
[25]
https://doi.org/10.1038/nri1349
[26]
https://doi.org/10.1038/ni.3691
[27]
Cell Type-Specific Regulation of Immunological Synapse Dynamics ...
... CTLA-4 and PKC-η act as positive regulators of Treg function. Since CTLA-4 binds to B7 proteins with significantly higher affinity than CD28 and exclusively ...
[28]
Regulatory mechanisms of PD-1/PD-L1 in cancers - Molecular Cancer
May 18, 2024 · This article aims to provide a comprehensive review of the roles of the PD-1/PD-L1 signaling in human autoimmune diseases and cancers.
[29]
Mechanisms regulating PD-L1 expression on tumor and immune cells
Nov 15, 2019 · Multiple cytokines found in an immune-reactive TME may induce PD-L1 expression on tumor and/or immune cells through distinct signaling mechanisms.
[30]
Differences in CD80 and CD86 transendocytosis reveal ... - Nature
Aug 23, 2022 · In this process, CTLA-4 physically captures its ligands from opposing cells and targets their destruction via T cell-mediated endocytosis and ...
[31]
CTLA-4: a moving target in immunotherapy | Blood - ASH Publications
CD28 and CTLA-4 are members of a family of immunoglobulin-related receptors that are responsible for various aspects of T-cell immune regulation.
[32]
The B7 & CD28 Superfamilies - R&D Systems
Binding to CTLA-4 has been shown to have a 20-100 fold higher affinity than binding to CD28. Both human and mouse B7-1 and B7-2 can bind to either human or ...
[33]
Induced expression of PD-1, a novel member of the immunoglobulin ...
These results suggest that activation of the PD-1 gene may be involved in the classical type of programmed cell death.
[34]
A Phase 2 Trial of Peresolimab for Adults with Rheumatoid Arthritis
May 18, 2023 · Peresolimab showed efficacy in a phase 2a trial in patients with rheumatoid arthritis. These results provide evidence that stimulation of the PD-1 receptor has ...
[35]
Safety, tolerability, and efficacy of the PD-1 agonist antibody JNJ ...
Oct 21, 2025 · Conclusion: JNJ-67484703 was well tolerated in participants with active RA and showed evidence for biologic and clinical activity in this small, ...
[36]
Review Immune checkpoint blockade in HIV - ScienceDirect.com
We here review recent evidence on the role of immune checkpoints in persistent HIV infection and discuss the potential for employing immune checkpoint blockade.
[37]
Anti-PD-1 blockade with nivolumab with and without therapeutic ...
We show that the PD-1 inhibitor, nivolumab, is safe and effective for the treatment of virally suppressed patients with CHB.
[38]
Transplantation tolerance induced by CTLA4-Ig - PubMed - NIH
These results demonstrate that CTLA4-Ig can induce transplantation tolerance in the adult murine cardiac allograft model.
[39]
PD-1-dependent mechanisms maintain peripheral tolerance of ...
Recent studies have examined the role of the PD-1 pathway in transplantation tolerance, primarily by blocking the pathway and demonstrating acceleration of ...
[40]
Advances in immune checkpoint-based immunotherapies for ...
Nov 9, 2023 · There is a rationale for developing immunotherapeutic strategies to induce inhibitory ICPs while suppressing stimulatory ICPs.
[41]
Immune checkpoint-based biomarkers for therapeutic response in ...
Oct 20, 2025 · Immune checkpoint-based biomarkers for therapeutic response in patients with multiple sclerosis - PMC.
[42]
Resistance mechanisms to immune checkpoint inhibitors
Jan 15, 2025 · In the current review, we summarize what is known so far about the mechanisms of resistance in terms of being tumor-intrinsic or tumor-extrinsic.
[43]
Resistance to checkpoint blockade therapy through inactivation of ...
Oct 26, 2017 · Treatment with immune checkpoint blockade (CPB) therapies often leads to prolonged responses in patients with metastatic melanoma.
[44]
The role of B2M in cancer immunotherapy resistance
Mar 21, 2025 · Accumulating evidence indicates that B2M mutation/defect is one of the key mechanisms underlying tumor immunotherapy resistance.
[45]
Adverse effects of immune-checkpoint inhibitors - Nature
May 15, 2019 · We provide an overview of the various types of irAEs that have emerged to date. We discuss the epidemiology of these events and their kinetics, risk factors, ...
[46]
Cancer and treatment specific incidence rates of immune-related ...
Nov 3, 2024 · This systematic review characterises irAE prevalence across current research that examines irAE risk factors across cancers and ICI.
[47]
Management of Immune-Related Adverse Events in Patients ...
A single-institution retrospective study found the real-world incidence of severe (grade 3 or higher) neurologic irAEs among 1,834 patients treated with ICPis ...
[48]
Chronic immune-related adverse events arising from immune ...
Jul 4, 2024 · Fatal events depend on the regimen received, with CTLA-4 deaths most often from colitis and anti PD-1 deaths most often from pneumonitis. 98 ...
[49]
Cardiac Adverse Events in Patients Receiving Immune Checkpoint ...
May 7, 2025 · Six percent of patients receiving ICIs experienced a cardiac AE vs. 4.6% of patients in the non‐ICI group, the most common being arrhythmias.