This review highlights T cell exhaustion as an adaptive differentiation trajectory, not dysfunction, showing how precursor, intermediate, and terminal exhausted states maintain antigen recognition while limiting tissue damage in chronic immune activation.
ABSTRACT
T cell exhaustion is now recognised as a structured, antigen-driven differentiation programme rather than a state of cellular fatigue. Under sustained antigen exposure, CD8+ T cells progress through distinct, hierarchically organised differentiation states, initiated by progenitor exhausted cells (TPEX), which retain self-renewal, multipotency, and responsiveness to immune checkpoint blockade. Continued stimulation drives differentiation into intermediate (TEXint) and terminally exhausted (TEX term) states, with TEXint retaining greater effector capacity than TEXterm despite both exhibiting restraint relative to functional effector T cells, alongside increasingly consolidated epigenetic architecture. Rather than reflecting immunological failure, exhaustion preserves long-term antigen surveillance while limiting tissue damage. Convergence between exhaustion-associated transcriptional modules and tissue-resident memory (TRM) programmes highlights shared mechanisms of adaptation to restrictive microenvironments. Yet TRM and TEX arise in distinct contexts and are not interchangeable. Recognising exhaustion as a context-dependent differentiation process reframes therapeutic strategies, in line with current evidence indicating that immune checkpoint blockade primarily acts by expanding and redirecting the TPEX pool rather than reversing terminal exhaustion. This framework integrates insights from chronic infection, tumour immunology, and tissue adaptation.