Abacavir induced T cell reactivity from drug naïve individuals shares features of allo-immune responses

Abacavir hypersensitivity is a severe hypersensitivity reaction which occurs exclusively in carriers of the HLA-B*57∶01 allele. In vitro culture of PBMC with abacavir results in the outgrowth of abacavir-reacting CD8⁺ T cells, which release IFNγ and are cytotoxic. How this immune response is induced and what is recognized by these T cells is still a matter of debate. We analyzed the conditions required to develop an abacavir-dependent T cell response in vitro. The abacavir reactivity was independent of co-stimulatory signals, as neither DC maturation nor release of inflammatory cytokines were observed upon abacavir exposure. Abacavir induced T cells arose in the absence of professional APC and stemmed from naïve and memory compartments. These features are reminiscent of allo-reactivity. Screening for allo-reactivity revealed that about 5% of generated T cell clones (n = 136) from three donors were allo-reactive exclusively to the related HLA-B*58∶01. The addition of peptides which can bind to the HLA-B*57∶01-abacavir complex and to HLA-B*58∶01 during the induction phase increased the proportion of HLA-B*58∶01 allo-reactive T cell clones from 5% to 42%. In conclusion, abacavir can alter the HLA-B*57∶01-peptide complex in a way that mimics an allo-allele (‘altered self-allele’) and create the potential for robust T cell responses.

T cells infiltrate the liver and kill hepatocytes in HLA-B(∗)57:01-associated floxacillin-induced liver injury

Drug-induced liver injury is a major safety issue. It can cause severe disease and is a common cause of the withdrawal of drugs from the pharmaceutical market. Recent studies have identified the HLA-B(∗)57:01 allele as a risk factor for floxacillin (FLUX)-induced liver injury and have suggested a role for cytotoxic CD8(+) T cells in the pathomechanism of liver injury caused by FLUX. This study aimed to confirm the importance of FLUX-reacting cytotoxic lymphocytes in the pathomechanism of liver injury and to dissect the involved mechanisms of cytotoxicity. IHC staining of a liver biopsy from a patient with FLUX-induced liver injury revealed periportal inflammation and the infiltration of cytotoxic CD3(+) CD8(+) lymphocytes into the liver. The infiltration of cytotoxic lymphocytes into the liver of a patient with FLUX-induced liver injury demonstrates the importance of FLUX-reacting T cells in the underlying pathomechanism. Cytotoxicity of FLUX-reacting T cells from 10 HLA-B(∗)57:01(+) healthy donors toward autologous target cells and HLA-B(∗)57:01-transduced hepatocytes was analyzed in vitro. Cytotoxicity of FLUX-reacting T cells was concentration dependent and required concentrations in the range of peak serum levels after FLUX administration. Killing of target cells was mediated by different cytotoxic mechanisms. Our findings emphasize the role of the adaptive immune system and especially of activated drug-reacting T cells in human leukocyte antigen-associated, drug-induced liver injury.

Seroprevalence of hantavirus infections in Switzerland in 2009: difficulties in determining prevalence in a country with low endemicity

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Serologic and molecular investigations of DAR1 (weak D Type 4.2), DAR1.2, DAR1.3, DAR2 (DARE), and DARA

BACKGROUND

The partial D variant DAR1 (weak D Type 4.2) is caused by three single-point mutations, 602C>G, 667T>G, and 1025T>C. Here we report a molecular study on different D variants belonging to the DAR category (DAR1, DAR1.2, DAR1.3, and DAR2) and their serologic data.

STUDY DESIGN AND METHODS

A total of 42 samples belonging to the DAR category were screened for the presence of the silent mutations 744C>T and 957G>A. The samples were phenotyped for RhD and RhCE, characterized for RhD epitope expression, and sequenced for RHD exons. Flow cytometry was performed to determine RhD antigen density.

RESULTS

The silent mutation 744C>T was found in all six samples previously typed as RHD*DAR2 (602C>G, 667T>G, 957G>A, 1025T>C). In addition to the three nucleotide changes originally reported for the RHD*DAR1 allele, the silent mutations 744C>T and 957G>A were found in 14 of 16 samples previously typed as RHD*DAR1. In the remaining two samples one additional silent mutation, 744C>T, was found. Serologically the DAR1.2 and DAR1.3 samples analyzed in this study showed no distinct difference in their anti-D reaction pattern compared to each other. The anti-D reaction pattern of DARA/DAR2 showed some distinct differences compared to those of DAR1.2 and DAR1.3.

CONCLUSION

RHD*DARA and RHD*DAR2 are the same allele. Furthermore, the alleles RHD*DAR1.2 and RHD*DAR1.3 both exist; however, the silent mutation 957G>A (V319) showed no influence on the RhD phenotype.

HLA haplotype determines hapten or p-i T cell reactivity to flucloxacillin

Drug-induced liver injury (DILI) is a main cause of drug withdrawal. A particularly interesting example is flucloxacillin (FLUX)-DILI, which is associated with the HLA-B*57:01 allele. At present, the mechanism of FLUX-DILI is not understood, but the HLA association suggests a role for activated T cells in the pathomechanism of liver damage. To understand the interaction among FLUX, HLA molecules, and T cells, we generated FLUX-reacting T cells from FLUX-naive HLA-B*57:01(+) and HLA-B*57:01(-) healthy donors and investigated the mechanism of T cell stimulation. We found that FLUX stimulates CD8(+) T cells in two distinct manners. On one hand, FLUX was stably presented on various HLA molecules, resistant to extensive washing and dependent on proteasomal processing, suggesting a hapten mechanism. On the other hand, in HLA-B*57:01(+) individuals, we observed a pharmacological interaction with immune receptors (p-i)-based T cell reactivity. FLUX was presented in a labile manner that was further characterized by independence of proteasomal processing and immediate T cell clone activation upon stimulation with FLUX in solution. This p-i-based T cell stimulation was restricted to the HLA-B*57:01 allele. We conclude that the presence of HLA-B*57:01 drives CD8(+) T cell responses to the penicillin-derivative FLUX toward nonhapten mechanism.

Contribution of rat intestinal metabolism to the xenobiotics clearance

Michaelis-Menten constants K m and V max values were determined by product formation and substrate depletion at several substrate concentrations of 4-methylumbelliferone using rat intestinal microsomes. K m and V max values determined by measuring product formation were in good agreement with substrate depletion approach. We also investigated hepatic and intestinal in vitro intrinsic clearance (CLint) in the liver and intestinal microsomes and compare with reports in the literature using nine test compounds, atorvastatin, 7-ethoxycoumarin, indomethacin, 4-methylumbelliferone, midazolam, nifedipine, testosterone, terfenadine and verapamil, in rats. CLint was determined from the substrate disappearance rate at 0.1 and 0.5 μM in the rat intestinal and liver microsomes, respectively. These results showed that both the liver and the intestine contributed to the metabolism of these compounds. The intestinal intrinsic clearance values of all these drugs, except for terfenadine in the rat intestinal microsomes, were lower than their hepatic intrinsic clearance per milligram protein, showing that there was an organ difference in metabolism between the liver and intestinal. These results make the evaluation using the intestinal more useful and provide a basis for predicting clearance using intestinal.

Establishment of T cell stimulation by flucloxacillin in HLA-B*5701+ flucloxacillin-naïve individuals (52.21)

Rational: Drug induced liver injury (DILI) is a main cause of drug withdrawal. A particularly interesting example is flucloxacillin (FLUX)-DILI, which is associated with the HLA-B*5701 allele. To better understand this side effect, we established an in vitro model for FLUX induced T cell activation. Methods: Peripheral blood mononuclear cells from FLUX-naïve, HLA-B*5701+ healthy donors were induced by iterative in vitro restimulations with FLUX. FLUX-specific T cells (FLUX-Tc) were enriched by positive selection of CD107a expressing cells and characterized by flow cytometry and 51Cr-release assay. Results: FLUX-Tc are mainly CD8+. They react by IFNγ secretion and CD107a upregulation upon drug stimulation and are cytotoxic against autologous antigen presenting cells (APC). Cytotoxicity and reactivity was observed only if free FLUX was added to the system. FLUX-pulsed APC were not able to elicit a FLUX specific T cell response if FLUX was not additionally added. The direct addition of FLUX to FLUX-Tc resulted in their activation even in the absence of APC. This self-presentation and reactivation was still observed in the presence of the proteasome inhibitors lactacystin and bortezomib. Conclusion: The APC independent T cell reactivity and the non-involvement of the proteasome is best explained by a direct interaction of FLUX with the restricting HLA-B*5701 molecule. How and why this activation leads to a preferential damage of liver cells needs further investigation.

Stimulation of the immune system by small chemicals can be independent of hapten-protein conjugate formation and is regulated by the TCR avidity for the HLA-drug complex (106.51)

Rationale: The antiretroviral drug abacavir (abc) elicits a strong CD8-mediated immune response in HLA-B*5701+ subjects. We used this model to study the interaction of small chemicals with the immune system. Methods: We generated abc-specific T-cell clones (abc-TCC) from HLA-B*5701+ donors and analyzed their specific activation in Ca2+ influx assays and by annexin V staining. Results: Abc-metabolizing enzymes were absent in immune cells and inhibition of the proteasome in antigen presenting cells did not affect TCC reactivity. Five out of 50 abc-TCC reacted instantly (~120 sec) to soluble abc presented on HLA-B*5701, whereas many other TCC reacted after 20 min or later. Increasing the number of HLA-B*5701/abc immunogenic complexes by increasing the abc concentrations and/or using transfected cells with a high HLA-B*5701 expression accelerated the abc-TCC activation kinetic. Analysis of several abc-TCC revealed different TCR Vβ-segments, demonstrating their polyclonality. Conclusions: Since the observed abc-reactivity was metabolism- and processing- independent, an immune activation by small chemicals can occur without covalent drug binding to a carrier protein. Moreover, titration experiments revealed different TCC reactivity patterns. This finding suggests a crucial role of the TCR avidity for the drug in regulating T cell activation. These data have implications in drug regulation of the immune system as well as for understanding drug hypersensitivity.

Short-term additional enfuvirtide therapy is associated with a greater immunological recovery in HIV very late presenters: a controlled pilot study

OBJECTIVES

To evaluate whether the addition of enfuvirtide to standard highly active antiretroviral therapy (HAART) could confer immunovirological benefits in human immunodeficiency virus (HIV)-infected very late presenters. The current study is an open comparative therapeutic trial of standard protease inhibitor (PI)-based HAART ± additional enfuvirtide in treatment-naïve deeply immunologically impaired HIV-positive patients.

METHODS

Very late presenters (CD4 <50/mm(3)), without tuberculosis and neoplasms, were alternatively allocated to two nucleoside reverse transcriptase inhibitors (NRTIs) and lopinavir/ritonavir without (control arm, CO) or with (ENF arm) enfuvirtide 90 mg bid. Enfuvirtide was administered until the achievement of viral load <50 copies/ml and for at least 24 weeks. The primary objective was the magnitude of CD4+ cell recovery at 6 months. HIV RNA was intensively monitored in the first month, and, thereafter, monthly, as for CD4+ cell count and percentage, clinical data, and plasma drug concentrations.

RESULTS

Of 22 enrolled patients (11 per arm), 19 completed the study (10 in the ENF arm). Baseline CD4+ cell counts and % were comparable, with 20 CD4+/mm(3) (12-37) and a percentage of 3.3 (1.7-7.1) in the ENF arm, and 16 CD4+/mm(3) (9-29) and a percentage of 3.1 (2.3-3.8) in the CO arm, respectively. The baseline viral load was also comparable between the two arms, with 5.77 log10 (5.42-6) and 5.39 log10 (5.06-6) in the ENF and CO arms, respectively. Enfuvirtide recipients had higher CD4+ percentage at week 8 (7.6 vs. 3.6%, p = 0.02) and at week 24 (10.7 vs. 5.9%, p = 0.02), and a greater CD4+ increase at week 24 (207 vs. 134 cells/mm(3), p = 0.04), with 70% of enfuvirtide intakers versus 12.5% of controls who achieved a CD4+ cell count >200/mm(3) (p = 0.01). At 48 weeks, patients in the ENF arm had CD4+ cell counts higher than controls (251 vs. 153cells/mm(3), p = 0.04) and were also found to be faster in reaching a CD4 cell count over 200/mm(3): 18 (8-24) versus 48 (36-108) weeks (p = 0.01). Viral load decay at week 4 was greater in the ENF arm (-3 vs. -2.2 log, p = 0.04), while the proportion of patients with viral load <50 copies/ml at week 24 was comparable.

CONCLUSIONS

In this pilot study, the addition of enfuvirtide to a lopinavir-based HAART was shown to be associated with a significantly faster and greater immunological recovery in newly discovered HIV-positive patients with very low CD4+ cell counts. Induction strategies using an enfuvirtide-based approach in such subjects warrant further investigation.

Cluster of travel-associated Legionnaires’ disease in Lazise, Italy, July to August 2011

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Platelet Recruitment during Multiple Donor Platelet Apheresis Differs between Cell Separators

SUMMARY: BACKGROUND: Recruitment of platelets (PLT) during donor PLT apheresis may facilitate the harvest of multiple units within a single donation. METHODS: We compared two PLT apheresis procedures (Amicus and Trima Accel) in a prospective, randomized, paired cross-over study in 60 donors. The 120 donations were compared for depletion of circulating PLT in the donors, PLT yields and PLT recruitment. A recruitment was defined as ratio of total PLT yield and donor PLT depletion > 1. RESULTS: Despite comparable differences of pre- and post-apheresis PLT counts (87 × 10(9)/l in Trima Accel vs. 92 × 10(9)/l in Amicus, p = 0.383), PLT yields were higher with Trima Accel (7.48 × 10(11) vs. 6.06 × 10(11), p < 0.001), corresponding to a higher PLT recruitment (1.90 vs. 1.42, p < 0.001). We observed a different increase of WBC counts after aphereses, which was more pronounced with Trima Accel than with Amicus (1.30 × 10(9)/l vs. 0.46 × 10(9)/l, p < 0.001). CONCLUSION: Both procedures induced PLT recruitment. This was higher in Trima Accel, contributing to a higher yield in spite of a comparable depletion of circulating PLT in the donors. This recruitment facilitates the harvest of multiple units within a single donation and seems to be influenced by the procedure utilized. The different increases of circulating donor white blood cells after donation need further investigation.

A comparative study of the CYP450 inhibition potential of marketed drugs using two fluorescence based assay platforms routinely used in the pharmaceutical industry

Semi-automated high throughput screening for the inhibition of major human cytochrome P450 enzymes (1A2, 2C9, 2C19, 2D6 and 3A4) expressed in Escherichia Coli (Cypex bactosomes) or human lymphoblastoid cells (Gentest cDNA microsomes) using fluorescent probes has been evaluated using 68 marketed drugs. In general lower IC50 values were obtained with Cypex bactosomes compared with Gentest cDNA microsomes. This could be due to use of higherconcentration of protein and also the lower activity of Gentest cDNA microsomes. Notably, when compared with in vivo clinical drug-drug interactions (cDDIs) gathered from clinical studies reported in the scientific literature Cypex bactosome data was better at predicting in vivo cDDI. Consequently, from the data obtained in this comparative study, a fluorescence based assay using Cypex bactosomes is more suitable as a front-line screen for the prediction of potential downstream CYP450 driven cDDIs.

Evaluation of different approaches to identifying a higher throughput assay for time-dependent inhibition (TDI)

The availability of a reliable in vitro assay to evaluate time-dependent inhibition (TDI) of cytchrome P450 enzymes by novel compounds is essential for the identification of candidate medicines. We have evaluated three assay methods, making use of 59 marketed compounds and 28 novel GSK compounds. Recombinant bactosomes expressing the CYP3A4 isozyme were used with two fluorescence-based methods: a "Re-addition" assay and a "30 min" assay. The third method evaluated used pooled human liver microsomes (PHLM) with LC-MS/MS detection (the data for GSK compounds were evaluated in this study, whereas data for marketed drugs were reported recently). Our evaluation showed that the Re-addition method is comparable to the LC-MS/MS method in terms of predictivity and reproducibility. In conclusion, Re-addition method is inexpensive, and provides a simple assessment of the risk of TDI for novel compounds. This assay is particularly appropriate for use during the early stages of drug discovery.

Non-covalent interaction of Abacavir with HLA-B*5701 generates an antigenic complex recognized by specific T cells (100.13)

Rationale: Abacavir (ABC) hypersensitivity is mediated by specific CD8+ T cells that interact with ABC in HLA-B*5701+ individuals. To understand how ABC is presented and recognized by T cells, we generated ABC specific T cell clones (ABC-TCC) and analysed the kinetic of ABC recognition. Methods: ABC-TCC from ABC naïve HLA-B*5701+ subjects were generated by limiting dilution. TCC activation by ABC was measured by means of Ca2+ influx kinetic analyses and Annexin V staining. Results: ABC-TCC in presence of autologous antigen-presenting cells (APC) reacted within a short time (3-25 min) to ABC in solution. Interestingly, APC that internalized the drug were able to present it already after 30 min on the cell surface leading to an immediate TCC activation (60 sec). Furthermore, no mRNA for alcoholdehydrogenases (ADH), the enzymes involved in ABC metabolism, was detected in the immune cells of peripheral blood. Conclusions: The rapid kinetic of TCC reactivity to ABC presented by HLA-B*5701 and the lack of ADH activity in peripheral blood mononuclear cells is best explained by a direct, metabolism and processing independent interaction of ABC with the restricting HLA-B*5701 molecule. This interaction either occurs intracellular or on the cell surface, leading to a modification of the HLA-complex able to induce a full T cell response. Our data underline that the immune stimulatory capacity of drugs is not uniquely restricted to the ability to form covalent bonds to proteins.