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Yadav AK, Lal A, Jha V. Association of circulating fractalkine (CX3CL1) and CX3CR1(+)CD4(+) T cells with common carotid artery intima-media thickness in patients with chronic kidney disease. J Atheroscler Thromb 2011; 18:958-65. [PMID: 21873805 DOI: 10.5551/jat.8722] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Fractalkine (CX3CL1), a chemokine, and its receptor CX3CR1 (expressed on T lymphocytes), have been shown to be abnormal in atherosclerosis. We investigated whether CX3CL1 levels and CX3CR1 expression were altered in patients with chronic kidney disease (CKD) and their association with common carotid artery intima-media thickness (CCA-IMT). METHODS CX3CR1 expression on CD4(+) T cells was analyzed by flow cytometry in 62 healthy controls (HC) and 128 Stage III-V CKD subjects. Fractalkine and highly sensitive C-reactive protein (hsCRP) were analyzed by ELISA. CCA-IMT was measured by ultrasound. RESULTS Compared to HC, CKD patients exhibited a 2.5-fold increase in the CD4(+)CX3CR1(+) T cell population (14.8±0.6 vs 5.9±0.34%, p < 0.0001). The expression of CX3CR1 was largely restricted to those CD4(+) cells that lacked CD28 co-stimulatory molecule. Fractalkine (pg/mL) and hsCRP (µg/mL) levels were increased in CKD subjects (510.6±61.6 vs. 239.7±9.67, p =0.003, and 93.8± 5.3 vs. 48.4±6.8, p < 0.0001), as was the CCA-IMT (0.71±0.01 vs. 0.56±0.01 mm, p < 0.0001). There was a significant relationship between CD4(+)CX3CR1(+) T cells and fractalkine levels (r = 0.2, p =0.01). CCA-IMT correlated positively with CX3CR1(+) T cells (r =0.34, p < 0.0001), CD4(+) CX3CR1(+) T cells (r =0.39, p < 0.0001), CD4(+)CD28(null)CX3CR1(+) T cells (r =0.23, p =0.02), fractalkine (r =0.3, p =0.001), age (r =0.33, p < 0.0001) and diabetes (p =0.01). On multiple regression, only CD4(+)CX3CR1(+) T cells and the presence of diabetes continued to show an association with IMT (p < 0.0001 and 0.0029 respectively). CONCLUSIONS CKD subjects showed an increase in CD4(+)CX3CR1(+) T cell population, plasma fractalkine and IMT; the association of CD4(+)CX3CR1(+) T cells and plasma fractalkine with CCA-IMT indicates that the fractalkine-CX3CR1 pathway may be important in the development and/or progression of atherosclerosis in CKD.
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Affiliation(s)
- Ashok Kumar Yadav
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wulff H. Spiro azepane-oxazolidinones as Kv1.3 potassium channel blockers: WO2010066840. Expert Opin Ther Pat 2010; 20:1759-65. [PMID: 20954790 DOI: 10.1517/13543776.2010.528392] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This article evaluates a patent application from Solvay Pharmaceuticals, which claims spiro azepane-oxazolidinones as novel blockers of the voltage-gated potassium channel Kv1.3 for the treatment of diabetes, psoriasis, obesity, transplant rejection and T-cell mediated autoimmune diseases such as rheumatoid arthritis and MS. The patent describes a new chemotype of Kv1.3 blockers and thus illustrates the growing interest of the pharmaceutical industry in Kv1.3 as a target of immunosuppression and metabolic disorders. This article briefly summarizes the chemistry and biological data provided in the patent and then compares the new compounds to Kv1.3 blockers previously disclosed by both academia and pharmaceutical companies.
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Affiliation(s)
- Heike Wulff
- University of California, Department of Pharmacology, Davis, Davis, CA 95616, USA.
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Eastwood D, Findlay L, Poole S, Bird C, Wadhwa M, Moore M, Burns C, Thorpe R, Stebbings R. Monoclonal antibody TGN1412 trial failure explained by species differences in CD28 expression on CD4+ effector memory T-cells. Br J Pharmacol 2010; 161:512-26. [PMID: 20880392 PMCID: PMC2990151 DOI: 10.1111/j.1476-5381.2010.00922.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/26/2010] [Accepted: 03/30/2010] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE In 2006, a life-threatening 'cytokine storm', not predicted by pre-clinical safety testing, rapidly occurred in all six healthy volunteers during the phase I clinical trial of the CD28 superagonist monoclonal antibody (mAb) TGN1412. To date, no unequivocal explanation for the failure of TGN1412 to stimulate profound cytokine release in vitro or in vivo in species used for pre-clinical safety testing has been established. Here, we have identified a species difference almost certainly responsible for this disparate immunopharmacology. EXPERIMENTAL APPROACH Polychromatic flow cytometry and intracellular cytokine staining were employed to dissect the in vitro immunopharmacology of TGN1412 and other therapeutic mAbs at the cellular level to identify differences between humans and species used for pre-clinical safety testing. KEY RESULTS In vitro IL-2 and IFN-γ release from CD4+ effector memory T-cells were key indicators of a TGN1412-type response. This mechanism of cytokine release differed from that of other therapeutic mAbs, which can cause adverse reactions, because these other mAbs stimulate cytokine release primarily from natural killer cells. In contrast to humans, CD28 is not expressed on the CD4+ effector memory T-cells of all species used for pre-clinical safety testing, so cannot be stimulated by TGN1412. CONCLUSIONS AND IMPLICATIONS It is likely that activation of CD4+ effector memory T-cells by TGN1412 was responsible for the cytokine storm. Lack of CD28 expression on the CD4+ effector memory T-cells of species used for pre-clinical safety testing of TGN1412 offers an explanation for the failure to predict a 'cytokine storm' in humans.
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Affiliation(s)
- D Eastwood
- Biotherapeutics Group, NIBSC, Potters Bar, Hertfordshire, UK
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54
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Perforin level in CD4+ T cells from patients with systemic lupus erythematosus. Rheumatol Int 2010; 30:1627-33. [PMID: 20049450 DOI: 10.1007/s00296-009-1329-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 12/20/2009] [Indexed: 10/20/2022]
Abstract
CD4(+) T cells from patients with systemic lupus erythematosus (SLE) exhibit increased expression of various proteins contributing to defective function of CD4(+) T cells. We evaluated the transcript and protein levels of perforin (PRF1) in CD4(+) T cells from SLE patients (n = 41) and healthy individuals (n = 34). The CD4(+) T cells were obtained by a positive biomagnetic separation system. The amounts of mRNA were determined by reverse transcription and real-time quantitative PCR. The protein levels in the CD4(+) T cells were evaluated by Western blotting analysis. We observed significantly higher levels of PRF1 protein (p = 0.013) in SLE CD4(+) T cells than in controls. There was no significant increase in PRF1 transcript levels (p = 0.908) in CD4(+) T cells from SLE patients as compared to healthy individuals. Moreover, we did not observe a correlation between PRF1 transcript and protein levels in SLE CD4(+) T cells and disease activity expressed by the SLEDAI scale. We confirmed previous observations that demonstrated higher levels of PRF1 protein in CD4(+) T cells from SLE patients. However, we did not find a correlation between PRF1 transcripts and proteins in CD4(+) T cells and SLE disease activity.
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Abstract
The human genome encodes 40 voltage-gated K(+) channels (K(V)), which are involved in diverse physiological processes ranging from repolarization of neuronal and cardiac action potentials, to regulating Ca(2+) signalling and cell volume, to driving cellular proliferation and migration. K(V) channels offer tremendous opportunities for the development of new drugs to treat cancer, autoimmune diseases and metabolic, neurological and cardiovascular disorders. This Review discusses pharmacological strategies for targeting K(V) channels with venom peptides, antibodies and small molecules, and highlights recent progress in the preclinical and clinical development of drugs targeting the K(V)1 subfamily, the K(V)7 subfamily (also known as KCNQ), K(V)10.1 (also known as EAG1 and KCNH1) and K(V)11.1 (also known as HERG and KCNH2) channels.
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56
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Weng NP, Akbar AN, Goronzy J. CD28(-) T cells: their role in the age-associated decline of immune function. Trends Immunol 2009; 30:306-12. [PMID: 19540809 DOI: 10.1016/j.it.2009.03.013] [Citation(s) in RCA: 444] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 03/23/2009] [Accepted: 03/23/2009] [Indexed: 02/06/2023]
Abstract
The accumulation of CD28(-) T cells, particularly within the CD8 subset, is one of the most prominent changes during T-cell homeostasis and function associated with aging in humans. CD28, a major co-stimulatory receptor, is responsible for the optimal antigen-mediated T-cell activation, proliferation and survival of T cells. CD28(-) T cells exhibit reduced antigen receptor diversity, defective antigen-induced proliferation and a shorter replicative lifespan while showing enhanced cytotoxicity and regulatory functions. Gene expression analyses reveal profound changes of CD28(-) T cells in comparison to their CD28(+) counterparts and corroborate their functional differences. Here we review recent advances in our understanding of CD28(-) T cells and their role in the age-associated decline of immune function.
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Affiliation(s)
- Nan-Ping Weng
- Laboratory of Immunology, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA.
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57
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Kamikozuru K, Fukunaga K, Hirota S, Hida N, Ohda Y, Yoshida K, Yokoyama Y, Tozawa K, Kawa K, Iimuro M, Nagase K, Saniabadi AR, Nakamura S, Miwa H, Matsumoto T. The expression profile of functional regulatory T cells, CD4+CD25high+/forkhead box protein P3+, in patients with ulcerative colitis during active and quiescent disease. Clin Exp Immunol 2009; 156:320-7. [PMID: 19292766 PMCID: PMC2759481 DOI: 10.1111/j.1365-2249.2009.03904.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Regulatory T cells (T(reg)) have an essential role in maintaining immune tolerance in the gut. The functional CD4(+) T(reg) express the transcription factor forkhead box protein 3 (FoxP3) or a CD25(high) in humans. Further, depletion of elevated granulocytes/monocytes by extracorporeal adsorption (GMA) induces immunomodulation in patients with ulcerative colitis (UC). We investigated the impact of GMA on T(reg). Thirty-one UC patients, clinical activity index (CAI) 12.1 +/- 2.97, refractory to conventional medications including intravenous corticosteroid and 13 healthy controls (HC), were included. Patients received five GMA sessions over 5 weeks. Biopsies from the rectal mucosa and blood samples at baseline and post-GMA were immunostained with anti-CD4/FoxP3 and anti-CD4/CD25 antibodies for immunohistochemistry and flow cytometry. Following GMA, 22 of 31 patients achieved remission (CAI <or= 4, P < 0.01) and their endoscopic activity index decreased from 10.6 +/- 2.32 to 4.75 +/- 1.48 (P = 0.003). The circulating CD4(+)CD25(high+) T(reg) level was low and increased markedly in responders (P < 0.02). In the nine non-responders, the baseline CD4(+)CD25(high+) T(reg) level was about 50% of the level in the responders (P < 0.03) or in the HC (P < 0.01), and all nine had to undergo colectomy. Conversely, the number of CD4(+)/FoxP3(+) mucosal T(reg) in GMA responders decreased significantly after the fifth GMA session compared with the baseline level (P < 0.05). It is believed that the CD4(+) T(reg) has an essential role in the control of immune pathology in UC patients and a net influx of these cells from the circulation into the mucosa may proceed to suppress inflammation. GMA can impact the circulating as well as the mucosal levels of T(reg).
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Affiliation(s)
- K Kamikozuru
- Department of Lower Gastroenterology, Hyogo College of Medicine, Hyogo, Japan
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Münz C, Lünemann JD, Getts MT, Miller SD. Antiviral immune responses: triggers of or triggered by autoimmunity? Nat Rev Immunol 2009; 9:246-58. [PMID: 19319143 PMCID: PMC2854652 DOI: 10.1038/nri2527] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The predisposition of individuals to several common autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus and multiple sclerosis, is genetically linked to certain human MHC class II molecules and other immune modulators. However, genetic predisposition is only one risk factor for the development of these diseases, and low concordance rates in monozygotic twins, as well as the geographical distribution of disease risk, suggest the involvement of environmental factors in the development of these diseases. Among these environmental factors, infections have been implicated in the onset and/or promotion of autoimmunity. In this Review, we outline the mechanisms by which viral infection can trigger autoimmune disease and describe the pathways by which infection and immune control of infectious disease might be dysregulated during autoimmunity.
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Affiliation(s)
- Christian Münz
- Viral Immunobiology, Institute of Experimental Immunology, University Hospital Zürich, Winterthurerstrasse 190, CH-8057 Zürich, Switzerland.
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59
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Lambers C, Hacker S, Posch M, Hoetzenecker K, Pollreisz A, Lichtenauer M, Klepetko W, Ankersmit HJ. T cell senescence and contraction of T cell repertoire diversity in patients with chronic obstructive pulmonary disease. Clin Exp Immunol 2009; 155:466-75. [PMID: 19220836 PMCID: PMC2669523 DOI: 10.1111/j.1365-2249.2008.03835.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2008] [Indexed: 01/08/2023] Open
Abstract
Pathogenetic mechanisms leading to chronic obstructive pulmonary disease (COPD) remain poorly understood. Because clonogenic T cells (CD4(+)CD28(null)) were shown to be increased in autoimmune diseases we hypothesized that CD4(+)CD28(null) T cells play a role in COPD. Here we describe that enhanced presence of CD4(+)CD28(null) cells is associated with impaired lung function. Sixty-four patients and controls were included. T cell phenotype was analysed using flow cytometry. Enzyme-linked immunosorbent assays were utilized to determine cytokines. Statistical evaluations were performed using non-parametric group comparisons and correlations. A logistic regression model was used to determine predictive values of CD4(+)CD28(null) in the diagnosis of COPD. Populations of CD4(+) T cells lacking surface co-stimulatory CD28 were enlarged significantly in evaluated patients when compared with controls. Natural killer (NK)-like T cell receptors (CD94, 158) and intracellular perforin, granzyme B were increased in CD4(+)CD28(null) cells. Cytokine production after triggering of peripheral blood mononuclear cells (PBMCs) was elevated in patients at early disease stages. Receiver operating characteristic curve plotting revealed that presence of CD4(+)CD28(null) T cells has a diagnostic value. These CD4(+)CD28(null) T cells show increased expression of NK-like T cell receptors (CD94, 158) and intracellular perforin and granzyme B. Furthermore, triggering of PBMCs obtained from patients with mild COPD led to increased interferon-gamma and tumour necrosis factor-alpha production in vitro compared with controls. Our finding of increased CD4(+)CD28(null) T cells in COPD indicates that chronic antigen exposure, e.g. through contents of smoke, leads to loss of CD28 and up-regulation of NK cell receptors expression on T cells in susceptible patients.
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Affiliation(s)
- C Lambers
- Department of Pulmonary Medicine, Medical University of Vienna, Vienna, Austria
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60
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Pennington MW, Beeton C, Galea CA, Smith BJ, Chi V, Monaghan KP, Garcia A, Rangaraju S, Giuffrida A, Plank D, Crossley G, Nugent D, Khaytin I, Lefievre Y, Peshenko I, Dixon C, Chauhan S, Orzel A, Inoue T, Hu X, Moore RV, Norton RS, Chandy KG. Engineering a stable and selective peptide blocker of the Kv1.3 channel in T lymphocytes. Mol Pharmacol 2009; 75:762-73. [PMID: 19122005 DOI: 10.1124/mol.108.052704] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Kv1.3 potassium channels maintain the membrane potential of effector memory (T(EM)) T cells that are important mediators of multiple sclerosis, type 1 diabetes mellitus, and rheumatoid arthritis. The polypeptide ShK-170 (ShK-L5), containing an N-terminal phosphotyrosine extension of the Stichodactyla helianthus ShK toxin, is a potent and selective blocker of these channels. However, a stability study of ShK-170 showed minor pH-related hydrolysis and oxidation byproducts that were exacerbated by increasing temperatures. We therefore engineered a series of analogs to minimize the formation of these byproducts. The analog with the greatest stability, ShK-192, contains a nonhydrolyzable phosphotyrosine surrogate, a methionine isostere, and a C-terminal amide. ShK-192 shows the same overall fold as ShK, and there is no evidence of any interaction between the N-terminal adduct and the rest of the peptide. The docking configuration of ShK-192 in Kv1.3 shows the N-terminal para-phosphonophenylalanine group lying at the junction of two channel monomers to form a salt bridge with Lys(411) of the channel. ShK-192 blocks Kv1.3 with an IC(50) of 140 pM and exhibits greater than 100-fold selectivity over closely related channels. After a single subcutaneous injection of 100 microg/kg, approximately 100 to 200 pM concentrations of active peptide is detectable in the blood of Lewis rats 24, 48, and 72 h after the injection. ShK-192 effectively inhibits the proliferation of T(EM) cells and suppresses delayed type hypersensitivity when administered at 10 or 100 microg/kg by subcutaneous injection once daily. ShK-192 has potential as a therapeutic for autoimmune diseases mediated by T(EM) cells.
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Affiliation(s)
- M W Pennington
- Bachem Bioscience Inc., King of Prussia, Pennsylvania, USA
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Mack DG, Lanham AK, Palmer BE, Maier LA, Watts TH, Fontenot AP. 4-1BB enhances proliferation of beryllium-specific T cells in the lung of subjects with chronic beryllium disease. THE JOURNAL OF IMMUNOLOGY 2008; 181:4381-8. [PMID: 18768897 DOI: 10.4049/jimmunol.181.6.4381] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In contrast to naive T cells, reactivation of memory cells is less dependent on CD28-mediated costimulation. We have shown that circulating beryllium-specific CD4(+) T cells from chronic beryllium disease patients remain CD28-dependent, while those present in the lung no longer require CD28 for T cell activation. In the present study, we analyzed whether other costimulatory molecules are essential for beryllium-induced T cell function in the lung. Enhanced proliferation of a beryllium-responsive, HLA-DP2-restricted T cell line was seen after the induction of 4-1BB ligand expression on the surface of HLA-DP2-expressing fibroblasts. Following beryllium exposure, CD4(+) T cells from blood and bronchoalveolar lavage of chronic beryllium disease patients up-regulate 4-1BB expression, and the majority of beryllium-responsive, IFN-gamma-producing CD4(+) T cells in blood coexpress CD28 and 4-1BB. Conversely, a significant fraction of IFN-gamma-producing bronchoalveolar lavage (BAL) T cells express 4-1BB in the absence of CD28. In contrast to blood, inhibition of the 4-1BB ligand-4-1BB interaction partially blocked beryllium-induced proliferation of BAL CD4(+) T cells, and a lack of 4-1BB expression on BAL T cells was associated with increased beryllium-induced cell death. Taken together, these findings suggest an important role of 4-1BB in the costimulation of beryllium-responsive CD4(+) T cells in the target organ.
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Affiliation(s)
- Douglas G Mack
- Department of Medicine, University of Colorado Denver, Denver, CO 80262, USA
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Association of Graves' disease and prevalence of circulating IFN-gamma-producing CD28(-) T cells. J Clin Immunol 2008; 28:464-72. [PMID: 18704663 DOI: 10.1007/s10875-008-9213-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2008] [Accepted: 05/19/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND Peripheral blood CD4(+) and CD8(+) T-cell subsets lacking surface CD28 have been suggested to predispose patients to immune-mediated disorders. MATERIALS AND METHODS To determine the role of CD28(-) T-cell subset in Graves' disease (GD), we characterized peripheral blood CD4(+)CD28(-) and CD8(+)CD28(-) T cell from early onset GD patients. RESULTS AND DISCUSSION GD patients had significantly higher percentages of CD4(+)CD28(-) and CD8(+)CD28(-) T cells than did healthy donors. Both CD28(-) T cells expressed mostly CD45RO, suggesting that they are activated and/or are memory T cells. GD patient-derived CD4(+)CD28(-) and CD8(+)CD28(-) T cells produced more intracellular IFN-gamma than their counterparts from healthy donors. Furthermore, CD4(+)CD28(-) and CD8(+)CD28(-) T cells from GD patients with Graves' ophthalmopathy (GO) secreted higher level of intracellular IFN-gamma than those CD28(-) T cells from GD patients without GO. Retrospective analysis showed that the increased levels of CD4(+)CD28(-) T cells and their IFN-gamma-producing subgroups were positively correlated to the serum anti-thyrotropin receptor (TSHR) autoantibodies (TRAb). Our observations suggest that increased IFN-gamma-producing CD28(-) T cells in GD patients may play an important role in the pathogenesis of GD.
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Elyaman W, Kivisäkk P, Reddy J, Chitnis T, Raddassi K, Imitola J, Bradshaw E, Kuchroo VK, Yagita H, Sayegh MH, Khoury SJ. Distinct functions of autoreactive memory and effector CD4+ T cells in experimental autoimmune encephalomyelitis. THE AMERICAN JOURNAL OF PATHOLOGY 2008; 173:411-22. [PMID: 18583313 DOI: 10.2353/ajpath.2008.080142] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The persistence of human autoimmune diseases is thought to be mediated predominantly by memory T cells. We investigated the phenotype and migration of memory versus effector T cells in vivo in experimental autoimmune encephalomyelitis (EAE). We found that memory CD4(+) T cells up-regulated the activation marker CD44 as well as CXCR3 and ICOS, proliferated more and produced more interferon-gamma and less interleukin-17 compared to effector T cells. Moreover, adoptive transfer of memory T cells into T cell receptor (TCR)alphabeta(-/-) recipients induced more severe disease than did effector CD4(+) T cells with marked central nervous system inflammation and axonal damage. The uniqueness of disease mediated by memory T cells was confirmed by the differential susceptibility to immunomodulatory therapies in vivo. CD28-B7 T cell costimulatory signal blockade by CTLA4Ig suppressed effector cell-mediated EAE but had minimal effects on disease induced by memory cells. In contrast, ICOS-B7h blockade exacerbated effector T cell-induced EAE but protected from disease induced by memory T cells. However, blockade of the OX40 (CD134) costimulatory pathway ameliorated disease mediated by both memory and effector T cells. Our data extend the understanding of the pathogenicity of autoreactive memory T cells and have important implications for the development of novel therapies for human autoimmune diseases.
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Affiliation(s)
- Wassim Elyaman
- Center for Neurologic Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA
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64
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Yokoyama Y, Fukunaga K, Fukuda Y, Tozawa K, Kamikozuru K, Ohnishi K, Kusaka T, Kosaka T, Hida N, Ohda Y, Miwa H, Matsumoto T. Demonstration of low-regulatory CD25High+CD4+ and high-pro-inflammatory CD28-CD4+ T-Cell subsets in patients with ulcerative colitis: modified by selective granulocyte and monocyte adsorption apheresis. Dig Dis Sci 2007; 52:2725-31. [PMID: 17404876 DOI: 10.1007/s10620-006-9560-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 08/03/2006] [Indexed: 12/12/2022]
Abstract
Low-CD25(High+)CD4(+), a subset of regulatory CD25(+)CD4(+) T cells and high-inflammatory CD28(-)CD4(+) T cells can exacerbate ulcerative colitis (UC). This study sought to investigate the frequency of CD25(High+)CD4(+) and CD28(-)CD4(+) T cells in patients with UC and the changes in these cells during Adacolumn granulocyte and monocyte adsorption apheresis (GMA). Subjects were 12 patients with active UC, 11 with quiescent UC, and 14 healthy volunteers (HVs). The mean clinical activity index was 15.7 +/- 2.2 in active UC and 4.5 +/- 1.1 in quiescent UC. Peripheral blood samples were stained with CD4, CD25, and CD28 antibodies for flow cytometry. Patients with active UC received GMA and blood samples were examined before and after the first GMA session. Patients with active UC (P < 0.04) or quiescent UC (P < 0.02) had a higher percentage of CD28(-)D4(+)T cells compared with HVs, while the percentage of CD28(+)CD4(+) T cells was lower in both UC groups compared with HVs (P = 0.03 and P < 0.02). Patients with active UC had a lower percentage of CD25(High+)CD4(+)T cells compared with quiescent UC patients (P < 0.001). A significant increase in CD25(High+)CD4(+) T cells was associated with GMA (P < 0.03). Low CD25(High+)CD4(+) and high CD28(-)CD4(+) are prominent features in UC. The increase in CD25(High+)CD4(+) T cells induced by GMA should contribute to improved immune function. Additional studies are warranted, since a low frequency of CD25(High+)CD4(+) (-) and a high frequency of CD28(-)CD4(+) (-) expressing T cells might be a predictor of clinical response to GMA.
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Affiliation(s)
- Yoko Yokoyama
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
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Saikali P, Antel JP, Newcombe J, Chen Z, Freedman M, Blain M, Cayrol R, Prat A, Hall JA, Arbour N. NKG2D-mediated cytotoxicity toward oligodendrocytes suggests a mechanism for tissue injury in multiple sclerosis. J Neurosci 2007; 27:1220-8. [PMID: 17267578 PMCID: PMC6673175 DOI: 10.1523/jneurosci.4402-06.2007] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
NKG2D is an activating or coactivating receptor expressed on human natural killer (NK) cells, CD8+ T cells, and gamma/delta T cells. NKG2D ligands have been detected on many tumor cell types and can be induced on nontransformed cells by environmental signals including DNA damage and inflammation. We investigated the contribution of NKG2D-NKG2D ligand interaction on CNS-directed immune responses. We observed that primary cultures of human adult oligodendrocytes and fetal astrocytes expressed ligands for NKG2D in vitro whereas neurons, microglia, and adult astrocytes did not. Disruption of the NKG2D-NKG2D ligand interaction using blocking antibodies significantly inhibited killing of primary human oligodendrocytes mediated by activated human NK cells, gamma/delta T cells, and allo-reactive CD8+ T cells. NKG2D ligands [major histocompatibility complex class I chain-related molecules A and B (MICA/B)] were detected in groups of cells and colocalized with an oligodendrocyte marker (adenomatous polyposis coli) in white matter sections obtained from multiple sclerosis lesions but not in normal control samples. CD8+ T cells could be detected in close proximity to MICA/B+ cells within multiple sclerosis lesions, supporting an in vivo interaction between these immune effectors and stressed MICA/B-expressing oligodendrocytes. These results imply that NKG2D-NKG2D ligand interaction can potentially contribute to cytotoxic responses mediated by activated immune effector cells in the inflamed CNS, as observed in multiple sclerosis.
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Affiliation(s)
| | - Jack P. Antel
- Neuroimmunology Unit, Montreal Neurological Institute, and
| | - Jia Newcombe
- NeuroResource, University College London, Institute of Neurology, London WC1N 1PJ, United Kingdom
| | - Zhihong Chen
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada K1H 8L6, and
| | - Mark Freedman
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada K1H 8L6, and
| | - Manon Blain
- Neuroimmunology Unit, Montreal Neurological Institute, and
| | - Romain Cayrol
- Research Center-Centre Hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada H2L 4M1
| | - Alexandre Prat
- Research Center-Centre Hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada H2L 4M1
| | - Jeffery A. Hall
- Division of Neurosurgery, McGill University, Montreal, Quebec, Canada H3A 2B4
| | - Nathalie Arbour
- Neuroimmunology Unit, Montreal Neurological Institute, and
- Research Center-Centre Hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada H2L 4M1
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Warrington KJ, Nair U, Carbone LD, Kang AH, Postlethwaite AE. Characterisation of the immune response to type I collagen in scleroderma. Arthritis Res Ther 2007; 8:R136. [PMID: 16879746 PMCID: PMC1779396 DOI: 10.1186/ar2025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 07/24/2006] [Accepted: 07/31/2006] [Indexed: 01/09/2023] Open
Abstract
This study was conducted to examine the frequency, phenotype, and functional profile of T lymphocytes that proliferate in response to type I collagen (CI) in patients with scleroderma (SSc). Peripheral blood mononuclear cells (PBMCs) from SSc patients, healthy controls, and rheumatoid arthritis disease controls were labeled with carboxy-fluorescein diacetate, succinimidyl ester (CFSE), cultured with or without antigen (bovine CI) for 14 days, and analysed by flow cytometry. Surface markers of proliferating cells were identified by multi-color flow cytometry. T-cell lines were derived after sorting for proliferating T cells (CFSElow). Cytokine expression in CI-responsive T cells was detected by intracellular staining/flow cytometry and by multiplex cytokine bead assay (Bio-Plex). A T-cell proliferative response to CI was detected in 8 of 25 (32%) SSc patients, but was infrequent in healthy or disease controls (3.6%; p = 0.009). The proliferating T cells expressed a CD4+, activated (CD25+), memory (CD45RO+) phenotype. Proliferation to CI did not correlate with disease duration or extent of skin involvement. T-cell lines were generated using in vitro CI stimulation to study the functional profile of these cells. Following activation of CI-reactive T cells, we detected intracellular interferon (IFN)-γ but not interleukin (IL)-4 by flow cytometry. Supernatants from the T-cell lines generated in vitro contained IL-2, IFN-γ, GM-CSF (granulocyte macrophage-colony-stimulating factor), and tumour necrosis factor-α, but little or no IL-4 and IL-10, suggesting that CI-responsive T cells express a predominantly Th1 cytokine pattern. In conclusion, circulating memory CD4 T cells that proliferate to CI are present in a subset of patients with SSc, but are infrequent in healthy or disease controls.
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Affiliation(s)
- Kenneth J Warrington
- Department of Medicine, Division of Connective Tissue Diseases, 956 Court Avenue, Room G326, Memphis, TN 38163
| | - Usha Nair
- Department of Medicine, Division of Connective Tissue Diseases, 956 Court Avenue, Room G326, Memphis, TN 38163
| | - Laura D Carbone
- Department of Medicine, Division of Connective Tissue Diseases, 956 Court Avenue, Room G326, Memphis, TN 38163
- Veterans Affairs Medical Center, Memphis, 1030 Jefferson Avenue, Memphis, TN 38104, USA
| | - Andrew H Kang
- Department of Medicine, Division of Connective Tissue Diseases, 956 Court Avenue, Room G326, Memphis, TN 38163
- Veterans Affairs Medical Center, Memphis, 1030 Jefferson Avenue, Memphis, TN 38104, USA
- Department of Molecular Sciences, University of Tennessee Health Science Center, 956 Court Avenue, Room A318, Memphis, TN 38163 USA
| | - Arnold E Postlethwaite
- Department of Medicine, Division of Connective Tissue Diseases, 956 Court Avenue, Room G326, Memphis, TN 38163
- Veterans Affairs Medical Center, Memphis, 1030 Jefferson Avenue, Memphis, TN 38104, USA
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67
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Azam P, Sankaranarayanan A, Homerick D, Griffey S, Wulff H. Targeting effector memory T cells with the small molecule Kv1.3 blocker PAP-1 suppresses allergic contact dermatitis. J Invest Dermatol 2007; 127:1419-29. [PMID: 17273162 PMCID: PMC1929164 DOI: 10.1038/sj.jid.5700717] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The voltage-gated potassium channel Kv1.3 has been recently identified as a molecular target that allows for selective pharmacological suppression of effector memory T (T(EM)) cells without affecting the function of naïve and central memory T cells. We here investigated whether PAP-1, a small molecule Kv1.3 blocker (EC50=2 nM), could suppress allergic contact dermatitis (ACD). In a rat model of ACD, we first confirmed that the infiltrating cells in the elicitation phase are indeed CD8+ CD45RC- memory T cells with high Kv1.3 expression. In accordance with its selective effect on T(EM) cells, PAP-1 did not impair sensitization, but potently suppressed oxazolone-induced inflammation by inhibiting the infiltration of CD8+ T cells and reducing the production of the inflammatory cytokines IFN-gamma, IL-2, and IL-17 when administered intraperitoneally or orally during the elicitation phase. PAP-1 was equally effective when applied topically, demonstrating that it effectively penetrates skin. We further show that PAP-1 is not a sensitizer or an irritant and exhibits no toxicity in a 28-day toxicity study. Based on these results we propose that PAP-1 could potentially be developed into a drug for the topical treatment of inflammatory skin diseases such as psoriasis.
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Affiliation(s)
- Philippe Azam
- Department of Medical Pharmacology and Toxicology, University of California, Davis, California, USA
| | | | - Daniel Homerick
- Department of Medical Pharmacology and Toxicology, University of California, Davis, California, USA
| | - Stephen Griffey
- Comparative Pathology Laboratory University of California, Davis, California, USA
| | - Heike Wulff
- Department of Medical Pharmacology and Toxicology, University of California, Davis, California, USA
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Abstract
T lymphocytes play a central role in the pathogenesis of multiple sclerosis (MS) (Zhang et al., 1992). Both CD4+ and CD8+ T cells have been demonstrated in MS lesions, with CD4+ T cells predominating in acute lesions and CD8+ T cells being observed more frequently in chronic lesions (Raine, 1994). Additionally, T cells are found in all four of the described histopathologic subtypes of MS (Lucchinetti et al., 2000). Activated myelin-reactive CD4+ T cells are present in the blood and cerebrospinal fluid (CSF) of MS patients; in contrast, only nonactivated myelin-reactive T cells are present in the blood of controls (Zhang et al., 1994). The success of several T-cell-targeted therapies in MS reinforces the importance of the role of the T cell in MS pathogenesis. Here, we outline basic concepts in CD4+ T-cell immunology and summarize the current understanding of the role of CD4+ T cells in the pathogenesis of MS.
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Affiliation(s)
- Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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69
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Beeton C, Wulff H, Standifer NE, Azam P, Mullen KM, Pennington MW, Kolski-Andreaco A, Wei E, Grino A, Counts DR, Wang PH, LeeHealey CJ, S. Andrews B, Sankaranarayanan A, Homerick D, Roeck WW, Tehranzadeh J, Stanhope KL, Zimin P, Havel PJ, Griffey S, Knaus HG, Nepom GT, Gutman GA, Calabresi PA, Chandy KG. Kv1.3 channels are a therapeutic target for T cell-mediated autoimmune diseases. Proc Natl Acad Sci U S A 2006; 103:17414-9. [PMID: 17088564 PMCID: PMC1859943 DOI: 10.1073/pnas.0605136103] [Citation(s) in RCA: 424] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Indexed: 12/25/2022] Open
Abstract
Autoreactive memory T lymphocytes are implicated in the pathogenesis of autoimmune diseases. Here we demonstrate that disease-associated autoreactive T cells from patients with type-1 diabetes mellitus or rheumatoid arthritis (RA) are mainly CD4+ CCR7- CD45RA- effector memory T cells (T(EM) cells) with elevated Kv1.3 potassium channel expression. In contrast, T cells with other antigen specificities from these patients, or autoreactive T cells from healthy individuals and disease controls, express low levels of Kv1.3 and are predominantly naïve or central-memory (T(CM)) cells. In T(EM) cells, Kv1.3 traffics to the immunological synapse during antigen presentation where it colocalizes with Kvbeta2, SAP97, ZIP, p56(lck), and CD4. Although Kv1.3 inhibitors [ShK(L5)-amide (SL5) and PAP1] do not prevent immunological synapse formation, they suppress Ca2+-signaling, cytokine production, and proliferation of autoantigen-specific T(EM) cells at pharmacologically relevant concentrations while sparing other classes of T cells. Kv1.3 inhibitors ameliorate pristane-induced arthritis in rats and reduce the incidence of experimental autoimmune diabetes in diabetes-prone (DP-BB/W) rats. Repeated dosing with Kv1.3 inhibitors in rats has not revealed systemic toxicity. Further development of Kv1.3 blockers for autoimmune disease therapy is warranted.
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MESH Headings
- Animals
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/immunology
- Arthritis, Rheumatoid/metabolism
- Arthritis, Rheumatoid/pathology
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/immunology
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/pathology
- Disease Models, Animal
- Electrophysiology
- Female
- Humans
- Kv1.3 Potassium Channel/antagonists & inhibitors
- Kv1.3 Potassium Channel/metabolism
- Pancreatitis-Associated Proteins
- Patch-Clamp Techniques
- Potassium Channel Blockers/pharmacology
- Rats
- Receptors, CCR7
- Receptors, Chemokine/metabolism
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- T-Lymphocytes/pathology
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Affiliation(s)
- Christine Beeton
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Heike Wulff
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | | | - Philippe Azam
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | | | | | - Aaron Kolski-Andreaco
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Eric Wei
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Alexandra Grino
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Debra R. Counts
- Department of Pediatrics, University of Maryland, Baltimore, MD 21201; and
| | - Ping H. Wang
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Christine J. LeeHealey
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Brian S. Andrews
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Ananthakrishnan Sankaranarayanan
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Daniel Homerick
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Werner W. Roeck
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Jamshid Tehranzadeh
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | - Kimber L. Stanhope
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Pavel Zimin
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Peter J. Havel
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Stephen Griffey
- Department of Medical Pharmacology and Toxicology, Department of Nutrition, and Comparative Pathology Laboratory, University of California, Davis, CA 95616
| | - Hans-Guenther Knaus
- **Division for Molecular and Cellular Pharmacology, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Gerald T. Nepom
- Benaroya Research Institute at Virginia Mason, Seattle, WA 98101
| | - George A. Gutman
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
| | | | - K. George Chandy
- *Departments of Physiology and Biophysics, Microbiology and Molecular Genetics, Medicine, and Radiological Sciences, University of California, Irvine, CA 92697
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Ichiki Y, Selmi C, Shimoda S, Ishibashi H, Gordon SC, Gershwin ME. Mitochondrial antigens as targets of cellular and humoral auto-immunity in primary biliary cirrhosis. Clin Rev Allergy Immunol 2006; 28:83-91. [PMID: 15879615 DOI: 10.1385/criai:28:2:083] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Several factors point toward an auto-immune pathogenesis for primary biliary cirrhosis(PBC), mostly based on the presence of serum auto-antibodies to mitochondrial antigens(AMAs) and autoreactive T cells (both helper and cytotoxic). Interestingly, epitopes recognized by AMA and T-cell clones are located within overlapping areas of the antigens. Moreover,a role for an imbalance in cytokine pattern and for natural-killer lymphocytes has also been proposed. Despite several experimental reports, no clear evidence is available regarding the interaction of these factors leading to bile duct destruction. This article reviews the current reports regarding the auto-immune reaction against mitochondrial auto-antigens in PBC.
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Affiliation(s)
- Yasunori Ichiki
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, TB192, Davis, CA, USA
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71
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Raffeiner B, Dejaco C, Duftner C, Kullich W, Goldberger C, Vega SC, Keller M, Grubeck-Loebenstein B, Schirmer M. Between adaptive and innate immunity: TLR4-mediated perforin production by CD28null T-helper cells in ankylosing spondylitis. Arthritis Res Ther 2005; 7:R1412-20. [PMID: 16277694 PMCID: PMC1297589 DOI: 10.1186/ar1840] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 08/26/2005] [Accepted: 09/27/2005] [Indexed: 11/10/2022] Open
Abstract
CD3+CD4+CD28null and CD3+CD8+CD28null T cells are enriched in patients with immune-mediated diseases compared with healthy controls. This study shows that CD4+CD28null T cells express Toll-like receptors recognizing bacterial lipopolysaccharides in ankylosing spondylitis, psoriatic arthritis and rheumatoid arthritis. In ankylosing spondylitis, TLR4 (23.1 +/- 21.9%) and, to a smaller extent, TLR2 (4.1 +/- 5.8%) were expressed on CD4+CD28null T cells, whereas expression was negligible on CD4+CD28+ and CD8+ T cells. CD4+CD28null T cells produced perforin upon stimulation with lipopolysaccharide, and this effect was enhanced by autologous serum or recombinant soluble CD14. Perforin production could be prevented with blocking antibodies directed against CD14 or TLR4. Incubation of peripheral blood mononuclear cells with tumour necrosis factor alpha led to an upregulation of TLR4 and TLR2 on CD4+CD28null T cells in vitro, and treatment of patients with antibodies specifically directed against tumour necrosis factor alpha resulted in decreased expression of TLR4 and TLR2 on CD4+CD28null T cells in vivo. We describe here a new pathway for direct activation of cytotoxic CD4+ T cells by components of infectious pathogens. This finding supports the hypothesis that CD4+CD28null T cells represent an immunological link between the innate immune system and the adaptive immune system.
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MESH Headings
- Adult
- Antibodies, Blocking/pharmacology
- Arthritis, Psoriatic/immunology
- Arthritis, Psoriatic/metabolism
- Arthritis, Psoriatic/pathology
- Arthritis, Rheumatoid/immunology
- Arthritis, Rheumatoid/metabolism
- Arthritis, Rheumatoid/pathology
- CD28 Antigens/metabolism
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- CD4-Positive T-Lymphocytes/pathology
- Cell Line
- Female
- Humans
- Immunity/immunology
- Leukocytes, Mononuclear/drug effects
- Leukocytes, Mononuclear/metabolism
- Leukocytes, Mononuclear/pathology
- Lipopolysaccharides/pharmacology
- Male
- Membrane Glycoproteins/genetics
- Membrane Glycoproteins/metabolism
- Middle Aged
- Perforin
- Pore Forming Cytotoxic Proteins
- RNA, Messenger/metabolism
- Spondylitis, Ankylosing/immunology
- Spondylitis, Ankylosing/metabolism
- Spondylitis, Ankylosing/pathology
- T-Lymphocytes, Helper-Inducer/drug effects
- T-Lymphocytes, Helper-Inducer/metabolism
- T-Lymphocytes, Helper-Inducer/pathology
- Toll-Like Receptor 4/genetics
- Toll-Like Receptor 4/metabolism
- Tumor Necrosis Factor-alpha/pharmacology
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Affiliation(s)
- Bernd Raffeiner
- Department of Internal Medicine, Innsbruck Medical University, Austria
| | - Christian Dejaco
- Department of Internal Medicine, Innsbruck Medical University, Austria
| | - Christina Duftner
- Department of Internal Medicine, Innsbruck Medical University, Austria
| | - Werner Kullich
- Ludwig Boltzmann Institute for Rehabilitation of Internal Diseases, Saalfelden, Austria
| | | | - Sandra C Vega
- Institute for Biomedical Aging Research, Austrian Academy of Science, Austria
| | - Michael Keller
- Institute for Biomedical Aging Research, Austrian Academy of Science, Austria
| | | | - Michael Schirmer
- Department of Internal Medicine, Innsbruck Medical University, Austria
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72
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Duftner C, Dejaco C, Kullich W, Klauser A, Goldberger C, Falkenbach A, Schirmer M. Preferential type 1 chemokine receptors and cytokine production of CD28- T cells in ankylosing spondylitis. Ann Rheum Dis 2005; 65:647-53. [PMID: 16219708 PMCID: PMC1798130 DOI: 10.1136/ard.2005.042085] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine serum levels of type 1 and type 2 chemokines and lymphocytic expression of chemokine receptors, and to compare the results with lymphocytic cytokine production in patients with ankylosing spondylitis (AS). METHODS Twelve patients with AS (mean (SD) age 44.9 (14.7) years) and 27 healthy controls (46.4 (12.8) years) were enrolled into the study. The expression of chemokine receptors (CCR-5, CXCR-3, CCR-4) and cytokines (interferon gamma (IFNgamma), interleukin (IL)2, IL4, IL10, tumour necrosis factor alpha (TNFalpha)) on CD28(+) and CD28(-) T cell subtypes was analysed by a three colour FACS technique of peripheral blood samples. Serum ELISAs were performed to detect the CCR-5 ligands CCL-5, CCL-3; the CXCR-3 ligands CXCL-10, CXCL-9; and the CCR-4 ligand, CCL-17 before and after administration of the TNFalpha blocking agent infliximab. RESULTS CD4(+)CD28(-) T cells had higher ratios of CXCR-3 to CCR-4 than CD4(+)CD28(+) T cells. Both, CD4(+) and CD8(+)CD28(-) T cells of patients with AS produced more IFNgamma, TNFalpha, and IL10 than their CD28(+) counterparts (p<0.05), and lacked the production of IL2 and IL4. Serum levels of CXCL-9 were increased in patients with AS to 59.2 pg/ml (34.1-730.5) compared with 32.5 pg/ml (20.0-79.5) in healthy controls (p = 0.016). The levels of both type 1 (CCL-5, CXCL-9) and type 2 chemokines (CCL-17) decreased under blockade of TNFalpha (p<0.05). CONCLUSIONS The profile of chemokine receptor expression and cytokine production by CD28(-) T cells suggests a type 1 immune reaction in AS, although IL10 is frequently produced by CD28(-) T cells. Treatment with TNFalpha blocking antibodies decreased both types of chemokines in patients' sera.
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Affiliation(s)
- C Duftner
- Department of Internal Medicine, Innsbruck Medical University, A-6020 Innsbruck, Anichstrasse 35, Austria
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73
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Beeton C, Pennington MW, Wulff H, Singh S, Nugent D, Crossley G, Khaytin I, Calabresi PA, Chen CY, Gutman GA, Chandy KG. Targeting effector memory T cells with a selective peptide inhibitor of Kv1.3 channels for therapy of autoimmune diseases. Mol Pharmacol 2005; 67:1369-81. [PMID: 15665253 PMCID: PMC4275123 DOI: 10.1124/mol.104.008193] [Citation(s) in RCA: 199] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The voltage-gated Kv1.3 K(+) channel is a novel target for immunomodulation of autoreactive effector memory T (T(EM)) cells that play a major role in the pathogenesis of autoimmune diseases. We describe the characterization of the novel peptide ShK(L5) that contains l-phosphotyrosine linked via a nine-atom hydrophilic linker to the N terminus of the ShK peptide from the sea anemone Stichodactyla helianthus. ShK(L5) is a highly specific Kv1.3 blocker that exhibits 100-fold selectivity for Kv1.3 (K(d) = 69 pM) over Kv1.1 and greater than 250-fold selectivity over all other channels tested. ShK(L5) suppresses the proliferation of human and rat T(EM) cells and inhibits interleukin-2 production at picomolar concentrations. Naive and central memory human T cells are initially 60-fold less sensitive than T(EM) cells to ShK(L5) and then become resistant to the peptide during activation by up-regulating the calcium-activated K(Ca)3.1 channel. ShK(L5) does not exhibit in vitro cytotoxicity on mammalian cell lines and is negative in the Ames test. It is stable in plasma and when administered once daily by subcutaneous injection (10 mug/kg) attains "steady state" blood levels of approximately 300 pM. This regimen does not cause cardiac toxicity assessed by continuous EKG monitoring and does not alter clinical chemistry and hematological parameters after 2-week therapy. ShK(L5) prevents and treats experimental autoimmune encephalomyelitis and suppresses delayed type hypersensitivity in rats. ShK(L5) might prove useful for therapy of autoimmune disorders.
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Affiliation(s)
- Christine Beeton
- Department of Physiology and Biophysics, 291 Irvine Hall, Medical School, University of California-Irvine, Irvine, CA 92697-4561, USA
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74
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García de Tena J, Manzano L, Leal JC, San Antonio E, Sualdea V, Alvarez-Mon M. Active Crohn's disease patients show a distinctive expansion of circulating memory CD4+CD45RO+CD28null T cells. J Clin Immunol 2005; 24:185-96. [PMID: 15024186 DOI: 10.1023/b:joci.0000019784.20191.7f] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In a previous study we found an expansion of circulating memory (CD45RO(+)) CD4(+) T cells in patients with Crohn's disease (CD). The aim of this work was to investigate the phenotypic and functional characteristics of this T-cell subset in CD. We analyzed in peripheral blood CD4(+)CD45RO(+) T cells from CD patients the expression of surface markers associated to immune activation, costimulation, and apoptosis. In sorted CD4(+)CD45RO(+) T cells apoptosis was quantified by fluorescent annexin V binding. Healthy subjects and patients with ulcerative colitis and acute bacterial enterocolitis served as control groups. An increased percentage of memory CD4(+)CD45RO(+) T cells lacking the expression of costimulatory receptor CD28 was detected in patients with active CD when compared to the other groups evaluated. This expanded CD4(+)CD45RO(+)CD28(null) T-cell subset expressed mostly the effector-cell marker CD57(+). Both CD28 downregulation and CD57 expression correlated to CDAI and surrogate markers of disease activity. These phenotypic changes observed on CD4(+)CD45RO(+) T cells from active CD returned to values similar to healthy controls after clinical remission. Moreover, this memory CD28(null) T-cell subset might express more intracytoplasmic TNF and IFN-gamma than their CD28(+) counterpart. Significantly lower frequencies of memory CD4(+)CD45RO(+) T cells expressing CD95 apoptosis receptor were found in patients with active CD. Moreover, sorted CD4(+)CD45RO(+)and CD4(+)CD45RO(+) CD28(null) T cells from patients with active CD exhibited a lower apoptotic rate than that found in healthy controls and inactive CD patients. According to our data, circulating T lymphocytes from active CD patients show distinctive phenotypic and functional changes, characterized by an expansion of memory CD4(+)CD45RO(+)CD28(null) T cells expressing effector-associated cell surface molecules and displaying enhanced resistance to apoptosis.
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Affiliation(s)
- Jaime García de Tena
- Laboratorio de Inmunología Clínica y Oncología, Unidad asociada I+D del Consejo Superior de Investigaciones Científicas, Departamento de Medicina, Universidad de Alcalá, Alcala de Henares, Spain
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75
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Hohlfeld R, Wekerle H. Autoimmune concepts of multiple sclerosis as a basis for selective immunotherapy: from pipe dreams to (therapeutic) pipelines. Proc Natl Acad Sci U S A 2004; 101 Suppl 2:14599-606. [PMID: 15306684 PMCID: PMC521993 DOI: 10.1073/pnas.0404874101] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Autoimmune T and B cell responses to CNS antigen(s) are thought to drive the pathogenesis of multiple sclerosis (MS), and thus are logical targets for therapy. Indeed, several immunomodulatory agents, including IFN-beta 1b, IFN-beta 1a, glatiramer acetate, and mitoxantrone, have had beneficial clinical effects in different forms of MS. However, because the available treatments are only partially effective, MS therapy needs to be further improved. Selective (antigen-specific) immunotherapies are especially appealing because in theory they combine maximal efficacy with minimal side effects. Indeed, several innovative immunotherapies have been successfully applied in experimental autoimmune encephalomyelitis. For example, autoreactive T cells can be selectively targeted by means of antigen, T cell receptor, or activation markers. However, experimental autoimmune encephalomyelitis is far from being a perfect approximation of MS because MS is more heterogeneous and the target antigen(s) is (are) not known. Further advances in MS therapy will depend on our growing understanding of the pathogenesis of this still incurable disease.
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Affiliation(s)
- Reinhard Hohlfeld
- Department of Neuroimmunology, Max Planck Institute for Neurobiology, Am Klopferspitz, D-82152 Martinsried, Germany.
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76
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Yu XZ, Albert MH, Martin PJ, Anasetti C. CD28 ligation induces transplantation tolerance by IFN-gamma-dependent depletion of T cells that recognize alloantigens. J Clin Invest 2004; 113:1624-30. [PMID: 15173889 PMCID: PMC419490 DOI: 10.1172/jci20940] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2003] [Accepted: 03/23/2004] [Indexed: 11/17/2022] Open
Abstract
Administration of an agonistic anti-CD28 mAb paradoxically inhibits donor T cell expansion and prevents graft-versus-host disease (GVHD) in mice. Here we examined the mechanism of anti-CD28-mediated immunosuppression and found that anti-CD28 mAb activated, rather than blocked, CD28-mediated signaling in vivo. Anti-CD28 treatment prevented GVHD by selectively depleting alloantigen-activated donor T cells through apoptosis but spared the T cells that did not recognize recipient alloantigens. Overexpression of Bcl-x(L) did not protect T cells from depletion and did not affect GVHD prevention after anti-CD28 treatment. Depletion of activated T cells mediated through CD28 did not depend on the expression of death receptors Fas and TNF receptors type I and II, but both the depletion of activated T cells and the suppressive effect of anti-CD28 mAb on GVHD lethality required donor-derived IFN-gamma production. This study demonstrates that agonistic Ab's specific for the CD28 costimulatory molecule may be used as novel therapeutic agents to abrogate pathogenic T cell responses by selective depletion of activated T cells.
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Affiliation(s)
- Xue-Zhong Yu
- Human Immunogenetics Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA.
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77
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Goronzy JJ, Weyand CM. Aging, autoimmunity and arthritis: T-cell senescence and contraction of T-cell repertoire diversity - catalysts of autoimmunity and chronic inflammation. Arthritis Res Ther 2004; 5:225-34. [PMID: 12932282 PMCID: PMC193735 DOI: 10.1186/ar974] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2003] [Revised: 07/21/2003] [Accepted: 07/24/2003] [Indexed: 01/01/2023] Open
Abstract
Rheumatoid arthritis (RA), like many other autoimmune syndromes, is a disease of adults, with the highest incidence rates reported in the elderly. The immune system undergoes profound changes with advancing age that are beginning to be understood and that need to be incorporated into the pathogenetic models of RA. The age-related decline in thymic function causes extensive remodeling of the T-cell system. Age-dependent changes in T-cell homeostasis are accelerated in patients with RA. The repertoire of naive and memory T cells is less diverse, possibly as a result of thymic insufficiency, and it is biased towards autoreactive cells. Presenescent T cells emerge that are resistant to apoptosis and that often expand to large clonal populations. These cells are under the regulatory control of nonconventional costimulatory molecules, display potent effector functions, and appear to be critical in the synovial and extra-articular manifestations of RA.
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Affiliation(s)
- Jörg J Goronzy
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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78
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Schönland SO, Lopez C, Widmann T, Zimmer J, Bryl E, Goronzy JJ, Weyand CM. Premature telomeric loss in rheumatoid arthritis is genetically determined and involves both myeloid and lymphoid cell lineages. Proc Natl Acad Sci U S A 2003; 100:13471-6. [PMID: 14578453 PMCID: PMC263838 DOI: 10.1073/pnas.2233561100] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In rheumatoid arthritis, peripheral blood T cells have age-inappropriate telomeric erosion. We examined whether HLA-DRB1*04 alleles, the major susceptibility genes for this disease, confer risk for T cell senescence. In healthy individuals, HLA-DRB1*04 alleles were associated with excessive loss of telomeres in CD4+ T cells. Accelerated telomeric erosion occurred during the first two decades of life and was followed by reduced homeostatic T cell proliferation during adulthood. Premature telomeric loss also affected granulocytes, suggesting that the hematopoietic stem cell is the primary target. Telomeric repair mechanisms were intact in HLA-DRB1*04+ donors. We propose that HLA-DRB1*04 alleles or genes in linkage disequilibrium regulate stem cell replication and contribute to the accumulation of senescent and autoreactive T cells in rheumatoid arthritis.
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Affiliation(s)
- Stefan O Schönland
- Department of Medicine and Immunology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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79
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Fontenot AP, Gharavi L, Bennett SR, Canavera SJ, Newman LS, Kotzin BL. CD28 costimulation independence of target organ versus circulating memory antigen-specific CD4+ T cells. J Clin Invest 2003; 112:776-84. [PMID: 12952926 PMCID: PMC182206 DOI: 10.1172/jci18317] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2003] [Accepted: 06/10/2003] [Indexed: 01/01/2023] Open
Abstract
T cell receptor engagement with CD28 costimulation is generally required for naive T cell activation, whereas reactivation of memory cells is less dependent on CD28 costimulation. We studied this process in chronic beryllium disease, in which the frequency of antigen-specific CD4+ T cells in the lung is large and circulating antigen-specific cells are also detectable. In the lung, a large fraction of CD4+ T cells stopped expressing CD28 mRNA and protein, and this change in phenotype correlated with lung inflammation. In the presence of concentrations of CTLA-4Ig that inhibited the CD28-B7 interaction, beryllium-specific CD4+ T cells in lung were still able to proliferate and secrete IFN-gamma in response to beryllium in culture. This functional independence of CD28 costimulation included lung CD28+ effector cells. Although lung CD4+CD28- cells retained the ability to secrete Th1-type cytokines in response to beryllium, they showed less proliferative capacity and were more susceptible to cell death compared with CD28+ T cells. In contrast to lung cells, inhibition of the CD28-B7 interaction markedly reduced responses of beryllium-specific T cells in blood. Taken together, these findings suggest transition within memory CD4+ T cells from CD28 dependence in central memory cells to functional independence and then loss of CD28 expression in effector cells.
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Affiliation(s)
- Andrew P Fontenot
- Department of Medicine,University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.
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80
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Wulff H, Calabresi PA, Allie R, Yun S, Pennington M, Beeton C, Chandy KG. The voltage-gated Kv1.3 K(+) channel in effector memory T cells as new target for MS. J Clin Invest 2003; 111:1703-13. [PMID: 12782673 PMCID: PMC156104 DOI: 10.1172/jci16921] [Citation(s) in RCA: 339] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Through a combination of fluorescence microscopy and patch-clamp analysis we have identified a striking alteration in K(+) channel expression in terminally differentiated human CCR7(-)CD45RA(-) effector memory T lymphocytes (T(EM)). Following activation, T(EM) cells expressed significantly higher levels of the voltage-gated K(+) channel Kv1.3 and lower levels of the calcium-activated K(+) channel IKCa1 than naive and central memory T cells (T(CM)). Upon repeated in vitro antigenic stimulation, naive cells differentiated into Kv1.3(high)IKCa1(low) T(EM) cells, and the potent Kv1.3-blocking sea anemone Stichodactyla helianthus peptide (ShK) suppressed proliferation of T(EM) cells without affecting naive or T(CM) lymphocytes. Thus, the Kv1.3(high)IKCa1(low) phenotype is a functional marker of activated T(EM) lymphocytes. Activated myelin-reactive T cells from patients with MS exhibited the Kv1.3(high)IKCa1(low) T(EM) phenotype, suggesting that they have undergone repeated stimulation during the course of disease; these cells may contribute to disease pathogenesis due to their ability to home to inflamed tissues and exhibit immediate effector function. The Kv1.3(high)IKCa1(low) phenotype was not seen in glutamic acid decarboxylase, insulin-peptide or ovalbumin-specific and mitogen-activated T cells from MS patients, or in myelin-specific T cells from healthy controls. Selective targeting of Kv1.3 in T(EM) cells may therefore hold therapeutic promise for MS and other T cell-mediated autoimmune diseases.
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Affiliation(s)
- Heike Wulff
- Department of Physiology and Biophysics, University of California Irvine, College of Medicine, Irvine, California 92697, USA
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81
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Pawlik A, Ostanek L, Brzosko I, Brzosko M, Masiuk M, Machalinski B, Gawronska-Szklarz B. The expansion of CD4+CD28- T cells in patients with rheumatoid arthritis. Arthritis Res Ther 2003; 5:R210-3. [PMID: 12823856 PMCID: PMC165060 DOI: 10.1186/ar766] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2002] [Revised: 02/26/2003] [Accepted: 04/08/2003] [Indexed: 11/16/2022] Open
Abstract
Clonal expansion of CD4+CD28- T cells is a characteristic finding in patients with rheumatoid arthritis (RA). Expanded CD4+ clonotypes are present in the peripheral blood, infiltrate into the joints, and persist for years. CD4+CD28- T cells are oligoclonal lymphocytes that are rare in healthy individuals but are found in high percentages in patients with chronic inflammatory diseases. The size of the peripheral blood CD4+CD28- T-cell compartment was determined in 42 patients with RA and 24 healthy subjects by two-color FACS analysis. The frequency of CD4+CD28- T cells was significantly higher in RA patients than in healthy subjects. Additionally, the number of these cells was significantly higher in patients with extra-articular manifestations and advanced joint destruction than in patients with limited joint manifestations. The results suggest that the frequency of CD4+CD28- T cells may be a marker correlating with extra-articular manifestations and joint involvement.
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Affiliation(s)
- Andrzej Pawlik
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Pomeranian University of Medicine, Szczecin, Poland.
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82
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Duftner C, Goldberger C, Falkenbach A, Würzner R, Falkensammer B, Pfeiffer KP, Maerker-Hermann E, Schirmer M. Prevalence, clinical relevance and characterization of circulating cytotoxic CD4+CD28- T cells in ankylosing spondylitis. Arthritis Res Ther 2003; 5:R292-300. [PMID: 12932293 PMCID: PMC193730 DOI: 10.1186/ar793] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2003] [Revised: 06/05/2003] [Accepted: 06/24/2003] [Indexed: 11/10/2022] Open
Abstract
Circulating CD3+CD4+CD28- cells exhibit reduced apoptosis and were found to be more enriched in patients with ankylosing spondylitis than in age-matched healthy control individuals (7.40 +/- 6.6% versus 1.03 +/- 1.0%; P < 0.001). Levels of CD4+CD28- T cells correlate with disease status as measured using a modified metrology score, but they are independent of age and duration of ankylosing spondylitis. CD4+CD28- T cells produce IFN-gamma and perforin, and thus they must be considered proinflammatory and cytotoxic. These T cells share phenotypic and functional properties of natural killer cells, strongly expressing CD57 but lacking the lymphocyte marker CD7. MHC class I recognizing and activating natural killer cell receptors on the surface of CD4+CD28- T cells may be involved in a HLA-B27 mediated co-stimulation of these proinflammatory and cytotoxic cells.
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MESH Headings
- Apoptosis/physiology
- CD28 Antigens/biosynthesis
- CD28 Antigens/metabolism
- CD4 Antigens/biosynthesis
- CD4 Antigens/metabolism
- Cell Line
- Cells, Cultured
- HLA-B27 Antigen/physiology
- Humans
- Killer Cells, Natural/chemistry
- Killer Cells, Natural/metabolism
- Killer Cells, Natural/physiology
- Leukocytes, Mononuclear/pathology
- Middle Aged
- Prevalence
- Spondylitis, Ankylosing/blood
- Spondylitis, Ankylosing/pathology
- T-Lymphocyte Subsets/chemistry
- T-Lymphocyte Subsets/pathology
- T-Lymphocyte Subsets/physiology
- T-Lymphocytes, Cytotoxic/chemistry
- T-Lymphocytes, Cytotoxic/pathology
- T-Lymphocytes, Cytotoxic/physiology
- Transfection
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Affiliation(s)
- Christina Duftner
- Department of Internal Medicine, University of Innsbruck, Innsbruck, Austria
| | | | | | - Reinhard Würzner
- Institute of Hygiene and Social Medicine, University of Innsbruck, Innsbruck, Austria
| | - Barbara Falkensammer
- Institute of Hygiene and Social Medicine, University of Innsbruck, Innsbruck, Austria
| | - Karl P Pfeiffer
- Institute of Biostatistics, University of Innsbruck, Innsbruck, Austria
| | | | - Michael Schirmer
- Department of Internal Medicine, University of Innsbruck, Innsbruck, Austria
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