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Kim A, Xie F, Abed OA, Moon JJ. Vaccines for immune tolerance against autoimmune disease. Adv Drug Deliv Rev 2023; 203:115140. [PMID: 37980949 PMCID: PMC10757742 DOI: 10.1016/j.addr.2023.115140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/21/2023]
Abstract
The high prevalence and rising incidence of autoimmune diseases have become a prominent public health issue. Autoimmune disorders result from the immune system erroneously attacking the body's own healthy cells and tissues, causing persistent inflammation, tissue injury, and impaired organ function. Existing treatments primarily rely on broad immunosuppression, leaving patients vulnerable to infections and necessitating lifelong treatments. To address these unmet needs, an emerging frontier of vaccine development aims to restore immune equilibrium by inducing immune tolerance to autoantigens, offering a potential avenue for a cure rather than mere symptom management. We discuss this burgeoning field of vaccine development against inflammation and autoimmune diseases, with a focus on common autoimmune disorders, including multiple sclerosis, type 1 diabetes, rheumatoid arthritis, inflammatory bowel disease, and systemic lupus erythematosus. Vaccine-based strategies provide a new pathway for the future of autoimmune disease therapeutics, heralding a new era in the battle against inflammation and autoimmunity.
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Affiliation(s)
- April Kim
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI 48109, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, USA
| | - Fang Xie
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI 48109, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, USA
| | - Omar A Abed
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, USA; Department of Chemical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - James J Moon
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI 48109, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, USA; Department of Chemical Engineering, University of Michigan, Ann Arbor, MI 48109, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor 48109, USA.
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2
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Czaja AJ. Introducing Molecular Chaperones into the Causality and Prospective Management of Autoimmune Hepatitis. Dig Dis Sci 2023; 68:4098-4116. [PMID: 37755606 PMCID: PMC10570239 DOI: 10.1007/s10620-023-08118-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
Molecular chaperones influence the immunogenicity of peptides and the activation of effector T cells, and their pathogenic roles in autoimmune hepatitis are unclear. Heat shock proteins are pivotal in the processing and presentation of peptides that activate CD8+ T cells. They can also induce regulatory B and T cells and promote immune tolerance. Tapasin and the transporter associated with antigen processing-binding protein influence the editing and loading of high-affinity peptides for presentation by class I molecules of the major histocompatibility complex. Their over-expression could enhance the autoimmune response, and their deficiency could weaken it. The lysosome-associated membrane protein-2a isoform in conjunction with heat shock cognate 70 supports the importation of cytosolic proteins into lysosomes. Chaperone-mediated autophagy can then process the peptides for activation of CD4+ T cells. Over-expression of autophagy in T cells may also eliminate negative regulators of their activity. The human leukocyte antigen B-associated transcript three facilitates the expression of class II peptide receptors, inhibits T cell apoptosis, prevents T cell exhaustion, and sustains the immune response. Immunization with heat shock proteins has induced immune tolerance in experimental models and humans with autoimmune disease by inducing regulatory T cells. Therapeutic manipulation of other molecular chaperones may promote T cell exhaustion and induce tolerogenic dendritic cells. In conclusion, molecular chaperones constitute an under-evaluated family of ancillary proteins that could affect the occurrence, severity, and outcome of autoimmune hepatitis. Clarification of their contributions to the immune mechanisms and clinical activity of autoimmune hepatitis could have therapeutic implications.
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Affiliation(s)
- Albert J Czaja
- Mayo Clinic College of Medicine and Science, 200 First Street S.W., Rochester, MN, 55905, USA.
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3
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Nijhuis L, Swart JF, Prakken BJ, van Loosdregt J, Vastert SJ. The clinical and experimental treatment of Juvenile Idiopathic Arthritis. Clin Exp Immunol 2023; 213:276-287. [PMID: 37074076 PMCID: PMC10571000 DOI: 10.1093/cei/uxad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/02/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and comprises of multiple subtypes. The most relevant disease subtypes, grouped upon current insight in disease mechanisms, are nonsystemic (oligo- and polyarticular) JIA and systemic JIA (sJIA). In this review, we summarize some of the main proposed mechanisms of disease in both nonsystemic and sJIA and discuss how current therapeutic modalities target some of the pathogenic immune pathways. Chronic inflammation in nonsystemic JIA is the result of a complex interplay between effector and regulatory immune cell subsets, with adaptive immune cells, specifically T-cell subsets and antigen-presenting cells, in a central role. There is, however, also innate immune cell contribution. SJIA is nowadays recognized as an acquired chronic inflammatory disorder with striking autoinflammatory features in the first phase of the disease. Some sJIA patients develop a refractory disease course, with indications for involvement of adaptive immune pathways as well. Currently, therapeutic strategies are directed at suppressing effector mechanisms in both non-systemic and sJIA. These strategies are often not yet optimally tuned nor timed to the known active mechanisms of disease in individual patients in both non-systemic and sJIA. We discuss current treatment strategies in JIA, specifically the 'Step-up' and 'Treat to Target approach' and explore how increased insight into the biology of disease may translate into future more targeted strategies for this chronic inflammatory disease at relevant time points: preclinical disease, active disease, and clinically inactive disease.
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Affiliation(s)
- L Nijhuis
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J F Swart
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - B J Prakken
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - J van Loosdregt
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - S J Vastert
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
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4
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Chen X, Elson CO, Dunkin D. Epicutaneous Immunotherapy with CBir1 Alleviates Intestinal Inflammation. Inflamm Bowel Dis 2023; 29:798-807. [PMID: 36651798 PMCID: PMC10152294 DOI: 10.1093/ibd/izac261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Inflammatory bowel disease may be due to failed tolerance to normal gut bacteria. We demonstrate that epicutaneous immunotherapy (ET) to ovalbumin can alleviate colitis in murine models. However, most people are tolerant to or have anergy to ovalbumin. Half of Crohn's disease (CD) patients have CBir1 antibodies that can be elevated years before CD development. We determined whether ET with a CBir1 multi-epitope peptide (MEP1) could alleviate colitis. METHODS Wild type mice (C57BL/6) were transferred with CBir1 T cell receptor (TCR) T cells followed by epicutaneous application of MEP1. Proliferating Foxp3+ T cells were measured in mesenteric lymph nodes (LNs), spleen, small intestine, and colon by flow cytometry. Lymphocytes from MEP1 epicutaneously exposed and immunized C57BL/6 mice were cultured with MEP1. Interferon (IFN)-γ production was measured. Colitis was induced by transferring CD4+CD45Rbhi T cells from CBIR1 TCR or C57BL/6 mice into RAG1-/- mice. Mice were treated with ET. Body weight, colon length, colonic cytokine production, histological inflammation, inflammatory genes, and regulatory T cells (Tregs) from lamina propria were measured. RESULTS ET with 10 μg of MEP1 induced CBir1-specific Tregs that migrated to the small intestine and colon and suppressed MEP1-specific IFN-γ production. ET alleviated colitis when the model utilized CBir1 TCR T cells in mice colonized with CBir1 or A4Fla2 positive bacteria. Treated mice had improved colon length and histological inflammation and reduced colonic IFN-γ production. CONCLUSION Epicutaneous immunotherapy with MEP1 induced Tregs that migrate to intestines and suppress inflammation in mice with CBir1 or A4Fla2-positive bacterial colonization. This could be a potential strategy to treat CD and warrants further study.
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Affiliation(s)
- Xin Chen
- Division of Pediatric Gastroenterology and the Mindich Child Health and Development Institute (MCHDI), The Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Charles O Elson
- Department of Medicine, Division of Gastroenterology and Hepatology, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Dunkin
- Division of Pediatric Gastroenterology and the Mindich Child Health and Development Institute (MCHDI), The Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
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5
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Ackun-Farmmer MA, Jewell CM. Delivery route considerations for designing antigen-specific biomaterial strategies to combat autoimmunity. ADVANCED NANOBIOMED RESEARCH 2023; 3:2200135. [PMID: 36938103 PMCID: PMC10019031 DOI: 10.1002/anbr.202200135] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Disease modifying drugs and biologics used to treat autoimmune diseases, although promising, are non-curative. As the field moves towards development of new approaches to treat autoimmune disease, antigen-specific therapies immunotherapies (ASITs) have emerged. Despite clinical approval of ASITs for allergies, clinical trials using soluble ASITs for autoimmunity have been largely unsuccessful. A major effort to address this shortcoming is the use of biomaterials to harness the features unique to specific delivery routes. This review focuses on biomaterials being developed for delivery route-specific strategies to induce antigen-specific responses in autoimmune diseases such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis, and celiac disease. We first discuss the delivery strategies used in ongoing and completed clinical trials in autoimmune ASITs. Next, we highlight pre-clinical biomaterial approaches from the most recent 3 years in the context of these same delivery route considerations. Lastly, we provide discussion on the gaps remaining in biomaterials development and comment on the need to consider delivery routes in the process of designing biomaterials for ASITs.
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Affiliation(s)
- Marian A Ackun-Farmmer
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742, USA
| | - Christopher M Jewell
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, 20742, USA
- US Department of Veterans Affairs, VA Maryland Health Care System, Baltimore, MD, 21201, USA
- Robert E. Fischell Institute for Biomedical Devices, College Park, MD, 20742, USA
- Department of Microbiology and Immunology, University of Maryland Medical School, Baltimore, MD, 21201, USA
- Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, 21201, USA
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6
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Domínguez-Horta MDC, Serrano-Díaz A, Hernández-Cedeño M, Martínez-Donato G, Guillén-Nieto G. A peptide derived from HSP60 reduces proinflammatory cytokines and soluble mediators: a therapeutic approach to inflammation. Front Immunol 2023; 14:1162739. [PMID: 37187739 PMCID: PMC10179499 DOI: 10.3389/fimmu.2023.1162739] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Cytokines are secretion proteins that mediate and regulate immunity and inflammation. They are crucial in the progress of acute inflammatory diseases and autoimmunity. In fact, the inhibition of proinflammatory cytokines has been widely tested in the treatment of rheumatoid arthritis (RA). Some of these inhibitors have been used in the treatment of COVID-19 patients to improve survival rates. However, controlling the extent of inflammation with cytokine inhibitors is still a challenge because these molecules are redundant and pleiotropic. Here we review a novel therapeutic approach based on the use of the HSP60-derived Altered Peptide Ligand (APL) designed for RA and repositioned for the treatment of COVID-19 patients with hyperinflammation. HSP60 is a molecular chaperone found in all cells. It is involved in a wide diversity of cellular events including protein folding and trafficking. HSP60 concentration increases during cellular stress, for example inflammation. This protein has a dual role in immunity. Some HSP60-derived soluble epitopes induce inflammation, while others are immunoregulatory. Our HSP60-derived APL decreases the concentration of cytokines and induces the increase of FOXP3+ regulatory T cells (Treg) in various experimental systems. Furthermore, it decreases several cytokines and soluble mediators that are raised in RA, as well as decreases the excessive inflammatory response induced by SARS-CoV-2. This approach can be extended to other inflammatory diseases.
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Affiliation(s)
- Maria del Carmen Domínguez-Horta
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Physiology Department, Latin American School of Medicine, Havana, Cuba
- *Correspondence: Maria del Carmen Domínguez-Horta,
| | - Anabel Serrano-Díaz
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Mabel Hernández-Cedeño
- Autoimmunity Project, Pharmaceutical Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gillian Martínez-Donato
- Biomedical Research Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gerardo Guillén-Nieto
- Physiology Department, Latin American School of Medicine, Havana, Cuba
- Biomedical Research Division, Center for Genetic Engineering and Biotechnology, Havana, Cuba
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7
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Rezende RM, Weiner HL. Oral tolerance: an updated review. Immunol Lett 2022; 245:29-37. [PMID: 35395272 DOI: 10.1016/j.imlet.2022.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 12/18/2022]
Abstract
Oral tolerance (OT) has classically been defined as the specific suppression of cellular and/or humoral immune responses to an antigen by prior administration of the antigen through the oral route. Multiple mechanisms have been proposed to explain the induction of OT including T cell clonal depletion and anergy when high doses of antigens are fed, and regulatory T (Treg) cell generation following oral administration of low and repeated doses of antigens. Oral antigen administration suppresses the immune response in several animal models of autoimmune disease, including experimental autoimmune encephalomyelitis, uveitis, thyroiditis, myasthenia, arthritis and diabetes, but also non-autoimmune inflammatory conditions such as asthma, atherosclerosis, graft rejection, allergy and stroke. However, human trials have given mixed results and a great deal remains to be learned about the mechanisms of OT before it can be successfully applied to people. One of the possible mechanisms relates to the gut microbiota and in this review, we will explore the cellular components involved in the induction of OT and the role of the gut microbiota in contributing to OT development.
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Affiliation(s)
- Rafael M Rezende
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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8
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With or without You: Co-Chaperones Mediate Health and Disease by Modifying Chaperone Function and Protein Triage. Cells 2021; 10:cells10113121. [PMID: 34831344 PMCID: PMC8619055 DOI: 10.3390/cells10113121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Heat shock proteins (HSPs) are a family of molecular chaperones that regulate essential protein refolding and triage decisions to maintain protein homeostasis. Numerous co-chaperone proteins directly interact and modify the function of HSPs, and these interactions impact the outcome of protein triage, impacting everything from structural proteins to cell signaling mediators. The chaperone/co-chaperone machinery protects against various stressors to ensure cellular function in the face of stress. However, coding mutations, expression changes, and post-translational modifications of the chaperone/co-chaperone machinery can alter the cellular stress response. Importantly, these dysfunctions appear to contribute to numerous human diseases. Therapeutic targeting of chaperones is an attractive but challenging approach due to the vast functions of HSPs, likely contributing to the off-target effects of these therapies. Current efforts focus on targeting co-chaperones to develop precise treatments for numerous diseases caused by defects in protein quality control. This review focuses on the recent developments regarding selected HSP70/HSP90 co-chaperones, with a concentration on cardioprotection, neuroprotection, cancer, and autoimmune diseases. We also discuss therapeutic approaches that highlight both the utility and challenges of targeting co-chaperones.
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9
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Gomez CR. Role of heat shock proteins in aging and chronic inflammatory diseases. GeroScience 2021; 43:2515-2532. [PMID: 34241808 PMCID: PMC8599533 DOI: 10.1007/s11357-021-00394-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 01/01/2023] Open
Abstract
Advanced age is associated with a decline in response to stress. This contributes to the establishment of chronic inflammation, one of the hallmarks of aging and age-related disease. Heat shock proteins (HSP) are determinants of life span, and their progressive malfunction leads to age-related pathology. To discuss the function of HSP on age-related chronic inflammation and illness. An updated review of literature and discussion of relevant work on the topic of HSP in normal aging and chronic inflammatory pathology was performed. HSP contribute to inflamm-aging. They also play a key role in age-associated pathology linked to chronic inflammation such as autoimmune disorders, neurological disease, cardiovascular disorder, and cancer. HSP may be targeted for control of their effects related to age and chronic inflammation. Research on HSP functions in age-linked chronic inflammatory disorders provides an opportunity to improve health span and delay age-related chronic disorders.
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Affiliation(s)
- Christian R Gomez
- Department of Pathology, University of Mississippi Medical Cent, er, 2500 N. State St, Jackson, MS, 39216, USA.
- Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State St, Jackson, MS, 39216, USA.
- Preclinical Research Unit, Center for Clinical and Translational Science, University of Mississippi, 2500 N. State St, Jackson, MS, 39216, USA.
- Cancer Center and Research Institute, University of Mississippi Medical Center, 2500 N. State St, Jackson, MS, 39216, USA.
- Division of Lung Diseases, National Institutes of Health (NIH), National Heart, Lung and Blood Institute (NHLBI), Bethesda, MD, USA.
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10
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Pinheiro-Rosa N, Torres L, Oliveira MDA, Andrade-Oliveira MF, Guimarães MADF, Coelho MM, Alves JDL, Maioli TU, Faria AMC. Oral tolerance as antigen-specific immunotherapy. IMMUNOTHERAPY ADVANCES 2021; 1:ltab017. [PMID: 35919733 PMCID: PMC9327124 DOI: 10.1093/immadv/ltab017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/23/2021] [Accepted: 08/23/2021] [Indexed: 12/19/2022] Open
Abstract
Summary
Oral tolerance is a physiological phenomenon described more than a century ago as a suppressive immune response to antigens that gain access to the body by the oral route. It is a robust and long-lasting event with local and systemic effects in which the generation of mucosally induced regulatory T cells (iTreg) plays an essential role. The idea of using oral tolerance to inhibit autoimmune and allergic diseases by oral administration of target antigens was an important development that was successfully tested in 1980s. Since then, several studies have shown that feeding specific antigens can be used to prevent and control chronic inflammatory diseases in both animal models and clinically. Therefore, oral tolerance can be classified as an antigen-specific form of oral immunotherapy (OIT). In the light of novel findings on mechanisms, sites of induction and factors affecting oral tolerance, this review will focus on specific characteristics of oral tolerance induction and how they impact in its therapeutic application.
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Affiliation(s)
- Natália Pinheiro-Rosa
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Lícia Torres
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Mariana de Almeida Oliveira
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Marcos Felipe Andrade-Oliveira
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Mauro Andrade de Freitas Guimarães
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Monique Macedo Coelho
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Juliana de Lima Alves
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Tatiani Uceli Maioli
- Departamento de Nutrição, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Ana M Caetano Faria
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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11
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Shams S, Martinez JM, Dawson JRD, Flores J, Gabriel M, Garcia G, Guevara A, Murray K, Pacifici N, Vargas MV, Voelker T, Hell JW, Ashouri JF. The Therapeutic Landscape of Rheumatoid Arthritis: Current State and Future Directions. Front Pharmacol 2021; 12:680043. [PMID: 34122106 PMCID: PMC8194305 DOI: 10.3389/fphar.2021.680043] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
Rheumatoid arthritis (RA) is a debilitating autoimmune disease with grave physical, emotional and socioeconomic consequences. Despite advances in targeted biologic and pharmacologic interventions that have recently come to market, many patients with RA continue to have inadequate response to therapies, or intolerable side effects, with resultant progression of their disease. In this review, we detail multiple biomolecular pathways involved in RA disease pathogenesis to elucidate and highlight pathways that have been therapeutic targets in managing this systemic autoimmune disease. Here we present an up-to-date accounting of both emerging and approved pharmacological treatments for RA, detailing their discovery, mechanisms of action, efficacy, and limitations. Finally, we turn to the emerging fields of bioengineering and cell therapy to illuminate possible future targeted therapeutic options that combine material and biological sciences for localized therapeutic action with the potential to greatly reduce side effects seen in systemically applied treatment modalities.
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Affiliation(s)
- Shahin Shams
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, United States
| | - Joseph M. Martinez
- Department of Pharmacology, University of California, Davis, Davis, CA, United States
| | - John R. D. Dawson
- Department of Physiology and Membrane Biology, University of California, Davis, Davis, CA, United States
| | - Juan Flores
- Center for Neuroscience, University of California, Davis, Davis, CA, United States
| | - Marina Gabriel
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, United States
| | - Gustavo Garcia
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, United States
| | - Amanda Guevara
- Department of Pharmacology, University of California, Davis, Davis, CA, United States
| | - Kaitlin Murray
- Department of Anatomy, Physiology, and Cell Biology, University of California, Davis, Davis, CA, United States
| | - Noah Pacifici
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, United States
| | | | - Taylor Voelker
- Department of Physiology and Membrane Biology, University of California, Davis, Davis, CA, United States
| | - Johannes W. Hell
- Department of Pharmacology, University of California, Davis, Davis, CA, United States
| | - Judith F. Ashouri
- Rosalind Russell and Ephraim R. Engleman Rheumatology Research Center, Department of Medicine, University of California, San Francisco, CA, United States
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12
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Chen XY, Du GS, Sun X. Targeting Lymphoid Tissues to Promote Immune Tolerance. ADVANCED THERAPEUTICS 2021. [DOI: 10.1002/adtp.202100056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xiao Yan Chen
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
| | - Guang Sheng Du
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
| | - Xun Sun
- Key Laboratory of Drug‐Targeting and Drug Delivery System of the Education Ministry Sichuan Engineering Laboratory for Plant‐Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology West China School of Pharmacy Sichuan University No.17, Block 3, Southern Renmin Road Chengdu 610041 China
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13
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Li C, Chen X, Luo X, Wang H, Zhu Y, Du G, Chen W, Chen Z, Hao X, Zhang Z, Sun X. Nanoemulsions Target to Ectopic Lymphoids in Inflamed Joints to Restore Immune Tolerance in Rheumatoid Arthritis. NANO LETTERS 2021; 21:2551-2561. [PMID: 33687217 DOI: 10.1021/acs.nanolett.0c05110] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Inducing immune tolerance through repeated administration of self-antigens is a promising strategy for treating rheumatoid arthritis (RA), and current research indicates that coadministration of immunomodulators can further orchestrate the tolerogenic response. However, most of the clinical trials based on tolerance induction have negligible therapeutic effects. Peripheral lymphoid organs play critical roles in immunotherapy. Here, we design an engineered nanoemulsion for targeted codelivery of self-antigens and an immunomodulator to ectopic lymphoid structures (ELSs) in inflamed joints of RA. Namely, a citrullinated multiepitope self-antigen (CitP) and rapamycin are incorporated into the nanoemulsions (NEs@CitP/Rapa), which are fabricated by a facial method using commercialized pharmaceutical excipients. After intravenous administration, the nanoemulsion shows satisfactory accumulation in the inflamed paws and provides enhanced anti-inflammatory effect in various experimental murine models of RA. Our study provides a promising targeting strategy to induce immune tolerance for the treatment of RA.
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Affiliation(s)
- Chenglong Li
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Xiaoyan Chen
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Xianjin Luo
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Hairui Wang
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Yining Zhu
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Guangshen Du
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Wenfei Chen
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Zhengjun Chen
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Xinyan Hao
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Zhirong Zhang
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
| | - Xun Sun
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu 610041, P.R. China
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Toes RE, Raza K. The autoimmune response as a potential target for tolerance induction before the development of rheumatoid arthritis. THE LANCET. RHEUMATOLOGY 2021; 3:e214-e223. [PMID: 38279384 DOI: 10.1016/s2665-9913(20)30445-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 01/28/2024]
Abstract
Rheumatoid arthritis is a chronic inflammatory disease that affects the synovial joints. Although treatment options and efficacy have increased substantially in the past two decades, the disease cannot be cured or prevented. Therefore, rheumatoid arthritis still has a considerable effect on the quality of life of patients, not only because life-long medication is often required, but also because residual disease activity leads to progressive loss of function in the musculoskeletal system and extra-articular morbidity. Key future goals in the management of rheumatoid arthritis are the ability to induce long-lasting drug-free remission in patients with the disease (ie, to achieve a cure), and to prevent disease before it emerges. To reach these goals, it is pivotal to understand the autoimmune response underlying rheumatoid arthritis pathogenesis and to develop ways to permanently silence it (ie, to induce tolerance). For preventive studies, the identification of markers (clinical, immunological, and biological) predictive of future disease is crucial, as prevention of disease will not be feasible without the ability to identify relevant at-risk target populations. In this Series paper, we review the autoimmune response underlying rheumatoid arthritis, how rheumatoid arthritis-specific autoimmunity develops and evolves during the transition from health to disease, and how tolerance studies could be designed to achieve prevention or cure of the disease.
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Affiliation(s)
- Rene Em Toes
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands.
| | - Karim Raza
- Research into Inflammatory Arthritis Centre Versus Arthritis and MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK; Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
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15
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Asthana P, Zhang G, Sheikh KA, Him Eddie Ma C. Heat shock protein is a key therapeutic target for nerve repair in autoimmune peripheral neuropathy and severe peripheral nerve injury. Brain Behav Immun 2021; 91:48-64. [PMID: 32858161 DOI: 10.1016/j.bbi.2020.08.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 12/27/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an autoimmune peripheral neuropathy and a common cause of neuromuscular paralysis. Preceding infection induces the production of anti-ganglioside (GD) antibodies attacking its own peripheral nerves. In severe proximal peripheral nerve injuries that require long-distance axon regeneration, motor functional recovery is virtually nonexistent. Damaged axons fail to regrow and reinnervate target muscles. In mice, regenerating axons must reach the target muscle within 35 days (critical period) to reform functional neuromuscular junctions and regain motor function. Successful functional recovery depends on the rate of axon regeneration and debris removal (Wallerian degeneration) after nerve injury. The innate-immune response of the peripheral nervous system to nerve injury such as timing and magnitude of cytokine production is crucial for Wallerian degeneration. In the current study, forced expression of human heat shock protein (hHsp) 27 completely reversed anti-GD-induced inhibitory effects on nerve repair assessed by animal behavioral assays, electrophysiology and histology studies, and the beneficial effect was validated in a second mouse line of hHsp27. The protective effect of hHsp27 on prolonged muscle denervation was examined by performing repeated sciatic nerve crushes to delay regenerating axons from reaching distal muscle from 37 days up to 55 days. Strikingly, hHsp27 was able to extend the critical period of motor functional recovery for up to 55 days and preserve the integrity of axons and mitochondria in distal nerves. Cytokine array analysis demonstrated that a number of key cytokines which are heavily involved in the early phase of innate-immune response of Wallerian degeneration, were found to be upregulated in the sciatic nerve lysates of hHsp27 Tg mice at 1 day postinjury. However, persistent hyperinflammatory mediator changes were found after chronic denervation in sciatic nerves of littermate mice, but remained unchanged in hHsp27 Tg mice. Taken together, the current study provides insight into the development of therapeutic strategies to enhance muscle receptiveness (reinnervation) by accelerating axon regeneration and Wallerian degeneration.
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Affiliation(s)
- Pallavi Asthana
- Department of Neuroscience, City University of Hong Kong, Tat Chee Avenue, Hong Kong Special Administrative Region
| | - Gang Zhang
- Department of Neurology, University of Texas Medical School at Houston, 6431 Fannin Street, Houston TX 77030, USA
| | - Kazim A Sheikh
- Department of Neurology, University of Texas Medical School at Houston, 6431 Fannin Street, Houston TX 77030, USA
| | - Chi Him Eddie Ma
- Department of Neuroscience, City University of Hong Kong, Tat Chee Avenue, Hong Kong Special Administrative Region; City University of Hong Kong Shenzhen Research Institute, Shenzhen, China.
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16
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Nel HJ, Malmström V, Wraith DC, Thomas R. Autoantigens in rheumatoid arthritis and the potential for antigen-specific tolerising immunotherapy. THE LANCET. RHEUMATOLOGY 2020; 2:e712-e723. [PMID: 38279365 DOI: 10.1016/s2665-9913(20)30344-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/19/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune diseases, including rheumatoid arthritis, develop and persist due to impaired immune self-tolerance, which has evolved to regulate inflammatory responses to injury or infection. After diagnosis, patients rarely achieve drug-free remission, and although at-risk individuals can be identified with genotyping, antibody tests, and symptoms, rheumatoid arthritis cannot yet be successfully prevented. Precision medicine is increasingly offering solutions to diseases that were previously considered to be incurable, and immunotherapy has begun to achieve this aim in cancer. Comparatively, modulating autoantigen-specific immune responses with immunotherapy for the cure of autoimmune diseases is at a relatively immature stage. Current treatments using non-specific immune or inflammatory suppression increase susceptibility to infection, and are rarely curative. However, early stage clinical trials suggesting that immunotherapy might allow extended duration of remission and even prevention of progression to disease suggest modulating tolerance in rheumatoid arthritis could be a promising opportunity for therapy.
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Affiliation(s)
- Hendrik J Nel
- University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Vivianne Malmström
- Division of Rheumatology, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden
| | - David C Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ranjeny Thomas
- University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
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17
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Tukaj S, Mantej J, Sobala M, Potrykus K, Sitko K. Autologous extracellular Hsp70 exerts a dual role in rheumatoid arthritis. Cell Stress Chaperones 2020; 25:1105-1110. [PMID: 32358783 PMCID: PMC7591667 DOI: 10.1007/s12192-020-01114-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 01/22/2023] Open
Abstract
Extracellular heat shock proteins (Hsp) influence the adaptive immune response and may ameliorate pathogenesis of autoimmune diseases. While some preclinical observations suggest that highly conserved bacterial and/or murine Hsp70 peptides have potential utility in treatment of rheumatoid arthritis (RA) via induction of T regulatory cells (Treg), the role of extracellular inducible human Hsp70 in adaptive immune processes requires further investigation. The present study evaluated Hsp70 influence on inflammatory cytokine-mediated modulation of T cell immunophenotype in ways that influence RA onset and severity. Initial experiments in the present investigation revealed that serum levels of Hsp70 are approximately 2-fold higher in RA patients versus healthy control subjects. To explore the effect of extracellular Hsp70 on key processes underlying the adaptive immune system, the effects of a highly pure, substrate-, and endotoxin-free human Hsp70 on polarization of the T helper cell subpopulations, including CD4+IL-17+ (Th17), CD4+FoxP3+ (Treg), CD4+IFN-γ+ (Th1), and CD4+IL-4+ (Th2), were studied in naïve human peripheral blood mononuclear cell (PBMC) cultures stimulated with anti-CD3/28 mAb. Major findings included an observation that while Hsp70 treatment increased Th17 frequencies and Th17/Treg ratio, the frequency of Th1 cells and the Th1/Th2 ratio were significantly decreased in the Hsp70-treated PBMC cultures. Moreover, data shown here provides preliminary suggestion that major contributing Hsp70-mediated immunomodulation includes interleukin 6 (IL-6) influence on Th17/Treg and Th1/Th2, since expression of this inflammatory cytokine is enhanced by in vitro Hsp70 treatment. These results are nevertheless preliminary and require further investigation to validate the above model.
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Affiliation(s)
- Stefan Tukaj
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland.
| | - Jagoda Mantej
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Michał Sobala
- Department of Bacterial Molecular Genetics, Faculty of Biology, University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Potrykus
- Department of Bacterial Molecular Genetics, Faculty of Biology, University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Sitko
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
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18
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Gusmao-Silva G, Aguiar SLF, Miranda MCG, Guimarães MA, Alves JL, Vieira AT, Cara DC, Miyoshi A, Azevedo VA, Oliveira RP, Faria AMC. Hsp65-Producing Lactococcocus lactis Prevents Antigen-Induced Arthritis in Mice. Front Immunol 2020; 11:562905. [PMID: 33072101 PMCID: PMC7538670 DOI: 10.3389/fimmu.2020.562905] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 08/18/2020] [Indexed: 01/22/2023] Open
Abstract
Oral tolerance is the physiological process that enables the immune system to differentiate between harmless dietary and microbiota antigens from pathogen derived antigens. It develops at the mucosal surfaces and can result in local and systemic regulatory and anti-inflammatory effects. Translation of these benefits to the clinical practice faces limitations involving specificity and doses of antigen as well as regimens of feeding. To circumvent these problems, we developed a recombinant Hsp65 delivered by the acid lactic bacteria Lactococcus lactis NCDO 2118 directy in the intestinal mucosa. Hsp65 is a ubiquitous protein overexpressed in inflamed tissues and capable of inducing immunoregulatory mechanisms. L. lactis has probiotic properties and is commonly and safely used in dairy products. In this study, we showed that continuous delivery of HSP65 in the gut mucosa by L. lactis is a potent tolerogenic stimulus inducing regulatory CD4+LAP+ T cells that prevented collagen-induced and methylated bovine serum albumin-induced arthritis in mice. Clinical and histological signs of arthritis were inhibited as well as levels of inflammatory cytokines such as IL-17 and IFN-γ, serum titers of anti-collagen antibodies and rheumatoid factor. Oral administration of L. lactis induced alterations in microbiota composition toward an increased abundance of anaerobic bacteria such as Bifidobacterium and Lactobacillus. Tolerance to HSP65 and arthritis prevention induced by the recombinant L. lactis was associated with increase in IL-10 production by B cells and it was dependent on LAP+ T cells, IL-10 and TLR2 signaling. Therefore, HSP65-producing treatment induced effective tolerance and prevented arthritis development suggesting it can be used as a therapeutic tool for autoimmune diseases.
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Affiliation(s)
- Guilherme Gusmao-Silva
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Sarah Leão Fiorini Aguiar
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Mauro Andrade Guimarães
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Juliana Lima Alves
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Angélica Thomaz Vieira
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Denise Carmona Cara
- Departamento de Morfologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Anderson Miyoshi
- Departamento de Genética, Evolução e Ecologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Vasco Ariston Azevedo
- Departamento de Genética, Evolução e Ecologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Ana Maria Caetano Faria
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Instituto de Investigação em Imunologia, São Paulo, Brazil
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19
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Abstract
Immune tolerance is defined by an active state of immune system unresponsiveness to foreign and self-antigens. Loss of immune tolerance to self-antigens and the resulting overexpression of autoantibodies can lead to tissue injury and development of various autoimmune diseases. In drug development, the goal of newly emerging immune tolerance therapies is to treat autoimmune disorders by restoring the immunoregulatory capacity of the immune system. Development of immune tolerance targets is initiated with the establishment of pharmacological efficacy in relevant disease animal models, followed by their stepwise translation to humans. This review discusses the major challenges to developing tolerance inducing pharmaceutical drugs, including the selection of appropriate disease models to establish efficacy, adequate, and acceptable in vitro and in vivo safety assessments, relevant biomarkers of human safety and efficacy, and finally, some regulatory guidelines to successfully develop immune tolerance therapeutics. [Box: see text].
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Affiliation(s)
- Zaher A Radi
- Pfizer Worldwide Research, Development and Medical, 2253Pfizer Inc, Cambridge, MA, USA
| | - Thomas A Wynn
- Pfizer Worldwide Research, Development and Medical, 2253Pfizer Inc, Cambridge, MA, USA
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20
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Tukaj S. Heat Shock Protein 70 as a Double Agent Acting Inside and Outside the Cell: Insights into Autoimmunity. Int J Mol Sci 2020; 21:ijms21155298. [PMID: 32722570 PMCID: PMC7432326 DOI: 10.3390/ijms21155298] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 02/07/2023] Open
Abstract
Heat shock proteins (Hsp) are a diverse group of constitutive and/or stress-induced molecules that are categorized into several classes on the basis of their molecular weight. Mammalian Hsp have been mostly regarded as intracellular chaperones that mediate a range of essential cellular functions, including proper folding of newly synthesized polypeptides, refolding of denatured proteins, protein transport, and stabilization of native proteins' structures. The well-characterized and highly evolutionarily conserved, stress-inducible 70-kDa heat shock protein (Hsp70), is a key molecular chaperone that is overexpressed in the cell in response to stress of various origin. Hsp70 exhibits an immunosuppressive activity via, e.g., downregulation of the nuclear factor-kappa B (NF-κB) activation, and pharmacological induction of Hsp70 can ameliorate the autoimmune arthritis development in animal models. Moreover, Hsp70 might be passively or actively released from the necrotic or stressed cells, respectively. Highly immunogenic extracellular Hsp70 has been reported to impact both the innate and adaptive immune responses, and to be implicated in the autoimmune reaction. In addition, preclinical studies revealed that immunization with highly conserved Hsp70 peptides could be regarded as a potential treatment target for autoimmune arthritis, such as the rheumatoid arthritis, via induction of antigen-specific regulatory T helper cells (also called Treg). Here, a dual role of the intra- and extracellular Hsp70 is presented in the context of the autoimmune reaction.
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Affiliation(s)
- Stefan Tukaj
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland
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21
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Vigario FL, Kuiper J, Slütter B. Tolerogenic vaccines for the treatment of cardiovascular diseases. EBioMedicine 2020; 57:102827. [PMID: 32574952 PMCID: PMC7322234 DOI: 10.1016/j.ebiom.2020.102827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022] Open
Abstract
Atherosclerosis is the main pathology behind most cardiovascular diseases. It is a chronic inflammatory disease characterized by the formation of lipid-rich plaques in arteries. Atherosclerotic plaques are initiated by the deposition of cholesterol-rich LDL particles in the arterial walls leading to the activation of innate and adaptive immune responses. Current treatments focus on the reduction of LDL blood levels using statins, however the critical components of inflammation and autoimmunity have been mostly ignored as therapeutic targets. The restoration of immune tolerance towards atherosclerosis-relevant antigens can arrest lesion development as shown in pre-clinical models. In this review, we evaluate the clinical development of similar strategies for the treatment of inflammatory and autoimmune diseases like rheumatoid arthritis, type 1 diabetes or multiple sclerosis and analyse the potential of tolerogenic vaccines for atherosclerosis and the challenges that need to be overcome to bring this therapy to patients.
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Affiliation(s)
- Fernando Lozano Vigario
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Einsteinweg 55, PO Box 9502, 2300RA Leiden, the Netherlands
| | - Johan Kuiper
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Einsteinweg 55, PO Box 9502, 2300RA Leiden, the Netherlands.
| | - Bram Slütter
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Einsteinweg 55, PO Box 9502, 2300RA Leiden, the Netherlands
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22
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Mititelu RR, Pădureanu R, Băcănoiu M, Pădureanu V, Docea AO, Calina D, Barbulescu AL, Buga AM. Inflammatory and Oxidative Stress Markers-Mirror Tools in Rheumatoid Arthritis. Biomedicines 2020; 8:E125. [PMID: 32429264 PMCID: PMC7277871 DOI: 10.3390/biomedicines8050125] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic progressive autoimmune disease, associated with significant morbidity, mainly due to progressive damage and consequent disability. Oxidative stress is an important part of RA pathophysiology, as in autoimmune disease the interaction between immune response and endogenous/exogenous antigens subsequently induce the production of reactive oxygen species. The oxidative stress process seems to be positively strongly correlated with inflammation and accelerated joint destruction. We were asking ourselves if the oxidative stress biomarkers are the mirror tools of disease activity, outcome, and inflammation level in a group of RA patients under standard or biological therapy compared to healthy age-matched controls. In order to do this, the oxidative stress damage biomarkers (lipids peroxide and protein carbonyl level), antioxidant defense capacity, and pro-inflammatory status of plasma were quantified. In this study, we took into account the complete picture of RA diseases and assessed, for the first time, the inflammatory level in correlation with the oxidative stress level and antioxidant capacity of RA patients. Our results revealed that protein oxidation through carbonylation is significantly increased in RA groups compared to controls, and both protein carbonyl Pcarb and thiobarbituric acid reactive substance (TBARS) are reliable markers of ROS damage. Therefore, it is unanimous that neutrophil/lymphocyte ratio (NLR), monocyte/lymphocyte ratio ( MLR), platelet/lymphocyte ratio (PltLR) correlated with Pcarb, and TBARS can provide a view of the complex phenomenon represented by proteins/lipids damage, key contributors to disease outcome, and an increased awareness should be attributed to these biomarkers.
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Affiliation(s)
- Radu Răzvan Mititelu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (R.R.M.); (R.P.)
| | - Rodica Pădureanu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (R.R.M.); (R.P.)
| | - Manuela Băcănoiu
- Department of Physical Therapy and Sports Medicine, University of Craiova, 200207 Craiova, Romania;
| | - Vlad Pădureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Andreea Lili Barbulescu
- Department of Pharmacology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ana Maria Buga
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (R.R.M.); (R.P.)
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23
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Peptide-Based Vaccination Therapy for Rheumatic Diseases. J Immunol Res 2020; 2020:8060375. [PMID: 32258176 PMCID: PMC7104265 DOI: 10.1155/2020/8060375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/28/2020] [Indexed: 02/06/2023] Open
Abstract
Rheumatic diseases are extremely heterogeneous diseases with substantial risks of morbidity and mortality, and there is a pressing need in developing more safe and cost-effective treatment strategies. Peptide-based vaccination is a highly desirable strategy in treating noninfection diseases, such as cancer and autoimmune diseases, and has gained increasing attentions. This review is aimed at providing a brief overview of the recent advances in peptide-based vaccination therapy for rheumatic diseases. Tremendous efforts have been made to develop effective peptide-based vaccinations against rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), while studies in other rheumatic diseases are still limited. Peptide-based active vaccination against pathogenic cytokines such as TNF-α and interferon-α (IFN-α) is shown to be promising in treating RA or SLE. Moreover, peptide-based tolerogenic vaccinations also have encouraging results in treating RA or SLE. However, most studies available now have been mainly based on animal models, while evidence from clinical studies is still lacking. The translation of these advances from experimental studies into clinical therapy remains impeded by some obstacles such as species difference in immunity, disease heterogeneity, and lack of safe delivery carriers or adjuvants. Nevertheless, advances in high-throughput technology, bioinformatics, and nanotechnology may help overcome these impediments and facilitate the successful development of peptide-based vaccination therapy for rheumatic diseases.
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Ludvigsson J. Autoantigen Treatment in Type 1 Diabetes: Unsolved Questions on How to Select Autoantigen and Administration Route. Int J Mol Sci 2020; 21:E1598. [PMID: 32111075 PMCID: PMC7084272 DOI: 10.3390/ijms21051598] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/11/2022] Open
Abstract
Autoantigen treatment has been tried for the prevention of type 1 diabetes (T1D) and to preserve residual beta-cell function in patients with a recent onset of the disease. In experimental animal models, efficacy was good, but was insufficient in human subjects. Besides the possible minor efficacy of peroral insulin in high-risk individuals to prevent T1D, autoantigen prevention trials have failed. Other studies on autoantigen prevention and intervention at diagnosis are ongoing. One problem is to select autoantigen/s; others are dose and route. Oral administration may be improved by using different vehicles. Proinsulin peptide therapy in patients with T1D has shown possible minor efficacy. In patients with newly diagnosed T1D, subcutaneous injection of glutamic acid decarboxylase (GAD) bound to alum hydroxide (GAD-alum) can likely preserve beta-cell function, but the therapeutic effect needs to be improved. Intra-lymphatic administration may be a better alternative than subcutaneous administration, and combination therapy might improve efficacy. This review elucidates some actual problems of autoantigen therapy in the prevention and/or early intervention of type 1 diabetes.
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Affiliation(s)
- Johnny Ludvigsson
- Crown Princess Victoria Children´s Hospital and Div of Pediatrics, Dept of Biomedical and Clinical Sciences, Lnköping university, SE 58185 Linköping, Sweden
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25
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Del Carmen Domínguez M, Cabrales A, Lorenzo N, Padrón G, Gonzalez LJ. Biodistribution and pharmacokinetic profiles of an altered peptide ligand derived from heat-shock proteins 60 in Lewis rats. Cell Stress Chaperones 2020; 25:133-140. [PMID: 31802366 PMCID: PMC6985321 DOI: 10.1007/s12192-019-01054-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/08/2019] [Accepted: 11/20/2019] [Indexed: 12/19/2022] Open
Abstract
Human heat-shock protein 60 (HSP60) is an autoantigen involved in the pathogenesis of rheumatoid arthritis (RA). Epitopes derived from HSP60 can trigger activation of regulatory T cells (Treg). CIGB-814 is an altered peptide ligand (APL) derived from HSP60. In preclinical models, this peptide had anti-inflammatory effects and increased Treg. The results from phase I clinical trial indicated that CIGB-814 was safe and activated mechanisms associated with induction of tolerance. Biodistribution profile for inducers of tolerance is crucial for triggering its effects. The primary goal of this study in Lewis rats was to identify (1) the target organs of CIGB-814 and (2) the pharmacokinetics (PK) profile. 125I-CIGB-814 administered subcutaneously at three dose levels was distributed in the thyroid gland, but also at considerable levels to the stomach and small and large intestines. In addition, concentration of CIGB-814 was increased in lymph nodes (LNs) at 24 h, compared with 4-h post-administration. Small intestine and LNs are excellent sites for induction of tolerance, due to the characteristics of dendritic cells in these tissues. Maximum concentration of CIGB-814 in blood of Lewis rats at 0.5 to 1 h agrees with PK profile determined for patients. Altogether, these results support therapeutic possibilities of CIGB-814 for RA.
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Affiliation(s)
- María Del Carmen Domínguez
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 11300, Havana, Cuba.
| | - Ania Cabrales
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 11300, Havana, Cuba
| | - Norailys Lorenzo
- Department of Science and Technology, National University of Quilmes, Bernal, Argentina
| | - Gabriel Padrón
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 11300, Havana, Cuba
| | - L J Gonzalez
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 11300, Havana, Cuba
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26
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Tukaj S, Kaminski M. Heat shock proteins in the therapy of autoimmune diseases: too simple to be true? Cell Stress Chaperones 2019; 24:475-479. [PMID: 31073900 PMCID: PMC6527538 DOI: 10.1007/s12192-019-01000-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/07/2019] [Accepted: 04/23/2019] [Indexed: 12/30/2022] Open
Abstract
Autoimmune diseases are characterized by the loss of immune tolerance to self-antigens which leads to an excessive immune responses and chronic inflammation. Although much progress has been made in revealing key players in pathophysiology of various autoimmune diseases, their therapy remains challenging and consists of conventional immunosuppressive treatments, including corticosteroids and more advanced biological therapies which are targeted at molecules involved in maintaining chronic inflammation. These therapies are focused on suppressing inflammation; nevertheless, a permanent balance between protective and pathogenic immune responses is not achieved. In addition, most of currently available therapies for autoimmune diseases induce severe side effects. Consequently, more effective and safer therapies are still required to control autoimmunity. Stress-induced cell protecting heat shock proteins (HSP) have been considered as a potential treatment targets for autoimmune diseases. HSP, predominantly intracellular components, might be released from bacteria or mammalian tissues and activate immune response. This activation may lead to either production of (auto)antibodies against HSP and/or induction of immune regulatory mechanisms, including expansion of desired T regulatory (Treg) cells. Because inadequate frequency or activity of Treg is a characteristic feature of autoimmune diseases, targeting this cell population is an important focus of immunotherapy approaches in autoimmunity.
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Affiliation(s)
- Stefan Tukaj
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland.
| | - Maciej Kaminski
- Department of Anaesthesiology and Intensive Therapy, University Clinical Centre, Gdańsk, Poland
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27
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Serra P, Santamaria P. Antigen-specific therapeutic approaches for autoimmunity. Nat Biotechnol 2019; 37:238-251. [PMID: 30804535 DOI: 10.1038/s41587-019-0015-4] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022]
Abstract
The main function of the immune system in health is to protect the host from infection by microbes and parasites. Because immune responses to nonself bear the risk of unleashing accidental immunity against self, evolution has endowed the immune system with central and peripheral mechanisms of tolerance, including regulatory T and B cells. Although the past two decades have witnessed the successful clinical translation of a whole host of novel therapies for the treatment of chronic inflammation, the development of antigen-based approaches capable of selectively blunting autoimmune inflammation without impairing normal immunity has remained elusive. Earlier autoantigen-specific approaches employing peptides or whole antigens have evolved into strategies that seek to preferentially deliver these molecules to autoreactive T cells either indirectly, via antigen-presenting cells, or directly, via major histocompatibility complex molecules, in ways intended to promote clonal deletion and/or immunoregulation. The disease specificity, mechanistic underpinnings, developability and translational potential of many of these strategies remain unclear.
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Affiliation(s)
- Pau Serra
- Institut D'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
| | - Pere Santamaria
- Institut D'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain. .,Julia McFarlane Diabetes Research Centre (JMDRC) and Department of Microbiology, Immunology and Infectious Diseases, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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28
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van Eden W, Jansen MAA, Ludwig IS, Leufkens P, van der Goes MC, van Laar JM, Broere F. Heat Shock Proteins Can Be Surrogate Autoantigens for Induction of Antigen Specific Therapeutic Tolerance in Rheumatoid Arthritis. Front Immunol 2019; 10:279. [PMID: 30873163 PMCID: PMC6401592 DOI: 10.3389/fimmu.2019.00279] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/01/2019] [Indexed: 12/30/2022] Open
Abstract
Technologies that enable induction of therapeutic tolerance may revolutionize the treatment of autoimmune diseases by their supposed potential to induce drug-free and lasting disease remission. In combination with diagnostic tests that screen for individuals at risk, these approaches may offer chances to halt disease before serious damage in the tissues can occur. In fact, for healthy individuals at risk, this could lead to a preventive form of vaccination. For therapeutic tolerance to re-instate natural self-tolerance it seems essential to induce tolerance for the critical autoantigens involved in disease. However, for most autoimmune diseases such antigens are poorly defined. This is the case for both disease inciting autoantigens and antigens that become involved through epitope spreading. A possible source of surrogate auto-antigens expressed in tissues during inflammation are heat shock proteins (HSP) or stress proteins. In this mini-review we discuss unique characteristics of HSP which provide them with the capacity to inhibit inflammatory processes. Various studies have shown that epitopes of HSP60 and HSP70 molecules can function as vaccines to downregulate a variety of autoimmune inflammatory diseases. Currently, several research groups are developing cell therapies with the intention to reach therapeutic tolerance. In this review, in which we are proposing to ex vivo load tolerant dendritic cells with a Treg inducing HSP70 derived peptide called B29, we are discussing the chances to develop this as an autologous tolDC therapeutic tolerance therapy for rheumatoid arthritis.
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Affiliation(s)
- Willem van Eden
- Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Manon A A Jansen
- Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands.,Faculty of Veterinary Medicine, Department of Infection and Immunity, Utrecht University, Utrecht, Netherlands
| | - Irene S Ludwig
- Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands.,Faculty of Veterinary Medicine, Department of Infection and Immunity, Utrecht University, Utrecht, Netherlands
| | - Paul Leufkens
- Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands.,Faculty of Veterinary Medicine, Department of Infection and Immunity, Utrecht University, Utrecht, Netherlands
| | | | | | - Femke Broere
- Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands.,Faculty of Veterinary Medicine, Department of Infection and Immunity, Utrecht University, Utrecht, Netherlands
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29
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Mantej J, Polasik K, Piotrowska E, Tukaj S. Autoantibodies to heat shock proteins 60, 70, and 90 in patients with rheumatoid arthritis. Cell Stress Chaperones 2019; 24:283-287. [PMID: 30465159 PMCID: PMC6363621 DOI: 10.1007/s12192-018-0951-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/11/2018] [Accepted: 11/14/2018] [Indexed: 12/20/2022] Open
Abstract
Heat shock proteins (HSP) have been reported to impact immune responses and to be associated with rheumatoid arthritis (RA). Recently, we provided evidence for a role of autoantibodies to Hsp40 in patients with RA. In this study, we aimed at investigating the humoral autoimmune response to Hsp60, Hsp70, and Hsp90 in RA patients (n = 39). In comparison with healthy controls (n = 40), circulating IgG, IgM, and IgA autoantibodies against Hsp60, Hsp70, and Hsp90 were significantly increased in RA patients. Non-parametric statistical analysis, however, revealed no significant association between anti-HSP and disease activity or disease progression. On the other hand, positive correlations between serum levels of anti-Hsp60 IgG and IL-4 (Th2-like cytokine) or between serum levels of anti-Hsp90 IgG and IFN-ɣ (Th1-like cytokine) were found to be statistically significant in RA. In addition, a significant inverse correlation was found for serum levels of anti-Hsp70 IgM and TNF-α (Th1-like cytokine) in RA. Our results suggest a pronounced anti-Hsp60, anti-Hsp70, and anti-Hsp90 humoral autoimmune response in RA patients that seems not to be directly linked to RA pathophysiology, however, may have a potential modulatory impact on inflammatory status in this disease. Further investigations are needed to clarify the role of anti-HSP autoantibodies in RA.
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Affiliation(s)
- Jagoda Mantej
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Kinga Polasik
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Ewa Piotrowska
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Stefan Tukaj
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland.
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30
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Pickles T, Christensen R, Tam LS, Simon LS, Choy EH. Early phase and adaptive design clinical trials in rheumatoid arthritis: a systematic review of early phase trials. Rheumatol Adv Pract 2018; 2:rky045. [PMID: 31431982 PMCID: PMC6649924 DOI: 10.1093/rap/rky045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective Adaptive designs can enable highly sophisticated and efficient early phase trials, but the clinical inference from these trials is surrounded by complexity, and currently there is a paucity but steadily increasing amount of use of these designs in all fields of medicine. We aim to review early phase trials in RA to discover those that have used adaptive designs and benchmark trial characteristics. Methods From an OVID search for journal articles reporting the results of early phase trials in rheumatology, 35 studies were found, with 9 subsequently excluded; 11 were added from manual searches and 19 from searching the references. Study characteristics were extracted from the 56 papers (describing 62 trials), including the number of arms, number of patients, the primary outcome and when it was measured. Result One early phase trial using an adaptive design was found. The benchmark early phase trial in RA is a phase II double-blinded randomized trial, with four arms (one control and three intervention), each with 34 patients, and ACR20 measured at 16 weeks as the primary outcome. Conclusion The one adaptive design reviewed here, and a simulation study found in the search, both indicate that adaptive designs can be applied to early phase trials in RA. We have described the benchmark, which the efficiency of early phase trials using an adaptive design needs to exceed. These efficient designs could drive down numbers required, time for data collection and thus cost. Changes have been suggested, but more needs to be done.
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Affiliation(s)
- Tim Pickles
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University.,Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lai-Shan Tam
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | - Ernest H Choy
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University
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31
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Leong JY, Guan YJ, Albani S, Arkachaisri T. Recent advances in our understanding of the pathogenesis of juvenile idiopathic arthritis and their potential clinical implications. Expert Rev Clin Immunol 2018; 14:933-944. [PMID: 30269617 DOI: 10.1080/1744666x.2018.1529757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Juvenile idiopathic arthritis (JIA) comprises systemic and non-systemic forms of chronic childhood arthritis diagnosed prior to age 16. Significant improvement in treatment outcomes has been witnessed since the introduction of biologics. In particular, advances in research in the area of multidimensional interrogation and network analysis have facilitated understanding of the complex cacophony of components orchestrating disease immunopathogenesis. Areas covered: In this review, we will examine the scientific advances that have augmented our understanding of JIA pathogenesis, focusing on the progress made in systemic, poly, and oligo JIA in four major aspects: (a) unraveling the pathogenic mechanisms, (b) disease classification, (c) therapeutic selection, and (d) decision for withdrawal of medications after achieving remission. Expert commentary: Dysregulation of innate immune cell physiology and function in sJIA will be highlighted. MicroRNAs contribute to monocyte/macrophage polarization with resulting consequences on macrophage activation syndrome development. The involvement of neutrophils, a major source of S100A8/9/12, in the active inflammatory phase of sJIA is compelling. In non-sJIA, circulating CD4 subsets in T effector and regulatory compartments possessing a strong synovial T-cell receptor coverage and disease activity correlation, acted as an accessible reservoir of pathogenic cells exploitable for clinical management.
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Affiliation(s)
- Jing Yao Leong
- a Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre , Singapore
| | - Yeo Joo Guan
- a Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre , Singapore.,b Rheumatology and Immunology Service, Department of Pediatric Subspecialties , KK Women's and Children's Hospital , Singapore.,c Duke-NUS Medical School , Singapore
| | - Salvatore Albani
- a Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre , Singapore.,b Rheumatology and Immunology Service, Department of Pediatric Subspecialties , KK Women's and Children's Hospital , Singapore.,c Duke-NUS Medical School , Singapore
| | - Thaschawee Arkachaisri
- b Rheumatology and Immunology Service, Department of Pediatric Subspecialties , KK Women's and Children's Hospital , Singapore.,c Duke-NUS Medical School , Singapore
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32
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Roh JS, Sohn DH. Damage-Associated Molecular Patterns in Inflammatory Diseases. Immune Netw 2018; 18:e27. [PMID: 30181915 PMCID: PMC6117512 DOI: 10.4110/in.2018.18.e27] [Citation(s) in RCA: 639] [Impact Index Per Article: 106.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/05/2018] [Accepted: 08/05/2018] [Indexed: 12/23/2022] Open
Abstract
Damage-associated molecular patterns (DAMPs) are endogenous danger molecules that are released from damaged or dying cells and activate the innate immune system by interacting with pattern recognition receptors (PRRs). Although DAMPs contribute to the host's defense, they promote pathological inflammatory responses. Recent studies have suggested that various DAMPs, such as high-mobility group box 1 (HMGB1), S100 proteins, and heat shock proteins (HSPs), are increased and considered to have a pathogenic role in inflammatory diseases. Here, we review current research on the role of DAMPs in inflammatory diseases, including rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, atherosclerosis, Alzheimer's disease, Parkinson's disease, and cancer. We also discuss the possibility of DAMPs as biomarkers and therapeutic targets for these diseases.
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Affiliation(s)
- Jong Seong Roh
- Department of Microbiology and Immunology, Pusan National University School of Medicine, Yangsan 50612, Korea
| | - Dong Hyun Sohn
- Department of Microbiology and Immunology, Pusan National University School of Medicine, Yangsan 50612, Korea
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33
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van Eden W. Immune tolerance therapies for autoimmune diseases based on heat shock protein T-cell epitopes. Philos Trans R Soc Lond B Biol Sci 2018; 373:rstb.2016.0531. [PMID: 29203716 DOI: 10.1098/rstb.2016.0531] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2017] [Indexed: 12/11/2022] Open
Abstract
Experimental models of autoimmune diseases have revealed the disease protective role of heat shock proteins (HSPs). Both the administration of exogenous extracellular, mostly recombinant, HSP and the experimental co-induction of endogenous intracellular HSP in models have been shown to lead to production of disease protective regulatory T cells (Tregs). Similar to HSP taken up from extracellular bodily fluids, due to stress-related autophagy upregulated HSP also from intracellular sources is a major provider for the major histocompatibility class II (MHCII) ligandome; therefore, both extracellular and intracellular HSP can be prominent targets of Treg. The development of therapeutic peptide vaccines for the restoration of immune tolerance in inflammatory diseases is an area of intensive research. In this area, HSPs are a target for tolerance-inducing T-cell therapy, because of their wide expression in inflamed tissues. In humans, in whom the actual disease trigger is frequently unknown, HSP peptides offer chances for tolerance-promoting interventions through induction of HSP-specific Treg. Recently, we have shown the ability of a bacterial HSP70-derived peptide, HSP70-B29, to induce HSP-specific Tregs that suppressed arthritis by cross-recognition of their mammalian HSP70 homologues, abundantly present in the MHCII ligandome of stressed mouse and human antigen-presenting cells in inflamed tissues.This article is part of the theme issue 'Heat shock proteins as modulators and therapeutic targets of chronic disease: an integrated perspective'.
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Affiliation(s)
- Willem van Eden
- Department of Infectious Diseases and Immunology, Utrecht University, Yalelaan 1, 3584CL Utrecht, The Netherlands
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34
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Langdon K, Haleagrahara N. Regulatory T-cell dynamics with abatacept treatment in rheumatoid arthritis. Int Rev Immunol 2018; 37:206-214. [PMID: 29757670 DOI: 10.1080/08830185.2018.1465943] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The progressive damage in rheumatoid arthritis (RA) has been linked to an increase in inflammatory Th1/Th17 cells and a decrease in number or function of immunomodulatory regulatory T cells (Tregs). Many therapies that are effective in RA are shown to affect Th1/Th17 cells and/or Tregs. One such therapy, abatacept, utilizes a physiologic immunomodulatory molecule called cytotoxic lymphocyte antigen-4 (CTLA-4) which causes contact-dependent inhibition of inflammatory T-cell activation. Recent advances in CTLA-4 research has uncovered the method by which this occurs physiologically but the actions of the CTLA-4Ig fusion protein are still not fully understood. The reported effects of the drug on Treg population number and suppressor function have been very mixed. In this review, we will discuss the current literature surrounding the effects of abatacept in rheumatoid arthritis and explore potential explanations for the differences in results. Future opportunities in this area include contributions to a unified definition for different immune cell populations, LAG3+ Tregs which may pose an avenue for further study or the stratification of patients with regards to their specific disease characteristics, resulting in optimized treatment for disease remission.
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Affiliation(s)
- Kane Langdon
- a College of Medicine and Dentistry , James Cook University , Douglas , Townsville , Australia
| | - Nagaraja Haleagrahara
- b College of Public Health, Medicine and Veterinary Sciences , James Cook University , Douglas , Townsville , Australia
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35
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Teng F, Sun J, Yu L, Li Q, Cui Y. Homology modeling and epitope prediction of Der f 33. ACTA ACUST UNITED AC 2018; 51:e6213. [PMID: 29561952 PMCID: PMC5875910 DOI: 10.1590/1414-431x20186213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 01/08/2018] [Indexed: 02/05/2023]
Abstract
Dermatophagoides farinae (Der f), one of the main species of house dust mites, produces more than 30 allergens. A recently identified allergen belonging to the alpha-tubulin protein family, Der f 33, has not been characterized in detail. In this study, we used bioinformatics tools to construct the secondary and tertiary structures and predict the B and T cell epitopes of Der f 33. First, protein attribution, protein patterns, and physicochemical properties were predicted. Then, a reasonable tertiary structure was constructed by homology modeling. In addition, six B cell epitopes (amino acid positions 34–45, 63–67, 103–108, 224–230, 308–316, and 365–377) and four T cell epitopes (positions 178–186, 241–249, 335–343, and 402–410) were predicted. These results established a theoretical basis for further studies and eventual epitope-based vaccine design against Der f 33.
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Affiliation(s)
- Feixiang Teng
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, China
| | - Jinxia Sun
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, China
| | - Lili Yu
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, China
| | - Qisong Li
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, China
| | - Yubao Cui
- Department of Clinical Laboratory, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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36
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van Eden W, Jansen MAA, Ludwig I, van Kooten P, van der Zee R, Broere F. The Enigma of Heat Shock Proteins in Immune Tolerance. Front Immunol 2017; 8:1599. [PMID: 29209330 PMCID: PMC5702443 DOI: 10.3389/fimmu.2017.01599] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/06/2017] [Indexed: 01/22/2023] Open
Abstract
The fundamental problem of autoimmune diseases is the failure of the immune system to downregulate its own potentially dangerous cells, which leads to destruction of tissue expressing the relevant autoantigens. Current immunosuppressive therapies offer relief but fail to restore the basic condition of self-tolerance. They do not induce long-term physiological regulation resulting in medication-free disease remissions. Heat shock proteins (HSPs) have shown to possess the capacity of inducing lasting protective immune responses in models of experimental autoimmune diseases. Especially mycobacterial HSP60 and HSP70 were shown to induce disease inhibitory IL-10-producing regulatory T cells in many different models. This in itself may seem enigmatic, since based on earlier studies, HSPs were also coined sometimes as pro-inflammatory damage-associated molecular patterns. First clinical trials with HSPs in rheumatoid arthritis and type I diabetes have also indicated their potential to restore tolerance in autoimmune diseases. Data obtained from the models have suggested three aspects of HSP as being critical for this tolerance promoting potential: 1. evolutionary conservation, 2. most frequent cytosolic/nuclear MHC class II natural ligand source, and 3. upregulation under (inflammatory) stress. The combination of these three aspects, which are each relatively unique for HSP, may provide an explanation for the enigmatic immune tolerance promoting potential of HSP.
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Affiliation(s)
- Willem van Eden
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
| | - Manon A A Jansen
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
| | - Irene Ludwig
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
| | - Peter van Kooten
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
| | - Ruurd van der Zee
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
| | - Femke Broere
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine (FVM), Utrecht University, Utrecht, Netherlands
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37
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Teng F, Yu L, Sun J, Wang N, Cui Y. Homology modeling and prediction of B‑cell and T‑cell epitopes of the house dust mite allergen Der f 20. Mol Med Rep 2017; 17:1807-1812. [PMID: 29257224 DOI: 10.3892/mmr.2017.8066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 04/06/2017] [Indexed: 11/05/2022] Open
Abstract
House dust mite allergens can cause allergic diseases, including asthma, atopic dermatitis and rhinitis. Der f 20 is a novel allergen of Dermatophagoides farina (Der f), which is an arginine kinase. In the present study, the B‑cell and T‑cell epitopes of Der f 20 were predicted. The protein attribution, patterns, physicochemical properties and secondary structure of Der f 20 were also predicted. Der f 20 is a member of the ATP:guanido phosphotransferase family and contains a phosphagen kinase pattern. Using homology modeling, the present study constructed a reasonable tertiary structure of Der f 20. Using BcePred, ABCpred, BCPred and BPAP systems, B‑cell epitopes at 20‑25, 41‑49, 111‑118, 131‑141, 170‑174 and 312‑321 were predicted. Using NetMHCIIpan‑3.0 and NetMHCII‑2.2, T‑cell epitopes were predicted at 194‑202, 239‑247 and 274‑282. These results provide a theoretical basis for the design off Der f 20 epitope‑based vaccines.
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Affiliation(s)
- Feixiang Teng
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu 224005, P.R. China
| | - Lili Yu
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu 224005, P.R. China
| | - Jinxia Sun
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu 224005, P.R. China
| | - Nan Wang
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu 224005, P.R. China
| | - Yubao Cui
- Department of Clinical Laboratory, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, P.R. China
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38
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Barbera Betancourt A, Lyu Q, Broere F, Sijts A, Rutten VPMG, van Eden W. T Cell-Mediated Chronic Inflammatory Diseases Are Candidates for Therapeutic Tolerance Induction with Heat Shock Proteins. Front Immunol 2017; 8:1408. [PMID: 29123529 PMCID: PMC5662553 DOI: 10.3389/fimmu.2017.01408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/11/2017] [Indexed: 12/21/2022] Open
Abstract
Failing immunological tolerance for critical self-antigens is the problem underlying most chronic inflammatory diseases of humans. Despite the success of novel immunosuppressive biological drugs, the so-called biologics, in the treatment of diseases such rheumatoid arthritis (RA) and type 1 diabetes, none of these approaches does lead to a permanent state of medicine free disease remission. Therefore, there is a need for therapies that restore physiological mechanisms of self-tolerance. Heat shock proteins (HSPs) have shown disease suppressive activities in many models of experimental autoimmune diseases through the induction of regulatory T cells (Tregs). Also in first clinical trials with HSP-based peptides in RA and diabetes, the induction of Tregs was noted. Due to their exceptionally high degree of evolutionary conservation, HSP protein sequences (peptides) are shared between the microbiota-associated bacterial species and the self-HSP in the tissues. Therefore, Treg mechanisms, such as those induced and maintained by gut mucosal tolerance for the microbiota, can play a role by targeting the more conserved HSP peptide sequences in the inflamed tissues. In addition, the stress upregulated presence of HSP in these tissues may well assist the targeting of the HSP induced Treg specifically to the sites of inflammation.
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Affiliation(s)
- Ariana Barbera Betancourt
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Qingkang Lyu
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Femke Broere
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Alice Sijts
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Victor P M G Rutten
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
| | - Willem van Eden
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, Netherlands
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39
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Khan NA, Spencer HJ, Nikiphorou E, Naranjo A, Alten R, Chirieac RM, Drosos AA, Géher P, Inanc N, Kerzberg E, Ancuta CM, Müller R, Ørnbjerg L, Sokka T. Intercentre variance in patient reported outcomes is lower than objective rheumatoid arthritis activity measures: a cross-sectional study. Rheumatology (Oxford) 2017; 56:1395-1400. [PMID: 28575509 DOI: 10.1093/rheumatology/kex076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Indexed: 01/18/2023] Open
Abstract
Objective To assess intercentre variability in the ACR core set measures, DAS28 based on three variables (DAS28v3) and Routine Assessment of Patient Index Data 3 in a multinational study. Methods Seven thousand and twenty-three patients were recruited (84 centres; 30 countries) using a standard protocol in the Quantitative Standard Monitoring of Patients with RA study. Analysis of variance (ANOVA) and mixed-effect analysis of covariance models were used to model the relationship between study centre and different patient-reported and physician-reported RA activity measures. These models were built to adjust for the remaining ACR core set measure (for each ACR core set measure or each composite index), socio-demographics and medical characteristics. ANOVA and analysis of covariance models yielded similar results, and ANOVA tables were used to present variance attributable to recruiting centre. Results The proportion of variances attributable to recruiting centre was lower for patient reported outcomes (PROs: pain, HAQ, patient global) compared with objective measures (joint counts, ESR, physician global) in all models. In the full model, variance in PROs attributable to recruiting centre ranged from 1.53% for patient global to 3.71% for HAQ compared with objective measures that ranged from 5.92% for physician global to 9.25% for ESR; and was lower for Routine Assessment of Patient Index Data 3 (2.6%) compared with DAS28v3 (11.75%). Conclusion Intercentre variability in PROs is lower than objective measures of RA activity demonstrating that PROs may be more comparable across centres, and the need for standardization of objective measures.
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Affiliation(s)
- Nasim Ahmed Khan
- Division of Rheumatology, University of Arkansas for Medical Sciences.,Central Arkansas Veterans Healthcare System
| | - Horace Jack Spencer
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Elena Nikiphorou
- Department of Rheumatology, The Whittington Hospital NHS Trust, London, UK
| | - Antonio Naranjo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr Negrin, University of Las Palmas, Las Palmas, Spain
| | - Rieki Alten
- Department of Internal Medicine, Rheumatology, Schlosspark-Klinik, Teaching Hospital Charite, Berlin, Germany
| | | | - Alexandros A Drosos
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Pál Géher
- 1st Department of Rheumatology, Hospitaller Brothers of St John of God, Budapest, Hungary
| | - Nevsun Inanc
- Division of Rheumatology, School of Medicine, University of Marmara, Istanbul, Turkey
| | - Eduardo Kerzberg
- Department of Rheumatology, University of Buenos Aires, Buenos Aires, Argentina
| | - Codrina Mihaela Ancuta
- Rheumatology 2 Department, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Rüediger Müller
- Division of Rheumatology, Immunology and Rehabilitation, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Lykke Ørnbjerg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, Denmark
| | - Tuulliki Sokka
- University of Eastern Finland, Faculty of Health Sciences, Kuopio and Jyvaskyla Central Hospital, Jyvaskyla, Finland
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Jansen MAA, Spiering R, Broere F, van Laar JM, Isaacs JD, van Eden W, Hilkens CMU. Targeting of tolerogenic dendritic cells towards heat-shock proteins: a novel therapeutic strategy for autoimmune diseases? Immunology 2017; 153:51-59. [PMID: 28804903 DOI: 10.1111/imm.12811] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 01/28/2023] Open
Abstract
Tolerogenic dendritic cells (tolDCs) are a promising therapeutic tool to restore immune tolerance in autoimmune diseases. The rationale of using tolDCs is that they can specifically target the pathogenic T-cell response while leaving other, protective, T-cell responses intact. Several ways of generating therapeutic tolDCs have been described, but whether these tolDCs should be loaded with autoantigen(s), and if so, with which autoantigen(s), remains unclear. Autoimmune diseases, such as rheumatoid arthritis, are not commonly defined by a single, universal, autoantigen. A possible solution is to use surrogate autoantigens for loading of tolDCs. We propose that heat-shock proteins may be a relevant surrogate antigen, as they are evolutionarily conserved between species, ubiquitously expressed in inflamed tissues and have been shown to induce regulatory T cells, ameliorating disease in various arthritis mouse models. In this review, we provide an overview on how immune tolerance may be restored by tolDCs, the problem of selecting relevant autoantigens for loading of tolDCs, and why heat-shock proteins could be used as surrogate autoantigens.
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Affiliation(s)
- Manon A A Jansen
- Division of Immunology, Department of Infectious Diseases and Immunology, Utrecht University, the Netherlands
| | - Rachel Spiering
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence (RACE), UK, UK.,NIHR-Newcastle Biomedical Research Centre in Ageing and Long-Term Conditions, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Femke Broere
- Division of Immunology, Department of Infectious Diseases and Immunology, Utrecht University, the Netherlands
| | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, the Netherlands
| | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence (RACE), UK, UK.,NIHR-Newcastle Biomedical Research Centre in Ageing and Long-Term Conditions, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Willem van Eden
- Division of Immunology, Department of Infectious Diseases and Immunology, Utrecht University, the Netherlands
| | - Catharien M U Hilkens
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence (RACE), UK, UK.,NIHR-Newcastle Biomedical Research Centre in Ageing and Long-Term Conditions, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
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41
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Kuehl C, Thati S, Sullivan B, Sestak J, Thompson M, Siahaan T, Berkland C. Pulmonary Administration of Soluble Antigen Arrays Is Superior to Antigen in Treatment of Experimental Autoimmune Encephalomyelitis. J Pharm Sci 2017. [PMID: 28625726 DOI: 10.1016/j.xphs.2017.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antigen-specific immunotherapy has been used to hyposensitize patients to allergens and offers an enticing approach for attenuating autoimmune diseases. Applying antigen-specific immunotherapy to mucosal surfaces such as the lungs may engage unique immune response pathways to improve efficacy. Pulmonary delivery of soluble antigen arrays (SAgAs) was explored in mice with experimental autoimmune encephalomyelitis (EAE), a multiple sclerosis model. SAgAs were designed to impede immune response to autoantigen epitopes and are composed of a hyaluronan backbone with peptides PLP139-151 (proteolipid protein) and LABL, a disease-causing proteolipid peptide epitope and an intracellular cell-adhesion molecule-1 ligand, respectively. Pulmonary instillation of SAgAs decreased disease score, improved weight gain, and decreased incidence of disease in EAE mice compared to pulmonary delivery of hyaluronic acid polymer, LABL, or PLP. Interestingly, treating with PLP alone also showed some improvement. Splenocytes from SAgA-treated animals showed increased interferon-gamma levels, and interleukin-6 (IL-6) and IL-17 were elevated in SAgA-treated animals compared to PLP treatments. IL-10, IL-2, and tumor necrosis factor-alpha levels showed no significant difference, yet trends across all cytokines suggested SAgAs induced a very different immune response compared to treatment with PLP alone. This work suggests that codelivery of peptide components is essential when treating EAE via pulmonary instillation, and the immune response may have shifted toward immune tolerance.
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Affiliation(s)
- Christopher Kuehl
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - Sharadvi Thati
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - Bradley Sullivan
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - Joshua Sestak
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - Michael Thompson
- Department of Pathology, Lawrence Memorial Hospital, Lawrence, Kansas 66044
| | - Teruna Siahaan
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047
| | - Cory Berkland
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas 66047; Department of Chemical and Petroleum Engineering, The University of Kansas, Lawrence, Kansas 66047.
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Chebotareva N, Bobkova I, Shilov E. Heat shock proteins and kidney disease: perspectives of HSP therapy. Cell Stress Chaperones 2017; 22:319-343. [PMID: 28409327 PMCID: PMC5425374 DOI: 10.1007/s12192-017-0790-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/11/2017] [Accepted: 03/20/2017] [Indexed: 12/11/2022] Open
Abstract
Heat shock proteins (HSPs) mediate a diverse range of cellular functions, prominently including folding and regulatory processes of cellular repair. A major property of these remarkable proteins, dependent on intracellular or extracellular location, is their capacity for immunoregulation that optimizes immune activity while avoiding hyperactivated inflammation. In this review, recent investigations are described, which examine roles of HSPs in protection of kidney tissue from various traumatic influences and demonstrate their potential for clinical management of nephritic disease. The HSP70 class is particularly attractive in this respect due to its multiple protective effects. The review also summarizes current understanding of HSP bioactivity in the pathophysiology of various kidney diseases, including acute kidney injury, diabetic nephropathy, chronic glomerulonephritis, and lupus nephritis-along with other promising strategies for their remediation, such as DNA vaccination.
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Affiliation(s)
- Natalia Chebotareva
- I.M. Sechenov First Moscow State Medical University, 2-4 Bolshaya Pirogovskaya st., Moscow, Russia, 119992.
| | - Irina Bobkova
- I.M. Sechenov First Moscow State Medical University, 2-4 Bolshaya Pirogovskaya st., Moscow, Russia, 119992
| | - Evgeniy Shilov
- I.M. Sechenov First Moscow State Medical University, 2-4 Bolshaya Pirogovskaya st., Moscow, Russia, 119992
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GV1001 immunotherapy ameliorates joint inflammation in a murine model of rheumatoid arthritis by modifying collagen-specific T-cell responses and downregulating antigen-presenting cells. Int Immunopharmacol 2017; 46:186-193. [PMID: 28314223 DOI: 10.1016/j.intimp.2017.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/22/2017] [Accepted: 03/08/2017] [Indexed: 11/24/2022]
Abstract
This study investigated whether GV1001 may be useful for treating rheumatoid arthritis (RA). Two collagen-induced arthritis (CIA) experiments showed that therapeutic, but not preventive, GV1001 treatment reduced the severity of joint inflammation in CIA. The third CIA experiment indicated that, compared to vehicle treatment, therapeutic GV1001 treatment was associated with a significantly smaller area under the curve for the overall clinical joint score over the 98day observation period (p<0.05). GV1001 treatment was also associated with lower Day 98 serum IL-6 levels (p<0.01) and histological joint scores (p<0.05). Moreover, splenocytes harvested from the GV1001-treated mice exhibited lower basal and collagen-stimulated production of IFN-γ and IL-6 on Days 49 and 98 than the splenocytes from vehicle-treated mice. The fourth and fifth experiments indicated that earlier treatment resulted in a better response. In addition, human (THP-1) and murine (RAW 264.7) macrophages and fibroblast-like synoviocytes (FLS) from RA patients were used for in vitro analyses. GV1001 treatment of lipopolysaccharide-stimulated macrophages derived from THP-1 and RAW 264.7 monocytes significantly reduced TNF-α and IL-6 secretion (THP-1: all p<0.05; RAW 264.7: all p<0.01). However, GV1001 treatment did not affect IL-6 expression in TNFα-stimulated RA FLS. GV1001 reduced the clinical joint scores, serum IL-6 levels, and histological joint scores of mice with CIA. In addition, GV1001 lowered the collagen-stimulated IFN-γ and IL-6 production of murine T-cells and reduced the TNF-α and IL-6 production of macrophages in vitro. Thus, GV1001 may ameliorate joint inflammation by modifying T-cell reactions to the triggering autoantigen and by reducing macrophage cytokine production.
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Koliński T, Marek-Trzonkowska N, Trzonkowski P, Siebert J. Heat shock proteins (HSPs) in the homeostasis of regulatory T cells (Tregs). Cent Eur J Immunol 2016; 41:317-323. [PMID: 27833451 PMCID: PMC5099390 DOI: 10.5114/ceji.2016.63133] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Heat shock proteins (HSPs) belong to the family of conservative polypeptides with a high homology of the primary structure. The uniqueness of this family lies in their ability to interact with a large number of different proteins and provide protection from cellular and environmental stress factors as molecular chaperones to keep protein homeostasis. While intracellular HSPs play a mainly protective role, extracellular or membrane-bound HSPs mediate immunological functions and immunomodulatory activity. In immune system are subsets of cells including regulatory T cells (Tregs) with suppressive functions. HSPs are implicated in the function of innate and adaptive immune systems, stimulate T lymphocyte proliferation and immunomodulatory functions, increase the effectiveness of cross-presentation of antigens, and induce the secretion of cytokines. HSPs are also important in the induction, proliferation, suppressive function, and cytokine production of Tregs, which are a subset of CD4+ T cells maintaining peripheral tolerance. Together HSPs and Tregs are potential tools for future clinical interventions in autoimmune disease.
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Affiliation(s)
- Tomasz Koliński
- Laboratory of Immunoregulation and Cellular Therapies, Department of Family Medicine, Medical University of Gdansk, Poland
| | - Natalia Marek-Trzonkowska
- Laboratory of Immunoregulation and Cellular Therapies, Department of Family Medicine, Medical University of Gdansk, Poland
| | - Piotr Trzonkowski
- Department of Clinical Immunology and Transplantology, Medical University of Gdansk, Poland
| | - Janusz Siebert
- Department of Family Medicine, Medical University of Gdansk, Poland
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46
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Lavric M, Miranda-García MA, Holzinger D, Foell D, Wittkowski H. Alarmins firing arthritis: Helpful diagnostic tools and promising therapeutic targets. Joint Bone Spine 2016; 84:401-410. [PMID: 27659403 DOI: 10.1016/j.jbspin.2016.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/22/2016] [Indexed: 12/11/2022]
Abstract
Alarmins are endogenous molecules with homeostatic roles that have reached the focus of research in inflammatory arthritis in the last two decades, mostly due to their ability to indicate tissue related damage after active or passive release from injured cells. From HMGB1, S100A8/A9 and S100A12 proteins, over heat-shock proteins (HSPs) and purine metabolites (e.g. uric acid, ATP) to altered matrix proteins and interleukin-33 (IL-33), a number of alarmins have been determined until now as having a role in rheumatoid arthritis, psoriatic and juvenile idiopathic arthritis, as well as spondyloarthritis and gout. Although formerly being linked to initiation and chronification of inflammatory arthritis, driving auto- and paracrine inflammatory loops, more recent research has also unraveled the alarmins' role in the crosstalk between innate and adaptive immunity and in resolution of inflammation. Providing a state-of-the-art overview of known alarmins, this review lists the known modes of action and pathologic contribution of alarmins to inflammatory arthritis, as well as biomarker potential of alarmins in the clinical setting for tracking disease severity. Based upon research on animal experimental models (CIA, AIA) and clinical trials, a look is made into potentially viable strategies for modifying alarmin secretion and their target receptor (e.g. TLR, RAGE) interaction with the purpose of attenuating arthritic disease.
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Affiliation(s)
- Miha Lavric
- Department of Paediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | | | - Dirk Holzinger
- Department of Paediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Dirk Foell
- Department of Paediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany.
| | - Helmut Wittkowski
- Department of Paediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
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47
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Spierings J, van Eden W. Heat shock proteins and their immunomodulatory role in inflammatory arthritis. Rheumatology (Oxford) 2016; 56:198-208. [PMID: 27411479 DOI: 10.1093/rheumatology/kew266] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/24/2016] [Indexed: 11/14/2022] Open
Abstract
Autoimmune diseases, including inflammatory arthritis, are characterized by a loss of self-tolerance, leading to an excessive immune responses and subsequent ongoing inflammation. Current therapies are focused on dampening this inflammation, but a permanent state of tolerance is seldom achieved. Therefore, novel therapies that restore and maintain tolerance are needed. Tregs could be a potential target to achieve permanent immunotolerance. Activation of Tregs can be accomplished when they recognize and bind their specific antigens. HSPs are proteins present in all cells and are upregulated during inflammation. These proteins are immunogenic and can be recognized by Tregs. Several studies in animal models and in human clinical trials have shown the immunoregulatory effects of HSPs and their protective effects in inflammatory arthritis. In this review, an overview is presented of the immunomodulatory effects of several members of the HSP family in general and in inflammatory arthritis. These effects can be attributed to the activation of Tregs through cellular interactions within the immune system. The effect of HSP-specific therapies in patients with inflammatory arthritis should be explored further, especially with regard to long-term efficacy and safety and their use in combination with current therapeutic approaches.
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Affiliation(s)
- Julia Spierings
- Department of Rheumatology, Maastricht University Medical Center, Maastricht
| | - Willem van Eden
- Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
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Barberá A, Lorenzo N, van Kooten P, van Roon J, de Jager W, Prada D, Gómez J, Padrón G, van Eden W, Broere F, Del Carmen Domínguez M. APL1, an altered peptide ligand derived from human heat-shock protein 60, increases the frequency of Tregs and its suppressive capacity against antigen responding effector CD4 + T cells from rheumatoid arthritis patients. Cell Stress Chaperones 2016; 21:735-44. [PMID: 27241313 PMCID: PMC4908004 DOI: 10.1007/s12192-016-0698-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 12/29/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by a chronic relapsing-remitting joint inflammation. Perturbations in the balance between CD4 + T cells producing IL-17 and CD4 + CD25(high)FoxP3 + Tregs correlate with irreversible bone and cartilage destruction in RA. APL1 is an altered peptide ligand derived from a CD4+ T-cell epitope of human HSP60, an autoantigen expressed in the inflamed synovium, which increases the frequency of CD4 + CD25(high)FoxP3+ Tregs in peripheral blood mononuclear cells from RA patients. The aim of this study was to evaluate the suppressive capacity of Tregs induced by APL1 on proliferation of effector CD4+ T cells using co-culture experiments. Enhanced Treg-mediated suppression was observed in APL1-treated cultures compared with cells cultured only with media. Subsequent analyses using autologous cross-over experiments showed that the enhanced Treg suppression in APL1-treated cultures could reflect increased suppressive function of Tregs against APL1-responsive T cells. On the other hand, APL1-treatment had a significant effect reducing IL-17 levels produced by effector CD4+ T cells. Hence, this peptide has the ability to increase the frequency of Tregs and their suppressive properties whereas effector T cells produce less IL-17. Thus, we propose that APL1 therapy could help to ameliorate the pathogenic Th17/Treg balance in RA patients.
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Affiliation(s)
- Ariana Barberá
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, Havana, 11300, Cuba
- Department of Medicine, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
| | - Noraylis Lorenzo
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, Havana, 11300, Cuba
| | - Peter van Kooten
- Infectious Diseases and Immunology Department, Faculty of Veterinary Medicine, University of Utrecht, P.O. Box 80165, NL-3508 TD, Utrecht, The Netherlands
| | - Joel van Roon
- Department of Rheumatology and Clinical and Laboratory of Translational Immunology, University Medical Centrum Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Wilco de Jager
- Department of Pediatric Immunology and Laboratory of Translational Immunology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Dinorah Prada
- Institute of Rheumatology, Ave 10 of October, No. 130, Havana, Cuba
| | - Jorge Gómez
- Institute of Rheumatology, Ave 10 of October, No. 130, Havana, Cuba
| | - Gabriel Padrón
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, Havana, 11300, Cuba
| | - Willem van Eden
- Infectious Diseases and Immunology Department, Faculty of Veterinary Medicine, University of Utrecht, P.O. Box 80165, NL-3508 TD, Utrecht, The Netherlands
| | - Femke Broere
- Infectious Diseases and Immunology Department, Faculty of Veterinary Medicine, University of Utrecht, P.O. Box 80165, NL-3508 TD, Utrecht, The Netherlands
| | - María Del Carmen Domínguez
- Biomedical Research Department, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, Havana, 11300, Cuba.
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Caruso I, Santandrea S, Gismondo M, Lombardi A, Montrone F, Caruso EM, Sarzi Puttini P. Vaccination with endosomal unknown epitopes produces therapeutic response in rheumatoid arthritis patients and modulates adjuvant arthritis of rats. J Transl Med 2016; 14:162. [PMID: 27268027 PMCID: PMC4897890 DOI: 10.1186/s12967-016-0908-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/16/2016] [Indexed: 01/07/2023] Open
Abstract
Background Our previous results showed that intrasynovial Rifamycin SV caused the lysis of synoviocites and freed the autoantigens which in turn stimulated the immunoregulatory rather than autoreactive T cell response in rheumatoid patients. Here, we hypothesize that disruption in vitro of peripheral blood mononuclear cells, by freeze/thawing or by lytic action of Rifamycin SV, would induce the release of endosomal pathogenic autoantigens from APCs present in the circulation, which could then be isolated from degrading enzymes by ultrafiltration. Methods The preparation of the ultrafiltrates are based on the rupture of PBMCs (5 × 106 cells/mL) by the addition of Rifamycin SV in culture (250 μg/mL), which causes the lysis of 90 % of the cells in 3 h, or by three cycles of freeze/thawing of the PBMC, from −80 °C to room temperature. The lysate and the fragmented cells were then centrifuged and ultrafiltered by passage through a filtration device with a cut-off of 10 kDa. Also the synovial fluid was subjected to ultrafiltration. Results and conclusions At clinical monitoring of the 30th day, 22/58 (38 %) patients subcutaneously treated with the autologous ultrafiltrate prepared by the freeze/thawing of PBMCs reached an ACR20. Comparable results were obtained with the other two ultrafiltrates. Cell cultures The addition of ultrafiltrates to rheumatoid PBMCs cultures led to the upregulation of a marker for T-regulatory cells, and downregulation of a cell proliferation marker; changes that together have the meaning of a global immunomodulatory response and that only a specific antigen (ultrafiltrate UF-f/t) might induce in the rheumatoid patient, probably by activating pre-existing protective network. Experimental arthritis All the ultrafiltrates except that prepared by Rifamycin SV were able to modulate the adjuvant arthritis in rats. In particular, longlasting synovial fluid induced a significant reduction of the severity of subsequent arthritis (p < 0.01) while SF from recent RA effusion (5–10 days after a previous complete extraction) and knee osteoarthrosis were ineffective. It is reasonable to assume there are at least two unknown endosomal immunoactive epitopes; one developing its immunotherapeutic property in RA, and the other, related to the molecule of HSP60, reduces the severity of oncoming arthritis. Both epitopes are present in humans, have a molecular weight of ≤10 kDa and do not appear to be bystander antigens. Please see Additional file 1 for the abstract in Italian. Electronic supplementary material The online version of this article (doi:10.1186/s12967-016-0908-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Innocenzo Caruso
- Past Chief Rheumatology Unit, L. Sacco Hospital Milano Italy, Corso Italia 11, 20122, Milan, Italy.
| | | | - Mariarita Gismondo
- Director of microbiology chair, University of Milan, L. Sacco Hospital Milano Italy, Milan, Italy
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Hoeppli RE, MacDonald KG, Levings MK, Cook L. How antigen specificity directs regulatory T-cell function: self, foreign and engineered specificity. HLA 2016; 88:3-13. [PMID: 27256587 DOI: 10.1111/tan.12822] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 04/29/2016] [Indexed: 02/06/2023]
Abstract
Regulatory T cells (Tregs) are a suppressive subset of T cells that have important roles in maintaining self-tolerance and preventing immunopathology. The T-cell receptor (TCR) and its antigen specificity play a dominant role in the differentiation of cells to a Treg fate, either in the thymus or in the periphery. This review focuses on the effects of the TCR and its antigen specificity on Treg biology. The role of Tregs with specificity for self-antigen has primarily been studied in the context of autoimmune disease, although recent studies have focused on their role in steady-state conditions. The role of Tregs that are specific for pathogens, dietary antigens and allergens is much less studied, although recent data suggest a significant and previously underappreciated role for Tregs during memory responses to a wide range of foreign antigens. The development of TCR- or chimeric antigen receptor (CAR)-transduced T cells means we are now able to engineer Tregs with disease-relevant antigen specificities, paving the way for ensuring specificity with Treg-based therapies. Understanding the role that antigens play in driving the generation and function of Tregs is critical for defining the pathophysiology of many immune-mediated diseases, and developing new therapeutic interventions.
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Affiliation(s)
- R E Hoeppli
- Department of Surgery, University of British Columbia and Child & Family Research Institute, Vancouver, Canada
| | - K G MacDonald
- Department of Surgery, University of British Columbia and Child & Family Research Institute, Vancouver, Canada
| | - M K Levings
- Department of Surgery, University of British Columbia and Child & Family Research Institute, Vancouver, Canada
| | - L Cook
- Department of Surgery, University of British Columbia and Child & Family Research Institute, Vancouver, Canada
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