Cyclosporin A inhibits the production of gamma interferon (IFN gamma), but does not inhibit production of virus-induced IFN alpha/beta

Etoposide Therapy of Cytokine Storm Syndromes

Etoposide has revolutionized the treatment of primary as well as secondary hemophagocytic lymphohistiocytosis (HLH), and it is, together with corticosteroids, the most widely used therapy for HLH. In the early 1980s, long-term survival in primary HLH was <5% but with the etoposide-/dexamethasone-based protocols HLH-94 and HLH-2004, in combination with stem cell transplantation, 5-year survival increased dramatically to around 60% in primary HLH, and based on analyses from the HLH-2004 study, there is likely room for further improvement. Biologically, etoposide administration results in potent selective deletion of activated T cells as well as efficient suppression of inflammatory cytokine production. Moreover, etoposide has also been reported to promote programmed cell death (apoptosis) rather than proinflammatory lytic cell death (pyroptosis), conceivably ameliorating subsequent systemic inflammation, i.e., a treatment very suitable for cytokine storm syndromes (CSS). The combination of etoposide and corticosteroids may also be beneficial in cases of severe or refractory secondary HLH (sHLH) with imminent organ failure, such as infection-associated HLH caused by Epstein-Barr virus (EBV) or malignancy-triggered HLH. In CSS associated with rheumatic diseases (macrophage activation syndrome, MAS or MAS-HLH), etoposide is currently used as second- or third-line therapy. Recent studies suggest that etoposide perhaps should be part of an aggressive therapeutic intervention for patients with severe refractory or relapsing MAS, in particular if there is CNS involvement. Importantly, awareness of sHLH must be further increased since treatment of sHLH is often delayed, thereby missing the window of opportunity for a timely, effective, and potentially life-saving HLH-directed treatment.

Oral cyclosporine is effective in stabilizing active vitiligo: Results of a randomized controlled trial

Oral dexamethasone mini pulse (OMP) is an established treatment modality for active vitiligo. Cyclosporine may have therapeutic role in active vitiligo but current evidence supporting its role is scarce. The objective of study was to compare the efficacy and safety of oral cyclosporine with OMP in patients of active vitiligo. Fifty patients with active vitiligo were randomized into two groups of 25 patients. Group 1 was treated with OMP (2.5 mg dexamethasone) on two consecutive days/week for 4 months while group 2 was treated with cyclosporine (3 mg/kg/day) for 4 months. Laboratory monitoring was performed as per the prevalent protocol. The patients were followed up for another 2 months after stopping treatment. Arrest of disease progression (ADP) was defined as change of vitiligo disease activity score from 4+ to 3+ (time elapsed since last disease activity being more than 6 weeks upto 3 months) during the study period (6 months). ADP was attained in 21 patients in group 1 and 22 patients in group 2 (84% vs. 88%, p = 1.00) at the end of 6 months. However, mean time to achieve ADP was significantly lower in group 2 as compared to group 1 (10.92 [4.12] weeks vs. 13.90 [3.92] weeks, p = 0.01). Extent of repigmentation, improvement in patient assessment score, vitiligo quality of life and clinical markers of disease activity were marginal and comparable in both groups. Cyclosporine leads to earlier disease stabilization in active vitiligo as compared to OMP. Although considered a rescue drug in dermatology, low dose cyclosporine can be an effective therapeutic alternative in vitiligo patients.

Recommendations for the Use of Etoposide-Based Therapy and Bone Marrow Transplantation for the Treatment of HLH: Consensus Statements by the HLH Steering Committee of the Histiocyte Society

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome requiring aggressive immunosuppressive therapy. Following 2 large international studies mainly targeting pediatric patients with familial disease and patients without underlying chronic or malignant disease, the HLH-94 protocol is recommended as the standard of care when using etoposide-based therapy by the Histiocyte Society. However, in clinical practice, etoposide-based therapy has been widely used beyond the study inclusion criteria, including older patients and patients with underlying diseases (secondary HLH). Many questions remain around these extended indications and published reports do not address several practical issues. To tackle these concerns, the HLH Steering Committee of the Histiocyte Society decided to issue guidance for use of the HLH-94 protocol. The group convened in a structured consensus finding process to define recommendations that are based largely on expert opinion backed up by available data from the literature. The recommendations address all main elements of HLH-94 including corticosteroids, cyclosporin, etoposide, intrathecal therapy, and hematopoietic stem cell transplantation (HSCT) and consider various forms of HLH and all age groups. Aspects covered include indications, applications, dosing, side effects, duration of therapy, salvage therapy, and HSCT. These recommendations aim to provide a framework to guide treatment decisions in this severe disease.

Confirmed efficacy of etoposide and dexamethasone in HLH treatment: long-term results of the cooperative HLH-2004 study

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome comprising familial/genetic HLH (FHL) and secondary HLH. In the HLH-94 study, with an estimated 5-year probability of survival (pSu) of 54% (95% confidence interval, 48%-60%), systemic therapy included etoposide, dexamethasone, and, from week 9, cyclosporine A (CSA). Hematopoietic stem cell transplantation (HSCT) was indicated in patients with familial/genetic, relapsing, or severe/persistent disease. In HLH-2004, CSA was instead administered upfront, aiming to reduce pre-HSCT mortality and morbidity. From 2004 to 2011, 369 children aged <18 years fulfilled HLH-2004 inclusion criteria (5 of 8 diagnostic criteria, affected siblings, and/or molecular diagnosis in FHL-causative genes). At median follow-up of 5.2 years, 230 of 369 patients (62%) were alive (5-year pSu, 61%; 56%-67%). Five-year pSu in children with (n = 168) and without (n = 201) family history/genetically verified FHL was 59% (52%-67%) and 64% (57%-71%), respectively (familial occurrence [n = 47], 58% [45%-75%]). Comparing with historical data (HLH-94), using HLH-94 inclusion criteria, pre-HSCT mortality was nonsignificantly reduced from 27% to 19% (P = .064 adjusted for age and sex). Time from start of therapy to HSCT was shorter compared with HLH-94 (P =020 adjusted for age and sex) and reported neurological alterations at HSCT were 22% in HLH-94 and 17% in HLH-2004 (using HLH-94 inclusion criteria). Five-year pSu post-HSCT overall was 66% (verified FHL, 70% [63%-78%]). Additional analyses provided specific suggestions on potential pre-HSCT treatment improvements. HLH-2004 confirms that a majority of patients may be rescued by the etoposide/dexamethasone combination but intensification with CSA upfront, adding corticosteroids to intrathecal therapy, and reduced time to HSCT did not improve outcome significantly.

Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy

Psoriasis is a chronic skin disease that affects millions of people throughout the world. Even though cutaneous signs and symptoms are the most common clinical manifestations, the nails can be involved in up to 50% of cases, and their involvement remains an important yet often overlooked aspect of the disease. There is a broad spectrum of nail dystrophies associated with psoriasis, ranging from the common pitting and loosening of the nail plate to the less frequent discoloration and splinter hemorrhages seen in the nail bed. This article discusses the normal anatomy and embryology of the nail unit as well as the current understanding of the pathogenesis of the disease. It also provides an extensive review of the existing literature with respect to psoriatic nail therapy. Although there have been many recent advances in the treatment of the cutaneous form of the disease-most notably in the field of immunotherapies-the options for nail psoriasis are far more limited. While a number of treatment alternatives currently exist for nail disease, the general paucity of clear evidence regarding these choices often makes it difficult to select the most efficient, safe, and optimal treatment for the patient. Even though the current literature has shown some support for the use of topical, intralesional, radiation, systemic, and combination therapies for nail psoriasis, the available studies lack sufficient power to extrapolate a standardized therapeutic regimen. Therefore, until better-documented evidence validating the treatment options emerges within the literature, clinicians and patients are left with a vague and relatively unproven approach to psoriatic nail disease.

Prolongation of heart allograft survival in rats by interferon-specific antibodies and low dose cyclosporin A

Interferons (IFNs) are important cytokines which exhibit antiviral, antitumor, anticellular, as well as immunoregulatory activities. Among these multiple activities, IFNs are potent inducers of MHC antigen expression of a great variety of cells, helper and maturation factors in B-cell antibody production, and macrophage function. IFNs may therefore play a critical role in triggering antigen recognition and allograft rejection. Cyclosporin A (CyA) is a potent immunosuppressor which selectively inhibits helper T-lymphocyte proliferation in response to alloantigen presentation. CyA has been reported to inhibit interleukin 2 and IFNgamma production by helper T lymphocytes. In addition, CyA may induce monocyte production of prostaglandin E2, which then reduces MHC class II expression on endothelial cells, monocytes, and macrophages. However, the clinical use of CyA is plagued by its toxic (in particular nephrotoxic) side-effects. These toxic effects are clearly dose-related. It may be very important to develop new products which can act synergistically with CyA to inhibit lymphokine production. The aim of this study was to investigate the effects of combined IFN-specific antibodies and low dose CyA on cardiac allografts in inbred strains of rats.

Sustained cyclosporine-induced erythropoietic response in identical male twins with diamond-blackfan anemia

After failing a trial of corticosteroid therapy, molecularly proven identical twins were treated for transfusion-dependent Diamond-Blackfan anemia with cyclosporine A, resulting in a robust erythropoietic response and a reversal of anemia. Clonogenic assays of marrow hematopoietic progenitors from both patients showed exuberant growth of BFU-E colonies but absent CFU-E. Clinically, the response has been sustained, and both patients have continued cyclosporine therapy and have been transfusion-independent for more than 27 months.

Homogenous enzyme immunoassay for cyclosporine in whole blood using the EMIT 2000 cyclosporine specific assay with the COBAS MIRA-plus analyzer

We describe the evaluation of the EMIT 2000 cyclosporine specific assay kit, an enzyme-multiplied immunoassay for cyclosporine in whole blood, with a COBAS MIRA-plus analyzer. The enzyme used for the assay was glucose-6-phosphate dehydrogenase (EC 1.1.1.49 G6PDH) from Leuconostoc mesenteroides; the monoclonal antibody is fairly specific for cyclosporine, and is not reactive with most metabolites. The assay principle is based on competitive immunoassay with G6PDH-labeled cyclosporine and cyclosporine in sample to the anticyclosporine mouse monoclonal antibody binding site. The within-assay coefficient of variation (CV) of this method was 2.7-4.2% (n = 10) at the levels of 56.2-339.7 microg/L. Day-to-day CVs ranged from 4.2-8.1% at the levels of 47.2-350.2 microg/L. The within-day CVs ranged from 2.0-6.4% at the levels of 43.3-330.5 microg/L. The functional detection limit was 24.9 microg/L. Samples treated with pretreatment reagent were stable at least 5 hr. Calibration was stable at least 10 days. The analytical recovery was 81-109%. The correlation between values obtained with the EMIT 2000 cyclosporine specific assay kit (y) and fluorescence polarization immunoassay (FPIA) (TDxFLx) (x) was: y = 0.880x - 13.053 microg/L (r = 0.984, Sy/x = 15.968, n = 71) with a mean difference of 31.42 +/- 19.89 microg/L ((TDxFLx - EMIT 2000) +/- SD); for the FPIA (AxSYM) (x): y = 0.989 - 4.144 microg/L (r = 0.981, Sy/x = 17.478, n = 71) with a mean difference of 5.56 +/- 17.38 microg/L ((AxSYM - EMIT 2000) +/- SD); and for the radioimmunoassay (RIA, CYCLO-Trac SP) (x): y = 0.893 - 6.764 microg/L (r = 0.993, Sy/x = 10.582, n = 71) with a mean difference of 22.18 +/- 14.98 microg/L ((RIA - EMIT 2000) +/- SD) using the Bland-Altman technique.

Diamond-blackfan anemia and cyclosporine therapy revisited

A girl with Diamond-Blackfan anemia diagnosed in infancy started cyclosporine A (CSA) therapy at 9 years and 8 months of age after experiencing unacceptable side effects while receiving prednisone. Since then, she has been followed-up for more than 4 years. She exhibited a dramatic response to CSA, with weaning and then cessation of steroid therapy after 5 months. She has remained transfusion-independent. Attempts to discontinue CSA therapy have been unsuccessful. Relapse of the anemia has occurred in the context of viral infections with missed CSA doses. The major clinical problem during treatment has been recurrent oral aphthous ulceration, which responds to topical therapy. She is currently maintained on CSA 100 mg twice daily with a hemoglobin of 10.2 g/dL and a reticulocyte count of 1.6%. A trial of CSA therapy should be considered in patients with Diamond-Blackfan anemia in whom steroid therapy has failed before a transfusion program is instituted or alternative donor stem cell transplantation is entertained.

The role of endogenous interleukin-2 in proliferation of human carcinoma cell lines

Interleukin (IL-2) and IL-2Rbeta/gamma have been shown to be expressed in human carcinomas in culture and in situ. Recently, expression of endogenous IL-2 and IL-2R in the cytoplasm was found to be up-regulated in tumour cells undergoing mitosis. This observation suggested that similar to its role in lymphocytes, the IL-2/IL-R pathway is involved in the regulation of carcinoma cell proliferation. Metabolic labelling followed by immunoprecipitation and Western blot results showed that IL-2 in carcinomas was identical to that in human lymphocytes. However, tumour cells did not secrete IL-2 detectable by immunoassays, although membrane-associated IL-2 was detectable on a proportion of these cells cultured in the absence of exogenous IL-2. Antibodies to IL-2 failed to inhibit proliferation of carcinoma cells, but antibodies specific for the ligand-binding site of the IL-2R were growth inhibitory. Growth of tumour cells was also inhibited by the immunosuppressive drugs, cyclosporin A (CsA), FK506 and rapamycin (RPA), known to interfere with the IL-2 pathway in lymphocytes. To further confirm the role of endogenous IL-2 in the growth of carcinomas, tumour cells were incubated with an IL-2-specific antisense oligonucleotide. The treatment was shown to transiently inhibit IL-2 mRNA and IL-2 protein expression as well as proliferation of tumour cells. Tumour cells treated with IL-2-specific antisense oligonucleotide demonstrated increased apoptosis in comparison to untreated or sense oligonucleotide-treated control cells. The data indicate that in human carcinomas, endogenous IL-2 promotes growth and protects tumour cells from apoptosis.

Acceptance of skin allografts in pigs by portal venous injection of donor bone marrow cells

OBJECTIVE

To confirm in pigs whether a new method for organ allografts, originally established in mice by the authors, might be applicable to humans.

SUMMARY BACKGROUND DATA

The authors recently established a new method for organ allografts in mice that includes the injection of donor bone marrow cells (BMCs) using the portal vein (PV), followed by the administration of cyclosporin A (CsA) on days 2 and 5, and the intravenous injection of BMCs on day 5. In the present study, they modify this method (a single-day protocol) and apply it to pigs.

METHODS

Allogeneic BMCs of donor pigs were injected using the PV (a superior mesenteric vein). The skin grafting was carried out on the day of the PV injection. The recipient pigs received donor grafts, autologous grafts, and third-party grafts at the same time. In addition, an open wound was made as the epithelized control. Full-thickness skin grafts were harvested from the dorsal wall of the donors. CsA (10 mg/kg) was injected intramuscularly into recipient pigs on days 2 and 5 after the PV injection.

RESULTS

One hundred percent of skin grafts survived for >300 days when donor BMCs were injected using the PV (n = 6). However, the skin grafts of the three pigs that had received BMCs using the intravenous route were rejected within 3 to 4 weeks after transplantation. The third-party skin grafts showed necrotic changes on day 21 after transplantation.

CONCLUSIONS

One hundred percent of skin allografts can be obtained, even in pigs, by injecting donor BMCs using the PV, carrying out skin allografts, and administering CsA on days 2 and 5. This single-day protocol would be of great advantage for human organ transplantation.

A strategy for organ allografts without using immunosuppressants or irradiation

A strategy to achieve regular and long lasting organ and tissue allografts without using immunosuppressants and/or irradiation has been established for mice. One hundred percent of skin allografts can be induced to survive >350 days after transplantation if spleen cells from the same donors are first injected into the portal vein of the recipients. The mechanisms underlying this long-term tolerance induction can be described as follows: (i) donor T cells from the spleen of the donor facilitate the acceptance of the allogeneic engraftment, (ii) donor-specific anergy is induced in the cytotoxic T-lymphocytes of the recipients, (iii) T helper type 2 cells become the dominant T cells in the recipients that are accepting the skin transplants, and (iv) a lasting chimerism (microchimerism) is established in these recipients. This strategy, perhaps with minor modifications, might permit one also to overcome major barriers to organ allografting in humans. If this were the case, it could represent production of long lasting immunologic tolerance without need for irradiation or cytotoxic chemo-preparative regimen and as such could greatly facilitate allotransplantation free of episodes of chronic or acute rejection or toxic and damaging preparatory regimens.

Immunotherapy of Psoriasis

Background:

Psoriasis is a common inflammatory skin disease, characterized by epidermal keratinocyte hyperproliferation and an inflammatory infiltrate. Current research indicates that epidermal hyperproliferation is, in part, dependent upon the milieu of cytokines and growth factors produced chiefly by T cells within the infiltrate and that the T cells play a central role in the pathogenesis of psoriasis.

Objective:

Recent developments in the treatment of psoriasis are discussed in the context of current understanding of the pathogenesis of this condition.

Conclusion:

Significant advances are being made in the treatment directed against these specific immunologic aberrations. Efficacy of immunosuppressive agents such as cyclosporine, FK506 (tacrolimus), anti-CD4 monoclonal antibodies, and IL-2 fusion-toxin in the treatment of psoriasis underscore its probable immune basis. Highly specific treatment directed against cytokines, angiogenesis, and adhesion molecules remains experimental, but shows promise for safer systemic treatment in the future.

Inhibition of reovirus-stimulated murine natural killer cell cytotoxicity by cyclosporine

Reovirus type 3 is a double-stranded RNA virus that is a potent inducer of murine natural killer (NK) cell cytotoxicity, most likely as a result of virus-induced interferon production. We determined that reovirus was an effective inducer of high levels of NK cytotoxicity. A single injection of cyclosporine (CS), administered concurrently with reovirus or delayed until three days after injecting CS, significantly inhibited NK cytotoxicity. CS significantly suppressed reovirus-induced NK cytotoxicity when added directly to the chromium-release assay. We determined that CS inhibited the ability of murine spleen cells to form conjugates with YAC-1 tumor target cells. Finally, CS was shown to directly inhibit reovirus replication in vitro. Our results demonstrate that CS is an effective inhibitor of reovirus-induced NK cytotoxicity and suggest that inhibition occurs through multiple mechanisms including direct effects on the NK cells and direct inhibition of virus replication.

Review article: the medical management of Crohn's disease

The choice of medical therapies for Crohn's disease continues to grow. Although our understanding of the mechanisms of the disease is incomplete, increasing knowledge of the pathogenesis of inflammation in general and Crohn's disease in particular allows targeting of therapies at various points in the immunoinflammatory cascade. In addition, the division of Crohn's disease into subtypes by location, aggressiveness, and the presence or absence of perianal and fistulizing disease allows the tailoring of medical therapy to the individual patient. For those patients with moderate to severe symptoms or frequent flares of disease activity, and those who have required surgical resection, maintenance therapy can substantially reduce the rate of recurrence. Despite these advances, available medical therapies for Crohn's disease remain imperfect, as evidenced by their sometimes substantial toxicities and the continued frequent need for surgery.

New immunosuppressive agents for pediatric transplantation

Pediatric transplantation has always been challenging for transplant surgeons. Although the higher immunoreactivity and the faster metabolism showed by this unique population when compared with adults requires a heavy immunosuppressive regimen, the possibility of disrupting the delicate balance of correct psychophysical development calls for a regimen of more selective and less toxic immunosuppressive drugs. In the past decade several new drugs have been investigated and some of them appear to be very promising, although pleiotropic toxicities have not yet been eliminated. An appropriate pharmacokinetic approach and the evaluation of synergistic multi-drug combinations by rigorous mathematical models would lead to highly selective immunosuppressive regimens which may result in virtually no toxicity.

The mechanisms of action of cyclosporin A in the treatment of psoriasis

This article describes the effects of cyclosporin A (CsA) on the immunopathological mechanisms operative in psoriasis, a human skin disease. The main focus is the effect of CsA on keratinocytes, T cells and antigen-presenting cells, the key players in lesional psoriatic skin. The effect of CsA on other cells, such as neutrophils and endothelial cells, which are important in the maintenance of psoriasis, are also discussed.

A comparative study on immunosuppressive effects of cyclosporin A and FK 506 on peripheral blood lymphocytes in dogs

Immunosuppressive effects of cyclosporin A (CsA) and FK 506 (FK) on peripheral blood lymphocytes were studied in dogs in respect to mixed lymphocyte reaction, proliferative responses to recombinant interleukin-2 (rIL-2), phytohemagglutinin (PHA) and concanavalin-A (Con-A); phenotypes of OKIa1, CD3, CD8 and surface IgM; cytotoxic activity against xenogeneic tumor cells. CsA (2.0 or 5.0 mg/kg, intravenously) or FK (0.16 mg/kg, intramuscularly) was given to mongrel dogs every morning for serial 21 days. The blood concentrations of CsA, measured as trough levels by fluorescence polarization method, ranged from 37 to 350 ng/ml in dogs administered at 2.0 mg/kg and from 170 to 894 ng/ml in dogs administered at 5.0 mg/kg during treatment, respectively. In dogs treated with FK at a dose of 0.16 mg/kg, the drug concentrations in the plasma during treatment ranged from 0.16 to 1.8 ng/ml. Mixed lymphocyte reaction and proliferative responses to rIL-2, PHA and Con-A, which were declined by CsA, were not affected by FK. In contrast, the proportion of OKIa1+ cells was not affected by CsA, whereas FK decreased the proportion of OKIa1+ cells progressively during the course of treatment. Cytotoxic activity was suppressed by both CsA and FK. These results possibly indicate that CsA and FK exert their immunosuppressive effects via different mechanisms.

Cyclosporine A in fat emulsion carrier: immunosuppressive effect in vitro

We have recently shown in a rat model that the acute decrease in glomerular filtration rate caused by intravenous Sandimmun can be avoided if Cyclosporine A (CyA) is given in a fat emulsion carrier instead. The present study was undertaken to determine the immunosuppressive effect in vitro of this new formulation. The inhibitory effect on the lymphocyte responsiveness of CyA in fat emulsion carrier was compared with that of CyA dissolved in alcohol, using mitogens as well as alloantigens as stimuli. In the mixed lymphocyte culture and cell-mediated lympholysis tests and in the interleukin-2 assay, both formulations seemed equally effective. CyA in fat emulsion was somewhat less effective than CyA in alcohol in the mitogen tests. In clinical practice the fat emulsion would be rapidly metabolized, and to further evaluate our new formulation, studies in experimental organ transplantation are needed.

Behavioral conditioning prolongs heart allograft survival in rats

Conditioned immunosuppression using a taste aversion paradigm has been demonstrated in a number of laboratory models but few reports have demonstrated changes in immunity sufficient to be of clinical relevance. The experiments reported here demonstrate that the survival of heart allografts in rats can be prolonged by behaviorally conditioned immunosuppression using cyclosporin A (CsA) as an unconditioned stimulus in taste aversion conditioning. Conditioned animals received saccharin as the conditioned stimulus paired with an injection of CsA at 10 and 6 days prior to transplantation. They were reexposed to saccharin alone 1 day prior to and 3 days after transplantation. On these occasions the conditioned group displayed taste aversion behavior when offered saccharin and a significant prolongation of heart graft survival was observed compared to the conditioned and nonconditioned control groups. These experiments suggest that behaviorally conditioned immunosuppression may have important clinical implications as an adjunct to drug treatments in transplantation medicine.

Protective effect of cyclosporin A on immune abnormalities observed in the murine acquired immunodeficiency syndrome

The murine leukemia viruses (MuLV) designated LP-BM5 induce an immunodeficiency disease in susceptible strains of mice with many features in common to human acquired immunodeficiency syndrome (AIDS), including lymphadenopathy and profound immunodeficiency associated with enhanced susceptibility to infection and terminal B cell lymphomas. The disease, termed murine AIDS (MAIDS), crucially depends on the presence of B cells and CD4+ T cells, suggesting that mutual activation of these two cell types is central in the pathogenesis of the immunodeficiency syndrome. Cyclosporin A (CsA), whose immunosuppressive effect is attributed mainly to inhibition of interleukin 2 and interferon-gamma expression, interferes in T-B cell interactions. Here we show that chronic treatment with CsA (40 or 60 mg/kg/day) before and after infection with LP-BM5 MuLV protects against the development of immunodeficiency disease as assessed by functional, serological and histopathological criteria. The protection was not complete, suggesting both CsA-sensitive and CsA-resistant components to the pathogenesis of this syndrome, and was found to be independent of ecotropic MuLV expression. These results underline immunopathological mechanisms in the progression of immune abnormalities in MAIDS that are susceptible to inhibition of CsA and may serve as an experimental basis for developing a treatment of the human disorder with immunomodulators.

Cyclosporine induces elevated procollagen alpha 1 (I) mRNA levels in the rat renal cortex

Chronic cyclosporine nephrotoxicity is a poorly understood drug side-effect characterized by renal cortical interstitial scarring. To evaluate procollagen mRNA levels as an early factor in the development of this form of renal fibrosis, we measured renal procollagen alpha 1 (I), alpha 1 (III), alpha 1 (IV) and beta-actin mRNA levels in rats treated with cyclosporine (CsA) or the olive oil vehicle (OO) for one or four weeks. Renal morphology was similar without atrophy or fibrosis in one week CsA and OO and four week OO rats. Four week CsA rats had focal cortical interstitial fibrosis and tubular atrophy. Cortical procollagen alpha 1 (I) mRNA levels were increased in CsA versus OO rats at one week (P less than 0.02) and four weeks (P less than 0.02). One week medullary procollagen alpha 1 (I) and all other one week medullary, and one and four week cortical procollagen and beta-actin mRNA levels were no different in CsA versus OO rats. The early increase in renal cortical procollagen alpha 1 (I) mRNA levels precedes renal morphologic abnormalities, and may represent an important step in the pathogenesis of cyclosporine-induced renal cortical fibrosis.

Protection against influenza A virus infection in mice by oral immunization with a polyvalent bacterial lysate

A study is presented which investigated whether oral immunization with a polyvalent bacterial lysate (Paspat oral) can sufficiently enhance cell-mediated defense mechanisms to protect mice against influenza A virus infection. It was found that oral immunization reduced mortality due to influenza A infection with 15-70%, depending on the quantity of virus administered and and the moment of infection. Cyclosporin A severely reduced the protective effect of oral immunization, suggesting that a major effect of oral immunization in these studies is T-cell activation. The effect of oral immunization on macrophageal activity was evaluated by measuring cyclic-AMP in alveolar macrophages (AMs) obtained by bronchoalveolar lavage. Before infection, basal activity levels of AMs in immunized mice were significantly lower than in controls. Five days after infection, however, basal activity level of AMs in immunized mice was significantly higher than AM activity in controls. Stimulation of AMs with PGE2 significantly reduced cellular activity in both groups, before and after infection. However, cellular activity of AMs from immunized animals was less reduced than cellular activity of control macrophages. Activity of AMs of immunized animals was significantly more reduced by histamine than activity of control macrophages. It is concluded that oral immunization with Paspat oral stimulates T-cell-dependent immune mechanisms, resulting in protection against influenza A virus infection in mice.

Effects of cyclosporine on immunologic mechanisms in psoriasis

A major impetus for further investigation of cellular immunologic mechanisms in psoriasis has been the discovery that cyclosporine, a potent immunosuppressive, is highly effective in the treatment of psoriasis. Cyclosporine has significant inhibitory effects on the ability of T cells to become activated. However, a direct activity of this drug on human keratinocyte signal transduction or growth has been difficult to demonstrate at relevant concentrations. Nevertheless, treatment of psoriasis or of 12-O-tetradecanoyl phorbol-13-acetate-treated murine skin with cyclosporine does reverse many epidermal abnormalities that are common to these two systems. This suggests that the compound exerts an indirect effect on epidermal keratinocytes in vivo, perhaps through immunocyte inhibition. During treatment of psoriasis patients, cyclosporine therapy resulted in selective changes in the numbers and functions of certain antigen-presenting cell subsets (which were distinct from Langerhans cells) and T-cell subsets. These changes were accompanied by indirect evidence of decreased T-cell lymphokine release. Lesional activity of cyclosporine-treated psoriasis patients was closely correlated with the degree of T-cell activation caused by antigen-presenting cells. Cyclosporine inhibition of lymphokine or cytokine release may result in decreased recruitment of non-Langerhans antigen-presenting cells into the epidermis and thus decreased immunoreactivity in the lesion.

Intracellular targets of cyclosporine

Since cyclosporine was first reported to improve psoriasis, investigators have been trying to determine its mechanism of action. In addition to the well-documented effects on cytokine production by T lymphocytes, a direct effect on keratinocytes has been proposed. Cyclophilin and calmodulin, two proteins that are present in both lymphocytes and keratinocytes, have been considered as possible intracellular targets for cyclosporine. Cyclophilin binds cyclosporine with high affinity and the ability to bind cyclophilin correlates with the immunosuppressive effects of cyclosporine analogs. Cyclophilin is identical to peptidyl-prolyl cis-trans isomerase, an enzyme that catalyzes refolding of proteins. The process of protein folding may be important in DNA-protein and protein-protein interactions. Calmodulin is an intracellular calcium-binding protein that is important in the regulation of cell proliferation. Cyclosporine binds to calmodulin with low affinity, and such binding of cyclosporine isomers does not reflect their immunosuppressive activity. The physiologic importance of calmodulin-to-cyclosporine binding is controversial.

Cyclophilin content of normal and psoriatic epidermis

The unique, immunosuppressive agent cyclosporine A has been shown to be of important therapeutic value in the treatment of psoriasis and other inflammatory dermatoses. To investigate the basis for its therapeutic efficacy, the tissue and cellular content of cyclophilin, a cytosolic receptor for cyclosporine A, has been determined in keratome biopsies from normal and psoriatic epidermis and in cultured, adult human keratinocytes. The mean cyclophilin content of normal (n = 10), involved (n = 10), and uninvolved (n = 10) psoriatic epidermal samples was not significantly different (0.126 +/- 0.016, 0.106 +/- 0.009, and 0.153 +/- 0.018 microgram cyclosporine A bound/mg cytosolic protein). Similarly, the cyclophilin content of keratinocytes cultured from normal and psoriatic epidermis (0.21 +/- 0.016 and 0.18 +/- 0.024 microgram/mg protein, respectively) did not differ significantly. Western blot analysis of normal and psoriatic epidermal extracts with monospecific rabbit anti-cyclophilin antisera revealed a single band of 17,000 daltons, which co-migrated with highly purified bovine cyclophilin. The intensity of this band was similar in normal and psoriatic samples, indicating that immunoreactive cyclophilin content was similar. Cyclophilin mRNA was readily detected in normal and involved psoriatic epidermis by RNA blot hybridization, and expression was not significantly different in normal and psoriatic epidermis. These findings indicate that cyclophilin is present in human keratinocytes and epidermis, where it may account for the accumulation of cyclosporine during therapy. However, the similar cyclophilin content of normal and diseased tissue suggests that differences in cyclosporine uptake probably do not account for its therapeutic efficacy in psoriasis.

Cyclosporin A inhibition of interleukin 2 gene expression, but not natural killer cell proliferation, after interferon induction in vivo

The IFN inducer, poly(I:C), elicits acute NK cell blastogenesis and proliferation in vivo. The role of IL-2 in mediating this proliferation was investigated in the studies presented here. Blast NK cells were isolated from poly(I:C)-treated, T cell-deficient athymic mice. Dividing cells, incorporating [3H]thymidine, were enriched in the J11d- low density populations isolated from poly(I:C)-treated mice, and were characterized as NK by the following criteria: (a) they were eliminated by treatment with anti-AGM1 in vivo; and (b) they directly mediated lysis of NK-sensitive target cells in a single cell cytotoxicity assay with autoradiography. These poly(I:C)-induced blast NK cells were responsive to IL-2, but, when compared with in vivo activated T cells, responsiveness required 1,000-fold higher concentrations of the factor. The technique of in situ hybridization was used to evaluate induction of IL-2 gene expression after poly(I:C) treatment in vivo. Treatment of euthymic, athymic, and severe combined immunodeficient mice with poly(I:C) activated IL-2 gene expression in a small percentage of spleen leukocytes. The transcription-positive cells were enriched in low density cell populations. These findings demonstrate that IL-2 transcription occurs after IFN induction in vivo, and suggest that an endogenous source of IL-2 exists other than the mature T cell. To assess the IL-2 dependence of in vivo NK cell expansion, poly(I:C)-treated athymic mice were given cyclosporin A (CsA), an agent that regulates IL-2 production at the level of gene transcription. The drug resulted in an 85-100% reduction in the percentages of cells transcribing IL-2. In contrast, CsA administration did not block IFN-enhanced NK cell cytolytic activity, expansion of large granular lymphocyte numbers, or NK cell proliferation. These findings demonstrate that although the proliferation of blast NK cells can be supported by IL-2, IL-2 is not an important mediator of IFN-induced NK cell expansion. Moreover, they establish that the acute proliferation of NK cells in response to IFNs is CsA insensitive.

Effects of cyclosporin A on the cells responsible for the anticryptococcal cell-mediated immune response and its regulation

Cyclosporin A (CsA), a potent immunosuppressive drug, was used to explore further the induction, expression, and regulation of lymphoid cells involved in the delayed-type hypersensitivity (DTH) response to cryptococcal antigen(s). We found that the induction of the cells responsible for DTH (TDH cells) was not affected by CsA, but their expression was inhibited in CsA-treated mice. The inhibition of expression of the TDH cells could not be attributed to the Cryptococcus neoformans-specific suppressor T (Ts) cells, even though the Ts cells were induced in CsA-treated mice. Instead, the suppressed expression of the TDH cells in CsA-treated mice was a direct effect of CsA or its products. Our studies with CsA also resulted in the first identification of a population of cells that significantly amplify the anticryptococcal DTH response. The amplifier cells were induced in mice that were given a primary immunizing dose of cryptococcal antigen in complete Freund adjuvant, and they amplified the anticryptococcal DTH response in recipient mice when they were transferred at the time of immunization of the recipient. The amplifier cell population was distinct from the TDH cells in that CsA inhibited the production of the amplifying cells but did not affect the induction of TDH cells. Amplification of the DTH response was a cell-mediated event, since cells but not serum from immunized mice mediated the amplified response in recipient mice. Thus, CsA enabled us to characterize anticryptococcal TDH and Ts cells further and to add to the immune cell circuit of the cryptococcal system a distinct population of cells that amplifies the anticryptococcal DTH response.

Effects of anti-inflammatory agents on lymphocyte migration stimulated by the interferons, tumor necrosis factor and cutaneous inflammation

Our goal was to examine the effect of anti-inflammatory agents on the migration of lymphocytes to cutaneous inflammatory sites and in response to cytokines. The accumulation of i.v. injected 111In-labelled peritoneal exudate lymphocytes in skin sites of rats injected with KLH to induce DTH reactions, LPS, poly I:C and the cytokines, IFN-gamma, IFN-alpha/beta and tumor necrosis factor was determined. Systemic dexamethasone (DEX) treatment strongly inhibited the migration of lymphocytes in response to all of the stimuli, however, the effective dose of DEX varied widely with the different recruiting agents. The lowest ED50 was observed with LPS, while IFN-alpha/beta was the least inhibited. DEX treatment increased lymphocyte accumulation in the bone marrow and spleen. Pretreatment of lymphocytes with DEX had no effect on their migration, while local i.d. hydrocortisone inhibited migration into the skin. Cyclosporin A treatment had no effect on lymphocyte recruitment in response to any of the cytokines or LPS but significantly inhibited migration to DTH reactions and poly I:C. Treatment of rats with indomethacin, ASA and BW755C produced only a marginal inhibition of lymphocyte migration in response to some of the stimuli tested. DEX is a potent inhibitor of lymphocyte migration to inflammation. In addition to suppressing cytokine production, it can suppress migration to cytokines, probably through inhibiting the effects of these agents on the vascular endothelium. Cyclosporin A decreases lymphocyte accumulation only through its ability to suppress lymphokine production, while inhibitors of arachidonate metabolism have little direct effect on lymphocyte migration.

Regulation of lymphocyte growth by antagonists of interleukin-2 or its cellular receptor

The dependence of T cell proliferation on the production, binding and utilization of the lymphokine growth factor IL-2 has fostered the development and testing of new classes of drugs which act to either inhibit IL-2 production or the interaction of IL-2 with its cellular receptor. We have reviewed evidence which documents the potent immunosuppressive effects of inhibitors of IL-2 synthesis and secretion, such as Ciclosporin A, and of anti-IL-2 receptor MAb. The similarities of the potency and specificity of these agents and their effectiveness in a wide range of clinical settings encourage further studies on their mechanism of action. Perhaps the most dramatic similarity is the induction of long-term nonresponsiveness after drug removal to antigens present at the time of drug therapy. This observation has profound importance both on clinical manipulation with these agents and n the origins and maintenance of self-tolerance.

The effects of immunosuppressive pharmacological agents on the induction of cytotoxic and suppressor T lymphocytes in vitro

The immune system is regulated by the interactions among several distinct functional subsets of T cells. The action of several commonly used immunosuppressive drugs on the activation of cytotoxic T lymphocytes (CTL) and suppressor T lymphocytes (Ts) in the primary mixed lymphocyte reaction (MLR) was investigated. Cyclosporin A, hydrocortisone, and azathioprine were all found to inhibit both CTL and Ts activation when present at pharmacological doses in culture. When these drug-inhibited cultures were reconstituted with interleukin-2, however, clear differences between the effects of these drugs was observed. Cyclosporin A and hydrocortisone allowed the selective activation of Ts in the presence of interleukin-2, while azathioprine inhibition was not reversed by interleukin-2. Thus, CTL precursors appear to be directly inhibited by all of these drugs, but Ts precursors apparently are not inhibited by cyclosporin A or hydrocortisone provided interleukin-2 is present. These findings are discussed in terms of the activation requirements of CTL vs. Ts and the implications of the selective activation of alloantigen-specific Ts for prevention of allograft rejection.

Reversal of the effects of cyclosporin A on the production of human interferon-gamma

Previous reports have documented that cyclosporin A (CsA) can inhibit the production of interferon-gamma (HuIFN-gamma) and interleukin-2 (IL-2). In this report we have extended these earlier findings and have demonstrated that the defect in the production of HuIFN-gamma persists even after the CsA is removed and is associated with altered synthesis of other lymphokines, mainly a cytotoxin and leukocyte migration inhibition factor. In the presence of recombinant exogenous IL-2, the effect of CsA on the synthesis of HuIFN-gamma can be reversed depending on the concentrations of both the IL-2 and CsA. In addition, the presence of the calcium ionophore A23187 partially reverses the inhibitory effect of CsA by synergistically enhancing the synthesis of HuIFN-gamma.

Immunosuppressive effect of cyclosporin A on Mycobacterium bovis BCG infections in mice

The effect of increasing doses of cyclosporin A (CsA) given to mice infected intravenously with Mycobacterium bovis BCG was investigated. Development of both tuberculin hypersensitivity and acquired antituberculous resistance was suppressed in a dose-responsive manner. Daily dosages at 100 mg/kg of body weight prevented any reduction in the BCG counts within the lungs, liver, or spleen. This effect was associated with lowered nonspecific resistance to a Listeria monocytogenes challenge and a decline in specific protective immunity adoptively transferred to naive recipients. CsA treatment had no effect on antilisterial activity by activated macrophages or on the antituberculous immunity expressed by specific memory T cells. CsA treatment inhibited the ability of BCG-vaccinated mice to produce gamma interferon (IFN-gamma) after a secondary stimulation with live BCG or with lipopolysaccharide. Spleen cells from BCG-infected mice which were exposed to daily treatment with CsA showed reduced IFN-gamma production in response to purified protein derivative or concanavalin A stimulation, suggesting that the immunosuppressive effect of CsA on BCG-infected mice was expressed by inhibiting the development of effector T cells responsible for the production of IFN-gamma.

Divergent effects of cyclosporine A on interferon- and mitogen-induced Ly-6A antigen suggest autocrine regulation of Ly-6A expression in activated T cells

The murine Ly-6A cell surface antigen is normally present on a minor subset of mature T cells. This marker has been shown to become highly expressed on mitogen-activated T cells. We found that expression of Ly-6A is also markedly increased in resting T cells by incubation with IFN-alpha/beta or IFN-gamma. Here, we compared the effect of the immunosuppressant cyclosporine A (CsA) on Ly-6A induction by IFN and concanavalin A (Con A). The augmentation of Ly-6A expression produced by treatment of T cells with IFN-alpha/beta or IFN-gamma was found not to be affected by CsA concentrations up to 2 micrograms/ml. In contrast, at doses as low as 50 ng/ml, CsA prevented the enhancement of Ly-6A expression in Con A-treated T-cell cultures. Culture supernatant transfer experiments were performed to further explore this effect of CsA. It was found that supernatants from Con A-activated T cells enhanced Ly-6A expression in resting T cells. This activity could be neutralized with an anti-IFN-gamma monoclonal antibody. Supernatants from T cells treated with Con A in presence of CsA lacked Ly-6A-enhancing activity. Taken together, these data suggest that the inhibition by CsA of Ly-6A induction in Con A-treated T cells reflects the known inhibitory effects of the drug on IFN-gamma secretion. This may imply the existence in T cells of an autocrine circuit involving IFN-gamma and regulating Ly-6A expression.

Effect of cyclosporin A, silica quartz dust, and protease inhibitors on virus-induced demyelination

Treatment with cyclosporin A, from the time of virus infection, suppressed inflammation and demyelination in the spinal cord of SJL/J or ASW(H-2s) mice persistently infected with Theiler's murine encephalomyelitis virus. Demyelination was not decreased if treatment was given after inflammation was established. The decrease was independent of serum titers of immunoglobulin G to purified viral antigen but did correlate with decreased proliferation of T lymphocytes to virus and myelin antigens. Silica quartz dust, a direct toxin of macrophages, suppressed demyelination and inflammation if begun at time of virus infection. No therapeutic effect was seen with inhibitors of plasminogen activators or other neutral proteases found primarily in macrophages.

Natural killer-cell activity, interferon-alpha 2 production, and interleukin-2 production in cyclosporine-treated and conventionally immunosuppressed human allograft recipients

Natural killer (NK) activity, interferon (IFN)-alpha production, and interleukin-2 (IL-2) production were measured in renal transplant recipients undergoing immunosuppression with either azathioprine and steroids (Az + P) or cyclosporine (CyA). Overall, both IFN-alpha production and IL-2 production were impaired in these two groups compared with identical studies in healthy individuals. However, on the basis of control data these two patient groups were divided into those with "normal" NK activity and those with "low" NK activity. In the CyA group those with a low NK reaction produced less IL-2 and IFN-alpha than those with normal NK activity. No such relationship between cytokine production and NK activity was discerned in the Az + P group. These data conflict with in vitro studies, which have failed to demonstrate any effect of CyA on IFN-alpha production. In addition, they suggest that whereas cyclosporine influences NK activity in vivo by inhibiting cytokine production, other factors may play a role in impairing NK activity in conventionally immunosuppressed patients.

T-cell-independent macrophage activation in mice induced with rRNA from Listeria monocytogenes and dimethyldioctadecylammonium bromide

Purified rRNA from Listeria monocytogenes or Pseudomonas aeruginosa injected in combination with dimethyldioctadecylammonium bromide (DDA), protects mice nonspecifically against a lethal challenge of various extra- and intracellular bacteria. In the present study vaccination of BALB/c as well as C57BL/Ka mice with listerial RNA-DDA resulted in activation of fixed-tissue macrophages, as measured by an enhanced in vivo L. monocytogenes killing in spleen and liver. Evidence was found that macrophage activation by vaccination with rRNA-DDA occurred by a T-cell-independent mechanism. Treatment of mice with cyclosporin A had no effect on the enhanced L. monocytogenes killing induced with RNA-DDA; in vitro exposure of RNA-DDA to spleen cell cultures did not give rise to any lymphocyte proliferation. No evidence could be found for a possible adjuvant activity for RNA-DDA in cellular responses; in fact, RNA-DDA had an inhibitory effect on lymphocyte proliferative responses to Listeria antigen and to concanavalin A.

Factors involved in decreased detection of class II histocompatibility antigens on blood mononuclear cells from transplanted patients receiving immunosuppressive drugs

Class II histocompatibility antigens were assessed by complement-dependent cytotoxicity on B enriched mononuclear cells and on purified monocytes isolated from the peripheral blood of renal patients before and after transplantation. After transplantation, a significant decrease of detection of DR alloantigens (cytotoxicity score before transplantation 3 +/- 0.1; after transplantation 0.95 +/- 0.1; p less than 0.001) was found. A similar defect was observed both on B enriched frozen cells and on purified monocytes isolated during the post-transplant period. Nevertheless, antigens could be adequately detected by a sensitive microabsorption method and by a procedure involving preincubation of mononuclear cells at 37 degrees C for 3 h followed by B cells enrichment by rosetting. The 37 degrees C induced reexpression could be inhibited by 10 micrograms/ml cycloheximide and by 50 microM monensin. No difference was found in the magnitude either of decreased expression or of temperature-induced reexpression between patients treated by CyS-Pred and those receiving Aza-Pred. It is concluded that transplanted recipients disclose a reversible defect of the expression of class II histocompatibility antigens probably related to perturbation of various steps of intracellular biosynthesis and traffic of these molecules.

Remission of idiopathic nephrotic syndrome after treatment with cyclosporin A

Nephrotic syndrome in minimal change lipoid nephrosis and focal segmental glomerulosclerosis may be due to alteration of glomerular anionic sites by a lymphokine. Six adults with nephrotic syndrome who were resistant to treatment with corticosteroids and immunosuppressants were treated with cyclosporin A. In three patients with minimal change lipoid nephrosis who had been nephrotic for 3.5 to 23 years proteinuria resolved within 12 to 42 days. Subsequently, these patients became dependent on cyclosporin A. In three patients with focal segmental glomerulosclerosis who had been nephrotic for four to six years mean (SD) 24 hour urinary protein decreased from 14.7 (8.4) g to 3.6 (0.6) g within 20 to 25 days, serum albumin concentration rose, and oedema subsided. One patient died of myocardial infarction when still in partial remission after 11 weeks' treatment. Two patients remained proteinuric despite continuing treatment with cyclosporin A, but control of sodium balance was easy and serum albumin concentrations remained higher than without cyclosporin A. In all patients renal function improved during treatment. These preliminary results show that cyclosporin A may be effective in the treatment of patients with nephrotic syndrome that resists every other form of treatment and especially in the treatment of those with minimal change lipoid nephrosis. The results are in keeping with a T lymphocyte mediated mechanism of minimal change lipoid nephrosis and focal segmental glomerulosclerosis, but they also suggest that minimal change lipoid nephrosis and focal segmental glomerulosclerosis are separate entities.

Effects of cyclosporine in experimental cryptococcal meningitis

We studied the effects of cyclosporine on experimental cryptococcal meningitis. Like cortisone, cyclosporine depressed the highly effective defense mechanisms of normal rabbits against inoculated Cryptococcus neoformans, causing them to develop progressive, fatal cryptococcal meningitis. Unlike cortisone, which causes a striking reduction in leukocytes in cerebrospinal fluid, cyclosporine depressed mononuclear cell function rather than numbers. Interleukin 2, a primary target for the immunodepressive action of cyclosporine, appears to be of central importance in central nervous system defenses against cryptococci. The findings suggest that humans receiving cyclosporine are likely to suffer increased incidence of cryptococcal infection.