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Keenan BP, Fong L, Kelley RK. Immunotherapy in hepatocellular carcinoma: the complex interface between inflammation, fibrosis, and the immune response. J Immunother Cancer 2019; 7:267. [PMID: 31627733 PMCID: PMC6798343 DOI: 10.1186/s40425-019-0749-z] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide and confers a poor prognosis. Beyond standard systemic therapy with multikinase inhibitors, recent studies demonstrate the potential for robust and durable responses from immune checkpoint inhibition in subsets of HCC patients across disease etiologies. The majority of HCC arises in the context of chronic inflammation and from within a fibrotic liver, with many cases associated with hepatitis virus infections, toxins, and fatty liver disease. Many patients also have concomitant cirrhosis which is associated with both local and systemic immune deficiency. Furthermore, the liver is an immunologic organ in itself, which may enhance or suppress the immune response to cancer arising within it. Here, we explore the immunobiology of the liver from its native state to chronic inflammation, fibrosis, cirrhosis and then to cancer, and summarize how this unique microenvironment may affect the response to immunotherapy.
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Affiliation(s)
- Bridget P Keenan
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, Room M1286, 505 Parnassus Ave., San Francisco, CA, 94143, USA. .,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | - Lawrence Fong
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, Room M1286, 505 Parnassus Ave., San Francisco, CA, 94143, USA.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Robin K Kelley
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, Room M1286, 505 Parnassus Ave., San Francisco, CA, 94143, USA.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
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Tanaka KA, Mazzeffi MA, Chow JH. Transfusion of Aged Red Blood Cells in Liver Transplantation: Et tu, Brute? Anesth Analg 2018; 127:5-6. [PMID: 29912051 DOI: 10.1213/ane.0000000000002811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kenichi A Tanaka
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Uibo R, Kisand K, Yang CY, Gershwin ME. Primary biliary cirrhosis: a multi-faced interactive disease involving genetics, environment and the immune response. APMIS 2012; 120:857-71. [PMID: 23009110 DOI: 10.1111/j.1600-0463.2012.02914.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 04/10/2012] [Indexed: 12/12/2022]
Abstract
Primary biliary cirrhosis (PBC) is considered a model autoimmune disease based on several features, including the presence of a highly directed and very specific immune response to mitochondrial autoantigens, a female predominance, a targeted destruction of the biliary epithelium, and homogeneity between patients. It is essentially a chronic progressive cholestatic liver disease characterized by immune-mediated destruction of small- and medium-sized intrahepatic bile ducts. There is considerable variation in the incidence and prevalence of the disease between regions of the world, although such differences likely reflect not only a true disparity in disease but also differences in awareness; for example, in the United States, PBC is often detected in an asymptomatic stage based on multi-phasic clinical testing. There has been considerable progress at defining the immune response in this disease, including quantitation of autoreactive T cells against PDC-E2, the major mitochondrial autoantigen. The overwhelming data suggests that patients develop PBC based on a genetic predisposition and loss of tolerance to one or more environmental agents. In this review, we will present an updated overview of PBC and place it in the context of autoimmunity.
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Affiliation(s)
- Raivo Uibo
- Institute of General and Molecular Pathology, Centre of Excellence for Translational Medicine, University of Tartu, Tartu, Estonia.
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Allina J, Hu B, Sullivan DM, Fiel MI, Thung SN, Bronk SF, Huebert RC, van de Water J, LaRusso NF, Gershwin ME, Gores GJ, Odin JA. T cell targeting and phagocytosis of apoptotic biliary epithelial cells in primary biliary cirrhosis. J Autoimmun 2007; 27:232-41. [PMID: 17222534 PMCID: PMC6200357 DOI: 10.1016/j.jaut.2006.11.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Revised: 11/22/2006] [Accepted: 11/23/2006] [Indexed: 12/21/2022]
Abstract
Primary biliary cirrhosis (PBC) is characterized by loss of tolerance against ubiquitously expressed mitochondrial autoantigens followed by biliary and salivary gland epithelial cell (BEC and SGEC) destruction by autoreactive T cells. It is unclear why BECs and SGECs are targeted. Previous work demonstrated that the reduced form of the major PBC autoantigen predominated in apoptotic BECs and SGECs as opposed to an oxidized form in other apoptotic cells. This led to the hypothesis that presentation of novel self-peptides from phagocytosed apoptotic BECs might contribute to BEC targeting by autoreactive T cells. The effect of autoantigen redox status on self-peptide formation was examined along with the phagocytic ability of BECs. Oxidation of PBC autoantigens first was shown to be due to protein S-glutathionylation of lipoyllysine residues. Absence of protein S-glutathionylation generated novel self-peptides and affected T cell recognition of a lipoyllysine containing peptide. Liver biopsy staining revealed BEC phagocytosis of apoptotic BECs (3.74+/-2.90% of BEC) was present in PBC (7 of 7 cases) but not in normal livers (0 of 3). BECs have the ability to present novel mitochondrial self-peptides derived from phagocytosed apoptotic BECs. Apoptotic cell phagocytosis by non-professional phagocytes may influence the tissue specificity of autoimmune diseases.
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Affiliation(s)
- Jorge Allina
- Department of Medicine, The Mount Sinai School of Medicine, New York, NY, USA
| | - Bin Hu
- Department of Medicine, The Mount Sinai School of Medicine, New York, NY, USA
| | | | - Maria Isabel Fiel
- Department of Pathology, The Mount Sinai School of Medicine, New York, NY, USA
| | - Swan N. Thung
- Department of Pathology, The Mount Sinai School of Medicine, New York, NY, USA
| | - Steven F. Bronk
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Robert C. Huebert
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Judy van de Water
- Department of Internal Medicine, School of Medicine of the University of California, Davis, CA, USA
| | | | - M. E. Gershwin
- Department of Internal Medicine, School of Medicine of the University of California, Davis, CA, USA
| | - Gregory J. Gores
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joseph A. Odin
- Department of Medicine, The Mount Sinai School of Medicine, New York, NY, USA
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Abstract
Gut flora and bacterial translocation (BT) play an important role in the pathogenesis of the complications of cirrhosis. Research on the pathogenesis of BT and its clinical significance transcends established boundaries between microbiology, cell biology, intestinal pathophysiology, and immunology. This review delineates multiple mechanisms involved in the process of BT, with an emphasis on alterations in intestinal flora and mucosal barrier function, particularly immunological defense mechanisms. Current knowledge on the innate and adaptive immune response that allows a "friendly" communication between bacteria and host is summarized, and alterations occurring in cirrhosis that may facilitate BT are discussed. In addition, definition of a "pathological" BT is proposed together with an analysis of the anatomical site and route of BT. Finally, therapeutic approaches for the prevention of BT in experimental and human cirrhosis are reviewed. Future research in the field of BT in cirrhosis will allow the development of new therapeutic targets in the prevention of infections and other complications of cirrhosis.
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Affiliation(s)
- Reiner Wiest
- Department of Internal Medicine I, University of Regensburg Hospital Franz-Josef-Strauss-Allee, Regensburg, Germany
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Rasaratnam B, Connelly N, Chin-Dusting J. Nitric oxide and the hyperdynamic circulation in cirrhosis: is there a role for selective intestinal decontamination? Clin Sci (Lond) 2004; 107:425-34. [PMID: 15270715 DOI: 10.1042/cs20040157] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abnormal vascular tone is responsible for many of the complications seen in cirrhosis making the identification of the pathophysiology of abnormal dilatation a major focus in hepatology research. The study of abnormal vascular tone is complicated by the multiple vascular beds involved (hepatic, splanchnic, peripheral, renal and pulmonary), the differences in the underlying cause of portal hypertension (hepatic versus pre-hepatic) and the slow evolution of the hyperdynamic state. The autonomic nervous system, circulating vasodilators and abnormalities in vascular smooth muscle cells (receptors, ion channels, signalling systems and contraction) have all been implicated. There is overwhelming evidence for an overproduction of NO (nitric oxide) contributing to the peripheral dilatation in both animal models of, and in humans with, cirrhosis and portal hypertension. This review focuses on the proposal that endotoxaemia, possibly from gut-derived bacterial translocation, causes induction of NOS (NO synthase) leading to increased vascular NO production, which is the primary stimulus for the development of vasodilatation in cirrhosis and its accompanying clinical manifestations. The current controversy lies not in whether NO production is elevated, but in which isoform of NOS is responsible. We review the evidence for endotoxaemia in cirrhosis and the factors contributing to gut-derived bacterial translocation, including intestinal motility and permeability, and finally discuss the possible role of selective intestinal decontamination in the management of circulatory abnormalities in cirrhosis.
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Affiliation(s)
- Brindhesha Rasaratnam
- Alfred and Baker Medical Unit, Wynn Domain, Baker Heart Research Institute, St Kilda Road, Melbourne, Victoria 3004, Australia
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Ballot E, Bandin O, Chazouilleres O, Johanet C, Poupon R. Immune response to lipopolysaccharide in primary biliary cirrhosis and autoimmune diseases. J Autoimmun 2004; 22:153-8. [PMID: 14987744 DOI: 10.1016/j.jaut.2003.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2003] [Revised: 10/29/2003] [Accepted: 11/10/2003] [Indexed: 02/03/2023]
Abstract
A bacteriological aetiology is suspected to be the triggering factor in primary biliary cirrhosis. We studied lipid A, the toxic and immunogenic moiety of gram-negative bacteria lipopolysaccharide, which accumulates abnormally in Kupffer cells, hepatocytes, and biliary epithelial cells in primary biliary cirrhosis patients. Anti-lipid A antibody levels from serum samples from 36 primary biliary cirrhosis patients, drawn before and after ursodeoxycholic acid treatment, were compared to those from patients with other liver diseases (n=236), non-hepatic diseases (n=249), and healthy subjects (n=75). In primary biliary cirrhosis patients, the prevalence of IgM anti-lipid A antibodies was higher before than after ursodeoxycholic acid therapy (64% vs 22%, respectively; P<0.001). Patients with anti-lipid A antibodies had significantly higher IgM levels than those without antibodies (8.7+/-1.1 g/l vs 4.4+/-0.8 g/l, P<0.02). Total IgM levels were correlated with anti-lipid A antibody levels (r=0.65, P<0.02). After therapy, the serum IgM levels decreased significantly (P<0.03). These results indicate that bacterial antigens may participate in the observed increase of serum IgM levels, and support an aetiological role of a gut-derived endotoxin antigen in the pathogenesis of primary biliary cirrhosis.
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Affiliation(s)
- Eric Ballot
- Service d'Immunologie, Hôpital Saint-Antoine, AP-HP, 184 rue du faubourg Saint-Antoine, 75012 Paris, France
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Abstract
Primary biliary cirrhosis and primary sclerosing cholangitis are the most common chronic cholestatic liver diseases in adults that lead to biliary cirrhosis and its inherent complications such as portal hypertension and liver failure. Although important advances in the understanding of the pathogenesis of these conditions have been accomplished in the last two decades, much work is needed to uncover the interaction of genetic and immunologic mechanisms involved in their pathogenesis. Ursodeoxycholic acid at dosage of 13 to 15 mg/kg/d is the only agent that can currently be recommended in the treatment of PBC. No medical therapy aimed at disrupting disease progression is available for patients with primary sclerosing cholangitis, although several agents with different properties are currently under evaluation. Liver transplantation is the treatment of choice for patients with primary biliary cirrhosis and primary sclerosing cholangitis with end-stage liver disease.
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Affiliation(s)
- P Angulo
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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Nilsson Ekdahl K, Lööf L, Ahrenstedt O, Nilsson UR, Nilsson B. Defective elimination of C3b/iC3b-coated autologous erythrocytes in patients with primary biliary cirrhosis, alcoholic cirrhosis, and ulcerative colitis. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 1997; 130:285-92. [PMID: 9341988 DOI: 10.1016/s0022-2143(97)90023-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Delayed in vivo elimination of autologous erythrocytes coated with immunoglobulin G has been reported in autoimmune and inflammatory gastrointestinal diseases. Our aim was to elucidate whether impairment of the macrophages was restricted to the Fc receptors of the reticuloendothelial system or whether complement receptors were also affected. We studied elimination by complement receptors of autologous erythrocytes coated with fragments of C3 and C4 in patients with primary biliary cirrhosis, ulcerative colitis, and alcoholic cirrhosis. Impaired function was seen in all patient groups as compared with function in normal subjects, both concerning the mean half-life of the injected cells and the total number of eliminated erythrocytes. Neither of these parameters correlated with the levels of C3 fragments bound to the injected autologous erythrocytes. This is the first report of defective complement receptor function in ulcerative colitis and alcoholic cirrhosis. Immunoglobulin G-dependent elimination of erythrocytes was confirmed to be lowered in all patient groups. The results suggest severe macrophage functional aberrations involving both complement receptors and Fc receptors as the basis of phagocytic defects in autoimmune/inflammatory conditions. In contrast, a general loss of macrophages might cause the functional loss in alcoholic cirrhosis.
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Affiliation(s)
- K Nilsson Ekdahl
- Department of Clinical Immunology and Transfusion Medicine, University Hospital, Uppsala, Sweden
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Ekdahl KN, Michaëlsson G, Gerdén B, Lööf L, Nilsson B. Impairments in complement receptor- and Fc receptor-mediated functions in vivo in patients with psoriasis. Arch Dermatol Res 1995; 287:225-30. [PMID: 7598525 DOI: 10.1007/bf01105070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The function of the fixed macrophage system in 18 psoriasis patients was evaluated by measuring the elimination rate of injected autologous erythrocytes coated with iC3b or IgG. The mean half-life of iC3b-coated erythrocytes was significantly prolonged in patients with psoriasis compared with healthy controls (4.7 +/- 0.8 vs 2.7 +/- 0.2 min, P = 0.01). There was also a decrease in the total number of cells eliminated from the circulation (2.5 +/- 0.2 x 10(8) vs 3.3 +/- 0.2 x 10(8), P = 0.01). There was an even more pronounced increase in the half-life of IgG-coated erythrocytes (85 +/- 18 vs 20 +/- 5 min, P < 0.001), with normal values in only 5 of 15 patients, and 4 of these 5 patients were receiving systemic treatment. The slow elimination was interpreted as being caused by primary or secondary defects in receptor function rather than by blocking of the receptors by immune complexes, since patients with psoriasis show normal levels of circulating immune complexes. Further studies are needed to elucidate the nature of these defects.
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Affiliation(s)
- K N Ekdahl
- Department of Medical and Physiological Chemistry, Biomedical Centre, Uppsala, Sweden
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Gomez F, Ruiz P, Schreiber AD. Impaired function of macrophage Fc gamma receptors and bacterial infection in alcoholic cirrhosis. N Engl J Med 1994; 331:1122-8. [PMID: 7935636 DOI: 10.1056/nejm199410273311704] [Citation(s) in RCA: 112] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Bacterial infection is a frequent and often fatal complication in patients with cirrhosis. Macrophages play an important part in the host defense against infection because their Fc gamma receptors recognize antibody-coated bacteria. METHODS We prospectively studied macrophage Fc gamma-receptor function in vivo and in vitro in 49 patients with alcoholic cirrhosis, 10 alcoholics without cirrhosis, and 20 normal volunteers. RESULTS The clearance of IgG-sensitized autologous red cells was decreased in 37 of the 49 patients with cirrhosis but in none of the subjects without cirrhosis. In the 49 patients clearance was inhibited by a mean (+/- SE) of 47 +/- 3 percent at 1 hour and 53 +/- 3 percent at 1 1/2 hours, as compared with the clearance in the normal controls (P < 0.001). The impairment of macrophage Fc gamma-receptor-dependent clearance correlated with the degree of liver insufficiency but not with age, sex, nutritional status, HLA haplotype, or the presence of circulating immune complexes. The clearance of unsensitized and heat-altered autologous erythrocytes was normal. In vitro recognition of IgG-sensitized red cells by monocytes from the patients was not significantly decreased. During a two-year follow-up period, 11 patients had severe bacterial infections, and in 4 they were fatal. The mean clearance of IgG-sensitized red cells in these 11 patients (half-time, 126.2 +/- 22 hours) was significantly impaired, as compared with that in the 38 patients without severe infection (half-time, 32.2 +/- 18 hours, P < 0.001). CONCLUSIONS The function of macrophage Fc gamma receptors is impaired in patients with alcoholic cirrhosis, and this impairment probably contributes to the high incidence of bacterial infections among such patients.
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Affiliation(s)
- F Gomez
- Department of Medicine, Hospital of the University of Cadiz, Puerto Real, Spain
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Nilsson B, Nilsson UR, Karlsson-Parra A, Sjölin-Forsberg G, Hällgren R. Reconstitution of the alternative pathway of complement by plasma infusions given to a patient with an SLE-like syndrome associated with a hereditary C3 dysfunction. Ann Rheum Dis 1994; 53:691-4. [PMID: 7979584 PMCID: PMC1005438 DOI: 10.1136/ard.53.10.691] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To reconstitute a dysfunctional form of complement factor C3 in a patient with a systemic lupus erythematosus (SLE)-like syndrome. METHODS The propositus was treated with plasma infusions during five sessions over a period of eight months. RESULTS The alternative pathway was reconstituted to normal levels for approximately two to three days after each infusion. C3 fragments were incorporated into previously detected deposits of IgG and IgM at the dermal-epidermal junction and the immune complex levels gradually decreased during the whole treatment period. CONCLUSION The reconstitution appears to result in the solubilisation of tissue immune complexes and a subsequent transportation to the fixed macrophage system.
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Affiliation(s)
- B Nilsson
- Department of Clinical Immunology and Transfusion Medicine, University Hospital, Uppsala, Sweden
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Affiliation(s)
- C A Toth
- Laboratory of Cancer Biology, New England Deaconess Hospital, Harvard Medical School, Boston, Massachusetts 02115
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