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Qi X, Li Z, Han J, Liu W, Xia P, Cai X, Liu X, Liu X, Zhang J, Yu P. Multifaceted roles of T cells in obesity and obesity-related complications: A narrative review. Obes Rev 2023; 24:e13621. [PMID: 37583087 DOI: 10.1111/obr.13621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/18/2023] [Accepted: 07/19/2023] [Indexed: 08/17/2023]
Abstract
Obesity is characterized by chronic low-grade inflammatory responses in the adipose tissue, accompanied by pronounced insulin resistance and metabolic anomalies. It affects almost all body organs and eventually leads to diseases such as fatty liver disease, type 2 diabetes mellitus, and atherosclerosis. Recently, T cells have emerged as interesting therapeutic targets because the dysfunction of T cells and their cytokines in the adipose tissue is implicated in obesity-induced inflammation and their complicated onset. Although several recent narrative reviews have provided a brief overview of related evidence in this area, they have mainly focused on either obesity-associated T cell metabolism or modulation of T cell activation in obesity. Moreover, at present, no published review has reported on the multifaceted roles of T cells in obesity and obesity-related complications, even though there has been a significant increase in studies on this topic since 2019. Therefore, this narrative review aims to comprehensively summarize current advances in the mechanistic roles of T cells in the development of obesity and its related complications. Further, we aim to discuss relevant drugs for weight loss as well as the contradictory role of T cells in the same disease so as to highlight key findings regarding this topic and provide a valid basis for future treatment strategies.
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Affiliation(s)
- Xinrui Qi
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Queen Mary School, Nanchang University, Nanchang, Jiangxi, China
| | - Zhangwang Li
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jiashu Han
- MD Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wenqing Liu
- Queen Mary School, Nanchang University, Nanchang, Jiangxi, China
| | - Panpan Xia
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xia Cai
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiao Liu
- Department of Cardiology, The Second Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xu Liu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Vollmer C, Dias A, Sales M, Sacramento PM, Silva JC, Oyamada HAA, Linhares UC, Gupta S, Kasahara TM, Bento CAM. Leptin favors imbalance of antigen-specific CD4 + T-cells associated with severity of cat allergy. Front Immunol 2023; 14:1290740. [PMID: 37954580 PMCID: PMC10639137 DOI: 10.3389/fimmu.2023.1290740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Obesity can complicate IgE-mediated allergic diseases. In the present study, we aimed to investigate the ability of obesity-related concentrations of leptin to modulate the in vitro effector and regulatory Fel d1-specific CD4+ T-cell subsets in patients allergic to cat, considered the third most common cause of respiratory allergy in humans. Methods For this study, plasma and peripheral blood mononuclear cells (PBMC) from 30 cat-allergic patients with mild, moderate and severe respiratory symptoms were obtained. The PBMC cultures were stimulated with Fel d1 antigen (10 µg/mL) in the presence or absence of obesity-related leptin dose (50 ηg/mL). After 6 days, the levels of cytokines and IgE in the supernatants were evaluated by multiplex and ELISA, respectively. The frequency of different non-follicular (CXCR5-) and follicular (CXCR5+) Fel d1-specific CD4+ T cell subsets was determined by flow cytometry. The plasma levels of leptin and IgE anti-cat titers were evaluated by ELISA and ImmunoCAP, respectively. Results and conclusions Fel d1 induced both IgE production and release of cytokines related to Th2, Th9 and Th17 cell phenotypes. Feld1 was more efficient in increasing the frequency of TFHIL-21- cells positive for IL-4, IL-5 and IL-13 than TFHIL-21+ cell subsets. Leptin favored the expansion Th2-like and Th9-like cells and TFHIL-21- cells positive for IL-4, IL-5 and IL-13, but reduced the proportion of conventional (Treg/Tr-1) and follicular (TFR) regulatory CD4+ T-cell subsets expressing or not CD39 marker. Finally, many of the imbalances between Fel d1-specific CD4+ T-cells were also correlated with plasma leptin and anti-Fel d1 IgE titers. In summary, hyperleptinemia should negatively impact on the severity of cat allergies by favoring the expansion of pathogenic Fel d1-specific CD4+ T-cell phenotypes and damaging the functional status of regulatory CD4+ T-cell subsets.
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Affiliation(s)
- Carolina Vollmer
- Post-graduate Program in Cellular and Molecular Biology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aleida Dias
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marisa Sales
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Priscila M. Sacramento
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Júlio Cesar Silva
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Hugo A. A. Oyamada
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ulisses C. Linhares
- Department of Morphological Sciences, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sudhir Gupta
- Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Taissa M. Kasahara
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cleonice A. M. Bento
- Post-graduate Program in Cellular and Molecular Biology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Bryant N, Muehling LM. T-cell responses in asthma exacerbations. Ann Allergy Asthma Immunol 2022; 129:709-718. [PMID: 35918022 PMCID: PMC9987567 DOI: 10.1016/j.anai.2022.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Asthma is a chronic lung disease comprising multiple endotypes and characterized by periodic exacerbations. A diverse array of T cells has been found to contribute to all endotypes of asthma in pathogenic and regulatory roles. Here, we review the contributions of CD4+, CD8+, and unconventional T cells in allergic and nonallergic asthma. DATA SOURCES Review of published literature pertaining to conventional and unconventional T-cell types in asthma. STUDY SELECTIONS Recent peer-reviewed articles pertaining to T cells in asthma, with additional peer-reviewed studies for context. RESULTS Much research in asthma has focused on the roles of CD4+ TH cells. Roles for TH2 cells in promoting allergic asthma pathogenesis have been well-described, and the recent description of pathogenic TH2A cells provides additional insight into these responses. Other TH types, notably TH1 and TH17, have been linked to neutrophilic and steroid-resistant asthma phenotypes. Beyond CD4+ T cells, CD8+ Tc2 cells are also strongly associated with allergic asthma. An emerging area for study is unconventional T-cell types, including γδT, invariant natural killer T, and mucosal-associated invariant T cells. Although data in asthma remain limited for these cells, their ability to bridge innate and adaptive responses likely makes them key players in asthma. A number of asthma therapies target T-cell responses, and, although data are limited, they seem to modulate T-cell populations. CONCLUSION Given the diversity and heterogeneity of asthma and T-cell responses, there remain many rich avenues for research to better understand the pathogenesis of asthma. Despite the breadth of T cells in asthma, approved therapeutics remain limited to TH2 networks.
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Affiliation(s)
- Naomi Bryant
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lyndsey M Muehling
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia.
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Vollmer CM, Dias ASO, Lopes LM, Kasahara TM, Delphim L, Silva JCC, Lourenço LP, Gonçalves HC, Linhares UC, Gupta S, Bento CAM. Leptin favors Th17/Treg cell subsets imbalance associated with allergic asthma severity. Clin Transl Allergy 2022; 12:e12153. [PMID: 35734271 PMCID: PMC9194742 DOI: 10.1002/clt2.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/29/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background Obesity has often been associated with severe allergic asthma (AA). Here, we analyzed the frequency of different circulating CD4+T‐cell subsets from lean, overweight and obese AA patients. Methods Mononuclear cells from peripheral blood were obtained from 60 AA patients and the frequency of different CD4+T‐cell subsets and type 1 regulatory B cells (Br1) was determined by cytometry. The effect of obese‐related leptin dose on cytokine production and Treg cell function in AA‐derived CD4+ T cell cultures was evaluated by ELISA and 3H thymidine uptake, respectively. Leptin levels were quantified in the plasma by ELISA. According to the BMI, patients were stratified as lean, overweight and obese. Results AA severity, mainly among obese patients, was associated with an expansion of hybrid Th2/Th17 and Th17‐like cells rather than classic Th2‐like cells. On the other hand, the frequencies of Th1‐like, Br1 cells and regulatory CD4+ T‐cell subsets were lower in patients with severe AA. While percentages of the hybrid Th2/Th17 phenotype and Th17‐like cells positively correlated with leptin levels, the frequencies of regulatory CD4+ T‐cell subsets and Br1 cells negatively correlated with this adipokine. Interestingly, the obesity‐related leptin dose not only elevated Th2 and Th17 cytokine levels, but also directly reduced the Treg function in CD4+ T cell cultures from lean AA patients. Conclusion In summary, our results indicated that obesity might increase AA severity by favoring the expansion of Th17‐like and Th2/Th17 cells and decreasing regulatory CD4+T cell subsets, being adverse effects probably mediated by leptin overproduction.
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Affiliation(s)
- Carolina M Vollmer
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Aleida S O Dias
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil.,Post-graduate Program in Microbiology University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Lana M Lopes
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil.,Post-graduate Program in Microbiology University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Taissa M Kasahara
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Letícia Delphim
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Júlio Cesar C Silva
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Lucas Paulo Lourenço
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | | | - Ulisses C Linhares
- Department of Morphological Sciences Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil
| | - Sudhir Gupta
- Department of Medicine University of California Irvine California USA
| | - Cleonice A M Bento
- Department of Microbiology and Parasitology Federal University of the State of Rio de Janeiro Rio de Janeiro Brazil.,Post-graduate Program in Microbiology University of the State of Rio de Janeiro Rio de Janeiro Brazil
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Abstract
Purpose of Review Obesity-associated difficult asthma continues to be a substantial problem and, despite a move to address treatable traits affecting asthma morbidity and mortality, it remains poorly understood with limited phenotype-specific treatments. The complex association between asthma, obesity, and inflammation is highlighted and recent advances in treatment options explored. Recent Findings Obesity negatively impacts asthma outcomes and has a causal link in the pathogenesis of adult-onset asthma. Imbalance in the adipose organ found in obesity favours a pro-inflammatory state both systemically and in airways. Obesity may impact currently available asthma biomarkers, and obesity-associated asthma specific biomarkers are needed. Whilst surgical weight loss interventions are associated with improvements in asthma control and quality of life, evidence for pragmatic conservative options are sparse. Innovative approaches tackling obesity-mediated airway inflammation may provide novel therapies. Summary The immunopathological mechanisms underlying obesity-associated asthma require further research that may lead to novel therapeutic options for this disease. However, weight loss appears to be effective in improving asthma in this cohort and focus is also needed on non-surgical treatments applicable in the real-world setting.
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Affiliation(s)
- Varun Sharma
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK. .,Glasgow Royal Infirmary, Glasgow, UK.
| | - Douglas C Cowan
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK. .,Glasgow Royal Infirmary, Glasgow, UK.
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de Candia P, Prattichizzo F, Garavelli S, Alviggi C, La Cava A, Matarese G. The pleiotropic roles of leptin in metabolism, immunity, and cancer. J Exp Med 2021; 218:211994. [PMID: 33857282 PMCID: PMC8056770 DOI: 10.1084/jem.20191593] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/11/2022] Open
Abstract
The discovery of the archetypal adipocytokine leptin and how it regulates energy homeostasis have represented breakthroughs in our understanding of the endocrine function of the adipose tissue and the biological determinants of human obesity. Investigations on leptin have also been instrumental in identifying physio-pathological connections between metabolic regulation and multiple immunological functions. For example, the description of the promoting activities of leptin on inflammation and cell proliferation have recognized the detrimental effects of leptin in connecting dysmetabolic conditions with cancer and with onset and/or progression of autoimmune disease. Here we review the multiple biological functions and complex framework of operations of leptin, discussing why and how the pleiotropic activities of this adipocytokine still pose major hurdles in the development of effective leptin-based therapeutic opportunities for different clinical conditions.
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Affiliation(s)
- Paola de Candia
- Istituto di Ricovero e Cura a Carattere Scientifico MultiMedica, Milan, Italy
| | | | - Silvia Garavelli
- Istituto per l'Endocrinologia e l'Oncologia Sperimentale, Consiglio Nazionale delle Ricerche, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, Università di Napoli "Federico II," Naples, Italy
| | - Antonio La Cava
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Giuseppe Matarese
- Istituto per l'Endocrinologia e l'Oncologia Sperimentale, Consiglio Nazionale delle Ricerche, Naples, Italy.,T reg Cell Lab, Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli "Federico II," Naples, Italy
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7
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Leija-Martínez JJ, Del-Río-Navarro BE, Sanchéz-Muñoz F, Muñoz-Hernández O, Hong E, Giacoman-Martínez A, Romero-Nava R, Patricio-Román KL, Hall-Mondragon MS, Espinosa-Velazquez D, Villafaña S, Huang F. Associations of TNFA, IL17A, and RORC mRNA expression levels in peripheral blood leukocytes with obesity-related asthma in adolescents. Clin Immunol 2021; 229:108715. [PMID: 33771687 DOI: 10.1016/j.clim.2021.108715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 01/10/2023]
Abstract
Obesity is associated with a unique non-T2 asthma phenotype, characterised by a Th17 immune response. Retinoid-related orphan receptor C (RORC) is the master transcription factor for Th17 polarisation. We investigated the association of TNFA, IL17A, and RORC mRNA expression levels with the non-T2 phenotype. We conducted a cross-sectional study in adolescents, subdivided as follows: healthy (HA), allergic asthma without obesity (AA), obesity without asthma (OB), and non-allergic asthma with obesity (NAO). TNFA, IL17A, and RORC mRNA expression in peripheral blood leukocytes were assessed by RT-PCR. NAO exhibited higher TNFA mRNA expression levels than HA or OB, as well as the highest IL17A and RORC mRNA expression levels among the four groups. The best biomarker for discriminating non-allergic asthma among obese adolescents was RORC mRNA expression levels (area under the curve: 0.95). RORC mRNA expression levels were associated with the non-T2 asthma phenotype, hinting at a therapeutic target in obesity-related asthma.
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Affiliation(s)
- José J Leija-Martínez
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico; Hospital Infantil de Mexico Federico Gómez, Research Laboratory of Pharmacology, Mexico City, Mexico
| | - Blanca E Del-Río-Navarro
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico; Hospital Infantil de México Federico Gómez, Department of Paediatric Allergy Clinical Immunology, Mexico City, Mexico
| | - Fausto Sanchéz-Muñoz
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico; Departamento de Inmunología, Instituto Nacional de Cardiología "Ignacio Chávez", Mexico City, Mexico
| | - Onofre Muñoz-Hernández
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico
| | - Enrique Hong
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico; Department of Pharmacobiology, Centro de Investigacion de Estudio Avanzados del Instituto Politecnico Nacional, Mexico City, Calz. de Los Tenorios 235, Col. Granjas Coapa, 14330, Mexico
| | - Abraham Giacoman-Martínez
- Hospital Infantil de Mexico Federico Gómez, Research Laboratory of Pharmacology, Mexico City, Mexico
| | - Rodrigo Romero-Nava
- Hospital Infantil de Mexico Federico Gómez, Research Laboratory of Pharmacology, Mexico City, Mexico; Laboratorio de Señalización Intracelular, Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico
| | - Karla L Patricio-Román
- Hospital Infantil de Mexico Federico Gómez, Research Laboratory of Pharmacology, Mexico City, Mexico; Laboratorio de Señalización Intracelular, Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico
| | - Margareth S Hall-Mondragon
- Hospital Infantil de México Federico Gómez, Department of Paediatric Allergy Clinical Immunology, Mexico City, Mexico; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social. IMSS, Mexico
| | - Dario Espinosa-Velazquez
- Hospital Infantil de México Federico Gómez, Department of Paediatric Allergy Clinical Immunology, Mexico City, Mexico
| | - Santiago Villafaña
- Laboratorio de Señalización Intracelular, Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico
| | - Fengyang Huang
- Universidad Nacional Autónoma de México, Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Mexico City, Mexico; Hospital Infantil de Mexico Federico Gómez, Research Laboratory of Pharmacology, Mexico City, Mexico.
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Bergantini L, Cameli P, d'Alessandro M, Vietri L, Perruzza M, Pieroni M, Lanzarone N, Refini RM, Fossi A, Bargagli E. Regulatory T Cells in Severe Persistent Asthma in the Era of Monoclonal Antibodies Target Therapies. Inflammation 2021; 43:393-400. [PMID: 31853715 DOI: 10.1007/s10753-019-01157-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Asthma is an immunoinflammatory disease characterized by bronchial hyper-reactivity to different external stimuli. New monoclonal target treatments have been developed, but few studies have investigated the role of regulatory T cells in severe asthma and the modulatory effect of biological therapy on regulatory T cell functions. Their dysfunction may contribute to the development and exacerbation of asthma. Here we review the recent literature on the potential immunological role of regulatory T cells in the pathogenesis of severe asthma. The analysis of the role of regulatory T cells was performed in terms of functions and their possible interactions with mechanisms of action of the novel treatment for severe asthma. In an era of biological therapies for severe asthma, little data is available on the potential effects of what could be a new therapy: monoclonal antibody targeting of regulatory T cell numbers and functions.
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Affiliation(s)
- L Bergantini
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy.
| | - P Cameli
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - M d'Alessandro
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - L Vietri
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - M Perruzza
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - M Pieroni
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - N Lanzarone
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - R M Refini
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - A Fossi
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
| | - E Bargagli
- Department of Medicine, Surgery and Neurosciences, Respiratory Diseases and Lung Transplantation Section, University of Siena, Viale Bracci, 1, 53100, Siena, Italy
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