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Central tolerance promoted by cell chimerism. Proc Natl Acad Sci U S A 2022; 119:e2214989119. [PMID: 36534805 PMCID: PMC9907097 DOI: 10.1073/pnas.2214989119] [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] [Indexed: 12/24/2022] Open
Abstract
Historically, successful allotransplantation was only achieved by utilizing powerful immunosuppressive drugs that were exposing the patient to severe opportunistic infections. The thymus of the transplant recipient renders such therapy obligatory as it constitutively blocks self-reactive T cells while allowing alloreactive T cells to mature and populate the periphery. In 1992, a follow-up study revealed the presence of donor leukocytes in long-term transplant survivors. The stable persistence of recipient and donor leukocytes in the transplanted patient, referred to as "chimerism", was considered the reason why in some cases it was even possible to stop immunosuppressive treatment without damaging the transplanted organ. Unfortunately, it quickly became evident that stable, persistent allogeneic chimerism was not easily achievable by design. Recently, a novel approach has been identified to help address this clinical gap in knowledge: Cotransplantation of a donor graft with a thymic organoid populated with donor precursor cells generates stable, long-term chimerism in the recipient. In humanized mice, the implantation of thymic organoids, populated with human donor inducible pluripotent stem cell (iPSC)-derived thymic epithelial cells (TECs) and the same donor CD34+ bone marrow precursors, induces tolerance to human leukocyte antigen (HLA)-matched donor tissues/organs. This technology will allow successful allotransplantation of cells/organs even between Major Histocompatibility Complex (MHC)-noncompatible individuals and allow getting rid of immunosuppressive treatments reducing recipient morbidity.
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Kong C, Ni X, Wang Y, Zhang A, Zhang Y, Lin F, Li S, Lv Y, Zhu J, Yao X, Dai Q, Mo Y, Wang J. ICA69 aggravates ferroptosis causing septic cardiac dysfunction via STING trafficking. Cell Death Dis 2022; 8:187. [PMID: 35397620 PMCID: PMC8994779 DOI: 10.1038/s41420-022-00957-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/03/2022] [Accepted: 03/16/2022] [Indexed: 12/30/2022]
Abstract
Previous studies have demonstrated that cardiomyocyte apoptosis, ferroptosis, and inflammation participate in the progress of sepsis-induced cardiomyopathy (SIC). Although Islet cell autoantigen 69 (ICA69) is an imperative molecule that could regulate inflammation and immune response in numerous illnesses, its function in cardiovascular disease, particularly in SIC, is still elusive. We confirmed that LPS significantly enhanced the expression of ICA69 in wild-type (WT) mice, macrophages, and cardiomyocytes. The knockout of ICA69 in lipopolysaccharide(LPS)-induced mice markedly elevated survival ratio and heart function, while inhibiting cardiac muscle and serum inflammatory cytokines, reactive oxygen (ROS), and ferroptosis biomarkers. Mechanistically, increased expression of ICA69 triggered the production of STING, which further resulted in the production of intracellular lipid peroxidation, eventually triggering ferroptosis and heart injury. Intriguingly, ICA69 deficiency only reversed the ferroptotic marker levels, such as prostaglandin endoperoxide synthase 2 (PTGS2), malonaldehyde (MDA), 4-hydroxynonenal (4HNE), glutathione peroxidase 4 (GPX4), superoxide dismutase (SOD), iron and lipid ROS, but had no effects on the xCT-dependent manner. Additionally, greater ICA69 level was identified in septic patients peripheralblood mononuclear cells (PBMCs) than in normal control groups. Generally, we unveil that ICA69 deficiency can relieve inflammation and ferroptosis in LPS-induced murine hearts and macrophages, making targeting ICA69 in heart a potentially promising treatment method for SIC.
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Klotz L, Eschborn M, Lindner M, Liebmann M, Herold M, Janoschka C, Torres Garrido B, Schulte-Mecklenbeck A, Gross CC, Breuer J, Hundehege P, Posevitz V, Pignolet B, Nebel G, Glander S, Freise N, Austermann J, Wirth T, Campbell GR, Schneider-Hohendorf T, Eveslage M, Brassat D, Schwab N, Loser K, Roth J, Busch KB, Stoll M, Mahad DJ, Meuth SG, Turner T, Bar-Or A, Wiendl H. Teriflunomide treatment for multiple sclerosis modulates T cell mitochondrial respiration with affinity-dependent effects. Sci Transl Med 2020; 11:11/490/eaao5563. [PMID: 31043571 DOI: 10.1126/scitranslmed.aao5563] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 08/20/2018] [Accepted: 04/02/2019] [Indexed: 01/06/2023]
Abstract
Interference with immune cell proliferation represents a successful treatment strategy in T cell-mediated autoimmune diseases such as rheumatoid arthritis and multiple sclerosis (MS). One prominent example is pharmacological inhibition of dihydroorotate dehydrogenase (DHODH), which mediates de novo pyrimidine synthesis in actively proliferating T and B lymphocytes. Within the TERIDYNAMIC clinical study, we observed that the DHODH inhibitor teriflunomide caused selective changes in T cell subset composition and T cell receptor repertoire diversity in patients with relapsing-remitting MS (RRMS). In a preclinical antigen-specific setup, DHODH inhibition preferentially suppressed the proliferation of high-affinity T cells. Mechanistically, DHODH inhibition interferes with oxidative phosphorylation (OXPHOS) and aerobic glycolysis in activated T cells via functional inhibition of complex III of the respiratory chain. The affinity-dependent effects of DHODH inhibition were closely linked to differences in T cell metabolism. High-affinity T cells preferentially use OXPHOS during early activation, which explains their increased susceptibility toward DHODH inhibition. In a mouse model of MS, DHODH inhibitory treatment resulted in preferential inhibition of high-affinity autoreactive T cell clones. Compared to T cells from healthy controls, T cells from patients with RRMS exhibited increased OXPHOS and glycolysis, which were reduced with teriflunomide treatment. Together, these data point to a mechanism of action where DHODH inhibition corrects metabolic disturbances in T cells, which primarily affects profoundly metabolically active high-affinity T cell clones. Hence, DHODH inhibition may promote recovery of an altered T cell receptor repertoire in autoimmunity.
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Affiliation(s)
- Luisa Klotz
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany.
| | - Melanie Eschborn
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Maren Lindner
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Marie Liebmann
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Martin Herold
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Claudia Janoschka
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Belén Torres Garrido
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Andreas Schulte-Mecklenbeck
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Catharina C Gross
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Johanna Breuer
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Petra Hundehege
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Vilmos Posevitz
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Béatrice Pignolet
- CRC-SEP, Neurosciences Department, Toulouse University Hospital and INSERM U1043 - CNRS UMR 5282, Centre de Physiopathologie Toulouse-Purpan, Université Toulouse III, 31300 Toulouse, France
| | - Giulia Nebel
- University of Münster, Institute of Molecular Cell Biology, 48149 Münster, Germany
| | - Shirin Glander
- University of Münster, Department of Genetic Epidemiology, 48149 Münster, Germany
| | - Nicole Freise
- University of Münster, Department of Immunology, 48149 Münster, Germany
| | - Judith Austermann
- University of Münster, Department of Immunology, 48149 Münster, Germany
| | - Timo Wirth
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Graham R Campbell
- University of Edinburgh, Centre for Clinical Brain Sciences, EH8 9YL Edinburgh, UK
| | - Tilman Schneider-Hohendorf
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Maria Eveslage
- University of Münster, Institute of Biostatistics and Clinical Research, 48149 Münster, Germany
| | - David Brassat
- CRC-SEP, Neurosciences Department, Toulouse University Hospital and INSERM U1043 - CNRS UMR 5282, Centre de Physiopathologie Toulouse-Purpan, Université Toulouse III, 31300 Toulouse, France
| | - Nicholas Schwab
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | - Karin Loser
- University Hospital Münster, Department of Dermatology, 48149 Münster, Germany
| | - Johannes Roth
- University of Münster, Department of Immunology, 48149 Münster, Germany
| | - Karin B Busch
- University of Münster, Institute of Molecular Cell Biology, 48149 Münster, Germany
| | - Monika Stoll
- University of Münster, Department of Genetic Epidemiology, 48149 Münster, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, Netherlands
| | - Don J Mahad
- University of Edinburgh, Centre for Clinical Brain Sciences, EH8 9YL Edinburgh, UK
| | - Sven G Meuth
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany
| | | | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Heinz Wiendl
- University Hospital Münster, Department of Neurology with Institute of Translational Neurology, 48149 Münster, Germany.,Brain and Mind Centre, Medical Faculty, University of Sydney, Sydney, Camperdown, NSW 2050, Australia
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Chiarelli F, Giannini C, Primavera M. Prediction and prevention of type 1 diabetes in children. Clin Pediatr Endocrinol 2019; 28:43-57. [PMID: 31384096 PMCID: PMC6646239 DOI: 10.1297/cpe.28.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/02/2019] [Indexed: 12/14/2022] Open
Abstract
Type 1 diabetes (T1D) is a chronic T-cell mediated autoimmune disease characterized by
destruction of beta cells. Although new data have better defined the complex etiology
underling the interrelation of genetic and environmental factors in the natural history of
T1D, relevant pieces of the puzzle still are missing. Genetic predisposition is mainly
associated to some histocompatibility leukocyte antigen (HLA) alleles; however, recent
data suggest that new as well as still unknown genes might better define the complex
multigenetic risk of the disease. In addition to the genetic effects, the concordance in
familial aggregation in T1D indicates a pivotal role of environmental factors in the
course of the disease, facilitating autoantibodies production. JDRF has recently proposed
a new early stage of T1D according to which the detection of two or more autoantibodies in
the blood, might describe those children at increased risk of developing T1D during the
following years. In contrast to the improvements reached by prediction models, to date
primary, secondary and tertiary prevention have still failed to achieve a safe and
efficacious intervention strategies. Anyway, the most recent progresses in this field pave
the way for future studies, with the aim of preventing T1D in children.
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Affiliation(s)
| | - Cosimo Giannini
- Department of Paediatrics, University of Chieti, Chieti, Italy
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Kraus AU, Penna-Martinez M, Shoghi F, Seidl C, Meyer G, Badenhoop K. HLA-DQB1 Position 57 Defines Susceptibility to Isolated and Polyglandular Autoimmunity in Adults: Interaction With Gender. J Clin Endocrinol Metab 2019; 104:1907-1916. [PMID: 30590628 DOI: 10.1210/jc.2018-01621] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/18/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Autoimmune endocrinopathies result from environmental triggers on the genetic background of risk alleles, especially HLA-DR and HLA-DQ with alanine (Ala) in HLA-DQB1 position 57 (Ala57), whereas amino acid Asp57 is protective. OBJECTIVES Differentiate the effects of HLA-DQB1 amino acid variants at position 57 in adult patients with isolated endocrinopathies and autoimmune polyglandular syndrome type 2 (APS-2) compared with healthy controls in relation to gender. SETTING University Hospital Frankfurt, Frankfurt, Germany. PARTICIPANTS Two hundred seventy-eight patients with APS-2 and 1373 patients with isolated endocrinopathies: [type 1 diabetes (T1D), n = 867], Addison disease (AD, n = 185), autoimmune thyroiditis (AIT, n = 321) and 526 healthy controls. RESULTS Homozygous HLA-DQB1 Ala57 was more frequent in polyglandular T1D/AIT (OR 11.7, Pc = 3 × 10-7) and AD/AIT (OR 4.0, Pc = 3 × 10-7), as well as in isolated T1D (OR 9.7, Pc = 3 × 10-7) and AD (OR 3.1, Pc = 3 × 10-7). Heterozygous HLA-DQB1 57 Ala/non-Ala was increased in women with isolated AD and polyglandular AD/AIT (both OR 1.7, Pc= 0.02) whereas the same amino acid variant was overrepresented in men with T1D compared with women (OR 1.6, Pc = 0.004). The amino acid Ala57 was more frequent (OR 2.0, Pc = 0.02) and the amino acid Asp57 was much more rare (OR 0.4, Pc = 0.007) in the APS-2 cohort T1D/AIT than in AD/AIT. CONCLUSION HLA-DQB1 confers strong susceptibility by Ala57 homozygosity and protection by non-Ala57, both in adult isolated and polyglandular diseases. Frequencies of HLA-DQB1 amino acids differentiate between APS-2 T1D/AIT and AD/AIT. HLA-DQB1 Ala57 heterozygous women are at increased risk for AD or AIT, whereas men were found to have an increased susceptibility for T1D.
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Affiliation(s)
- Anna U Kraus
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Frankfurt, Germany
| | - Marissa Penna-Martinez
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Frankfurt, Germany
| | - Firouzeh Shoghi
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Seidl
- Institute of Transfusion Medicine and Immunohematology, Department of Transplantation Immunology and Immunogenetics, University Hospital Frankfurt, Frankfurt, Germany
| | - Gesine Meyer
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Frankfurt, Germany
| | - Klaus Badenhoop
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Frankfurt, Germany
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Tajima A, Pradhan I, Geng X, Trucco M, Fan Y. Construction of Thymus Organoids from Decellularized Thymus Scaffolds. Methods Mol Biol 2019; 1576:33-42. [PMID: 27730537 PMCID: PMC5389928 DOI: 10.1007/7651_2016_9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
One of the hallmarks of modern medicine is the development of therapeutics that can modulate immune responses, especially the adaptive arm of immunity, for disease intervention and prevention. While tremendous progress has been made in the past decades, manipulating the thymus, the primary lymphoid organ responsible for the development and education of T lymphocytes, remains a challenge. One of the major obstacles is the difficulty to reproduce its unique extracellular matrix (ECM) microenvironment that is essential for maintaining the function and survival of thymic epithelial cells (TECs), the predominant population of cells in the thymic stroma. Here, we describe the construction of functional thymus organoids from decellularized thymus scaffolds repopulated with isolated TECs. Thymus decellularization was achieved by freeze-thaw cycles to induce intracellular ice crystal formation, followed by detergent-induced cell lysis. Cellular debris was removed with extensive wash. The decellularized thymus scaffolds can largely retain the 3D extracellular matrix (ECM) microenvironment that can support the recolonization of TECs. When transplanted into athymic nude mice, the reconstructed thymus organoids can effectively promote the homing of bone marrow-derived lymphocyte progenitors and support the development of a diverse and functional T cell repertoire. Bioengineering of thymus organoids can be a promising approach to rejuvenate/modulate the function of T-cell mediated adaptive immunity in regenerative medicine.
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Affiliation(s)
- Asako Tajima
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
| | - Isha Pradhan
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
| | - Xuehui Geng
- Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
- Department of Microbiology and Immunology, Medical College of Drexel University, Philadelphia, PA, USA
| | - Yong Fan
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, USA.
- Department of Microbiology and Immunology, Medical College of Drexel University, Philadelphia, PA, USA.
- Institute of Cellular Therapeutics, Allegheny Health Network, Room 1107 South Tower, 320 East North Avenue, Pittsburgh, PA, 15212, USA.
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Tajima A, Liu W, Pradhan I, Bertera S, Lakomy RA, Rudert WA, Trucco M, Meng WS, Fan Y. Promoting 3-D Aggregation of FACS Purified Thymic Epithelial Cells with EAK 16-II/EAKIIH6 Self-assembling Hydrogel. J Vis Exp 2016. [PMID: 27404995 DOI: 10.3791/54062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Thymus involution, associated with aging or pathological insults, results in diminished output of mature T-cells. Restoring the function of a failing thymus is crucial to maintain effective T cell-mediated acquired immune response against invading pathogens. However, thymus regeneration and revitalization proved to be challenging, largely due to the difficulties of reproducing the unique 3D microenvironment of the thymic stroma that is critical for the survival and function of thymic epithelial cells (TECs). We developed a novel hydrogel system to promote the formation of TEC aggregates, based on the self-assembling property of the amphiphilic EAK16-II oligopeptides and its histidinylated analogue EAKIIH6. TECs were enriched from isolated thymic cells with density-gradient, sorted with fluorescence-activated cell sorting (FACS), and labeled with anti-epithelial cell adhesion molecule (EpCAM) antibodies that were anchored, together with anti-His IgGs, on the protein A/G adaptor complexes. Formation of cell aggregates was promoted by incubating TECs with EAKIIH6 and EAK16-II oligopeptides, and then by increasing the ionic concentration of the medium to initiate gelation. TEC aggregates embedded in EAK hydrogel can effectively promote the development of functional T cells in vivo when transplanted into the athymic nude mice.
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Affiliation(s)
- Asako Tajima
- Institute of Cellular Therapeutics, Allegheny Health Network
| | - Wen Liu
- Division of Pharmaceutical Sciences, Mylan School of Pharmacy, Duquesne University
| | - Isha Pradhan
- Institute of Cellular Therapeutics, Allegheny Health Network
| | - Suzanne Bertera
- Institute of Cellular Therapeutics, Allegheny Health Network
| | - Robert A Lakomy
- Institute of Cellular Therapeutics, Allegheny Health Network
| | | | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network; Department of Biological Sciences, Carnegie Mellon University
| | - Wilson S Meng
- Division of Pharmaceutical Sciences, Mylan School of Pharmacy, Duquesne University
| | - Yong Fan
- Institute of Cellular Therapeutics, Allegheny Health Network; Department of Biological Sciences, Carnegie Mellon University;
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Tajima A, Pradhan I, Trucco M, Fan Y. Restoration of Thymus Function with Bioengineered Thymus Organoids. CURRENT STEM CELL REPORTS 2016; 2:128-139. [PMID: 27529056 PMCID: PMC4982700 DOI: 10.1007/s40778-016-0040-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The thymus is the primary site for the generation of a diverse repertoire of T-cells that are essential to the efficient function of adaptive immunity. Numerous factors varying from aging, chemotherapy, radiation exposure, virus infection and inflammation contribute to thymus involution, a phenomenon manifested as loss of thymus cellularity, increased stromal fibrosis and diminished naïve T-cell output. Rejuvenating thymus function is a challenging task since it has limited regenerative capability and we still do not know how to successfully propagate thymic epithelial cells (TECs), the predominant population of the thymic stromal cells making up the thymic microenvironment. Here, we will discuss recent advances in thymus regeneration and the prospects of applying bioengineered artificial thymus organoids in regenerative medicine and solid organ transplantation.
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Affiliation(s)
- Asako Tajima
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA 15212
| | - Isha Pradhan
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA 15212
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA 15212
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA 19104
| | - Yong Fan
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA 15212
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA 19104
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Beuers U, Gershwin ME. Unmet challenges in immune-mediated hepatobiliary diseases. Clin Rev Allergy Immunol 2016; 48:127-31. [PMID: 25820618 DOI: 10.1007/s12016-015-8484-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It is ironic that the liver, which serves a critical function in immune tolerance, itself becomes the victim of an autoimmune attack. Indeed, liver autoimmunity and the autoimmune diseases associated with both innate and adaptive responses to hepatocytes and/or cholangiocytes are models of human autoimmunity. For example, in primary biliary cirrhosis, there exists a well-defined and characteristic autoantibody and considerable homogeneity between patients. In autoimmune hepatitis, there are clinical characteristics that allow a rigorous subset definition and well-defined inflammatory infiltrates. In both cases, there are defects in a variety of immune pathways and including regulatory cells. In primary sclerosing cholangitis, with its characteristic overlap with inflammatory bowel disease, there are unique defects in innate immunity and particular important contribution of lymphoid homing to disease pathogenesis. In these diseases, as with other human autoimmune processes, there is the critical understanding that pathogenesis requires a genetic background, but is determined by environmental features, and indeed the concordance of these diseases in identical twins highlights the stochastic nature of immunopathology. Unfortunately, despite major advances in basic immunology and in immunopathology in these diseases, there remains a major void in therapy. The newer biologics that are so widely used in rheumatology, neurology, and gastroenterology have not yet seen success in autoimmune liver disease. Future efforts will depend on more rigorous molecular biology and systems analysis in order for successful application to be made to patients.
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Affiliation(s)
- Ulrich Beuers
- Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, P.O. Box 22600, 1100 DD, Amsterdam, The Netherlands,
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Abstract
Primary biliary cirrhosis (PBC) is characterized histologically by the presence of chronic non-suppurative destructive cholangitis of the small interlobular bile duct, leading to chronic progressive cholestasis. Most PBC patients are asymptomatic and have a reasonable prognosis, but a few develop esophageal varices or jaundice, rapidly leading to liver failure within a short period. As multiple factors appear to be involved in the onset of PBC, its clinical course may be complicated. Therefore, the use of an animal model would be valuable for clarifying the pathogenesis of PBC. Here, we review recent data of selected PBC models, particularly spontaneous models, xenobiotic immunized models, and infection-triggered models. There are a number of spontaneous models: the NOD.c3c4, dominant-negative TGF-β receptor II, IL-2Rα-/-, Scurfy, and Ae2a,b-/- mice. These animal models manifest distinct clinical and immunological features similar, but also often different, from those of human PBC. It is clear that a combination of genetic predisposition, environmental factors, and immunological dysfunction contribute to the pathogenesis of PBC. The diverse clinical course and complexity of the immunological mechanisms of PBC cannot be fully recapitulated solely any single animal model. The challenge remains to develop a progressive PBC disease model that exhibits fibrosis, and ultimately hepatic failure.
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Michels A, Zhang L, Khadra A, Kushner JA, Redondo MJ, Pietropaolo M. Prediction and prevention of type 1 diabetes: update on success of prediction and struggles at prevention. Pediatr Diabetes 2015; 16. [PMID: 26202050 PMCID: PMC4592445 DOI: 10.1111/pedi.12299] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Type 1 diabetes mellitus (T1DM) is the archetypal example of a T cell-mediated autoimmune disease characterized by selective destruction of pancreatic β cells. The pathogenic equation for T1DM presents a complex interrelation of genetic and environmental factors, most of which have yet to be identified. On the basis of observed familial aggregation of T1DM, it is certain that there is a decided heritable genetic susceptibility for developing T1DM. The well-known association of T1DM with certain human histocompatibility leukocyte antigen (HLA) alleles of the major histocompatibility complex (MHC) was a major step toward understanding the role of inheritance in T1DM. Type 1 diabetes is a polygenic disease with a small number of genes having large effects (e.g., HLA) and a large number of genes having small effects. Risk of T1DM progression is conferred by specific HLA DR/DQ alleles [e.g., DRB1*03-DQB1*0201 (DR3/DQ2) or DRB1*04-DQB1*0302 (DR4/DQ8)]. In addition, the HLA allele DQB1*0602 is associated with dominant protection from T1DM in multiple populations. A concordance rate lower than 100% between monozygotic twins indicates a potential involvement of environmental factors on disease development. The detection of at least two islet autoantibodies in the blood is virtually pre-diagnostic for T1DM. The majority of children who carry these biomarkers, regardless of whether they have an a priori family history of the disease, will develop insulin-requiring diabetes. Facilitating pre-diagnosis is the timing of seroconversion which is most pronounced in the first 2 yr of life. Unfortunately the significant progress in improving prediction of T1DM has not yet been paralleled by safe and efficacious intervention strategies aimed at preventing the disease. Herein we summarize the chequered history of prediction and prevention of T1DM, describing successes and failures alike, and thereafter examine future trends in the exciting, partially explored field of T1DM prevention.
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Affiliation(s)
- Aaron Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - Li Zhang
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - Anmar Khadra
- Department of Physiology, McGill University, Montreal, QC Canada
| | - Jake A. Kushner
- Division of Diabetes Pediatric Endocrinology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Maria J. Redondo
- Division of Diabetes Pediatric Endocrinology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Massimo Pietropaolo
- Division of Diabetes, Endocrinology and Metabolism, McNair Medical Institute, Baylor College of Medicine, Houston, Texas,To Whom Correspondence May be Addressed: Massimo Pietropaolo, M.D., Division of Diabetes, Endocrinology and Metabolism, Alkek Building for Biomedical Research, R 609, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030
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Tajima A, Liu W, Pradhan I, Bertera S, Bagia C, Trucco M, Meng WS, Fan Y. Bioengineering mini functional thymic units with EAK16-II/EAKIIH6 self-assembling hydrogel. Clin Immunol 2015; 160:82-9. [DOI: 10.1016/j.clim.2015.03.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/14/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022]
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Johar AS, Mastronardi C, Rojas-Villarraga A, Patel HR, Chuah A, Peng K, Higgins A, Milburn P, Palmer S, Silva-Lara MF, Velez JI, Andrews D, Field M, Huttley G, Goodnow C, Anaya JM, Arcos-Burgos M. Novel and rare functional genomic variants in multiple autoimmune syndrome and Sjögren's syndrome. J Transl Med 2015; 13:173. [PMID: 26031516 PMCID: PMC4450850 DOI: 10.1186/s12967-015-0525-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/08/2015] [Indexed: 12/16/2022] Open
Abstract
Background Multiple autoimmune syndrome (MAS), an extreme phenotype of autoimmune disorders, is a very well suited trait to tackle genomic variants of these conditions. Whole exome sequencing (WES) is a widely used strategy for detection of protein coding and splicing variants associated with inherited diseases. Methods The DNA of eight patients affected by MAS [all of whom presenting with Sjögren’s syndrome (SS)], four patients affected by SS alone and 38 unaffected individuals, were subject to WES. Filters to identify novel and rare functional (pathogenic–deleterious) homozygous and/or compound heterozygous variants in these patients and controls were applied. Bioinformatics tools such as the Human gene connectome as well as pathway and network analysis were applied to test overrepresentation of genes harbouring these variants in critical pathways and networks involved in autoimmunity. Results Eleven novel and rare functional variants were identified in cases but not in controls, harboured in: MACF1, KIAA0754, DUSP12, ICA1, CELA1, LRP1/STAT6, GRIN3B, ANKLE1, TMEM161A, and FKRP. These were subsequently subject to network analysis and their functional relatedness to genes already associated with autoimmunity was evaluated. Notably, the LRP1/STAT6 novel mutation was homozygous in one MAS affected patient and heterozygous in another. LRP1/STAT6 disclosed the strongest plausibility for autoimmunity. LRP1/STAT6 are involved in extracellular and intracellular anti-inflammatory pathways that play key roles in maintaining the homeostasis of the immune system. Further; networks, pathways, and interaction analyses showed that LRP1 is functionally related to the HLA-B and IL10 genes and it has a substantial impact within immunological pathways and/or reaction to bacterial and other foreign proteins (phagocytosis, regulation of phospholipase A2 activity, negative regulation of apoptosis and response to lipopolysaccharides). Further, ICA1 and STAT6 were also closely related to AIRE and IRF5, two very well known autoimmunity genes. Conclusions Novel and rare exonic mutations that may account for autoimmunity were identified. Among those, the LRP1/STAT6 novel mutation has the strongest case for being categorised as potentially causative of MAS given the presence of intriguing patterns of functional interaction with other major genes shaping autoimmunity. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0525-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angad S Johar
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Claudio Mastronardi
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Adriana Rojas-Villarraga
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia.
| | - Hardip R Patel
- Genome Discovery Unit, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Aaron Chuah
- Genome Discovery Unit, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Kaiman Peng
- Biomolecular Resource Facility, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Angela Higgins
- Biomolecular Resource Facility, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Peter Milburn
- Biomolecular Resource Facility, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Stephanie Palmer
- Biomolecular Resource Facility, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Maria Fernanda Silva-Lara
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Jorge I Velez
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Dan Andrews
- Immunogenomics and Bioinformatics Group, Immunology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Matthew Field
- Immunogenomics and Bioinformatics Group, Immunology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Gavin Huttley
- Biomolecular Resource Facility, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Chris Goodnow
- Immunogenomics and Bioinformatics Group, Immunology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia.
| | - Mauricio Arcos-Burgos
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, ACT, Australia.
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Fan Y, Tajima A, Goh SK, Geng X, Gualtierotti G, Grupillo M, Coppola A, Bertera S, Rudert WA, Banerjee I, Bottino R, Trucco M. Bioengineering Thymus Organoids to Restore Thymic Function and Induce Donor-Specific Immune Tolerance to Allografts. Mol Ther 2015; 23:1262-1277. [PMID: 25903472 DOI: 10.1038/mt.2015.77] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 04/05/2015] [Indexed: 02/07/2023] Open
Abstract
One of the major obstacles in organ transplantation is to establish immune tolerance of allografts. Although immunosuppressive drugs can prevent graft rejection to a certain degree, their efficacies are limited, transient, and associated with severe side effects. Induction of thymic central tolerance to allografts remains challenging, largely because of the difficulty of maintaining donor thymic epithelial cells in vitro to allow successful bioengineering. Here, the authors show that three-dimensional scaffolds generated from decellularized mouse thymus can support thymic epithelial cell survival in culture and maintain their unique molecular properties. When transplanted into athymic nude mice, the bioengineered thymus organoids effectively promoted homing of lymphocyte progenitors and supported thymopoiesis. Nude mice transplanted with thymus organoids promptly rejected skin allografts and were able to mount antigen-specific humoral responses against ovalbumin on immunization. Notably, tolerance to skin allografts was achieved by transplanting thymus organoids constructed with either thymic epithelial cells coexpressing both syngeneic and allogenic major histocompatibility complexes, or mixtures of donor and recipient thymic epithelial cells. Our results demonstrate the technical feasibility of restoring thymic function with bioengineered thymus organoids and highlight the clinical implications of this thymus reconstruction technique in organ transplantation and regenerative medicine.
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Affiliation(s)
- Yong Fan
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Asako Tajima
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Saik Kia Goh
- Department of Chemical and Petroleum Engineering, University of Pittsburgh School of Engineering, Pittsburgh, Pennsylvania, USA
| | - Xuehui Geng
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Giulio Gualtierotti
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maria Grupillo
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Antonina Coppola
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Current address: Section of Endocrinology, Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), University of Palermo, Palermo, Italy
| | - Suzanne Bertera
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - William A Rudert
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Ipsita Banerjee
- Department of Chemical and Petroleum Engineering, University of Pittsburgh School of Engineering, Pittsburgh, Pennsylvania, USA
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
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Morran MP, Vonberg A, Khadra A, Pietropaolo M. Immunogenetics of type 1 diabetes mellitus. Mol Aspects Med 2015; 42:42-60. [PMID: 25579746 PMCID: PMC4548800 DOI: 10.1016/j.mam.2014.12.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/20/2014] [Accepted: 12/15/2014] [Indexed: 02/06/2023]
Abstract
Type 1 diabetes mellitus (T1DM) is an autoimmune disease arising through a complex interaction of both genetic and immunologic factors. Similar to the majority of autoimmune diseases, T1DM usually has a relapsing remitting disease course with autoantibody and T cellular responses to islet autoantigens, which precede the clinical onset of the disease process. The immunological diagnosis of autoimmune diseases relies primarily on the detection of autoantibodies in the serum of T1DM patients. Although their pathogenic significance remains uncertain, they have the practical advantage of serving as surrogate biomarkers for predicting the clinical onset of T1DM. Type 1 diabetes is a polygenic disease with a small number of genes having large effects (i.e. HLA), and a large number of genes having small effects. Risk of T1DM progression is conferred by specific HLA DR/DQ alleles [e.g., DRB1*03-DQB1*0201 (DR3) or DRB1*04-DQB1*0302 (DR4)]. In addition, HLA alleles such as DQB1*0602 are associated with dominant protection from T1DM in multiple populations. A discordance rate of greater than 50% between monozygotic twins indicates a potential involvement of environmental factors on disease development. Viral infections may play a role in the chain of events leading to disease, albeit conclusive evidence linking infections with T1DM remains to be firmly established. Two syndromes have been described in which an immune-mediated form of diabetes occurs as the result of a single gene defect. These syndromes are termed autoimmune polyglandular syndrome type I (APS-I) or autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), and X-linked poyendocrinopathy, immune dysfunction and diarrhea (XPID). These two syndromes are unique models to understand the mechanisms involved in the loss of tolerance to self-antigens in autoimmune diabetes and its associated organ-specific autoimmune disorders. A growing number of animal models of these diseases have greatly helped elucidate the immunologic mechanisms leading to autoimmune diabetes.
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Affiliation(s)
- Michael P Morran
- Laboratory of Immunogenetics, The Brehm Center for Diabetes Research, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew Vonberg
- Laboratory of Immunogenetics, The Brehm Center for Diabetes Research, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Anmar Khadra
- Department of Physiology, McGill University, Montreal, QC, Canada
| | - Massimo Pietropaolo
- Laboratory of Immunogenetics, The Brehm Center for Diabetes Research, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Fan Y, Fang X, Tajima A, Geng X, Ranganathan S, Dong H, Trucco M, Sperling MA. Evolution of hepatic steatosis to fibrosis and adenoma formation in liver-specific growth hormone receptor knockout mice. Front Endocrinol (Lausanne) 2014; 5:218. [PMID: 25566190 PMCID: PMC4270248 DOI: 10.3389/fendo.2014.00218] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 12/01/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver diseases closely associated with obesity and insulin resistance; deficient growth hormone (GH) action in liver has been implicated as a mechanism. Here, we investigated the evolution of NAFLD in aged mice with liver-specific GHR deletion. METHODS We examined glucose tolerance, insulin responsiveness, and lipid profiles in aged male mice (44-50 weeks) with GHRLD. We performed proteomics analysis, pathway-based Superarray assay, as well as quantitative RT-PCR to gain molecular insight into the mechanism(s) of GHR-deficiency-mediated NAFLD. In addition, we examined the pathological changes of livers of aged GHRLD male mice. RESULTS The biochemical profile was consistent with that of the metabolic syndrome: abnormal glucose tolerance, impaired insulin secretion, and hyperlipidemia. RT-qPCR analysis of key markers of inflammation revealed a three- to fivefold increase in TNFα and CCL3, confirming the presence of inflammation. Expression of fibrotic markers (e.g., Col1A2 and Col3A1) was significantly increased, together with a two- to threefold increase in TGFβ transcripts. Proteomics analyses showed a marked decrease of Mup1 and Selenbp2. In addition, pathway-analysis showed that the expression of cell cycle and growth relevant genes (i.e., Ccnd1, Socs2, Socs3, and Egfr) were markedly affected in GHRLD liver. Microscopic analyses (H&E) of GHRLD livers revealed the presence of hepatic adenomas of different stages of malignancy. CONCLUSION Abrogation of GH signaling in male liver leads to metabolic syndrome, hepatic steatosis, increased inflammation and fibrosis, and development of hepatic tumor. Since obesity, a common precursor of NAFLD, is a state of deficient GH secretion and action, the GHRLD model could be used to unravel the contribution of compromised hepatic GH signaling in these pathological processes, and help to identify potential targets for intervention.
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Affiliation(s)
- Yong Fan
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- *Correspondence: Yong Fan, Institute of Cellular Therapeutics, Allegheny Health Network, 11th Floor, South Tower, 320 E North Avenue, Pittsburgh, PA 15212, USA e-mail: ; Mark A. Sperling, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA e-mail:
| | - Xin Fang
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Pediatrics, Fujian Medical University Union Hospital, Fuzhou, China
| | - Asako Tajima
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Xuehui Geng
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Henry Dong
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Massimo Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
- Division of Immunogenetics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mark A. Sperling
- Division of Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- *Correspondence: Yong Fan, Institute of Cellular Therapeutics, Allegheny Health Network, 11th Floor, South Tower, 320 E North Avenue, Pittsburgh, PA 15212, USA e-mail: ; Mark A. Sperling, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA e-mail:
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