1
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Dartois V, Bonfield TL, Boyce JP, Daley CL, Dick T, Gonzalez-Juarrero M, Gupta S, Kramnik I, Lamichhane G, Laughon BE, Lorè NI, Malcolm KC, Olivier KN, Tuggle KL, Jackson M. Preclinical murine models for the testing of antimicrobials against Mycobacterium abscessus pulmonary infections: Current practices and recommendations. Tuberculosis (Edinb) 2024; 147:102503. [PMID: 38729070 PMCID: PMC11168888 DOI: 10.1016/j.tube.2024.102503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/12/2024]
Abstract
Mycobacterium abscessus, a rapidly growing nontuberculous mycobacterium, is increasingly recognized as an important pathogen of the human lung, disproportionally affecting people with cystic fibrosis (CF) and other susceptible individuals with non-CF bronchiectasis and compromised immune functions. M. abscessus infections are extremely difficult to treat due to intrinsic resistance to many antibiotics, including most anti-tuberculous drugs. Current standard-of-care chemotherapy is long, includes multiple oral and parenteral repurposed drugs, and is associated with significant toxicity. The development of more effective oral antibiotics to treat M. abscessus infections has thus emerged as a high priority. While murine models have proven instrumental in predicting the efficacy of therapeutic treatments for M. tuberculosis infections, the preclinical evaluation of drugs against M. abscessus infections has proven more challenging due to the difficulty of establishing a progressive, sustained, pulmonary infection with this pathogen in mice. To address this issue, a series of three workshops were hosted in 2023 by the Cystic Fibrosis Foundation (CFF) and the National Institute of Allergy and Infectious Diseases (NIAID) to review the current murine models of M. abscessus infections, discuss current challenges and identify priorities toward establishing validated and globally harmonized preclinical models. This paper summarizes the key points from these workshops. The hope is that the recommendations that emerged from this exercise will facilitate the implementation of informative murine models of therapeutic efficacy testing across laboratories, improve reproducibility from lab-to-lab and accelerate preclinical-to-clinical translation.
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Affiliation(s)
- Véronique Dartois
- Center for Discovery and Innovation & Department of Medical Sciences, Hackensack Meridian School of Medicine, Hackensack Meridian Health, Nutley, NJ, USA.
| | - Tracey L Bonfield
- Genetics and Genome Sciences and National Center for Regenerative Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jim P Boyce
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Charles L Daley
- Department of Medicine, National Jewish Health, Denver, CO, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas Dick
- Center for Discovery and Innovation & Department of Medical Sciences, Hackensack Meridian School of Medicine, Hackensack Meridian Health, Nutley, NJ, USA; Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
| | - Mercedes Gonzalez-Juarrero
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523-1682, USA
| | - Shashank Gupta
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Igor Kramnik
- National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, 02215, USA; Department of Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Gyanu Lamichhane
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Barbara E Laughon
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nicola I Lorè
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kenneth C Malcolm
- Department of Medicine, National Jewish Health, Denver, CO, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kenneth N Olivier
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, USA; Marsico Lung Institute, Chapel Hill, 27599-7248, NC, USA
| | | | - Mary Jackson
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523-1682, USA.
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2
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De M, Serpa G, Zuiker E, Hisert KB, Liles WC, Manicone AM, Hemann EA, Long ME. MEK1/2 inhibition decreases pro-inflammatory responses in macrophages from people with cystic fibrosis and mitigates severity of illness in experimental murine methicillin-resistant Staphylococcus aureus infection. Front Cell Infect Microbiol 2024; 14:1275940. [PMID: 38352056 PMCID: PMC10861668 DOI: 10.3389/fcimb.2024.1275940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Chronic pulmonary bacterial infections and associated inflammation remain a cause of morbidity and mortality in people with cystic fibrosis (PwCF) despite new modulator therapies. Therapies targeting host factors that dampen detrimental inflammation without suppressing immune responses critical for controlling infections remain limited, while the development of lung infections caused by antimicrobial resistant bacteria is an increasing global problem, and a significant challenge in CF. Pharmacological compounds targeting the mammalian MAPK proteins MEK1 and MEK2, referred to as MEK1/2 inhibitor compounds, have potential combined anti-microbial and anti-inflammatory effects. Here we examined the immunomodulatory properties of MEK1/2 inhibitor compounds PD0325901, trametinib, and CI-1040 on CF innate immune cells. Human CF macrophage and neutrophil phagocytic functions were assessed by quantifying phagocytosis of serum opsonized pHrodo red E. coli, Staphylococcus aureus, and zymosan bioparticles. MEK1/2 inhibitor compounds reduced CF macrophage pro-inflammatory cytokine production without impairing CF macrophage or neutrophil phagocytic abilities. Wild-type C57BL6/J and Cftr tm1kth (F508del homozygous) mice were used to evaluate the in vivo therapeutic potential of PD0325901 compared to vehicle treatment in an intranasal methicillin-resistant Staphylococcus aureus (MRSA) infection with the community-acquired MRSA strain USA300. In both wild-type and CF mice, PD0325901 reduced inflammation associated body mass loss. Wild-type mice treated with PD0325901 had significant reduction in neutrophil-mediated inflammation compared to vehicle treatment groups, with preserved clearance of bacteria in lung, liver, or spleen 1 day after infection in either wild-type or CF mouse models. In summary, this study provides the first data evaluating the therapeutic potential of MEK1/2 inhibitor to modulate CF immune cells and demonstrates that MEK1/2 inhibitors diminish pro-inflammatory responses without impairing host defense mechanisms required for acute pathogen clearance.
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Affiliation(s)
- Mithu De
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
| | - Gregory Serpa
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
| | - Eryn Zuiker
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
| | | | - W. Conrad Liles
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, WA, United States
- Center for Lung Biology, University of Washington, Seattle, WA, United States
| | - Anne M. Manicone
- Center for Lung Biology, University of Washington, Seattle, WA, United States
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Emily A. Hemann
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
| | - Matthew E. Long
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH, United States
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
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3
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Casey M, Simmonds NJ. Why don't anti-inflammatories work in cystic fibrosis? Expert Rev Respir Med 2024; 18:1-3. [PMID: 38386416 DOI: 10.1080/17476348.2024.2323189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/21/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Michelle Casey
- Adult Cystic Fibrosis Centre, Royal Brompton & Harefield Hospitals, part of Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton & Harefield Hospitals, part of Guys & St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
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4
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De M, Hisert KB, Liles WC, Manicone AM, Hemann EA, Long ME. MEK1/2 inhibition decreases pro-inflammatory responses in macrophages from people with cystic fibrosis and mitigates severity of illness in experimental murine methicillin-resistant Staphylococcus aureus infection. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.22.525092. [PMID: 36712028 PMCID: PMC9882267 DOI: 10.1101/2023.01.22.525092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic pulmonary bacterial infections and associated inflammation remain a cause of morbidity and mortality in people with cystic fibrosis (PwCF) despite new modulator therapies. Therapies targeting host factors that dampen detrimental inflammation without suppressing immune responses critical for controlling infections remain limited, while the acquisition of antibiotic resistance bacterial infections is an increasing global problem, and a significant challenge in CF. Pharmacological compounds targeting the mammalian MAPK proteins MEK1 and MEK2, referred to as MEK1/2 inhibitor compounds, have potential combined anti-microbial and anti-inflammatory effects. Here we examined the immunomodulatory properties of MEK1/2 inhibitor compounds PD0325901, trametinib, and CI-1040 on CF innate immune cells. Human CF macrophage and neutrophil phagocytic functions were assessed by quantifying phagocytosis of serum opsonized pHrodo red E. coli , Staphylococcus aureus , and zymosan bioparticles. MEK1/2 inhibitor compounds reduced CF macrophage pro-inflammatory cytokine production without impairing CF macrophage or neutrophil phagocytic abilities. Wild-type C57BL6/J and Cftr tm1kth (F508del homozygous) mice were used to evaluate the in vivo therapeutic potential of PD0325901 compared to vehicle treatment in an intranasal methicillin-resistant Staphylococcus aureus (MRSA) infection with the community-acquired MRSA strain USA300. In both wild-type and CF mice, PD0325901 reduced infection related weight loss compared to vehicle treatment groups but did not impair clearance of bacteria in lung, liver, or spleen 1 day after infection. In summary, this study provides the first data evaluating the therapeutic potential of MEK1/2 inhibitor to modulate CF immune cells, and demonstrates that MEK1/2 inhibitors dampen pro-inflammatory responses without impairing host defense mechanisms mediating pathogen clearance.
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5
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Laucirica DR, Stick SM, Garratt LW, Kicic A. Bacteriophage: A new therapeutic player to combat neutrophilic inflammation in chronic airway diseases. Front Med (Lausanne) 2022; 9:1069929. [PMID: 36590945 PMCID: PMC9794625 DOI: 10.3389/fmed.2022.1069929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Persistent respiratory bacterial infections are a clinical burden in several chronic inflammatory airway diseases and are often associated with neutrophil infiltration into the lungs. Following recruitment, dysregulated neutrophil effector functions such as increased granule release and formation of neutrophil extracellular traps (NETs) result in damage to airway tissue, contributing to the progression of lung disease. Bacterial pathogens are a major driver of airway neutrophilic inflammation, but traditional management of infections with antibiotic therapy is becoming less effective as rates of antimicrobial resistance rise. Bacteriophages (phages) are now frequently identified as antimicrobial alternatives for antimicrobial resistant (AMR) airway infections. Despite growing recognition of their bactericidal function, less is known about how phages influence activity of neutrophils recruited to sites of bacterial infection in the lungs. In this review, we summarize current in vitro and in vivo findings on the effects of phage therapy on neutrophils and their inflammatory mediators, as well as mechanisms of phage-neutrophil interactions. Understanding these effects provides further validation of their safe use in humans, but also identifies phages as a targeted neutrophil-modulating therapeutic for inflammatory airway conditions.
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Affiliation(s)
- Daniel R. Laucirica
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Stephen M. Stick
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
- Department of Respiratory and Sleep Medicine, Perth Children’s Hospital, Nedlands, WA, Australia
- Centre for Cell Therapy and Regenerative Medicine, School of Medicine and Pharmacology, The University of Western Australia and Harry Perkins Institute of Medical Research, Nedlands, WA, Australia
| | - Luke W. Garratt
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Anthony Kicic
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
- Department of Respiratory and Sleep Medicine, Perth Children’s Hospital, Nedlands, WA, Australia
- Centre for Cell Therapy and Regenerative Medicine, School of Medicine and Pharmacology, The University of Western Australia and Harry Perkins Institute of Medical Research, Nedlands, WA, Australia
- School of Population Health, Curtin University, Bentley, WA, Australia
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6
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New TMA (4,6,4'-Trimethyl angelicin) Analogues as Anti-Inflammatory Agents in the Treatment of Cystic Fibrosis Lung Disease. Int J Mol Sci 2022; 23:ijms232214483. [PMID: 36430961 PMCID: PMC9699093 DOI: 10.3390/ijms232214483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022] Open
Abstract
A series of new-generation TMA (4,6,4'-trimethyl angelicin) analogues was projected and synthetized in order to ameliorate anti-inflammatory activity, with reduced or absent toxicity. Since the NF-κB transcription factor (TF) plays a critical role in the expression of IL-8 (Interluekin 8), a typical marker of lung inflammation in Cystic Fibrosis (CF), the use of agents able to interfere with the NF-κB pathway represents an interesting therapeutic strategy. Through preliminary EMSA experiments, we identified several new TMA derivatives able to inhibit the NF-κB/DNA complex. The selected active molecules were then analyzed to evaluate the anti-inflammatory effect using both Pseudomonas aeruginosa (PAO1) infection and TNF-alpha stimulus on the CF IB3-1 cell line. It was demonstrated that mainly two TMA analogues, GY971a mesylate salt (6-p-minophenyl-4,4'-dimethyl-angelicin) and GY964 (4-phenyl-6,4'-dimethyl-angelicin), were able to decrease the IL-8 gene expression. At the same time, these molecules were found to have no pro-apoptotic, mutagenic and phototoxic effects, facilitating our decision to test the efficacy in vivo by using a mouse model of acute P. aeruginosa lung infection. The anti-inflammatory effect of GY971a was confirmed in vivo; this derivative was able to deeply decrease the total number of inflammatory cells, the neutrophil count and the cytokine/chemokine profile in the P. aeruginosa acute infection model, without evident toxicity. Considering all the obtained and reported in vitro and in vivo pre-clinical results, GY971a seems to have interesting anti-inflammatory effects, modulating the NF-κB pathway, as well as the starting lead compound TMA, but without side effects.
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7
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Efficacy of selective histone deacetylase 6 inhibition in mouse models of Pseudomonas aeruginosa infection: A new glimpse for reducing inflammation and infection in cystic fibrosis. Eur J Pharmacol 2022; 936:175349. [DOI: 10.1016/j.ejphar.2022.175349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022]
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8
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De Leo F, Rossi A, De Marchis F, Cigana C, Melessike M, Quilici G, De Fino I, Mantonico MV, Fabris C, Bragonzi A, Bianchi ME, Musco G. Pamoic acid is an inhibitor of HMGB1·CXCL12 elicited chemotaxis and reduces inflammation in murine models of Pseudomonas aeruginosa pneumonia. Mol Med 2022; 28:108. [PMID: 36071400 PMCID: PMC9449960 DOI: 10.1186/s10020-022-00535-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/25/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND High-mobility group box 1 protein (HMGB1) is an ubiquitous nuclear protein that once released in the extracellular space acts as a Damage Associated Molecular Pattern and promotes inflammation. HMGB1 is significantly elevated during Pseudomonas aeruginosa infections and has a clinical relevance in respiratory diseases such as Cystic Fibrosis (CF). Salicylates are HMGB1 inhibitors. To address pharmacological inhibition of HMGB1 with small molecules, we explored the therapeutic potential of pamoic acid (PAM), a salicylate with limited ability to cross epithelial barriers. METHODS PAM binding to HMGB1 and CXCL12 was tested by Nuclear Magnetic Resonance Spectroscopy using chemical shift perturbation methods, and inhibition of HMGB1·CXCL12-dependent chemotaxis was investigated by cell migration experiments. Aerosol delivery of PAM, with single or repeated administrations, was tested in murine models of acute and chronic P. aeruginosa pulmonary infection in C57Bl/6NCrlBR mice. PAM efficacy was evaluated by read-outs including weight loss, bacterial load and inflammatory response in lung and bronco-alveolar lavage fluid. RESULTS Our data and three-dimensional models show that PAM is a direct ligand of both HMGB1 and CXCL12. We also showed that PAM is able to interfere with heterocomplex formation and the related chemotaxis in vitro. Importantly, PAM treatment by aerosol was effective in reducing acute and chronic airway murine inflammation and damage induced by P. aeruginosa. The results indicated that PAM reduces leukocyte recruitment in the airways, in particular neutrophils, suggesting an impaired in vivo chemotaxis. This was associated with decreased myeloperoxidase and neutrophil elastase levels. Modestly increased bacterial burdens were recorded with single administration of PAM in acute infection; however, repeated administration in chronic infection did not affect bacterial burdens, indicating that the interference of PAM with the immune system has a limited risk of pulmonary exacerbation. CONCLUSIONS This work established the efficacy of treating inflammation in chronic respiratory diseases, including bacterial infections, by topical delivery in the lung of PAM, an inhibitor of HMGB1.
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Affiliation(s)
- Federica De Leo
- Biomolecular NMR Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| | - Alice Rossi
- Infection and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Cristina Cigana
- Infection and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Medede Melessike
- Infection and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Quilici
- Biomolecular NMR Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ida De Fino
- Infection and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Malisa Vittoria Mantonico
- Biomolecular NMR Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| | - Chantal Fabris
- Biomolecular NMR Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Bragonzi
- Infection and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Marco Emilio Bianchi
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy. .,Chromatin Dynamics Unit, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | - Giovanna Musco
- Biomolecular NMR Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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9
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Pathogenesis of pneumonia and acute lung injury. Clin Sci (Lond) 2022; 136:747-769. [PMID: 35621124 DOI: 10.1042/cs20210879] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022]
Abstract
Pneumonia and its sequelae, acute lung injury, present unique challenges for pulmonary and critical care healthcare professionals, and these challenges have recently garnered global attention due to the ongoing Sars-CoV-2 pandemic. One limitation to translational investigation of acute lung injury, including its most severe manifestation (acute respiratory distress syndrome, ARDS) has been heterogeneity resulting from the clinical and physiologic diagnosis that represents a wide variety of etiologies. Recent efforts have improved our understanding and approach to heterogeneity by defining sub-phenotypes of ARDS although significant gaps in knowledge remain. Improving our mechanistic understanding of acute lung injury and its most common cause, infectious pneumonia, can advance our approach to precision targeted clinical interventions. Here, we review the pathogenesis of pneumonia and acute lung injury, including how respiratory infections and lung injury disrupt lung homoeostasis, and provide an overview of respiratory microbial pathogenesis, the lung microbiome, and interventions that have been demonstrated to improve outcomes-or not-in human clinical trials.
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10
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Keir HR, Chalmers JD. Neutrophil extracellular traps in chronic lung disease: implications for pathogenesis and therapy. Eur Respir Rev 2022; 31:31/163/210241. [PMID: 35197267 PMCID: PMC9488971 DOI: 10.1183/16000617.0241-2021] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/28/2021] [Indexed: 12/20/2022] Open
Abstract
Neutrophilic inflammation has a key role in the pathophysiology of multiple chronic lung diseases. The formation of neutrophil extracellular traps (NETs) has emerged as a key mechanism of disease in neutrophilic lung diseases including asthma, COPD, cystic fibrosis and, most recently, bronchiectasis. NETs are large, web-like structures composed of DNA and anti-microbial proteins that are able to bind pathogens, prevent microbial dissemination and degrade bacterial virulence factors. The release of excess concentrations of proteases, antimicrobial proteins, DNA and histones, however, also leads to tissue damage, impaired mucociliary clearance, impaired bacterial killing and increased inflammation. A number of studies have linked airway NET formation with greater disease severity, increased exacerbations and overall worse disease outcomes across the spectrum of airway diseases. Treating neutrophilic inflammation has been challenging in chronic lung disease because of the delicate balance between reducing inflammation and increasing the risk of infections through immunosuppression. Novel approaches to suppressing NET formation or the associated inflammation are in development and represent an important therapeutic target. This review will discuss the relationship between NETs and the pathophysiology of cystic fibrosis, asthma, COPD and bronchiectasis, and explore the current and future development of NET-targeting therapies. NETs contribute to the pathophysiology of chronic lung disease. Immunomodulating therapies that may reduce inflammatory mediators and NET formation, without compromising bacterial clearance, offer a new treatment path for patients. https://bit.ly/3fyJC6I
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Affiliation(s)
- Holly R Keir
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
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11
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The Effect of CFTR Modulators on Airway Infection in Cystic Fibrosis. Int J Mol Sci 2022; 23:ijms23073513. [PMID: 35408875 PMCID: PMC8998472 DOI: 10.3390/ijms23073513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/08/2023] Open
Abstract
The advent of Cystic fibrosis transmembrane receptor (CFTR) modulators in 2012 was a critical event in the history of cystic fibrosis (CF) treatment. Unlike traditional therapies that target downstream effects of CFTR dysfunction, CFTR modulators aim to correct the underlying defect at the protein level. These genotype-specific therapies are now available for an increasing number of CF patients, transforming the way we view the condition from a life-limiting disease to one that can be effectively managed. Several studies have demonstrated the vast improvement CFTR modulators have on normalization of sweat chloride, CFTR function, clinical endpoints, and frequency of pulmonary exacerbation. However, their impact on other aspects of the disease, such as pathogenic burden and airway infection, remain under explored. Frequent airway infections as a result of increased susceptibility and impaired innate immune response are a serious problem within CF, often leading to accelerated decline in lung function and disease progression. Current evidence suggests that CFTR modulators are unable to eradicate pathogenic organisms in those with already established lung disease. However, this may not be the case for those with relatively low levels of disease progression and conserved microbial diversity, such as young patients. Furthermore, it remains unknown whether the restorative effects exerted by CFTR modulators extend to immune cells, such as phagocytes, which have the potential to modulate the response of people with CF (pwCF) to infection. Throughout this review, we look at the potential impact of CFTR modulators on airway infection in CF and their ability to shape impaired pulmonary defences to pathogens.
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12
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Kim SK, Hong SJ, Yoo DM, Min C, Choi HG. Association between asthma or chronic obstructive pulmonary disease and chronic otitis media. Sci Rep 2022; 12:4228. [PMID: 35273329 PMCID: PMC8913729 DOI: 10.1038/s41598-022-08287-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/11/2022] [Indexed: 11/09/2022] Open
Abstract
We hypothesized that asthma/chronic obstructive pulmonary disease (COPD) might increase the risk of chronic otitis media (COM), as asthma or COPD affects other diseases. The aim of this research was to investigate whether the incidence of COM is affected by a diagnosis of asthma or COPD in patients compared to matched controls from the national health screening cohort. A COM group (n = 11,587) and a control group that was 1:4 matched for age, sex, income, and residence area (n = 46,348) were selected. The control group included participants who never received treatment for COM from Korean National Health Insurance Service-Health Screening Cohort from 2002 to 2015. The crude and adjusted odds ratios (ORs) of previous asthma/COPD before the index date for COM were analyzed using conditional logistic regression. The analyses were stratified by age, sex, income, and region of residence. The period prevalence of asthma (17.5% vs. 14.3%, p < 0.001) and COPD (6.6% vs. 5.0%, p < 0.001) were significantly higher in the COM group than in the control group. In addition, the odds of asthma and COPD were significantly higher in the COM group than in the control group. Both asthma (adjusted OR 1.23, 95% confidence interval [CI] 1.16-1.31, p < 0.001) and COPD (adjusted OR 1.23, 95% CI 1.13-1.35, p < 0.001) increased the ORs for COM. This positive association between asthma/COPD and COM indicates that asthma/COPD might increase the incidence of COM.
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Affiliation(s)
- Sung Kyun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Dongtan, Korea.,Laboratory of Brain & Cognitive Sciences for Convergence Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Seok Jin Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Dongtan, Korea
| | - Dae Myoung Yoo
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Korea
| | - Chanyang Min
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Korea.,Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Hyo Geun Choi
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Korea. .,Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170, Anyang, Gyeonggi, 14068, Republic of Korea.
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13
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Affiliation(s)
- Merete B Long
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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14
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Elborn JS, Konstan MW, Taylor-Cousar JL, Fajac I, Horsley A, Sutharsan S, Aaron SD, Daines CL, Uluer A, Downey DG, Lucidi VV, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. Empire-CF study: A phase 2 clinical trial of leukotriene A4 hydrolase inhibitor acebilustat in adult subjects with cystic fibrosis. J Cyst Fibros 2021; 20:1026-1034. [PMID: 34538755 DOI: 10.1016/j.jcf.2021.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is characterized by neutrophilic inflammation in the airways. Leukotriene B4 (LTB4) is a neutrophil chemoattractant and has been implicated in CF pathogenesis. Acebilustat, a novel, synthetic, small-molecule leukotriene A4 hydrolase inhibitor, reduces LTB4 production. We report findings from a randomized placebo-controlled trial of acebilustat in adult subjects with mild-to-moderate lung disease. METHODS Subjects were randomized (1:1:1) to once-daily acebilustat 50 mg, 100 mg or placebo for 48 weeks, concomitantly with their current therapeutic regimen. Subjects were stratified by use of concomitant CF transmembrane conductance regulator (CFTR) modulators, baseline percent predicted forced expiratory volume in 1 second (ppFEV1) 50-75 and >75, and number of pulmonary exacerbations in the past year (1 or >1). Primary endpoints were the change from baseline in ppFEV1 and safety. Secondary endpoints included the rate of pulmonary exacerbations. RESULTS Overall, 199 subjects were randomized and dosed (acebilustat 50 mg, n=67; acebilustat 100 mg, n=66; placebo, n=66). Baseline demographics and disease profile were well balanced among treatment groups. Acebilustat had no statistically significant effect on the primary endpoint of change in ppFEV1 at week 48 or the secondary endpoint pulmonary exacerbations. There was a trend towards reduced pulmonary exacerbations in subjects receiving acebilustat in pre-specified populations with ppFEV1>75 (35% rate reduction) and those on concomitant CFTR modulator therapy (20% rate reduction). Acebilustat was well tolerated. CONCLUSIONS Acebilustat did not improve lung function. A trend towards reduced pulmonary exacerbations in subjects with an earlier stage of lung disease suggests a potential effect in this population.
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Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine Health and Life sciences Queens University School of Medicine, Belfast, UK
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | | | - Isabelle Fajac
- Physiology Department, Cochin Hospital, APHP Centre, Paris, France; Université de Paris, Paris, France
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine EssenRuhrlandklinik, University of DuisburgEssen, Essen, Germany
| | - Shawn D Aaron
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Ahmet Uluer
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Vincenzina V Lucidi
- Cystic Fibrosis Center, Children's Hospital and Research Institute, Bambino Gesu, Rome, Italy
| | | | | | | | | | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center and Department of Medicine, University of Alabama at Birmingham, 1918 University Blvd, MCLM 804, Birmingham 35294, AL, USA.
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15
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Abstract
Bronchiectasis is a complex, heterogeneous disorder defined by both a radiological abnormality of permanent bronchial dilatation and a clinical syndrome. There are multiple underlying causes including severe infections, mycobacterial disease, autoimmune conditions, hypersensitivity disorders, and genetic conditions. The pathophysiology of disease is understood in terms of interdependent concepts of chronic infection, inflammation, impaired mucociliary clearance, and structural lung damage. Neutrophilic inflammation is characteristic of the disease, with elevated levels of harmful proteases such as neutrophil elastase associated with worse outcomes. Recent data show that neutrophil extracellular trap formation may be the key mechanism leading to protease release and severe bronchiectasis. Despite the dominant of neutrophilic disease, eosinophilic subtypes are recognized and may require specific treatments. Neutrophilic inflammation is associated with elevated bacterial loads and chronic infection with organisms such as Pseudomonas aeruginosa. Loss of diversity of the normal lung microbiota and dominance of proteobacteria such as Pseudomonas and Haemophilus are features of severe bronchiectasis and link to poor outcomes. Ciliary dysfunction is also a key feature, exemplified by the rare genetic syndrome of primary ciliary dyskinesia. Mucus symptoms arise through goblet cell hyperplasia and metaplasia and reduced ciliary function through dyskinesia and loss of ciliated cells. The contribution of chronic inflammation, infection, and mucus obstruction leads to progressive structural lung damage. The heterogeneity of the disease is the most challenging aspect of management. An understanding of the pathophysiology of disease and their biomarkers can help to guide personalized medicine approaches utilizing the concept of "treatable traits."
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Affiliation(s)
- Holly R Keir
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
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16
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Turner MJ, Abbott-Banner K, Thomas DY, Hanrahan JW. Cyclic nucleotide phosphodiesterase inhibitors as therapeutic interventions for cystic fibrosis. Pharmacol Ther 2021; 224:107826. [PMID: 33662448 DOI: 10.1016/j.pharmthera.2021.107826] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/05/2021] [Accepted: 02/22/2021] [Indexed: 12/13/2022]
Abstract
Cystic Fibrosis (CF) lung disease results from mutations in the CFTR anion channel that reduce anion and fluid secretion by airway epithelia. Impaired secretion compromises airway innate defence mechanisms and leads to bacterial colonization, excessive inflammation and tissue damage; thus, restoration of CFTR function is the goal of many CF therapies. CFTR channels are activated by cyclic nucleotide-dependent protein kinases. The second messengers 3'5'-cAMP and 3'5'-cGMP are hydrolysed by a large family of cyclic nucleotide phosphodiesterases that provide subcellular spatial and temporal control of cyclic nucleotide-dependent signalling. Selective inhibition of these enzymes elevates cyclic nucleotide levels, leading to activation of CFTR and other downstream effectors. Here we examine members of the PDE family that are likely to regulate CFTR-dependent ion and fluid secretion in the airways and discuss other actions of PDE inhibitors that can influence cyclic nucleotide-regulated mucociliary transport, inflammation and bronchodilation. Finally, we review PDE inhibitors and the potential benefits they could provide as CF therapeutics.
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Affiliation(s)
- Mark J Turner
- Department of Physiology, McGill University, Montreal, QC, Canada; Cystic Fibrosis Translational Research Centre, McGill University, Montreal, QC, Canada.
| | | | - David Y Thomas
- Cystic Fibrosis Translational Research Centre, McGill University, Montreal, QC, Canada; Department of Biochemistry, McGill University, Montreal, QC, Canada
| | - John W Hanrahan
- Department of Physiology, McGill University, Montreal, QC, Canada; Cystic Fibrosis Translational Research Centre, McGill University, Montreal, QC, Canada
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17
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Yonker LM, Barrios J, Mou H, Hurley BP. Untapped Potential: Therapeutically Targeting Eicosanoids and Endocannabinoids in the Lung. Clin Pharmacol Ther 2021; 110:69-81. [PMID: 33423293 DOI: 10.1002/cpt.2165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/20/2020] [Indexed: 02/05/2023]
Abstract
Inflammation of the airway involves the recruitment of highly active immune cells to combat and clear microbes and toxic factors; however, this inflammatory response can result in unintended damage to lung tissue. Tissue damage resulting from inflammation is often mitigated by resolving factors that limit the scope and duration of the inflammatory response. Both inflammatory and resolving processes require the actions of a vast array of lipid mediators that can be rapidly synthesized through a variety of airway resident and infiltrating immune cells. Eicosanoids and endocannabinoids represent two major classes of lipid mediators that share synthetic enzymes and have diverse and overlapping functions. This review seeks to provide a summary of the major bioactive eicosanoids and endocannabinoids, challenges facing researchers that study them, and their roles in modulating inflammation and resolution. With a special emphasis on cystic fibrosis, a variety of therapeutics are discussed that have been explored for their potential anti-inflammatory or proresolving impact toward alleviating excessive airway inflammation and improving lung function.
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Affiliation(s)
- Lael M Yonker
- Massachusetts General Hospital, Department of Pediatrics, Pulmonary Division, Boston, Massachusetts, USA.,Massachusetts General Hospital, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, USA.,Harvard Medical School, Department of Pediatrics, Boston, Massachusetts, USA
| | - Juliana Barrios
- Massachusetts General Hospital, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, USA.,Harvard Medical School, Department of Pediatrics, Boston, Massachusetts, USA
| | - Hongmei Mou
- Massachusetts General Hospital, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, USA.,Harvard Medical School, Department of Pediatrics, Boston, Massachusetts, USA
| | - Bryan P Hurley
- Massachusetts General Hospital, Mucosal Immunology and Biology Research Center, Boston, Massachusetts, USA.,Harvard Medical School, Department of Pediatrics, Boston, Massachusetts, USA
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18
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Lin WC, Fessler MB. Regulatory mechanisms of neutrophil migration from the circulation to the airspace. Cell Mol Life Sci 2021; 78:4095-4124. [PMID: 33544156 PMCID: PMC7863617 DOI: 10.1007/s00018-021-03768-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/22/2020] [Accepted: 01/16/2021] [Indexed: 02/07/2023]
Abstract
The neutrophil, a short-lived effector leukocyte of the innate immune system best known for its proteases and other degradative cargo, has unique, reciprocal physiological interactions with the lung. During health, large numbers of ‘marginated’ neutrophils reside within the pulmonary vasculature, where they patrol the endothelial surface for pathogens and complete their life cycle. Upon respiratory infection, rapid and sustained recruitment of neutrophils through the endothelial barrier, across the extravascular pulmonary interstitium, and again through the respiratory epithelium into the airspace lumen, is required for pathogen killing. Overexuberant neutrophil trafficking to the lung, however, causes bystander tissue injury and underlies several acute and chronic lung diseases. Due in part to the unique architecture of the lung’s capillary network, the neutrophil follows a microanatomic passage into the distal airspace unlike that observed in other end-organs that it infiltrates. Several of the regulatory mechanisms underlying the stepwise recruitment of circulating neutrophils to the infected lung have been defined over the past few decades; however, fundamental questions remain. In this article, we provide an updated review and perspective on emerging roles for the neutrophil in lung biology, on the molecular mechanisms that control the trafficking of neutrophils to the lung, and on past and ongoing efforts to design therapeutics to intervene upon pulmonary neutrophilia in lung disease.
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Affiliation(s)
- Wan-Chi Lin
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, NIH, 111 T.W. Alexander Drive, P.O. Box 12233, MD D2-01, Research Triangle Park, NC, 27709, USA
| | - Michael B Fessler
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, NIH, 111 T.W. Alexander Drive, P.O. Box 12233, MD D2-01, Research Triangle Park, NC, 27709, USA.
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19
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Giam YH, Shoemark A, Chalmers JD. Neutrophil dysfunction in bronchiectasis: an emerging role for immunometabolism. Eur Respir J 2021; 58:13993003.03157-2020. [DOI: 10.1183/13993003.03157-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/12/2021] [Indexed: 12/22/2022]
Abstract
Bronchiectasis is a heterogenous disease with multiple underlying causes. The pathophysiology is poorly understood but neutrophilic inflammation and dysfunctional killing of pathogens is believed to be key. There are, however, no licensed therapies for bronchiectasis that directly target neutrophilic inflammation. In this review, we discuss our current understanding of neutrophil dysfunction and therapeutic targeting in bronchiectasis. Immunometabolic reprogramming, a process through which inflammation changes inflammatory cell behaviour by altering intracellular metabolic pathways, is increasingly recognised across multiple inflammatory and autoimmune diseases. Here, we show evidence that much of the neutrophil dysfunction observed in bronchiectasis is consistent with immunometabolic reprogramming. Previous attempts at developing therapies targeting neutrophils have focused on reducing neutrophil numbers, resulting in increased frequency of infections. New approaches are needed and we propose that targeting metabolism could theoretically reverse neutrophil dysfunction and dysregulated inflammation. As an exemplar, 5' adenosine monophosphate (AMP)-activated protein kinase (AMPK) activation has already been shown to reverse phagocytic dysfunction and neutrophil extracellular trap (NET) formation in models of pulmonary disease. AMPK modulates multiple metabolic pathways, including glycolysis which is critical for energy generation in neutrophils. AMPK activators can reverse metabolic reprogramming and are already in clinical use and/or development. We propose the need for a new immunomodulatory approach, rather than an anti-inflammatory approach, to enhance bacterial clearance and reduce bronchiectasis disease severity.
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20
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Perrem L, Ratjen F. Designing Clinical Trials for Anti-Inflammatory Therapies in Cystic Fibrosis. Front Pharmacol 2020; 11:576293. [PMID: 33013419 PMCID: PMC7516261 DOI: 10.3389/fphar.2020.576293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/24/2020] [Indexed: 01/15/2023] Open
Abstract
The inflammatory response in the CF airway begins early in the disease process and becomes persistent through life in most patients. Inflammation, which is predominantly neutrophilic, worsens airway obstruction and plays a critical role in the development of structural lung damage. While cystic fibrosis transmembrane regulator modulators will likely have a dramatic impact on the trajectory of CF lung disease over the coming years, addressing other important aspects of lung disease such as inflammation will nevertheless remain a priority. Considering the central role of neutrophils and their products in the inflammatory response, potential therapies should ultimately affect neutrophils and their products. The ideal anti-inflammatory therapy would exert a dual effect on the pro-inflammatory and pro-resolution arms of the inflammatory cascade, both of which contribute to dysregulated inflammation in CF. This review outlines the key factors to be considered in the design of clinical trials evaluating anti-inflammatory therapies in CF. Important lessons have been learned from previous clinical trials in this area and choosing the right efficacy endpoints is key to the success of any anti-inflammatory drug development program. Identifying and validating non-invasive biomarkers, novel imaging techniques and sensitive lung function tests capable of monitoring disease activity and therapeutic response are important areas of research and will be useful for the design of future anti-inflammatory drug trials.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
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21
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Poerio N, De Santis F, Rossi A, Ranucci S, De Fino I, Henriquez A, D’Andrea MM, Ciciriello F, Lucidi V, Nisini R, Bragonzi A, Fraziano M. Liposomes Loaded With Phosphatidylinositol 5-Phosphate Improve the Antimicrobial Response to Pseudomonas aeruginosa in Impaired Macrophages From Cystic Fibrosis Patients and Limit Airway Inflammatory Response. Front Immunol 2020; 11:532225. [PMID: 33117337 PMCID: PMC7562816 DOI: 10.3389/fimmu.2020.532225] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 01/02/2023] Open
Abstract
Despite intensive antimicrobial and anti-inflammatory therapies, cystic fibrosis (CF) patients are subjected to chronic infections due to opportunistic pathogens, including multidrug resistant (MDR) Pseudomonas aeruginosa. Macrophages from CF patients show many evidences of reduced phagocytosis in terms of internalization capability, phagosome maturation, and intracellular bacterial killing. In this study, we investigated if apoptotic body-like liposomes (ABLs) loaded with phosphatidylinositol 5-phosphate (PI5P), known to regulate actin dynamics and vesicular trafficking, could restore phagocytic machinery while limiting inflammatory response in in vitro and in vivo models of MDR P. aeruginosa infection. Our results show that the in vitro treatment with ABL carrying PI5P (ABL/PI5P) enhances bacterial uptake, ROS production, phagosome acidification, and intracellular bacterial killing in human monocyte-derived macrophages (MDMs) with pharmacologically inhibited cystic fibrosis transmembrane conductance regulator channel (CFTR), and improve uptake and intracellular killing of MDR P. aeruginosa in CF macrophages with impaired bactericidal activity. Moreover, ABL/PI5P stimulation of CFTR-inhibited MDM infected with MDR P. aeruginosa significantly reduces NF-κB activation and the production of TNF-α, IL-1β, and IL-6, while increasing IL-10 and TGF-β levels. The therapeutic efficacy of ABL/PI5P given by pulmonary administration was evaluated in a murine model of chronic infection with MDR P. aeruginosa. The treatment with ABL/PI5P significantly reduces pulmonary neutrophil infiltrate and the levels of KC and MCP-2 cytokines in the lungs, without affecting pulmonary bacterial load. Altogether, these results show that the ABL/PI5P treatment may represent a promising host-directed therapeutic approach to improve the impaired phagocytosis and to limit the potentially tissue-damaging inflammatory response in CF.
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Affiliation(s)
- Noemi Poerio
- Dipartimento di Biologia, Università degli Studi di Roma “Tor Vergata”, Roma, Italy
| | - Federica De Santis
- Dipartimento di Biologia, Università degli Studi di Roma “Tor Vergata”, Roma, Italy
| | - Alice Rossi
- Unità di Infezioni e Fibrosi Cistica, Istituto Scientifico San Raffaele, Milano, Italy
| | - Serena Ranucci
- Unità di Infezioni e Fibrosi Cistica, Istituto Scientifico San Raffaele, Milano, Italy
| | - Ida De Fino
- Unità di Infezioni e Fibrosi Cistica, Istituto Scientifico San Raffaele, Milano, Italy
| | - Ana Henriquez
- Dipartimento di Biologia, Università degli Studi di Roma “Tor Vergata”, Roma, Italy
| | - Marco M. D’Andrea
- Dipartimento di Biologia, Università degli Studi di Roma “Tor Vergata”, Roma, Italy
| | - Fabiana Ciciriello
- Unità Operativa Complessa Fibrosi Cistica, Dipartimento di Medicina Pediatrica, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Vincenzina Lucidi
- Unità Operativa Complessa Fibrosi Cistica, Dipartimento di Medicina Pediatrica, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Roberto Nisini
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, Roma, Italy
| | - Alessandra Bragonzi
- Unità di Infezioni e Fibrosi Cistica, Istituto Scientifico San Raffaele, Milano, Italy
| | - Maurizio Fraziano
- Dipartimento di Biologia, Università degli Studi di Roma “Tor Vergata”, Roma, Italy
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22
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Hisert KB, Birkland TP, Schoenfelt KQ, Long ME, Grogan B, Carter S, Liles WC, McKone EF, Becker L, Manicone AM, Gharib SA. CFTR Modulator Therapy Enhances Peripheral Blood Monocyte Contributions to Immune Responses in People With Cystic Fibrosis. Front Pharmacol 2020; 11:1219. [PMID: 33013356 PMCID: PMC7461946 DOI: 10.3389/fphar.2020.01219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background CFTR modulators decrease some etiologies of CF airway inflammation; however, data indicate that non-resolving airway infection and inflammation persist in individuals with CF and chronic bacterial infections. Thus, identification of therapies that diminish airway inflammation without allowing unrestrained bacterial growth remains a critical research goal. Novel strategies for combatting deleterious airway inflammation in the CFTR modulator era require better understanding of cellular contributions to chronic CF airway disease, and how inflammatory cells change after initiation of CFTR modulator therapy. Peripheral blood monocytes, which traffic to the CF airway, can develop both pro-inflammatory and inflammation-resolving phenotypes, represent intriguing cellular targets for focused therapies. This therapeutic approach, however, requires a more detailed knowledge of CF monocyte cellular programming and phenotypes. Material and Methods In order to characterize the inflammatory phenotype of CF monocytes, and how these cells change after initiation of CFTR modulator therapy, we studied adults (n=10) with CF, chronic airway infections, and the CFTR-R117H mutations before and 7 days after initiation of ivacaftor. Transcriptomes of freshly isolated blood monocytes were interrogated by RNA-sequencing (RNA-seq) followed by pathway-based analyses. Plasma concentrations of cytokines and chemokines were evaluated by multiplex ELISA. Results RNAseq identified approximately 50 monocyte genes for which basal expression was significantly changed in all 10 subjects after 7 days of ivacaftor. Of these, the majority were increased in expression post ivacaftor, including many genes traditionally associated with enhanced inflammation and immune responses. Pathway analyses confirmed that transcriptional programs were overwhelmingly up-regulated in monocytes after 7 days of ivacaftor, including biological modules associated with immunity, cell cycle, oxidative phosphorylation, and the unfolded protein response. Ivacaftor increased plasma concentrations of CXCL2, a neutrophil chemokine secreted by monocytes and macrophages, and CCL2, a monocyte chemokine. Conclusions Our results demonstrate that ivacaftor causes acute changes in blood monocyte transcriptional profiles and plasma chemokines, and suggest that increased monocyte inflammatory signals and changes in myeloid cell trafficking may contribute to changes in airway inflammation in people taking CFTR modulators. To our knowledge, this is the first report investigating the transcriptomic response of circulating blood monocytes in CF subjects treated with a CFTR modulator.
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Affiliation(s)
- Katherine B Hisert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, United States.,Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Timothy P Birkland
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Kelly Q Schoenfelt
- Ben May Department for Cancer Research, University of Chicago, Chicago, IL, United States
| | - Matthew E Long
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Brenda Grogan
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Suzanne Carter
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - W Conrad Liles
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Edward F McKone
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Lev Becker
- Ben May Department for Cancer Research, University of Chicago, Chicago, IL, United States
| | - Anne M Manicone
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Sina A Gharib
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
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23
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Cabrini G, Rimessi A, Borgatti M, Lampronti I, Finotti A, Pinton P, Gambari R. Role of Cystic Fibrosis Bronchial Epithelium in Neutrophil Chemotaxis. Front Immunol 2020; 11:1438. [PMID: 32849500 PMCID: PMC7427443 DOI: 10.3389/fimmu.2020.01438] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022] Open
Abstract
A hallmark of cystic fibrosis (CF) chronic respiratory disease is an extensive neutrophil infiltrate in the mucosa filling the bronchial lumen, starting early in life for CF infants. The genetic defect of the CF Transmembrane conductance Regulator (CFTR) ion channel promotes dehydration of the airway surface liquid, alters mucus properties, and decreases mucociliary clearance, favoring the onset of recurrent and, ultimately, chronic bacterial infection. Neutrophil infiltrates are unable to clear bacterial infection and, as an adverse effect, contribute to mucosal tissue damage by releasing proteases and reactive oxygen species. Moreover, the rapid cellular turnover of lumenal neutrophils releases nucleic acids that further alter the mucus viscosity. A prominent role in the recruitment of neutrophil in bronchial mucosa is played by CF bronchial epithelial cells carrying the defective CFTR protein and are exposed to whole bacteria and bacterial products, making pharmacological approaches to regulate the exaggerated neutrophil chemotaxis in CF a relevant therapeutic target. Here we revise: (a) the major receptors, kinases, and transcription factors leading to the expression, and release of neutrophil chemokines in bronchial epithelial cells; (b) the role of intracellular calcium homeostasis and, in particular, the calcium crosstalk between endoplasmic reticulum and mitochondria; (c) the epigenetic regulation of the key chemokines; (d) the role of mutant CFTR protein as a co-regulator of chemokines together with the host-pathogen interactions; and (e) different pharmacological strategies to regulate the expression of chemokines in CF bronchial epithelial cells through novel drug discovery and drug repurposing.
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Affiliation(s)
- Giulio Cabrini
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy.,Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Alessandro Rimessi
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Monica Borgatti
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Ilaria Lampronti
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Alessia Finotti
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Paolo Pinton
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Roberto Gambari
- Center for Innovative Therapies in Cystic Fibrosis, University of Ferrara, Ferrara, Italy.,Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
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24
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Di Pietro C, Öz HH, Murray TS, Bruscia EM. Targeting the Heme Oxygenase 1/Carbon Monoxide Pathway to Resolve Lung Hyper-Inflammation and Restore a Regulated Immune Response in Cystic Fibrosis. Front Pharmacol 2020; 11:1059. [PMID: 32760278 PMCID: PMC7372134 DOI: 10.3389/fphar.2020.01059] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/30/2020] [Indexed: 12/11/2022] Open
Abstract
In individuals with cystic fibrosis (CF), lung hyper-inflammation starts early in life and is perpetuated by mucus obstruction and persistent bacterial infections. The continuous tissue damage and scarring caused by non-resolving inflammation leads to bronchiectasis and, ultimately, respiratory failure. Macrophages (MΦs) are key regulators of immune response and host defense. We and others have shown that, in CF, MΦs are hyper-inflammatory and exhibit reduced bactericidal activity. Thus, MΦs contribute to the inability of CF lung tissues to control the inflammatory response or restore tissue homeostasis. The non-resolving hyper-inflammation in CF lungs is attributed to an impairment of several signaling pathways associated with resolution of the inflammatory response, including the heme oxygenase-1/carbon monoxide (HO-1/CO) pathway. HO-1 is an enzyme that degrades heme groups, leading to the production of potent antioxidant, anti-inflammatory, and bactericidal mediators, such as biliverdin, bilirubin, and CO. This pathway is fundamental to re-establishing cellular homeostasis in response to various insults, such as oxidative stress and infection. Monocytes/MΦs rely on abundant induction of the HO-1/CO pathway for a controlled immune response and for potent bactericidal activity. Here, we discuss studies showing that blunted HO-1 activation in CF-affected cells contributes to hyper-inflammation and defective host defense against bacteria. We dissect potential cellular mechanisms that may lead to decreased HO-1 induction in CF cells. We review literature suggesting that induction of HO-1 may be beneficial for the treatment of CF lung disease. Finally, we discuss recent studies highlighting how endogenous HO-1 can be induced by administration of controlled doses of CO to reduce lung hyper-inflammation, oxidative stress, bacterial infection, and dysfunctional ion transport, which are all hallmarks of CF lung disease.
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Affiliation(s)
| | | | | | - Emanuela M. Bruscia
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
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25
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Perrem L, Ratjen F. Anti-inflammatories and mucociliary clearance therapies in the age of CFTR modulators. Pediatr Pulmonol 2019; 54 Suppl 3:S46-S55. [PMID: 31715088 DOI: 10.1002/ppul.24364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
Cystic fibrosis (CF) is a genetic and life-limiting disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. This multi-system disease is characterized by progressive lung disease and pancreatic insufficiency amongst other manifestations. CFTR primarily functions as a chloride channel that transports ions across the apical membrane of epithelial cells but has other functions, including bicarbonate secretion and inhibition of sodium transport. Defective CFTR disrupts these functions, causing viscous and dehydrated mucus to accumulate, compromising the airway lumen and contributing to obstructive pulmonary disease. The combination of CFTR dysfunction, mucus obstruction, and infection drive an exaggerated and dysfunctional inflammatory response, which contributes to irreversible airway destruction and fibrosis. CFTR modulators, an exciting new class of drugs, increase the expression and/or function of CFTR variant protein and improve multiple clinical endpoints, such as lung function, pulmonary exacerbation rates, and nutritional status. However, these genotype-specific drugs are not universally available, the clinical response is variable, and lung function still declines over time when bronchiectasis is established. Consequently, even in the age of CFTR modulators, we must target other important aspects of the CF airway disease, such as inflammation and mucociliary clearance. This review highlights the mechanisms of inflammation and mucus accumulation in the CF lung and discusses anti-inflammatory and mucociliary clearance agents that are currently in development focusing on compounds for which clinical trial data have recently become available.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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26
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McElvaney OJ, Wade P, Murphy M, Reeves EP, McElvaney NG. Targeting airway inflammation in cystic fibrosis. Expert Rev Respir Med 2019; 13:1041-1055. [PMID: 31530195 DOI: 10.1080/17476348.2019.1666715] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The major cause of morbidity and mortality in patients with cystic fibrosis (CF) is lung disease. Inflammation in the CF airways occurs from a young age and contributes significantly to disease progression and shortened life expectancy. Areas covered: In this review, we discuss the key immune cells involved in airway inflammation in CF, the contribution of the intrinsic genetic defect to the CF inflammatory phenotype, and anti-inflammatory strategies designed to overcome what is a critical factor in the pathogenesis of CF lung disease. Review of the literature was carried out using the MEDLINE (from 1975 to 2018), Google Scholar and The Cochrane Library databases. Expert opinion: Therapeutic interventions specifically targeting the defective CF transmembrane conductance regulator (CFTR) protein have changed the clinical landscape and significantly improved the outlook for CF. As survival estimates for people with CF increase, long-term management has become an important focus, with an increased need for therapies targeted at specific elements of inflammation, to complement CFTR modulator therapies.
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Affiliation(s)
- Oliver J McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Patricia Wade
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Mark Murphy
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Emer P Reeves
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital , Dublin , Ireland
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27
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Scholte BJ, Horati H, Veltman M, Vreeken RJ, Garratt LW, Tiddens HAWM, Janssens HM, Stick SM. Oxidative stress and abnormal bioactive lipids in early cystic fibrosis lung disease. J Cyst Fibros 2019; 18:781-789. [PMID: 31031161 DOI: 10.1016/j.jcf.2019.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Clinical data indicate that airway inflammation in children with cystic fibrosis (CF) arises early, is associated with structural lung damage, and predicts progression. In bronchoalveolar lavage fluid (BALF) from CFTR mutant mice, several aspects of lipid metabolism are abnormal that contributes to lung disease. We aimed to determine whether lipid pathway dysregulation is also observed in BALF from children with CF, to identify biomarkers of early lung disease and potential therapeutic targets. METHODS A comprehensive panel of lipids that included Sphingolipids, oxylipins, isoprostanes and lysolipids, all bioactive lipid species known to be involved in inflammation and tissue remodeling, were measured in BALF from children with CF (1-6 years, N = 33) and age-matched non-CF patients with unexplained inflammatory disease (N = 16) by HPLC-MS/MS. Lipid data were correlated with chest CT scores and BALF inflammation biomarkers. RESULTS The ratio of long chain to very long chain ceramide species (LCC/VLCC) and lysolipid levels were enhanced in CF compared to non-CF patients, despite comparable neutrophil counts and bacterial load. In CF patients both LCC/VLCC and lysolipid levels correlated with inflammation and chest CT scores. The ceramide precursors Sphingosine, Sphinganine, Sphingomyelin, correlated with inflammation, whilst the oxidative stress marker isoprostane correlated with inflammation and chest CT scores. No correlation between lipids and current bacterial infection in CF (N = 5) was observed. CONCLUSIONS Several lipid biomarkers of early CF lung disease were identified, which point toward potential disease monitoring and therapeutic approaches that can be used to complement CFTR modulators.
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Affiliation(s)
- Bob J Scholte
- Erasmus MC, Rotterdam, the Netherlands, Cell Biology; Erasmus MC, Sophia Children Hospital, Pediatric Pulmonology, the Netherlands.
| | - Hamed Horati
- Erasmus MC, Sophia Children Hospital, Pediatric Pulmonology, the Netherlands
| | - Mieke Veltman
- Erasmus MC, Rotterdam, the Netherlands, Cell Biology; Erasmus MC, Sophia Children Hospital, Pediatric Pulmonology, the Netherlands
| | - Rob J Vreeken
- Netherlands Metabolomics Centre, LACDR, Leiden, the Netherlands
| | - Luke W Garratt
- Telethon Kids Institute, University of Western Australia, Subiaco, 6008, Western Australia, Australia
| | - Harm A W M Tiddens
- Erasmus MC, Sophia Children Hospital, Pediatric Pulmonology, the Netherlands
| | - Hettie M Janssens
- Erasmus MC, Sophia Children Hospital, Pediatric Pulmonology, the Netherlands
| | - Stephen M Stick
- Telethon Kids Institute, University of Western Australia, Subiaco, 6008, Western Australia, Australia; Division of Paediatrics and Child Health, University of Western Australia, Nedlands, 6009, Western Australia, Australia; Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, 6009, Western Australia, Australia; Centre for Cell Therapy and Regenerative Medicine, School of Medicine and Pharmacology, University of Western Australia, Nedlands, 6009, Western Australia, Australia
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28
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Roesch EA, Nichols DP, Chmiel JF. Inflammation in cystic fibrosis: An update. Pediatr Pulmonol 2018; 53:S30-S50. [PMID: 29999593 DOI: 10.1002/ppul.24129] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
Inflammation plays a critical role in cystic fibrosis (CF) lung pathology and disease progression making it an active area of research and important therapeutic target. In this review, we explore the most recent research on the major contributors to the exuberant inflammatory response seen in CF as well as potential therapeutics to combat this response. Absence of functional cystic fibrosis transmembrane conductance regulator (CFTR) alters anion transport across CF airway epithelial cells and ultimately results in dehydration of the airway surface liquid. The dehydrated airway surface liquid in combination with abnormal mucin secretion contributes to airway obstruction and subsequent infection that may serve as a trigger point for inflammation. There is also evidence to suggest that airway inflammation may be excessive and sustained relative to the infectious stimuli. Studies have shown dysregulation of both pro-inflammatory mediators such as IL-17 and pro-resolution mediators including metabolites of the eicosanoid pathway. Recently, CFTR potentiators and correctors have garnered much attention in the CF community. Although these modulators address the underlying defect in CF, their impact on downstream consequences such as inflammation are not known. Here, we review pre-clinical and clinical data on the impact of CFTR modulators on inflammation. In addition, we examine other cell types including neutrophils, macrophages, and T-lymphocytes that express CFTR and contribute to the CF inflammatory response. Finally, we address challenges in developing anti-inflammatory therapies and highlight some of the most promising anti-inflammatory drugs under development for CF.
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Affiliation(s)
- Erica A Roesch
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - David P Nichols
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - James F Chmiel
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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29
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Bell SC, Elborn JS, Byrnes CA. Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention. Respirology 2018; 23:1006-1022. [PMID: 30207018 DOI: 10.1111/resp.13398] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/20/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022]
Abstract
Interest in bronchiectasis has increased over the past two decades, as shown by the establishment of disease-specific registries in several countries, the publication of management guidelines and a growing number of clinical trials to address evidence gaps for treatment decisions. This review considers the evidence for defining and treating pulmonary exacerbations, the approaches for eradication of newly identified airway pathogens and the methods to prevent exacerbations through long-term treatments from a pragmatic practice-based perspective. Areas for future studies are also explored. Watch the video abstract.
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Affiliation(s)
- Scott C Bell
- Lung Bacteria Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Joseph S Elborn
- Adult Cystic Fibrosis Department, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Queen's University, Belfast, UK
| | - Catherine A Byrnes
- Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Respiratory Service, Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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30
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Elborn JS, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. EMPIRE-CF: A phase II randomized placebo-controlled trial of once-daily, oral acebilustat in adult patients with cystic fibrosis - Study design and patient demographics. Contemp Clin Trials 2018; 72:86-94. [PMID: 30056216 DOI: 10.1016/j.cct.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 12/15/2022]
Abstract
Inflammation causes irreparable damage in the cystic fibrosis (CF) lung. Despite high standards of care and the advent of new therapies, inflammation continues to cause significant loss of lung function and morbidity. Acebilustat is a once-daily, oral molecule with anti-inflammatory activity through the inhibition of LTA4 hydrolase and modulation of LTB4. It has potential to reduce lung function decline and pulmonary exacerbations in patients with CF and is currently being tested in a Phase II multicenter, randomized, double-blind, placebo-controlled, parallel-group study (EMPIRE-CF). Strict inclusion criteria based on modeling of the Cystic Fibrosis Foundation Patient Registry data were selected to enrich the trial with patients most likely to benefit from chronic anti-inflammatory therapy that reduces lung function decline. 200 patients between 18 and 30 years of age, with an FEV1 percent predicted (pp) ≥50%, and ≥1 exacerbation in the past year have been enrolled. Patients are randomized 1:1:1 to placebo, acebilustat 50 mg or 100 mg for 48 weeks, taken concomitantly with their current standard of care, and stratified based on concomitant CFTR modulator use, baseline FEV1pp (50% to 75% and >75%), and number of exacerbations in the past year (1 or >1). The primary endpoints are absolute change from baseline in FEV1pp and safety outcomes. Secondary endpoints include rate of pulmonary exacerbations and time to first pulmonary exacerbation. Biomarkers of inflammation will also be assessed. EMPIRE-CF is expected to identify the optimal patient population, dose, duration and endpoints for future acebilustat trials, and widen understanding of the drug's efficacy in patients with CF.
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Affiliation(s)
- J Stuart Elborn
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK.
| | - Sanjeev Ahuja
- Celtaxsys, Inc., 201 17th St NW #530, Atlanta, GA, USA.
| | | | - John Mershon
- Celtaxsys, Inc., 201 17th St NW #530, Atlanta, GA, USA.
| | | | - Steven M Rowe
- Departments of Medicine, Pediatrics, Cell Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA; Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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31
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Alhazmi A. Spleen Tyrosine Kinase as a Target Therapy for Pseudomonas aeruginosa Infection. J Innate Immun 2018; 10:255-263. [PMID: 29925062 DOI: 10.1159/000489863] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/29/2018] [Indexed: 12/11/2022] Open
Abstract
Spleen tyrosine kinase (SYK) is a nonreceptor tyrosine kinase which associates directly with extracellular receptors, and is critically involved in signal transduction pathways in a variety of cell types for the regulation of cellular responses. SYK is expressed ubiquitously in immune and nonimmune cells, and has a much wider biological role than previously recognized. Several studies have highlighted SYK as a key player in the pathogenesis of a multitude of diseases. Pseudomonas aeruginosa is an opportunistic gram-negative pathogen, which is responsible for systemic infections in immunocompromised individuals, accounting for a major cause of severe chronic lung infection in cystic fibrosis patients and subsequently resulting in a progressive deterioration of lung function. Inhibition of SYK activity has been explored as a therapeutic option in several allergic disorders, autoimmune diseases, and hematological malignancies. This review focuses on SYK as a therapeutic target, and describes the possibility of how current knowledge could be translated for therapeutic purposes to regulate the immune response to the opportunistic pathogen P. aeruginosa.
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Affiliation(s)
- Alaa Alhazmi
- Department of Biology, Lakehead University, Thunder Bay, Ontario, Canada.,Department of Medical Laboratory Technology, Jazan University, Jazan, Saudi Arabia
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32
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Lorè NI, Veraldi N, Riva C, Sipione B, Spagnuolo L, De Fino I, Melessike M, Calzi E, Bragonzi A, Naggi A, Cigana C. Synthesized Heparan Sulfate Competitors Attenuate Pseudomonas aeruginosa Lung Infection. Int J Mol Sci 2018; 19:ijms19010207. [PMID: 29315274 PMCID: PMC5796156 DOI: 10.3390/ijms19010207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 12/19/2022] Open
Abstract
Several chronic respiratory diseases are characterized by recurrent and/or persistent infections, chronic inflammatory responses and tissue remodeling, including increased levels of glycosaminoglycans which are known structural components of the airways. Among glycosaminoglycans, heparan sulfate (HS) has been suggested to contribute to excessive inflammatory responses. Here, we aim at (i) investigating whether long-term infection by Pseudomonas aeruginosa, one of the most worrisome threat in chronic respiratory diseases, may impact HS levels, and (ii) exploring HS competitors as potential anti-inflammatory drugs during P. aeruginosa pneumonia. P. aeruginosa clinical strains and ad-hoc synthesized HS competitors were used in vitro and in murine models of lung infection. During long-term chronic P. aeruginosa colonization, infected mice showed higher heparin/HS levels, evaluated by high performance liquid chromatography-mass spectrometry after selective enzymatic digestion, compared to uninfected mice. Among HS competitors, an N-acetyl heparin and a glycol-split heparin dampened leukocyte recruitment and cytokine/chemokine production induced by acute and chronic P. aeruginosa pneumonia in mice. Furthermore, treatment with HS competitors reduced bacterial burden during chronic murine lung infection. In vitro, P. aeruginosa biofilm formation decreased upon treatment with HS competitors. Overall, these findings support further evaluation of HS competitors as a novel therapy to counteract inflammation and infection during P. aeruginosa pneumonia.
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Affiliation(s)
- Nicola Ivan Lorè
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
- Vita-Salute San Raffaele University, Milano 20132, Italy.
| | - Noemi Veraldi
- Istituto di Ricerche Chimiche e Biochimiche "G. Ronzoni", Milano 20133, Italy.
| | - Camilla Riva
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Barbara Sipione
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Lorenza Spagnuolo
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Ida De Fino
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Medede Melessike
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Elisa Calzi
- Istituto di Ricerche Chimiche e Biochimiche "G. Ronzoni", Milano 20133, Italy.
| | - Alessandra Bragonzi
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
| | - Annamaria Naggi
- Istituto di Ricerche Chimiche e Biochimiche "G. Ronzoni", Milano 20133, Italy.
| | - Cristina Cigana
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy.
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33
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Giddings O, Esther CR. Mapping targetable inflammation and outcomes with cystic fibrosis biomarkers. Pediatr Pulmonol 2017; 52:S21-S28. [PMID: 28714611 PMCID: PMC5664212 DOI: 10.1002/ppul.23768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/02/2017] [Accepted: 06/20/2017] [Indexed: 01/01/2023]
Abstract
Cystic fibrosis is characterized by an overly exuberant neutrophilic inflammatory response to pathogens and other stimuli that starts very early in disease. The overwhelming nature of this response is a primary cause of remodeling and destruction of the airways, suggesting that anti-inflammatory therapies could be beneficial in CF. However, finding therapies that can effectively reduce the inflammatory response without compromising host defenses remains elusive. New approaches towards mapping inflammatory targets promise to aid in developing novel therapeutic strategies and improve outcomes in individuals with CF.
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Affiliation(s)
- Olivia Giddings
- Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles R Esther
- Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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34
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Bhatt L, Roinestad K, Van T, Springman E. Recent advances in clinical development of leukotriene B4 pathway drugs. Semin Immunol 2017; 33:65-73. [DOI: 10.1016/j.smim.2017.08.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/04/2017] [Accepted: 08/08/2017] [Indexed: 12/23/2022]
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35
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Yonker LM, Pazos MA, Lanter BB, Mou H, Chu KK, Eaton AD, Bonventre JV, Tearney GJ, Rajagopal J, Hurley BP. Neutrophil-Derived Cytosolic PLA2α Contributes to Bacterial-Induced Neutrophil Transepithelial Migration. THE JOURNAL OF IMMUNOLOGY 2017; 199:2873-2884. [PMID: 28887431 DOI: 10.4049/jimmunol.1700539] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/17/2017] [Indexed: 11/19/2022]
Abstract
Eicosanoids are a group of bioactive lipids that are shown to be important mediators of neutrophilic inflammation; selective targeting of their function confers therapeutic benefit in a number of diseases. Neutrophilic airway diseases, including cystic fibrosis, are characterized by excessive neutrophil infiltration into the airspace. Understanding the role of eicosanoids in this process may reveal novel therapeutic targets. The eicosanoid hepoxilin A3 is a pathogen-elicited epithelial-produced neutrophil chemoattractant that directs transepithelial migration in response to infection. Following hepoxilin A3-driven transepithelial migration, neutrophil chemotaxis is amplified through neutrophil production of a second eicosanoid, leukotriene B4 (LTB4). The rate-limiting step of eicosanoid generation is the liberation of arachidonic acid by phospholipase A2, and the cytosolic phospholipase A2 (cPLA2)α isoform has been specifically shown to direct LTB4 synthesis in certain contexts. Whether cPLA2α is directly responsible for neutrophil synthesis of LTB4 in the context of Pseudomonas aeruginosa-induced neutrophil transepithelial migration has not been explored. Human and mouse neutrophil-epithelial cocultures were used to evaluate the role of neutrophil-derived cPLA2α in infection-induced transepithelial signaling by pharmacological and genetic approaches. Primary human airway basal stem cell-derived epithelial cultures and micro-optical coherence tomography, a new imaging modality that captures two- and three-dimensional real-time dynamics of neutrophil transepithelial migration, were applied. Evidence from these studies suggests that cPLA2α expressed by neutrophils, but not epithelial cells, plays a significant role in infection-induced neutrophil transepithelial migration by mediating LTB4 synthesis during migration, which serves to amplify the magnitude of neutrophil recruitment in response to epithelial infection.
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Affiliation(s)
- Lael M Yonker
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Michael A Pazos
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Bernard B Lanter
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Hongmei Mou
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115.,Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114
| | - Kengyeh K Chu
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114.,Department of Pathology, Harvard Medical School, Boston, MA 02115
| | - Alexander D Eaton
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114
| | - Joseph V Bonventre
- Department of Medicine, Harvard Medical School, Boston, MA 02115.,Renal Division, Brigham and Women's Hospital, Boston, MA 02115; and.,Biomedical Engineering Division, Brigham and Women's Hospital, Boston, MA 02115
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114.,Department of Pathology, Harvard Medical School, Boston, MA 02115
| | - Jayaraj Rajagopal
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114.,Department of Medicine, Harvard Medical School, Boston, MA 02115
| | - Bryan P Hurley
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA 02114; .,Department of Pediatrics, Harvard Medical School, Boston, MA 02115
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36
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Efficacy of Rhesus Theta-Defensin-1 in Experimental Models of Pseudomonas aeruginosa Lung Infection and Inflammation. Antimicrob Agents Chemother 2017; 61:AAC.00154-17. [PMID: 28559270 DOI: 10.1128/aac.00154-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/21/2017] [Indexed: 12/19/2022] Open
Abstract
Chronic airway infection and inflammation contribute to the progressive loss of lung function and shortened survival of patients with cystic fibrosis (CF). Rhesus theta defensin-1 (RTD-1) is a macrocyclic host defense peptide with antimicrobial and immunomodulatory activities. Combined with favorable preclinical safety and peptide stability data, RTD-1 warrants investigation to determine its therapeutic potential for treatment of CF lung disease. We sought to evaluate the therapeutic potential of RTD-1 for CF airway infection and inflammation using in vitro, ex vivo, and in vivo models. We evaluated RTD-1's effects on basal and Pseudomonas aeruginosa-induced inflammation in CF sputum leukocytes and CF bronchial epithelial cells. Peptide stability was evaluated by incubation with CF sputum. Airway pharmacokinetics, safety, and tolerance studies were performed in naive mice. Aerosolized RTD-1 treatment effects were assessed by analyzing lung bacterial burdens and airway inflammation using an established model of chronic P. aeruginosa endobronchial infection in CF (ΔF508) mice. RTD-1 directly reduces metalloprotease activity, as well as inflammatory cytokine secretion from CF airway leukocyte and bronchial epithelial cells. Intrapulmonary safety, tolerability, and stability data support the aerosol administration route. RTD-1 reduced the bacterial lung burden, airway neutrophils, and inflammatory cytokines in CF mice with chronic P. aeruginosa lung infection. Collectively, these studies support further development of RTD-1 for treatment of CF airway disease.
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37
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Lin CK, Kazmierczak BI. Inflammation: A Double-Edged Sword in the Response to Pseudomonas aeruginosa Infection. J Innate Immun 2017; 9:250-261. [PMID: 28222444 DOI: 10.1159/000455857] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/05/2017] [Indexed: 12/22/2022] Open
Abstract
The Gram-negative opportunistic pathogen Pseudomonas aeruginosa exploits failures of barrier defense and innate immunity to cause acute infections at a range of anatomic sites. We review the defense mechanisms that normally protect against P. aeruginosa pulmonary infection, as well as the bacterial products and activities that trigger their activation. Innate immune recognition of P. aeruginosa is critical for pathogen clearance; nonetheless, inflammation is also associated with pathogen persistence and poor host outcomes. We describe P. aeruginosa adaptations that improve this pathogen's fitness in the inflamed airway, and briefly discuss strategies to manipulate inflammation to benefit the host. Such adjunct therapies may become increasingly important in the treatment of acute and chronic infections caused by this multi-drug-resistant pathogen.
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38
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Airway mucus, inflammation and remodeling: emerging links in the pathogenesis of chronic lung diseases. Cell Tissue Res 2017; 367:537-550. [PMID: 28108847 DOI: 10.1007/s00441-016-2562-z] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022]
Abstract
Airway mucus obstruction is a hallmark of many chronic lung diseases including rare genetic disorders such as cystic fibrosis (CF) and primary ciliary dyskinesia, as well as common lung diseases such as asthma and chronic obstructive pulmonary disease (COPD), which have emerged as a leading cause of morbidity and mortality worldwide. However, the role of excess airway mucus in the in vivo pathogenesis of these diseases remains poorly understood. The generation of mice with airway-specific overexpression of epithelial Na+ channels (ENaC), exhibiting airway surface dehydration (mucus hyperconcentration), impaired mucociliary clearance (MCC) and mucus plugging, led to a model of muco-obstructive lung disease that shares key features of CF and COPD. In this review, we summarize recent progress in the understanding of causes of impaired MCC and in vivo consequences of airway mucus obstruction that can be inferred from studies in βENaC-overexpressing mice. These studies confirm that mucus hyperconcentration on airway surfaces plays a critical role in the pathophysiology of impaired MCC, mucus adhesion and airway plugging that cause airflow obstruction and provide a nidus for bacterial infection. In addition, these studies support the emerging concept that excess airway mucus per se, probably via several mechanisms including hypoxic epithelial necrosis, retention of inhaled irritants or allergens, and potential immunomodulatory effects, is a potent trigger of chronic airway inflammation and associated lung damage, even in the absence of bacterial infection. Finally, these studies suggest that improvement of mucus clearance may be a promising therapeutic strategy for a spectrum of muco-obstructive lung diseases.
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Margaroli C, Tirouvanziam R. Neutrophil plasticity enables the development of pathological microenvironments: implications for cystic fibrosis airway disease. Mol Cell Pediatr 2016; 3:38. [PMID: 27868161 PMCID: PMC5136534 DOI: 10.1186/s40348-016-0066-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/04/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The pathological course of several chronic inflammatory diseases, including cystic fibrosis, chronic obstructive pulmonary disease, and rheumatoid arthritis, features an aberrant innate immune response dominated by neutrophils. In cystic fibrosis, neutrophil burden and activity of neutrophil elastase in the extracellular fluid have been identified as strong predictors of lung disease severity. REVIEW Although neutrophils are generally considered to be rigid, pre-programmed effector leukocytes, recent studies suggest extensive plasticity in how neutrophil functions unfold upon recruitment to peripheral tissues, and how they choose their ultimate fate. Indeed, upon migration to cystic fibrosis airways, neutrophils display dysregulated lifespan, metabolic activation, and altered effector and regulatory functions, consistent with profound adaptation and phenotypic reprogramming. Licensed by signals present in cystic fibrosis airway microenvironment to survive and develop these novel functions, neutrophils orchestrate, in partnership with the epithelium and with the resident microbiota, the evolution of a pathological microenvironment. This microenvironment is defined by altered proteolytic, redox, and metabolic balance and the presence of stable luminal structures in which neutrophils and microbes coexist. CONCLUSIONS The elucidation of molecular mechanisms driving neutrophil plasticity in vivo will open new treatment opportunities designed to modulate, rather than block, the crucial adaptive functions fulfilled by neutrophils. This review aims to outline emerging mechanisms of neutrophil plasticity and their participation in the building of pathological microenvironments in the context of cystic fibrosis and other diseases with similar features.
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Affiliation(s)
- Camilla Margaroli
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, 30322, USA
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, 30322, USA
- Emory + Children's Center, 2015 Uppergate Dr NE, Rm 344, Atlanta, GA, 30322-1014, USA
| | - Rabindra Tirouvanziam
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, 30322, USA.
- Center for CF and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, 30322, USA.
- Emory + Children's Center, 2015 Uppergate Dr NE, Rm 344, Atlanta, GA, 30322-1014, USA.
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Elborn JS, Horsley A, MacGregor G, Bilton D, Grosswald R, Ahuja S, Springman EB. Phase I Studies of Acebilustat: Biomarker Response and Safety in Patients with Cystic Fibrosis. Clin Transl Sci 2016; 10:28-34. [PMID: 27806191 PMCID: PMC5351012 DOI: 10.1111/cts.12428] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 12/21/2022] Open
Abstract
There is a significant unmet need for safe and effective anti‐inflammatory treatment for cystic fibrosis. The aim of this study was to evaluate the safety of acebilustat, a leukotriene A4 hydrolase inhibitor, and its effect on inflammation biomarkers in patients with cystic fibrosis. Seventeen patients with mild to moderate cystic fibrosis were enrolled and randomized into groups receiving placebo or doses of 50 mg or 100 mg acebilustat administered orally, once daily for 15 days. Sputum neutrophil counts were reduced by 65% over baseline values in patients treated with 100 mg acebilustat. A modestly significant 58% reduction vs. placebo in sputum elastase was observed with acebilustat treatment. Favorable trends were observed for reduction of serum C‐reactive protein and sputum neutrophil DNA in acebilustat‐treated patients. No changes in pulmonary function were observed. Acebilustat was safe and well tolerated. The results of this study support further clinical development of acebilustat for treatment of cystic fibrosis.
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Affiliation(s)
- J S Elborn
- Centre for Infection and Immunity, Dentistry, and Biomedical Sciences, Queens University School of Medicine, Belfast, UK
| | - A Horsley
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
| | - G MacGregor
- West of Scotland CF Centre, Gartnavel General Hospital, Glasgow, UK
| | - D Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | | | - S Ahuja
- Celtaxsys, Inc, Atlanta, Georgia, USA
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De Boeck K, Amaral MD. Progress in therapies for cystic fibrosis. THE LANCET RESPIRATORY MEDICINE 2016; 4:662-674. [DOI: 10.1016/s2213-2600(16)00023-0] [Citation(s) in RCA: 254] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 12/19/2022]
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Efficacy of the Novel Antibiotic POL7001 in Preclinical Models of Pseudomonas aeruginosa Pneumonia. Antimicrob Agents Chemother 2016; 60:4991-5000. [PMID: 27297477 DOI: 10.1128/aac.00390-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/04/2016] [Indexed: 12/13/2022] Open
Abstract
The clinical development of antibiotics with a new mode of action combined with efficient pulmonary drug delivery is a priority against untreatable Pseudomonas aeruginosa lung infections. POL7001 is a macrocycle antibiotic belonging to the novel class of protein epitope mimetic (PEM) molecules with selective and potent activity against P. aeruginosa We investigated ventilator-associated pneumonia (VAP) and cystic fibrosis (CF) as indications of the clinical potential of POL7001 to treat P. aeruginosa pulmonary infections. MICs of POL7001 and comparators were measured for reference and clinical P. aeruginosa strains. The therapeutic efficacy of POL7001 given by pulmonary administration was evaluated in murine models of P. aeruginosa acute and chronic pneumonia. POL7001 showed potent in vitro activity against a large panel of P. aeruginosa isolates from CF patients, including multidrug-resistant (MDR) isolates with adaptive phenotypes such as mucoid or hypermutable phenotypes. The efficacy of POL7001 was demonstrated in both wild-type and CF mice. In addition to a reduced bacterial burden in the lung, POL7001-treated mice showed progressive body weight recovery and reduced levels of inflammatory markers, indicating an improvement in general condition. Pharmacokinetic studies indicated that POL7001 reached significant concentrations in the lung after pulmonary administration, with low systemic exposure. These results support the further evaluation of POL7001 as a novel therapeutic agent for the treatment of P. aeruginosa pulmonary infections.
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Considerations for the Conduct of Clinical Trials with Antiinflammatory Agents in Cystic Fibrosis. A Cystic Fibrosis Foundation Workshop Report. Ann Am Thorac Soc 2016; 12:1398-406. [PMID: 26146892 DOI: 10.1513/annalsats.201506-361ot] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Inflammation leads to lung destruction and loss of pulmonary function in patients with cystic fibrosis (CF). Drugs that modulate the cystic fibrosis transmembrane conductance regulator (CFTR) have recently been approved. Although the impact of CFTR modulators on sweat chloride and lung function are exciting, they have not yet demonstrated an effect on inflammation. Therefore, CF antiinflammatory drug development must continue. Unfortunately, the lack of clarity with this process has left investigators and industry sponsors frustrated. The Cystic Fibrosis Foundation established a working group in early 2014 to address this issue. There are many inflammatory processes disrupted in CF, and, therefore, there are many potential targets amenable to antiinflammatory therapy. Regardless of a drug's specific mechanism of action, it must ultimately affect the neutrophil or its products to impact CF. The working group concluded that before bringing new antiinflammatory drugs to clinical trial, preclinical safety studies must be conducted in disease-relevant models to assuage safety concerns. Furthermore, although studies of antiinflammatory therapies must first establish safety in adults, subsequent studies must involve children, as they are most likely to reap the most benefit. The working group also recommended that pharmacokinetic-pharmacodynamic studies and early-phase safety studies be performed before proceeding to larger studies of longer duration. In addition, innovative study designs may improve the likelihood of adequately assessing treatment response and mitigating risk before conducting multiyear studies. Learning from past experiences and incorporating this knowledge into new drug development programs will be instrumental in bringing new antiinflammatory therapies to patients.
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Lorè NI, Cigana C, Riva C, De Fino I, Nonis A, Spagnuolo L, Sipione B, Cariani L, Girelli D, Rossi G, Basso V, Colombo C, Mondino A, Bragonzi A. IL-17A impairs host tolerance during airway chronic infection by Pseudomonas aeruginosa. Sci Rep 2016; 6:25937. [PMID: 27189736 PMCID: PMC4870500 DOI: 10.1038/srep25937] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/22/2016] [Indexed: 11/09/2022] Open
Abstract
Resistance and tolerance mechanisms participate to the interplay between host and pathogens. IL-17-mediated response has been shown to be crucial for host resistance to respiratory infections, whereas its role in host tolerance during chronic airway colonization is still unclear. Here, we investigated whether IL-17-mediated response modulates mechanisms of host tolerance during airways chronic infection by P. aeruginosa. First, we found that IL-17A levels were sustained in mice at both early and advanced stages of P. aeruginosa chronic infection and confirmed these observations in human respiratory samples from cystic fibrosis patients infected by P. aeruginosa. Using IL-17a−/− or IL-17ra−/− mice, we found that the deficiency of IL-17A/IL-17RA axis was associated with: i) increased incidence of chronic infection and bacterial burden, indicating its role in the host resistance to P. aeruginosa; ii) reduced cytokine levels (KC), tissue innate immune cells and markers of tissue damage (pro-MMP-9, elastin degradation, TGF-β1), proving alteration of host tolerance. Blockade of IL-17A activity by a monoclonal antibody, started when chronic infection is established, did not alter host resistance but increased tolerance. In conclusion, this study identifies IL-17-mediated response as a negative regulator of host tolerance during P. aeruginosa chronic airway infection.
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Affiliation(s)
- Nicola Ivan Lorè
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Cristina Cigana
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Camilla Riva
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Ida De Fino
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Nonis
- University Center for Statistics in the Biomedical Sciences (CUSSB), Vita-Salute San Raffaele University, Milano, Italy
| | - Lorenza Spagnuolo
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Barbara Sipione
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Lisa Cariani
- Cystic Fibrosis Microbiology Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Daniela Girelli
- Cystic Fibrosis Microbiology Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Giacomo Rossi
- School of Biosciences and Veterinary Medicine, University of Camerino, Italy
| | - Veronica Basso
- Lymphocytes Activation Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Carla Colombo
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Mondino
- Lymphocytes Activation Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Alessandra Bragonzi
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
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O’Dwyer CA, O’Brien ME, Wormald MR, White MM, Banville N, Hurley K, McCarthy C, McElvaney NG, Reeves EP. The BLT1 Inhibitory Function of α-1 Antitrypsin Augmentation Therapy Disrupts Leukotriene B4Neutrophil Signaling. THE JOURNAL OF IMMUNOLOGY 2015; 195:3628-41. [DOI: 10.4049/jimmunol.1500038] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 08/12/2015] [Indexed: 12/15/2022]
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De Soyza A, Pavord I, Elborn JS, Smith D, Wray H, Puu M, Larsson B, Stockley R. A randomised, placebo-controlled study of the CXCR2 antagonist AZD5069 in bronchiectasis. Eur Respir J 2015; 46:1021-32. [PMID: 26341987 DOI: 10.1183/13993003.00148-2015] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/28/2015] [Indexed: 11/05/2022]
Abstract
This randomised double-blind placebo-controlled parallel-group multicentre phase IIa study evaluated the effect of the CXCR2 antagonist AZD5069 on sputum neutrophil counts in adults with bronchiectasis.Patients were randomised 1:1 to receive AZD5069 80 mg or placebo orally twice daily for 28 days. Assessments included blood cell counts, inflammatory markers in blood, morning spontaneous sputum, lung function, safety and tolerability and patients completed daily BronkoTest diary cards. The primary outcome measure was the change in absolute sputum neutrophil count.Of 52 randomised patients, 45 completed treatment, 20 (76.9%) out of 26 receiving AZD5069 and 25 (96.2%) out of 26 receiving placebo. AZD5069 reduced the absolute neutrophil cell count in morning sputum by 69% versus placebo (p=0.004); percentage sputum neutrophil count was reduced by 36% (p=0.008). The number of infections/exacerbations was similar with AZD5069 and placebo (nine versus eight), but these led to more study discontinuations with AZD5069 (four versus zero). Sputum interleukin (IL)-6 and growth-regulated oncogene (GRO)-α and serum GRO-α, IL-1ß and IL-8 levels increased with AZD5069 versus placebo (all p<0.001), while serum high-sensitivity C-reactive protein levels did not change. AZD5069 was well tolerated.AZD5069 markedly reduced absolute sputum neutrophil counts in bronchiectasis patients, although this was not associated with improvements in clinical outcomes in this exploratory study.
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Affiliation(s)
- Anthony De Soyza
- Institute of Cellular Medicine, Newcastle University and Freeman Hospital, Sir William Leech Research Centre, Respiratory Department, Newcastle upon Tyne, UK
| | - Ian Pavord
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - J Stuart Elborn
- Centre for Infection and Immunity, Queens University, Belfast, UK
| | - David Smith
- Respiratory Research Unit, Southmead Hospital, Bristol, UK
| | - Heather Wray
- Innovative Medicines, Respiratory, Inflammation and Autoimmunity (iMED RIA), AstraZeneca R&D, Mölndal, Sweden
| | - Margareta Puu
- Innovative Medicines, Respiratory, Inflammation and Autoimmunity (iMED RIA), AstraZeneca R&D, Mölndal, Sweden
| | - Bengt Larsson
- Innovative Medicines, Respiratory, Inflammation and Autoimmunity (iMED RIA), AstraZeneca R&D, Mölndal, Sweden
| | - Robert Stockley
- Respiratory Department, Queen Elizabeth Hospital, Birmingham, UK
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Fritzsching B, Zhou-Suckow Z, Trojanek JB, Schubert SC, Schatterny J, Hirtz S, Agrawal R, Muley T, Kahn N, Sticht C, Gunkel N, Welte T, Randell SH, Länger F, Schnabel P, Herth FJF, Mall MA. Hypoxic epithelial necrosis triggers neutrophilic inflammation via IL-1 receptor signaling in cystic fibrosis lung disease. Am J Respir Crit Care Med 2015; 191:902-13. [PMID: 25607238 DOI: 10.1164/rccm.201409-1610oc] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE In many organs, hypoxic cell death triggers sterile neutrophilic inflammation via IL-1R signaling. Although hypoxia is common in airways from patients with cystic fibrosis (CF), its role in neutrophilic inflammation remains unknown. We recently demonstrated that hypoxic epithelial necrosis caused by airway mucus obstruction precedes neutrophilic inflammation in Scnn1b-transgenic (Scnn1b-Tg) mice with CF-like lung disease. OBJECTIVES To determine the role of epithelial necrosis and IL-1R signaling in the development of neutrophilic airway inflammation, mucus obstruction, and structural lung damage in CF lung disease. METHODS We used genetic deletion and pharmacologic inhibition of IL-1R in Scnn1b-Tg mice and determined effects on airway epithelial necrosis; levels of IL-1α, keratinocyte chemoattractant, and neutrophils in bronchoalveolar lavage; and mortality, mucus obstruction, and structural lung damage. Furthermore, we analyzed lung tissues from 21 patients with CF and chronic obstructive pulmonary disease and 19 control subjects for the presence of epithelial necrosis. MEASUREMENTS AND MAIN RESULTS Lack of IL-1R had no effect on epithelial necrosis and elevated IL-1α, but abrogated airway neutrophilia and reduced mortality, mucus obstruction, and emphysema in Scnn1b-Tg mice. Treatment of adult Scnn1b-Tg mice with the IL-1R antagonist anakinra had protective effects on neutrophilic inflammation and emphysema. Numbers of necrotic airway epithelial cells were elevated and correlated with mucus obstruction in patients with CF and chronic obstructive pulmonary disease. CONCLUSIONS Our results support an important role of hypoxic epithelial necrosis in the pathogenesis of neutrophilic inflammation independent of bacterial infection and suggest IL-1R as a novel target for antiinflammatory therapy in CF and potentially other mucoobstructive airway diseases.
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Chalmers JD, Loebinger M, Aliberti S. Challenges in the development of new therapies for bronchiectasis. Expert Opin Pharmacother 2015; 16:833-50. [DOI: 10.1517/14656566.2015.1019863] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Cantin AM, Hartl D, Konstan MW, Chmiel JF. Inflammation in cystic fibrosis lung disease: Pathogenesis and therapy. J Cyst Fibros 2015; 14:419-30. [PMID: 25814049 DOI: 10.1016/j.jcf.2015.03.003] [Citation(s) in RCA: 315] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/08/2015] [Accepted: 03/08/2015] [Indexed: 11/16/2022]
Abstract
Lung disease is the major cause of morbidity and mortality in patients with cystic fibrosis (CF). Although CF lung disease is primarily an infectious disorder, the associated inflammation is both intense and ineffective at clearing pathogens. Persistent high-intensity inflammation leads to permanent structural damage of the CF airways and impaired lung function that eventually results in respiratory failure and death. Several defective inflammatory responses have been linked to cystic fibrosis transmembrane conductance regulator (CFTR) deficiency including innate and acquired immunity dysregulation, cell membrane lipid abnormalities, various transcription factor signaling defects, as well as altered kinase and toll-like receptor responses. The inflammation of the CF lung is dominated by neutrophils that release oxidants and proteases, particularly elastase. Neutrophil elastase in the CF airway secretions precedes the appearance of bronchiectasis, and correlates with lung function deterioration and respiratory exacerbations. Anti-inflammatory therapies are therefore of particular interest for CF lung disease but must be carefully studied to avoid suppressing critical elements of the inflammatory response and thus worsening infection. This review examines the role of inflammation in the pathogenesis of CF lung disease, summarizes the results of past clinical trials and explores promising new anti-inflammatory options.
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Affiliation(s)
- André M Cantin
- Pulmonary Division, University of Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC, Canada.
| | - Dominik Hartl
- CF Center, Children's Hospital of the University of Tübingen, Tübingen, Germany
| | - Michael W Konstan
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - James F Chmiel
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Yonker LM, Cigana C, Hurley BP, Bragonzi A. Host-pathogen interplay in the respiratory environment of cystic fibrosis. J Cyst Fibros 2015; 14:431-439. [PMID: 25800687 DOI: 10.1016/j.jcf.2015.02.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/11/2015] [Accepted: 02/19/2015] [Indexed: 01/01/2023]
Abstract
Significant advances have been made in the understanding of disease progression in cystic fibrosis (CF), revealing a complex interplay between host and pathogenic organisms. The diverse CF microbiota within the airway activates an aberrant immune response that is ineffective in clearing infection. An appreciation of how the CF host immune system interacts with these organisms is crucial to understanding the pathogenesis of CF pulmonary disease. Here we discuss the microbial complexity present in the lungs of individuals with CF, review emerging concepts of innate and adaptive immune responses to pathogens that chronically inhabit the CF lung, and discuss therapies that target the aberrant inflammatory response that characterizes CF. A greater understanding of the underlying mechanisms will shed light on pathogenesis and guide more targeted therapies in the future that serve to reduce infection, minimize lung pathology, and improve the quality of life for patients with CF.
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Affiliation(s)
- Lael M Yonker
- Mucosal Immunology & Biology Research Center, Pediatrics, Harvard Medical School, Massachusetts General Hospital for Children , Charlestown, MA, U.S.A
| | - Cristina Cigana
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Bryan P Hurley
- Mucosal Immunology & Biology Research Center, Pediatrics, Harvard Medical School, Massachusetts General Hospital for Children , Charlestown, MA, U.S.A
| | - Alessandra Bragonzi
- Infections and Cystic Fibrosis Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milano, Italy
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