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Aqeel F, Geetha D. Kidney Failure in Pauci-immune Crescentic Glomerulonephritis: Rationale for Immunosuppression to Improve Kidney Outcome. Curr Rheumatol Rep 2024; 26:290-301. [PMID: 38709420 DOI: 10.1007/s11926-024-01150-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE OF REVIEW Pauci-immune crescentic glomerulonephritis is the hallmark finding in ANCA-associated vasculitis (AAV) when the kidneys are affected. The rationale for immunosuppression in AAV is based on the underlying autoimmune nature of the disease. Overall remission rates, kidney outcomes, and the burden of disease have greatly improved since the discovery of various immunosuppressive therapies, but relapses remain common, and a significant proportion of patients continue to progress to end-stage kidney disease. Here, we review the role of immunosuppressive therapies for the treatment of pauci-immune crescentic glomerulonephritis. RECENT FINDINGS Besides the recognized role of B and T cells in the pathogenies of AAV, the focus on the contribution of inflammatory cytokines, neutrophil extracellular traps (NETs), and the complement system allowed the discovery of new therapies. Specifically, the C5a receptor blocker (avacopan) has been approved as a glucocorticoid-sparing agent. Additionally, based on observational data, more clinicians are now using combination therapies during the induction phase. There is also an evolving understanding of the role of plasma exchange in removing ANCA antibodies. Furthermore, the recent development of risk score systems provides physicians with valuable prognostic information that can influence decisions on immunosuppression, although future validation from larger cohorts is needed. The over-activation of various immune pathways plays a significant role in the pathogenesis of pauci-immune crescentic glomerulonephritis in AAV. Immunosuppression is, therefore, an important strategy to halt disease progression and improve overall outcomes. Relapse prevention while minimizing adverse events of immunosuppression is a major long-term goal in AAV management.
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Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Baltimore, MD, USA.
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2
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Reggiani F, Stella M, Calatroni M, Sinico RA. Treatment strategies for ANCA-associated vasculitides: from standard protocols to future horizons. Expert Rev Clin Immunol 2024; 20:765-780. [PMID: 38445642 DOI: 10.1080/1744666x.2024.2326628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION ANCA-associated vasculitides (AAV), classified into granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis represent a group of disorders characterized by necrotizing vasculitis of small vessels, endothelial injury and tissue damage. The outcomes and prognosis of AAV have undergone significant changes with the introduction of glucocorticoids (GCs) and other immunosuppressants (cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil). The enhanced understanding of pathogenesis has subsequently led to the incorporation into clinical practice of drugs targeting specific therapeutic targets. AREAS COVERED After an extensive literature search of Pubmed, Medline, Embase of the most recent evidence, we provide an overview of available treatments, highlighting how newer drugs have integrated into standard protocols. Our review also explores potential new therapeutic targets, including B cell depletion and inhibition, T cell inhibition, complement inhibition, and IL-5 and IgE inhibition. EXPERT OPINION There is hope that the new treatment targets currently under study in AAV may enable a faster and more lasting clinical response, ensuring the reduction of possible side effects from therapies. Moreover, numerous aspects necessitate further exploration in the future, such as tailoring of GCs, integration of GCs-sparing agents, efficacy of combination therapy, optimal maintenance therapy, to reduce organ-damage and improve quality of life.
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Affiliation(s)
- Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matteo Stella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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3
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Dolgyras P, Anyfanti P, Lazaridis A, Gavriilaki E, Koletsos N, Triantafyllou A, Barbara N, Mastrogiannis K, Yiannaki E, Papakonstantinou A, Galanapoulou V, Douma S, Gkaliagkousi E. Endothelial dysfunction and complement activation are independently associated with disease duration in patients with systemic vasculitis. Microvasc Res 2024; 154:104692. [PMID: 38705254 DOI: 10.1016/j.mvr.2024.104692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Systemic vasculitis is a heterogenous group of autoimmune diseases characterized by enhanced cardiovascular mortality. Endothelial dysfunction is associated with accelerated vascular damage, representing a core pathophysiologic mechanism contributing to excess CV risk. Recent studies have also shown that complement activation holds significant role in the pathogenesis of Anti-Neutrophilic Cytoplasmic Autoantibody (ANCA) -associated vasculitis (AAV). Given the potential crosstalk between the endothelium and complement, we aimed to assess, for the first time simultaneously, easily accessible biomarkers of endothelial dysfunction and complement activation in SV. METHODS We measured circulating endothelial microvesicles (EMVs) and soluble complement components representative of alternative, classical and terminal activation (C5b-9, C1q, Bb fragments, respectively) in a meticulously selected group of patients with systemic vasculitis, but without cardiovascular disease. Individuals free from systemic diseases, who were matched with patients for cardiovascular risk factors(hypertension, diabetes, smoking, dyslipidemia), comprised the control group. RESULTS We studied 60 individuals (30 in each group). Patients with systemic vasculitis had elevated EMVs, higher levels of C5b-9 [536.4(463.4) vs 1200.94457.3), p = 0.003] and C1q [136.2(146.5 vs 204.2(232.9), p = 0.0129], compared to controls [232.0 (243.5) vs 139.3(52.1), p < 0.001]. In multivariate analysis both EMVs and C5b-9 were independently associated with disease duration (p = 0.005 and p = 0.004 respectively), yet not with disease activity. CONCLUSION Patients with systemic vasculitis exhibit impaired endothelial function and complement activation, both assessed by easily accessible biomarkers, even in the absence of cardiovascular disease manifestations. EMVs and soluble complement components such as C5b-9 and C1q could be used as early biomarkers of endothelial dysfunction and complement activation, respectively, in clinical practice during the course of SV, yet their predictive value in terms of future cardiovascular disease warrants further verification in appropriately designed studies.
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Affiliation(s)
- Panagiotis Dolgyras
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Lazaridis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Gavriilaki
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Koletsos
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Areti Triantafyllou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaidou Barbara
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Mastrogiannis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efi Yiannaki
- Hematology Laboratory, Theagenion Cancer Center, Thessaloniki, Greece
| | - Anna Papakonstantinou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Stella Douma
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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4
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Snelson M, Deliyanti D, Tan SM, Drake AM, de Pasquale C, Kumar V, Woodruff TM, Wilkinson-Berka JL, Coughlan MT. Dietary resistant starch enhances immune health of the kidney in diabetes via promoting microbially-derived metabolites and dampening neutrophil recruitment. Nutr Diabetes 2024; 14:46. [PMID: 38902253 PMCID: PMC11190267 DOI: 10.1038/s41387-024-00305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 06/05/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Dietary-resistant starch is emerging as a potential therapeutic tool to limit the negative effects of diabetes on the kidneys. However, its metabolic and immunomodulatory effects have not yet been fully elucidated. METHODS Six-week-old db/db mice were fed a diet containing 12.5% resistant starch or a control diet matched for equivalent regular starch for 10 weeks. db/m mice receiving the control diet were utilised as non-diabetic controls. Freshly collected kidneys were digested for flow cytometry analysis of immune cell populations. Kidney injury was determined by measuring albuminuria, histology, and immunohistochemistry. Portal vein plasma was collected for targeted analysis of microbially-derived metabolites. Intestinal histology and tight junction protein expression were assessed. RESULTS Resistant starch limited the development of albuminuria in db/db mice. Diabetic db/db mice displayed a decline in portal vein plasma levels of acetate, propionate, and butyrate, which was increased with resistant starch supplementation. Diabetic db/db mice receiving resistant starch had a microbially-derived metabolite profile similar to that of non-diabetic db/m mice. The intestinal permeability markers lipopolysaccharide and lipopolysaccharide binding protein were increased in db/db mice consuming the control diet, which was not seen in db/db mice receiving resistant starch supplementation. Diabetes was associated with an increase in the kidney neutrophil population, neutrophil activation, number of C5aR1+ neutrophils, and urinary complement C5a excretion, all of which were reduced with resistant starch. These pro-inflammatory changes appear independent of fibrotic changes in the kidney. CONCLUSIONS Resistant starch supplementation in diabetes promotes beneficial circulating microbially-derived metabolites and improves intestinal permeability, accompanied by a modulation in the inflammatory profile of the kidney including neutrophil infiltration, complement activation, and albuminuria. These findings indicate that resistant starch can regulate immune and inflammatory responses in the kidney and support the therapeutic potential of resistant starch supplementation in diabetes on kidney health.
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Affiliation(s)
- Matthew Snelson
- Department of Diabetes, School of Translational Medicine, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia.
| | - Devy Deliyanti
- Department of Anatomy and Physiology, School of Biomedical Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Sih Min Tan
- Department of Diabetes, School of Translational Medicine, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia
| | - Anna M Drake
- Department of Diabetes, School of Translational Medicine, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia
| | - Cassandra de Pasquale
- Department of Diabetes, School of Translational Medicine, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia
| | - Vinod Kumar
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Trent M Woodruff
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Jennifer L Wilkinson-Berka
- Department of Anatomy and Physiology, School of Biomedical Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Melinda T Coughlan
- Department of Diabetes, School of Translational Medicine, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Alfred Medical Research and Education Precinct, Monash University, Melbourne, VIC, Australia
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, VIC, Australia
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5
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024:S0085-2538(24)00389-2. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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6
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Salvati L, Palterer B, Lazzeri E, Vivarelli E, Amendola M, Allinovi M, Caroti L, Mazzoni A, Lasagni L, Emmi G, Cavigli E, Del Carria M, Di Pietro L, Scavone M, Cammelli D, Lavorini F, Tomassetti S, Rosi E, Parronchi P. Presentation and progression of MPO-ANCA interstitial lung disease. J Transl Autoimmun 2024; 8:100235. [PMID: 38445024 PMCID: PMC10912625 DOI: 10.1016/j.jtauto.2024.100235] [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: 01/03/2024] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024] Open
Abstract
The association between MPO-ANCA-associated vasculitis (AAV) and interstitial lung disease (ILD) has been well established. Pulmonary fibrosis may coexist with, follow, or even precede the diagnosis of AAV, and its presence adversely affects the prognosis. The optimal approach to investigating ANCA in patients with ILD remains a subject of ongoing debate. Here we aim to describe presentation and progression of MPO-ANCA ILD. We conducted a retrospective evaluation of a cohort of individuals diagnosed with MPO-ANCA ILD, with or without accompanying renal impairment, at the Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy, between June 2016 and June 2022. Clinical records, imaging studies, pathologic examinations, and laboratory test results were collected. Among the 14 patients identified with MPO-ANCA ILD, we observed a significant association between MPO-ANCA titers assessed at the time of ILD diagnosis and renal involvement. Renal impairment in these cases often manifested as subclinical or slowly progressive kidney damage. Interestingly, complement C3 deposits were consistently found in all renal biopsy specimens, thereby suggesting the potential for novel therapeutic targets in managing renal complications associated with MPO-ANCA ILD. The presentation of MPO-ANCA vasculitis as ILD can be the first and only clinical manifestation. MPO-ANCA levels at ILD diagnosis could warn on the progression to renal involvement in patients with MPO-ANCA ILD, hence caution is needed because renal disease can be subclinical or smoldering.
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Affiliation(s)
- Lorenzo Salvati
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Boaz Palterer
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Lazzeri
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Emanuele Vivarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marina Amendola
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Marco Allinovi
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Leonardo Caroti
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Flow Cytometry Diagnostic Center and Immunotherapy, Careggi University Hospital, Florence, Italy
| | - Laura Lasagni
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Edoardo Cavigli
- Department of Emergency Radiology, Careggi University Hospital, Florence, Italy
| | - Marco Del Carria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Linda Di Pietro
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mariangela Scavone
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniele Cammelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Interventional Pulmonology Unit, Careggi University Hospital, Florence, Italy
| | - Elisabetta Rosi
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy
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7
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Arnold S, Kitching AR, Witko-Sarsat V, Wiech T, Specks U, Klapa S, Comdühr S, Stähle A, Müller A, Lamprecht P. Myeloperoxidase-specific antineutrophil cytoplasmic antibody-associated vasculitis. THE LANCET. RHEUMATOLOGY 2024; 6:e300-e313. [PMID: 38574743 DOI: 10.1016/s2665-9913(24)00025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 04/06/2024]
Abstract
Myeloperoxidase (MPO)-specific antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (MPO-ANCA-associated vasculitis) is one of two major ANCA-associated vasculitis variants characterised by systemic necrotising vasculitis with few or no immune deposits. MPO-ANCA-associated vasculitis predominantly affects small blood vessels and, in contrast to its counterpart proteinase 3-ANCA-associated vasculitis, is generally not associated with granulomatous inflammation. The kidneys and lungs are the most commonly affected organs. The pathogenesis of MPO-ANCA-associated vasculitis is characterised by loss of tolerance to the neutrophil enzyme MPO. This loss of tolerance leads to a chronic immunopathological response where neutrophils become both the target and effector of autoimmunity. MPO-ANCA drives neutrophil activation, leading in turn to tissue and organ damage. Clinical trials have improved the therapeutic approach to MPO-ANCA-associated vasculitis. However, there remains substantial unmet need regarding relapse frequency, toxicity of current treatment, and long-term morbidity. In this Series paper, we present the current state of research regarding pathogenesis, diagnosis, and treatment of MPO-ANCA-associated vasculitis.
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Affiliation(s)
- Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia; Departments of Nephrology and Pediatric Nephrology, Monash Health, Clayton, VIC, Australia
| | - Veronique Witko-Sarsat
- INSERM U1016, Institut Cochin, CNRS UMR8104, Université Paris Cité et Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Thorsten Wiech
- Section of Nephropathology, Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sebastian Klapa
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Sara Comdühr
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Anja Stähle
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Antje Müller
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany.
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8
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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9
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Odler B, Tieu J, Artinger K, Chen-Xu M, Arnaud L, Kitching RA, Terrier B, Thiel J, Cid MC, Rosenkranz AR, Kronbichler A, Jayne DRW. The plethora of immunomodulatory drugs: opportunities for immune-mediated kidney diseases. Nephrol Dial Transplant 2023; 38:ii19-ii28. [PMID: 37816674 DOI: 10.1093/ndt/gfad186] [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: 04/24/2023] [Indexed: 10/12/2023] Open
Abstract
In recent decades, insights into the molecular pathways involved in disease have revolutionized the treatment of autoimmune diseases. A plethora of targeted therapies have been identified and are at varying stages of clinical development in renal autoimmunity. Some of these agents, such as rituximab or avacopan, have been approved for the treatment of immune-mediated kidney disease, but kidney disease lags behind more common autoimmune disorders in new drug development. Evidence is accumulating as to the importance of adaptive immunity, including abnormalities in T-cell activation and signaling, and aberrant B-cell function. Furthermore, innate immunity, particularly the complement and myeloid systems, as well as pathologic responses in tissue repair and fibrosis, play a key role in disease. Collectively, these mechanistic studies in innate and adaptive immunity have provided new insights into mechanisms of glomerular injury in immune-mediated kidney diseases. In addition, inflammatory pathways common to several autoimmune conditions exist, suggesting that the repurposing of some existing drugs for the treatment of immune-mediated kidney diseases is a logical strategy. This new understanding challenges the clinical investigator to translate new knowledge into novel therapies leading to better disease outcomes. This review highlights promising immunomodulatory therapies tested for immune-mediated kidney diseases as a primary indication, details current clinical trials and discusses pathways that could be targeted in the future.
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Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Johanna Tieu
- Faculty of Health and Medical Sciences, University of Adelaide; Adelaide, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia
- Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Katharina Artinger
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Chen-Xu
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
| | - Richard A Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
- Departments of Nephrology and Paediatric Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Benjamin Terrier
- Department of Internal Medicine, National Reference Center for Autoimmune Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - Jens Thiel
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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10
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Alvarez L, Kambham N, Su R. Renal improvement and remission in a patient with refractory ANCA-associated vasculitis treated with avacopan. J Nephrol 2023; 36:2365-2370. [PMID: 37036661 PMCID: PMC10638159 DOI: 10.1007/s40620-023-01614-y] [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: 10/23/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023]
Abstract
Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is associated with end-organ damage resulting in significant morbidity and mortality. Most recently, avacopan, an orally administered selective antagonist of the C5a receptor, was approved by the US Food and Drug Administration as an adjunctive treatment of adult patients with severe, active ANCA-associated vasculitis (granulomatosis with polyangiitis and microscopic polyangiitis) in combination with standard therapy including glucocorticoids. This case study describes a 58-year-old Asian female with severe ANCA-associated vasculitis and acute renal failure who responded to adjunctive therapy with avacopan despite being refractory to rituximab and glucocorticoid therapy.
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Affiliation(s)
- Luis Alvarez
- Division of Nephrology, Department of Medicine and Nephrology, Palo Alto Medical Foundation, Palo Alto, CA, USA.
| | - Neeraja Kambham
- Division of Renal Pathology, Stanford University, Stanford, CA, USA
| | - Robert Su
- Division of Rheumatology, Sutter Health System, Fremont, CA, USA
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11
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Tan Z, Hall P, Costin A, Crawford SA, Ramm G, Wong CHY, Kitching AR, Hickey MJ. Removal of the endothelial surface layer via hyaluronidase does not modulate monocyte and neutrophil interactions with the glomerular endothelium. Microcirculation 2023; 30:e12823. [PMID: 37494581 PMCID: PMC10909409 DOI: 10.1111/micc.12823] [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: 05/25/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE The endothelial surface layer (ESL), a layer of macromolecules on the surface of endothelial cells, can both impede and facilitate leukocyte recruitment. However, its role in monocyte and neutrophil recruitment in glomerular capillaries is unknown. METHODS We used multiphoton intravital microscopy to examine monocyte and neutrophil behavior in the glomerulus following ESL disruption with hyaluronidase. RESULTS Constitutive retention and migration of monocytes and neutrophils within the glomerular microvasculature was unaltered by hyaluronidase. Consistent with this, inhibition of the hyaluronan-binding molecule CD44 also failed to modulate glomerular trafficking of these immune cells. To investigate the contribution of the ESL during acute inflammation, we induced glomerulonephritis via in situ immune complex deposition. This resulted in increases in glomerular retention of monocytes and neutrophils but did not induce marked reduction in the glomerular ESL. Furthermore, hyaluronidase treatment did not modify the prolonged retention of monocytes and neutrophils in the acutely inflamed glomerular microvasculature. CONCLUSIONS These observations indicate that, despite evidence that the ESL has the capacity to inhibit leukocyte-endothelial cell interactions while also containing adhesive ligands for immune cells, neither of these functions modulate trafficking of monocytes and neutrophils in steady-state or acutely-inflamed glomeruli.
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Affiliation(s)
- ZheHao Tan
- Centre for Inflammatory Diseases, Monash University Department of MedicineMonash Medical CentreClaytonVictoriaAustralia
| | - Pam Hall
- Centre for Inflammatory Diseases, Monash University Department of MedicineMonash Medical CentreClaytonVictoriaAustralia
| | - Adam Costin
- Monash Ramaciotti Centre for Cryo‐Electron MicroscopyMonash UniversityClaytonVictoriaAustralia
| | - Simon A. Crawford
- Monash Ramaciotti Centre for Cryo‐Electron MicroscopyMonash UniversityClaytonVictoriaAustralia
| | - Georg Ramm
- Monash Ramaciotti Centre for Cryo‐Electron MicroscopyMonash UniversityClaytonVictoriaAustralia
| | - Connie H. Y. Wong
- Centre for Inflammatory Diseases, Monash University Department of MedicineMonash Medical CentreClaytonVictoriaAustralia
| | - A. Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of MedicineMonash Medical CentreClaytonVictoriaAustralia
- Department of NephrologyMonash Medical CentreClaytonVictoriaAustralia
- Department of Pediatric NephrologyMonash Medical CentreClaytonVictoriaAustralia
| | - Michael J. Hickey
- Centre for Inflammatory Diseases, Monash University Department of MedicineMonash Medical CentreClaytonVictoriaAustralia
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12
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Shiratori-Aso S, Nakazawa D. The involvement of NETs in ANCA-associated vasculitis. Front Immunol 2023; 14:1261151. [PMID: 37781373 PMCID: PMC10539550 DOI: 10.3389/fimmu.2023.1261151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a serious autoimmune disease that is characterized by vascular necrosis. The pathogenesis of AAV includes ANCA-mediated neutrophil activation, subsequent release of inflammatory cytokines and reactive oxygen species (ROS), and formation of neutrophil extracellular traps (NETs). Excessive NETs could participate not only in ANCA-mediated vascular injury but also in the production of ANCAs per se as autoantigens. Thus, a vicious cycle of NET formation and ANCA production is critical for AAV pathogenesis. Elucidating the molecular signaling pathways in aberrant neutrophil activation and NETs clearance systems will allow specific therapeutics to regulate these pathways. Currently, standard therapy with high doses of glucocorticoids and immunosuppressants has improved outcomes in patients with AAV. However, AAV frequently develops in elderly people, and adverse effects such as severe infections in the standard regimens might contribute to the mortality. Mechanistically, cytokines or complement factors activate and prime neutrophils for ANCA-binding; thus, C5a receptor blocker has garnered attention as potential replacement for glucocorticoids in clinical settings. Recent studies have demonstrated that receptor-interacting protein kinases (RIPK3) and cyclophilin D (CypD), which regulate cell necrosis, may be involved in ANCA-induced NETs formation. Meanwhile, targeting NETs clearance, including the addition of deoxyribonuclease I (DNase I) and macrophage engulfment, may improve vasculitis. In this review, we focus on the pathogenesis of NETs and discuss potential targeted therapies for AAV based on recent experimental evidence.
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Affiliation(s)
| | - Daigo Nakazawa
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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13
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Maruyama Y, Yoshida T, Maruyama I. [Pharmacological and clinical profiles of avacopan (TAVNEOS ® capsule), a selective C5a receptor antagonist]. Nihon Yakurigaku Zasshi 2023; 158:399-407. [PMID: 37460300 DOI: 10.1254/fpj.22161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Avacopan (TAVNEOS® capsules) is an orally available selective C5a receptor (C5aR) antagonist. It has been approved in Japan since 2021 for the treatment of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA), the two major subtypes of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The current standard therapy combining glucocorticoids (GC) and immunosuppressants has greatly improved the prognosis of AAV, however, issues such as side effects associated with GC use remain to be resolved. Avacopan suppresses priming of neutrophils induced by the complement component C5a, a process deeply involved in the pathogenesis of AAV. In pre-clinical studies, avacopan inhibited chemotaxis and priming of neutrophils induced by C5a-C5aR signaling. It also significantly suppressed nephritis and renal damage in an ANCA-induced glomerulonephritis mouse model. In the global phase 3 study "ADVOCATE", avacopan achieved both primary endpoints being 1) non-inferior to prednisone in inducing remission at week 26 and 2) superior in sustained remission at week 52 for MPA and GPA patients. Additionally, with avacopan, GC toxicity score was significantly lower and fewer adverse events possibly related to GC were observed. Furthermore, avacopan increased estimated glomerular filtration rate (eGFR) more than prednisone indicating improved renal function. Thus, the novel mechanism of avacopan targeting the complement system is a promising new therapeutic option for AAV with fewer GC-related side effects and better improvement of renal function.
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Affiliation(s)
- Yuya Maruyama
- Pharmacology Research Laboratory, Kissei Pharmaceutical Co., Ltd
| | | | - Itaru Maruyama
- Pharmacology Research Laboratory, Kissei Pharmaceutical Co., Ltd
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14
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Schanzenbacher J, Hendrika Kähler K, Mesler E, Kleingarn M, Marcel Karsten C, Leonard Seiler D. The role of C5a receptors in autoimmunity. Immunobiology 2023; 228:152413. [PMID: 37598588 DOI: 10.1016/j.imbio.2023.152413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/04/2023] [Accepted: 06/10/2023] [Indexed: 08/22/2023]
Abstract
The complement system is an essential component of the innate immune response and plays a vital role in host defense and inflammation. Dysregulation of the complement system, particularly involving the anaphylatoxin C5a and its receptors (C5aR1 and C5aR2), has been linked to several autoimmune diseases, indicating the potential for targeted therapies. C5aR1 and C5aR2 are seven-transmembrane receptors with distinct signaling mechanisms that play both partially overlapping and opposing roles in immunity. Both receptors are expressed on a broad spectrum of immune and non-immune cells and are involved in cellular functions and physiological processes during homeostasis and inflammation. Dysregulated C5a-mediated inflammation contributes to autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, epidermolysis bullosa acquisita, antiphospholipid syndrome, and others. Therefore, targeting C5a or its receptors may yield therapeutic innovations in these autoimmune diseases by reducing the recruitment and activation of immune cells that lead to tissue inflammation and injury, thereby exacerbating the autoimmune response. Clinical trials focused on the inhibition of C5 cleavage or the C5a/C5aR1-axis using small molecules or monoclonal antibodies hold promise for bringing novel treatments for autoimmune diseases into practice. However, given the heterogeneous nature of (systemic) autoimmune diseases, there are still several challenges, such as patient selection, optimal dosing, and treatment duration, that require further investigation and development to realize the full therapeutic potential of C5a receptor inhibition, ideally in the context of a personalized medicine approach. Here, we aim to provide a brief overview of the current knowledge on the function of C5a receptors, the involvement of C5a receptors in autoimmune disorders, the molecular mechanisms underlying C5a receptor-mediated autoimmunity, and the potential for targeted therapies to modulate their activity.
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Affiliation(s)
- Jovan Schanzenbacher
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Katja Hendrika Kähler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Evelyn Mesler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Marie Kleingarn
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | | | - Daniel Leonard Seiler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany.
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15
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Anders HJ, Kitching AR, Leung N, Romagnani P. Glomerulonephritis: immunopathogenesis and immunotherapy. Nat Rev Immunol 2023; 23:453-471. [PMID: 36635359 PMCID: PMC9838307 DOI: 10.1038/s41577-022-00816-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/14/2023]
Abstract
'Glomerulonephritis' (GN) is a term used to describe a group of heterogeneous immune-mediated disorders characterized by inflammation of the filtration units of the kidney (the glomeruli). These disorders are currently classified largely on the basis of histopathological lesion patterns, but these patterns do not align well with their diverse pathological mechanisms and hence do not inform optimal therapy. Instead, we propose grouping GN disorders into five categories according to their immunopathogenesis: infection-related GN, autoimmune GN, alloimmune GN, autoinflammatory GN and monoclonal gammopathy-related GN. This categorization can inform the appropriate treatment; for example, infection control for infection-related GN, suppression of adaptive immunity for autoimmune GN and alloimmune GN, inhibition of single cytokines or complement factors for autoinflammatory GN arising from inborn errors in innate immunity, and plasma cell clone-directed or B cell clone-directed therapy for monoclonal gammopathies. Here we present the immunopathogenesis of GN and immunotherapies in use and in development and discuss how an immunopathogenesis-based GN classification can focus research, and improve patient management and teaching.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany.
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
- Department of Nephrology, Monash Health, Clayton, VIC, Australia
- Department of Paediatric Nephrology, Monash Health, Clayton, VIC, Australia
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Paola Romagnani
- Department of Experimental and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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16
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Osman M, Cohen Tervaert JW, Pagnoux C. Avacopan for the treatment of ANCA-associated vasculitis: an update. Expert Rev Clin Immunol 2023; 19:461-471. [PMID: 36545762 DOI: 10.1080/1744666x.2023.2162041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids (GC) have been part of the standard treatment of anti-neutrophil cytoplasm autoantibodies (ANCA)-associated vasculitides (AAV) for more than 60 years. Various therapeutic advances have occurred over the past 2 decades and led to a significant reduction of GC exposure, but most patients still have to suffer from complications of GC, including infections, metabolic abnormalities, and cardiovascular morbidity. In 2007, activation of the complement pathway was demonstrated to play a role in the pathogenesis of AAV. Avacopan, an oral competitive inhibitor of the C5a receptor (C5aR1, CD88), was then developed, with an additional aim to decrease the use of GC. AREAS COVERED In this article, we briefly summarize the rationale for targeting the complement pathway in AAV, and review relevant findings from pre-clinical, phase I, II, and III studies, subsequent and more recent case reports and series on the efficacy and safety of avacopan. EXPERT OPINION Based on the results of these studies, avacopan was approved in most countries since late 2021, as an adjunctive induction treatment for patients with AAV. Several newer questions now are pending answers, including as to how avacopan should be used in real-world practice, beyond how it was given in the original clinical trials.
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Affiliation(s)
- Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Christian Pagnoux
- Vasculitis clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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17
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Clinicopathological features and prognosis of primary membranous nephropathy in combination with crescent. Int Urol Nephrol 2023; 55:1523-1530. [PMID: 36622536 DOI: 10.1007/s11255-022-03457-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 12/27/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The incidence of primary membranous nephropathy with crescentic bodies is low, but the specificity of its clinical presentation, pathology and prognosis is of great interest. In this study, we retrospectively analyzed the clinicopathological and prognostic characteristics of patients with crescentic MN in our hospital over the past 4 years. METHODS Ten patients with combined crescentic primary membranous nephropathy diagnosed by renal biopsy at our hospital from 2018 to 2021 were retrospectively analysed and compared with 39 patients with PMN (simple random sample) during the same period for clinicopathological and prognostic comparisons. RESULTS The 10 patients had higher 24 h urine protein quantification, creatinine levels on renal biopsy, interstitial fibrosis and tubular atrophy, and interstitial inflammatory cell infiltration than the control group (P < 0.05); there were no significant differences in anti-PLA2R antibodies and PLA2R staining of renal tissue (P > 0.05); At follow-up, the poor outcome of crescentic MN treatment and the low clinical remission rate were found, with the percentage of crescentic bodies being a factor in patient prognosis (P < 0.05). CONCLUSION Crescentic MN has a low prevalence and maybe a specific type of PMN; it has more severe clinical symptoms and pathology than PMN, and the crescentic proportion is strongly associated with renal prognosis. Intensive treatment is recommended for these patients.
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18
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Mazzariol M, Manenti L, Vaglio A. The complement system in antineutrophil cytoplasmic antibody-associated vasculitis: pathogenic player and therapeutic target. Curr Opin Rheumatol 2023; 35:31-36. [PMID: 36301247 DOI: 10.1097/bor.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the role of the complement system in the pathogenesis of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) as well as the employment of complement inhibitors in AAV treatment. RECENT FINDINGS AAV has traditionally been considered a pauci-immune disease until recent findings demonstrated the pathogenic role of the complement system. The complement alternative pathway is crucial in AAV, and C5a seems to be a key molecule for AAV to develop. Avacopan, a C5a-receptor (C5aR) antagonist, proved effective in achieving AAV remission and ameliorating kidney function. SUMMARY The increased circulating levels of some complement components - as well as the consumption of others - in patients with AAV suggested a systemic activation of the complement system. Low C3 levels correlate with a more aggressive disease and a worse renal prognosis. In ANCA-associated glomerulonephritis, renal deposits of C3d and properdin, suggestive of local alternative pathway activation, correlate with glomerular crescents and proteinuria. The interaction between C5a and neutrophil triggers alternative pathway activation, suggesting the central role of C5a in AAV pathogenesis. Avacopan, a C5aR inhibitor, showed beneficial effects in AAV and represents a promising therapy to achieve sustained remission and to spare glucocorticoids.
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Affiliation(s)
- Martina Mazzariol
- Department of Medical Sciences, University of Torino, Torino
- Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's Hospital, Firenze
| | | | - Augusto Vaglio
- Nephrology and Dialysis Unit, Department of Pediatrics, Meyer Children's Hospital, Firenze
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio," University of Firenze, Firenze, Italy
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19
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Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
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Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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20
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Emtenani S, Holtsche MM, Stahlkopf R, Seiler DL, Burn T, Liu H, Parker M, Yilmaz K, Dikmen HO, Lang MH, Sadik CD, Karsten CM, van Beek N, Ludwig RJ, Köhl J, Schmidt E. Differential expression of C5aR1 and C5aR2 in innate and adaptive immune cells located in early skin lesions of bullous pemphigoid patients. Front Immunol 2022; 13:942493. [PMID: 36466856 PMCID: PMC9716273 DOI: 10.3389/fimmu.2022.942493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/05/2022] [Indexed: 10/20/2023] Open
Abstract
Bullous pemphigoid (BP), the by far most frequent autoimmune subepidermal blistering disorder (AIBD), is characterized by the deposition of autoantibodies against BP180 (type XVII collagen; Col17) and BP230 as well as complement components at the dermal-epidermal junction (DEJ). The mechanisms of complement activation in BP patients, including the generation of C5a and regulation of its two cognate C5aRs, i.e., C5aR1 and C5aR2, are incompletely understood. In this study, transcriptome analysis of perilesional and non-lesional skin biopsies of BP patients compared to site-, age-, and sex-matched controls showed an upregulated expression of C5AR1, C5AR2, CR1, and C3AR1 and other complement-associated genes in perilesional BP skin. Of note, increased expressions of C5AR2 and C3AR1 were also observed in non-lesional BP skin. Subsequently, double immunofluorescence (IF) staining revealed T cells and macrophages as the dominant cellular sources of C5aR1 in early lesions of BP patients, while C5aR2 mainly expressed on mast cells and eosinophils. In addition, systemic levels of various complement factors and associated molecules were measured in BP patients and controls. Significantly higher plasma levels of C3a, CD55, and mannose-binding lectin-pathway activity were found in BP patients compared to controls. Finally, the functional relevance of C5aR1 and C5aR2 in BP was explored by two in vitro assays. Specific inhibition of C5aR1, resulted in significantly reduced migration of human neutrophils toward the chemoattractant C5a, whereas stimulation of C5aR2 showed no effect. In contrast, the selective targeting of C5aR1 and/or C5aR2 had no effect on the release of reactive oxygen species (ROS) from Col17-anti-Col17 IgG immune complex-stimulated human leukocytes. Collectively, this study delineates a complex landscape of activated complement receptors, complement factors, and related molecules in early BP skin lesions. Our results corroborate findings in mouse models of pemphigoid diseases that the C5a/C5aR1 axis is pivotal for attracting inflammatory cells to the skin and substantiate our understanding of the C5a/C5aR1 axis in human BP. The broad expression of C5aRs on multiple cell types critical for BP pathogenesis call for clinical studies targeting this axis in BP and other complement-mediated AIBDs.
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Affiliation(s)
- Shirin Emtenani
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Maike M. Holtsche
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Richard Stahlkopf
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Daniel L. Seiler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Timothy Burn
- Incyte Research Institute, Wilmington, DE, United States
| | - Huiqing Liu
- Incyte Research Institute, Wilmington, DE, United States
| | - Melissa Parker
- Incyte Research Institute, Wilmington, DE, United States
| | - Kaan Yilmaz
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Hasan O. Dikmen
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Markus Huber Lang
- Institute of Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christian D. Sadik
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Christian M. Karsten
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Nina van Beek
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Centre, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, Allergy, and Venereology, University of Lübeck, Lübeck, Germany
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21
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Schanzenbacher J, Köhl J, Karsten CM. Anaphylatoxins spark the flame in early autoimmunity. Front Immunol 2022; 13:958392. [PMID: 35958588 PMCID: PMC9358992 DOI: 10.3389/fimmu.2022.958392] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
The complement system (CS) is an ancient and highly conserved part of the innate immune system with important functions in immune defense. The multiple fragments bind to specific receptors on innate and adaptive immune cells, the activation of which translates the initial humoral innate immune response (IR) into cellular innate and adaptive immunity. Dysregulation of the CS has been associated with the development of several autoimmune disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ANCA-associated vasculitis, and autoimmune bullous dermatoses (AIBDs), where complement drives the inflammatory response in the effector phase. The role of the CS in autoimmunity is complex. On the one hand, complement deficiencies were identified as risk factors to develop autoimmune disorders. On the other hand, activation of complement can drive autoimmune responses. The anaphylatoxins C3a and C5a are potent mediators and regulators of inflammation during the effector phase of autoimmunity through engagement of specific anaphylatoxin receptors, i.e., C3aR, C5aR1, and C5aR2 either on or in immune cells. In addition to their role in innate IRs, anaphylatoxins regulate humoral and cellular adaptive IRs including B-cell and T-cell activation, differentiation, and survival. They regulate B- and T-lymphocyte responses either directly or indirectly through the activation of anaphylatoxin receptors via dendritic cells that modulate lymphocyte function. Here, we will briefly review our current understanding of the complex roles of anaphylatoxins in the regulation of immunologic tolerance and the early events driving autoimmunity and the implications of such regulation for therapeutic approaches that target the CS.
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Affiliation(s)
- Jovan Schanzenbacher
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Christian M. Karsten
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- *Correspondence: Christian M. Karsten,
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22
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Meuleman MS, Duval A, Fremeaux-Bacchi V, Roumenina LT, Chauvet S. Ex Vivo Test for Measuring Complement Attack on Endothelial Cells: From Research to Bedside. Front Immunol 2022; 13:860689. [PMID: 35493497 PMCID: PMC9041553 DOI: 10.3389/fimmu.2022.860689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/21/2022] [Indexed: 01/04/2023] Open
Abstract
As part of the innate immune system, the complement system plays a key role in defense against pathogens and in host cell homeostasis. This enzymatic cascade is rapidly triggered in the presence of activating surfaces. Physiologically, it is tightly regulated on host cells to avoid uncontrolled activation and self-damage. In cases of abnormal complement dysregulation/overactivation, the endothelium is one of the primary targets. Complement has gained momentum as a research interest in the last decade because its dysregulation has been implicated in the pathophysiology of many human diseases. Thus, it appears to be a promising candidate for therapeutic intervention. However, detecting abnormal complement activation is challenging. In many pathological conditions, complement activation occurs locally in tissues. Standard routine exploration of the plasma concentration of the complement components shows values in the normal range. The available tests to demonstrate such dysregulation with diagnostic, prognostic, and therapeutic implications are limited. There is a real need to develop tools to demonstrate the implications of complement in diseases and to explore the complex interplay between complement activation and regulation on human cells. The analysis of complement deposits on cultured endothelial cells incubated with pathologic human serum holds promise as a reference assay. This ex vivo assay most closely resembles the physiological context. It has been used to explore complement activation from sera of patients with atypical hemolytic uremic syndrome, malignant hypertension, elevated liver enzymes low platelet syndrome, sickle cell disease, pre-eclampsia, and others. In some cases, it is used to adjust the therapeutic regimen with a complement-blocking drug. Nevertheless, an international standard is lacking, and the mechanism by which complement is activated in this assay is not fully understood. Moreover, primary cell culture remains difficult to perform, which probably explains why no standardized or commercialized assay has been proposed. Here, we review the diseases for which endothelial assays have been applied. We also compare this test with others currently available to explore complement overactivation. Finally, we discuss the unanswered questions and challenges to overcome for validating the assays as a tool in routine clinical practice.
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Affiliation(s)
- Marie-Sophie Meuleman
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Anna Duval
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | | | - Lubka T Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Sophie Chauvet
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
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23
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Huang SUS, O’Sullivan KM. The Expanding Role of Extracellular Traps in Inflammation and Autoimmunity: The New Players in Casting Dark Webs. Int J Mol Sci 2022; 23:ijms23073793. [PMID: 35409152 PMCID: PMC8998317 DOI: 10.3390/ijms23073793] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023] Open
Abstract
The first description of a new form of neutrophil cell death distinct from that of apoptosis or necrosis was discovered in 2004 and coined neutrophil extracellular traps "(NETs)" or "NETosis". Different stimuli for NET formation, and pathways that drive neutrophils to commit to NETosis have been elucidated in the years that followed. Critical enzymes required for NET formation have been discovered and targeted therapeutically. NET formation is no longer restricted to neutrophils but has been discovered in other innate cells: macrophages/monocytes, mast Cells, basophils, dendritic cells, and eosinophils. Furthermore, extracellular DNA can also be extruded from both B and T cells. It has become clear that although this mechanism is thought to enhance host defense by ensnaring bacteria within large webs of DNA to increase bactericidal killing capacity, it is also injurious to innocent bystander tissue. Proteases and enzymes released from extracellular traps (ETs), injure epithelial and endothelial cells perpetuating inflammation. In the context of autoimmunity, ETs release over 70 well-known autoantigens. ETs are associated with pathology in multiple diseases: lung diseases, vasculitis, autoimmune kidney diseases, atherosclerosis, rheumatoid arthritis, cancer, and psoriasis. Defining these pathways that drive ET release will provide insight into mechanisms of pathological insult and provide potential therapeutic targets.
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24
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New Insights into the Treatment of Glomerular Diseases: When Mechanisms Become Vivid. Int J Mol Sci 2022; 23:ijms23073525. [PMID: 35408886 PMCID: PMC8998908 DOI: 10.3390/ijms23073525] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 12/23/2022] Open
Abstract
Treatment for glomerular diseases has been extrapolated from the experience of other autoimmune disorders while the underlying pathogenic mechanisms were still not well understood. As the classification of glomerular diseases was based on patterns of juries instead of mechanisms, treatments were typically the art of try and error. With the advancement of molecular biology, the role of the immune agent in glomerular diseases is becoming more evident. The four-hit theory based on the discovery of gd-IgA1 gives a more transparent outline of the pathogenesis of IgA nephropathy (IgAN), and dysregulation of Treg plays a crucial role in the pathogenesis of minimal change disease (MCD). An epoch-making breakthrough is the discovery of PLA2R antibodies in the primary membranous nephropathy (pMN). This is the first biomarker applied for precision medicine in kidney disease. Understanding the immune system’s role in glomerular diseases allows the use of various immunosuppressants or other novel treatments, such as complement inhibitors, to treat glomerular diseases more reasonable. In this era of advocating personalized medicine, it is inevitable to develop precision medicine with mechanism-based novel biomarkers and novel therapies in kidney disease.
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25
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Talaat IM, Elemam NM, Saber-Ayad M. Complement System: An Immunotherapy Target in Colorectal Cancer. Front Immunol 2022; 13:810993. [PMID: 35173724 PMCID: PMC8841337 DOI: 10.3389/fimmu.2022.810993] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/14/2022] [Indexed: 12/26/2022] Open
Abstract
Colorectal cancer (CRC) is the third most common malignant tumor and the second most fatal cancer worldwide. Several parts of the immune system contribute to fighting cancer including the innate complement system. The complement system is composed of several players, namely component molecules, regulators and receptors. In this review, we discuss the complement system activation in cancer specifically CRC and highlight the possible interactions between the complement system and the various TME components. Additionally, the role of the complement system in tumor immunity of CRC is reviewed. Hence, such work could provide a framework for researchers to further understand the role of the complement system in CRC and explore the potential therapies targeting complement activation in solid tumors such as CRC.
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Affiliation(s)
- Iman M. Talaat
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Noha Mousaad Elemam
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- *Correspondence: Noha Mousaad Elemam, ; Maha Saber-Ayad,
| | - Maha Saber-Ayad
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Medicine, Cairo University, Cairo, Egypt
- *Correspondence: Noha Mousaad Elemam, ; Maha Saber-Ayad,
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26
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Kitching AR, Hickey MJ. Immune cell behaviour and dynamics in the kidney - insights from in vivo imaging. Nat Rev Nephrol 2022; 18:22-37. [PMID: 34556836 DOI: 10.1038/s41581-021-00481-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/08/2023]
Abstract
The actions of immune cells within the kidney are of fundamental importance in kidney homeostasis and disease. In disease settings such as acute kidney injury, anti-neutrophil cytoplasmic antibody-associated vasculitis, lupus nephritis and renal transplant rejection, immune cells resident within the kidney and those recruited from the circulation propagate inflammatory responses with deleterious effects on the kidney. As in most forms of inflammation, intravital imaging - particularly two-photon microscopy - has been critical to our understanding of immune cell responses in the renal microvasculature and interstitium, enabling visualization of immune cell dynamics over time rather than statically. These studies have demonstrated differences in the recruitment and function of these cells from those in more conventional vascular beds, and provided a wealth of information on the actions of blood-borne immune cells such as neutrophils, monocytes and T cells, as well as kidney-resident mononuclear phagocytes, in a range of diseases affecting different kidney compartments. In particular, in vivo imaging has furthered our understanding of leukocyte function within the glomerulus in acute glomerulonephritis, and in the tubulointerstitium and interstitial microvasculature during acute kidney injury and following transplantation, revealing mechanisms of immune surveillance, antigen presentation and inflammation in the kidney.
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Affiliation(s)
- A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia. .,Departments of Nephrology and Paediatric Nephrology, Monash Medical Centre, Clayton, Victoria, Australia.
| | - Michael J Hickey
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
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27
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Eerhart MJ, Reyes JA, Blanton CL, Danobeitia JS, Chlebeck PJ, Zitur LJ, Springer M, Polyak E, Coonen J, Capuano S, D’Alessandro AM, Torrealba J, van Amersfoort E, Ponstein Y, Van Kooten C, Burlingham W, Sullivan J, Pozniak M, Zhong W, Yankol Y, Fernandez LA. Complement Blockade in Recipients Prevents Delayed Graft Function and Delays Antibody-mediated Rejection in a Nonhuman Primate Model of Kidney Transplantation. Transplantation 2022; 106:60-71. [PMID: 34905763 PMCID: PMC8674492 DOI: 10.1097/tp.0000000000003754] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Complement activation in kidney transplantation is implicated in the pathogenesis of delayed graft function (DGF). This study evaluated the therapeutic efficacy of high-dose recombinant human C1 esterase inhibitor (rhC1INH) to prevent DGF in a nonhuman primate model of kidney transplantation after brain death and prolonged cold ischemia. METHODS Brain death donors underwent 20 h of conventional management. Procured kidneys were stored on ice for 44-48 h, then transplanted into ABO-compatible major histocompatibility complex-mismatched recipients. Recipients were treated with vehicle (n = 5) or rhC1INH 500 U/kg plus heparin 40 U/kg (n = 8) before reperfusion, 12 h, and 24 h posttransplant. Recipients were followed up for 120 d. RESULTS Of vehicle-treated recipients, 80% (4 of 5) developed DGF versus 12.5% (1 of 8) rhC1INH-treated recipients (P = 0.015). rhC1INH-treated recipients had faster creatinine recovery, superior urinary output, and reduced urinary neutrophil gelatinase-associated lipocalin and tissue inhibitor of metalloproteinases 2-insulin-like growth factor-binding protein 7 throughout the first week, indicating reduced allograft injury. Treated recipients presented lower postreperfusion plasma interleukin (IL)-6, IL-8, tumor necrosis factor-alpha, and IL-18, lower day 4 monocyte chemoattractant protein 1, and trended toward lower C5. Treated recipients exhibited less C3b/C5b-9 deposition on day 7 biopsies. rhC1INH-treated animals also trended toward prolonged mediated rejection-free survival. CONCLUSIONS Our results recommend high-dose C1INH complement blockade in transplant recipients as an effective strategy to reduce kidney injury and inflammation, prevent DGF, delay antibody-mediated rejection development, and improve transplant outcomes.
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Affiliation(s)
- Michael J. Eerhart
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jose A. Reyes
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- Department of Surgery, New York Medical College at Metropolitan Hospital Center, New York, NY, United States
| | - Casi L. Blanton
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Juan S. Danobeitia
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Peter J. Chlebeck
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Laura J. Zitur
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Megan Springer
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Erzsebet Polyak
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jennifer Coonen
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Saverio Capuano
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Anthony M. D’Alessandro
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | | | - Cees Van Kooten
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - William Burlingham
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jeremy Sullivan
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Myron Pozniak
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Yucel Yankol
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Luis A. Fernandez
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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28
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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29
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McCullough LD, Roy-O'Reilly M, Lai YJ, Patrizz A, Xu Y, Lee J, Holmes A, Kraushaar DC, Chauhan A, Sansing LH, Stonestreet BS, Zhu L, Kofler J, Lim YP, Venna VR. Exogenous inter-α inhibitor proteins prevent cell death and improve ischemic stroke outcomes in mice. J Clin Invest 2021; 131:144898. [PMID: 34580244 DOI: 10.1172/jci144898] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 07/12/2021] [Indexed: 12/14/2022] Open
Abstract
Inter-α inhibitor proteins (IAIPs) are a family of endogenous plasma and extracellular matrix molecules. IAIPs suppress proinflammatory cytokines, limit excess complement activation, and bind extracellular histones to form IAIP-histone complexes, leading to neutralization of histone-associated cytotoxicity in models of sepsis. Many of these detrimental processes also play critical roles in the pathophysiology of ischemic stroke. In this study, we first assessed the clinical relevance of IAIPs in stroke and then tested the therapeutic efficacy of exogenous IAIPs in several experimental stroke models. IAIP levels were reduced in both ischemic stroke patients and in mice subjected to experimental ischemic stroke when compared with controls. Post-stroke administration of IAIP significantly improved stroke outcomes across multiple stroke models, even when given 6 hours after stroke onset. Importantly, the beneficial effects of delayed IAIP treatment were observed in both young and aged mice. Using targeted gene expression analysis, we identified a receptor for complement activation, C5aR1, that was highly suppressed in both the blood and brain of IAIP-treated animals. Subsequent experiments using C5aR1-knockout mice demonstrated that the beneficial effects of IAIPs are mediated in part by C5aR1. These results indicate that IAIP is a potential therapeutic candidate for the treatment of ischemic stroke.
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Affiliation(s)
- Louise D McCullough
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Meaghan Roy-O'Reilly
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Yun-Ju Lai
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Anthony Patrizz
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Yan Xu
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Juneyoung Lee
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Aleah Holmes
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Daniel C Kraushaar
- Genomic and RNA Profiling Core, Baylor College of Medicine, Houston, Texas, USA
| | - Anjali Chauhan
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lauren H Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Barbara S Stonestreet
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, The Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Liang Zhu
- Biostatistics and Epidemiology Research Design Core, Center for Clinical and Translational Sciences, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Julia Kofler
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yow-Pin Lim
- ProThera Biologics Inc., Providence, Rhode Island, USA.,Department of Pathology and Laboratory Medicine, The Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Venugopal Reddy Venna
- Department of Neurology, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
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30
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Prendecki M, McAdoo SP. Targeting complement in ANCA-associated vasculitis: insights from ADVOCATE. Nat Rev Nephrol 2021; 17:439-440. [PMID: 33762727 DOI: 10.1038/s41581-021-00417-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maria Prendecki
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Imperial College London, London, UK.,Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Imperial College London, London, UK. .,Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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31
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Osman M, Cohen Tervaert JW, Pagnoux C. Avacopan for the treatment of ANCA-associated vasculitis. Expert Rev Clin Immunol 2021; 17:717-726. [PMID: 34006155 DOI: 10.1080/1744666x.2021.1932466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Anti-neutrophil cytoplasm autoantibodies (ANCA)-associated vasculitides (AAVs) are a group of rare heterogeneous diseases characterized by blood vessel inflammation resulting in organ destruction and death. Although various treatment strategies have resulted in marked improvement in vasculitis-specific outcomes, many patients with AAV continue to suffer from complications related to the prolonged use of glucocorticoids (GC) such as infections, metabolic abnormalities, and increased cardiovascular morbidity. Recently, activation of the alternative complement pathway has been implicated in the augmentation of the damage caused by AAV via the complement C5a receptor (C5aR1, CD88). Specifically targeting this pathway may lead to improved outcomes in patients with AAV.Areas covered: In this article, we have summarized the rationale for targeting the complement pathway in AAV. The relevant pre-clinical, phase I, II and III findings with emphasis on the efficacy, and safety of avacopan, a new oral competitive inhibitor that interferes with the binding of C5a to C5aR1 (CD88), are reviewed.Expert opinion: These results are encouraging, may led to major changes in the treatment approach for AAV, and give rise to future studies utilizing complement inhibitors in AAV patients, and potentially in other immune mediated diseases.
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Affiliation(s)
- Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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32
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Gan PY, Dick J, O’Sullivan KM, Oudin V, Cao Le A, Koo Yuk Cheong D, Shim R, Alikhan M, Kitching AR, Ooi JD, Holdsworth SR. Anti-CD20 mAb-Induced B Cell Apoptosis Generates T Cell Regulation of Experimental Myeloperoxidase ANCA-Associated Vasculitis. J Am Soc Nephrol 2021; 32:1071-1083. [PMID: 33789951 PMCID: PMC8259682 DOI: 10.1681/asn.2020060834] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Myeloperoxidase ANCA-associated vasculitis is a major cause of ESKD. Efficacy of anti-CD20 mAb treatment was tested in a mouse model of the disease. METHODS MPO immunization induced anti-MPO autoimmunity, and a subnephritogenic dose of sheep anti-mouse GBM globulin triggered GN. RESULTS Anti-CD20 mAb treatment increased the numbers and immunomodulatory capacity of MPO-specific T regulatory cells (Tregs) and attenuated T cell-mediated and humoral anti-MPO autoimmunity and GN. Disabling of Tregs negated the therapeutic benefit of anti-CD20 treatment. The mechanism of enhancement of Treg activity could be attributed to anti-CD20 mAb effects on inducing B cell apoptosis. Administering anti-CD20 mAb-induced apoptotic splenocytes to mice developing anti-MPO GN was as effective as anti-CD20 mAb treatment in inducing Tregs and attenuating both anti-MPO autoimmunity and GN. A nonredundant role for splenic macrophages in mediating the anti-CD20 mAb-induced immunomodulation was demonstrated by showing that administration of anti-CD20 mAb ex vivo-induced apoptotic splenocytes to unmanipulated mice attenuated autoimmunity and GN, whereas deletion of splenic marginal zone macrophages prevented anti-CD20 mAb-induced immunomodulation and treatment efficacy. Six days after administering anti-CD20 mAb to mice with murine anti-MPO GN, cell-mediated anti-MPO responses and GN were attenuated, and Tregs were enhanced, but ANCA levels were unchanged, suggesting humoral autoimmunity was redundant at this time point. CONCLUSIONS Collectively, these data suggest that, as well as reducing humoral autoimmunity, anti-CD20 mAb more rapidly induces protective anti-MPO Treg-mediated immunomodulation by splenic processing of anti-CD20-induced apoptotic B cells.
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Affiliation(s)
- Poh-Yi Gan
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia,Department of Immunology, Monash Medical Center, Clayton, Victoria, Australia
| | - Jonathan Dick
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Kim M. O’Sullivan
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Virginie Oudin
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anne Cao Le
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Daniel Koo Yuk Cheong
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Raymond Shim
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Maliha Alikhan
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - A. Richard Kitching
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia,Department of Nephrology, Monash Medical Center, Clayton, Victoria, Australia,Department of Pediatric Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Joshua D. Ooi
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Stephen R. Holdsworth
- Center for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia,Department of Immunology, Monash Medical Center, Clayton, Victoria, Australia,Department of Nephrology, Monash Medical Center, Clayton, Victoria, Australia
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Monti S, Brandolino F, Milanesi A, Xoxi B, Delvino P, Montecucco C. Novel Therapies for ANCA-associated Vasculitis. Curr Rheumatol Rep 2021; 23:38. [PMID: 33909172 DOI: 10.1007/s11926-021-01010-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the most recent evidence on the treatment innovations and future prospective in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). RECENT FINDINGS In AAV, a growing body of research is available on novel treatment options for remission induction and to clarify some uncertainties concerning the optimal use of available drugs. Efforts are being made to reduce the toxicity associated with high-dose, prolonged glucocorticoids (GC) regimens. Despite major advances in the prognosis of AAV, relapses are still common and the intensity and duration of remission treatment constitute a great challenge in the management of these chronic conditions. A paradigm shift in practice in the management of AAV is being supported by recent evidence suggesting the comparable efficacy and improved safety profile of schemes with a reduced dose of GC for the induction and maintenance of remission in patients with severe granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Moreover, recent appraisal of pathogenetic mechanisms, including complement activation pathways, has introduced the revolutionary concept of an alternative to GC, such as avacopan. Plasma exchange failed to prevent end-stage renal disease and mortality in patients with severe renal involvement or pulmonary haemorrhage according to a large multicentre randomised trial. Intensified immunosuppressive strategies for patients with life-threatening manifestations, including the combination of rituximab (RTX) with cyclophosphamide (CYC) have revealed promising preliminary data. New evidence for the use of alternative immunosuppressive agents (e.g. mycophenolate mofetil or abatacept) for the induction of remission in patients with non-severe disease is emerging. Several studies have been recently published, or are ongoing, to assess the optimal strategy and duration of maintenance of remission with the available treatment options (GC, azathioprine, and RTX). Preliminary evidence supports the superiority of a more prolonged course of maintenance treatment. The management of refractory or relapsing eosinophilic granulomatosis with polyangiitis (EGPA) has been improved by the recent demonstration of efficacy and safety of an interleukin-5 inhibitor, mepolizumab. Ongoing randomised studies will clarify the role of RTX in patients with severe manifestations of EGPA.
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Affiliation(s)
- Sara Monti
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - Fabio Brandolino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Alessandra Milanesi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Blerina Xoxi
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
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Garred P, Tenner AJ, Mollnes TE. Therapeutic Targeting of the Complement System: From Rare Diseases to Pandemics. Pharmacol Rev 2021; 73:792-827. [PMID: 33687995 PMCID: PMC7956994 DOI: 10.1124/pharmrev.120.000072] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The complement system was discovered at the end of the 19th century as a heat-labile plasma component that "complemented" the antibodies in killing microbes, hence the name "complement." Complement is also part of the innate immune system, protecting the host by recognition of pathogen-associated molecular patterns. However, complement is multifunctional far beyond infectious defense. It contributes to organ development, such as sculpting neuron synapses, promoting tissue regeneration and repair, and rapidly engaging and synergizing with a number of processes, including hemostasis leading to thromboinflammation. Complement is a double-edged sword. Although it usually protects the host, it may cause tissue damage when dysregulated or overactivated, such as in the systemic inflammatory reaction seen in trauma and sepsis and severe coronavirus disease 2019 (COVID-19). Damage-associated molecular patterns generated during ischemia-reperfusion injuries (myocardial infarction, stroke, and transplant dysfunction) and in chronic neurologic and rheumatic disease activate complement, thereby increasing damaging inflammation. Despite the long list of diseases with potential for ameliorating complement modulation, only a few rare diseases are approved for clinical treatment targeting complement. Those currently being efficiently treated include paroxysmal nocturnal hemoglobinuria, atypical hemolytic-uremic syndrome, myasthenia gravis, and neuromyelitis optica spectrum disorders. Rare diseases, unfortunately, preclude robust clinical trials. The increasing evidence for complement as a pathogenetic driver in many more common diseases suggests an opportunity for future complement therapy, which, however, requires robust clinical trials; one ongoing example is COVID-19 disease. The current review aims to discuss complement in disease pathogenesis and discuss future pharmacological strategies to treat these diseases with complement-targeted therapies. SIGNIFICANCE STATEMENT: The complement system is the host's defense friend by protecting it from invading pathogens, promoting tissue repair, and maintaining homeostasis. Complement is a double-edged sword, since when dysregulated or overactivated it becomes the host's enemy, leading to tissue damage, organ failure, and, in worst case, death. A number of acute and chronic diseases are candidates for pharmacological treatment to avoid complement-dependent damage, ranging from the well established treatment for rare diseases to possible future treatment of large patient groups like the pandemic coronavirus disease 2019.
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Affiliation(s)
- Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
| | - Andrea J Tenner
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
| | - Tom E Mollnes
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
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O'Sullivan KM, Holdsworth SR. Neutrophil Extracellular Traps: A Potential Therapeutic Target in MPO-ANCA Associated Vasculitis? Front Immunol 2021; 12:635188. [PMID: 33790907 PMCID: PMC8005609 DOI: 10.3389/fimmu.2021.635188] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/18/2021] [Indexed: 12/19/2022] Open
Abstract
Our understanding of immune recognition and response to infection and non-infectious forms of cell damage and death is rapidly increasing. The major focus is on host immunity and microbiological invasion. However, it is also clear that these same pathways are important in the initiation and maintenance of autoimmunity and the damage caused to targeted organs. Understanding the involvement of cell death in autoimmune disease is likely to help define critical pathways in the immunopathogenesis of autoimmune disease and new therapeutic targets. An important immune responder cell population in host defense and autoimmunity is the neutrophil. One autoimmune disease where neutrophils play important roles is MPO-ANCA Microscopic Vasculitis. This a severe disease that results from inflammation to small blood vessels in the kidney, the glomeruli (high blood flow and pressure filters). One of the best studied ways in which neutrophils participate in this disease is by cell death through NETosis resulting in the discharge of proinflammatory enzymes and nuclear fragments. In host defense against infection this process helps neutralize pathogens however in auto immunity NETosis results in injury and death to the surrounding healthy tissues. The major autoimmune target in this disease is myeloperoxidase (MPO) which is found uniquely in the cytoplasm of neutrophils. Although the kidney is the major organ targeted in this disease MPO is not expressed in the kidney. Autoantibodies target surface MPO on activated circulating neutrophils resulting in their lodgment in glomerular capillaries where they NETose releasing extracellularly MPO and nuclear fragments initiating injury and planting the key autoantigen MPO. It is the cell death of neutrophils that changes the kidney from innocent bystander to major autoimmune target. Defining the immunopathogenesis of this autoimmune disease and recognizing critical injurious pathways will allow therapeutic intervention to block these pathways and attenuate autoimmune injury. The insights (regarding mechanisms of injury and potential therapeutic targets) are likely to be highly relevant to many other autoimmune diseases.
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Affiliation(s)
- Kim M O'Sullivan
- Department of Medicine, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Stephen R Holdsworth
- Department of Medicine, Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia.,Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia.,Department of Immunology, Monash Medical Centre, Clayton, VIC, Australia
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36
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Wauters E, Van Mol P, Garg AD, Jansen S, Van Herck Y, Vanderbeke L, Bassez A, Boeckx B, Malengier-Devlies B, Timmerman A, Van Brussel T, Van Buyten T, Schepers R, Heylen E, Dauwe D, Dooms C, Gunst J, Hermans G, Meersseman P, Testelmans D, Yserbyt J, Tejpar S, De Wever W, Matthys P, Neyts J, Wauters J, Qian J, Lambrechts D. Discriminating mild from critical COVID-19 by innate and adaptive immune single-cell profiling of bronchoalveolar lavages. Cell Res 2021; 31:272-290. [PMID: 33473155 PMCID: PMC8027624 DOI: 10.1038/s41422-020-00455-9] [Citation(s) in RCA: 191] [Impact Index Per Article: 63.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/20/2020] [Indexed: 02/08/2023] Open
Abstract
How the innate and adaptive host immune system miscommunicate to worsen COVID-19 immunopathology has not been fully elucidated. Here, we perform single-cell deep-immune profiling of bronchoalveolar lavage (BAL) samples from 5 patients with mild and 26 with critical COVID-19 in comparison to BALs from non-COVID-19 pneumonia and normal lung. We use pseudotime inference to build T-cell and monocyte-to-macrophage trajectories and model gene expression changes along them. In mild COVID-19, CD8+ resident-memory (TRM) and CD4+ T-helper-17 (TH17) cells undergo active (presumably antigen-driven) expansion towards the end of the trajectory, and are characterized by good effector functions, while in critical COVID-19 they remain more naïve. Vice versa, CD4+ T-cells with T-helper-1 characteristics (TH1-like) and CD8+ T-cells expressing exhaustion markers (TEX-like) are enriched halfway their trajectories in mild COVID-19, where they also exhibit good effector functions, while in critical COVID-19 they show evidence of inflammation-associated stress at the end of their trajectories. Monocyte-to-macrophage trajectories show that chronic hyperinflammatory monocytes are enriched in critical COVID-19, while alveolar macrophages, otherwise characterized by anti-inflammatory and antigen-presenting characteristics, are depleted. In critical COVID-19, monocytes contribute to an ATP-purinergic signaling-inflammasome footprint that could enable COVID-19 associated fibrosis and worsen disease-severity. Finally, viral RNA-tracking reveals infected lung epithelial cells, and a significant proportion of neutrophils and macrophages that are involved in viral clearance.
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Affiliation(s)
- Els Wauters
- grid.5596.f0000 0001 0668 7884Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Pierre Van Mol
- grid.410569.f0000 0004 0626 3338Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Abhishek Dinkarnath Garg
- grid.5596.f0000 0001 0668 7884Laboratory for Cell Stress & Immunity (CSI), Department of Cellular and Molecular Medicine (CMM), KU Leuven, Leuven, Belgium
| | - Sander Jansen
- grid.5596.f0000 0001 0668 7884Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Yannick Van Herck
- grid.5596.f0000 0001 0668 7884Laboratory of Experimental Oncology, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Lore Vanderbeke
- grid.5596.f0000 0001 0668 7884Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ayse Bassez
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Bram Boeckx
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Bert Malengier-Devlies
- grid.5596.f0000 0001 0668 7884Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Anna Timmerman
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Thomas Van Brussel
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Tina Van Buyten
- grid.5596.f0000 0001 0668 7884Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Rogier Schepers
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
| | - Elisabeth Heylen
- grid.5596.f0000 0001 0668 7884Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Dieter Dauwe
- grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Christophe Dooms
- grid.5596.f0000 0001 0668 7884Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Gunst
- grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Hermans
- grid.5596.f0000 0001 0668 7884Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Philippe Meersseman
- grid.5596.f0000 0001 0668 7884Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Dries Testelmans
- grid.5596.f0000 0001 0668 7884Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Jonas Yserbyt
- grid.5596.f0000 0001 0668 7884Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Sabine Tejpar
- grid.5596.f0000 0001 0668 7884Molecular Digestive Oncology, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Walter De Wever
- grid.5596.f0000 0001 0668 7884Department of Imaging & Pathology, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- grid.5596.f0000 0001 0668 7884Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | | | - Johan Neyts
- grid.5596.f0000 0001 0668 7884Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Joost Wauters
- grid.5596.f0000 0001 0668 7884Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Junbin Qian
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006 China
| | - Diether Lambrechts
- grid.5596.f0000 0001 0668 7884Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium ,grid.511459.dVIB Center for Cancer Biology, VIB, Leuven, Belgium
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Karasu E, Demmelmaier J, Kellermann S, Holzmann K, Köhl J, Schmidt CQ, Kalbitz M, Gebhard F, Huber-Lang MS, Halbgebauer R. Complement C5a Induces Pro-inflammatory Microvesicle Shedding in Severely Injured Patients. Front Immunol 2020; 11:1789. [PMID: 32983087 PMCID: PMC7492592 DOI: 10.3389/fimmu.2020.01789] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022] Open
Abstract
Initially underestimated as platelet dust, extracellular vesicles are continuously gaining interest in the field of inflammation. Various studies addressing inflammatory diseases have shown that microvesicles (MVs) originating from different cell types are systemic transport vehicles carrying distinct cargoes to modulate immune responses. In this study, we focused on the clinical setting of multiple trauma, which is characterized by activation and dysfunction of both, the fluid-phase and the cellular component of innate immunity. Given the sensitivity of neutrophils for the complement anaphylatoxin C5a, we hypothesized that increased C5a production induces alterations in MV shedding of neutrophils resulting in neutrophil dysfunction that fuels posttraumatic inflammation. In a mono-centered prospective clinical study with polytraumatized patients, we found significantly increased granulocyte-derived MVs containing the C5a receptor (C5aR1, CD88) on their surface. This finding was accompanied by a concomitant loss of C5aR1 on granulocytes indicative of an impaired cellular chemotactic and pro-inflammatory neutrophil functions. Furthermore, in vitro exposure of human neutrophils (from healthy volunteers) to C5a significantly increased MV shedding and C5aR1 loss on neutrophils, which could be blocked using the C5aR1 antagonist PMX53. Mechanistic analyses revealed that the interaction between C5aR1 signaling and the small GTPase Arf6 acts as a molecular switch for MV shedding. When neutrophil derived, C5a-induced MV were exposed to a complex ex vivo whole blood model significant pro-inflammatory properties (NADPH activity, ROS and MPO generation) of the MVs became evident. C5a-induced MVs activated resting neutrophils and significantly induced IL-6 secretion. These data suggest a novel role of the C5a-C5aR1 axis: C5a-induced MV shedding from neutrophils results in decreased C5aR1 surface expression on the one hand, on the other hand it leads to profound inflammatory signals which likely are both key drivers of the neutrophil dysfunction which is regularly observed in patients suffering from multiple traumatic injuries.
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Affiliation(s)
- Ebru Karasu
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
| | - Julia Demmelmaier
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
| | - Stephanie Kellermann
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
| | - Karlheinz Holzmann
- Center for Biomedical Research, Genomics-Core Facility, Ulm University, Ulm, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany.,Division of Immunobiology, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Christoph Q Schmidt
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Ulm, Germany
| | - Florian Gebhard
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Ulm, Germany
| | - Markus S Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
| | - Rebecca Halbgebauer
- Institute of Clinical and Experimental Trauma Immunology, University Hospital Ulm, Ulm, Germany
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Kitching AR, Anders HJ, Basu N, Brouwer E, Gordon J, Jayne DR, Kullman J, Lyons PA, Merkel PA, Savage COS, Specks U, Kain R. ANCA-associated vasculitis. Nat Rev Dis Primers 2020; 6:71. [PMID: 32855422 DOI: 10.1038/s41572-020-0204-y] [Citation(s) in RCA: 407] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
The anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of disorders involving severe, systemic, small-vessel vasculitis and are characterized by the development of autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). The three AAV subgroups, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis and eosinophilic GPA (EGPA), are defined according to clinical features. However, genetic and other clinical findings suggest that these clinical syndromes may be better classified as PR3-positive AAV (PR3-AAV), MPO-positive AAV (MPO-AAV) and, for EGPA, by the presence or absence of ANCA (ANCA+ or ANCA-, respectively). Although any tissue can be involved in AAV, the upper and lower respiratory tract and kidneys are most commonly and severely affected. AAVs have a complex and unique pathogenesis, with evidence for a loss of tolerance to neutrophil proteins, which leads to ANCA-mediated neutrophil activation, recruitment and injury, with effector T cells also involved. Without therapy, prognosis is poor but treatments, typically immunosuppressants, have improved survival, albeit with considerable morbidity from glucocorticoids and other immunosuppressive medications. Current challenges include improving the measures of disease activity and risk of relapse, uncertainty about optimal therapy duration and a need for targeted therapies with fewer adverse effects. Meeting these challenges requires a more detailed knowledge of the fundamental biology of AAV as well as cooperative international research and clinical trials with meaningful input from patients.
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Affiliation(s)
- A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia. .,Departments of Nephrology and Paediatric Nephrology, Monash Health, Clayton, Victoria, Australia.
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians University, Munich, Germany
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elisabeth Brouwer
- Vasculitis Expertise Centre Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Jennifer Gordon
- Department of Neuroscience and Center for Neurovirology, Temple University School of Medicine, Philadelphia, PA, USA
| | - David R Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine and Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline O S Savage
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Renate Kain
- Department of Pathology, Medical University Vienna, Vienna, Austria
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39
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Bantis K, Stangou M, Kalpakidis S, Hatziadamou M, Daikidou DV, Lioulios G, Mitsoglou Z, Chatzidrosou H, Nikolaidou C, Fylaktou A, Papagianni A. Systemic complement activation in anti-neutrophil cytoplasmic antibody-associated vasculitis and necrotizing glomerulonephritis. Nephrology (Carlton) 2020; 26:30-37. [PMID: 32602136 DOI: 10.1111/nep.13747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 12/28/2022]
Abstract
AIM Due to the accumulating evidence of complement activation in anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV), we decided to investigate the possibility of systemic complement activation in patients with Necrotizing Glomerulonephritis secondary to AAV. METHODS Clinical, laboratory and histological findings, and serum levels of complement components, C3a, C5a and Bb fragment of Factor B and C4d, were estimated in patients with AAV and glomerulonephritis, at time of diagnosis, before any treatment had been applied. All patients were treated with the same immunosuppressive protocol and followed up for total 24 months. Twenty age and sex matched healthy individuals served as controls. RESULTS Serum levels of all complement components were significantly increased in patients, compared to controls; C5a: 19.9(0.02-48) vs 9.06(2.1-16.3)pg/mL, P = .002, Bb: 7.3(0.02-31.4) vs 0.2(0.02-1.6)pg/mL, P < .0001, C3a: 4.7(0.4-7.2) vs 2.4(1.09-5)pg/mL, P = .05 and C4d: 11.6(0.07-70) vs 0.7(0.07-8.2)pg/mL, P = .001, respectively. There was strong correlation between serum Bb levels and eGFR and FFS2009 score at time of diagnosis (r = -.41, P = .002 and r = .41, P = .003 respectively). Also, serum Bb levels were increased in patients with severe interstitial infiltration (P = .04) and focal necrosis (P = .01) on renal biopsy. Serum Bb levels could also predict renal function outcome during the acute phase of disease, but not at the end of follow up. CONCLUSION We provided strong evidence of systemic activation of complement alternative pathway in the development and progression of AAV and glomerulonephritis. Serum Bb seem to play a critical role in the induction, also predicting disease activity and outcome, yet activation of classical pathway cannot be excluded.
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Affiliation(s)
- Kostas Bantis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Maria Stangou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Savvas Kalpakidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Maria Hatziadamou
- Department of Immunology, National Peripheral Histocompatibility Center, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitra-Vasilia Daikidou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - George Lioulios
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Zoi Mitsoglou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Helen Chatzidrosou
- Department of Immunology, National Peripheral Histocompatibility Center, Hippokration Hospital, Thessaloniki, Greece
| | | | - Asimina Fylaktou
- Department of Immunology, National Peripheral Histocompatibility Center, Hippokration Hospital, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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Anguiano L, Kain R, Anders HJ. The glomerular crescent: triggers, evolution, resolution, and implications for therapy. Curr Opin Nephrol Hypertens 2020; 29:302-309. [PMID: 32132388 PMCID: PMC7170443 DOI: 10.1097/mnh.0000000000000596] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Crescents are classical histopathological lesions found in severe forms of rapidly progressive glomerulonephritis, also referred to as crescentic glomerulonephritis (CGN). Crescent formation is a consequence of diverse upstream pathomechanisms and unraveling these mechanisms is of great interest for improving the management of patients affected by CGN. Thus, in this review, we provide an update on the latest insight into the understanding on how crescents develop and how they resolve. RECENT FINDINGS Cellular crescents develop from activated parietal epithelial cells (PECs) residing along Bowman's capsule and their formation has as a consequence the decline in glomerular filtration rate (GFR). Cellular crescents can be reversible, but when multilevel growth of PECs associate with an epithelial--mesenchymal transition-like change in cell phenotype, fibrous crescents form, and crescents become irreversible also in terms of GFR recovery. Different molecular pathways trigger the activation of PECs and are a prime therapeutics target in CGN. First, crescent formation requires also vascular injury causing ruptures in the glomerular basement membrane that trigger plasmatic coagulation within Bowman's space. This vascular necrosis can be triggered by different upstream mechanisms, such as small vessel vasculitides, immune complex glomerulonephritis, anti-GBM disease, and C3 glomerulonephritis, that all share complement activation but involve diverse upstream immune mechanisms outside the kidney accessible for therapeutic intervention. SUMMARY Knowing the upstream mechanisms that triggered crescent formation provides a tool for the development of therapeutic interventions for CGN.
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Affiliation(s)
- Lidia Anguiano
- Renal Division, Department of Medicine IV, University Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, University Hospital of the Ludwig Maximilian University, Munich, Germany
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Shochet L, Holdsworth S, Kitching AR. Animal Models of ANCA Associated Vasculitis. Front Immunol 2020; 11:525. [PMID: 32373109 PMCID: PMC7179669 DOI: 10.3389/fimmu.2020.00525] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/09/2020] [Indexed: 01/05/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a rare and severe autoimmune multisystemic disease. Its pathogenesis involves multiple arms of the immune system, as well as complex interactions between immune cells and target organs. Experimental animal models of disease can provide the crucial link from human disease to translational research into new therapies. This is particularly true in AAV, due to low disease incidence and substantial disease heterogeneity. Animal models allow for controlled environments in which disease mechanisms can be defined, without the clinical confounders of environmental and lifestyle factors. To date, multiple animal models have been developed, each of which shed light on different disease pathways. Results from animal studies of AAV have played a crucial role in enhancing our understanding of disease mechanisms, and have provided direction toward newer targeted therapies. This review will summarize our understanding of AAV pathogenesis as has been gleaned from currently available animal models, as well as address their strengths and limitations. We will also discuss the potential for current and new animal models to further our understanding of this important condition.
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Affiliation(s)
- Lani Shochet
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia.,Department of Nephrology, Monash Health, Clayton, VIC, Australia
| | - Stephen Holdsworth
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia.,Department of Nephrology, Monash Health, Clayton, VIC, Australia.,Department of Immunology, Monash Health, Clayton, VIC, Australia
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia.,Department of Nephrology, Monash Health, Clayton, VIC, Australia.,Department of Pediatric Nephrology, Monash Health, Clayton, VIC, Australia
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Metzemaekers M, Gouwy M, Proost P. Neutrophil chemoattractant receptors in health and disease: double-edged swords. Cell Mol Immunol 2020; 17:433-450. [PMID: 32238918 PMCID: PMC7192912 DOI: 10.1038/s41423-020-0412-0] [Citation(s) in RCA: 221] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/05/2020] [Indexed: 02/08/2023] Open
Abstract
Neutrophils are frontline cells of the innate immune system. These effector leukocytes are equipped with intriguing antimicrobial machinery and consequently display high cytotoxic potential. Accurate neutrophil recruitment is essential to combat microbes and to restore homeostasis, for inflammation modulation and resolution, wound healing and tissue repair. After fulfilling the appropriate effector functions, however, dampening neutrophil activation and infiltration is crucial to prevent damage to the host. In humans, chemoattractant molecules can be categorized into four biochemical families, i.e., chemotactic lipids, formyl peptides, complement anaphylatoxins and chemokines. They are critically involved in the tight regulation of neutrophil bone marrow storage and egress and in spatial and temporal neutrophil trafficking between organs. Chemoattractants function by activating dedicated heptahelical G protein-coupled receptors (GPCRs). In addition, emerging evidence suggests an important role for atypical chemoattractant receptors (ACKRs) that do not couple to G proteins in fine-tuning neutrophil migratory and functional responses. The expression levels of chemoattractant receptors are dependent on the level of neutrophil maturation and state of activation, with a pivotal modulatory role for the (inflammatory) environment. Here, we provide an overview of chemoattractant receptors expressed by neutrophils in health and disease. Depending on the (patho)physiological context, specific chemoattractant receptors may be up- or downregulated on distinct neutrophil subsets with beneficial or detrimental consequences, thus opening new windows for the identification of disease biomarkers and potential drug targets.
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Affiliation(s)
- Mieke Metzemaekers
- Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Herestraat 49 bus 1042, B-3000, Leuven, Belgium
| | - Mieke Gouwy
- Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Herestraat 49 bus 1042, B-3000, Leuven, Belgium
| | - Paul Proost
- Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Herestraat 49 bus 1042, B-3000, Leuven, Belgium.
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Catz SD, McLeish KR. Therapeutic targeting of neutrophil exocytosis. J Leukoc Biol 2020; 107:393-408. [PMID: 31990103 PMCID: PMC7044074 DOI: 10.1002/jlb.3ri0120-645r] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 12/11/2022] Open
Abstract
Dysregulation of neutrophil activation causes disease in humans. Neither global inhibition of neutrophil functions nor neutrophil depletion provides safe and/or effective therapeutic approaches. The role of neutrophil granule exocytosis in multiple steps leading to recruitment and cell injury led each of our laboratories to develop molecular inhibitors that interfere with specific molecular regulators of secretion. This review summarizes neutrophil granule formation and contents, the role granule cargo plays in neutrophil functional responses and neutrophil-mediated diseases, and the mechanisms of granule release that provide the rationale for development of our exocytosis inhibitors. We present evidence for the inhibition of granule exocytosis in vitro and in vivo by those inhibitors and summarize animal data indicating that inhibition of neutrophil exocytosis is a viable therapeutic strategy.
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Affiliation(s)
- Sergio D. Catz
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Kenneth R. McLeish
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY
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Kumar V, Lee JD, Clark RJ, Noakes PG, Taylor SM, Woodruff TM. Preclinical Pharmacokinetics of Complement C5a Receptor Antagonists PMX53 and PMX205 in Mice. ACS OMEGA 2020; 5:2345-2354. [PMID: 32064396 PMCID: PMC7017397 DOI: 10.1021/acsomega.9b03735] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/21/2020] [Indexed: 05/16/2023]
Abstract
The cyclic hexapeptides PMX53 and PMX205 are potent noncompetitive inhibitors of complement C5a receptor 1 (C5aR1). They are widely utilized to study the role of C5aR1 in mouse models, including central nervous system (CNS) disease, and are dosed through a variety of routes of administration. However, a comprehensive pharmacokinetics analysis of these drugs has not been reported. In this study, the blood and CNS pharmacokinetics of PMX53 and PMX205 were performed in mice following intravenous, intraperitoneal, subcutaneous, and oral administration at identical doses. The absorption and distribution of both drugs were rapid and followed a two-compartment model with elimination half-lives of ∼20 min for both compounds. Urinary excretion was the major route of elimination following intravenous dosing with ∼50% of the drug excreted unchanged within the first 12 h. Oral bioavailability of PMX205 was higher than that of PMX53 (23% versus 9%), and PMX205 was also more efficient than PMX53 at entering the intact CNS. In comparison to other routes, subcutaneous administration of PMX205 resulted in high bioavailability (above 90%), as well as prolonged plasma and CNS exposure. Finally, repeated daily oral or subcutaneous administration of PMX205 demonstrated no accumulation of drug in blood, the brain, or the spinal cord, promoting its safety for chronic dosing. These results will be helpful in correlating the desired therapeutic effects of these C5aR1 antagonists with their pharmacokinetic profile. It also suggests that subcutaneous dosing of PMX205 may be an appropriate route of administration for future clinical testing in neurological disease.
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Affiliation(s)
- Vinod Kumar
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - John D. Lee
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
- University
of Queensland Centre for Clinical Research, the University of Queensland, Brisbane, QLD 4029, Australia
| | - Richard J. Clark
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - Peter G. Noakes
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
- Queensland
Brain Institute, the University of Queensland,
St Lucia, Brisbane, QLD 4072, Australia
| | - Stephen M. Taylor
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - Trent M. Woodruff
- School
of Biomedical Sciences, The University of
Queensland, St Lucia, Brisbane, QLD 4072, Australia
- Wesley
Medical Research, The Wesley Hospital, Auchenflower, Brisbane, QLD 4066, Australia
- . Phone: +61-7-336 52924. Fax: +61-7-336-51766
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Hu X, Feng J, Deng S, Tang J, Liao Z, Luo L, Luo L, Meng T, Gong G, Li X. Anaphylatoxins enhance Th9 cell recruitment via the CCL20-CCR6 axis in IgA nephropathy. J Nephrol 2020; 33:1027-1036. [PMID: 32036611 DOI: 10.1007/s40620-020-00708-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/31/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND CD4+ T cells are involved in the pathogenesis of immunoglobulin A nephropathy (IgAN); T helper (Th) 1, Th17 and Th22 cells promote the occurrence and amplification of inflammatory reactions, while regulatory T (Treg) cells produce the opposite effects. However, whether Th9 cells, a subset of CD4+ T cells, participate in IgAN development is still unknown. METHODS Human peripheral blood mononuclear cells (PBMCs) were isolated from IgAN patients for Th9 cells detection by flow cytometry. Wild-type (WT) mouse was used to establish an IgAN mouse model while C3aR and C5aR inhibitor treated IgAN mouse. Kidney disease and function was assessed by histology and albumin-to-creatinine ratio. C3aR and C5aR expression was examined by immunohistochemical (IHC) assay. Th9 cell proportions in the blood of IgAN mouse was detected. C3a, C5a and interleukin (IL)-9 levels were tested by ELISA. Moreover, co-culture system between human mesangial cells (HMCs) and CD4+ T cells were constructed with or without C3a, C5a and anti-CCL20 mAb stimulation for transwell assay to examine Th9 cell chemotaxis. RESULTS We observed the numbers of Th9 cell and the levels of IL-9 were increased in IgAN patients and IgAN mice. Furthermore, C3a and C5a level in serum and kidney, C3aR and C5aR expression was increased in IgAN mice compared to WT mice. Most interestingly, C3aR and C5aR inhibitor could reduce kidney damage, Th9 cell numbers and IL-9 levels. We also observed that C3a and C5a enhanced CCL20 production in HMCs. Notably, C3a and C5a also increased the recruitment of Th9 cells and IL-9 levels by HMCs through enhancing the CCL20-CCR6 pathway. CONCLUSIONS Our results support that C3a and C5a increase the production of CCL20 by HMCs and consequently augment Th9 cell recruitment and IL-9 levels, resulting in IgAN exacerbation.
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Affiliation(s)
- Xinyue Hu
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Juntao Feng
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Shuanglinzi Deng
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Jiale Tang
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Zhonghua Liao
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Lisha Luo
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Liying Luo
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Guanghui Gong
- Department of Pathology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China.
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Abstract
PURPOSE OF REVIEW To provide a comprehensive overview of the current insight into the role of complement activation in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). In addition, the therapeutic options targeting the complement system in AAV are discussed. RECENT FINDINGS It has become increasingly clear that complement, and more specifically signalling through the C5a receptor, contributes to the immunopathology of AAV. This has led to the design of clinical trials with a C5a receptor blocker. The first results show a reduction in tissue damage and a favourable safety profile, as other parts of the complement defence system are left intact. SUMMARY Although AAV was initially regarded as a pauci-immune disease, it is now well established that, in addition to autoantibodies, complement plays an essential role in the disease process. Animal models delivered the first insight, but the effective therapeutic interventions using complement inhibitors provided the proof that indeed complement activation contributes to disease activity and tissue damage in human AAV.
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Tan SM, Ziemann M, Thallas-Bonke V, Snelson M, Kumar V, Laskowski A, Nguyen TV, Huynh K, Clarke MV, Libianto R, Baker ST, Skene A, Power DA, MacIsaac RJ, Henstridge DC, Wetsel RA, El-Osta A, Meikle PJ, Wilson SG, Forbes JM, Cooper ME, Ekinci EI, Woodruff TM, Coughlan MT. Complement C5a Induces Renal Injury in Diabetic Kidney Disease by Disrupting Mitochondrial Metabolic Agility. Diabetes 2020; 69:83-98. [PMID: 31624141 DOI: 10.2337/db19-0043] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/08/2019] [Indexed: 11/13/2022]
Abstract
The sequelae of diabetes include microvascular complications such as diabetic kidney disease (DKD), which involves glucose-mediated renal injury associated with a disruption in mitochondrial metabolic agility, inflammation, and fibrosis. We explored the role of the innate immune complement component C5a, a potent mediator of inflammation, in the pathogenesis of DKD in clinical and experimental diabetes. Marked systemic elevation in C5a activity was demonstrated in patients with diabetes; conventional renoprotective agents did not therapeutically target this elevation. C5a and its receptor (C5aR1) were upregulated early in the disease process and prior to manifest kidney injury in several diverse rodent models of diabetes. Genetic deletion of C5aR1 in mice conferred protection against diabetes-induced renal injury. Transcriptomic profiling of kidney revealed diabetes-induced downregulation of pathways involved in mitochondrial fatty acid metabolism. Interrogation of the lipidomics signature revealed abnormal cardiolipin remodeling in diabetic kidneys, a cardinal sign of disrupted mitochondrial architecture and bioenergetics. In vivo delivery of an orally active inhibitor of C5aR1 (PMX53) reversed the phenotypic changes and normalized the renal mitochondrial fatty acid profile, cardiolipin remodeling, and citric acid cycle intermediates. In vitro exposure of human renal proximal tubular epithelial cells to C5a led to altered mitochondrial respiratory function and reactive oxygen species generation. These experiments provide evidence for a pivotal role of the C5a/C5aR1 axis in propagating renal injury in the development of DKD by disrupting mitochondrial agility, thereby establishing a new immunometabolic signaling pathway in DKD.
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Affiliation(s)
- Sih Min Tan
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | - Mark Ziemann
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
- School of Life and Environmental Sciences, Deakin University, Geelong, Victoria, Australia
| | - Vicki Thallas-Bonke
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | - Matthew Snelson
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | - Vinod Kumar
- School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrienne Laskowski
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | | | - Kevin Huynh
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Michele V Clarke
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Renata Libianto
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Scott T Baker
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - Alison Skene
- Department of Anatomical Pathology, Austin Health, Melbourne, Victoria, Australia
| | - David A Power
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Nephrology and Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne, Victoria, Australia
| | | | - Rick A Wetsel
- Research Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine for the Prevention of Human Diseases, University of Texas-Houston, Houston, TX
| | - Assam El-Osta
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Scott G Wilson
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Josephine M Forbes
- Glycation and Diabetes Group, Mater Research Institute-The University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
| | - Elif I Ekinci
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Trent M Woodruff
- School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda T Coughlan
- Department of Diabetes, Central Clinical School, Alfred Medical Research and Education Precinct, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
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Abstract
A role for the alternative complement pathway has emerged in the understanding of ANCA vasculitis pathogenesis. Current therapies of ANCA vasculitis are limited by partial efficacy and toxicity and many patients pursue a relapsing course. Improved therapies are needed. Inhibition of the alternative complement pathway component C5a is attractive due to its role in neutrophil activation and migration, and engagement of other inflammatory and thrombotic mechanisms. Two inhibitors of C5a are in clinical development for ANCA vasculitis: avacopan, an oral C5a receptor inhibitor has demonstrated efficacy, safety and steroid sparing in two Phase II trials; and IFX-1, a monoclonal antibody to C5a which is entering Phase II development. Complement inhibition has the potential to contribute to remission induction protocols achieving a higher quality of remission as well as replacing steroids. Confirmation of safety, especially infective risk, and the potential to replace steroids depends on further studies and a role in relapse prevention needs to be explored.
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Hu X, Feng J, Zhou Q, Luo L, Meng T, Zhong Y, Tang W, Deng S, Li X. Respiratory Syncytial Virus Exacerbates Kidney Damages in IgA Nephropathy Mice via the C5a-C5aR1 Axis Orchestrating Th17 Cell Responses. Front Cell Infect Microbiol 2019; 9:151. [PMID: 31134161 PMCID: PMC6514197 DOI: 10.3389/fcimb.2019.00151] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 04/23/2019] [Indexed: 11/13/2022] Open
Abstract
Respiratory viral infections can directly lead to kidney damage such as IgA nephropathy (IgAN), partly due to mucosal immune system dysfunction. Although the activated C5a-C5aR1 axis results in increased Th1 and Th17 frequencies but reduced Treg frequencies in Respiratory syncytial virus (RSV) infection, how this axis affects Th cell disorders in RSV-induced IgAN exacerbation remains unknown. Here, we used a mouse model to dissect the activation of C5a-C5aR1 by RSV and the consequences on the regulation of Th1, Th17, and Treg immune responses in IgA nephropathy. RSV fusion protein was clearly deposited not only in the pulmonary interstitium but also in the glomerulus in RSV-IgAN mice, and RSV infection led to more severe pathological changes in the kidneys in IgAN mice. Blocking the C5a-C5aR1 axis resulted in a decrease in the albumin-to-creatinine ratio, and the attenuation of kidney damage in IgAN and RSV-IgAN mice might be partly attributed to the inhibition of Th cell and cytokine dysfunction. Th1, Th17 and Treg immune responses and their corelative cytokines were disrupted by RSV infection and rescued by C5aR1 inhibition. Moreover, we constructed a coculture system of human mesangial cells and CD4+ T cells and found that RSV infection might lead to CD4+ T cell production via human mesangial cells-enhanced CD4+ T cell proliferation, consequently increasing IL-17 levels. These pathological behaviors were augmented by C5a stimulation and decreased by C5aR1 inhibition. Thus, C5aR1 inhibition alters both kidney damage and Th1, Th17, and Treg cell dysfunction in RSV-induced IgAN exacerbation and locally regulates HMC antigen presentation function in the kidney. Taken together, our data offer profound evidence that blocking the C5a-C5aR1 axis might be a potential therapy for RSV-induced IgAN.
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Affiliation(s)
- Xinyue Hu
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Key Cite of National Clinical Research Center for Respiratory Disease, Central South University, Changsha, China
| | - Juntao Feng
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Key Cite of National Clinical Research Center for Respiratory Disease, Central South University, Changsha, China
| | - Qiaoling Zhou
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Lisha Luo
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Key Cite of National Clinical Research Center for Respiratory Disease, Central South University, Changsha, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Tang
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Key Cite of National Clinical Research Center for Respiratory Disease, Central South University, Changsha, China
| | - Shuanglinzi Deng
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Key Cite of National Clinical Research Center for Respiratory Disease, Central South University, Changsha, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
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