Crohn's disease as an immunodeficiency

Novel Microbial-Based Immunotherapy Approach for Crohn's Disease

Background: Current Crohn's disease (CD) therapies focus on suppressing immune function and come with consequent risk, such as infection and cancer. Notwithstanding, most CD patients still experience disease progression. There is a need for new CD treatment strategies that offer better health outcomes for patients.

Aims: To assess safety, efficacy, and tolerability of a novel microbial-derived immunotherapy, QBECO, that aims to restore rather than suppress immune function in CD.

Methods: A randomized, double-blind, placebo-controlled trial was conducted in 68 patients with moderate-to-severe CD. Primary endpoints: safety and Week 8 clinical improvement. Secondary endpoints: Week 8 clinical response and remission. Week 8 responders continued blinded treatment through Week 16; non-responders received open-label QBECO from Weeks 9–16. Exploratory analyses included immune biomarker and genotype assessments.

Results: QBECO was well-tolerated. Mean reduction in Crohn's Disease Activity Index (CDAI) score was −68 for QBECO vs. −31 for placebo at Week 8. Improvement with QBECO continued through Week 16 (-130 CDAI reduction). Week 8 QBECO clinical response, improvement and remission rates were 41.2%, 32.4%, 29.4% vs. 26.5%, 23.5%, 23.5% for placebo. TNFα inhibitor-naïve subjects achieved higher response rates at Week 8 with QBECO (64%) vs. placebo (26%). Specific immune biomarkers were identified that linked to QBECO response.

Conclusion: This proof-of-concept study supports further investigation for the use of QBECO as a novel immunotherapy approach for CD. Biomarker analyses suggests it may be feasible to personalize CD treatment with QBECO. Larger trials are now needed to confirm clinical improvement and the unique biological findings.

Clinical Trial Number: NCT01809275 (https://clinicaltrials.gov/ct2/show/NCT01809275)

Systems Pharmacological Approach of Pulsatillae Radix on Treating Crohn's Disease

In East Asian traditional medicine, Pulsatillae Radix (PR) is widely used to treat amoebic dysentery and renowned for its anti-inflammatory effects. This study aimed to confirm evidence regarding the potential therapeutic effect of PR on Crohn's disease using a system network level based in silico approach. Study results showed that the compounds in PR are highly connected to Crohn's disease related pathways, biological processes, and organs, and these findings were confirmed by compound-target network, target-pathway network, and gene ontology analysis. Most compounds in PR have been reported to possess anti-inflammatory, anticancer, and antioxidant effects, and we found that these compounds interact with multiple targets in a synergetic way. Furthermore, the mRNA expressions of genes targeted by PR are elevated significantly in immunity-related organ tissues, small intestine, and colon. Our results suggest that the anti-inflammatory and repair and immune system enhancing effects of PR might have therapeutic impact on Crohn's disease.

The Drosophila CD36 Homologue croquemort Is Required to Maintain Immune and Gut Homeostasis during Development and Aging

Phagocytosis is an ancient mechanism central to both tissue homeostasis and immune defense. Both the identity of the receptors that mediate bacterial phagocytosis and the nature of the interactions between phagocytosis and other defense mechanisms remain elusive. Here, we report that Croquemort (Crq), a Drosophila member of the CD36 family of scavenger receptors, is required for microbial phagocytosis and efficient bacterial clearance. Flies mutant for crq are susceptible to environmental microbes during development and succumb to a variety of microbial infections as adults. Crq acts parallel to the Toll and Imd pathways to eliminate bacteria via phagocytosis. crq mutant flies exhibit enhanced and prolonged immune and cytokine induction accompanied by premature gut dysplasia and decreased lifespan. The chronic state of immune activation in crq mutant flies is further regulated by negative regulators of the Imd pathway. Altogether, our data demonstrate that Crq plays a key role in maintaining immune and organismal homeostasis.

Dietary Fiber Intake is Associated with Increased Colonic Mucosal GPR43+ Polymorphonuclear Infiltration in Active Crohn's Disease

G protein-coupled receptor 43/free fatty acid receptor 2 (GPR43/FFAR2) is essential for polymorphonuclear (PMN) recruitment. We investigated the expression of GPR43/FFAR2 in the colon from Crohn’s disease patients and whether dietary fiber in enteral nutrition increases GPR43+ polymorphonuclear infiltration in mucosa. Segments of ascending colon and white blood cells from peripheral blood were obtained from 46 Crohn’s disease patients and 10 colon cancer patients. The Crohn’s disease patients were grouped by the activity of disease (active or remission) and enteral nutrition with or without dietary fiber. Histological feature, expression and location of GPR43/FFAR2 and level of tumor necrosis factor-α (TNF-α), interleukine-6 (IL-6) and myeloperoxidase were assessed. The results of hematoxylin-eosin and immunohistochemistry staining revealed that the infiltration of immune cells, including GPR43+ PMN, was more severe in active Crohn’s disease patients who consumed normal food or enteral nutrition with dietary fiber than in remission patients and colon cancer patients. This finding was supported by the results of GPR43 and myeloperoxidase expression. Active Crohn’s disease (CD) patients who consumed enteral nutrition without dietary fiber exhibited severe immune cell infiltration similar to the other active CD patients, but GPR43+ PMNs were rarely observed. The level of TNF-α mRNA in active Crohn’s disease patients was higher than those of the other patients. In conclusion, the use of dietary fiber in enteral nutrition by active Crohn’s disease patients might increase GPR43+ PMNs infiltration in colon mucosa. This effect was not observed in Crohn’s disease patients in remission.

Site-Specific Immunomodulator: A Novel Treatment for Crohn's Disease

We investigated the mechanism of action, safety, and efficacy of the Site-Specific Immunomodulator (SSI) QBECO, a novel immunotherapy for Crohn's disease (CD). Using human monocytic THP-1 cells, we demonstrate that SSI QBECO (derived from the common colon bacteria E. coli) activates macrophages to an M1 phenotype (associated with enhanced capacity to eliminate bacteria and activate innate immune responses). We assessed SSI QBECO in a compassionate use protocol of ten adult patients with active CD. Patients with moderate to severe clinical symptoms receiving conventional CD treatments and/or complementary therapies were included, except patients receiving anti-TNF medications. SSI QBECO was self-administered subcutaneously every second day, for a minimum of 2.5 months and a maximum of 11 months. All 10 patients reported improvement of symptoms while on the SSI QBECO treatment. Seven patients reported full resolution of clinical symptoms during a course of SSI QBECO of at least three months. Three patients have experienced ongoing sustained clinical remission after discontinuing all medications, including SSI treatment. The longest case of clinical remission is still ongoing (>4 years). No serious severe adverse clinical events were reported. Collectively, we conclude that treatment with the immunoactive SSI QBECO was well tolerated and effective for treatment of Crohn's disease in this case series.

Principal component analysis characterizes shared pathogenetics from genome-wide association studies

Genome-wide association studies (GWASs) have recently revealed many genetic associations that are shared between different diseases. We propose a method, disPCA, for genome-wide characterization of shared and distinct risk factors between and within disease classes. It flips the conventional GWAS paradigm by analyzing the diseases themselves, across GWAS datasets, to explore their "shared pathogenetics". The method applies principal component analysis (PCA) to gene-level significance scores across all genes and across GWASs, thereby revealing shared pathogenetics between diseases in an unsupervised fashion. Importantly, it adjusts for potential sources of heterogeneity present between GWAS which can confound investigation of shared disease etiology. We applied disPCA to 31 GWASs, including autoimmune diseases, cancers, psychiatric disorders, and neurological disorders. The leading principal components separate these disease classes, as well as inflammatory bowel diseases from other autoimmune diseases. Generally, distinct diseases from the same class tend to be less separated, which is in line with their increased shared etiology. Enrichment analysis of genes contributing to leading principal components revealed pathways that are implicated in the immune system, while also pointing to pathways that have yet to be explored before in this context. Our results point to the potential of disPCA in going beyond epidemiological findings of the co-occurrence of distinct diseases, to highlighting novel genes and pathways that unsupervised learning suggest to be key players in the variability across diseases.

Intestinal dendritic cell and macrophage subsets: Tipping the balance to Crohn's disease?

Dendritic cells and macrophages play an essential role in immune homeostasis in the intestine. They have the critical task of maintaining the balance between tolerance to the intestinal microflora and potential food antigens while retaining the ability to initiate immunity against pathogens. For patients with Crohn's Disease, the tolerance/immunity balance is disturbed and these individuals suffer from chronic intestinal inflammation driven by aberrant T cell reactivity to intestinal bacteria. As antigen presenting cells are required for T cell activation, intestinal phagocytes with the capacity to present antigens from intestinal bacteria to T cells are likely involved in initiating and propagating Crohn's Disease. Recent data describe unique subsets of human intestinal phagocytes that may be involved in the aberrant reactivity to commensal flora that drives Crohn's Disease pathogenesis. This review summarizes the current knowledge of phagocyte subsets in the intestine and mesenteric lymph nodes in healthy individuals and Crohn's Disease patients. Deciphering the function of intestinal phagocytes in health and disease is crucial to advance our understanding of the cellular mechanisms underlying this debilitating disease, provides a potential way to improve treatment for patients with inflammatory bowel disease.

Repurposing miltefosine for the treatment of immune-mediated disease?

Miltefosine is an ether lipid that was initially developed for cancer treatment in the early 1980s. Miltefosine largely failed development for oncology, although it was approved for the topical treatment of breast cancer metastasis. It was subsequently discovered that miltefosine is a highly effective treatment of visceral Leishmaniasis, a parasitic disease that affects millions worldwide and causes an estimated 30,000 fatalities each year. Oral treatment with miltefosine is generally well tolerated and has relatively few adverse effects. The exact mechanism of action of miltefosine treatment is still under investigation. Its close resemblance to phospholipids allows it to be quickly taken up by cell membranes and affect related processes, such as lipid metabolism and signaling through lipid rafts. These processes play an important role in the immune response and it comes as no surprise that miltefosine has been successfully tested for the treatment of a number of immune-mediated diseases in preclinical models of disease. Drug repurposing of miltefosine for immune-mediated diseases may provide an opportunity to expand the limited number of drugs that are currently available for therapeutic use.

Evidence for non-neutralizing autoantibodies against IL-10 signalling components in patients with inflammatory bowel disease

Background

Inflammatory bowel disease constitutes a heterogeneous group of conditions, whose aetiology is only partly understood. The prevailing hypothesis on its pathogenesis is that IBD is the result of an inadequate immune response to the resident bacterial flora of the intestine. An autoimmune background, however, has been discussed since the 1950s. Lately, it has been shown that failures in interleukin-10 (IL-10) signalling due to IL-10- and IL-10 receptor (IL-10R) mutations result in IBD. Our study aimed at investigating the existence of inhibitory autoantibodies against IL-10 and IL-10R in IBD patients capable of down-modulating IL-10 signalling thereby mimicking IL-10 or IL-10R deficiency.

Results

Thirteen IBD patients had IgG autoantibodies against IL-10, IL-10RA and/or IL-10RB, and three patients had IgA autoantibodies against IL-10. However, the absolute OD values of the serum antibodies measured by ELISA were low, there was overall no significant difference between patients and controls, and positive sera had no neutralizing activity.

Conclusion

No evidence for an involvement of autoantibodies against IL-10 or IL-10R in the pathogenesis of inflammatory bowel disease could be established.

What is wrong with granulocytes in inflammatory bowel diseases?

The neutrophil plays a central role in the acute inflammatory response, a crucial mechanism required for the efficient clearance of invading microorganisms and antigenic material. Patients with primary immunodeficiencies of neutrophil function, particularly chronic granulomatous disease, are predisposed to develop bowel inflammation that is indistinguishable from Crohn's disease (CD) on the basis of clinical, endoscopic and histopathological features. The intrinsic function of the neutrophil is normal in the vast majority of patients with CD; however, there is clear evidence of an impairment of neutrophil recruitment to sites of trauma and bacterial infection. This is associated with an inability to adequately clear bacteria that have penetrated the tissues, resulting in the formation of granulomata, the histological hallmark of the disease, and the subsequent initiation of a chronic adaptive immune response. The reduced secretion of proinflammatory cytokines by macrophages, most notably TNF-α, may account for the attenuated neutrophil recruitment observed in CD. Stimulation of the innate immune system in CD, particularly in patients in remission, may be an alternative therapeutic strategy that could reduce the risk of future disease relapses.

Impaired autophagy leads to abnormal dendritic cell-epithelial cell interactions

BACKGROUND AND AIMS

Dendritic cells (DC) are key players in intestinal immunity, as these cells can direct the immune response to either a tolerogenic or an immunogenic phenotype. In the intestine, DC sample and process luminal antigens by protruding dendrites through the epithelial cell layer. At the same time barrier integrity is maintained through the continuous formation of tight junctions. Aberrations in these interactions may lead to altered antigen sampling and improper immune responses. We have recently shown that autophagy, a process implicated in the pathogenesis of Crohn's disease, regulates cellular interactions in the context of DC and T cells. In this study we aimed to determine whether autophagy also regulates DC-epithelial cell interactions and whether this influences the ensuing immune response.

METHODS

DC were generated from peripheral blood monocytes of healthy volunteers. For interaction studies, DC were co-cultured with intestinal epithelial cells on the baso-lateral side of a transwell insert. Modulation of autophagy was achieved using atg16l1 specific siRNA or pharmacological inhibitors. Intraepithelial protrusion of dendrites was determined by confocal microscopy. Luminal sampling and DC activation status were analyzed by flow cytometry. Protein expression was measured by immunoblotting and cytometric bead assay.

RESULTS

Adhesion molecules E-cadherin and occludin partly localized to autophagosomes and increased autophagy resulted in decreased levels of these proteins. Reduced autophagy in either DC, epithelial cells or both resulted in the decreased formation of transepithelial protrusions by DC as well as a reduction in antigen sampling. Moreover, when autophagy was inhibited in the co-culture model, DC expressed increased levels of HLA-DR and costimulatory molecule CD86. Furthermore, decreased levels of autophagy resulted in lower IL-10 production by DC and these cells induced significantly more T-cell proliferation in an allogeneic mixed lymphocyte reaction.

CONCLUSIONS

In intestinal DC-epithelial cell interactions, autophagy deficiency leads to decreased antigen sampling, increased DC maturation and a more pro-inflammatory type of DC.

Autophagy attenuates the adaptive immune response by destabilizing the immunologic synapse

BACKGROUND & AIMS

Variants in the genes ATG16L1 and IRGM affect autophagy and are associated with the development of Crohn's disease. It is not clear how autophagy is linked to loss of immune tolerance in the intestine. We investigated the involvement of the immunologic synapse-the site of contact between dendritic cells (DCs) and T cells, which contains molecules involved in antigen recognition and regulates immune response.

METHODS

DC autophagy was reduced using small interfering RNAs or pharmacologic inhibitors. DC phenotype and function were analyzed by confocal microscopy, time-lapse microscopy, and flow cytometry. We also examined DCs isolated from patients with Crohn's disease who carried the ATG16L1 risk allele.

RESULTS

Immunologic synapse formation induced formation of autophagosomes in DCs; the autophagosomes were oriented toward the immunologic synapse and contained synaptic components. Knockdown of ATG16L1 and IRGM with small interfering RNAs in DCs resulted in hyperstable interactions between DCs and T cells, increased activation of T cells, and activation of a T-helper 17 cell response. LKB1 was recruited to the immunologic synapse, and induction of autophagy in DC required inhibition of mammalian target of rapamycine signaling by the LKB1-AMP activated protein kinase (AMPK) pathway. DCs from patients with Crohn's disease who had an ATG16L1 risk allele had a similar hyperstability of the immunologic synapse.

CONCLUSIONS

Autophagy is induced upon formation of the immunologic synapse and negatively regulates T-cell activation. This mechanism might increase adaptive immunity in patients with Crohn's disease who carry ATG16L1 risk alleles.

A Potential 'Curative' Modality for Crohn's Disease---Modeled after Prophylaxis of Bovine Johne's Disease

A naturally occurring, gastrointestinal disorder of ruminants (Johne's disease) is a chronic, debilitating, lethal disease. The causative agent is Mycobacterium avium subspecies paratuberculosis (MAP). Exposure that leads to disease occurs primarily in utero and/or during the neonatal period. Outside a dietzia probiotic treatment, there are no preventive/curative therapies. Interestingly, MAP is at the center of a controversy as to its role (cause of, perpetuate of, innocent bystander) in Crohn's disease, ulcerative colitis, irritable bowel syndrome, diabetes, sarcoidosis, Blau syndrome, and multiple sclerosis-diseases in which the incidence of systemic MAP is higher than that in the general population. Conventional therapeutic modalities, including biologic agents, for the majority of these diseases are, in general, directed at curtailing processes that are an intricate part of inflammation, with goals to induce and maintain remission. Most possess side effects of varying severity, lose therapeutic value, and more importantly, few are directed at prevention, attainment of long lasting remissions or cures, and essential none at reduction/elimination of MAP. This report presents a rationale for how/why Dietzia subsp. C79793-74 should be clinically evaluated for efficacy in patients with IBD. Arguments are based on previous studies that demonstrated (a) clinical similarities of Johne's disease and Crohn's disease, (b) inhibition of growth of MAP by Dietzia under specific culture conditions, (c) safe usage for extended daily treatments of adult cattle (up to 24 months), and (d) when used as a probiotic, curtailed diarrhea and cured 40% of adult cattle with early stage paratuberculosis.

Successful treatment of asymptomatic or clinically terminal bovine Mycobacterium avium subspecies paratuberculosis infection (Johne's disease) with the bacterium Dietzia used as a probiotic alone or in combination with dexamethasone: Adaption to chronic human diarrheal diseases

A naturally occurring gastrointestinal disease, primarily of ruminants (Johne disease), is a chronic debilitating disease that is caused by Mycobacterium avium subspecies paratuberculosis (MAP). MAP infection occurs primarily in utero and in newborns. Outside our Dietzia probiotic treatment, there are no preventive/curative therapies for bovine paratuberculosis. Interestingly, MAP is at the center of controversy as to its role in (cause of) Crohn disease (CD) and more recently, its role in diabetes, ulcerative colitis, and irritable bowel syndrome (IBS); the latter two, like CD, are considered to be a result of chronic intestinal inflammation. Treatments, both conventional and biologic agents, which induce and maintain remission are directed at curtailing processes that are an intricate part of inflammation. Most possess side effects of varying severity, lose therapeutic value, and more importantly, none routinely result in prevention and/or cures. Based on (a) similarities of Johne disease and Crohn disease, (b) a report that Dietzia inhibited growth of MAP under specific culture conditions, and (c) findings that Dietzia when used as a probiotic, (i) was therapeutic for adult bovine paratuberculosis, and (ii) prevented development of disease in MAP-infected calves, the goal of the present investigations was to design protocols that have applicability for IBD patients. Dietzia was found safe for cattle of all ages and for normal and immunodeficient mice. The results strongly warrant clinical evaluation as a probiotic, in combination with/without dexamethasone.