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He PY, Wu MY, Zheng LY, Duan Y, Fan Q, Zhu XM, Yao YM. Interleukin-33/serum stimulation-2 pathway: Regulatory mechanisms and emerging implications in immune and inflammatory diseases. Cytokine Growth Factor Rev 2024; 76:112-126. [PMID: 38155038 DOI: 10.1016/j.cytogfr.2023.12.001] [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: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
Interleukin (IL)- 33, a nuclear factor and pleiotropic cytokine of the IL-1 family, is gaining attention owing to its important role in chronic inflammatory and autoimmune diseases. This review extends our knowledge of the effects exerted by IL-33 on target cells by binding to its specific receptor serum stimulation-2 (ST2). Depending on the tissue context, IL-33 performs multiple functions encompassing host defence, immune response, initiation and amplification of inflammation, tissue repair, and homeostasis. The levels and activity of IL-33 in the body are controlled by complex IL-33-targeting regulatory pathways. The unique temporal and spatial expression patterns of IL-33 are associated with host homeostasis and the development of immune and inflammatory disorders. Therefore, understanding the origin, function, and processes of IL-33 under various conditions is crucial. This review summarises the regulatory mechanisms underlying the IL-33/ST2 signalling axis and its potential role and clinical significance in immune and inflammatory diseases, and discusses the current complex and conflicting findings related to IL-33 in host responses.
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Affiliation(s)
- Peng-Yi He
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100853, China; School of Medicine, Nankai University, Tianjin 300071, China
| | - Meng-Yao Wu
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100853, China
| | - Li-Yu Zheng
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100853, China
| | - Yu Duan
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100853, China
| | - Qi Fan
- Emergency Medicine Center, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325015, China
| | - Xiao-Mei Zhu
- Tissue Repair and Regeneration Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, China.
| | - Yong-Ming Yao
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100853, China; School of Medicine, Nankai University, Tianjin 300071, China.
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Wang Z, Pan B, Qiu J, Zhang X, Ke X, Shen S, Wu X, Yao Y, Tang N. SUMOylated IL-33 in the nucleus stabilizes the transcription factor IRF1 in hepatocellular carcinoma cells to promote immune escape. Sci Signal 2023; 16:eabq3362. [PMID: 36917642 DOI: 10.1126/scisignal.abq3362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Interleukin-33 (IL-33) functions both as a secreted cytokine and as a nuclear factor, with pleiotropic roles in cancer and immunity. Here, we explored its role in hepatocellular carcinoma (HCC) and identified that a posttranslational modification altered its nuclear activity and promoted immune escape for HCC. IL-33 abundance was overall decreased but more frequently localized to the nucleus in patient HCC tissues than in normal liver tissues. In human and mouse HCC cells in culture and in vivo, IL-33 overexpression inhibited proliferation and repressed the abundance of programmed death ligand 1 (PD-L1) at the transcriptional level by promoting the ubiquitin-dependent degradation of interferon regulatory factor 1 (IRF1). However, this interaction was disrupted by SUMOylation of IL-33 at Lys54 mediated by the E3 ligase RanBP2. IL-33 SUMOylation correlated with its nuclear localization in HCC cells and tumors. An increase in SUMOylated IL-33 in HCC cells in cocultures and in vivo stabilized IRF1 and increased PD-L1 abundance and chemokine IL-8 secretion, which prevented the activation of cytotoxic T cells and promoted the M2 polarization of macrophages, respectively. Mutating the SUMOylation site in IL-33 reversed these effects and suppressed tumor growth. These findings indicate that SUMOylation of nuclear IL-33 in HCC cells impairs antitumor immunity.
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Affiliation(s)
- Zengbin Wang
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Banglun Pan
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Jiacheng Qiu
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Xiaoxia Zhang
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Xiaoling Ke
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Shuling Shen
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Xiaoxuan Wu
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Yuxin Yao
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China
| | - Nanhong Tang
- Department of Hepatobiliary Surgery and Fujian Institute of Hepatobiliary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001 China.,Cancer Center of Fujian Medical University, Fujian Medical University Union Hospital, Fuzhou 350001, China.,Key Laboratory of Gastrointestinal Cancer (Fujian Medical University), Ministry of Education, Fuzhou 350122, China
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Murdaca G, Paladin F, Tonacci A, Borro M, Greco M, Gerosa A, Isola S, Allegra A, Gangemi S. Involvement of IL-33 in the Pathogenesis and Prognosis of Major Respiratory Viral Infections: Future Perspectives for Personalized Therapy. Biomedicines 2022; 10:biomedicines10030715. [PMID: 35327516 PMCID: PMC8944994 DOI: 10.3390/biomedicines10030715] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Interleukin (IL)-33 is a key cytokine involved in type-2 immunity and allergic airway disease. At the level of lung epithelial cells, where it is clearly expressed, IL-33 plays an important role in both innate and adaptive immune responses in mucosal organs. It has been widely demonstrated that in the course of respiratory virus infections, the release of IL-33 increases, with consequent pro-inflammatory effects and consequent exacerbation of the clinical symptoms of chronic respiratory diseases. In our work, we analyzed the pathogenetic and prognostic involvement of IL-33 during the main respiratory viral infections, with particular interest in the recent SARS-CoV-2 virus pandemic and the aim of determining a possible connection point on which to act with a targeted therapy that is able to improve the clinical outcome of patients.
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Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, Ospedale Policlinico San Martino, 16132 Genoa, Italy; (F.P.); (A.G.)
- Correspondence:
| | - Francesca Paladin
- Department of Internal Medicine, Ospedale Policlinico San Martino, 16132 Genoa, Italy; (F.P.); (A.G.)
| | - Alessandro Tonacci
- Clinical Physiology Institute, National Research Council of Italy (IFC-CNR), 56124 Pisa, Italy;
| | - Matteo Borro
- Internal Medicine Department, San Paolo Hospital, 17100 Savona, Italy; (M.B.); (M.G.)
| | - Monica Greco
- Internal Medicine Department, San Paolo Hospital, 17100 Savona, Italy; (M.B.); (M.G.)
| | - Alessandra Gerosa
- Department of Internal Medicine, Ospedale Policlinico San Martino, 16132 Genoa, Italy; (F.P.); (A.G.)
| | - Stefania Isola
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy; (S.I.); (S.G.)
| | - Alessandro Allegra
- Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, Division of Hematology, University of Messina, 98125 Messina, Italy;
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy; (S.I.); (S.G.)
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Demyanets S, Stojkovic S, Huber K, Wojta J. The Paradigm Change of IL-33 in Vascular Biology. Int J Mol Sci 2021; 22:ijms222413288. [PMID: 34948083 PMCID: PMC8707059 DOI: 10.3390/ijms222413288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/30/2022] Open
Abstract
In this review, we focus on the actual understanding of the role of IL-33 in vascular biology in the context of the historical development since the description of IL-33 as a member of IL-1 superfamily and the ligand for ST2 receptor in 2005. We summarize recent data on the biology, structure and signaling of this dual-function factor with both nuclear and extracellular cytokine properties. We describe cellular sources of IL-33, particularly within vascular wall, changes in its expression in different cardio-vascular conditions and mechanisms of IL-33 release. Additionally, we summarize the regulators of IL-33 expression as well as the effects of IL-33 itself in cells of the vasculature and in monocytes/macrophages in vitro combined with the consequences of IL-33 modulation in models of vascular diseases in vivo. Described in murine atherosclerosis models as well as in macrophages as an atheroprotective cytokine, extracellular IL-33 induces proinflammatory, prothrombotic and proangiogenic activation of human endothelial cells, which are processes known to be involved in the development and progression of atherosclerosis. We, therefore, discuss that IL-33 can possess both protective and harmful effects in experimental models of vascular pathologies depending on experimental conditions, type and dose of administration or method of modulation.
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Affiliation(s)
- Svitlana Demyanets
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Stefan Stojkovic
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Kurt Huber
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Clinic Ottakring, 1160 Vienna, Austria;
- Medical School, Sigmund Freud University, 1020 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, 1090 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Cardiovascular Research, 1090 Vienna, Austria
- Core Facilities, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-73500; Fax: +43-1-40400-73586
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Perez F, Ruera CN, Miculan E, Carasi P, Dubois-Camacho K, Garbi L, Guzman L, Hermoso MA, Chirdo FG. IL-33 Alarmin and Its Active Proinflammatory Fragments Are Released in Small Intestine in Celiac Disease. Front Immunol 2020; 11:581445. [PMID: 33133101 PMCID: PMC7578377 DOI: 10.3389/fimmu.2020.581445] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Initially described as Th2 promoter cytokine, more recently, IL-33 has been recognized as an alarmin, mainly in epithelial and endothelial cells. While localized in the nucleus acting as a gene regulator, it can be also released after injury, stress or inflammatory cell death. As proinflammatory signal, IL-33 binds to the surface receptor ST2, which enhances mast cell, Th2, regulatory T cell, and innate lymphoid cell type 2 functions. Besides these Th2 roles, free IL-33 can activate CD8+ T cells during ongoing Th1 immune responses to potentiate its cytotoxic function. Celiac Disease (CD) is a chronic inflammatory disorder characterized by a predominant Th1 response leading to multiple pathways of mucosal damage in the proximal small intestine. By immunofluorescence and western blot analysis of duodenal tissues, we found an increased expression of IL-33 in duodenal mucosa of active CD (ACD) patients. Particularly, locally digested IL-33 releases active 18/21kDa fragments which can contribute to expand the proinflammatory signal. Endothelial (CD31+) and mesenchymal, myofibroblast and pericyte cells from microvascular structures in villi and crypts, showed IL-33 nuclear location; while B cells (CD20+) showed a strong cytoplasmic staining. Both ST2 forms, ST2L and sST2, were also upregulated in duodenal mucosa of CD patients. This was accompanied by increased number of CD8+ST2+ T cells and the expression of T-bet in some ST2+ intraepithelial lymphocytes and lamina propria cells. IL-33 and sST2 mRNA levels correlated with IRF1, an IFN induced factor relevant in responses to viral infections and interferon mediated proinflammatory responses highly represented in duodenal tissues in ACD. These findings highlight the potential contribution of IL-33 and its fragments to exacerbate the proinflammatory circuit and potentiate the cytotoxic activity of CD8+ T cells in CD pathology.
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Affiliation(s)
- Federico Perez
- Instituto de Estudios Inmunológicos y Fisiopatológicos (IIFP), UNLP, CONICET, CIC PBA, Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Carolina N Ruera
- Instituto de Estudios Inmunológicos y Fisiopatológicos (IIFP), UNLP, CONICET, CIC PBA, Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Emanuel Miculan
- Instituto de Estudios Inmunológicos y Fisiopatológicos (IIFP), UNLP, CONICET, CIC PBA, Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Paula Carasi
- Instituto de Estudios Inmunológicos y Fisiopatológicos (IIFP), UNLP, CONICET, CIC PBA, Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Karen Dubois-Camacho
- Innate Immunity Laboratory, Immunology Program, Faculty of Medicine, Biomedical Sciences Institute, Universidad de Chile, Santiago, Chile
| | - Laura Garbi
- Servicio de Gastroenterologia, Hospital General San Martin, La Plata, Argentina
| | - Luciana Guzman
- Servicio de Gastroenterologia, Sor Maria Ludovica, Hospital de Niños, La Plata, Argentina
| | - Marcela A Hermoso
- Innate Immunity Laboratory, Immunology Program, Faculty of Medicine, Biomedical Sciences Institute, Universidad de Chile, Santiago, Chile
| | - Fernando G Chirdo
- Instituto de Estudios Inmunológicos y Fisiopatológicos (IIFP), UNLP, CONICET, CIC PBA, Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
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Gao Y, Wang Y, Liu H, Liu Z, Zhao J. Mitochondrial DNA from hepatocytes induces upregulation of interleukin-33 expression of macrophages in nonalcoholic steatohepatitis. Dig Liver Dis 2020; 52:637-643. [PMID: 32360132 DOI: 10.1016/j.dld.2020.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the present study, we propose that lipotoxicity induces the release of mitochondrial DNA (mtDNA) from hepatocytes, which in turn upregulates IL-33 expression in macrophages. METHODS The mtDNA levels of plasma were determined in methionine- and mholine-deficient diet (MCD)-fed mice and NASH patients. Cultured hepatocytes were pre-incubated with Mito-TEMPO or rapamycin and were then stimulated with palmitic acid. The mtDNA levels in the cytosol were measured. The mtDNA from hepatocytes of mice was added to bone marrow-derived macrophages (BMDMs) in the presence of IRS (TLR9 antagonist). The expression of IL-33 in BMDMs was measured. RESULTS Levels of mtDNA were higher in NASH patients and MCD-fed mice. Treatment of hepatocytes with palmitic acid in vitro induced mtDNA release into cytosol, which was attenuated by mito-TEMPO or rapamycin, and aggravated by inhibition of autophagy. Treatment of BMDMs with mtDNA enhanced IL-33 expression, which was attenuated by knockdown of TLR9. Treatment of BMDMs with mtDNA enhanced lipopolysaccharide (LPS)-induced production of IL-1β and TNF-α, which was attenuated by pretreatment with soluble ST2. CONCLUSION mtDNA released from injured hepatocytes under lipid overload induced the upregulation of IL-33 expression in macrophages via TLR9, and enhanced LPS-induced inflammatory cytokine production.
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Affiliation(s)
- Yinjie Gao
- Department of Pathology and Hepatology, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China; Liver Transplantation and Research Center, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China
| | - Yijin Wang
- Department of Pathology and Hepatology, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China
| | - Hongling Liu
- Liver Transplantation and Research Center, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China
| | - Zhenwen Liu
- Liver Transplantation and Research Center, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China.
| | - Jingmin Zhao
- Department of Pathology and Hepatology, the 5th Medical Centre, Chinese PLA General Hospital, No. 100, Xisi Ring Middle Road, Beijing, 100039, China.
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Syed A, Tainer JA. The MRE11-RAD50-NBS1 Complex Conducts the Orchestration of Damage Signaling and Outcomes to Stress in DNA Replication and Repair. Annu Rev Biochem 2018; 87:263-294. [PMID: 29709199 PMCID: PMC6076887 DOI: 10.1146/annurev-biochem-062917-012415] [Citation(s) in RCA: 255] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Genomic instability in disease and its fidelity in health depend on the DNA damage response (DDR), regulated in part from the complex of meiotic recombination 11 homolog 1 (MRE11), ATP-binding cassette-ATPase (RAD50), and phosphopeptide-binding Nijmegen breakage syndrome protein 1 (NBS1). The MRE11-RAD50-NBS1 (MRN) complex forms a multifunctional DDR machine. Within its network assemblies, MRN is the core conductor for the initial and sustained responses to DNA double-strand breaks, stalled replication forks, dysfunctional telomeres, and viral DNA infection. MRN can interfere with cancer therapy and is an attractive target for precision medicine. Its conformations change the paradigm whereby kinases initiate damage sensing. Delineated results reveal kinase activation, posttranslational targeting, functional scaffolding, conformations storing binding energy and enabling access, interactions with hub proteins such as replication protein A (RPA), and distinct networks at DNA breaks and forks. MRN biochemistry provides prototypic insights into how it initiates, implements, and regulates multifunctional responses to genomic stress.
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Affiliation(s)
- Aleem Syed
- Department of Molecular and Cellular Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA; ,
| | - John A Tainer
- Department of Molecular and Cellular Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA; ,
- Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, California 94720, USA
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Becerra-Díaz M, Wills-Karp M, Heller NM. New perspectives on the regulation of type II inflammation in asthma. F1000Res 2017; 6:1014. [PMID: 28721208 PMCID: PMC5497827 DOI: 10.12688/f1000research.11198.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic inflammatory disease of the lungs which has been thought to arise as a result of inappropriately directed T helper type-2 (Th2) immune responses of the lungs to otherwise innocuous inhaled antigens. Current asthma therapeutics are directed towards the amelioration of downstream consequences of type-2 immune responses (i.e. β-agonists) or broad-spectrum immunosuppression (i.e. corticosteroids). However, few approaches to date have been focused on the primary prevention of immune deviation. Advances in molecular phenotyping reveal heterogeneity within the asthmatic population with multiple endotypes whose varying expression depends on the interplay between numerous environmental factors and the inheritance of a broad range of susceptibility genes. The most common endotype is one described as "type-2-high" (i.e. high levels of interleukin [IL]-13, eosinophilia, and periostin). The identification of multiple endotypes has provided a potential explanation for the observations that therapies directed at typical Th2 cytokines (IL-4, IL-5, and IL-13) and their receptors have often fallen short when they were tested in a diverse group of asthmatic patients without first stratifying based on disease endotype or severity. However, despite the incorporation of endotype-dependent stratification schemes into clinical trial designs, variation in drug responses are still apparent, suggesting that additional genetic/environmental factors may be contributing to the diversity in drug efficacy. Herein, we will review recent advances in our understanding of the complex pathways involved in the initiation and regulation of type-2-mediated immune responses and their modulation by host factors (genetics, metabolic status, and the microbiome). Particular consideration will be given to how this knowledge could pave the way for further refinement of disease endotypes and/or the development of novel therapeutic strategies for the treatment of asthma .
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Affiliation(s)
- Mireya Becerra-Díaz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Marsha Wills-Karp
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Nicola M. Heller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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