T-cell activation follows Th1 rather than Th2 pattern in haemodialysis patients

BACKGROUND

Patients on chronic intermittent haemodialysis (HD) show an impaired cellular and humoral immune response that clinically appears with frequent infectious complications and low vaccination responses. This immune defect strongly correlates with reduced in vitro proliferative responses of T cells. The defect is localized in antigen presenting cells, which show a decreased co-stimulatory activity. Furthermore, the impaired immune response correlates with an increased production of pro-inflammatory cytokines. In response to primary activation, CD4 positive T helper (Th) cells mainly differentiate into either Th1 or Th2 cells. Th1 cells support cell mediated immunity whereas Th2 cells enhance humoral immune responses. Since both types of responses mutually inhibit each other, the impaired humoral immune response seen in HD patients could either be due to a reduced number of Th2 cells or to a predominant Th1 response.

METHODS

We analysed the Th cell profile in HD patients using flow cytometry. Monocytic cytokine expression was analysed using both flow cytometry and enzyme linked immunoadsorbant assays.

RESULTS

Our data demonstrate that the cytokine differentiation profile in circulating T cells from HD patients is dysregulated and characterized by an increase in Th1 cells, but a normal amount of Th2 cells. Moreover, the skewed helper cell responses correlate with a higher percentage of monocytes capable of secreting the Th1 promoting cytokine interleukin 12 (IL-12).

CONCLUSIONS

Our findings contribute to a better understanding of the pathogenesis of impaired cellular immune functions in dialysis patients and, in particular, the decreased antibody production after vaccination. They provide a link between overproduction of pro-inflammatory cytokines (IL-12) and imbalanced T-cell activation.

Molecular aspects of T- and B-cell function in uremia

Chronic renal failure is associated with severe alterations of the immune system. Infections are responsible for a large part of the mortality in hemodialysis patients, and vaccination is mostly ineffective. Global tests of the immune function show greatly diminished activation of T cells. However, the intrinsic function of T and B cells is normal when they are provided with normal signaling from antigen-presenting cells (APCs). Patients with chronic renal failure show a defective function of costimulation derived from APCs leading to impaired activation of effector lymphocytes. Two major components of immune deviation are relevant: reduced signaling caused by impaired expression of the costimulatory molecule B7-2 (CD86) on monocytes leads to low activation of helper T cells. This dysfunction is associated with uremia and may be improved by high-efficiency renal replacement therapy. The other component is inflammatory activation of APCs mainly due to the hemodialysis procedure. Inflammation, characterized by overproduction of cytokines such as interleukin-1beta (IL-1beta) or IL-6, correlates with low effector activation. Furthermore, inflammatory cytokines such as IL-12 deviate the functional pattern of T-cell activation toward Th1 differentiation, thus leading to an additional reduction of Th2- and B-cell function. The individual severity of inflammatory alterations is partially controlled by the negatively regulating cytokine IL-10, which, on a genetic basis, can be up-regulated to a different extent in individual patients. Therapeutic interventions to improve immune dysfunction include the enhancement of dialysis efficiency and the reduction of inflammatory alterations by the use of highly biocompatible dialyzers.

Production of proinflammatory and regulatory monokines in hemodialysis patients shown at a single-cell level

Immunologic complications of chronic renal failure are associated with the overproduction of proinflammatory cytokines by monocytes. This is partly due to renal failure itself but is further enhanced by hemodialysis treatment with frequent contact between blood and dialyzer membranes. Previous studies have shown an imbalance of proinflammatory and regulatory monokines in these patients. This study examines monokine production in hemodialysis patients using for the first time a very sensitive method of cytokine detection at a single-cell level by flow cytometry ("cytoflow technique"). Monocytes were stained intracellularly for the production of interleukin-6 (IL-6) and IL-10 after 20 h of culture with lipopolysaccharide. It was shown that high levels of proinflammatory IL-6 in hemodialysis patients are due to an increased number of monocytes producing this cytokine, while IL-6 synthesis per cell remains unchanged. In contrast, elevated levels of regulatory IL-10 are due to an increased synthesis per cell. This study demonstrates that in healthy subjects there is a population of monocytes producing exclusively IL-10 after 20 h of stimulation by lipopolysaccharide. This distinct population of regulatory monocytes is infrequent in dialysis patients, in whom most of the IL-10-positive monocytes also produce IL-6. These findings indicate that overproduction of proinflammatory factors in dialysis patients is at least in part due to a loss of cytokine-specific differentiation in monocytes.

Defective expression of B7-2 (CD86) on monocytes of dialysis patients correlates to the uremia-associated immune defect

BACKGROUND

Specific cellular immune reactions in patients with chronic renal failure (CRF) are impaired by a defect of the antigen-presenting cells. To elucidate the molecular background for this defect, we determined the expression of human lymphocyte antigen (HLA)-DR and costimulatory molecules on monocytes of hemodialysis patients.

METHODS

The expression of HLA-DR, B7-1 (CD80), and B7-2 (CD86) molecules was determined on CD14+ monocytes of chronic hemodialysis patients prior to a dialysis session. Mononuclear cells of these patients were cultured, and expression of the respective antigens was determined after in vitro activation by various stimuli. Results were correlated with in vitro proliferation of T cells in a phytohemagglutinin (PHA) assay and the clinical response to a hepatitis B vaccination. All data were compared with healthy controls and patients with CRF who were not on dialysis.

RESULTS

Monocytes of chronic hemodialysis patients but not CRF patients expressed low levels of costimulatory B7-2, while HLA-DR expression was normal. B7-1 was only expressed on activated monocytes, and the expression reached normal levels in hemodialysis patients. Baseline expression of B7-2 highly correlated with the results of T-cell proliferation assays in hemodialysis patients and also with the clinical immune response.

CONCLUSIONS

Impaired expression and up-regulation of B7-2 is an important feature of the cellular immune defect in chronic hemodialysis patients. It leads to reduced costimulation and effector activation of T cells and contributes to a molecular explanation for the impaired response of hemodialysis patients to the hepatitis B vaccination.

Molecular aspects of T- and B-cell function in uremia

Chronic renal failure is associated with severe alterations of the immune system. Infections are responsible for a large part of the mortality in hemodialysis patients, and vaccination is mostly ineffective. Global tests of the immune function show greatly diminished activation of T cells. However, the intrinsic function of T and B cells is normal when they are provided with normal signaling from antigen-presenting cells (APCs). Patients with chronic renal failure show a defective function of costimulation derived from APCs leading to impaired activation of effector lymphocytes. Two major components of immune deviation are relevant: reduced signaling caused by impaired expression of the costimulatory molecule B7-2 (CD86) on monocytes leads to low activation of helper T cells. This dysfunction is associated with uremia and may be improved by high-efficiency renal replacement therapy. The other component is inflammatory activation of APCs mainly due to the hemodialysis procedure. Inflammation, characterized by overproduction of cytokines such as interleukin-1beta (IL-1beta) or IL-6, correlates with low effector activation. Furthermore, inflammatory cytokines such as IL-12 deviate the functional pattern of T-cell activation toward Th1 differentiation, thus leading to an additional reduction of Th2- and B-cell function. The individual severity of inflammatory alterations is partially controlled by the negatively regulating cytokine IL-10, which, on a genetic basis, can be up-regulated to a different extent in individual patients. Therapeutic interventions to improve immune dysfunction include the enhancement of dialysis efficiency and the reduction of inflammatory alterations by the use of highly biocompatible dialyzers.

Strong depletion of CD14(+)CD16(+) monocytes during haemodialysis treatment

BACKGROUND

The immune defect in haemodialysis (HD) patients is associated with a monocytic dysfunction, including an increased production of proinflammatory cytokines. Monocytes fall into subpopulations comprising CD14(++)CD16(-) and CD14(+)CD16(+) cells. Circulating numbers of the latter can rapidly increase during infectious episodes and inflammation.

METHODS

We determined the amount of CD14(+)CD16(+) monocytes in HD patients and characterized their fate during HD treatment. In 34 HD patients and 17 healthy controls, the distinct cell populations were determined by differential blood counts and flow cytometry. Cells from 14 HD patients were analysed at the start, 10, 30 and 120 min thereafter, and at the end of HD treatment.

RESULTS

Before HD, patients show a monocytosis with a strongly increased CD14(+)CD16(+) subpopulation. Early during HD treatment, circulating leukocyte numbers decrease, with monocytes being most profoundly influenced. Interestingly, among them, sequestration is most pronounced in the CD14(+) CD16(+) subpopulation. After 30 min, approximately 83+/-9% of CD14(+)CD16(+) cells are removed from circulation. This sequestration does not differ between patients treated with polyamide or haemophan membranes. The sequestration is a short-lived temporary effect and cell numbers are replenished within 120 min of treatment for the entire monocyte population. Beyond that time point, cellular activation by the dialyser membrane becomes visible. Reappearence kinetics of CD14(+)CD16(+) monocytes is slower; however, initial numbers are reached by the end of treatment.

CONCLUSION

Haemodiaysis leads to temporary removal of monocytes from the bloodstream followed by the reappearance of activated cells. This might contribute to the state of chronic microinflammation, which is reflected by high levels of CD14(+)CD16(+) monocytes.

The interleukin-10 promoter genotype determines clinical immune function in hemodialysis patients

BACKGROUND

Immune dysfunction and the impaired hepatitis B vaccination response are complications of chronic renal failure that are tightly associated with inflammation induced by uremia and blood-membrane contacts. Proinflammatory cytokines, such as interleukin (IL)-6, are counter-regulated by IL-10 with a large interindividual variability. Part of the variability of cytokine production is genetically determined since polymorphisms in the cytokine gene promoters lead to high or low production. The aim of this study was to detect the genetic influence of the IL-10 promoter on immune function of chronic hemodialysis patients.

METHODS

The IL-10 genotype (polymorphic bases at positions -1082 and -819) was determined in 272 chronic hemodialysis patients using highly specific PCR and related to the patients' response to a triple vaccination against hepatitis B. Secretion of IL-10 and IL-6 by peripheral blood leucocytes in vitro was determined by ELISA.

RESULTS

The prevalence of the IL-10 genotypes in dialysis patients with well-preserved immune function (vaccination responders) was similar to the general population. In contrast, prevalence of the -1082G* allele (associated with high production of IL-10) was low in the nonresponders. The relative risk of vaccination nonresponse in patients homozygous for the -1082A* allele was 1.394 (95% CI, 1.091 to 1.781, P < 0.05) compared to those homozygous for -1082G*. There was no relationship between the IL-10 genotype and the type of renal disease.

CONCLUSIONS

The IL-10 genotype determines IL-10 production in dialysis patients, which down-regulates uremia- and dialysis-induced chronic inflammation and helps to preserve immune defense functions.

Initiation of hemodialysis treatment leads to improvement of T-cell activation in patients with end-stage renal disease

Patients with chronic renal failure show an immunodeficiency characterized by frequent infectious complications and a low response to vaccinations. This is paralleled in vitro by a low T-cell proliferation on mitogenic stimuli because of an impaired costimulation by accessory cells. Furthermore, alterations of the cytokine profile are correlated with impaired immune function. The immune system is influenced by both uremia and renal replacement therapy. To evaluate the influence of hemodialysis on immune parameters, we studied patients before and after the initiation of chronic hemodialysis therapy. Fourteen patients with end-stage renal failure were tested before dialysis initiation and during the first 6 weeks of hemodialysis treatment. We determined the in vitro T-cell proliferation, as well as plasma levels of interleukin-6 (IL-6) and the release of IL-6 and IL-10 into culture supernatant poststimulation with lipopolysaccharide. After 6 weeks of intermittent hemodialysis, in vitro T-cell proliferation on stimulation improved significantly (stimulation index, 21.6 +/- 18.5 versus 58.1 +/- 45.5; P < 0.01). This improvement occurred regardless of whether synthetic dialyzers or cellulosic membranes were used for the initiation of dialysis. Plasma IL-6 levels, as well as IL-6 and IL-10 secretion, did not change during the study period. In patients with end-stage renal disease, the initiation of hemodialysis led to a significant improvement of in vitro T-cell proliferation. This effect may have a role for an improvement of immune function in vivo. The expected normalization of IL-6 and IL-10 production may be masked by cytokine induction through hemodialysis membranes.

Prospective crossover trial of the influence of vitamin E-coated dialyzer membranes on T-cell activation and cytokine induction

Cytokine induction by dialyzer membranes has been related to several acute and chronic side effects of hemodialysis treatment, among them being immune dysfunction and progressive atherosclerosis. Surface modification of cuprophane dialyzers with the antioxidant vitamin E is a new approach to enhance biocompatibility and improve cytokine levels, as well as immune function. Twenty-one patients undergoing treatment with hemophane (HE) dialyzers were enrolled onto a crossover study with a vitamin E-coated (VE) dialyzer or a synthetic polyamide (PA) dialyzer. In vitro assays of lymphocyte activation and measurements of cytokine induction were performed to evaluate biocompatibility. Four weeks of treatment with either VE or PA dialyzers enhanced in vitro proliferation of peripheral blood leukocytes in comparison to treatment with HE membranes used before study entry. Enhancement of lymphocyte function was independent of dialysis efficiency, which was kept constant during the study. In the interdialytic interval, preactivation of monocytes for the production of interleukin-6 (IL-6) did not differ between VE or PA dialysis. In contrast, the VE membrane reduced acute production of IL-6 during a dialysis treatment, whereas the PA membrane did not. Unlike IL-6, the regulatory cytokine IL-10 is not inhibited by either membrane. This is important because IL-10 is believed to have a beneficial effect on immune function in dialysis patients. The VE membrane, despite being based on a cuprophane backbone, is similar to the highly biocompatible PA dialyzer in terms of its effect on lymphocyte function, whereas it exerts an additional suppressive effect on the overproduction of proinflammatory cytokines.

Glucocorticoids inhibit activation-dependent expression of costimulatory molecule B7-1 in human monocytes

BACKGROUND

Glucocorticoids act as immunosuppressive drugs mainly via their effects on antigen-presenting cells. They are known to influence production of cytokines as well as expression of cell surface molecules. B7 molecules belong to the most important costimulatory signals for T-cell activation during transplant rejection. They are expressed on antigen-presenting cells and up-regulated during the immune response. We studied the influence of glucocorticoids on the regulation of these accessory signals.

METHODS

Human monocytes were purified from peripheral blood of healthy volunteers by centrifugal counterflow elutriation. Activation-dependent transcription and expression of B7-1 (CD80) and B7-2 (CD86) were detected by reverse transcription-polymerase chain reaction and flow cytometry in the absence or presence of glucocorticoids.

RESULTS

The expression pattern of B7-1 and B7-2 on monocytes depends on the type of stimulation. Activation by interferon-gamma induces both B7-1 and B7-2, whereas cAMP exclusively up-regulates B7-2. Glucocorticoids selectively inhibit the expression of B7-1 while leaving B7-2 unaffected. The effect occurs at concentrations that are reached during therapeutical application of the substances in humans. It is mediated via the cytoplasmic glucocorticoid receptor, as it can be abrogated by the glucocorticoid receptor antagonist RU38486. Inhibition of B7-1 occurs at the transcriptional level. Up-regulation of the molecule can similarly be inhibited by hydrocortisone, prednisolone, and dexamethasone at equipotent doses.

CONCLUSIONS

Inhibition of the up-regulation of B7-1 by glucocorticoids is a previously unknown mechanism of action of these substances and may relevantly contribute to their effects as immunosuppressive drugs.

Selective sequestration of cytokine-producing monocytes during hemodialysis treatment

Hemodialysis treatment leads to leukocyte activation and cytokine production. Studying this effect has been complicated because cell activation by blood membrane contact also induces adherence factors on leukocytes, leading to margination of cells to the endothelium of the lung. Using single-cell cytokine determination, we studied the relation between cytokine production and cell sequestration during dialysis therapy. Blood was sampled in 11 chronic hemodialysis patients using hemophane dialyzers before hemodialysis and at 20 and 120 minutes of treatment. Lipopolysaccharide (LPS)-induced cytokine production in monocytes was studied by intracellular staining for interleukin-6 (IL-6) and IL-10 and flow cytometry. Results obtained in dialysis patients were compared with samples from an ex vivo dialysis system. Monocyte maturation stage was evaluated by detection of several surface markers through flow cytometry. Within 20 minutes of hemodialysis, the numbers of circulating monocytes decreased to one third of initial values. Before dialysis, 56.7% +/- 15.7% of circulating monocytes responded to LPS by the production of IL-6. This fraction decreased to 21.1% +/- 17.3% (P < 0.001 versus before hemodialysis) at 20 minutes and 32.3% +/- 13.8% (P < 0.001 versus before hemodialysis) at 120 minutes of treatment. A similar decrease occurred for IL-10. Cytokine-positive cells did not decrease during ex vivo dialysis. Surface marker studies showed that mature monocytes expressing HLA-DR or CD86 were predominantly removed. We provide the first evidence for a subtype-specific sequestration of monocytes caused by dialysis treatment. Fully differentiated cells capable of cytokine production and antigen presentation are removed and relatively immature cells remain in circulation.

High prevalence of hepatitis G virus (HGV) infections in dialysis staff

BACKGROUND

Patients on renal replacement therapy, haemodialysis (HD), or after kidney transplantation (TX), are known to be at risk of acquiring blood-borne infections (HBV, HCV). GBV-C/Hepatitis G virus (HGV) has been described recently and is considered to cause blood-borne infections. The aim of this study was to analyse the risk for the medical staff of HD and TX patients to acquire HGV infection.

METHODS

Eighty-five HD patients and 86 TX recipients were compared with 49 health-care workers and 64 blood donors as controls. The HGV prevalence was determined by RT-PCR and antibodies to E2 protein.

RESULTS

A high prevalence of HGV was found in the medical staff (24%) which nearly corresponded to the prevalence of the patients (TX 36%, HD 25%) but not to the controls (9%). In contrast, the prevalence of HCV was low in the medical staff (2%) and controls (0%) but high in HD (13%) and TX (13%). Age and duration of employment in the department did not significantly influence the HGV prevalence in staff. The number of viraemic subjects in staff was high, possibly indicating a more recent infection.

CONCLUSION

An occupational risk for HGV exists in medical staff of dialysis and transplant patients. Further routes of transmission than only parenteral may play a role in this setting.

Analysis of nicotinic acetylcholine receptor subunits in the cochlea of the mouse

The present study was designed to catalogue and compare nicotinic receptor subunit messages in the mammalian cochlea. Fourteen nicotinic acetylcholine receptor subunit messages were examined by polymerase chain reaction (PCR) analysis and nucleotide sequencing. Total RNA was extracted from the auditory organs of 14- to 18-day-old CBAJ mice, and mRNA was purified using oligo-dT cellulose. After reverse transcription, resulting cDNA was amplified by PCR with the use of primers specific for the nucleotide sequences representing the following nicotinic receptor subunits: muscle types alpha 1, beta 1, gamma, delta and epsilon and neuronal types alpha 2,3,4,5,6,7 and beta 2,3,4. cDNA from cochlear tissue corresponding to the muscle-type receptor subunit beta 1 and to neuronal-type receptor subunits alpha 2,4,5,6 and beta 2,3 was amplified, whereas cDNA for muscle types alpha 1, gamma, delta and epsilon and neuronal types alpha 3,7 and beta 4 was not. All PCR products were homologous in nucleotide sequence to the corresponding reference cDNAs from which the primers were designed. The current results indicate that nicotinic acetylcholine receptor (nAChR) subunits that are similar or identical to the stated muscle and neuronal types are expressed in the murine cochlea. The presence of messages corresponding to the muscle-type beta 1 and neuronal-type nAChR subunits may be correlated with the atypical cholinergic response of cochlear hair cells to agonists and antagonists.

Respiratory healthcare by design: Computational approaches bringing respiratory precision and personalised medicine closer to bedside

Precision medicine represents a potentially powerful means to alleviate the growing burden of chronic respiratory diseases. To realise its potential, however, we need a systems level understanding of how biological events (signalling pathways, cell-cell interactions, tissue mechanics) integrate across multiple spatial and temporal scales to give rise to pathology. This can be achieved most practically in silico: a paradigm that offers tight control over model parameters and rapid means of testing and generating mechanistic hypotheses. Patient-specific computational models that can enable identification of pathological mechanisms unique to patients' (omics, physiological, and anatomical) profiles and, therefore, personalised drug targets represent a major milestone in precision medicine. Current patient-based models in literature, especially medical devices, cardiac modelling, and respiratory medicine, rely mostly on (partial/ordinary) differential equations and have reached relatively advanced level of maturity. In respiratory medicine, patient-specific simulations mainly include subject scan-based lung mechanics models that can predict pulmonary function, but they treat the (sub)cellular processes as "black-boxes". A recent advance in simulating human airways at a cellular level to make clinical predictions raises the possibility of linking omics and cell level data/models with lung mechanics to understand respiratory pathology at a systems level. This is significant as this approach can be extended to understanding pathologies in other organs as well. Here, I will discuss ways in which computational models have already made contributions to personalised healthcare and how the paradigm can expedite clinical uptake of precision medicine strategies. I will mainly focus on an agent-based, asthmatic virtual patient that predicted the impact of multiple drug pharmacodynamics at the patient level, its potential to develop efficacious precision medicine strategies in respiratory medicine, and the regulatory and ethical challenges accompanying the mainstream application of such models.

Aortic valve stenosis as a cause of major systemic embolism--a case report

This is the first documented case of a patient suffering from embolic occlusion of the left brachial artery caused by a large embolus growing on a lesion of a stenosed calcified aortic valve. Supported by their own additional observations the authors suggest that severe calcified aortic valve stenosis should be considered as an indication for anticoagulation in the period before surgical valve replacement.