Aetiopathogenesis of Autoimmune Hepatitis ence of ...
Transcript of Aetiopathogenesis of Autoimmune Hepatitis ence of ...
Aetiopathogenesis of
Autoimmune Hepatitis
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Aetiopathogenesis of autoimmune
hepatitis
He
pa
tite
s
Au
to-i
mm
un
es
Positive AAB and high IgG
Progressive inflammatory disorder
Exclusion of other pathology
(Wilson, HCV, HBV, NASH)
Anti-Smooth Muscle (SMA) &
Anti-Nuclear (ANA) autoantibodies
Liver Kidney Microsomal antibody
Liver Cytosol Type 1 antibody
Interface
hepatitis
M IFNγ
TNFα
IL1
CTL
IL2
IFNγ
NK
P
IL13 IL10
IL4 B
Th2
IL4 Tr
Co-
stimuli
Th0
Th1
Class I
Class II
Liver
cell
APC
IL12
Tr
Co-
stimuli
Th0
APC
Co-
stimuli
Th0
APC
Tr
Longhi MS et al - Impairment of CD4(+)CD25(+) regulatory T-cells in autoimmune liver disease. J Hepatol. 2004;41:31-7
Longhi MS, et al. Effect of CD4+CD25+ regulatory T-cells on CD8 T-cell function in autoimmune liver disease. J Autoimmunity 2005;25:63-71
Longhi MS, et al. Functional study of CD4+CD25+ regulatory T-cells in health and autoimmune hepatitis. J Immunol. 006;176:4484-91
Longhi MS, et al. Expansion and de novo generation of potentially therapeutic regulatory T cells inpatients with autoimmune hepatitis. Hepatology. 2008;47:581-91
Longhi MS, et al. Vigorous activation of monocytes in juvenile autoimmune liver disease escapes the control of regulatory T-cells. Hepatology. 2009; 50: 30-42
Longhi MS, et al. Auto-antigen-specific regulatory T-cells, a potential tool for immune-tolerance reconstitution in type-2 autoimmune hepatitis. Hepatology. 2011; 53: 536-547
Longhi MS, et al. Inhibition of interleukin-17 promotes differentiation of CD25– cells into stable T regulatory cells in patients with autoimmune hepatitis. Gastroenterology 2012;14:1526-1535
Liberal R, et al. The impaired immune regulation of autoimmune hepatitis is linked to a defective Galectin-9/Tim-3 pathway. Hepatology 2012;56:677-686
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
Diagnosis Remission
2.50%
4.20%
CD
4 C
D2
5
Elevated Immunoglobulin G
Co-
stimuli
Class I
Class II
Liver
cell
APC
Th2
NK
P
IL13 IL10
IL4 B
IL4
Th0
Tr
Class I Co-
stimuli
Class II
Liver
cell
APC
Th2
NK
P
IL13 IL10
IL4 B
IL4
Th0
Tr
Autoantigen
CYP2D6
497 aa
Immunodominant epitopes
254-271
CYP2D6
410-429 321-350
373-389
193-212
Kerkar N, et al. Cytochrome P4502D6(193-212): a new
Immunodominant... J Immunol 2003;170:1841-9
Gut 2000;46;553-561
Liver kidney microsomal antibody type 1 targets CYP2D6
on hepatocyte plasma membrane
L Muratori, M Parola, A Ripalti, G Robino, P Muratori, G Bellomo,
R Carini, M Lenzi, M P Landini, E Albano and F B Bianchi
Th2
IL4 Tr
Co-
stimuli
Th0
Th1
Class I
Class II
Liver
cell
APC
IL12
M IFNγ
TNFα
IL1
CTL
IL2
IFNγ
NK
P
IL13 IL10
IL4 B
Th2
IL4 Tr
Co-
stimuli
Th0
Th1
Class I
Class II
Liver
cell
APC
IL12
NKT
Predisposing HLA-Class II
allele in AIH-2
DR7 a
b
Prediction of DR7
binding peptides
7 predicted high binders
induced proliferation
full length CYP2D6 497 aa 1 aa
20-mer peptides, overlapping by 12 aa and spanning
the entire molecule of CYP2D6 were constructed
overlapping peptides
Sixty-one in total
DR7 positive patients
SI 3
6
9
12
1 11 21 31 41 51 61
High
Medium
Low
2 months of immunosuppressive treatment
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61
4
8
12
SI
at relapse 6 years after diagnosis
4
8
12
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61
SI
0
100
200
300
400
500
600
pg/ml
IFN
-g
1 11 21 31 41 51 61
0
100
200
300
400
500
600
IL-4
pg/ml
1 11 21 31 41 51 61
pg/ml
IL-1
0
1 11 21 31 41 51 61
0 100
200 300
400
500
600
Controls
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61
3
6
9
SI
Viral liver disease
Other autoimmune liver disease 0/46
Non autoimmune liver disease 0/17
HBV 0/3
HCV 4/7
CYP2D6313-332 TLAWGLLLMILHPDVQRRVQ
Similarity between HCV and CYP2D6
GLMALTLSP HCV825-833
WPLLLLLL HCV794-801
LLMCAVHP HCV875-882
HCV1246-1258 AQGYKVLVLNPSV
HCV402-412 LLAPGKKQNVQ
IL2
IFNγ
Tr
Co-
stimuli
Th0
Th1
Class I
Class II
Liver
cell
APC
IL12 CTL
Peptide number
Amino acid position
Binding score
1 176-185 G L L D K A V S N V 28
2 204-213 R L L D L A Q E G L 24
3 2-11 G L E A L V P L A V 22
4 245-254 K A F L T Q L D E L 22
5 393-402 T T L I T N L S S V 22
6 177-186 L L D K A V S N V I 21
7 306-314 G M V T T S T T L 21
Cytotoxicity of CYP2D6-specific CD8 T cells
% c
yto
tox
icit
y
0
10
20
30
40
50
60
70
80
p2 p3 p4 p5 p7 Hbc18-27
Diagnosis
% c
yto
tox
icit
y
0
10
20
30
40
50
60
70
80
p2 p3 p4 p5 p7 Hbc18-27
Remission
%
0
1
2
3
4
5
6
7
8
9
p2 p3 p4 p5 p7
IFNg producing CYP2D6-specific CD8 T cells
Diagnosis
%
0
1
2
3
4
5
6
7
8
9
p2 p3 p4 p5 p7
Remission
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
Cytotoxity IFN-g
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21306-31457
HLA-A*0201 nonamers
21177-1866
22393-40245
22245-25434
222-1123
24204-21312
28176-1851
Amino acid position
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
21G M V T T S T T L306-31457
HLA-A*0201 nonamers
21L L D K A V S N V I177-1866
22T T L I T N L S S V393-40245
22K A F L T Q L D E L245-25434
22G L E A L V P L A V2-1123
24R L L D L A Q E G L204-21312
28G L L D K A V S N V-1
1 2 3 4 5 6 7 8 9 10
Binding
scoreCYP2D6 sequence
HLA-A*0201
decamers
Tetramer
number
Peptide
number
Tetramers
Tetramer
labelled
with
phycoerythrin
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
p2 Tetramer p3 Tetramer p4 Tetramer p5 Tetramer p7 Tetramer HBVcore18-
27 Tetramer
%
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
p2 Tetramer p3 Tetramer p4 Tetramer p5 Tetramer p7 Tetramer HBVcore18-
27 Tetramer
%
% T
etr
am
er p
ositiv
e C
D8
T c
ells
Diagnosis
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
p2 Tetramer p3 Tetramer p4 Tetramer p5 Tetramer p7 Tetramer HBVcore18-
27 Tetramer
%
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
p2 Tetramer p3 Tetramer p4 Tetramer p5 Tetramer p7 Tetramer HBVcore18-
27 Tetramer
%
Remission
CYP2D6245-254 tetramer positive
CD8 T cells
M IFNγ
TNFα
IL1
CTL
IL2
IFNγ
NK
P
IL13 IL10
IL4 B
Th2
IL4 Tr
Co-
stimuli
Th0
Th1
Class I
Class II
Liver
cell
APC
IL12
Th17
IL6
TGFβ Th17
IL17
IL17
IL13 IL10
IL4
Th2
IL4 Tr
Co-
stimuli
Th0
Th1
APC
IL12
Th17
IL6
TGFβ IFNγ
IL2
IL17
Liberal R, et al. The impaired immune regulation of autoimmune hepatitis is linked to a defective Galectin-9/Tim-3 pathway. Hepatology 2012;56:677-686
Impairment of regulatory T cells
CD4 and CD8 autoepitopes defined
Expand regulatory T cells
What next?
Attempt new modes of treatment
Correlation with disease activity
T-regs
T-regs + T-regs T-regs T-regs
semi-mature DCs
First-in-human clinical trial
Thank you
Children’s Liver Disease
Foundation