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Utama S, Cale JM, Mitrpant C, Fletcher S, Wilton SD, Aung-Htut MT. Is Exon Skipping a Viable Therapeutic Approach for Vascular Ehlers-Danlos Syndrome with Mutations in COL3A1 Exon 10 or 15? Int J Mol Sci 2024; 25:8816. [PMID: 39201504 PMCID: PMC11354334 DOI: 10.3390/ijms25168816] [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: 07/01/2024] [Revised: 08/05/2024] [Accepted: 08/11/2024] [Indexed: 09/02/2024] Open
Abstract
Vascular Ehlers-Danlos syndrome or Ehlers-Danlos syndrome type IV (vEDS) is a connective tissue disorder characterised by skin hyperextensibility, joint hypermobility and fatal vascular rupture caused by COL3A1 mutations that affect collagen III expression, homo-trimer assembly and secretion. Along with collagens I, II, V and XI, collagen III plays an important role in the extracellular matrix, particularly in the inner organs. To date, only symptomatic treatment for vEDS patients is available. Fibroblasts derived from vEDS patients carrying dominant negative and/or haploinsufficiency mutations in COL3A1 deposit reduced collagen III in the extracellular matrix. This study explored the potential of an antisense oligonucleotide (ASO)-mediated splice modulating strategy to bypass disease-causing COL3A1 mutations reported in the in-frame exons 10 and 15. Antisense oligonucleotides designed to redirect COL3A1 pre-mRNA processing and excise exons 10 or 15 were transfected into dermal fibroblasts derived from vEDS patients and a healthy control subject. Efficient exon 10 or 15 excision from the mature COL3A1 mRNA was achieved and intracellular collagen III expression was increased after treatment with ASOs; however, collagen III deposition into the extracellular matrix was reduced in patient cells. The region encoded by exon 10 includes a glycosylation site, and exon 15 encodes hydroxyproline and hydroxylysine-containing triplet repeats, predicted to be crucial for collagen III assembly. These results emphasize the importance of post-translational modification for collagen III homo-trimer assembly. In conclusion, while efficient skipping of target COL3A1 exons was achieved, the induced collagen III isoforms generated showed defects in extracellular matrix formation. While therapeutic ASO-mediated exon skipping is not indicated for the patients in this study, the observations are restricted to exons 10 and 15 and may not be applicable to other collagen III in-frame exons.
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Affiliation(s)
- Sasiwimon Utama
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (S.U.); (C.M.)
- Centre of Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA 6150, Australia; (J.M.C.); (S.F.); (S.D.W.)
| | - Jessica M. Cale
- Centre of Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA 6150, Australia; (J.M.C.); (S.F.); (S.D.W.)
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Nedlands, WA 6009, Australia
| | - Chalermchai Mitrpant
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (S.U.); (C.M.)
| | - Sue Fletcher
- Centre of Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA 6150, Australia; (J.M.C.); (S.F.); (S.D.W.)
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, WA 6009, Australia
| | - Steve D. Wilton
- Centre of Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA 6150, Australia; (J.M.C.); (S.F.); (S.D.W.)
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Nedlands, WA 6009, Australia
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Nedlands, WA 6009, Australia
| | - May T. Aung-Htut
- Centre of Molecular Medicine and Innovative Therapeutics, Murdoch University, Murdoch, WA 6150, Australia; (J.M.C.); (S.F.); (S.D.W.)
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Nedlands, WA 6009, Australia
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Čimborová K, Kotasová H, Pelková V, Sedláková V, Hampl A. Decellularization of Pig Lung to Yield Three-Dimensional Scaffold for Lung Tissue Engineering. Methods Mol Biol 2024; 2764:21-33. [PMID: 38393586 DOI: 10.1007/978-1-0716-3674-9_3] [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] [Indexed: 02/25/2024]
Abstract
Lately, the need for three-dimensional (3D) cell culture has been recognized in order to closely mimic the organization of native tissues. Thus, 3D scaffolds started to be employed to facilitate the 3D cell organization and enable the artificial tissue formation for the emerging tissue engineering applications. 3D scaffolds can be prepared by various techniques, each with certain advantages and disadvantages. Decellularization is an easy method based on removal of cells from native tissue sample, yielding extracellular matrix (ECM) scaffold with preserved architecture and bioactivity. This chapter provides a detailed protocol for decellularization of pig lung and also some basic assays for evaluation of its effectivity, such as determination of DNA content and histological verification of the selected ECM components. Such decellularized scaffold can subsequently be used for various tissue engineering applications, for example, for recellularization with cells of interest, for natural ECM hydrogel preparation, or as a bioink for 3D bioprinting.
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Affiliation(s)
- Katarína Čimborová
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hana Kotasová
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vendula Pelková
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Veronika Sedláková
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Aleš Hampl
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.
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Nietfeld F, Höltig D, Willems H, Valentin-Weigand P, Wurmser C, Waldmann KH, Fries R, Reiner G. Candidate genes and gene markers for the resistance to porcine pleuropneumonia. Mamm Genome 2020; 31:54-67. [PMID: 31960078 PMCID: PMC7060169 DOI: 10.1007/s00335-019-09825-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/31/2019] [Indexed: 12/30/2022]
Abstract
Actinobacillus (A.) pleuropneumoniae is one of the most important respiratory pathogens in global pig production. Antimicrobial treatment and vaccination provide only limited protection, but genetic disease resistance is a very promising alternative for sustainable prophylaxis. Previous studies have discovered multiple QTL that may explain up to 30% of phenotypic variance. Based on these findings, the aim of the present study was to use genomic sequencing to identify genetic markers for resistance to pleuropneumonia in a segregating commercial German Landrace line. 163 pigs were infected with A. pleuropneumoniae Serotype 7 through a standardized aerosol infection method. Phenotypes were accurately defined on a clinical, pathological and microbiological basis. The 58 pigs with the most extreme phenotypes were genotyped by sequencing (next-generation sequencing). SNPs were used in a genome-wide association study. The study identified genome-wide associated SNPs on three chromosomes, two of which were chromosomes of QTL which had been mapped in a recent experiment. Each variant explained up to 20% of the total phenotypic variance. Combined, the three variants explained 52.8% of the variance. The SNPs are located in genes involved in the pathomechanism of pleuropneumonia. This study confirms the genetic background for the host's resistance to pleuropneumonia and indicates a potential role of three candidates on SSC2, SSC12 and SSC15. Favorable gene variants are segregating in commercial populations. Further work is needed to verify the results in a controlled study and to identify the functional QTN.
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Affiliation(s)
- Florian Nietfeld
- Department for Veterinary Clinical Sciences, Justus-Liebig-University, Giessen, Germany
| | - Doris Höltig
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Hermann Willems
- Department for Veterinary Clinical Sciences, Justus-Liebig-University, Giessen, Germany
| | - Peter Valentin-Weigand
- Institute for Microbiology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Christine Wurmser
- Chair of Animal Breeding, Technical University of Munich, Freising, Germany
| | - Karl-Heinz Waldmann
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Ruedi Fries
- Chair of Animal Breeding, Technical University of Munich, Freising, Germany
| | - Gerald Reiner
- Department for Veterinary Clinical Sciences, Justus-Liebig-University, Giessen, Germany.
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Hachem RR. The impact of non-HLA antibodies on outcomes after lung transplantation and implications for therapeutic approaches. Hum Immunol 2019; 80:583-587. [PMID: 31005400 DOI: 10.1016/j.humimm.2019.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 01/12/2023]
Abstract
The role of donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) in lung allograft rejection has been recognized over the past 20 years. During this time, there has been growing experience and recognition of an important role for non-HLA antibodies in lung allograft rejection. Multiple self-antigens have been identified that elicit autoimmune responses including collagen V, K-α 1 tubulin, angiotensin type 1 receptor, and endothelin type A receptor, but it is likely that other antigens elicit similar responses. The paradigm for the pathogenesis of these autoimmune responses consists of exposure of sequestered self-antigens followed by loss of peripheral tolerance, which then promotes allograft rejection. Studies have focused mainly on the impact of autoimmune responses on the development of Bronchiolitis Obliterans Syndrome or its mouse model surrogate. However, there are emerging data that illustrate that non-HLA antibodies can induce acute antibody-mediated rejection (AMR) after lung transplantation. Treatment has focused on antibody-depletion protocols, but experience is limited to cohort studies and appropriate controlled trials have not been conducted. It is noteworthy that depletion of non-HLA antibodies has been associated with favorable clinical outcomes. Clearly, additional studies are needed to identify the optimal therapeutic approaches to non-HLA antibodies in clinical practice.
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Affiliation(s)
- Ramsey R Hachem
- Washington University School of Medicine, Division of Pulmonary & Critical Care, 4523 Clayton Ave., Campus Box 8052, St. Louis, MO 63110, United States.
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Leeming DJ, Byrjalsen I, Sand JMB, Bihlet AR, Lange P, Thal-Singer R, Miller BE, Karsdal MA, Vestbo J. Biomarkers of collagen turnover are related to annual change in FEV 1 in patients with chronic obstructive pulmonary disease within the ECLIPSE study. BMC Pulm Med 2017; 17:164. [PMID: 29202744 PMCID: PMC5716018 DOI: 10.1186/s12890-017-0505-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 11/16/2017] [Indexed: 01/06/2023] Open
Abstract
Background Change in forced expiratory volume in one second (FEV1) is important for defining severity of chronic obstructive pulmonary disease (COPD). Serological neoepitope markers of collagen turnover may predict rate of change in FEV1. Methods One thousand COPD subjects from the observational, multicentre, three-year ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) study (NCT00292552, trial registration in February 2006) were included. Matrix metalloproteinase (MMP)-generated fragments of collagen type I, and type VI (C1M and C6M) were assessed in month six serum samples. A random-coefficient model with both a random intercept and a random slope was used to test the ability of the markers to predict post-dose bronchodilator FEV1 (PD-FEV1) change over two years adjusting for sex, age, BMI, smoking, bronchodilator reversibility, prior exacerbations, emphysema and chronic bronchitis status at baseline. Results Annual change of PD-FEV1 was estimated from a linear model for the two-year study period. Serum C1M and C6M were independent predictors of lung function change (p = 0.007/0.005). Smoking, bronchodilator reversibility, plasma hsCRP and emphysema were also significant predictors. The effect estimate between annual change in PD-FEV1 per one standard deviation (1SD) increase of C1M and C6M was +10.4 mL/yr. and +8.6 mL/yr. C1M, and C6M, had a significant association with baseline FEV1. Conclusion We demonstrated that markers of tissue turnover were significantly associated with lung function change. These markers may function as prognostic biomarkers and possibly as efficacy biomarkers in clinical trials focusing on lung function change in COPD. Trial registration NCT00292552, Retrospectively registered, trial registration in February 2006. Electronic supplementary material The online version of this article (10.1186/s12890-017-0505-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Diana J Leeming
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev Hovedgade 207, DK-2730, Herlev, Denmark.
| | - Inger Byrjalsen
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev Hovedgade 207, DK-2730, Herlev, Denmark
| | - Jannie M B Sand
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev Hovedgade 207, DK-2730, Herlev, Denmark.,Section of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Asger R Bihlet
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev Hovedgade 207, DK-2730, Herlev, Denmark
| | - Peter Lange
- Section of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ruth Thal-Singer
- GlaxoSmithKline Research and Development, King of Prussia, PA, United States.
| | - Bruce E Miller
- GlaxoSmithKline Research and Development, King of Prussia, PA, United States.
| | - Morten A Karsdal
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev Hovedgade 207, DK-2730, Herlev, Denmark
| | - Jørgen Vestbo
- Centre for Respiratory Medicine and Allergy, Manchester Academic Science Centre, The University of Manchester and University Hospital South Manchester NHS Foundation Trust, Manchester, UK.
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Rasmussen DGK, Sand JMB, Karsdal MA, Genovese F. Development of a Novel Enzyme-Linked Immunosorbent Assay Targeting a Neo-Epitope Generated by Cathepsin-Mediated Turnover of Type III Collagen and Its Application in Chronic Obstructive Pulmonary Disease. PLoS One 2017; 12:e0170023. [PMID: 28076408 PMCID: PMC5226775 DOI: 10.1371/journal.pone.0170023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/25/2016] [Indexed: 11/29/2022] Open
Abstract
A high level of extracellular matrix (ECM) turnover characterizes several lung diseases with fibrotic features. Type III collagen is one of the most abundant collagens in lung parenchyma, and cathepsins play a role in lung pathology, being responsible for tissue remodeling. In this study, we explore the diagnostic features of neo-epitope fragments of type III collagen generated by cathepsins that could reflect the pathological tissue turnover in patients with different diseases. A novel enzyme-linked immunosorbent assay (ELISA) measuring cathepsins B, L, S and K -generated type III collagen fragments (C3C) was developed for assessment in serum and plasma. The assay was biologically validated in serum from patients with chronic obstructive pulmonary disease (COPD). Serological levels of C3C were significantly elevated in patients with COPD compared to healthy controls (p = 0.0006). Levels of C3C in serum and heparin plasma of COPD patients had a highly significant correlation (R2 = 0.86, p<0.0001). The data suggests that the C3C fragment is elevated in patients with COPD compared to healthy controls.
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Affiliation(s)
- Daniel Guldager Kring Rasmussen
- Nordic Bioscience, Biomarkers and Research, Herlev, Denmark
- University of Southern Denmark, Institute of Molecular Medicine, Cardiovascular and Renal Research, Institute of Clinical Research, Odense, Denmark
- * E-mail:
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Hernández-Morera P, Castaño-González I, Travieso-González CM, Mompeó-Corredera B, Ortega-Santana F. Quantification and Statistical Analysis Methods for Vessel Wall Components from Stained Images with Masson's Trichrome. PLoS One 2016; 11:e0146954. [PMID: 26761643 PMCID: PMC4711946 DOI: 10.1371/journal.pone.0146954] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/22/2015] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To develop a digital image processing method to quantify structural components (smooth muscle fibers and extracellular matrix) in the vessel wall stained with Masson's trichrome, and a statistical method suitable for small sample sizes to analyze the results previously obtained. METHODS The quantification method comprises two stages. The pre-processing stage improves tissue image appearance and the vessel wall area is delimited. In the feature extraction stage, the vessel wall components are segmented by grouping pixels with a similar color. The area of each component is calculated by normalizing the number of pixels of each group by the vessel wall area. Statistical analyses are implemented by permutation tests, based on resampling without replacement from the set of the observed data to obtain a sampling distribution of an estimator. The implementation can be parallelized on a multicore machine to reduce execution time. RESULTS The methods have been tested on 48 vessel wall samples of the internal saphenous vein stained with Masson's trichrome. The results show that the segmented areas are consistent with the perception of a team of doctors and demonstrate good correlation between the expert judgments and the measured parameters for evaluating vessel wall changes. CONCLUSION The proposed methodology offers a powerful tool to quantify some components of the vessel wall. It is more objective, sensitive and accurate than the biochemical and qualitative methods traditionally used. The permutation tests are suitable statistical techniques to analyze the numerical measurements obtained when the underlying assumptions of the other statistical techniques are not met.
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Affiliation(s)
- Pablo Hernández-Morera
- IUMA Information and Communication Systems, University of Las Palmas de Gran Canaria, Campus Universitario de Tafira, Las Palmas de Gran Canaria, Spain
- Department of Telematic Engineering, University of Las Palmas de Gran Canaria, Campus Universitario de Tafira, Las Palmas de Gran Canaria, Spain
- * E-mail:
| | - Irene Castaño-González
- Department of Dermatology, Doctor Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Carlos M. Travieso-González
- Institute for Technological Development and Innovation in Communications (IDeTIC), University of Las Palmas de Gran Canaria, Campus Universitario de Tafira, Las Palmas de Gran Canaria, Spain
| | - Blanca Mompeó-Corredera
- Department of Morphology, University of Las Palmas de Gran Canaria, Campus de San Cristobal, Las Palmas de Gran Canaria, Spain
| | - Francisco Ortega-Santana
- Department of Morphology, University of Las Palmas de Gran Canaria, Campus de San Cristobal, Las Palmas de Gran Canaria, Spain
- CliniVar, Clínica de Varices, Las Palmas de Gran Canaria, Spain
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Dunphy SE, Bratt JA, Akram KM, Forsyth NR, El Haj AJ. Hydrogels for lung tissue engineering: Biomechanical properties of thin collagen–elastin constructs. J Mech Behav Biomed Mater 2014; 38:251-9. [DOI: 10.1016/j.jmbbm.2014.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 12/13/2022]
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Leeming DJ, Sand JM, Nielsen MJ, Genovese F, Martinez FJ, Hogaboam CM, Han MK, Klickstein LB, Karsdal MA. Serological investigation of the collagen degradation profile of patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis. Biomark Insights 2012; 7:119-26. [PMID: 23012495 PMCID: PMC3448496 DOI: 10.4137/bmi.s9415] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In both chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF), abnormally high collagen remodeling occurs within the lung tissue. Matrix metalloproteinase (MMP)-degraded type I, III, IV, V and VI collagen and a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-degraded type III collagen were assessed in serum of patients diagnosed with mild COPD (n = 10) or IPF (n = 30), and healthy controls (n = 15). The collagen degradation markers C1M, C3M, C5M and C6M were significantly elevated in serum of both mild COPD and IPF patients, versus controls. C3A and C4M were only elevated in patients with mild COPD, compared with controls. The most reliable indicators of mild COPD versus controls were: C1M (area under the receiver-operating characteristics (AUROC = 0.94, P < 0.0001), C3M (AUROC = 0.95, P < 0.0001), and C5M (AUROC = 0.95, P < 0.0001). The most reliable markers for the diagnosis of IPF were achieved by C1M (AUROC = 0.90, P < 0.0001) and C3M (AUROC = 0.93, P < 0.0001). Collagen degradation was highly up-regulated in patients with IPF and mild COPD, indicating that degradation fragments of collagens are potential markers of pulmonary diseases. Interestingly, C4M and C3A were only elevated in patients with mild COPD, indicating that these markers could be used to distinguish between the two pathologies.
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Furness MC, Bienzle D, Caswell JL, Delay J, Viel L. Immunohistochemical identification of collagen in the equine lung. Vet Pathol 2010; 47:982-90. [PMID: 20571145 DOI: 10.1177/0300985810375051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recurrent airway obstruction (RAO) in the horse is a disease characterized by reversible bronchoconstriction and by mucus and neutrophil accumulation in the airways. It has been hypothesized that in horses with RAO, remodeling changes occur that are similar to those described in humans with asthma. Although collagen fibrils are present surrounding normal airways, they are a prominent feature of airway remodeling in human asthma with evidence of enhanced collagen III and I fibril deposition. An immunolabeling method was developed to identify collagen I and III in equine lung and to describe the collagen fiber type and distribution within the walls of the noncartilagenous bronchioles. The health status of 14 horses was characterized by clinical respiratory exam, bronchoalveolar lavage cytology, and pulmonary function tests. Following postmortem examination and histological assessment, horses were divided into RAO-affected (n = 4) and nonaffected (n = 10) groups. Eight sections per horse from all lung regions were evaluated histologically. Results of the study showed that collagens I and III were present in the lamina propria and adventitial area of the noncartilaginous bronchioles. There was clear staining differentiation between collagen I or III, airway smooth muscle, and the airway epithelium. Collagen I and III were present in the lamina propria and adventitial areas of the noncartilaginous bronchioles of horses, and there was no significant difference in the relative amount of collagen I and III between this group of RAO-affected and nonaffected horses.
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Affiliation(s)
- M C Furness
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada, N1G 2W1
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11
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Bobadilla JL, Jankowska-Gan E, Xu Q, Haynes LD, Munoz del Rio A, Meyer K, Greenspan DS, De Oliveira N, Burlingham WJ, Maloney JD. Reflux-induced collagen type v sensitization: potential mediator of bronchiolitis obliterans syndrome. Chest 2010; 138:363-70. [PMID: 20418369 DOI: 10.1378/chest.09-2610] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Lung transplantation continues to have poor long-term survival partly because of the high incidence of bronchiolitis obliterans syndrome (BOS). Gastroesophageal reflux disease (GERD) has been implicated in BOS pathogenesis. We investigated the role of collagen type V [col(V)] sensitization in this process. METHODS Only primary lung transplant recipients were included. Reflux status was assessed with pH monitoring, impedance plethysmography, and esophagogastroduodenoscopy. Sensitivity to col(V) was determined with trans vivo delayed-type hypersensitivity reaction (DTH). Kaplan-Meier analyses were performed. RESULTS Of the 54 recipients, 26 had proven GERD. There were no significant between-group differences in diagnosis; donor and recipient age; sex; ischemic time; single vs bilateral; human leukocyte antigen A, B, and DR matching cytomegalovirus status; acute rejections; or mean follow-up period. The mean DTH response in the GERD group was 25.7 x 10(-4) inches vs 18.3 x 10(-4) inches in the non-GERD group (P = .023). There was a significant reduction in BOS-free survival in the GERD group for both BOS-I (GERD+, 28.3%; GERD-, 86.6%; P = .0001) and BOS-II/III (GERD+, 66.2%; GERD-, 91.7%; P = .0374). A second cohort of 53 patients awaiting lung transplantation also was assayed. The mean DTH response in the GERD group was 24.0 x 10(-4) inches vs 13.1 x 10(-4) inches in the non-GERD group (P = .003). There were no differences in age or sex. CONCLUSIONS GERD is strongly associated with the development of BOS after primary lung transplantation. Col(V) sensitization is associated with reflux and BOS and may play an intermediary role in the pathogenesis of BOS. Trials using col(V) reactivity to assess the impact of antireflux procedures in patients with lung transplantation and idiopathic pulmonary fibrosis are warranted.
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Affiliation(s)
- Joseph L Bobadilla
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin-Madison, Madison, WI 53792, USA.
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12
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Muñoz-Pinto D, Whittaker P, Hahn MS. Lamina propria cellularity and collagen composition: an integrated assessment of structure in humans. Ann Otol Rhinol Laryngol 2009; 118:299-306. [PMID: 19462852 DOI: 10.1177/000348940911800411] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES In this study, we quantitatively examined cell density, collagen types I and III, and regional variations in collagen fiber thickness and orientation in the human midmembranous vocal fold lamina propria (LP). METHODS Lamina propria samples were solubilized with proteinase K or with cyanogen bromide. Cell density was assessed in proteinase K digests by measuring DNA and normalizing it to tissue total protein. Collagen types I and III were quantified by enzyme-linked immunosorbent assay-based detection of collagen type-specific peptides generated by cyanogen bromide digestion. In addition, LP total collagen was determined by measuring sample hydroxyproline levels. Variations in collagen fiber thickness and orientation with LP region were evaluated by examining picrosirius red-stained LP sections with circularly polarized light. RESULTS The mean (+/-SEM) cell density in the LP and associated epithelium was approximately 0.57 +/- 0.09 million cells per milligram of tissue total protein. Collagen type III composed an average of 34% to 40% of LP total collagen. Quantitative histology indicated that the superficial LP contained an average of 70% thin, 26% intermediate, and 4% thick collagen fibers. This is in contrast to the intermediate and deep LPs, each of which contained less than 25% thin and more than 50% thick collagen fibers. The angular deviations in collagen fiber orientation were relatively large and were similar in magnitude across all LP layers. CONCLUSIONS The total cell density of the LP and associated epithelium was intermediate between that of hyaline cartilage and dermis. The ratio of collagen type III to total collagen in the LP was similar to that of highly elastic lung parenchyma and roughly twice that of the comparatively less-elastic dermis. The average thickness of collagen fibers increased markedly with increasing LP depth, and the relatively large angular deviations in fiber orientation appeared to correspond in part to the crimped nature of LP collagen fibers.
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Affiliation(s)
- Dany Muñoz-Pinto
- Department of Chemical Engineering, Texas A&M University, College Station, Texas 77843-3122, USA
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Huang HJ, Yusen RD, Meyers BF, Walter MJ, Mohanakumar T, Patterson GA, Trulock EP, Hachem RR. Late primary graft dysfunction after lung transplantation and bronchiolitis obliterans syndrome. Am J Transplant 2008; 8:2454-62. [PMID: 18785961 PMCID: PMC2678949 DOI: 10.1111/j.1600-6143.2008.02389.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) is a common early complication after lung transplantation. We conducted a retrospective cohort study of 334 recipients to evaluate the impact of PGD graded at 24, 48 and 72 h on the risk of bronchiolitis obliterans syndrome (BOS) development (stage 1) and progression (stages 2 and 3). We constructed multivariable Cox proportional hazards models to determine the risk of BOS attributable to PGD in the context of other potential risk factors including acute rejection, lymphocytic bronchitis and respiratory viral infections. All grades of PGD at all time points were significant risk factors for BOS development and progression independent of acute rejection, lymphocytic bronchitis and respiratory viral infections. Specifically, PGD grade 1 at T24 was associated with a relative risk of BOS stage 1 of 1.93, grade 2 with a relative risk of 2.29 and grade 3 with a relative risk of 3.31. Furthermore, this direct relationship between the severity of PGD and the risk of BOS persisted at all time points. We conclude that all grades of PGD at all time points are independent risk factors for BOS development and progression. Future strategies that might attenuate the severity of PGD may mitigate the risk of BOS.
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Affiliation(s)
- H. J. Huang
- Division of Pulmonary and Critical Care Medicine Washington University School of Medicine
| | - R. D. Yusen
- Division of Pulmonary and Critical Care Medicine Washington University School of Medicine
| | - B. F. Meyers
- Division of Cardiothoracic Surgery Washington University School of Medicine
| | - M. J. Walter
- Division of Pulmonary and Critical Care Medicine Washington University School of Medicine
| | - T. Mohanakumar
- Department of Surgery Washington University School of Medicine
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Department of Pathology and Immunology Washington University School of Medicine
| | - G. A. Patterson
- Division of Cardiothoracic Surgery Washington University School of Medicine
| | - E. P. Trulock
- Division of Pulmonary and Critical Care Medicine Washington University School of Medicine
| | - R. R. Hachem
- Division of Pulmonary and Critical Care Medicine Washington University School of Medicine
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Jerold A. Last Richard Gould Kathar. LUNG COLLAGEN TYPES ARE ALTERED IN RATS CHRONICALLY EXPOSED TO OZONE. Inhal Toxicol 2008. [DOI: 10.1080/089583798197565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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15
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Bobadilla JL, Love RB, Jankowska-Gan E, Xu Q, Haynes LD, Braun RK, Hayney MS, Munoz del Rio A, Meyer K, Greenspan DS, Torrealba J, Heidler KM, Cummings OW, Iwata T, Brand D, Presson R, Burlingham WJ, Wilkes DS. Th-17, monokines, collagen type V, and primary graft dysfunction in lung transplantation. Am J Respir Crit Care Med 2008; 177:660-8. [PMID: 18174545 DOI: 10.1164/rccm.200612-1901oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The pathogenesis of primary graft dysfunction (PGD), a serious complication of lung transplantation, is poorly understood. Human studies and rodent models have shown that collagen type V (col[V]), stimulates IL-17-dependent cellular immunity after lung transplantation. OBJECTIVES To determine whether patients with end-stage lung disease develop pretransplant col(V)-specific cellular immunity, and if so, the impact of this response on PGD. METHODS Trans-vivo delayed-type hypersensitivity (TV-DTH) assays were used to evaluate memory T-cell responses to col(V) in 55 patients awaiting lung transplantation. Pa(O(2))/Fi(O(2)) index data were used to assess PGD. Univariate risk factor analysis was performed to identify variables associated with PGD. Rats immunized with col(V) or irrelevant antigen underwent lung isografting to determine if prior anti-col(V) immunity triggers PGD in the absence of alloreactivity. MEASUREMENTS AND MAIN RESULTS We found that 58.8% (10/17) of patients with idiopathic pulmonary fibrosis, and 15.8% (6/38) of patients without idiopathic pulmonary fibrosis tested while on the wait list for a lung transplant were col(V) DTH positive. Col(V) reactivity was CD4(+) T-cell and monocyte mediated, and dependent on IL-17, IL-1beta, and tumor necrosis factor (TNF)-alpha. Pa(O(2))/Fi(O(2)) indices were impaired significantly 6-72 hours after transplantation in col(V)-reactive versus nonreactive patients. Univariate risk factor analysis identified only preoperative TV-DTH to col(V) and ischemic time as predictors of PGD. Finally, in a rat lung isograft model, col(V) sensitization resulted in significantly lower Pa(O(2))/Fi(O(2)), increased local TNF-alpha and IL-1beta production, and a moderate-to-severe bronchiolitis/vasculitis when compared with control isografts. CONCLUSIONS The data suggest that activation of innate immunity by col(V)-specific Th-17 memory cells represents a novel pathway to PGD after lung transplantation.
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Affiliation(s)
- Joseph L Bobadilla
- Microbiology and Immunology, Director, Center for Immunobiology, Indiana University School of Medicine, Van Nuys Medical Sciences Building MS224, 635 Barnhill Drive, Indianapolis, IN 46202-5120, USA
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16
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Richter M, Ray SJ, Chapman TJ, Austin SJ, Rebhahn J, Mosmann TR, Gardner H, Kotelianski V, deFougerolles AR, Topham DJ. Collagen distribution and expression of collagen-binding alpha1beta1 (VLA-1) and alpha2beta1 (VLA-2) integrins on CD4 and CD8 T cells during influenza infection. THE JOURNAL OF IMMUNOLOGY 2007; 178:4506-16. [PMID: 17372009 DOI: 10.4049/jimmunol.178.7.4506] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Most viral infections occur in extralymphoid tissues, yet the mechanisms that regulate lymphocytes in these environments are poorly understood. One feature common to many extralymphoid environments is an abundance of extracellular matrix. We have studied the expression of two members of the beta(1) integrin family of collagen-binding receptors, alpha(1)beta(1) and alpha(2)beta(1) (CD49a, VLA-1 and CD49b, VLA-2, respectively), on CD4 and CD8 T cells during the response to influenza infection in the lung. Flow cytometry showed that whereas T cells infiltrating the lung and airways can express both CD49a and CD49b, CD49a expression was most strongly associated with the CD8+ subset. Conversely, though fewer CD4+ T cells expressed CD49a, most CD4+ cells in the lung tissue or airways expressed CD49b. This reciprocal pattern suggested that CD4 and CD8 T cells might localize differently within the lung tissue and this was supported by immunofluorescent analysis. CD8+ cells tended to localize in close proximity to the collagen IV-rich basement membranes of either the airways or blood vessels, whereas CD4+ cells tended to localize in the collagen I-rich interstitial spaces, with few in the airways. These observations suggest that CD4 T cell interaction with the tissue microenvironment is distinct from CD8 T cells and support the concept that CD4+ T cells in peripheral tissues are regulated differently than the CD8 subset.
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Affiliation(s)
- Martin Richter
- Department of Microbiology and Immunology, David H. Smith Center for Vaccine Biology and Immunology, Aab Institute of Biomedical Sciences, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA
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17
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Bharat A, Fields RC, Trulock EP, Patterson GA, Mohanakumar T. Induction of IL-10 suppressors in lung transplant patients by CD4+25+ regulatory T cells through CTLA-4 signaling. THE JOURNAL OF IMMUNOLOGY 2007; 177:5631-8. [PMID: 17015751 DOI: 10.4049/jimmunol.177.8.5631] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
T cell-mediated autoimmunity to collagen V (col-V), a sequestered yet immunogenic self-protein, can induce chronic lung allograft rejection in rodent models. In this study we characterized the role of CD4+ CD25+ regulatory T cells (Tregs) in regulating col-V autoimmunity in human lung transplant (LT) recipients. LT recipients revealed a high frequency of col-V-reactive, IL-10-producing CD4+ T cells (T IL-10 cells) with low IL-2-, IFN-gamma-, IL-5-, and no IL-4-producing T cells. These T(IL-10) cells were distinct from Tregs because they lacked constitutive expression of both CD25 and Foxp3. Expansion of T IL-10 cells during col-V stimulation in vitro involved CTLA-4 on Tregs, because both depleting and blocking Tregs with anti-CTLA4 F(ab')2 mAbs resulted in loss of T IL-10 cells with a concomitant increase in IFN-gamma producing Th1 cells (TIFN-gamma cells). A Transwell culture of col-V-specific T IL-10 cells with Th1 cells (those generated in absence of Tregs) from the same patient resulted in marked inhibition of IFN-gamma and proliferation of T(IFN-gamma) cells, which was reversed by neutralizing IL-10. Furthermore, the T IL-10 cells were HLA class II restricted because blocking HLA class II on APCs resulted in the loss of IL-10 production. Chronic lung allograft rejection was associated with the loss of Tregs with a concomitant decrease in T IL-10 cells and an increase in T IFN-gamma cells. We conclude that LT patients have col-V-specific T cells that can be detected in the peripheral blood. The predominant col-V-specific T cells produce IL-10 that suppresses autoreactive Th1 cells independently of direct cellular contact. Tregs are pivotal for the induction of these "suppressor" T IL-10 cells.
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Affiliation(s)
- Ankit Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis. MO 63110, USA
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18
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Bharat A, Fields RC, Steward N, Trulock EP, Patterson GA, Mohanakumar T. CD4+25+ regulatory T cells limit Th1-autoimmunity by inducing IL-10 producing T cells following human lung transplantation. Am J Transplant 2006; 6:1799-808. [PMID: 16889540 DOI: 10.1111/j.1600-6143.2006.01383.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chronic human lung allograft rejection is manifested by bronchiolitis obliterans syndrome (BOS). BOS has a multifactorial etiology. Previous studies have indicated that both cellular and humoral alloimmunity play a significant role in the pathogenesis of BOS. Recently, autoimmunity has also been demonstrated to contribute to lung allograft rejection in animal models. However, the significance of autoimmunity in BOS remains unknown. In this report, we investigated the role of naturally occurring CD4(+)CD25(+) regulatory T cells (T-regs) in modulating cellular autoimmunity to collagen type V (col-V), a 'sequestered' yet immunogenic self-protein present in the lung tissue, following lung transplantation (LT). We demonstrated that col-V reactive CD4(+) T cells could be detected in the peripheral blood of lung transplant recipients. There was a predominance of IL-10 producing T cells (T(IL-10)) reactive to col-V with significantly lower levels of IFN-gamma and IL-2 producing T cells (Th1 cells). The col-V specific T(IL-10) cells suppressed the proliferation and expansion of col-V specific Th1 cells by IL-10-dependent and contact-independent pathways. The T(IL-10) cells were distinct but their development was dependent on the presence of T-regs. Furthermore, during chronic lung allograft rejection there was a significant decline of T(IL-10) cells with concomitant expansion of col-V-specific IFN-gammaproducing Th1 cells.
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Affiliation(s)
- A Bharat
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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19
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Enríquez-Verdugo I, Guerrero AL, Serrano JJ, Godínez D, Rosales JL, Tenorio V, de la Garza M. Adherence of Actinobacillus pleuropneumoniae to swine-lung collagen. MICROBIOLOGY-SGM 2004; 150:2391-2400. [PMID: 15256580 DOI: 10.1099/mic.0.27053-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Actinobacillus pleuropneumoniae serotype 1 adhered to immobilized swine-lung collagen. Bacteria bound to collagen type I, III, IV and V. At 5 min incubation, 30 % of bacteria adhered to collagen, reaching saturation in around 90 min. Treatment of bacteria with divalent-metal chelators diminished their attachment to collagen, and Ca(2+) but not Mg(2+) increased it, suggesting Ca(2+) dependence for adherence. Proteolytic enzymes drastically reduced bacterial adherence to collagen, showing that binding involved bacterial surface proteins. Porcine fibrinogen, haemoglobin and gelatin partially reduced collagen adhesion. A 60 kDa outer-membrane protein of A. pleuropneumoniae recognized the swine collagens by overlay. This membrane protein was apparently involved in adhesion to collagen and fibrinogen, but not to fibronectin and laminin. Antibodies against the 60 kDa protein inhibited the adhesion to collagen by 70 %, whereas pig convalescent-phase antibodies inhibited it by only 40 %. Serotypes 1 and 7 were the most adherent to pig collagen (taken as 100 %); serotypes 6 and 11 were the lowest (approximately 50 %), and neither showed the 60 kDa adhesin to biotinylated collagens. By negative staining, cells were observed initially to associate with collagen fibres in a polar manner, and the adhesin was detected on the bacterial surface. The results suggest that swine-lung collagen is an important target for A. pleuropneumoniae colonization and spreading, and that the attachment to this protein could play a relevant role in pathogenesis.
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Affiliation(s)
- Idalia Enríquez-Verdugo
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ap. 14-740, México, DF 07000, Mexico
| | - Alma L Guerrero
- Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Blvd Universidad 940, Aguascalientes, Ags 20100, Mexico
| | - J Jesús Serrano
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ap. 14-740, México, DF 07000, Mexico
| | - Delfino Godínez
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ap. 14-740, México, DF 07000, Mexico
| | - J Luis Rosales
- Departamento de Patología Experimental, Centro de Investigación y de Estudios Avanzados del IPN, Ap. 14-740, México, DF 07000, Mexico
| | - Víctor Tenorio
- CENID-Microbiología, INIFAP, Carretera a Toluca Km 15.5, México, DF, Mexico
| | - Mireya de la Garza
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ap. 14-740, México, DF 07000, Mexico
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20
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Sumpter TL, Wilkes DS. Role of autoimmunity in organ allograft rejection: a focus on immunity to type V collagen in the pathogenesis of lung transplant rejection. Am J Physiol Lung Cell Mol Physiol 2004; 286:L1129-39. [PMID: 15136293 DOI: 10.1152/ajplung.00330.2003] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lung transplantation is the only definitive treatment modality for many forms of end-stage lung disease. However, the lung is rejected more often than any other type of solid organ allograft due to chronic rejection known as bronchiolitis obliterans (BO). Indeed, BO is the primary reason why the 5- and 7-yr survival rates are worse for the lung than for any other transplanted organ. Alloimmunity to donor antigens is established as the primary mechanism that mediates rejection responses. However, newer immunosuppressive regimens designed to abrogate alloimmune activation have not improved survival. Therefore, these data suggest that other antigens, unrelated to donor transplantation antigens, are involved in rejection. Utilizing human and rodent studies of lung transplantation, our laboratory has documented that a native collagen, type V collagen [col(V)], is a target of the rejection response. Col(V) is highly conserved; therefore, these data indicate that transplant rejection involves both alloimmune and autoimmune responses. The role of col(V) in lung transplant rejection is described in this review article. In addition, the potential role of regulatory T cells that are crucial to modulating autoimmunity and alloimmunity is also discussed.
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Affiliation(s)
- Tina L Sumpter
- Department of Medicine, Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medicine Center, 1481 W. 10th St. 111P, Indianapolis, IN 46202, USA
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21
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Ray SJ, Franki SN, Pierce RH, Dimitrova S, Koteliansky V, Sprague AG, Doherty PC, de Fougerolles AR, Topham DJ. The collagen binding alpha1beta1 integrin VLA-1 regulates CD8 T cell-mediated immune protection against heterologous influenza infection. Immunity 2004; 20:167-79. [PMID: 14975239 DOI: 10.1016/s1074-7613(04)00021-4] [Citation(s) in RCA: 262] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Accepted: 01/01/2004] [Indexed: 11/22/2022]
Abstract
A common feature of many infections is that many pathogen-specific memory T cells become established in diverse nonlymphoid tissues. A mechanism that promotes the retention and survival of the memory T cells in diverse tissues has not been described. Our studies show that the collagen binding alpha1beta1 integrin, VLA-1, is expressed by the majority of influenza-specific CD8 T cells recovered from nonlymphoid tissues during both the acute and memory phases of the response. Antibody treatment or genetic deficiency of VLA-1 decreased virus-specific CTL in the lung and other nonlymphoid tissues, and increased them in the spleen. In spite of the increase in the spleen, secondary heterosubtypic immunity against flu was compromised. This suggests that VLA-1 is responsible for retaining protective memory CD8 T cells in the lung and other tissues via attachment to the extracellular matrix.
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Affiliation(s)
- Steven J Ray
- Department of Microbiology and Immunology, David H. Smith Center for Vaccine Biology and Immunology, Aab Institute of Biomedical Sciences, University of Rochester, Rochester, NY 14642, USA
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