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Quinn CT, Saraf SL, Gordeuk VR, Fitzhugh CD, Creary SE, Bodas P, George A, Raj AB, Nero AC, Terrell CE, McCord L, Lane A, Ackerman HC, Yang Y, Niss O, Taylor MD, Devarajan P, Malik P. Losartan for the nephropathy of sickle cell anemia: A phase-2, multicenter trial. Am J Hematol 2017; 92:E520-E528. [PMID: 28589652 DOI: 10.1002/ajh.24810] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 01/26/2023]
Abstract
Nephropathy is a common and progressive complication of sickle cell anemia (SCA). In SCA mice, we found that hyperangiotensinemia in the absence of hypertension underlies nephropathy, and its downregulation by losartan, an angiotensin-II-receptor-1 blocker, reduced albuminuria and progression of nephropathy. Therefore, we performed a phase-2 trial of oral losartan, given for 6 months, to explore whether it reduced albuminuria in children and adults with SCA. Participants were allocated to groups defined by class of baseline urinary albumin-to-creatinine ratio (UACR): no albuminuria (NoA), microalbuminuria (MicroA), and macroalbuminuria (MacroA). The primary endpoint was a ≥25% reduction UACR from baseline. There were 32 evaluable participants (mean age 24 years; NoA = 14, MicroA = 12, MacroA = 6). The primary endpoint was met in 83% of the MacroA group (P < 0.0001) and 58% of the MicroA group (P < 0.0001). Median fold-change in UACR was -0.74 for MacroA and -0.46 for MicroA. In MacroA and MicroA, UACR classification improved in 50% but worsened in 11%. Urine osmolality and estimated glomerular filtration rate (eGFR) did not change significantly. Losartan was discontinued in three participants [leg cramps, N = 1; decline in eGFR >25% (142➝104 mL/minute/1.73 m2 ), N = 1; rise in serum creatinine >50% (0.2➝0.3 mg/dL), N = 1]. Albuminuria was associated with diastolic dysfunction and impaired functional capacity, although cardiopulmonary status was unchanged after 6 months of losartan therapy. In summary, losartan decreased urinary albumin excretion in most participants with albuminuria. Those with macroalbuminuria had the greatest benefit. This study forms the basis for a phase-3, randomized, placebo-controlled trial of losartan for the nephropathy of SCA.
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Affiliation(s)
- Charles T. Quinn
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Santosh L. Saraf
- Hematology/Oncology, University of Illinois at Chicago; Chicago Illinois
| | - Victor R. Gordeuk
- Hematology/Oncology, University of Illinois at Chicago; Chicago Illinois
| | - Courtney D. Fitzhugh
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Susan E. Creary
- Hematology, Oncology & BMT, Nationwide Children's Hospital; Columbus Ohio
| | - Prasad Bodas
- Hematology and Oncology, Akron Children's Hospital; Akron Ohio
| | - Alex George
- Hematology Center, Texas Children's Hospital; Houston Texas
| | - Ashok B. Raj
- Pediatric Cancer & Blood Disorders, University of Louisville; Louisville Kentucky
| | - Alecia C. Nero
- Hematology-Oncology, UT Southwestern Medical Center; Dallas Texas
| | - Catherine E. Terrell
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Lisa McCord
- Clinical and Translational Research, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Adam Lane
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Hans C. Ackerman
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Yu Yang
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Omar Niss
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Michael D. Taylor
- Cardiology, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Prasad Devarajan
- Nephrology, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Punam Malik
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
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Tiwari S, Hontz A, Terrell CE, Arumugam P, Carmo M, Risma K, Jordan M, Malik P. High Level of Perforin Expression Is Required for Effective Correction of Hemophagocytic Lymphohistiocytosis. Hum Gene Ther 2016; 27:847-859. [PMID: 27471778 DOI: 10.1089/hum.2016.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Perforin-1 mutations result in a potentially fatal hemophagocytic lymphohistiocytosis (HLH) with heightened immune activation, hypercytokinemia, pancytopenia, and end-organ damage. At present, hematopoietic stem cell (HSC) transplantation is curative, but limited by donor availability and associated mortality, making gene therapy an attractive alternative approach for HLH. We reported that perforin expression driven by cellular promoters in lentiviral (LV) vectors resulted in significant, albeit partial, correction of the inflammatory features in a murine model of HLH. We hypothesized that the level of perforin expression achieved per cell from ectopic moderate-strength cellular promoters (phosphoglycerate kinase gene/perforin-1 gene) is inadequate and thus engineered an LV vector using a viral promoter (MND; a modified Moloney murine leukemia virus long terminal repeat with myeloproliferative sarcoma virus enhancer) containing microRNA126 target sequences to restrict perforin expression in HSCs. We show here that the MND-LV vector restored perforin expression to normal levels in a perforin-deficient human natural killer cell line and perforin gene-corrected Perforin1-/- transplant recipients, whereas cellular promoters drove only partial correction. On lymphocytic choriomeningitis virus challenge, the clinical scores and survival improved only with the MND-LV vector, but inflammatory markers and cytotoxicity were improved with all LV vectors. Our studies suggest that although moderate levels of expression can result in partial amelioration of the HLH phenotype, high levels of perforin expression per cell are required for complete correction of HLH.
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Affiliation(s)
- Swati Tiwari
- 1 Department of Molecular Genetics, Biochemistry, and Microbiology, University of Cincinnati , Cincinnati, Ohio.,2 Division of Experimental Hematology and Oncology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio
| | - Adrianne Hontz
- 3 Division of Allergy/Immunology, Department of Pediatrics, CCHMC , Cincinnati, Ohio
| | - Catherine E Terrell
- 2 Division of Experimental Hematology and Oncology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio
| | - Paritha Arumugam
- 2 Division of Experimental Hematology and Oncology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio
| | - Marlene Carmo
- 4 Infection, Immunity, Inflammation, and Physiological Medicine Programme, Molecular and Cellular Immunology Section, UCL Institute of Child Health , London, United Kingdom
| | - Kimberly Risma
- 3 Division of Allergy/Immunology, Department of Pediatrics, CCHMC , Cincinnati, Ohio
| | - Michael Jordan
- 5 Division of Immunobiology, CCHMC , Cincinnati, Ohio.,6 Department of Bone Marrow Transplantation and Immune Deficiency, CCHMC , Cincinnati, Ohio
| | - Punam Malik
- 2 Division of Experimental Hematology and Oncology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio
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McNally JP, Elfers EE, Terrell CE, Grunblatt E, Hildeman DA, Jordan MB, Katz JD. Eliminating encephalitogenic T cells without undermining protective immunity. J Immunol 2013; 192:73-83. [PMID: 24277699 DOI: 10.4049/jimmunol.1301891] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The current clinical approach for treating autoimmune diseases is to broadly blunt immune responses as a means of preventing autoimmune pathology. Among the major side effects of this strategy are depressed beneficial immunity and increased rates of infections and tumors. Using the experimental autoimmune encephalomyelitis model for human multiple sclerosis, we report a novel alternative approach for purging autoreactive T cells that spares beneficial immunity. The moderate and temporally limited use of etoposide, a topoisomerase inhibitor, to eliminate encephalitogenic T cells significantly reduces the onset and severity of experimental autoimmune encephalomyelitis, dampens cytokine production and overall pathology, while dramatically limiting the off-target effects on naive and memory adaptive immunity. Etoposide-treated mice show no or significantly ameliorated pathology with reduced antigenic spread, yet have normal T cell and T-dependent B cell responses to de novo antigenic challenges as well as unimpaired memory T cell responses to viral rechallenge. Thus, etoposide therapy can selectively ablate effector T cells and limit pathology in an animal model of autoimmunity while sparing protective immune responses. This strategy could lead to novel approaches for the treatment of autoimmune diseases with both enhanced efficacy and decreased treatment-associated morbidities.
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Affiliation(s)
- Jonathan P McNally
- Division of Immunobiology, Cincinnati Children's Research Foundation, Cincinnati, OH 45229
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Johnson TS, Terrell CE, Millen SH, Katz JD, Hildeman DA, Jordan MB. Etoposide selectively ablates activated T cells to control the immunoregulatory disorder hemophagocytic lymphohistiocytosis. J Immunol 2013; 192:84-91. [PMID: 24259502 DOI: 10.4049/jimmunol.1302282] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an inborn disorder of immune regulation caused by mutations affecting perforin-dependent cytotoxicity. Defects in this pathway impair negative feedback between cytotoxic lymphocytes and APCs, leading to prolonged and pathologic activation of T cells. Etoposide, a widely used chemotherapeutic drug that inhibits topoisomerase II, is the mainstay of treatment for HLH, although its therapeutic mechanism remains unknown. We used a murine model of HLH, involving lymphocytic choriomeningitis virus infection of perforin-deficient mice, to study the activity and mechanism of etoposide for treating HLH and found that it substantially alleviated all symptoms of murine HLH and allowed prolonged survival. This therapeutic effect was relatively unique among chemotherapeutic agents tested, suggesting distinctive effects on the immune response. We found that the therapeutic mechanism of etoposide in this model system involved potent deletion of activated T cells and efficient suppression of inflammatory cytokine production. This effect was remarkably selective; etoposide did not exert a direct anti-inflammatory effect on macrophages or dendritic cells, and it did not cause deletion of quiescent naive or memory T cells. Finally, etoposide's immunomodulatory effects were similar in wild-type and perforin-deficient animals. Thus, etoposide treats HLH by selectively eliminating pathologic, activated T cells and may have usefulness as a novel immune modulator in a broad array of immunopathologic disorders.
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Affiliation(s)
- Theodore S Johnson
- Cancer Immunology, Inflammation and Tolerance Program, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Georgia Regents University Cancer Center, Georgia Regents University, Augusta, GA 30912
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Zoller EE, Lykens JE, Terrell CE, Aliberti J, Filipovich AH, Henson PM, Jordan MB. Hemophagocytosis causes a consumptive anemia of inflammation. ACTA ACUST UNITED AC 2011; 208:1203-14. [PMID: 21624938 PMCID: PMC3173248 DOI: 10.1084/jem.20102538] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cytopenias of uncertain etiology are commonly observed in patients during severe inflammation. Hemophagocytosis, the histological appearance of blood-eating macrophages, is seen in the disorder hemophagocytic lymphohistiocytosis and other inflammatory contexts. Although it is hypothesized that these phenomena are linked, the mechanisms facilitating acute inflammation-associated cytopenias are unknown. We report that interferon γ (IFN-γ) is a critical driver of the acute anemia observed during diverse microbial infections in mice. Furthermore, systemic exposure to physiologically relevant levels of IFN-γ is sufficient to cause acute cytopenias and hemophagocytosis. Demonstrating the significance of hemophagocytosis, we found that IFN-γ acts directly on macrophages in vivo to alter endocytosis and provoke blood cell uptake, leading to severe anemia. These findings define a unique pathological process of broad clinical and immunological significance, which we term the consumptive anemia of inflammation.
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Affiliation(s)
- Erin E Zoller
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH 45229, USA
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Lykens JE, Terrell CE, Zoller EE, Divanovic S, Trompette A, Karp CL, Aliberti J, Flick MJ, Jordan MB. Mice with a selective impairment of IFN-gamma signaling in macrophage lineage cells demonstrate the critical role of IFN-gamma-activated macrophages for the control of protozoan parasitic infections in vivo. J Immunol 2010; 184:877-85. [PMID: 20018611 PMCID: PMC2886308 DOI: 10.4049/jimmunol.0902346] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
IFN-gamma has long been recognized as a cytokine with potent and varied effects in the immune response. Although its effects on specific cell types have been well studied in vitro, its in vivo effects are less clearly understood because of its diverse actions on many different cell types. Although control of multiple protozoan parasites is thought to depend critically on the direct action of IFN-gamma on macrophages, this premise has never been directly proven in vivo. To more directly examine the effects of IFN-gamma on cells of the macrophage lineage in vivo, we generated mice called the "macrophages insensitive to IFN-gamma" (MIIG) mice, which express a dominant negative mutant IFN-gamma receptor in CD68+ cells: monocytes, macrophages, dendritic cells, and mast cells. Macrophage lineage cells and mast cells from these mice are unable to respond to IFN-gamma, whereas other cells are able to produce and respond to this cytokine normally. When challenged in vitro, macrophages from MIIG mice were unable produce NO or kill Trypanosoma cruzi or Leishmania major after priming with IFN-gamma. Furthermore, MIIG mice demonstrated impaired parasite control and heightened mortality after T. cruzi, L. major, and Toxoplasma gondii infection, despite an appropriate IFN-gamma response. In contrast, MIIG mice displayed normal control of lymphocytic choriomeningitis virus, despite persistent insensitivity of macrophages to IFN-gamma. Thus, the MIIG mouse formally demonstrates for the first time in vivo, the specific importance of direct, IFN-gamma mediated activation of macrophages for controlling infection with multiple protozoan parasites.
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Affiliation(s)
- Jennifer E Lykens
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
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Varker KA, Terrell CE, Welt M, Suleiman S, Thornton L, Andersen BL, Carson WE. Impaired natural killer cell lysis in breast cancer patients with high levels of psychological stress is associated with altered expression of killer immunoglobin-like receptors. J Surg Res 2007; 139:36-44. [PMID: 17292412 PMCID: PMC1932802 DOI: 10.1016/j.jss.2006.08.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Revised: 08/29/2006] [Accepted: 08/30/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND We previously reported that cancer-related psychological stress is associated with reduced natural killer (NK) cell lysis. We hypothesized that reduced NK cell cytotoxicity in patients with increased levels of stress would correlate with alterations in the expression of inhibitory NK cell receptors (killer immunoglobulin-like receptors, or KIRs). The specific aim of this study was to examine KIR expression in patients with high or low levels of psychologic stress and correlate alterations in KIR expression with NK cell function. MATERIALS AND METHODS Two hundred twenty-seven patients underwent baseline evaluation of cancer-related psychological stress and were randomized to psychosocial intervention versus observation. From this population, two groups were defined based on pretreatment measurements of NK lytic activity, stress levels, and the availability of cryopreserved peripheral blood mononuclear cells (PBMC). Group I (n=9) had low stress by the Impact of Events Scale (IES), and high NK cell lysis at the 50:1 effector: target ratio (NK(50)=52-89%). Group II (n=8) had high stress and low NK(50) (27-52%). Lymphokine activated killer (LAK) activity, antibody dependent cellular cytotoxicity (ADCC), and expression of cytokine receptors, adhesion molecules, and killer immunoglobulin-like receptors (KIRs) were assessed in PBMC. RESULTS Incubation of PBMC with NK-stimulatory cytokines (IL-2, IL-12, or IL-15) led to significant increases in cytotoxic activity regardless of IES/NK(50) scores. There were no significant group differences in NK cell surface expression of the IL-2 receptor components CD25 and CD122, antibody-dependent lysis of HER2/neu-positive SKBr3 cells treated with an anti-HER2/neu monoclonal antibody, expression of adhesion molecules (CD2, CD11a, CD18) and markers of activation (CD69), or expression of the KIRs CD158a, NKG2a, NKB1, and CD161. However, levels of CD158b were significantly higher in Group I after incubation in media alone or with IL-2, and CD94 expression was significantly lower in Group I after incubation with IL-2. CONCLUSIONS In this study of a small subset of breast cancer patients chosen from a previous clinical trial of psychosocial intervention for breast cancer, impaired NK lysis in breast cancer patients with high levels of psychological stress was associated with alterations in surface expression of killer immunoglobulin-like receptors. However, immune effectors retained the ability to lyse antibody-coated targets and to initiate lymphokine-activated killer activity, irrespective of stress levels or baseline NK(50).
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Affiliation(s)
- Kimberly A. Varker
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
| | - Catherine E. Terrell
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
- Department of Psychology, The Ohio State University, Columbus, OH 43210
| | - Marilyn Welt
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
- Department of Psychology, The Ohio State University, Columbus, OH 43210
| | - Samer Suleiman
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
- Department of Psychology, The Ohio State University, Columbus, OH 43210
| | - Lisa Thornton
- Department of Psychology, The Ohio State University, Columbus, OH 43210
| | - Barbara L. Andersen
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
- Department of Psychology, The Ohio State University, Columbus, OH 43210
- Institute of Behavioral Medical Research, The Ohio State University, Columbus, OH 43210
| | - William E. Carson
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210
- College of Medicine, The Ohio State University, Columbus, OH 43210
- Department of Surgery, The Ohio State University, Columbus, OH 43210
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Bintzler DA, Terrell CE. 10-nmol oligonucleotide synthesis for the ABI model 394 DNA synthesizer. J Biomol Tech 2000; 11:122-134. [PMID: 19499048 PMCID: PMC2291632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Sequencing and gene contig assembly generally involve primer walking, in which an oligonucleotide primer is used once and then discarded. Because the smallest commonly available scale for commercial oligonucleotide synthesizers is the 40-nmol scale, a large excess of product is produced. This results in reagent waste, excess cost to the researcher, and increased production time. A logical solution would be to develop a smaller scale for the commercial synthesizers. A 10-nmol scale was developed for the Applied Biosystems ABI model 394 DNA synthesizer. To develop the 10-nmol scale, a column support was first developed from commonly available materials. Then a 10-nmol cycle was developed from the systematic reduction of the reagents. The final product of the 10-nmol cycle was tested for quality by monitoring the coupling efficiency, polyacrylamide gel electrophoresis, and automated DNA sequencing.The final cycle reduces the cost of the oligonucleotide and decreases the time required to produce it.
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Affiliation(s)
- D A Bintzler
- University of Cincinnati DNA Core Facility, Cincinnati, OH, USA.
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