Is COPD an Autoimmune Disease ?Is COPD an Autoimmune Disease ?

Professor Bill MacNeeProfessor Bill MacNeeE.L.E.G.I. / Colt Laboratories E.L.E.G.I. / Colt Laboratories

MRC Centre for Inflammation ResearchMRC Centre for Inflammation ResearchUniversity of EdinburghUniversity of Edinburgh

and the Royal Infirmary of Edinburghand the Royal Infirmary of EdinburghScotland, UKScotland, UK

ELEGI

Is COPD an Autoimmune Disease ?

• Persistent inflammation in the absence of smoking

• What evidence is needed to prove an autoimmune aetiology in a disease ? • Evidence of an autoimmune inflammatory response in COPD ?

• Implications for treatment

The pathogenesis of Chronic Obstructive Pulmonary Disease (COPD) is not well understood.

Established facts are:

Tobacco smoking is the main risk factor for the development of COPD, but only a percentage of smokers (so-called susceptible smokers) develop the disease2.

Tobacco smoking elicits an inflammatory response in the lungs of all smokers, but this is enhanced and fails to resolve after quitting smoking in those who develop COPD3-6.

This clearly indicates that the regulation of the inflammatory response is abnormal in COPD.

What is not known is (are) the mechanism(s) underlying this abnormal regulation

Important for the development of future treatment strategies

1..Celli B, MacNee W et al ER.J 2004; 23:932; 2.Hogg et al N EJ M 2004; 350:2645. 3.Retamales et al 2001. AJRCCM 2004;164:469. 4. Willemse et al. ERJ 2005; 26:835. 6. Rutgers et al. Thorax 2000;55:12.

Standards for the diagnosis and treatment of patients with COPD : a summary of the ATS/ERS

position paper

Definition

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.

The inflammatory responses in COPD D

Hogg et al. N Engl J Med 2004;24:2645

Innate Immune Response Acquired Immune Response

ABNORMAL REGULATION OF INFLAMMATION IN COPD

Innate immunity Acquired Immunity

Enhanced Response Impaired resolution

Not discussed in this presentation

ABNORMAL REGULATION OF INFLAMMATION IN COPD

Innate immunity Acquired Immunity

Epigenetic mechanisms

Enhanced Response Impaired resolution

Enhanced Oxidative Stress

The nature of small-airway obstruction in COPD

Hogg et al. N Engl J Med 2004;24:2645

These studies suggest a response to an antigen

Innate Immune Response Acquired Immune Response

ABNORMAL REGULATION OF INFLAMMATION IN COPD

Innate immunity Acquired Immunity

Epigenetic mechanisms

Self-antigen(autoimmunity)

Non-self antigen(bacteria, virus, particles)

Enhanced Response Impaired resolution

Enhanced oxidative Stress

Pathogenesis of COPD Pathogenesis of COPD

• Does infection of the lower respiratory tract result in and enhanced adaptive immune response ? Hogg et al NEJM 2004;24:2645

• Is there an Autoimmune component which enhances airspace inflammation in COPD ? Agusti, MacNee, Donaldson and Cosio Thorax 2003 , Barnes and Cosio PLoS Med 2004

LATENT ADENOVIRUS INFECTIONLATENT ADENOVIRUS INFECTION IN THE IN THE PATHOGENISIS OF COPDPATHOGENISIS OF COPD

In situ hybridisation for adenovirus EIA

Adenovirus probe Control probe

COPD lung

No COPD COPDEIA PCR+ Ave density ratio 0.480.17 1.49 0.94* * p<0.002

Matuse et al ARRD 1992;146:177

E1A Interaction with co-activators enhances binding and activity of transcription factors

AP-1

Increased transcription

E1A

NF-B

CBP/p300

CREB

Inflammation

Sethi et al AJRCCM 2006;173:991

Bacterial colonisation of the airways is associated withNeutrophilic inflammation in ex smoking COPD patients

Is COPD an Autoimmune Disease ?

• Persistent inflammation in the absence of smoking

• What evidence is needed to prove an autoimmune aetiology in a disease ? • Evidence of an autoimmune inflammatory response in COPD ?

• Implications for treatment

Evidence of autoimmunity in clinical diseaseWitebsky’s Postulates

Direct proofTransfer of disease by Autoantibody Experimental Maternal To animalsIndirect proofTransfer of disease by cells to SCID miceInduction of disease in animals by autoantigenIdentification with lesions of: AB / T-cellsTransfer of disease by lymphocytes in experimental modelsGenetic modelsAuto-antibodies or self-reactive T cells

Circumstantial evidence from clinical clues

Increased susceptibility to pulmonary emphysema among HIV-seropositive smokers

Diaz et al. Ann Intern Med 2000;132:369

Age 34 yrs, 16 pack yrs, HIV +ve Age 30yrs, 9 pack yrs,HIV +ve

Kanazawa, H. et al. Chest 2003;123:596-599

The rate of annual decline in FEV1 and DLCO during the 5-year follow-up period in COPD patients with or without Hepatitis C virus – response to INF

Cosio, M. G. et al. Chest 2002;121:160-165S

Inflammatory cell profile in the lungs of nonsmokers (NS), smokers without anatomic emphysema (SNE), and smokers with emphysema (SE)

Cosio, M. G. et al. Chest 2002;121:160-165S

Correlation between emphysema (expressed as the density of alveolar walls [Vv1 ALV]) and the numbers of neutrophils (PMN), T lymphocytes, and alveolar

macrophages per mm3 in the alveolar walls of 6 nonsmokers and 15 smokers

Barcelo et al ERJ 2008

Phenotypic characterisation of T-lymphocytes in COPD:Abnormal CD4+CD25+ regulatory T-lymphocytes in response to tobacco smoke

CD4+CD25+ are increased in BAL In smokers but not in COPD

CD4+CD25+ cells are identified as (bright) regulatory T-lymphocytes

• Regulatory T-lymphocytes have important anti-inflammatory and immunmodulatory effects

Barcelo et al ERJ 2008

Phenotypic characterisation of T-lymphocytes in COPD:Abnormal CD4+CD25+ regulatory T-lymphocytes in response to tobacco smoke

Suggestive of :• a final maturation–activation state of CD8+ T-lymphocytes in COPD• a blunted regulatory T-cell response to tobacco smoking in COPD• supports a potential involvement of acaquired immune system in COPD

Smyth, L. J. C. et al. Chest 2007;132:156-163

T-regulatory cell expression of activation and memory markersIn BAL in COPD

An animal model of autoimmune emphysema

Taraseviciene-Stewart et al. AJRCCM 2005;171:734

Levels of antibodies in serum in rats immunised with human umbilical vein EC (HUVEC) or human pulmonary artery smooth muscle cells (HPASMC)

Rat lungs develop emphysema following IP injection of HUVECs (d), but not HPASCs (e)

Control

HPASC

HUVEC

An animal model of autoimmune emphysema

Taraseviciene-Stewart et al. AJRCCM 2005;171:734

Adoptive transfer of CD4+ lymphocytes from HUVEC–immunised rats develop airspace enlargement

0

2000

500

1000

1500

2500

Control CD4

*

Pix

els

/mm

2

Control CD4

Oligoclonal CD4+ T cells in the lungs of patients with severe emphysema

(C) A density plot of CD4 versus CD8 expression on CD3+ T cells from a representative subject with emphysema after in vitro culture in the presence of IL-2 is shown.

Sullivan et al AJRCCM 2005;172:590

Blasting of lung T cells from subjects with emphysema and normalsubjects after 2 weeks in culture with interleukin (IL) 2.

(A) Light microscopy of lung tissue

(B) Forward- versus side-scatter density plots are shown for representative emphysema (left panel) and control (right panel) lung tissue culture. Blasting lymphocytes are found within the upper gate with the resting lymphocytes in the lower gate.

Seung-Hyo Lee Nature Medicine 2007

Anti-elastin autoimmunity ( peripheral blood T and B cell responses to elastin peptides )in emphysema

Autoantibodies in COPD

Feghali-Bostwick et al AJRCCM 2007;177:156

Anti epithelial antibodies in patients with COPD

IgG deposition in lung explants

COPD Normal control

COPD Normal isotype antibody

Autoantibodies in COPD

Feghali-Bostwick et al AJRCCM 2007;177:156

Compliment (C3)deposition COPD Normal subject

Incubation of airway epithelial cells with COPD plasma enhances allogeneic cytotoxicity

Auto antibodies associated with clinical COPD phenotype

Autoimmune diseasesTherapeutic approachesAlteration of thresholds of immune activation Blockade of costimulatory factors Antagonism of inflammatory cytokines or protective cytokines Inhibition of signaling cascades by small molecules

Modulation of antigen-specific cells Induction of regulatory cells (intravenous, subcutaneous, or oral delivery of antigen) Alteration of peptide ligands Formation of complexes of peptide and major-histocompatibility-complex molecules Development of T-cell receptor vaccines Induction of B-cell tolerance Immune deviation from type I to type 2 helper T cells

Reconstitution of the immune system Bone marrow ablation with autologous stem cells Bone marrow ablation with donor stem cells Bone marrow ablation without stem cells

Sparing of target organs Antagonism of complement Antagonism of chemokines Use of antiinflammatory agents Inhibition of matrix metalloproteases Inhibition of nitric oxide synthase

Davidson et al. N Engl J Med 2001;345;5:340

Evidence of autoimmunity in clinical diseaseWitebsky’s Postulates

Direct proofTransfer of disease by Autoantibody Experimental Maternal To animalsIndirect proofTransfer of disease by cells to SCID miceInduction of disease in animals by autoantigenIdentification with lesions of: AB / T-cellsTransfer of disease by lymphocytes in experimental modelsGenetic modelsAuto-antibodies or self-reactive T cells

Circumstantial evidence from clinical clues

Conclusions

• There is good direct and indirect evidence of autoimmunity as a pathogenic mechanism in COPD

• Proof of concept therapeutic trials are necessary to support test this hypothesis

Seung-Hyo Lee Nature Medicine 2007

Anti-elastin autoimmunity ( peripheral blood T and B cell responses to elastin peptides )in emphysema

EFFECT OF SMOKING AND COPD ON CYTOPLASMIC HDAC2 LEVELS IN LUNG TISSUE

Compared with non-smokers, * P<0.05 ** p<0.01

Compared with healthy smokers, # P<0.05

*

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

non-smokers(n=8)

0 (n=16) I (n=9) II (n=2)

GOLD Categories

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Szulakowski et al AJRCCM 2006;171:41

*

**#

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0.3

0.4

0.5

0.6

0.7

0.8

0.9

non-smokers(n=8)

healthysmokers

(n=11)

currentsmoker COPD

(n=10)

ex-smokerCOPD (n=6)

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InflammationHAT

HDAC

Histone acetylation

Gene transcription

HDAC2 expression and activity following cigarette smoke exposure in vitro (alveolar epithelial cells) and in vivo (rat lungs)

Marwick J et al AJRCCM 2004;31:633-642

Post-translational modification of

proteins by oxidants in cigarette smoke

→ targets of proteolytic degradation → resulting in decreased

HDAC2 expression inflammation

120

40

80

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HD

AC

2 ac

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ty (

% c

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Control CSC GEA 4HNE Acrolein Treatment

*** ****** ***

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MIP-1 alpha MIP-2 3 days smoke exposure

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4HNE Nitration Acrolein Modification

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Smoke exposed rats

Smoke exposed alveolar epithelial cells