James D. Gorham

Diagnosis and management of autoimmune hepatitis

Clinical practice guidelines are defined as ‘‘systematically developed statements to assist practitioner and patient decisions about appropriate heath care for specific clinical circumstances.’’ (All references are available in the Supporting Information.) These guidelines on autoimmune hepatitis provide a data-supported approach to the diagnosis and management of this disease. They are based on the following: (1) formal review and analysis of the recently-published world literature on the topic [Medline search]; (2) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines; (3) guideline policies, including the AASLD Policy on the Development and Use of Practice Guidelines and the American Gastroenterological Association Policy Statement on Guidelines; and (4) the experience of the authors in the specified topic. These recommendations, intended for use by physicians, suggest preferred approaches to the diagnostic, therapeutic and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting the recommendations, the Practice Guidelines Committee of the AASLD requires a class (reflecting benefit versus risk) and level (assessing strength or certainty) of evidence to be assigned and reported with each recommendation. The grading system applied to the recommendations has been adapted from the American College of Cardiology and the American Heart Association Practice Guidelines, and it is given below (Table 1).

Bone marrow stromal cells use TGF-β to suppress allergic responses in a mouse model of ragweed-induced asthma

Bone marrow stromal cells [BMSCs; also known as mesenchymal stem cells (MSCs)] effectively suppress inflammatory responses in acute graft-versus-host disease in humans and in a number of disease models in mice. Many of the studies concluded that BMSC-driven immunomodulation is mediated by the suppression of proinflammatory Th1 responses while rebalancing the Th1/Th2 ratio toward Th2. In this study, using a ragweed induced mouse asthma model, we studied if BMSCs could be beneficial in an allergic, Th2-dominant environment. When BMSCs were injected i.v. at the time of the antigen challenge, they protected the animals from the majority of asthma-specific pathological changes, including inhibition of eosinophil infiltration and excess mucus production in the lung, decreased levels of Th2 cytokines (IL-4, IL-5, and IL-13) in bronchial lavage, and lowered serum levels of Th2 immunoglobulins (IgG1 and IgE). To explore the mechanism of the effect we used BMSCs isolated from a variety of knockout mice, performed in vivo blocking of cytokines and studied the effect of asthmatic serum and bronchoalveolar lavage from ragweed challenged animals on the BMSCs in vitro. Our results suggest that IL-4 and/or IL-13 activate the STAT6 pathway in the BMSCs resulting in an increase of their TGF-β production, which seems to mediate the beneficial effect, either alone, or together with regulatory T cells, some of which might be recruited by the BMSCs. These data suggest that, in addition to focusing on graft-versus-host disease and autoimmune diseases, allergic conditions—specifically therapy resistant asthma—might also be a likely target of the recently discovered cellular therapy approach using BMSCs.

TGF-β1 Uses Distinct Mechanisms to Inhibit IFN-γ Expression in CD4+ T Cells at Priming and at Recall: Differential Involvement of Stat4 and T-bet

TGF-β1 plays a critical role in restraining pathogenic Th1 autoimmune responses in vivo, but the mechanisms that mediate TGF-β1’s suppressive effects on CD4+ T cell expression of IFN-γ expression remain incompletely understood. To evaluate mechanisms by which TGF-β1 inhibits IFN-γ expression in CD4+ T cells, we primed naive wild-type murine BALB/c CD4+ T cells in vitro under Th1 development conditions in the presence or the absence of added TGF-β1. We found that the presence of TGF-β1 during priming of CD4+ T cells suppressed both IFN-γ expression during priming as well as the development of Th1 effector cells expressing IFN-γ at a recall stimulation. TGF-β1 inhibited the development of IFN-γ-expressing cells in a dose-dependent fashion and in the absence of APC, indicating that TGF-β1 can inhibit Th1 development by acting directly on the CD4+ T cell. During priming, TGF-β1 strongly inhibited the expression of both T-bet (T box expressed in T cells) and Stat4. We evaluated the importance of these two molecules in the suppression of IFN-γ expression at the two phases of Th1 responses. Enforced expression of T-bet by retrovirus prevented TGF-β1’s inhibition of Th1 development, but did not prevent TGF-β1’s inhibition of IFN-γ expression at priming. Conversely, enforced expression of Stat4 partly prevented TGF-β1’s inhibition of IFN-γ expression during priming, but did not prevent TGF-β1’s inhibition of Th1 development. These data show that TGF-β1 uses distinct mechanisms to inhibit IFN-γ expression in CD4+ T cells at priming and at recall.

MDSC in autoimmunity

Myeloid derived suppressor cells (MDSC) were first described nearly two decades ago. Until recently, however, descriptions of MDSC populations were found almost exclusively in animal models of cancer or in cancer patients. Over the last few years, an increasing number of reports have been published describing populations of myeloid cells with MDSC-like properties in murine models of autoimmune disease. In contrast to the proposed deleterious role of MDSC in cancer--where these cells likely inhibit tumor immunity--in the context of autoimmunity, MDSC have the potential to suppress the autoimmune response, thereby limiting tissue injury. A logical corollary of this hypothesis is that a failure of endogenous MDSC to appropriately control autoimmune T cell responses in vivo may actually contribute to the pathogenesis of autoimmune disease.

Genetic regulation of autoimmune disease: BALB/c background TGF-beta 1-deficient mice develop necroinflammatory IFN-gamma-dependent hepatitis.

Autoimmune hepatitis (AIH) in humans arises spontaneously in genetically susceptible individuals and is associated with the presence of Th1 cells in the liver. The understanding of AIH has advanced more slowly than that of other organ-specific autoimmune diseases, however, largely because of the lack of an appropriate animal model. We now describe a new mouse model characterized by spontaneous development of necroinflammatory hepatitis that is restricted by genetic background. Mice deficient in the immunomodulatory cytokine TGF-β1 were extensively back-bred to the BALB/c background. The BALB/c background dramatically modified the phenotype of TGF-β1−/− mice: specifically, BALB/c-TGF-β1−/− mice developed a lethal necroinflammatory hepatitis that was not observed in TGF-β1−/− mice on a different genetic background. BALB/c background TGF-β1−/− livers contained large numbers of activated CD4+ T cells that produced large quantities of IFN-γ, but little IL-4, identifying them as Th1 cells. BALB/c background TGF-β1−/−/IFN-γ−/− double knockout mice, generated by cross-breeding, did not develop necroinflammatory hepatitis, demonstrating that IFN-γ is mechanistically required for its pathogenesis. This represents the first murine model of hepatitis that develops spontaneously, is restricted by genetic background, and is dependent upon the Th1 cytokine IFN-γ, and that thus recapitulates these important aspects of AIH.

Enhanced efficacy and reduced toxicity of multifactorial adjuvants compared with unitary adjuvants as cancer vaccines

Identification of Toll-like receptors (TLRs) and their ligands, and tumor necrosis factor-tumor necrosis factor receptor (TNF-TNFR) pairs have provided the first logical, hypothesis-based strategies to molecularly concoct adjuvants to elicit potent cell-mediated immunity via activation of innate and adaptive immunity. However, isolated activation of one immune pathway in the absence of others can be toxic, ineffective, and detrimental to long-term, protective immunity. Effective engineered vaccines must include agents that trigger multiple immunologic pathways. Here, we report that combinatorial use of CD40 and TLR agonists as a cancer vaccine, compared with monotherapy, elicits high frequencies of self-reactive CD8(+) T cells, potent tumor-specific CD8(+) memory, CD8(+) T cells that efficiently infiltrate the tumor-burdened target organ; therapeutic efficacy; heightened ratios of CD8(+) T cells to FoxP3(+) cells at the tumor site; and reduced hepatotoxicity. These findings provide intelligent strategies for the formulation of multifactorial vaccines to achieve maximal efficacy in cancer vaccine trials in humans.

TGF-β1 Inhibits T-bet Induction by IFN-γ in Murine CD4+ T Cells through the Protein Tyrosine Phosphatase Src Homology Region 2 Domain-Containing Phosphatase-1

TGF-β1 prevents the development of autoimmune disease by restraining the development of autoreactive Th1 cells. TGF-β1 inhibits Th1 development in part by suppressing the expression of T-bet, an IFN-γ-induced transcription factor that promotes Th1 differentiation, but how TGF-β1 suppresses T-bet is not known. In this study we show that TGF-β1 suppresses IFN-γ-induced T-bet expression through the hemopoietic protein tyrosine phosphatase (PTP) Src homology region 2 domain-containing phosphatase-1 (Shp-1). In murine CD4+ T cells, IFN-γ rapidly induced the expression of T-bet as well as of IFN regulatory factor-1, another transcription factor important for Th1 development. TGF-β1 antagonized the effects of IFN-γ, inhibiting IFN-γ’s induction of both Th1 transcription factors. In the presence of IFN-γ, TGF-β1 rapidly induced in Th cells the synthesis of the PTP Shp-1, but did not induce Shp-2 or several members of the suppressor of cytokine signaling family of Jak-Stat inhibitors. We tested the requirement for Shp-1 by using T cells from the Shp-1-deficient mev/mev mouse strain. Shp-1 was required for TGF-β1’s suppressive effects, because its suppression of T-bet and IFN regulatory factor-1 was completely abrogated in mev/mev CD4+ T cells. Receptor-proximal responses to IFN-γ, such as the induction of Jak-Stat phosphorylation, were inhibited by TGF-β1 in wild-type T cells, but not in mev/mev T cells. Consistent with a direct role for Shp-1, TGF-β1’s inhibition of IFN-γ-induced Stat1 phosphorylation was sensitive to the general PTP inhibitor pervanadate. Together, these data show that TGF-β1 suppresses IFN-γ signaling and transcriptional responses in CD4+ T cells through the PTP Shp-1.

Type 1 T Helper Cells Induce the Accumulation of Myeloid-Derived Suppressor Cells in the Inflamed Tgfb1 Knockout Mouse Liver†

Immune‐mediated liver injury in hepatitis is due to activated T cells producing interferon‐γ (IFN‐γ). It is important to identify negative feedback immune mechanisms that can regulate T cell activity. In this study, we demonstrate that liver inflammation mediated by type 1 T helper (Th1) cells can induce the accumulation of myeloid‐derived suppressor cells (MDSCs), pleiomorphic cells capable of modulating T cell–mediated immunity, that heretofore have been studied almost exclusively in the context of tumor‐associated inflammation. Mice deficient in the gene encoding transforming growth factor‐β1 (Tgfb1−/− mice) acutely develop liver necroinflammation caused by IFN‐γ–producing clusters of differentiation 4–positive (CD4+) T cells. Liver Th1 cell accumulation was accompanied by myeloid cells expressing CD11b and Gr1, phenotypic hallmarks of MDSCs. Isolated Tgfb1−/− liver CD11b+Gr1+ cells were functional MDSCs, readily suppressing T cell proliferation in vitro. Pharmacologic inhibitors of inducible nitric oxide (NO) synthase completely eliminated suppressor function. Suppressor function and the production of NO were dependent on cell–cell contact between MDSCs and T cells, and upon IFN‐γ, and were specifically associated with the “monocytic” CD11b+Ly6G− Ly6Chi subset of liver Tgfb1−/− CD11b+ cells. The rapid accumulation of CD11b+Gr1+ cells in Tgfb1−/− liver was abrogated when mice were either depleted of CD4+ T cells or rendered unable to produce IFN‐γ, showing that Th1 activity induces MDSC accumulation. Conclusion: Th1 liver inflammation mobilizes an MDSC response that, through the production of NO, can inhibit T cell proliferation. We propose that MDSCs serve an important negative feedback function in liver immune homeostasis, and that insufficient or inappropriate activity of this cell population may contribute to inflammatory liver pathology. (HEPATOLOGY 2010;)

The effects of additive solution pH and metabolic rejuvenation on anaerobic storage of red cells

BACKGROUND: Red cell (RBC) storage can be extended to 9 weeks under anaerobic or alkaline conditions. Simultaneous use of these approaches has not provided additive benefit. Our objective was to determine whether anaerobic storage with acidified additive solution (AS) coupled with metabolic rejuvenation might further improve the benefits of anaerobic storage.

CD28 co-stimulation regulates the effect of transforming growth factor-β1 on the proliferation of naı̈ve CD4+ T cells

Transforming growth factor-beta1 (TGF-beta1) is a critical regulator of T cell responses in vivo. In vitro, TGF-beta1 can either enhance or inhibit T cell proliferative responses, but the relevant factors that determine the T cell response to TGF-beta1 remain obscure. Here, we present evidence that CD28 co-stimulation modifies the effects of TGF-beta1 on T cell proliferation. In the absence of CD28 co-stimulation, TGF-beta1 potently suppressed TCR-stimulated proliferation of naïve T cells. In the presence of CD28 co-stimulation, TGF-beta1 potently inhibited T cell apoptosis and enhanced TCR-stimulated proliferation. A similar effect of CD28 co-stimulation was not observed in memory/effector cells, whose proliferation was enhanced by TGF-beta1, whether co-stimulated or not. We examined the mechanism by which CD28 modulates naïve T cell responses to TGF-beta1. Since CD28 co-stimulation classically is a potent enhancer of interleukin (IL)-2 production, we anticipated observing high IL-2 production from naïve T cells stimulated with anti-CD3/anti-CD28 and TGF-beta1. Surprisingly, however, TGF-beta1 strongly inhibited production of IL-2 from naïve CD4(+) T cells, even when CD28 was engaged. Even though IL-2 levels were strongly suppressed by TGF-beta1 to trace levels, antibody neutralization studies showed that IL-2 is still a basic requirement for the proliferation of anti-CD3/anti-CD28/TGF-beta1-stimulated naïve T cells. These data show that CD28s modulation of T cell responses to TGF-beta1 is not via the production of high levels of IL-2, and suggest that engagement of CD28 may activate additional downstream pathways that modulate the responses of naïve T cells to TGF-beta1.