Paul Szabo

18-Month study of intravenous immunoglobulin for treatment of mild Alzheimer disease.

Intravenous immunoglobulin (IVIg) has been proposed as a potential agent for Alzheimers disease (AD) immunotherapy because it contains antibodies against beta-amyloid (Abeta). We carried out an open label dose-ranging study in 8 mild AD patients in which IVIg was added to approved AD therapies for 6 months, discontinued, and then resumed for another 9 months. Infusions were generally well-tolerated. Anti-Abeta antibodies in the serum from AD patients increased in proportion to IVIg dose and had a shorter half-life than anti-hepatitis antibodies and total IgG. Plasma Abeta levels increased transiently after each infusion. Cerebrospinal fluid Abeta decreased significantly at 6 months, returned to baseline after washout and decreased again after IVIg was re-administered for an additional 9 months. Mini-mental state scores increased an average of 2.5 points after 6 months, returned to baseline during washout and remained stable during subsequent IVIg treatment. Our findings confirm and extend those obtained by Dodel et al. [Dodel, R.C., Du, Y., Depboylu, C., Hampel, H., Frolich, L., Haag, A., Hemmeter, U., Paulsen, S., Teipel, S.J., Brettschneider, S., Spottke, A., Nolker, C., Moller, H.J., Wei, X., Farlow, M., Sommer, N., Oertel, W.H., 2004. Intravenous immunoglobulins containing antibodies against beta-amyloid for the treatment of Alzheimers disease. J. Neurol. Neurosurg. Psychiatry 75, 1472-1474] from a 6-month trial of IVIg in 5 AD patients and justify further studies of IVIg for treatment of AD.

Patients with Alzheimer disease have lower levels of serum anti-amyloid peptide antibodies than healthy elderly individuals.

Active immunization with the human amyloid peptide (Abeta42) or passive immunization with anti-Abeta42 antibodies protects mice that express a mutant human amyloid precursor protein (APP) transgene from cerebral amyloid deposits. If anti-Abeta42 antibodies protect APP-transgenic mice, a model of Alzheimers disease (AD), a high titer of anti-Abeta42 antibodies may protect humans from AD. The titer of anti-Abeta42 antibodies in serum from individuals with and without late onset AD was measured using an ELISA. The titer of Ig (IgM, IgG and IgA) and IgG anti-Abeta42 peptide antibodies was significantly higher in serum from elderly controls than AD patients. Furthermore, IgG but not Ig anti-Abeta42 antibodies distinguished sera from AD patients and elderly controls that did not have the apolipoprotein E4 allele. The low titer of anti-Abeta42 antibodies in AD patients does not reflect the well-established, age-associated defect in the antibody response to most protein antigens, as there was no positive correlation between the serum titer of anti-Abeta42 antibodies and anti-influenza hemagglutinin antibodies induced by influenza vaccine in elderly humans. The lower titer of serum anti-Abeta42 peptide antibodies in AD patients may reflect the reported specific impairment of helper T cell activity for B cells that produce anti-amyloid-beta42 peptide antibodies in APP-transgenic mice.

The Effect of Age on the B-Cell Repertoire

The antibody repertoire changes with age. This change reflects, in part, the age-associated impairment in the production of a diverse population of naive B cells in the bone marrow and, in part, by the decreased diversification of B cells in the germinal center where affinity maturation and isotype switching takes place. B cell number is strictly regulated and despite the decreased output of B cells by the bone marrow does not decline during aging. Self-renewal of peripheral B cells is sufficient to assure the stability of peripheral B cell number. However, when B cell production is stressed as, for example, following drug-induced lymphopenia, the rate of recovery of B cell number as well as of B cell diversity is compromised in old compared to young mice. Finally, aging is associated with the appearance of B cell clonal expansions which not only limit the diversity of the B cell repertoire but very likely give rise to monoclonal serum immunoglobulins and B cell neoplasms.

Effect of age on humoral immunity, selection of the B-cell repertoire and B-cell development

Summary: The age‐associated changes in humoral Immunity affect the quality more than the quality of the antibody response. Changes in the quality of the antibody response with age include shifts in antibody specificities from foreign to autoantigens. in antibody isotypes from IgG to IgM, in antibody affinities from HIGH to low and in the antibody idiotypic repertoire. These changes can be traced to an impaired capacity of T cells to facilitate: (a) the maturation of B cells respect to isotype and affinity maturation in the periphery and (b) the development of a diverse B‐cell repertoire from precursors within the bone marrow. In contrast, there is no evidence that the amount of immunoglobulin produced before or after immunization diminishes with age. Nonetheless, the impaired responses of the elderly to most vaccines and the greater susceptibility of the elderly to infections has fostered a view that immune senescence leads to a state of immune deficiency. However, it is more precise to describe immune senescence as leading to a state of immune dysregulation. The dysregulation of the humoral immunity is manifested by a shift from adaptive humoral Immunity, characterized by the production of a highly specific, high‐affinity, IgG antibody response to foreign antigens, to a process of natural antibody‐mediated immunity, dominated by low‐affinity, polyreactive, IgM antibodies which react with autoantigens, Age‐associated T‐cell impairments appear to be the basis for the shift from adaptive to natural humoral immunity and their reversal should permit the restoration of an adaptive antibody response in the elderly.

Regulation of cyclooxygenase-2 expression in aortic smooth muscle cells.

Activation of the gene for inducible cyclooxygenase (cyclooxygenase-2 [Cox-2], prostaglandin endoperoxide synthase) is an early response to injury in vascular smooth muscle cells. We used in vitro and in vivo models to demonstrate that activation of quiescent smooth muscle cells by mitogens leads to a rapid, short-term rise in mRNA for Cox-2, followed by synthesis of new Cox-2 enzyme protein and a marked increase in prostaglandin production that depends on new enzyme synthesis. Moreover, the Cox-2 mRNA response observed in smooth muscle cells differs in both time and degree, depending on the particular mitogenic stimulus. Serum, platelet-derived growth factor, epidermal growth factor, and thrombin are strong inducers of Cox-2 mRNA, whereas acidic and basic fibroblast growth factors and interleukin-1 alpha are weak inducers. In contrast to the transient activation of Cox-2 in vitro after introduction of a mitogenic stimulus, the Cox-2 response after in vivo vascular injury extends over many days and may represent protracted cellular activation. During induction of Cox-2 message and protein, expression of constitutive cyclooxygenase (Cox-1) remains unchanged, however. These data suggest a pathophysiological role for Cox-2 in the early modulation of vascular responses to injury.

Natural human antibodies to amyloid beta peptide

Properties of human, natural anti-Abeta antibodies and commercially available intravenous immunoglobulin (IVIg) have been examined in light of the beneficial effects of passive immunotherapy with IVIg for patients with mild to moderate Alzheimers disease (AD). Anti-Abeta antibodies in IVIg recognize conformation-specific epitopes as well as linear epitopes from different regions of the Abeta peptide. Anti-Abeta antibodies in circulation, especially those with high avidity, are often masked by ligands and the avidity of these antibodies increases upon dissociation of the bound ligands from the antibodies. Such natural anti-Abeta antibodies have the capacity to prevent Abeta oligomer-induced neurotoxicity in N2A neuroblastoma cells. This neuro-protective effect may reflect the therapeutic potential of the natural anti-Abeta antibodies found in IVIg for the treatment of patients with AD.

Autoantibody-catalyzed Hydrolysis of Amyloid β Peptide

We describe IgM class human autoantibodies that hydrolyze amyloid β peptide 1–40 (Aβ40). A monoclonal IgM from a patient with Waldenströms macroglobulinemia hydrolyzed Aβ40 at the Lys-28—Gly-29 bond and Lys-16—Ala-17 bonds. The catalytic activity was inhibited stoichiometrically by an electrophilic serine protease inhibitor. Treatment with the catalytic IgM blocked the aggregation and toxicity of Aβ40 in neuronal cell cultures. IgMs purified from the sera of patients with Alzheimer disease (AD) hydrolyzed Aβ40 at rates superior to IgMs from age-matched humans without dementia. IgMs from non-elderly humans expressed the least catalytic activity. The reaction rate was sufficient to afford appreciable degradation at physiological Aβ and IgM concentrations found in peripheral circulation. Increased Aβ concentrations in the AD brain are thought to induce neurodegenerative effects. Peripheral administration of Aβ binding antibodies has been suggested as a potential treatment of AD. Our results suggest that catalytic IgM autoantibodies can help clear Aβ, and they open the possibility of using catalytic Abs for AD immunotherapy.

IL-1, IL-6, and PDGF mRNA expression in alveolar cells following stimulation with a tobacco-derived antigen.

To test the hypothesis that inflammatory cytokine production might be an early event in the development of the disease associated with smoking, we used alveolar cells from healthy nonsmokers stimulated with TGP as a model system. TGP, a phenol-rich glycoprotein which is present in tobacco leaves and cigarette smoke condensate, activates the immune system. It stimulates polyclonal B cell differentiation, induces primarily an IgE response, and activates human leukocytes to produce IL-1. Using in situ nucleic acid hybridization we show that the steady-state levels of IL-1 alpha, IL-1 beta, IL-6, platelet-derived growth factor (PDGF)-A, and PDGF-B mRNAs are consistently elevated in the alveolar cells of all donors following TGP stimulation. The kinetics of mRNA expression suggest that IL-1 alpha and IL-1 beta mRNAs are independently regulated in alveolar cells, while the regulation of PDGF-A and PDGF-B mRNA seems to be similar. The activated cells also synthesize elevated levels of IL-1 and IL-6. These findings lend support to the suggestion that some clinical consequences of smoking might be initiated and enhanced by the production of inflammatory cytokines. Moreover, IL-6 could also activate a polyclonal B cell response, which could lead to the synthesis of autoantibodies and thus cause immune-mediated tissue injury.

The immune system, amyloid-beta peptide, and Alzheimer's disease.

Summary:  In this review, the case is made that amyloid‐β peptide in the brain of patients with Alzheimers disease is a primary cause of the disease and that immunotherapy directed against this peptide has the potential to halt and/or reverse disease progression. This supposition is supported by the capacity of anti‐β‐amyloid peptide antibodies to prevent or reverse the disease in mouse models of Alzheimers disease. Furthermore, preliminary results obtained in a small number of patients with Alzheimers disease are consistent with the observations made in the mouse model of this disease. We review the relationship between the immune system, amyloid‐β peptide, and Alzheimers disease and the progress made in applying immunotherapy to patients with Alzheimers disease.

Human plasma semicarbazide sensitive amine oxidase (SSAO), β-amyloid protein and aging

Semicarbazide sensitive amine oxidase (SSAO) metabolizes oxidative deamination of primary aromatic and aliphatic amines. The final products of its catalysis, ammonia, hydrogen peroxide (H2O2) and the corresponding aldehyde, may contribute to diseases involving vascular degeneration. SSAO is selectively expressed in blood vessels in the brain, but is also present in blood plasma. We have previously reported that membrane-bound SSAO is overexpressed in the cerebrovascular tissue of Alzheimers disease (AD) patients. The aim of the present work is to study whether the circulating SSAO is also altered in this neurodegenerative disease. SSAO activity was determined in plasma of control cases (n = 23) and patients suffering sporadic Alzheimer dementia, distributed according to the Global Deterioration Scale (GDS): mild (n = 33), moderate (n = 14), moderate-severe (n = 15) and severe dementia (n = 19). Results show a clear increase of plasma SSAO activity (p < 0.001) in moderate-severe and severe AD patients, with patient age being an independent correlative factor. However, plasma SSAO activity was not altered in AD patients with mild or moderate dementia compared to controls. beta-Amyloid (Abeta) (40-42) immunoreactivity in plasma samples was also determined, and no correlation was observed between Abeta 40-42 levels and the severity of the dementia or the plasma SSAO activity. Our results suggest that an increase in circulating SSAO activity could contribute to oxidative stress and vascular damage in advanced Alzheimers disease.