Wolf-Dietrich Döcke

Mechanisms involved in the side effects of glucocorticoids

Glucocorticoids (GCs) represent the most important and frequently used class of anti-inflammatory drugs. While the therapeutic effects of GCs have been known and used for more than 50 years, major progress in discovering the underlying molecular mechanisms has only been made in the last 10-15 years. There is consensus that the desired anti-inflammatory effects of GCs are mainly mediated via repression of gene transcription. In contrast, the underlying molecular mechanisms for GC-mediated side effects are complex, distinct, and frequently only partly understood. Recent data suggest that certain side effects are predominantly mediated via transactivation (e.g., diabetes, glaucoma), whereas others are predominantly mediated via transrepression (e.g., suppression of the hypothalamic-pituitary-adrenal axis). For a considerable number of side effects, the precise molecular mode is either so far unknown or both transactivation and transrepression seem to be involved (e.g., osteoporosis). The differential molecular regulation of the major anti-inflammatory actions of GCs and their side effects is the basis for the current drug-finding programs aimed at the development of dissociated GC receptor (GR) ligands. These ligands preferentially induce transrepression by the GR, but only reduced or no transactivation. This review summarizes the current knowledge of the most important GC-mediated side effects from a clinical to a molecular perspective. The focus on the molecular aspects should be helpful in predicting the potential advantages of selective GR agonists in comparison to classical GCs.

IL-22 regulates the expression of genes responsible for antimicrobial defense, cellular differentiation, and mobility in keratinocytes : a potential role in psoriasis

IL‐22 is an IFN–IL‐10 cytokine family member, which is produced by activated Th1 and NK cells and acts primarily on epithelial cells. Here we demonstrate that IL‐22, in contrast to its relative IFN‐γ, regulates the expression of only a few genes in keratinocytes. This is due to varied signal transduction. Gene expressions regulated by IL‐22 should enhance antimicrobial defense [psoriasin (S100A7), calgranulin A (S100A8), calgranulin B (S100A9)], inhibit cellular differentiation (e.g., profilaggrin, keratins 1 and 10, kallikrein 7), and increase cellular mobility [e.g., matrix metalloproteinease 1 (MMP1, collagenase 1), MMP3 (stromelysin 1), desmocollin 1]. In contrast, IFN‐γ favored the expression of MHC pathway molecules, adhesion molecules, cytokines, chemokines, and their receptors. The IL‐22 effects were transcriptional and either independent of protein synthesis and secretion, or mediated by a secreted protein. Inflammatory conditions, but not keratinocyte differentiation, amplified the IL‐22 effects. IL‐22 application in mice enhanced cutaneous S100A9 and MMP1 expression. High IL‐22 levels in psoriatic skin were associated with strongly up‐regulated cutaneous S100A7, S100A8, S100A9, and MMP1 expression. Psoriatic patients showed strongly elevated IL‐22 plasma levels, which correlated with the disease severity. Expression of IL‐22 and IL‐22‐regulated genes was reduced by anti‐psoriatic therapy. In summary, despite similarities, IFN‐γ primarily amplifies inflammation, while IL‐22 may be important in the innate immunity and reorganization of epithelia.

Dissociation of transactivation from transrepression by a selective glucocorticoid receptor agonist leads to separation of therapeutic effects from side effects

Glucocorticoids (GCs) are the most commonly used antiinflammatory and immunosuppressive drugs. Their outstanding therapeutic effects, however, are often accompanied by severe and sometimes irreversible side effects. For this reason, one goal of research in the GC field is the development of new drugs, which show a reduced side-effect profile while maintaining the antiinflammatory and immunosuppressive properties of classical GCs. GCs affect gene expression by both transactivation and transrepression mechanisms. The antiinflammatory effects are mediated to a major extent via transrepression, while many side effects are due to transactivation. Our aim has been to identify ligands of the GC receptor (GR), which preferentially induce transrepression with little or no transactivating activity. Here we describe a nonsteroidal selective GR-agonist, ZK 216348, which shows a significant dissociation between transrepression and transactivation both in vitro and in vivo. In a murine model of skin inflammation, ZK 216348 showed antiinflammatory activity comparable to prednisolone for both systemic and topical application. A markedly superior side-effect profile was found with regard to increases in blood glucose, spleen involution, and, to a lesser extent, skin atrophy; however, adrenocorticotropic hormone suppression was similar for both compounds. Based on these findings, ZK 216348 should have a lower risk, e.g., for induction of diabetes mellitus. The selective GR agonists therefore represent a promising previously undescribed class of drug candidates with an improved therapeutic index compared to classical GCs. Moreover, they are useful tool compounds for further investigating the mechanisms of GR-mediated effects.

CYTOMEGALOVIRUS INFECTION IN TRANSPLANT RECIPIENTS : THE ROLE OF TUMOR NECROSIS FACTOR

Human cytomegalovirns (CMV) infection is an important cause of morbidity and mortality in transplant recipients. CMV infection commonly results from the reactivation of a latent infection. Using a set of monoclonal anti-CMV antibodies, we found CMV antigen expression in peripheral blood mononuclear cells (PBMNC), particularly in monocytes, in 312 of 816 samples from 190 allograft recipients. The detection of CMV-IE antigens and CMV-IE DNA in PBMNC indicates that positive cells may represent truly infected cells. The relation between increased cytokine plasma levels (particularly following treatment by pan-T cell antibodies) and the appearance of CMV antigens in PBMNC suggests that cytokines may play an important role in the reversal of CMV latency. This hypothesis is supported by our finding that tumor necrosis factor-alpha (TNF) is able to stimulate the activity of the CMV-IE enhancer/promoter region in the human monocytic cell line, HL-60. The interleukins 1,2,3,4,6,8 and 10; transforming growth factor-β: interferongamma; and granulocyte/macrophage colony-stimulating factor did not show any enhancing effect on the CMV promoter activity. Thus, TNF-alpha seems to play a key role in regulating the balance between latency and reactivation of CMV infection. Inhibition of TNF-alpha release or action may be an alternative strategy for preventing CMV-associated morbidity in allograft recipients.

Expression profiling of IL-10-regulated genes in human monocytes and peripheral blood mononuclear cells from psoriatic patients during IL-10 therapy.

Interleukin‐10 (IL‐10), originally identified as an inhibitor of pro‐inflammatory cytokine production, exerts multiple immunomodulatory functions. Its ability to inhibit a Th1 response has been used in clinical trials for the treatment of inflammatory diseases including psoriasis. However, little is known about the molecular mechanisms of IL‐10 functions. We aimed at identifying possiblemediators of in vitro IL‐10 treatment in monocytes by gene chip technology using Hu95a Affymetrix mRNA arrays with 12,000 genes. To prove relevance of the identified genes for the clinicalsituation we compared these in vitro results with genes being regulated by IL‐10 in peripheral blood mononuclear cells from psoriatic patients undergoing IL‐10 therapy. A high proportion of the 1,600 genes up‐regulated and 1,300 genes down‐regulated in vitro was found to be similarly regulated in vivo. Some genes, which were previously unknown to be regulated by IL‐10, can be assigned to known IL‐10 functions like e.g. the increase of pathogen clearance. Other new potentially immunomodulating genes have been identified to be regulated by IL‐10, but their impact needs to be experimentally evaluated. We could confirm a recently reported up‐regulation of heme oxygenase‐1 (HO‐1). However, we demonstrate that the anti‐inflammatory mechanisms of IL‐10 remain functional even when HO‐1 is irreversibly inhibited.

Late acute rejection in long-term renal allograft recipients. Diagnostic and predictive value of circulating activated T cells.

Episodes of acute rejection can occur in functional renal grafts even at a very late stage after transplantation. They are not necessarily due to patient non-compliance. The incidence of late acute rejection is commonly underestimated because the diagnosis generally requires histopathology in order to rule out other origins of declining graft function, even more so, as the typical signs of acute rejection as seen in the early posttransplantation period (sudden and rapid increase of creatinine serum level, inflammatory signs) are missing. Histology revealed acute rejection in 157 of 412 renal allograft recipients suffering from progressive graft deterioration between the 2nd and 18th year after Tx. Late acute rejection was clearly associated with elevated levels of activated HLA-DR+ T cells in the peripheral blood. These cells were characterized by flow cytometry to be postmitotic activated effector-T cells belonging to the CD4+ and CD8+ “memory” T cell pool. The high sensitivity (97%) and specificity (88%) of flow cytometric analysis allows for the discrimination between late acute rejection and other causes of deteriorating graft function (infection, toxicity, arteriopathy, chronic rejection). Additionally, this immune monitoring can predict the success of antirejection therapy as early as a few days after initiation of treatment while conventional parameters do not reflect the therapeutic result until 1–3 weeks later. In addition to this, peripheral T cell activation also seems to identify a subgroup of patients with chronic rejection who would respond, at least partially, to steroid bolus therapy. As a result, this parameter is very useful for the clinical management of patients suffering from late deterioration of renal graft function.

Immunological monitoring of the inflammatory process: which variables? when to assess?

Monitoring the immune responses in critically ill patients helps us to understand pathophysiological aspects of inflammation, immune deficiency, and infection, and to assess objective measures of therapeutic success. Monitoring should be adapted to the individual therapeutic approach. We recommend the measurement of substances in plasma that indicate systemic inflammatory processes, such as tumour necrosis factor (TNF), interleukin (IL)-6, and C-reactive protein (CRP), and invasive infection or endotoxaemia, such as procalcitonin (PCT). Moreover, it is important to evaluate the functional activity of the immune system, which can fail like other organs in the process of multiple organ failure. The resulting immunodeficiency results in failure to eliminate invading pathogens. Plasma concentration of IL-10 and of monocytic function and phenotype (HLA-DR+, CD14+ monocytes, ex vivo TNF secretion capacity) are the most valuable measurements for this purpose.

Human Cytomegalovirus Reactivation in Bone-Marrow-Derived Granulocyte/Monocyte Progenitor Cells and Mature Monocytes

Monocyte/granulocyte progenitor cells of the bone marrow are a major site of human cytomegalovirus (HCMV) latency. The mechanisms of establishment and maintenance of HCMV latency are still unknown. Reactivation of the latent virus in bone-marrow-derived progenitor cells has been demonstrated in vitro and suggested to occur also in vivo. Clinical studies have shown that reactivation is a rather frequent event not only in immunosuppressed but also in nonimmunosuppressed patients and in healthy blood donors. At least three independent mechanisms of virus reactivation are discussed: systemic inflammation connected with strong tumor necrosis factor alpha release; application of cAMP-elevating drugs, and highly stressful events associated with increased plasma catecholamine levels.

IL-10 protects monocytes and macrophages from complement-mediated lysis

Phagocytes, such as monocytes and macrophages, are important cells of the innate immunity in the defense against microbes. So far, it is unclear how these cells survive at the site of combat against microbes, where a hostile inflammatory environment prevails with strong complement activity. We hypothesized that IL‐10, a key cytokine involved in the resolution of inflammation, induces resistance to complement attack. Here, we demonstrate for the first time such a cell‐protective effect of IL‐10 on human monocytes and macrophages. IL‐10 is indeed able to protect these cell types in an in vitro model of complement lysis triggered by an anti‐MHCI antibody or by binding of zymosan. Investigating potential underlying mechanisms, we found that IL‐10 up‐regulated the expression of complement regulatory membrane protein CD59 and the general cell‐protective stress protein HO‐1 in human monocytes. However, further functional analysis failed to link these individual IL‐10‐mediated effects with the increased protection from complement lysis. Blocking the protective effect of CD59 with an antibody increased complement lysis but did not abrogate the IL‐10‐protective effect. Interestingly, chemical interference with HO‐1 activity did abrogate the protective effect of IL‐10, but siRNA‐mediated knockdown of HO‐1 did not confirm this observation. Our results suggest that IL‐10 generates pathogen‐clearing phagocytes, which are resistant to complement lysis and thereby, enabled to survive longer in a hostile inflammatory environment.

Reduced monocyte CD86 expression in postinflammatory immunodeficiency.

Objective:Major surgery, polytrauma, stroke, and pancreatitis frequently lead to a compensatory anti-inflammatory response syndrome that often predisposes patients to lethal infections. This temporary postinflammatory immunodeficiency is characterized by altered function of blood monocytes. These cells show strongly reduced inflammatory and antigen-presentation capacity. Diminished monocyte expression of the major histocompatibility complex class II molecule human leukocyte antigen (HLA)-DR is a well-established diagnostic marker of this immunodeficiency. To further characterize the monocytic cells in this clinical state, we analyzed their expression of CD86, the most important co-stimulatory molecule. Design:Analysis of blood samples that entered the clinical immunologic diagnostics and of cells from an in vitro model of postinflammatory immunodeficiency. Setting:University laboratory. Subjects:Healthy donors and intensive care unit (ICU) patients at the university hospital. Interventions:None. Measurements and Main Results:The expression of HLA-DR on monocytes and of CD86 and CD80 on monocytes and B cells was analyzed by flow cytometry. Messenger RNA expression of CD86 was analyzed in isolated monocytes by real-time polymerase chain reaction on reverse transcribed. The normal range of monocyte CD86 expression in healthy subjects was established to be from 2128 to 5102 surface molecules per cell and was independent of age, gender, and leukocyte and monocyte count. The CD86 expression on monocytes in ICU patients correlated with HLA-DR expression. Approximately 40% of the ICU patients with long-term reduced monocyte HLA-DR expression had a long-term reduction of CD86 expression. Patients in whom the expression of both molecules was diminished had an unfavorable prognosis. The diminished number of CD86 surface molecules on monocytes was associated with reduced CD86 messenger RNA levels in these cells. The expression of CD86 in B cells was not diminished in immunodeficient patients. The expression of CD80 in both monocytes and B-cells was minimal in healthy donors and not clearly changed in patients. Conclusions:The monocyte CD86 expression may be a helpful diagnostic variable in ICU patients.