Autoimmunity
and
Diabetes
Ola Winqvist
Type 1 Diabetes Mellitus
Ola Winqvist
2016-10-03
2
Diabetes Type 1 (IDDM)
§
§
§
§
§
Ola Winqvist
5 – 10 % of all diabetes
500 children and young adults/year in Sweden
Interplay between genes and environment determines the risk of
developing disease
Life long Insulin dependency
Long term side effects if poor regiments will lead to injure vessels
and may result in blindness, kidney disease
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Langerhans Islet
a cell Glucagon
b cell Insulin
d cell Somatostatin
PP cell Pancreas polypeptide
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IDDM
§ Monogenic:
Single gene defect.
APS-I: AIRE autosomal recessive
IPEX: Scurfy Gene X-linked, Lack of regulatory T cells
§ Polygenic:
Summation of small effects of
multiple genes creating diabetes
susceptibility (e.g. NOD mouse)
§ Oligogenic:
MHC+few major genes
Genetic heterogeneity with
different major non-MHC genes
for different families (e.g. BB rat)
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Requirements for the development
of an autoimmune disease
Nature Immunology (9): 759-761 (2001)
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Causes of Autoimmune disease
§ Genetical predisposition
§ HLA
§ Molecular mimicry
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Inherited Susceptibility Loci IDDM
LOCUS
IDDM1
IDDM2
IDDM3
IDDM4
IDDM5
IDDM6
IDDM7
IDDM8
IDDM9
IDDM10
IDDM11
IDDM12
IDDM13
IDDM14
IDDM15
IDDM16
IDDM17
OTHERS
X
X
X
X
X
X
CHROMOSOME
CANDIDATE GENES or MICROSATELLITES
6p21
HLA-DQ\DR
11p15
INS VNTR
15q26
D15s107
11q13
MDU1, ZFM1, RT6, FADD/MORT1, LRP5
6q24-27
ESR, MnSOD
18q12-q21
D18s487, D18s64, JK (Kidd locus)
2q31
D2s152, IL-1, NEUROD, GALNT3
6q25-27
D6s264, D6s446, D6s281
3q21-25
D3s1303
10p11-q11
D10s193, D10s208, D10s588
14q24.3-q31
D14s67
2q33
CTLA-4, CD28
2q34
D2s137, D2s164, IGFBP2, IGFBP5
?
NCBI # 3413
6q21
D6s283, D6s434, D6s1580
?
NCBI # 3415
10q25
D10s1750-D10s1773
X= “little support” linkage Concannon et al Diabetes 54:2995, 2005
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IDDM 1
HLA
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Klass II presentation
PEPTID
Ola Winqvist
X
X
X
X X
X
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Klass II och Diabetes
PEPTID
X
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HLA och diabetes
§ Oladdad aa i HLA-DQB1
àposition 57 (non Asp)
§ aa lysine i HLA-DQA1
àposition 69
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DQB1*0402
a -chain
Leu56b
b-chain
BDC
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Asp57b
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IDDM2 Locus Insulin
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Insulin 1 nödvändigt för diabetes utveckling
Nature 2005
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T celler från IDDM patienter känner igen insulin
Kent et al Nature 2005
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The IDDM2 Locus
IDDM2
Insulin Gene (INS)
Predisposing
Class I VNTR
26-63 repeats
21 alleles
IDDM2
Insulin Gene (INS)
Protective
Class III VNTR
140-200 repeats
15 alleles
VNTR = Variable Number of Tandem Repeats
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ß-actin mRNA
Ola Winqvist
-No RNA
-Skin
-Lung
-Intestinal Mucosa
-Islet Cells (undiluted)
-Islet Cell (1:2500)
-Thymus
-Thymus
-No RNA
-Skin
-Lung
-Intestinal Mucosa
-Islet Cells (undiluted)
-Thymus
-Thymus
INS uttrycks i Human Thymus
INS mRNA
Pugliese et al. Nature Genetics 15:293-297, 1997
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VNTR alleler påverkar INS
transcription i thymus
Thymus INS Transcription
Predisposing
Class I VNTR
Protective
Class III VNTR
Pancreas INS Transcription
Predisposing
Class I VNTR
Protective
Class III VNTR
Pugliese et al. Nature Genetics 15:293-297, 1997
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Ectopic autoantigen expression
Autoantigen derived
peptide
Aire
class II
TCR
Mec
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AIRE defficiency will then lead
survival of autoreactive T cells
X
class II
Mec
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TCR
AUTOREACTIVE
T CELLS
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RIP-HEL, HEL TCR TG
negative selection
Aire
class II
TCR
HEL
Mec
Influence of Aire on
ectopic expression?
Ola Winqvist
Rip promotor
HEL
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RIP-HEL, HEL TCR TG
negative selection is Aire dependent
Aire-/-
X
class II
TCR
HEL
Mec
120
100
80
Escape of HEL
Autoreactive T cell
60
40
20
0
Liston Nature Immunol 2003
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wt
KO
Wt KO
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Escape of autoreactive HEL recognizing
T cells results in diabetes
X
class II
TCR
HEL
Mec
120
100
Escape of HEL
Autoreactive T cell
80
60
40
20
0
wt
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Liston Nature Immunol 2003
KO
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INS-VNTR varierar med antalet
Autoreaktiva T celler som känner igen Insulin
Predisp
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Protekt
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Peripheral tolerance
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Lymphocytic choriomenigitis virus model
RIP- GP
RIP GP/GP TCR transgenic CD8
GP-TCR transgenic
Rip promotor
GP
b cell
Tolerance
Anergi
PNAS 1994
LCMV injection
CD8+ Tc
DANGER HYPOTHESIS
PNAS 1994
RIP GP/GP TCR transgenic CD8
GP-TCR transgenic
B7.1
Rip promotor
GP
Rip promotor
B7.1
b cell
RIP-GP, GP-TCR, RIP-B7
“spontaneous diabetes”
CD8+ Tc
SECOND SIGNAL
IDDM 12 CTLA-4, CD28
PNAS 1994
Molecular mimicry
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Molecular Mimicry?
Molecular reflection
Coxsackie B
CMV
Hepatitis
Rubella
?
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Fig. 2. Reactivity to VP-1 enteroviral peptide in type 1 diabetic islet cells
Dotta, Francesco et al. (2007) Proc. Natl. Acad. Sci. USA 104, 5115-5120
Ola Winqvist
Copyright ©2007 by the National Academy of Sciences
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Diabetes Typ 1 –autoimmune disease
§
§
Ola Winqvist
Lack of tolerance
Autoreactive T and B cells with destruction of Insulin producing b
cells
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Langerhans Islet
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Gradual insulinitis
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until b-cell destruction is complete
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Typ 1-diabetes is initiated long
before clinical symptoms
2
1
Time
Normal
b cell
Ola Winqvist
100%
Insulinitis but intact
Glucose homeostasis
75%
Diabetes
5%
0%
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Stages in Development of IDDM
BETA CELL MASS
GENETICALLY AT RISK
MULTIPLE ANTIBODY
POSITIVE
LOSS OF FIRST PHASE
INSULIN RESPONSE
GENETIC
PREDISP
INSULITIS
BETA CELL INJURY
“PRE”DIABETES
DIABETES
J. Skyler
Ola Winqvist
TIME
NEWLY
DIAGNOSED
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Where is the autoreactivity initiated?
The clonal expansion of autoreactive T cells
occurs initially in the draining lymph node
1. Increased presentation of
endogenous antigens in HLA
Lymph node
Ola Winqvist
2. Increased number of
autoreactive T cells in
lymph node
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Expanded T cells from pancreatic lymph nodes
of type 1 diabetic subjects recognize an insulin epitope
§
Pancreatic LN: Single cell cloning – PHA
§
2/3 Patients Clonal expansion
duration diabetes 29 and 15 years
§
Vbeta29-1*03J2-3(50%)/Valpha8-3*02 J44*01(25%)
Vbeta5-1*01 J2-3(52%)/Valpha39*01 J33*01(26%)
§
DRB1*0401 Restricted
Insulin A1-15
Kent et al, Nature 435:224, 2005
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Tc reacts with normal
proteins expressed in the b-cells
§ Insulin
§ Enzyme GAD (regulates inulin release)
§ IA-2 (regulates inulin release)
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Autoantibodies and IDDM
ICA
GAD
Insulin
IA-2
b cell in pancreas
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Diabetes
IDDM
Complement?
ADCC
B
Tc
b-cell
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GAD autoantibodies
Hög sensitivitet och specificitet
GAD autoantikroppar är inte patogena
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Diabetes screening autoantikroppar
Positive Predictive value
Positive Prediktivt värde
Sen
Risk by 3 years
Risk by 5 years
GADAb
90%
28%
52%
GADAb and IAA
68%
41%
68%
GADAb and IA-2Ab
62%
45%
86%
GADAb, IAA and IA-2Ab
52%
49%
100%
Verge et al Diabetes 1996
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IDDM associerad autoimmunitet
Barker J Clin Endocrin Metab 2006
Vi mäter autoantikroppar som
markör för autoimmun sjukdom
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HLA
Central Tolerance
Virus, bacteria
Molecular mimicry
Peripheral
tolerance
Herrath Nature 2005
Kan vi behandla diabetes genom
att påverka immunsystemet?
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Original Article
GAD65 Antigen Therapy in Recently Diagnosed
Type 1 Diabetes Mellitus
Johnny Ludvigsson, M.D., Ph.D., David Krisky, M.D., Ph.D., Rosaura Casas, Ph.D.,
Tadej Battelino, M.D., Ph.D., Luis Castaño, M.D., Ph.D., James Greening, M.D., Olga
Kordonouri, M.D., Timo Otonkoski, M.D., Ph.D., Paolo Pozzilli, M.D., Jean-Jacques
Robert, M.D., Ph.D., Henk J. Veeze, M.D., Ph.D., and Jerry Palmer, M.D.
N Engl J Med
Volume 366(5):433-442
February 2, 2012
Study Overview
• This trial assessed alum-formulated glutamic acid decarboxylase, the 65kD isoform (GAD65), a major autoantigen in type 1 diabetes..
C-Peptide and GAD65 Autoantibody Levels, According to Study Group.
Ludvigsson J et al. N Engl J Med 2012;366:433-442
Conclusions
• Treatment with GAD-alum did not significantly reduce the loss of
stimulated C peptide or improve clinical outcomes over a 15-month
period.
Low-dose interleukin 2 in patients with type
1 diabetes: a phase 1/2 randomised, doubleblind, placebo-controlled trial
Agnès Hartemann, Gilbert Bensimon, Christine A Payan, Sophie Jacqueminet, Olivier Bourron, Nathalie Nicolas, Michèle
Fonfrede, Michelle Rosenzwajg, Claude Bernard, David Klatzmann
The Lancet Diabetes & Endocrinology, Volume 1, Issue 4, 2013, 295–305
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IL-2 ökar Tregs antalet?
IL-2
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Figure 2. Treg pharmacodynamics variables (intention-to-treat population)Variation in proportion of regulatory T (Treg) cells was
monitored over the assessment period (day 1–60). Incremental maximum effect (iEmax) is defined as the maximum increase from
baseli...
Ingen effekt på glukoshomeostasen
The Lancet Diabetes & Endocrinology, Volume 1, Issue 4, 2013, 295–305
Discuss 2 and 2
a) 2 things You have learnt
b) 2 things You have not understood
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[email protected]
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