Genetics, Pathophysiology, and Treatment of Recessive Autoinflammatory Diseases

隐性自身炎症性疾病的遗传学、病理生理学和治疗

• 批准号: 8565567
• 负责人: Daniel Kastner
• 金额: $ 112.3万
• 依托单位: NATIONAL HUMAN GENOME RESEARCH INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8565567
• 关键词: 4 year old; Admission activity; Adverse event; Age; Anemia; Animal Model; Animals; Apple; Area; Arthralgia; Autoimmune Process; Berlin; Biochemical; Biology; Blood Proteins; Candidate Disease Gene; Cell Line; Chronic; Clinical Trials; Coagulation Process; Colchicine; Collaborations; Complex; Cysteine; Data; Dermatitis; Development; Diagnosis; Diarrhea; Dideoxy Chain Termination DNA Sequencing; Disease; Dose; Double-Blind Method; Event; Familial Mediterranean Fever; Family; Female; Fever; Frequencies; Functional disorder; Genes; Genetic; Goals; Human; Inheritance Patterns; Inherited; Injection Site Reaction; Injection of therapeutic agent; Intensive Care Units; Interleukin-1; Internal Medicine; KLK3 gene; Laboratories; Lead; Life; Lipodystrophy; Marriage; Molecular; Mutation; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Odds Ratio; Panniculitis; Paper; Participant; Patients; Phenotype; Placebos; Play; Prekallikrein; Prolonged Partial Thromboplastin Time; Proteins; Randomized; Recruitment Activity; Recurrence; Reporting; Research Personnel; Resistance; Role; Safety; Sampling Studies; Screening procedure; Shock; Site; Son; Syndrome; Tail; Temperature; Tertiary Protein Structure; Variant; anakinra; cohort; cytokine; disulfide bond; early onset; efficacy testing; exome; improved; knockin animal; knockout animal; male; man; marenostrin; multicatalytic endopeptidase complex; mutant; receptor; skin lesion; standard care; therapy design; vascular inflammation

During the current reporting period we have made significant progress in three areas: (1) in collaboration with Dr. Phil Hashkes, now in Jerusalem, we completed a clinical trial testing the efficacy of rilonacept, a long-acting interleukin-1 blocker, in patients with FMF who are unresponsive to or intolerant of the standard treatment, colchicine, and now have a paper in press describing these results in the Annals of Internal Medicine; (2) in collaboration with Dr. Raphaela Goldbach-Mansky of NIAMS, using a combination of candidate gene analysis and whole-exome sequencing, we have identified mutations in 4 proteasome components in patients with a new recessively inherited autoinflammatory disease characterized by atypical neutrophilic dermatitis with lipodystrophy and elevated temperature (CANDLE syndrome); and (3) we have utilized whole-exome sequencing in small families with unexplained recurrent fevers and autoinflammatory disease to identify possible recessively inherited causal variants. Rilonacept in FMF Currently there is no proven alternative for FMF patients resistant to or intolerant of colchicine. Previous data from our laboratory have implicated interleukin-1 as a key proinflammatory cytokine in FMF. We assessed the efficacy and safety of rilonacept, an interleukin-1 decoy receptor, using a double-blind, single-subject alternating treatment design. Subjects over 4 years old with at least 1 monthly attack despite adequate doses of colchicine, or who were colchicine intolerant, were recruited at 6 U.S. sites. Subjects were randomized to 1 of 4 treatment sequences that included two 3-month courses of rilonacept 2.2 mg/kg (max 160 mg) by weekly SC injection, and two 3-month courses of placebo. Eight males and six females with a mean age of 24.4 years (SD, 11.8) were randomly assigned. Among 12 participants who completed 2 or more courses, the rilonacept-placebo attack risk ratio was 0.59 (SD, 0.12) (equal-tail 95% credible interval, 0.39 to 0.85). The median number of attacks per month was 0.77 (0.18 and 1.20 attacks in the first and third quartiles, respectively) with rilonacept versus 2.00 (0.90 and 2.40, respectively) with placebo (median difference, -1.74 95% CI, -3.4 to -0.1, P = 0.027). There were more treatment courses of rilonacept without attacks (29% vs. 0%; P = 0.004), and with a decrease in attacks of greater than 50% compared with the baseline rate during screening (75% vs. 35%, P = 0.006) than with placebo. However, the duration of attacks did not differ between placebo and rilonacept (median difference, 1.2 days -0.5 and 2.4 days in the first and third quartiles, respectively; P = 0.32). Injection site reactions were more frequent with rilonacept (median difference, 0 events per patient treatment month medians of -4 and 0 in the first and third quartiles, respectively; P = 0.047), but no differences were seen in other adverse events. From this study we conclude that rilonacept reduces the frequency of FMF attacks and seems to be a treatment option for colchicine-resistant or intolerant FMF. Mutational Analysis in CANDLE During the previous reporting period our laboratory participated in a collaborative study that identified homozygous T75M PSMB8 mutations in 4 of 8 patients with CANDLE, a syndrome characterized by onset during the first year of life, recurrent fevers, purpuric skin lesions, arthralgia, progressive lipodystrophy, anemia, and delayed physical development. Nevertheless, there remained patients with the CANDLE phenotype with only a single demonstrable PSMB8 mutation, and other patients with no demonstrable PSMB8 mutations. We hypothesized that mutations in other components of the multi-molecular immunoproteasome complex or of the constitutive proteasome might also cause this phenotype. We therefore systematically performed Sanger sequencing on the genes encoding the various proteasome components, in conjunction with whole-exome sequencing to exclude other possible candidates. Preliminary data from these sequencing studies identify mutations in 3 other genes encoding various components of the proteasome in patients with the CANDLE phenotype, but not in large cohorts of appropriately matched controls. In collaboration with investigators in Berlin, we are assessing the functional consequences of these mutations. Our genetic data suggest that early-onset panniculitis is a molecular disorder of the proteasome, with possible digenic inheritance of multiple interacting subunits. Whole-exome Sequencing in Patients with Unexplained Autoinflammatory Phenotypes We have utilized whole-exome sequencing in a number of small families with unexplained, possibly recessively inherited autoinflammatory phenotypes. In one such case, we performed whole-exome analysis in a south Indian man, the son of an uncle-niece marriage, with chronic diarrhea, a prolonged partial thromboplastin time (PTT), and episodes of fever and shock requiring repeated intensive care unit admissions. This patient is homozygous for the G355C mutation in KLKB1, which encodes prekallikrein, a blood protein that plays a role in inflammation, vascular tone, and coagulation. The mutation introduces an unpaired ninth cysteine residue into the fourth apple domain of the protein, potentially causing abnormal disulfide bonding. Functional studies of the mutant protein are under way. We are also analyzing whole-exome data on several other small families with unexplained, possibly recessive disease.

在本报告所述期间，我们在三个领域取得了重大进展：（1）与目前在耶路撒冷的Phil Hashkes博士合作，我们完成了一项临床试验，测试利洛那塞（一种长效白细胞介素-1阻滞剂）在对标准治疗秋水仙碱无反应或不耐受的FMF患者中的疗效，现在，《内科学年鉴》上有一篇描述这些结果的论文正在出版;（2）与NIAMS的Raphaela Goldbach-Mansky博士合作，使用候选基因分析和全外显子组测序的组合，我们已经在一种新的复发性遗传性自身炎症性疾病患者中鉴定了4种蛋白酶体组分的突变，该疾病的特征是伴有脂肪营养不良和体温升高的非典型嗜中性皮炎（CANDLE综合征）;（3）我们已充分利用-外显子组测序在不明原因的反复发热和自身炎症性疾病的小家庭，以确定可能的反复遗传的致病变异。 FMF中的奥那西普 目前，对于对秋水仙碱耐药或不耐受的FMF患者，还没有经证实的替代方案。我们实验室以前的数据表明，白细胞介素-1是FMF中关键的促炎细胞因子。我们采用双盲、单受试者交替治疗设计，评估了利洛那塞（一种白细胞介素-1诱饵受体）的疗效和安全性。在6个美国研究中心招募了4岁以上的受试者，尽管使用了足够剂量的秋水仙碱，但至少每月发作一次，或秋水仙碱不耐受。受试者被随机分配至4个治疗序列中的1个，包括每周SC注射2个3个月疗程的利洛那塞2.2 mg/kg（最大160 mg）和2个3个月疗程的安慰剂。随机分配了8名男性和6名女性，平均年龄为24.4岁（SD，11.8）。在12名完成2个或更多疗程的参与者中，利洛那塞-安慰剂发作风险比为0.59（SD，0.12）（等尾95%可信区间，0.39至0.85）。利洛那西普组每月发作次数的中位数为0.77次（第一和第三四分位数分别为0.18和1.20次），安慰剂组为2.00次（分别为0.90和2.40次）（中位数差异，-1.74 95% CI，-3.4至-0.1，P = 0.027）。与安慰剂组相比，利洛那塞组有更多的疗程没有发作（29%比0%; P = 0.004），并且与筛选期间的基线率相比，发作减少超过50%（75%比35%，P = 0.006）。然而，安慰剂和利洛那塞之间的发作持续时间没有差异（中位数差异，第一和第三四分位数分别为1.2天-0.5天和2.4天; P = 0.32）。利洛那塞组注射部位反应更频繁（中位差异，每个患者治疗月0起事件，第一和第三四分位数的中位数分别为-4和0; P = 0.047），但在其他不良事件中未观察到差异。 从这项研究中，我们得出结论，利洛那塞减少频率的FMF攻击，似乎是一种治疗选择秋水仙素耐药或不耐受的FMF。 CANDLE中的突变分析 在之前的报告期间，我们的实验室参与了一项合作研究，在8例CANDLE患者中的4例中鉴定了纯合子T75 M PSMB 8突变，CANDLE是一种综合征，其特征是在生命的第一年内发病，反复发热，紫癜性皮肤病变，关节痛，进行性脂肪营养不良，贫血和身体发育延迟。 然而，仍有仅具有单一可证实的PSMB 8突变的CANDLE表型的患者，以及没有可证实的PSMB 8突变的其他患者。我们推测，在多分子免疫蛋白酶体复合物或组成型蛋白酶体的其他组件的突变也可能导致这种表型。 因此，我们对编码各种蛋白酶体组分的基因进行了系统的桑格测序，并结合全外显子组测序以排除其他可能的候选者。这些测序研究的初步数据确定了CANDLE表型患者中编码蛋白酶体各种组分的其他3个基因的突变，但在适当匹配的对照组的大队列中没有发现。我们与柏林的研究人员合作，正在评估这些突变的功能后果。我们的遗传数据表明早发性脂膜炎是一种蛋白酶体的分子紊乱，可能具有多个相互作用的亚基的双基因遗传。 不明原因自身炎性表型患者的全外显子组测序 我们已经在一些具有不明原因的、可能复发的遗传性自身炎症表型的小家族中使用了全外显子组测序。在一个这样的情况下，我们进行了全外显子组分析在南印度男子，叔叔侄女婚姻的儿子，慢性腹泻，延长部分凝血活酶时间（PTT），发烧和休克发作需要反复重症监护病房入院。该患者是KLKB 1中G355 C突变的纯合子，KLKB 1编码前激肽释放酶，这是一种在炎症，血管张力和凝血中起作用的血液蛋白。该突变将未配对的第九个半胱氨酸残基引入蛋白质的第四个苹果结构域，可能导致异常的二硫键。对突变蛋白的功能研究正在进行中。我们还分析了其他几个不明原因的，可能是隐性疾病的小家庭的全外显子组数据。