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)与现在耶路撒冷的Phil Hashkes博士合作，我们完成了一项临床试验，测试长效白细胞介素1阻滞剂利洛那普对标准治疗秋水仙碱无效或不耐受的FMF患者的疗效，目前正在出版的一篇论文在《内科医学年鉴》上描述了这些结果；(2)我们与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相结合的方法，在一种新的隐性遗传性自体炎症性疾病患者中鉴定了4种蛋白酶体成分的突变，该疾病的特征是非典型中性粒细胞皮炎伴脂肪营养不良和体温升高(蜡烛综合征)；以及(3)我们已经在原因不明的反复发烧和自体炎性疾病的小家庭中利用全外显子组测序来确定可能的隐性遗传性原因变体。 利洛那普在FMF中的应用 目前，对于耐秋水仙碱或不耐受秋水仙碱的FMF患者，还没有得到证实的替代方案。我们实验室以前的数据表明，白介素1是FMF中一个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，评估了白介素1诱饵受体利洛那普的有效性和安全性。在美国的6个地点招募了4岁以上的受试者，尽管有足够剂量的秋水仙碱，但每月至少发作1次，或者秋水仙碱不耐受。受试者被随机分成4个治疗序列中的一个，其中包括两个为期3个月的疗程，利洛那普2.2 mg/kg(最大160 mg)每周SC注射，以及两个为期3个月的安慰剂疗程。随机分配8名男性和6名女性，平均年龄24.4岁(SD，11.8岁)。在完成两个或两个以上疗程的12名参与者中，利洛那塞-安慰剂攻击风险比为0.59(SD，0.12)(等尾95%可信区间，0.39至0.85)。服用利洛那普的患者每月发作次数的中位数为0.77次(第一和第三四分位分别为0.18次和1.2次)，安慰剂组为2.00次(分别为0.90次和2.4次)(中位数差异为-1.74 95%CI，-3.4%至-0.1%，P=0.027)。与安慰剂组相比，未发作的利洛那塞的疗程更多(29%比0%；P=0.004)，与筛查期间的基线发作率(75%比35%，P=0.006)相比，发作率下降了50%以上。然而，安慰剂和利洛那普的发作持续时间没有差异(中位数差异1.2天-第一和第三四分位数分别为0.5天和2.4天；P=0.32)。注射部位反应在利洛那普组中更为常见(中位数差异，第一和第三个四分位数中位数分别为-4和0，每个患者治疗月发生0.047次事件；P=0.05)，但在其他不良事件中没有发现差异。 从这项研究中，我们得出结论，利洛那普可减少FMF发作的频率，似乎是治疗秋水仙碱耐药或不耐受FMF的一种选择。 蜡烛中的突变分析 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名蜡烛患者中发现了4名纯合子T75M PSMB8突变，这种综合征的特征是在出生第一年起病，反复发烧，紫癜性皮损，关节痛，进行性脂肪营养不良，贫血和身体发育延迟。然而，仍然有仅有一个可证明的PSMB8突变的蜡烛表型患者，以及其他没有可证明的PSMB8突变的患者。我们假设，多分子免疫蛋白酶体复合体或构成蛋白酶体的其他成分的突变也可能导致这种表型。 因此，我们系统地对编码各种蛋白酶体成分的基因进行了Sanger测序，并结合整个外显子组测序来排除其他可能的候选基因。来自这些测序研究的初步数据在蜡烛表型患者中发现了编码蛋白酶体各种成分的另外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突变。我们正在与柏林的调查人员合作，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，可能存在多个相互作用的亚基的双基因遗传。 不明原因自身炎症表型患者的全外显子组测序 我们在一些原因不明，可能是隐性遗传的自体炎症表型的小家庭中使用了全外显子组测序。在一个这样的案例中，我们对一名南印度男子进行了全外显子组分析，他是一位叔叔侄女结婚的儿子，患有慢性腹泻，部分凝血活酶时间(PTT)延长，发烧和休克发作，需要反复住进重症监护病房。这位患者是KLKB1中G355C突变的纯合子，KLKB1编码前激肽释放酶，这是一种在炎症、血管紧张性和凝血中发挥作用的血液蛋白。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。我们还在分析其他几个患有不明原因、可能是隐性疾病的小家庭的全外显组数据。