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.

在本报告期内，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，测试利洛西普（一种长效白细胞介素 1 阻滞剂）对对标准治疗秋水仙碱无反应或不耐受的 FMF 患者的疗效，目前正在出版的一篇论文在《内科医学年鉴》中描述了这些结果； (2) 与NIAMS的Raphaela Goldbach-Mansky博士合作，结合候选基因分析和全外显子组测序，我们在一种新的隐性遗传性自身炎症性疾病患者中鉴定出了4种蛋白酶体成分的突变，该疾病的特征是伴有脂肪营养不良和体温升高的非典型中性粒细胞性皮炎（CANDLE综合征）； (3)我们在患有不明原因反复发烧和自身炎症性疾病的小家庭中利用全外显子组测序来识别可能的隐性遗传致病变异。 FMF 中的利洛西普 目前，对于对秋水仙碱耐药或不耐受的 FMF 患者，尚无经过验证的替代方案。我们实验室之前的数据表明，IL-1 是 FMF 中关键的促炎细胞因子。我们使用双盲、单受试者交替治疗设计评估了利洛西普（一种白介素-1 诱饵受体）的有效性和安全性。在美国 6 个地点招募了 4 岁以上的受试者，尽管服用了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。受试者被随机分配至 4 种治疗序列中的 1 种，其中包括每周皮下注射利洛那西普 2.2 mg/kg（最大 160 mg）两个为期 3 个月的疗程，以及两个为期 3 个月的安慰剂疗程。 8 名男性和 6 名女性被随机分配，平均年龄为 24.4 岁（SD，11.8）。在完成 2 个或更多课程的 12 名参与者中，利洛西普-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）。利洛西普组每月发作次数中位数为 0.77 次（第一和第三四分位数分别为 0.18 次和 1.20 次发作），安慰剂组为 2.00 次（分别为 0.90 和 2.40 次）（中位差，-1.74 95% CI，-3.4 至 -0.1，P = 0.027）。与安慰剂相比，利洛那西普无发作的治疗疗程较多（29% vs. 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% vs. 35%，P = 0.006）。然而，安慰剂和利洛西普之间的发作持续时间没有差异（中位差异，第一和第三四分位数分别为 1.2 天 -0.5 和 2.4 天；P = 0.32）。利洛那西普的注射部位反应更频繁（中位差异，每个患者治疗月发生 0 起事件，第一和第三四分位数中位分别为 -4 和 0；P = 0.047），但其他不良事件没有差异。 从这项研究中，我们得出结论，利洛西普降低了 FMF 发作的频率，并且似乎是秋水仙碱耐药或不耐受 FMF 的治疗选择。 CANDLE 中的突变分析 在上一个报告期间，我们的实验室参与了一项合作研究，该研究在 8 名 CANDLE 患者中发现了 4 名纯合 T75M PSMB8 突变，CANDLE 是一种以出生后第一年发病、反复发烧、紫癜性皮肤病变、关节痛、进行性脂肪营养不良、贫血和身体发育迟缓为特征的综合征。 尽管如此，仍然存在具有 CANDLE 表型的患者仅具有单个可证明的 PSMB8 突变，以及其他患者没有可证明的 PSMB8 突变。我们假设多分子免疫蛋白酶体复合物或组成型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发现，在具有 CANDLE 表型的患者中，其他 3 个编码蛋白酶体各种成分的基因发生了突变，但在大量适当匹配的对照组中却没有发现突变。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，早发性脂膜炎是蛋白酶体的一种分子疾病，可能具有多个相互作用亚基的双基因遗传。 不明原因自身炎症表型患者的全外显子组测序 我们在许多具有无法解释的、可能是隐性遗传的自身炎症表型的小家庭中使用了全外显子组测序。在一个这样的病例中，我们对一名南印度男性进行了全外显子组分析，他是叔侄女婚姻的儿子，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室。该患者的 KLKB1 中的 G355C 突变是纯合子，该突变编码前激肽释放酶，这是一种在炎症、血管张力和凝血中发挥作用的血液蛋白。该突变将不配对的第九个半胱氨酸残基引入到蛋白质的第四个苹果结构域中，可能导致异常的二硫键。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子组数据。