Monocyte accumulation in renal allografts is associated with allograft dysfunction. As monocyte influx occurs acutely following reperfusion, we investigated the effect of ischemia-reperfusion injury (IRI) on monocyte colony stimulating factor (m-CSF), a key cytokine in monocyte recruitment. We hypothesized that renal tubule epithelial cells (RTECs) could produce m-CSF in response to IRI, which could in turn promote monocyte activation. Real time PCR was used to measure levels of intragraft m-CSF transcripts in patients during IRI and clinical rejection. Also, m-CSF production by RTECs following IRI simulation in vitro was measured using ELISA. Monocyte expression of CD40 and CD80 was then analyzed using flow cytometry following co-culture with supernatants of RTECs after IRI. Monocyte expression of CD40, CD80 and HLA-DR was then examined following treatment with rh-m-CSF (10, 36, and 100 ng/ml), as was monocyte size and granularity. We found that intragraft m-CSF transcription was significantly increased postreperfusion (P = 0.002) and during clinical rejection (P = 0.002). We also found that RTECs produced m-CSF in response to IRI in vitro (P = 0.036). Monocytes co-cultured with the supernatants of postischemic RTECs became activated as evidenced by increased expression of CD40 and CD80. Also, monocytes treated with recombinant m-CSF assumed an activated phenotype exhibiting increased size, granularity and expression of CD40, CD80, CD86, and HLA-DR, and demonstrating enhanced phagocytic activity. Taken together, we suggest that renal tubular cell derived m-CSF is a stimulus for monocyte activation and may be an important target for control of IRI-associated immune activation.

Goldbach-Mansky R, Dailey NJ, Canna SW, et al. N Engl J Med. 2006;355:581–592 PURPOSE OF THE STUDY. Neonatal-onset multisystem inflammatory disease (NOMID) is a chronic inflammatory disease that develops in infancy and is characterized by an urticarial rash, arthropathy, and central nervous system disease, including aseptic meningitis, cerebral atrophy, mental retardation, seizures, and vision and hearing loss. Approximately 60% of patients have a mutation in the cold-induced autoinflammatory syndrome 1 (CIAS1) gene, which is involved in the interleukin 1β (IL-1β) pathway. This study evaluated the effect of anakinra (Kineret, Amgen), an IL-1 receptor antagonist, on the various clinical and laboratory aspects of NOMID. STUDY POPULATION. A cohort of 18 patients aged 4 to 32 years with clinical NOMID (67% with mutations in CIAS1) who had active disease despite treatment with other antiinflammatory agents. METHODS. Patients were given a daily subcutaneous dose of anakinra. The drug was withdrawn from 11 patients at 3 months with the development of a clinical flare. Thereafter, all patients were continued on daily treatments up to 24 months. Clinical and laboratory assessments were made at 1, 3, and 6 months during therapy with anakinra. Primary end points included changes in a disease-specific daily diary score and changes in the serum levels of acute-phase reactants. RESULTS. All patients had an immediate response to anakinra with resolution of rash and conjunctivitis. There was an improvement in diary scores at 3 months that was maintained at 6 months. Serum amyloid A, C-reactive protein, and the erythrocyte sedimentation rate significantly declined with treatment. All the patients had headache at baseline, which resolved or improved with therapy, and cochlear and leptomeningeal lesions were improved on MRI. Serum levels of IL-1β, which were initially higher than those in healthy controls, decreased over the first 6 months of therapy. All the patients who underwent a treatment withdrawal experienced rapid improvement of their symptoms after resuming anakinra. Other than injection-site reactions, which resolved with continued treatment, there were no serious adverse events. CONCLUSIONS. Anakinra may be a safe and effective treatment for patients with NOMID. REVIEWER COMMENTS. This study suggests that anakinra may have a role in the treatment of other diseases in which IL-1β mediates inflammation (eg, systemic juvenile rheumatoid arthritis). Additional studies are needed to determine its long-term effects and clinical application. This study is an example of how specific immunomodulatory therapy may be useful in treating those diseases that have a defined molecular pathophysiologic profile.

We examined the role of CD40/CD40L interactions on the development of experimental autoimmune uveoretinitis (EAU), a cell-mediated, Th1-driven autoimmune disease that serves as a model for autoimmune uveitis in humans. EAU-susceptible B10.RIII mice immunized with the retinal autoantigen interphotoreceptor retinoid binding protein in CFA and treated with anti-CD40L Ab (MR1) had reduced incidence and severity of disease. Real-time PCR analysis revealed that the innate and adaptive responses of protected mice were reduced, without an obvious shift toward a Th2 cytokine profile. In contrast to some other reports, no evidence was found for regulatory cells in adoptive transfer experiments. To determine whether CD40L blockade resulted in long-term tolerance, mice protected by treatment with MR1 Ab were rechallenged for uveitis after circulating MR1 Ab levels dropped below the detection limit of ELISA. MR1-treated mice developed severe EAU and strong cellular responses to interphotoreceptor retinoid binding protein, comparable to those of control mice. These responses were higher than in mice that had not received the primary immunization concurrently with anti-CD40L treatment. We conclude that 1) CD40/CD40L interaction is required for EAU and its disruption prevents disease development; 2) CD40L blockade inhibits the innate response to immunization and reduces priming, but does not result in immune deviation; and 3) protection is dependent on persistence of anti-CD40L Abs, and long-term tolerance is not induced. Furthermore, immunological memory develops under cover of CD40L blockade causing enhanced responses upon rechallenge. Taken together, our data suggest that ongoing CD40/CD40L blockade might be required to maintain a therapeutic effect against uveitis.

T wo different depletional induction protocols were evaluated in transplant recipients treated at the National Institutes of Health Transplant and Autoimmunity Branch in Bethesda, MD. The first protocol studied the use of a polyclonal antibody as induction therapy followed by monotherapy maintenance immunosuppression with sirolimus.1 This study was designed to evaluate several theoretic advantages associated with the use of a polyclonal antibody. These include effective and durable lymphocyte depletion combined with coating of up-regulated adhesion, costimulation, and injury-related molecules during the ischemia-reperfusion period. The second protocol used a monoclonal antibody– based therapy followed by no maintenance immunosuppression.2 The benefits associated with the use of a monoclonal agent include antigenic consistency, rapid lymphocyte clearance, and relatively low side effect profile. Serum creatinine levels, lymphocyte and monocyte counts, and recovery patterns of all cells including memory and naive cells were performed throughout both studies. Protocol-directed biopsies were obtained at 2 weeks, 30 days, and 6 months and then yearly after transplantation to monitor for potential rejection episodes. Biopsies were also performed whenever clinically indicated. In addition to histologic evaluation of the biopsy tissue, evaluation of the quantitative expression of various extracted messenger RNA transcripts was performed. In the polyclonal antibody–based protocol, 18 patients were treated with a total of 20 mg/kg of rabbit antithymocyte globulin (ATG) given at a dose of 2.5 mg/kg per day for 8 days. Methylprednisolone was administered as premedication for the first 3 doses of ATG, and 15 mg of sirolimus was given on the first posttransplant day. The dose of sirolimus was decreased to 5 mg/d thereafter and adjusted to a maintenance level of 10 to 15 ng/mL. All patients experienced rapid and prolonged depletion of lymphocytes and monocytes. Whereas the absolute lymphocyte count remained depressed for more than 18 months after the administration of ATG, the peripheral blood monocyte level was largely recovered within 2 to 3 months. Figures 1 and 2 show the mean absolute lymphocyte and monocyte counts, respectively, over time. In the first 12 patients evaluated, 3 mild clinical rejection episodes (Banff IA and IB) were observed, 2 of which were manifested clinically with an increased serum creatinine level and 1 that was diagnosed on a protocol biopsy without any associated increase in the serum creatinine value. All 3 of these rejection episodes responded rapidly to a short course of steroids, and the patients were maintained on sirolimus monotherapy regimen without recurrent rejection episodes. This experience formed the basis of our initial report.1 Subsequently, 6 additional patients were accrued into this study, 5 of them manifesting a rejection episode within the first 6 months after transplantation. Two of these were instances of humoral rejection associated with the observation of donor human leukocyte antigen–specific antibody. The remaining 3 instances were cellular rejection episodes. Most cellular rejection episodes were temporally associated with subtherapeutic sirolimus levels, which points out the perils associated with monotherapy immunosuppression. From the Transplant Section and Medicine Section, Transplant and Autoimmunity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD; Transplantation Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC; Laboratory of Pathology, National Cancer Institute, National Institutes of Health; Bethesda, MD; and Naval Medical Research Center, Silver Spring, MD. Address reprint requests to Douglas A. Hale, MD, Transplant Section, Transplant and Autoimmunity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892. This is a US government work. There are no restrictions on its use. 0955-470X/03/1704-0000$30.00/0 doi:10.1016/S0955-470X(03)00078-8

Polymorphisms in the regulatory regions of cytokine genes are associated with high and low cytokine production and may modulate the magnitude of alloimmune responses following transplantation. Ethnicity influences allograft half-life and the incidence of acute and chronic rejection. We have questioned whether ethnic-based differences in renal allograft survival could be due in part to inheritance of cytokine polymorphisms. To address that question, we studied the inheritance patterns for polymorphisms in several cytokine genes (IL-2, IL-6, IL-10, TNF-alpha, TGF-beta, and IFN-gamma) within an ethnically diverse study population comprised of 216 Whites, 58 Blacks, 25 Hispanics, and 31 Asians. Polymorphisms were determined by allele-specific polymerase chain reaction and restriction fragment length analysis. We found striking differences in the distribution of cytokine polymorphisms among ethnic populations. Specifically, significant differences existed between Blacks and both Whites and Asians in the distribution of the polymorphic alleles for IL-2. Blacks, Hispanics and Asians demonstrated marked differences in the inheritance of IL-6 alleles and IL-10 genotypes that result in high expression when compared with Whites. Those of Asian descent exhibited an increase in IFN-gamma genotypes that result in low expression as compared to Whites. In contrast, we did not find significant ethnic-based differences in the inheritance of polymorphic alleles for TNF-alpha. Our results show that the inheritance of certain cytokine gene polymorphisms is strongly associated with ethnicity. These differences may contribute to the apparent influence of ethnicity on allograft outcome.