The impact of cytokine modulation in acquired and inherited inflammatory disease and AA ...

216 Pages·2016·5.88 MB·English

The impact of cytokine modulation in
acquired and inherited inflammatory
disease and AA amyloidosis
Thirusha Lane
National Amyloidosis Centre,
Centre for Amyloidosis and Acute Phase Proteins
University College London
Division of Medicine
Rowland Hill Street, London, NW3 2PF
Submitted for the degree of
Doctor of Philosophy
2016
Declaration
I, Thirusha Lane, confirm that the work presented in this thesis is my own. Where
informationhasbeenderivedfromothersources,thishasbeendeclaredwithinthethesis.
Signature:
(Electronicallysigned)
Date: 11th May 2016
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Abstract
Background
Inflammatory disorders(IDs)cause significantmorbidity. SAA andCRPareacute phase
proteinsusedtodiagnoseandmonitorIDs.SAAisalsotheprecursortoAAamyloidosis
(AAA), a serious complication of chronic inflammation, causing renal failure and poor
quality of life (QoL). The aim of treatment is thus to prevent AAA or to halt its
progression to renal failure, protect renal allografts, and restore QoL. Novel biological
therapies have transformed the landscape, but their longer term effects are yet to be
elucidated.
Aims
Wesetupanurse-ledclinictoexploresafetyandefficacyofmodulationofcytokinesIL-
1 and IL-6 in patients with IDs and AAA, and studied the changing epidemiology of
AAA. We alsosoughttoinvestigate whetherCRPwasitselfpro-inflammatory.
Results
SuppressingSAAusinganti-IL-1andanti-IL-6agentsresultedinstabilisationofamyloid
depositsandinsome, amyloidregressionandimprovedrenal function. Treatmentswere
safe and effective in dialysis and renal transplantation, even where the underlying cause
of AAA was uncertain. Improvement was seen in almost all anti-IL-1-treated CAPS
patients. Common adverse events were infections. QoL improved when treatment was
effective. Referral rates of AAA have remained steady whilst other types have increased.
ThecommonestcausesofAAAarechanging;unknownaetiologyhasincreased.Injection
ofpurifiedCRPintovolunteersdidnotprovoke inflammation.
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Conclusions
Suppressing SAA by effectively treating the underlying ID can lead to improved renal
function and regression of amyloid, even when the cause is uncertain. Anti-cytokine
agentsofferthepossibilityoftargetedtherapiestosuppresssystemicinflammation.Work
reported here shows safety, even in dialysis and transplantation. AAA is becoming less
commonassomeIDshavebecomeeasiertocontrol.Singlecytokineblockadehasproved
useful inAAA ofunknown aetiology andtreatmentgenerally improvessymptomatology
andinflammation. CRPisitselfnotpro-inflammatory.
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EthicalApproval
IndependentResearchEthicsCommittee(REC)approvalwassoughtandreceivedforall
clinical studies, including retrospective work. The applicable REC reference number is
quotedineachchapter.
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Acknowledgements
Iwouldliketothankmysupervisors,ProfessorPhilipHawkinsandDrHelenLachmann.
I am grateful to Professor Sir Mark Pepys for guidance. I would also like to thank the
wonderfulstaffattheNationalAmyloidosisCentrefortheirsupportandencouragement,
in particular, my colleagues Darren Foard, Lisa Rannigan and Rene Williams who
supportedmeandheldthefortwhilstIwaswriting;andJeanBerkeleywhoassistedwith
references. Iamgrateful tomy partnerDavidHuttforhis supportandpatience.
I am grateful to the patients and healthy volunteers who took part in these studies and
who consented to the analysis and publication of their data for the greater good. I am in
awe of their sacrifices and contributions, and humbled by their trust, gratitude and
support.
Finally, I would like to acknowledge my parents, Pam and Flynn Nair, without whose
innumerable silent sacrifices in my early life, I would not have been able to achieve this
today. Thisthesisisdedicatedtothem.
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Contents
Declaration...................................................................................................................................2
Abstract.........................................................................................................................................3
Ethical Approval.........................................................................................................................5
Acknowledgements.....................................................................................................................6
Contents........................................................................................................................................7
ListofFigures............................................................................................................................12
Listof Tables.............................................................................................................................14
ChapterOne: Introduction......................................................................................................15
1.1 The Innate Immune System....................................................................................16
1.2 Autoinflammatory pathogenic mechanisms.........................................................17
1.2.1 The NLRP3 inflammasome............................................................................17
1.2.2 Otherplayersandmechanismsdriving inflammation................................18
1.3 Systemic Autoinflammatory Diseases.........................................................................24
1.3.1 Familial MediterraneanFever...............................................................................27
1.3.2 Cryopyrin-AssociatedPeriodic Syndrome..........................................................30
1.3.3 TumorNecrosisFactorReceptor-AssociatedPeriodic Syndrome.................31
1.3.4 Mevalonate KinaseDeficiency.............................................................................32
1.4 Amyloidosis.....................................................................................................................33
1.4.1 Precursorproteinsandfibrillogenesis.................................................................34
1.4.2 Non-fibrillarcomponents......................................................................................36
1.5 Systemic AAamyloidosis..............................................................................................36
1.6 HepaticAcute PhaseProteins......................................................................................38
1.6.1 C-Reactive Protein..................................................................................................39
1.6.2 SerumAmyloidA Protein.....................................................................................39
1.7 Diagnosing AAamyloidosis.........................................................................................40
1.7.1 Histology andimmunohistochemistry.................................................................40
1.7.2 SAPscintigraphy.....................................................................................................41
1.7.3 Otherinvestigations...............................................................................................41
1.8 Diagnosing systemic autoinflammatory syndromes..................................................42
1.9 Measuring quality oflife (QoL)....................................................................................42
1.10 The UKNational AmyloidosisCentre.....................................................................45
Aims............................................................................................................................................46
ChapterTwo: Methods............................................................................................................49
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2.1 Methodsperformedby the author..............................................................................50
2.1.1 Patientselectionandethical approval..................................................................50
2.1.2 CAPS/Inflammationnurse-ledclinic protocol..................................................50
2.1.3 Definitionofresponse totherapy inSAIDs......................................................51
2.1.4 AssessmentofCAPS disease activity...................................................................51
2.1.5 Venepuncture andinjectionofradio-iodinatedSAP........................................51
2.1.6 Quality oflifeassessments....................................................................................52
2.1.7 Statisticalanalysis....................................................................................................52
2.2 Methodsperformedorcontributedby others...........................................................53
2.2.1 Criteria fordiagnosisofamyloidosisanddefinitionoforganresponse.........53
2.2.2 Histology andimmunohistochemistry.................................................................54
2.2.3 Serumandplasmaassays.......................................................................................55
2.2.4 Geneticanalysis.......................................................................................................56
2.2.5 PurificationofhumanCRP...................................................................................56
2.2.6 SAPscintigraphy.....................................................................................................57
ChapterThree: EstablishmentofNurse-ledClinical andResearchServices...................59
3.1 Background.....................................................................................................................60
3.2 Aims.................................................................................................................................61
3.3 Patientsandmethods.....................................................................................................61
3.3.1 Patients, volunteersanddiagnosis........................................................................61
3.3.2 Administrationoftherapies..................................................................................61
3.3.3 Othermethods........................................................................................................62
3.4 Results..............................................................................................................................62
3.4.1 CAPS nurse clinic protocol...................................................................................62
3.4.2 Protocolsforothertherapies................................................................................65
3.5 Discussion.......................................................................................................................65
ChapterFour: CharacterisationofAA AmyloidosisComplicating Systemic
Autoinflammatory Diseases.....................................................................................................67
4.1 Background.....................................................................................................................68
4.2 Aims.................................................................................................................................68
4.3 PatientsandMethods....................................................................................................68
4.3.1 Patientsanddiagnosis............................................................................................68
4.3.2 Othermethods........................................................................................................69
4.4 Results..............................................................................................................................69
4.4.1 Wholecohortcharacteristics.................................................................................69
4.4.2 FMFpatients...........................................................................................................72
4.4.3 TRAPS patients.......................................................................................................72
4.4.4 CAPS patients.........................................................................................................73
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4.4.5 MKDpatients.........................................................................................................73
4.4.6 Wholecohortrenal function.................................................................................76
4.4.7 Wholecohortsurvival............................................................................................76
4.5 Discussion.......................................................................................................................76
ChapterFive: Safety andEfficacy ofInhibitionofInterleukin-6 inChronic
Inflammatory DiseasesandAutoinflammation....................................................................80
5.1 Background.....................................................................................................................81
5.2 Aims.................................................................................................................................83
5.3 Methods...........................................................................................................................83
5.3.1 Patients.....................................................................................................................83
5.3.2 Othermethods........................................................................................................84
5.4 Results..............................................................................................................................84
5.4.1 Wholecohortcharacteristics.................................................................................84
5.4.2 Serial monitoring ofthe acute phase response...................................................84
5.4.3 Change inrenal functioninAA amyloidcases..................................................85
5.4.4 Monitoring ofamyloiddeposits...........................................................................85
5.3.5 QoLbefore andaftertreatment...........................................................................87
5.3.6 Adverse events........................................................................................................87
5.4 Discussion.......................................................................................................................90
ChapterSix: Safety andEfficacy ofInhibitionofInterleukin-1 inInflammatory
DisordersandAA Amyloidosis..............................................................................................95
ChapterSix PartI: Interleukin-1 InhibitioninCryopyrin-AssociatedPeriodic Syndrome
–A 13-Year, Single-Centre Experience ofSafetyandEfficacy.........................................98
6.1.1 Background..................................................................................................................99
6.1.2. Aims...........................................................................................................................100
6.1.3 PatientsandMethods...............................................................................................100
6.1.3.1 Patientsandassessments..................................................................................100
6.1.3.2 Othermethods...................................................................................................101
6.1.4 Results.........................................................................................................................101
6.1.4.1 Whole cohortcharacteristics............................................................................101
6.1.4.2 General characteristicsofthe analysiscohort...............................................102
6.1.4.3 Clinicalcharacteristicsofthe analysiscohort................................................106
6.1.4.4 Efficacy ofanti-IL-1 therapy...........................................................................107
6.1.4.5 Non-respondersorinadequate responders...................................................111
6.1.4.6. Breakthroughsymptoms.................................................................................115
6.1.4.7 Quality oflife.....................................................................................................116
6.1.4.8 Safety...................................................................................................................122
6.1.5 Discussion..................................................................................................................122
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ChapterSix PartII: SafetyandEfficacy ofEmpiricalInterleukin-1 InhibitioninAA
AmyloidosisofUncertainAetiology....................................................................................126
6.2.1 Background................................................................................................................127
6.2.2 Aims............................................................................................................................128
6.2.3 PatientsandMethods...............................................................................................128
6.2.3.1 Patients................................................................................................................128
6.2.3.2 Othermethods...................................................................................................133
6.2.4 Results.........................................................................................................................133
6.2.4.1 Whole cohortcharacteristics............................................................................133
6.2.4.2 Response toanakinra........................................................................................133
6.2.4.3 Serial monitoring ofSAA.................................................................................133
6.2.4.4 Renal function....................................................................................................134
6.2.4.5 Monitoring ofamyloiddeposits......................................................................136
6.2.5 Discussion..................................................................................................................138
ChapterSeven: ChangingEpidemiology ofAA Amyloidosis–Clinical Observations
Over25 Yearsata SingleNational Referral Centre...........................................................140
7.1 Background...................................................................................................................141
7.2 Aims...............................................................................................................................142
7.3 Patientsandmethods...................................................................................................142
7.3.1 Patients...................................................................................................................142
7.3.2 Diagnosis................................................................................................................142
7.3.3 Othermethods......................................................................................................142
7.4 Results............................................................................................................................143
7.4.1 Whole-cohortcharacteristics..............................................................................143
7.4.2 Comparisonofcohorts........................................................................................144
7.5 Discussion.....................................................................................................................148
ChapterEight: TheClassical Acute Phase Protein-The Non-Pathogenic RoleofSerum
C-Reactive Protein..................................................................................................................150
8.1 Background...................................................................................................................151
8.2 Aims...............................................................................................................................152
8.3 SubjectsandMethods..................................................................................................152
8.3.1 Subjects..................................................................................................................152
8.3.2 Study investigationsandprocedures..................................................................152
8.3.3 Regulatory andEthical Aspects..........................................................................154
8.3.4 Othermethods......................................................................................................154
8.4 Results............................................................................................................................154
8.5 Discussion.....................................................................................................................160
ChapterNine: General Conclusions.....................................................................................163
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