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Département Hospitalo-Universitaire AUToimmune and HORmonal diseaseS Uth rs DHU DIABETES ADRENAL DISEASES VASCULITIDES L’immunomodulation du diabète. Quelles applications? quel avenir ?
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Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Jul 19, 2018

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Page 1: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Département Hospitalo-Universitaire

AUToimmune and HORmonal diseaseS

Uth rs

DHU

DIABETES

ADRENAL DISEASES

VASCULITIDES

L’immunomodulation du diabète. Quelles applications? quel avenir ?

Page 2: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

TYPE 1 DIABETES MELLITUS

• insulitis

Gepts W 1965, Diabetes

Gianani R 2010, Diabetologia

b cell selectivity

an autoimmune disease

• islet cell autoantibodies

Bottazzo & Doniach 1974, Lancet

anti-GAD

anti-IA2

anti-insulin

anti-ZnT8

increasing incidence ( 3-4%/year) & geographical

incidence variation (> 65/105/year in Finland)

0

20

40

60

1921 50s 1972 1992

incid

en

ce [

105/y

ear]

absence of a unique environmental factor

genes

environment numerous

numerous

Page 3: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Allegheny County

childhood-onset (< 18) T1D registry

diagnosed 1965-79

Secrest et al. Diabetes 2010

acute

renal

cardio

vascular

infections

cancer

n = 1075

age

Controls

mortality rate

/10 3 person-yr

standardized

mortality rate

0-4 1.4880 2.0

5-9 0.1511 3.7

19-14 0.2218 4.6

15-19 0.7166 3.3

20-24 0.8752 2.3

25-29 0.9381 4.5

30-34 1.1388 6.3

35-39 1.4270 3.3

0-4 1.2640 0.0

5-9 0.1550 0.0

19-14 0.1289 4.6

15-19 0.2802 5.8

20-24 0.2927 3.2

25-29 0.3477 4.6

30-34 0.5285 5.1

35-39 0.7086 2.7

Skrivarhaug et al. Diabetologia 2006 [Norway]

T1D MORTALITY

3.9

4.0

increased mortality compared to

the general population

Intermediate disease compared

to high risk autoimmune diseases

Page 4: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

TYPE 1 DIABETES: A CHRONIC DISEASE ß

ce

ll m

as

s

diabetes

hyperglycemia

Bingley et al. Diabetologia 2006 heterogeneity

patient duration of

diabetes

diabetes

recurrence Insulitis ICA

1 22 years 60 days CD8+ T cells -

2 17 years 44 days CD8+ T cells -

3 27 years 92 days CD8+ T cells +

Page 5: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

b cell

GRZ/perforin

APC

Cl II

Cl I Cl II

TNF-a, IFN-g… T CD4

autoantibodies

NKT

CD1d

IL-4, IFN-g…

NK

NKG2D/MIC

IFN-g…

T reg

IL-10, TGF-b

TYPE I DIABETES

Pancreatic islet

Page 6: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

b cell

GRZ/perforin

APC

Cl II

Cl I Cl II

TNF-a, IFN-g… T CD4

TYPE I DIABETES

Pancreatic islet

immunosuppression

b cell mass restoration

graft

regeneration

insulin replacement

therapy

tolerance induction

Page 7: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

b cell

GRZ/perforin

APC

Cl II

Cl I Cl II

TNF-a, IFN-g… T CD4

TYPE I DIABETES

Pancreatic islet

cyclosporin A

azathioprine + corticoids

anti-thymoglobulin ± corticoids

anti-CD3

autoantibodies

anti-CD20

[Rituximab]

anti-TNFa

[Etanercept]

IL1 antagonists

[Anakinra]

intensive

Insulin

therapy

nicotinamide

Page 8: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

TREATMENT OF DIABETES WITH ANTI-CD3

Herold KC et al. 2002, N Engl J Med

+0.20 ± 1.86 nmol/l

per month

-5.52 ± 1.30 nmol/l

per month

Page 9: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Keymeulen B et al. 2005, N Engl J Med

months months months

n = 40 (placebo) n = 40 (anti-CD3)

TREATMENT OF DIABETES WITH ANTI-CD3

Page 10: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Keymeulen B et al. N Engl J Med 2005

TREATMENT OF DIABETES WITH ANTI-CD3

Page 11: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

b cell

GRZ/perforin

APC

Cl II

Cl I Cl II

TNF-a, IFN-g… T CD4

TYPE I DIABETES

Pancreatic islet

insulin

GAD IA2,ZnT8 DiaPep277

T reg

IL-10, TGF-b

extrinsic T cell tolerance

peptides

intrinsic T cell tolerance • anergy

• changes in gene expression profiles

low-dose IL-2

Rapamycin/IL-2

Page 12: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

84 228 first and second degree relatives

3152 autoantibody positive

5 year risk > 50% in 372/2103

randomization to

observation (n = 70)

versus

s.c. insulin twice daily 0.25 units/kg (n = 69)

mean follow up 3.7 years

TREATMENT OF PREDIABETES WITH INSULIN

s.c./i.v. & oral insulin (DPT1, 2002, N Engl J Med)

Nasal insulin (Näntö-Salonen, 2008, Lancet)

Page 13: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

103391 first and second degree relatives

3483 autoantibody positive

5 year risk 26-50% in 388/2103

randomization to

oral insulin 7.7 mg/24h (n = 186, mean IAA 382 ± 555 nU/ml)

versus

placebo (n = 186, mean IAA 346 ± 336 nU/ml)

TREATMENT OF PREDIABETES WITH ORAL INSULIN

Diabetes Prevention Trial-Type 1

Skyler J et al Diabetes Care 2005

6.4%/year

8.2%/year

IAA ≥ 80 nU/ml

6.2%/year

10.4%/year

Page 14: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Ludvigsson et al, N Engl J Med, 2008

n = 35

n = 34

20 mg GAD-alum days 1 & 30

within 6 months following onset

response to GAD up to 15 months

IL-5/-10/-13/-17/IFNg/TNFa

~ IL-6/-12

GAD-induced expression of

FoxP3 & TNFa

GAD VACCINATION IN RECENT-ONSET T1D

[Intention to treat analysis]

Page 15: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

TrialNet intervention studies: within 100 days from diagnosis

• Anti-IL1β [Canakinumab]

• CTLA-4 Ig [Abatacept] in Recent Onset Diabetes

• Glutamic acid decarboxylase (GAD) in New Onset T1DM

• Metabolic Control in New Onset Diabetes

• Rituximab Study (Anti-CD20)

• Mycophenolate mofitil / dacliumab (MMF/DZB) study

http://www.diabetestrialnet.org: accessed 1st March, 2014.

TrialNet prevention studies • Oral insulin for prevention of Type 1 diabetes Study

• Anti-CD3 [Teplizumab] for prevention in relatives

• CTLA4-Ig [Abatacept] for prevention in relatives

• The Nutritional Intervention to Prevent Type 1 diabetes Study

Page 16: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

T CD8

b cell

T CD4 TNF-a, IFN-g…

APC

TYPE 1 DIABETES T CELLS TO DIABETES PREVENTION

Page 17: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

CHAINE B

MALLVHFLPLLALLALWEPKPTQAFVKQHLCGPHLVEALYLVCGERGFFYTPK SRREVEDPQVEQLELGGSPGDLQTLALEVARQKRGIVDQCCTSICSLYQLENYCN

MALWMRFLPLLALLFLWESHPTQAFVKQHLCGSHLVEALYLCGERGFFYTPM SRREVEDPQVAQLELGGGPGAGDLQTLALEVAQQKRGIVDQCCTSICSLYQLENYCN

B9-23

PEPTIDE C CHAINE A

TRREAED 61LQVGQVELGG 71GPGAGSLQPL 81ALEGSLQKRG 91IVEQCCTSIC101SLYQLENYCN

HUMAN INSULIN

1MALWMRLLPL11LALLALWGPD 21PAAA FVNQHL 31CGSHLVEALY 41LVCGERGFFY 51TPK

PEPTIDE SIGNAL

Page 18: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

peptide sequence class I allele

2-11

ALWMRLLPLL

A2

A24

ALWMRLLPLL B8

6-14 RLLPLLALL

A2

RLLPLLALL A26

6-16 RLLPLLALLAL

A2

14-23 LALWGPDPAA

A2

LALWGPDPAA A26

15-24 ALWGPDPAAA

A2

ALWGPDPAAA A26

Toma et al, PNAS 2005; Diabetes 2009

peptide sequence HLA class I

34-42 HLVEALYLV A2

38-46 ALYLVCGER

A3

A11

39-48 LYLVCGERGF A24

41-50

LVCGERGFFY A1

LVCGERGFFY

A3

A11

42-51

VCGERGFFYT A1

VCGERGFFYT A2

VCGERGFFYT B8

VCGERGFFYT B18

44-51

GERGFFYT A1

GERGFFYT B8

45-53 ERGFFYTPK A3

49-57 FYTPKTRRE B8

51-61 TPKTRREAEDL B8

CLASS I ALLELE-SPECIFIC PEPTIDES

Page 19: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

peptide binding % CD8+ IFN♂ response

10-4

M 10-6

M long

standing

recent

onset

total

34-42* 58% 37% 2/4 4/10 6/14

6-14* 36% 65% 7/13 1/4 8/17

6-16* 96% 71% 5/15 2/4 7/19

14-23* 44% 36% 7/13 0/4 44%

15-24* 96% 94% 7/13 1/4 8/17

Toma et al, PNAS2005; Toma et al. Diabetes 2009

CD8+ T CELL RESPONSE TO A2-RESTRICTED PREPROINSULIN PEPTIDES [ELISPOTassay]

CD8+ IFN♂ response

long

standing

recent

onset

total

2/4 4/10 6/14

7/13 1/4 8/17

5/15 2/4 7/19

7/13 0/4 7/17

7/13 1/4 8/17

* Val42

, L14

, L16

, A23

& A24

were identified as C-terminal residues

generated by proteasome digestion in vitro.

** 6-14

or

6-16

immunization

anti-6-14

or

anti-6-16

T cell clones

cross-reactives responses

to 6-14 and 6-16

Page 20: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

class I preproinsulin peptide

A2.1 2-11

A2.1 6-14

A2.1 15-24

A2.1 30-39

A2.1 33-42

A2.1 34-42

A2.1 42-51

A2.1 101-109

controls PDHase 2008-216 MATA2 58-66 Nef

83-91

b cells

TCD8+

TETRAMER RECOGNITION OF BLOOD CD8+ T CELLS

class I

peptide

biotin

streptavidin

100

101

102

103

104

100

101

102

103

104

Dt1A5 TTM A2 PPIh_Dt1A5 TTM A2 33-42.fcsÉCD3+ CD8+

PerCP-A: CD8 PerCP-A

PE

-A: T

TM

PE

-A

0.810 0.79

99.20

100

101

102

103

104

100

101

102

103

104

Dt1A5 TTM A2 PPIh_Dt1A5 TTM A2 6-14.fcsÉCD3+ CD8+

PerCP-A: CD8 PerCP-A

PE

-A: T

TM

PE

-A

0.0370 0.037

1000

100

101

102

103

104

100

101

102

103

104

25-01-08_D124D 6-14.fcsÉCD3+ CD8+

PerCP-A: CD8 PerCP-A

PE

-A: T

TM

PE

-A

0.60 0.54

99.60

Sandrine Luce

TCD8+

A2.1-restricted peptides

Luce et al. Diabetes 2011

Page 21: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Luce et al. Diabetes 2011

central memory T cells effector memory T cells

single cell PCR

A2.1-restricted peptides

TETRAMER RECOGNITION OF BLOOD CD8+ T CELLS

Page 22: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

s.c./i.v. & oral insulin (DPT1, 2002, N Engl J Med)

Nasal insulin (Näntö-Salonen, 2008, Lancet)

NEW PRECLINICAL T1D MODELS

insulin/A2.1/DQ8 mice

YES

Insulin

A2.1

DQ8 genes

OUF

A2/DQ8 Tg Human insulin

x

Luce et al. unpublished

♂ ♂ ♀ ♀

YES

YES Col

Col

Intraperitoneal glucose tolerance test

AU

C m

g.h

/dL

beta cell mass

mg

Page 23: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

DIABETES IN RIP-B7 TRANSGENIC YES MICE

T cell

Age (weeks)

dia

be

tes (

%)

% t

ota

l is

lets

non diabetic diabetic

CD4

CD

8

CD11b

CD

11

c

CD19

TC

R♂

dapi anti-glucagon anti-CD3

RIP-B7 YES B7.2

CD28

CD4

MHC

TCR

Luce et al. unpublished

Page 24: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

DIABETES IN RIP-B7 TRANSGENIC YES MICE

BrDU proliferation assay CD8+ IFNγ Elispot assay

CD8+ TMr+ expansion assay

Luce et al. unpublished

Page 25: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

FROM PALLIATIVE TREATMENT TO PREVENTION OF TYPE 1

DIABETES

diabetes

T CD4

APC

T CD8

NKT NK

T reg

B

damaged

islet of Langerhans

FROM RESEARCH TO CLINIC

diagnosis immunotherapy

YES mice

Luce S et al. Diabetes 2011 Carlier et al. PloSOne 2012

Class II-restricted epitopes

modified by inclusion of a

thiol-disulfide oxidoreductase

motif within flanking residues

Immunotherapy

EU FP7 project

HLA peptide

autoantigen

T diagnostics

prediabetes

Uth rs

DHU

Page 26: Uth rs DIABETES DHU ADRENAL DISEASES VASCULITIDES … · A2.1 6-14 A2.1 15-24 A2.1 30-39 A2.1 33-42 A2.1 34-42 A2.1 42-51 A2.1 101-109 controls PDHase 2008-216 MATA2 58-66 Nef 83-91

Département Hospitalo-Universitaire

AUToimmune and HORmonal diseaseS

Uth rs

DHU

DIABETES

ADRENAL DISEASES

VASCULITIDES

Andrea Toma Sandrine Luce

Etienne Larger Roberto Mallone

François Lemonnier

Agnès Lehuen

Sylvianne Muller, Jean Paul Briand (CNRS, Strasbourg)

Decio Eizirik (Brussels)

Charbel Masaad (Paris)

Laurent Drouot,

Olivier Boyer (Rouen)