Dr Allister Grant

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The extra-intestinal manifestations of IBD

• Dr Allister Grant
• Consultant Hepatologist
• University Hospitals Leicester

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Aims

• Ease you in
• Explain the adhesion cascade
• Explain how adhesion molecules introduce tissue
  specific homing properties to activated
  lymphocytes
• Experimental data/techniques
• Anti-adhesion/inflammation strategies in IBD

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Inflammatory Bowel Disease
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Erythema Nodosum
Pyoderma Gangrenosum
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Episcleritis
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Ankylosing spondylitis
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Cirrhosis
Expanded Portal Tracts (Blue)
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BACKGROUND
Inflammatory Bowel Disease and
PSC Incidence of IBD 3-9 per 100
000 Prevalence of IBD 40-200 per 100
000 2-10 of patients with IBD will subsequently
develop PSC 70 of patients with PSC have
evidence of IBD 20-40 of patients with end
stage PSC develop
cholangiocarcinoma
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Lymphocytes on endothelium
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The Adhesion Cascade
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Margination of Lymphocytes
Blood
Endothelium
Tissue
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Endothelial Cell
PNAd mucin
P-selectin
E-selectin
L-selectin
CLA mucin
PSGL-1 mucin
LYMPHOCYTE
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2. Lymphocyte Activation
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Chemokine family of cytokines

• Small 8 - 12 kD proteins
• Over 50 human chemokines
• Produced by many cell types
• Secreted in large quantities
• Rapid effect on target cells by activating
  specific G-protein linked receptors
• Ability to trigger adhesion in seconds

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Chemokines
a-sub family
b-sub family
C
C
CXC
CC
C
C
IL-8 ENA-78 GRO
MCP-1 MIP-1a MIP-1b RANTES
IP-10 HuMIG ITAC
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Proteoglycans in the endothelial glycocalyx
retain and present chemokines to lymphocytes
Integrin activation Cytoskeletal reorganisation
Migration
Lymphocyte
Endothelium
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3. Firm Adhesion
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Endothelial Cell
VCAM-1
ICAM-1
a
b
Inactive integrin
Active LFA-1
Active a4ß1
LYMPHOCYTE
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Activation signal
Arrest of Lymphocytes on Integrins
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Ctyoskeletal Rearrangement
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Adhesion cascade
Blood Flow
Lymphocyte
Endothelium
Transmigration
Tethering Rolling
Arrest Activation
Selectins Integrins
Integrins Chemokine receptors
Chemokine receptors
Chemokines
Addressins Chemokines
Carbohydrate ligands Addressins
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Thymocytes
BLOOD
THYMUS
Naïve T cells
TISSUE
LYMPH NODE
DC
DC
BLOOD
Memory lymphocytes
Effector T cells
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TISSUE SPECIFIC HOMING OF MEMORY EFFECTOR T
LYMPHOCYTES
I Weissman, E Butcher, C Mackay, S Shaw and S
Jalkanen
TISSUE
BLOOD
BLOOD
Lymph Node
Naïve T cell
Memory T cell
Gut
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Tissue specific T cell recruitment
Memory/effector T cell
Naïve T cell CCR7 L-selectin
CCR4 CLA
CCR9 a4b7
PNaD CCL21(SLC)
E-selectin CCL17(TARC)
MAdCAM-1 CCL25(TECK)
LYMPH NODE
SKIN
GUT
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Blood Flow
Lymphocyte
Endothelium
Tethering Rolling
Activation
Arrest
CCR5
VAP-1 receptor
VAP-1 receptor
?
?
CCR5 ligands
glycocalyx
VAP-1
VAP-1
Liver
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EXPRESSION OF VAP-1 IN HUMAN ENDOTHELIUMSalmi et
al. J. Ex. Med.1993 McNab et al Gastro 1996
NORMAL INFLAMED LIVER vascular
sinusoidal LYMPH
NODE GUT _
KIDNEY SKIN
_ SYNOVIUM _
BRAIN _
_ HEART
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MAdCAM-1 Expression in PSC Liver Grant et al
Hepatology 2001, Hillan et al Liver 1999
Positive Staining of Portal Vascular Endothelium
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ACT-1(a4b7) STAINING OF PSC LIVER
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Immunofluorescent Staining of a Portal Vessel in
PSC
MAdCAM-1 (red)
a4b7 (green)
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Adhesion Assay Under Conditions of Shear Stress
Media reservoir
37?C Incubator
Cell sample
Microslide
Microscope
Syringe pump
2-way electronic valve
Video/computer analysis system
www.expertreviews.org
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Lymphocyte rolling
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Lymphocyte Transmigration
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Adhesion Assays Under Conditions of Shear Stress
100
90
80
70
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Adhesion of PSC PBL
as of Control
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40
30
20
10
0
Control
MAdCAM-1
a4b7
CD62L
Target of Blocking Monoclonal Antibody
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Tissue specific T cell recruitment
CCR9 a4b7
CXCR3 VAP-1r
VAP-1 IP-10
MAdCAM-1 CCL25(TECK)
NORMAL LIVER
GUT
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A
B
C
D
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CCL25
?-actin
Western Immunoblotting for CCL25.
P PSC NL Normal PB PBC ALD
Alcoholic Liver Disease
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Tissue specific T cell recruitment
CCR9 a4b7
CXCR3 VAP-1r
VAP-1 IP-10
MAdCAM-1 CCL25(TECK)
NORMAL LIVER
GUT
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Summary

• Populations of memory lymphocytes arise as a
  consequence of bowel inflammation and these cells
  express homing receptors that direct their
  subsequent migration not only to the gut but also
  to the liver.
• Long-lived cells may re-circulate to the liver
  for many years and, in the absence of a local
  activating stimulus, will not cause damage.

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Summary

• If lymphocytes are subsequently activated in the
  liver this leads to the development of
  inflammation and tissue damage which promotes the
  recruitment of more mucosal lymphocytes resulting
  in persistent inflammation and disease.
• Recent findings that MAdCAM-1 and CCL25,
  previously thought to be restricted to the gut,
  are up-regulated in the liver during inflammatory
  liver diseases that complicate IBD support the
  concept that common mechanisms control lymphocyte
  recruitment to the inflamed liver and gut

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IL-2
Th1 Response
IL-12
IL-18
TNF-a
Pro-inflammatory
Regulatory cytokines
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CD3
aLb2
Flow
Leukocyte
Gut Endothelium
ICAM-1 ICAM-2
IL-2
Th1 Response
IL-12
IL-18
CD3CD4/8
TNF-a
Pro-inflammatory
IL-10
IL-11
Regulatory cytokines
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Abstracts from America
PSC and Crohns disease 2 patients with colonic
CD Rx with infliximab GGT 486 232 GGT
446 193 ALP 979 669 ALP 1377 408 ALT 188 52 ALT
106 49 AST 221 92 AST 154 51
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a4b7
a4b1
MAdCAM-1 VCAM-1
IL-2
Natulizamab LDP-02 MLN-02
Th1 Response
IL-12
IL-18
TNF-a
Pro-inflammatory
Regulatory cytokines
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a4b7
a4b1
MAdCAM-1 VCAM-1
Daclizumab Basiliximab
IL-2
Th1 Response
IL-12
J695
IL-18
TNF-a
Pro-inflammatory
IL-10
IL-11
IL-10 Lactobacillus Lactis
Regulatory cytokines
Numega
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a4b7
a4b1
MAdCAM-1 VCAM-1
IL-2
Th1 Response
IL-12
CD3CD4/8
IL-18
TNF-a
Visilizumab
Pro-inflammatory
Regulatory cytokines
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This is not the end. This is not even the
beginning of the end. But it is, perhaps, the end
of the beginning Winston Churchill(1942)