Regulatory T Cells and Oxidative Stress in Minimal Change Nephropathy

Published on 02/05/2016 by admin

Filed under Nephrology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 3.2 (26 votes)

This article have been viewed 3411 times

Ref.
TNFα
IL2
IL1β
IL4
IL6
IL8
IL10
IL12
IL13
IFN-γ
Surany et al. [14]
Serum +
Serum −
Serum −
           
Garin et al. [19]
         
Cell mRNA +
                 
Serum +
       
Bustos et al. [15]
Cells +
 
 
         
Neuhaus et al. [17]
 
Serum −
 
PBMC +/−
 
PBMC −
     
PBMC −
PBMC +
               
Matsumoto et al. [51]
             
PBMC +
                 
MCN, IgA
   
Cho et al. [18]
     
PBMC +
           
Araya et al. [16]
PBMC +
T cell −
     
PBMC +
T cell −
mRNA −
PBMC −
PBMC −
 
PBMC +
               
B cells are target of anti-CD20 monoclonal antibodies that have been recently introduced with success in the treatment of MCN with rituximab given very early in the course of the disease [911]. Considering we did not definitely recognize cell target of RTX, data coming from rituximab should be view as if something modified by this drug plays a role. The effect on Th17 is an example [20] (see below).
Finally, an interplay between T and B cells is demonstrated by recent observations on CD80. CD80 (also known as B7-1) is a co-stimulatory molecule expressed by both B cells and other antigen-presenting cells that interacts with CD28/CTLA-4 expressed on activated T cells and on regulatory T cells (Tregs) [21, 22]. Incidentally, CD80 is also expressed by podocytes under inflammatory stimuli and its urinary levels are increased in MCN patients [23]. Data from Garin and colleagues [24] suggested that urinary CD80 in MCN comes from the glomeruli that do not exclude ultrafiltration. Activation of podocyte CD80 is not unique to MCN since it is also described in patients with diabetic nephropathy [25]. The message coming from this study is that an interaction between T cells and B cells may constitute a main feature of MCN suggesting more studies must be devoted to characterize circulating cell expression especially after rituximab.

7.3 Innate Immunity/Oxidative Stress

Findings in animal models and in humans more directly suggest an involvement of innate immunity associated with a Treg imbalance. Experimental models of nephrotic syndrome may be induced in mice and rats utilizing molecules deriving from natural killer (NK) cell stimulation such as LPS [23] or by oxidants such as Adriamycin (ADR) and puromycin aminonucleoside (PAN) that mimic in some way free radicals produced in the first phases of innate immunity [2629]. We also know that activated Treg infusion can reverse proteinuria and renal lesions in several models of nephrotic syndrome [3032, 33], which implies a main role of regulatory mechanisms in this model. The interplay among innate immunity, oxidant stress, and modulation of Treg activity suggests the discussion of all the different aspects in successive steps.

7.3.1 Animal Models Suggest Innate Immunity/ROS Activity

The suggestion about a pathogenetic role of both innate immunity and reactive oxygen species (ROS) in MCN derives from studies carried out in experimental models that reproduce, in the acute phase, minimal glomerular lesions and then evolve to more structured glomerulosclerosis. PAN and ADR are two compounds that can be classified as oxidants and have been for years utilized to induce proteinuria in rats [27, 28]. Metabolic studies and protection by antioxidants support an entirely oxidative stress in these models. Infusion of lipopolysaccharide (LPS) induces transient proteinuria in mice [23]. This model of proteinuria is of interest for studying the immunomodulatory link since LPS upregulates B7-1, a co-stimulatory molecule expressed by B cells and by other antigen-presenting cells that serves as signal for T cells. Mice lacking B7-1 are protected from LPS proteinuria [23] that suggests this is the mechanism for LPS nephropathy. In spite of transient proteinuria, LPS nephropathy is characterized by progressive signs of renal involvement resulting in glomerulosclerosis that mimics in some way the natural history of patients with MCN. Findings in humans with posttransplant recurrence of glomerulosclerosis treated with abatacept, the inhibitor of B7-1 molecule [34, 35], support the same conclusion. Connected with the B7-1 story is the possibility that the direct activation of B7-1 in podocyte by an inflammatory trigger producing LPS is the true mechanism for proteinuria and is independent of T or B cells. Experiments in severe combined immunodeficiency (SCID) mice, missing both cell lineages but still developing proteinuria after LPS, are central to this demonstration [23]. Overall, this conflicts with the general idea of a circulating factor and contributes to maintain unsolved clues that require further explanations.

7.3.2 Neutrophils in MCN Produce More Oxidants

Polymorphonuclear leukocytes (PMN) in children affected by INS produce high quantities of oxidants. Results indicate that soluble factors deriving from circulating cells regulate oxidant production and that this regulatory circuit is altered in MCN [36]. It has been proposed that Treg and probably B cells play a key role in the regulation of oxidant production by PMNs. The evidence for Tregs comes from a unique observation in a child with INS associated with immune dysregulation, polyendocrinopathy, enteropathy x-linked (IPEX) syndrome that is due to loss of function mutation of forkhead box P3 (Foxp3), a transcriptional factor specific to Tregs that makes these cells functionally negative [36]. Oxidant production in this child was 100 times higher during exacerbation of clinical symptoms and restored a near normal level in remission. On the side of B cells, there is the finding that rituximab decreased ROS production by 60 % [36].
Studies by Bertelli and colleagues [37] showed that the percentage of Tregs (CD39+CD4+CD25+) was markedly reduced in patients with nephrotic syndrome. It was also noted that generation of oxidants by PMN was indirectly correlated with the amount of CD39 on Tregs. Apyrase (CD39) is the key enzyme that transforms ATP into adenosine, the latter metabolite playing an inhibitory role on oxidant production. Overall, this indicated a key function of Tregs in modulating the oxidative stress in MCN (see below).
An indirect confirmation of these findings comes from the observation that, concomitant with proteinuria, a significant part of serum albumin is oxidated in MCN patients. Candiano and colleagues studied serum albumin in children with MCN by mean of mass spectrometry and showed that albumin is highly oxidized during the proteinuric phase. The site of oxidation was shown to be a free cystein of the albumin sequence 31Cys that was chemically transformed in a sulfonic group upon oxidation [38, 39].

7.4 Regulatory T Cell Balance and MCN

7.4.1 Tregs Are Involved in Experimental MCN

Tregs could be involved in MCN as a second step in a cascade where the first hit remains unidentified. The evidence of a Treg involvement in MCN is entirely based on results coming from experimental nephrosis (i.e., in Buffalo/Mna rats and in ADR nephrosis that are two recognized models of chronic proteinuria leading to glomerulosclerosis and renal failure) [31, 40]. More recently, experimental data have been expanded to LPS nephropathy (see above) and some unexpected results to new pathogenic horizons [33]. Le Berre and colleagues [31] utilized Buffalo/Mna rats that spontaneously develop glomerulosclerosis showing that pre- and posttransplant proteinuria was reduced by infusion of Tregs; regression of the nephropathy was obtained as well. Several authors reported the same protective role of Tregs in ADR nephrosis that was mediated by adenosine or by direct infusion of FOXP3-transduced T cells [41].
IL2 has been utilized to enhance Treg proliferation and lifespan. To escape from bystander effects of this cytokine due to its wide-ranging action, the association of IL2 and anti-IL2 antibodies has demonstrated as a valid stratagem to improve its in vivo selectivity toward Treg population [42, 43]. In this case the binding of the cytokine to the α and β receptor chains, which are present on the CD8 and NK cell surface, is inhibited by preferential binding of anti-IL2, whereas the γ receptor chain, uniquely expressed by activated CD4+ (or effector T cell (Teff)) and by Treg cells, remains available for IL2 recognition and activity. The administration of low doses of IL2 coupled to this specific antibody was indeed proven to induce high levels of Tregs, being ineffective on CD8, on NK, and also on Teff counterpart. Polhill and colleagues [32] induced Treg expansion by IL2/anti-IL2 antibodies in rats with ADR nephrosis and documented improvement of renal function, reduced inflammation, and less pathologic injury. More articulated are the results of the study by Bertelli and colleagues [33] who utilized the same approach with IL2/ anti-IL2 antibodies in mice with LPS nephropathy. In fact, IL2/anti-IL2 antibody administration in mice exposed to LPS had no effect on the progression of the resulting renal damage, enhancing significantly peripheral tissue Treg levels, whereas IL2 infused alone elicited some protection despite less Tregs. Therefore, these results partially contradict a direct role of Tregs (higher after IL2/anti-IL2 administration) and supported hitherto undefined mechanisms.

7.4.2 Functional Characteristics of Tregs: Modulator or Targets of Innate Immunity

Several of the molecules described in the context of MCN participate in Treg regulation. A description of regulatory compounds and functions may simplify the comprehension of pathology.
Tregs are a dynamic cell population whose levels can be rapidly modified and made active, with alternative functions, in any inflammatory context [44]. At equilibrium, Treg concentration in periphery is low, but when necessary they are produced from nonactivated T conventional (Tconv) cells through induction of FOXP3 in CD4+. Tconv can also differentiate into activated CD4+ CD25+ cytotoxic cells (Teff) by IL2. Mature Tregs play a bifunctional role: the first is to switch off the inflammatory burst by means of anti-inflammatory cytokines (IL10) and/or by adenosine deriving from ATP (see below) and the second is that pro-inflammatory cytokine is activated by IL17 that induces a Th17 phenotype [45]. Therefore, there are at least three cell subsets (e.g., Treg/Teff/Th17), all deriving from the same progenitor, that play antagonistic effects and determine the thin limit between inflammation and normal status: when Teff/Tregs or Th17/Tregs is high, the signal is to maintain inflammation, and, vice versa, when Tregs are higher than Teff and Th17, inflammation is switched off [46]. Co-stimulatory molecules, CD80 and CD86 (also known as B7-1 and B7-2, respectively), play a key role in this balance by interacting with CD28 that is expressed on both Teff and Tregs and with CTLA-4, a second ligand only present on activated T cell and on Tregs [47]. By interacting with CD28, CD80 and CD86 ligands induce proliferation of Tregs, and, alternately, by interacting with CTLA-4, CD80 suppress Treg function. The presence of two receptors on Tregs is suggestive for a feedback regulation in which these cells are switched on or off upon alternative stimulation of CD28 and CTLA-4 [48].

7.5 ATP: A Pleiotropic Molecule

ATP is from a time considered a “danger sensor” depending on its extracellular concentration that varies from a nanomolar to a micromolar range [49, 50]. Two main mechanisms modify ATP levels and drive the cell response. The first mechanism is based on a simultaneous presence of CD39 and CD73 on the surface of Tregs that together produces the potent immunosuppressive adenosine from ATP. Being CD39 and CD73 simultaneously present only on Tregs, it is clear that these cells have the power to blunt inflammation.
Purinergic receptors P2X and P2Y located on the surface of immune cells represent the second mechanism for the ATP regulatory functions. At low ATP concentrations, P2x7R promotes dendritic cell maturation and IL10 secretion thus enhancing immune suppression [49, 50]; at micromolar concentrations, P2x7R promotes the inflammatory cascade driven by the nucleotide-binding oligomerization domain receptor family (NLRP3) and that finishes with IL1-β secretion.
Results by Bertelli and colleagues [37] of the analysis of ATP metabolism in MCN that included P2x7 expression by PMN and their regulation showed a major protection elicited by both apyrase and antagonists of ATP. Attempts to limit oxidant generation with adenosine analogs (2’-chloroadenosine and 5’-N-ethylcarboxamidoadenosine) produced minor effects. Overall, results highlighted CD39+CD4+CD25+ expression and impairment of ATP degradation in MCN.

7.6 Conclusions

Given the increasing number of studies supporting the decisive role of mature Tregs and of their regulatory molecule panels in experimental MCN, it is possible that, in a near future, the passage will be from bench to bedside. One possibility could be infusion of Tregs in human beings. In spite this seems an achievable goal, direct cell infusion could contain some difficulties. Using ancillary mediators of Treg function is another possibility. Infusion of IL2 at low amount has been already utilized in human beings and is an opportunity. Another strategy is the use of specific P2x7R antagonists that downregulate the inflammasome; given their anti-inflammatory properties, these molecules have been tested in many experimental diseases as potential therapeutic agents and are being currently challenged in preclinical studies for pathologies affecting the central nervous system other than rheumatic diseases. MCN should come later, given the possibility of well-defined therapies and the recent use of rituximab.
References
1.
Vincenti F, Ghiggeri GM. New insights into the pathogenesis and the therapy of recurrent focal glomerulosclerosis. Am J Transplant. 2005;5:1179–85.CrossRefPubMed
2.
Pollak MR. Familial FSGS. Adv Chronic Kidney Dis. 2014;21:422–5.PubMedCentralCrossRefPubMed
3.
KDIGO. Clinical practice guideline for glomerulonephritis. Kidney Int. 2012;2:181–5.CrossRef
4.
Shalhoub RJ. Pathogenesis of lipoid nephrosis: a disorder of T-cell function. Lancet. 1974;2:556–60.CrossRefPubMed
5.
Karras A, de Montpreville V, Fakhouri F, Grunfeld JP, Lesavre P. Renal and thymic pathology in thymoma-associated nephropathy: report of 21 cases and review of the literature. Nephrol Dial Transplant. 2005;20:1075–82.CrossRefPubMed
6.
Koenecke C, Ukena SN, Ganser A, Franzke A. Regulatory T cells as therapeutic target in Hodgkin’s lymphoma. Expert Opin Ther Targets. 2008;12:769–82.CrossRefPubMed
7.
Koyama A, Fujisaki M, Kobayashi M, Igarashi M, Narita M. A glomerular permeability factor produced by human T cell hybridomas. Kidney Int. 1991;40:453–60.CrossRefPubMed
8.
Lama G, Luongo I, Tirino G, Borriello A, Carangio C, Salsano ME. T-lymphocyte populations and cytokines in childhood nephrotic syndrome. Am J Kidney Dis. 2002;39:958–65.CrossRefPubMed
9.
Ravani P, Magnasco A, Edefonti A, et al. Short-term effects of rituximab in children with steroid- and calcineurin-dependent nephrotic syndrome: a randomized controlled trial. Clin J Am Soc Nephrol. 2011;6:1308–15.PubMedCentralCrossRefPubMed
10.
Ravani P, Ponticelli A, Siciliano C, et al. Rituximab is a safe and effective long-term treatment for children with steroid and calcineurin inhibitor-dependent idiopathic nephrotic syndrome. Kidney Int. 2013;84:1025–33.CrossRefPubMed
11.
Ravani P, Rossi R, Bonanni A, et al. Rituximab in children with steroid-dependent nephrotic syndrome: a multicenter, open-label, noninferiority, randomized controlled trial. J Am Soc Nephrol. 2015. doi:10.​1681/​ASN.​2014080799.
12.
Lai KW, Wei CL, Tan LK, et al. Overexpression of interleukin-13 induces minimal-change-like nephropathy in rats. J Am Soc Nephrol. 2007;18:1476–85.CrossRefPubMed
13.
Liu LL, Qin Y, Cai JF, et al. Th17/Treg imbalance in adult patients with minimal change nephrotic syndrome. Clin Immunol. 2011;139:314–20.CrossRefPubMed
14.
Suranyi MG, Guasch A, Hall BM, Myers BD. Elevated levels of tumor necrosis factor-alpha in the nephrotic syndrome in humans. Am J Kidney Dis. 1993;21:251–9.CrossRefPubMed
15.
Bustos C, Gonzalez E, Muley R, Alonso JL, Egido J. Increase of tumour necrosis factor alpha synthesis and gene expression in peripheral blood mononuclear cells of children with idiopathic nephrotic syndrome. Eur J Clin Invest. 1994;24:799–805.CrossRefPubMed
16.
Araya C, Diaz L, Wasserfall C, et al. T regulatory cell function in idiopathic minimal lesion nephrotic syndrome. Pediatr Nephrol. 2009;24:1691–8.PubMedCentralCrossRefPubMed
17.
Neuhaus TJ, Wadhwa M, Callard R, Barratt TM. Increased IL-2, IL-4 and interferon-gamma (IFN-gamma) in steroid-sensitive nephrotic syndrome. Clin Exp Immunol. 1995;100:475–9.PubMedCentralCrossRefPubMed
18.
Cho BS, Yoon SR, Jang JY, Pyun KH, Lee CE. Up-regulation of interleukin-4 and CD23/Fcepsilon RII in minimal change nephrotic syndrome. Pediatr Nephrol. 1999;13:199–204.CrossRefPubMed
19.
Garin EH, Blanchard DK, Matsushima K, Djeu JY. IL-8 production by peripheral blood mononuclear cells in nephrotic patients. Kidney Int. 1994;45:1311–7.CrossRefPubMed
20.
van de Veerdonk FL, Lauwerys B, Marijnissen RJ, et al. The anti-CD20 antibody rituximab reduces the Th17 cell response. Arthritis Rheum. 2011;63:1507–16.CrossRefPubMed
21.
Abbas AK, Sharpe AH. T-cell stimulation: an abundance of B7s. Nat Med. 1999;5:1345–6.CrossRefPubMed
22.
Henry J, Miller MM, Pontarotti P. Structure and evolution of the extended B7 family. Immunol Today. 1999;20:285–8.CrossRefPubMed
23.
Reiser J, von Gersdorff G, Loos M, et al. Induction of B7-1 in podocytes is associated with nephrotic syndrome. J Clin Invest. 2004;113:1390–7.PubMedCentralCrossRefPubMed
24.
Garin EH, Diaz LN, Mu W, et al. Urinary CD80 excretion increases in idiopathic minimal-change disease. J Am Soc Nephrol. 2009;20:260–6.PubMedCentralCrossRefPubMed
25.
Fiorina P, Vergani A, Bassi R, et al. Role of podocyte B7-1 in diabetic nephropathy. J Am Soc Nephrol. 2014;25:1415–29.PubMedCentralCrossRefPubMed
26.
Bertelli R, Ginevri F, Gusmano R, Ghiggeri GM. Cytotoxic effect of adriamycin and agarose-coupled adriamycin on glomerular epithelial cells: role of free radicals. In Vitro Cell Dev Biol. 1991;27A:799–804.CrossRefPubMed
27.
Ginevri F, Gusmano R, Oleggini R, et al. Renal purine efflux and xanthine oxidase activity during experimental nephrosis in rats: difference between puromycin aminonucleoside and adriamycin nephrosis. Clin Sci (Lond). 1990;78:283–93.CrossRef
28.
Ghiggeri GM, Cercignani G, Ginevri F, et al. Puromycin aminonucleoside metabolism by glomeruli and glomerular epithelial cells in vitro. Kidney Int. 1991;40:35–42.CrossRefPubMed
29.
Marshall CB, Pippin JW, Krofft RD, Shankland SJ. Puromycin aminonucleoside induces oxidant-dependent DNA damage in podocytes in vitro and in vivo. Kidney Int. 2006;70:1962–73.CrossRefPubMed
30.
Le Berre L, Godfrin Y, Gunther E, et al. Extrarenal effects on the pathogenesis and relapse of idiopathic nephrotic syndrome in Buffalo/Mna rats. J Clin Invest. 2002;109:491–8.PubMedCentralCrossRefPubMed
31.
Le Berre L, Bruneau S, Naulet J, et al. Induction of T regulatory cells attenuates idiopathic nephrotic syndrome. J Am Soc Nephrol. 2009;20:57–67.PubMedCentralCrossRefPubMed
32.
Polhill T, Zhang GY, Hu M, et al. IL-2/IL-2Ab complexes induce regulatory T cell expansion and protect against proteinuric CKD. J Am Soc Nephrol. 2012;23:1303–8.PubMedCentralCrossRefPubMed
33.
Bertelli R, Di Donato A, Cioni M, et al. LPS nephropathy in mice is ameliorated by IL-2 independently of regulatory T cells activity. PLoS One. 2014;9:e111285.PubMedCentralCrossRefPubMed
34.
Yu CC, Fornoni A, Weins A, et al. Abatacept in B7-1-positive proteinuric kidney disease. N Engl J Med. 2013;369:2416–23.PubMedCentralCrossRefPubMed
35.
Alachkar N, Carter-Monroe N, Reiser J. Abatacept in B7-1-positive proteinuric kidney disease. N Engl J Med. 2014;370:1263–4.PubMed
36.
Bertelli R, Trivelli A, Magnasco A, et al. Failure of regulation results in an amplified oxidation burst by neutrophils in children with primary nephrotic syndrome. Clin Exp Immunol. 2010;161:151–8.PubMedCentralPubMed
37.
Bertelli R, Bodria M, Nobile M, et al. Regulation of innate immunity by the nucleotide pathway in children with idiopathic nephrotic syndrome. Clin Exp Immunol. 2011;166:55–63.PubMedCentralCrossRefPubMed
38.
Musante L, Candiano G, Petretto A, et al. Active focal segmental glomerulosclerosis is associated with massive oxidation of plasma albumin. J Am Soc Nephrol. 2007;18:799–810.CrossRefPubMed
39.
Bruschi M, Grilli S, Candiano G, et al. New iodo-acetamido cyanines for labeling cysteine thiol residues. A strategy for evaluating plasma proteins and their oxido-redox status. Proteomics. 2009;9:460–9.CrossRefPubMed
40.
Wang YM, Zhang GY, Wang Y, et al. Foxp3-transduced polyclonal regulatory T cells protect against chronic renal injury from adriamycin. J Am Soc Nephrol. 2006;17:697–706.CrossRefPubMed
41.
Wang YM, Zhang GY, Hu M, et al. CD8+ regulatory T cells induced by T cell vaccination protect against autoimmune nephritis. J Am Soc Nephrol. 2012;23:1058–67.PubMedCentralCrossRefPubMed
42.
Boyman O, Kovar M, Rubinstein MP, Surh CD, Sprent J. Selective stimulation of T cell subsets with antibody-cytokine immune complexes. Science. 2006;311:1924–7.CrossRefPubMed
43.
Kim MG, Koo TY, Yan JJ, et al. IL-2/anti-IL-2 complex attenuates renal ischemia-reperfusion injury through expansion of regulatory T cells. J Am Soc Nephrol. 2013;24:1529–36.PubMedCentralCrossRefPubMed
44.
Josefowicz SZ, Lu LF, Rudensky AY. Regulatory T cells: mechanisms of differentiation and function. Annu Rev Immunol. 2012;30:531–64.CrossRefPubMed
45.
Koenen HJ, Smeets RL, Vink PM, van Rijssen E, Boots AM, Joosten I. Human CD25highFoxp3pos regulatory T cells differentiate into IL-17-producing cells. Blood. 2008;112:2340–52.CrossRefPubMed
46.
Noack M, Miossec P. Th17 and regulatory T cell balance in autoimmune and inflammatory diseases. Autoimmun Rev. 2014;13:668–77.CrossRefPubMed
47.
Gardner D, Jeffery LE, Sansom DM. Understanding the CD28/CTLA-4 (CD152) pathway and its implications for costimulatory blockade. Am J Transplant. 2014;14:1985–91.CrossRefPubMed
48.
Chen L, Flies DB. Molecular mechanisms of T cell co-stimulation and co-inhibition. Nat Rev Immunol. 2013;13:227–42.PubMedCentralCrossRefPubMed
49.
Di Virgilio F. Purinergic signalling in the immune system. A brief update. Purinergic Signal. 2007;3:1–3.PubMedCentralCrossRefPubMed
50.
Di Virgilio F, Borea PA, Illes P. P2 receptors meet the immune system. Trends Pharmacol Sci. 2001;22:5–7.CrossRefPubMed
51.
Matsumoto et al. Clin Exp Immunol. 1999;117(2):361–7.