hepatobiliary immunopathology unit ic davis, ca i · 1 pietro invernizzi primary biliary cirrhosis...

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Pietro Invernizzi

Primary biliary cirrhosis

Hepatobiliary Immunopathology UnitIRCCS Istituto Clinico Humanitas,

Rozzano, Italy

A.I.S.F., Rome, 25 February 2010

Dept of Internal MedicineUniversity of California,

Davis, CA

CI I IISTITUTO CLINICO

HUMANITAS

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Autoimmune liver diseasesPrimary target of immune-mediated injury

Primary biliary cirrhosis

Autoimmunehepatitis

CHOLANGIOCYTE HEPATOCYTE

OverlapsyndromePrimary sclerosing cholangitis

Invernizzi et al. Semin Liver Dis 2007

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Outline

Genetics/environment

Female/male

Target organ

Novel biomarkers

Novel drugs

?

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Etiopathogenesis of PBC

Autoimmunity

ENVIRONMENTALFACTORS

GENETICFACTORS

?

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Geo-epidemiology of PBC prevalence

Local clustering

Risk factors

Experimental evidence for a role of xenobiotics, infectious agents

ENVIRONMENTALFACTORS

GENETICFACTORS

Etiopathogenesis of PBC

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The 2005 US PBC Epidemiology Group Study

1032 patients with PBC from US tertiary referral centers

1041 random-digit dialed healthy controls matched for race, sex, and telephone area code

Gershwin et al. Hepatology 2005

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PBC Risk FactorsUSA PBC Epidemiology Study vs. previous studies

-WeakHair dye use

Suggested

Yes

Yes

-

No

Suggested

No

No

No

Yes

Yes

Yes

PREVIOUS STUDIES

NOT CONFIRMED / DEBATED

NOVEL

CONFIRMED

YesYearly income

YesFamilial SLE

YesFamilial Sjogren

No

No

No

Breast cancer

Psoriasis

Eczema

YesFrequent nail polish use

YesUse of HRT

YesPregnancies/Age

YesSmoking habit

YesRecurrent UTIs

YesFamilial PBC

2005 UPEG

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Familial clustering (high risk for

PBC development within a

family)

High concordance rate of PBC

in monozygotic twins

Polymorphisms associated with

susceptibility and progression

ENVIRONMENTALFACTORS

GENETICFACTORS

Etiopathogenesis of PBC

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Familial clustering (high risk

for PBC development within a

family)

High concordance rate of PBC

in monozygotic twins

Polymorphisms associated with

susceptibility and progression

ENVIRONMENTALFACTORS

GENETICFACTORS

Etiopathogenesis of PBC

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Country Year No. Of Familial ReferencePatients Prevalence

%

United States 1994 396 4.3 Bach

England 1995 736 1.33 Brind

England 1999 157 6.4 Jones

Sweden 1990 111 4.5 Danielsson

Italy 1997 156 3.8 Floreani

Japan 1999 156 5.1 Tsuji

United States 2005 1032 5.9 Gershwin

Familial PBC: epidemiological studies

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Familial clustering (high risk for

PBC development within a

family)

High concordance rate of

PBC in monozygotic twins

Polymorphisms associated with

susceptibility and progression

ENVIRONMENTALFACTORS

GENETICFACTORS

Etiopathogenesis of PBC

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PBC concordance rate in twins

MZ Twins

5 out of 8 pairs concordant for PBC (CR 0.63)

DZ Twins

No pair [out of 9] concordant for PBC (CR 0)

Selmi et al. Gastroenterology 2004

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Familial clustering (high risk for

PBC development within a

family)

High concordance rate of PBC

in monozygotic twins

Polymorphisms associated

with susceptibility and

progression

ENVIRONMENTALFACTORS

GENETICFACTORS

Etiopathogenesis of PBC

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Year Country Significant association with

1979 Spain DRw31983 Japan DR21987 England C4B21987 USA DR8 / DR5 (decreased in PBC)1990 USA DRw81991 Germany DRw8 / C4AQ01992 England DR81992 Denmark DR31993 Japan DQ3 / DPB1*0501 / DR52 (DRB3) decreased1994 Japan DRB1*0803 / DQA1*0103 / DQB1*06011994 USA DRB1*0801 / DRB1*0901 / DQA1*0401/0601

DQA1*0102 decreased / DQB1*0602 decreased1995 Germany DPB1*03012002 Sweden DRB1*0801 / DQB1*04022002 Canada DRB1*08 / DQB1*04

Polymorphisms of HLA genes

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Year Country Significant association with

1979 Spain DRw31983 Japan DR21987 England C4B21987 USA DR8 / DR5 (decreased in PBC)1990 USA DRw81991 Germany DRw8 / C4AQ01992 England DR81992 Denmark DR31993 Japan DQ3 / DPB1*0501 / DR52 (DRB3) decreased1994 Japan DRB1*0803 / DQA1*0103 / DQB1*06011994 USA DRB1*0801 / DRB1*0901 / DQA1*0401/0601

DQA1*0102 decreased / DQB1*0602 decreased1995 Germany DPB1*03012002 Sweden DRB1*0801 / DQB1*04022002 Canada DRB1*08 / DQB1*04

HLA DRB1*08

Polymorphisms of HLA genes

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HLA PBC Controls Pc Odds Ratio (95% C.I.)(n=186) (n=558)

(%) (%)

DRB1*08 6.7 5.3 N.S. - -

DRB1*11 10.7 27.6 0.000 0.3 0.2-0.5

Invernizzi et al. J Hepatol 2003

HLA polymorphisms in Italian PBC

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HLA polymorphisms in Italian PBCMulticenter Study

HLA PBC Controls Pc Odds Ratio (95% C.I.)(n=664) (n=1992)

(%) (%)

DRB1*08 7.2 2.3 0.000 3.3 2.4-4.5

DRB1*11 13.6 30.0 0.000 0.4 0.3-0.4

DRB1*13 8.6 11.2 0.000 0.7 0.3-0.9

Invernizzi et al. Hepatology 2008

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UK PBC Controls Pc Odds Ratio (95% C.I.)(n=412) (n=236)

DRB1*11 28% 47% 0.007 0.42 0.2-0.5DRB1*13 14% 20% 0.042 0.65 0.2-0.5

Donaldson et al. Hepatology 2006

FRANCE (n=358) (n=555)

DRB1*11 22% 38% 0.002 0.39 0.2-0.5DRB1*13 12% 17% 0.033 0.60 0.2-0.5

Poupon et al. Hepatology 2007 (abstract)

HLA protective variants

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Hirschfield et al. NEJM 2009

Genome-wide association study in PBC

536 Canadian & US PBC vs. 1536 controls (> 300.000 SNPs)

Risk variants:

HLA

IL12A

IL12RB2

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Risk variants:

HLA

IL12A

IL12RB2

IRF5

IKZF3/ORMDL3

SPIB

Manuscript submitted

536 Canadian & US PBC vs. 1536 controls (300K SNPs)

PLUS 457 Italian PBC vs. 947 controls (1Mb SNPs)

Genome-wide association study in PBC

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HLA protection against infections

DRB1*11 human immunodeficiency virus PNAS 1994;91:11472Ann Intern Med 1990;112:3J Immunol 1999;162:6942

hepatitis C virus Gastroenterology 1997;113:1675Genes Immun 2004;5:237

human papilloma viruses J Gen Virol 1999;80 ( Pt 2):399

DRB1*13 human immunodeficiency virus J Clin Invest 2001;107:505

hepatitis B virus N Engl J Med 1995;332:1065J Hepatol 1997;26:503

hepatitis C virus Hepatology 2001;33:224

human papilloma viruses Virus Res 2002;89:229

malaria Nature 1991;352:595

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Risk variants:

HLA

IL-12A

IL-12RB2

IRF5

IKZF3/ORMDL3

SPIB

Manuscript submitted

536 Canadian & US PBC vs. 1536 controls (300K SNPs)

PLUS 457 Italian PBC vs. 947 controls (1Mb SNPs)

Genome-wide association study in PBC

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Antigenstimulation

p35

p40

IL-12P70

Dendriticcell

p19

p40

IL-23

IL12

Rββ ββ2

IL12

Rββ ββ1

IL23

R

IL12

Rββ ββ1

IL-12 IL-23

STAT4 STAT3

STAT4

+ +

TH1 cell T H17 cell Modified fromHepatology 2009;50:1347

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Female preponderance

Sex chromosomes

22.3

22.1

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11.4

11.2

11.3

21

2223

25262728

11.2

11.211.3

12

X

Y

22.2

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Sex chromosomes and PBC

A considerable number of sex- and immune-related genes are located within the X chromosome

Major disorders of X chromosome, such as X-linked immunodeficiencies, Turner’s syndrome, as well as premature ovarian failure, may be accompanied by autoimmune features and by chronic cholestasis

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X monosomy in PBC

FISH on peripheral blood cell nuclei of a woman with PBC

A B

Pink dye: chromosome 15 Green dye: X chromosome

Invernizzi et al. Lancet 2004

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X chromosome monosomyIn autoimmune diseases

Monosomy X(%)

PBC (n=100) 5.2 ± 1.7

Scleroderma (n=44) 6.2 ± 0.26

AI thyroiditis (n=44) 4.3 ± 0.26

Chronic Hep C (n=50) 3.2 ± 1.5

Healthy (n=73) 2.9 ± 0.20

Invernizzi et al. Lancet 2004Invernizzi et al. J Immunol 2005

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X chromosome preferential loss in PBC

Miozzo et al. Hepatology 2007

0.001

8 (38%)

0

PBC

(n=21)

Controls

(n=27)

P valueImbalanced ratio

in ≥3 STR

Informative cases

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The X chromosome in PBC: a unifying hypothesis

Haploinsufficiency related to X monosomy and preferential loss

unmasks PBC susceptibility genes

Miozzo et al. Hepatology 2007

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Target organ of autoimmune aggression

Cholangiocytes

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Apotopes and the biliary specificity of PBC

*

*

Apoptoticcells

Untreatedcells

HeLa

*

HIBEC

Human keratinocytes

**

Lleo et al. Hepatology 2009

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Manuscript submitted

Biliary apotopes and AMA activate innate immune responses in PBC

PBC Healthy controls

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Serum biomarkers

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• More widespread resort to laboratory examinations led to PBC being diagnosed with increasing frequency during the earliest disease stages, when patients are asymptomatic and have not yet entered a phase of progressive bilirubin or Mayo score elevation

• New prognostic indicators are needed for asymptomatic patients

Natural history models in PBC

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Prognostic role of AMA in PBCLiver failure-free survival

Invernizzi et al. Hepatology 1997

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PBC-specific ANA

Rim like

Invernizzi et al. Semin Liver Dis 2005

Nuclear-dot

Sp100 and PMLNuclear porecomplex (NPC)gp210 and p62

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YES1%65%Greece/Spain

2005

YES1%19%Italy2003

YES0%26%Japan 2003

YES3%27% Italy2001

YES0% 27%Japan 1996

NO15%30%US1994

NO-29%France1990

NO0.7%53%Spain1988

Association withmore advanced

disease

Prevalencein Controls

(n)

Prevalencein PBC

(n)

CountryYear

Cross-sectional studies of the clinical significance of anti-NPC in PBC

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Prognostic role of anti-NPC in PBCMoratlity rate

Wesierska-Gadek et al. Hepatology 2006

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Therapy

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THERAPY – Recommendations (I)

Patients with PBC, including those with asymptomatic disease, should be treated with UDCA (13-15 mg/kg/d) (I / A1) on a long-term basis (II-2 / B1).

Favorable long-term effects of UDCA are observed in patients with early disease and in those with good biochemical response (II-2 / B1) which should be assessed after one year. A good biochemical response after one year of UDCA treatment is currently defined by a serum bilirubin < 1 mg/dL (17 mmol/L), AP <3 x ULN and AST < 2 x ULN (“Paris criteria”) or by a decrease of 40% or normalization of serum AP (“Barcelona criteria”) (II-2 / B1).

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THERAPY – Recommendations (II)There is currently no consensus on how to treat patients with a suboptimal biochemical response to UDCA . One suggested approach is the combination of UDCA and budesonide (6 to 9 mg/d) in non-cirrhotic patients (stage 1-3) (III / C2). Further studies of this and other combination regimes should be a priority.

Liver transplantation should be strongly considered in patients with advanced disease as reflected by serum bilirubin exceeding 6 mg/dL (103 µmol/L) or decompensated cirrhosis with an unacceptable quality of life or anticipated death within a year due to treatment-resistant ascites and spontaneous bacterial peritonitis, recurrent variceal bleeding, encephalopathy or hepatocellularcarcinoma (II-2 / A1).

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Murine models for PBC

dnTGFββββRII Ae2(a.b)-deficient

Gastroenterology2008;134:1482

J Immunol2006;177:1655

Xenobioticon C57BL/6

N. Aromaticivoranson NOD 1101

Cell Host Microbe2008;3:304

Hepatology2008;48:531

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Anti-CD20 (Rituximab) for PBC

dnTGFββββRII Anti-CD20

less severe cholangitis

Moritoki et al. Hepatology 2009

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Anti-CD20 (Rituximab) for PBC

dnTGFββββRII Anti-CD20

less severe cholangitis

Moritoki et al. Hepatology 2009

Xenobioticon C57BL/6

more severe cholangitis

Manuscript submitted

Anti-CD20 Xenobiotic

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Anti-IL-6R (Tocilizumab) for PBC

dnTGFββββRII

Elevated serum levels of IL-6

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Anti-IL-6R (Tocilizumab) for PBC

dnTGFββββRII IL-6-/-

dnTGFββββRII

Elevated serum levels of IL-6

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Anti-IL-6R (Tocilizumab) for PBC

dnTGFββββRII IL-6-/-

more severe cholangitis

Hepatology 2010 in press

dnTGFββββRII

Elevated serum levels of IL-6

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Hepatobiliary Immunopathology Unit

MEMBERSIRCCS Istituto Clinico HumanitasMauro PoddaFrancesca BernuzziIlaria BianchiCarlo SelmiLisa CaliariAna Lleo

San Paolo HospitalAndrea CrosignaniPier Maria BattezzatiEmanuela BertoliniChicca CamisascaPaola ZermianiMassimo Zuin

COLLABORATORSDomenico Alvaro (Rome ITA)Gianfranco Alpini (US)Antonio Benedetti (Ancona ITA)Ulrich Beuers (Holland)Kirsten Boberg (Norway)Dimitrios Bogdanos (UK)Eric Gershwin (US)Tom Karlsen (Norway)Keith Lindor (US)Haiying Liu (China)Ian Mackay (Australia)Marco Marzioni (Ancona ITA)Ken Setchell (US)Atsushi Tanaka (Japan)Diego Vergani (UK)Ren-Qian Zhong (China)

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Thank you