Autoimmunità e Vitamina D: quali evidenze?congresso2014.sibioc.it › dia › 8408.pdf ·...
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Autoimmunità e Vitamina D: quali evidenze?
Laura Andreoli U.O. Reumatologia e Immunologia Clinica
Spedali Civili di Brescia
Dipartimento di Scienze Cliniche e Sperimentali
Università degli Studi di Brescia
Vitamin D: the need for sunlight
Cholecalciferol
Calcidiol
Calcitriol Image modified from Holick, NEJM 2007
80%
20%
Serum levels of Vitamin D:
>30 ng/ml: sufficiency 10-30 ng/ml: insufficiency <10 ng/ml: deficiency
DOSED IN CLINICAL PRACTICE
BIOLOGICALLY ACTIVE FORM
Macrophages, dendritic cells, T cells & B cells express:
- Vit D receptor (VDR)
- key vitamin metabolizing enzymes:
• CYP27A1: 25-hydroxylase
• CYP27B1: 1--hydroxylase
1,25 (OH)2D3 binds to the
VDR in the cytoplasm. The
1,25 (OH)2D3 -VDR complex
enters the nucleus where it
binds to VITAMIN D
RESPONSIVE ELEMENTS
(VDRE) located on DNA
Vitamin D: from the Skeleton……
…….to the Immune System
Mora JR, et al. Nat Rev Immunol 2008; 8: 685-98
VDR POLYMORPHISMS
Vitamin D immunomodulatory properties
Image modified from Shoenfeld, Ann Rheum Dis 2007
Th1 and Th17 Response
Th2 Response
T regulatory
Differentiation
Proliferation
Antibody production
B cells
Tolerogenic properties of DCs
IFNalfa signature
Aranow C. J Invest Med 2011; 59:881-6. Ben-Zvi I et al, PLoS One 2010; 5:e9193
Ritterhouse LL et al, Ann Rheum Dis 2011; 70:1569-74.
Mathieu C et al, J Steroid Biochem Mol Biol 2004; 89-90:449-52.
Adorini L, Cellular Immunology 2005
Adorini & Penna, Nat Clin Pract Rheumatol 2008
Animal models of autoimmune diseases
Beneficial effects of VDR agonists treatment
EXPERIMENTAL
MODELS
MAIN EFFECT REFERENCES
ARTHRITIS Decreased incidence and severity of collagen-
induced or Lyme arthritis, also when given at
disease onset
Larsson 1998
Cantorna 1998
AUTOIMMUNE
DIABETES
Inhibition of insulitis and reduction of diabetes, even
when given after islet infiltration
Mathieu 1994&1995,
Casteels 1998,
Inaba 1992
EXPERIMENTAL
ALLERGIC
ENCEPHALOMYELITIS
Prevention and treatment of disease, inhibition of
relapses
Mattner 2000,
Lemire 1991,
Branisteanu 1995,
Nashold 2001
INFLAMMATORY
BOWEL DISEASE
Significant amelioration of symptoms, block of
disease progression
Cantorna 2000
PSORIASIS Inhibition of leukocyte activation and amelioration of
histological and clinical signs of disease in human
psoriatic skin grafts transplanted to SCID mice
Dam 1999
SYSTEMIC LUPUS
ERYTHEMATOSUS
Inhibition of proteinuria, prevention of skin lesions Koizumi 1995
Lemire 1992
274 162
99 57 229 199 151
935 European patients
Orbach H, et al., Ann.N.Y.Acad.Sci. 1109, 385-400; 2007
Vit D in autoimmune diseases
Antico A, Tozzoli R, Giavarina D, Tonutti E & Bizzaro N, Clin Rev Allergy Immunol 2012
Vit. D in the general population
Distribution of 25-OH vit.D
concentration
in 36,384 subjects
of the Northeast Italian
population
Mean vit.D level 21.7 ng/ml
Upper reference limits
9.4 – 43.7 ng/ml
Epidemiological studies on vit.D
in systemic and organ-specific autoimmune diseases
Agmon-Levin N et al., Clinic Rev Allerg Immunol 2012
AUTOIMMUNE DISEASE LOWER VIT.D
LEVELS vs.
HEALTHY
SUBJECTS
CORRELATION WITH
CLINICAL
MANIFESTATIONS OR
DISEASE ACTIVITY
VIT.D RECEPTORS
POLYMORPHISM
SYSTEMIC LUPUS ERYTHEMATOSUS + + +
ANTIPHOSPHOLIPID SYNDROME + + NR
RHEUMATOID ARTHRITIS + + +
SYSTEMIC SCLEROSIS + + NR
SJOGREN DISEASE Normal levels + NR
UNDIFFERENTIATED CONNECTIVE
TISSUE DISEASE + +/- NR
MIXED CONNECTIVE TISSUE DISEASE + NR NR
INFLAMMATORY MYOPATHIES Normal levels - NR
MULTIPLE SCLEROSIS + + +
AUTOIMMUNE THYROID DISEASE + + +
CELIAC DISEASE Normal levels - NR
DIABETES MELLITUS + + +
CROHN’S DISEASE + + +
PRIMARY BILIARY CIRRHOSIS + + +
AUTOIMMUNE SKIN DISEASES + NR NR
ALOPECIA AREATA + NR +
Autoimmunity Reviews 2012; 12:127-136
Autoimmunity Reviews 2012; 12:127-136
Low vit.D levels are
widespread in most
autoimmune diseases
Severe vit.D deficiency
(<10 ng/ml) is associated
with a more severe
disease course
Mechanism: loss of
immune tolerance in
subjects with predisposing
VDR polymorphisms
Observational
design,
uncontrolled
studies
Different type of
compound
Different dose
Different duration
of supplementation
Need for RCTs
No association
with the risk of
developing
Rheumatoid
Arthritis
Lower risk of
Multiple Sclerosis
in young white
subjects
Autoimmunity Reviews 2012; 12:127-136
Vitamin D intake & risk of developing autoimmune diseases:
Type 1 Diabetes Mellitus
INFANCY INTAKE MATERNAL INTAKE
The risk of T1DM was reduced in infants who were supplemented with vitamin D (pooled OR 0.71; 95% CI 0.60 to 0.84)
Dose-response effect Timing of supplementation: lower chances of developing T1DM if between 7
and 12 months of age rather than between 0 and 6 months
Vitamin D & Autoimmunity
Sjögren’s Syndrome
Neonatal Lupus (Congenital Heart Block)
Antiphospholipid Syndrome
Systemic Lupus Erythematosus
Novel aspects of Sjögren’s Syndrome in 2012
Vitamin-D levels were determined in 176 primary SS patients and 163 matched
healthy volunteers utilizing the LIAISON chemiluminescent immunoassays
(DiaSorin-Italy). Mean vitamin-D levels were comparable between SS
patients and controls (21.2±9.4ng/ml and 22.4±10ng/ml)
PHERIPHERAL NEUROPATHY
was diagnosed in 23% of SS
patients and associated with
lower vitamin-D levels
(18.6±5.5ng/ml vs. 22.6±8ng/ml
(p=0.04)).
LYMPHOMA was diagnosed in
4.3% of SS patients, who had
lower levels of vitamin-D,
13.2±6.25 ng/ml, compared to
SS patients without lymphoma
(22±8 ng/ml; p=0.03).
Agmon-Levin N, Kivity S, Tzioufas AG, López Hoyos M, Rozman B, Efes I, Shapira Y, Shamis A, Amital H, Youinou P, Shoenfeld Y:
Low levels of vitamin-D are associated with neuropathy and lymphoma among patients with Sjögren's syndrome. J
Autoimmun 2012, 39(3):234-9.
Fibroblast polarization in
myofibroblast and
collagen production
Myocardial
fibrosis
Proposed pathogenic mechanism of cardiac damage in Neonatal Lupus Buyon JP et al, Arthritis Rheum 2004; 50:173-82; Figure from Tincani A et al, Lupus 2006, 15: 1-7
Macrophages bind
opsonized cardiocytes
A greater proportion of children with CHB
were born during the summer.
This means that the gestational period of
enhanced CHB susceptibility (18-24 weeks
of gestation) occurred during January-
March, which was the time of the year in
which vitamin D levels were at their lowest.
The seasonal timing of the
pregnancy may be critical
to the onset of CHB and
vitamin D is possibly the
mediator of such seasonal
variations.
CHB and Vitamin D
Di Santo G, BMC Medicine 2012; 10:69
APRIL
OCTOBER
Vitamin D levels in APS
Agmon-Levin N, et al., Ann Rheum Dis. 2011; 70(1):145-50 EUROPEAN MULTICENTER STUDY
APS is close to SLE from a clinical, serological and
genetic point of view, but:
•patients are generally not advised to avoid sun
exposure and to use sunscreen;
•patients do not usually take corticosteroids or
other immunosuppressive drugs and therefore
Vitamin D supplementation is rare.
September December April
Se
rum
25
-OH
vit
. D
(n
g/m
l)
p<<0,01 p=0,03 p=ns
NORMAL SUBJECTS
(median value)
PAPS PATIENTS
(median value)
115 PAPS PATIENTS vs 128 NORMAL SUBJECTS
Rheumatology and Clinical
Immunology, Brescia – Italy
Lupus 2012; 21:736-40
Grouped
manifestations
Vit-D <15
ng/ml
Vit-D ≥15
ng/ml
p
Thrombotic 58% 42% 0.04
Pulmonary 42% 24% 0.02
Livedo reticularis
Skin ulcers
42%
26%
22.5%
8.5%
0.01
0.006
Neurologic 70% 54% 0.05
Ophthalmic 26% 10% 0.01
Obstetric 32.4% 41% NS
Arthritis, arthralgia 44% 45% NS
Hematologic 40% 37% NS
Renal 15% 11% NS
Cardiac/valvular 19.5% 15% NS
Thrombosis: the main clinical manifestation of APS
Any relationship with Vitamin D levels?
Agmon-Levin N, et al., Ann Rheum Dis. 2011; 70:145-50
SEPTEMBER
THROMBOSIS
(n=74) OBSTETRIC
DISEASE
(n=40)
P=0,01
se
rum
25
-OH
vit
. D
(n
g/m
l)
Rheumatology and Clinical Immunology, Brescia - Italy
A = anti- 2GPI (APS Patient 1)
B = anti- 2GPI (APS Patient 1) + 1,25 OH vitamin D 10 nM
C = anti- 2GPI (APS Patient 2)
D = anti- 2GPI (APS Patient 2) + 1,25 OH vitamin D 10 nM
E = control IgG
F = control IgG + vitamin D 10 nM (including ethanol)
A B C D E F
Tissue Factor expression
GAPDH expression
Vitamin-D inhibits anti- b2GPI mediated tissue factor expression
Agmon-Levin N, et al., Ann Rheum Dis. 2011; 70(1):145-50
1. Eritema malare
2. Rash discoide
3. Fotosensibilità
4. Ulcere orali
5. Artrite non erosiva
6. Sierosite (pleurite e/o pericardite)
7. Alterazioni renali (proteinuria o cilindruria)
8. Coinvolgimento neurologico (epilessia o psicosi)
9. Alterazioni ematologiche (anemia emolitica; leucopenia; linfopenia; piastrinopenia)
10. Alterazioni immunologiche: positività per anticorpi Anti-DNA nativo, Anti-Sm, Anti-fosfolipidi (Anti-cardiolipina, LAC)
11. Positività per anticorpi Anti-Nucleo (ANA).
Criteri classificativi Lupus Eritematoso Sistemico (LES): American College of Rheumatology (ACR) 1997
Almeno 4 di questi criteri
per la diagnosi di LES
Radiazioni UV
Cute
Chemochine Cellule Apoptotiche Cellule Necrotiche
Apoptosi
Antigene LE
IFN α IFN γ
Cellule T
pDC
Immagine modificata da Meller et al. Arthritis Rheum 2005; 52-1504
I pazienti con LES
vengono invitati a non
esporsi al sole e ad
applicare creme solari a
protezione totale.
IL LES e la mancata esposizione solare
SLE & Vit. D in human studies: contrasting results
POSITIVE RESULTS NEGATIVE RESULTS
CROSS-SECTIONAL STUDIES
Amital H, 2010
Wu PW, 2009
Wright TB, 2009
Borba VZC, 2009
Cutolo M, 2008
Thudy A, 2008
Kamen D, 2006
Birmingham DJ, 2012
Brescia cohort (in press)
Kim HA, 2011
Toloza SMA, 2010
Ruitz-Irastorza G, 2010
Chen S, 2007
Muller K, 1995
DISEASE ACTIVITY
CARDIOVASCULAR DISEASE
WINTER FLARES
Wu PW, 2009 (CV risk)
Przybelski RJ, 2007 (CV risk)
Reynolds, 2012 (vascular stiffness)
Moc CC, 2012
(subclinical atherosclerosis)
Winter flares are associated with lower vit.D levels
Winter FLARE
Winter REMISSION
Summer REMISSION
Rheumatology and Clinical Immunology, Brescia - Italy
SLE & Vit. D in PROSPECTIVE studies: contrasting results
POSITIVE RESULTS NEGATIVE RESULTS
Studio Terrier B. Aranow C. Abou-Raya A. Petri M.
Anno 2012 2012 2013 2013
N. di pazienti 24 57 267 1006
Metodo di supplementazione
Per 2 mesi 100.000 UI/sett D3, poi per 6 mesi 100.000 UI/mese D3
Per 3 mesi: • Gruppo 1: 2.000 UI/die D3 • Gruppo 2: 4.000 UI/die D3
Per 12 mesi: 2.000 UI/die D3
Per 32 mesi: 50.000 UI/sett D2 + 200 UI/2 volte die di calcio e D3
SLEDAI a T0 2
(media) <5
4,8 (media)
NR
Modificazioni in relazione alla supplementazione
Anti-dsDNA Riduzione
NR ma non diminuita l’espressione
genica dell’IFN
Riduzione Nessuna variazione
Complemento Nessuna
variazione Aumento Aumento
SLEDAI Nessuna
variazione Riduzione Riduzione
Ipercalcemia Nessun caso Nessun caso 2% 0,002 % (2 casi)
STUDIO PROSPETTICO di supplementazione in donne premenopausali con LES
CARDIOVASCULAR ASSESSMENT
(at baseline, 12 and 24 months)
• transtoracic echocardiography (assessment
of left ventricular and valvular function, in
addition to indexes of myocardial tissue
characterization)
• carotid ultrasound (with evaluation of carotid
intima-media thickness and local
distensibility)
• pulse wave velocity and analysis (carotid-
femoral) for large-artery stiffness
• ABPM
EVERY 3 MONTHS:
• 25-OH vitamin D, Intact PTH
• lupus activity (SLEDAI), including serology (anti-DNA,
C3, C4, CH50)
• serum calcium and phosphorus
EVERY 6 MONTHS:
• T regs (phenotype study): CD3+CD4+ (CD25highCD127low)
• central memory T cells (CM) CCR7+CD45Ra-
• effector memory T cells (EM) CCR7-CD45Ra-
• terminal differentiated effector memory (TDEM) CCR7-CD45Ra+
• CD28- T cells, an effector T subtype able to resist to apoptosis
(senescent cells) and to bypass regulation mediated by Treg
In collaborazione con Spedali Civili e Università degli Studi di Brescia
Laboratorio di Diagnostica Cardiovascolare – 2^Divisione di Medicina
Laboratorio di Immunologia e Patologia Generale
BASELINE 12 MONTHS 24 MONTHS
STANDARD REGIMEN
STANDARD REGIMEN
INTENSIVE REGIMEN
INTENSIVE REGIMEN
STANDARD REGIMEN: CHOLECALCIPHEROL 25.000 UI once a month (300.000 UI annually) INTENSIVE REGIMEN: CHOLECALCIPHEROL 300.000 UI starting bolus, 50.000 UI once a month (850.000 UI annually)
Efficacia della supplementazione
T12
STANDARD
28% sufficienti
INTENSIVO
75% sufficienti
p = 0,02 Test del Chi Quadrato
NESSUN CASO DI SUPERAMENTO DELLA SOGLIA DI TOSSICITÀ
Test di Mann-Whitney
34 donne con LES in età premenopausale
31,7
24,8 23,8 25,7 24,8
31,9
40,6
31,1 32,5 32,0
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
T1 T2 T3 T4 T5 T6 T7
25-O
H v
it. D
(n
g/m
l)
Tempo (mesi)
Livelli di 25-OH vit.D
STANDARD
INTENSIVO
T0 T3 T6 T9 T12
p = 0,38 p = 0,002
p = 0,0047
p = 0,0075 p = 0,047
Sicurezza della supplementazione
• Nessun caso di ipercalcemia • Nessun caso di soppressione del PTH • 3 casi di ipercalciuria transitoria, non sintomatica
T0 vs. T12
GRUPPO INTENSIVO
T0 vs. T3
PTH (pg/ml)
0
10
20
30
40
50
60
70
T0 T12 T0 T12
STD INT
PTH (pg/ml)
10
15
20
25
30
35
40
T0 T3
8,4
8,6
8,8
9
9,2
9,4
9,6
9,8
10
Ca sierico (mg/dl)
T0 T3
Ca urinario (mg/24h)
0
50
100
150
200
250
300
350
T0 T0 T12 T12
STD INT
Ca sierico (mg/dl)
7
7,5
8
8,5
9
9,5
10
10,5
T0 T12 T0 T12
STD INT
Effetti sui parametri sierologici e sull’attività di malattia
• T0 vs. T12: nessuna variazione significativa • Gruppo intensivo T0 vs. T3: nessuna variazione significativa • Standard vs. Intensivo (C3, C4 e CH50): nessuna differenza significativa • SLEDAI stabile nei 12 mesi di controllo
Anti ds-DNA (UI/ml)
0
10
20
30
40
50
60
70
T0 T12 T0 T12
STD INT
C3 (mg/dl)
50
60
70
80
90
100
110
120
130
T0 T0 T12 T12
STD INT
C4 (mg/dl)
0
5
10
15
20
25
30
T0 T0 T12 T12
STD INT
CH50 (%)
0
20
40
60
80
100
120
140
160
180
T0 T0 T12 T12
STD INT
PAZIENTI CLINICAMENTE SILENTI, SIEROLOGICAMENTE ATTIVE
Steiman A. J. et coll. Arthritis Care & Research 2012
IMMUNOMODULATORY PROPERTIES THAT REDUCE
AUTOIMMUNITY
ANIMAL MODELS
IN VITRO STUDIES
1, 25-OH Vitamin D (CALCITRIOL)
25-OH Vitamin D (COLECALCIPHEROL)
HUMAN STUDIES
VDR POLYMORPHISMS
NON-HYPERCALCEMIC
VDR AGONISTS (PARICALCITOL and
others) PREVENTION OR
TREATMENT OF THE DISEASE
DISCORDANT RESULTS ON THE EFFECTS ON DISEASE ACTIVITY AND SEVERITY
REPARTO e LABORATORIO
U.O. Reumatologia e Immunologia Clinica
Direttore: Prof.ssa Angela Tincani
Laboratorio di Diagnostica
Cardiovascolare –
2^Divisione di Medicina Generale
Laboratorio di Immunologia –
Dip. Medicina Molecolare e
Traslazionale
DiaSorin S.p.A.
Abiogen S.p.A.