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1 Société Tunisienne d Immunologie Cirrosi biliare primitiva Pietro Invernizzi Liver Unit Center for Autoimmune Liver Diseases Humanitas Clinical and Research Center Rozzano, Italy Dept of Internal Medicine University of California, Davis, CA AMEA, Bologna, 7 October 2013

2 Etiopathogenesis of PBC Autoimmunity? GENETIC FACTORS ENVIRONMENTAL FACTORS

3 Etiopathogenesis of PBC Geo-epidemiology of PBC prevalence Local clustering GENETIC FACTORS ENVIRONMENTAL FACTORS Risk factors Experimental evidence for a role of xenobiotics, infectious agents

4 Etiopathogenesis of PBC Familial clustering (high risk for PBC development within a family) High concordance rate of PBC in monozygotic twins Polymorphisms associated with susceptibility and progression GENETIC FACTORS ENVIRONMENTAL FACTORS

5 Genome-wide association studies (GWAS) Pre GWAS GWAS 2007 Common variants Rare variants Dense arrays DNA sequencing RNA sequencing Other populations Genotype-Phenotype Families

6 Center for Autoimmune Liver Diseases AIH (n = 70) PSC (n = 80) PBC (n = 250) BASIC Raggi, PhD Bernuzzi, PhD Lleo, MD PhD * Mascheroni, Student Correnti, Student * Basic and clinical activities TRANSLATIONAL / CLINICAL Ceriani, MD Covini, MD Bianchi, MD PhD Lleo, MD PhD * Caliari, MD, Resident Sogno, PhD, Data manager Cortellazzi, Research nurse Podda, Senior consultant

7 Research lines Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis (Cholangiocarcinoma) BASIC Genetics/Epigenetics Immunology Neuroendocrine Carcinogenesis New drugs TRANSLATIONAL / CLINICAL Biomarkers Clinical trials Epidemiology

8 IRCCS Istituto Clinico Humanitas, Rozzano, Italy Università degli Studi di Milano, Milan, Italy San Raffaele Scientific Institute, Milan, Italy Gradenigo Hospital, Turin, Italy University of Padova, Padova, Italy Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy University of Bologna, Bologna, Italy Università di Palermo, Palermo, Italy Azienda Ospedaliera Universitaria Pisana, Pisa, Italy University Sapienza of Rome, Rome, Italy University of Florence, Florence, Italy Università Politecnica delle Marche, Ancona, Italy University of Milan-Bicocca, Monza, Italy University of Bari, Bari, Italy University of Trieste, Trieste, Italy Ospedale Fatebene Fratelli e Oftalmico, Milan, Italy Ospedale Niguarda, Milan, Italy Santa Croce Carle Hospital, Cuneo, Italy University of Udine, Udine, Italy University of Genoa, Genoa, Italy Azienda Ospedaliero-Universitaria di Parma, Parma, Italy Treviglio Hospital, Treviglio, Italy Desio Hospital, Desio, Italy Magenta Hospital, Magenta, Italy Università degli Studi di Napoli Federico II, Napoli, Italy Department of Internal Medicine, AO Lecco, Lecco, Italy AO Valduce, Como, Italy Ospedale di Negrar, Verona, Italy 2004 Italian PBC Genetic Study Group

9 Genome-wide association study in PBC 536 Canadian & US PBC vs controls (300K SNPs) PLUS 457 Italian PBC vs. 947 controls (1Mb SNPs) Risk variants: HLA IL12A IL12RB2 IRF5 IKZF3/ORMDL3 SPIB Liu & Invernizzi Nature Genetics 2010

10 PBC gene list 2013 Increasing study size Pre-GWAS Gene Loci Canada/US Italy- Canada/US UK Japan HLA Yes Yes Yes Yes Yes IL12A - Yes Yes Yes - IL12RB2 - Yes Yes Yes - IRF5/TNPO3 - Yes Yes Yes - ORMDL3/IKZF3 - Yes - Yes Yes MMEL1 - Yes - Yes - SPIB - Yes Yes Yes - DENND1B - - Yes Yes - CTLA-4 Yes STAT4 - Yes - Yes - CD Yes Yes NFKB Yes - IL7R Yes Yes CXCR Yes - TNFRSF1A Yes - TNFSF Yes POU2AF Yes

11 Sex chromosomes X Y

12 Sex chromosomes and PBC A considerable number of sex- and immunerelated 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

13 X monosomy in PBC FISH on blood cell nuclei of a woman with PBC A B Pink dye: chromosome 15 Green dye: X chromosome Invernizzi et al. Lancet 2004

14 X chromosome monosomy In 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 2004 Invernizzi et al. J Immunol 2005

15 X chromosome preferential loss in PBC Informative cases PBC (n=21) Controls (n=27) Imbalanced ratio in 3 STR 8 (38%) 0 P value Miozzo et al. Hepatology 2007

16 Y chromosome loss in male PBC Lleo et al. J Autoimmun 2012

17 The sex chromosomes in PBC: a unifying hypothesis Haploinsufficiency related to X monosomy, preferential loss, and Y chromosome loss unmasks PBC susceptibility genes Miozzo et al. Hepatology 2007

18 Epigenetics of X chromosome in PBC PBC patients with high IgM levels show lower levels of CD40L promoter methylation Methylation level *** *** *** *** *** *** *** *** *** *** normal IgM high IgM IgM (mg/ml) r 2 = p = CpG sites CD40L methylation level Lleo et al. Hepatology 2012

19 Sex chromosomes in PBC

20 GEOEPIDEMIOLOGY OF PBC Area Year Patients (No.) Prevalence (per mln) Incidence (per mln/yr) Age (years) Sex (M:F) Europe :10 Sweden :6 Newcastle, UK :9 Ontario, Canada :13 Victoria, Australia :11 Estonia :22 Newcastle, UK :10 Norway :9 Minnesota, USA :8 Newcastle, UK :10 Victoria, Australia :9 Japan :9 Canada :5

21 LOMBARDIA POPULATION Inhabitants at January 1st, 2010: SEX Number Percentuage Female ,8 Male ,2 Total ,0 M:F PBC RATIO = 1:2

22 DENMARK POPULATION Inhabitants at January 1, 2010: SEX Number Percentage Female ,9 Male ,1 Totale ,0 M:F PBC RATIO = 1:4

23 SURVIVAL LOMBARDIA Female: 89% (CI 88%-91%) at 1 year 77% (CI 75%-78%) at 5 years 67% (CI 65%-70%) at 10 years Male: 78% (CI 75%-80%) at 1 year 55% (CI 52%-59%) at 5 years 47% (CI 43%-51%) at 10 years Survival from diagnosis months Number at risk Femmine Maschi % CI 95% CI Female Male Survival from diagnosis months Number at risk Femmine Maschi % CI 95% CI Female Male DENMARK Female: 90% (CI 87%-92%) at 1 year 73% (CI 69%-77%) at 5 years 60% (CI 53%-67%) at 10 years Male: 72% (CI 63%-79%) at 1 year 42% (CI 32%-51%) at 5 years 27% (CI 14%-43%) at 10 years

24 RELATIVE SURVIVAL ANALYSIS

25 Clinical trials PBC Anti-CXCL10 (IP-10) antibody NOVIMMUNE (phase 2a) Anti-IL 12 antibody (Stelara) J&J (phase 2) FXR agonist (Obeticholic acid) INTERCEPT (phase 3) Inhibition of CD28-CD80 interaction (RhuDex) MEDIGENE (phase 2a) PSC Monoclonal Antibody Against Lysyl Oxidase Like 2 (LOXL2) (Sintuzumab) GILEAD (phase 2a) NASH Monoclonal Antibody Against Lysyl Oxidase Like 2 (LOXL2) (Sintuzumab) GILEAD (phase 2a)

26 Novel drugs for pruritus anti-autotaxin (?) Research nurse

27 Liver Unit & Center Autoimmune Liver Diseases Humanitas Clinical and Research Center, Rozzano (Milan) MEMBERS COLLABORATORS Mauro Podda Ana Lleo Ilaria Bianchi Lisa Caliari Roberto Ceriani Giovanni Covini Chiara Raggi Francesca Bernuzzi Ilaria Sogno Chiara Cortellazzi Domenico Alvaro (Italy) Gianfranco Alpini (USA) Antonio Benedetti (Italy) Ulrich Beuers (Holland) Kirsten Boberg (Norway) Dimitrios Bogdanos (UK) Eric Gershwin (USA) Tom Karlsen (Norway) Keith Lindor (USA) Haiying Liu (China) Ian Mackay (Australia) Marco Marzioni (Italy) Ken Setchell (USA) Atsushi Tanaka (Japan) Diego Vergani (UK) Renqian Zhong (China)

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