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
Etiopathogenesis of PBC Autoimmunity? GENETIC FACTORS ENVIRONMENTAL FACTORS
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
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
Genome-wide association studies (GWAS) Pre GWAS GWAS 2007 Common variants Rare variants Dense arrays DNA sequencing RNA sequencing Other populations Genotype-Phenotype Families
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
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
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
Genome-wide association study in PBC 536 Canadian & US PBC vs. 1536 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
PBC gene list 2013 Increasing study size Pre-GWAS 2009 2010 2011 2012 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 - CD80 - - - Yes Yes NFKB1 - - - Yes - IL7R - - - Yes Yes CXCR5 - - - Yes - TNFRSF1A - - - Yes - TNFSF1 - - - - Yes POU2AF1 - - - - Yes
Sex chromosomes 22.3 22.2 22.1 21 11.4 11.2 11.3 21 11.3 11.2 11.2 12 X 22 23 25 26 27 28 Y
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
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
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
X chromosome preferential loss in PBC Informative cases PBC (n=21) Controls (n=27) Imbalanced ratio in 3 STR 8 (38%) 0 P value 0.001 Miozzo et al. Hepatology 2007
Y chromosome loss in male PBC Lleo et al. J Autoimmun 2012
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
Epigenetics of X chromosome in PBC PBC patients with high IgM levels show lower levels of CD40L promoter methylation Methylation level 1.0 0.5 *** *** *** *** *** *** *** *** *** *** normal IgM high IgM IgM (mg/ml) 1000 800 600 400 200 r 2 = 0.5448 p = 0.0011 0.0-363 -358-100 -95-71 -38-30 78 103 110 CpG sites 0 0.3 0.4 0.5 0.6 0.7 0.8 CD40L methylation level Lleo et al. Hepatology 2012
Sex chromosomes in PBC
GEOEPIDEMIOLOGY OF PBC Area Year Patients (No.) Prevalence (per mln) Incidence (per mln/yr) Age (years) Sex (M:F) Europe 1984 569 23 54 54 1:10 Sweden 1985 111 151 13.3 55 1:6 Newcastle, UK 1989 347 154 19 58 1:9 Ontario, Canada 1990 225 22 3.3 59 1:13 Victoria, Australia 1995 84 19 - - 1:11 Estonia 1995 69 27 2.3-1:22 Newcastle, UK 1997 160 240 22 66 1:10 Norway 1998 21 146 16-1:9 Minnesota, USA 2000 46 402 27-1:8 Newcastle, UK 2001 770 251 31-1:10 Victoria, Australia 2004 249 51-61 1:9 Japan 2005 9761 78 - - 1:9 Canada 2009 137 227 30 53 1:5
LOMBARDIA POPULATION Inhabitants at January 1st, 2010: 9.742.676 SEX Number Percentuage Female 2.073 69,8 Male 897 30,2 Total 2.970 100,0 M:F PBC RATIO = 1:2
DENMARK POPULATION Inhabitants at January 1, 2010: 5.534.738 SEX Number Percentage Female 584 80,9 Male 138 19,1 Totale 722 100,0 M:F PBC RATIO = 1:4
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 0.25.5.75 1 Survival from diagnosis 0 12 24 36 48 60 72 84 96 108 120 months Number at risk Femmine 2073 1746 1561 1409 1252 1066 912 753 608 432 233 Maschi 897 627 516 442 382 324 273 230 173 120 64 95% CI 95% CI Female Male 0.25.5.75 1 Survival from diagnosis 0 12 24 36 48 60 72 84 96 108 120 months Number at risk Femmine 584 485 401 340 278 230 177 120 78 40 3 Maschi 138 90 72 56 43 29 21 15 10 2 0 95% 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
RELATIVE SURVIVAL ANALYSIS
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)
Novel drugs for pruritus anti-autotaxin (?) Research nurse
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)