L E W I S H . K U L L E R , M D , D R P H
P R O F E S S O R E M E R I T U S
T H U R S D A Y , M A Y 7 , 2 0 1 5
To Cytokine or Not to Cytokine
1
Definition of Cytokine
Taber’s Cyclopedic Medical Dictionary, 22nd ed, 2013
2
The acute phase response is the name
given to a characteristic pattern of
alterations in the concentrations of
plasma proteins that occurs following
a wide variety of different forms of
inflammation.
Kuller LH et al. Relation of C-reactive protein and coronary heart disease in the MRFIT nested case-control study. Am J Epidemiol 1996;144:537-47
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WHI Talk 5-2015
Cytokines are Produced by Several Inflammatory and Vascular Cells
IL-12 and IL-18, produced by
macrophages (Mac), are
potent inducers of IFN-γ and
promote the differentiation of
naïve T cells into
proatherogenic Th1 cells.
Macrophage-derived cytokines
activate SMC and EC to
produce an array of
proinflammatory mediators.
On the other hand, the
antiinflammatory cytokines
IL-10 and TGF-β, also
produced by macrophages,
promote antiatherogenic Treg
cell differentiation. Other
antiinflammatory mediators
with potent antiatherogenic
properties include 33,
IL-1ra, and IL-18 binding protein
(IL-18BP). In naive CD4+ T
cells from mice, Th17 cells are
induced in response to a
combination of IL-6 or IL-21
and TGF-β and require
induction of the transcription
factor RORγt. In human (h),
Th17 differentiation requires
TGF-β, IL-1β, and IL-6.
Psaty B et al.
5
Characteristics of Innate and Adaptive Immune
Responses
Weyand CM et al. T-cell immunity in acute coronary syndromes. Mayo Clin Proc 2001;76:1011-20
6
Feedforward Loop Between Innate and Adaptive
Immune Systems in Systemic Autoimmunity
Factors of the innate system activate
and promote adaptive components,
which feedback into the innate arm
to promote immune activation.
Central components of the innate
system that feed into the adaptive
system in systemic autoimmune
diseases include type 1 interferon
and other cytokines, MHC II, and
apoptotic debris, while important
factors from the adaptive system
promoting innate responses
encompass proinflammatory
cytokines, autoantibodies, and
immune complexes. BAFF=B-cell
activating factor (TNFSF13B).
IFNα=interferon α. IL=interleukin.
LTα= lymphotoxin α. TGF
β=transforming growth factor β.
TNFα=tumour necrosis factor α.
Wahren M et al. Autoimmune rheumatic diseases 3. Immunopathogenic mechanisms of systemic autoimmune disease. Lancet 2013;382:819-31
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WHI Talk 5-2015
8
Pathophysiologic Relevance of Cytokines in
Chronic Liver Disease
Most types of cells in the liver, including
Kupffer cells, hepatocytes, and stellate
cells, either synthesize or respond to
cytokines. In the early phase of chronic
liver disease, specific agents such as
viruses, ethanol, and toxins may stimulate
the production of cytokines. In the late
phase, endotoxin may be the key agent
stimulating cytokine production. Clinical
features of chronic liver disease that are
mediated by cytokines include cachexia,
cholestasis, fibrosis, synthesis of
acute-phase proteins, and
hypergammaglobulinemia. Whereas
proinflammatory cytokines such as tumor
necrosis factor α (TNF-α) and
interleukin-6 are mainly involved in cholestasis and
the synthesis of acute-phase proteins,
transforming growth factor β (TGF-β)
released by activated Kupffer cells and
hepatocytes may be one of the critical
cytokines involved in fibrosis. In patients
with progressive liver disease, the balance
between proinflammatory and
antiinflammatory cytokines may be
shifted toward the proinflammatory axis,
thus the counteracting antiinflammatory
cytokines are unable to control
inflammation and fibrosis.
Tilg H, et al. Cytokines in alcoholic and nonalcholic steatohepatitis. N Engl J Med 2000;343:1467-76
9
Wong E et al. Epidemiology of cytokines. The Women On the Move through Activity and Nutrition (WOMAN) Study. Am J Epidemiol 2008;168:443-53
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WHI Talk 5-2015
Changes in IL-1a, IL-6, CRP by Weight Loss
Categories
WHI Talk 5-2015
Number of Split Samples Above 25% Difference by
Cytokine (WHI BA20 RA Study), N=153
Cytokine
N
%
IL-1B
33
21
IL-2
60
39
IL-4
68
44
IL-5
37
18
IL-6
30
20
IL-7
23
15
IL-8
23
15
IL-10
32
20
IL-12
41
26
IL-13
40
26
IL-17
67
44
IL-18
33
22
TNF-a
51
33
MIP-18
17
11
G-CSF
42
27
MCP-1
26
17
GM-CSF
12
8
12
WHI Talk 5-2015WHI Talk 5-2015
The CVs for 40 blinded duplicates, 20
placed within the same batch, and 20
placed across different batches.
Results are shown separately for 67
Bio-Rad markers (A–C) and 97
Millipore markers (D–F) across 3
specimen types–heparin plasma,
serum, and EDTA plasma.(D–F)
across 3 specimen types—serum,
heparin plasma, and EDTA plasma.
Chaturvedi AK et al. Evaluation of multiplexed cytokine and inflammation marker measurements: a methodologic study. Cancer Epidemiol Biomarkers Prevention 2011;20:1902-11
Median Values of Cytokines by RA+/-
Cytokine (pg/mL)
Likely RA Neg
(n=2135)
Likely RA (n=742)
P value
IL1B
1.53
1.92
<0.0001
IL2
3.31
6.18
<0.0001
IL4
1.61
2.00
<0.0001
IL5
3.03
3.57
<0.0001
IL6
6.13
9.30
<0.0001
IL7
6.91
7.82
<0.0001
IL8
8.49
9.36
<0.0001
IL10
2.41
2.76
<0.0001
IL12
12.7
16.9
<0.0001
IL13
2.44
3.21
<0.0001
IL17
0.35
2.85
<0.0001
GCSF
146.8
159.0
0.0005
MCP_1
14.5
18.4
<0.0001
MIP_1B
41.9
45.1
0.0014
IFN-Y
42.1
55.1
<0.0001
Birru, et al. WHI BA20 RA ms proposal. Associations of HLA-DR Shared Epitope Alleles and Serum Cytokines Among Postmenopausal women with and without
Comparison of Extremes of IL6 (1Q vs. 4Q) Among
anti-CCP+ or DMARD+ at Baseline (WHI BA20 RA Study)
IL6 1Q
IL6 4Q
P
value
N
%
N
%
BMI
≤25
53
43.1
70
56.9
0.109
25.1-30
62
56.4
48
43.6
30.1-35
29
46.0
34
54.0
>35
25
59.5
17
40.5
Smoking
Never
79
56.8
60
43.2
0.028
Ever
89
44.7
110
55.3
Joint Pain
Not severe
138
53.9
118
46.1
0.014
Severe
31
38.3
50
61.7
Health
Good/excellen
t
134
55.4
108
44.6
0.004
Fair/poor
36
37.9
59
62.1
15
WHI Talk 5-2015Comparison of Extremes of IL6 (1Q vs. 4Q) Among
anti-CCP+ or DMARD+ at Baseline (WHI BA20 RA Study)
IL6 1Q
IL6 4Q
P value
N
%
N
%
anti-CCP
-
72
86.8
11
13.3
<.0001
+
98
38.1
159
61.9
RF
-
97
91.5
9
8.5
<.0001
+
73
31.2
161
68.8
Age
≤60
73
56.2
57
43.9
0.015
61-69
72
51.8
67
48.2
>69
25
35.2
46
64.8
# of shared epitopes
0
89
64.5
49
35.5
<.0001
1
66
46.2
77
53.9
2
9
19.6
37
80.4
16
WHI Talk 5-2015Cytokines by CHD Case – Control Among Anti-CCP+
Participants (WHI BA20 RA Study)
Cytokines (pg/mL)
No CHD
Median
CHD
Median
P-value
IL-1B
2.32
2.18
0.956
IL-2
10.00
11.06
0.480
IL-4
3.21
2.45
0.362
IL-5
4.42
4.26
0.997
IL-6
15.35
13.43
0.626
IL-7
9.25
9.24
0.610
IL-8
11.08
11.05
0.814
IL-10
3.03
3.02
0.862
IL-12
20.84
24.65
0.269
IL-13
4.13
3.91
0.704
G-CSF
180.09
178.03
0.847
MCP-1
19.70
18.76
0.991
MIP-1
40.84
44.99
0.752
TNF-a
39.08
35.26
0.976
IFH-g
71.31
66.53
0.884
IL-17
4.45
4.25
0.901
Kuller LH et al. WHI Rheumatoid Arthritis BA20 data
17
Cytokine
(pg/mL)
Alive at 2009
(n=461)
Deceased by 2009
(n=78)
Median
25
th
Percentile
75
th
Percentile
Median
25
th
Percentile
75
th
Percentile
P-value
IL-1B
2.0
1.3
3.8
2.5
1.6
6.6
0.070
IL-2
7.6
3.3
27.7
11.0
4.4
47.6
0.076
IL-4
2.0
1.1
3.2
2.2
1.5
3.6
0.185
IL-5
3.6
2.6
5.2
3.9
3.0
5.5
0.266
IL-6
11.0
6.2
25.5
13.0
8.4
49.5
0.028
IL-7
7.8
5.6
11.2
8.1
6.3
11.2
0.310
IL-8
9.4
6.9
12.2
9.6
8.0
13.3
0.034
IL-10
2.9
2.1
4.2
3.2
2.4
5.4
0.045
IL-12
17.8
10.9
36.2
22.2
14.9
66.9
0.015
Cytokines by Alive vs Dead for Anti-CCP+ Rheumatoid Arthritis
Participants (Excluding Women with Baseline CVD or Cancer)
Kuller LH et al. WHI Rheumatoid Arthritis BA20 data
Median
a
Cytokine Levels at Baseline by Anti-CCP and RF
Status Among Participants in the WHI RA Study
1.6
6.3
2.5
0.8
5.5
2.4 15.2 3.2 4.2 6.20
2
4
6
8
10
12
14
16
IL-1b*
IL-6*
IL-10
IL-17
WBC
Count
Med
ia
n
C
yt
oki
ne
Lev
el
p
g/
m
L
RF- (n=157)
RF+ (n-613)
Anti-CCP+ (n=770)
b
1.5
6.1
2.4
0.4
5.8
1.8
7.5
2.7
2.3
5.37
IL-1b*
IL-6*
IL-10
IL-17
WBC
Count
RF- (n=1912)
RF+ (n=302)
Anti-CCP- (n=2214)
c
Kuller LH, et al. Am J Epidemiol 2014;179:917-26
*p=<.01
a Wilcoxon test of median values. bInformation on RF status was missing for 2 women; information on
cytokine levels was missing for 2 women. cInformation on RF status was missing for 2 women; information on
cytokine levels was missing for 3 women.
19
1.06
1.73
2.31
2.49
1.04
1.24
1
1.53
1.17
1.56
1.05
2.77
1.23
1.14
1.12
2.09
0
0.5
1
1.5
2
2.5
3
RF+
IL6*
RF+
IL6*
RF+
IL6*
RF+
IL6*
CHD
Death
*4Q (vs IL6 1Q)
Anti-CCP+ or
DMARD+
Anti-CCP+
Anti-CCP- and
DMARD-
Anti-CCP- and
DMARD+
Cox Model, Covariate = Age, excluding RA at FU only or CVD at BL
Ag
e-A
dj
ust
ed HR
6.51
4.1
8.86
4.23
0
1
2
3
4
5
6
7
8
9
10
Q1
Q2
Q3
Q4
W
ei
gh
te
d
A
ge
-A
d
jus
te
d
Ra
te
/
1000 p
er
so
n
-yea
rs
Anti-CCP-/Baseline DMARD-
CHD Event by IL-6 excluding those with RA at
follow up only and those with CVD at baseline
N=1718 # of events 109 N=1478 # of events 78 N=1288 # of events 123 N=605 # of events 31
21
WHI Talk 5-2015Journal of Thrombosis and Haemostasis;
Volume 12, Issue 9,
pages 1391-1400, 23 JUL 2014 DOI: 10.1111/jth.12646
http://onlinelibrary.wiley.com/doi/10.1111/jth.12646/full#jth12646-fig-0002
Schematic mechanism of platelet and clotting activation elicited by
bacteria in pneumonia. The dotted lines indicate inhibition; the solid
lines indicate activation
22
Risk of Death Associated with Biomarker Levels
at Study Entry
Biomarker
Analysis
Type of
<25
th
Percentile
(Ref)
25
th-49
thPercentile
50
th-74
thPercentile
≥75
thPercentile
OR associated with
One IQR Higher
Biomarker Level
after Log10
Transformation
OR
(95% CI)
P-
value
OR
(95% CI)
P-
value
OR
(95% CI)
P-value
OR
(95% CI)
P-value
hsCRP
(µg/ml)
No.
aAdjusted
16/45
1.0 (ref.)
9/42
0.6 (0.2-1.5)
0.50
20/28
2.5 (0.9-7.2)
0.08
40/55
3.1 (1.2-8.0)
0.02
2.3 (1.4-3.7)
0.001
IL-6
(pg/ml)
No.
Adjusted
8/48
1.0 (ref.)
10/41
1.0 (0.3-3.6)
0.98
26/48
4.5 (1.4-14.2)
0.01
40/29
12.4 (3.6-42.0)
<0.0001
4.1 (2.3-7.3)
<0.0001
D-dimer
(µg/ml)
No.
Adjusted
8/51
1.0 (ref.)
22/54
8.3 (1.9-36.8)
0.005
18/40
12.6
(2.4-65.1)
0.003
37/25
41.2 (7.5-225.6)
<0.0001
5.3 (2.6-10.9)
<0.0001
Kuller LH et al. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. PLoS Med 2008;5:e203
23
Relationship Between Plasma Interleukin-6 Levels by Genotype in Groups Stratified
by (a) Demographics, (b) Presence of Metabolic Abnormalities, and (c) Lifestyle
Parameters
Jiang CQ et al. Interleukin-6 receptor gene polymorphism modulates interleukin-6 levels and the metabolic syndrome: GBCS-CVD. Obesity 2010;18:1969-74
24
Alterations of the T-cell repertoire during chronological aging
Vallejo AN. Immune remodeling: lessons from repertoire alterations during chronological aging and in immune-mediated disease. Trends Mol Med 2007;13:94-102
Thymic involution with age impairs production of new naïve T cells. Exposure to antigens throughout life results in the reduction of the size of the naïve reserve and the expansion of the memory compartment. Clonal expansion of memory cells along with antigen-independent homeostatic expansion help to maintain the number of circulating T cells. The rate of homeostatic expansion of naïve T cells increases late in life as a compensatory mechanism for the overall depletion of the naïve compartment. Clonal expansion of memory cells and homeostatic expansion of both naïve and memory cells cause telomere erosion that shortens the proliferative lifespan of T cells. Expansion of the memory compartment involves accumulation of oligoclonal T cells rather than the maintenance of overall TCR-repertoire
diversity. As depicted, 65 years is arbitrarily set to demarcate ‘young’ and ‘old’ age categories, and is seemingly the age at which slopes of telomere length and thymic output are minimal.
25
Age- and Sex-Standardized Prevalence of Individual
Infections
Zajacova A et al. Socioeconomic and race/ethnic patterns in persistent infection burden among U.S. adults. J Gerontol A Biol Sci Med Sci 2009;64A:272-9
26
Changes in TREC+ cells with age
Nasi M et al. Thymic output and functionality of the IL-7/IL-7 receptor system in centenarians: implications for the neolymphogenesis at the limit of human life. Aging Cell 2006;5:167-75
The percentage of sj-TREC
positive cells undergoes a
dramatic age-dependent
decline from young to
middle-aged subjects and
centenarians. Kruskal–
Wallis test among the
three groups revealed
a P < 0.0001. No
significant difference was
observed between young
and middle-aged donors.
Note that only the values
from individuals with
detectable TREC levels (all
young subjects, 10 out of
13 middle-aged donors, 4
out of 25 centenarians)
are shown here.
27
McElhaney JE, et al. Immunosenescence: what does it mean to health outcomes in older adults? Curr Opin Immunol 2009;21:418-24
28
Schematic diagram for the cardiovascular
inflammation reduction trial (CIRT)
Ridker PM. Testing the inflammatory hypothesis of atherothrombosis: scientific rationale for the cardiovascular inflammation reduction trial (CIRT). J Thromb Haemost 2009;7(Suppl1):332-9
29
Balancing the IL-1β system and its contributions to human disease. MWS
indicates Muckle-Wells syndrome; NOMID, neonatal-onset multisystem
inflammatory disease
Ridker PM et al. Interleukin-1β inhibition and the prevention of recurrent cardiovascular events: Rationale and design of the canakinumab anti-inflammatory thrombosis outcomes study (CANTOS). Am Heart J 2011;162:597-605
30
Ridker PM et al. Interleukin-1β inhibition and the prevention of recurrent cardiovascular events: Rationale and design of the canakinumab anti-inflammatory thrombosis outcomes study (CANTOS). Am Heart J 2011;162:597-605