Infections and autoimmunity; how to harness nature to treat autoimmunity
Yehuda Shoenfeld, Tel Hashomer, Israel
Chairs:Hans-Joachim Anders, Munich, Germany
Vladimir Tesar, Prague, Czech Republic
Prof. Yehuda Shoenfeld
Sheba Medical Center
Tel-Hashomer, Israel
 
slide 1
Mr Chairman actually, I have something to declare. I’m neither a nephrologist nor a rheumatologist. I’m an auto-immunologist.
 
slide 2
Therefore, I will switch gear and my talk will concentrate on the mosaic of different aspects of SLE and how they may affect the kidney as well as how they may affect different autoimmune diseases and the kidney affliction. I will talk about some aspects, which are controversial and we will discuss them also in our next congress of controversy in Sorrento next year
 
slide 3
as well in a congress on auto immunology, which will take place in Leipzig in 2016.
 
slide 4
So autoimmune
 
slide 5
diseases
 
slide 6
are multifactorial. In none of the patients will you find only one cause of autoimmune disease.
 
slide 7
There is no question that they are genetic and we will discuss genetics in a minute. There might be some kind of a defect in each one of those patients; one of the common defects is IgA deficiency, which afflicts about one out of 400 healthy subjects. There is no question that hormones are involved like oestrogens in which today we know that oestrogens may react with oestrogen receptors on lymphocytes increasing the B lymphocyte stimulating factor. But there are additional aspects like prolactin and there are some physicians in the world who treat their patients with Bromocriptine, which is an anti-prolactin antibody in quite a successful rate. I will not have the time today to discuss the effect of vitamin D.
 
slide 8
Last but not least, the date of the emergence of the disease and most probably many of the exacerbations are induced by infection. So I will end my talk with a revolutionary therapy which is based on actually nature and this
 
slide 9
is how helminths can prevent autoimmune diseases.
 
slide 10
So let’s go
 
slide 11
to the history of autoimmunity when the first actual animal model
 
slide 12
of SLE was described the NZB/NZW, which came from a hybrid of New Zealand Black and New Zealand White and only one of them had autoimmune haemolytic anaemia. Only by breeding them the mice developed systemic lupus erythematosus indicating to where the genetic background was. As you can see, in our centre, the ethical committee do not allow us to expose the mice to each other and I am quite worried that in the next year they will ask each one of the mice to sign an informed consent.
 
slide 13
Be it as it may,
 
slide 14
as you can see the NZB/NZW
 
slide 15
actually developed systemic lupus erythematosus. So this indicates that genetics is extremely important
 
slide 16
as you can see here in the copy-paste. But by and large in most autoimmune diseases as you will see, there is no 100%of concordance just to indicate that the environmental factors are extremely important. In multiple sclerosis only 26%, in SLE 33% and so forth.
 
slide 17
So as you can see, the environmental factors are instrumental in this case. But we do have haplotypes, which are indicating a higher incidence or risk of developing autoimmune disease and one of them is A1, B8, DR3 which actually makes you more prone by 10-fold to develop autoimmune disease. This may enable actually us to predict who will develop an autoimmune disease in the future. We do have other haplotypes like that
 
slide 18
but unfortunately, we were disappointed when we believed that when we analysed the genes, we would find one gene, one disease. You can see here that in lupus alone, we have more than 33 different genes, which by the way added to the mosaic explaining the differences between one patient and the other and actually from one member of the family to another member of the family.
 
slide 19
This is just to explain the differences even between ethnic groups, between Europeans and Japanese eluding to the idea that there are different genes in these different complex
 
slide 20
ethnic groups.
 
slide 21
Even the diet that we eat may indicate whether
 
slide 22
we will have an exacerbation or not, these are two old studies that we carried out on NZB/NZW supplying them with high-unsaturated fatty acids showing that we could reduce significantly the proteinuria in these mice. I’m not sure how many among you older clinicians actually pay attention to the diet and take time to instruct the patients on the diet unless they ask about it and recommend them with high unsaturated fatty acids, vitamin D and additional supplements.
 
slide 23
How does the diet affect the patient? Actually, it has been shown that these high unsaturated fatty acids may affect the secretion of inflammatory cytokines. So just by simple actions or simple diet we can determine if the patient will enter into remission or may actually avoid exacerbation.
 
slide 24
In the last few years, another aspect of the diet, which might be of great interest to nephrologists, came up in an unknown journal called New England Journal of Medicine and in another unknown journal called Nature and this is a high salt diet in patients with autoimmune disease.
 
slide 25
It has been shown that a high salt diet may increase the secretion of inflammatory cytokines and specifically IL-17, IL-21 and IL-23.
 
slide 26
There is a mechanism by which this high salt environment or hypertonic environment may activate the kinases and specifically, SGK1 kinase and eventually lead to the production of IL-17.
 
slide 27
So, this balance of high salt and low salt will be important in the future
 
slide 28
when we determine the diet of our patient. Actually, when you take an experimental model of rheumatoid arthritis, collagen-induced arthritis and you support the mice with a high salt diet or a low salt diet, you can see how you can avoid the exacerbation just by reducing the salt in these subjects.
 
slide 29
So, this is an additional aspect that we should take into consideration before we talk about biological and as was mentioned by David previously about IVIG that is very expensive. I’m not sure that IVIG today is more expensive than the biological therapies and especially the new ones but definitely recommending a low salt diet or unsaturated fatty acids might
 
slide 30
have an impact
 
slide 31
in this case.
 
slide 32
Let’s go for a moment to systemic lupus erythematosus. In a paper that we published long ago, which referred to the explosion of autoantibodies and SLE, we showed that there were about 117 different autoantibodies and each one of them may affect the patient in a different way. Today we are submitting a new paper about 184 different autoantibodies in SLE in which each one of them may affect the kidney or other organs in our body.
 
slide 33
I would like to just show you one example of one antibody, which is called anti-ribosomal P antibody.
 
slide 34
These antibodies were found to be very interesting. They affect only 10-20% of the patients and may determine what kind of kidney involvement you will develop
 
slide 35
and specifically as you will see, the membranous nephropathy that we know today. This is just some of the autoantibodies that we know that we may find in patents with SLE.
 
slide 36
So this anti-ribosomal P became very famous when in the New England Journal of Medicine it was reported to be associated with psychiatric manifestations. It was just an association but the question is why did the editor publish the paper about associations of an antibody with psychiatric manifestations because it could elude to the idea that maybe idiopathic psychiatric manifestations may have autoimmune nature. Idiopathic, which means that we are idiots, that we don’t know the pathology. Indeed, in a paper that was published in the Journal of Autoimmunity recently just by injecting these anti-P ribosomal antibodies into the ventricles of the brain of mice they were able to show how they develop depression, showing how they don’t swim in water and how by giving them an anti-depressive drug, they can immediately start to swim. So these anti-P ribosomals also were found to correlate with a specific kidney affliction in this patient.
 
slide 37
This paper was published in our practice – by – showing that the patients 10-20% had a higher incidence of membranous glomerulonephritis.
 
slide 38
So we challenged this idea again by actively immunising mice with the P-ribosomal antibodies
 
slide 39
with adjuvants.
 
slide 40
As you can see, eventually the mice developed not only anti-P ribosomal just again indicating that there is a network of connection between the different antibodies, which we call the idiotypic network and the mice also developed higher levels of anti-DNA antibodies and eventually,
 
slide 41
developed the proteinuria
 
slide 42
or accelerated proteinuria and by histology were able to show that
 
slide 43
they developed eventually
 
slide 44
membranous glomerulonephritis. Similarly, we wanted to see if this would happen also in mice who are not prone to develop SLE, namely NZB/NZW but -- NZW mice
 
slide 45
and were able
 
slide 46
to show that
 
slide 47
these mice also develop the anti-P ribosomal, also the anti-DNA
 
slide 48
and eventually, kidney involvement. So the anti-P ribosomal might be one out of the 184 antibodies that we may direct in our therapy to avoid or to prevent the eventual development of proteinuria in this case.
 
slide 49
By passive transport of the antibodies from the mice in which we have induced them to naive mice, we were able to also show the induction of these diseases. That just to show the pathogenicity of these so to speak rarely found anti-P ribosomal antibodies.
 
slide 50
To our great surprise, some of the antibodies also developed the alopecia, which as you know, is one of the markers
 
slide 51
that we can see
 
slide 52
in patients with SLE.
 
slide 53
So I would like to finish my talk with a story which led eventually to the development of a new therapy that we hope will be expanded as a new therapy for autoimmunity, as well as for kidney involvement in autoimmune disease. This is called the hygiene theory that you can see being exemplified in this boy as you can see here. The idea is that the less or the more you are exposed to some kind of infecting agent and especially helminths or parasites, the less you will develop autoimmune diseases in the future. This is just exemplified here in the paper showing that subjects who were exposed in the farm to animals like dogs and cats, would less develop rheumatoid factors in the future.
 
slide 54
It’s well known epidemiologically that where there is malaria there is no systemic lupus erythematosus. As we go further from the equator all autoimmune diseases are more prevalent whether to the north or to the south there are many explanations for that. One of them is the exposure to the sun and the level of vitamin D but it is believed that the further you are from the equator; there are less prevalent infestations of different helminths. There is one island, which is exceptional in this geo-epidemiology of autoimmune disease, and this is Sardinia, one of the biggest islands in the Mediterranean belonging to Italy, a beautiful island with nice seashores, which has mountains and valleys. In the valleys until 1940/1945, malaria prevailed. The patients or the participants or citizens developed a way to find malaria by changing the genes to thalassemia genes. This reminds very much of the Sickle cell anaemia in blacks which counteract or do not enable the mosquito to not infect the red blood cells and induce malaria. Having said that, in 1946 the Rockefeller Institute Scientists decided to DDT and to actually extinguish malaria from Sardinia and ten years later Sardinia became the island with the highest prevalence of autoimmune disease in the world, 1 out of 300 have multiple sclerosis and 1 out of 280 have diabetes type 1. So the relationship between actually extinction of malaria and the emergence of autoimmune disease is just one story in many places in the world where the replacement of the helminths by drugs etc. evolved into autoimmune diseases.
 
slide 55
So the idea came that maybe we should treat patients with helminths. Was it done? Yes, it was done. There were several patients with multiple sclerosis who were given helminths like macaroni or spaghetti and in all of them it helped, they entered into remission and once they didn’t take these macaroni, the exacerbation emerged. So it’s not pleasant and many of the female patients and maybe also many patients are disgusted from having live helminths being given to them and inducing a switch from inflammatory cytokines to non-inflammatory cytokines and eventually also inducing T regulatory cells. So the idea was to give eggs of helminths to these patients. Indeed these eggs did the job. The problem with the eggs was that the eggs hatched and the helminths came from below. Again an unpleasant event. So Joel Weinstock from the United States came up with the idea to give patients eggs of helminths but the final horse is a pig and the eggs do not hatch and even if they hatch the larva die very quickly. There are currently at least 2 or 3 companies in the world that supply eggs of helminths in which the horse is a pig and not a human being. There are claims that it helps and there are studies showing in Crohn’s disease and in some other diseases the switch from inflammatory to anti-inflammatory as well as the induction of T regulatory cells and many, many experimental models were shown in animal models. So, our idea was not to be dependent on the helminths and every day – to lay eggs.
 
slide 56
We asked the question which is the molecule on the eggs or on the helminths which does the job of switching from inflammatory to non-inflammatory cases and we came up with a very a simple molecule called phosphorylcholine. We injected phosphorylcholine into mice with different autoimmune diseases, unfortunately, it’s not immunogenic.
 
slide 57
Therefore, we came up with another idea
 
slide 58
to bind to these antibodies,
 
slide 59
to this small molecule another molecule which is called – that is a 5 amino acid molecule, which is produced by the spleen and therefore, actually enables us to overcome and capsulate bacteria. We injected this molecule into mice with SLE, as well as with colitis as well as with collagen-induced arthritis
 
slide 60
and you can see here our preliminary results in which when the mice were injected with this molecule, which exists on the helminths and the eggs, there was a significant amelioration
 
slide 61
of the glomerulonephritis in the mice. Their proteinuria was reduced significantly and the survival time,
 
slide 62
as you can see, increased tremendously. Moreover, what we were able to show was not only the cytokine switch but also the induction of T reg cells.
 
slide 63
So what can I do? Or what can I say? I’m trying to tell you that sometimes we have to go back and learn from nature and to harness nature to treat better our patients. I do hope that this drug eventually will become a drug that has almost no side effects to treat also the kidney affliction of the patient. Thank you very much for your attention.
 
slide 64 questions
Chairman: Thanks for this exciting lecture. Are there questions from the audience? Maybe a question is the helminth concept I think is largely based on the Th1, Th2 concept of immunity. We are used to thinking that lupus is neither pure Th1 or Th2 but that rather both components contribute to that so wouldn’t you think that if you give it a Th2 twist that you rather increase the humoral part of immunity and get more immune complex problems?

Prof. Shoenfeld: That’s a very interesting question. But starting your sentence you said ‘we believe that it’s either Th1 or Th2’, it’s never either/or, it’s a combination. Yet I have to say that in our experimental models just switching to Th2 was always beneficial in SLE, definitely in colitis we were able to show histological improvements in those mice who were treated with a Th1 or Th2 switch. The same with collagen-induced arthritis. But we believe that also in SLE it will work very well as it worked with the experimental models.

Chairman: Maybe another question related to the salt issue that you raised, which is certainly very interesting. What could be the evolutional reason to have salt regulating the immune system?

Prof. Shoenfeld: Let me start with the idea that when your father’s father’s father’s father was born, he didn’t use salt. Salt was artificially introduced to the diet. It was tasty, it was the same as gluten; it was the same for glucose. Therefore, originally or historically or evolutionarily we can say we didn’t need salt that much in the beginning. Therefore, I believe that it was also one of the mechanisms to avoid the activation of the inflammatory cytokines. But we human beings like salt so much that we add it to our diet and as you know, in nephrology salt is not recommended for other reasons too. Just to mention to you that salt was so important in the past that it was exchanged as money. Therefore, there is a salt mine somewhere near Innsbruck called Delares and people believe that this is the source of the word Dollar. This doesn’t mean to say that you don’t need dollars to avoid autoimmune diseases.

Chairman: So you’re sure that the change in the incidence of autoimmune diseases in Sardinia was not related to an increase in salt intake also in the same period.

Prof. Shoenfeld: Yes, it was tested, this confounder was tested, yes.

Question: Doctor Shoenfeld I really enjoyed your nice lecture and I also have a question related to salt intake. You suggested that the mechanism of salt --- mediated by SGK1 and this is autosomal regulated molecule. So are there any data that patients with primary aldosteronism for instance have a higher rate of autoimmunity or spironolactone immunosuppressive drug or not?

Prof. Shoenfeld: This has not been checked yet. I think that we should do these studies also in patients. This is being done currently more on animal models. But you know in analogy I believe it works very similarly also in human beings.

Question: Thank you very much.

Chairman: Thank you.