US20100183541A1 - Methods of Treating Autoimmune Diseases - Google Patents

Methods of Treating Autoimmune Diseases Download PDF

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US20100183541A1
US20100183541A1 US12/241,345 US24134508A US2010183541A1 US 20100183541 A1 US20100183541 A1 US 20100183541A1 US 24134508 A US24134508 A US 24134508A US 2010183541 A1 US2010183541 A1 US 2010183541A1
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tgf
cells
mammal
autoimmune disease
latent tgf
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Johanne M. Kaplan
John M. McPherson
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Genzyme Corp
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Genzyme Corp
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Priority to US13/680,667 priority patent/US9744233B2/en
Priority to US15/666,743 priority patent/US20170326203A1/en
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Definitions

  • This invention relates to methods of treating autoimmune diseases.
  • the methods of the invention involve the use of latent TGF- ⁇ or other agents that stimulate regulatory T cells, alone or in combination with lymphocyte-depleting agents.
  • lymphocyte-depleting agents such as, e.g., anti-thymocyte globulin (ATG).
  • ATG anti-thymocyte globulin
  • Autoantibodies and autoreactive T cells can cause severe tissue damage (e.g., as in lupus nephritis) or loss of blood components (e.g., as in immune thrombocytopenia purpura).
  • autoimmune diseases are treated with nonspecific immunosuppressive agents, such as, e.g., cyclophosphamide, methotrexate, azathioprine, and cyclosporine, that impede the immune cells from attacking the organs and tissues.
  • immunosuppressive agents are often associated with significant side effects (e.g., toxicity, the undesired suppression of the immune system, etc.).
  • TGF- ⁇ transforming growth factor-beta
  • TGF-6 is a pluripotent cytokine—besides having immunosuppressive properties, it is in involved in the extracellular matrix production, and other biological processes.
  • TGF- ⁇ thelial growth factor- ⁇
  • organ fibrosis Kerman et al., Am. J. Resp. Crit. Care Med., 152:2163-2169 (1995); George et al., Prot. Natl. Acad. Sci., 96:2719-12724 (1999); Kuwahara et al., Circulation, 106:130-135 (2002)
  • systemic administration of active TGF- ⁇ has been associated with unacceptable toxicity.
  • TGF- ⁇ may be used to circumvent systemic toxicity of active TGF-13.
  • Activation of latent TGF- ⁇ requires removal of the latency-associated peptide (LAP) which can occur in vivo through a number of mechanisms including proteolytic cleavage, exposure to reactive oxygen species, and interactions with thrombospondin and other proteins.
  • LAP latency-associated peptide
  • Murphy-Ullrich et al. Cytokine Growth Factor Rev., 11:59-69 (2000). It is theorized, but not relied on for the purposes of this invention, that such conditions are likely to occur in areas of autoimmune inflammation, such as in the kidney in lupus patients.
  • the methods of the invention involve systemic administration of inactive TGF- ⁇ (e.g., latent TGF- ⁇ ) to a mammal, whereupon the activation and/or action of TGF- ⁇ is limited to sites of inflammation and tissue damage.
  • inactive TGF- ⁇ e.g., latent TGF- ⁇
  • the present invention is further based, in part, on the discovery and demonstration that depletion of lymphocytes by anti-thymocyte globulin (ATG) followed by administration of latent TGF- ⁇ is effective in improving kidney function and increasing survival rates in a murine model of systemic lupus erythematosus. Accordingly, in some embodiments of the invention, host lymphocytes are depleted prior to the administration of latent TGF- ⁇ so as to yield the therapeutically desired effect of the latent TGF- ⁇ administration.
  • AGT anti-thymocyte globulin
  • TGF- ⁇ is achieved, in part, due to the stimulatory effects of TGF- ⁇ on the growth of regulatory T cells. Therefore, in some embodiments of the invention, another agent that promotes the expansion of regulatory T cells may be administered in place of, or in addition to, latent TGF- ⁇ .
  • This invention provides methods for treating a mammal (e.g., a human) with an autoimmune disease, e.g., systemic lupus erythematosus (SLE), rheumatoid arthritis (RA).
  • an autoimmune disease e.g., systemic lupus erythematosus (SLE), rheumatoid arthritis (RA).
  • the treatment results in slowing the progression of disease and/or improvement in symptoms.
  • the invention further provides methods of preserving or improving kidney function in a mammal with an autoimmune disease that impairs kidney function, such as, e.g., SLE, Goodpasture's syndrome, Wegener's syndrome, and Berger's disease.
  • the methods of the invention include the following steps:
  • the depletion of lymphocytes is accomplished by administering anti-thymocyte antibody (e.g., Thymoglobulie®, AtgamTM, FreseniusTM, and TecelacTM) or another antibody specific for an antigen(s) expressed on T cells.
  • anti-thymocyte antibody e.g., Thymoglobulie®, AtgamTM, FreseniusTM, and TecelacTM
  • another antibody specific for an antigen(s) expressed on T cells e.g., Thymoglobulie®, AtgamTM, FreseniusTM, and TecelacTM
  • repopulation phase a therapeutically effective amount of one or more of the following agents is administered to the mammal: (1) latent TGF-6 (e.g., the latent form of any one of TGF ⁇ 1-TGF(33) and/or (2) one or more, other agents that promotes expansion of regulatory T cells (e.g., IL-10, IL-10 and IL-4, IL-10 and IFN- ⁇ , vitamin D3 and dexamethasone, vitamin D3 and mycophenolate mofetil, and rapamycin).
  • latent TGF-6 e.g., the latent form of any one of TGF ⁇ 1-TGF(33) and/or
  • other agents that promotes expansion of regulatory T cells e.g., IL-10, IL-10 and IL-4, IL-10 and IFN- ⁇ , vitamin D3 and dexamethasone, vitamin D3 and mycophenolate mofetil, and rapamycin.
  • kidney function is compromised due to autoimmune disease
  • the treatment methods result.
  • improvement of kidney function in the mammal e.g., slowing the loss thereof as indicated by, e.g., a change in systemic blood pressure, proteinuria, albuminuria, glomerular filtration rate, and/or renal blood flow.
  • FIG. 1 shows an alignment of amino acid sequences of the precursors of human TGF- ⁇ 1 (SEQ ID NO:1), TGF- ⁇ 2 (SEQ ID NO:2), and TGF- ⁇ 3 (SEQ ID NO:3).
  • TGF-62 is shown in the ‘long’ alternatively spliced form in which a 28 amino acid insertion is found in the pre-pro domain beginning at residue 119. conserveed sequences are boxed in.
  • Arrows indicate the sites of proteolytic processing resulting in cleavage of the signal peptide and of the mature C-terminal TGF- ⁇ 1 fragment.
  • * refers to RGD integrin recognition site found in the latency-associated peptide (LAP) proteins of TGF- ⁇ 1 and TGF-6 ⁇ .
  • + refers to cysteine residues involved in disulfide bonds between the two monomeric LAP proteins.
  • # refers to a cysteine residue involved in formation of the single disulfide bond TGF- ⁇ monomers.
  • FIG. 2 shows the therapeutic effect of the ATG/latent TGF- ⁇ 1 combination treatment on kidney function.
  • MRUMPJ-Tnfrs6 lpr mice (a murine model of SLE) were injected with 500 ⁇ g of ATG intraperitoneally (i.p.) twice, three days apart, with, or without 4 ⁇ g of latent TGF- ⁇ 1 in 100 ⁇ l of phosphate buffered saline (PBS).
  • PBS phosphate buffered saline
  • Four micrograms of latent TGF- ⁇ 1 corresponds to a 1 ⁇ g ( ⁇ 0.05 mg/kg) dose of the active (mature, non-LAP-associated) portion of the molecule.
  • the latent TGF- ⁇ 1 When included in a treatment, the latent TGF- ⁇ 1 was administered daily for twelve days beginning eleven days after the second ATG injection.
  • SLE mice As a negative control, SLE mice were treated with 500 ⁇ g of normal rabbit immunoglobulin (Ig) i.p. twice, three days apart. An additional treatment group received normal rabbit immunoglobulin and latent TGF- ⁇ 1 administered as above.
  • Ig normal rabbit immunoglobulin
  • latent TGF- ⁇ 1 As a positive control, SLE mice were treated with 100 mg/kg i.p. of cyclophosphamide in 200 ⁇ l saline weekly. Proteinuria was significantly lower in SLE mice treated with latent TGF- ⁇ 1 and ATG as compared to SLE mice treated with either ATG alone, control Ig+TGF- ⁇ 1, or control Ig alone. Mean total urine protein of the combination treatment group approached the level' achieved with cyclophosphamide, a current treatment for lupus.
  • FIG. 3 shows the effect of the combination treatment on the development of severe kidney disease. Mice were treated as described above for FIG. 2 . SLE mice treated with ATG and latent TGF- ⁇ 1 together exhibited a decrease in the incidence of severe proteinuria (>500 mg/dl/day) as compared to SLE mice treated with either ATG alone, control. Ig+TGF- ⁇ 1, or control Ig alone.
  • FIG. 4 shows the effect of the combination treatment on kidney function. Mice were treated as described above for FIG. 2 .
  • the mean urine albumin levels were decreased in SLE mice treated with the combination of ATG and latent TGFL- ⁇ 1 in comparison with SLE mice treated with either ATG alone, control. Ig+TGF- ⁇ 1, or control Ig alone.
  • ATG and latent TGF- ⁇ 1 combination treatment resulted in mean urine albumin levels near those achieved with cyclophosphamide treatment.
  • FIG. 5 shows the effect of the combination treatment on the development of severe kidney disease. Mice were treated as described above for FIG. 2 . The percent of SLE mice having severe albuminuria (>10 mg/dl/day) was decreased in the combination treatment group in comparison with either ATG alone, control Ig+TGE- ⁇ 1, or control Ig alone.
  • FIGS. 6A-6E show the effect of the combination treatment on the development of autoantibodies. Arrows indicate start of treatment. Mice were treated as described above for FIG. 2 and indicated accordingly in FIGS. 6A-6E . Overall, SLE mice treated with ATG and latent TGF- ⁇ 1 showed a considerable delay in the rise of IgG anti-dsDNA antibody titers in comparison to mice treated with either ATG alone, control Ig+TGF- ⁇ 1, or control Ig alone.
  • FIG. 7 shows the effect of the combination treatment on survival of SLE mice. Mice were treated as described above for FIG. 2 . SLE mice treated with ATG and latent TGF-81 survived significantly longer than SLE mice treated with either ATG alone, control Ig+TGF-81, or control Ig alone.
  • FIG. 8 shows the survival data obtained in a repeat study with MRL/MPJ-Tnfrs6 lrp mice treated as described above for FIG. 2 .
  • the study was extended to 40 weeks of age (as opposed to 24 weeks in the first study) to assess the durability of the effect of transient treatment with ATG and latent TGF- ⁇ 1.
  • the survival benefit did in fact persist and the survival of mice treated with ATG and latent TGF- ⁇ 1 was comparable to that obtained with cyclophosphamide, the positive control (90% vs. 100%, respectively).
  • FIG. 9A shows the absolute number of CD4 + CD25 + cells in cultures of splenocytes exposed to various treatments.
  • Splenocytes were pooled from ten MRL/lpr mice with active disease.
  • Six different conditions (8 wells/condition) were assayed: 1) cells alone, 2) ATG (100 ⁇ g/ml)+ active TGF- ⁇ 1 (10 ng/ml; Genzyme), 3) ATG alone (100 ⁇ g/ml), 4) control rabbit IgG (100 ⁇ g/ml)+active TGF- ⁇ 1 (10 ng/ml), 5) control rabbit IgG alone (100 ⁇ g/ml), and 6) active TGF- ⁇ 1 alone (10 ng/ml).
  • FIG. 9B shows the absolute number of CD4 + CD25 + FOXP3 + cells in cultures of splenocytes treated as described for FIG. 9A . Additionally, for intracellular detection of FOXP3, cells stained for surface CD4/CD25 were permeabilized overnight and stained for FOXP3.
  • This invention provides methods of treating a mammal with an autoimmune disease.
  • such methods include methods of improving kidney function in a mammal with an autoimmune disease that compromises kidney function.
  • the methods of the invention involve systemic administration of latent TGF- ⁇ to a mammal, wherein the activation and/or action of TGF- ⁇ is limited to sites of inflammation and tissue damage.
  • methods of the invention comprise the following steps:
  • Depletion of circulating lymphocytes can be accomplished by administering a lymphocyte-depleting agent to the mammal or otherwise exposing the mammal to conditions that result in a loss of a substantial fraction of lymphoid cells (e.g., lymphocytes, natural killer (NK) cells, monocytes, and/or dendritic cells, etc.) in the mammal.
  • lymphoid cells e.g., lymphocytes, natural killer (NK) cells, monocytes, and/or dendritic cells, etc.
  • Lymphocytes to be depleted may be T lymphocytes (T cells) and/or T and B lymphocytes.
  • T cell counts are reduced by at least 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, or more, and optionally, B lymphocyte (B cell) counts are reduced by at least 30%, 40, 50%, 60%, 70%, 80%, 90%, 95%, or more.
  • the depleted lymphocytes are predominantly T cells, which means that the percentage of depleted T cells is greater (e.g., 1.2-, 1.5-, 2-, 5-, 10-fold, or more) than the percentage of depleted B cells.
  • the level of lymphocyte depletion can be readily assessed by, for example, measuring the amount of peripheral blood lymphocytes (PBLs). Lymphocyte counts can be determined using conventional clinical laboratory techniques (e.g., by flow cytometry). Reference values for normal PBL levels in humans are presented in Table 1.
  • the lymphocyte-depleting agent is an anti-lymphocyte antibody, e.g., anti-T cell antibodies, e.g., anti-thymocyte globulin (ATG), such as, e.g., Thymoglobulin®, Atgam®, FreseniusTM, and TetelacTM.
  • ATG is a polyclonal antibody directed against thymocytes.
  • Currently marketed ATG products are produced by injecting thymocytes from one species (e.g., human) into another species (e.g., rabbit or horse).
  • ATG binds to cell surface proteins such as lymphocyte surface antigens CD2, CD3, CD4, CD8, CD11a, CD18, CD25, HLA DR, and HLA class I (Bourdage-et al., Transplantation, 59:1194-1200 (1995)).
  • ATG is believed to induce immunosuppression primarily as a result of T cell depletion (see, e.g., Bonnefoy-Bernard et al., Transplantation, 51:669-673 (1991)) and has been previously used for pretreating transplant patients to reduce the risk of rejection in the context of organ transplantation.
  • the lymphocyte-depleting agent consists of or comprises a monoclonal or polyclonal antibody directed to one or more specific lymphocyte surface antigens, e.g., anti-CD52 antibody (e.g., Campath®), anti-CD3 antibody (e.g., OKT3®), anti-CD4 antibody (OKTTM), anti-CD25 (IL-2R) antibody (e.g., daclizumab), anti-CD5 antibody, anti-CD7 antibody, anti-TCR antibody, anti-CD2 (e.g., SiplizumabTM), or an antibody against any of other lymphocyte surface antigens specified above, etc.
  • anti-CD52 antibody e.g., Campath®
  • anti-CD3 antibody e.g., OKT3®
  • anti-CD4 antibody OKTTM
  • anti-CD25 (IL-2R) antibody e.g., daclizumab
  • anti-CD5 antibody anti-CD7 antibody
  • anti-TCR antibody anti-CD2
  • the lymphocyte-depleting agent is a corticosteroid.
  • conditions that result in depletion of lymphocytes include exposure to gamma radiation.
  • a combination of any suitable agents and/or conditions to deplete lymphocytes can be also used.
  • lymphocytes of the mammal are allowed to begin repopulating by withdrawing the lymphocyte-depleting agent or mitigating the conditions that resulted in the loss of lymphocytes.
  • the agent of step (c) i.e., TGF- ⁇ or another agent that specifically stimulates regulatory T cells
  • the agent of step (c) can be administered to the mammal immediately at the start of the replenishment phase, in other cases, the agent is administered after some repopulation has occurred.
  • the lymphocytes may be allowed to repopulate to less than 50%, 40%, 30%, 20%, 10%, 5%, or lower, as compared to the pre-depletion level.
  • lymphocytes repopulate to pre-depletion levels at different, rates depending on the depleting agent. For example, with ATG, a complete repopulation may take two to four months, while after treatment with CampathTM, the repopulation may take several years. Accordingly, in some embodiments, the length of time between the end of the depletion phase of the lymphocytes and the administration of step (c) agent is, for example, 0, 1, 2, 3, 4, 5, 6 days; 1, 2, 3, 4, or 5 weeks, or longer.
  • the methods of the invention involve administration of inactive TGF- ⁇ which is activated after administration.
  • inactive TGF- ⁇ is administered in the form of latent TGF- ⁇ .
  • inactive TGF- ⁇ is administered in the form of a TGF- ⁇ -encoding DNA which expresses active TGF- ⁇ upon induction.
  • TGF- ⁇ is naturally secreted in either a so-called “small latent complex” (100 kDa) in which the biologically active TGF- ⁇ is noncovalently associated with its pro domain (“latency-associated peptide,” LAP) and in a so-called “large latent complex” (220 kDa) additionally containing latent TGF- ⁇ biding protein (LTBP).
  • LAP latency-associated peptide
  • LTBP latent TGF- ⁇ biding protein
  • the latent forms are unable to bind to TGF- ⁇ receptors until active, i.e., mature, TGF- ⁇ , is, released from the complex.
  • the term “latent TGF-R” refers to TGF- ⁇ associated with LAP (covalently or noncovalently) and, optionally, additionally associated with LTBP (covalently or noncovalently). The term, therefore, refers to small and large latent TGF- ⁇ complexes. Other forms of inactive TGF- ⁇ that could be activated in the locations and at the time periods desired would also be useful in the methods of this invention.
  • TGF- ⁇ 1 to TGF- ⁇ 3 There are three known mammalian isoforms of TGF- ⁇ (TGF- ⁇ 1 to TGF- ⁇ 3), all of which are homologous among each other (60-80% identity).
  • Table 2 A partial listing of protein accession number for the three mammalian isoforms is shown in Table 2; an alignment of human TGF- ⁇ s is shown in FIG. 1 .
  • TGF- ⁇ as well as TGF- ⁇ receptors are well known. See, e.g., Cytokine Reference, eds. Oppenheim et al., Academic Press, San Diego, Calif., 2001.
  • inactivated form a of engineered TGF- ⁇ s that retain the ability to bind to one or more TGF- ⁇ receptors would also be useful in the methods of the invention.
  • Such inactivated forms of engineered TGF- ⁇ may contain only a partial or a mutated amino acid sequence of the naturally occurring TGF- ⁇ .
  • inactivated forms of engineered TGF- ⁇ may contain native sequences in which conservative substitutions were made and/or nonessential amino acids were deleted.
  • the methods of the invention involve administration of an agent that promotes regulatory T cells expansion.
  • Regulatory T cells also known as Tregs or suppressor T cells
  • Regulatory T cells are cells that are capable of inhibiting the proliferation and/or function of other lymphoid cells via contact-dependent or contact-independent (e.g. cytokine production) mechanisms.
  • cytokine production e.g. cytokine production
  • ⁇ T cells Natural Killer T (NKT) cells
  • CD8 + T cells e.g., CD4 + T cells
  • double negative CD4 ⁇ CD8 ⁇ T cells e.g., Bach et al., Immunol., 3:189-98 (2003).
  • the so-called “naturally occurring” regulatory T cells are CD4 + CD25 + and express the forkhead family transcription factor FOXP3 (forkhead box p3).
  • FOXP3 forkhead box p3
  • a minor population of CD8 + FOXP3-expressing cells are also regulatory T cells.
  • CD4 + Tregs can be further divided into induced regulatory T cells that secrete interleukin-10 (IL-10) and TGF- ⁇ such as Tr1 cells and T-helper 3 (Th3) cells.
  • Additional surface markers for CD4 + CD25 + regulatory T cells include CD45RB, CD38, GITR, surface TGF- ⁇ , CTLA4, CD103, CD134 and CD62L.
  • the regulatory T cells that are being stimulated include one or more of the following groups: (1) regulatory T cells that express IL-10; (2) regulatory T cells that express TGF- ⁇ (including Tr1 cells and Th3 cells); (3) CD4 + CD25 + cells (including cells having additional markers CD45RB + , CD38 + , GITR, surface TGF- ⁇ , CTLA-4, CD103, CD134 and/or CD62L); (4) FOXP3-expressing T cells (including CD8 + cells and CD4 + cell's); (5) ⁇ T cells; (6) NK T cells; and (7) double negative CD4 ⁇ CD8 ⁇ T cells.
  • TGF- ⁇ in addition to its direct immunosuppressive activity, may also be capable of stimulating regulatory.
  • T cells Gorelik and Flavell, Nature Reviews Immunology, 2:46-53 (2002); Chen et al., J. Exp. Med., 198:1875-1886 (2003); Marie et al., J. Exp. Med., 7:1061-1067 (2005); Huber et al., J. Immunol., 173:6526-6531 (2004).
  • an increase of, e.g., at least 10%, 20%, 30%, 40%, 50%, 100%, or more in the expansion of regulatory T cells in the presence of an: agent as opposed to its absence is considered indicative of the agent's capacity to promote regulatory T cells expansion.
  • TGF- ⁇ and other agents can be assayed for their capacity to promote regulatory T Cell expansion using routine methods. Examples of some of the more frequently used in vitro assays include the following:
  • cytokine profiling as described in, e.g., Barrat, supra, and Jonuleit, supra.
  • a supernatant from cultured regulatory T cells is analyzed for the presence of the immunosuppressive cytokines such as, e.g., IL-10 and TGF- ⁇ , known to be produced by regulatory T cells.
  • immunosuppressive cytokines such as, e.g., IL-10 and TGF- ⁇ , known to be produced by regulatory T cells.
  • the methods of the invention can be used to treat a mammal that has an autoimmune disease such as, e.g., systemic lupus erythematosus (SLE) and autoimmune rheumatoid arthritis (RA).
  • an autoimmune disease such as, e.g., systemic lupus erythematosus (SLE) and autoimmune rheumatoid arthritis (RA).
  • mammals include humans or other primates (e.g., chimpanzees), rodents (e.g., mice, rats, or guinea pigs), rabbits, cats, dogs, horses, cows, and pigs.
  • the treatment is expected to result in inhibiting the progression of disease and/or improvement in symptoms.
  • autoimmune diseases include insulin-dependent diabetes mellitus (IDDM; type I diabetes), inflammatory bowel disease (IBD), graft-versus-host disease (GVHD), celiac disease, autoimmune thyroid disease, Sjögren's syndrome, autoimmune gastritis, autoimmune hepatitis, cutaneous autoimmune diseases, autoimmune dilated cardiomyopathy, multiple sclerosis (MS), myasthenia gravis (MG), vasculitis (e.g., Takayasu's arteritis and Wegener's granulomatosis), autoimmune diseases of the muscle, autoimmune diseases of the testis, autoimmune ovarian disease, autoimmune uveitis, Graves' disease, psoriasis, ankylosing spondylitis, Addison disease, Hashimoto, thyroiditis, idiopathic thrombocytopenic purpura, and vitiligo.
  • IDDM insulin-dependent diabetes mellitus
  • IBD inflammatory bowel disease
  • the methods of the invention are expected to slow the progression of autoimmune disease, improve at leak some symptoms, and/or increase survival.
  • the methods of the invention may result in a reduction in the levels of autoantibodies, B cells producing autoantibodies, and/or autoreactive T cells.
  • the reduction in any of these parameters can be, for example, at least 10%, 20%, 30%, 50%, 70% or more as compared to pretreatment levels.
  • the invention further provides methods of preserving or improving kidney function in a mammal with an autoimmune disease that compromises kidney function.
  • autoimmune diseases that may compromise kidney function include SLE (e.g., lupus nephritis), Goodpasture's syndrome, Wegener's granulomatosis (Wegener's syndrome), Berger's disease (IgA nephropathy), and IgM nephropathy.
  • the treatment is expected to result in improvement of kidney function (e.g., slowing the loss of, preserving, or improving the same) as indicated by, e.g., a change in systemic blood pressure, proteinuria, albuminuria, glomerular filtration rate, and/or renal blood flow.
  • renal function refers to the ability of a kidney to perform its physiological functions such as pressure filtration, selective reabsorption, tubular secretion, and/or systemic blood pressure regulation.
  • Methods for assessing renal function are well known in the art and include, but are not limited to measurements of blood systemic and glomerular capillary pressure, proteinuria, albuminuria, microscopic and macroscopic hematuria, serum creatinine level (e.g., one formula for estimating renal function in humans equates a creatinine level of 2.0 mg/dl to 50% of normal kidney function and 4.0 mg/dl to 25%), decline in the glomerular filtration rate (GFR), (e.g., as indicated by the rate of creatinine clearance, or using inulin assays), and degree of tubular damage.
  • GFR glomerular filtration rate
  • the methods of the invention may be useful in patients having an autoimmune disease with reduced or diminished renal reserve, renal insufficiency, renal failure, or end-stage renal disease.
  • methods of the invention may be used in patient with microalbuminuria, macroalbuminuria, and/or proteinuria levels over 1, 2, 3, 4, 5; 6, 7, 8, 9, or 10 g or more per a 24-hour period, and/or serum creatinine levels of about 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 7.0, 8.0, 9.0, 10 mg/dl or higher.
  • the methods of the invention reduce the amount of protein secreted in the urine (proteinuria), amount of albumin secreted in the urine (albuminuria), and/or the patient's serum creatinine levels by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, or more, relative to control subjects. In other embodiments, the methods of the invention slow the loss of renal function by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, or more, relative to control subjects.
  • Nonlimiting illustrative methods for assessing renal function are described herein and, for example, in WO 01/66140.
  • “administration” is not limited to any particular delivery system and may include, without limitation, parenteral (including subcutaneous, intravenous, intramedullary, intraarticular, intramuscular, or intraperitoneal injection), rectal, topical, transdermal, or oral (for example, in capsules, suspensions, or tablets). Administration to an individual may occur in a single dose or in repeat administrations, and in any of a variety of physiologically acceptable salt forms, and/or with an acceptable pharmaceutical carrier and/or additive as part of a pharmaceutical composition.
  • Physiologically acceptable salt forms and standard-pharmaceutical formulation techniques and excipients are well known to persons skilled in the art (see, e.g., Physicians' Desk Reference (PDR®) 2005, 59 th ed., Medical Economics Company, 2004; and Remington: The Science and Practice of eds. Gennado et al. 21th ed., Lippincott, Williams & Wilkins, 2005).
  • Latent TGF- ⁇ can also be administered by means of gene therapy (i.e., by administering a TGF- ⁇ -encoding DNA in an appropriate vector), for example, as described in Kitani et al., J. Exp. Med., 192(1):41-52 (2000).
  • the appropriate effective doses for the latent TGF-13, agents promoting Tregs, and lymphocyte depleting agents will be chosen by a treating clinician and will range roughly from 0.01 ⁇ g/kg to 25 mg/kg, from 0.1 ⁇ g/kg to 10 mg/kg, from 1 ⁇ g/kg to 1 mg/kg, 10 ⁇ g/kg to 1 mg/kg, from 10 ⁇ g/kg to 100 ⁇ g/kg, from 100 ⁇ g/kg to 1 mg/kg, and from 500 ⁇ g/kg to 5 mg/kg.
  • specific dosages indicated in the Examples, or in the PDR® 2005 and later editions may be used to arrive at the desired dosage.
  • the currently approved uses of Thymoglobulin® in the United States include transplantation (from 1 mg/kg to 2.5 mg/kg for 2-14 days) and aplastic anemia (from 2.5 mg/kg to 3.5 mg/kg for 5 days).
  • Effective dosages achieved in one animal may be converted for use in another animal, including humans, using conversion factors known in the art. See; e.g., Freireich et al.) Cancer Chemother. Reports, 50(4):219-244 (1966) and Table 4 for equivalent surface area dosage factors. Examples of autoimmune disease models and appropriate methods can be found in, e.g., Cohen et al. (eds.) Autoimmune Disease Models, Acadernic Press, 2005.
  • Recombinant human latent TGF- ⁇ 1 was produced in CHO cells (Genzyme, Framingham, Mass.). Disruption of LAP from latent TGF- ⁇ 1 was achieved through acidification.
  • LAP-TGF- ⁇ 1 was diluted to 200 ng/mL in assay medium (DMEM plus non-essential amino acids, L-glutamine, pen-strep, and 10% FBS). Five hundred microliters of the diluted sample, was activated by adding 100 ⁇ L of 1N HCl and incubating at room temperature for 20 minutes. The sample was subsequently neutralized with 100 ⁇ L of 1.2 N NaOH/0.5 M HEPES.
  • the activated TGF- ⁇ 1 sample was analyzed using the A549 Cell Potency Assay and the activity assessed in comparison to a human recombinant TGF- ⁇ 2 (Genzyme, Framingham, Mass.) control.
  • the A549 potency assay is based on the TGF- ⁇ 1-induced release of IL-11 by the human lung epithelial cell line, A549 and is described in Wang et al., Am. J. Physiol., 276:L175-L185 (1999).
  • IL-11 release from the A549 cells in response to TGF- ⁇ 1 was measured using an ELISA procedure (R&D Systems, Minneapolis, Minn.).
  • mice Male MRL/lpr mice were obtained from the Jackson Laboratory (Bar Harbor, Me.) and were received at 5-6 weeks of age. ATG was generated by the immunization of rabbits with Balb/c mouse thymocytes as follows. Rabbits were immunized subcutaneously with 5 ⁇ 10 7 fresh thymocytes on day 0 and boosted intravenously with 5 ⁇ 10 7 fresh thymocytes on day 14. Serum collected on days 20, 22, and 25 was pooled and the IgG fraction was isolated by chromatography and sodium sulfate precipitation. A commercial preparation of IgG from na ⁇ ve rabbits was used as a negative control (Sigma, St. Louis, Mo.). Recombinant human latent TGF- ⁇ 1 was produced in CHO cells (Genzyme, Framingham, Mass.). Cyclophosphamide was purchased from VWR Scientific Products (West Chester, Pa.).
  • Treatment Animals were monitored for proteinuria, albuminuria, and titers of IgG antibodies to double-stranded DNA (dsDNA) every three weeks (see below). Therapeutic treatment was initiated when animals started developing antibodies to dsDNA and/or elevated proteinuria at 12-13 weeks of age. Treatment with ATG or control rabbit IgG consisted of two intraperitoneal (i.p.) injections of 500 ⁇ g ( ⁇ 25 mg/kg) delivered three days apart (days 0 and 3). Latent TGF- ⁇ 1 was given from days 14-25 as twelve daily i.p. injections of 4 ⁇ g per mouse.
  • a 4 ⁇ g dose of latent TGF- ⁇ 1 corresponds to a 1 ⁇ g ( ⁇ 0.05 mg/kg) dose of the active (mature, non-LAP-associated) portion of the molecule.
  • Cyclophosphamide was used as a positive control and was delivered i.p. weekly at a dose of 100 mg/kg from 12-13 weeks of age until the end of the study at 24-25 weeks of age.
  • the treatment groups consisted of control rabbit IgG, control rabbit IgG+ latent TGF- ⁇ 1, ATG, ATG+ latent TGF- ⁇ 1, or cyclophosphamide with ten animals per group.
  • Proteinuna and Albuminuria Levels of protein in the urine of individual mice were measured using a colorimetric assay designed to measure total protein concentration. Levels of albumin in the urine were assessed with a quantitative ELISA assay.
  • a 24-hour urine collection was performed every three weeks by placing mice into individual metabolic cages. Proteinuria was measured using the Microprotein-PRTM kit from Sigma (St. Louis, Mo.) according to manufacturer's instructions. Briefly, urine was added to a reagent solution containing pyrogallol red-molybdate complex. The mixture was incubated at 37° C. for ten minutes to allow for binding of the reagent to basic amino groups on proteins leading to a shift in absorbance at 600 nM. The increase in optical density (O.D.) at 600 nM is directly proportional to protein concentration, and a reference standard was used to calculate the protein concentration of test samples according to the following formula:
  • Anti-dsDNA ELISA Titers of IgG antibodies to dsDNA in serum samples from individual mice were measured by ELISA.
  • mice Serum samples from individual mice were collected every three weeks. Titers of antibodies to dsDNA were assessed by ELISA.
  • Mouse double-stranded DNA (The Jackson Laboratory) was digested with S1 nuclease (Invitrogen, Carlsbad, Calif.) to remove any single-stranded DNA and, was then used to coat the wells of a 96-well ELISA plate (100 ⁇ l/well of 1 ⁇ g/ml dsDNA) overnight at 4° C.
  • the plates were pretreated with 0.01% protamine sulfate in water (150 ⁇ l/well for 90 minutes at room temperature) to facilitate adhesion of the DNA. After coating, the plates were incubated with 2.5% BSA blocking buffer for one hour at 37° C. and washed.
  • H&E hematoxylin and eosin
  • PAS periodic acid-Schiff
  • Focal synechiation of glomerular tuft to the Bowman's capsular epithelium is often present and may be the only prominent finding; if synechiation is the only finding, a score of 3 will be assigned if less than 75% of the glomerular tufts are affected.
  • 4 Moderate to severe disease with same characteristics as score 3, but affecting 25-50% of the glomerular tufts 5 Severe disease with same characteristics as score 3, but affecting 50-75% of the glomerular tufts 6 Severe disease with same characteristics as score 3, but affecting greater than 75% of the glomerular tufts
  • Scores 3-6 divide WHO scores III and IV into four sub-scores
  • Antibodies to dsDNA The majority of mice in the negative control group (normal rabbit Ig) as well as the latent TGF- ⁇ 1+ control Ig and ATG-treated groups, gradually developed rising titers of IgG antibodies against dsDNA with comparable kinetics. By comparison, there was a considerable delay in the rise of anti-dsDNA titers in the group treated with the combination of ATG and latent TGF- ⁇ 1 ( FIG. 6 ). Deposition of the immune complexes (DNA-anti-DNA complexes) in the glomerula is believed to play an important role in the inflammation and renal pathology characteristic of lupus. However, the apparent inhibition in the development of antibodies to dsDNA in the combination treatment group could not entirely account for the preservation of kidney function, as there was a poor correlation between titers of antibodies and degree of proteinuria at the end of the study.
  • mice treated with ATG and latent TGF- ⁇ 1 exhibited lesser degrees of glomerulopathy compared to control mice or mice that received either ATG alone or latent TGF- ⁇ 1 and control Ig. These histologic findings correlated with clinical findings of decreased proteinuria/albuminuria and improved survival in the combination-treated animals.
  • a repeat study was: performed with MRL/MPJ-Tnfrs6 lpr mice following the same treatment regimen as described above. In this instance, the study was, extended to 40 weeks of age (as opposed to 24 weeks in the first study) to assess the durability of the effect of transient treatment with ATG+ latent TGF- ⁇ 1. The results showed a long-term survival benefit.
  • a 90% survival rate was observed in mice treated with ATG and latent TGF- ⁇ 1 as compared to 30% survival in mice receiving control rabbit Ig, and 10% survival in the group treated with ATG. This compares favorably with cyclophosphamide which provided 100% survival but required chronic weekly injections as opposed to a one time transient course of treatment with ATG+ latent TGF- ⁇ 1 ( FIG. 8 ).
  • NZB/NZWF1 mice Another model of spontaneous lupus.
  • the same treatment regimen was used and, under these conditions, there was no statistically significant effect of treatment with ATG and latent TGF- ⁇ 1 or either agent alone, on the course or severity of disease. Due to differences in the characteristics and kinetics of disease between the two models, it is likely that the treatment regimen needs to be optimized for the NZB/NZWF1 strain.
  • spleen cells from MRL/lpr lupus mice were cultured in vitro with ATG+/ ⁇ TGF- ⁇ 1 and the cells recovered were analyzed by FAGS for the presence of Tregs.
  • Pooled spleen cells from ten MRL/lpr mice with active disease ( ⁇ 25 weeks old) were resuspended at 2 ⁇ 10 6 cells/ml in serum-free AIM-V medium (Gibco, Grand Island, N.Y.) supplemented with 100 U/ml penicillin, 100 ⁇ g/ml streptomycin and 2 mM glutamine.
  • the cells were cultured in 24-well plates containing 2 ml cells/well under six different conditions (8 wells/condition): 1) cells alone, 2) ATG (100 ⁇ g/ml)+active TGF- ⁇ 1 (10 ng/ml; Genzyme), 3) ATG alone (100 ⁇ g/ml), 4) control rabbit IgG (100 ⁇ g/ml)+active TGF- ⁇ 1 (10 ng/ml), 5) control rabbit IgG alone 100 ⁇ g/ml), and 6) active TGF- ⁇ 1 alone (10 ng/ml). Active TGF- ⁇ 1 was used to mimic the activation process that would normally occur in vivo. The cells were incubated for five days at 37° C. and 5% CO 2 .
  • the number of CD4 + CD25 + T-cells recovered was the greatest in cultures containing ATG+TGF- ⁇ 1. Regulatory T cells typically express a CD4 + CD25 + phenotype but activated T cells can also exhibit this phenotype. Additional FOXP3 staining provides further evidence of a Treg phenotype and the results obtained confirmed that treatment with ATG+TGF- ⁇ 1 produced the greatest number of CD4 + CD25 + FOXP3 + Tregs. Treatment with ATG alone also appeared to lead to a slight increase in this population (compared to cells alone) which was enhanced by the addition of TGF- ⁇ 1. These results support the hypothesis that treatmentwith ATG+TGF- ⁇ 1 can promote the expansion of Tregs and that such cells may provide a therapeutic benefit under conditions of autoimmunity.
  • ATG+/ ⁇ TGF- ⁇ 1 was tested in a collagen-induced arthritis mouse model.
  • DBA/1 mice Jackson Laboratory
  • bovine type II Collagen Cat. No. 2002-2, Chondrex
  • a booster immunization with collagen in incomplete Freund's adjuvant was given on day 22.
  • Treatment with ATG or control rabbit IgG consisted of two intraperitoneal (i.p.) injections of 500 ⁇ g ( ⁇ 25 mg/kg) delivered three days apart (days 23 and 26).
  • Latent TGF- ⁇ 1 was given from days 28-37 as ten daily i.p.
  • a 4 ⁇ g dose of latent TGF- ⁇ 1 corresponds to a 1 ⁇ g ( ⁇ 0.05 mg/kg) dose of the active (mature, non-LAP-associated) portion of the molecule.
  • the treatment groups included (1) control rabbit IgG, (2) control rabbit IgG+latent TGF-81, (3) ATG, and (4).
  • the collagen-induced arthritis is a short-term animal model, in which the treatment takes place on a timescale of weeks, versus months for the lupus model. This shorter timescale might be insufficient to observe the benefit added by administering TGF- ⁇ 1 with the ATG, which was seen in the lupus model. Thus, different dosing regimens or further testing of additional animal models may show benefits of combined administration of ATG and latent TGF- ⁇ .
  • mice (Jackson Laboratory) were immunized subcutaneously on day 0 with 100 ⁇ g of amino acids 161-180 of human interphotoreceptor retinoid binding protein (IRBP 161-180 ) (custom synthesis, New England Peptide) in complete Freund's adjuvant at two sites (between shoulder blades and in pelvic region). Starting on day 10, funduscopic examinations were performed on individual mice and a disease score was assigned. To perform the examination, the eyes of Mice were dilated using one or two drops of MydriacylTM1% (Cat. No.
  • mice 1120, JA Webster
  • Mice were manually restrained and the retinas of both eyes visualized using an indirect opthalmoscope with a 78 diopter lens.
  • the eyes were scored for inflammation using a progressive scoring system between 0 and 5, as described in Table 9.
  • Treatment with ATG or control rabbit IgG was initiated at disease onset (score of 1) and consisted of two i.p. injections of 500 ⁇ g ( ⁇ 25 mg/kg) delivered four days apart (days 10 and 14).
  • Latent TGF- ⁇ 1 was given from days 15-27 as thirteen daily i.p. injections of 4 ⁇ g per mouse.
  • a 4 ⁇ g dose of latent TGF- ⁇ 1 corresponds to a 1 ⁇ g ( ⁇ 0.05 mg/kg) dose of the active (mature, non-LAP-associated) portion of the molecule.
  • the treatment groups included (1) phosphate buffered saline (PBS) control (2) control rabbit IgG, (3) control rabbit IgG+latent TGF- ⁇ 1, (4) ATG, and (5) ATG+latent TGF- ⁇ 1, with six animals per group.
  • PBS phosphate buffered saline
  • control rabbit IgG (3) control rabbit IgG+latent TGF- ⁇ 1, (4) ATG, and (5) ATG+latent TGF- ⁇ 1, with six animals per group.
  • Treatment with ATG alone resulted in a reduction in disease scores and the addition of latent TGF- ⁇ 1 did not appear to provide an additional benefit under the conditions tested.
  • the results are shown in Table 10.
  • the uveitis model is a short-term animal model, in which the treatment fakes place on a timescale of weeks, versus months for the lupus model. This shorter timescale might be insufficient to observe the benefit added by administering TGF- ⁇ 1 with the ATG, which was seen in the lupus model. Thus, different dosing regimens or further testing of additional animal models may show benefits of combined administration of ATG and latent TGF- ⁇ .

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