Subclinical Reactivation of Cytomegalovirus Drives CD4+CD28null T-Cell Expansion and Impaired Immune Response to Pneumococcal Vaccination in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Dimitrios Chanouzas, Michael Sagmeister, Sian Faustini, Peter Nightingale, Alex Richter, Charles J Ferro, Matthew David Morgan, Paul Moss, Lorraine Harper, Dimitrios Chanouzas, Michael Sagmeister, Sian Faustini, Peter Nightingale, Alex Richter, Charles J Ferro, Matthew David Morgan, Paul Moss, Lorraine Harper

Abstract

Background: Infection is the leading cause of death in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Expansion of CD4+CD28null T cells is associated with increased risk of infection and mortality, but is only present in cytomegalovirus (CMV)-seropositive individuals. We hypothesized that subclinical CMV reactivation drives CD4+CD28null T-cell expansion, that this is associated with impaired immune response to heterologous antigens, and that antiviral therapy may ameliorate this.

Methods: In a proof-of-concept open-label clinical trial, 38 CMV-seropositive AAV patients were randomized to receive valacyclovir for 6 months or no intervention. CMV reactivation was measured monthly in plasma and urine. CD4+CD28null T cells were enumerated at baseline and at 6 months. At 6 months, 36 patients were vaccinated with a 13-valent pneumococcal vaccine. Serotype-specific immunoglobulin G was assayed before and 4 weeks postvaccination to calculate the antibody response ratio.

Results: Valacyclovir treatment suppressed subclinical CMV reactivation and reduced CD4+CD28null T-cell proportion. CD4+CD28null T-cell reduction correlated with improved vaccine response, whereas CMV reactivation associated with reduced response to vaccination. Furthermore, expansion of CD4+CD28null T cells was associated with a reduction in the functional capacity of the CD4 compartment.

Conclusions: Suppression of CMV may improve the immune response to a T-cell-dependent pneumococcal vaccination in patients with AAV, thus offering potential clinical benefit.

Clinical trials registration: NCT01633476.

Figures

Figure 1.
Figure 1.
Clinical trial flowchart. *One patient electively stopped taking the study drug within 1 month of commencement. One patient developed an episode of acute kidney injury that led to discontinuation of valacyclovir within 1 month. Both patients completed subsequent trial visits fully, although the study drug was not restarted. †Two patients in the control group declined to attend visits following the initial 6-month period. Abbreviations: CMV, cytomegalovirus; IgG, immunoglobulin G.
Figure 2.
Figure 2.
Subclinical cytomegalovirus (CMV) reactivation drives the expansion of CD4+CD28null T cells, and antiviral therapy limits this expansion. A, Time to first CMV reactivation in treatment (n = 19, dashed) vs control (n = 19, solid) groups (hazard ratio, 8.2; 95% confidence interval [CI], 1.1–59.1; P = .037) and reactivation episodes in treated (dashed) and control (solid) patients during the course of the study. On the second plot, each line represents a single patient; the end of the treatment period is indicated by a dashed vertical line at month 6. B, There was a significant reduction in CD4+CD28null T-cell percentage and absolute count from baseline (M0) to end of treatment (M6) in treated patients. There was no change in controls. Bars show mean with 95% CI. C, Proportionate change in anti-CMV immunoglobulin G (IgG) titer during the course of the study. There was a significant reduction in anti-CMV IgG titer in treated patients (dashed line; slope –1.305; P < .001). There was no significant change in controls (solid line; slope 0.218; P = .521). D, Control patients (n = 19) with CMV reactivation had an increase in CD4+CD28null T cells during the course of the study compared to patients with no reactivation. Bars show medians. Abbreviations: CMV, cytomegalovirus; IgG, immunoglobulin G; M0, baseline; M6, month 6.
Figure 3.
Figure 3.
Subclinical reactivation of cytomegalovirus (CMV) is associated with impaired immune response to pneumococcal vaccination. A, Spider graph showing median antibody response ratio (ARR) for each individual pneumococcal serotype for patients with subclinical CMV reactivation during the 6 months prior to administration of 13-valent pneumococcal conjugate vaccine (PCV13) (n = 5, solid line) and those without (n = 31, dotted line). B, Patients with subclinical CMV reactivation (n = 5) had a lower mean ARR to PCV13 compared to those without (n = 31). Abbreviations: ARR, antibody response ratio; Pn, pneumococcal serotype.
Figure 4.
Figure 4.
Expansion of CD4+CD28null T cells is associated with impaired immune response to pneumococcal vaccination. A, Correlation between prevaccination CD4+CD28null T-cell percentage (at end of valacyclovir treatment period) and mean antibody response ratio (ARR) to 13-valent pneumococcal conjugate vaccine (PCV13) (n = 36). B, Correlation between proportionate change in CD4+CD28null T-cell percentage from baseline to end of valacyclovir treatment period (month 6 CD4+CD28null T-cell % / baseline CD4+CD28null T-cell %) and mean ARR to PCV13 (n = 36). C, Spider graph showing median ARR for each individual pneumococcal serotype for patients with prevaccination CD4+CD28null T cells <2% (n = 7; dotted line), 2%–10% (n = 10; dashed line), and >10% (n = 19; solid line). D, Mean ARR across all serotypes measured for patients with prevaccination CD4+CD28null T-cell percentage <2%, 2%–10%, and >10%, indicating patients with a low, moderate, and high impact, respectively, of CMV on the immune system, exhibiting a graded immune response to PCV13 vaccination across these 3 categories. Bars represent the median, and error bars represent the interquartile range. Abbreviations: ARR, antibody response ratio; Pn, pneumococcal serotype.
Figure 5.
Figure 5.
Expansion of CD4+CD28null T cells is associated with reduced functional capacity of the CD4 compartment. A, Correlation between CD4+CD28null T-cell percentage and proportion of multifunctional (CD154+tumor necrosis factor alpha [TNF-α]+interleukin 2 [IL-2]+) cells within staphylococcal enterotoxin B (SEB)–responsive interferon gamma (IFN-γ+) CD4 T cells. B, Spider graph showing median percentage of cells with CD154, TNF-α, or IL-2 coexpression within SEB-responsive CD4 T cells in patients with small (<2%, gray line), moderate (2%–10%, dashed line), and large (>10%, solid black line) CD4+CD28null T-cell expansions. C, Spider graph showing median percentage of cells with IFN-γ expression only (1F), IFN-γ and one of CD154, TNF-α, or IL-2 coexpression (2F; double functional), IFN-γ and 2 of CD154, TNF-α, or IL-2 coexpression (3F; triple functional), or multifunctional (4F) capacity within SEB-responsive CD4 T cells for patients with small (<2%, gray line), moderate (2%–10%, dashed line), and large (>10%, solid black line) CD4+CD28null T-cell expansions. D, Correlation between proportion of multifunctional (4F) cells within the SEB-responsive CD4 compartment and mean antibody response ratio to the 13-valent pneumococcal conjugate vaccine. Abbreviations: IL-2, interleukin 2; SEB, staphylococcal enterotoxin B; TNF-α, tumor necrosis factor alpha.

References

    1. Jennette JC, Falk RJ, Andrassy K, et al. . Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 1994, 37:187–92.
    1. Flossmann O, Berden A, de Groot K, et al. . European Vasculitis Study Group Long-term patient survival in ANCA-associated vasculitis. Ann Rheum Dis 2011; 70:488–94.
    1. David Morgan M, Richter A, Al-Ali S, et al. . Association of low B cell count and IgG levels with infection, and poor vaccine response with all-cause mortality in an immunosuppressed vasculitis population. Arthritis Care Res (Hoboken) 2016; 68:853–60.
    1. Morgan MD, Pachnio A, Begum J, et al. . CD4+CD28– T cell expansion in granulomatosis with polyangiitis (Wegener’s) is driven by latent cytomegalovirus infection and is associated with an increased risk of infection and mortality. Arthritis Rheum 2011; 63:2127–37.
    1. Schmidt D, Goronzy JJ, Weyand CM. CD4+ CD7– CD28– T cells are expanded in rheumatoid arthritis and are characterized by autoreactivity. J Clin Invest 1996; 97:2027–37.
    1. Ugarte-Gil MF, Sánchez-Zúñiga C, Gamboa-Cárdenas RV, et al. . Circulating CD4+CD28null and extra-thymic CD4+CD8+ double positive T cells are independently associated with disease damage in systemic lupus erythematosus patients. Lupus 2016; 25:233–40.
    1. Schmidt D, Martens PB, Weyand CM, Goronzy JJ. The repertoire of CD4+ CD28– T cells in rheumatoid arthritis. Mol Med 1996; 2:608–18.
    1. Eriksson P, Sandell C, Backteman K, Ernerudh J. Expansions of CD4+CD28– and CD8+CD28– T cells in granulomatosis with polyangiitis and microscopic polyangiitis are associated with cytomegalovirus infection but not with disease activity. J Rheumatol 2012; 39:1840–3.
    1. Shabir S, Smith H, Kaul B, et al. . Cytomegalovirus-associated CD4(+) CD28(null) cells in NKG2D-dependent glomerular endothelial injury and kidney allograft dysfunction. Am J Transplant 2016; 16:1113–28.
    1. Thewissen M, Somers V, Hellings N, Fraussen J, Damoiseaux J, Stinissen P. CD4+CD28null T cells in autoimmune disease: pathogenic features and decreased susceptibility to immunoregulation. J Immunol 2007; 179:6514–23.
    1. Hooper M, Kallas EG, Coffin D, Campbell D, Evans TG, Looney RJ. Cytomegalovirus seropositivity is associated with the expansion of CD4+CD28- and CD8+CD28– T cells in rheumatoid arthritis. J Rheumatol 1999; 26:1452–7.
    1. Wills M, Akbar A, Beswick M, et al. . Report from the second cytomegalovirus and immunosenescence workshop. Immun Ageing 2011; 8:10.
    1. Koch S, Larbi A, Ozcelik D, et al. . Cytomegalovirus infection: a driving force in human T cell immunosenescence. Ann N Y Acad Sci 2007; 1114:23–35.
    1. Khan N, Hislop A, Gudgeon N, et al. . Herpesvirus-specific CD8 T cell immunity in old age: cytomegalovirus impairs the response to a coresident EBV infection. J Immunol 2004; 173:7481–9.
    1. Olsson J, Wikby A, Johansson B, Löfgren S, Nilsson BO, Ferguson FG. Age-related change in peripheral blood T-lymphocyte subpopulations and cytomegalovirus infection in the very old: the Swedish longitudinal OCTO immune study. Mech Ageing Dev 2000; 121:187–201.
    1. Solana R, Tarazona R, Aiello AE, et al. . CMV and immunosenescence: from basics to clinics. Immun Ageing 2012; 9:23.
    1. Sansoni P, Vescovini R, Fagnoni FF, et al. . New advances in CMV and immunosenescence. Exp Gerontol 2014; 55:54–62.
    1. Nikolich-Žugich J, van Lier RAW. Cytomegalovirus (CMV) research in immune senescence comes of age: overview of the 6th International Workshop on CMV and Immunosenescence. Geroscience 2017; 39:245–9.
    1. Arens R, Remmerswaal EB, Bosch JA, van Lier RA. 5th International Workshop on CMV and Immunosenescence: a shadow of cytomegalovirus infection on immunological memory. Eur J Immunol 2015; 45:954–7.
    1. Chanouzas D, Dyall L, Nightingale P, et al. . Valaciclovir to prevent cytomegalovirus mediated adverse modulation of the immune system in ANCA-associated vasculitis (CANVAS): study protocol for a randomised controlled trial. Trials 2016; 17:338.
    1. Yates M, Watts RA, Bajema IM, et al. . EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016; 75:1583–94.
    1. Whitelegg AM, Birtwistle J, Richter A, et al. . Measurement of antibodies to pneumococcal, meningococcal and haemophilus polysaccharides, and tetanus and diphtheria toxoids using a 19-plexed assay. J Immunol Methods 2012; 377:37–46.
    1. Kapetanovic MC, Roseman C, Jönsson G, Truedsson L, Saxne T, Geborek P. Antibody response is reduced following vaccination with 7-valent conjugate pneumococcal vaccine in adult methotrexate-treated patients with established arthritis, but not those treated with tumor necrosis factor inhibitors. Arthritis Rheum 2011; 63:3723–32.
    1. Wall NA, Chue CD, Edwards NC, et al. . Cytomegalovirus seropositivity is associated with increased arterial stiffness in patients with chronic kidney disease. PLoS One 2013; 8:e55686.
    1. Pera A, Broadley I, Davies KA, Kern F. Cytomegalovirus as a driver of excess cardiovascular mortality in rheumatoid arthritis: a red herring or a smoking gun?Circ Res 2017; 120:274–7.
    1. Dunn HS, Haney DJ, Ghanekar SA, Stepick-Biek P, Lewis DB, Maecker HT. Dynamics of CD4 and CD8 T cell responses to cytomegalovirus in healthy human donors. J Infect Dis 2002; 186:15–22.
    1. Pittet MJ, Zippelius A, Speiser DE, et al. . Ex vivo IFN-gamma secretion by circulating CD8 T lymphocytes: implications of a novel approach for T cell monitoring in infectious and malignant diseases. J Immunol 2001; 166:7634–40.
    1. Rauwel B, Jang SM, Cassano M, Kapopoulou A, Barde I, Trono D. Release of human cytomegalovirus from latency by a KAP1/TRIM28 phosphorylation switch. eLife 2015, 4. doi:10.7554/eLife.06068.
    1. Pourgheysari B, Khan N, Best D, Bruton R, Nayak L, Moss PA. The cytomegalovirus-specific CD4+ T-cell response expands with age and markedly alters the CD4+ T-cell repertoire. J Virol 2007; 81:7759–65.
    1. Sylwester AW, Mitchell BL, Edgar JB, et al. . Broadly targeted human cytomegalovirus-specific CD4+ and CD8+ T cells dominate the memory compartments of exposed subjects. J Exp Med 2005; 202:673–85.
    1. Derhovanessian E, Maier AB, Hähnel K, McElhaney JE, Slagboom EP, Pawelec G. Latent infection with cytomegalovirus is associated with poor memory CD4 responses to influenza A core proteins in the elderly. J Immunol 2014; 193:3624–31.
    1. Ballesteros-Tato A, León B, Graf BA, et al. . Interleukin-2 inhibits germinal center formation by limiting T follicular helper cell differentiation. Immunity 2012; 36:847–56.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj