Role of orbital fibroblasts in tissue remodeling of Graves' orbitopathy - involvement of hypoxia dependent and independent pathways

Graves’ disease (GD) is an autoimmune disease caused by autoantibodies directed mainly against the thyrotropin stimulating hormone receptor (TSHR) leading to hyperthyroidism. Graves’ orbitopathy (GO) is the common extra-thyroidal manifestation of Graves’ disease is characterized by inflammation and expansion of the retroocular connective/fat tissue and of the extraocular muscles (EOM). The expansion of the orbital tissue within the limited space of the bony orbit leads to proptosis, extraocular muscle dysfunction, and, in severe cases, to an optic nerve compression. Inflammation and enlargement of the orbital tissue can cause hypoxia and consequently induce hypoxia-inducible-factor 1 (HIF-1) pathways. The work presented in this thesis addressed the role of orbital fibroblast (OF) and/or mesenchymal stem cells (MSC) for pathogenesis of GO in patients and mouse model. We aimed to characterize human and mouse OF and/or MSC and involvement of hypoxia depending and independent pathways in the pathophysiological process leading to GO. The central cell type in this pathophysiologic process are the orbital fibroblasts (OF) which we derived either from fat biopsies of GO patients/control persons or from orbital tissue of GO/control mouse model. Additionally, we identified MSC in the fat tissue of GO patients and showed that OF shared all biological characteristics of MSC: Both the OF and the MSC expressed a typical MSC surface marker set, suppressed T cell proliferation and secreted cytokines. Furthermore, the cells produced hyaluronan and were able to differentiate along adipogenic, osteogenic, chondrogenic, myogenic, and neuronal pathways. It appears that OF population comprises undifferentiated progenitor cells responsible for adipogensis and/or myogenesis in GO. To analyze whether hypoxia dependent pathways are involved in tissue remodeling of GO we investigated the role of HIF-1 action for angiogenesis and adipogensis. Most likely as a consequence of hypoxia we found increased vascularization and HIF-1α positive cells in the connective/fat tissue of GO patients. OF derived thereof expressed higher HIF-1α levels and secreted elevated levels of VEGF in an HIF-1 dependent manner. Furthermore, hypoxia induced HIF-1 dependent adipogenic differentiation of OF which could be further increased by stimulation of TSHR using TSH indicating an unfavorable marriage between hypoxia and effects of autoimmunity. Smoking is the strongest risk factor for GO and develops it full effect most likely through smoke ingredients and hypoxia. Interestingly, we found that OF derived from GO smoker more strongly induced HIF-1α levels in response to cigarette smoke extract and hypoxia compared to GO non-smoker. Increased HIF-1α expression can contribute to the strong tissue expansion observed GO smoker. To investigate pathological changes in OF during the course of GO we established a preclinical mouse model of GO induced by genetic immunization of human TSHR A- subunit plasmid. The pathological features of GO in the experimental mouse model were similar in orbital pathology to those present in patients with GO; GO mice developed TSHR antibodies with different levels of stimulating and blocking activity as well as TSHR antigen specific response of splenic T cells. Furthermore GO mice just like GO patients developed thyroid dysfunction and orbital disease with mice showing either more enlargement of orbital adipose tissue or myopathy of EOM. We derived OF from tissue comprise of EOM and adipose of the immunized mice. Mouse OF (mOF) expressed MSC marker, elevated levels of TSHR and insulin-like growth factor 1 receptor (IGF-1R) similar to OF derived from GO patients. Likewise, mOF showed increased adipogenesis and enhanced hyaluronan secretion by activation of TSHR and IGF-1R. Moreover, in response to hypoxia OF derived from GO mice enhanced HIF-1α levels, suggesting that hypoxia dependent signaling is involved in orbital pathogenesis. Thus, OF derived from GO mice display a pathogenic cell type similar to OF derived from GO patients. In conclusion, OF and MSC are central for GO pathogenesis in patients and mouse model. HIF-1 dependent pathways are involved in tissue remodeling and expansion during pathogenesis of GO. The understanding of the contribution of different orbital cell populations for tissue remodeling in response to hypoxia during the course of the eye disease will be further studied in the GO mouse model. In addition the role of hypoxia for inflammation in context of autoimmunity remains to be discovered. This will lead to a better insight of disease pathogenesis and is fundamental to develop potential novel therapeutic targets.Morbus Basedow (Graves‘ Disease) ist eine Schilddrüsenerkrankung, die durch Autoantikörper verursacht wird, die hauptsächlich gegen den Thyreotropin-stimulierenden Hormonrezeptor (TSHR) gerichtet sind und eine Hyperthyreose zur Folge haben. Endokrine Orbitopathie (Graves' Orbitopathie, GO) ist eine extrathyroidale Manifestation, die üblicherweise im Zusammenhang mit Morbus Basedow auftritt und durch Entzündung und Ausdehnung des retrookularen Bindegewebes und der extraokulären Muskeln (EOM) gekennzeichnet ist. Die Ausdehnung des orbitalen Gewebes in die räumlich begrenzte, knöcherne Orbita führt zu Proptosis, Muskeldysfunktion und in schweren Fällen zu einer Kompression des Sehnervs. Die Entzündung und Ausdehnung des orbitalen Gewebes kann eine Sauerstoffunterversorgung (Hypoxie) des Gewebes verursachen und somit zu einer Induktion von Hypoxie-induzierbarer Faktor 1 (HIF-1) abhängigen Signalwege führen. Die vorliegende Arbeit beschäftigt sich mit der Rolle orbitaler Fibroblasten (OF) und/oder mesenchymaler Stammzellen (MSC) in der Pathogenese von GO Patienten und im GO Mausmodell. Ziel war die Charakterisierung humaner und muriner OF und/oder MSC im Hinblick auf Hypoxie-abhängige und unabhängige pathophysiologische Prozesse der GO. Orbitale Fibroblasten sind der zentrale Zelltyp im pathophysiologischen Prozess, und wurden entweder aus Fettbiopsien von GO Patienten/Kontrollpersonen oder aus orbitalem Gewebe eines GO Mausmodells/Kontrollmäuse gewonnen. Darüber hinaus identifizierten wir MSC im orbitalen Fettgewebe von GO Patienten und zeigten, dass OF alle biologischen Merkmale der MSC teilten: Sowohl OF als auch MSC exprimierten typische MSC Oberflächen-Marker, unterdrückten die T-Zellproliferation und sezernierten Zytokine. Des Weiteren produzierten sie Hyaluronsäure und waren in der Lage sowohl adipogen, osteogen und chondrogen als auch myogen und neuronal zu differenzieren. Dies zeigte, dass die OF Population undifferenzierte Vorläuferzellen beinhaltet, die für die gesteigerte Adipogenese und/oder Myogenese im Gewebe von GO Patienten verantwortlich sein könnten. Um zu untersuchen, ob Hypoxie-abhängige Signalwege in den Gewebeumbau bei GO involviert sind, analysierten wir die Rolle von HIF-1 für die Angiogenese und Adipogenese unter hypoxischen Bedingungen. Als eine mögliche Folge der Hypoxiewirkung fanden wir eine erhöhte Vaskularisierung und HIF-1α-positive Zellen im Binde-/Fettgewebe von GO Patienten. Die aus dem Fettgewebe der Patienten gezüchteten OF zeigten eine höhere HIF-1 Expression und sezernierten HIF-1 abhängig mehr VEGF. Des Weiteren wurde unter Hypoxie die adipogene Differenzierung der OF HIF-1 abhängig induziert. Die durch Hypoxie induzierte Adipogenese konnte durch Stimulation des TSHR unter Verwendung von TSH noch weiter gesteigert werden, was das ungünstige Zusammenwirken von Hypoxie und Effekten der Autoimmunität widerspiegelt. Rauchen ist der stärkste Risikofaktor für den Schweregrad einer GO und entfaltet seine Wirkung wahrscheinlich durch die Kombination von Rauchbestandteilen und Hypoxie. Interessanterweise konnten wir feststellen, dass OF von GO Rauchern im Vergleich zu GO Nichtrauchern höhere HIF-1α Mengen in Reaktion auf Zigarettenrauchextrakt und Hypoxie aufwiesen. Die erhöhte HIF-1α Expression bei GO Rauchern könnte die starke Gewebsexpansion, welche bei GO Rauchern beobachtet wird, begünstigen. Um die pathologischen Veränderungen der OF im Verlauf einer GO untersuchen zu können, etablierten wir ein präklinisches GO Mausmodell, das durch genetische Immunisierung mit einem Plasmid, welches für die humane TSHR A-Untereinheit kodierte, induziert werden konnte. Die TSHR immunisierten Mäuse entwickelten alle Anzeichen von Morbus Basedow mit GO: Die Mäuse entwickelten TSHR-Antikörper mit unterschiedlichen Mengen an stimulierenden- und/oder blockierenden Antikörpern, eine TSHR-Antigen-spezifische Antwort von T-Zellen der Milz, Schilddrüsenfunktionsstörungen und Orbitopathie. Dabei entwickelten die Mäuse ähnlich wie GO Patienten im unterschiedlichen Maße eine Vergrößerung des orbitalen Fettgewebes und/oder eine Myopathie der EOM. Aus dem orbitalen Gewebe der Mäuse, welches überwiegend aus EOM und Fett bestand, isolierten und charakterisierten wir Fibroblasten. Ähnlich wie die OF von Patienten, exprimierten die Maus OF (mOF) typische MSC Marker, TSHR und Insulin Wachstumsfaktor-1-Rezeptor (IGF-1R). Ebenso zeigten mOF eine gesteigerte Adipogenese und vermehrte Hyaluronsäure Sekretion in Antwort auf TSHR und IGF-1R Aktivierung. Darüber hinaus, zeigten OF von GO Mäusen erhöhte HIF-1α Mengen unter hypoxischen Bedingungen, was darauf hindeutete, dass Hypoxie-abhängige Signalwege an der Pathogenese einer GO bei Mäusen beteiligt sein könnten. Somit zeigten die OF von GO Mäusen einen pathogenen Zelltyp, der den OF von GO Patienten ähnlich ist. Zusammengefasst konnte gezeigt werden, dass OF und/oder MSC eine zentrale Zellpopulation in der Pathogenese von GO Patienten und GO Mausmodell darstellen. HIF-1 abhängige Signalwege sind am Gewebeumbau und -expansion beteiligt. Das Verständnis, wie verschiedene orbitale Zellpopulationen am Gewebeumbau als Reaktion auf Hypoxie mitwirken, wird während des Verlaufs der Augenerkrankung im GO Mausmodell noch weiter untersucht. Darüber hinaus ist es von Interesse die Rolle von Hypoxie-abhängigen Signalwege im Entzündungsprozess im Kontext der Autoimmunität aufzuklären. Dies kann zu einem besseren Einblick in die Pathogenese der GO führen und ist von grundlegender Bedeutung für die Entwicklung neuer therapeutischer Ansätze

Sphingolipids in thyroid eye disease

Graves’ disease (GD) is caused by an autoimmune formation of autoantibodies and autoreactive T-cells against the thyroid stimulating hormone receptor (TSHR). The autoimmune reaction does not only lead to overstimulation of the thyroid gland, but very often also to an immune reaction against antigens within the orbital tissue leading to thyroid eye disease, which is characterized by activation of orbital fibroblasts, orbital generation of adipocytes and myofibroblasts and increased hyaluronan production in the orbit. Thyroid eye disease is the most common extra-thyroidal manifestation of the autoimmune Graves’ disease. Several studies indicate an important role of sphingolipids, in particular the acid sphingomyelinase/ceramide system and sphingosine 1-phosphate in thyroid eye disease. Here, we discuss how the biophysical properties of sphingolipids contribute to cell signaling, in particular in the context of thyroid eye disease. We further review the role of the acid sphingomyelinase/ceramide system in autoimmune diseases and its function in T lymphocytes to provide some novel hypotheses for the pathogenesis of thyroid eye disease and potentially allowing the development of novel treatments

Potential involvement of the bone marrow in experimental Graves’ disease and thyroid eye disease

IntroductionGraves’ disease is an autoimmune disorder caused by auto-antibodies against the thyroid stimulating hormone receptor (TSHR). Overstimulation of the TSHR induces hyperthyroidism and thyroid eye disease (TED) as the most common extra thyroidal manifestation of Graves’ disease. In TED, the TSHR cross talks with the insulin-like growth factor 1 receptor (IGF-1R) in orbital fibroblasts leading to inflammation, deposition of hyaluronan and adipogenesis. The bone marrow may play an important role in autoimmune diseases, but its role in Graves’ disease and TED is unknown. Here, we investigated whether induction of experimental Graves’ disease and accompanying TED involves bone marrow activation and whether interference with IGF-1R signaling prevents this activation.ResultsImmunization of mice with TSHR resulted in an increase the numbers of CD4-positive T-lymphocytes (p ≤0.0001), which was normalized by linsitinib (p = 0.0029), an increase of CD19-positive B-lymphocytes (p= 0.0018), which was unaffected by linsitinib and a decrease of GR1-positive cells (p= 0.0038), which was prevented by linsitinib (p= 0.0027). In addition, we observed an increase of Sca-1 positive hematopietic stem cells (p= 0.0007) and of stromal cell-derived factor 1 (SDF-1) (p ≤0.0001) after immunization with TSHR which was prevented by linsitinib (Sca-1: p= 0.0008, SDF-1: p ≤0.0001). TSHR-immunization also resulted in upregulation of CCL-5, IL-6 and osteopontin (all p ≤0.0001) and a concomitant decrease of the immune-inhibitory cytokines IL-10 (p= 0.0064) and PGE2 (p ≤0.0001) in the bone marrow (all p≤ 0.0001). Treatment with the IGF-1R antagonist linsitinib blocked these events (all p ≤0.0001). We further demonstrate a down-regulation of arginase-1 expression (p= 0.0005) in the bone marrow in TSHR immunized mice, with a concomitant increase of local arginine (p ≤0.0001). Linsitinib induces an upregulation of arginase-1 resulting in low arginase levels in the bone marrow. Reconstitution of arginine in bone marrow cells in vitro prevented immune-inhibition by linsitinib.ConclusionCollectively, these data indicate that the bone marrow is activated in experimental Graves’ disease and TED, which is prevented by linsitinib. Linsitinib-mediated immune-inhibition is mediated, at least in part, by arginase-1 up-regulation, consumption of arginine and thereby immune inhibition

Linsitinib, an IGF-1R inhibitor, attenuates disease development and progression in a model of thyroid eye disease

IntroductionGraves’ disease (GD) is an autoimmune disorder caused by autoantibodies against the thyroid stimulating hormone receptor (TSHR) leading to overstimulation of the thyroid gland. Thyroid eye disease (TED) is the most common extra thyroidal manifestation of GD. Therapeutic options to treat TED are very limited and novel treatments need to be developed. In the present study we investigated the effect of linsitinib, a dual small-molecule kinase inhibitor of the insulin-like growth factor 1 receptor (IGF-1R) and the Insulin receptor (IR) on the disease outcome of GD and TED.MethodsLinsitinib was administered orally for four weeks with therapy initiating in either the early (“active”) or the late (“chronic”) phases of the disease. In the thyroid and the orbit, autoimmune hyperthyroidism and orbitopathy were analyzed serologically (total anti-TSHR binding antibodies, stimulating anti TSHR antibodies, total T4 levels), immunohistochemically (H&E-, CD3-, TNFa- and Sirius red staining) and with immunofluorescence (F4/80 staining). An MRI was performed to quantify in vivo tissue remodeling inside the orbit.ResultsLinsitinib prevented autoimmune hyperthyroidism in the early state of the disease, by reducing morphological changes indicative for hyperthyroidism and blocking T-cell infiltration, visualized by CD3 staining. In the late state of the disease linsitinib had its main effect in the orbit. Linsitinib reduced immune infiltration of T-cells (CD3 staining) and macrophages (F4/80 and TNFa staining) in the orbita in experimental GD suggesting an additional, direct effect of linsitinib on the autoimmune response. In addition, treatment with linsitinib normalized the amount of brown adipose tissue in both the early and late group. An in vivo MRI of the late group was performed and revealed a marked decrease of inflammation, visualized by 19F MR imaging, significant reduction of existing muscle edema and formation of brown adipose tissue.ConclusionHere, we demonstrate that linsitinib effectively prevents development and progression of thyroid eye disease in an experimental murine model for Graves’ disease. Linsitinib improved the total disease outcome, indicating the clinical significance of the findings and providing a path to therapeutic intervention of Graves’ Disease. Our data support the use of linsitinib as a novel treatment for thyroid eye disease

Cigarette smoke causes a bioenergetic crisis in RPE cells involving the downregulation of HIF-1α under normoxia

Abstract Age-related macular degeneration (AMD) is the most common blinding disease in the elderly population. However, there are still many uncertainties regarding the pathophysiology at the molecular level. Currently, impaired energy metabolism in retinal pigment epithelium (RPE) cells is discussed as one major hallmark of early AMD pathophysiology. Hypoxia-inducible factors (HIFs) are important modulators of mitochondrial function. Moreover, smoking is the most important modifiable risk factor for AMD and is known to impair mitochondrial integrity. Therefore, our aim was to establish a cell-based assay that enables us to investigate how smoking affects mitochondrial function in conjunction with HIF signaling in RPE cells. For this purpose, we treated a human RPE cell line with cigarette smoke extract (CSE) under normoxia (21% O2), hypoxia (1% O2), or by co-treatment with Roxadustat, a clinically approved HIF stabilizer. CSE treatment impaired mitochondrial integrity, involving increased mitochondrial reactive oxygen species, disruption of mitochondrial membrane potential, and altered mitochondrial morphology. Treatment effects on cell metabolism were analyzed using a Seahorse Bioanalyzer. Mitochondrial respiration and ATP production were impaired in CSE-treated cells under normoxia. Surprisingly, CSE-treated RPE cells also exhibited decreased glycolytic rate under normoxia, causing a bioenergetic crisis, because two major metabolic pathways that provide ATP were impaired by CSE. Downregulation of glycolytic rate was HIF-dependent because HIF-1α, the α-subunit of HIF-1, was downregulated by CSE on the protein level, especially under normoxia. Moreover, hypoxia incubation and treatment with Roxadustat restored glycolytic flux. Taken together, our in vitro model provides interesting insights into HIF-dependent regulation of glycolysis under normoxic conditions, which will enable us to investigate signaling pathways involved in RPE metabolism in health and disease

Graves’ orbitopathy occurs sex-independently in an autoimmune hyperthyroid mouse model

Abstract Graves’ orbitopathy (GO) is the most common extra thyroidal complication of Graves’ disease (GD) and occurs predominantly in women but more severe in men. The reason for this effect of gender on GO is unknown. Herein we studied the manifestation of GO in both sexes of an induced mouse model in absence of additional risk factors present in patients like advanced age, genetic variabilities or smoking. Male and female mice were immunized with human TSHR A-subunit encoding plasmid. Both sexes comparably developed autoimmune hyperthyroidism characterized by TSHR stimulating autoantibodies, elevated T4 values, hyperplastic thyroids and hearts. Autoimmune mice developed inflammatory eye symptoms and proptosis, although males earlier than females. Serial in vivo 1H/19F-magnetic resonance imaging revealed elevated inflammatory infiltration, increased fat volume and glycosaminoglycan deposition in orbits of both sexes but most significantly in female mice. Histologically, infiltration of T-cells, extension of brown fat and overall collagen deposition were characteristics of GO in male mice. In contrast, female mice developed predominately macrophage infiltration in muscle and connective tissue, and muscle hypertrophy. Apart from sex-dependent variabilities in pathogenesis, disease classification revealed minor sex-differences in incidence and total outcome. In conclusion, sex does not predispose for autoimmune hyperthyroidism and associated GO

Comparative assessment of female mouse model of Graves' orbitopathy under different environments, accompanied by pro-inflammatory cytokine and T cell responses to thyrotropin hormone receptor antigen

We recently described a preclinical model of Graves' orbitopathy (GO), induced by genetic immunization of eukaryotic expression plasmid encoding human TSH-receptor (hTSHR) A-subunit by muscle electroporation in female BALB/c mice. The onset of orbital pathology is characterized by muscle inflammation, adipogenesis and fibrosis. Animal models of autoimmunity are influenced by their environmental exposures. This follow-up study was undertaken to investigate the development of experimental GO in two different locations, run in parallel under comparable housing conditions. Functional antibodies to TSHR were induced in TSHR A-subunit plasmid immunized animals, and antibodies to IGF-1 receptor α subunit were also present, while control animals were negative in both locations. Splenic T cells from TSHR A-subunit primed animals undergoing GO in both locations showed proliferative responses to purified TSHR antigen and secreted IFN-γ, IL-10, IL-6 and TNF-α cytokines. Histopathological evaluation showed orbital tissue damage in mice undergoing GO, manifest by adipogenesis, fibrosis and muscle damage with classic signs of myopathy. Although no inflammatory infiltrate was observed in orbital tissue in either location, the appearances were consistent with a 'hit and run' immune-mediated inflammatory event. A statistically significant increase of cumulative incidence of orbital pathology when compared to control animals was shown for both locations, confirming onset of orbital dysimmune myopathy. Our findings confirm expansion of the model in different environments, accompanied with increased prevalence of T cell derived pro-inflammatory cytokines, with relevance for pathogenesis. Wider availability of the model makes it suitable for mechanistic studies into pathogenesis and undertaking of novel therapeutic approaches