Inhibitory Phenotype of HBV-Specific CD4⁺ T-Cells Is Characterized by High PD-1 Expression but Absent Coregulation of Multiple Inhibitory Molecules

Background: T-cell exhaustion seems to play a critical role in CD8(+) T-cell dysfunction during chronic viral infections. However, up to now little is known about the mechanisms underlying CD4(+) T-cell dysfunction during chronic hepatitis B virus (CHB) infection and the role of inhibitory molecules such as programmed death 1 (PD-1) for CD4(+) T-cell failure. Methods: The expression of multiple inhibitory molecules such as PD-1, CTLA-4, TIM-3, CD244, KLRG1 and markers defining the grade of T-cell differentiation as CCR7, CD45RA, CD57 and CD127 were analyzed on virus-specific CD4(+) T-cells from peripheral blood using a newly established DRB1*01-restricted MHC class II Tetramer. Effects of in vitro PD-L1/2 blockade were defined by investigating changes in CD4(+) T-cell proliferation and cytokine production. Results: CD4(+) T-cell responses during chronic HBV infection was characterized by reduced Tetramer(+)CD4(+) T-cell frequencies, effector memory phenotype, sustained PD-1 but low levels of CTLA-4, TIM-3, KLRG1 and CD244 expression. PD-1 blockade revealed individualized patterns of in vitro responsiveness with partly increased IFN-gamma, IL-2 and TNF-alpha secretion as well as enhanced CD4(+) T-cell expansion almost in treated patients with viral control. Conclusion: HBV-specific CD4(+) T-cells are reliably detectable during different courses of HBV infection by MHC class II Tetramer technology. CD4(+) T-cell dysfunction during chronic HBV is basically linked to strong PD-1 upregulation but absent coregulation of multiple inhibitory receptors. PD-L1/2 neutralization partly leads to enhanced CD4(+) T-cell functionality with heterogeneous patterns of CD4(+) T-cell rejunivation

Tracking Virus-Specific CD4+ T Cells during and after Acute Hepatitis C Virus Infection

CD4+ T cell help is critical in maintaining antiviral immune responses and such help has been shown to be sustained in acute resolving hepatitis C. In contrast, in evolving chronic hepatitis C CD4+ T cell helper responses appear to be absent or short-lived, using functional assays. Here we used a novel HLA-DR1 tetramer containing a highly targeted CD4+ T cell epitope from the hepatitis C virus non-structural protein 4 to track number and phenotype of hepatitis C virus specific CD4+ T cells in a cohort of seven HLA-DR1 positive patients with acute hepatitis C in comparison to patients with chronic or resolved hepatitis C. We observed peptide-specific T cells in all seven patients with acute hepatitis C regardless of outcome at frequencies up to 0.65% of CD4+ T cells. Among patients who transiently controlled virus replication we observed loss of function, and/or physical deletion of tetramer+ CD4+ T cells before viral recrudescence. In some patients with chronic hepatitis C very low numbers of tetramer+ cells were detectable in peripheral blood, compared to robust responses detected in spontaneous resolvers. Importantly we did not observe escape mutations in this key CD4+ T cell epitope in patients with evolving chronic hepatitis C. During acute hepatitis C a CD4+ T cell response against this epitope is readily induced in most, if not all, HLA-DR1+ patients. This antiviral T cell population becomes functionally impaired or is deleted early in the course of disease in those where viremia persists

No relevant effect of ursodeoxycholic acid on cytochrome P450 3A metabolism in primary biliary cirrhosis

Induction of cytochrome P450 3A (CYP3A) has been suggested as a mechanism of action of ursodeoxycholic acid (UDCA) in cholestasis. CYP3A is of key importance in human drug metabolism, being involved in presystemic extraction of more than 50% of all drugs currently available and of various endogenous compounds. Therefore, we compared the induction potential of UDCA with that of the prototypical inducer rifampicin in a human model study with the CYP3A substrates budesonide and cortisol. Twelve patients with early-stage primary biliary cirrhosis and eight healthy volunteers were treated with UDCA (15 mg/kg daily) for 3 weeks and subsequently with rifampicin (600 mg/d) for 1 week. Extensive pharmacokinetic profiling of oral budesonide (3 mg) was performed by determination of budesonide and phase I metabolites (6beta-hydroxybudesonide, 16alpha-hydroxyprednisolone) in plasma and urine at baseline and at the end of each treatment. In parallel, urinary 6beta-hydroxycortisol, a validated marker of CYP3A induction, was determined. UDCA did not affect biotransformation of budesonide and urinary excretion of 6beta-hydroxycortisol either in patients or in healthy volunteers. Ratios of areas under plasma concentration-time curves (AUC(0-12 h) during UDCA/AUC(0-12 h) before UDCA) of both metabolites were not higher than those of budesonide itself. In contrast, administration of rifampicin markedly induced CYP3A metabolism, resulting in abolished budesonide plasma levels and high urinary excretion of 6beta-hydroxycortisol. Metabolite formation was enhanced by rifampicin, but not by UDCA (e.g., AUC(16alpha-hydroxyprednisolone)/AUC(budesonide) in patients: baseline, 8.6 +/- 3.9; UDCA, 10.7 +/- 7.1; rifampicin, 527.0 +/- 248.7). In conclusion, UDCA is not a relevant inducer of CYP3A enzymes in human

Effect of PD-L1/2 blockade on CD4⁺ T-cell expansion.

<p>Induction of CD4⁺ T-cell proliferation in chronic HBV (n = 23) from h0 (<i>left</i>) to antigenic stimulation (<i>middle</i>) and PD-L1/2 blockade (<i>right</i>) illustrated as point to point graphs from (<b>A</b>) PD-L1/2 responders (n = 9) and (<b>B</b>) Non-responders (n = 14). Contour plots are shown for each group. (<b>C</b>) Patients treated with nucleosid/nucleotid analogs (<i>black bars</i>) responded to PD-1 blockade using Chi²-test, indicating that viral control let enhance patients susceptibility as (<b>D</b>) treated patients are characterized by low viremia. (<b>E</b>) Decreased PD-1 expression in PD-L1/2 responders (R) (n = 6) versus non-responders (NR) (n = 6). (<b>F</b>) CD4⁺ T-cell frequencies upon antigenic stimulation (<i>black bars</i>) and PD-L1/2 inhibition (<i>grey bars</i>) in relation to PD-1 expression.</p

Baseline Characteristics^*.

<p>*presented as median values.</p><p>**nucleosid/nucleotide analogs.</p><p>***not determined.</p

Inhibitory phenotype of HBV-specific CD4⁺ T-cells.

<p>(<b>A</b>) PD-1 (n = 29), CTLA-4 (n = 8), TIM-3 (n = 14), KLRG1 (n = 12) and CD244 (n = 8) expression is displayed on Tetramer⁺CD4⁺ T-cells during chronic HBV. (<b>B</b>) PD-1 expression in chronic (<i>black points</i>) (n = 29) and acute HBV (<i>black squares</i>) (n = 7), resolved HBV (<i>white squares</i>) (n = 5), EBV (<i>grey points</i>) (n = 15) and Flu (<i>white points</i>) (n = 21) infection. (<b>C</b>) Contour plots illustrate patterns of PD-1 expression during HBV, EBV and Flu infection. (<b>D</b>) CD127 expression on HBV-specific (<i>black points</i>) (n = 11) and Flu-specific CD4⁺ T-cells (<i>white points</i>) (n = 9). (<b>E</b>) Contour plots display CD127 expression on CD14⁻, CD19⁻, Via Probe⁻, Tetramer⁺ T-cells. (<b>F</b>) CD127 defines PD-1 expression as examined in HBV (<i>black bars</i>) and Flu infection (<i>white bar</i>). (<b>G</b>) Influence of viral load on CD127 expression.</p

Effect of PD-L1/2 blockade on cytokine release.

<p>Analysis of cytokine⁺CD4⁺ T-cells allows to differ (<b>A</b>) PD-L1/2 responders (n = 4) from (<b>B</b>) Non-responders (n = 9). Floating bars illustrate mean values ranging from minimun to maximum production of IFN-γ, IL-2 and TNF-α seperatly following antigen stimulation (<i>white bars</i>) and PD-1 blockade (<i>grey bars</i>). Contour plots are shown for IFN-γ (<i>top</i>), IL-2 (<i>middl</i>e) and TNF-α (<i>bottom</i>) secretion upon antigen stimulation (<i>left</i>) and PD-1 pathway neutralization (<i>right</i>) after gating on CD3⁺CD4⁺ T-cells.</p