Rosanna Coppo has documented that she has no relevant financial relationships to disclose or conflict of interest to resolve.

Transcription

1 Rosanna Coppo has documented that she has no relevant financial relationships to disclose or conflict of interest to resolve.

2 Symposium Immune Mediated Disorders New drugs entering in portfolio of treatments of immune mediated glomerular diseases Rosanna Coppo

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5 The proteasome ubiquitinylated protein 19S 20S α α β β β β α α α α α β β β β α Trypsin Chymotrypsin-like Glutamyl-peptidase caspase-like β β β β β β β 26 S proteasome

6 ubiquitin- proteasome system From a «cellular waste disposal service» turned out to be a system selective complex controlled strictly coordinated

7 NF-kB oxydative stress products cytokines TLR ligation IKK α karyopherins IKK γ NEMO IKK p50 p65 NF-kB responsive genes transcriptional activation IkB p50 p65 Ub-Ub-Ub-Ub 26S proteasome E3IkB Ub ligase p p IkB p α

8 Cell cycle Cyclins and inhibitors Apoptosis prb Syntesis and replication Caspases G1 DNA G2 Smac/Diablo Mitosis Switch Bcl-2 Bfl-1 Proteasomal regulation

9 PROTEASOME DEGRADATION OF PROTEINS IS CRUCIALS FOR peptide Class I preparation for antigen presentation transcription factors and cyclines activation (NF-kB, STAT, Smad, p53, cdkip21) pro-inflammatory cytokines release (IL2, IL6, IL10, IL13, IFNγ, TNFα) cell-cycle progression apoptosis mechanisms of cellular response and survival

10 UBIQUITIN-PROTEASOME DYSREGULATION IN VARIOUS DISEASES multiple sclerosis amyotropic lateral sclerosis Alzheimer s disease asthma cancer ischemia-reperfusion injury cachexia autoimmune thyroid disease, type I diabetes hepatitis B inflammatory bowel disease sepsis RENAL DISEASES can proteasome be targeted?

11 Proteasome (PS) inhibitors Natural PS inhibitors Lactacystin and derivates (MLN5, PS-519, PS-519) Epoxyketones (epoxomicin and eponemycin ) Peptide boronates Dipeptidyl boronic acid, Bortezomib (PS-341, Velcade); MG 262; PS-341 reversible and selective inhibitor of chymotryptic threonine protease activity of PS PR-171 (Carfilzomib) : a novel epoxyketone-based irreversible PS inhibitor. Well known drugs provided with anti proteasome activity: Cyclosporin Tacrolimus Glucocorticoids Levamisole Vincristin HIV protease inhibitors

12 Proteasome inhibitors anti-proliferative and pro-apoptotic action Cancer transcription factors (NF-kB) inhibition Cancerous cells are more sensitive than normal cells to proteasome inhibition

13 Plasma cell tumor MULTIPLE MYELOMA

14 Multiple myeloma Plasma cells are terminally differentiated B-cells specialized for the mass production of immunoglobulins. Plasma cells are particularly sensitive to proteasome inhibitors and Myeloma B cells 20 times more

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16 Bortezomib continues to demonstrate improved survival versus dexamethasone

17 Bortezomib interferes with the neural metabolism Painful neuropathy was reported in 30% of patients receiving >6 courses of bortezomib for multiple myeloma

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19 Mechanisms of action of bortezomib NFkB Interest of proteasome inhibitors in transplantation costimulation apoptosis

20 Proteasome inhibitors and antibody mediated rejection (AMR)

21 In vitro effect of bortezomib on plasma cells ATG Rituximab Bortezomib

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24 Bortezomib: 1.3 mg/m2 at days 1, 4, 8, 11 after other treatments RTX included START trial in adults : In 81 AMR episodes bortezomib induced a reduction by >50% DSA levels in > 50% of patients Graft loss Stabilization of renal function

25 Proteasome inhibitors anti-proliferative and pro-apoptotic action transcription factor (NF-kB) inhibition inflammatory disorders Proteasome inhibitors in immune mediate renal diseases

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27 Proteasome inhibitors in lupus erythematosus In SLE autoantibodies to double strand DNA and IFNα are the clue for disease development and progression. B cell depletion approach: anti CD20 Rituximab. Rituximab has a variable effect on autoantibodies levels The sources of Ab production (plasma cells) do not express CD20 Plasma cells are very sensitive to proteasome inhibitors

28 in murine SLE poteasome inhibitors have a dual effect: inhibition of autoantibody production by plasma cells inhibition of the pathway activated in dendritic cells by TLR signaling, which leads to release of large amount of INFα. BTZ: bortezomib CFZ: carfizomib ONX 0914

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33 Proteasome inhibition: a new therapeutic option in lupus nephritis? Van der Vlag and Berden, NDT 2008

34 Phase IV study

35 NF-kB in minimal change nephropathy (Zhao et al CMJ, 2009) NF-kB A: control kidney B: nephrotic syndrome

36 NFkB AND PROTEASOME INVOLVEMENT IN NEPHROTIC SYNDROME

37 NFkB AND PROTEASOME IN NEPHROTIC SYNDROME

38 HIV protease inhibitors: competitive inhibitors of proteasome enzymes RITONAVIR SAQUINAVIR

39 In vitro reduction of NF-kB activation by HIV protease inhibitors RITONAVIR SAQUINAVIR Basal 10μM 20 μm 40 μm Basal 20 μm 40 μm P65 NF-kB PMA/Ca-ionophore stimulation

40 10 patients: difficult cases of SDNS or SRNS Age: median 13.5 (7-38 years) Past history of NS for years Saquinavir 30 mg/kg/day for at least 6 months Decreased PS activation Decreased NF-kB activation

41 Favourable effects in 6/10 cases

42 NF-kB activation The trial is recruiting patients with IgAN on therapy after at least four months with ACE-I or and/or ARB and proteinuria and > 1g/day IgAN to receive Bortezomib (Velcade ) at 1.3 mg/m 2, on days 1, 4, 8, 11. A second cycle is to be given a month later for non-responders. The primary end-point for this study is reduction in proteinuria

43 NF-kB nuclear translocation in mesangial cells treated with desialylated/degalactosylated IgA Mesangial cells treated with desialylated/degalactosylated IgA +Lactacystin (protasome inhibitor)

44 R.Coppo, L. Peruzzi, A. Amore et al NF-kB activation in PBMC of patients with IgAN

45 INNATE IMMUNITY MICROBICAL AGENTS TLR4 TLR3 NF-kB IFN-α Dendritic cell Proteasome switch to a more active proteasome form: the immuneproteasome

46 Summary and conclusion Proteasome inhibitors: significant results in multiple myeloma. A fascinating research area for progressive immune mediated renal diseases and antibody mediated rejection. Powerful drugs with rather high toxicity, particularly using repeated cycles. In relatively mild clinical conditions there is a need for very limited side effects. A promising area is the search for combination with synergic strategies Protease inhibitors P-glycoprotein inhibitors Autophagy inhibitors (histone deacetylase inhibitors) BAFF or April inhibitors IL-6 inhibitors

47 Thank you