CC BY
10
Toychiev Abdurakhim Khodjiakbarovich, Junior researcher, Research Institute of Epidemiology, microbiology and infectious diseases, Tashkent Uzbekistan Pazilova Dinora Ubaydullaevna, Head of the department of coloproctology, the 1st Republican clinical hospital, Tashkent Uzbekistan
Olimov Jakhongir,
Student, Tashkent Medical Academy, Tashkent Uzbekistan Davis Nikolay Aleksandrovich, researcher, Research Institute of Epidemiology, microbiology and infectious diseases, Tashkent Uzbekistan
Osipova Svetlana Olegovna, Head of the department, Research Institute of Epidemiology, microbiology and infectious diseases, Tashkent Uzbekistan Navruzov Bexzod Sarimbekovich, Professor, Tashkent Medical Academy, Tashkent Uzbekistan E-mail: davisnikolay@gmail.com
IMMUNE STATE OF PATIENTS WITH ULCERATIVE COLITIS
Abstract: Cellular and humoral immunity in patients with ulcerative colitis at the period of exacerbation and after colectomy were studied. Immunologic shifts were analyzed for the purpose of defining their possible role in the monitoring of specific therapy efficacy and clarifying some aspects of ulcerative colitis pathogenesis. Keywords: Ulcerative colitis, cellular immunity, humoral immunity, IgE, IgA.
Introduction. Ulcerative colitis (UC) is a chronic intestinal inflammatory disease of unknown etiology. Main attributable causes include genetic and environmental factors as well as a multifactorial immune disorders [1, 220-226; 2, 727-737; 3, 323-331]. The gastrointestinal tract in which this disease occurs is central to the immune system, and the innate and the adaptive immune systems are balanced in complex interactions with intestinal microbiota under homeostatic conditions. In UC this homeostasis is disrupted and uncontrolled intestinal inflammation is perpetuated [4, 3-10; 5, 928-937]. UC is characterized by chronic relapsing inflammation of the intestine. Heterogeneity among UC patients is poorly understood and represents a significant barrier to efficiency of conventional therapy, including 5-ASA, corticosteroids, 6 mercaptopurin. The treatment goal in UC is the induction and maintenance of remission. However, 20% to 40% of UC patients do not respond to conventional medications [6, 1582-1592; 7, 1-25]. In such cases they should receive biological therapy (monoclonal antibodies to TNF-a (infliximab and other preparations) or colectomy [8, 660-671].
There is some information on cellular and humoral immunity in UC and it is partly controversial: inhibition of cellular immunity and activation of humoral one [9, 25], exhaustion of NK cells and increase CD8+ cells [10, 25] and elevation of CD16 [11, 115-126], but studies of immune state after colectomy in patients with UC refractory to conditional therapy are practically absent.
The purpose of the study: to characterize cellular and humoral immunity in patients with UC at the period of exacerbation and after colectomy before restorative surgery.
Materials and methods. Study was conducted on the basis of Research Institute of Epidemiology, Microbiology and Infectious Diseases and the First Republican Clinical Hospital. 30 patients with UC were admitted at the First Republican Clinical Hospital, coloproctology department. All of them were hospitalized at the period of exacerbation. Diagnosis was based on clinical, laboratory, endoscopic and histological data. Total and distal forms were diagnosed in 28 and 2 patients respectively. Activity of UC was estimated according to Mayo Clinic Score. Moderate and severe diseases were detected in 8 and 22 patients respectively.
Age of patients was at the range of 17-78 years and an average age was 42 years. There were 16 males and 14 females. Conservative therapy included salofalk, glucocorticoides, probiotics. All of the patients were examined upon admission to the hospital, 14 of them were refractory to conventional therapy.
The standard surgical treatment for UC is restorative proctocolectomy with ileo-pouchanal anastomosis and protective ileos-toma (a double-staged procedure). The subtotal colectomy without any intestinal anastomosis, with a transient ileostoma, followed by proctectomy and pouch creation at a later time are applied in active UC [12, 72-82]. All the patients were undergone to colectomy with a transient ileostoma and they were examined additionally before reconstructive rehabilitation surgery. It was carried out in 5-6 months after the first stage of surgery.
The control group included 30 residents of Tashkent city without any complaints from gastrointestinal tract matched by gender and age to the patients with UC.
IMMUNE STATE OF PATIENTS WITH ULCERATIVE COLITIS
Table 1. - Indices of cellular immunity in patients with UC
Cohort under study CD3+ CD4+ CD8+ CD4+/CD8+ CD16+ CD25+ CD95+ CD20+
Healthy individuals 59,9 ± 0,9 36,0 ± 2,4 21,4 ± 2,2 1,6 ± 0,1 10,2 ± 1,1 2,4 ± 0,2 21,8 ± 2,2 20,0 ± 1,2
Patients with active UC 57,4 ± 3,5 31,7 ± 3,2 28,2 ± 2,5* 1,1 ± 0,1* ** 15,4 ± 0,9* ** 1,7 ± 0,1* ** 15,2 ± 1,1* ** 23,2 ± 2,1
Patients with UC after colectomy 60,4 ± 7,1 35,2 ± 3,1 20,9 ± 3,3 1,7 ± 0,1 9,7 ± 1,3* 2,7 ± 0,1 22,3 ± 2,4 21,3 ± 1,8
*Significant difference with healthy individuals **Significant difference with condition after colectomy
CD3+-, CD4+-, CD8+-, CD20+-, CD16+-, CD25+-, CD95+- lymphocytes in peripheric blood were detected by the method of indirect rosette formation with appropriate monoclonal antibodies, production of LLC "Medbiospectrum", Moscow, Russia [13, 12-14]. The level of serum IgM, IgG and IgA was detected by the method of Mancini et al. [14, 235-248], the level of total serum IgE was detected by the ELISA method (reagents production of ZAO "Vector-Best", Novosibirsk, Russia).
The study was approved by the Medical Ethics Committee of the Medical Association of the Republic of Uzbekistan in accordance with the Declaration of Helsinki. Informed consent was obtained from each participant prior to their enrolment.
Results and discussion. Subpopulation of lymphocytes of peripheric blood are represented in table 1.No significant difference were found between UC patients and control group in proportions of circulating CD3+- and CD4+-lymphocytes, although the tendency to decrease of CD4+-lymphocytes percentage was observed. CD8+ lymphocytes percentage was increased and the CD4+/CD8+ ratio in UC patients at the period of exacerbation were significantly lower than in controls.
Peripheral blood CD4+CD25+ regulatory cells have a central role in the immunopathology of a number of diseases, mediated by inflammation, autoimmunity and neoplasia [15, 29-38]. Comparison of CD4+CD25 lymphocytes in UC patients at the period of exacerbation and in patients after colectomy showed that the highest value was obtained in UC patients after colectomy and CD4+CD25+ lymphocytes percentage was significantly decreased in active UC. It can indicate their role in alleviation of inflamma-
Serum concentration of IgE, as well as the prevalence of patients with a highIgE level were significantly increased in patients with UC. An elevated serum level of IgE was observed in 7 UC patients with allergy (food allergy, urticaria, allergic rhinitis) as well as in 23 patients without allergic manifestations. Maximal values of IgE level were observed both in patients with allergic manifestations and without them. The cause of the IgE elevation in patients without clinical aller-
tion. Our results are in some accordance with data of Dahlen et al. [16, 275-284] that positive results of infliximab in UC treatment is followed by reduced expression of CD25+ in CD4+ and CD8+ T cell population. The count of circulating CD4+CD25+ regulatory cells in UC patients may serve as additional diagnostic test for estimation of relapse and/or indicator for efficiency of therapy.
We found a decrease of percentage of CD95+ lymphocytes, it reflects low apoptosis readiness, typical for severe forms of UC. CD95+ may plays a role in protecting the colon from inflammation and it was demonstrated by Park et al on experimental model of colitis [17, 1063-1070].
CD16+ lymphocytes are responsible for antitumor, antiviral and transplantation immunity. Decrease in the number of CD16+ lymphocytes results in development of oncologic diseases and increased severity of the course of viral and autoimmune diseases. CD16+ cells possess a high cytotoxicity and ability to produce a lot of cytokines, mainly TNF-a, IL-1 and IL-12 [18, 584-592]. We detected that peripheral blood CD16+ lymphocytes were increased significantly in active UC and decreased after colectomy indicating their crucial role in inflammation.
Table 2 shows that level of serum IgM and IgG in patients with active UC insignificantly differed from normal values as well as in patients after colectomy. An elevated level of serum IgA was detected. A tendency to decrease of IgG level was observed. It is at some extent in accordance with data of Tarun Rai et al. [19, 115-121] who described a low level of serum IgG in UC patients and connected it with disease duration and hypoalbuminemia. In our case it can be connected with a great number of the patients refractory to conventional therapy.
gic manifestations is unclear, but there is information of clinical and pathophysiological similarities between IBD and non-pulmonary allergic phenomena [20, 11-23].
Effective treatment offood allergy in UC patients by specific immunotherapy and butyrate-production probiotics improve of the clinical symptoms of UC [21, 37] On the experimental model of ox-azolone induced colitis was shown that development of pathological
Table 2. - Indices of humoral immunity in patients with UC
Cohort under study IgM (mg/%) IgG (mg/%) IgA (mg/%) IgE (IU/ml)
Healthy individuals 141,1 ± 5,1 1225,8 ± 38.8 153,5 ± 7,1 55,0 ± 7,2
Patients with active UC 155,9 ± 10,2 1175,3 ± 44,0 189,9 ± 9,4* ** 277,6 ± 14,1* **
Patients with UC after colectomy 162,4 ± 12,5 1210,6 ± 57,0 172,0 ± 8,1 169,2 ± 11,2
*Significant difference with healthy individuals **Significant difference with condition after colectomy
process is mediated by IL-13 and IgE production by Th2 and B cells respectively [22, 96-108]. So a high level of total serum IgE could indicate its participation in pathological process.
Conclusion. The main changes found in UC patients with dominating severe form of the disease at the period of exacerbation were elevation of percentage of CD16+ lymphocytes and decrease ofCD25+- and CD95+-lymphocytes. Humoral immunity was char-
acterized by significant increase of serum concentration IgA and especially IgE. Colectomy induced clinical improvement and decrease of circulating CD16+ and increase of CD25+ - and CD95+ lymphocytes. These shifts could be considered as importance of these subpopulations for inflammatory process. Significant elevation of the concentration of total serum IgE after colectomy allows to suspect that allergy is a factor of UC pathogenesis.
References:
1. Basso P. J., Fonseca M. T. C., Bonfá G., Alves V. B.F., Sales-Campos H., Nardini V., Cardoso C. R. B. Association among genetic predisposition, gut microbiota, and host immune response in the etiopathogenesis of inflammatory bowel disease. Braz J Med Biol Res. - 2014. Sep 47 (9). - P. 727-737.
2. Cai M., Zeng L., Li L. J., Mo L. H., Xie R. D., Feng B. S., Zheng P. Y., Liu Z. G., Liu Z. J., Yang P. C. Specific immunotherapy ameliorates ulcerative colitis. Allergy Asthma Clin Immunol. - 2016. - Aug 5. - P. 12-37.
3. Cheon J. H. Genetics of inflammatory bowel diseases: a comparison between Western and Eastern perspectives. J Gastroenterol Hepatol. - 2013. - 28. - P. 220-226.
4. Choi C. H., Kim Y. H., Kim Y. S., et al. Guidelines for the management of ulcerative colitis. Intest Res. - 2012. - 10. - P. 1-25.
5. Dahlén R., Strid H., Lundgren A., Isaaksson S. Raghavan, S. Magnusson M. K, Simrén M., Stovall H., Ohman L. Infliximab Inhibits Activation and Effector Functions of Peripheral Blood T Cells in vitro from Patients with Clinically Active Ulcerative Colitis. Human Immunology. - Volume 78. - Issue 3. - September - 2013. - P. 275-284.
6. Geremia A1., Biancheri P., Allan P., Corazza G. R., Di Sabatino A. Innate and adaptive immunity in inflammatory bowel disease. Autoimmun Rev. - 2014. - Jan 13 (1). - P. 3-10.
7. Hanauer S. B. Medical therapy for ulcerative colitis - 2004. Gastroenterology - 2004. - 126. - P. 1582-92.
8. Hoving J. C., Kirstein F., Nieuwenhuizen N. E., Fick L. C., Hobeika E., Reth M., Brombacher F.B cells that produce immunoglobulin E mediate colitis in BALB / c mice. Gastroenterology. - 2012. - Jan 142 (1). - P. 96-108.
9. Jagger A. L., Evans H. G., Walter G. J., et al. FAS / FAS-L dependent killing of activated human monocytes and macrophages by CD4+CD25- responder T cells, but not CD4+CD25+ regulatory T cells. J Autoimmun. - 2012. - 38. - P. 29-38.
10. Kotlyar D. S., Shum M., Hsieh J., Blonski W., Greenwald D. A. Non-pulmonary allergic diseases and inflammatory bowel disease: a qualitative review. World J. Gastroenterol. - 2014. - August 28. - No. 20 (32). - P. 1123-11032.
11. Malahova N.S Clinical features of distal form of ulcerative colitis Abstract of a thesis and med sci. - M.: - 2005. - 25 p.
12. Mancini G., Carbonara A., Heremans J. Immunochemical quantitation of antigen by single radial immunodiffusion // Immunochem-istry. - 1965 - No. 2. - P. 235-248.
13. Martinez-Chamorro A., Moreno A., Gómez-García M., Cabello M. J., Martin J., Lopez-Nevot MA. MICA*A4 protects against ulcerative colitis, whereas MICAA5.1 is associated with abscess formation and age of onset. Clin Exp Immunol. - 2016. - Jun 184 (3). - P. 323-31.
14. Park S. M., Chen L., Zhang M., Ashton-Rickardt P., Turner J. R., Peter M. E. CD 95 is cytoprotective for intestinal epithelial cells in colitis. Inflamm Bowel Dis. - 2010. - Jun 16 (6). - P. 1063-70. doi: 10.1002/ibd.21195.
15. Podolsky D. K. Inflammatory bowel disease. N Engl J Med. - 1991. - 325. - P. 928-937.
16. Steel A. W., Mela C. M., Lindsay J. O., Gazzard B. G., Goodier M. R. increased proportion of CD16+ NK cells in the colonic lamina propria of inflammatory bowel disease patients, but notafter azathioprine treatmnent. Aliment. Pharmacol. Ther. - 2011. - Jan. 33 (1). - P. 115-26.
17. Stidham R. W., Lee T. C., Higgins P. D., et al. Systematic review with network meta-analysis: the efficacy of anti-tumour necrosis factor-alpha agents for the treatment of ulcerative colitis. Aliment Pharmacol Ther. - 2014. - 39. - P. 660-671.
18. Tarun Rai, Xianrui Wu, Bo Shen. Frequency and risk factor of low immunoglobulin levels in patients with inflammatory bowel disease. Gastroenterol. Rep. (Oxf). - 2015. - May 3 (2). - P. 115-121.
19. Tutina O. A. Clinical and immunological features and correction of therapy of chronic inflammatory disease of colon in children. Abstract of a thesis and med sci. - M.: - 2010. - 25 p.
20. Wehkamp J., Gotz M., Herrlinger K., Steurer W. E. F. Inflammatory Bowel Disease. Crohn's disease and ulcerative colitis. Dtsch Arz-tebl Int. - 2016. - Feb 113 (5). - P. 72-82.
21. Zalyalieva M. V., Prokhorova R. S. Method of determination of lymphocyte subpopulations. Rasmiy axborot. - 2001. - No. 4. - P. 12-14.
22. Ziegler-Heitbrock L. The CD14+ CD16+ blood monocytes: their role in infection and inflammation. J Leukoc Biol. - 2007. - Mar 81 (3). - P. 584-92.
