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1From the Departments of Ophthalmology and 3Clinical Transplantation Laboratory, Guys, Kings and St. Thomas Hospital Medical Schools, London, United Kingdom; and the 2Academic Unit of Ophthalmology, University of Birmingham, Birmingham, United Kingdom.
| Abstract |
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METHODS. DNA was prepared from whole blood of 126 patients with RV and 95 healthy individuals by a standard salting-out procedure. Two polymorphisms, V249I and T280M, were analyzed by multiplex polymerase chain reactionsequence-specific primers (PCR-SSPs).
RESULTS. There was no significant difference between the prevalence of V249 or I249 variants in patients with RV or in control subjects. By contrast, the 280M variant was significantly raised in patients compared with control subjects (P = 0.01), the IV/MT haplotype was also more prevalent in patients with RV than in control subjects (P = 0.006), and the I249/M280 haplotype was associated with retinal vasculitis (P = 0.01). The 280M variant was significantly associated with the nonischemic form of RV compared with healthy control subjects (P = 0.009).
CONCLUSIONS. Polymorphisms related to a functional decrease in ligand binding activity of CX3CR1 are associated with disease in U.K. patients with retinal vasculitis. CX3CR1 and its ligand CX3CL1 have been implicated in leukocyte adhesion and neuronal protection. Changes in the activity of this interaction may have a role in the pathogenesis of RV.
Uveitis is characterized by leukocyte infiltration of retinal tissue.2 For migrating leukocytes to enter ocular, tissue they must cross the complex bloodretinal barrier (BRB) formed by retinal endothelial and pigment epithelial cells. A critical question in the pathogenesis of uveitis is how leukocytes cross the normally impervious BRB and thus initiate subsequent pathologic damage.
Chemokines are a group of small (810 kDa), secreted proteins that were initially identified by their ability to attract leukocytes. These molecules induce leukocytes to migrate along concentration gradients, and modulate interactions with endothelial cells through the upregulation and reversible activation of integrins.3 One such chemokine, (or fractalkine) CX3CL1, has a structure that differs from that of other chemokines, as it is bound directly to cell membranes via a mucin stalk.4 CX3CL1 is widely expressed in the rodent brain and located principally in neurons, and the expression of its receptor, CX3CR1, has been shown on microglia and neurons.5 CX3CL1 expression on endothelium has been described; and, under flow conditions, CX3CL1 captures leukocytes. Cell lines transfected with other chemokines attached to the CX3CR1 mucin stalk show increased binding due to a slower release rate from the linked receptor than from the natural form.6
CX3CL1 has been found in the eye. Cadaveric iris and retinal explants constitutively express CX3CL1 protein in microvascular endothelial and several stromal cell types. Similarly both expressed CX3CL1 mRNA. TNF upregulated CX3CL1 mRNA in iris explants and in cultured iris and retinal endothelial cells. TNF and IFN
increase CX3CL1 binding to iris endothelial cells (ECs) both separately and synergistically, whereas IL-4 significantly decreases binding, The cytokine results suggest that a Th1 response would upregulate CX3CL1 expression whereas a Th2 response would downregulate it.7 It has been suggested that CX3CL1 may be involved in the mechanisms of immune surveillance of ocular tissue.
Recent studies have identified two single nucleotide polymorphisms (SNPs) in the gene encoding CX3CR1; 839 C
T (rs3732378; T280M) and 745 G
A (rs3732379; V249I). Patients homozygous for the variant haplotype, I249-M280, progress to AIDS more rapidly than patients with other haplotypes, possibly due to compromise of normal immune responses, which accelerates progression to disease.8 9 By comparison, a reduced prevalence and severity of coronary artery disease (CAD) was associated with I249-M280, compared with individuals homozygous for V249, and it has been postulated that the effect was mediated through a reduced recruitment of inflammatory cells to the atherogenic site.10 11
Against this background, we hypothesized that the form, severity, and outcome of disease might differ in patients with retinal vasculitis with the I249-M280 haplotype compared with other variants. We specifically looked for associations between the haplotypes and the form of disease (whether or not retinal capillary closure was present) and for associations with disease outcome at five years after presentation. The results show that the M280 was significantly raised in patients with nonischemic RV and that the I249-M280 genotype was associated with disease.
| Materials and Methods |
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Cytokine Gene Polymorphisms
DNA was prepared from venous blood obtained from patients and control subjects by proteinase K digestion and high salt extraction and stored at 70°C until use.12 polymerase chain reactionsequence-specific primers (PCR-SSPs) were designed to amplify between the nonsynonymous single nucleotide polymorphisms C839T (T280M) and G745A (V249I) of the CX3CR1 gene giving amplification products of 135 base pairs: forward primer 1, 5'-CTTCTggACACCCTAACAAg-3'; forward primer 2, 5'-TCTTCTggACACCCTACAACA-3'; reverse primer 3, 5' AACAATggCTAAATgCAACCg-3'; and reverse primer 4, 5' AACAATggCTAAATGCAACCA 3'.
By using the four reactions between primer 1 and primers 3 and 4, and primer 2 with primers 3 and 4, the haplotypes were unequivocally derived. The conditions for amplification were 96°C, 25 seconds; 70°C, 45 seconds; and 72°C, 30 seconds; for five cycles, 96°C, 25 seconds; 65°C, 45 seconds; and 72°C, 30 seconds for 20 cycles, and finally 96°C, 25 seconds; 55°C, 60 seconds; and 72°C, 120 seconds for five cycles. Associations with disease, disease type and outcome were calculated by both allelic frequency and haplotype analysis.
Analysis of Data
Associations between CX3CR1 variants, ocular disease, disease type, and outcome, were identified by
2 analysis, using Yates correction with the odds ratio and 95% confidence intervals calculated.
| Results |
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2 = 5.9, P = 0.01; OR, 2.05). This increase was due to the higher number of heterozygotes in the RV patient population (35/126 [28%] vs. 12/95 [13%]) and the concordant fewer wild-type homozygotes (84/126 [67%] vs. 79/95 [83%]; Table 1 ).
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2 = 7.5, P = 0.006; OR, 3), and a consequent decrease in haplotype 1 (VV/TT; 71/126 [56%] vs. 63/95 [66%]; Table 2 ).
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2 = 6.7, P = 0.01; OR, 2.2) in patients compared with control subjects (Table 3) .
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2 = 9.6, P = 0.002, OR, 5.2; Table 4 ). Furthermore, analysis of each group showed that patients with ischemic disease were never homozygous for the mutant alleles, and the I249 variant was underrepresented in the ischemic population and overrepresented in the nonischemic patients, although these results did not reach significance (ischemic versus nonischemic patients;
2 = 0.8, P = 0.4). By comparison, the M280 variant was significantly raised in patients with nonischemic RV compared with the control (
2 = 6.7, P = 0.009, OR, 2.2) (Table 5) . Therefore, nonischemic patients with RV were more likely to possess the M280 variant and be female; however, when analyzed on the basis of gender there was no significant difference in the distribution of the either variant in males and females (data not shown). Therefore M280 was directly linked to the nonischemic form of RV.
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| Discussion |
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We have used the term retinal vasculitis to define our population. It is our belief that the definition that we have given, which includes patients with intermediate and posterior uveitis without choroidal or retinal pigment epithelial involvement, is reasonable in the absence of criteria that define a separate nosologic entity.15 We specifically excluded any patient with choroiditis, because the natural history and systemic associations of patients in this category are uncertain. There are potential sources of bias in this study that relate to the patient population. First, there may have been referral and selection bias. Our patients were derived from a tertiary referral population, and although they were observed as a routine for extended periods, those who had mild disease or in whom disease had regressed may have been lost to follow-up. Accordingly, only patients with more severe disease may have been included in the analysis. Second, because this was a review of case records, it is possible that further improvements in visual acuity after 5 years may have been achieved with more aggressive treatment (i.e., the best recorded visual acuity at the end of 5 years of follow-up was not necessarily the best possible). However, in all cases, the patients were seen during the fifth year by senior ophthalmologists experienced in the management of intraocular inflammation, and our policy of administering intraocular steroids when conventional treatment had not worked make this less likely. Third, although unlikely, it is still possible that patients will develop an associated systemic disease, even at this stage (i.e., the reported population may not be truly idiopathic). Multiple sclerosis has been reported to occur after 7 years of follow-up, and a recent study showed that the mean time from the onset of uveitis to development of MS was 8.5 years.16 17
The effect of polymorphism in CX3CR1 in relation to function is complex. Initial studies with soluble CX3CL1 showed that I249-M280+ cells display impaired chemokine binding, calcium response, and chemotaxis, due to a reduction in the total number of binding sites that reduced CX3CL1 binding affinity.8 10 18 Recent studies have not confirmed these findings and have demonstrated increased binding of CX3CR1 I249-M280+ cells to membrane-bound CX3CL1.19 20 The discrepancies in these results may be due to experimental differences, or may define a loss of function of CX3CR1 in the chemotactic response to soluble CX3CL1, and gain of function to the membrane-bound form. These mechanisms require further study.
The potential role CX3CR1 in retinal disease is equally complex. CX3CL1/ mice did not show any overt behavioral abnormalities or gross changes in the brain and had a normal hematologic profile except for a decrease in the number of F4/80 cells. Despite this decrease there was no difference in response to thioglycollate, suggesting there was no inherent loss of migratory function in the macrophage population. Similarly, delayed-type hypersensitivity (DTH) responses to keyhole-limpet hemocyanin (KLH) were the same. Finally, no difference in responses to colitis induction or infection with Listeria monocytogenes was seen.21 Therefore, a direct role for CX3CR1 in leukocyte trafficking into the retina during inflammation cannot be confirmed.
Recent studies have identified two subsets of blood monocytes based on their expression of CX3CR1. High expression identified a population associated with immune surveillance and precursors of resident tissue macrophages. CX3R1lo have been found to infiltrate sites of inflammation, possibly via CCR2, and may be precursors of circulating dendritic cells. Moreover, binding of CX3L1 was suggested to provide a survival signal to CX3R1hi monocytes.22 In support of this CX3CR1+ microglia express CD95 and CD95L, and CX3CL1 treatment of microglia maintains cell survival and inhibits Fas-ligand induced apoptosis in vitro. Survival is related to inhibition of the proapoptotic molecules BAD and BID and upregulation of Bcl-xL.23 Therefore, it is possible that CX3CR1 M280, which is related to reduced function, affects recruitment of CX3R1hi resident monocyte precursors, but has little influence on inflammatory monocytes. Of note, in support of this hypothesis, monocytes have a sentinel protective role against age-related macular degeneration.24 An association between CX3CR1 I249 and M280 has been described in patients with AMD compared with control subjects. Moreover, retinal cells microdissected from AMD and normal archival tissue were analyzed in a recent study. The M280 allele was found at a significantly higher frequency in cells from patients with AMD than in the normal population. Moreover, cells from patients with AMD had less CX3CR1 transcript and protein, which suggests that both altered function and expression of CX3CR1 contribute to AMD, possibly through a decrease in chemoattraction of inflammatory cells.25 26
A final possibility is that CX3CR1 is involved in neuronal cell protection. It is strongly expressed on Müller cells in human retina.7 Both CX3CR1 and CX3CL1 are highly expressed in human and rodent brain.5 Resident microglia in the parenchyma, the choroid plexus, and meninges express CX3CR1, neurons express both receptor and ligand, whereas astrocytes and oligodendrocytes express neither. In a prion-induced model of brain inflammation, upregulation of CX3CL1 and CX3CR1 expression in astrocytes and microglia, respectively, correlated with neuronal loss. In contrast, acute activation of resident microglia and astrocytes resulting from intracerebral LPS injection did not result in a significant increase in either CX3CL1 or CX3CR1, and intracerebral injection of CX3CL1 induced microglia activation without the recruitment of blood-borne cells.27 Moreover, CX3CR1-CX3CL1 interaction inhibited the release of TNF, IL-6, and nitric oxide by monocytes and activated microglia, and reduced neuronal cytotoxicity by neurotoxins.28 29 Therefore, it is possible that the differential function of these molecules in acute and chronic neurodegeneration reflects the local cytokine environment, which switches microglia from a pro- to anti-inflammatory phenotype and protects against neuronal cell death. The effect of CX3CR1 polymorphisms on retinal microglia have yet to be elucidated.
Our data that demonstrate an association between a haplotype linked to reduced function for CX3CR1 are intriguing because of the potentially opposing nature of CX3CR1-mediated responses. If CX3CR1 were involved directly in leukocyte trafficking into retinal tissue, then a reduced function would be beneficial to patients with RV. However, if mechanisms such as those involved in the protection of neuronal cells (i.e., photoreceptor cells) from cell death are involved in retinal vasculitis, expression of a genetic haplotype of CX3CR1 associated with reduced function would lead to more destructive disease and loss of visual acuity. Further functional work is needed to assess these two possibilities.
| Footnotes |
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Submitted for publication December 21, 2005; revised February 23 and March 16, 2006; accepted May 15, 2006.
Disclosure: G.R. Wallace, None; R.W. Vaughan, None; E. Kondeatis, None; R. Mathew, None; Y. Chen, None; E.M. Graham, None; M.R. Stanford, None
The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked "advertisement" in accordance with 18 U.S.C.
1734 solely to indicate this fact.
Corresponding author: Graham R. Wallace, Academic Unit of Ophthalmology, Division of Immunity and Infection, University of Birmingham, Birmingham B15 2TT, UK; g.r.wallace{at}bham.ac.uk.
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