Systemic Complement Inhibition Research Articles

POS-042 C3d-Directed Factor H Targeting Delivers Potent and Durable Complement Inhibition and Disease-Modifying Efficacy In Kidney and Skin Without Inhibiting Systemic Complement

POS-042 C3d-Directed Factor H Targeting Delivers Potent and Durable Complement Inhibition and Disease-Modifying Efficacy In Kidney and Skin Without Inhibiting Systemic Complement

Systemic Complement Activation Profiles in Nonexudative Age-Related Macular Degeneration: A Meta-Analysis.

Although complement inhibition has emerged as a possible therapeutic strategy for age-related macular degeneration (AMD), there is not a clear consensus regarding what aspects of the complement pathway are dysregulated in AMD and when this occurs relative to disease stage. We recently published a systematic review describing systemic complement activation profiles in patients with early/intermediate AMD or geographic atrophy (GA) compared to non-AMD controls. Here, we sought to meta-analyze these results to estimate the magnitude of complement dysregulation in AMD using restricted maximum likelihood estimation. The seven meta-analyzed studies included 710 independent participants with 23 effect sizes. Compared with non-AMD controls, patients with early/intermediate nonexudative AMD (N = 246) had significantly higher systemic complement activation, as quantified by the levels of complement proteins generated by common final pathway activation, and significantly lower systemic complement inhibition. In contrast, there were no statistically significant differences in the systemic levels of complement common final pathway activation products or complement inhibition in patients with GA (N = 178) versus non-AMD controls. We provide evidence that systemic complement over-activation is a feature of early/intermediate nonexudative AMD; no such evidence was identified for patients with GA. These findings provide mechanistic insights and inform future clinical trials.

Tissue-specific complement inhibition by antibody-Complement Regulatory Protein (CRP) fusions utilizing Therapeutic Autoimmune reguLatOry proteiN (TALON™) platform

Abstract The complement system plays a major role in humoral innate immunity. Upon activation, complement proteins trigger a cascade of enzymatic events leading to the production of inflammatory mediators and membrane attack complexes. Tight regulation of complement proteins is essential for immune homeostasis due to their potency and abundance in fluid phase. Complement Regulatory Proteins (CRPs) that are membrane-bound (e.g., CD59), or in fluid phase (e.g., Factor H), prevent aberrant activation of complement pathways against self and mitigate autoimmunity. The importance of CRPs is underscored by the finding that genetic variations in the CRPs can lead to autoimmune diseases such as paroxysmal nocturnal hemoglobinuria (PNH) characterized by the lysis of host red blood cells from dysregulated complement system. Systemic complement inhibition via anti-C5 antibody has clinically been shown to benefit some patients with complement-mediated disorders, but the therapy requires a high, frequent dosing scheme and supplemental vaccinations to compensate for systemic immunosuppression. In addition, other diseases such as C3 glomerulopathy affect specific tissues and involve pathways beyond C5, limiting treatment options. To this end, local immunomodulation through targeted delivery of CRPs to specific tissues is an attractive strategy to restore homeostasis in complement-mediated autoimmune diseases while circumventing the need for high dose systemic inhibition of complement factors. Here, we present a proof-of-concept study for the design, generation, and evaluation of tissue-tethering antibodies fused with CRPs. Also, we demonstrate the pharmacokinetics and pharmacodynamics of tissue-targeting CRP fusions in mouse models.

Ex vivo delivery of Mirococept: A dose-finding study in pig kidney after showing a low dose is insufficient to reduce delayed graft function in human kidney.

The complement system plays a pivotal role in the pathogenesis of ischemia-reperfusion injury in solid organ transplantation. Mirococept is a potent membrane-localizing complement inhibitor that can be administered ex vivo to the donor kidney prior to transplantation. To evaluate the efficacy of Mirococept in reducing delayed graft function (DGF) in deceased donor renal transplantation, we undertook the efficacy of mirococept (APT070) for preventing ischaemia-reperfusion injury in the kidney allograft (EMPIRIKAL) trial (ISRCTN49958194). A dose range of 5-25mg would be tested, starting with 10mg in cohort 1. No significant difference between Mirococept at 10mg and control was detected; hence the study was stopped to enable a further dose saturation study in a porcine kidney model. The optimal dose of Mirococept in pig kidney was 80mg. This dose did not induce any additional histological damage compared to controls or after a subsequent 3hours of normothermic machine perfusion. The amount of unbound Mirococept postperfusion was found to be within the systemic dose range considered safe in the Phase I trial. The ex vivo administration of Mirococept is a safe and feasible approach to treat DGF in deceased donor kidney transplantation. The porcine kidney study identified an optimal dose of 80mg (equivalent to 120mg in human kidney) that provides a basis for further clinical development.

A Novel Injury Site-Targeted Complement Inhibitor Which Protects against Lung Transplant Ischemia Reperfusion Injury

Purpose Self-reactive natural Abs initiate complement activation and injury following ischemia and reperfusion of certain tissues, but their role in post-ischemic lung injury is unknown. Here, we investigated the expression of two previously identified post-ischemic neoepitopes, namely a modified annexin IV epitope recognized by B4 IgM mAb, and an epitope consisting of a subset of phospholipids recognized by C2 IgM mAb, and additionally determined their role in lung transplant ischemia reperfusion injury (IRI). Methods Lungs from C57Bl/6 mice were orthotopically transplanted into Rag1-/- (antibody-deficient) mice reconstituted with either B4 and C2 mAbs. Results Rag1-/- mice were protected from lung IRI, but reconstitution with either B4 or C2 natural IgM mAbs restored lung IRI. The C2 mAb was more effective than the B4 mAb at restoring injury, as determined by histological and micro-CT analysis. Based on this information, we developed and characterized a therapeutic strategy that exploited the post-ischemia recognition system of natural antibodies. We constructed a single-chain antibody (scFv) derived from C2 mAb and linked it to Crry, an inhibitor of C3 activation (C2scFv-Crry). In models of syngeneic (B6-B6) and allogeneic (Balb/c-B6) lung transplant models in which recipients contain a full natural antibody repertoire, a single post-transplant injection of C2scFv-Crry blocked the binding of endogenous IgM to the graft, inhibited complement activation, and significantly reduced graft inflammation and injury as determined by histology, μCT, and immunhistochemical analysis. The severity of IRI is associated with the onset of acute rejection. Conclusion We identified pathophysiologically important epitopes expressed within the lung after lung ischemia and reperfusion post transplantation. We further describe a novel translatable strategy for complement inhibition that is specifically targeted to the transplanted lung, and that has several advantages over currently available approaches that rely on systemic complement inhibition. Significantly, the C2 epitope has been identified in both mouse and man, increasing the translational relevance of the approach.

Recent approaches to evaluating and monitoring geographic atrophy.

Given the increasing prevalence of geographic atrophy from age-related macular degeneration as the number of individuals over 85 increases throughout the world, as well as the recent increase in potential treatments to slow growth of geographic atrophy, this article discusses recent findings regarding retinal imaging of geographic atrophy to detect its presence or expansion over time. During the review period, the COMPLETE (Systemic complement inhibition with eculizumab for geographic atrophy in age-related macular degeneration) and the GATE (Randomized trial to evaluate tandospirone in geographic atrophy secondary to age-related macular degeneration) studies, respectively, reported no beneficial effects of intravenous eculizumab or tandospirone eye drops, respectively, identified on the growth of geographic atrophy. Several imaging and visual function studies have evaluated the role of various techniques using fundus autofluorescence, optical coherence tomography, microperimetry, or other investigator-initiated tools to assess geographic atrophy growth or progression over time, although the ideal imaging for geographic atrophy remains unknown. Some predictive factors for geographic atrophy growth recently suggested include genetic features, geographic atrophy characteristics in the fellow eye, or the presence of outer retinal tubulation on optical coherence tomography. Quantification of geographic atrophy is important for evaluating growth of geographic atrophy. Numerous new imaging techniques of geographic atrophy beyond human grading of fundus photographs or fluorescein angiograms have emerged, but the ideal imaging for geographic atrophy has yet to be determined.

A novel protocol allowing oral delivery of a protein complement inhibitor that subsequently targets to inflamed colon mucosa and ameliorates murine colitis.

While there is evidence of a pathogenic role for complement in inflammatory bowel disease, there is also evidence for a protective role that relates to host defence and protection from endotoxaemia. There is thus concern regarding the use of systemic complement inhibition as a therapeutic strategy. Local delivery of a complement inhibitor to the colon by oral administration would ameliorate such concerns, but while formulations exist for oral delivery of low molecular weight drugs to the colon, they have not been used successfully for oral delivery of proteins. We describe a novel pellet formulation consisting of cross-linked dextran coated with an acrylic co-polymer that protects the complement inhibitor CR2-Crry from destruction in the gastrointestinal tract. CR2-Crry containing pellets administered by gavage, were characterized using a therapeutic protocol in a mouse model of dextran sulphate sodium (DSS)-induced colitis. Oral treatment of established colitis over a 5-day period significantly reduced mucosal inflammation and injury, with similar therapeutic benefit whether or not the proton pump inhibitor, omeprazole, was co-administered. Reduction in injury was associated with the targeting of CR2-Crry to the mucosal surface and reduced local complement activation. Treatment had no effect on systemic complement activity. This novel method for oral delivery of a targeted protein complement inhibitor will reduce systemic effects, thereby decreasing the risk of opportunistic infection, as well as lowering the required dose and treatment cost and improving patient compliance. Furthermore, the novel delivery system described here may provide similar benefits for administration of other protein-based drugs, such as anti-tumour necrosis factor-α antibodies.

Mechanisms of rejection

To provide the reader with an up-to-date comprehensive review of recent findings that highlight advances describing how proteins of the complement cascades contribute to the pathogenesis of solid organ rejection. The review is focussed mainly on renal transplantation. Of note are recent advances in elucidating the interactions between anaphylatoxins and their receptors in organ transplantation; there is evidence of direct engagement of C5aR on donor tubules and in addition, mechanisms by which the allostimulatory capacity of dendritic cells is modulated by complement are more fully understood. Activation of the lectin pathway is increasingly implicated in allograft rejection and the role of complement in modulating regulatory T cells is being vigorously investigated. As an alternative to systemic complement inhibition, there is continued focus on the design of targeted anti-complement therapies, directed to the donor organ. Complement has evolved as the first line of defence against pathogens, employing well defined effector mechanisms to rapidly remove infectious material. However, complement effector mechanisms are also triggered during inflammation associated with solid organ transplantation. Hence, complement has a significant role in mediating donor organ injury during both the initial ischaemia/reperfusion phase and the subsequent adaptive immune responses. Research on mechanisms of complement-mediated injury in transplantation provide a basis for the development of therapies that are aimed at transiently blocking complement activation at the site of injury, whereas leaving systemic anti-bacterial complement effector mechanisms intact.

Change in Drusen Volume as a Novel Clinical Trial Endpoint for the Study of Complement Inhibition in Age-related Macular Degeneration

To evaluate the change in drusen volume following treatment with eculizumab, a systemic inhibitor of complement component 5. Single-center, prospective, randomized, double-masked clinical trial. Patients were randomized 2:1 to receive intravenous eculizumab or placebo over 26 weeks. decrease in drusen volume of at least 50% at 26-week follow-up. Mean drusen cube root volumes were 0.49 mm and 0.47 mm (P = .64) at baseline and 0.51 mm and 0.42 mm (P = .17) at 26 weeks in the eculizumab and placebo groups, respectively. In the placebo group, one eye had a decrease in drusen volume of at least 50% and two eyes developed neovascularization through 26 weeks. Systemic complement inhibition with eculizumab did not significantly reduce drusen volume. Drusen growth was dependent on the number of complement at-risk alleles. Future trials should consider the use of a composite clinical trial endpoint in which efficacy is defined by the treatment’s ability to prevent drusen growth, neovascularization, and the formation of geographic atrophy over 1 year.

Systemic Complement Inhibition with Eculizumab for Geographic Atrophy in Age-Related Macular Degeneration: The COMPLETE Study

To evaluate the effect of eculizumab, a systemic inhibitor of complement component (C5), on the growth of geographic atrophy (GA) in patients with age-related macular degeneration (AMD). Prospective, double-masked, randomized clinical trial. Patients with GA measuring from 1.25 to 18 mm(2) based on spectral-domain optical coherence tomography imaging. Patients were randomized 2:1 to receive intravenous eculizumab or placebo over 6 months. In the eculizumab treatment arm, the first 10 patients received a low-dose regimen of 600 mg weekly for 4 weeks followed by 900 mg every 2 weeks until week 24, and the next 10 patients received a high-dose regimen of 900 mg weekly for 4 weeks followed by 1200 mg every 2 weeks until week 24. The placebo group was infused with saline. Patients were observed off treatment for an additional 26 weeks. Both normal-luminance and low-luminance visual acuities were measured throughout the study, and the low-luminance deficits were calculated as the difference between the letter scores. Change in area of GA at 26 weeks. Thirty eyes of 30 patients were enrolled. Eighteen fellow eyes also met inclusion criteria and were analyzed as a secondary endpoint. For the 30 study eyes, mean square root of GA area measurements ± standard deviation at baseline were 2.55 ± 0.94 and 2.02 ± 0.74 mm in the eculizumab and placebo groups, respectively (P = 0.13). At 26 weeks, GA enlarged by a mean of 0.19 ± 0.12 and 0.18 ± 0.15 mm in the eculizumab and placebo groups, respectively (P = 0.96). At 52 weeks of follow-up, GA enlarged by a mean of 0.37 ± 0.22 mm in the eculizumab-treated eyes and by a mean of 0.37 ± 0.21 mm in the placebo group (P = 0.93, 2 sample t test). None of the eyes converted to wet AMD. No drug-related adverse events were identified. Systemic complement inhibition with eculizumab was well tolerated through 6 months but did not decrease the growth rate of GA significantly. However, there was a statistically significant correlation between the low-luminance deficit at baseline and the progression of GA over 6 months.

A Protein Toxin from the Sea Anemone Phyllodiscus semoni Targets the Kidney and Causes a Severe Renal Injury with Predominant Glomerular Endothelial Damage

Envenomation by the sea anemone Phyllodiscus semoni causes fulminant dermatitis and, rarely, acute renal failure in humans. Here, we investigated whether the venom extracted from the nematocysts (PsTX-T) was nephrotoxic when administered intravenously in rats and whether PsTX-T induced activation of the complement system. Although small dose of PsTX-T induced acute tubular necrosis in rats resembling pathology seen in patients, kidneys displayed glomerular injury with glomerular endothelial damage, thrombus formation, mesangiolysis, and partial rupture of glomerular basement membrane, accompanied by severe tubular necrosis at 24 hours after administration of 0.03 mg of PsTX-T per animal, similar to the glomerular findings typical of severe hemolytic uremic syndrome. The early stage injury was accompanied by specific PsTX-T binding, massive complement C3b, and membrane attack complex deposition in glomeruli in the regions of injury and decreased glomerular expression of complement regulators. A pathogenic role for complement was confirmed by demonstrating that systemic complement inhibition reduced renal injury. The isolated nephrotoxic component, a 115-kd protein toxin (PsTX-115), was shown to cause identical renal pathology. The demonstration that PsTX-T and PsTX-115 were highly nephrotoxic acting via induction of complement activation suggests that inhibition of complement might be used to prevent acute renal damage following envenomation by P. semoni.

Complement and glomerulonephritis: new insights

The last few years have seen a huge increase in our understanding of the role of the complement system and its regulation in glomerular disease. Our aim is to summarize the most important advances in this field. The role of complement in systemic lupus erythematosus continues to be elucidated. Classical pathway components protect from the development of autoimmunity, at least in part, through their role in the clearance of apoptotic cells. In contrast, the alternative pathway plays a direct role in exacerbating glomerular injury. Anti-C1q antibodies are related to activity in lupus nephritis and recent studies have shown that they are directly pathogenic in animal models. Proteinuria, whatever the cause, may lead to tubulointerstitial injury and complement activation adds to this process. In particular, deposition of terminal components of complement in the tubular lumen contributes to interstitial myofibroblast activation. There is increasing evidence for the role of complement regulatory proteins in glomerular injury. In particular, abnormalities of factor H or of CD46 may predispose to atypical haemolytic uraemic syndrome. The control proteins also protect against injury in immune complex glomerulonephritis. Advances in our understanding of the role of complement in glomerular injury point to the likely therapeutic benefits of targeting the complement system. Many new drugs are becoming available. Careful dissection of the pro and antiinflammatory effects of the complement system which the experimental models allow will assist in designing directed therapy that will avoid the detrimental effects of nonspecific systemic complement inhibition.

The effect of soluble complement receptor type 1 on acute humoral xenograft rejection in hDAF‐transgenic pig‐to‐primate life‐supporting kidney xenografts

In pig-to-nonhuman primate solid organ xenotransplantation using organs from donors transgenic for human decay-accelerating factor (hDAF), the main type of rejection is antibody-mediated (acute humoral xenograft rejection, AHXR). This occurs despite the complement-regulatory function of the transgene, neutralization of natural antibodies to Galalpha1-3Gal (Gal) using soluble glycoconjugates, and chronic immunosuppression. As complement components play a major role in graft destruction after antibody binding, we evaluated the efficacy of chronic complement inhibition by soluble complement receptor type 1 (TP10). Life-supporting hDAF-transgenic kidney transplantation was performed in cynomolgus monkeys, using cyclophosphamide induction, and maintenance immunosuppression with cyclosporin A, mycophenolate sodium, and tapering steroids. Rejection was treated with bolus steroid injections: if not successful animals were terminated. Three groups were studied: in group 1 (n=4) GAS914 (a soluble glycoconjugate comprising Gal on a poly-L-lysine backbone) was added before and after transplantation; group 2 (n=2) received GAS914 as in group 1 and in addition TP10 before and after transplantation; in group 3 (n=4) GAS914 was only given before transplantation and TP10 as in group 2. Monitoring included the regular assessment of anti-porcine antibodies, complement activity (soluble C5b-9), therapeutic drug monitoring, and graft histology. Survival in group 1 was 6, 12, 31 and 37 days, respectively, and in all four cases graft histology showed AHXR. The two animals in groups 2 survived 3 and 15 days, respectively, and similarly showed AHXR in graft histology. In group 3 two animals showed AHXR (10 and 37 days survival, respectively), and two others did not show AHXR (20 and 32 days survival, respectively). The diagnosis AHXR included the deposition of complement activation products in the graft, which were present at lower intensity in animals treated with TP10. In all animals GAS914 effectively neutralized circulating anti-Gal antibody. Antibodies were detectable in the circulation of all animals using porcine erythrocytes in a hemolytic assay, although at lower levels than before transplantation. Soluble C5b-9 was not detectable in the circulation of animals receiving TP10, and circulating TP10 concentrations in these animals were in a presumed pharmacologically active range. The inclusion of TP10 in the immunosuppressive protocol does not clearly lead to improved xenograft survival. Despite effective neutralization of anti-Gal antibodies and effective inhibition of systemic complement activity, AHXR was apparent in four of six animals under chronic TP10 treatment, including deposits of complement activation products in the graft. Apparently, effective systemic complement inhibition by TP10 in combination with local complement regulation by the hDAF transgene product does not necessarily result in effective inhibition of complement activation at locations in the xenograft upon binding of anti-porcine antibodies to the grafted endothelium.

Tailoring anti-complement therapeutics.

Complement is a core component of the immune system, which performs vital roles in immune surveillance. However, the active products that enable complement to perform its physiological roles can inappropriately target self tissues and cause pathology. Complement-mediated inflammation and tissue destruction is an important drive to pathology in diseases as diverse as rheumatoid arthritis and dementia. Two decades ago there were no agents that could be used therapeutically to inhibit the activation of complement, but increased understanding of the natural control of complement in vivo has markedly changed this situation. The realization that drugs mimicking the action of the complement regulatory proteins present on self cells, and in plasma, could effectively control pathological activation of complement has opened the door to the use of anticomplement therapy in disease. Here we will review the development of anticomplement therapeutics from the first generation agents, which are unmodified recombinant forms of natural regulators, to recent strategies for making better drugs. We will describe strategies for targeting the anticomplement activity to the site of disease, and for extending the plasma half-life of the agent. Finally, we will illustrate a novel approach to the delivery of anticomplement agents, making prodrugs that are activated only at disease sites thus minimizing the deleterious effects of systemic complement inhibition.

Soluble complement receptor one (sCR1) inhibits the development and progression of rat collagen-induced arthritis.

We set out to determine whether inhibition of complement using sCR1 could influence the development and progression of collagen arthritis in the Lewis rat. Collagen arthritis was successfully established in the Lewis rat, using a novel immunization schedule. In separate experiments, cobra venom factor (CVF) and sCR1 were used to achieve systemic complement inhibition. Their respective effects on disease onset and on the progression of established disease compared with saline-treated control animals was explored. Arthritis was assessed by measurement of clinical score, paw diameter and paw volume. Complement inhibition using either CVF or sCR1, prior to the onset of clinical signs of inflammation, delayed the development of disease. CVF was ineffective in the treatment of established disease, whereas sCR1 delayed the progression of disease in affected joints and prevented the recruitment of further joints while the animals were complement-depleted. In the control saline-treated groups the disease continued to progress relentlessly. We conclude that complement activation is important in the initiation and maintenance of inflammation in collagen arthritis. The potent disease-modulating effect of sCR1 provides persuasive evidence that specific complement inhibiting agents may be an effective approach to the treatment of inflammatory joint diseases