# Patent

## Title
Therapeutic use for ALPHA1 proteinase inhibitor in hematopoiesis

## Abstract

A previously unrecognized fundamental property of α1Proteinase Inhibitor (α1PI) is to regulate the phenotypic composition of circulating and tissue-associated cells derived from hematopoietic stem cells. The present invention comprises screening for various unmodified and modified α1PI's which are useful in the treatment of abnormalities in the number of cells of myeloid or lymphoid lineage that are associated with HIV-1 infection, microbial infection, leukemia, solid tumor cancers, atherosclerosis, autoimmunity, stem cell transplantation, organ transplantation, and other diseases affected by cells of the immune system. The interaction of α1PI with its receptors, Human Leukocyte Elastase Cell Surface (HLECS) and Low Density Lipoprotein-Receptor Related Protein (LRP), influences the level of cells of different lineages. Genetic and proteolytic modification of α1PI is used to target these receptors to increase or decrease specific cell populations, as needed, in the various disease states.

## Background
This application claims priority under 35 U.S.C. §119(e) from Provisional Application No. 60/748,137 filed Dec. 6, 2005.


SEQUENCE LISTING
The instant application contains a Sequence Listing which has been submitted in ASCII format via EFS-Web and is hereby incorporated by reference in its entirety. Said ASCII copy, created on Feb. 15, 2012, is named 86519CON.txt and is 11,216 bytes in size.
BACKGROUND OF THE INVENTION
Full length active α1proteinase inhibitor (α1PI, α1antitripsin) is composed of 394 amino acids (aa) having a mass of approximately 55 kDa when fully glycosylated (Berninger, 1985). Hepatocytes are the primary source of α1PI, and in normal, healthy individuals, the range of circulating α1PI is 20-53 μM between the 5th and 95th percentiles (Brandy et al., 1991; Bristow et al., 1998). However, during the acute phase of the inflammatory response, α1PI may increase as much as 4-fold to 200 μM (Kushner, 1982). There are four common alleles of α1PI, and these are synthesized and secreted principally by hepatocytes (OMIM, 2000). However, there are more than a hundred genetic variants, some of which produce a molecule that prohibits secretion, and affected individuals manifest with 10-15% of the normal level of α1PI in blood (Benninger, 1985). Individuals with this inherited form of α1PI deficiency, especially males, are notably susceptible to respiratory infections and emphysema, and 80% who survive to adulthood succumb to respiratory failure between the fourth and sixth decades of life (Berninger, 1985). Prevalence is 0.03%, and α1PI augmentation therapy in affected individuals is the only approved therapeutic application of α1PI (OMIM, 2000).
Traditionally, α1PI has been characterized as a proteinase inhibitor which has highest affinity for soluble granule-released elastase (HLEG). Evidence now suggests α1PI also interacts with cell surface HLE (HLECS) (Bristow et al., 2003; Tavor. S. et al., 2005). Both HLECS and HLEG are synthesized and processed as a single molecular protein; however, HLE is targeted exclusively for the cell surface early in ontogeny and for granule compartmentalization later in ontogeny (Gullberg et al., 1995; Garwicz et al., 2005). Mutations in the HLE encoding gene that result in decreased HLE expression produce periodic cycling in hematopoiesis that affect monocytes in the opposite phase to neutrophils (Horwitz et al., 1999; Horwitz et al., 2004). Mutations that result in increased HLE produce twice fewer absolute numbers of circulating CD4+ and CD8+ lymphocytes, and 7 times more monocytic cells (Person et al., 2003).
The proteinases and proteinase inhibitors that govern cell motility and hematopoiesis have evolved a different functional pattern in mice from man, but there are many parallels. For example, in mice, it has been shown that high concentrations of HLE accumulate in bone marrow following granulocyte colony-stimulating factor (G-CSF) induced stem cell mobilization (Winkler et al., 2005). This accumulation was found to result from the down-regulation of α1PI expression. In man, the liver is the primary source of both α1PI and stem cells. As opposed to its function to inhibit the enzymatic activity of HLEG, α1PI binding to HLECS induces cell migration in a manner that does not appear to involve enzymatic activity (Wolf et al., 2003). The effect of α1PI on cell motility is especially profound during migration of stem cells and early progenitor cells. Hematopoiesis begins with stem cell migration from fetal liver through the periphery to the stromal area of hematopoietic tissue, retention, differentiation, and release of maturing progenitor cells back into the periphery. Migration of stem cells to, and myeloid-committed progenitor cells from bone marrow is controlled by HLECS, the chemokine stromal cell-derived factor-1 (SDF-1), and the SDF-1 receptor CXCR4 (Tavor. S. et al., 2005; Lapidot and Petit, 2002). Cell migration is dependent on the localization of HLECS into podia formation at the leading edge of the cell (Tavor. S. et al., 2005; Cepinskas et al., 1999), and podia formation is induced by binding of active α1PI to HLECS in a manner that includes co-localization of HLECS with CD4 and CXCR4 (Bristow et al., 2003). The current method for therapeutic mobilization of myeloid-committed progenitor cells from bone marrow is by the action of G-CSF, and it has been shown that G-CSF mediates this activity by antagonizing CXCR4 and HLECS (Lapidot and Petit, 2002). The molecular mechanisms that mobilize lymphoid-committed progenitors from hematopoietic tissue are not known. Evidence described in this application now suggests active α1PI mediates this activity (Examples 1-3 below). Following treatment with α1PI in animal models, the migration of transplanted human leukemia cells into circulation is decreased, but the migration of stem cells to hematopoietic tissue is increased (Tavor. S. et al., 2005). These results suggest that α1PI influences the migration of cells into and out of circulation depending, in part, on the stage of differentiation of the cell.
When bone marrow-derived erythroid progenitors cells (burst-forming units-erythroid) are incubated with α1PI in vitro, growth of immature cells is significantly suppressed (42.5%±5.5%) (Graziadei et al., 1994). In contrast, growth of mature cells is unaffected by α1PI (3.6%±3.4%). These results demonstrate that in addition to myeloid- and lymphoid-committed progenitors, α1PI influences the genesis of erythroid-committed progenitor cells dependent on their stage of differentiation.
Previous therapeutic application of α1PI has been restricted to augmentation in patients diagnosed with inherited α1PI deficiency for the purpose of ameliorating respiratory distress such as occurs in emphysema and chronic obstructive pulmonary disease (COPD). Considerable interest in producing recombinant α1PI has resulted in development of several successful expression systems including bacterial and plant cell expression as well as viral vector and oral delivery (Chowanadisai et al., 2003; Luisetti and Travis, 1996). Recombinant α1PI is in phase I clinical trials for augmentation in individuals with inherited α1PI deficiency (Flotte et al., 2004), and is in phase II clinical trials for treatment of atopic dermatitis. Recombinant α1PI has been tested for preventing the onset of type I diabetes in genetically predisposed mice (Song et al., 2004). Nevertheless, there is a need in the art for developing recombinant α1PI with due consideration of its conformation-dependent function to mobilize either lymphoid-lineage or myeloid-lineage maturing cells. As recognized by the inventor herein, because α1PI induces cell motility depending on its active or proteolytic ally modified conformation, various active and modified α1PI's provide powerful new therapeutics for mobilizing targeted cell subsets through tissue.
SUMMARY OF THE INVENTION
This invention is directed to the use of α1PI and modified α1PI to control the phenotypic composition of circulating and tissue-associated cells derived from hematopoietic stem cells. Various modified α1PI's are also provided. Screening methods and treatment for abnormalities in the phenotypic profile of blood cells are also provided. Such abnormalities are associated with, e.g., HIV-1 infection, microbial infection, leukemia, solid tumor cancers, atherosclerosis, autoimmunity, stem cell transplantation, organ transplantation, and other diseases affected by cells of the immune system. The invention is based, in part, on a previously unrecognized fundamental property of α1PI to regulate the phenotypic composition of circulating and tissue-associated cells derived from hematopoietic stem cells.
Accordingly, this invention provides a method for identifying a modified α1PI as suitable for use in treating a disease, disorder or condition in a subject, comprising: (a) producing the modified α1PI; and (b) measuring a biological activity of the modified α1PI in a biological assay for predicting effectiveness in treating the disease, disorder or condition in the subject, wherein the modified α1PI is identified as suitable for treating the disease, disorder or condition from a change in the biological activity relative to a control activity measured for a wild-type α1PI. In one embodiment, the modified α1PI is produced by site-directed mutagenesis, proteolysis, or both. In another embodiment, the disease, disorder or condition is selected from the group consisting of HIV-1 infection, bacterial infection, leukemia, a solid tumor, atherosclerosis, an autoimmune disease, organ transplantation, and stem cell transplantation. In another embodiment, the stem cell transplantation is autologous stem cell transplantation.
In another embodiment, the biological assay is selected from the group consisting of an elastase inhibition assay, a receptor co-capping assay, a cell motility assay, a lymphoid-committed progenitor cell mobilization assay, an HIV-1 gp120 antibody cross-reactivity assay, and an HIV-1 infectivity facilitation assay. In another embodiment, the subject is a human or a non-human animal. In another embodiment, proteolysis comprises contacting a wild-type or a recombinant α1PI with a protease selected from the group consisting of elastase, stromelysin-3, matrix metalloproteinase, collagenase, gelatinase, pepsin, plasmin, urokinase, chymotrypsin, thrombin, CD26, complement component C1, and complement component C3.
In another embodiment, site-directed mutagenesis comprises changing at least two wild-type amino acid residues selected from the group consisting of residues 370-374 and 385 to a non-wild-type residue, wherein one changed residue is at position 385. In another embodiment, at least one amino acid selected from the group consisting of residues 370-374 and 385 is changed from wild-type to glycine, threonine, or a hydrophobic amino acid. In another embodiment, the hydrophobic amino acid is selected from the group consisting of isoleucine, leucine, phenylalanine, tyrosine and valine.
This invention provides a modified human α1PI comprising a change in a wild-type amino acid residue selected from the group consisting of residues 370-374 and 385. In one embodiment, the genetically modified α1PI further comprises modification by proteolysis. In another embodiment, the wild-type amino acid residue is changed to glycine, threonine, or a hydrophobic amino acid. In another embodiment, the hydrophobic amino acid is selected from the group consisting of isoleucine, leucine, phenylalanine, tyrosine and valine. In another embodiment, the modified human α1PI comprises at least two changes in wild-type amino acid residues comprising a change at position 385 and a change at a position selected from the group consisting of positions 370-374. In another embodiment, the methionine at position 385 is changed to a non-methionine amino acid. In another embodiment, the non-methionine amino acid is selected from the group consisting of glycine, isoleucine, leucine, phenylalanine, threonine, and valine. In another embodiment, the modified human α1PI is capable of a reduced binding activity in an HIV-1 gp120 antibody cross-reactivity assay, relative to a wild-type α1PI. In another embodiment, the residue changes in the modified human α1PI comprise the following three amino acid substitutions: Phe372Gly; Leu373Gly; and Met 385Val. In another embodiment, the residue changes in the modified human α1PI consist of the following three amino acid substitutions: Phe372Gly; Leu373Gly; and Met 385Val.
This invention provides a method of treating a disease, disorder or condition in a subject in need of said treatment, comprising administering an effective amount of an unmodified or modified α1PI to the subject. In one embodiment, the modified α1PI is produced by site-directed mutagenesis, proteolysis, or both. In another embodiment, the disease, disorder or condition is selected from the group consisting of HIV-1 infection, bacterial infection, leukemia, a solid tumor, atherosclerosis, an autoimmune disease, organ transplantation, and stem cell transplantation. In another embodiment, the subject is a human or a non-human animal. In another embodiment, the modified α1PI comprises a change in a wild-type amino acid residue selected from the group consisting of residues 370-374, and further comprises a change in methionine at position 385. In another embodiment, methionine at position 385 is changed to a non-methionine amino acid selected from the group consisting of glycine, isoleucine, leucine, phenylalanine, threonine, and valine. In another embodiment, the modified α1PI is capable of a reduced binding activity in an HIV-1 gp120 antibody cross-reactivity assay, relative to a wild-type α1PI. In another embodiment, the amino acid changes in the modified α1PI comprise the following three amino acid substitutions: Phe372Gly; Leu373Gly; and Met 385Val. In another embodiment, the amino acid changes in the modified α1PI consist of the following three amino acid substitutions: Phe372Gly; Leu373Gly; and Met 385Val. In another embodiment, the treatment method further comprises administration of HIV-1 antiretroviral therapy. In another embodiment, the effective amount of modified α1PI is a dose equivalent to about 42 mg/kg of active wild-type α1PI.
This invention provides a method of treating a disease, disorder or condition in a subject in need of said treatment, comprising administering an effective amount of an active α1PI to the subject, wherein the disease, disorder or condition is selected from the group consisting of HIV-1 infection, bacterial infection, leukemia, a solid tumor, atherosclerosis, an autoimmune disease, organ transplantation, and stem cell transplantation. In one embodiment, the stem cell transplantation is autologous stem cell transplantation.
This invention provides a method of treating a disease, disorder or condition in a subject in need of said treatment, comprising administering an effective amount of an active α1PI to the subject, wherein the subject is characterized as having an abnormal or ineffective number of lymphocytes, monocytes, or dendritic cells.
This invention provides a method of treating a disease, disorder or condition in a subject in need of said treatment, comprising administering an effective amount of an inactive α1PI to the subject, wherein the disease, disorder or condition is selected from the group consisting of bacterial infection, neutropenia and immunosuppression.
This invention provides a method of treating a disease, disorder or condition in a subject in need of said treatment, comprising administering an effective amount of an inactive α1PI to the subject, wherein the subject is characterized as having an abnormal or ineffective number of granulocytes, monocytes, dendritic cells, eosinophils, or basophils. In one embodiment, the subject is a human or a non-human animal.



BRIEF DESCRIPTION OF DRAWINGS
FIG. 1(a-c). Correlation of CD4 lymphocyte levels with active α1PI, HLECS and SDF-1 in healthy individuals. (a) Increased active α1PI and decreased HLECS+ lymphocytes predict increased CD4+ lymphocytes in healthy subjects specifically selected to represent a wide spectrum of α1PI concentrations. CD4+ lymphocytes (%)=50.48+0.27*active α1PI (μM)−2.67* HLECS+ lymphocytes (%) (r2=0.937, p<0.05, n=6). (b) Increased active α1PI and decreased HLECS+ lymphocytes predict increased CD4+ lymphocytes in healthy subjects representing the general population. CD4+ lymphocytes (%)=37.80+0.43*active α1PI (μM)−1.56*HLECS+ lymphocytes (%) (r2=0.803, p<0.05, n=16). When SDF-1 is included in the model, CD4+ lymphocytes (%)=44.46+0.54*active α1PI (μM)−1.65* HLECS+ lymphocytes (%)−0.03* SDF-1 (pM) (r2=0.875, p<0.05, n=16). (c) Active α1PI (▪) and CD4+ lymphocytes (●) increase proportionally during the acute phase of an enteric infection in a volunteer who was otherwise healthy.
FIG. 2(a-e). Binding of anti-gp120 antibody to human, but not chimpanzee α1PI. (a) Monoclonal antibody 3F5 binding to α1PI in sera from 18 healthy humans and 20 healthy chimpanzees was measured in ELISA. Antibody bound (A490 nm) was normalized for the serum α1PI concentration in each specimen and is represented as A490 nm/α1PI(μM). Binding of 3F5 was 8- to 14-fold greater to human than to chimpanzee α1PI (p<0.001). Measurements were repeated 6 times using 3F5 and once using monoclonal antibody 1C1. Representative measurements are depicted. Bars represent mean values. (b) The presence of IgG-α1PI immune complexes in sera (A490 nm) was detected in 11 of 38 HIV-1 infected patients, but not in sera from 9 healthy individuals, 20 healthy chimpanzees, nor in 2 chimpanzees 42 months following HIV-1 inoculation. Serum collected from healthy volunteers into tubes containing clot activating additive were excluded from immune complex analysis because of buffer incompatibility. Measurements were repeated at least 3 times, and representative data are depicted. Bars represent mean values. (c) Active α1PI concentration in HIV-1 infected patients (median 17 μM) was significantly below normal (median 26 μM, p<0.001). Active α1PI in sera from 20 healthy chimpanzees (median 35 μM) and 2 chimpanzees post-HIV-1 inoculation median (39 μM) was significantly greater (p<0.02) than from 18 human sera (median 26 μM). Active α1PI was measured in 8 serial dilutions of each serum sample. (d) Inactive α1PI concentration in HIV-1 infected patients (median 19 μM) was above normal (median 4 μM, p<0.001). (e) After incubating sera from 5 healthy individuals with monoclonal antibody 3F5, active α1PI (12±7 μM) was significantly lower than in control sera incubated with medium alone (18±7 μM, p<0.001). Bars represent mean values.
FIG. 3(a-d). Corresponding conformation at the 3F5-recognized domains in α1PI and CD4-complexed HIV-1 gp120. Structures for human α1PI (1HP7) and CD4-complexed HIV-1 gp120 (1RZJ) from the NCBI Molecular Modeling Database (MMDB) were analyzed using Cn3D software. Small carbohydrate structures were already associated with 1RZJ in MMDB, and the three associated with 1HP7 were added using Adobe Photoshop. HIV-1 gp120 is depicted from two perspectives (a,b) with two α-helices highlighted (aa 21-39 and 306-313). The gp120 peptide immunogen used to raise 1C1 and 3F5 (aa 300-321) is located at the C-terminus of gp120, and the linear segment YKVV (aa 315-318, SEQ ID NO: 1) along with the M-17 and the oligosaccharide-linked NGT (aa 92-94), are within 8A° of the conformational epitope. The gp120-homologous domain in α1PI is also located at the C-terminus of the protein, and is depicted from two perspectives (c,d) with the highlighted antiparallel β-sheet strand at the base of the cleft (aa 369-389), as well as the α-helices that form the mouth of the cleft (aa 28-44 and 259-277). M-385, which distinguishes human from chimpanzee α1PI, is indicated along with GKVV (aa 386-389, SEQ ID NO: 2), the oligosaccharide, and oligosaccharide-linked NST (aa 46-48). The proteinase reactive site M-358, is indicated for orientation.
FIG. 4. Correlation between CD4+ lymphocytes and active α1PI levels in HIV-1 infected patients. In 23 patients with <500 HIV RNA copies/ml, CD4+ lymphocyte levels correlate with active α1PI. Three parameter sigmoid regression yields CD4 (cells/μl)=1+e−(active α1PI(μM)−25)/11), r2=0.927, n=23). CD4+ lymphocyte levels also correlate with inactive α1PI. Two parameter exponential decay regression yields CD4 (cells/μl)=834*e−0.034 inactive α1PI(μM), r2=0.906, n=23). Patients receiving protease inhibitor therapy are depicted by squares. All other patients are depicted by circles. In 13 patients with >500 HIV RNA copies/ml, no correlation was found to exist between CD4+ lymphocyte levels and active α1PI.



DETAILED DESCRIPTION OF THE INVENTION
Definitions:
Human α1PI—Alpha1-Proteinase Inhibitor (Human) is a sterile, stable, lyophilized preparation of highly purified human alpha1-proteinase inhibitor (α1PI) also known as alpha1-antitrypsin derived from human plasma. There are three products of alpha1-Proteinase Inhibitor (Human) that are currently FDA approved for treatment. Prolastin® produced by Talecris Biotherapeutics, Zemaira® produced by ZLB Behring, and AralastTM produced by Baxter Healthcare Corp.
Active α1PI—the fraction of α1PI in plasma or other fluids that has the capacity to inhibit elastase activity.
Inactive α1PI—the fraction of α1PI in plasma or other fluids that does not have the capacity to inhibit elastase activity. Active α1PI may be inactivated by proteolytic cleavage, proteinase complexing, antibody complexing, or oxidation.
Genetically modified α1PI—active α1PI synthesized from the cDNA encoding human α1PI which has been modified by site-directed mutagenesis. There are no current recombinant products that have been FDA approved for treatment.
Proteolytically modified α1PI—active or genetically modified human α1PI which has been further modified by limited proteolysis to generate fragments. Proteolytic modification inactivates α1PI.
Pharmaceutical Composition—When formulated in a pharmaceutical composition, the therapeutic compound of the invention can be admixed with a pharmaceutically acceptable carrier or excipient. The phrase “pharmaceutically acceptable” refers to molecular entities and compositions that are “generally regarded as safe”, e.g., that are physiologically tolerable and do not typically produce an allergic or similar untoward reaction, such as gastric upset, dizziness and the like, when administered to a human. Preferably, as used herein, the term “pharmaceutically acceptable” means approved by a regulatory agency of the Federal or a statement government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and, more particularly, in humans. The term “carrier” refers to a diluent, adjuvant, excipient, or vehicle with which the compound is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like. Water or aqueous solution saline solutions and aqueous dextrose and glycerol solutions are preferably employed as carriers, particularly for injectable solutions. Alternatively, the carrier can be a solid dosage form carrier, including but not limited to one or more of a binder (for compressed pills), a glidant, an encapsulating agent, a flavorant, and a colorant. Suitable pharmaceutical carriers are described in “Remington's Pharmaceutical Sciences” by E. W. Martin.
1. Treatment population: Active α1PI promotes migration of lymphocytes and monocytic cells expressing HLECS (Bristow et al., 2003) (Examples 1-3 below). Inactive α1PI promotes migration of neutrophils and cells expressing the LDL-receptor related protein, LRP (Kounnas et al., 1996; Weaver et al., 1997), Treatment with active human α1PI is indicated in individuals manifesting abnormal numbers of functional lymphocytes, monocytic cells, or dendritic cells such as in HIV-1 disease, stem cell transplantation, solid organ transplantation, autoimmune exacerbations, diabetes, leukemia, lymphoma, solid tumors, and, atherosclerosis. Treatment with inactive human α1PI is indicated in individuals manifesting abnormal numbers of functional granulocytic, monocytic cells, dendritic, eosinophilic, or basophilic cells such as in microbial infection, neutropenia, and immunosuppressed patients. Treatment outcome is determined as described below in Section 7 of the Detailed Description.
2. Treatment regimen: According to the Prolastin® Product Monograph, the Zemaira® prescribing information literature, and the AralastTM prescribing information, the recommended dosage for α1PI is repeated weekly infusions of 60 mg/kg at a rate of 0.08 ml/kg/minute leading to the historical target threshold of 11 μM α1PI in serum. The ideal blood threshold is 34 μM α1PI, but this level has not been achieved therapeutically. Delivery is traditionally by infusion, but recombinant α1PI is also produced for ingestion (Chowanadisai et al., 2003).
The specific activity of Zemaira® is 70%, Prolastin® is 35%, and AralastTM is 55% where specific activity is defined as inhibition of porcine pancreatic elastase (PPE) as described in the package insert. Thus, the recommended dose of Zemaira® α1PI may be stated as 42 mg/kg active α1PI, Prolastin® as 21 mg/kg, and AralastTM as 33 mg/kg active α1PI. Conversely, the inactive fraction of Zemaira® is 30% or 18 mg/kg, of Prolastin® is 65% or 39 mg/kg, and of AralastTM is 45% or 27 mg/kg
The dosage of genetically modified α1PI is determined by its capacity to inhibit PPE as described in Section 6 of the Detailed Description (see also, U.S. Pat. No. 6,887,678). In accordance with the recommended treatment regimen using wild-type α1PI, subjects are infused with genetically modified α1PI at a dosage that is in the range of 1 to 420 mg/kg active α1PI, with a target blood threshold of 35 μM genetically modified α1PI. In some cases, either active or genetically modified α1PI are further modified by limited proteolytic cleavage to generate fragments that are chemotactic for myeloid-lineage cells. For example, in microbial infections that attend neutropenia, proteolytically modified α1PI is used to recruit neutrophils into infected tissue. In this case, individuals are infused with proteolytically modified α1PI at the concentration that is equivalent to 39 mg/kg inactive α1PI. In addition to being monitored for PPE inhibitory activity, proteolytically modified α1PI is screened as described in Section 3.2 of the Detailed Description for its capacity of to induce receptor capping and cell motility of myeloid-lineage blood cells such as neutrophils.
3. Recombinant α1PI: In addition to plasma-derived α1PI, recombinant α1PI has the capacity to mobilize progenitor cells. A bioengineered form of α1PI has been shown to partition into two cleavage fragments (Jean et al., 1998), and an α1PI-insulin-like growth factor chimera has been shown to induce chemotaxis (Sandoval et al., 2003). Modifications of recombinant α1PI provide an improvement specific to HIV-1 and other diseases for mobilization of specific progenitor cells.
3.1 Structural features of α1PI: The following represents the full length amino acid sequence for α1PI (accession # K01396) including the 24 aa signal peptide (SEQ ID NO: 3):









−24
MPSSVSWGIL LLAGLCCLVP VSLA



 


1
EDPQGDAAQK TDTSHHDQDH PTFNKITPNL AEFAFSLYRQ LAHQSNSTNI


 


51
FFSPVSIATA FAMLSLGTKA DTHDEILEGL NFNLTEIPEA QIHEGFQELL


 


101
RTLNQPDSQL QLTTGNGLFL SEGLKLVDKF LEDVKKLYHS EAFTVNFGDT


 


151
EEAKKQINDY VEKGTQGKIV DLVKELDRDT VFALVNYIFF KGKWERPFEV


 


201
KDTEEEDFHV DQVTTVKVPM MKRLGMFNIQ HCKKLSSWVL LMKYLGNATA


 


251
IFFLPDEGKL QHLENELTHD IITKFLENED RRSASLHLPK LSITGTYDLK


 


301
SVLGQLGITK VFSNGADLSG VTEEAPLKLS KAVHKAVLTI DEKGTEAAGA


 


351
MFLEAIPMSI PPEVKFNKPF VFLMIEQNTK SPLFMGKVVN PTQK






The known Asn-linked carboxylation sites (denoted in bold underlined letters) are found at aa 46, 83, and 247 (Nukiwa et al., 1986; Jeppsson et al., 1985). The oligosaccharide structure at each site is either tri-antenary or bi-antenary, and the various combinations give the protein a characteristic electrophoretic charge denoted as phenotypic subtypes of the four common genotypic alleles, M1A, M1V, M2, and M3.
The frequencies in, US Caucasians of M1A, M1V, M2, and M3 are 0.20-0.23, 0.44-0.49, 0.1-0.11, and 0.14-0.19, respectively, accounting for 95% of this population (Jeppsson et al., 1985). M1A is thought to be the oldest variant, and M1V has a single aa substitution, at position 213, Ala to Val. The M3 allele has a single aa difference with M1V, Glu to Asp at position 376. The M2 allele has a single aa difference with M3, Arg to His at position 101.
More than a hundred genotypic alleles have been identified, but except for the S and Z alleles, most of them are exceedingly rare (OMIM, 2000). The S allele, frequency 0.02-0.04, has a single aa substitution at position 264, Glu to Val, and individuals homozygous for this allele manifest 60% normal α1PI blood levels, but are not at risk for emphysema or other known diseases except in combination with the Z allele (Brantly et al., 1991; Sifers et al., 1988). The Z allele, frequency 0.01-0.02, has a single aa substitution at position 342, Glu to Lys, and individuals homozygous for this allele manifest 10% normal α1PI blood levels, and are at risk for emphysema and autoimmunity.
3.2 Functional properties of α1PI: There are three distinct activities of α1PI that are determined by sites in the C-terminal region of α1PI defined herein as aa 357-394 (SEQ ID NO: 4),
PMSI PPEVKFNKPF VFLMIEQNTK SPLFMGKVVN PTQK
The crystal structure for active α1PI (1HP7, NIH NCBI Molecular Modeling DataBase mmdbId:15959) is depicted in FIG. 3 with Met (aa 358) and Met (aa 385) designated. The β-sheet formation of the C-terminal region of α1PI (aa 369-394) is designated. Two α-helix domains (aa 27-44 and 257-280) shield the β-sheet domain in a manner resembling the antigen-binding cleft of the major histocompatibility complex.
The first activity of α1PI is its well characterized proteinase inhibition which is a property only of active, uncleaved α1PI. The reactive site for this activity is Met (aa 358) contained in the domain Pro-Met-Ser-Ile-Pro (PMSIP, aa 357-361, SEQ ID NO: 5). Active α1PI may be inactivated by proteinase complexing, cleavage, or oxidation of Met (aa 358). Interaction at the scissile bond Met-Ser (aa 358-359) may be mediated by many proteinases including HLEG. The two cleavage products of α1PI may dissociate under some circumstances, but may remain associated in a new, rearranged configuration that may irreversibly incorporate HLEG, but may not incorporate other proteinases, for example metalloproteinases (Perkins et al., 1992).
The tertiary structure for the rearranged α1PI configuration has not been solved (Mellet et al., 1998); however, X-ray diffraction and kinetic analyses of cleaved α1PI suggest that the strand SIPPEVKFNKP (aa 359-369, SEQ ID NO: 6) may separate 70A° from its original position and insert into the β-sheet formation on the opposite face of the molecule (β-sheet A) in a manner that would significantly alter proteinase and receptor recognition (Elliott et al., 2000). Thus, four configurations of the C-terminal region of α1PI are thought to occur (Table 1).







TABLE 1







Functions of the C-terminal region of α1PI














Lymphoid

anti-
HIV-1



Proteinase
cell
Myeloid cell
gp120
entry co-



Inhibition
migration
migration
binding
factor
















Native configuration in the active α1PI
+
+
−
+
+


Rearranged configuration in cleaved
−
−
Unknown
+
−


α1PI


Complexed with HLE in cleaved α1PI
−
−
+
Unknown
−


Independent of other α1PI cleavage
−
Unknown
+
Unknown
Unknown


products









Because the cleaved configuration of α1PI lacks proteinase inhibitory activity, in deficient concentrations of active α1PI, the result is emphysema and respiratory-related infections which are facilitated by the presence of certain environmental factors, cigarette smoke, microbial factors, and inherited mutations that prohibit successful production of active α1PI.
A second activity of α1PI is the stimulation of cell migration, and this activity is a property of both cleaved and uncleaved α1PI. Cleaved α1PI is recognized by LRP, and stimulates migration of myeloid-lineage cells including neutrophils and monocytic cells (Joslin et al., 1992). Active, uncleaved α1PI is recognized by HLECS and stimulates migration of lymphoid-lineage cells and myeloid-committed progenitor cells (Bristow et al., 2003). Cell migration is initiated by α1PI-induced co-capping of receptors such as HLECS, CXCR4, and CD4 into podia formation (Cepinskas et al., 1999; Banda et al., 1988). In addition to the participation of podia formation during cell migration, this configuration is also the preferred binding site for HIV-1 (Bristow et al., 2003). The reactive site in α1PI for this activity is Phe-Val-Phe-Leu-M (FVFLM, aa 370-374, SEQ ID NO: 7).
A third non-physiologic activity of α1PI is binding to antibodies reactive with HIV-1 envelope protein gp120, and this activity results in inactivation of α1PI and blocking of the other two activities described above. The anti-gp120 monoclonal antibodies 1C1 (Repligen, Inc., Cambridge, Mass.) and 3F5 (hybridoma culture supernatant, 0085-P3F5-D5-F8, Dr. Larry Arthur, NCI-Frederick) were previously shown to be reactive with an epitope near the gp120 C5 domain (Moore et al., 1994). The antibody cross-reactive site of human α1PI is contained in the domain Phe-Leu-Met-Ile-Glu-Gln-Asn-Thr-Lys-Ser-Pro-Leu-Phe-Met-Gly-Lys-Val-Val (FLMIEQNTKSPLFMGKVV, aa 372-389, SEQ ID NO: 8) (Bristow et al., 2001) Chimpanzee α1PI, which differs from human α1PI by a single amino acid, Val (aa 385), does not bind anti-gp120, consistent with the ability of chimpanzees to resolve HIV-1 infection and regain normal CD4+ lymphocyte levels. This suggests that the anti-gp120 cross-reactive site in human α1PI is determined primarily by the Met residue (aa 385).
3.3 Expression of recombinant α1PI: Any method known in the art may be used for producing genetically modified α1PI's according to the invention. Two preferred methods are briefly described below for producing such recombinant α1PI's; one method allows expression of α1PI in rice cells and the other allows bacterial expression. The cDNA encoding human α1PI is obtained from a human cDNA bank by and amplification of the fragment in accession number K01396 using two PCR primers: N-terminal primer 5′ GAGGATCCCCAGGGAGATGCTGCCCAGAA 3′ (SEQ ID NO: 9) and C-terminal primer 5′CGCGCTCGAGTTATTTTTGGGTGGGATTCACCAC 3′ (SEQ ID NO: 10) as previously described (Courtney et al., 1984; Terashima et al., 1999; Jean et al., 1998).
For expression in rice cells, expression cassettes are prepared by using a 1.1 kb NheI-PstI fragment, derived from p1AS1.5, is cloned into the vector pGEM5zf- (Promega, Madison, Wis.): ApaI, AatII, SphI, Ncol, SstII, EcoRV, SpeI, NotI, PstI, SalI, NdeI, SacI, MluI, NsiI at the SpeI and PstI sites to form pGEM5zf-(3D/NheI-PstI). The GEM5zf-(3D/NheI-PstI) is digested with PstI and SacI and ligated in two nonkinased 30mers with the complementary sequences 5′ GCTTG ACCTG TAACT CGGGC CAGGC GAGCT 3′ (SEQ ID NO: 11) and 5′ CGCCT AGCCC GAGTT ACAGG TCAAG CAGCT 3′ (SEQ ID NO: 12) to form p3DProSig. A 5-kb BamHI-KpnI fragment from lambda clone □OSg1 A is used as a terminator. Hygromycin resistance is obtained from the 3-kb BamHI fragment containing the 35S promoter-Hph-NOS of the plasmid pMON410.
Microprojectile bombardment is applied for transforming a Japonica rice variety TP309. The bombarded calli are then transferred to NB medium containing 50 mg/l hygromycin and incubated in the dark at 25° C. for 10±14 days. Rice cells are cultured at 28° C. (dark) using a shaker with rotation speed 115 rpm in the AA(+sucrose) media. The medium is changed every 5 days to maintain cell lines. AA(−sucrose) is used for α1PI expression. A bioreactor is used for 2-1-scale culture. The reactor is operated at 28° C. (dark) at agitation speed 30±50 rpm with aeration rate 100 ml/min. During the growth phase (10 days), the pH of the media is controlled at pH 5.7, while in the production phase the PH is 5.7±6.3 (un-controlled).
Recombinant α1PI is purified using polyclonal anti-human α1PI antibody (Enzyme Research Laboratories, South Bend, Ind.) immobilized to a CNBr-activated bead-formed agarose-based gel-filtration matrix (Sepharose® 4B) with a concentration of 1.5 mg/ml gel. The gel (3.5 ml) is packed in a column (inner diameter 1.26 cm), and equilibrated with 50 mM Tris-HCl buffer (pH 7.6). Crude medium is applied to the column at 1.0 m./min. Absorbance at 280 nm is monitored at the outlet of the column. After washing with the equilibrium buffer, α1PI is eluted with 0.1N HCl solution. A peak fraction is collected, and its pH is immediately adjusted with 1M Tris-HCl buffer (pH 8.0). These methods yield an estimated 5.7 mg α1PI/g dry cell.
Alternatively, the α1PI cDNA are expressed in Escherichia coli strain BL21 transformed with pDS56α1PI/hf (Invitrogen, Carlsbad, Calif.). Protein expression is induced by addition of 1 mM isopropyl b-D-thiogalactoside, and cultures are grown overnight at 31° C. The cells are washed in metal-chelation chromatography binding buffer (5 mM imidazole/0.5M NaCl/20 mM Tris, pH 7.9) and disrupted by cavitation. The clarified and filtered supernatants containing soluble α1PI variants are applied to a Ni2+-agarose column, and bound proteins are eluted with 100 mM EDTA. The eluates are adjusted to 3.5M NaCl and applied to a hydrophobic interaction chromatography (HIC) column, (phenyl Sepharose®). The bound α1PI/hf is eluted with 20 mM Bis-Tris, pH 7.0 and concentrated (4 mg/ml final) by diafiltration in the same buffer.
4. Genetic modification of active WTI: Recombinant active α1PI is expressed according to the procedures described in Section 3 of the Detailed Description. Wild-type human α1PI is modified genetically to diminish or enhance sequence-specific reactive sites. For example, in HIV-1 disease, therapeutic α1PI variants maintain its inhibition of soluble HLEG and its induction of cell migration, but diminish its capacity to facilitate HIV-1 entry and bind antibodies reactive with HIV-1.
The genetic modifications of interest are described in Section 4.1 of the Detailed Description. Site-directed mutagenesis of active α1PI is performed using standard procedures which are well known in the art (e.g., Parfrey et al., 2003; Current Protocols in Molecular Biology, 2002). For example, the DNA sequence encoding the human α1PI signal peptide in pDS56α1PI/hf is replaced with sequences encoding the epitope (FLAG)-tag by insertion of the annealed complimentary oligos
5′ CTAGAGGATCCCATGGACTACAAGGACGACGATGACAAGGAA 3′ (SEQ ID NO: 13) and 5′GATCTTCCTTGTCATCGTCGTCCTTGTAGTCCATGGGATCCT 3′ (SEQ ID NO: 14). The resulting cDNA is subcloned into pDS56-6His to generate pDS56α1PI/hf. To generate pDS56α1PI/hf carrying an amino acid substitution, the DNA sequences encoding the wild-type amino acid are replaced by the complimentary oligos coding for the amino acids described in Section 4.1 of the Detailed Description. The resulting ORFs directed cytosolic expression of the recombinant proteins initiating with a Met followed by the His and FLAG tags and the mature sequences of mutant α1PI.
4.1 Genetic modification within the domain that determines cell migration (FVFLM, aa 370-374, SEQ ID NO: 7) is prepared by site-directed mutagenesis of specific amino acids:

    
    
        4.1.1 Phe (aa 370) to Ile, Leu, Val, Tyr, or Gly.
        4.1.2 Val (aa 371) to Phe, Leu, Ile, or Gly.
        4.1.3 Phe (aa 372) to Ile, Leu, Val, Tyr or Gly.
        4.1.4 Leu (aa 373) to Ile, Val, Phe, or Gly.
        4.1.5 Met (aa 374) to Phe, Thr, Ile, Leu, Val, or Gly.
    
    


4.2 Modification within the domain that determines HIV-1 gp120 antibody recognition is prepared by site-directed mutagenesis of Met (aa 385) to Phe, Thr, Be, Leu, Val, or Gly.
5. Proteolytic modification of active or recombinant α1PI: Proteolytic fragments of chemotactic molecules, such as complement, thrombin, and α1PI, impart a primordial system of immune clearance mediators producing discrete classes of cellular responses. The appearance of variant chemotactic molecules avails immediate recruitment of pathogen-responsive immune cells as a direct function of the proteases specific to each pathogen. To replicate this system for therapeutic application, active or recombinant α1PI are modified proteolytically to diminish or enhance conformation-specific reactive sites.
Cleavage of α1PI producing inactive α1PI maybe accomplished using a variety of proteinases. Cleavage by elastase is between Met-Ser (aa 358-359) (Berninger, 1985), and by stromelysin-3, a stromal cell-derived matrix metalloproteinase (MMP), between Ala-Met (aa 350-351) (Pei et al., 1994). Cleavage of α1PI by neutrophil collagenase or gelatinase is between Phe-Leu (aa 352-353) producing inactive α1PI (Desrochers et al., 1992). Other MMPs have also been shown to cleave α1PI (Mast et al., 1991). Significantly, α1PI is cleaved by proteinase derived from pathogenic organisms such as Pseudomonas elastase (Barbey-Morel and Perlmutter, 1991).
The C-terminal α1PI proteolytic fragments acquire attributes that allow interaction with the LDL receptor-related protein (LRP) (Poller et al., 1995) and other receptors that recognize a pentapeptide sequence FVFLM (aa 370-374, SEQ ID NO: 7) (Joslin et al., 1992) in a manner that produces, chemotaxis of neutrophils, increased LDL binding to monocytes, upregulated LDL receptors, increased cytokine production, and α1PI synthesis (Banda et al., 1988; Janciauskiene et al., 1999; Janciauskiene et al., 1999). It has been shown that fibrillar aggregates of the C-terminal fragment of α1PI facilitate uptake of LDL by LRP on the hepatolastoma cell line HepG2 (Janciauskiene and Lindgren, 1999), and these fragments participate in atherosclerosis (Dichtl et al., 2000).
Specifically, active or recombinant α1PI are incubated at the relevant optimal conditions with one or a combination of pepsin, plasmin, urokinase, chymotrypsin, thrombin, CD26, matrix metalloproteinases, complement components C1 or C3, and other proteinases that facilitate the generation of chemotactic fragments of α1PI (Methods in Enzymology, 1970; Hooper, 2002). Cleavage of α1PI is then terminated by changing the optimal conditions in the proteinase mixture to conditions that prevent proteinase activity, for example at temperature or pH extremes (Methods in Enzymology, 1970; Hooper, 2002).
6. Functional capacity of active, genetically modified, and proteolytically modified α1PI: Various unmodified and modified α1PI's are screened and selected for use in treatment of specific diseases by determining their capacity in vitro and/or in vivo to perform the following functions in the following assays:
6.1 Inhibit elastase: The procedures for measuring the capacity of α1PI to inhibit soluble forms of porcine pancreatic elastase (PPE) or HLEG are well established (U.S. Pat. No. 6,887,678) (Bristow et al., 1998). Briefly, PPE is incubated for 2 min with α1PI, and to this mixture is added, the elastase substrate succinyl-L-Ala-L-Ala-L-Ala-p-nitroanilide (SA3NA). Results are detected by measuring the color change at 405 nm.
In complex mixtures, α1PI competes for binding to PPE with other proteinase inhibitors or ligands present in the mixture. For example, PPE has higher affinity for α2macroglobulin (α2M) than for α1PI, and when complexed with α2M, PPE retains the ability to cleave small substrates. In the presence of α2M, PPE binds α2M and is protected from inhibition by α1PI, and the complexation of PPE with α2M can be measured by detecting the activity of PPE using SA3NA. To measure the inhibitory capacity of α1PI in complex mixtures such as serum, two-fold serial dilutions of serum are incubated with a constant, saturating concentration of PPE. The added PPE is bound by, α2M and α1PI in the diluted serum dependant on their concentrations, the greater the concentration of serum, the greater the concentration of α2M and α1PI. Since there is more α1PI in serum than α2M, as serum is diluted, α2M is diluted out, and in the absence of α2M, PPE is bound and inhibited by α1PI. The complexation of PPE with α1PI can be measured by detecting the loss of activity of PPE using SA3NA. As serum is further diluted, α1PI is also diluted out, and the loss of complexation of PPE with α1PI can be measured by detecting the gain in activity of PPE using SA3NA. The plot of PPE activity versus serum dilution makes a V shaped curve, PPE activity first decreasing as serum is diluted, and then increasing as serum is further diluted. The nadir of PPE activity is used to calculate the precise concentration of active α1PI in the mixture (Bristow et al., 1998).
6.2 Induce receptor co-capping and cell motility: The procedures for inducing receptor capping have been described (Bristow et al., 2003). The cells of interest (monocytes, lymphocytes, neutrophils, or other blood cells, e.g. leukemic cells) are isolated from blood or tissue using standard techniques (Messmer et al., 2002) and examined for reactivity with α1PI.
To examine receptor capping, cells are incubated with active or modified α1PI for 15 min in humidified 5% CO2 at 37° C. Cells are applied to the sample chambers of a cytospin apparatus (Shandon Inc. Pittsburgh, Pa.), and slides are centrifuged at 850 rpm for 3 min. Slides are fixed by application of 50 μl 10% formalin to the sample chambers of the cytospin apparatus followed by an additional centrifugation at 850 rpm for 5 min. Slides are incubated for 90 min at 20° C. with fluorescently-labeled monoclonal antibodies having specificity for the receptors of interest and examined by microscopy.
Cell motility results from selective and sequential adherence and release produced by activation and deactivation of receptors (Wright and Meyer, 1986; Ali et al., 1996), consequent polar segregation of related membrane proteins to the leading edge or trailing uropod, and both clockwise and counterclockwise propagation of Ca++ waves which initiate from different locations in the cell (Kindzelskii and Petty, 2003). Thus, several aspects of the complex process may be quantitated. The most direct and most easily interpreted method for quantitating cell motility is the enumeration of adherent cells in response to a chemotactic agent such as α1PI.
For detecting adherence, sterile coverslips are washed in endotoxin-free water, and to each coverslip is delivered various dilutions of active or modified α1PI. Cells are subsequently delivered to the coverslips, mixed to uniformity with α1PI, and incubated for 30 min in humidified 5% CO2 at 37° C. without dehydration. After stringently washing the coverslips free of non-adherent cells, adherent cells are fixed by incubation for 10 min at 20° C. with 4% paraformaldehyde containing 2.5 mM of the nuclear staining fluorescent dye, acridine orange (3,6-bis[dimethylamino]acridine. Slides are examined by microscopy, and means and standard deviations are determined by counting adherent cells in at least three fields/coverslip.
6.3 Mobilize lymphoid-committed progenitor cells: In the nonobese diabetic/severe combined immunodeficiency (NOD/SCID) mouse model, bone marrow-engrafted human cells can be mobilized by G-CSF (Petit et al., 2002). This model is adapted to assess the capacity of active or modified α1PI to mobilize human lymphoid- or myeloid-lineage cells, respectively.
NOD/SCID mice are housed under defined flora conditions in individually ventilated (HEPA-filtered air) sterile micro-isolator cages. Human chimeric mice are obtained after sublethal irradiation (375 cGy at 67 cGy/min) and injection of 2×107 human cord blood mononuclear cells. Four to five weeks post transplantation, mobilization is performed by application of either G-CSF or α1PI. For mobilization of myeloid-committed progenitors, mice receive daily subcutaneous injections of 300 mg/kg G-CSF (Filgrastim, Neupogen® or Neulasta®, Amgen, Inc.) in 250 μl of 0.9% NaCl, 5% fetal calf serum for 4-5 days. Alternatively, mice receive twice weekly infusion via the dorsal tail vein of inactive or modified α1PI (39 mg/kg) at a rate of 0.08 ml/kg/minute. For mobilization of lymphoid-committed progenitors, mice receive twice weekly infusion via the dorsal tail vein of active or modified α1PI (42 mg/kg) at a rate of 0.08 ml/kg/minute. Mice are asphyxiated with dry ice, peripheral blood is collected by cardiac aspiration into heparinized tubes, and bone marrow is harvested, and cells are flushed from femurs and tibias into single-cell suspensions. Peripheral blood and bone marrow cells are analyzed by flow cytometry for the presence of myeloid and lymphoid markers including CD34 CD38, CD10, CD11b, CD11c, CD13, CD14, CD19, CD3, CD4, CD8, CD45, CD184 (CXCR4), CD66, and HLECS (U.S. Pat. No. 6,858,400).
6.4 Bind anti-HIV-1 gp120: Active or modified α1PI are incubated in fluid phase with monoclonal antibodies reactive with HIV-1 gp120. The anti-gp120 monoclonal antibodies 3F5 (hybridoma culture supernatant, 0085-P3F5-D5-F8) is reactive with an epitope near the gp120 C5 domain (Moore et al., 1994). Clone α70 (ICN Biochemicals, Aurora, Ohio) is reactive with the V3-loop of gp120, a domain that is identical to the HLE ligand inter-α-trypsin inhibitor (Pratt et al., 1987). Immune complexes are captured by incubating mixtures in wells of a microtiter plate pre-coated with chicken anti-human α1PI IgG. Binding is detected using horse radish peroxidase-conjugated rabbit anti-mouse IgG followed by substrate, orthophenylene diamine HCl.
6.5 Facilitate HIV-1 infectivity: Primary non-syncytium inducing HIV-1 clinical isolates (Advanced Biotechnologies, Rivers Park, Ill.) are used to infect peripheral blood mononuclear cells maintained in wells of a 96 well tissue culture plate at 2×106 cells/ml in RPMI-1640 containing 20% autologous serum and 10% IL-2 (Cellular Products, Buffalo, N.Y.). Prior to addition of HIV-1, cells are incubated with active or modified α1PI for 0 min or 60 min at 37° C., 5% CO2. In vitro infectivity outcome is determined in triplicate by p24 accumulation or by RT activity as previously described (Bristow, 2001). Cell counts and viability are determined at the final time point.
7. Treatment outcome measurements:
7.1 To determine the effectiveness of treatment on elastase inhibitory capacity, individuals are monitored weekly for active and inactive α1PI blood levels (Bristow et al., 1998) (U.S. Pat. No. 6,887,678). Briefly, a constant amount of active site-titrated PPE is allowed to incubate with serial dilutions of serum for 2 min at 37° C. after which a PPE substrate is added. Determination of the molecules of substrate cleaved by residual, uninhibited PPE is used to calculate the molecules of active and inactive α1PI in blood.
7.2 To determine the effectiveness of treatment on inducing changes in levels of targeted blood cell populations, treated individuals are monitored weekly for changes in complete blood count and differential, as well as for changes in specific subsets of blood cells such as CD4+ cells and HLECS+ cells using flow cytometry (Bristow et al., 2001; Bristow, 2001) (U.S. Pat. No. 6,858,400). Briefly, 100 μl of whole blood is incubated with a panel of fluorescently-labeled monoclonal antibodies approved by the FDA for medical diagnostics. These antibodies are selected to specifically recognize the cell receptors that uniquely identify the cell population of interest. Identification and enumeration of the cells in blood that are bound to the monoclonal antibodies is performed using flow cytometry.
7.3 To determine the influence of treatment on disease progression, individuals are monitored for the specific pathologic determinants of disease which are well known in the art for the various indications, e.g. in stem cell transplantation, organ transplantation, autoimmunity, diabetes, leukemia, cancer, HIV-1 infection, atherosclerosis, and other diseases influenced by blood cells. For example, in HIV-1 disease, individuals are monitored for changes in CD4+ lymphocyte levels and HIV levels (Bristow et al., 2001; Bristow, 2001), In leukemia or cancer, individuals are monitored for changes in the presence of leukemic or cancerous cells (Tavor. S. et al., 2005). In stem cell transplantation, individuals are monitored for changes in normal blood cells (Jansen et al., 2005). In organ transplantation, individuals are monitored for organ rejection (Kirschfink, 2002). In autoimmunity, individuals are monitored for the presence of autoantibodies and specific functions of the affected organs (Marinaki et al., 2005). In diabetes and atherosclerosis, individuals are monitored for changes in total cholesterol, LDL, HDL, and triglyceride levels (Talmud et al., 2003).
EXAMPLES
1. Increased CD4+ lymphocytes are correlated with increased α1PI and decreased HLECS+ lymphocytes in healthy individuals. In healthy individuals, circulating α1PI ranges from 18-53 μM between the 5th and 95th percentiles, and 90-100% of this protein is in its active form as determined by inhibition of porcine pancreatic elastase (Bristow et al., 2001). To investigate the relationship between active α1PI, HLECS+, and CD4+ lymphocytes, 6 healthy HIV-1 seronegative adults, 3 males and 3 females, were specifically selected to represent a wide spectrum of α1PI (1.9-61.5 μM). Subjects were measured for CD4, CXCR4, CCR5, HLECS, active and inactive α1PI levels, and α2-macroglobulin (α2M). Independently, neither active α1PI, HLECS+ lymphocytes, α2M, CXCR4+ lymphocytes, nor CCR5+ lymphocytes were correlated with CD4+ lymphocytes. However, by multilinear regression analysis, it was found that higher numbers of CD4+ lymphocytes (% lymphocytes) were correlated (r2=0.937) with two counterbalancing variables together, higher active α1PI (p=0.008) and lower HLECS+ lymphocytes (p=0.034) (FIG. 1a).
To investigate CD4+ lymphocyte levels in the general population, blood was collected from an additional 18 healthy, HIV-1 seronegative adults, 9 males and 9 females, who were measured for CD4, CXCR4, CCR5, SDF-1, active and inactive α1PI levels. HLECS was measured in 16 of these individuals. Values for active α1PI (19-37 μM) and SDF-1 levels (191-359 pM) for these volunteers were found to be within normal ranges. Higher CD4+ lymphocytes (%) were again found to be correlated (r2=0.803) with higher active α1PI (p<0.007) and lower HLECS+ lymphocytes (p<0.001) (FIG. 1b). Along with active α1PI and HLECS+ lymphocytes, lower SDF-1 concentration (p=0.02) also significantly contributed to predicting higher CD4+ lymphocytes (r2=0.875). Although CXCR4+ lymphocytes were not significantly related to CD4+ lymphocytes, this may reflect the detection of both active and inactive configurations of CXCR4 on individual cells (Percherancier et al., 2005).
There was no statistical difference between the volunteers in FIGS. 1a and b in their active α1PI levels (median=23 and 24, respectively) and CD4+ lymphocytes (mean=48% and 45%, respectively); however, in volunteers depicted in FIG. 1a the range is wide (1.9-61.5 μM) and standard deviation is large (s=24), whereas in volunteers depicted in FIG. 1b, the range of active α1PI is narrow (19-37 μM) and the standard deviation is small (s=6), and this suggests CD4+ lymphocyte levels are sensitive to small differences in α1PI levels. The sensitivity of CD4+ lymphocyte levels to α1PI levels is further exemplified during the acute phase of an enteric infection in one volunteer who was otherwise healthy (FIG. 1c). In this individual, an increase in total lymphocytes (1.15-fold) and CD4+ lymphocytes (1.2 fold) was found to occur in concert with an increase in total α1PI (2.7-fold), increase in active α1PI (1.5 fold), and decrease in HLECS (2.9-fold).
2. Monoclonal anti-gp120 binds human, but not chimpanzee α1PI. Two monoclonal antibodies (1C1 and 3F5) which bind a conformationally determined epitope near the C5 domain of gp120 (Moore et al., 1994) were found to also bind human α1PI (Bristow et al., 2001). It was hypothesized that anti-gp120 mediated depletion of active α1PI might be pathognomonic for HI-1 AIDS. If true, chimpanzee α1PI should differ from human α1PI since HIV-1 infected chimpanzees survive infection and regain normal levels of CD4+ lymphocytes (Rutjens et al., 2003). Sequence comparison revealed that human α1PI differs from chimpanzee α1PI by one amino acid (aa 385) caused by a single nucleotide change (NCBI accession numbers BT019455 and XP_522938), and this aa difference lies in the gp120-homologous region of α1PI. To determine whether this sequence difference affects the binding of anti-gp120 to α1PI, 20 human and 20 chimpanzee sera were compared. Both 1C1 (data not shown) and 3F5 exhibited 8- to 14-fold greater binding to human, than chimpanzee α1PI in 6 repeat measurements (p<0.001) (FIG. 2a). Negative control monoclonal antibody α70 which reacts with the V3-loop of gp120 failed to bind human α1PI (data not shown) consistent with previous findings (Bristow et al., 2001). Serum α1PI in two human subjects exhibited much greater affinity for 3F5 than that from other subjects, and this suggests the epitope of α1PI recognized by 3F5 may be phenotypically determined. When these two subjects were omitted from the comparison, the statistical difference between binding of 3F5 to human or chimpanzee α1PI was maintained (p<0.001).
To examine the relationship between lower CD4+ lymphocyte levels and lower active α1PI levels in HIV-1 disease, blood from 38 HIV-1 infected patients was analyzed. Of these 38 patients, 29% had detectable IgG-α1PI immune complexes, 89% were on antiretroviral therapy, and 60% had <500 HIV-1 RNA copies/ml (FIG. 2b). The number of patients exhibiting detectable IgG-α1PI immune complexes in this study differs from a previous study of 68 HIV-1 patients in which 60% had detectable IgG-α1PI immune complexes, 53% were on antiretroviral therapy (AZT only), and 16% had <500 HIV-1 RNA copies/ml (Bristow et al., 2001). This reason for this difference may be related to the improved antiretroviral therapy in place today.
None of the sera from healthy chimpanzees, nor sera collected from 2 chimpanzees post-HIV-1 inoculation, had evidence of detectable IgG-α1PI immune complexes. The HIV-1 inoculated chimpanzees were confirmed to be HIV-1 infected, but had normal CD4+ lymphocytes (Girard et al., 1998). In addition, despite the presence of anti-gp120, we found no evidence of IgG-α1PI immune complexes in 10 rhesus macaques following immunization with simian/human immunodeficiency virus (SHIV 89.6) gp120 or gp140, or in 3 macaques infected with SHIV (data not shown). Extensive in vitro analyses failed to demonstrate bi-molecular complexes between gp120 and α1PI (data not shown), and the absence of detection of IgG-α1PI immune complexes in sera from HIV-1 infected chimpanzees suggests gp120 and α1PI are not associated by aggregation in sera. These results suggest that IgG-α1PI immune complexes are unique to HIV-1 disease in humans.
Consistent with evidence from a previous patient study, active α1PI in the HIV-1 infected patients was significantly below normal (median 17 μM, p<0.001) (FIG. 2c) and inactive α1PI was significantly above normal (median 19 μM, p<0.001) (FIG. 2d) (Bristow et al., 2001). In contrast to humans, active α1PI levels in sera collected from the 2 chimpanzees post-HIV-1 inoculation (39 μM) were not different from normal chimpanzee and human sera (p=0.810) (FIG. 2c).
To determine whether α1PI becomes inactivated after complexing with the 3F5 anti-gp120 monoclonal antibody, 3F5 was incubated with sera samples from five healthy individuals. In comparison to untreated sera, α1PI activity was significantly diminished to the same degree in all sera (mean difference=5.8±0.5 μM, p<0.001) (FIG. 2e).
The gp120 epitope recognized by 1C1 and 3F5 is considered to be conformation-dependent (Moore et al., 1994). The gp120 peptide immunogen used to raise 1C1 and 3F5 (aa 300-321, GGGDMRDNWRSELYKYKVVK (SEQ ID NO: 15) (Ratner et al., 1985) contains both an α-helix (aa 306-313) and linear strand (aa 314-321) (FIG. 3a,b), but other epitope determinants of the antibodies are not known. In human α1PI (FIG. 3c,d), the gp120-homologous sequence (aa 369-389, PFVFLMIDQNTKSPLFMGKVV (SEQ ID NO: 16) folds to form a two-stranded antiparallel β-sheet that lies at the base of a cleft (4A° deep by 20A° long by 5A° wide) topped by two α-helices (aa 28-47 and 259-277) in a smaller, but similar configuration as the antigen-binding cleft of MHC (10A° deep by 25A° long by 10A° wide) (Bjorkman et al., 1987). At the far end of the first of these α-helices is the N-linked mannose-containing oligosaccharide that confers structural polymorphism to α1PI (aa 46) (Jeppsson et al., 1985). In the center of the α-sheet that lies in the cleft, is M-385 which distinguishes human from chimpanzee α1PI (V-385): The function of this cleft is not known, but a sequence in the center of the β-sheet formation (aa 370-374, FVFLM (SEQ ID NO: 7) is homologous to the fusion domain of HIV-1 gp41, and this sequence has been implicated in binding HLECS (Bristow et al., 1995; Bristow et al., 2003) and stimulating cell motility (Joslin et al., 1991).
In α1PI, the sequence GKVV (aa 386-389, SEQ ID NO: 2) lies within 5A° of M-385, N-46, and the N-linked oligosaccharide in a space occupying 5A° by 5A° by 5A°. In gp120, in the same relative orientation as in α1PI, the sequence YKVV (aa 315-318, SEQ ID NO: 1) lies within 5A° of M-17 and 8A° of N-92 and the N-linked mannose-containing oligosaccharide (Leonard et al., 1987) in a space occupying 5A° by 5A° by 8A°. Evidence that α1PI polymorphisms may influence 3F5 binding (FIG. 2a) suggests the polymorphism-determining N-46 oligosaccharide participates in 3F5 recognition of α1PI. Thus, the 3F5 conformational epitope is suggested by these analyses to occupy a 5A° by 5A° by 8A° space including KVV, M, N, and the N-linked oligosaccharide. This proposed conformational epitope is consistent with previously characterized antigen configurations that contain oligosaccharide determinants (Cygler et al., 1991) as well as with results demonstrating that gp120 N-92 is invariant (Wei et al., 2003).
3. Active α1PI is rate limiting for CD4+ lymphocytes in HIV-1 disease. Of the 36 patients included in the study population, 23 were below 500 and 13 were above 500 HIV RNA copies/ml at the time of blood collection. All patients were measured for CD4, CXCR4, CCR5, SDF-1 levels, active and inactive α1PI. Only 28 of these patients were additionally measured for HLECS. Neither CXCR4 nor CCR5 were found to correlate individually or in combination with any parameters of disease being investigated in these patients. Eleven of the 38 HIV-1 patients had active liver disease as defined by detectable Hepatitis B or C, or elevated liver enzymes. HIV-1 patients with liver disease were not different from patients without liver disease in active α1PI (p=0.95), total α1PI (p=0.79), CXCR4 (p=0.63), or CCR5 (p=0.9), but exhibited significantly higher SDF-1 (p<0.001), HLECS+ lymphocytes (p<0.001), and CD4+ lymphocytes (p=0.04).
In the 23 patients with <500 HIV-1 RNA copies/ml, higher CD4+ lymphocyte levels were correlated with higher active α1PI concentration (r2=0.927) and lower inactive α1PI concentration (r2=0.946) (FIG. 4). Prediction of CD4 levels from active α1PI levels with 95% confidence had a standard error of 151 cells/μl, and prediction from inactive α1PI levels with 95% confidence had a standard error of 105 cells/4 Of these 23 patients, only 16 had been additionally measured for HLECS. As in Healthy individuals (FIG. 1), lower HLECS+ lymphocytes was itself not correlated with higher CD4+ lymphocytes, but in combination with higher active α1PI was significantly correlated (p=0.01). That CD4+ lymphocyte levels could be predicted by active α1PI alone with such a high degree of accuracy in patients controlling their viral load suggests that, unlike the normal population, active α1PI is rate limiting for CD4+ lymphocyte levels in HIV-1 disease. In patients with >500 HIV RNA copies/ml, there was no relationship between CD4+ lymphocyte levels and active or inactive α1PI (FIG. 4), and this suggests either HIV-1 itself, or other host processes had contributed to disrupting the regulation of CD4+ lymphocyte levels.
4. α1PI augmentation therapy in HIV-1 infected patients. The number of CD4+ T lymphocytes in patients with <500 HIV-1 RNA copies/ml is controlled by their circulating concentration of α1PI (Example 2). These patients have below normal levels of circulating α1PI (Bristow et al., 2001). Approximately 10% clinic patients in New York City who have <500 HIV-1 RNA copies/ml also have <200 CD4 cells/μl, and these patients benefit from α1PI augmentation by increasing their CD4+ T lymphocyte numbers. Treatment of HIV-1 infected patients with α1PI augmentation is indicated in patients who are simultaneously receiving one or a combination of the four currently known classes, nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, HIV-1 aspartyl protease inhibitors, and fusion inhibitors.
Patients with <500 HIV-1 RNA copies/ml and <200 CD4 cells/μl who are receiving antiretroviral therapy are treated using Zemaira® α1PI. Patients receive weekly infusions of Zemaira® at 60 mg/kg as described in Section 2 of the Detailed Description. Treatment outcome is monitored as described in Section 7.3 of the Detailed Description. Specifically, patients receiving Zemaira® are monitored weekly for changes in active and inactive α1PI levels as well as for CD4+ T lymphocytes and other subsets of circulating blood cells. Patients are also monitored for changes in HIV-1 RNA copies/ml, LDL, HDL, cholesterol, triglycerides, and the occurrence of infections designated by the CDC as parameters of HIV-1 disease progression (Castro et al., 1992). To determine possible adverse effects of immune complex disease, individuals are monitored for the presence of antibodies reactive with α1PI as well as for the occurrence of glomerulonephritis by measuring either proteinuria or serum creatinine levels (Bristow et al., 2001; Virella et al., 1981).
5. α1PI augmentation therapy in HIV-1 infected patients using genetically modified α1PI. Antibodies that recognize HIV-1 are the only diagnostic marker of infectivity. The presence of an anti-gp120 antibody that also binds α1PI has been detected in most HIV-1 infected individuals (Bristow et al., 2001), and this antibody inactivates and produces deficient levels of α1PI. Anti-gp120 does not bind chimpanzee α1PI which differs from human α1PI by a single amino acid (aa 385) (Example 2). To therapeutically augment α1PI in HIV-1 infected individuals, it is desirable to use genetically modified α1PI which substitutes a different aa in place of Met (aa 385). In addition, a hydrophobic domain (aa 370-374) near Met (aa 385) has been shown to facilitate HIV-1 entry (Bristow et al., 2001). Thus, it is also desirable to change one or more of the aa in this hydrophobic domain for treatment in HIV-1 disease.
α1PI is genetically modified as described in Section 4 of the Detailed Description with three substitutions, aa 385 (Met to Val), aa 372 (Phe to Gly), and aa 373 (Leu to Gly), and is designated α1PI.β.F372G.L373G.M385V (α1PI.β. The α1PI.β sequence with aa changes represented in bold underlined letters is as follows (SEQ ID NO: 17):









−24
MPSSVSWGIL LLAGLCCLVP VSLA



 


1
EDPQGDAAQK TDTSHHDQDH PTFNKITPNL AEFAFSLYRQ LAHQSNSTNI


 


51
FFSPVSIATA FAMLSLGTKA DTHDEILEGL NFNLTEIPEA QIHEGFQELL


 


101
RTLNQPDSQL QLTTGNGLFL SEGLKLVDKF LEDVKKLYHS EAFTVNFGDT


 


151
EEAKKQINDY VEKGTQGKIV DLVKELDRDT VFALVNYIFF KGKWERPFEV


 


201
KDTEEEDFHV DQVTTVKVPM MKRLGMFNIQ HCKKLSSWVL LMKYLGNATA


 


251
IFFLPDEGKL QHLENELTHD IITKFLENED RRSASLHLPK LSITGTYDLK


 


301
SVLGQLGITK VFSNGADLSG VTEEAPLKLS KAVHKAVLTI DEKGTEAAGA


 


351
MFLEAIPMSI PPEVKFNKPF VGGMIEQNTK SPLFVGKVVN PTQK






The functional capacity of α1PI.β depicted in Table 2 is determined as described in Section 6 of the Detailed Description.







TABLE 2







Functions of the C-terminal region of α1PI.β














Lymphoid






Proteinase
cell
Myeloid cell
anti-gp120
HIV-1 entry



Inhibition
migration
migration
binding
co-factor
















Native configuration in the active α1PI.β
+
−
−
−
+


Rearranged configuration in cleaved α1PI.β
−
−
−
−
−


Complexed with HLE in cleaved α1PI.β
−
−
−
−
−


Independent of other α1PI.β cleavage
−
−
−
−
Unknown


products









The recommended dose of α1PI is 60 mg/kg. The specific activity of Zemaira® is 70%, where specific activity is defined as inhibition of PPE (Bristow et al., 1998). Thus, the recommended dose of Zemaira® α1PI may be stated as 42 mg/kg active α1PI. In accordance with the recommended Zemaira® treatment regimen, HIV-1 patients with <500 HIV-1 RNA copies/ml and <200 CD4 cells/μl who are receiving antiretroviral therapy are infused with the concentration of α1PI.β that is in the range of 1 to 420 mg/kg active α1PI with a target blood threshold of 35 μM α1PI.β. Treatment of HIV-1 infected patients with α1PI.β is indicated in patients who are simultaneously receiving one or a combination of the four currently known classes, nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, HIV-1 aspartyl protease inhibitors, and fusion inhibitors. Treatment outcome is monitored as described in Section 7.3 of the Detailed Description. Specifically, patients receiving α1PI.β are monitored weekly for changes in active and inactive α1PI levels as well as for CD4+ T lymphocytes and other subsets of circulating blood cells. Patients are also monitored for changes in HIV-1 RNA copies/nil, LDL, HDL, cholesterol, triglycerides, and the occurrence of infections designated by the CDC as parameters of HIV-1 disease progression (Castro et al., 1992). To determine possible adverse effects of immune complex disease, individuals are monitored for the presence of antibodies reactive with α1PI as well as for the occurrence of glomerulonephritis by measuring either proteinuria or serum creatinine levels (Bristow et al., 2001; Virella et al., 1981).
6. α1PI inhibits SDF-1 induced migration of human leukemic cells in, but enhances migration of human stem cells. Human acute myeloid leukemia cells (AML) not only secrete HLEG, but also express HLECS constitutively on the cell surface in a manner that is regulated by the CXCR4/SDF-1 axis (Tavor. S. et al., 2005). Preincubation of AML cells with α1PI significantly reduced their SDF-1 dependent migration in all AML cells tested using an in vitro transwell assay (Tavor. S. et al., 2005). Further, in a mouse model it was found that α1PI inhibited homing of transplanted human stem cells to bone marrow and egress of transplanted AML cells from bone marrow. The influence of α1PI was shown to occur by its action on HLECS. When AML cells were treated with α1PI, SDF-1 induced pseudopodia formation was prevented. These results are in contrast to previous studies using a U937 promonocytic cell line which demonstrated that α1PI-induced pseudopodia formation was prevented by pretreatment with SDF-1 (Bristow et al., 2003), and this difference emphasizes the importance of α1PI and SDF-1 in promoting cell migration of various cells dependent on their stage of differentiation. Augmentation with active and modified α1PI is used therapeutically to control the proliferation and spread of leukemia and lymphoma cells. Active α1PI is used to prevent proliferation and spread of leukemia and lymphoma cells triggered by SDF-1. Inactive α1PI is used to prevent proliferation and spread of leukemia and lymphoma cells triggered by active α1PI. Patients receive therapeutic augmentation with active or modified α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for changes in the number of AML cells in circulation using flow cytometry.
7. α1PI augmentation therapy in patients with a microbial infection. High levels of neutrophils and HLEG are present in the respiratory secretions of patients with cystic fibrosis. The primary cause of this inflammatory situation is chronic infection with Pseudomonas aeruginosa and other bacteria. Abundant α1PI is present in these patients, but is predominantly inactivated by HLEG and P. aeruginosa elastase (Barbey-Morel and Perlmutter, 1991). Prolastin® has demonstrated improvement by reducing elastase activity, neutrophil counts, and bacterial colonies in a rat model (Cantin and Woods, 1999). Inactivated α1PI is a chemoattractant for neutrophils (Joslin et al., 1992). In addition to the therapeutic benefit of inhibiting the elevated elastase activity that attends the inflammatory sequelae of microbial infection, augmentation with active α1PI diminishes the inactivated α1PI-induced neutrophil infiltrate. Patients receive active α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for changes in the number of neutrophils in circulation using flow cytometry and changes in infection driven inflammation.
8. α1PI augmentation therapy for neutropenia. In the majority of patients with severe congenital neutropenia, mutations are found in the gene encoding HLE or in the gene encoding the receptor for G-CSF (Horwitz et al., 1999; Benson et al., 2003). HLE mutations that prevent localization to the plasma membrane cause cyclic neutropenia, and mutations that cause exclusive localization to the plasma membrane cause the pre-leukemic disorder, severe congenital neutropenia (Benson et al., 2003). Because inactive α1PI mobilizes neutrophils (Joslin et al., 1992), augmentation with inactive α1PI is used therapeutically for the purpose of increasing the number of neutrophils in circulation. Patients receive inactive α1PI with a target of 39 mg/kg inactive α1PI and are monitored for active and inactive α1PI levels as well as for changes in the number of neutrophils in circulation using flow cytometry.
9. α1PI augmentation therapy for solid tumors. Tumor cell lines and biopsy specimens exhibit inverse correlations of α1PI and the metalloproteinase MMP-26 (Li et al., 2004). Expression of MMP-26 in estrogen-dependent neoplasms is likely to contribute to the inactivation of α1PI promoting matrix destruction and malignant progression. Furthermore, evidence suggests α1PI participates in tumor cell migration (Nejjari et al., 2004).
A serious side effect of myelosuppressive chemotherapy for solid tumors, is neutropenia. G-CSF (Filgrastim, Neupogen® or Neulasta®, Amgen, Inc.) is currently used to mobilize neutrophils in patients on myelosuppressive chemotherapy. In combination with G-CSF, using active α1PI therapeutically to mobilize lymphoid-lineage cells in patients receiving myelosuppressive chemotherapy offers the additional benefit of controlling tumor metastasis. Patients receive active α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for changes in the number of myeloid-lineage, lymphoid-lineage, and tumor cells in circulation using flow cytometry.
10. α1PI augmentation therapy in atherosclerosis. Diminished active α1PI promotes atherogenesis (Talmud et al., 2003). Oxidized α1PI has no proteinase inhibitory activity, and instead associates with LDL in vivo (Mashiba et al., 2001). The C-terminal fragment of α1PI is present in atherosclerotic plaques (Dichtl et al., 2000). The oxidized and proteolyzed inactivation of α1PI is thought to result from subclinical infections of the arterial intima by bacteria such as Porphyromonas gingivalis (Brodala et al., 2005; Beck et al., 2005). Augmentation with active α1PI is used therapeutically to mobilize lymphoid-lineage cells into the infected tissue for the purpose of controlling and clearing the infection. Patients receive augmentation with active α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for intimal wall thickness and atherosclerotic plaque formation.
11. α1PI augmentation therapy in insulin-dependent diabetes. Increased inactive α1PI is present in insulin-dependent diabetes due to the presence of subclinical infections (Bristow et al., 1998; Sandler et al., 1988) and hyperglycemia (Sandler et al., 1988). Recombinant adeno-associated virus-mediated α1PI gene therapy in a murine model reduced the level of insulin autoantibodies and the frequency of overt diabetes (Song et al., 2004). Augmentation with active α1PI is used therapeutically to mobilize lymphoid-lineage cells into the infected tissue for the purpose of controlling and clearing the infection as well as to ameliorate the incidence of autoantibodies in diabetes. Patients receive augmentation with active α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for the presence of anti-insulin antibodies.
12. α1PI augmentation therapy in autoimmune diseases. A predisposing condition for the occurrence of autoimmune disease is the inborn deficiency of a proteinase or proteinase inhibitor involved in homeostasis. Wegener's granulomatosis is caused by autoimmunity to the α1PI ligand, proteinase 3 (Pendergraft et al., 2003; Csernok et al., 1990). Active α1PI ameliorates the autoimmune pathogenesis of Wegener's granulomatosis (Rooney et al., 2001). Systemic lupus erythematosis can arise in patients with complement deficiencies or α1PI deficiency (Sinico et al., 2005) Elevated HLEG activity is detected in patients with rheumatoid arthritis (Adeyemi et al., 1986). These patients benefit from augmentation with active α1PI. Patients receive augmentation with active α1PI with a target blood threshold of 35 μM active α1PI and are monitored for active and inactive α1PI levels as well as for autoimmune-mediated inflammation.
13. α1PI augmentation therapy in solid organ transplantation. Excessive activation of proteinase cascade systems has been associated with post-transplantation inflammatory disorders and organ rejection (Kirschfink, 2002). Augmentation with active α1PI diminishes post-transplantation inflammation; however, this therapy also mobilizes both lymphoid-lineage and myeloid-lineage cells potentially facilitating organ rejection. To overcome this adverse affect, α1PI is genetically modified to prevent interaction with receptors and to prevent stimulation of cell motility (see Example 5). Augmentation with genetically modified α1PI is used therapeutically to diminish inflammation and prevent recruitment of inflammatory blood cells and their products into transplants. Patients receive genetically modified α1PI with a target blood threshold of 35 μM genetically modified α1PI and are monitored for active and inactive α1PI levels as well as for markers of organ rejection.
14. α1PI augmentation therapy in stem cell transplantation. Migration of stem cells to, and progenitor cells from bone marrow is controlled by HLECS, SDF-1, CXCR4 (Tavor. S. et al., 2005; Lapidot and Petit, 2002) and α1PI (Examples 1-3 herein). Active α1PI mobilizes lymphoid-lineage cells and inactive α1PI mobilizes myeloid-lineage cells. Active and modified α1PI are used therapeutically to mobilize stem cells to hematopoietic tissue and progenitor cells from hematopoietic tissue during stem cell transplantation.
Patients undergoing stem cell transplantation are treated with G-CSF (Filgrastim, Neupogen® or Neulasta®, Amgen, Inc.) to mobilize progenitor cells into circulation, and these are primarily myeloid-committed progenitor cells (Cottler-Fox et al., 2003). Progenitor cells are harvested from blood and placed in culture in vitro for the purpose of proliferation before transplantation. Proliferation and differentiation is monitored using flow cytometry. Active α1PI is given therapeutically with a target blood threshold of 200 μM active α1PI to mobilize lymphoid-lineage cells into circulation. Mobilized lymphoid-committed progenitor cells are harvested from blood and placed in culture in vitro for the purpose of proliferation before transplantation. Patients receiving mobilization treatment with active α1PI are monitored for active and inactive α1PI levels. Harvested lymphoid-committed progenitor cells are monitored for proliferation and differentiation using flow cytometry prior to reinjection.
15. α1PI in producing dendritic cell-based vaccines. Autologous stem cell transplantation involves a process of harvesting stem cells from circulation, culturing the cells in vitro to proliferate, and reinjection into the patient. This same principle is used to produce autologous dendritic cell-based vaccines. Dendritic cells are used as a vector to deliver selected immunogens to the lymph nodes where their interaction with T lymphocytes initiates an immune response to the selected immunogen. Dendritic cell-based vaccines are currently being used to induce immunity to tumor antigens (Schuler et al., 2003). Monocytic or lymphocytic cells are harvested from the blood of a patient with cancer, for example, malignant melanoma. Harvested cells are cultured in vitro in the presence of a cocktail of cytokines including G-CSF and GM-CSF that induces their differentiation into either monocyte-derived dendritic cells or plasmacytoid dendritic cells depending on the combination of cytokines used (Messmer et al., 2002). Dendritic cells are loaded with an antigen, for example melanoma peptide, and reinjected into the patient (Palucka et al., 2005; Schuler et al., 2003). Patients are monitored for the presence of melanoma-specific lymphocytes.
Active α1PI is used to stimulate in vitro differentiation of lymphoid-lineage and myeloid-lineage blood cells into dendritic cells. Differentiation and function of dendritic cells is monitored using flow cytometry and cytokine secretion as described previously (Messmer et al., 2002). Dendritic cells are pulsed with antigen and reinjected into the patient. Patients receiving α1PI-induced dendritic cells are monitored for the presence of immunogen-specific lymphocytes.
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The present invention is not to be limited in scope by the specific embodiments described herein. Indeed, various modifications of the invention in addition to those described herein will be apparent to those skilled in the art from the foregoing description and the accompanying figures.
Patents, patent applications, publications, product descriptions, and protocols are cited throughout this application, the disclosures of which are incorporated herein by reference in their entireties for all purposes.

## Claims

1. A method for increasing the number of circulating CD4+ lymphocytes in an HIV-1-infected human subject having less than 500 HIV-1 RNA copies per ml and receiving antiretroviral therapy comprising administering to a subject in need of such treatment a pharmaceutical composition comprising an amount of an active al proteinase inhibitor (α1PI) consisting of the amino acid sequence as set forth in SEQ ID NO: 3 effective to increase the number of circulating CD4+ lymphocytes in said subject.

2. The method of claim 1 further comprising administering a pharmaceutically acceptable carrier or excipient.

3. The method of claim 1 wherein said effective amount is 60 mg/kg per week.

4. The method of claim 3 further comprising monitoring said patients for changes in complete blood count, differential and CD4+ T-cells using flow cytometry.

5. A method for increasing the number of CD4+ T-cells in a subject infected with HIV-1 having less than 500 copies HIV-1 RNA per ml and receiving antiretroviral therapy comprising administering to a subject in need of such treatment a pharmaceutical composition comprising an amount of an active al proteinase inhibitor (α1PI) consisting of the amino acid sequence as set forth in SEQ ID NO: 3 effective to increase the number of said CD4+ T-cells in said subject.

6. The method of claim 5 further comprising administering a pharmaceutically acceptable carrier or excipient.

7. The method of claim 6 wherein said effective amount is 60 mg/kg per week.

8. The method of claim 7 further comprising monitoring said patients for changes in complete blood count, differential and CD4+ T-cells using flow cytometry.