Abstract:
A method of diagnosing or determining the degree of an arterial aneurysm, especially an abdominal aortic aneurysm, which comprises determining the presence or level of interleukin-1α (IL-1α) in a serum or plasma sample.

Description:
[0001]    The present invention relates to use of Interleukin-1 alpha (IL-1α) as a serum or plasma biomarker for arterial aneurysm, especially abdominal aortic aneurysm (AAA). 
       BACKGROUND TO THE INVENTION 
       [0002]    Arterial aneurysm (referred to herein as AAA in relation to the disease associated with the aorta, i.e. abdominal aortic aneurysm, but relevant to other arterial vessels) is pathological ballooning of the artery, which is defined as a focal dilation of the artery generally exceeding 150% of normal diameter (Johnston et al. ‘Suggested standards for reporting on arterial aneurysms’, J. Vascular Surg. (1991) 13, 452-458). AAA is thought to occur in about 2-13% of the adult population and rupture of AAA is a significant clinical problem in the elderly with about 1% of men over 65 thought to suffer from ruptured AAA with an associated mortality of greater than 70%. There is currently no comprehensive screening strategy for AAA; individuals with significant disease are usually identified during investigation for other conditions. 
         [0003]    The cellular and molecular pathology of AAA is poorly understood. However, it is probable that aortic dilation progresses from the inappropriate remodelling of the vessel wall in response to the chronic inflammatory process within the artery. Certainly, there is significant inflammatory infiltrate into the vessel wall and the secretion of matrix metalloproteinases (MMPs) such as MMP-9 by monocyte-macrophages may contribute to loss and for disorganisation of the structural elastic lamina which support the arterial architecture (Gong et al., J. Clin Invest. (2008) 118, 3012-3024; Carmeliet et al. J. Clin. Invest. (2000) 105, 1519-1520). The cellular complexity of the aneurysm is substantially increased by the deposition of a mural thrombus which is rich in neutrophilic granulocytes (Houard et al. ‘Differential inflammatory activity across human abdominal aortic aneurysms reveals neutrophil-derived leukotriene B4 as a major chemotactic factor released from the intraluminal thrombus’ FASEB J. (2009) 23, 1376-1383). Nevertheless, much remains unknown about the molecular mechanisms which initiate or support the progression of AAA, although risk factors include the male gender, smoking and family history. 
         [0004]    IL-1α has been previously implicated as having a role as an inflammatory factor in the development of both atherosclerosis and AAA, but neither in atherosclerosis nor AAA has this been linked with measureable presence as a serum factor. Rather in relation to atherosclerosis, there has been much interest in correlation between reduced risk of atherosclerosis and atherosclerosis-related disorders and high titres of IL-1α auto-antibodies (Published International Applications WO 2007/015128 and WO 2007/132338 of Xbiotech, Inc.). The reason for such auto-antibodies has not been elucidated, but they have also been reported in sera of apparently healthy humans, older men being found to have the highest titres. Attempts to measure IL-1α in such samples led to the conclusion that IL-1α molecules are usually inaccessible for immunometric assay (Hanson et al. Eur. J. Clin. Invest. (1994) 24, 212-218). 
         [0005]    The majority of pro-IL-1α is found in the plasma membrane or the nucleus of cells (W. P. Arend, Cytokine and Growth Factor Reviews (2008) 13, 323-340). Mature IL-1α is known to be released by the enzyme calpain and binds to the IL-1 receptor resulting in translocation of the transcription factor NF-kB to the nucleus. More recently, IL-1α has been found to be expressed on the minor sub-set of monocytes which also coexpress CD14 and CD16 (Published International Application no. 2010/030979 of Xbiotech, Inc), but such monocytes have not been linked to measureable serum IL-1α in AAA patients In Lindeman et al. Clin Sci. (2008) 114, 687-697, it is reported that IL-1α mRNA is increased in aneurysmal wall samples compared to atherosclerotic wall samples, but no results are given for IL-1α protein. Hence, while IL-1α has been implicated in the inflammatory process associated with development of AAA, it has not previously been recognised as having any value as a serum biomarker for that condition. 
         [0006]    That this is indeed the case was an unexpected finding of the inventors from carrying out studies aimed at resolving whether endovascular aneurysm repair using stent grafts (EVAR), now generally favoured over open surgical repair (OSR) for treatment of AAA, reduces the systemic inflammatory response, even though it leaves a substantial volume of diseased tissue and mural thrombus in situ. 
       SUMMARY OF THE INVENTION 
       [0007]    The inventors have established that IL-1α is elevated in serum of pre-operative AAA patients but that EVAR causes significant reduction in serum level of IL-1α by 6 months. This mirrors a similar pattern seen with IL-8, a cytokine which has previously been linked with AAA. 
         [0008]    Hence, the present invention provides a method of diagnosing or determining the degree of an arterial aneurysm, especially an abdominal aortic aneurysm (AAA), which comprises determining the presence or level of IL-1α in a serum or plasma sample. 
         [0009]    That such measurement of IL-1α has physiological relevance in relation to the development of AAA is further supported by the studies of the inventors reported herein which show that serum of pre-operative AAA patients will prime cultured endothelial cells for increased neutrophil recruitment in response to low dose tumour necrosis factor-α (TNF-α) in a flow-based neutrophil adhesion assay, but this response is lost in post-EVAR serum by 6 months; this correlates with reduced serum titre of IL-1α and the addition of functional neutralising antibody against IL-1α, but not IL-8, to pre-operative serum also inhibits neutrophil recruitment in the same assay. 
       DETAILED DESCRIPTION 
       [0010]    Measurement of Il-1α may be made in more than one sample taken at different time points. Thus, measurement of IL-1α may be made in samples taken at different time points pre- and/or post-operatively to predict, for example, rate of disease progression, likelihood of, or projected time to surgical intervention and/or progress to normalisation post-EVAR. Observation of re-establishment of high titres after EVAR may also be diagnostic of late technical graft failure. 
         [0011]    Such reliance on IL-1α as a biomarker will preferably employ an immunoassay for detecting IL-1α. Suitable assays for this purpose are well known. They include double-sandwich ELISA employing for example rabbit polyclonal antibodies specific for recombinant IL-1α as described in Hansen et al. (ibid). A commercially available assay system may be employed, e.g. a Milliplex MAP immunoassay from Milllipore (Millipore, Billerica, Mass., USA) as used for the studies reported herein. This is based on the Luminex bead system and may be conveniently used to assay a variety of analytes of interest simultaneously in a single sample. 
         [0012]    Thus it may be desired to measure IL-1α together with one or more further analytes whose presence in serum is known to correlate with risk or progression of AAA, either in the same sample or one or more equivalent samples. These include, for example, IL-8 (Lindeman at al. ibid; Norgren et al. J. Endovascular Surgery 4, 169-173; Parodi et al. J. Endovascular Therapy (2001) 8, 114-124) and secreted metaloproteinases such as MMP-9 as noted above. The studies reported herein further support additional use of IL-8 as biomarker for AAA since reduction of serum IL-8 between pre- and post-EVAR samples was found, although antibody blockade of IL-8 in pre-operative serum had no effect on neutrophil recruitment to TNF-α primed endothelial cells. Monitoring of both IL-1α and IL-8 in serum or plasma, preferably by measurement in the same sample, may be preferred in relation to predicting AAA progression, either alone or as part of data collection for a multi-variate predictive algorithm. 
         [0013]    Finding of IL-1α, or both of IL-1α and IL-8, at a serum concentration of at least about 50 pg/ml, e.g. about 50-100 pg/ml, may be taken as indicative of AAA, especially where there has been previous diagnosis of atherosclerosis. 
         [0014]    In some circumstances a functional assay for IL-α and for IL-8 may be carried out as well as or instead of an immunoassay. 
         [0015]    Detection of IL-1α in accordance with the invention may be supplemented by assessment of aneurysm size by ultrasound or CT scan and/or assessment of burden of mural thrombus by CT scan to aid determination of disease progression and/or necessity for surgical intervention. 
         [0016]    The studies reported below provide background to the invention and illustrate the invention by way of exemplification with reference to the following figures. 
     
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
         [0017]      FIG. 1 . Schematic diagram illustrating the flow based adhesion assay: Ibidi slides containing endothelial cells were mounted on the stage of a video-microscope and attached via silicon tubing to a 50 ml glass syringe and an electronic switching valve. Isolated neutrophils or PBS/Alb were perfused through the slides at a wall shear stress of 0.05 Pa. Experiments were conducted in a 37° C. Perspex cabinet and video recordings made. 
           [0018]      FIG. 2 . Cytokine and chemokine expression in AAA patient serum following EVAR. (A) Levels of 10 cytokines and chemokines in pre- and post-operative patient serum were measured using luminex and presented as pg/ml±SEM, n=17. (B) Levels of IL-1α in pre- and post operative serum for individual patients. (C) Levels of IL-8 in pre and post-operative serum for individual patients. *=p&lt;0.05, **p&lt;0.01 for comparison between pre- and post surgery by paired t-test. 
           [0019]      FIG. 3 . Patient serum does not induce endothelial cell activation. (A) Adhesion of neutrophils to endothelial cells which were untreated, treated with 5 U/ml or 100 U/ml TNF for 4 h as a control, or pre-treated with pre- or post-operative patient serum for 24 hrs. ANOVA=p&lt;0.01, **=p&lt;0.01 using Bonferroni&#39;s multiple comparison test. (B) Behaviour of recruited neutrophils to endothelial cells stimulated with 100 or 5 U/ml TNF for 4 hrs          =rolling;          =firmly adherent;          =transmigrated. There is a significant decrease in the proportion of neutrophils rolling on endothelial cells stimulated with 100 U/ml compared to 5 U/ml TNF, and a significantly higher level of transmigrated neutrophils. *=p&lt;0.05, **p&lt;0.01 by paired t-test respectively; Data are mean±SEM; n=3. 
           [0020]      FIG. 4 . Neutrophil behaviour on endothelial cells. Neutrophils recruited to endothelial cells treated with (A) 5 U/ml TNF-α, (B) 100 U/ml TNF-α, (C) Pre-op, (D) Post-op serum. Phase bright cells are rolling or firmly adherent to the endothelial cell surface, transmigrated neutrophils are phase dark and underneath the endothelial cell monolayer. R=rolling neutrophils; SA=surface adherent neutrophils; TM=transmigrated neutrophils. 
           [0021]      FIG. 5 . Pre-operative serum from AAA patients primes endothelial responses to low dose TNF-α resulting in altered neutrophil behaviour. Control and patient serum was used to prime endothelial cell for 24 hrs and 5 U/ml TNF-α added for the final 4 h. Total neutrophil adhesion was assessed (A) and levels of neutrophil transmigration quantified (B). There is a significant difference between levels of transmigrated neutrophils on control vs pre-operative serum **=p&lt;0.01 by paired t-test. There is a significant inhibition of neutrophil transmigration on endothelial cells cultured with post-operative serum compared to pre-operative serum,*=p&lt;0.05 by paired t-test; Data are mean±SEM; n=17. 
           [0022]      FIG. 6 . Correlation between AIL-1α concentration and Δ transmigration. The changes in IL-1α concentration and neutrophil transmigration pre- and post-surgery were calculated as a ratio and plotted against each other. There is a significant correlation between the change in IL-1α and the change in levels of neutrophil transmigration, p&lt;0.01. 
           [0023]      FIG. 7 . Neutralising IL-1α inhibits endothelial cell priming by pre-operative serum from AAA patients. Neutralisation of IL-1α in the presence of pre-operative serum reduces neutrophil transmigration across endothelial cells pre-treated with pre-operative serum. IgG control antibody and anti-IL-8 had no effect on neutrophil transmigration. ANOVA p=&lt;0.001; Data are mean±SEM; n=6. 
       
    
    
     EXAMPLE 
     Summary of Study 
       [0024]    The serum of patients with AAA was screened for the presence of a number of cytokines before and 6 months after EVAR. Patient serum was also utilised to stimulate cultured endothelial cells, which were subsequently tested in a flow-based neutrophil adhesion assay. In such flow assays, pre-operative serum did not directly activate endothelial cells to support neutrophil adhesion unless such cells were exposed to TNF-α. With such priming, there was significant increase in the number of neutrophils recruited into the sub-endothelial environment. In serum collected 6 months after EVAR, both IL-8 and IL-1α were found to be significantly reduced compared to levels seen in pre-operative serum and were normalised to the levels seen in control samples. Moreover, reductions in the concentrations of these cytokines correlated with a loss in the ability of patient serum to cause neutrophil recruitment to TNF-a exposed endothelial cells. As also already noted above, antibody neutralisation of IL-1α in pre-operative serum, but not IL-8, also completely removed the capacity for neutrophil recruitment in the same flow assay. 
       Methods 
     Patient Cohorts 
       [0025]    Seventeen patients with a mean age 80.3 (range 69-88) and who were undergoing elective EVAR, had a mean aneurysm size of 6.9 cm (range 5.4-10). Fourteen patients had Zenith and three had Excluder devices implanted. All patients with AAA were asymptomatic, but one had a contained rupture. Four patients had fenestrated EVAR for juxta-renal abdominal aortic aneurysm. The control cohort consisted of 8 patients with a mean age of 72.5 (range 65-89), with no aortic aneurysm, as proven by computerized tomography (CT) scan performed for other diseases. 
       Collection of Patient Serum 
       [0026]    Blood samples were collected into vacuette Z Serum Sep Clot Activator tubes (Greiner Bio One) from patients undergoing elective EVAR protocols pre-operatively and 6 months post-operatively. Serum was isolated via centrifugation, aliquoted and stored until use at −80° C. 
       Measurement of Inflammatory Cytokines and Chemokines in Serum 
       [0027]    Milliplex MAP immunoassay was purchased from Millipore (Millipore, Billerica, Mass., USA). This assay is based on the Luminex bead system which can assay over 20 analytes in a small volume (50 μl) using flow cytometery technology. The serum concentration of IL-1-α, IL-1β, IL-4, IL-6, IL-8, IL-10, IFN-γ, IP-10, MCP-1, TNF-α and TNF-β were measured using the luminex assay, carried out according to manufacturers instructions and as previous published (Tull et al. PLOS Biology (2009) e1000177). Serum concentrations were measured on a LX100 machine (Luminex Corp, USA) and calibrated against titrations of recombinant standard for each analyte using STarStation software (ACS, USA). 
       Endothelial Cell Isolation and Culture 
       [0028]    Human umbilical vein endothelial cells were isolated as previously described (Cooke et al. Microvascular Res. (1993) 45, 33-45) and cultured in M199 (Gibco Invitrogen Compounds, Paisley, Scotland) supplemented with 10 ng/ml epidermal growth factor, 35 μg/ml gentamycin, 1 μg/ml hydrocortisone (all from Sigma, UK), 2.5 μg/ml amphotericin B (Gibco Invitrogen Compounds) and 20% FCS (Sigma). Primary cells were sub-cultured into six channel p-Slide VI flow chambers (Ibidi, Munich, Germany) until confluent. Confluent endothelial cells were cultured for 24 h with medium in which FCS was substituted for 30% serum from patients or aged matched controls. An additional control was endothelial cells cultured continuously in 20% FCS. Endothelial cells were then stimulated with 5 U/ml TNF-a (Sigma, UK) for the final 4 hours of culture before flow assay. In some experiments function neutralising antibodies against IL-1α or IL-8 (10 μg/ml, both from R&amp;D Systems, UK) were added to patient serum prior to addition to culture medium. 
       Flow Based Adhesion Assay 
       [0029]    Human neutrophils were isolated from the blood of healthy donors by density-gradient centrifugation (Histopaque-1077 and Histopaque-1119; Sigma) and suspended in phosphate buffered saline containing 0.1% bovine serum albumin (Sigma) (PBS/Alb). Six channel μ-Slide VI flow chambers were mounted on a phase contrast video microscope (Inverted Labovert, Leitz).  FIG. 1  shows a schematic representation of the assay with slide in situ. Neutrophils were perfused across endothelial cells at 10 6  cells/ml at a wall shear stress of 0.05 Pa for 4 minutes, followed by wash buffer (PBS/Alb) to remove non-adherent cells. Video recordings of 8-10 fields along the centre of the channel were made between 2 and 4 minutes of perfusion of wash buffer. Records were digitized using Image-Pro Plus (MediaCybernetics, Bethesda, Md.) and analysed for cell behaviour. The following parameters were evaluated: total numbers of neutrophils captured by endothelial cells from flow expressed as absolute adhesion/mm 2 /10 6  cells perfused; the proportions (expressed as a percentage) of these adherent cells that rolled (phase bright spherical cells, revolving slowly over the surface), became stably adherent (phase bright, stationary cells typically spreading on the surface) or which transmigrate through the endothelial monolayer (phase-dark, spread cells migrating under the endothelial cells). 
       Statistics 
       [0030]    Differences between individual treatments were evaluated by paired t-test. p&lt;0.05 were considered statistically significant. Variation between multiple treatments was evaluated using ANOVA, followed by Bonferroni&#39;s multiple comparison test. Correlation was calculated using GraphPad in built analysis. 
       Results 
     EVAR Changes the Concentration of Cytokines and Chemokines in Patient Serum 
       [0031]    The concentrations of cytokines and chemokines were analysed in serum collected from EVAR patients pre-operatively and 6 months post-operatively ( FIG. 2   a ). One analyte (IL-4) was not detectable in the serum of donors. IFN-γ, IL-1β, IL-10, TNF-α and TNF-β were detectable at low levels (≦10 pg/ml), but showed no variation between the pre- and post-operative EVAR patients. IL-6 was more abundant (≈50 pg/ml), but again there was no significant change at the two time points assayed. IP10 (CXCL10) and MCP-1 (CCL2) were present in high concentrations of ≈1 and ≈2.5 ng/ml respectively. These levels were maintained up to 6 months after EVAR. IL-1α and IL-8 were of particular interest, as they were present at relatively high concentrations (50-100 pg/ml) in pre-operative serum and these levels were significantly reduced following EVAR ( FIG. 2   a ). In fact the response of these two analytes to EVAR was remarkably consistent within the test group. All 17 patients showing a reduction in IL-8 titres, while IL-1α was reduced in 12 out of 17 patients ( FIGS. 2   b  and  2   c ). 
         [0000]    Patient Serum does not Directly Activate Cultured Endothelial Cells. 
         [0032]    As the serum levels of some inflammatory cytokines and chemokines were reduced by the EVAR protocol, it was investigated whether these changes would be functionally relevant in an integrated inflammatory model of leukocyte recruitment. Endothelial cells cultured in flow chambers were stimulated with 30% patient serum in endothelial cell culture medium. For comparison, matched endothelial cells were also stimulated with either low (5 U/ml) or high (100 U/ml) dose TNF-α. Unstimulated endothelial cells did not support the adhesion of flowing neutrophils ( FIG. 3   a ). When endothelial cells were stimulated with 100 U/ml TNF-α, they supported the adhesion of substantial numbers of purified flowing neutrophils ( FIGS. 3   a  and  4   b ). Analysis of neutrophil behaviour showed that after 4 minutes of perfusion and 2 minutes of wash to remove non-adherent cells, only a few were rolling while the majority were activated and apically adherent or activated and migrated through the endothelial cell monolayer ( FIGS. 3   b  and  4   b ). In comparison, endothelial cells stimulated with a 5 U/ml concentration of TNF-a recruited significantly fewer flowing neutrophils ( FIGS. 3   a  and  4   a ) and their behaviour was different ( FIGS. 3   b  and  4   a ). A greater proportion were rolling or apically adherent after activation, while very few transmigrated into the sub-endothelial space. Endothelial cells incubated with pre-operative or post-operative patient serum maintained confluent monolayers that were indistinguishable from TNF-α stimulated cells ( FIGS. 4   c  and  4   d ). However, in the absence of exogenous TNF-α, serum treated cells did not support the adhesion of flowing neutrophils ( FIGS. 3   a ,  4   c  and  4   d ). 
       Pre-Operative but not Post-Operative Patient Serum Primes the Response of Endothelial Cells to Low Dose TNF-α. 
       [0033]    Although patient serum did not directly stimulate cultured endothelial cells to recruit flowing neutrophils, it was found that incubation of the endothelial cells with pre-operative serum primed the endothelial cells for responses to TNF-α. Comparing neutrophil adhesion to endothelial cells pre-incubated with different serums prior to activation with 5 U/ml TNF-α, showed that there was a non-significant trend to increased neutrophil recruitment in the presence of patient serum compared to serum from the control cohort ( FIG. 5   a ). However, the behaviour of recruited neutrophils was markedly different on endothelial cell monolayers which had been incubated with pre-operative serum. The number of neutrophils that transmigrated across the endothelial cell monolayer was dramatically increased ( FIG. 5   b ). Importantly however, post-operative serum could promote the recruitment of significantly fewer neutrophils. Importantly, the ability of patient serum to prime endothelial cells for this response was absent in serum taken from patients 6 months after EVAR ( FIG. 5   a ), implying that the agent(s) responsible for endothelial cell priming was no longer present in the serum. Interestingly, the change in IL-1α concentration between pre- and post surgery correlates with the observed change in transmigration ( FIG. 6 ), suggesting a causal relationship. 
         [0000]    The Ability of Pre-Operative Sera to Prime Endothelial Cells for Response to TNF-α is Lost when the Biological Activity of IL-1α is Neutralised. 
         [0034]    The ability of patient sera to prime endothelial cells was dramatically reduced after EVAR, and this loss of activity was associated with a consistent and significant reduction in the levels of IL1-α and IL-8 in the sera. Thus, it was hypothesised that one of these molecules might be the endothelial cell priming agent. To examine this thesis, a number (n=6) of pre-operative serum samples were re-tested before and after the addition of function neutralising antibodies against IL-8 or IL-1α.  FIG. 7  shows that a non-specific IgG control antibody or a function neutralising antibody against IL-8 had no effect on the ability of pre-operative patient sera to prime endothelial cells when assessed by quantifying neutrophil transmigrating into the sub-endothelial space. Importantly however, the ablation of IL-1α activity in the pre-operative sera completely abolished endothelial cell priming. Indeed, the levels of neutrophil transmigration were reduced to those seen in the post operative patient sera tested in parallel in the same experiments (i.e. matched for endothelial cell and neutrophil donors). 
       DISCUSSION 
       [0035]    By these studies, IL-1α has been implicated in the molecular and cellular pathology of AAA and is indicated to be a convenient serum biomarker for aneurysm severity and for determining successful outcome of EVAR. It is concluded that EVAR is a procedure which not only prevents AAA rupture, but also reduces levels of chronic systemic inflammation and this can account for the good long term outcome observed in EVAR patients. 
         [0036]    Norgren et al. (J. Endovascular Surgery (1997) 4, 169-173) measured levels of TNF-α, IL-6 and IL-8 in EVAR patients pre-operatively, 24 hr post operative and 7 days post-operatively. Levels of each were found to increase following surgical insult, as expected, but returned to baseline by 7 days. Pardoi et al. (J. Endovascular Therapy) measured IL-8 by ELISA in EVAR patients pre-surgery, and up to 72 hrs following surgery, finding that levels increased immediately after surgery, and fell by 72 hrs, although not to pre-operative levels. However, in those studies there was no measurement of IL-1α in the serum of AAA patients. Detection of IL-1α at high concentration in pre-operative serum of AAA patients was a surprising finding contrary to prior indication that IL-1α is not a highly secreted molecule.