Method for screening adverse reactions to implants and compounds therefor

Abstract

The present invention relates to methods of screening subjects to determine whether they are at risk of having an adverse reaction to metal wear debris (ARMD), also known as adverse local tissue reaction (ALTR), methods of screening compounds for use in preventing or ameliorating such adverse responses, and compounds for use in treating subjects.

Description

[Technical Field]

[0001] The present invention relates to methods for screening subjects to determine whether they are at risk of having an adverse reaction to metal wear debris (ARMD), also known as adverse local tissue reaction (ALTR), methods for screening compounds for use in preventing or ameliorating such adverse responses, and compounds for use in treating subjects. An example of such a reaction is sterile lymphocyte-predominant vasculitis associated lesions (ALVAL). In particular, the present invention relates to determining whether a subject is at risk of having an adverse reaction to an implant. [Background technology]

[0002] Hip replacement or hip arthroplasty is a procedure in which the hip joint is replaced with an artificial implant. A total hip replacement consists of replacing the acetabulum and femoral head, while a hemiarthroplasty replaces only the femoral head.

[0003] Metal-on-metal (MoM) hip replacements were reintroduced worldwide at the end of this century (Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br. 2005;87(2):167-70). They rapidly gained popularity with surgeons worldwide due to their promise of improved stability (reduced risk of dislocation) and reduced wear (12th Annual Report. National Joint Registry of England and Wales. 2015). Intended to be more durable than traditional plastic hip replacements, they were primarily implanted in younger patients to allow them to return to as active a lifestyle as possible (McMinn D, Daniel J. History and modern concepts in surface replacement. Proc Inst Mech Eng H. 2006;220(2):239-51).

[0004] Unfortunately, complications began to emerge, primarily due to an adverse immune response that patients developed to metal wear debris (composed primarily of cobalt and chromium particles) generated by the hip prosthesis (Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7):847-51).

[0005] Two general cellular responses appear to exist (Natu S, Sidaginamale RP, Gandhi J, Langton DJ, Nargol AV. Adverse reactions to metal debris: histopathological features of periprosthetic soft tissue reactions seen in association with failed metal on metal hip arthroplasties. J Clin Pathol. 2012;65(5):409-18). With high metal exposures, the predominant cellular response is macrophage-mediated, and the resulting damage is mostly limited to bone. (10) With intermediate levels of metal exposure, a cellular response accompanied by macrophage infiltration (known as sterile lymphocyte-predominant vasculitis-associated lesions, or "ALVAL") (11) may develop. ALVAL is associated with the development of massive fluid loss and extensive soft tissue necrosis (Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AV. Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement: A consequence of excess wear. J Bone Joint Surg Br. 2010;92(1):38-46). Risk factors for the development of ALVAL are poorly understood.

[0006] Unfortunately, ARMD / ALTR(Langton DJ,Joyce TJ,Jameson SS,Natu S,Holland JP,Nargol AVF,De Smet K.Adverse reaction to metal debris following hip resurfacing the influence of component type,orientation and volumetric wear.Journal of Bone and Joint Surgery(Br)2011;93:566;Langton DJ,Jameson SS,Joyce TJ,Natu S,Nargol AVF.Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement.A CONSEQUENCE OF EXCESS WEAR.Journal of Bone and Joint Surgery(Br)2010;92-B; and Pseudotumours associated with metal-on-metal hip resurfacings.Pandit H,Glyn-Jones S,McLardy-Smith P,Gundle R,Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW. J Bone Joint Surg Br. 2008 Jul;90(7):847-51) is not limited to metal-on-metal devices (Jacobs JJ, Cooper HJ, Urban RM, Wixson RL, Della Valle CJ. What do we know about taper corrosion in total hip arthroplasty? J Arthroplasty. 2014;29(4):668-9).Over the past decade, there has been a global trend toward adopting larger diameter bearings as the standard, regardless of the bearing combination (i.e., metal vs. plastic vs. ceramic) (12th Annual Report. National Joint Registry of England and Wales. 2015). However, during this period, the support structures to accommodate these larger diameter heads (male tapers / trunnions) have been reduced in size (Langton DJ, Sidaginamale R, Lord JK, Nargol AV, Joyce TJ. Taper junction failure in large-diameter metal-on-metal bearings. Bone Joint Res. 2012;1(4):56-63). We have observed several patients who suffered severe reactions from this interface, or "taper junction" (Langton DJ, Jameson SS, Joyce TJ, Gandhi JN, Sidaginamale R, Mereddy P, et al. Accelerating failure rate of the ASR total hip replacement. J Bone Joint Surg Br. 2011;93(8):1011-6). [Prior art documents] [Non-patent literature]

[0007] [Non-Patent Document 1] Treacy RB,McBryde CW,Pynsent PB.Birmingham hip resurfacing arthroplasty.A minimum follow up of five years.J Bone Joint Surg Br.2005;87(2):167-70 [Non-patent document 2] 12th Annual Report.National Joint Registry of England and Wales.2015 [Non-patent document 3] McMinn D, Daniel J. History and modern concepts in surface replacement. Proc Inst Mech Eng H. 2006;220(2):239 - 51

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[0008] Applicants believe there will be a global problem with early failure of joint replacements over the next decade. Accordingly, Applicants have determined that identifying patients at highest risk for developing ARMD / ALTR would be beneficial in order to streamline patient monitoring and / or to explore alternative approaches to avoid potentially catastrophic patient reactions in certain cases.

[0009] It may also facilitate the development of therapeutic interventions. [Means for solving the problem]

[0010] According to the present invention, there is provided a method of screening a subject to determine the likelihood of an adverse response to metal debris (ARMD) or adverse local tissue reaction (ALTR), comprising the steps of: i) contacting a biological sample from a subject with a means for detecting the presence and / or absence of a marker associated with an adverse response or reaction; ii) determining whether the subject has a marker associated with an adverse response or reaction; and optionally, and iii) treating the subject with a therapeutic agent to ameliorate or prevent the adverse response or reaction.

[0011] Adverse local tissue reactions (ALTR), such as adverse reactions to metal wear debris (ARMD) or ALVAL, are newly described pathological responses that can occur in response to implanted metallic devices, often accompanied by significant pain, disability, and irreversible tissue destruction. This is a poorly understood condition that potentially affects hundreds of thousands of patients with metal implants worldwide.

[0012] While the use of MoM hip prostheses has been significantly reduced due to such complications, the number of reported ALVALs in MoP (metal-on-plastic) devices is increasing. ARMD / ALTR may be an unrecognized cause of unexplained pain and reduced patient satisfaction after joint replacement surgery, even for decades. Therefore, improving our understanding of ARMD / ALTR is important for the current management of at-risk patients, the future development of prosthetic devices, and possibly the investigation and treatment of other immune-mediated / inflammatory conditions. Furthermore, it could pave the way for personalized joint replacement guided by an individual's genetically determined responsiveness to specific compounds. As an example, despite its negative reputation, MoM resurfacing hip replacement has been extremely successful in young, active male patients.

[0013] Markers associated with ARMD / ALTR may include any one or more of the HLA genotypes associated with common autoimmune inflammatory conditions.

[0014] Markers associated with ARMD / ALTR may include any one or more of the following: rheumatoid arthritis (e.g., HLA-DRB1*01, DRB1*04, DRB1*10 (18, 19)), celiac disease (DQA1*05:01 / DQB1*02:01), and / or Crohn's disease (e.g., HLA-DRB1*07, HLA-DRB1*0103, HLA-DRB1*04, and HLA-DRB3*0301. (20)), etc.

[0015] Markers associated with ARMD / ALTR can include any one or more of the following alleles: HLA-DRB1*01, DRB1*04, DRB1*10 (18, 19), DQA1*05:01 / DQB1*02:01, HLA-DRB1*07, HLA-DRB1*0103, HLA-DRB1*04, and HLA-DRB3*0301. (20)

[0016] Applicants have determined that certain HLA genotypes associated with common autoimmune inflammatory conditions (which Applicants refer to as "pro-responsive"), such as rheumatoid arthritis (e.g., HLA-DRB1*01, DRB1*04, DRB1*10 (18, 19)), celiac disease (DQA1*05:01 / DQB1*02:01), and Crohn's disease (e.g., HLA-DRB1*07, HLA-DRB1*0103, HLA-DRB1*04, and HLA-DRB3*0301 (20)), are associated with the development of ALVAL.

[0017] ALVAL is a lymphocyte-driven response that is associated with CoCr alloys and rarely with non-cobalt-containing components.

[0018] ALVAL can result in widespread, irreversible tissue damage.

[0019] When metal particles are released from the prosthesis, they bind to carrier proteins to form metalloproteins. The metalloproteins are ingested by dendritic cells or macrophages in a process called "phagocytosis." After phagocytosis, the particle is transported to the lysosome, where it is acidified and the particle is fragmented into its constituent peptide chains. In the lysosome, a structure called the major histocompatibility complex (MHC) can bind to one of these peptides. This occurs in a part of its structure called the "peptide-binding groove."

[0020] After the MHC molecule binds the fragment with sufficient stability, the MHC molecule and the newly bound peptide migrate to the cell surface and "present" the peptide to the external environment (for this reason, macrophages and dendritic cells are called "antigen-presenting cells"). Any passing lymphocytes then bind to this complex and become activated, releasing cytokines and able to migrate to the source of antigen release. This lymphocyte "activation" is a critical step that determines whether ALVAL develops.

[0021] The three-dimensional structure of the peptide-binding groove is important in determining which peptides are "presented." This structure is genetically encoded. Some individuals have genes that encode very different peptide-binding grooves—hence, some individuals may respond differently to different antigens.

[0022] The biological sample may include a solid and / or fluid sample. The fluid sample may be a blood sample, saliva, or blood extract sample. The biological sample may include, for example, skin cells from the buccal cavity.

[0023] The method may be an in vitro method.

[0024] The method can be used prior to joint replacement surgery to determine a patient's risk of developing an ARMD / ALTR-associated disorder, and / or can be used in situ on a joint in combination with blood metal ion concentrations to determine future risk of an ARMD / ALTR-associated disorder.

[0025] According to another aspect of the present invention, there is provided a method of screening compounds for use in preventing or ameliorating the likelihood of adverse response to metal wear debris (ARMD) or adverse local tissue reaction (ALTR) in a subject, the method comprising identifying a compound that interferes with an MHC-mediated immune response.

[0026] According to a further aspect of the present invention there is provided a composition for use in preventing or ameliorating the potential for adverse response to metal wear debris (ARMD) or adverse local tissue reaction (ALTR) in a subject.

[0027] The composition may include testosterone or a metabolic precursor thereof.

[0028] Preferably, the sample is a whole blood sample.

[0029] Applicant has reverse engineered thousands of explanted prostheses to determine the amount of wear that occurs in the body. The total amount of material lost is called "volumetric wear."

[0030] The applicants used existing software to computer-model the shape of the resulting peptide-binding groove when the DQA1 / DQB1 genetic combination was input. The software predicted the strength of binding of various peptide fragments to each candidate peptide-binding groove combination. The applicants found that patients with genotypes appropriate for the N-terminal peptide fragment of albumin were significantly more likely to develop ALVAL. Other genotypes were associated with pain in the presence of a macrophage-only ARMD response.

[0031] Using regression statistical modeling that includes patient age and sex as variables, applicants have devised a means to estimate a patient's relative risk of developing ARMD (either macrophage-dominant or lymphocyte-dominant (ALVAL)), which can be used postoperatively to advise follow-up strategies, but also preoperatively to guide implant selection.

[0032] HLA genes (specifically the class II genes DQA1 / DQB1) can be collected using non-invasive methods such as from a cheek swab.

[0033] Patients who mount an ALVAL response are likely to develop antibodies to the "antigen." Once the antigen is known to have a specific affinity for a genetically determined peptide-binding groove, a blood test can be used to determine whether ALVAL will be active in at-risk patients.

[0034] The methods of the present invention may involve the use of an enzyme-linked immunosorbent assay (ELISA). [Brief explanation of the drawings]

[0035] The present invention will now be described, by way of example only, with reference to the accompanying examples and drawings. [Figure 1] FIG. 1 is a table showing the results of experiments to determine the affinity of particular alleles for ATCUN binders, MMBS binders, and nonspecific binding. [Figure 2] FIG. 2 shows the affinity rankings for ATCUN and MMBS. [Figure 3] Figure 3 is a table summarizing the results of the data collected from the dataset. [Figure 4] FIG. 4 is a table showing the correlation between the likelihood of ALVAL response and celiac disease markers. [Example]

[0036] Resected tissue is routinely subjected to semiquantitative grading by a consulting histopathologist as previously described. (13, 17) From this patient pool, three lists were generated:

[0037] The severe ALVAL patient group (Group A) had the lowest wear rate

[0038] ALVAL patient group exposed to high abrasion (group B)

[0039] Patients without ALVAL findings (Group C)

[0040] The HLA class I and class II genes of these patients were tested using next-generation sequencing to six orders of magnitude of accuracy.

[0041] Genotypes were compared between groups and with a background population of approximately 8500 patients from previous studies.

[0042] Certain DQA1 / DQB1 combinations were found to be more common in patients in group A compared with group C and control groups.

[0043] Identification and isolation of group C patients with pain and low-volume exposure wear demonstrated an abnormal distribution of gene haplotypes compared with the control population. These haplotypes were identical to those associated with ALVAL response. This indicated that these patients either 1. were recruited before the development of lymphocytic infiltration (ALVAL) or 2. these genes were associated with hyperreactive macrophages that can cause adverse clinical sequelae without lymphocyte recruitment.

[0044] These combinations were input into published software to determine which peptides the genetically encoded peptide-binding groove bound with higher affinity.

[0045] The results indicate that there are certain relatively common genotypes that predispose patients to mount clinically deleterious lymphocyte responses to metal wear debris. The alleles that showed the most pronounced distribution differences between patients with and without ALVAL were found at the DQA1 / DQB1 locus. At the outset of this study, we focused on this region of the genome because ALVAL shares clinical and pathological features with several inflammatory autoimmune / autoimmune-like conditions, such as celiac disease. These results appear to substantiate our hypothesis that these MHC molecules indeed play an important role in lymphocyte recruitment in addition to the nonspecific, primarily macrophage-dominated response to particulate wear debris. ALVAL Immunogenetics

[0046] The present inventors focused on the differential cellular responses associated with the development of ALVAL. We specifically focused on ALVAL for two primary clinical reasons. First, the relationship between ALVAL and blood metal ion testing appears to be complex, and ion concentrations appear not to be reliable diagnostic indicators for determining the condition. Second, ALVAL appears to be an important, if not the most important, factor in the development of progressive and irreversible soft tissue damage.

[0047] Lymphocyte recruitment to macrophage-driven inflammatory areas is closely related to the handling of particle wear debris by MHC II molecules on the membrane of APCs and their presentation to CD4+ T cells. Peptide-MHC binding is a prerequisite for T cell immunogenicity, and multiple studies have shown a strong correlation between MHC-peptide binding strength and peptide immunogenicity. Peptides that form stable peptide-MHC complexes accumulate on the cell surface, and the total number of peptide-MHC complexes has been shown to be important for T cell activation.

[0048] When particulate matter is ingested by macrophages, peptide fragments produced in the lysosomes compete for the binding groove of MHC molecules.

[0049] Applicant believes that the antigens (epitopes) presented by APCs to initiate lymphocyte recruitment are peptides derived from the degradation of albumin-Co metalloproteins. Furthermore, MHC II genes whose frequencies differ between ALVAL and non-ALVAL patient groups appear to exhibit greater relative binding affinity for albumin-derived peptides. Therefore, given the protection likely conferred on younger ages and males, testosterone-derived peptides may compete with albumin for these binding sites.

[0050] Each patient has four possible DQA1 / DQB1 combinations. Therefore, when investigating the effects of the three-dimensional structure, it is not ideal to study only some of the building blocks in isolation, i.e., by simply comparing the allele frequencies of a single gene across patient groups. By calculating theoretical binding affinities, we obtained a quantitative measure of a patient's genetic makeup that goes beyond the classical approach of classifying patients as homozygous, heterozygous, or absent at individual alleles.

[0051] The present inventors discovered that DQ molecules that are particularly suited to binding to albumin fragments are significantly associated with the development of ALVAL. Conversely, DQ molecules that bind to testosterone fragments with higher affinity are negatively associated with the development of ALVAL. The present inventors believe that it is particularly important that trans DQ isoforms have relatively little impact on statistical modeling compared to cis DQ isoforms. The cis DQ isoform is thought to form more readily, be more abundant on the cell membrane, and be more important for T cell activation. Albumin Binding and Antigen Presentation

[0052] After antigen recognition and lymphocyte activation, chemokine release leads to the development of fluid exudates, resulting in the formation of higher concentrations of albumin in the synovial fluid. Thus, lymphocytes become sensitized to the antigen, which then becomes even more abundant, potentially creating a vicious cycle. As the proportion of metal bound to proteins increases, the amount of metal leaving the joint via the lymphatic system, rather than directly through the synovial membrane, also increases, as smaller solutes and ions are available. Testosterone Regulatory Effects

[0053] Sex hormones play an important role in immune regulation. Furthermore, testosterone is present in the synovial fluid of healthy and arthritic joints at concentrations comparable to those of metal ions generated from low-wear MoM devices. A significant portion of testosterone is bound to albumin, meaning that particles digested by macrophages and dendritic cells are likely to contain varying amounts of Co, Cr, albumin, and testosterone-derived peptides. The levels of gonadal steroids in synovial fluid show an inverse relationship with age. Clearly, the regulation of immune responses by sex hormones is highly complex. However, we suggest that one reason why women and older patients may be more vulnerable to ALVAL may be due to their reduced synovial testosterone concentrations and, therefore, reduced competition for MHC binding space.

Claims

1. 1. A method of screening a subject to determine likelihood of adverse metal wear debris response (ARMD) or adverse local tissue reaction (ALTR), comprising: i) contacting in vitro a biological sample from a subject with a means for detecting the presence and / or absence of said ARMD- or ALTR-associated marker; ii) determining whether the subject has the marker; iii) if the subject has the marker, comparing the subject to criteria that the subject is likely to have the ARMD or the ALTR and is a candidate for treatment with a therapeutic agent to ameliorate the ARMD or the ALTR; Including, The method, wherein the ARMD or the ALTR is sterile lymphocyte-predominant vasculitis associated disease (ALVAL) and the marker is the combination DQA1 / DQB1.

2. 2. The method of claim 1, wherein the marker comprises an HLA genotype associated with celiac disease.

3. The method of claim 1 , wherein the marker comprises DQA1*05:01 / DQB1*02:

01.

4. The method of any one of claims 1 to 3, wherein the biological sample comprises a solid and / or a fluid sample.

5. 5. The method of claim 4, wherein the fluid sample comprises one or more of a blood sample, saliva, skin cell or blood extract sample.

6. 5. The method of claim 4, wherein the biological sample comprises skin cells from the buccal cavity.

7. 7. The method of any one of claims 1 to 6 for use in screening a subject before, during and / or after an implant procedure.

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