U.S. patent application number 16/333561 was filed with the patent office on 2019-08-22 for methods of diagnosing and treating cd55 deficiency, hyperactivation of complement, angiopathic thrombosis and protein losing ent.
The applicant listed for this patent is The United States of America, as represented by the Secretary, Department of Health and Human Serv, The United States of America, as represented by the Secretary, Department of Health and Human Serv. Invention is credited to Rico Chandra Ardy, Kaan Boztug, William Andrew Comrie, Michael J. Lenardo, Ahmet Oguzhan Ozen, Helen Su.
Application Number | 20190256915 16/333561 |
Document ID | / |
Family ID | 60084054 |
Filed Date | 2019-08-22 |
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United States Patent
Application |
20190256915 |
Kind Code |
A1 |
Lenardo; Michael J. ; et
al. |
August 22, 2019 |
METHODS OF DIAGNOSING AND TREATING CD55 DEFICIENCY, HYPERACTIVATION
OF COMPLEMENT, ANGIOPATHIC THROMBOSIS AND PROTEIN LOSING
ENTEROPATHY (CHAPLE), A NEWLY IDENTIFIED ORPHAN DISEASE
Abstract
Disclosed herein are methods of diagnosing, and treating and/or
preventing CD55-deficiency, hyperactivation of complement,
angiopathic thrombosis and protein-losing enteropathy (CHAPLE). The
method of diagnosing includes: providing a sample from a patient;
performing an assay detecting at least one of at least one mutation
in a DNA sequence of a CD55 gene, at least one mutation in a RNA
sequence of a CD55 transcript, at least one mutation in a DNA
sequence of a CD55 complementary-DNA (cDNA), CD55 protein, CD55
protein binding, complement deposition or combinations thereof; and
diagnosing the patient with CHAPLE. The method of treating and/or
preventing at least one symptom of CHAPLE includes: administering
an effective amount of a composition comprising at least one
complement inhibitor to a subject in need thereof, wherein the
composition is effective in treating or preventing at least one
symptom of CHAPLE. The disclosure further relates to compositions
effective at treating and/or preventing CHAPLE.
Inventors: |
Lenardo; Michael J.;
(Bethesda, MD) ; Su; Helen; (Bethesda, MD)
; Ozen; Ahmet Oguzhan; (Istanbul, TR) ; Comrie;
William Andrew; (Rockville, MD) ; Boztug; Kaan;
(Vienna, AT) ; Ardy; Rico Chandra; (Vienna,
AT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
The United States of America, as represented by the Secretary,
Department of Health and Human Serv |
Bethesda |
MD |
US |
|
|
Family ID: |
60084054 |
Appl. No.: |
16/333561 |
Filed: |
September 13, 2017 |
PCT Filed: |
September 13, 2017 |
PCT NO: |
PCT/US2017/051413 |
371 Date: |
March 14, 2019 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
62394630 |
Sep 14, 2016 |
|
|
|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
C12Q 1/6851 20130101;
C12Q 1/6883 20130101; C12Q 1/6827 20130101; G01N 33/6893 20130101;
C12Q 2600/156 20130101 |
International
Class: |
C12Q 1/6883 20060101
C12Q001/6883; C12Q 1/6851 20060101 C12Q001/6851; C12Q 1/6827
20060101 C12Q001/6827 |
Goverment Interests
GOVERNMENT FUNDING
[0002] Research supporting this application was carried out by the
United States of America as represented by the Secretary,
Department of Health and Human Services.
Claims
1. A method of diagnosing a patient with CD55 deficiency,
hyperactivation of complement, angiopathic thrombosis and protein
losing enteropathy (CHAPLE), the method comprising: providing a
sample from a patient; detecting at least one of: at least one
mutation in a DNA sequence of a CD55 gene; at least one mutation in
a RNA sequence of a CD55 transcript; at least one mutation in a DNA
sequence of a CD55 complementary DNA (cDNA); CD55 protein; CD55
protein binding; complement deposition; or combinations thereof,
wherein a mutation in the CD55 gene, transcript or cDNA, or absence
or decrease in activity of CD55 protein is indicative of a patient
at risk of developing or having CHAPLE; and diagnosing the patient
as having or not having CHAPLE.
2. The method of claim 1, wherein the patient is diagnosed with
CHAPLE when at least one of the following is detected: at least one
mutation in a DNA sequence, an RNA sequence or a cDNA sequence of
CD55 that results in a CD55 protein with substantially diminished
functional activity, a CD55 protein with no functional activity, a
lack of expression of CD55 protein (i.e., no CD55 protein
expression), or a substantially diminished expression of CD55
protein; a CD55 protein with substantially diminished functional
activity; a CD55 protein with no functional activity; a lack of
expression of CD55 protein (i.e., no CD55 protein expression); a
substantially diminished expression of CD55 protein; or
combinations thereof.
3. The method of claim 1, wherein the patient is diagnosed with
CHAPLE when the patient has at least one CHAPLE related symptom and
at least one of the following is detected: at least one mutation in
a DNA sequence, an RNA sequence or a cDNA sequence of CD55 that
results in a CD55 protein with substantially diminished functional
activity, a CD55 protein with no functional activity, a lack of
expression of CD55 protein (i.e., no CD55 protein expression), or a
substantially diminished expression of CD55 protein; a CD55 protein
with substantially diminished functional activity; a CD55 protein
with no functional activity; a lack of expression of CD55 protein
(i.e., no CD55 protein expression); a substantially diminished
expression of CD55 protein; or combinations thereof.
4. The method of claim 3, wherein the CHAPLE related symptom is
selected from the group consisting of: inflammatory bowel disease,
enteropathy, protein losing enteropathy, protein losing enteropathy
associated with hypoalbuminemia, hypoalbuminemia,
hypogammaglobulinemia, intestinal lymphangiectasia,
lymphangiectasia, thrombotic events, thromboembolism,
hyperactivation of complement, angiopathic thrombosis,
hypoproteinemia, or combinations thereof.
5. The method of claim 1, further comprising administering an
effective amount of a composition comprising at least one
complement inhibitor to the subject with CHAPLE, wherein the
composition is effective in treating or preventing at least one
symptom of CHAPLE, wherein the complement inhibitor is selected
from the group consisting of a serine protease inhibitor, a soluble
complement regulator, a therapeutic antibody or an antigen-binding
fragment thereof, a complement component inhibitor, and an
anaphylatoxin receptor antagonist.
6. (canceled)
7. The method of claim 1, wherein the mutation in the DNA sequence
of the CD55 gene or in the RNA sequence of the CD55 transcript
results in a near to complete absence of CD55 protein expression or
the expression of CD55 protein with substantially diminished
function or that is non-functional.
8. The method of claim 1, wherein the mutation in the DNA sequence
of the CD55 gene is at least one of: c.149-150delAA;
c.149-150insCCTT; c.109delC; c.800G>C; c.287-1G>C;
c.149-150delAAinsCCTT; or combinations thereof.
9. The method of claim 1, wherein detecting includes at least one
of: sequencing at least a portion of the CD55 gene or the CD55
transcript or the CD55 cDNA; or contacting a labeled nucleic acid
probe to at least a portion of the CD55 gene or the CD55 transcript
or the CD55 cDNA; or contacting at least a portion of the CD55 gene
or CD55 transcripts or cDNA thereof with a microarray; or
combinations thereof.
10. The method of claim 9, wherein hybridization of the labeled
nucleic acid probe is indicative of a mutation in the portion of
the CD55 gene or CD55 transcript.
11. The method of claim 9, wherein hybridization of the labeled
nucleic acid probe is indicative of the portion of the CD55 gene or
CD55 transcript having a wild-type sequence at the location of
hybridization.
12. The method of claim 9, wherein sequencing at least a portion of
the CD55 gene or CD55 transcript or cDNA thereof includes
amplifying at least one region of interest for sequencing with at
least one polymerase chain reaction (PCR) with at least one of the
following primer sets: TABLE-US-00004 (Exon 1)
CTACTCCACCCGTCTTGTTTGT and TTTGGGGGTTAAGGATACAGTC; (Exon 2)
CAGGTGTGGCATTTCAAGG and ACCCTGGGGTTTAGTAACGC; (Exon 3)
AAGTACTAAATATGCGCAAAGCAG and ATGGTCCTATCAAGAAACATCC; (Exon 4)
GTTACCTTCTTTGTGTGTATGCC and GCTGTGAATACCAGTCATGAAAC; (Exon 5)
AACCTGGAGAATTTGAGGAAAG and TGTGCTAATATTCTTAAGGGGC; (Exon 6)
GCATTTATAAGCATCTCTTGTTGG and TCATTGAATGTCTGCAACCC; (Exon 7)
CTAGGTGTTTGTGGGGAGAGAG and TCTGGTGGGTTTCTGAAGAGTT; (Exon 8)
TTTACGCAGAGTCCTTCAGC and CCATTTAATCCTGCAATCTTGG; (Exon 9)
TGGAAATTTGAGTTGCTTTCG and TCTCCCAGGAATATGGATTG; (Exon 10)
GCACCCCAAATTAACTGATTC and ATGTGATTCCAGGACTGCC; or combinations
thereof.
13. The method of claim 9, wherein contacting a labeled nucleic
acid probe to at least a portion of the CD55 gene or the CD55
transcript or the CD55 cDNA is performed using real-time PCR.
14. The method of claim 9, wherein contacting a labeled nucleic
acid probe to at least a portion of the CD55 transcripts or cDNA
thereof comprises: isolating CD55 transcripts; reverse transcribing
at least a portion of the CD55 transcripts; and contacting the cDNA
with the labeled nucleic acid probe.
15. The method of claim 1, wherein the microarray includes probes
designed to detect DNA, transcript, or cDNA mutations that result
in the complete absence in CD55 protein or a non-functional CD55
protein.
16. The method of claim 9, wherein detecting CD55 protein
comprises: contacting the sample with at least one CD55 binding
polypeptide, wherein the binding peptide includes a detectable
label, or is an anti-CD55 antibody or a CD55-binding fragment of an
antibody.
17.-23. (canceled)
24. The method of claim 1, wherein the detecting of CD55 binding
function includes examining the at least one of C3b affinity, C3b
avidity, C4b affinity, C4b avidity, or combinations thereof.
25. The method of claim 1, wherein detecting complement deposition
includes detecting C3d deposition.
26. A method of treating a patient having CD55 deficiency,
hyperactivation of complement, angiopathic thrombosis and protein
losing enteropathy (CHAPLE) or preventing at least one symptom of
CHAPLE in a patient at risk of developing the same, the method
comprising: administering an effective amount of a composition
comprising at least one complement inhibitor to a subject in need
thereof, wherein the composition is effective in treating or
preventing at least one symptom of CHAPLE.
27. The method of claim 26, wherein the complement inhibitor is
selected from the group consisting of a serine protease inhibitor,
a soluble complement regulator, a therapeutic antibody or an
antigen-binding fragment thereof, a complement component inhibitor,
and an anaphylatoxin receptor antagonist.
28. The method of claim 27, wherein: the serine protease inhibitor
is at least one of a C3 convertase inhibitor, a C5 convertase
inhibitor, a C1 inhibitor, a C1r inhibitor, a C1s inhibitor, a C2a
inhibitor, a MASP-1 inhibitor, a MASP-2 inhibitor, a factor D
inhibitor, a factor B inhibitor, a factor I inhibitor or
combinations thereof; the soluble complement regulator is at least
one of a soluble form of a membrane cofactor protein (MCP or CD46),
a soluble form of a decay-accelerating factor (DAF or CD55), a
soluble form of a membrane attack complex-inhibitor protein (MAC-IP
or CD59), a soluble form of complement receptor 1 (CD35) or
combinations thereof; the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or combinations thereof,
wherein said binding inhibits complement activation by at least one
of blocking association/binding with other complement proteins,
blocking association/binding with receptor proteins, blocking
serine protease activity or combinations thereof; the complement
component inhibitor is a peptide, nucleic acids, a synthetic
molecule or a combination thereof that disrupts protein functions
by steric hindrance or the induction of conformational changes; and
the anaphylatoxin receptor antagonist is at least one of a C5aR
antagonist, a C5L2 antagonist, a C3a receptor antagonist, a
functional blocking antibody of an anaphylatoxin or combinations
thereof.
29.-37. (canceled)
38. A therapeutic composition for treating or preventing at least
one symptom of CD55 deficiency, hyperactivation of complement,
angiopathic thrombosis and protein losing enteropathy (CHAPLE), the
composition comprising: an effective amount of two or more agents,
wherein at least one of the agents is a complement inhibitor to a
subject in need thereof; and a pharmaceutically acceptable carrier,
wherein the composition is effective in treating or preventing at
least one symptom of CHAPLE.
39. The composition of claim 38, wherein the complement inhibitor
is selected from the group consisting of a serine protease
inhibitor, a soluble complement regulator, a therapeutic antibody
or an antigen-binding fragment thereof, a complement component
inhibitor, and an anaphylatoxin receptor antagonist.
40. (canceled)
41. The composition of claim 39, wherein: the serine protease
inhibitors is at least one of a C3 convertase inhibitor, a C5
convertase inhibitor, a C1 inhibitor, a C1r inhibitor, a C1s
inhibitor, a C2a inhibitor, a MASP-1 inhibitor, a MASP-2 inhibitor,
a factor D inhibitor, a factor B inhibitor, a factor I inhibitor or
combinations thereof; the soluble complement regulator is at least
one of a soluble form of a membrane cofactor protein (MCP or CD46),
a soluble form of a decay-accelerating factor (DAF or CD55), a
soluble form of a membrane attack complex-inhibitor protein (MAC-IP
or CD59), a soluble form of complement receptor 1 (CD35) or
combinations thereof; the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or combinations thereof,
wherein said binding inhibits complement activation by at least one
of blocking association/binding with other complement proteins,
blocking association/binding with receptor proteins, blocking
serine protease activity or combinations thereof; the complement
component inhibitor is a peptide, nucleic acids, a synthetic
molecule or a combination thereof that disrupts protein functions
by steric hindrance or the induction of conformational changes; and
the anaphylatoxin receptor antagonist is at least one of a C5aR
antagonist, a C5L2 antagonist, a C3a receptor antagonist, a
functional blocking antibody of an anaphylatoxin or combinations
thereof.
42.-50. (canceled)
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] The present application claims priority to U.S. Provisional
Application No. 62/394,630, filed on 14 Sep. 2016, the contents of
which are incorporated here by reference in its entirety.
INCORPORATION BY REFERENCE
[0003] In compliance with 37 C.F.R. .sctn. 1.52(e)(5), the sequence
information contained in electronic file name:
1420378_459WO2_Sequence_Listing_ST25.txt; size 77 KB; created on:
24 Aug. 2017; using Patent-In 3.5, and Checker 4.4.0 is hereby
incorporated herein by reference in its entirety.
BACKGROUND
1. Field of the Invention
[0004] The present disclosure relates to methods of detecting
mutations associated with and diagnosing CD55 deficiency,
hyperactivation of complement, angiopathic thrombosis and protein
losing enteropathy (CHAPLE), methods for the treatment of CHAPLE,
and therapeutic compositions for treating CHAPLE.
2. Background Invention
[0005] A rare disease is generally accepted as being any disease
that affects a small percentage of the population, but there is no
single definition. For example, rare diseases are referred to as
Orphan Diseases in the United States and defined as conditions that
affect fewer than 200,000 people in the United States. Orphan
diseases include, inter alia, cystic fibrosis, Lou Gehrig's
disease, and Tourette's syndrome, Hamburger disease, Job syndrome,
atypical hemolytic uremic syndrome, paroxysmal nocturnal
hemoglobinuria, acromegaly (or "gigantism"). An accurate diagnosis
of a rare disease can generally take up to 5 years because early
stage symptoms could be absent, masked, misunderstood, or confused
with other more prevalent diseases. New orphan diseases are
discovered each year and are typically caused by inherited gene
mutations.
[0006] Protein-losing enteropathy (PLE) is characterized by
excessive loss of serum proteins through the gastrointestinal (GI)
tract resulting in hypoproteinemia, edema, and, in some cases,
pleural and pericardial effusions. Pathogenic mechanisms of PLE can
involve (1) impaired barrier function of the GI mucosa, often in
association with inflammatory bowel disease (IBD) and (2) impaired
lymphatic drainage, either due to primary intestinal
lymphangiectasia, or secondary to systemic conditions that impair
lymph flow, such as cardiac diseases. Although most cases of PLE
are sporadic, primary intestinal lymphangiectasia has been reported
in multiple siblings of several families, suggesting a genetic
etiology in certain cases.
[0007] Identifying rare monogenetic defects can elucidate the
pathophysiology of disease, improve diagnosis, and promote targeted
therapies for specific inherited syndromes and related common
diseases. These efforts have been greatly aided by massively
parallel DNA sequencing technologies, increasingly comprehensive
datasets of human genetic variation, and new gene validation
technologies. Several intestinal diseases related to early onset
IBD (EO-IBD) have been attributed to Mendelian gene defects.
Recently, a loss-of-function (LOF) mutation in the plasmalemma
vesicle associated protein gene was reported in a young infant with
severe PLE associated with disruption of endothelial fenestrated
diaphragms in the intestinal vasculature, demonstrating that PLE
may also arise from Mendelian gene defects.
[0008] The complement system is a vital part of the immune system
of the body that protect against pathogens (e.g., bacteria, fungi,
viruses, etc.). The complement system is a complex collection of
greater than 25 plasma proteins and membrane factors. The
complement components interact through a series of intricate
enzymatic cleavages and membrane binding events, which result in
the production of products with opsonic, immunoregulatory, and
lytic functions. Because complement has potent effects on immunity
and cell physiology, it must be tightly controlled.
[0009] The complement cascade includes three pathways referred to
as the classical pathway, the lectin pathway, or the alternative
pathway. The classical pathway of complement activation is
initiated or triggered by an antibody recognizing (i.e., binding)
an antigen located on a target cell. The lectin pathway of
complement activation is initiated or triggered by the binding of a
mannose-binding protein that is present in blood plasma to
mannose-containing proteoglycans on the surfaces of bacteria and
yeast, which has structural similarities to the antibody initiation
of the classical pathway. As such, the lectin pathway then proceeds
in a similar fashion as the classical pathway. The alternative
pathway of complement activation is initiated or triggered by
constituents of bacterial surfaces, as will be discussed in greater
detail below.
[0010] Each of the three pathways lead to the covalent bonding of a
particular fragment of a complement component (i.e., the C3b
fragment of C3) to the pathogen surface, which is recognized by C3b
receptors on macrophages and neutrophils. This deposition of C3b
fragments on the surface of the pathogen is mediated by a C3
convertase, which is a protease that cleaves the complement
component C3 to yield C3a and C3b. The C3b fragment is an osponin,
which mediates interaction with phagocytes (e.g., macrophages,
neutrophils, and dendritic cells, which promote inflammatory immune
reactions) through their C3b receptors. As such, the opsonized
pathogens are targeted by phagocytes. The opsonic function of C3b
is one of the most important functions of the complement system,
and its disruption leads to a susceptibility to a broad range of
pathogens. C3b can then be progressively broken down by Factor I (a
protease) and a cofactor (i.e., Factor H, CR1, MCP, or C4BP) to
iC3b, then C3c+C3dg, and finally C3d. The C3a fragment is a potent
anaphylatoxin that stimulates mast cell degranulation, which
results in the release of histamine from basophils and mast cells.
Histamine enhances vascular permeability, smooth muscle
contraction, and leukocyte activation, as well as being an
attractant (chemotractic factor) for granulocytes (e.g.,
neutrophils, eosinophils, basophils) and macrophages.
[0011] Complement component C3, which is the most abundant
complement protein and is abundantly present in plasma, is
spontaneously hydrolyzed (the alternative pathway). In particular,
there is a spontaneous cleavage of a thioester bond in C3 that
forms C3i or C3(H.sub.2O). The alternative pathway is facilitated
by surfaces that support the binding of activated C3 (i.e., C3i or
C3(H.sub.2O)), as well as surfaces that have neutral or positive
charge characteristics (such as those found in bacteria). The
plasma protein Factor B binds to the C3i surface bound protein.
Factor D then subsequently cleaves Factor B, thereby producing Ba
and Bb. The Bb fragment remains bound to C3i to form a C3iBb, which
is a C3 convertase that functions as described above and may be
referred to as the alternative pathway C3 convertase. The
alternative pathway C3 convertase is stabilized by the binding of
properdin (although not required). The alternative pathway C3
convertase has an amplification affect because each of the
fluid-phase C3 convertase (i.e., the alternative pathway C3
convertase) can cleave multiple C3 proteins into C3a and C3b, which
results in the deposition of additional C3b covalently bound to the
surface (e.g., a bacterial surface). In a similar fashion, the
alternative pathway C5 convertase is formed by the addition of a
second C3b monomer to the alternative pathway C3 convertase (i.e.,
add C3b to C3iBb, which is referred to as (C3b).sub.2Bb), which is
also stabilized by the binding of properdin (although not
required). The alternative pathway C3 convertase bind and cleaves
C5.
[0012] The classical pathway C3 convertase is formed when
complement component C1 (comprising a complex of C1q, C1r, and C1s)
is activated by an antibody-target-antigen complex (e.g., a
microbial antigen). That is, the binding of C1q to the
antibody-target-antigen complex results in a conformational change
in C1, which activates C1r. Activated C1r cleaves/activates C1s.
Active C1s is a serene protease that cleaves complement component
C4 into C4b and C4a and complement component C2 into C2b and C2a.
C4b fragments contain a reactive thiol that readily forms amide or
ester bonds with suitable molecules on a target surface (e.g., a
microbial cell surface). Activated C4b and C2a form the classical
pathway C3 convertase, which functions as described above. When a
C3b monomer is added to the classical pathway convertase, the
classical pathway C5 convertase (C4b, C2a, C3b) is formed.
[0013] As discussed above, the lectin pathway is homologous to the
classical pathway with a mannose-binding lectin (MBL, which is
similar to C1q) to mannose residues on the surface of a pathogen.
This binding activates the MBL-associated serine proteases MASP-1
and MASP-2 (which are very similar to C1r and C1s, respectively).
This complex functions in the same fashion as C1 in the classical
complement pathway.
[0014] The alternative, classical, and lectin pathway C5
convertases cleave C5, which is found in normal human serum, into
C5a and C5b. Similar to C3a, C5a is a potent anaphylatoxin and
chemotactic factor. C5a receptors are present on the surfaces of:
bronchial and alveolar epithelial cells, bronchial smooth muscle
cells, eosinophils, mast cells, monocytes, neutrophils, and
activated lymphocytes.
[0015] C5b binds to C6 and C7 to form a complex that interacts with
C8 and subsequently numerous C9 proteins, thereby producing a
membrane attack complex (MAC) or lytic unit
(C5b,6,7,8).sub.1(9).sub.n(n=10-16 molecules) on the targeted cell
membrane, which is a pore that extends through the cell membrane.
When a sufficient number of MACs are present in the target cell
membranes, hypotonic lysis of the targeted cell is achieved. C5a
and C5b-9 also amplify the release of downstream inflammatory
factors (e.g., hydrolytic enzymes, reactive oxygen species,
arachidonic acid metabolites and various cytokines).
[0016] The complement system provides a robust defense against
infection. However, misregulation or inappropriate activation of
the complement system is associated with the pathogenesis of a
variety of disorders including (e.g., rheumatoid arthritis; lupus
nephritis; asthma; ischemia-reperfusion injury; atypical hemolytic
uremic syndrome (aHUS); dense deposit disease; paroxysmal nocturnal
hemoglobinuria (PNH); macular degeneration; hemolysis, elevated
liver enzymes, and low platelets syndrome; thrombotic
thrombocytopenic purpura; spontaneous fetal loss; Pauci-immune
vasculitis; epidermolysis bullosa; recurrent fetal loss; multiple
sclerosis; traumatic brain injury; and injury resulting from
myocardial infarction, cardiopulmonary bypass and hemodialysis).
Complement inhibition has been demonstrated to be effective in
treating several complement-associated disorders in animal models
and in humans (see, e.g., Rother et al. (2007) Nature Biotechnology
25(11):1256-1264; Wang et al. (1996) Proc Natl Acad Sci USA
93:8563-8568; Wang et al. (1995) Proc Natl Acad Sci USA
92:8955-8959; Rinder et al. (1995) J Clin Invest 96:1564-1572;
Kroshus et al. (1995) Transplantation 60:1194-1202; Homeister et
al. (1993) J Immunol 150:1055-1064; Weisman et al. (1990) Science
249:146-151; Amsterdam et al. (1995) Am J Physiol 268:H448-H457;
and Rabinovici et al. (1992) J Immunol 149:1744 1750.
[0017] CD55 (decay accelerating factor or DAF) is a widely
expressed GPI-linked cell surface protein that regulates complement
activation by reducing the activity of C3 and C5 convertases and
accelerating their disassembly. Specifically, DAF recognizes C4b
and C3b fragments that are created during the C4 activation
(classical complement pathway and lectin pathway) and C3 activation
(alternate complement pathway). DAF interferes with the conversion
of C2 to C2a through its interaction with the cell-associated C4b
of the classical and lectin pathways. This prevents the formation
of the C4b2a C3 convertase. Similarly, DAF interferes with the
conversion of factor B to Bb by factor D through its interaction
with C3b of the alternative pathway. This prevents the formation of
the C3bBb C3 convertase of the alternative pathway. As a result,
the amplification provided by 3C convertases of the complement
cascade are limited by the interaction of DAF (or CD55) with C4b
and C3b, which results in indirectly blocking the formation of the
MAC. A rare CD55 deficiency on red blood cells (RBCs), known as the
Inab phenotype, is detected by the loss of Cromer blood group
antigens. This rare CD55 deficiency has been associated with
complement dysregulation, formation of a strong RBC alloantibody
agglutinin, and GI abnormalities. However, a disease resulting from
the germline loss of CD55 has not been clearly defined to date.
[0018] As mentioned above, rare diseases are often misdiagnosed,
and new rare diseases are regularly identified. For example, the
present disclosure describes a newly identified rare
disease--CHAPLE disease/syndrome. As such, there exists a need to
accurately detect the mutations associated with CHAPLE
disease/syndrome, as well as diagnose and treat individuals with
CHAPLE disease/syndrome with a therapeutic composition.
SUMMARY
[0019] The present disclosure relates to the surprising and
unexpected discovery of the cause of CHAPLE, and therefore, methods
of diagnosing CHAPLE, as well as methods of treating patients with
CHAPLE symptom(s) and methods of preventing a symptom(s) of CHAPLE
in individuals predisposed to develop CHAPLE syndrome with a
therapeutic composition.
[0020] In an aspect, the disclosure provides a method of diagnosing
a patient with CD55 deficiency, hyperactivation of complement,
angiopathic thrombosis and protein losing enteropathy (CHAPLE). The
method comprises: providing a sample from a patient; performing an
assay to detect at least one of: at least one mutation in a DNA
sequence of a CD55 gene, at least one mutation in a RNA sequence
(or mRNA sequence) of a CD55 transcript, at least one mutation in a
DNA sequence of a CD55 complementary DNA (cDNA), decay-accelerating
factor (DAF) or CD55 protein, complement deposition, or a
combination thereof, and diagnosing the patient with CHAPLE.
[0021] In an embodiment, the patient is diagnosed with CHAPLE when
at least one of the following is detected: (i) at least one
mutation in a DNA sequence, an RNA sequence or a cDNA sequence of
CD55 that results in a CD55 protein with substantially diminished
functional activity, a CD55 protein with no functional activity, a
lack of expression of CD55 protein (i.e., no CD55 protein
expression), or a substantially diminished expression of CD55
protein; (ii) a CD55 protein with substantially diminished
functional activity; (iii) a CD55 protein with no functional
activity; (iv) a lack of expression of CD55 protein (i.e., no CD55
protein expression); (v) a substantially diminished expression of
CD55 protein; or (vi) a combination thereof.
[0022] In another embodiment, the patient is diagnosed with CHAPLE
when the patient has at least one CHAPLE related symptom and at
least one of the following is detected: (i) at least one mutation
in a DNA sequence, an RNA sequence or a cDNA sequence of CD55 that
results in a CD55 protein with substantially diminished functional
activity, a CD55 protein with no functional activity, a lack of
expression of CD55 protein (i.e., no CD55 protein expression), or a
substantially diminished expression of CD55 protein; (ii) a CD55
protein with substantially diminished functional activity; (iii) a
CD55 protein with no functional activity; (iv) a lack of expression
of CD55 protein (i.e., no CD55 protein expression); (v) a
substantially diminished expression of CD55 protein; or (vi) a
combination thereof.
[0023] In some embodiments, the CHAPLE related symptom is selected
from the group consisting of: inflammatory bowel disease,
enteropathy, protein losing enteropathy, protein losing enteropathy
associated with hypoalbuminemia, hypoalbuminemia,
hypogammaglobulinemia, intestinal lymphangiectasia,
lymphangiectasia, thrombotic events, thromboembolism,
hyperactivation of complement, angiopathic thrombosis,
hypoproteinemia, or a combination thereof.
[0024] In other embodiments, the CHAPLE related symptom is selected
from the group consisting of inflammatory bowel disease, protein
losing enteropathy associated with hypoalbuminemia,
hypogammaglobulinemia, intestinal lymphangiectasia, thrombotic
events or a combination thereof. For example, in certain
embodiments, the patient has at least 3 of the following symptoms:
inflammatory bowel disease, protein losing enteropathy associated
with hypoalbuminemia, hypogammaglobulinemia, intestinal
lymphangiectasia, or thrombotic events.
[0025] In a particular embodiment, the method further comprises
administering an effective mount of a composition comprising at
least one complement inhibitor to the subject with CHAPLE, wherein
the composition is effective in treating or preventing at least one
symptom of CHAPLE.
[0026] In a further embodiment, the complement inhibitor is
selected from the group consisting of a serine protease inhibitor,
a soluble complement regulator, a therapeutic antibody or an
antigen-binding fragment thereof, a complement component inhibitor,
and an anaphylatoxin receptor antagonist.
[0027] In certain embodiments, the mutation in the DNA sequence of
the CD55 gene or in the RNA sequence of the CD55 transcript results
in a near to complete absence of CD55 protein expression or the
expression of CD55 protein with substantially diminished function
or that is non-functional.
[0028] In an embodiment, the mutation in the DNA sequence of the
CD55 gene is at least one of c.149-150delAA, c.149-150insCCTT,
c.109delC, c.800G>C, c.287-1G>C, c.149-150delAAinsCCTT or a
combination thereof.
[0029] In further embodiments, detecting includes at least one of:
(i) sequencing at least a portion of the CD55 gene or the CD55
transcript or the CD55 cDNA; or (ii) contacting a labeled nucleic
acid probe to at least a portion of the CD55 gene or the CD55
transcript or the CD55 cDNA; or (iii) contacting at least a portion
of the CD55 gene or CD55 transcripts or the CD55 cDNA with a
microarray; or (iv) a combination thereof.
[0030] In a particular embodiment, hybridization of the labeled
nucleic acid probe is indicative of a mutation in the portion of
the CD55 gene or the CD55 transcript or the CD55 cDNA. In another
particular embodiment, hybridization of the labeled nucleic acid
probe is indicative of the portion of the CD55 gene or the CD55
transcript or the CD55 cDNA having a wild-type sequence at the
location of hybridization.
[0031] In certain other embodiments, sequencing at least a portion
of the CD55 gene or CD55 transcript or CD55 cDNA thereof includes
amplifying at least one region of interest for sequencing with at
least one polymerase chain reaction (PCR) that includes at least
one of the following primer sets: (i) CTACTCCACCCGTCTTGTTTGT and
TTTGGGGGTTAAGGATACAGTC (Exon 1); (ii) CAGGTGTGGCATTTCAAGG and
ACCCTGGGGTTTAGTAACGC (Exon 2); (iii) AAGTACTAAATATGCGCAAAGCAG and
ATGGTCCTATCAAGAAACATCC (Exon 3); (iv) GTTACCTTCTTTGTGTGTATGCC and
GCTGTGAATACCAGTCATGAAAC (Exon 4); (v) AACCTGGAGAATTTGAGGAAAG and
TGTGCTAATATTCTTAAGGGGC (Exon 5); (vi) GCATTTATAAGCATCTCTTGTTGG and
TCATTGAATGTCTGCAACCC (Exon 6); (vii) CTAGGTGTTTGTGGGGAGAGAG and
TCTGGTGGGTTTCTGAAGAGTT (Exon 7); (viii) TTTACGCAGAGTCCTTCAGC and
CCATTTAATCCTGCAATCTTGG (Exon 8); (ix) TGGAAATTTGAGTTGCTTTCG and
TCTCCCAGGAATATGGATTG (Exon 9); (x) GCACCCCAAATTAACTGATTC and
ATGTGATTCCAGGACTGCC (Exon 10); or (xi) a combination thereof.
[0032] In yet another embodiment, contacting a labeled nucleic acid
probe to at least a portion of the CD55 gene or the CD55 transcript
or the CD55 cDNA is performed using real-time PCR. In an
embodiment, hybridization of a real-time PCR probe is indicative of
a mutation in the portion of the CD55 gene or CD55 transcript or
the CD55 cDNA. In another embodiment, hybridization of a real-time
PCR probe is indicative of the portion of the CD55 gene or CD55
transcript or the CD55 cDNA having a wild-type sequence (or not
having a CHAPLE related mutations) at the location of
hybridization.
[0033] In some embodiments, contacting a labeled nucleic acid probe
to at least a portion of the CD55 cDNA comprises: isolating CD55
transcripts; reverse transcribing at least a portion of the CD55
transcripts; and contacting the cDNA with the labeled nucleic acid
probe.
[0034] In further embodiments, the microarray includes probes
(e.g., immobilized probes) designed to detect DNA, transcripts
(i.e., RNA or mRNA), or cDNA mutations that result in the complete
absence in CD55 protein or a CD55 protein with substantially
diminished function or that is virtually non-functional.
[0035] In certain embodiments, detecting CD55 protein comprises:
contacting the sample with at least one CD55 binding polypeptide.
The CD55 binding polypeptides can include a detectable label.
Furthermore, the binding polypeptide can be an anti-CD55 antibody
or a CD55-binding fragment thereof.
[0036] In other embodiments, detecting CD55 protein further
comprises contacting the sample or a CD55-CD55 binding polypeptide
complex with at least one secondary polypeptide that binds
specifically to the CD55 binding polypeptide. The secondary
polypeptide can include a detectable label. The secondary
polypeptide can be an antibody or fragment thereof that binds the
CD55 binding polypeptide.
[0037] In an embodiment, detecting CD55 protein is performed using
at least one of the following assays: western blot, flow cytometry,
an immunoassay or a combination thereof. For example, the
immunoassay can be at least one assay selected from the group
consisting of flow cytometry, enzyme-linked immunosorbent assay
(ELISA), radioimmunoassay, magnetic immunoassay, enzyme-linked
immunospot (ELISPOT), and immunofluorescence.
[0038] In another embodiment, the detecting of CD55 binding
function includes examining at least one of C3b affinity, C3b
avidity, C4b affinity, C4b avidity or a combination thereof.
[0039] In a particular embodiment, detecting complement deposition
includes detecting C3d deposition. In an embodiment, detecting
complement deposition is determined by flow cytometry.
[0040] In a further aspect, the disclosure provides a method of
treating a patient having CD55 deficiency, hyperactivation of
complement, angiopathic thrombosis and protein losing enteropathy
(CHAPLE) or preventing CHAPLE in a patient at risk of developing
the same. The method comprises administering an effective amount of
a composition comprising at least one complement inhibitor to a
subject in need thereof. The composition is effective in treating
and/or preventing at least one symptom of CHAPLE.
[0041] In some embodiments, the complement inhibitor is selected
from the group consisting of a serine protease inhibitor, a soluble
complement regulator, a therapeutic antibody or an antigen-binding
fragment thereof, a complement component inhibitor, and an
anaphylatoxin receptor antagonist.
[0042] In certain embodiments, the serine protease inhibitors is at
least one of a C3 convertase inhibitor, a C5 convertase inhibitor,
a C1 inhibitor, a C1r inhibitor, a C1s inhibitor, a C2a inhibitor,
a MASP-1 inhibitor, a MASP-2 inhibitor, a factor D inhibitor, a
factor B inhibitor, a factor I inhibitor or a combination thereof.
For example, the serine protease inhibitor can be at least one of
BCX-1470 (BioCryst, Birmingham, Ala., USA), C1s-INH-248
(Knoll/Abbott, Abbott Park, Ill., USA), compstatin, Cetor.RTM.
(Sanquin, Amsterdam, Netherlands), Berinert.RTM. (CSL Behring, King
of Prussia, Pa., USA), Cinryze.TM. (ViroPharma, Exton, Pa., USA),
rhC 1INH (Pharming Group N.V., Leiden, Netherlands), Ruconest.RTM.
(Salix Pharmaceuticals, Inc., Raleigh, N.C., USA) or a combination
thereof.
[0043] In other embodiments, the soluble complement regulator is at
least one of a soluble form of a membrane cofactor protein (MCP or
CD46), a soluble form of a decay-accelerating factor (DAF or CD55),
a soluble form of a membrane attack complex-inhibitor protein
(MAC-IP or CD59), a soluble form of complement receptor 1 (CD35) or
a combination thereof. For example, the soluble complement
regulator can be at least one of sCR1 (TP10; Advant
Immunotherapeutics, Needham, Mass., USA), sCR1-sL.sup.ex (TP10;
Advant Immunotherapeutics, Needham, Mass., USA), sDAG-sMCP hybrid
(MLN-2222, Millennium, Cambridge, Mass., USA), a membrane-tethered
sCD59 (Mirococept or APT070; Inflazyme Pharmaceuticals, Vancouver,
British Columbia, Canada) or a combination thereof.
[0044] In further embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or a combination thereof. The
binding can inhibit complement activation by at least one of
blocking association/binding with other complement proteins,
blocking association/binding with receptor proteins, blocking
serine protease activity or a combination thereof. For example, the
therapeutic antibody or the antigen-binding fragment thereof can be
at least one of eculizumab (Soliris.RTM.; Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ALXN1007 (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), neutrazumab (G2 Therapies,
Darlinghurst, NSW, Australia), Pexelizumab (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ofatumumab (Genmab A/S, Copenhagen,
Denmark), HuMax-CD38 (Benmab A/S, Copenhagen, Denmark), TNX-558
(Tanox, South San Francisco, Calif., USA), TNX-234 (Tanox, South
San Francisco, Calif., USA), TA106 (Taligen, Aurora, Colo., USA),
anti-properdin (Novelmed, Cleveland, Ohio, USA) or a combination
thereof.
[0045] In yet other embodiments, the complement component inhibitor
(e.g., a small molecule) is a peptide, nucleic acids, a synthetic
molecule or a combination thereof that disrupts protein functions
by steric hindrance or the induction of conformational changes. For
example, the complement component inhibitor can be at least one of
compstatin, anti-C5 RNA aptamer (ARC1905; Archemix, Cambridge,
Mass., USA), or analogs or derivatives thereof, or a combination
thereof.
[0046] In another embodiment, the anaphylatoxin receptor antagonist
is at least one of a C5aR antagonist, a C5L2 antagonist, a C3a
receptor antagonist, a functional blocking antibody of an
anaphylatoxin or a combination thereof. For example, the
anaphylatoxin receptor antagonist is at least one of PMX-53
(PepTech Corp, Bedform, Mass., USA), PMX-205 (PepTech Corp,
Bedform, Mass., USA), JPE-1375 (Jerini, Berlin, Germany), JSM-7717
(Jerini, Berlin, Germany), rhMBL (Enzon Pharmaceuticals, Cranford,
N.J., USA), NTD 9513727 (Tocris Bioscience, Bristol, United
Kingdom) or a combination thereof.
[0047] In another aspect, the disclosure provides a composition for
treating or preventing at least one symptom of CD55 deficiency,
hyperactivation of complement, angiopathic thrombosis and protein
losing enteropathy (CHAPLE) in a subject in need thereof. The
therapeutic composition comprises an effective amount of two or
more agents and a pharmaceutically acceptable carrier, wherein at
least one of the agents is a complement inhibitor, wherein the
composition is effective in treating or preventing at least one
symptom of CHAPLE. In an embodiment, at least two of the agents are
a complement inhibitor. In another embodiment the effective amount
is a synergistically effective amount of the agents.
[0048] In an additional embodiment, the complement inhibitor is
selected from the group consisting of a serine protease inhibitor,
a soluble complement regulator, a therapeutic antibody or an
antigen-binding fragment thereof, a complement component inhibitor
(e.g., a small molecule), and an anaphylatoxin receptor
antagonist.
[0049] In further embodiments, the complement inhibitors include a
C3 convertase inhibitor and a C5 convertase inhibitor. In another
embodiment, the complement inhibitors includes: a soluble form of
CD55; and at least one of a C3 convertase inhibitor, a C5
convertase inhibitor or a combination thereof.
[0050] In certain embodiments, the serine protease inhibitors is at
least one of a C3 convertase inhibitor, a C5 convertase inhibitor,
a C1 inhibitor, a C1r inhibitor, a C1s inhibitor, a C2a inhibitor,
a MASP-1 inhibitor, a MASP-2 inhibitor, a factor D inhibitor, a
factor B inhibitor, a factor I inhibitor or a combination
thereof.
[0051] In a particular embodiment, the serine protease inhibitor is
at least one of BCX-1470 (BioCryst, Birmingham, Ala., USA),
C1s-INH-248 (Knoll/Abbott, Abbott Park, Ill., USA), compstatin,
Cetor.RTM. (Sanquin, Amsterdam, Netherlands), Berinert.RTM. (CSL
Behring, King of Prussia, Pa., USA), Cinryze.TM. (ViroPharma,
Exton, Pa., USA), rhC1INH (Pharming Group N.V., Leiden,
Netherlands), Ruconest.RTM. (Salix Pharmaceuticals, Inc., Raleigh,
N.C., USA) or a combination thereof.
[0052] In other embodiments, the soluble complement regulator is at
least one of a soluble form of a membrane cofactor protein (MCP or
CD46), a soluble form of a decay-accelerating factor (DAF or CD55),
a soluble form of a membrane attack complex-inhibitor protein
(MAC-IP or CD59), a soluble form of complement receptor 1 (CD35) or
a combination thereof.
[0053] In an embodiment, the soluble complement regulator is at
least one of sCR1 (TP10; Advant Immunotherapeutics, Needham, Mass.,
USA), sCR1-sL.sup.ex (TP10; Advant Immunotherapeutics, Needham,
Mass., USA), sDAG-sMCP hybrid (MLN-2222, Millennium, Cambridge,
Mass., USA), a membrane-tethered sCD59 (Mirococept or APT070;
Inflazyme Pharmaceuticals, Vancouver, British Columbia, Canada) or
a combination thereof.
[0054] In other embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or a combination thereof,
wherein said binding inhibits complement activation by, e.g., at
least one of blocking association/binding with other complement
proteins, blocking association/binding with receptor proteins,
blocking serine protease activity or a combination thereof.
[0055] In certain embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one of eculizumab
(Soliris.RTM.; Alexion Pharmaceuticals Inc., New Haven, Conn.,
USA), ALXN1007 (Alexion Pharmaceuticals Inc., New Haven, Conn.,
USA), neutrazumab (G2 Therapies, Darlinghurst, NSW, Australia),
Pexelizumab (Alexion Pharmaceuticals Inc., New Haven, Conn., USA),
ofatumumab (Genmab A/S, Copenhagen, Denmark), HuMax-CD38 (Benmab
A/S, Copenhagen, Denmark), TNX-558 (Tanox, South San Francisco,
Calif., USA), TNX-234 (Tanox, South San Francisco, Calif., USA),
TA106 (Taligen, Aurora, Colo., USA), anti-properdin (Novelmed,
Cleveland, Ohio, USA) or a combination thereof.
[0056] In yet other embodiments, the complement component inhibitor
is a peptide, nucleic acids, a synthetic molecule or a combination
thereof that disrupts protein functions by steric hindrance or the
induction of conformational changes.
[0057] In a particular embodiment, the complement component
inhibitor is at least one of compstatin, anti-C5 RNA aptamer
(ARC1905; Archemix, Cambridge, Mass., USA), or analogs or
derivatives thereof, or a combination thereof.
[0058] In additional embodiments, the anaphylatoxin receptor
antagonist is at least one of a C5aR antagonist, a C5L2 antagonist,
a C3a receptor antagonist, a functional blocking antibody of an
anaphylatoxin or a combination thereof.
[0059] In certain embodiments, the anaphylatoxin receptor
antagonist is at least one of PMX-53 (PepTech Corp, Bedform, Mass.,
USA), PMX-205 (PepTech Corp, Bedform, Mass., USA), JPE-1375
(Jerini, Berlin, Germany), JSM-7717 (Jerini, Berlin, Germany),
rhMBL (Enzon Pharmaceuticals, Cranford, N.J., USA) or a combination
thereof.
[0060] The preceding general areas of utility are given by way of
example only and are not intended to be limiting on the scope of
the present disclosure and appended claims. Additional objects and
advantages of the present invention will be appreciated by one of
ordinary skill in the art in light of the instant claims,
description, and examples. For example, the various aspects and
embodiments of the invention may be utilized in numerous
combinations, all of which are expressly contemplated by the
present description. These additional objects and advantages are
expressly included within the scope of the present invention.
BRIEF DESCRIPTION OF THE DRAWINGS
[0061] The accompanying drawings, which are incorporated into and
form a part of the specification, illustrate several embodiments of
the present invention and, together with the description, serve to
explain the principles of the invention. The drawings are only for
the purpose of illustrating an embodiment of the invention and are
not to be construed as limiting the invention.
[0062] FIGS. 1A, 1B, 1C, 1D, 1E, 1F, 1G, and 1H. Clinical
presentation of 7 families with familial early onset PLE. Pedigrees
of seven families with affected individuals homozygous for
alternative allele indicated by solid symbols, heterozygous
individuals indicated by half solid symbols, and affected
individuals with an unknown genotype indicated by open symbols with
a slash through it. The double line between parents in each family
indicates presence of consanguinity (A). Serum levels of
immunoglobulin G (IgG, left Y axis) in relation to serum albumin
(right Y axis) concentrations as a function of age in years.
Age-specific lower cutoff value for IgG is denoted by the red
dotted curve, whereas the reference for albumin level is >3.5
g/dl (indicated by hatched line on right Y axis). Each arrow
denotes an episode of pneumonia. Presented data for Patients 1.1,
2.1, 3.1, and 4.1 (B). Radiological exams showing bowel wall
edema/thickening in Patient 6.1. Double arrows indicate diffuse
target-water small bowel wall enhancement and single arrow
indicates scattered area of dilatation (C). The hematoxylin and
eosin stained histological section from the resection specimen from
P2.1 shows lymphangiectasia (D). Immunohistochemical stains for
PROX-1 and D2-40 (Podoplanin) (inset). Radiographs showing large
occlusive thrombi in the inferior vena cava (IVC) and right atrium
(arrows in E, left). Radiograph showing pulmonary embolus and lack
of vascular flow in right pulmonary artery branches (arrows in E,
center). Radiograph showing irregular peripheral arteriovenous
malformations (ovals in E, right). Colonoscopy photographs of
Patient 1.1 showing exudate formation (upper, arrow) and a mucosal
ulcer (lower, arrow) in the terminal ileum (F). Histopathology of
colon biopsy specimen taken from hematoxylin and eosin sections of
ileum of Patient 2.1 demonstrating prominent lymphoid nodules
evident within both the mucosa and beneath the muscularis mucosa;
and immunohistochemistry showing infiltrates of B cells (CD20) and
T cells (CD3) within lymphoid nodules (G). Abdominal CT image from
Patient 2.1 with intestinal obstruction showing mucosal thickening
of the distal ileal segments and luminal narrowing (the lead pipe
sign, arrow) (H).
[0063] FIGS. 2A, 2B, 2C, and 2D. Nucleotide and amino acid
alignments for c.149_150delAAinsCCTT (A), c.109delG (B),
c.287-1G>A (C), c.800G>C (D) to wild-type CD55 sequences
(CD55 genomic reference sequence NG_007465.1, SEQ ID NO: 1, CD55
mRNA reference sequence transcript NM_000574.4, SEQ ID NO: 2; and
CD55 protein reference sequence NP_000565.1, SEQ ID NO: 3).
[0064] FIGS. 3A, 3B, 3C, and 3D. Pedigrees and chromatograms for
families 1 and 7, families 2, 3, and 5, family 4, and family 6 are
shown in 3A, 3B, 3C, and 3D respectively. Extended pedigrees for
patient families, with affected individuals homozygous for
alternative allele indicated by solid symbols, heterozygous
individuals indicated by half solid symbols, and affected
individuals with an unknown genotype indicated by open symbols with
a slash. The double line between parents in each family indicates
presence of consanguinity. Chromatograms showing the specific
nucleotide mutations in the CD55 gene in patients relative to the
reference sequence. Families are grouped by unique mutation
status.
[0065] FIG. 4. Show Table 2, which shows clinical and immunological
characteristics of patients with CD 55 deficiency. Symptoms present
at first clinical presentation are indicated by red
text..dagger-dbl. The patient received colchicine for the treatment
of suspected Familial Mediterranean fever (FMF). Numbers in
boldface indicate values below the normal range. N/A: Not
applicable (P4.2 and P4.3 were not evaluated by endoscopy). IVC:
Inferior vena cava.
[0066] FIGS. 5A, 5B, and 5C. Albumin levels and weight/height
curves. Serum albumin levels from P5.1 and 5.2 on a weekly basis
and from P6.1 over years. Periodic abrupt rises represent partial
albumin restoration following transfusion (A). Height and weight
curves for Patients 1.1, 2.1, 6.1, and 7.1 relative to the normal
range (B and C). Supplementation therapy with vitamins and dietary
intervention led to a variable benefit on patients' growth. Whereas
Patient 2.1 was within the third and tenth weight and height
percentiles at presentation, she reached the 25.sup.th and
50.sup.th percentiles for weight and height, respectively. On the
other hand Patient 1.1 had only partial recovery, with persistent
stunting despite weight gain. Patient 6.1 demonstrated significant
growth retardation, worsening after age 14 when the patient
developed severe thrombosis. Patient 7.1 has a current height for
age value below 3.sup.rd percentile.
[0067] FIGS. 6A, 6B, 6C, 6D, and 6E. Mutations in CD55 lead to loss
of protein expression. Schematic of the complement cascade (A). The
identified mutations relative to the CD55 protein structure
depicting the four short consensus repeat (SCR) domains and exon
location (B). QRT-PCR determination of CD55 mRNA in cycling patient
CD4.sup.+ T cell blasts (C). Flow cytometry histograms of CD55
surface expression on CD4.sup.+ T lymphocytes for the patients
compared to healthy controls. Gray shaded histogram shows isotype
control and the red histogram denotes experimental sample (D).
Western blot denoting CD55 expression in activated CD4.sup.+ T
cells (E).
[0068] FIGS. 7A and 7B. 3D structure of CD55 showing mutation in
Family 4 Location of the mutation in Family 4 within the crystal
structure of CD55 (A). Close up of the affected disulfide bond in
SCR4 of CD55 (B).
[0069] FIG. 8A, 8B, 8C, 8D, 8E. Loss of CD55 leads to spontaneous
complement activation by the alternative pathway. Representative
flow cytometry plots of C3d deposition on the surface of CD4.sup.+
T cell blasts from P1 and P2 (A, left). Pooled analyses of C3d
deposition on T cells of five CD55 deficient patients after
incubation with normal or acidified (pH 6.4) media containing
pooled nHS (A, right). Patient CD4.sup.+ T cells were transduced
with either wild type (WT) CD55 or Thy1.1 expressing lentivirus (B,
top). CD55 or Thy1.1 transduced cells were incubated with acidified
normal human serum and the deposition of C3d determined and plotted
for the CD55 positive and negative fractions or the Thy1.1 positive
or negative fractions (B, bottom left and right, respectively).
CD55 expression in a CD55-deficient Jurkat cell line (C, left). C3d
deposition on CD55 knock out Jurkat T cells treated with acidified
nHS for the indicated amount of time. Knockout cells were a mixture
of cells that had been deleted by CRISPR technology and cells that
had not been. CD55 positive and negative cells were assessed for
C3d deposition within this mixed population (C, right). C3d
deposition on HT29 cells with CD55 knocked down using two different
shRNAs. Correlation between the geometric MFI values of C3d and
CD55 was assessed on scatter plot graphs. Samples were color coded
as; Red: Sh-1 CD55, blue: Sh-2 CD55, green: Mock. Circles: No
TNF-.alpha. pretreatment, Squares: pre-treated with TNF-.alpha..
Samples treated with acidified serum are illustrated with solid
symbols and corresponding samples treated with control serum are
represented with open symbols (D). C3d deposition by live/dead
staining for control and patient T cells (D, left) and
quantification of C3d deposition and annexin-V/live/dead staining
(E).
[0070] FIGS. 9A, 9B, 9C, 9D, 9E, 9F, 9G, 9H, 9I, 9J, 9K, 9L, 9M,
9N, 90, and 9P.
[0071] Changes in inflammatory cytokine production by CD55
deficient cells promote pro-thrombotic changes in endothelial
cells. Cytokine secretion in control and patient T cells following
restimulation with anti-CD3 for 48 hours. Cells were either left
untreated or treated with a combination of C3aR and C5aR1
inhibitors, both at 10 .mu.M final concentration. Each patient
point represents the average of at least three independent
experiments. Results are for TNF.alpha., IL10, or IFN.gamma. (A, B,
and C respectively). Anaphylatoxin receptor surface expression on
proliferating CD4.sup.+ T cells grown in complete RPMI supplemented
with 100 u/mL IL2, isotype: filled grey line, sample: solid black
line (D). C3aR expression on proliferating CD4.sup.+ T cells grown
in serum free X-vivo 15 media supplemented with 100 u/mL IL-2 w/wo
10 nM ATRA, grey and black line respectively, isotype: filled grey
line (E). IL-10 production in control and patient T cells
stimulated with anti-CD3 and stimulatory antibodies directed
against the indicated costimulatory molecules (F). Flow plots of
thrombomodulin (TM) and Tissue Factor (TF) expression on HUVECs
cultured for 24 hours w/wo 10 ng/mL TNF.alpha. (G). Quantification
of the change in TM and TF expression on HUVECs in response to 24
hour culture with increasing doses of TNF.alpha. (H). Flow plots of
CD46 and CD59 expression on HUVECs cultured for 24 hours w/wo 10
ng/mL TNF.alpha. (I). Quantification of CD46, CD59, and CD55
expression on HUVECs in response to 24 hour culture with increasing
doses of TNF.alpha. (J, K, and L, respectively). Quantification of
the change in TM and TF expression on HUVECs in response to 48 hour
culture with increasing doses of ATRA (M). Quantification of CD46,
CD59, and CD55 expression on HUVECs in response to 48 hour culture
with increasing doses of ATRA (N, O, and P, respectively). (not
significant (n.s.), * p<0.05, **p<0.01, ***p<0.001).
[0072] FIGS. 10A, 10B, 10C, 10D, 10E, 10F, 10G, 10H, and 10I.
Primary T cell stimulation, gut homing phenotype induction by ATRA,
and CD55 mediated costimulation of T cell activation. Time course
of TNF.alpha. secretion upon stimulation of Naive human CD4.sup.+ T
cells in serum free media for P1, P2, and P4-P6 (A). Time course of
IL-10 secretion upon stimulation of Naive CD4.sup.+ T cells in
serum free media for P1, P2, and P4-P6 (B). Time course of
IFN.gamma. secretion upon stimulation of Naive CD4.sup.+ T cells in
serum free media for P1, P2, and P4-P6 (C). Surface expression of
the gut-homing integrin .alpha.4.beta.7 in human T cells grown in
serum free conditions w/wo supplementation with 10 nM ATRA (D).
Surface expression of the gut-homing chemokine receptor CCR9 in
Naive human CD4.sup.+ T cells grown in serum free conditions w/wo
supplementation with 10 nM ATRA (E). CD69 expression after
stimulation of control and patient T cells with the indicated dose
of anti-CD3 antibody w/wo costimulation with anti-CD55 (F). Percent
of Control and patient T cells that upregulated CD25 and CD69
expression after stimulation anti-CD3 antibody w/wo costimulation
with anti-CD28 or anti-CD55 (G). CFSE dilution in control or
patient T cells stimulation with 10 .mu.g/mL anti-CD3 and the
indicated co-stimulatory molecules (H). IL10 secretion of control
and patient cells in response to varying stimuli (I).
[0073] FIGS. 11A, 11B, and 11C. (A) C3d deposition on patient and
control T cells were incubated in the presence or absence of 5% nHS
with or without the addition of 100 .mu.M Compstatin to block
complement activation. (B) Ratio of C3a to C4a in culture
supernatants after 24 hours of incubation with 5% nHS w/wo 100
.mu.M compstatin. (C) Ratio of C5a to C4a in culture supernatants
after 24 hours of incubation with 5% nHS or without 100 .mu.M
compstatin. ***=p<0.001.
[0074] FIGS. 12A and 12B. Model of CHAPLE syndrome molecular
pathogenesis leading to PLE. In healthy individuals CD55 prevents
complement activation and generation of anaphylatoxins. T cells
produce an inflammatory cytokine mileu that is balanced towards
production of IL10 and control of intestinal immune responses. CD55
further protects from complement activation on other host cells,
including prevention of complement activation on endothelial cells.
CD55 deficiency associated with CHAPLE syndrome results in
increased complement activation and anaphylatoxin production. The
lack of CD55 and signaling by anaphylatoxins produces an
inflammatory environment characterized by low IL-10 production and
increased TNF.alpha. production. Lower IL-10 production likely
allows for further immunological activation, while TNF.alpha.
drives an inflammatory environment and endothelial cell changes
characterized by the down regulation of complement regulatory
proteins CD46 and CD59 and skewing of tissue factor and
thrombomodulin expression towards a procoagulative state. Lack of
CD55 on endothelial cells further exasperates the changes caused by
TNF.alpha. production leading to uncontrolled activation of the
coagulation and complement cascades on endothelial surfaces. This
directly leads to endothelial barrier damage and protein/fluid loss
into interstitial spaces. The presence of high concentrations of
retinoic acid in intestinal tissues drives the upregulation of CD55
and down regulation of thrombomodulin, likely accounting for the
predisposition to intestinal manifestations in CHAPLE syndrome (A).
Proinflammatory and procoagulant changes described in A, and
various pathological processes driven by excessive complement
effectors generated by immune response to the gut-microbiome lead
to lymph vessel distortion and compromised lymphatic flow. Ensuing
lymphangiectasia results in GI protein loss and malabsorption of
fat and micronutrients. Aggravation of the mucosal edema due to
hypoproteinemia and the pathological inflammation drives worsening
enteropathy. Intraluminal complement activation likely impacts
intestinal epithelial function. This, combined with
hypercoagulability within blood vessels impairs circulatory
dynamics thus aggravating the PLE (B).
DETAILED DESCRIPTION
[0075] As described herein, individuals with a CD55 gene mutation
are afflicted with CD55 deficiency, hyperactivation of complement,
angiopathic thrombosis and protein losing enteropathy (CHAPLE),
which includes debilitating symptoms such as inflammatory bowel
disease, protein losing enteropathy (which can be associated with
hypoalbuminemia), hypogammaglobulinemia, intestinal
lymphangiectasia, and/or thrombotic events.
[0076] The present disclosure is related, in part, to the
surprising and unexpected discovery individuals afflicted with the
above symptoms have a CD55 deficiency due to at least one CD55 gene
mutations that results in the near to complete lack of expression
of CD55 protein and/or the expression of a CD55 protein that has
substantially diminished functional activity or that is devoid of
functional activity.
[0077] Unless otherwise defined, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which this disclosure belongs. All
publications, patent applications, patents, and other references
mentioned herein are incorporated by reference in their entireties.
In the case of conflict, the present specification, including
definitions, will control. In addition, the examples are
illustrative only and not intended to be limiting.
[0078] Where a range of values is provided, it is understood that
each intervening value, to the tenth of the unit of the lower limit
unless the context clearly dictates otherwise (such as in the case
of a group containing a number of amino acids in which case each
amino acid number falling within the range is provided), between
the upper and lower limit of that range and any other stated or
intervening value in that stated range is encompassed within the
invention. The upper and lower limits of these smaller ranges may
independently be included in the smaller ranges is also encompassed
within the invention, subject to any specifically excluded limit in
the stated range. Where the stated range includes one or both of
the limits, ranges excluding either both of those included limits
are also included in the invention.
[0079] The following terms are used to describe the present
invention. In instances where a term is not specifically defined
herein, that term is given an art-recognized meaning by those of
ordinary skill applying that term in context to its use in
describing the present invention.
[0080] The articles "a" and "an" as used herein and in the appended
claims are used herein to refer to one or to more than one (i.e.,
to at least one) of the grammatical object of the article unless
the context clearly indicates otherwise. By way of example, "an
element" means one element or more than one element.
[0081] The phrase "and/or," as used herein in the specification and
in the claims, should be understood to mean "either or both" of the
elements so conjoined, i.e., elements that are conjunctively
present in some cases and disjunctively present in other cases.
Multiple elements listed with "and/or" should be construed in the
same fashion, i.e., "one or more" of the elements so conjoined.
Other elements may optionally be present other than the elements
specifically identified by the "and/or" clause, whether related or
unrelated to those elements specifically identified. Thus, as a
non-limiting example, a reference to "A and/or B", when used in
conjunction with open-ended language such as "comprising" can
refer, in one embodiment, to A only (optionally including elements
other than B); in another embodiment, to B only (optionally
including elements other than A); in yet another embodiment, to
both A and B (optionally including other elements); etc.
[0082] As used herein in the specification and in the claims, "or"
should be understood to have the same meaning as "and/or" as
defined above. For example, when separating items in a list, "or"
or "and/or" shall be interpreted as being inclusive, i.e., the
inclusion of at least one, but also including more than one, of a
number or list of elements, and, optionally, additional unlisted
items. Only terms clearly indicated to the contrary, such as "only
one of" or "exactly one of," or, when used in the claims,
"consisting of," will refer to the inclusion of exactly one element
of a number or list of elements. In general, the term "or" as used
herein shall only be interpreted as indicating exclusive
alternatives (i.e., "one or the other but not both") when preceded
by terms of exclusivity, such as "either," "one of," "only one of,"
or "exactly one of."
[0083] In the claims, as well as in the specification above, all
transitional phrases such as "comprising," "including," "carrying,"
"having," "containing," "involving," "holding," "composed of," and
the like are to be understood to be open-ended, i.e., to mean
including but not limited to. Only the transitional phrases
"consisting of" and "consisting essentially of" shall be closed or
semi-closed transitional phrases, respectively, as set forth in the
United States Patent Office Manual of Patent Examining Procedures,
Section 2111.03.
[0084] As used herein in the specification and in the claims, the
phrase "at least one," in reference to a list of one or more
elements, should be understood to mean at least one element
selected from anyone or more of the elements in the list of
elements, but not necessarily including at least one of each and
every element specifically listed within the list of elements and
not excluding any combinations of elements in the list of elements.
This definition also allows that elements may optionally be present
other than the elements specifically identified within the list of
elements to which the phrase "at least one" refers, whether related
or unrelated to those elements specifically identified. Thus, as a
non-limiting example, "at least one of A and B" (or, equivalently,
"at least one of A or B," or, equivalently "at least one of A
and/or B") can refer, in one embodiment, to at least one,
optionally including more than one, A, with no B present (and
optionally including elements other than B); in another embodiment,
to at least one, optionally including more than one, B, with no A
present (and optionally including elements other than A); in yet
another embodiment, to at least one, optionally including more than
one, A, and at least one, optionally including more than one, B
(and optionally including other elements); etc.
[0085] It should also be understood that, in certain methods
described herein that include more than one step or act, the order
of the steps or acts of the method is not necessarily limited to
the order in which the steps or acts of the method are recited
unless the context indicates otherwise.
[0086] The phrases "pharmaceutically or pharmacologically
acceptable" refer to molecular entities and compositions that do
not preclude use in a human or animal.
[0087] The terms "co-administration" and "co-administering" or
"combination therapy" refer to both concurrent administration
(administration of two or more therapeutic agents at the same time)
and time varied administration (administration of one or more
therapeutic agents at a time different from that of the
administration of an additional therapeutic agent or agents), as
long as the therapeutic agents are present in the patient to some
extent, preferably at effective amounts, at the same time. In
certain preferred aspects, one or more of the present compounds
described herein, are co-administered in combination with at least
one additional bioactive agent, especially including an anticancer
agent. In particularly preferred aspects, the co-administration of
compounds results in synergistic activity and/or therapy, including
anticancer activity.
[0088] The term "compound", as used herein, unless otherwise
indicated, refers to any specific chemical compound disclosed
herein and includes tautomers, regioisomers, geometric isomers, and
where applicable, stereoisomers, including optical isomers
(enantiomers) and other stereoisomers (diastereomers) thereof, as
well as pharmaceutically acceptable salts and derivatives
(including prodrug forms) thereof where applicable, in context.
Within its use in context, the term compound generally refers to a
single compound, but also may include other compounds such as
stereoisomers, regioisomers and/or optical isomers (including
racemic mixtures) as well as specific enantiomers or
enantiomerically enriched mixtures of disclosed compounds. The term
also refers, in context to prodrug forms of compounds which have
been modified to facilitate the administration and delivery of
compounds to a site of activity. It is noted that in describing the
present compounds, numerous substituents and variables associated
with same, among others, are described. It is understood by those
of ordinary skill that molecules which are described herein are
stable compounds as generally described hereunder. When the bond is
shown, both a double bond and single bond are represented within
the context of the compound shown.
[0089] The term "polypeptide" encompasses two or more naturally
occurring or synthetic amino acids linked by a covalent bond (e.g.,
an amide bond). Polypeptides as described herein include full
length proteins (e.g., fully processed proteins such as antibodies)
as well as shorter amino acids sequences (e.g., fragments of
naturally occurring proteins or synthetic polypeptide fragments
such as antigen-binding fragments of antibodies).
[0090] The term "patient" or "subject" is used throughout the
specification to describe an animal, preferably a human or a
domesticated animal, to whom treatment, including prophylactic
treatment, with the compositions according to the present
disclosure is provided. For treatment of those conditions or
disease states which are specific for a specific animal such as a
human patient, the term patient refers to that specific animal. In
general, in the present disclosure, the term patient refers to a
human patient unless otherwise stated or implied from the context
of the use of the term.
[0091] The term "effective" is used to describe an amount of a
compound, composition or component which, when used within the
context of its intended use, effects an intended result. The term
effective subsumes all other effective amount or effective
concentration terms, which are otherwise described or used in the
present application.
[0092] The term "inflammatory bowel disease" refers to The term
"lymphangiectasia" refers to a pathologic dilation of lymph nodes,
which causes a disease known as "intestinal lymphagiectasia."
[0093] The term "intestinal lymphangiectasia" refers to a disease
characterized by lymphatic vessel dilation, chronic diarrhea, and
loss of proteins, such as serum albumin and globulin. Considered to
be the cause of a chronic form of protein-losing enteropathy.
[0094] The term "enteropathy" refers to any pathology of the
intestine.
[0095] The term "protein losing enteropathy" (PLE) refers to any
condition of the gastrointestinal tract (e.g., damage to the gut
wall) that results in a net loss of protein from the body. Symptoms
include, e.g., diarrhea, fever, general abdominal discomfort,
hypoproteinemia, and/or edema. See, also, the discussion of PLE
above.
[0096] The term "thrombosis" refers to the formation of a blood
clot inside a blood vessel, thereby obstructing blood flow through
the circulatory system.
[0097] The term "thrombotic events" refers to the formation of a
blood clot inside a blood vessel, thereby obstructing blood flow
through the circulatory system
[0098] The term "thromboembolism" refers to the obstruction of a
blood vessel by a blood clot that has become dislodged from another
site in the circulatory system.
[0099] The term "hypoproteinemia" refers to a condition in which
there is an abnormally low level of protein in the blood and is
often accompanied with edema.
[0100] The term "angiopathic thrombosis" (or microangiopathic
hemolytic anemia) refers to the pathology that relates from
thrombosis in small blood vessels (such as capillaries and
arterioles). The thrombosis is usually a consequence of endothelial
cell injury, which results in fibrin exudation, fibrinoid necrosis,
platelet aggregation, and thus, the thrombosis of small blood
vessels
[0101] The term "hypogammaglobulinemia" refers to a type of
hypoproteinemia, in which the level of gamma globulins is
abnormally low, which results in primary immune deficiency
disease.
[0102] The term "hypoalbuminemia" refers to a type of
hypoproteinemia in which the level of albumin in the blood is
abnormally low.
[0103] The term "hyperactivation of complement" refers to a medical
sign in which the complement pathway is overly active.
[0104] The term "disease" refers to any condition that impairs the
normal functioning of the body. As such, diseases are associated
with dysfunctioning of the body's normal homeostatic processes.
[0105] The term "syndrome" refers to the association of several
medical signs, symptoms, and/or other characteristics that often
occur together, which may have a single or a multifactorial
cause.
[0106] The term "antibody" is used in the broadest sense and
specifically covers monoclonal antibodies (including full length
monoclonal antibodies), polyclonal antibodies, multi-specific
antibodies (e.g., bispecific antibodies), and antibody fragments so
long as they exhibit the desired biological activity.
[0107] "Antibody fragments" (i.e., an antigen-binding fragment of
an antibody), as defined for the purpose of the present disclosure,
comprise a portion of an intact antibody, generally including the
antigen binding or variable region of the intact antibody and
optionally the Fc region of an antibody. Examples of antibody
fragments include linear antibodies, single-chain antibody
molecules (e.g., scFv), F(ab').sub.2 fragments, Fab' fragments, and
multi-specific antibodies formed from antibody fragments. The
antibody fragments may retain at least part of the hinge and
optionally the C.sub.H1 region of an IgG heavy chain. The antibody
fragments may retain the entire constant region of an IgG heavy
chain, and include an IgG light chain.
[0108] The term "Fc region" is used to define a C-terminal region
of an immunoglobulin heavy chain. Although the boundaries of the Fc
region of an immunoglobulin heavy chain might vary, the human IgG
heavy chain Fc region is usually defined to stretch from an amino
acid residue at position Cys226, or from Pro230, to the
carboxyl-terminus thereof. The Fc region of an immunoglobulin
generally comprises two constant domains, C.sub.H2 and
C.sub.H3.
[0109] The term "F(ab) fragment" is defined as a fragment of an
immunoglobulin molecule that comprises the variable regions of a
light chain and a heavy chain. That is, a Fab fragment is a
monovalent antigen binding structure of an immunoglobulin without
the Fc portion, and which results from the treatment of an
immunoglobulin with papain.
[0110] The term "F(ab)' fragment" is defined as a fragment of an
immunoglobulin molecule that comprises the variable regions of a
light chain and a heavy chain. That is, the fragment is monovalent
and most of the Fc portion is removed, which can be achieved
through the treatment of an immunoglobulin molecule with pepsin and
.beta.-mercaptoethanol.
[0111] The term "F(ab').sub.2 fragment" is defined as a fragment of
an immunoglobulin molecule that comprises two F(ab) fragments and a
portion of the hinge region. That is, most of the Fc portion is
removed, which can be achieved through the treatment of an
immunoglobulin molecule with pepsin.
[0112] The term "single-chain variable fragments" (scFvs) is
defined as a polypeptide engineered to comprise the variable
regions (i.e., the antigen-binding domains) of a light
immunoglobulin chain and a heavy immunoglobulin chain. The light
chain and heavy chain can be joined by a flexible linker
sequence.
[0113] The term "monoclonal antibody" as used herein refers to an
antibody obtained from a population of substantially homogeneous
antibodies, i.e., the individual antibodies comprising the
population are identical except for possible naturally occurring
mutations that may be present in minor amounts. Monoclonal
antibodies are highly specific, being directed against a single
antigenic site. Furthermore, in contrast to conventional
(polyclonal) antibody preparations that typically include different
antibodies directed against different determinants (epitopes), each
monoclonal antibody is directed against a single determinant on the
antigen. The modifier "monoclonal" indicates the character of the
antibody as being obtained from a substantially homogeneous
population of antibodies, and is not to be construed as requiring
production of the antibody by any particular method. For example,
the monoclonal antibodies to be used in accordance with the present
disclosure may be made by the hybridoma method first described by
Kohler and Milstein 1975 Nature 256:495, or may be made by
recombinant DNA methods. The "monoclonal antibodies" may also be
isolated from phage antibody libraries.
[0114] The monoclonal antibodies herein specifically include
"chimeric" antibodies (immunoglobulins) in which a portion of the
heavy and/or light chain is identical with or homologous to
corresponding sequences in antibodies derived from a particular
species or belonging to a particular antibody class or subclass,
while the remainder of the chain(s) is identical with or homologous
to corresponding sequences in antibodies derived from another
species or belonging to another antibody class or subclass, as well
as fragments of such antibodies, so long as they exhibit the
desired biological activity.
[0115] "Humanized" forms of non-human (e.g., murine) antibodies are
chimeric antibodies that contain minimal sequence derived from
non-human immunoglobulin. For the most part, humanized antibodies
are human immunoglobulins (recipient antibody) in which residues
from a hypervariable region of the recipient are replaced by
residues from a hypervariable region of a non-human species (donor
antibody) such as mouse, rat, rabbit or nonhuman primate having the
desired specificity, affinity, and capacity. In some instances, Fv
framework region (FR) residues of the human immunoglobulin are
replaced by corresponding non-human residues. Furthermore,
humanized antibodies may comprise residues that are not found in
the recipient antibody or in the donor antibody. These
modifications are made to further refine antibody performance. In
general, the humanized antibody will comprise substantially all of
at least one, and typically two, variable domains, in which all or
substantially all of the hypervariable loops correspond to those of
a non-human immunoglobulin and all or substantially all of the FR
regions are those of a human immunoglobulin sequence. The humanized
antibody optionally also will comprise at least a portion of an
immunoglobulin constant region (Fc), typically that of a human
immunoglobulin.
[0116] The term "hypervariable region" when used herein refers to
the amino acid residues of an antibody that are responsible for
antigen-binding. The hypervariable region comprises amino acid
residues from a "complementarity determining region" or "CDR"
(i.e., residues 24-34 (L1), 50-56 (L2) and 89-97 (L3) in the light
chain variable domain and 31-35 (H1), 50-65 (H2) and 95-102 (H3) in
the heavy chain variable domain and/or those residues from a
"hypervariable loop" (i.e., residues 26-32 (L1), 50-52 (L2) and
91-96 (L3) in the light chain variable domain and 26-32 (H1), 53-55
(H2) and 96-101 (H3) in the heavy chain variable domain).
"Framework" or "FR" residues are those variable domain residues
other than the hypervariable region residues as herein defined.
[0117] An "isolated" polypeptide is one that has been identified
and separated and/or recovered from a component of its natural
environment. Contaminant components of its natural environment are
materials that would interfere with diagnostic or therapeutic uses
for the polypeptide, and may include enzymes, hormones, and other
proteinaceous or nonproteinaceous solutes. In preferred
embodiments, the polypeptide will be purified (1) to greater than
95% by weight of polypeptide as determined by the Lowry method, and
most preferably more than 99% by weight, (2) to a degree sufficient
to obtain at least 15 residues of N-terminal or internal amino acid
sequence by use of a spinning cup sequenator, or (3) to homogeneity
by SDS-PAGE under reducing or non-reducing conditions using
Coomassie blue or, preferably, silver stain. Isolated polypeptide
includes the polypeptide in situ within recombinant cells since at
least one component of the polypeptide's natural environment will
not be present. Ordinarily, however, isolated polypeptides will be
prepared by at least one purification step.
[0118] In an aspect, the disclosure provides a method of diagnosing
a patient or subject with CD55 deficiency, hyperactivation of
complement, angiopathic thrombosis and protein losing enteropathy
(CHAPLE). The method comprises: providing a sample from a patient;
performing an assay to detect at least one of: at least one
mutation in a DNA sequence of a CD55 gene, at least one mutation in
a RNA sequence of a CD55 transcript as compared to wild-type, at
least one mutation in a DNA sequence of a CD55 complementary DNA
(cDNA), decay-accelerating factor (DAF) or CD55 protein, complement
deposition, or a combination thereof; and diagnosing the patient
with CHAPLE. In an embodiment, the mutations in the DNA sequence of
the CD55 gene or cDNA or the mutation in the RNA sequence of the
CD55 RNA/transcript results in diminished CD55 protein expression
(e.g., substantially diminished or devoice of CD55 expression) or
diminished or non-functional CD55 protein function (e.g., a CD55
that has diminished or that is incapable of binding C3b and/or
C4b).
[0119] In an embodiment, the patient is diagnosed with CHAPLE when
at least one of the following is detected: (i) at least one
mutation in a DNA sequence, an RNA sequence or a cDNA sequence of
CD55 that results in a CD55 protein with substantially diminished
functional activity, a CD55 protein with no functional activity, a
lack of expression of CD55 protein (i.e., no CD55 protein
expression), or a substantially diminished expression of CD55
protein; (ii) a CD55 protein with substantially diminished
functional activity; (iii) a CD55 protein with no functional
activity; (iv) a lack of expression of CD55 protein (i.e., no CD55
protein expression); (v) a substantially diminished expression of
CD55 protein; or (vi) a combination thereof.
[0120] In another embodiment, the patient is diagnosed with CHAPLE
when the patient has at least one CHAPLE related symptom and at
least one of the following is detected: (i) at least one mutation
in a DNA sequence, an RNA sequence or a cDNA sequence of CD55 that
results in a CD55 protein with substantially diminished functional
activity, a CD55 protein with no functional activity, a lack of
expression of CD55 protein (i.e., no CD55 protein expression), or a
substantially diminished expression of CD55 protein; (ii) a CD55
protein with substantially diminished functional activity; (iii) a
CD55 protein with no functional activity; (iv) a lack of expression
of CD55 protein (i.e., no CD55 protein expression); (v) a
substantially diminished expression of CD55 protein; or (vi) a
combination thereof.
[0121] The sample can be any sample that would contain genome DNA
(gDNA) or that normally contains CD55 (i.e., a sample in which CD55
is found/expressed in an individual without CHAPLE). For example,
the sample may be a blood sample, such as peripheral blood
mononuclear cells (PBMC). Providing a sample can comprise at least
one of: obtaining a sample from a patient (e.g., at least one
PBMC), isolating gDNA from a patient sample, isolating (and/or
purifying) protein from a patient sample or a combination
thereof.
[0122] The CHAPLE associated symptom can include at least one of
the following symptoms: inflammatory bowel disease, enteropathy,
protein losing enteropathy, protein losing enteropathy associated
with hypoalbuminemia, hypoalbuminemia, hypogammaglobulinemia,
intestinal lymphangiectasia, lymphangiectasia, thrombotic events,
thromboembolism, hyperactivation of complement, angiopathic
thrombosis, hypoproteinemia, or a combination thereof. For example,
the patient may have at least one, at least two, at least three, at
least four, at least five, at least six, at least seven, at least
eight, at least nine, at least ten, at least eleven, at least
twelve or all thirteen of the symptoms. In particular embodiments,
the patient may have at least one of the following symptoms:
inflammatory bowel disease, protein losing enteropathy associated
with hypoalbuminemia, hypogammaglobulinemia, intestinal
lymphangiectasia, thrombotic events or a combination thereof. For
example, the patient can have at least two of the symptoms, at
least three of the symptoms, at least four of the symptoms, or all
five of the symptoms. That is, in certain embodiments, the patient
has inflammatory bowel disease, protein losing enteropathy
associated with hypoalbuminemia, hypogammaglobulinemia, intestinal
lymphangiectasia, and thrombotic events.
[0123] The method can further comprise administering an effective
amount of a composition of the present disclosure to the subject
with CHAPLE, wherein the composition is effective in treating or
preventing at least one symptom of CHAPLE. For example, the
composition may comprise at least one complement inhibitor. The
complement inhibitor can be selected from the group consisting of
at least one serine protease inhibitor, at least one soluble
complement regulator, at least one therapeutic antibody or
antigen-binding fragment thereof, at least one complement component
inhibitor, and at least one anaphylatoxin receptor antagonist.
[0124] In a further embodiment, the method further includes
administering at least one additional agent selected from the group
consisting of an anticoagulant or a thrombolytic agent,
somatostatin analogues (e.g., octreotide), glucocorticoids,
mesalizine, another immunosuppressive agent (e.g., TNF-.alpha.
blocker), an albumin transfusion, intravenous immunoglobulins or a
combination thereof. The additional agent can be included within
the composition where appropriate or co-administered, as discussed
above.
[0125] In an embodiment, the method of diagnosing a patient with
CHAPLE can further comprise confirming the diagnosis by
administering the composition of the present disclosure, thereby
treating at least one symptom of CHAPLE (i.e., a CHAPLE related
symptom) or preventing the reoccurrence of at least one symptom of
CHAPLE.
[0126] The mutation of the present disclosure, i.e., mutations in
the DNA sequence of the CD55 gene (which can be determined or
detected by a mutation in the RNA sequence of the CD55 transcript
(e.g., mRNA) or the DNA sequence of CD55 cDNA), can result in a
near to complete absence of CD55 protein expression or the
expression of CD55 protein with substantially diminished function
or that is non-functional. That is, the mutant CD55 protein can
have diminished (or decreased) function relative to wild-type CD55.
For example, mutant CD55 may bind C4b and/or C3b with lesser (or
decreased) affinity and/or avidity, or not at all. In certain
embodiments, CD55 is not present or substantially not present in
patients with CHAPLE syndrome/disease.
[0127] As discussed above, the mutation in the DNA sequence of the
CD55 gene (and therefore, the RNA sequence of the transcript and
the DNA sequence of the cDNA of the CD55 gene) can be any mutation
that results in: (i) the expression of CD55 protein with decreased
function relative to wild-type CD55 (e.g., CD55 protein with
substantially no ability to bind C3b and/or C4b); and/or (ii) a
decreased amount of CD55 expression relative to wild-type CD55
(e.g., no expression of CD 55 protein). For example, the mutation
in the DNA sequence of the CD55 gene (which one skilled in the art
would appreciate that these mutations can be detected in the RNA
and DNA sequences of CD55 transcripts and cDNA, respectively) can
be at least one of c.149-150delAA, c.149-150insCCTT, c.109delC,
c.800G>C, c.287-1G>C, c.149-150delAAinsCCTT or a combination
thereof. That is, in an embodiment, the DNA sequence of the CD55
gene has at least one, at least two, at least three, or all four of
the above-mentioned mutations in the DNA sequence of the CD55 gene,
or the related transcript or cDNA.
[0128] In further embodiments, detecting can include at least one
of: (i) sequencing at least a portion of the CD55 gene or the CD55
transcript or the CD55 cDNA (or amplicons produced from the CD55
gene, transcript, or cDNA); or (ii) contacting a labeled nucleic
acid probe (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more probes) to
at least a portion of the CD55 gene or the CD55 transcript or the
CD55 cDNA (or amplicons produced from the CD55 gene, transcript, or
cDNA); or (iii) contacting at least a portion of the CD55 gene or
CD55 transcripts or the CD55 cDNA (or amplicons produced from the
CD55 gene, transcript, or cDNA) with a microarray; or (iv) a
combination thereof.
[0129] Hybridization of the labeled nucleic acid probe brought into
contact with CD55 gDNA, RNA transcripts, or cDNA (or amplicons
produced from the CD55 gene, transcript, or cDNA) from the
patient's sample can be indicative of a mutation in the portion of
the CD55 gene or CD55 transcript or the CD55 cDNA. Alternatively,
hybridization of the labeled nucleic acid probe that was brought
into contact with CD55 gDNA, RNA transcripts, or cDNA (or amplicons
produced from the CD55 gene, transcript, or cDNA) from the
patient's sample can be indicative of the portion of the CD55 gene
or CD55 transcript or the CD55 cDNA having a wild-type sequence at
(or lacking CD55 associated mutations in the portion hybridized)
the location of hybridization.
[0130] Sequencing at least a portion of the CD55 gene (or the CD55
transcript or CD55 cDNA that is produced from the CD55 transcripts)
can include amplifying at least one region of interest for
sequencing. The region of interest for sequencing can include any
coding sequence (exon) of the CD55 gene or any CD55 exon and
portions that flank the exons. For example, in a particular
embodiment, at least one polymerase chain reaction (PCR) is
performed with at least one of the following primer sets to produce
amplicons of the CD55 gene, mRNA (e.g., transcripts), and/or cDNA:
(i) CTACTCCACCCGTCTTGTTTGT and TTTGGGGGTTAAGGATACAGTC (Exon 1);
(ii) CAGGTGTGGCATTTCAAGG and ACCCTGGGGTTTAGTAACGC (Exon 2); (iii)
AAGTACTAAATATGCGCAAAGCAG and ATGGTCCTATCAAGAAACATCC (Exon 3); (iv)
GTTACCTTCTTTGTGTGTATGCC and GCTGTGAATACCAGTCATGAAAC (Exon 4); (v)
AACCTGGAGAATTTGAGGAAAG and TGTGCTAATATTCTTAAGGGGC (Exon 5); (vi)
GCATTTATAAGCATCTCTTGTTGG and TCATTGAATGTCTGCAACCC (Exon 6); (vii)
CTAGGTGTTTGTGGGGAGAGAG and TCTGGTGGGTTTCTGAAGAGTT (Exon 7); (viii)
TTTACGCAGAGTCCTTCAGC and CCATTTAATCCTGCAATCTTGG (Exon 8); (ix)
TGGAAATTTGAGTTGCTTTCG and TCTCCCAGGAATATGGATTG (Exon 9); (x)
GCACCCCAAATTAACTGATTC and ATGTGATTCCAGGACTGCC (Exon 10); or (xi) a
combination thereof.
[0131] Contacting a labeled nucleic acid probe to at least a
portion of the CD55 gene (or the CD55 transcript or the CD55 cDNA
produced from the CD55 transcript, or amplicons produced from the
CD55 gene, transcript, or cDNA) can be performed or accomplished
with real-time PCR. Hybridization of a real-time PCR probe can be
indicative of a mutation in the portion of the CD55 gene or CD55
transcript or CD55 cDNA (or amplicons produced from the CD55 gene,
transcript, or cDNA). Alternatively, hybridization of a real-time
PCR probe can be indicative of the portion of the CD55 gene or CD55
transcript or CD55 cDNA (or amplicons produced from the CD55 gene,
transcript, or cDNA) having a wild-type sequence at the location of
hybridization (or amplicons produced from the CD55 gene,
transcript, or cDNA). Furthermore, contacting a labeled nucleic
acid probe to at least a portion of the CD55 cDNA (or amplicons
produced from the CD55 transcripts or cDNA) may comprise: isolating
CD55 transcripts; reverse transcribing at least a portion of the
CD55 transcripts; and contacting the cDNA with the labeled nucleic
acid probe. This may further comprise amplifying a portion or
region of interest via PCR (see discussion above) prior to
contacting the amplicons produced from CD55 cDNA with the labeled
nucleic acid probe.
[0132] The microarray can include probes (e.g., immobilized probes)
designed or configured to detect or bind CD55 gene (i.e., the sense
and/or antisense DNA stand(s)), transcripts (i.e., mRNA), or cDNA
sequence (or amplicons produced from the CD55 gene, transcript, or
cDNA) of a patient with at least one mutation that result in the
complete absence in CD55 protein or a CD55 protein with
substantially diminished or devoid of function, as described above.
Alternatively, the microarray can include probes (e.g., immobilized
probes) designed or configured to detect or bind a wild-type CD55
DNA, transcript (i.e., RNA), or cDNA sequence (or amplicons
produced from the CD55 gene, transcript, or cDNA) of a patient or
subject. In a further embodiment, the microarray may include probes
designed or configured to individually detect (i.e., separately
detect) both CD55 mutations and wild-type CD55.
[0133] As used herein, the terms "probe(s)" and "primer(s)" refers
to oligonucleotide sequences that may readily be prepared based on
the CD55 nucleic acids described herein. A probe may comprise an
isolated nucleic acid attached to a detectable label or reporter
molecule. In any aspect or embodiment described herein, the
detectable label or label is selected from the group consisting of
an enzyme, a chemiluminescent agent, a ligand, biotin,
streptavidin, a radioactive molecule, and an immunofluorescent
protein or dye. Methods for labeling and guidance in the choice of
labels appropriate for various purposes are discussed, e.g., in
Sambrook et al. (1989) and Ausubel et al. (1987). "Primers" are
short nucleic acids, such as DNA oligonucleotides 15 nucleotides or
more in length (e.g., 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,
23, 24, 25, 26, 27, 28, 29, or 30 nucleotides in length). Primers
may be annealed to a complementary target DNA strand by nucleic
acid hybridization to form a hybrid between the primer and the
target DNA strand, and then extended along the target DNA strand by
a DNA polymerase enzyme. Primer pairs can be used for amplification
of a nucleic acid sequence, e.g., by the polymerase chain reaction
(PCR) or other nucleic-acid amplification methods known in the
art.
[0134] Methods for preparing and using probes and primers are
described, for example, in Sambrook et al. (1989), Ausubel et al.
(1987), and Innis et al., (1990). PCR primer pairs can be derived
from a known sequence, for example, by using computer programs
intended for that purpose such as Primer (Version 0.5, 1991,
Whitehead Institute for Biomedical Research, Cambridge, Mass.). One
of skill in the art will appreciate that the specificity of a
particular probe or primer increases with its length. Thus, for
example, a primer comprising 20 consecutive nucleotides of the
human CD55 cDNA, RNA, or gene will anneal to a-target sequence such
as a CD55 gene within a genomic DNA sample with a higher
specificity than a corresponding primer of only 15 nucleotides.
Thus, in order to obtain greater specificity, probes and primers
may be selected that comprise 20, 25, 30, 35, 40, 50 or more
consecutive nucleotides that are complementary to the nucleotide
sequence at the site of a mutation as described herein or the
wild-type sequence at the same location.
[0135] Thus, the probe or probes of the present disclosure can
include a nucleic acid sequence that is complementary (e.g.,
hybridizes under stringent conditions) to the site of a mutation as
described herein or the wild-type nucleic acid sequence at the same
location. The probe can include complementary bases 5' and 3' of
the site of mutation. For example, the probe includes complementary
bases 5' of the site of mutation by at least 1, 2, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24,
25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41,
42, 43, 44, 45, 45, 46, 47, 48, 49, or 50 nucleotides (e.g., the
probe include complementary bases 5' of the site of mutation by 1,
2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43, 44, 45, 45, 46, 47, 48, 49, or 50
nucleotides). For example, the probe includes complementary bases
3' of the site of mutation by at least 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43,
44, 45, 45, 46, 47, 48, 49, or 50 nucleotides (e.g., the probe
include complementary bases 3' of the site of mutation by 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38,
39, 40, 41, 42, 43, 44, 45, 45, 46, 47, 48, 49, or 50 nucleotides).
As described above, in certain embodiments, the probe is
complementary to the wild-type sequence, wherein no hybridization
is indicative of a mutation and/or hybridization is indicative of
no mutation. In other embodiments, the probe is complementary to a
mutation as described herein, wherein hydridization is indicative
of a mutation and/or no hybridization is indicative of no mutation.
As described above, the probe can be complementary to the mRNA, the
DNA sense strand, the DNA antisense strand, and/or cDNA.
[0136] In any aspect or embodiments described herein, the nucleic
acid probes and/or primes of the disclosure hybridize specifically
to target polynucleotides of interest (i.e., a wild-type nucleic
acid sequence or a mutation containing nucleic acid sequence as
described herein) under stringent conditions. Two molecules
hybridizing to each other under stringent conditions is an
indication that the two nucleic acid sequences are substantially
identical. Stringent conditions are sequence dependent and
different under different environmental parameters and for
different assays. As used herein, "stringent conditions" or
"stringent hybridization conditions" means any conditions in which
hybridization will occur when there is at least about 95%, at least
96%, at least 97%, at feat 98%, or at least 99% nucleotide
complementarity or identity (e.g., about 95% to about 100% or about
97 to about 100%, such as about 95%. about 96%. about 97%, about
98%, about 99%, or about 100%) between the nucleic acids (e.g., a
polynucleotide of interest and a nucleic acid probe). For example,
stringent conditions for may be selected to be about 5.degree. C.
to 20.degree. C. lower than the thermal melting point (T.sub.m) the
specific sequence at a defined ionic strength and pH. The T.sub.m
is the temperature (under defined ionic strength and pH) at which
50% of the target sequence hybridizes to a perfectly matched probe.
Conditions for nucleic acid hybridization and calculation of
stringencies can be found in Sambrook et al. (1989) and Tijssen
(1993) and are otherwise known in the art.
[0137] For example, appropriate high stringent hybridization
conditions for microarray may include, e.g., hybridization in a
buffer, such as 6.times.SSPE-T (0.9 M NaCl, 60 mM
NaH.sub.2PO.sub.4, 6 mM EDTA and 0.05% Triton X-100) for between
about 10 minutes and about at least 3 hours (e.g., at least about
15 minutes) at a temperature ranging from about 4.degree. C. to
about 37.degree. C. In an embodiment, hybridization under high
stringent conditions is carried out in 5.times.SSC, 50% dionized
Formamide, 0.1% SDS at 42.degree. C. overnight.
[0138] Hybridization specificity can be evaluated by comparing the
hybridization of specificity-control nucleic acid probes to
specificity-control target polynucleotides that are added to a
sample in a known amount. The specificity-control target
polynucleotides may have one or more sequence mismatches compared
with the corresponding nucleic acid probes. In this manner, whether
only complementary target polynucleotides are hybridizing to the
nucleic acid probes or whether mismatched hybrid duplexes are
forming is determined.
[0139] Hybridization reactions can be performed in absolute or
differential hybridization formats. In the absolute hybridization
format, target polynucleotides from one sample are hybridized to
the probes in an array (e.g., in a microarray format) and signals
detected after hybridization complex formation correlate to target
polynucleotide levels in a sample. In the differential
hybridization format, the differential expression of a set of genes
in two biological samples is analyzed. For differential
hybridization, target polynucleotides from both biological samples
are prepared and labeled with different labeling moieties. A
mixture of the two labeled target polynucleotides is added to an
array (e.g., a microarray). The array is then examined under
conditions in which the emissions from the two different labels are
individually detectable. Probes in the array that are hybridized to
substantially equal numbers of target polynucleotides derived from
both biological samples give a distinct combined fluorescence
(Shalon et al. PCT publication WO95/35505). In a preferred
embodiment, the labels are fluorescent labels with distinguishable
emission spectra.
[0140] After hybridization, the array (e.g., microarray) is washed
to remove nonhybridized polynucleotides and complex formation
between the hybridizable array elements and the target
polynucleotides is detected. Methods for detecting complex
formation are well known to those skilled in the art. In a
preferred embodiment, the target polynucleotides are labeled with a
fluorescent label and levels and patterns of fluorescence
indicative of complex formation are measured. In one embodiment,
the measurement is accomplished by fluorescence microscopy,
preferably confocal fluorescence microscopy. An argon ion laser
excites the fluorescent label, emissions are directed to a
photomultiplier and the amount of emitted light detected and
quantitated. The detected signal should be proportional to the
amount of probe/target polynucleotide complex at each position of
the microarray. The fluorescence microscope can be associated with
a computer-driven scanner device to generate a quantitative
two-dimensional image of hybridization intensity. The scanned image
is examined to determine the abundance/expression level of each
hybridized target polynucleotide. In another embodiment, the
measurement of levels and patterns of fluorescence is accomplished
with a fluorescent imaging device, such as a microarray scanner
(e.g., Axon scanner with GenePix Pro software). As with the
previous measurement method, the measurements can be used to
determine the abundance/expression level of each hybridized target
polynucleotide, thereby determining whether there is a mutation as
described herein and/or the expression level of CD55 dependening
upon the technique utilized.
[0141] Detecting CD55 protein can be performed via any known
protein detection technique, e.g., western blot, flow cytometry, an
immunoassay, microscopy, protein immunostaining,
immunoelectrophoresis, spectrophotometry, etc. For example,
detecting CD55 protein can comprise: contacting the sample with at
least one CD55 binding polypeptide. The CD55-binding polypeptide
can be an anti-CD55 antibody or a CD55-binding fragment thereof.
The CD55-binding polypeptide may be used in any assay that can
detect either a wild-type CD55 protein or a mutant CD55 protein
that has substantially diminished functional activity, for example,
the CD55 has decreased or no binding activity for C3b and/or C4b
(discussed in greater detail above), or both. The CD55 binding
polypeptides can include a detectable label. For example, the
labelled CD55 binding polypeptide can include a fluorescent label
or an enzyme, which facilitates the detection of the CD55 protein
(mutant and/or wild-type, as discussed above) via flow cytometry or
ELISA/western blot, respectively. One skilled in the art would
appreciate that the CD55-binding polypeptide may be utilized in
numerous other techniques, e.g., see above and below, to detect
mutant CD55 protein, wild-type CD55 protein, or both mutant and
wild-type CD55 protein.
[0142] Detecting CD55 protein can further comprise contacting the
sample or a CD55-CD55-binding polypeptide complex with at least one
secondary polypeptide that binds specifically to the CD55 binding
polypeptide. The secondary polypeptide can include a detectable
label. The secondary polypeptide can be an antibody or fragment
thereof that binds the CD55 binding polypeptide. For example, the
labelled secondary polypeptide can include a fluorescent label or
an enzyme, which facilitates the detection of the CD55 protein
(mutant and/or wild-type, as discussed herein) via flow cytometry
or ELISA/western blot, respectively.
[0143] The present disclosure contemplates the use of any suitable
detection assay, which is known or becomes known to those skilled
in the art. As would be appreciated by the skilled artisan in view
of the present disclosure, any particular detection assay could be
employed with no more than routine experimentation. In certain
embodiments, the step of detecting CD55 protein is performed using
at least one of a western blot, flow cytometry, an immunoassay, or
a combination thereof. For example, the immunoassay can be at least
one assay selected from the group consisting of enzyme-linked
immunosorbent assay (ELISA), flow cytometry, radioimmunoassay,
magnetic immunoassay, enzyme-linked immunospot (ELISPOT), and
immunofluorescence. For example, detecting CD55 protein can be
performed using a western blot of protein isolated from (e.g., a
crude or purified protein isolate) the patient sample (e.g., PBMCs)
or flow cytometry performed on, e.g., PBMCs, in which CD55 is
detected with a CD55-binding polypeptide, which includes a
detectable label (or marker) or via at least one secondary
polypeptide that includes a detectable label (or marker).
Alternatively, a sandwich (or capture) ELISA could be utilized, in
which the PBMCs are captured by, e.g., an antibody known to bind
the surface of a PBMC (or a CD55 binding protein) thereby capturing
the PBMCs, and detecting CD55 protein through the binding of a
CD55-binding polypeptide. The CD55-binding polypeptide can include
a detectable label or a secondary polypeptide with a detectable
label may be used, as discussed herein.
[0144] In another embodiment, the detecting of CD55 binding
function includes examining at least one of C3b affinity, C3b
avidity, C4b affinity, C4b avidity or a combination thereof. That
is, CD55 binding to C3b and/or C4b may be assessed by determining
the affinity and/or avidity of the CD55-C3b or CD55-C4b
interaction/binding. Examination of this function interaction
(e.g., affinity and/or avidity) can be performed by methods
well-known in the art with routine experimentation for one skilled
in the art.
[0145] In a particular embodiment, detecting complement deposition
includes detecting C3d deposition. For example, the patient sample
(e.g., PBMCs) may be contacted with a C3d binding polypeptide. The
Cd3 bound Cd3 binding polypeptide can include a detectable label
(or marker) or the complex may be detected with a secondary
polypeptide that is specific for the Cd3 binding polypeptides and
has a detectable label. As such, Cd3 may be detected by any of the
methods articulated for detecting CD55, such as flow cytometry or
ELISA.
[0146] In a further aspect, the disclosure provides a method of
treating a patient having CD55 deficiency, hyperactivation of
complement, angiopathic thrombosis and protein losing enteropathy
(CHAPLE) or preventing at least one symptom of CHAPLE in a patient
at risk of developing the same. The method comprises administering
an effective amount of a composition comprising at least one (e.g.,
at least two, at least three, at least four, or at least five)
complement inhibitor (e.g., one, two, three, four, five, six,
seven, eight, nine, or ten complement inhibitors) to a subject in
need thereof, wherein the composition is effective in treating
and/or preventing at least one symptom of CHAPLE.
[0147] In some embodiments, the complement inhibitor is at least
one of a serine protease inhibitor, a soluble complement regulator,
a therapeutic antibody or an antigen-binding fragment thereof, a
complement component inhibitor (e.g., a small molecule), an
anaphylatoxin receptor antagonist, or a combination thereof.
[0148] In certain embodiments, the serine protease inhibitors is at
least one of a C3 convertase inhibitor, a C5 convertase inhibitor,
a C1 inhibitor, a C1r inhibitor, a C1s inhibitor, a C2a inhibitor,
a MASP-1 inhibitor, a MASP-2 inhibitor, a factor D inhibitor, a
factor B inhibitor, a factor I inhibitor or a combination thereof.
For example, the serine protease inhibitor can be at least one of
the metBCX-1470 (BioCryst, Birmingham, Ala., USA), C1s-INH-248
(Knoll/Abbott, Abbott Park, Ill., USA), compstatin, Cetor.RTM.
(Sanquin, Amsterdam, Netherlands), Berinert.RTM. (CSL Behring, King
of Prussia, Pa., USA), Cinryze.TM. (ViroPharma, Exton, Pa., USA),
rhC 1INH (Pharming Group N.V., Leiden, Netherlands), Ruconest.RTM.
(Salix Pharmaceuticals, Inc., Raleigh, N.C., USA) or a combination
thereof. Eculizumab is a recombinant humanized monoclonal antibody
to C5, which inhibits the cleavage of C5 to C5a and C5b by the C5
convertase. As such, eculizumab is a terminal complement inhibitor
that prevents C5b-9 formation (see, e.g., U.S. Pat. No. 9,409,980).
Eculizumab was approved by the US Food and Drug Administration
(FDA) in 2007 for the treatment of PNH and in 2011 for the
treatment of aHUS.
[0149] In other embodiments, the soluble complement regulator is at
least one of a soluble form of a membrane cofactor protein (MCP or
CD46), a soluble form of a decay-accelerating factor (DAF or CD55),
a soluble form of a membrane attack complex-inhibitor protein
(MAC-IP or CD59), a soluble form of complement receptor 1 (CD35) or
a combination thereof. For example, the soluble complement
regulator can be at least one of sCR1 (TP10; Advant
Immunotherapeutics, Needham, Mass., USA), sCR1-sL.sup.ex (TP10;
Advant Immunotherapeutics, Needham, Mass., USA), sDAG-sMCP hybrid
(MLN-2222, Millennium, Cambridge, Mass., USA), a membrane-tethered
sCD59 (Mirococept or APT070; Inflazyme Pharmaceuticals, Vancouver,
British Columbia, Canada) or a combination thereof.
[0150] In further embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or a combination thereof. The
binding can inhibit complement activation by at least one of
blocking association/binding with other complement proteins,
blocking association/binding with receptor proteins, blocking
serine protease activity or a combination thereof. For example, the
therapeutic antibody or the antigen-binding fragment thereof can be
at least one of eculizumab (Soliris.RTM.; Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ALXN1007 (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), neutrazumab (G2 Therapies,
Darlinghurst, NSW, Australia), Pexelizumab (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ofatumumab (Genmab A/S, Copenhagen,
Denmark), HuMax-CD38 (Benmab A/S, Copenhagen, Denmark), TNX-558
(Tanox, South San Francisco, Calif., USA), TNX-234 (Tanox, South
San Francisco, Calif., USA), TA106 (Taligen, Aurora, Colo., USA),
anti-properdin (Novelmed, Cleveland, Ohio, USA) or a combination
thereof. The therapeutic antibody or antigen-binding fragment
thereof, may be a linear antibodies, single-chain antibody
molecules (e.g., scFv), F(ab').sub.2 fragments, Fab' fragments, or
multi-specific antibodies formed from antibody fragments.
Furthermore, the antibody or antigen-binding fragment thereof may
be a humanized antibody, e.g. a humanized anti-C5 antibody.
Additionally, the antibody may be a monoclonal antibody, such as an
anti-C5 monoclonal antibody. For example, the antibody may be a
monoclonal, humanized anti-C5 antibody.
[0151] In yet other embodiments, the complement component inhibitor
is a peptide, nucleic acids, a synthetic molecule or a combination
thereof that disrupts protein functions by steric hindrance or the
induction of conformational changes. For example, the complement
component inhibitor can be at least one of compstatin, anti-C5 RNA
aptamer (ARC1905; Archemix, Cambridge, Mass., USA), or analogs or
derivatives thereof, or a combination thereof.
[0152] In another embodiment, the anaphylatoxin receptor antagonist
is at least one of a C5aR antagonist, a C5L2 antagonist, a C3a
receptor antagonist, a functional blocking antibody of an
anaphylatoxin or a combination thereof. For example, the
anaphylatoxin receptor antagonist is at least one of PMX-53
(PepTech Corp, Bedform, Mass., USA), PMX-205 (PepTech Corp,
Bedform, Mass., USA), JPE-1375 (Jerini, Berlin, Germany), JSM-7717
(Jerini, Berlin, Germany), rhMBL (Enzon Pharmaceuticals, Cranford,
N.J., USA) or a combination thereof.
[0153] In another aspect, the disclosure provides a composition for
treating or preventing at least one symptom of CD55 deficiency,
hyperactivation of complement, angiopathic thrombosis and protein
losing enteropathy (CHAPLE). The composition comprises an effective
amount of two or more agents, wherein at least one of the agents is
a complement inhibitor to a subject in need thereof, and the
composition is effective in treating or preventing at least one
symptom of CHAPLE. In an embodiment, the least two of the agents
are a complement inhibitor, e.g., a C3 convertase inhibitor and a
C5 convertase inhibitor. In another embodiment, the effective
amount is a synergistically effective amount. In another
embodiment, the composition is a therapeutic composition further
comprising a pharmaceutically acceptable carrier.
[0154] In an additional embodiment, the complement inhibitor is
selected from the group consisting of a serine protease inhibitor,
a soluble complement regulator, a therapeutic antibody or an
antigen-binding fragment thereof, a complement component inhibitor,
and an anaphylatoxin receptor antagonist, each as described
herein.
[0155] In further embodiments, the complement inhibitors include a
C3 convertase inhibitor and a C5 convertase inhibitor. In other
embodiments the complement inhibitors include a soluble form of a
CD55 and at least one of a C3 convertase inhibitor, a C5 convertase
inhibitor or a combination thereof.
[0156] In certain embodiments, the serine protease inhibitors is at
least one of a C3 convertase inhibitor, a C5 convertase inhibitor,
a C1 inhibitor, a C1r inhibitor, a C1s inhibitor, a C2a inhibitor,
a MASP-1 inhibitor, a MASP-2 inhibitor, a factor D inhibitor, a
factor B inhibitor, a factor I inhibitor or a combination
thereof.
[0157] In a particular embodiment, the serine protease inhibitor is
at least one of BCX-1470 (BioCryst, Birmingham, Ala., USA),
C1s-INH-248 (Knoll/Abbott, Abbott Park, Ill., USA), compstatin,
Cetor.RTM. (Sanquin, Amsterdam, Netherlands), Berinert.RTM. (CSL
Behring, King of Prussia, Pa., USA), Cinryze.TM. (ViroPharma,
Exton, Pa., USA), rhC1INH (Pharming Group N.V., Leiden,
Netherlands), Ruconest.RTM. (Salix Pharmaceuticals, Inc., Raleigh,
N.C., USA) or a combination thereof.
[0158] In other embodiments, the soluble complement regulator is at
least one of a soluble form of a membrane cofactor protein (MCP or
CD46), a soluble form of a decay-accelerating factor (DAF or CD55),
a soluble form of a membrane attack complex-inhibitor protein
(MAC-IP or CD59), a soluble form of complement receptor 1 (CD35) or
a combination thereof.
[0159] In an embodiment, the soluble complement regulator is at
least one of sCR1 (TP10; Advant Immunotherapeutics, Needham, Mass.,
USA), sCR1-sL.sup.ex (TP10; Advant Immunotherapeutics, Needham,
Mass., USA), sDAG-sMCP hybrid (MLN-2222, Millennium, Cambridge,
Mass., USA), a membrane-tethered sCD59 (Mirococept or APT070;
Inflazyme Pharmaceuticals, Vancouver, British Columbia, Canada) or
a combination thereof.
[0160] In other embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one polypeptide that
binds C3, C3a, C3b, C3 convertase, C5, C5a, C5b, C5 convertase, C7,
C8, or C9, factor B, factor D, C4, C2, C1, properdin, a functional
blocking antibody of an anaphylatoxin or a combination thereof,
wherein said binding inhibits complement activation by at least one
of blocking association/binding with other complement proteins,
blocking association/binding with receptor proteins, blocking
serine protease activity or a combination thereof.
[0161] In certain embodiments, the therapeutic antibody or the
antigen-binding fragment thereof is at least one of eculizumab
(Soliris.RTM.; Alexion Pharmaceuticals Inc., New Haven, Conn.,
USA), ALXN1007 (Alexion Pharmaceuticals Inc., New Haven, Conn.,
USA), neutrazumab (G2 Therapies, Darlinghurst, NSW, Australia),
Pexelizumab (Alexion Pharmaceuticals Inc., New Haven, Conn., USA),
ofatumumab (Genmab A/S, Copenhagen, Denmark), HuMax-CD38 (Benmab
A/S, Copenhagen, Denmark), TNX-558 (Tanox, South San Francisco,
Calif., USA), TNX-234 (Tanox, South San Francisco, Calif., USA),
TA106 (Taligen, Aurora, Colo., USA), anti-properdin (Novelmed,
Cleveland, Ohio, USA) or a combination thereof.
[0162] In yet other embodiments, the complement component inhibitor
is a peptide, nucleic acids, a synthetic molecule or a combination
thereof that disrupts protein functions by steric hindrance or the
induction of conformational changes.
[0163] In a particular embodiment, the complement component
inhibitor is at least one of compstatin, anti-C5 RNA aptamer
(ARC1905; Archemix, Cambridge, Mass., USA), or analogs or
derivatives thereof, or a combination thereof.
[0164] In additional embodiments, the anaphylatoxin receptor
antagonist is at least one of a C5aR antagonist, a C5L2 antagonist,
a C3a receptor antagonist, a functional blocking antibody of an
anaphylatoxin or a combination thereof.
[0165] In certain embodiments, the anaphylatoxin receptor
antagonist is at least one of PMX-53 (PepTech Corp, Bedform, Mass.,
USA), PMX-205 (PepTech Corp, Bedform, Mass., USA), JPE-1375
(Jerini, Berlin, Germany), JSM-7717 (Jerini, Berlin, Germany),
rhMBL (Enzon Pharmaceuticals, Cranford, N.J., USA) or a combination
thereof.
[0166] Therapeutic Compositions
[0167] Pharmaceutical compositions comprising combinations of an
effective amount of at least two agents (e.g., therapeutic agents),
wherein one or more of the agents is a complement inhibitor, all in
effective amounts (e.g., synergistically effective amounts), in
combination with a pharmaceutically effective amount of a carrier,
additive or excipient, represents a further aspect of the present
disclosure.
[0168] The present disclosure includes, where applicable, the
compositions comprising the pharmaceutically acceptable salts, in
particular, acid or base addition salts of the compounds (e.g.,
agents and/or complement inhibitors) of the composition described
herein. The acids which are used to prepare the pharmaceutically
acceptable acid addition salts of the aforementioned base compounds
useful according to this aspect are those which form non-toxic acid
addition salts, i.e., salts containing pharmacologically acceptable
anions, such as the hydrochloride, hydrobromide, hydroiodide,
nitrate, sulfate, bisulfate, phosphate, acid phosphate, acetate,
lactate, citrate, acid citrate, tartrate, bitartrate, succinate,
maleate, fumarate, gluconate, saccharate, benzoate,
methanesulfonate, ethanesulfonate, benzenesulfonate,
p-toluenesulfonate and pamoate [i.e.,
1,1'-methylene-bis-(2-hydroxy-3 naphthoate)]salts, among numerous
others.
[0169] Pharmaceutically acceptable base addition salts may also be
used to produce pharmaceutically acceptable salt forms of the
compounds or derivatives according to the present disclosure. The
chemical bases that may be used as reagents to prepare
pharmaceutically acceptable base salts of the present compounds
that are acidic in nature are those that form non-toxic base salts
with such compounds. Such non-toxic base salts include, but are not
limited to those derived from such pharmacologically acceptable
cations such as alkali metal cations (e.g., potassium and sodium)
and alkaline earth metal cations (e.g., calcium, zinc and
magnesium), ammonium or water-soluble amine addition salts such as
N-methylglucamine-(meglumine), and the lower alkanolammonium and
other base salts of pharmaceutically acceptable organic amines,
among others.
[0170] The compounds as described herein may, in accordance with
the disclosure, be administered in single or divided doses by the
oral, parenteral or topical routes. Administration of the active
compound may range from continuous (intravenous drip) to several
oral administrations per day (for example, Q.I.D.) and may include
oral, topical, parenteral, intramuscular, intravenous,
sub-cutaneous, transdermal (which may include a penetration
enhancement agent), buccal, sublingual and suppository
administration, among other routes of administration. Enteric
coated oral tablets may also be used to enhance bioavailability of
the compounds from an oral route of administration. The most
effective dosage form will depend upon the pharmacokinetics of the
particular agent chosen as well as the severity of disease in the
patient. Administration of compounds according to the present
disclosure as sprays, mists, or aerosols for intra-nasal,
intra-tracheal or pulmonary administration may also be used. The
present disclosure therefore also is directed to pharmaceutical
compositions comprising an effective amount of compound as
described herein, optionally in combination with a pharmaceutically
acceptable carrier, additive or excipient. Compounds according to
the present disclosure may be administered in immediate release,
intermediate release or sustained or controlled release forms.
Sustained or controlled release forms are preferably administered
orally, but also in suppository and transdermal or other topical
forms. Intramuscular injections in liposomal form may also be used
to control or sustain the release of compound at an injection
site.
[0171] The compositions as described herein may be formulated in a
conventional manner using one or more pharmaceutically acceptable
carriers and may also be administered in controlled-release
formulations. Pharmaceutically acceptable carriers that may be used
in these pharmaceutical compositions include, but are not limited
to, ion exchangers, alumina, aluminum stearate, lecithin, serum
proteins, such as human serum albumin, buffer substances such as
phosphates, glycine, sorbic acid, potassium sorbate, partial
glyceride mixtures of saturated vegetable fatty acids, water, salts
or electrolytes, such as prolamine sulfate, disodium hydrogen
phosphate, potassium hydrogen phosphate, sodium chloride, zinc
salts, colloidal silica, magnesium trisilicate, polyvinyl
pyrrolidone, cellulose-based substances, polyethylene glycol,
sodium carboxymethylcellulose, polyacrylates, waxes,
polyethylene-polyoxypropylene-block polymers, polyethylene glycol
and wool fat.
[0172] The compositions as described herein may be administered
orally, parenterally, by inhalation spray, topically, rectally,
nasally, buccally, vaginally or via an implanted reservoir. The
term "parenteral" as used herein includes subcutaneous,
intravenous, intramuscular, intra-articular, intra-synovial,
intrasternal, intrathecal, intrahepatic, intralesional and
intracranial injection or infusion techniques. Preferably, the
compositions are administered orally, intraperitoneally or
intravenously.
[0173] Sterile injectable forms of the compositions as described
herein may be aqueous or oleaginous suspension. These suspensions
may be formulated according to techniques known in the art using
suitable dispersing or wetting agents and suspending agents. The
sterile injectable preparation may also be a sterile injectable
solution or suspension in a non-toxic parenterally-acceptable
diluent or solvent, for example as a solution in 1,3-butanediol.
Among the acceptable vehicles and solvents that may be employed are
water, Ringer's solution and isotonic sodium chloride solution. In
addition, sterile, fixed oils are conventionally employed as a
solvent or suspending medium. For this purpose, any bland fixed oil
may be employed including synthetic mono- or di-glycerides. Fatty
acids, such as oleic acid and its glyceride derivatives are useful
in the preparation of injectables, as are natural
pharmaceutically-acceptable oils, such as olive oil or castor oil,
especially in their polyoxyethylated versions. These oil solutions
or suspensions may also contain a long-chain alcohol diluent or
dispersant, such as Ph. Helv or similar alcohol.
[0174] The pharmaceutical compositions as described herein may be
orally administered in any orally acceptable dosage form including,
but not limited to, capsules, tablets, aqueous suspensions or
solutions. In the case of tablets for oral use, carriers which are
commonly used include lactose and corn starch. Lubricating agents,
such as magnesium stearate, are also typically added. For oral
administration in a capsule form, useful diluents include lactose
and dried corn starch. When aqueous suspensions are required for
oral use, the active ingredient is combined with emulsifying and
suspending agents. If desired, certain sweetening, flavoring or
coloring agents may also be added.
[0175] Alternatively, the pharmaceutical compositions as described
herein may be administered in the form of suppositories for rectal
administration. These can be prepared by mixing the agent with a
suitable non-irritating excipient, which is solid at room
temperature but liquid at rectal temperature and therefore will
melt in the rectum to release the drug. Such materials include
cocoa butter, beeswax and polyethylene glycols.
[0176] The pharmaceutical compositions as described herein may also
be administered topically. Suitable topical formulations are
readily prepared for each of these areas or organs. Topical
application for the lower intestinal tract can be effected in a
rectal suppository formulation (see above) or in a suitable enema
formulation. Topically-acceptable transdermal patches may also be
used.
[0177] For topical applications, the pharmaceutical compositions
may be formulated in a suitable ointment containing the active
component suspended or dissolved in one or more carriers. Carriers
for topical administration of the compounds of this disclosure
include, but are not limited to, mineral oil, liquid petrolatum,
white petrolatum, propylene glycol, polyoxyethylene,
polyoxypropylene compound, emulsifying wax and water. In certain
preferred aspects of the disclosure, the compounds may be coated
onto a stent which is to be surgically implanted into a patient in
order to inhibit or reduce the likelihood of occlusion occurring in
the stent in the patient.
[0178] Alternatively, the pharmaceutical compositions can be
formulated in a suitable lotion or cream containing the active
components suspended or dissolved in one or more pharmaceutically
acceptable carriers. Suitable carriers include, but are not limited
to, mineral oil, sorbitan monostearate, polysorbate 60, cetyl
esters wax, cetearyl alcohol, 2-octyldodecanol, benzyl alcohol and
water.
[0179] For ophthalmic use, the pharmaceutical compositions may be
formulated as micronized suspensions in isotonic, pH adjusted
sterile saline, or, preferably, as solutions in isotonic, pH
adjusted sterile saline, either with our without a preservative
such as benzylalkonium chloride. Alternatively, for ophthalmic
uses, the pharmaceutical compositions may be formulated in an
ointment such as petrolatum.
[0180] The pharmaceutical compositions as described herein may also
be administered by nasal aerosol or inhalation. Such compositions
are prepared according to techniques well-known in the art of
pharmaceutical formulation and may be prepared as solutions in
saline, employing benzyl alcohol or other suitable preservatives,
absorption promoters to enhance bioavailability, fluorocarbons,
and/or other conventional solubilizing or dispersing agents.
[0181] The amount of compound in a pharmaceutical composition as
described herein that may be combined with the carrier materials to
produce a single dosage form will vary depending upon the host and
disease treated, the particular mode of administration. Preferably,
the compositions should be formulated to contain between about 0.05
milligram to about 750 milligrams or more, more preferably about 1
milligram to about 600 milligrams, and even more preferably about
10 milligrams to about 500 milligrams of active ingredient, alone
or in combination with at least one other compound according to the
present disclosure.
[0182] It should also be understood that a specific dosage and
treatment regimen for any particular patient will depend upon a
variety of factors, including the activity of the specific compound
employed, the age, body weight, general health, sex, diet, time of
administration, rate of excretion, drug combination, and the
judgment of the treating physician and the severity of the
particular disease or condition being treated.
[0183] A patient or subject in need of therapy using compounds
according to the methods described herein can be treated by
administering to the patient (subject) an effective amount of the
compound according to the present disclosure including
pharmaceutically acceptable salts, solvates or polymorphs, thereof
optionally in a pharmaceutically acceptable carrier or diluent,
either alone, or in combination with other agents as otherwise
identified herein.
[0184] These compounds can be administered by any appropriate
route, for example, orally, parenterally, intravenously,
intradermally, subcutaneously, or topically, including
transdermally, in liquid, cream, gel, or solid form, or by aerosol
form.
[0185] The active compound is included in the pharmaceutically
acceptable carrier or diluent in an amount sufficient to deliver to
a patient a therapeutically effective amount for the desired
indication, without causing serious toxic effects in the patient
treated. A preferred dose of the active compound for all of the
herein-mentioned conditions is in the range from about 10 ng/kg to
300 mg/kg, preferably 0.1 to 100 mg/kg per day, more generally 0.5
to about 25 mg per kilogram body weight of the recipient/patient
per day. A typical topical dosage will range from 0.01-5% wt/wt in
a suitable carrier.
[0186] The compound is conveniently administered in any suitable
unit dosage form, including but not limited to one containing less
than 1 mg, 1 mg to 3000 mg, preferably 5 to 500 mg of active
ingredient per unit dosage form. An oral dosage of about 25-250 mg
is often convenient.
[0187] The active ingredient is preferably administered to achieve
peak plasma concentrations of the active compound of about
0.00001-30 mM, preferably about 0.1-30 .mu.M. This may be achieved,
for example, by the intravenous injection of a solution or
formulation of the active ingredient, optionally in saline, or an
aqueous medium or administered as a bolus of the active ingredient.
Oral administration is also appropriate to generate effective
plasma concentrations of active agent.
[0188] The concentration of the active compound in the drug
composition will depend on absorption, distribution, inactivation,
and excretion rates of the drug as well as other factors known to
those of skill in the art. It is to be noted that dosage values
will also vary with the severity of the condition to be alleviated.
It is to be further understood that for any particular subject,
specific dosage regimens should be adjusted over time according to
the individual need and the professional judgment of the person
administering or supervising the administration of the
compositions, and that the concentration ranges set forth herein
are exemplary only and are not intended to limit the scope or
practice of the claimed composition. The active ingredient may be
administered at once, or may be divided into a number of smaller
doses to be administered at varying intervals of time.
[0189] Oral compositions will generally include an inert diluent or
an edible carrier. They may be enclosed in gelatin capsules or
compressed into tablets. For the purpose of oral therapeutic
administration, the active compound or its prodrug derivative can
be incorporated with excipients and used in the form of tablets,
troches, or capsules. Pharmaceutically compatible binding agents,
and/or adjuvant materials can be included as part of the
composition.
[0190] The tablets, pills, capsules, troches and the like can
contain any of the following ingredients, or compounds of a similar
nature: a binder such as microcrystalline cellulose, gum tragacanth
or gelatin; an excipient such as starch or lactose, a dispersing
agent such as alginic acid, Primogel, or corn starch; a lubricant
such as magnesium stearate or Sterotes; a glidant such as colloidal
silicon dioxide; a sweetening agent such as sucrose or saccharin;
or a flavoring agent such as peppermint, methyl salicylate, or
orange flavoring. When the dosage unit form is a capsule, it can
contain, in addition to material of the above type, a liquid
carrier such as a fatty oil. In addition, dosage unit forms can
contain various other materials which modify the physical form of
the dosage unit, for example, coatings of sugar, shellac, or
enteric agents.
[0191] The active compound or pharmaceutically acceptable salt
thereof can be administered as a component of an elixir,
suspension, syrup, wafer, chewing gum or the like. A syrup may
contain, in addition to the active compounds, sucrose as a
sweetening agent and certain preservatives, dyes and colorings and
flavors.
[0192] The active compound or pharmaceutically acceptable salts
thereof can also be mixed with other active materials that do not
impair the desired action, or with materials that supplement the
desired action. In certain preferred aspects of the disclosure, one
or more compounds according to the present disclosure are
coadministered with another bioactive agent including an
antibiotic, as otherwise described herein.
[0193] Solutions or suspensions used for parenteral, intradermal,
subcutaneous, or topical application can include the following
components: a sterile diluent such as water for injection, saline
solution, fixed oils, polyethylene glycols, glycerin, propylene
glycol or other synthetic solvents; antibacterial agents such as
benzyl alcohol or methyl parabens; antioxidants such as ascorbic
acid or sodium bisulfite; chelating agents such as
ethylenediaminetetraacetic acid; buffers such as acetates, citrates
or phosphates and agents for the adjustment of tonicity such as
sodium chloride or dextrose. The parental preparation can be
enclosed in ampoules, disposable syringes or multiple dose vials
made of glass or plastic.
[0194] If administered intravenously, preferred carriers are
physiological saline or phosphate buffered saline (PBS).
[0195] In one embodiment, the active compounds are prepared with
carriers that will protect the compound against rapid elimination
from the body, such as a controlled release formulation, including
implants and microencapsulated delivery systems. Biodegradable,
biocompatible polymers can be used, such as ethylene vinyl acetate,
polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and
polylactic acid. Methods for preparation of such formulations will
be apparent to those skilled in the art.
[0196] Liposomal suspensions may also be pharmaceutically
acceptable carriers. These may be prepared according to methods
known to those skilled in the art, for example, as described in
U.S. Pat. No. 4,522,811 (which is incorporated herein by reference
in its entirety). For example, liposome formulations may be
prepared by dissolving appropriate lipid(s) (such as stearoyl
phosphatidyl ethanolamine, stearoyl phosphatidyl choline,
arachadoyl phosphatidyl choline, and cholesterol) in an inorganic
solvent that is then evaporated, leaving behind a thin film of
dried lipid on the surface of the container. An aqueous solution of
the active compound is then introduced into the container. The
container is then swirled by hand to free lipid material from the
sides of the container and to disperse lipid aggregates, thereby
forming the liposomal suspension.
[0197] The present disclosure also includes pharmaceutically
acceptable formulations of the compounds described. These
formulations include salts of the above compounds, e.g., acid
addition salts, for example, salts of hydrochloric, hydrobromic,
acetic acid, and benzene sulfonic acid.
[0198] A pharmacological composition or formulation refers to a
composition or formulation in a form suitable for administration,
e.g., systemic administration, into a cell or subject, preferably a
human. By "systemic administration" is meant in vivo systemic
absorption or accumulation of drugs in the blood stream followed by
distribution throughout the entire body. Suitable forms, in part,
depend upon the use or the route of entry, for example oral,
transdermal, or by injection. Such forms should not prevent the
composition or formulation from reaching a target cell (i.e., a
cell to which the negatively charged polymer is desired to be
delivered to). For example, pharmacological compositions injected
into the blood stream should be soluble. Other factors are known in
the art, and include considerations such as toxicity and forms
which prevent the composition or formulation from exerting its
effect.
[0199] Administration routes which lead to systemic absorption
include, without limitations: intravenous, subcutaneous,
intraperitoneal, inhalation, oral, intrapulmonary and
intramuscular. The rate of entry of a drug into the circulation has
been shown to be a function of molecular weight or size. The use of
a liposome or other drug carrier comprising the compounds of the
present disclosure can potentially localize the drug, for example,
in certain tissue types, such as the tissues of the reticular
endothelial system (RES). A liposome formulation which can
facilitate the association of drug with the surface of cells, such
as, lymphocytes and macrophages is also useful.
[0200] The present disclosure also features the use of the
composition comprising surface-modified liposomes containing poly
(ethylene glycol) lipids (PEG-modified, or long-circulating
liposomes or stealth liposomes). Polypeptides and compositions of
the present disclosure can also comprise covalently attached PEG
molecules of various molecular weights. These formulations offer a
method for increasing the accumulation of drugs in target tissues.
This class of drug carriers resists opsonization and elimination by
the mononuclear phagocytic system (MPS or RES), thereby enabling
longer blood circulation times and enhanced tissue exposure for the
encapsulated drug (Lasic et al. Chem. Rev. 1995, 95, 2601-2627;
Ishiwata et al., Chem. Pharm. Bull. 1995, 43, 1005-1011).
Long-circulating liposomes are also likely to protect drugs from
nuclease degradation to a greater extent compared to cationic
liposomes, based on their ability to avoid accumulation in
metabolically aggressive MPS tissues such as the liver and spleen.
All of these references are incorporated by reference herein.
[0201] The present disclosure also includes compositions prepared
for storage or administration which include a pharmaceutically
effective amount of the desired compounds (e.g., agents and/or
complement inhibitors) in a pharmaceutically acceptable carrier or
diluent. Acceptable carriers or diluents for therapeutic use are
well known in the pharmaceutical art, and are described, for
example, in Remington's Pharmaceutical Sciences, Mack Publishing
Co. (A. R. Gennaro edit. 1985) hereby incorporated by reference
herein. For example, preservatives, stabilizers, dyes and flavoring
agents can be provided. These include sodium benzoate, sorbic acid
and esters of p-hydroxybenzoic acid. In addition, antioxidants and
suspending agents can be used.
[0202] An effective amount, pharmaceutically effective dose,
therapeutically effective amount, or pharmaceutically effective
amount is that dose required to prevent, inhibit the occurrence, or
treat (alleviate a symptom to some extent, preferably all of the
symptoms) of a disease state or pathological condition. The
effective amount depends on the type of disease, the composition
used, the route of administration, the type of mammal being
treated, the physical characteristics of the specific mammal under
consideration, concurrent medication, and other factors which those
skilled in the medical arts will recognize. Generally, an amount
between 0.1 mg/kg and 1000 mg/kg body weight/day of active
ingredients is administered dependent upon potency of the
negatively charged polymer. In addition, effective amounts of the
compositions of the disclosure encompass those amounts utilized in
the examples to facilitate the intended or desired biological
effect.
[0203] Toxicity and therapeutic efficacy of such compounds can be
determined by standard pharmaceutical procedures in cell cultures
or experimental animals, e.g., for determining the LD50 (the dose
lethal to 50% of the population) and the ED50 (the dose
therapeutically effective in 50% of the population). The dose ratio
between toxic and therapeutic effects is the therapeutic index and
it can be expressed as the ratio LD50/ED50. Compounds (e.g., agents
and/or complement inhibitors) that exhibit large therapeutic
indices are preferred. While compounds that exhibit toxic side
effects may be used, care should be taken to design a delivery
system that targets such compounds to the site of affected tissue
in order to minimize potential damage to uninfected cells and,
thereby, reduce side effects. The data obtained from the cell
culture assays and animal studies can be used in formulating a
range of dosage for use in humans. The dosage of such compounds
lies preferably within a range of circulating concentrations that
include the ED50 with little or no toxicity. The dosage may vary
within this range depending upon the dosage form employed and the
route of administration utilized. For any compound used in the
method of the present disclosure, the therapeutically effective
dose can be estimated initially from cell culture assays. A dose
may be formulated in animal models to achieve a circulating plasma
concentration range that includes the IC50 (i.e., the concentration
of the test compound which achieves a half-maximal inhibition of
symptoms) as determined in cell culture. Such information can be
used to more accurately determine useful doses in humans. Levels in
plasma may be measured, for example, by high performance liquid
chromatography.
[0204] The formulations can be administered orally, topically,
parenterally, by inhalation or spray or rectally in dosage unit
formulations containing conventional non-toxic pharmaceutically
acceptable carriers, adjuvants and vehicles. The term parenteral as
used herein includes percutaneous, subcutaneous, intravascular
(e.g., intravenous), intramuscular, or intrathecal injection or
infusion techniques and the like. In addition, there is provided a
pharmaceutical formulation comprising at least two agents, wherein
at least one is a complement inhibitor, and a pharmaceutically
acceptable carrier. For example, two or more complement inhibitors
can be present in association with one or more non-toxic
pharmaceutically acceptable carriers and/or diluents and/or
adjuvants, and if desired other active ingredients. The
pharmaceutical compositions of the present disclosure can be in a
form suitable for oral use, for example, as tablets, troches,
lozenges, aqueous or oily suspensions, dispersible powders or
granules, emulsion, hard or soft capsules, or syrups or
elixirs.
[0205] Compositions intended for oral use can be prepared according
to any method known to the art for the manufacture of
pharmaceutical compositions and such compositions can contain one
or more such sweetening agents, flavoring agents, coloring agents
or preservative agents in order to provide pharmaceutically elegant
and palatable preparations. Tablets contain the active ingredient
in admixture with non-toxic pharmaceutically acceptable excipients
that are suitable for the manufacture of tablets. These excipients
can be for example, inert diluents, such as calcium carbonate,
sodium carbonate, lactose, calcium phosphate or sodium phosphate;
granulating and disintegrating agents, for example, corn starch, or
alginic acid; binding agents, for example starch, gelatin or
acacia, and lubricating agents, for example magnesium stearate,
stearic acid or talc. The tablets can be uncoated or they can be
coated by known techniques. In some cases such coatings can be
prepared by known techniques to delay disintegration and absorption
in the gastrointestinal tract and thereby provide a sustained
action over a longer period. For example, a time delay material
such as glyceryl monosterate or glyceryl distearate can be
employed. Formulations for oral use can also be presented as hard
gelatin capsules wherein the active ingredient is mixed with an
inert solid diluent, for example, calcium carbonate, calcium
phosphate or kaolin, or as soft gelatin capsules wherein the active
ingredient is mixed with water or an oil medium, for example peanut
oil, liquid paraffin or olive oil.
[0206] Aqueous suspensions contain the active materials in
admixture with excipients suitable for the manufacture of aqueous
suspensions. Such excipients are suspending agents, for example
sodium carboxymethylcellulose, methylcellulose,
hydropropyl-methylcellulose, sodium alginate, polyvinylpyrrolidone,
gum tragacanth and gum acacia; dispersing or wetting agents can be
a naturally-occurring phosphatide, for example, lecithin, or
condensation products of an alkylene oxide with fatty acids, for
example polyoxyethylene stearate, or condensation products of
ethylene oxide with long chain aliphatic alcohols, for example
heptadecaethyleneoxycetanol, or condensation products of ethylene
oxide with partial esters derived from fatty acids and a hexitol
such as polyoxyethylene sorbitol monooleate, or condensation
products of ethylene oxide with partial esters derived from fatty
acids and hexitol anhydrides, for example polyethylene sorbitan
monooleate. The aqueous suspensions can also contain one or more
preservatives, for example ethyl, or n-propyl p-hydroxybenzoate,
one or more coloring agents, one or more flavoring agents, and one
or more sweetening agents, such as sucrose or saccharin.
[0207] Oily suspensions can be formulated by suspending the active
ingredients in a vegetable oil, for example arachis oil, olive oil,
sesame oil or coconut oil, or in a mineral oil such as liquid
paraffin. The oily suspensions can contain a thickening agent, for
example beeswax, hard paraffin or cetyl alcohol. Sweetening agents
and flavoring agents can be added to provide palatable oral
preparations. These compositions can be preserved by the addition
of an anti-oxidant such as ascorbic acid.
[0208] Dispersible powders and granules suitable for preparation of
an aqueous suspension by the addition of water provide the active
ingredient in admixture with a dispersing or wetting agent,
suspending agent and one or more preservatives. Suitable dispersing
or wetting agents or suspending agents are exemplified by those
already mentioned above. Additional excipients, for example
sweetening, flavoring and coloring agents, can also be present.
Pharmaceutical compositions of the present disclosure can also be
in the form of oil-in-water emulsions. The oily phase can be a
vegetable oil or a mineral oil or mixtures of these. Suitable
emulsifying agents can be naturally-occurring gums, for example gum
acacia or gum tragacanth, naturally-occurring phosphatides, for
example soy bean, lecithin, and esters or partial esters derived
from fatty acids and hexitol, anhydrides, for example sorbitan
monooleate, and condensation products of the said partial esters
with ethylene oxide, for example polyoxyethylene sorbitan
monooleate. The emulsions can also contain sweetening and flavoring
agents.
[0209] Syrups and elixirs can be formulated with sweetening agents,
for example glycerol, propylene glycol, sorbitol, glucose or
sucrose. Such formulations can also contain a demulcent, a
preservative and flavoring and coloring agents. The pharmaceutical
compositions can be in the form of a sterile injectable aqueous or
oleaginous suspension. This suspension can be formulated according
to the known art using those suitable dispersing or wetting agents
and suspending agents that have been mentioned above. The sterile
injectable preparation can also be a sterile injectable solution or
suspension in a non-toxic parentally acceptable diluent or solvent,
for example as a solution in 1,3-butanediol. Among the acceptable
vehicles and solvents that can be employed are water, Ringer's
solution and isotonic sodium chloride solution. In addition,
sterile, fixed oils are conventionally employed as a solvent or
suspending medium. For this purpose any bland fixed oil can be
employed including synthetic mono- or diglycerides. In addition,
fatty acids such as oleic acid find use in the preparation of
injectables.
[0210] For administration to non-human animals, the composition can
also be added to the animal feed or drinking water. It can be
convenient to formulate the animal feed and drinking water
compositions so that the animal takes in a therapeutically
appropriate quantity of the composition along with its diet. It can
also be convenient to present the composition as a premix for
addition to the feed or drinking water. The composition can also be
administered to a subject in combination with other therapeutic
compounds to increase the overall therapeutic effect. The use of
multiple compounds to treat an indication can increase the
beneficial effects while reducing the presence of side effects.
[0211] A further object of the present disclosure is to provide a
kit comprising a suitable container, the therapeutic of the present
disclosure in a pharmaceutically acceptable form disposed therein,
and instructions for its use.
[0212] Preparations for administration of the therapeutic of the
present disclosure include sterile aqueous or non-aqueous
solutions, suspensions, and emulsions. Examples of non-aqueous
solvents are propylene glycol, polyethylene glycol, vegetable oils
such as olive oil, and injectable organic esters such as ethyl
oleate. Aqueous carriers include water, alcoholic/aqueous
solutions, emulsions or suspensions, including saline and buffered
media. Vehicles include sodium chloride solution, Ringer's
dextrose, dextrose and sodium chloride, lactated Ringer's
intravenous vehicles including fluid and nutrient replenishers,
electrolyte replenishers, and the like. Preservatives and other
additives may be added such as, for example, antimicrobial agents,
anti-oxidants, chelating agents and inert gases and the like.
[0213] The compounds or peptides (e.g., agent, agents, and/or
complement inhibitors; also referred to herein as "active
compounds") of the disclosure, and derivatives, fragments, analogs
and homologs thereof, can be incorporated into pharmaceutical
compositions suitable for administration. Such compositions
typically comprise the compound or protein and a pharmaceutically
acceptable carrier. As used herein, "pharmaceutically acceptable
carrier" is intended to include any and all solvents, dispersion
media, coatings, antibacterial and antifungal agents, isotonic and
absorption delaying agents, and the like, compatible with
pharmaceutical administration. Suitable carriers are described in
the most recent edition of Remington's Pharmaceutical Sciences, a
standard reference text in the field, which is incorporated herein
by reference. Preferred examples of such carriers or diluents
include, but are not limited to, water, saline, finger's solutions,
dextrose solution, and 5% human serum albumin. Liposomes and
non-aqueous vehicles such as fixed oils may also be used. The use
of such media and agents for pharmaceutically active substances is
well known in the art. Except insofar as any conventional media or
agent is incompatible with the active compound, use thereof in the
compositions is contemplated. Supplementary active compounds can
also be incorporated into the compositions.
[0214] A pharmaceutical composition of the present disclosure is
formulated to be compatible with its intended route of
administration. Examples of routes of administration include
parenteral, e.g., intravenous, intradermal, subcutaneous, oral
(e.g., inhalation), transdermal (i.e., topical), transmucosal,
intraperitoneal, and rectal administration. Solutions or
suspensions used for parenteral, intradermal, or subcutaneous
application can include the following components: a sterile diluent
such as water for injection, saline solution, fixed oils,
polyethylene glycols, glycerine, propylene glycol or other
synthetic solvents; antibacterial agents such as benzyl alcohol or
methyl parabens; antioxidants such as ascorbic acid or sodium
bisulfite; chelating agents such as ethylenediaminetetraacetic acid
(EDTA); buffers such as acetates, citrates or phosphates, and
agents for the adjustment of tonicity such as sodium chloride or
dextrose. The pH can be adjusted with acids or bases, such as
hydrochloric acid or sodium hydroxide. The parenteral preparation
can be enclosed in ampoules, disposable syringes or multiple dose
vials made of glass or plastic.
[0215] Pharmaceutical compositions suitable for injectable use
include sterile aqueous solutions (where water soluble) or
dispersions and sterile powders for the extemporaneous preparation
of sterile injectable solutions or dispersion. For intravenous
administration, suitable carriers include physiological saline,
bacteriostatic water, Cremophor.TM.. (BASF, Parsippany, N.J.) or
phosphate buffered saline (PBS). In all cases, the composition must
be sterile and should be fluid to the extent that easy
syringeability exists. It must be stable under the conditions of
manufacture and storage and must be preserved against the
contaminating action of microorganisms such as bacteria and fungi.
The carrier can be a solvent or dispersion medium containing, for
example, water, ethanol, polyol (for example, glycerol, propylene
glycol, and liquid polyethylene glycol, and the like), and suitable
mixtures thereof. The proper fluidity can be maintained, for
example, by the use of a coating such as lecithin, by the
maintenance of the required particle size in the case of dispersion
and by the use of surfactants. Prevention of the action of
microorganisms can be achieved by various antibacterial and
antifungal agents, for example, parabens, chlorobutanol, phenol,
ascorbic acid, thimerosal, and the like. In many cases, it will be
preferable to include isotonic agents, for example, sugars,
polyalcohols such as manitol, sorbitol, sodium chloride in the
composition. Prolonged absorption of the injectable compositions
can be brought about by including in the composition an agent which
delays absorption, for example, aluminum monostearate and
gelatin.
[0216] For oral administration, the pharmaceutical compositions may
take the form of, for example, tablets or capsules prepared by
conventional means with pharmaceutically acceptable excipients such
as binding agents (e.g., pregelatinised maize starch,
polyvinylpyrrolidone or hydroxypropyl methylcellulose); fillers
(e.g., lactose, microcrystalline cellulose or calcium hydrogen
phosphate); lubricants (e.g., magnesium stearate, talc or silica);
disintegrants (e.g., potato starch or sodium starch glycolate); or
wetting agents (e.g., sodium lauryl sulphate). The tablets may be
coated by methods well known in the art. Liquid preparations for
oral administration may take the form of, for example, solutions,
syrups, or suspensions, or they may be presented as a dry product
for constitution with water or other suitable vehicle before use.
Such liquid preparations may be prepared by conventional means with
pharmaceutically acceptable additives such as suspending agents
(e.g., sorbitol syrup, cellulose derivatives or hydrogenated edible
fats); emulsifying agents (e.g., lecithin or acacia); non-aqueous
vehicles (e.g., almond oil, oily esters, ethyl alcohol or
fractionated vegetable oils); and preservatives (e.g., methyl or
propyl-p-hydroxybenzoates or sorbic acid). The preparations may
also contain buffer salts, flavoring, coloring, and sweetening
agents as appropriate. Preparations for oral administration may be
suitably formulated to give controlled release of the active
compound. For buccal administration the compositions may take the
form of tablets or lozenges formulated in conventional manner. For
administration by inhalation, the compounds for use according to
the present disclosure are conveniently delivered in the form of an
aerosol spray presentation from pressurized packs or a nebuliser,
with the use of a suitable propellant, e.g.,
dichlorodifluoromethane, trichlorofluoromethane,
dichlorotetrafluoroethane, carbon dioxide or other suitable gas. In
the case of a pressurized aerosol the dosage unit may be determined
by providing a valve to deliver a metered amount. Capsules and
cartridges of e.g. gelatin for use in an inhaler or insufflator may
be formulated containing a powder mix of the compound and a
suitable powder base such as lactose or starch. The compounds may
be formulated for parenteral administration by injection, e.g., by
bolus injection or continuous infusion. Formulations for injection
may be presented in unit dosage form, e.g., in ampoules or in
multi-dose containers, with an added preservative. The compositions
may take such forms as suspensions, solutions, or emulsions in oily
or aqueous vehicles, and may contain formulatory agents such as
suspending, stabilizing, and/or dispersing agents. Alternatively,
the active ingredient may be in powder form for constitution with a
suitable vehicle, e.g., sterile pyrogen-free water, before use. The
compounds may also be formulated in rectal compositions such as
suppositories or retention enemas, e.g., containing conventional
suppository bases such as cocoa butter or other glycerides. In
addition to the formulations described previously, the compounds
may also be formulated as a depot preparation. Such long acting
formulations may be administered by implantation (for example
subcutaneously or intramuscularly) or by intramuscular injection.
Thus, for example, the compounds may be formulated with suitable
polymeric or hydrophobic materials (for example, as an emulsion in
an acceptable oil) or ion exchange resins, or as sparingly soluble
derivatives, for example, as a sparingly soluble salt.
[0217] In one embodiment, the active compounds are prepared with
carriers that will protect the compound against rapid elimination
from the body, such as a controlled release formulation, including
implants and microencapsulated delivery systems. Biodegradable,
biocompatible polymers can be used, such as ethylene vinyl acetate,
polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and
polylactic acid. Methods for preparation of such formulations will
be apparent to those skilled in the art. The materials can also be
obtained commercially from Alza Corporation and Nova
Pharmaceuticals, Inc. Liposomal suspensions (including liposomes
targeted to infected cells with monoclonal antibodies to viral
antigens) can also be used as pharmaceutically acceptable carriers.
These can be prepared according to methods known to those skilled
in the art, for example, as described in U.S. Pat. No.
4,522,811.
[0218] It is especially advantageous to formulate oral or
parenteral compositions in dosage unit form for ease of
administration and uniformity of dosage. Dosage unit form as used
herein refers to physically discrete units suited as unitary
dosages for the subject to be treated; each unit containing a
predetermined quantity of active compound calculated to produce the
desired therapeutic effect in association with the required
pharmaceutical carrier. The specification for the dosage unit forms
of the disclosure are dictated by and directly dependent on the
unique characteristics of the active compound and the particular
therapeutic effect to be achieved, and the limitations inherent in
the art of compounding such an active compound for the treatment of
individuals.
[0219] Additional objects and advantages of the present disclosure
will be appreciated by one of ordinary skill in the art in light of
the current description and examples of the preferred embodiments,
and are expressly included within the scope of the present
disclosure.
Examples
[0220] Materials and Methods.
[0221] Study Participants.
[0222] Three initial patients, their unaffected parents, and then
seven additional patients presenting with a similar clinical
presentation were evaluated (FIGS. 1A and 3). The patients were
followed in Marmara University, Istanbul, Turkey; Cerraphasa
University, Istanbul, Turkey; Baskent University, Ankara, Turkey;
Gazi University, Ankara, Turkey, and Sami Ulus Hospital, Ankara,
Turkey. All of the patients were enrolled in a clinical protocol
which had been approved by the institutional review boards of the
respective institutions and NIH. All study participants or their
parents provided written informed consent.
[0223] Genetic and Functional Analysis.
[0224] Whole exome DNA sequencing (WES) was performed on the
initial three patients and their unaffected parents and siblings
followed by specific CD55 DNA sequencing in the other patients and
family members. Complement deposition assays, cytokine secretion
and T-cell stimulation assays were performed on patient samples and
healthy controls. Complement deposition was verified using
lentiviral and clustered regularly-interspaced short palindromic
repeats (CRISPR) mediated CD55 knockdown/knockout in Jurkat T cells
and HT29 epithelial cells.
[0225] Human Subjects.
[0226] All human subjects (or their legal guardians) in this study
provided written informed consent in accordance with Helsinki
principles for enrollment in research protocols that were approved
by the Institutional Review Boards of the National Institute of
Allergy and Infectious Diseases, National Institutes of Health
(NIH) or the CeMM Research Center for Molecular Medicine of the
Austrian Academy of Sciences. Patient and healthy control blood was
obtained at the respective Turkish institutions overseeing patient
care under approved protocols, and shipped to either the NIH or the
CeMM Research Center for Molecular Medicine of the Austrian Academy
of Sciences. Additional healthy control blood was obtained at the
NIH clinical center under approved protocols. Mutations will be
archived by Online Mendelian inheritance in Man (OMIM), and
whole-exome data will be submitted in dbGaP. A webpage through the
National Center for Biotechnology Information (NCBI) will also be
created to accumulate patient mutation data in the format of the
Leiden Online Variant Database (LOVD) as patients are
identified.
[0227] Genetic Analysis Methods.
[0228] Genomic DNA (gDNA) was obtained from probands and family
members by isolation and purification from peripheral blood
mononuclear cells (PBMCs) using DNeasy.RTM. Blood and Tissue Kit
(QIAGEN.RTM., Hilden, Germany). DNA was then submitted for Whole
Exome Sequencing (WES) or targeting sequencing of the CD55 gene.
For whole exome sequencing, the Human All Exon 50 Mb kit (Agilent
Technologies, Santa Clara, Calif., USA) coupled with massively
parallel sequencing by Illumina.RTM. HiSeg.TM. Sequencing System
(IIlumina, Inc., San Diego, Calif., USA) was performed using the
collected DNA. For individual samples, WES produced approximately
50-100.times. sequence coverage for targeted regions. WES was
performed on patients 1.1, 2.1 along with 3.1 and 5.1 in which WES
was combined with homozygosity mapping. As described previously,
all sequenced DNA reads were mapped to the hg19 human genome
reference by Burrows-Wheeler Aligner with default parameters.
Single nucleotide variant and indel calling were performed using
the Genome Analysis Toolkit (Broad Institute, Cambridge, Mass.,
USA). All SNVs/indels were annotated by SeattleSeq Annotation and
an in-house custom analysis pipeline was used to filter and
prioritize for autosomal recessive or de novo disease-causal
variants based on the clinical pedigree for Patients 1.1 and 2.1,
the mutations were identified by targeted gene screening of the WES
data based on the similarity of clinical phenotype in the cohort
(Lucas C L, et al. Heterozygous splice mutation in PIK3R1 causes
human immunodeficiency with lymphoproliferation due to dominant
activation of PI3K. J Exp Med 2014; 211: 2537-47).
[0229] For targeted sequencing, CD55/DAF exons 1 through 10 were
PCR amplified, purified, or gel extracted using QIAGEN's
MinElute.RTM. PCR Purification Kit (QIAGEN.RTM., Hilden, Germany)
or QIAquick.RTM. Gel Extraction Kit (QIAGEN.RTM., Hilden, Germany),
respectively. Samples were submitted to the National Institute of
Allergy and Infectious Disease Research Technologies Branch Core
Sequencing facility for Sanger sequencing. DNA sequences were
analyzed using SEQUENCHER.RTM. V.5.3 (Gene Codes Corporation, Ann
Arbor, Mich., USA). The primers used for Sanger sequencing and the
amplicons produced therefrom are shown in Table 1, below.
TABLE-US-00001 TABLE 1 Primer Sequences for mutation detection in
CD55 SEQ SEQ Exon # Forward Primer Sequence ID N Reverse Primer
sequence ID NO Exon 1 CTACTCCACCCGTCTTGTTTGT 4
TTTGGGGGTTAAGGATACAGTC 5 Exon 2 CAGGTGTGGCATTTCAAGG 6
ACCCTGGGGTTTAGTAACGC 7 Exon 3 AAGTACTAAATATGCGCAAAGCAG 8
ATGGTCCTATCAAGAAACATCC 9 Exon 4 GTTACCTTCTTTGTGTGTATGCC 10
GCTGTGAATACCAGTCATGAAAC 11 Exon 5 AACCTGGAGAATTTGAGGAAAG 12
TGTGCTAATATTCTTAAGGGGC 13 Exon 6 GCATTTATAAGCATCTCTTGTTGG 14
TCATTGAATGTCTGCAACCC 15 Exon 7 CTAGGTGTTTGTGGGGAGAGAG 16
TCTGGTGGGTTTCTGAAGAGTT 17 Exon 8 TTTACGCAGAGTCCTTCAGC 18
CCATTTAATCCTGCAATCTTGG 19 Exon 9 TGGAAATTTGAGTTGCTTTCG 20
TCTCCCAGGAATATGGATTG 21 Exon 10 GCACCCCAAATTAACTGATTC 22
ATGTGATTCCAGGACTGCC 23
[0230] Primary Cells and Cell Lines.
[0231] Patient or control blood was subjected to a ficoll density
gradient centrifugation, after which peripheral blood mononuclear
cells (PBMCs) were collected from the interface. Naive or total
CD4.sup.+ T cells were then isolated by negative selection using
the Naive CD4.sup.+ T Cell Isolation Kit II or the human CD4.sup.+
T cell isolation kit, respectively (Miltenyi Biotec Inc., Auburn,
Calif., USA). Jurkat E6, HEK 293T, HT29 and Caco-2 cells were
purchased from the American Type Culture Collection (ATCC.RTM.;
Manassas, Va., USA). Pooled Human Umbilical Vein Endothelial Cells
(HUVECs) were from Lonza.RTM. (Walkersville, Md., USA).
[0232] Media.
[0233] Human T cells and Jurkat T cells were either grown in either
RPMI 1640 (Gibco.TM./ThermoFisher Scientific, Waltham, Mass., USA)
supplemented with 10% heat-shocked FBS (Gibco.TM./ThermoFisher
Scientific, Waltham, Mass., USA), 1% Penicillin/Streptomycin, 1%
L-Glutamine and 100units/mL IL-2 (complete RPMI) or X-Vivo 15
(Lonza) supplemented with 1% Penicillin/Streptomycin, 1%
L-Glutamine and 100units/mL IL-2 (complete X-vivo 15). HT29 and
HEK293T cells were grown in DMEM media (Gibco.TM./ThermoFisher
Scientific, Waltham, Mass., USA) supplemented with 10% heat-shocked
FBS (Gibco.TM./Thermo Fisher Scientific, Waltham, Mass., USA), 1%
Penicillin/Streptomycin, and 1% L-Glutamine. HUVECS were cultured
in Endothelial Cell Basal Medium (Lonza.RTM., Walkersville, Md.,
USA) supplemented with the contents of EGM.TM. SingleQuot.TM. Kit
Suppl. & Growth Factors kit (Lonza, Walkersville, Md., USA).
Caco-2 cells were cultured in Minimum Essential Media (Gibco.TM.,
Waltham, Mass., USA) supplemented with 20% non-heat inactivated FBS
(Sigma), 1% Penicillin/Streptomycin, 1% L-Glutamine, and 10 mM
HEPES.
[0234] Antibodies and Inhibitors.
[0235] Anti-CD25 FITC, Anti-CD69 APC, Anti-CD4 PE, Anti-CD55 FITC,
anti-CD59 FITC, anti-CD46 APC, anti-CD141/Thrombomodulin APC,
anti-CD142/Thrombin PE, anti-CCR9 APC, anti-integrin .alpha.4 PE,
anti-integrin .beta.7, anti-C5aR FITC, anti-C5L2 PE, and anti-C3aR
APC were purchased from BioLegend.RTM. (San Diego, Calif., USA) or
eBisociences, Inc. (San Diego, Calif., USA). The anti-C3d antibody
used in complement deposition experiments was purchased from
Hycult.RTM. Biotech (Plymouth Meeting, Pa., USA). LIVE/DEAD.TM.
Fixable Near-IR Dead Cell Stain Kit used for cell viability assay
was purchased from ThermoFisher Scientific (Waltham, Mass., USA)
and APC labeled Annexin-V was from BioLegend.RTM. (San Diego,
Calif., USA). The anti-CD3 antibody HIT3a used in T cell
re-stimulation experiments was purchased from BioLegend.RTM. (San
Diego, Calif., USA). The anti-CD55 antibody (clone BRIC 216) used
to costimulate T cells was from EMD Millipore (Billerica, Mass.,
USA) or International Blood Group Reference Laboratory (IBGRL)
(Filton, UK). Human CD97-fc recombinant protein used for T cell
costimulation was purchased from Creative BioMart.RTM. (Shirley,
N.Y., USA). The C3aR inhibitor, SB 290157, was purchased from
Calbiochem.RTM. (San Diego, Calif., USA). The C5aR1 inhibitor, NDT
9513727, was purchased from Tocris Bioscience (Bristol, UK).
Anti-CD55 used for western blotting was from Sigma-Aldrich.RTM.
(St. Louis, Mo., USA).
[0236] Flow Cytometry. Adherent cells were treated with 0.05%
trypsin EDTA to lift them from the surface followed by addition of
5% FBS to inactivate the trypsin. Suspension cells were collected
from culture following mixture of the culture by repeat pipetting.
Cells were washed and resuspended in FACS buffer (1% FBS, 0.05%
sodium azide, and 5 mM EDTA in PBS) at 2.times.10.sup.6 cells/mL.
Staining or isotype antibodies were added at 1:200 final dilutions
and incubated with cells at 4.degree. C. for 30 minutes to 1 hour.
Cells were then washed 3.times. and resuspended in FACS buffer with
1% PFA and analyzed by flow cytometry. Flow files were analyzed on
FlowJo version 9.9 or above (FlowJo, LLC, Ashland, Oreg., USA).
[0237] Complement Deposition.
[0238] T cells (Patient CD4.sup.+ T cell blasts or Jurkat T cells)
were collected and washed 3.times. in basal RPMI. Cells were then
resuspended in basal media and rested for 2-3 hours at 37.degree.
C. to allow any deposited complement components to be cleared from
the cell surface. Rested cells were then collected and resuspended
in basal RPMI or basal RPMI that had been adjusted to pH 6.5
(acidified media) to a final concentration of 1.times.10.sup.6
cells/mL. Non-heat shocked pooled normal human serum was then added
to cell suspension for the indicated amount of time. Human serum
that had been heat shocked at 56.degree. C. for 30 minutes was used
as a negative control for complement activation. At the indicated
times cells were transitioned to 4.degree. C., and kept chilled for
the remainder of the experiment. Cells were stained with a 1:300
dilution of anti-C3d antibody for 30 minutes, washed 3.times. and
then stained with an anti-rat antibody conjugated with alexa fluor
488 at a 1:500 dilution for 30 minutes. Cells were washed 3.times.
and resuspended in FACS buffer (PBS, 1% FBS) and analyzed for C3d
deposition by flow cytometry. To analyze C3d deposition on HT29
cells, cells were either left untreated or treated overnight with
10 ng/mL TNF.alpha. to upregulate CD55 expression. Cells were then
treated with trypsin/EDTA to release cells into suspension, washed,
and then analyzed for C3d deposition as above.
[0239] Preparation of T cell Stimulatory Surfaces.
[0240] Tissue culture treated 48, or 96 well plates were incubated
with the indicated concentration of anti-CD3 in PBS for 2 hours at
37.degree. C. Plates were then washed 3.times. in PBS and incubated
with either anti-CD28, anti-CD55, or CD97fc for 2 hours at
37.degree. C. Plates were again washed 3.times. with PBS before
using in T cell stimulations.
[0241] T cell Stimulation and Cytokine Secretion.
[0242] To measure T cell activation isolated CD4 T cells were
either left alone or stained with 1 .mu.M CFSE for 5 minutes at
room temperature, protected from light. Labelled cells were washed
3.times. in complete RPMI prior to use and resuspended at
1.times.10.sup.6 cells/mL in complete RPMI. Cells were then added
to stimulatory surfaces, pre-coated with the indicated
concentrations of activating antibodies/proteins. To measure CD25
and CD69 upregulation, non-CFSE labeled T cells were collected
after 24 hours and analyzed by flow cytometry for CD25 and CD69
expression, as detailed above. To assess T cell proliferation, CFSE
labeled T cell cultures were collected after 96 hours of
stimulation and analyzed by flow cytometry for CFSE dilution.
[0243] For cytokine secretion upon primary stimulation, Naive
CD4.sup.+ T cells were isolated via negative selection using the
Naive CD4.sup.+ T Cell Isolation Kit II, human isolation kit
(Miltenyi Biotec Inc., Auburn, Calif., USA). Naive T cells were
then resuspended in complete X-Vivo 15 media. Dynabeads.RTM.
CD3/CD28 T cell activator (Invitrogen.TM., Carlsbad, Calif., USA)
were then added to cells (1 bead/2 cells) and cells and dynabeads
were centrifuged at 300.times.g for 5 minutes to complex beads and
T cells. Cells were resuspended and added to 48 well plates at a
final concentration of 5.times.10.sup.4/mL in complete X-vivo 15
media. Cell culture supernatants were collected every 24 hours
starting at 96 hours post-activation for the indicated time course.
Cell cultures were stored at .sup.-80.degree. C. until analyzed. To
analyze cytokine secretion upon restimulation cells were collected
from day 12 to 14 of culture in complete X-Vivo 15 media, washed
and resuspended in basal media at 37.degree. C. for 3 hours to
rest. Cells were then collected and resuspended in complete X-Vivo
15 media and stimulated for 48 hours at 37.degree. C. with 1
.mu.g/mL plate-bound anti-CD3. Cell supernatants were then
collected and stored at .sup.-80.degree. C. until analyzed.
[0244] Lentiviral Construction and Transfection Protocol.
[0245] Lentiviral packaging constructs psPAX2 and PDM2.G were kind
gifts of Dr. Nir Hacohen, Broad Institute. shRNA constructs against
CD55 or empty vector were purchased from Sigma-Aldrich.RTM. (St.
Louis, Mo., USA). To generate lentiviral particles,
1.2.times.10.sup.6 HEK293T cells were seeded in each well of a six
well plate the day prior to transfection. Cells were then
cotransfected using lipofectamine 2000 (Invitrogen.TM., Carlsbad,
Calif., USA) with 900 ng of psPAX2 and 100 ng of pDM2.G, together
with 1 .mu.g of the vector of interest (shRNA or lentiCRISPRv2).
Alternatively, lentivirus was produced by the conventional calcium
chloride transfection method. Supernatants were harvested 24 and 48
hours after transfection and frozen at .sup.-80.degree. C. HT29
cells were transduced by spin infection with lentivirus. Lentivirus
and 8 .mu.g/ml Polybrene (Sigma-Aldrich.RTM., St. Louis, Mo., USA)
were added to the wells of a 24-well culture plate and centrifuged
at 2000 rpm and 37.degree. C. for 2 hours. Lentivirus-containing
media was then replaced with 293T media, and the cultures were
maintained as described above. On day 5 of culture, puromycin
(Sigma-Aldrich.RTM., St. Louis, Mo., USA) was added to a final
concentration of 2 .mu.g/ml to select for virally transduced cells.
Selected cells were maintained in 2 .mu.g/mL puromycin following
initial selection.
[0246] CRISPR Materials/Methods.
[0247] CRISPRs targeting CD55 were designed using an online tool
(crispr.mit.edu) as previously described and cloned into a
lentiCRISPRv2 vector (Ran F A et al. Genome Engineering using the
CRISPR-Cas9 system. Nature Protocols 2013; 8: 2281-308; and Sanjana
N E, et al. Improved vectors and genome-wide libraries for CRISPR
screening. Nat Methods 2014; 11: 783-4). CRISPR lentivirus was
produced according to the above protocol. Transductions were
performed as above, with minor changes. For Jurkats, selection with
1 .mu.g/mL puromycin was performed for 3 days. For Caco-2,
selection with 5 .mu.g/mL puromycin was performed for 6 days,
changing the media every 2 days.
[0248] HUVEC Experiments.
[0249] Huvecs grown to 80% confluency, and before passage 8, were
trypsonized and replated in 24 well tissue culture plates at
200,000 cells/well in Huvec media. Twenty-four hours later the
indicated concentrations of TNF.alpha., IL10, or all trans retinoic
acid (ATRA) were added. Twenty-four hours later in the cast of
TNF.alpha. or IL10 treatment or 48 hours later in the case of ATRA,
cells were trypsonized and stained for the indicated surface
markers following the described flow cytometry staining protocol.
Cells were then immediately analyzed.
[0250] Western Blotting.
[0251] CD4.sup.+ T cells were washed in PBS and lysed in 1% Triton
X-100, 50 mM Tris-C1, pH 8, 150 mM NaCl, 2 mM EDTA, 10% glycerol,
complete protease inhibitor cocktail (Roche Diagnostics,
Indianapolis, Ind., USA), and phosphatase inhibitor cocktails
(Sigma-Aldrich.RTM., St. Louis, Mo., USA) on ice for 20 minutes.
The lysates were then clarified by centrifugation at 15,000.times.g
at 4.degree. C. for 10 minutes. Protein concentration was
determined by BCA assay (Thermo Fisher Scientific.RTM., Waltham,
Mass., USA). Lysates were then diluted with 2.times. SDS sample
buffer (quality biologicals) supplemented with 5% BME to make
reducing sample buffer. Approximately 5 .mu.g of total protein was
separated by SDS-PAGE on 4-20% precast gels (Invitrogen.TM.,
Carlsbad, Calif., USA) and transferred to a nitrocellulose membrane
(Bio-Rad Laboratories, Philadelphia, Pa., USA). Membranes were
blocked with 5% nonfat dry milk in Tris-buffered saline (TBS) with
0.01% Tween-20 (TBST) for 30 minutes at room temperature before
incubating with primary antibody overnight at 4.degree. C. After
three 5 minute washes with TBST at room temperature with rocking,
HRP-conjugated secondary antibody was added for an additional hour
at room temperature. After five 5 minute washes, HRP substrate
(Luminata Forte; EMD Millipore, Billerica, Mass., USA) was added to
the membranes, which were then exposed to autoradiography film and
developed.
[0252] Statistical Analysis.
[0253] Statistics were computed using the analysis options in Prism
(Graphpad Software, Inc., La Jolla, Calif., USA). Either the
Mann-Whitney U test or a two-tailed unpaired T test with Welch's
correction was used to compare sample means. *=p<0.05,
**=p<0.01, ***=p<0.001.
[0254] Patient Clinical Histories.
[0255] Patient 1.1, a 7 year-old girl born to consanguineous
Turkish parents, presented with bloody diarrhea and vomiting at 4
weeks of age, and continued with episodes throughout childhood. At
6 months of age, she was admitted to hospital with persistent
diarrhea, pneumonia, and facial/extremity edema, for which she
received antibiotics and albumin replacement therapy. Endoscopic
examination revealed ulcers, exudate formation and nodularity in
the colon. Although the patient's gastrointestinal (GI) symptoms
improved with treatment and she subsequently gained weight,
long-term remission could not be achieved. The patient was placed
on infliximab therapy at 6 years of age to deal with ongoing GI
symptoms. Apart from GI symptoms she experienced recurrent
respiratory infections at an unusually high frequency from 6 months
of age. Immunologic evaluation revealed pan-hypogammaglobulinemia
and she was treated with intravenous immunoglobulin (IVIG), leading
to a decrease in the frequency of infections. To determine the
specific antibody production we tested isohemagglutin levels, with
normal Anti-A and Anti-B titers. Despite WIG, trough levels of IgG
remained below the desired range, and tracked well with levels of
serum albumin (FIG. 1B). Fecal excretion of alpha-1 antitrypsin was
found to be elevated, implying the role of protein losing
enteropathy in refractory hypogammaglobulinemia. In addition to the
biallelic loss of function in CD55, this patient was additionally
positive for a homozygous LOF mutation in CD21 that resulted in
loss of protein expression (data not shown).
[0256] Patient 2.1, a 22-year-old female born to consanguineous
Turkish parents, presented with fever, productive coughing and
hemoptysis at the age of 6 years when she was diagnosed with
pneumonia. She continued to have recurring respiratory symptoms
with breathing difficulty, wheezing, chronic coughing, and multiple
attacks of pneumonia leading to the development of bronchiectasis
and finger clubbing. Following the onset of respiratory illness,
she developed GI complaints, with abdominal pain and distention,
diarrhea, and, eventually, cessation of growth. Clinical
presentation included vomiting, diarrhea, periorbital and pretibial
edema and she was found to have hypoalbuminemia and decreased serum
levels of Vitamin B12, folate, iron, and hypothyroxinemia. When she
was 11 years old her serum immunoglobulins levels were determined
due to suspected immunodeficiency. These tests revealed
hypogammaglobulinemia and she was started on IVIG replacement
therapy. While on IVIG the frequency of infections decreased
substantially, leading to the recovery of bronchiectasis. Despite
IVIG, serum immunoglobulin G levels remained within the lower range
and correlated with the serum albumin levels over time, suggesting
the loss of immunoglobulins through the GI tract (FIG. 1B). In
order to assess the patient's capacity to produce specific
antibodies, we evaluated isohemaglutinin titers and antibody
response to pneumococcal vaccine, with normal results. After
several years of loss to follow up, she presented to the
gastroenterology clinic with persisting symptoms and received
treatment for IBD. Despite treatment, she experienced symptoms of
intestinal obstruction at the age of 22 years and underwent surgery
for the resection of the narrowed intestinal segment (FIG. 1H). The
resection material showed fissuring ulcers, cryptitis and crypt
abscesses, villous blunting, diffuse epithelial regeneration, and
dramatic lymphangiectasis.
[0257] Patient 3.1, a 16-year-old boy born to consanguineous
Turkish parents, presented with edema due to hypoalbuminemia at 27
months of age. Serial colonoscopies revealed progressive
macroscopic hyperemic lesions with ulcers, cryptitis, crypt abcess,
and lymphoid cell infiltration that did not respond to steroids and
azathioprine treatment alone. Over time, addition of mesalazine to
treat IBD and supplementation therapy with calcium, vitamin B12 and
folic acid led to clinical improvement. Of note, the patient did
not present with classical VEO-IBD symptoms such as bloody stools
at the beginning of the disease. The patient presented with protein
losing enteropathy with hypoalbuminemia and serial serum
immunoglobulin investigation revealed reduced levels of IgG.
Lymphocyte counts were also reported as normal. This patient has
not, as of yet, presented with recurrent/severe lower respiratory
tract infections despite hypogammaglobulinemia. In addition, no
infectious trigger was found throughout GI episodes indicated by
normal C-reactive protein (C-RP) levels, as well as a normal
erythrocyte sedimentation rate (ESR).
[0258] Patient 4.1, a 3-year-old girl born to consanguineous
parents, presented with puffy eyes, diarrhea and vomiting at 1 year
of age. She continued to have recurrent episodes of periorbital and
pretibial edema, mostly triggered by the bouts of bloody and mucous
diarrhea. She was found to have persistent hypoalbuminemia, for
which she received intermittent albumin infusions. Evaluation for
other serum proteins revealed hypogammaglobulinemia, with low IgG,
IgA and IgM levels. At presentation, anthropometric indices
revealed wasting with weight within the 3.sup.rd to 10.sup.th
percentile and height within the 50.sup.th percentile for her age.
The patient currently receives supplementation therapy for the
deficiency of vitamin B12. Despite low immunoglobulin levels she
has not experienced any significant or recurrent infections as of
yet. Evaluation for infectious etiology during attacks of diarrhea
and vomiting proved negative, along with normal levels of
inflammatory markers such as C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR). Evaluation for the
differential diagnoses including food allergy and cystic fibrosis
or celiac disease was also negative.
[0259] Patient 4.2, a 17 year-old boy and brother of Patient 4.1
and 4.3, has a history of occasional and self-limiting
presentations with facial and extremity edema, for which no medical
intervention was required. Despite testing positive for
hypogammaglobulinemia, he denied any history of infections of
unusual severity or frequency. The patient has not experienced any
significant GI symptoms thus far.
[0260] Patient 4.3, an 18-year-old boy and brother of patient 4.1
and 4.2, has been mostly asymptomatic. Laboratory evaluation
revealed low-normal levels of serum proteins and vitamin B12. The
patient has not experienced any significant GI symptoms thus far,
and has not reported any history of edema.
[0261] Patient 4.4 was an affected female cousin of patients
4.1-4.3 with an unknown genotype. Clinically, this patient
presented with recurrent facial and extremity edema, chronic bloody
diarrhea, chronic malnutrition, low serum protein levels, with
hypoalbuminemia (albumin: 1.9 g/dl) and hypogammaglobulinemia.
Histopathology revealed the presence of dramatic lymphangiectasis
in the small intestine. The patient was treated with
immunosuppressive treatment including steroids and azathioprine due
to suspected IBD. Interestingly, she had a history of thrombosis
and cerebral vascular disease with hypodense brain lesion in the
lateral ventricule and received anticoagulation therapy with low
molecular weight heparin. Angiographic studies demonstrated various
vascular pathologies at the intra-abdominal and cerebral vessels
including: (1) narrowed superior mesenteric vein with multiple
collateral veins, suggestive of chronic thrombosis, and (2)
decreased blood flow in internal carotid arteries, particularly in
cavernous and intracranial segments and undetectable middle
cerebral artery. She eventually developed an intestinal obstruction
and underwent intestinal resection surgery to remove the narrow
segments. Histopathological evaluation of the resection material
revealed lymphangiectasia, a focus of ulceration, and abundant
ectatic vascular elements with vessel wall thickening. At 33 years
of age, this patient died of thrombosis, cardiac arrhythmia, and
respiratory distress syndrome developing after surgical resection
to remove a severe intestinal obstruction. We were unable to
successfully obtain a genetic analysis of this patient due to not
having access to patient tissue.
[0262] Patient 5.1 is a 10-year-old boy and the sibling of Patient
5.2 born to consanguineous Turkish parents. The patient was first
admitted to a hospital at the age of one year with diarrhea and
vomiting. He was diagnosed with intestinal lymphangiectasia with
severe hypoproteinemia, with low albumin and immunoglobulin levels.
The patient required frequent albumin infusions and was put on a
protein rich diet with medium-chain triglyceride (MCT) supplements.
At the age of 7 years old, Patient 5.1 underwent abdominal surgery
for the resection of lymphangiectatic segments, which led to a
temporary recovery of his symptoms. He has had multiple recurrent
thrombotic events in mesenteric and hepatic veins, as well as in
the vena cava inferior, atrial and ventricular thrombosis. He
received anticoagulation treatment with warfarin following cardiac
surgery for atrial thrombosis. He also presented with intracranial
bleeding and underwent neurosurgical operations. Currently, the
patient is prescribed octreotide irregularly. The patient is not
reported to have an increased rate of respiratory infection despite
low immunoglobulin levels. There was no evidence of
gastrointestinal infection, and sweat chloride test, celiac
markers, and lipid profiling were normal. Colonic biopsy revealed
edema and eosinophilic infiltrates, from which a diagnosis of
eosinophilic colitis was made. The patient is in poor condition and
requires frequent hospital admissions.
[0263] Patient 5.2, is the 12-year-old affected sister of Patient
5.1. The patient presented with frequent abdominal pain, and a
similar manifestation of hypogammaglobulinemia and hypoalbuminemia
as Patient 5.1, which required frequent albumin transfusions. Due
to episodes of intestinal obstruction, she underwent resection of
edematous small bowel segments to remove lymphangiectatic segments,
upon which she experienced some clinical remission. Of note, this
patient did not present with any thrombotic events, infectious
history, or bloody diarrhea.
[0264] Patient 5.3, an affected sister of patients 5.1 and 5.2 of
unknown genotype, was admitted at 15 months old with complains of
eyelid and extremity edema and diarrhea. The patient presented with
hypoalbuminemia, hypogammaglobulinemia, thrombocytosis and anemia.
Endoscopy and histopathological examination of the duodenum
revealed intestinal lymphangiectasis. The patient had severe
malnutrition, with reduced levels of calcium, magnesium, and
phosphorus and various vitamins. The patient was treated with
intravenous calcium, albumin, vitamin, and mineral supplements on
top of medium chain triglyceride supplements and octreotide. These
treatments led to temporary clinical improvement. Small bowel
resection was performed three times over a period of 2 years with
only transient clinical improvement. Parenteral nutrition efforts
were interrupted by Candida and S. Aureus infections along with
sepsis. She developed a thrombus in the vena cava superior leading
to vena cava superior syndrome and anti-thrombotic treatment with
low molecular weight heparin and tissue plasminogen activator was
initiated. The patient developed ascites, pleural effusion, and
pulmonary infection and died when she was 4.5 years old.
[0265] Patient 6.1, a 15-year-old boy born to consanguineous
Turkish parents, presented with facial and extremity edema at 1.5
years of age and was found to have hypoalbuminemia. He had frequent
hospital admissions due to vomiting, diarrhea and abdominal pain.
Endoscopic examination revealed intestinal lymphangiectasia and he
was put on steroid treatment. Evaluation for common causes of
secondary lymphangiectasia including heart diseases and abdominal
mass lesions was negative. Upon persistence of his symptoms he was
started on octreotide treatment and prescribed a diet low in fat
and high in high quality protein along with MCT supplements. Along
with chronic gastrointestinal symptoms he developed deficiencies in
the major micronutrients and vitamins such as iron, calcium,
magnesium and vitamin D leading to growth retardation. Frequent
exacerbations of facial and extremity edema and abdominal symptoms
in relation to severe intestinal wall edema (FIG. 1C) required
repeated albumin transfusions. In line with the low albumin levels,
serum immunoglobulins were also decreased (Table 2, shown as FIG.
4). Apart from chronic gastrointestinal symptoms he experienced
frequent respiratory symptoms with chronic cough and finger
clubbing. Computed tomography of the chest revealed fibrotic
changes in the posterobasal lung segments. When he was 14 years of
age, he suffered severe thrombotic events, with a thrombus
originating from a stalk 2 cm distal to the inferior vena cava
(IVC) extending into the right atrium, which was impairing the
venous blood flow. He also had thrombi in the pulmonary arteries.
He underwent thoracic surgery for thrombectomy and was commenced on
anticoagulation treatment with low molecular weight heparin and low
dose aspirin. Despite prophylactic anticoagulation treatment,
during the follow up he experienced recurrence of thrombosis with
reformation of the clot in the right atrium. Screening for common
congenital hypercoagulable states such as Factor V Leiden or
prothrombin G20210A mutations that lead to over activity of
coagulation factors, or arising from a deficiency of the natural
anticoagulants Protein C, S and anti-thrombin III was negative. The
patient was found heterozygous for the thermolabile variant of the
methylenetetrahydrofolate reductase (MTHFR) gene, C677T and no
A1298C mutation was observed in this gene along with normal plasma
homocystein level, suggesting no increased risk of thrombosis
attributable to hyperhomocysteinemia. The patient was also tested
for anticardiolipin and anti-phospholipid antibodies and for
paroxysmal nocturnal hemoglobinuria through Fluorescein-labeled
proaerolysin (FLAER) flow cytometry assay, with negative results.
The patient currently suffers a debilitating disease with frequent
hospital admissions.
[0266] Patient 7.1, a 4-year-old girl born to consanguineous Syrian
parents, presented with facial and extremity edema at 1 year of
age, with continued relapses thereafter. She has experienced
recurrent gastrointestinal symptoms, with chronic diarrhea and was
found to have hypoalbuminemia. She was diagnosed with suspected
intestinal lymphangiectasia and commenced on octreotide treatment.
She has growth retardation, with height for age below the 3.sup.rd
percentile. Due to micronutrient deficiencies she received
supplementation therapy with vitamin D, vitamin B 12,
multivitamins, and was transfused with erythrocyte suspension due
to anemia. She was prescribed a diet low in fat and high in high
quality proteins, MCT supplements, and further supplementation by
enteral feeding and albumin transfusion as required. Measurement of
serum immunoglobulins revealed low IgG, IgA and IgM (Table 2).
Immunologic evaluation revealed normal isohemaglutinin titers and
the proportion of the lymphocyte subsets was within normal limits.
She has experienced recurrent lower respiratory infections and
received parenteral antibiotics and was put on prophylactic
antibiotic treatment with co-trimoxazole.
[0267] Clinical Phenotype.
[0268] Demographic data and the clinical presentations of the 10
patients in the study are shown in Table 2 (FIG. 4), and patient
descriptions were described above. Patients 1.1-3.1 were born to
unaffected consanguineous parents with a distinct PLE syndrome
comprising severe hypoalbuminemia, hypogammaglobulinemia and
chronic diarrhea. After gene discovery in these initial cases,
additional patients were found by evaluating early-onset PLE
patients.
[0269] Overall, patients presented with facial and extremity edema
accompanied by chronic persistent bloody diarrhea with remissions
and exacerbations in disease severity (Table 3). Individual
patients had additional disease manifestations, some with multiple
thrombotic events and vascular alterations and others having a
history of recurrent respiratory infections.
[0270] All patients exhibited persistent hypoproteinemia, with
reductions both in albumin and gammaglobulins (FIG. 1B and FIG.
5A). The degree of hypoproteinemia and the severity of symptoms
varied among individual cases. Patients 4.2 and 4.3 had mild
disease with occasional facial and extremity edema whereas others
had profound hypoalbuminemia and a severe progressive disease
course (Table 2). Radiological exams, taken from patients in the
presence of acute GI symptoms, showed that the patients had bowel
wall edema/thickening (FIG. 1C, arrows) sometimes together with
partial intestinal obstruction, which responded favorably to
albumin replacement therapy. The hypoproteinemia was attributed to
GI protein loss because the nadir of albumin levels correlated with
the flares of bloody and mucous diarrhea and increased excretion of
.alpha.-1 antitrypsin was detected in feces in Patient 1.1. Other
causes of hypoproteinemia, including hepatic disease, decreased
nutritional intake, or heavy proteinuria, were excluded in all
cases. Endoscopic evaluation revealed relatively mild alterations
in the mucosa given the severity of protein loss, whereas
histopathology of small intestinal biopsies demonstrated dilatation
of the lacteals and distension of the lymphatic vessels in Patients
2.1, 5.1, 5.2, 6.1 and 7.1 (Table 2, FIG. 1D). Evaluation for
common systemic conditions that could lead to secondary
lymphangiectasia, such as cancer, heart disease or obstructive
lesions involving the lymphatic system, was negative, indicating a
diagnosis of primary intestinal lymphangiectasia as the cause of
PLE. Surgical removal of the localized lymphangiectatic segments in
Patients 5.1 and 5.2 resulted in substantial, but temporary,
reversal of PLE in the case of Patient 5.1, and symptom alleviation
in the case of Patient 5.2.
[0271] The patients eventually developed an intestinal
malabsorption syndrome, with anemia and major micronutrients
deficiencies including iron, calcium, magnesium, folate and
vitamins D and B12, ultimately leading to retarded growth (Table 2
and FIGS. 5B and 5C). Supplementation therapy with vitamins and
micronutrients along with dietary modification and albumin and
blood transfusions as required led to improved growth in some of
the patients, whereas others had a more refractory course with
progressive malnutrition (FIG. 5).
[0272] Some of the patients had hypercoagulability with recurrent
thrombosis and vascular alterations. Patient 6.1, who initially had
relatively stable GI disease, developed severe thrombotic disease
during follow up. Large occlusive thrombi occurred in the inferior
vena cava (IVC) and right atrium together with thrombi in the
pulmonary arteries (FIG. 1E, left panel), which was accompanied by
arteriovenous malformations in the lung (FIG. 1E, center and right
panels). Despite surgical removal of blood clots and
anticoagulation therapy, continuing thrombosis caused an overall
worsening of symptoms. Similarly, Patient 5.1 had multiple
thrombotic events in the mesenteric and hepatic veins as well as
the right atrium and ventricle, which was treated with low
molecular weight heparin anticoagulation. He also had a history of
intracranial hemorrhage, which required cranial surgery. Of note, a
cousin of Patients 4.1-4.3 and a sibling of Patients 5.1 and 5.2
(FIG. 3), with undetermined genotypes, had a similar course of
disease leading to death at 33 and 4.5 years of age respectively.
These patients presented with PLE with lymphangiectasia leading to
malnutrition, and a history of thrombotic events, which in Patient
4.4 led to cerebral ischemia, mesenteric vein narrowing with
development of multiple collateral vessels and histopathologic
evidence of ectasia of the vascular elements in the submucosa of
the small intestine. Patient 4.4 died of cardiac, thrombotic, and
respiratory complications following surgery to remove an intestinal
obstruction, while Patient 5.3 died following development of
ascites, pleural effusion, and pulmonary infection.
[0273] Some of the patients had endoscopic and histopathology
features resembling Crohn's disease although without granulomas.
Patients 1.1-3.1 showed mucosal ulcers and inflammatory exudate in
the terminal ileum and colonic sites (FIG. 1F). In the endoscopic
biopsy materials from Patients 1.1, 2.1, and 3.1, there were mixed
infiltrates of T and B cells, sometimes with eosinophils (FIG. 1G).
Although these three patients received recommended therapy for IBD
that reduced their bowel symptoms, a sustained remission was not
achieved and GI protein loss continued (Table 2, FIG. 1B, and
Figure. 5). Patient 2.1, who recently developed symptoms of
intestinal obstruction, underwent surgical resection of a narrowed
ileal segment (FIG. 1H) which included dilated lymphatic vessels,
leading to resolution of GI symptoms, weight gain and recovery of
serum albumin levels during the short term follow up (not shown).
None of the patients exhibited extraintestinal manifestations
commonly associated with IBD, such as skin eruptions, perianal
lesions, fistulas or uveitis.
[0274] Patients 1.1, 2.1, 6.1, and 7.1 experienced recurrent
respiratory infections in association with hypogammaglobulinemia
(Table 2, FIG. 1B (arrows)), while other patients did not report
any significant or recurrent infections. As major immunological
subsets and specific antibody production were largely normal in the
patients (Table 3), it is believe these infections were largely due
to loss of serum immunoglobulins. Clinical evaluation of patient
peripheral blood immunological subsets of Table 3, provided as
either (cells/mm.sup.3) or % of total cells. Notably, use of
intravenous immunoglobulin (IVIG) replacement therapy decreased the
frequency of infections in Patients 1.1 and 2.1 and led to
resolution of bronchiectasis in Patient 2.1.
TABLE-US-00002 TABLE 3 Lymphocyte subset characterization in CHAPLE
patient peripheral blood Patient ID P 1.1 P 2.1 P 3.1 P 4.1 P 4.2 P
4.3 P 5.1 P 5.2 P 6.1 P 7.1 Lymphocyte Subsets (cells/mm.sup.3) or
% of total cells CD3.sup.+ 7400 2262 78% 1552 1742 1748 56% 80% 75%
78% (900-4500) (800-3500) (55-78) (900-4500) (800-3500) (800-3500)
(55-78) (55-78) (52-78) (43-76) CD3.sup.+CD4.sup.+ 3630 1222 28%
994 962 874 27% 44% 49% 37% (500-2400) (400-2100) (27-53)
(500-2400) (400-2100) (400-2100) (27-53) (27-53) (25-48) (23-48)
CD3.sup.+CD8.sup.+ 3080 832 39% 534 676 879 24% 21% 28% 37%
(300-1600) (200-1200) (19-34) (300-1600) (200-l200) (200-1200)
(19-34) (19-34) (9-35) (14-33) CD19.sup.+ 94 156 24% 378 364 179
29% 8% 6% 14% (200-2100) (100-500) (10-31) (200-2100) (100-500)
(100-500) (10-31) (10-31) (8-24) (14-44) CD3.sup.+ 198 78 12% 120
390 176 11% 7% 1% 3% CD16.sup.+/CD56.sup.+ (100-1000) (90-600)
(4-26) (100-1000) (90-600) (90-600) (4-26) (4-26) (6-27) (4-23)
[0275] Identification of CD55 Mutations.
[0276] Given the consanguinity in all families under study, an
autosomal recessive (AR) mode of inheritance was assumed. WES in
Patients 1.1 and 2.1, and combined with homozygosity mapping in
Patient 3.1 and 5.1 as described previously (Dobbs K, et al.,
Inherited DOCK2 Deficiency in Patients with Early-Onset Invasive
Infections. The New England Journal of Medicine 2015; 372:
2409-22), revealed potentially deleterious homozygous
loss-of-function (LOF) mutations in CD55/Decay Accelerating Factor
(DAF), showing perfect segregation under assumption of AR
inheritance. CD55 is a negative regulator of the complement cascade
ubiquitously expressed on the surface of eukaryotic cells (FIG.
6A). The CD55 nucleotide variants were confirmed by Sanger DNA
sequencing (FIG. 3). Additional patients were then screened with a
diagnosis of PLE and identified 5 additional patients from Families
4, 6, and 7 with rare biallelic CD55 LOF nucleotide variants.
Patient 1.1 and 7.1 were homozygous for dinucleotide deletion and 4
nucleotide insertions at position c.149-150 and patients 2.1, 3.1,
5.1 and 5.2 were homozygous for a single base pair deletion at
position c.109, each resulting in frameshift and premature
termination codons in CD55. In Family 4, a novel homozygous
missense mutation was identified (c.800G>C) in CD55 resulting in
a single amino acid substitution (p.Cys267Ser) in the 4.sup.th
short consensus repeat (SCR) domain, predicted by computational
analyses to be deleterious. In Family 6, a mutation was found in
the splice acceptor site of exon 3. The locations of the identified
mutations within the CD55 protein/gene are depicted in FIG. 6B, and
deleterious predictions are shown in Table 4. Mutation and impact
score of Table 4 were calculated from indicated predictive
algorithm (either the SIFT, Polyphen2 and CADD algorithms). This
scoring system was not applicable (N/A) to frameshift or splice
site mutations present in majority of our patients. Predictions
were based on a reference sequence from ENST00000367064, GRCh37.
Altogether, we identified 4 distinct homozygous, novel rare
mutations in CD55 in a total of 11 patients of Turkish (2 with
unknown genotype), and 1 of Syrian origin (FIG. 6B).
TABLE-US-00003 TABLE 4 Predicted impact scored for identified CD55
varients Mutation Chromosome Position SIFT Polyphen2 CADD
c.149_150delAAinsCCTT 1 207495774 N/A N/A 5.585 c.109delC 1
207495734 N/A N/A 12.37 c.800G > C 1 207504588 0 0.99 (probably
23.1 (deleterious) damaging) c. 287-1G > A 1 207497903 N/A N/A
23.9
[0277] Effects of CD55 Mutations on Messenger RNA and Protein
Expression.
[0278] Patients 1.1, 2.1, 3.1, 5.1, and 5.2 harbored frameshift
mutations that led to nonsense-mediated loss of mRNA in 1.1 and 2.1
(FIG. 6C). The mutation present in Patients 4.1, 4.2, and 4.3 is a
missense mutation (p.Cys267Ser) that does not alter mRNA expression
level (FIG. 6C). Cys267 participates in an intrachain disulfide
bond with Cys225 and loss of this bond could lead to CD55 protein
misfolding and degradation (FIGS. 7A and 7B) (Nakano Y, et al.
Complete Determination of disulfide bonds localized within the
short consensus repeat units of decay accelerating factor (CD55
antigen). Biochim Biophys Acta 1992; 1116: 235-40). Absent, or
severely reduced, CD55 surface expression was observed by flow
cytometry or western blot in all patients (FIGS. 6D and 6E).
Patient 6.1, harboring a splice acceptor site mutation, is the only
patient with residual protein expression by flow, possibly
suggesting exon skipping.
[0279] Increased Complement Deposition on CD55-Deficient Cells.
[0280] As CD55 is a negative regulator of the complement pathway,
it was hypothesized that CD55 deficiency would lead to increased C3
cleavage and deposition on host cells. Activation of the
alternative pathway, marked by C3 cleavage, can be enhanced by
serum acidification, used previously for the diagnosis of
paroxysmal nocturnal hemoglobinuria (PNH) (Ham T H, et al., Studies
on Destruction of Red blood Cells. Li. Chronic Hemolytic Anemia
with Paroxysmal Nocturnal Hemoglobinuria: Certain Immunological
Aspects of the Hemolytic Mechanism with Special Reference to Serum
Complement. J. Clin Invest 1939: 18: 657-72). Hence, control
CD4.sup.+ T-cell blasts, which highly express CD55 on their cell
surface (FIG. 6D), were compared with those from patients after
incubation with normal or acidified pooled normal human serum
(nHS), both of which caused surface deposition of the complement
split product C3d. We observed that C3d was deposited to a greater
degree on T cells from multiple patients compared to controls (FIG.
8A). Increased complement activation was due to loss of CD55 as
lentiviral transduction of patient T-cell blasts with CD55
protected them from complement deposition (FIG. 8B). The finding
was verified on Jurkat T cells, which also constitutively express
cell surface CD55, after CRISPR-mediated deletion of the CD55 gene.
Increased C3d deposition was observed in the genetically deficient
(CD55-) compared to CD55-expressing (CD55+) Jurkat cells (FIG. 8C).
C3b (not shown) was unable to detect, suggesting that deposited C3b
is rapidly degraded, possibly by serum factor I and the cofactor
CD46 or factor H (FIG. 6A). It is known that human intestinal
epithelial cells (IECs) express CD55, and that it is upregulated
upon TNF.alpha. treatment. Thus, it was hypothesized that it may
protect IECs from complement activation and damage by anaphylatoxin
signaling or direct attack of the terminal complement cascade. We
therefore knocked down CD55 in the human IEC line HT29 using
lentiviral shRNA transduction and found that this permitted
increased C3d deposition. Using various conditions, it was found
that the CD55 mean fluorescent intensity (MFI) was inversely
correlated with C3d staining indicating that as the level of
surface CD55 decreases, the activation of complement increases
(FIG. 8D). In all cell types tested, lack of CD55 in patient cells
led to increased complement deposition, however,
serum/complement-mediated cell death was not observed (FIG. 8E),
suggesting that CD55-deficient cells allow early steps in
complement activation to occur, but this does not progress to
terminal formation of the "membrane attack complex" (MAC).
[0281] CD55-Deficient T Cells have an Increased Inflammatory
Cytokine Profile.
[0282] Complement proteins are mainly produced in the liver, but
also locally by cells of the immune system (dendritic cells and T
cells). Immune cell complement can provide costimulatory and Thl
differentiation signals to T cells through either CD46-mediated
sensing of deposited C3b or through the C3a/C5a anaphylatoxins
signaling through the anaphylatoxin receptors (AnR) C3aR and C5aR.
CD55 governs complement activation and consequent immune
stimulation. Cytokine secretion by patient CD4.sup.+ T cells was
measured during primary and secondary stimulation with TCR
agonistic antibodies and found increased TNF.alpha. and less IL-10
production compared to controls (FIGS. 9A, 9B, 10A, and 10B). No
consistent differences were detected for IFN.gamma. secretion
(FIGS. 9C and 10C). To determine if the altered cytokine secretion
was dependent on increased AnR signaling, small molecule inhibitors
of C3aR and C5aR1 were used to block anaphylatoxin signaling. AnR
inhibition decreased overall TNF.alpha. production and abrogated
the difference between patient cells and controls (FIG. 9A).
However, AnR inhibition did not rescue IL-10 production in patient
T cells suggesting that the IL-10 secretion defect did not require
AnR stimulation. Activated human CD4.sup.+ T cells expressed C3aR,
but not C5aR1 or C5aR2, suggesting that C3a may play a larger role
than C5a in T-cell activation (FIG. 9D). Interestingly, surface
expression of C3aR on T cells depended on the presence of all trans
retinoic acid (ATRA) and there was comparable expression between
patient and control cells (FIG. 9E). As previously demonstrated, T
cells grown in the presence of ATRA expressed the chemokine
receptor CCR9 and the integrin .alpha.4.beta.7 that promote gut
homing (FIGS. 10D and 10E). This suggests that gut homing T cells
are also best suited to respond to anaphylatoxin products of
complement activation.
[0283] In addition to complement regulation, CD55 mediates a
co-stimulatory signal through interactions with CD97 that enhances
T-cell activation and the production of the anti-inflammatory
cytokine IL-10. Patient cells failed to respond to anti-CD55 or
CD97, the natural ligand for CD55, mediated costimulation as
reflected by CD69 and CD25 upregulation and proliferation (FIG.
10F-10H). Additionally, patient T cells lacked CD55-dependent IL-10
production (FIGS. 9F and 101). Taken together, these data
demonstrate a critical role for CD55 in controlling complement and
non-complement mediated production of proinflammatory and
anti-inflammatory cytokines, respectively.
[0284] TNF.alpha. and ATRA Regulate Complement and Coagulation
Regulatory Proteins on Endothelial Cells.
[0285] CD55-deficient patients are susceptible to thrombotic
events, suggesting an abnormality in the regulation of the
coagulation cascade Inflammatory cytokines, such as TNF.alpha., can
modulate the coagulant and thrombotic properties of endothelial
cells by down regulating thrombomodulin TM and up regulating tissue
factor (TF) expression. As T cells from the patients make more
TNF.alpha. compared to controls, next it was determined how
TNF.alpha. modulates complement and coagulation. As previously
demonstrated, TNF.alpha. treatment induces procoagulatory TM and TF
expression on the surface of treated endothelial cells (FIGS. 9G
and 9H). Interestingly, inventors also found that TNF.alpha.
treatment decreased CD46 and CD59 expression, while modestly
increasing CD55 expression on endothelial cells (FIG. 9I-9L). It
was previously determined that ATRA increased surface expression of
C3aR on human CD4.sup.+ T cells and next sought to determine if
ATRA similarly affected endothelial cells. While no expression of
C3aR, C5aR, or C5aR2 was found on HUVEC cells either with or
without ATRA addition (data not shown), ATRA treatment did result
in a dose-dependent decrease in thrombomodulin expression with a
concomitant increase in CD55 expression and no change in either
CD46 or CD59 (FIGS. 9M-9P). Combined, these data suggest that the
proinflammatory cytokines preferentially secreted by patient immune
cells predispose endothelial cells to the activation of both the
complement and coagulation cascades. This may be further
exacerbated by high local concentrations of ATRA, which are often
found in intestinal tissues due to dietary intake and absorption of
retinols.
[0286] Compstatin Inhibits C3d Deposition on Human Cells.
[0287] FIG. 11A illustrates that Compstatin inhibits C3d deposition
on human T cells. C3d deposition was substantially increased in
patient T cells treated with 5% nHS, as compared to control
treatments and T cells. The increase was substantially inhibited by
the addition of 100 .mu.M Compstatin. Similarly, as shown in FIG.
11B, the ratio of C3a to C4a in culture supernatants from patient T
cells after 24 hours of incubation with 5% nHS 100 .mu.M Compstatin
was considerably decreased relative to patient samples not treated
with Compstatin. In FIG. 11C, the ratio of C5a to C4a in culture
supernatants of patient T cells after 24 hours of incubation with
5% nHS and 100 .mu.M Compstatin is decreased, as compared to
patient T cells not treated with Compstatin. ***=p<0.001.
[0288] Discussion
[0289] A severe chronic syndrome of inherited PLE is described with
lymphangiectasia, thrombotic angiopathy, and atypical IBD caused by
loss-of-function (LOF) mutations in the CD55 gene. Our results show
that loss of CD55 causes dysregulated complement activation,
anaphylatoxin signaling, inflammatory cytokine production, and
thrombophilia via induction of the coagulation cascade. CD55
deficiency, Hyperactivation of complement, Angiopathic thrombosis
and Protein Losing Enteropathy (CHAPLE) syndrome is defined herein
as a heritable cause of complement-mediated lymphangiectasia. The
cohort described herein shows that CHAPLE syndrome presents with
variable expressivity, from subclinical to life threatening
presentations, potentially explaining the variation in intestinal
disease previously associated with the Inab phenotype.
[0290] Complement is a tightly regulated system of plasma and cell
surface proteins that promotes the phagocytosis and destruction of
microbes and modulates the local immune response through soluble
anaphylatoxins. Inherited or acquired defects in complement
inhibitory proteins lead to distinct syndromes in different organ
systems which include paroxysmal nocturnal hemoglobinuria (PNH),
atypical hemolytic uremic syndrome (aHUS), dense deposit disease,
and age-related macular degeneration (FIG. 6A). PNH results from
somatic mutations of the PIGA gene in hematopoietic precursors.
This leads to the loss of GPI-anchored complement inhibitory
proteins, including CD55 and CD59, causing terminal-complement
mediated hemolysis with secondary thrombotic risk due to platelet
activation. Germline LOF mutations affecting the complement
regulatory proteins Factor H, Factor I, and CD46 or the
anti-coagulatory protein thrombomodulin, result in the development
of aHUS which is characterized by activation and damage of
glomerular microvascular endothelial cells by complement
intermediates and the membrane-attack complex, hemolysis due to
mechanical injury, and kidney failure due to microthrombotic
angiopathy. Defects in these same genes can cause age-related
macular degeneration due to complement deposition in the retina.
Unlike PNH and aHUS, hemolysis or kidney failure was not observed
in CHAPLE patients. By contrast, CHAPLE patients, like PNH and aHUS
patients, have an increased risk of thrombosis, highlighting that
excessive complement activation can lead to induction of the
coagulation cascade. The differences in clinical phenotype between
PNH, aHUS, and CHAPLE syndrome may be due to varying cellular
tropisms of the affected complement regulatory proteins or due to
differences in the extent of complement activation. For instance,
hemolysis or complement-dependent cell death was not detected in
CHAPLE patients, suggesting little, if any, membrane-attack complex
forms, differentiating this disease from PNH and aHUS.
[0291] Interestingly, it was observed that CD55 deficiency
primarily manifests as an intestinal disease, occasionally
complicated by life-threatening thromboembolism. The locations
affected by thrombotic disease in CHAPLE patients (abdomen and
brain) was similar to PNH and dissimilar to aHUS, which primarily
affects the kidneys. This may reflect expression patterns of CD55
and other complement regulatory proteins. Supporting this idea,
CD55 protein expression was found to be increased on endothelial
cells in response to both TNF.alpha. and ATRA. During normal immune
responses TNF.alpha. induction of CD55 may limit complement
activation and prevent host damage. ATRA is a biologically active
metabolite of Vitamin A/retinol, which is strictly acquired through
diet. As such, intestinal tissues are exposed to a high amount of
retinol and its metabolites and these metabolites play key roles in
controlling the intestinal innate and adaptive immune response.
Another possibility is that the constant microbial challenge in the
intestinal tract predisposes this area to complement activation and
activation of innate and adaptive immune responses, which may be
hyperactivated by the absence of CD55. Additionally, TNF.alpha. and
IL-10, whose production is altered in patient T cells, are critical
for the regulation of universal inflammatory responses and
deficiency of these cytokines preferentially causes intestinal
disease, suggesting that intestinal tissues are sensitive to
changes in the inflammatory cytokine milieu. Given the observation
that ATRA drives both C3aR expression and a gut homing phenotype on
human CD4.sup.+ T cells, it is likely that T cells in the
intestinal tissues are sensitized to the detection and activation
by complement components. Collectively, these factors likely drive
the intestinal disease associated with CD55 deficiency.
[0292] The hallmarks of CHAPLE syndrome or disease are early-onset
PLE with lymphangiectasia and IBD. This is attributable to 3
relevant pathogenic mechanisms: i) impaired endothelial or
epithelial barrier function due to signaling by anaphylatoxins or
sub-lytic MAC deposition, ii) increased pressure due to thrombotic
events, and iii) changes to the inflammatory cytokine environment.
CD55-deficient mice show increased complement-dependent
susceptibility to dextran sodium sulfate (DSS)-induced colitis,
with complement deposition on IECs. The thrombotic events in CHAPLE
patients, when localized to mesenteric tissue, may drive increased
lymphatic pressure and exacerbate intestinal lymphangiectasia and
chronic PLE. CD55-deficient patient T cells produce more TNF.alpha.
and less IL-10, thereby creating a pro-inflammatory milieu.
TNF.alpha. production was found to be dependent on anaphylatoxin
signaling, while decreased IL-10 production was likely due to loss
of CD55-mediated T-cell costimulation. CD55-deficient mice show
similar alterations in cytokines. Taken together, these data show
that complement activation is critical to disease pathogenesis
(FIGS. 12A and 12B).
[0293] The patients with CHAPLE disease described herein have a
chronic and severely debilitating, sometimes fatal, clinical
course. As such patients with early-onset PLE should be screened
for CD55 expression. CHAPLE patients have responded well to protein
infusion and resection of localized lymphangiectatic intestinal
segments; though albumin infusion provides only a transient
palliation of symptoms and patients require ongoing treatment.
Attempts to treat this disorder with conventional
immunosuppressants, somatostatin analogues, or anticoagulants have
been met with only a moderate degree of success in individual
patients. Given the complement-mediated pathogenesis of this
disorder, it is believed that agents that inhibit the
complement-pathway (e.g., the complement-inhibitory monoclonal
antibody Eculizumab, which has been used successfully in PNH and
aHUS, or Compstatin), would be effective at treating CHAPLE
patients. Eculizumab blocks C5 cleavage, thereby preventing the
formation of the potent anaphylatoxin C5a and progression to the
terminal complement cascade, two critical mediators of effector
function in the complement cascade. While CD55 regulates the C5
convertase, making Eculizumab a good target therapy, it also
regulates the C3 convertase. Furthermore, Compstatin is a peptide
inhibitor (i.e., a cyclic tridecapeptide) of the complement system.
In particular, Compstatin binds component C3, thereby inhibiting C3
activation/cleavage. As such, any complement-pathway inhibitors,
including C3 convertase and C5 convertase inhibitors are possible
therapeutic agents for treating patients with CHAPLE disease.
Specific Embodiments
[0294] An aspect provided by the present disclosure is a method of
diagnosing a patient with CD55 deficiency, hyperactivation of
complement, angiopathic thrombosis and protein losing enteropathy
(CHAPLE) is provided. The method comprises: providing a sample from
a patient; detecting at least one of: at least one mutation in a
DNA sequence of a CD55 gene; at least one mutation in a RNA
sequence of a CD55 transcript; at least one mutation in a DNA
sequence of a CD55 complementary DNA (cDNA); CD55 protein; CD55
protein binding; complement deposition; or combinations thereof,
wherein a mutation in the CD55 gene, transcript or cDNA, or absence
or decrease in activity of CD55 protein is indicative of a patient
at risk of developing or having CHAPLE; and diagnosing the patient
as having or not having CHAPLE.
[0295] In any aspect or embodiment described herein, the patient is
diagnosed with CHAPLE when at least one of the following is
detected: at least one mutation in a DNA sequence, an RNA sequence
or a cDNA sequence of CD55 that results in a CD55 protein with
substantially diminished functional activity, a CD55 protein with
no functional activity, a lack of expression of CD55 protein (i.e.,
no CD55 protein expression), or a substantially diminished
expression of CD55 protein; a CD55 protein with substantially
diminished functional activity; a CD55 protein with no functional
activity; a lack of expression of CD55 protein (i.e., no CD55
protein expression); a substantially diminished expression of CD55
protein; or combinations thereof.
[0296] In any aspect or embodiment described herein, the patient is
diagnosed with CHAPLE when the patient has at least one CHAPLE
related symptom and at least one of the following is detected: at
least one mutation in a DNA sequence, an RNA sequence or a cDNA
sequence of CD55 that results in a CD55 protein with substantially
diminished functional activity, a CD55 protein with no functional
activity, a lack of expression of CD55 protein (i.e., no CD55
protein expression), or a substantially diminished expression of
CD55 protein; a CD55 protein with substantially diminished
functional activity; a CD55 protein with no functional activity; a
lack of expression of CD55 protein (i.e., no CD55 protein
expression); a substantially diminished expression of CD55 protein;
or combinations thereof.
[0297] In any aspect or embodiment described herein, the CHAPLE
related symptom is selected from the group consisting of:
inflammatory bowel disease, enteropathy, protein losing
enteropathy, protein losing enteropathy associated with
hypoalbuminemia, hypoalbuminemia, hypogammaglobulinemia, intestinal
lymphangiectasia, lymphangiectasia, thrombotic events,
thromboembolism, hyperactivation of complement, angiopathic
thrombosis, hypoproteinemia, or combinations thereof.
[0298] In any aspect or embodiment described herein, the method
further comprises administering an effective amount of a
composition comprising at least one complement inhibitor to the
subject with CHAPLE, wherein the composition is effective in
treating or preventing at least one symptom of CHAPLE.
[0299] In any aspect or embodiment described herein, the complement
inhibitor is selected from the group consisting of a serine
protease inhibitor, a soluble complement regulator, a therapeutic
antibody or an antigen-binding fragment thereof, a complement
component inhibitor, and an anaphylatoxin receptor antagonist.
[0300] In any aspect or embodiment described herein, the mutation
in the DNA sequence of the CD55 gene or in the RNA sequence of the
CD55 transcript results in a near to complete absence of CD55
protein expression or the expression of CD55 protein with
substantially diminished function or that is non-functional.
[0301] In any aspect or embodiment described herein, the mutation
in the DNA sequence of the CD55 gene is at least one of:
c.149-150delAA; c.149-150insCCTT; c.109delC; c.800G>C;
c.287-1G>C; c.149-150delAAinsCCTT; or combinations thereof.
[0302] In any aspect or embodiment described herein, detecting
includes at least one of: sequencing at least a portion of the CD55
gene or the CD55 transcript or the CD55 cDNA; or contacting a
labeled nucleic acid probe to at least a portion of the CD55 gene
or the CD55 transcript or the CD55 cDNA; or contacting at least a
portion of the CD55 gene or CD55 transcripts or cDNA thereof with a
microarray; or combinations thereof.
[0303] In any aspect or embodiment described herein, hybridization
of the labeled nucleic acid probe is indicative of a mutation in
the portion of the CD55 gene or CD55 transcript.
[0304] In any aspect or embodiment described herein, hybridization
of the labeled nucleic acid probe is indicative of the portion of
the CD55 gene or CD55 transcript having a wild-type sequence at the
location of hybridization.
[0305] In any aspect or embodiment described herein, sequencing at
least a portion of the CD55 gene or CD55 transcript or cDNA thereof
includes amplifying at least one region of interest for sequencing
with at least one polymerase chain reaction (PCR) with at least one
of the following primer sets: CTACTCCACCCGTCTTGTTTGT and
TTTGGGGGTTAAGGATACAGTC (Exon 1); CAGGTGTGGCATTTCAAGG and
ACCCTGGGGTTTAGTAACGC (Exon 2); AAGTACTAAATATGCGCAAAGCAG and
ATGGTCCTATCAAGAAACATCC (Exon 3); GTTACCTTCTTTGTGTGTATGCC and
GCTGTGAATACCAGTCATGAAAC (Exon 4); AACCTGGAGAATTTGAGGAAAG and
TGTGCTAATATTCTTAAGGGGC (Exon 5); GCATTTATAAGCATCTCTTGTTGG and
TCATTGAATGTCTGCAACCC (Exon 6); CTAGGTGTTTGTGGGGAGAGAG and
TCTGGTGGGTTTCTGAAGAGTT (Exon 7); TTTACGCAGAGTCCTTCAGC and
CCATTTAATCCTGCAATCTTGG (Exon 8); TGGAAATTTGAGTTGCTTTCG and
TCTCCCAGGAATATGGATTG (Exon 9); GCACCCCAAATTAACTGATTC and
ATGTGATTCCAGGACTGCC (Exon 10); or combinations thereof.
[0306] In any aspect or embodiment described herein, contacting a
labeled nucleic acid probe to at least a portion of the CD55 gene
or the CD55 transcript or the CD55 cDNA is performed using
real-time PCR.
[0307] In any aspect or embodiment described herein, contacting a
labeled nucleic acid probe to at least a portion of the CD55
transcripts or cDNA thereof comprises: isolating CD55 transcripts;
reverse transcribing at least a portion of the CD55 transcripts;
and contacting the cDNA with the labeled nucleic acid probe.
[0308] In any aspect or embodiment described herein, the microarray
includes probes designed to detect DNA, transcript, or cDNA
mutations that result in the complete absence in CD55 protein or a
non-functional CD55 protein.
[0309] In any aspect or embodiment described herein, detecting CD55
protein comprises: contacting the sample with at least one CD55
binding polypeptide.
[0310] In any aspect or embodiment described herein, the CD55
binding polypeptide includes a detectable label.
[0311] In any aspect or embodiment described herein, the binding
polypeptide is an anti-CD55 antibody or a CD55-binding fragment
thereof.
[0312] In any aspect or embodiment described herein, detecting CD55
protein further comprises contacting the sample or a CD55-CD55
binding polypeptide complex with at least one secondary polypeptide
that binds specifically to the CD55 binding polypeptide.
[0313] In any aspect or embodiment described herein, the secondary
polypeptide includes a detectable label.
[0314] In any aspect or embodiment described herein, the secondary
polypeptide is an antibody or fragment thereof that binds the CD55
binding polypeptide.
[0315] In any aspect or embodiment described herein, the detecting
of CD55 protein is performed using at least one of a western blot,
flow cytometry, an immunoassay, or combinations thereof.
[0316] In any aspect or embodiment described herein, the
immunoassay is at least one assay selected from the group
consisting of enzyme-linked immunosorbent assay (ELISA),
radioimmunoassay, magnetic immunoassay, enzyme-linked immunospot
(ELISPOT), immunofluorescence; and combinations thereof.
[0317] In any aspect or embodiment described herein, the detecting
of CD55 binding function includes examining the at least one of C3b
affinity, C3b avidity, C4b affinity, C4b avidity, or combinations
thereof.
[0318] In any aspect or embodiment described herein, detecting
complement deposition includes detecting C3d deposition.
[0319] A further aspect provided by the present disclosure is a
method of treating a patient with CD55 deficiency, hyperactivation
of complement, angiopathic thrombosis and protein losing
enteropathy (CHAPLE) or preventing at least one symptom of CHAPLE
in a patient at risk of developing the same. The method comprises:
administering an effective amount of a composition comprising at
least one complement inhibitor to a subject in need thereof,
wherein the composition is effective in treating or preventing at
least one symptom of CHAPLE.
[0320] In any aspect or embodiment described herein, the complement
inhibitor is selected from the group consisting of a serine
protease inhibitor, a soluble complement regulator, a therapeutic
antibody or an antigen-binding fragment thereof, a complement
component inhibitor, and an anaphylatoxin receptor antagonist.
[0321] In any aspect or embodiment described herein, the serine
protease inhibitors is at least one of a C3 convertase inhibitor, a
C5 convertase inhibitor, a C1 inhibitor, a C1r inhibitor, a C1s
inhibitor, a C2a inhibitor, a MASP-1 inhibitor, a MASP-2 inhibitor,
a factor D inhibitor, a factor B inhibitor, a factor I inhibitor or
combinations thereof.
[0322] In any aspect or embodiment described herein, the serine
protease inhibitor is at least one of BCX-1470 (BioCryst,
Birmingham, Ala., USA), C1s-INH-248 (Knoll/Abbott, Abbott Park,
Ill., USA), compstatin, Cetor.RTM. (Sanquin, Amsterdam,
Netherlands), Berinert.RTM. (CSL Behring, King of Prussia, Pa.,
USA), Cinryze.TM. (ViroPharma, Exton, Pa., USA), rhC 1INH
[0323] (Pharming Group N.V., Leiden, Netherlands), Ruconest.RTM.
(Salix Pharmaceuticals, Inc., Raleigh, N.C., USA) or combinations
thereof.
[0324] In any aspect or embodiment described herein, the soluble
complement regulator is at least one of a soluble form of a
membrane cofactor protein (MCP or CD46), a soluble form of a
decay-accelerating factor (DAF or CD55), a soluble form of a
membrane attack complex-inhibitor protein (MAC-IP or CD59), a
soluble form of complement receptor 1 (CD35) or combinations
thereof.
[0325] In any aspect or embodiment described herein, the soluble
complement regulator is at least one of sCR1 (TP10; Advant
Immunotherapeutics, Needham, Mass., USA), sCR1-sL.sup.ex (TP10;
Advant Immunotherapeutics, Needham, Mass., USA), sDAG-sMCP hybrid
(MLN-2222, Millennium, Cambridge, Mass., USA), a membrane-tethered
sCD59 (Mirococept or APT070; Inflazyme Pharmaceuticals, Vancouver,
British Columbia, Canada) or combinations thereof.
[0326] In any aspect or embodiment described herein, the
therapeutic antibody or the antigen-binding fragment thereof is at
least one polypeptide that binds C3, C3a, C3b, C3 convertase, C5,
C5a, C5b, C5 convertase, C7, C8, or C9, factor B, factor D, C4, C2,
C1, properdin, a functional blocking antibody of an anaphylatoxin
or combinations thereof, wherein said binding inhibits complement
activation by at least one of blocking association/binding with
other complement proteins, blocking association/binding with
receptor proteins, blocking serine protease activity or
combinations thereof.
[0327] In any aspect or embodiment described herein, the
therapeutic antibody or the antigen-binding fragment thereof is at
least one of eculizumab (Soliris.RTM.; Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ALXN1007 (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), neutrazumab (G2 Therapies,
Darlinghurst, NSW, Australia), Pexelizumab (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ofatumumab (Genmab A/S, Copenhagen,
Denmark), HuMax-CD38 (Benmab A/S, Copenhagen, Denmark), TNX-558
(Tanox, South San Francisco, Calif., USA), TNX-234 (Tanox, South
San Francisco, Calif., USA), TA106 (Taligen, Aurora, Colo., USA),
anti-properdin (Novelmed, Cleveland, Ohio, USA) or combinations
thereof.
[0328] In any aspect or embodiment described herein, the complement
component inhibitor is a peptide, nucleic acids, a synthetic
molecule or a comination thereof that disrupts protein functions by
steric hindrance or the induction of conformational changes.
[0329] In any aspect or embodiment described herein, the complement
component inhibitor is at least one of compstatin, anti-C5 RNA
aptamer (ARC1905; Archemix, Cambridge, Mass., USA), or analogs or
derivatives thereof, or combinations thereof.
[0330] In any aspect or embodiment described herein, the
anaphylatoxin receptor antagonist is at least one of a C5aR
antagonist, a C5L2 antagonist, a C3a receptor antagonist, a
functional blocking antibody of an anaphylatoxin or combinations
thereof.
[0331] In any aspect or embodiment described herein, the
anaphylatoxin receptor antagonist is at least one of PMX-53
(PepTech Corp, Bedform, Mass., USA), PMX-205 (PepTech Corp,
Bedform, Mass., USA), JPE-1375 (Jerini, Berlin, Germany), JSM-7717
(Jerini, Berlin, Germany), rhMBL (Enzon Pharmaceuticals, Cranford,
N.J., USA) or combinations thereof.
[0332] An additional aspect provided by the present disclosure is a
therapeutic composition for treating or preventing at least one
symptom of CD55 deficiency, hyperactivation of complement,
angiopathic thrombosis and protein losing enteropathy (CHAPLE). The
composition comprises: an effective amount of two or more agents,
wherein at least one of the agents is a complement inhibitor to a
subject in need thereof; and a pharmaceutically acceptable carrier,
wherein the composition is effective in treating or preventing at
least one symptom of CHAPLE.
[0333] In any aspect or embodiment described herein, the complement
inhibitor is selected from the group consisting of a serine
protease inhibitor, a soluble complement regulator, a therapeutic
antibody or an antigen-binding fragment thereof, a complement
component inhibitor, and an anaphylatoxin receptor antagonist.
[0334] In any aspect or embodiment described herein, the complement
inhibitors include a C3 convertase inhibitor and a C5 convertase
inhibitor.
[0335] In any aspect or embodiment described herein, the serine
protease inhibitors is at least one of a C3 convertase inhibitor, a
C5 convertase inhibitor, a C1 inhibitor, a C1r inhibitor, a C1s
inhibitor, a C2a inhibitor, a MASP-1 inhibitor, a MASP-2 inhibitor,
a factor D inhibitor, a factor B inhibitor, a factor I inhibitor or
combinations thereof.
[0336] In any aspect or embodiment described herein, the serine
protease inhibitor is at least one of BCX-1470 (BioCryst,
Birmingham, Ala., USA), C1s-INH-248 (Knoll/Abbott, Abbott Park,
Ill., USA), compstatin, Cetor.RTM. (Sanquin, Amsterdam,
Netherlands), Berinert.RTM. (CSL Behring, King of Prussia, Pa.,
USA), Cinryze.TM. (ViroPharma, Exton, Pa., USA), rhC 1INH (Pharming
Group N.V., Leiden, Netherlands), Ruconest.RTM. (Salix
Pharmaceuticals, Inc., Raleigh, N.C., USA) or combinations
thereof.
[0337] In any aspect or embodiment described herein, the soluble
complement regulator is at least one of a soluble form of a
membrane cofactor protein (MCP or CD46), a soluble form of a
decay-accelerating factor (DAF or CD55), a soluble form of a
membrane attack complex-inhibitor protein (MAC-IP or CD59), a
soluble form of complement receptor 1 (CD35) or combinations
thereof.
[0338] In any aspect or embodiment described herein, the soluble
complement regulator is at least one of sCR1 (TP10; Advant
Immunotherapeutics, Needham, Mass., USA), sCR1-sL.sup.ex (TP10;
Advant Immunotherapeutics, Needham, Mass., USA), sDAG-sMCP hybrid
(MLN-2222, Millennium, Cambridge, Mass., USA), a membrane-tethered
sCD59 (Mirococept or APT070; Inflazyme Pharmaceuticals, Vancouver,
British Columbia, Canada) or combinations thereof.
[0339] In any aspect or embodiment described herein, the
therapeutic antibody or the antigen-binding fragment thereof is at
least one polypeptide that binds C3, C3a, C3b, C3 convertase, C5,
C5a, C5b, C5 convertase, C7, C8, or C9, factor B, factor D, C4, C2,
C1, properdin, a functional blocking antibody of an anaphylatoxin
or combinations thereof, wherein said binding inhibits complement
activation by at least one of blocking association/binding with
other complement proteins, blocking association/binding with
receptor proteins, blocking serine protease activity or
combinations thereof.
[0340] In any aspect or embodiment described herein, the
therapeutic antibody or the antigen-binding fragment thereof is at
least one of eculizumab (Soliris.RTM.; Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ALXN1007 (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), neutrazumab (G2 Therapies,
Darlinghurst, NSW, Australia), Pexelizumab (Alexion Pharmaceuticals
Inc., New Haven, Conn., USA), ofatumumab (Genmab A/S, Copenhagen,
Denmark), HuMax-CD38 (Benmab A/S, Copenhagen, Denmark), TNX-558
(Tanox, South San Francisco, Calif., USA), TNX-234 (Tanox, South
San Francisco, Calif., USA), TA106 (Taligen, Aurora, Colo., USA),
anti-properdin (Novelmed, Cleveland, Ohio, USA) or combinations
thereof.
[0341] In any aspect or embodiment described herein, the complement
component inhibitor is a peptide, nucleic acids, a synthetic
molecule or a combination thereof that disrupts protein functions
by steric hindrance or the induction of conformational changes.
[0342] In any aspect or embodiment described herein, the complement
component inhibitor is at least one of compstatin, anti-C5 RNA
aptamer (ARC1905; Archemix, Cambridge, Mass., USA), or analogs or
derivatives thereof, or combinations thereof.
[0343] In any aspect or embodiment described herein, the
anaphylatoxin receptor antagonist is at least one of a C5aR
antagonist, a C5L2 antagonist, a C3a receptor antagonist, a
functional blocking antibody of an anaphylatoxin or combinations
thereof.
[0344] In any aspect or embodiment described herein, the
anaphylatoxin receptor antagonist is at least one of PMX-53
(PepTech Corp, Bedform, Mass., USA), PMX-205 (PepTech Corp,
Bedform, Mass., USA), JPE-1375 (Jerini, Berlin, Germany), JSM-7717
(Jerini, Berlin, Germany), rhMBL (Enzon Pharmaceuticals, Cranford,
N.J., USA) or combinations thereof.
[0345] It is understood that the detailed examples and embodiments
described herein are given by way of example for illustrative
purposes only, and are in no way considered to be limiting to the
invention. Various modifications or changes in light thereof will
be suggested to persons skilled in the art and are included within
the spirit and purview of this application and are considered
within the scope of the appended claims. For example, the relative
quantities of the ingredients may be varied to optimize the desired
effects, additional ingredients may be added, and/or similar
ingredients may be substituted for one or more of the ingredients
described. Additional advantageous features and functionalities
associated with the systems, methods, and processes of the present
invention will be apparent from the appended claims.
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Sequence CWU 1
1
37146495DNAHomo sapiens 1cctgaagaac tcatgtataa gaaatgggag
agtccactca tttgttttca tttattaaaa 60aataccctta ttctgtgaag cagaattacc
tgtatttgca gctgcatgac aaaaatgcct 120caatataaag ctccccccaa
cccccacccc ccgcccattg gctattttaa gataagttgg 180caataaattt
aggctgagtt agaatgtaaa tatgaaatag actggttcct cagatgtgag
240gcatagatag gcacattaca tactttggta gcatagagga aggtaccagg
tatgatgcaa 300tggcaaggga gattttctgg aggaatgttg cctggccagt
ctaacagagg tgttaagatc 360ctaagcacta gttctactgc cagcaagcca
tgtggtttgg ggctagtttc ttaacttccc 420taaacaccag ctggttcact
tgcaatgagg gtgataatat ttgctcacag ttttgtattc 480cttggctttc
aagaaattgc acaatcctct ttcctttcca ctaccttctc ctttcccttt
540ctctgtcatt tgtactttct aacgtggggc tcctcaagtc tcacaccttg
ggcttctcta 600tttccacatg ctatgctccc ttggttcaaa ccttgcctgc
agtcacatct ctacccactc 660cacctcaatc ttgcctccgt ttcaatcgca
tgctggacat ttccacgtag acactctgcc 720aaggcatttg aaattcaaca
agtgtaaagc tgaatatgga tagttctttt aaatagggct 780gctaatctca
caaactccaa acttccgagt cctcttcaac atctttttcc ccactgttcc
840ttatctaatc agttgccaaa ttctgtggct tattactttg aaacttgttt
ggtcagagca 900ggaatggaaa ttcaaaagtc tataataatt gtgtcaggag
ttttacagag caacaggact 960ggaactcctt aatatagatt tattaatttt
aaaactaaaa gacatttttg ttctctaaac 1020acctggactg ttgtaattag
ctaaattgga tctttgctta cacagccatt cccattccag 1080catcttagat
gcaaattcca aattacccag gtgcttcctc cttacaagtg tcaaccgtcc
1140tttaatgctt ctgaatggtg taaaaggcac aggccttgcc tttaaggctc
tctcaaatct 1200ctttccagcc tctcttaccc tcttgttcca ttgccattgc
ctcaattcag ttctccatac 1260tctccctaaa ctaaactcct tactattcct
ggaatcaaca ggactgaccc caaacctttg 1320ttcgtatctc atctcttttc
ctatttttgc cctattgcat tgacacttgt catatttagt 1380tgaatcactg
ggcctttagc cttccccgct ccaattacca cactcccttc tttcctttct
1440gaagccccat accactttgg ttgtgatatt tgtatagcat ttatcatgga
aaacctccct 1500actagattgt agattctcaa acacaagtat tgacacttag
tgggtttctg tatactaggg 1560aagtttatta aacagtcttt gatttagtca
ttgtatggtt cctgggataa gagtaagaac 1620cgtggtccct tgctctgtca
aaatcataaa cctattttct ttgtattttg acttaattac 1680ataagcttgt
tttggattgg aaggtctata gagactattt tagtgccaaa tgctatttaa
1740tcaatgcaga aataagccct tgagaggtgc agtgactcag ctgaggacac
actgatagtt 1800tctggtagat aagtatgaag ccttggaact acttctcata
tcataagccc ctgggttccc 1860aaatcacctc cccaagtacc taattcatca
tcctctgcat acaagaaatt tttgctcatt 1920ccaataaaaa gaatgtagta
cggcaggaca ggagaagtac aggttttgga atcaaactag 1980gtttagattc
tgacctggtc gctagttagt gcatgggctt tggtaaacag cctctcagcc
2040tgtttccttg tctgcaaaat atggatagtt atcttcactt catgaagttg
tgttggtgaa 2100atggtataat gtgtataaag caactggaac acaacaaatg
aggccattta tttaaaataa 2160tctttagtaa gttataaatt cacatatttg
cttttttctg aggaatgctt agattttatc 2220atagatctct tttctaaatt
gagtaaatac atagtggatt tctttgtttc cttcccctca 2280gaatgttgaa
atttggctga ttgtaactat tacttaagac tctatccagt aattgttcgt
2340aaaatttctt ttcttttttt ttttttgaga cggagttttg ctctcgtccc
ccaggctgga 2400gtgcaatggc gcgatcttgg ctcactgcaa cctccgcctc
ccaggttcaa gtgattctcc 2460cgcctcagcc tcccaagtag ctgggattac
aggcacctgc cacaacgccc agccaatttt 2520tgtattttta gtagagacgg
ggtttcacca tgttggccag gctagtctgg aactcctgac 2580ctcaggtgat
cctcctgcct tggcctccca aagtgctgag attacaggcg tgagccacca
2640cgcccggcca aaatttcctt ttaaaaaaag ttattgccaa taactaagta
tgctggaagg 2700tgaatgctta ggacatttag tgtcactgag ctgtgtgata
gagataatat ttttgacact 2760ttgcagagct cattgttttc tctccatata
aagctatgac attcacataa taaacatgta 2820gagagcttta acagacttca
atgttaagtc ttctaacagc tgcataactg gtcttgcttg 2880aacctgtctt
tttcataatg ctaccttgcc tttcacacca attctgtgag cccaagcagg
2940aatgaagatt acctatctct aatggcagga cagaagggag tggtggttaa
ggttactgga 3000ggttattggg ggaataaatg aagacctcat gccacttcta
aacactgcca ggacctaaca 3060taccttgtgt ttttatatcc aatatgggag
taaaggttag atattttaac atcaaatatg 3120aggatgacac tagatggttt
taaaagcccc ccaccataac ttctaaactc cacaatgttc 3180gaatattgtt
aggtttcagt gaaatcctac agtagtccct tgcttggaat cactgtagga
3240ttggctccag caatgggcaa cacaaggttt ggttctatac agtaggtatg
ggtcaaagaa 3300aatgctatga ttgaaaaatt gctgttttcc tcctcaaaaa
gctcatacca accaggaaag 3360agctatcaga aaaccttcag gaaagaatat
aatgatagga tataacaaat acccccacag 3420ctggtccata gaccaaagta
taattccaag tagggaattt cacttaacga ggtaaggcat 3480ttaagggaaa
aggaatctag gctaggactc tgctagccag acccagataa attattacag
3540ggaagcatgt tcttgaggct attctctatg aagaagggca acccaccttg
ccatctatat 3600cctttctgtt ttcgacaggg gtggtcctaa gctggataga
tctttactct gaccagtacc 3660atataggtct gtggttctca aacctggctg
cacagtgtgg cactttaagt aatcctgata 3720cccagtccca tccccaaaga
tgctgattta atttgtctaa ggtgcagttt gggcctctgg 3780attggaacca
acccatatac ccatcaatga tagactggat aaagaaaatg tggcacatat
3840acaccataga atactacaca gccataaaaa aggatgagtt catgtcctat
gcagggacat 3900ggatgaagct ggaaaccatc aacctcagca aactaacata
agaccagaaa accaaacact 3960gcatgttctt actcataagt gggagttgaa
caatgagaat acacagacac agggagggga 4020acatcacaca cgggggcctg
ttggagggtg ggggttaggg gagggatagc attaggagaa 4080atacctaatg
tagatgttgg gttgatgggt gcagcaaacc accatggcac gtgtatacct
4140atgtaacaaa cctgcatgtt ctgcacatgt attccagaac ttaaagaata
tatatttata 4200tatgtataaa tatatatgaa tatataaata taaatatata
tataagctcc ccacgtgatt 4260ctaatgtgtg gccagtcttg caaacctcag
gctatttatt ctaaagggtt tgtaacaagc 4320cttcctctta aaatccaccc
caccaccatt cagcgttttg gggtctgttt gtttttattg 4380ttatcccacc
ccacaccgcc ccgaggcgcg cgcgcgcgcg cgcacacaca cacacacaca
4440cacacacaca catacacaca cgcacactgg tgaatttctc tctacagtca
gtctggagta 4500atcccaaagt ggtgtctttc gtaaataagg agaacccggg
tgaagaaaat gactcccacc 4560cgaacaaggc atgaacaatg ttcactccct
actgtgttat tcaacctgtt tccccaggtc 4620tctgttttca cattagagag
tgttctagga gatgacgccc ttcctcctta gttatttccc 4680caccctcgtg
ctggcctttg acagacctcc cagtagaggg cccaagacgc gggtagagca
4740ccgcgtctca gcgcctgagt ctcagccccc gaactccacc gcacctgcag
gtccccttgg 4800cagcactcaa gcgcggggat gctccgctta gacgaactca
cgtgcgggca gcaaggcctg 4860cgatacttga gcacccctcc ccctctcccg
tttacacccc gtttgtgttt acgtagcgag 4920gagatattta ggtttctaga
aggcaggtca tcgcaggccc cacccagcag tggagagagt 4980gagtcccaga
gggtgttgcc agcgagctcc tcctccttcc cctccccact ctccccgagt
5040ctagggcccc cggggcgtat gacgccggag ccctctgacc gcacctctga
ccacaacaaa 5100cccctactcc acccgtcttg tttgtcccac ccttggtgac
gcagagcccc agcccagacc 5160ccgcccaaag cactcattta actggtattg
cggagccacg aggcttctgc ttactgcaac 5220tcgctccggc cgctgggcgt
agctgcgact cggcggagtc ccggcggcgc gtccttgttc 5280taacccggcg
cgccatgacc gtcgcgcggc cgagcgtgcc cgcggcgctg cccctcctcg
5340gggagctgcc ccggctgctg ctgctggtgc tgttgtgcct gccggccgtg
tggggtgagt 5400aggggcccgg cggccgggga agcccctggg ctgggtggga
ggtccaagtc ggtctctgag 5460acacgcacag gggccggcga cttggcaggt
ggggagcttg gcccgcggtc gtggttcccg 5520ccgtcctgtg cctttaaggc
tctcgccgct caccagcatt tggggctcct gctgtgtcgg 5580cccccagctg
acttggcttt aggggtcggc gtggagggtt aaagaggccc cggctgggtt
5640tgcggagcag ccaagcctgg caaaatcgaa agggagggct caaagagact
gtatccttaa 5700cccccaaaaa gctggtctaa aaggatggga ggccagaccg
ctgaccgttc cccactctcg 5760acagagtcca gccgtgtgga gcacacgatg
ctgcaaactt gcatgtcatc tctttcaggt 5820gtggcatttc aagggggctt
gtgtcttgaa aacagcaact gtgaggacac ttgatagtca 5880tttccttcag
ttctgctttt gtctccctag gtgactgtgg ccttccccca gatgtaccta
5940atgcccagcc agctttggaa ggccgtacaa gttttcccga ggatactgta
ataacgtaca 6000aatgtgaaga aagctttgtg aaaattcctg gcgagaagga
ctcagtgatc tgccttaagg 6060gcagtcaatg gtcagatatt gaagagttct
gcaatcgtaa gttcttcatc tttttagaaa 6120agttctggga atggaatgta
tcttaaattt atttttatat acctttggag tgactagtaa 6180ttgatagttc
tctagcgtta ctaaacccca gggtataccc tgttggcacg tcacactcca
6240gctaattgaa gacatttacc accctgagta ggtcctgctg cttcattaag
agtttttctt 6300cctaacactg tacctcttga acgaactagt agagaaaata
aacaataggt attgtttagg 6360gagtaaacat ataaaatata tttggcaatt
gccttgagac acatagcgta aatgatatgt 6420tttcttaagt attttataaa
gtaggactta ccaaatacaa ctctgtggtg gcatttttaa 6480aagctctcaa
tatttacttc aaaatctgtt atacttgtac atatttatag ggtacatgtg
6540atattctggc acatgcatac agtgtgtcat gatcaatcag ggtaattgga
tagccagtac 6600ctcaaacact tggtgtttgt gtggagaata ttccaaatct
tctcttcttg ctactttgaa 6660aaaatatatg tatatatata aattgggata
tatatatagg gagagagata tatataattg 6720ggatatatat atataaggag
atatataatt gggatatata taaggagata tatataggga 6780gagatatata
tatataggga gatatatata tatagggaga gagatatata tagggagaga
6840gagatgtata aactgggata tagacaggta gataggttga ttgttaaaaa
tgaataagag 6900gcccagtgaa gagttgtttg ggggctaaca cagtaaccgt
gtttgatact gatacctagt 6960agaattaaaa gaaatgaaga tttcttgttt
taggtgaata tacatacagt catccacacc 7020ttatgtgccc tttgatttca
taaaatatat attggcatta tcttggagga aaaaaatctg 7080ttacttacat
agccctgtat tagctttgag atatatgagt agagataaag ataaagagac
7140ccgataacct gactttgaac aacttaaatc aatagaagct actgtaaata
cagaaattgg 7200cacaaatacc tttagaagcc atgcgtgaaa taggctttaa
ctttttattt ttatccacaa 7260tagaggcagt aggatgaagt acatagtctt
tgcacatgta tcatgtttta actcttcccc 7320atgttattac tttatccaat
cctccaaaca accttatgag gtaagttggg gctcttacac 7380tctttttatg
gcggaggaga cagaccccag tagtttaata acttcctcaa gagcagcagc
7440ttttacgcca aaaccaaggt gtaaacttgg gtcttctgac tacaaatcca
atgatgaccc 7500ttccacttga ccatgcctct ctagattcac atttgtgggc
aatctgttta cagatgtaaa 7560tactttatgt atacaatttg tgggcaatct
gtttacaggt gtaaatactt tatgtataca 7620attgactcat ccttgccccc
agggctcatg ggaattaaat gagtttgtac gtaaataaat 7680attagctgct
attattgttg tgcaggacat tagtccaggg gtctggaaat accctattcc
7740tgtactgtat ggtgctgtgt agttctttag ggcagggtaa ggaaaccaac
atttattgaa 7800tgccagaact gggccaggca acttaaattt tttttttttt
ttaagtgggg atagtgatat 7860gtgtgtacca actctacttc ctaagcctct
agtaactagg aaacaaagta tacatgtgaa 7920tacatttgct acattgcaag
tgccatggtg atattaatat agttaagtac taaatatgcg 7980caaagcagta
aagaaagggg gttattaggg tccagataat taaatataga ttataaaaca
8040aaaattgata ctacattttt tgttgctgct tttgttaata cttttaggta
gctgcgaggt 8100gccaacaagg ctaaattctg catccctcaa acagccttat
atcactcaga attattttcc 8160agtcggtact gttgtggaat atgagtgccg
tccaggttac agaagagaac cttctctatc 8220accaaaacta acttgccttc
agaatttaaa atggtccaca gcagtcgaat tttgtaaaag 8280tgagtaaaat
tttttaaagt attttcaacc atctggtgtt tgggggaaat agtatccctt
8340ccttcattca tgctagaact ctatgtgtat atattattat ataggatgtt
tcttgatagg 8400accatgagtg tcaatttatt ttgaattaga ctaaatattt
atgtggtagg aatacttatt 8460cattcaaaaa tttcacattt aattagtttg
aggttaccta aaataaaaca agtatatatt 8520ctaaattcgt tgctttttca
aaacttatta taaagagaaa ttagaattaa agaagtctaa 8580gggtcaggca
tggtggctca tacctgtaat cccagcactt tgggagacag aggcaggtgg
8640accacttgag gtcaggagat tgagagtagc ctggccaaca tgatgaaacc
ctgactctac 8700taaaaataca aaaactagct gggtgtggtg gcgcatgcct
gtaatcccag cttcttggaa 8760ggctgaggca ggagaatccc ttgaacctgg
gaggcagagg ttgcagtgag ctgagattat 8820gtcaccgcgc tccagcctgg
gcaacagagc aaaactccat ctcaaaaaaa aaaaaaaaaa 8880agtctaagga
taagaaatat caatggttca gatgatgaat ttacatatat gtgcttgata
8940attttttcaa aatttttacc tgagctttat tgaggtataa tcgacaaata
ttatcttagg 9000tgtacaacat gatgttttga tatatgtgca cattgtgaaa
tgattaacac agtcaagcta 9060attaacatat ctaccacctc acatagttac
cttctttgtg tgtatgcctg ataatttaat 9120tttaaaaaat caatttgtat
tctattctag agaaatcatg ccctaatccg ggagaaatac 9180gaaatggtca
gattgatgta ccaggtggca tattatttgg tgcaaccatc tccttctcat
9240gtaacacagg gtaagtttgg gcatactaaa accctgtatt taggaaatga
gaaaacaaat 9300taggacttaa ggtgagattg ttagtttcat gactggtatt
cacagctagt agcaattaaa 9360acaatccctc tcctcaaaga cccttcatca
tgagctcatc acagttaaat ttagtaaaat 9420gggggcaaga aaggaagatt
tcttaaacca ccagaattct ctaaattctg atttcagtaa 9480atatgtgatt
caatataaaa ttttaaatgt gattaataaa aaaatttgag atgatgatac
9540ttgcagaaat cttcaaatgt taaatactaa accaatcttt agttgaccta
aataatgaat 9600ttgcatgagt ttttctatat gcaaacaagc tgttacaaaa
cagcatgagt taaagacatt 9660cctagtgtga aagtattcta agttctttga
taagttctct gtatagggag aaggaactca 9720ttcattgagt accatcaatg
tctcagacac tgttgaaaac tttacattta ttttctcatt 9780tcatatctgt
aaattaaata attctatttt actctgtgtg tgtccctatt ctttataaag
9840taaaaatatc agtatcactt gtctcctata cgaaacacag atattggtta
ggtcatgaac 9900acaaaatctg ggaagtactt tgaacccttt aaatataagt
acattctatt attctgtgaa 9960gcccatattt agaactcaga ggtataaaat
gttcaatcat ctatgtcatt taaaaatgtt 10020taaaacactt ttatgctttc
taacatattc cccatgcaaa taaaaaatgt acatgtctta 10080tctgttttta
ctctttggat gtcacgtttt taaacttaat ttttcttttc ctttaaacta
10140ctgtgtggac ttttatcaac tactgtttta tattcaccta attgtgtagt
aaatatttta 10200agataataac ctggagaatt tgaggaaagt caaatatgtg
tgaatgtaac aaactctttt 10260ttcttcccct gttgctttag gtacaaatta
tttggctcga cttctagttt ttgtcttatt 10320tcaggcagct ctgtccagtg
gagtgacccg ttgccagagt gcagaggtaa gagttaaaaa 10380atctaagcac
tcagattgtg aggctgagta ctcaatgata aattaatttc tgccccttaa
10440gaatattagc acagtgtgta tttgtagcaa acccaccttt caatatatga
gtgctttgct 10500aattttaaga ccttttctag tgatgttcct tcatttagca
gctgtgaaga taaaccagca 10560agttttctga gtcccaattc ccaaattgta
gaatgaggat taaaaacaaa cttaggtttg 10620tattgcactt ggtcatttat
tgtctaacca ttacttctaa agtcaagtat gataggtgaa 10680agatttccgc
cccacaattt tgtgtaagaa aatagtgtca atcagagggt ctgtaagact
10740tgaccccata tcctaaaaca agtggcaatg gaaggcattt aaccaggtct
cttatttcaa 10800acccagcatt tttctaaaat ccagtgttgc ctacatgctg
cttcttagga ttaaaataat 10860taaccgagat aattatctag aggggtttta
aggtgtgata tattcttatc attagagaga 10920taagcttata ccgtcaagaa
gaaatactgt gtctgtattt gagaatcttc tcaaagaaag 10980atatggtgca
gaaataatat tataaatgga tatatatcca gtcaaattta tgtcaattag
11040agacacatgt ctcttggaaa ttgagaggaa taaaatacat gcaacatttt
aaaatgtagg 11100cttgctttct ttccatcctt ctctctctcc acacacaatg
tgccctcctg caaatgactt 11160ctgaaggccc tattgtcaaa attattgata
agttaaagtt tttgtatgtt actaggggaa 11220gaaaactaga gtagatttag
tgtaatttat caagcattta tcgattgaca ctctggtagg 11280caacgtgtac
ggtcaactga cacgaagaca aataaaatga agccgtgcca ttaaggagcc
11340tgtccctgcc acacccacca tgtgcccttc tttttgagat gtcatactac
tacctttttt 11400ttctcattgt agttgttttt aaatttttca tcattgctac
ccagtagcac ctttcccatt 11460ttcgttgtcc agtaagagac attgtaaatg
atagtaaatt aaagatagaa aacaaggaaa 11520agctgggcca tatcttttgt
ttgacccagg caacatgtca caaagttcag acaaacagtc 11580tcccatctga
agccagtatt ttcacaagca cctgctgtgt catgaatttg acagaaatgc
11640aaacccactt tatcttcctg cttgcacatc taggccacag ccttgcttcc
ctatctggtg 11700tcttgaactc catgctgaat attctgatgt tcatgttttc
ctccttgact cttctatcct 11760ctctgtgact cagcaaccac tgacatctgc
atcctgtagg aaagagcccc tgttcttaag 11820caatcccagt gccttcaaat
atccctataa ggccttactt ctttcaggat cattttgatt 11880ttccacataa
cttgttttga ccataccaaa aagattgaat ggaaagtgaa ttcttaaaca
11940atgtactgct tcacctcaag tatgtagccc tagactataa acacatgagg
ttgcttcagt 12000gtccatgcgt gaatatggat acgaagaagg aaagaacagt
ggacacattc actaattgtc 12060tatagttata cagaaaacag aggtgctgct
agtttacctc tgaatagagc ctcactgtca 12120gaggacctgt ttgcttatct
ctctgccaat gttttctttt tcaaaatttt agttgactga 12180tggtatctgc
taacctagaa tcaatccctg ctatatgact atcatgccag acccttctct
12240ttatcttaac tccccacatc tcatccctaa atcattgtgc tttacctcct
caatctgttt 12300ttcaaacttg tgttttgctc tccatctgta tatttctagc
atagtttatt attcctcctg 12360tggactattg caattagggc cacccctaac
attttcaggg cccaggcaag aatataaatg 12420gaggtcgctg gcctaagacc
caccttgtat caaatagccc ttcctcttcc cacactgtat 12480gggttctctg
gtgcacataa gcggacaact cagcctacat acccaagaca tgtccaccac
12540atccaccata acttgtatcc accctccatt gtctgttggg ttagaggtga
gtatatcagc 12600aggatagacc accctcaaga acatggacca gtgggaggga
ccctctcagg ccctggaagg 12660ggtgttggca cagggaattc tgggtgctag
ttcctggagc atgttctgga atggaggaga 12720agtcgtagga caggctgtca
ttgagtatat gctatcagcc tacaaacatc ccaccaacag 12780gggagaaatg
catccagagg agggccagag cacagccttt taaaatgtgg ggtttgaggc
12840agcaatctta gttgcctgag ttcaagagtg acactgatag caatggcctc
ctgcctccat 12900tctttcactc tattaatgtt tcatccatat tttacccaga
gcgatctgaa acacagatgt 12960gacttagaca tctatttcct ccttagagct
tattcatatc tcctatcact taaaaagccc 13020aaattcctta gtatagtgta
caaggcagcc atggtctacc tactgcttga cactcaggtc 13080ttgccttcat
gttttatgcc ttatacatgc aaactgctgt ggtttccatg tacctctttt
13140ttttcttttt tttaaattga gacagggtct cactctgttg cccaggctga
agtgcagtgg 13200tgcgatcaca gctcactgca gcctcaacct ccttggccca
agtgatcctc ccacctcagc 13260ctcccttgta gctgggacta taggtgcaca
ccaccatgcc cagctaattt atgtattttt 13320tgcatagaca gggcttcctc
atgttgtcca ggctggtctc gaactcctgg gctcaagcag 13380tctgcccgcc
tcagcctccc aaagttctgg gattacaggt gtgaaccacc atgccccgct
13440gccccttctt tacttagcta tattttcctt actaagagtt agttccctag
cccatcagaa 13500agattcccag gctggctact tcgggatgac ccttgcattt
tttattgaaa tcatttctga 13560atcttttttc ccactagctt ttaagacata
ggaactatat cttgttcagc tttgcgcttc 13620caattataaa aaaatgcctg
gcgtgtgtta ggcactcaga aaatgtttga actgaaccaa 13680tggtgtgtgt
gtctctgcac actctaagtt agtgtaaatc agaacagctt gttgttgctg
13740cttgttttga tccaagacca aagagtgatt gataaatgtg ctaagtattt
tctgtgttct 13800taagtatgtt tggtgtaaca taatttggca tacacacata
ttaaattgcc ttcattctta 13860aaaaaaaaaa aaaggacaac aacatcatgc
ctttagatta tgtggaacca ttgaattttt 13920tctcagggta actgccaggg
agtggtccct ttttacagta taactaaaaa aacttctgct 13980tgtatttatt
ttgtaagttc agctgctcag taagattgtt ttgagtgaag tctctgtgag
14040tccatatgtg ctaaaaattt ttactctaga agtcaaaatg taatcctgac
atttaagatc 14100tctgctgtat ccaaaatgat ctatacttaa ctcttaaaca
tgctgcttga attttcaact 14160ccttgcattt gctagcgttt ccctcttaga
gtgaagagca acgctttctc cgctgttctc 14220tctcaaaagc atggtacata
ttaggtttaa actcaagttc tatttccctg cccaagtctt 14280ctctgactac
actgctttca tctctaaaat cctgcagcat tcacttttcc tagcaccgtt
14340ttgatatgca cacatcttac tataattttt cttttacata catgttctga
atcttattat 14400ttctatgaat tggtctcaag gttagcattt gtcttctaca
ccatttgcat tcaaagctcc 14460cacatactac caattactta ataggcattt
ataagcatct cttgttggta atgctgaatt 14520tagaaaaatg atattttgat
ttctttaaaa tataatcttt aacatgtttt gatcttattt 14580gtaaaaatac
tttactagtt ttatttattt aaaagatgtt ggaattgttt tttaagaaat
14640ttattgtcca gcaccaccac aaattgacaa tggaataatt caaggggaac
gtgaccatta 14700tggatataga cagtctgtaa cgtatgcatg taataaagga
ttcaccatga ttggagagca 14760ctctatttat tgtactgtga ataatgatga
aggagagtgg agtggcccac cacctgaatg 14820cagaggtaat cactttggat
agttatattt ttgctttatt cttaccctca ggtctatatg 14880tgggttgcag
acattcaatg aaccccctaa gaaaaaaatg taaaatgttt acatatacat
14940atttgtattt ttctgtggga cacaattttt ctacagcttc tcagaagggt
ctatggcttg 15000tatacacaca cacacacaca tactcacaca tattatgatg
tgtatatata aaataggcct 15060catatttttg gcaaatttgc ttacatttgc
tgttttatac catgttgctt tcagtaagtt 15120aatataggta ctttgtttat
acaaagagat ataaagtggt ttattggagg gagaatctta 15180gattgaaggc
tctagatagt gatcatacct gttgcaacaa ctgggaaact cttgccatct
15240gttgacttca ctgaattaac attcaattct tttctgcctc cagaatttct
attattatcc 15300attctccttc atccttctag acgtttttct ttcaatgtct
ttttataccc agaaggtact 15360ctcagaatcc ttcgaactgc tttttaaata
tattttaaaa gaaatattta gaagatcagt 15420gaagctggac taaacattgc
ctagtatcaa taggtggcgt ttaagtagtg gtgaatacca 15480acatgactca
agcatttgag tatttacttt tataattata attgaaattt tattagtatg
15540aattttaaaa attccttatt aaaatagatt tttattataa gtgttataca
tagacataat 15600gacataatat taaagccagg gagatgagta caaaatggga
agtgaaagtc tcttctctat 15660cactagtcct actcggagag gtaacaattt
tttacaaatt cttttgtttt attctagaat 15720ataaataaac atacaaatat
tttttattta ttatatcaat ggtgtgggta ttcatttatc 15780taaccagtcc
tctattgatg acaatttagg ttttttgttc tagtttgatt ttttttatga
15840actattatta caaatgatgc tataatattc ttgtacatct gtcactgcac
atatatgcaa 15900gtacatttgt acaataaatt ccttgtagta taattattta
taacaaaggt atgtgaatta 15960catttttcat gcccattagt agcactgctt
tttaaaagac tgtaccaatt tagtctccca 16020ctgatacaac atcattgtgg
tgtttgcacc tttaatgata atgattgtta gggagatttg 16080acaatgtaaa
tggtaaaaat ttgtattatt tgaattcatt taattatgaa gtttagtgtg
16140tgtgcttttt taatttggcc atttgatcca gttcatattt atttttccaa
gttttattaa 16200atgatcagtt atttagagct taaaaaacca tatggaagta
cccaagtagg tcatggcagg 16260ctgatgcttc cattaaaacg actataaaat
ctcaatagat taccaaaaaa ttatattttt 16320taaggcataa gatacagctg
tggaagcaac aaggtctgaa tgaactaaaa ttcctggggg 16380caggtggtga
aggcaaccca tcctgatgta aggcagtttt ccctagggac ctttgctgat
16440tctgaacctg gactaaggat tcaccttgac ccagacaaaa gaccacttct
aggaaagaga 16500aaccagcaaa gctttaatgg ttatggaggg atagggtaat
acactggaaa ttgaggccct 16560caaatgcaga accaattttt cctaaaggcc
atttgcaaat tttggggctg catgtgaggc 16620tgggaaggtt gacccagagc
ttctaaagta caaaatgaaa tctctcagaa cctgatggta 16680tttggatagc
atatacccac cagaggaaca ggcttttatc tagcatacca caggtctccc
16740ctttagcaca tctgtgctca ttttgaaact gtatagggaa ggacattagg
tggctgggag 16800aactctgaag gacagacctg gatctcctgc caccttccaa
aggtgaaaca acaaaaatcc 16860gccaggcttt cagtcagaag cccggaaggg
ccactcccaa ggaacagagg caagagcaga 16920agtagatgga gtcttactga
aactgaaacc cagctcaatt cctaataggt tgaagatatg 16980attacctcaa
tgcagtctgc ttatcagaaa ggcatatcat atcatccgga tggtttatat
17040acaatgtttg gcatacaaca aaagactgtt agatatggaa ggaagcaaga
aaatgtgacc 17100aaatcaagag aaaacaaaac caaataaaga atatccagat
aattgagtta gcaaatgaga 17160accttaaaat aactgattaa caagtttaag
atgataaaag aaaagagaac ttcagttgga 17220atctgcaaaa atggtgtaaa
atgaatattc tacaactgga aaatatctga aattaagaac 17280acaatagata
ggtttagcta ttcaggcaga gcaggaaaca gtattaggaa ctgaaagatc
17340ggttaaaaat acccaaactg atgcacaaag agaaaaagga atgtgaaata
tagataaaag 17400tttgagacat ttgagacatg ttaaactgtg ctaacacatt
aggaaaaaga gaaagtgaga 17460caaaaaggaa gaggggaagg aggaggagga
gaagagaaat aggagcagaa gaaatattta 17520aaatgatact tactcagaat
tttccaaaac tgataaagta cattagccaa cagattcaag 17580aagctctctg
actctaagct gaataaaaat aaaaccactt tagcaaaaaa tctaactcta
17640agctgaacaa aaataaaacc actcgtagca aaaacaaaca acaaaaactt
caaagaagca 17700acagtataac tgattactgc tcagcaaaaa atgatgcaaa
ccaaaagaca ataagaagaa 17760atctttaaaa tactgtaaga aaattactgt
tcacctagaa ttttataccc agttaatata 17820tccttcaaaa ctgaatgcaa
aatagagatg tattcagaca aaaaccaaga aaactttgca 17880ctagcagacc
aaacatgcac agaatgagaa actaaaggaa attcttcaag tagaatgaaa
17940ataatgccag gtaaaacatg aaaatacaaa aggaaatgaa cagtgacaag
gataaatgaa 18000tactgagttt acaaacagtg aatgtaatgt cctgtggggt
ctgaattata catagaatac 18060aaatgcacaa taacaatgcg aaaggcagaa
agaggtaaat tcatttaaag gttacacagt 18120tctagcagta ctgaaaaggt
ggtaaaagtg atagtttgca taattgactt atagtctaat 18180aaatattgtg
atctctaggg ttgctacaaa tgaatgacag aagaatacat aaatcacaag
18240ctaataaaag aataataatg gatatttaat ccaaaagaga acgagagaga
gagaagcaga 18300aaggaacaca gaatagatgg gagaaataga aaactaataa
ggttgttgat ataaacccaa 18360gtatgtcagt aattatgtta agtgcaattt
gaccaagatt gtcagactta aaaagatttt 18420aaaaagaacc tagttcttta
ctatttacaa gagacacagt ttaattacaa gaacacagaa 18480tagttgaaag
taaaggatgg aaaaatatac catgcaaata ttaacccttc aaaataagct
18540gacacagtta cattaatatc aatgtatatt ttaagatgaa acagttcata
atgataagga 18600ggccaactca acagtaatat atcataatct ggaatctata
tgtacttgat aaaatagctt 18660caatctatat gtagcaaaaa tggacagaaa
aaatagacaa atacacactc atagttagaa 18720aattccacac ctatctcaat
agctaatagg acaagcaacc aaaaatcagt gagactaaag 18780atctgagcaa
caattaaaca tatatacata tgagaccatt gaatctatta ggaccgatga
18840caggtatgtt ttttcaagtg cgcatgggct atttaccaaa attgaccctt
tgctgggctc 18900taagctacaa tacattgcaa aagattgaag ttattcagag
cataccttct agccacagtg 18960gaattaaact agatgtcagt aacgaaaaga
taactaaaaa attaacttct aggaaattta 19020aactctaagg tagtatatac
attctctgga tcaaaactga gaactaactt gatagaacaa 19080agaataattt
agaatagttt ttatatagga gggtcttaga atgaaaagtt cataaaaaaa
19140ctttacttat cttaataatg attatcattg tttgagtgcc tgctaaatgc
tgttacctgc 19200taggcgtttt actcaattta tcccttatag cagcctgtga
gataggttag gaggcagaaa 19260aaaatgaccg ataccatctg agttcctagg
gcatcccgtg tgtgatgggg ctggcaacag 19320tcatcctgga tgatgtaatc
tcttgcttca gggacagaca ctgtgaaata gcttactcaa 19380ttatttccct
taatccttcc tcaataataa ttactcaatc tgttctgctt ttatcctcat
19440tttacagatg aggaaactat agcttagaag ggttagggac ttgctagagc
tcactaatac 19500gtggtgaaat caggcttcgg cactacccaa tactgcctca
acaggggact ttgtataagt 19560gacccaatgg cagttgggct ctgaagactg
aaaaagttgc tctgctgtta gatttatgct 19620tttcagaata tgttcttaat
gaaagtttca cctgacttgt tatctagtct gaaatctaaa 19680gaggaactgg
tgtatggaaa gttggtaacc agcacaagag aattaaaagg agttattttt
19740actcagactc gagtatcact ttaaacaaga cgtgaaacaa aacaaattct
caggctcatt 19800aaggttaagt gatagaaaag gctgtgactg tctctgttgg
cttagttgtt ctagaacaac 19860atcctgttgt tctttagtat tagcacaaaa
gataatttgg gagacaaaat agagatgtgc 19920cacagaataa gatcactagt
gactctttga tttgtttatt tcacaagaag cagcttaagc 19980acctcagtat
actttggtat aagtcttctt tagttaccca taggtataat ttatatcaaa
20040gcaaacgcaa cttagaactt cagctccttg agaaatactc aataagagtt
ggtttcctga 20100aagtcatacc taggtgtttg tggggagaga gaaaggatag
ccacagagca agcaatggct 20160aagaatgtta atgtggccag caatatttag
ctaacttgtt tctcaacctt ttctttcaca 20220ggaaaatctc taacttccaa
ggtcccacca acagttcaga aacctaccac agtaaatgtt 20280ccaactacag
aagtctcacc aacttctcag aaaaccacca caaaaaccac cacaccaaat
20340gctcaaggta cagagactcc atcagttctt caaaaacaca ccacagaaaa
tgtttcagct 20400acaagaaccc caccaactcc tcagaaaccc accacagtaa
atgtcccagc tacaatagtc 20460acaccaacac cttagaaacc caccacaata
aatgttccag ctacaggagt ctcatcaaca 20520cctcaaagac acaccatagt
aaatgtttca gctacaggaa ccctaccaac tcttcagaaa 20580cccaccagag
caaatgattc agccaccaaa tccccagcag cagctcagac atctttcata
20640tcaaaaaccc tatctacaaa gaccccttct gcagctcaga atcccatgat
gacaaatgct 20700tctgctacac aggccacact aacagcccaa aaattcacca
cagcaaaagt tgcatttacg 20760cagagtcctt cagcagcacg taagtccact
aatgtacatt ccccagtgac taatggtctc 20820aagagtacac aaagattccc
ttctgctcat attacagcaa cacggagtac acctgtttcc 20880aggacaacca
agcattttca tgaaacaacc ccaaataaag gaagtggaac cacttcaggt
20940cagttgacac tgttcaggtt tactgagtat ggatctaatg tgctatggtg
gaaatatgaa 21000cttgaccaag attgcaggat taaatggtct ctaatttatt
gtagccaggg tttttcatac 21060taatactttt tactttattt ggaagcggac
ttggattgta ctagggcaaa tctttaaaaa 21120aagaaacatt tacaataata
gagaaaaaga ctgtggcccc attaaaaaaa tgctaaatta 21180agattggtaa
aaaaaaaaaa attctgtttc ctgtagtagt tttagggagt caacgaatta
21240ttcaagaccc cttcaaagaa ccaaatatgt actgtcttta aggctgagtc
ctgggtctgg 21300ttcattgata gagatccatc cctcaaagta tgctaaggaa
tcttcccgga ttccctagag 21360ttgcagatct gctaaagcat ctcaatagtg
tcgtctaagt aattgaaaat acagagatcc 21420tttcaaatag ttcgtattat
tacaaggctc tataaacgat aggttctcag tggcaccaag 21480taattgtgtt
ttatctatag ttttacccat tatgaccgta ttttcaaaat gattttatat
21540atttcataat tgttaccttg aagcctattt tgccagcacc tggatatttt
taagaattta 21600aacattatgg atgttatcgt taaagttccc ttaaaacatt
tccccagccc atttttctcc 21660ctctaaggca attactgccc tgaaactgat
gtgcttactt cctgtctgtt ttcattctta 21720tactccatgt ttccataagt
agtacataat aatgtttcat atttttaaaa taatttacag 21780aaactgtgta
tgtttcatta cctcttagca ctcagcattg gttttgtggc ttacattgat
21840taatttagat ttactatact aattttaatt ctttatgtgg tttttttact
tctttacaat 21900tttatgactt ctcttggtct aaaatttcta ggttgaacac
gtccagtttt taatagggca 21960aggcaaagag aaataagcat cacttataaa
tttgttatag aactaacttt attgacatat 22020ttccttctgt aaaaagtata
agataattta agacatttaa actgaacctg atgagtcaat 22080tataatatat
caatatttgg gatcaaattt tactcttagg tacaattaat ttactctttc
22140agggcacaat ataaaaaaat tgtagccacc acttactgag tatatactat
agtgatatgt 22200tccgttcacc ttctgtttga tgccactcgt ctgtaccaca
accttgcaaa gtatcttcag 22260attgatttta tagatgagga attagaggct
tagagattaa ttcatccagt tcatatccag 22320tgcacagttt aatcctgcac
tttttctgct gagtaatatt gcttgttcta aatggcactc 22380ttgagtcaat
gtgttcacct cgcttaggag agcagcttat ttattgttat aaatatgctt
22440atctgaaagt aaatttattt ttgcaatgcc ccatccgtag tcattgaaag
atataaataa 22500taaggtgata tggcattttt gagttttgat atagtctgct
aaaagggact tagtcgtctt 22560atagtttctt gttagtagga ttggatcagc
aattatttac tgtttaagtt ttcaaacatg 22620tttcttgccc tcaagtccta
taaccaaatt taaatggcat ttgttttggt aatcaataac 22680tctttatcat
aatttatatt tacagtgttg attctgttga acaggtatag acagtaatgt
22740ttacattcta cttgattaag ttaatgtgta attgttttta taaatttata
attatttcat 22800ttgtggaaat ttgagttgct ttcgagtttt ctagtgtagt
ttattgatag tatatgaaat 22860tgctagcaaa tcaatgactt taacaaattt
ttgttgttaa tccttttttt ccccttcgtc 22920tgtaggtact acccgtcttc
tatctggtaa gtttggctct caggccatta aaagaaattg 22980ttttcactgt
gggatataca atccatattc ctgggagata atattgtctt cttgttttta
23040aaaaaatgta tcctgcaatt tatttttaaa ctttttagta tggaaaactt
taaacgtcac 23100tcaaataggg aaaatagtac agtgaatcct catatactcg
ctcggattca gcaattttca 23160actcatggat acccacttca cccacactcc
ctggattatt tggaagataa tcccagacat 23220cgtatcattt ccttcataaa
catttcacta agtaaccttt ataaaaacat aaccatgtag 23280catacctaaa
aaaatccagt aattccttaa tatcagcaaa tatttagtca atatccaaac
23340ttccctgatt atcttataat tttttaattg atacataatg ttttatatat
ttatgaggta 23400catgtgatat tttgttacat gcatggactg tgtgattctc
aagttggtat ttggggtatt 23460catcaccttg agtattattt ttgtgtgttg
gaaacatttt aggtcctttc ttctagtgac 23520tatgaaaaat atatcacaca
ttattgctaa ctatactcac cctactctgc tattgaatat 23580tagaatgtaa
tccttctatc taattgtatg tttataccca tcggccaaag tctcttcatc
23640ctccctccta ctcacacact tttctcagcc tctggtatct aacattcttc
tctctacctc 23700catgagaact tttttaggtc tcacatgtga gtaagagcat
gtgatatttg tcttttttgc 23760ttggcttatt tcatttaata taatggcctc
tagttccatt catgttgctg caaatgacat 23820aactttattc tttttatggc
tgaatgtatt tcattctata tatgctagat ttgttttctt 23880tcttttcttt
tttttatttt tatttttttt ttgagacagg ttctcgtcct gtcacccagg
23940ctggtatgcg gtggtgtgat cgtagctcac tgcagtctcg aactcctggg
ttcaagcgat 24000ccttccactt cagcctccca agtagctggt actacaggtg
tgtgccacga cacccggcta 24060agtttttgaa atttattttt tgtagagaca
ggattttcct atgttgccca ggctggtttc 24120aaactcctgg ccgtaagcga
tttttccggc ctcccaaaac gttgcgatta taagtgtgag 24180ccactgcacc
tggccccaca ttttctttat ccatttgtac attgatggac acttaagatg
24240attccatatc tttgctattg tgaatagtgc ttcaataaat atgtgaatgc
acatatcttt 24300ttgatatatt ggttttattt tcctttggat aaatacccag
tagtgggatt gctggatcct 24360aagatagtta tattttttta tgttttcagg
aacctccata ttgttttcca cagtggttgt 24420actaatttac attctcacca
acagtatata agatttccct tttcttcacg tcctcaccag 24480cgtctgttat
tttttgtcta aaaatggcca ttctaactga ggttaagaac tgatagctca
24540ttgtggagct tgatttgcat ttccatgatg attagtgatg agcagttttt
catatacctg 24600ctgagaaatg tctgttcatg tcttttgccc actttttagt
gtgattattt gtttttcgct 24660agtaagttga gttcgttgta tattctggat
attagtacct ttacagatga atagtttata 24720gatattttct tccatttagc
aggttgtctc ttcactctgt tgattgtttc ctttgctgta 24780cacaagcttt
ttagtttaat atagtcctat ttatctattt ttgtttttat tgtctatgct
24840tttgaggttt tagccattaa acctttgcct agactaatgt cctgtagcat
cttcctgatg 24900ttttcttcta gtatttttat agttgtggat cttatgttta
agtttttaat catctcgatt 24960tgatttttgt acatggtgag gggcagaggt
ccagtttcat tcttctgtat tttcccagca 25020ctatttattg aagaaggtat
ccattttcca atgtatgttc ttggcacctt tgtaaaaaaa 25080tcagttagct
ataaatatgt ggatttattt ctgggttctc tattctgttc cattattctg
25140tgtgcctgtt tttataccaa taccatgctg tttttggtta ctataacctt
atattttgaa 25200gtcaggtagc gtgatgctgc cagctttgtt tttgctcggg
ttgtgttagc tctttggact 25260cttttggttc cacaatcatt ttaggacttt
tttttttcta tttctgtgaa aaatggcatt 25320gatatcttga taggggttgt
actgaatctt tagattgctt tggcagtgta gtcattttaa 25380caataatagc
tcttccagtc cgtgagcatg ggatgtcttt ccctttgtgc cctcttcgat
25440ttcttttatc tatgttttgt agttttcctt gtaggggtct ttcacctcct
tagttaaatc 25500tgttcctagg tattttattt atttttttag ttattgtcaa
tggaattgcc ttcttgattt 25560ctttctcagt ttgttcatta ttgtatagaa
atgttattga tttttgtatg ttgatcttgt 25620ttcctgcaac tgtactgaat
ttatcagatc taagagtttt tggtgaagtc tttaaggatt 25680tttttttaca
tataaaatcg tatcattaaa aaagagggac aatttgactt cctctattcc
25740agtttggatg ccttttattt ctttcttttg cctggctgca agttaataaa
tgaaaacttg 25800gttctctatg agccaaatga aacttggttc ttcaatgaaa
tggaaactag ggcttacagc 25860attatgttga atagaagtgg tgaaagtaga
catccttctc ttgatccagt tcttagaaga 25920aaggctttca gcttttcctc
attcaacaga atattagctg tgggtttgtc atgtatgacc 25980tttatgatgt
taatatgctt cttctatgcc tagtttgttg agagttttat tgatttctat
26040gtgttgaatc atccttgcat ccctggtcga aatcccactt ggtcttggca
tactaatttt 26100ttgatgtggt gttggatttg gtttgctaat actttgctga
gaatttttgt gtctatattc 26160atcaagagta ttggcctgtg attttgttgt
tcttgttgtg ttcttgtctg gttttggtat 26220cagggtaatg ctggccttat
agaatgagtt agggaaagtt tcctcctctt caattttttg 26280gaattgtttc
aggagaattg gtattagttc tcttttgtat gtttggtagc atttggcttt
26340gaatccatcc agtcctgggc ttttctttgt caggagactt tttattacaa
ttcagtctta 26400ctactcatta ttggtctgtt cagattttct gtttcttcct
gactcagtct tgatagggag 26460catgtctcca agaatttatt catttcctct
aggttttcca gtttgtcaat gtataggtgt 26520ttataatagt ctctgatatt
ttgtatttct gtggtatcag ttgtaatgtc tcttttttca 26580tttctgattt
tatttggggc ttctctcttt ttttcttggt tagtctagca agtactttat
26640cagtttggtt tatcttttca aaaaaacaag ttttcacttt attgtttttt
agtctctatt 26700ttgtttagct ctgctctgat ttttcttact tctttccttc
tgctaatttt ggggttggtt 26760tgttcttcct tctctagttc cttaagatgc
attgttagat tgtttatttg aaatctttct 26820acttttttga tgtaatcatt
tattgctgta aacttccctg ttagcactgc ttttgctatg 26880tctgataagt
tttgctacac tgttgccatt tctatttttt caagaaattt tttgtctaat
26940cctgaatttc tcccttgacc taatggtcat tcagaagcat gttgtttaat
tttcatttat 27000ttgtacggtt tccaaagttc ctgttgttat taatttctag
tttaattcca ttatggtttg 27060agaagatact tgatacaatt ttgacttttt
caaatttatt gagacttgtt tggtatccta 27120acatatgttc tattctggag
attgtttcat gtgccattga gaaaattctg tagctattgg 27180gtgaactctt
ctgttagtgt ctgttaggtc catttggtct aatgtgcaat ttaaatccaa
27240tgtttctttg tgaatttttt gtccagatga gctaatgctg acagtgggat
gttgaagttc 27300ttaacaatta ttgtattgga gtctatccct ttagattgga
caatatttgc tttatatgtt 27360tgggtactcc aggattgggt gcatacatac
ttagaattgt tatatcctct tgctgaattg 27420atctctttgt caattatata
atgacctcct ttgtctcttt ttactgtttt ttacctaaag 27480tctgtttcat
ctgatataag tacagctact cctgtttgtt tttggtttgt gttagcatgg
27540agtatctttt tccatctctt tactttcagt cacaatgtgt tttcacagat
gagatgaatt 27600tcttgaaaga aacgtatagt tgggttgtgt ttttgcatcc
attcagccag tatacatctt 27660ttaagaggaa agtttaatct gtttacattc
agggttattg atatgtgagg aattattcct 27720gtcatcttat taattgattt
ctggttgttt tgttcctttt gttctctctt attattgtga 27780tgtagagttt
ttctttcata acattttagt cttttctctt ctttgtgtgt ttgctctacc
27840agtggttttt aaaatttctg tgtgttttca tgattgtaga tatcattctt
tctcttctgg 27900gtatagcact cccttaagca tttcttgtaa gccatctcat
ggtgatgaat tccatcatgg 27960tgattaattc catcagcttt cttttgtctg
ggaaagacat tgtttctcct tcatttatga 28020aggataactt tcctaatcct
tggttggtag tctttttctt tcagcgcttt gagtatatca 28080tcccgttctc
tcctggcctg taaggtttct gctgagaaat ccattgttag tctgatgggt
28140ttcctttata agtgactaga tgcttttccc ttgctgtttt tagaactctc
tctgtctttg 28200acttttgaca gtttgagtat agtttgtcat ggagaaaacc
tttttttttt tttggttttg 28260agacagagtc tcattctgtc actcagcctg
gagtacagtg gcgcaatctc agctcactgc 28320agcctctgcc tcccaagttc
aagcgattct cccacctcag cctcctgagt agtagctggg 28380attacaggtg
tgtgttacca cacccatcta atttttgtat ttttaataga gacagggttt
28440caccatgttg gccagtctgg tctcgaactc ctgacctcag gtgatccacc
tgcctcggcc 28500tcccaaagtg ctgggattac aggcatgagc caccgcaccg
ggccagagaa gaccttttta 28560aattgtatct acttggtgat ctctgagcct
cctgtgtcag gatgtctaca tttcttgtta 28620gacttgagaa attttcctct
gttgttttag taatagattt tctaatcctt tcactttctc 28680ttcaccttct
gagactccta aaatttgaat agttggccac tttagggtgt cccatatgtc
28740atgtaaactt tgcccatttt tttattcttt tttccttatt cttatctgac
tgtgttatct 28800caaaagacct gtcttcaagt tctgagattc tttcttctgc
ttgatctagc ctattattga 28860tgctttcaag tatattatgt atttaatatt
tcatcaagta tattatgtat ttcatcaata 28920aattatttcc agaagttgtt
tggttctttt atatgtatct ttttttgata aacatctcat 28980taatatcctg
aattgttttt ctgatttctt tgtatttttt taaaacaaat tttaaagttt
29040gtatctcacc tccctgagct tttttaatat cacaactttg aattcttttc
ccagaatttt 29100gtaagtttac ttttgattgg gatctgttgc tggagaatta
ttgtgttcct ttggtggtat 29160catattttct tgttttttca cgtttcctgc
atcctgaagt tgatatctgt gcatctgatg 29220tgatatttgc tgtttctaat
ttttcaaatt tgcttttgta ggggaggact tttcctgaag 29280atgtatttat
ggtgtcagtt aggtggggca ctttggcttt aattctgggt gcatgcagta
29340gtgtagtttc tgtatgactt tcagctgtaa atatcatcag tggtatctgt
catttcctca 29400gtgctttagg atgcggttac tagtggagat ttgctaggga
ataggatgcc atgtgggcca 29460atgttcggac ccaagtgttg gcagtggtgg
gctgagtttg cctgtccttg ggcccagggt 29520gatgttgctg gcaccagtgt
tagcaagccc aatcaggcca gttattgggt ctccaggtgg 29580ctcacttggg
tgccagaaat ggcgggtgac ctggttctca ggctacttgg cagcaagtgg
29640gggcatgggt gatggcagta gtagtggtgg gacaaccctg tgggacacaa
gcagtctgtg 29700ccagtgttgg ctgtgggtgc ggtgattggg tggatcagtt
tccaggtctg caggtggctt 29760accagctgtg atgttagtgg caggttgagt
gggcctgact tcagacacca ggaagagtgc 29820tcagctgcta ttggtggtgg
actggctgag catccgggta cctgatggca ggcttgtgta 29880ctgagagggt
gacgctgggc cagatggact tgtcctcagg cctccctgtg gtgcatgtga
29940gtgctggctg tggtaggaag aggtagagta ttcctaggct actggtggaa
tgcttaggtg 30000aggacagtgt ggctgtgctg tggaccagct acttgggaca
gcagtgttgt tttcagttgg 30060gagcagccac agagaggtgg ctggggcaca
tgcagtttgc
tcatgcctca gcccaaagca 30120gccagcagca gccatagccg catgcactgg
aatttgtcct cagggaacca gaaaatgcct 30180ggctgctcct ctattggggg
tgtcaggtcg ctgccagtgg ctcctgcttt ggcttaggca 30240acagtggcca
cagagcaaga tgcagtctgg gaggggctgg gctctcaaaa tagtcttgtg
30300ctgtggctgc ttaggactca gtggtttata gtactcagtg tgaacttact
ctctggagta 30360atgccatcac actgtctcca ggcagcttcc tatgttagat
ctagagccta cgagaatcaa 30420gggactcctg tagctaggat tgtgggagtc
ttcagaggga atgtggactg ctggggttct 30480ctcacttact cttttcctgc
attagggagt ctctccaggc ttccaggcaa tctcagccaa 30540acaggctgcc
ttgcttctgt ctccttcctt gctttggtgc atcctgtcac ttgtttgtta
30600aattctagtg ttctctcttt gatgatctct tcaaaatgtg attatgtaat
tcctgcttag 30660gtttctctcc atggaagagg agaagaccag aggcatctag
tcagacatct tgaagccact 30720ccccatgata ctgtcttagg aaaacaatca
acatgtagca ttcatggata ccaaagggaa 30780aatgggtaaa cacatttttt
tttttttaga cggaatctcg ctctgtcacc caggctggag 30840tgcagtggcg
tgatctcggc tcactgcaag ctctgcctcc cgggttcacg ccattctcct
30900gcctcagcct cccaagtagc tgggactata ggcgcctgcc accacacccg
gctaattttt 30960tgtatttttc agtagagacg gtgtttcacc gtgttatcca
ggatggtctt gatctcctgg 31020cctcgagatc tgcctgcctc ggcctcccaa
agtgctggga ttacaggcgt gagccaccgc 31080acctggccag gtaaacacat
tttttttctt ccacctttta ttttaggttt gggaggtaca 31140ggtgaaggtt
tgttacatgg gtaaattgtg tgtcattagg gttgagtgta cataatattt
31200catcacccag gtagtgagct tagtacccaa taggtagttt attgattctc
accctcctcc 31260caccttccat tctcaaataa gccctggtgg ccattgttcc
cttctttgca tccatgtgta 31320ctcattgttt agttcccact tataggtgag
aagatgcagt atttggtttt ctgttcctgc 31380attaattcac ttaggataat
ggtttccagc tgcatccata ttactgcaaa ggacatgatt 31440tcattccttt
ctatgtttgt gtaatatccc gtggtgtata tataccacat tttctttatc
31500cagttcacca ctgatgtgca tctaggttga ttccatgtta ttgtgaaaag
tgctgatgaa 31560catatgtgtg catatgtctt tatggtagaa tgatttttgt
tggtttgggt atatacccaa 31620taatgagatt gctaggtcac atggtggttc
taagttcttt gagaaatctc caaactgctt 31680tccacagagg ctgaactaat
tacattccca ccagcaatgt ataagtgttc tctgttttcc 31740acaaccttac
caacatttgt tattttttca ctttttaata atagccattc tgtctgctat
31800gagatggtat ctcattgtgg ttttgattgc atttctctaa tgattagtga
tgttgagcat 31860ttttttcata tgcttgttgg cctcatgtat gtcttctttt
gagaagtgtc tgtttatgtc 31920ctttgcccat tttttaaggg ttggtttgat
ttttgtttgt tgatttgttt aagttcctta 31980gagattttga atattagaac
tttgttagat gcatagtttg caaatatttt ctccttttct 32040gtaggttgtc
tgttttctct gttgatatat atttttttgc catgcagaag cactttagtt
32100taattatgtc ccacttgtca atttttgttt ttgttgcaat tgcttttgga
gacctcatca 32160tgaaatattt accaacacct atgtcagaat ggtatttcct
aggttttctt ctagagtttt 32220tatactttta ggttttaagt ttaattcttt
aatccatatt gagttgattt ttgtatatgg 32280tgaaaggtag gggtccattt
tcaatcttct gcatatggct agccagttat agcatttatt 32340gaatagagaa
tccattcccc attgcttgtt attgtcgact tcattgaaga tcagatggtt
32400gtaggggtgt ggctttatat ctgggttttc taacctcttc cattggtcta
tgtgtctatt 32460tttgtaccag taccatgctg ttttggttac tgtagccttg
taatatagtt tgaaatcagg 32520tagtgtgatg cttccagctt tgttcttttt
acttacggtt gttttggcta tttgggttct 32580tttttgattc catatgaatt
ttagaatgta tattttttaa ttctctgaaa gatatcattg 32640gtagtttgat
aggaatagca ttggatctat aaattgcttt aggcagtatg gcccttttta
32700aaaattttgt attaattttt tttttttttg agacagagtc tcactctgtc
actcaggctg 32760gagtgcagtg gcatgatctt ggttcactgc aacctccgtc
tcctgggttc aagtgattct 32820cttgcctcag cctcccaagt agctacgatt
acaggtgcac accaccacac ccagctaatt 32880tttgtatttc tagtagagat
gaggtttcac catgttggcc aagctagtct caaactcctg 32940acctcaagtg
atccacctgc ctcagccttg caaagtgctg ggattacagg catgagccac
33000catgcccgca gtatggccct tttaaaaata tttattcttc ctatgcatga
gcatggaata 33060tttttccatt tgtttgtatt gtctctgtct tctttgtttt
gtatttctct atagagatca 33120ttcacctccc tggttagctg tattcatagg
tattttatcc ttttgtggct attgtgaata 33180ggattgcatt cttgatttgg
ctgtcagctt gacattgttg gtgtatagaa atgcttctga 33240tttttgtacc
ccgaagcttt actgatgttg tttaacagtt ctaaaagctt ttgggcagac
33300tatggagtat tctaggttta aactcatatc atctgtgaag agagatagtt
tacttcctct 33360cttcctatat ggatgccttt tatttccttg cctgattgct
gtggctagga tttccagtac 33420catgttgaat aggaatgata ataatggaca
tccttgtctt gtactggttt tcaaggtgaa 33480tgcttccagc ttttgctcat
tcagtatgat gttggctgtg ggtttttcct ggcggctctt 33540attattttgt
ggtatgttcc tttgatgcct agtttgttga tgacttttaa catgaaggga
33600tgttgaatgt tgtcaaaagc cttttctaca acaattgaga tgatcatgtg
gtttttttgt 33660ttgtagttct gtttatgtga tgaatcacat ttattgattt
ggatatgttg agccaacctt 33720gcatcccagg aataaagcct acttgatcgt
ggtaagttag gtatttgatg tgctgctgga 33780tttgatctgc tagtattttg
ttgaggattt ttgcatttac tttcatcagg gatgttggcc 33840tgaagttttc
tttttttgtc ctgtctcttt gccagatttt ggtatcagtg tgatgctggc
33900cttatagaat gaggagtccc tcctccttga tttttggcat agtttcagta
tgattggtac 33960cggctcttgt ttgtatgttt ggtggaattt gtctgtgaat
ccatctggta cagggctctt 34020tctggttggt aggtttttta aattactgat
tcaatttaag aacttgttat tggtctgttc 34080aggtatttaa tttcttcctg
gttcaatctt aggaggttgt atttttccaa gaatttacca 34140tttcttctac
gttttctagt ttatgtacat agaggtgttc aaaatagtct ctgagggtgt
34200tttgtatttc tgtggggttg gtggtaatgt cccctttgtc atctgagatt
gtgtttattt 34260ggatgttctc tctctttatt aatctagcta gttgtctatc
aatcttattt attctttcaa 34320aaaaccagct ttggttttgt tgatcttttg
tatggatttt tgcatctcaa ttttattcag 34380ttcagctctg attttggtta
ttttttttct tctgctagct tttgggttgg tttgctcttg 34440ttttttctac
atcctctaga ggtgatgtta ctttgttaat ttgagatttt tctaacattt
34500tgatgtaggt gtttaatgct acaaactttc ctcttgacat tgttctggct
gtgtcccaga 34560cactctggta tgttgtatct ttgttttcac tagtttcaaa
gaatttcttg atttctgcct 34620taattttcag aatgccaaaa gtcattcagg
attaggttgt ttaatttcca tgttattgta 34680tagttttaag agatcttcct
ggtattgatt tatattttat gctgtggcct aagagtatgg 34740ttagtatgat
tttggttttt tgaatttgtt taaaattgct ttatggttga gcatgtggtc
34800aatcttagag tatgtgctat gtgcagatga gaagaatgta tatcctgttg
ttcttgggtg 34860taatgttatg tagatgtctg ttaagtccat ttggtcaagt
gtcaagttta ggtcatgaat 34920atctttgtta gttttctgcc ttgattatgt
gtctaacatt gtcaatgggg tgttgaagtc 34980tcccactata ttgtgtggtt
atttccatct cttcataggt ctttaagaac ttgtcttatg 35040aatctggatg
atccagtgtt ggatctgaaa agagtaataa aaacattatc attactatca
35100ttattattta ttgtggttat tttatatttt gaatgaactt ctaagctaaa
agatttatct 35160tgaaagattc caactgttgg aattcacttt gttttaaata
gaaataaatg tgtttcaaat 35220gaaagtctga tgatttaatg atcacaaaag
tgatgagttt aataaatgag ttttttctca 35280cctgctcaat ggcactcaat
gaaggtttga aatgcctttt tttcctgaaa ttctttaagt 35340attataccct
ttgattttct agaaaacttt ccttagtcgg cattccagct tgtgttaaaa
35400aataaagagg aagtccttcc ttcttaaact ggacatatgg caacattttt
tgtgtgtgat 35460ttcatatttg taggacataa acctgaaaat tatattcatt
aaatttatta tgtgaatgag 35520gttactcttc tttaaagata aattaactct
actgcaagaa aattgtttca tcaattacac 35580tgcaatgtaa gtaaaatgat
acagatgatc tttgaatttt ggaagtattt gatttttttt 35640tcctattctg
ctaaggaaga aagactgact aatgttacag aactttctaa tttgccttgt
35700aaatgaagca tgtgttgtga attttaaatc ttttcttccg ttggctttgt
ataagtgttt 35760cccaattttt ttttgtgggg ggtggggggt gcgttaattc
ttgctctctt ctcaccaaag 35820acctttttag acattttttt ttgatcatcc
tccaccacac atatactgta aatcagttta 35880tgtatcacat atatatctgc
actctgtact taaaaaagga aaattttttt ttaactttca 35940tcaggtatca
cccccattga gaatgcttgc tttctgttgg ttttgttttt attgttttta
36000aagacaaaat catatagaag aaagagctta acctctggag tcaaaccagt
cggatgttgg 36060tttgaatcct gtttttttca cttagtaatt attcaaccca
agtgattaag tgattaactt 36120aatctctctg agactcagtt ttctcattta
agagatagag attgtgattc ctatgtgaag 36180tatttgaagc ttaatgtgat
tagtgggtat gaaaactcca agcacagtcc taaaagttga 36240ataaatatta
gcttaaggaa gtcactgcat gcaatcacta ttattttcct aagctggatt
36300tctgataatt tcatcactcc ctctggccac accaaagaat aagaacagtc
ttttattcag 36360gtaatattta catgttttct ctgtggcaag tactgtactg
atttttttta atgtattatt 36420tcatattctt ctcacaacaa tcttataatg
tagcattttt atcccatttt cagctaagat 36480aactgtggtt ttgcaaaatt
tgtaacttgc ctttcacaga gctagtaggc aataaataga 36540ggccgatgac
tagtttctct attaccaggt tttttttttt tttttttttt ttttggatgg
36600gggacagggt ctcactctgt cacccaggct ggtgtgcagt ggtgcaatct
cggctcacgg 36660caacctctgt ttcccaggct caagtgatct tcccaggtac
tttaaaagat agaaagatgc 36720tcatcctagt gacagaccaa gagacaatac
aacccaaatt ggacaattaa ggtgccgtga 36780ttccctacaa gtattgcttt
attcccctct gttgccaaag tcctatactg agacattcat 36840aagtccctca
tggggactaa tagatcaatt taaagaataa taaataagaa gtcaggaaat
36900attcagtgaa atatagaaaa tattttttct gtatccccta acaattgtgt
acttatttat 36960cctttaaact tgaatatggc atatattaca gactagccca
aatctaaatg tactttcaag 37020agtcttgact cttaagtagc tatttgaagt
taataagatg tggttacagg ggtctttatg 37080tcttattaca tgcccctata
catgacaaac ttaagtccca ttataaagtg acatcagtta 37140tctgcctgtt
attcaggttt aagtcagata atataatcat ataatctttc tgtgatacgt
37200ttagtctgga aaaggaagta tgtgaatttc ccttattaaa aaaattgaag
aaatacagag 37260gtacagaaaa tccaacgatg atggcaagac acttaaaggg
tcctgtggat gtctctctga 37320ggaagcagag ttgaatctgc atttacaaaa
tggaaaattt aagggttact caagcatact 37380gtttttcaaa tcatctacga
aaatctcttc ccagggtgcc ttcacttgtc cacaggccct 37440ttattctgtt
acattaagta tgatataagc aagaacaaaa cctttccata actttttgtt
37500ttcatagcac atgcattgca tttccacttt gttagctctg caagttagac
cttttgaagt 37560gtctgggtca tcccacattt cttcaaaaaa gatgatgtgc
atcctctagg tcactccagt 37620tcttggaggt aggtagatag aattctaagt
tgggttcttt ggcagtgaag atgataccct 37680atatattaat gtagtatctg
tctaatgtaa attttgtttg atgaatatca ggtattttat 37740tgaaaatatt
tcaaacagtt aaaattatgg cctgaatctg gggctagaag tgagtttttc
37800tatggcaata aactgactta ccctttcttg gtctcagttt tcttatctgg
aaacaagata 37860ttaagtgcaa tttaataaat atttgttaaa cactttctac
tgtttgccat gtactgtgtt 37920aataatgaga ggtgatcaaa tgagataata
ggtggcaaac tgctttgcaa tgttttcaac 37980actgcaatac agttctacat
gatggggaac cttactaaaa tactcctttt gtgggggaga 38040aaaccttttt
ctaacattat gttattttcc cacctaagag ctcttcagtt taatcttagg
38100aacattggaa tcataattat tatttcattc attatttcat actttcattt
ttcccaagtt 38160gtataaatct taatgttgat tcacctttgg ttttctgtag
ataccaagtg aattttgaga 38220tcataaacag ttgcctttga acctgaaagt
tttgtttcta atttgggaga taatatgctc 38280ttattaattt actgagaaga
tacgtagaat tttgtttttc atatttctgt gttttgcctt 38340ggttttctgt
taaaccatca gcctctacac tttcttctag aactatgtat atgtgttgag
38400cattgttctg ggaatagcct tttacttctg tcatctggat gttctagatc
actctgaatt 38460ttctgtcttg atttagtatt caaataaaaa ataagatatt
gaaagtggtg gaattagtgg 38520gaactggtga cagaaagggg gaaacccaaa
attttttagg agctgtgatt tatttcatgg 38580atagtctctc taagttaatg
atacaattct aggggatcag ttaaataaac ttctaaagta 38640aaatactgta
aaaacttacc tgtggtagaa atagctgttt tttaaatcac aattttcaca
38700tggcagtgca attgtacagt gtctctattt tgctgatttg gagccaaata
cactcattag 38760tcacgttaga ttcagttact attctagtgt catctgtcat
ttcctttgta gtaaagacca 38820atagagttga gtccaaggac actgggcagg
gttggtgggg gtggtggtgg gaggggggct 38880gttggtgagg aaagagagaa
tgaggatggt gagagaaaag ggcaaatggg tgcatttgag 38940aagaaagatt
gtgtaagcta taaaaatgat ttgatgttga tcaacttatt tgaccaatta
39000tttgctgttg ttcagctcaa aatagtgctt tgaatcttaa aagtgaatat
aatttttgaa 39060atgaaattta atctaccata gactgaacac taaaaagcat
attctgtagg caaagtaaat 39120atagtttgcc ctccaatctc agatgataat
agtacaggca tatttcctgt gatggagaaa 39180tgtctacata tctgttatat
ctactgtaaa ctaggtaaat gtccttccca ttaaccacat 39240atgttaatgt
tcaacttcct tctgagactc aatttactca tctaaaaaat gaaagtgaac
39300tctaagatgc tttctagctc taaaataaca taattctgtc accatatttg
aatgctcaac 39360gatcaaaaca tttaaaatcg agcatgattg ggttgaaaca
cttaagaagc ctctcaaacc 39420tgtcaaaaaa ttttatttga gcattgtgat
attctaaata tatttcttcc tttttctttc 39480gaagaaaaca ggacaaataa
aacatgcatt tgtcaaaaat ttgtgacata aggaagccat 39540atacaaaatg
caattaatat ctcctatttg taactcactt cataaccagt atgtatgtca
39600ttgtgaaact ataatgtaat tttaattgct catgtttcta ttaactgtgt
taccatatct 39660tttccccttc aaggatttct tgctggtact ctattaattg
gtaccctaat tctagtcatt 39720ggactatgga aaatcagagt gagcagaaat
tctgatgatt tttaaaaatt tattcctagt 39780ttatttccag taaaatttgg
tactgtatca gtagatgact ctcttagctt tatttaaatt 39840ttggcgtgtc
tctgtattca tttttgtctg taattactat cctggattaa cagacttcat
39900gtctgttttt tctcaatata ttcaaaggcg catttcaaag caaagtgact
tgaagtctca 39960ttttgtgatc tattaatcca ctgatttttt tccactcagt
gtaatttatg atagtatcta 40020gtgttgcaca gaagcaaaga aatctaggaa
aaatcaacct ctaacatact gtgaaattgc 40080ctgtgattag ggctttttct
cacttatatt aatagatgcc agtccagctc aaaacagcac 40140agtggttaag
gcagcagaca aatgggggaa atatagtacc tacctcatat gattataatc
40200atatatcaaa tgagttgcca cctgtcaagt gcttagaaca ttgcttggca
catagtaagc 40260actcagatat taaaacaaca acagcacaca cacacatcag
tattatttaa aatatctaat 40320ctgcattgaa tatacataat gttaagtata
aatgtcacga ttggctctga tgtgtcctgt 40380agacagatga tgatttaaat
cgaccctctt ctgttttgta gttttaactg ttcagaaaac 40440tagttgtgga
atttatacaa acttgagtta tttctaagct gccctaatgc ctgtccgttt
40500ttcccattaa taagaaaact attaatttaa tgctgttatt aaattgtctg
ttttaattct 40560ttagatgatg tgacctatct cctttttacc ctctacaatt
tttctactta aattaagaat 40620attacttaag cctattataa gttaaagcat
gtaaatattc tttaactcac taaatgagtc 40680agtcttgtag aaaaatattt
gaccattagg tccaggggag tgattaataa tttttacagg 40740catttgttta
atatcaacaa aatattctag ctgtcatgat agcaaatata gtaagacata
40800actttttctc cagatatatc agaaacgttt taggaatgtg atttagagcc
tagcaaaaac 40860tcacagttag tactaagtca tctaaagtga gttggtatgg
aagcatcagc aaagctactc 40920tgaaaaaaaa taaaaccacc aatcttacgt
actttcttgt acttgttcca actttccttt 40980tgaaatactg ttatcagttt
atcaagttat aaagtatcaa tgtatagagt attatcaatt 41040taccaaagct
actgctttga gactccctgg atcggtggga atggagactg ggcgggggag
41100ggcggagggc gggcgggggc agggcagcaa gatgtgataa gtttaccagg
tgctgtctct 41160tggctttcat cagtttcttt acatactttg gtaaggtgat
tggctgtgat acttgtatgt 41220cctattaagg acataaagta ctggaacatc
gaaggaggga atacagtaat ttctgcttat 41280cctcggttgg ggggcagggt
gtttcaagaa cccccagtga atgcttgaaa caacagatag 41340tgcctaaccc
tatatatgct gtgttttttc ctgtatgtac atacctatga gataaagttt
41400aatttataaa tgaggcacag taagagatta acaccaacga ataatcaatt
agaacaattt 41460attgtagcaa aagttatgtg aatggggtct ctctctctct
caaaatatct tattgtattg 41520tactcaccta ttttcagatt gcagttgact
gtgggtaact gaaaccacag ataagcagac 41580taatgtattt gttttgaatt
gtattttggg gttttgcagt gaacttaatt gcttattttc 41640tgaattagag
ggaaagtcat gcaaactcct aagaaagaat ttgtcttttt tatgtgcaca
41700taaaaaacac tccacttgct ttattttgga aacataagct gttgagggta
agagctagct 41760ttatatatgt ttggctagcc tcctgatttc atactgattt
aattaaatat ttgatcttaa 41820ttaagacagg atatagttaa tgtgcaagtg
ataatgtggt ttcatttaat gattcttcat 41880gtttgcctat cagaggattg
atttatttct tttagaagag ttaggtctgt atgataaatt 41940ttagtttagg
gatggaagtg taagcagatg cctgacttcg ttttttgatt gaaatgacag
42000ttacataatt caattcaata gtttttttct tctctactat tcagctctta
taatgcacat 42060gagagcaaca aagtactcaa tgttgtgttt gaccatttaa
gtgtgactgg tggtacctca 42120gaaataagac tttctggtaa attataaaag
gtatatatgg tttaataaaa ttacatttct 42180gtatcttgca aaatatccat
taataccctt ggctaggggg ttcttcatga cttttaaagg 42240ataatagagg
cttaagtctc tgtcactaga gttgtttttt tctttgttga atgactaata
42300cattgaatct ctcattacta tgacatatcg tcagttctgg acttggtagc
agtaatgctt 42360atcatctcat cctacatttt gaactcagtt tattgtaacg
attagatgct ataatgccac 42420aaatattcgg ggggaaaggg atgatacatt
aggactttta aagagaatgc cttcattatg 42480ataatttgca tcatgagatg
gttgacctac cttgtatttc tccttttgct tggtggcttt 42540tagagttttc
aatgtttaag aaaaattata atatgtgcta agatatcctt ttataggtca
42600tgtttataga tcttaaaaga catctcatat ctttatacaa aattatcaca
caaaaataac 42660ttggtgtaaa tgtatctgta aaactttctg agtgtcttca
tctcttaatc ttctcttcca 42720catgtagtag tattcagggg tttttattta
tttttatatt tttttaacat ctcccacact 42780taggaattca ttgactttta
atctgaaggt accttaattc attctagctt agccactgtt 42840caactcgaga
aactaaaaac tccacgtcac attttagttg ttgctgtagc tgataaaccc
42900cacctgtaga atcttgtcca tattctatta ctcattattt tttttgtttt
gcaccccaaa 42960ttaactgatt ctttttggtg atttatcaca tagtaactaa
aaatttatat ttatcactag 43020taaataaaat cattttgatt ttaacttttt
tttttttttt tttttaattt tcagggcaca 43080cgtgtttcac gttgacaggt
ttgcttggga cgctagtaac catgggcttg ctgacttagc 43140caaagaagag
ttaagaagaa aatacacaca agtatacaga ctgttcctag tttcttagac
43200ttatctgcat attggataaa ataaatgcaa ttgtgctctt catttaggat
gctttcattg 43260tctttaagat gtgttaggaa tgtcaacaga gcaaggagaa
aaaaggcagt cctggaatca 43320cattcttagc acacctacac ctcttgaaaa
tagaacaact tgcagaattg agagtgattc 43380ctttcctaaa agtgtaagaa
agcatagaga tttgttcgta tttagaatgg gatcacgagg 43440aaaagagaag
gaaagtgatt tttttccaca agatctgtaa tgttatttcc acttataaag
43500gaaataaaaa atgaaaaaca ttatttggat atcaaaagca aataaaaacc
caattcagtc 43560tcttctaagc aaaattgcta aagagagatg aaccacatta
taaagtaatc tttggctgta 43620aggcattttc atctttcctt cgggttggca
aaatatttta aaggtaaaac atgctggtga 43680accaggggtg ttgatggtga
taagggagga atatagaatg aaagactgaa tcttcctttg 43740ttgcacaaat
agagtttgga aaaagcctgt gaaaggtgtc ttctttgact taatgtcttt
43800aaaagtatcc agagatacta caatattaac ataagaaaag attatatatt
atttctgaat 43860cgagatgtcc atagtcaaat ttgtaaatct tattcttttg
taatatttat ttatatttat 43920ttatgacagt gaacattctg attttacatg
taaaacaaga aaagttgaag aagatatgtg 43980aagaaaaatg tatttttcct
aaatagaaat aaatgatccc attttttggt atcatgtagt 44040atgtgaaatt
tattcttaaa cgtgactact ttatttctaa ataagaaatt ccctacctgc
44100ttcctacaag cagttcagaa tgccatgcct tggttgtcct agtgtgaata
attttcagct 44160actttaaaat tatattgtac tttctcaagc atgtcatatc
ctttcctatt agagtatcta 44220tattacttgt tactgattta cctgaaggca
atctgattaa tttctaggtt tttaccatat 44280tcttgtcatc ttgccaatta
cattttaagt gttagactag actaagatgt actagttgta 44340tagaatataa
ctagatttat tatggcaatg tttattttgt cattttgctt catctgtttt
44400gttgttgaag tactttaaat ttcatacgtt catggcattt cactgtaaag
actttaatgt 44460gtatttctta aaataaaact ttttttcctc cttaaccaca
gttatcacaa ctagcagttg 44520tgatagtttc taatttccta atagtttcta
atattaggaa attctttgaa ctttcctaga 44580agttctaaga gtaggcacat
atccatccac ctattcattc attcatttgt taaatatgag 44640ggcccgctct
gcctattctg taataaccca gtgcttccag ggatagcaat aacactggct
44700cagctattca gaaaaaaagc tgagtgccta ctatgtgcaa gttgtcatat
gctaaaatgt 44760gagcttacca agataactgc aagtgtctgc cctcaagttg
cttatagttt gccacaggaa 44820gaccaaaata tatacttatt gagagaaaga
agataaagtt acgagtgtta cagccccgaa 44880tatggtgggt gcttaagctg
tttgttaagc agttgagtgg cagggaggga gatattcaag 44940gcagaaagct
gattgagaaa gcagtaatag atgagattat agtggcagga tggtcgaagt
45000aggaaaggct tagagcaagg gctagactat gtcatgtgtt ctgtgtagaa
gtgaaaattt 45060gtaagctcta gactttttat tctgctcgat ctaattagaa
tcagtgagca taaaataggt 45120ttctaatagc aagaacttgc tatttagata
agggtaaaag
cggaaatact attaaacagt 45180catttacctt gaagaaaata taaacagtag
gcttgtgagg gtaaagatat tttcttgtag 45240gatttatatt taccgtgtat
cctgtagtta tgaggttgag tggttttatt tttgcttaag 45300ataacctctc
ctgtgagatt ttactttgat tgcaaaggtt gtattgcttt tcctcttgag
45360actgatgtat ttgttacagc aagttatacc tgctcactgt agaaatttga
gttttataat 45420atttagcccc ctatcactgt cacttttctg ggaatacttg
aacatgaata atttttgtct 45480tgtcacaccc tagccctgtt tgctttggtt
aatgtccaat gtgcaaatgc ctcattttcc 45540tcccacccat cctgagtgtt
ttcttcctcc ttaccgaaac taaaaacagc cccttccctg 45600aaggtactgc
ttcctttgca gcctattcca gtggtggctg gtttattttc atccatatga
45660ctcattgtta agaggtggcg gaggtgtttt ccttgttcct ttgtcatgtc
ttccatctca 45720acccccacac acatctcttt aaaaagagta actgtccatt
cactctggta gggtaattta 45780ctaaaatgtc aaatgttttt cctataattc
tccttggtga aaagcatgga ttctggagac 45840aaatcggagc cctggcattt
atcagctgca ggactcaagg gatgttcctt gtcagtgtac 45900cttagttatc
tatgtgtaaa gtgggcctaa aatcagtacc agcctcatag gatttgcaat
45960gagaattaag ttaatacacg tagagcttaa aatagtgcca gccatgtagt
aagtgctcag 46020taagttttag ctctttttag tgcacaggtg gagagattgc
cttaggtgga agcatgcagg 46080gcttcagtac atactaggag ggaactgttg
caggtgggtt ggagatgccc atggtggcag 46140cttttggaaa ttgatttcac
atttcttctg ttttctcagg gacatataca tcaaggtcat 46200cataaaaatg
atgacacatg aggaggtgtt atgtttgaag acaggcagag aaggaaagga
46260ctagagacat ttagtcaatt agcaggcaat gctaaagacc cagttgaggt
gagtgctcat 46320gaatttagag tgcaatcatc aagcttcgtt ctgagttttt
ctgcagtcat atttagcttt 46380ctagatacag tctcagaaaa aaccagttgc
ttggatttaa tcatgattgg gtgttcccag 46440gtgaatttga tgacgtgagt
tgagcatgtg cacaagggag tgattaaaat gatgg 4649522796DNAHomo sapiens
2agcgagctcc tcctccttcc cctccccact ctccccgagt ctagggcccc cggggcgtat
60gacgccggag ccctctgacc gcacctctga ccacaacaaa cccctactcc acccgtcttg
120tttgtcccac ccttggtgac gcagagcccc agcccagacc ccgcccaaag
cactcattta 180actggtattg cggagccacg aggcttctgc ttactgcaac
tcgctccggc cgctgggcgt 240agctgcgact cggcggagtc ccggcggcgc
gtccttgttc taacccggcg cgccatgacc 300gtcgcgcggc cgagcgtgcc
cgcggcgctg cccctcctcg gggagctgcc ccggctgctg 360ctgctggtgc
tgttgtgcct gccggccgtg tggggtgact gtggccttcc cccagatgta
420cctaatgccc agccagcttt ggaaggccgt acaagttttc ccgaggatac
tgtaataacg 480tacaaatgtg aagaaagctt tgtgaaaatt cctggcgaga
aggactcagt gatctgcctt 540aagggcagtc aatggtcaga tattgaagag
ttctgcaatc gtagctgcga ggtgccaaca 600aggctaaatt ctgcatccct
caaacagcct tatatcactc agaattattt tccagtcggt 660actgttgtgg
aatatgagtg ccgtccaggt tacagaagag aaccttctct atcaccaaaa
720ctaacttgcc ttcagaattt aaaatggtcc acagcagtcg aattttgtaa
aaagaaatca 780tgccctaatc cgggagaaat acgaaatggt cagattgatg
taccaggtgg catattattt 840ggtgcaacca tctccttctc atgtaacaca
gggtacaaat tatttggctc gacttctagt 900ttttgtctta tttcaggcag
ctctgtccag tggagtgacc cgttgccaga gtgcagagaa 960atttattgtc
cagcaccacc acaaattgac aatggaataa ttcaagggga acgtgaccat
1020tatggatata gacagtctgt aacgtatgca tgtaataaag gattcaccat
gattggagag 1080cactctattt attgtactgt gaataatgat gaaggagagt
ggagtggccc accacctgaa 1140tgcagaggaa aatctctaac ttccaaggtc
ccaccaacag ttcagaaacc taccacagta 1200aatgttccaa ctacagaagt
ctcaccaact tctcagaaaa ccaccacaaa aaccaccaca 1260ccaaatgctc
aagcaacacg gagtacacct gtttccagga caaccaagca ttttcatgaa
1320acaaccccaa ataaaggaag tggaaccact tcaggtacta cccgtcttct
atctgggcac 1380acgtgtttca cgttgacagg tttgcttggg acgctagtaa
ccatgggctt gctgacttag 1440ccaaagaaga gttaagaaga aaatacacac
aagtatacag actgttccta gtttcttaga 1500cttatctgca tattggataa
aataaatgca attgtgctct tcatttagga tgctttcatt 1560gtctttaaga
tgtgttagga atgtcaacag agcaaggaga aaaaaggcag tcctggaatc
1620acattcttag cacacctaca cctcttgaaa atagaacaac ttgcagaatt
gagagtgatt 1680cctttcctaa aagtgtaaga aagcatagag atttgttcgt
atttagaatg ggatcacgag 1740gaaaagagaa ggaaagtgat ttttttccac
aagatctgta atgttatttc cacttataaa 1800ggaaataaaa aatgaaaaac
attatttgga tatcaaaagc aaataaaaac ccaattcagt 1860ctcttctaag
caaaattgct aaagagagat gaaccacatt ataaagtaat ctttggctgt
1920aaggcatttt catctttcct tcgggttggc aaaatatttt aaaggtaaaa
catgctggtg 1980aaccaggggt gttgatggtg ataagggagg aatatagaat
gaaagactga atcttccttt 2040gttgcacaaa tagagtttgg aaaaagcctg
tgaaaggtgt cttctttgac ttaatgtctt 2100taaaagtatc cagagatact
acaatattaa cataagaaaa gattatatat tatttctgaa 2160tcgagatgtc
catagtcaaa tttgtaaatc ttattctttt gtaatattta tttatattta
2220tttatgacag tgaacattct gattttacat gtaaaacaag aaaagttgaa
gaagatatgt 2280gaagaaaaat gtatttttcc taaatagaaa taaatgatcc
cattttttgg tatcatgtag 2340tatgtgaaat ttattcttaa acgtgactac
tttatttcta aataagaaat tccctacctg 2400cttcctacaa gcagttcaga
atgccatgcc ttggttgtcc tagtgtgaat aattttcagc 2460tactttaaaa
ttatattgta ctttctcaag catgtcatat cctttcctat tagagtatct
2520atattacttg ttactgattt acctgaaggc aatctgatta atttctaggt
ttttaccata 2580ttcttgtcat cttgccaatt acattttaag tgttagacta
gactaagatg tactagttgt 2640atagaatata actagattta ttatggcaat
gtttattttg tcattttgct tcatctgttt 2700tgttgttgaa gtactttaaa
tttcatacgt tcatggcatt tcactgtaaa gactttaatg 2760tgtatttctt
aaaataaaac tttttttcct ccttaa 27963381PRTHomo sapiens 3Met Thr Val
Ala Arg Pro Ser Val Pro Ala Ala Leu Pro Leu Leu Gly1 5 10 15Glu Leu
Pro Arg Leu Leu Leu Leu Val Leu Leu Cys Leu Pro Ala Val 20 25 30Trp
Gly Asp Cys Gly Leu Pro Pro Asp Val Pro Asn Ala Gln Pro Ala 35 40
45Leu Glu Gly Arg Thr Ser Phe Pro Glu Asp Thr Val Ile Thr Tyr Lys
50 55 60Cys Glu Glu Ser Phe Val Lys Ile Pro Gly Glu Lys Asp Ser Val
Ile65 70 75 80Cys Leu Lys Gly Ser Gln Trp Ser Asp Ile Glu Glu Phe
Cys Asn Arg 85 90 95Ser Cys Glu Val Pro Thr Arg Leu Asn Ser Ala Ser
Leu Lys Gln Pro 100 105 110Tyr Ile Thr Gln Asn Tyr Phe Pro Val Gly
Thr Val Val Glu Tyr Glu 115 120 125Cys Arg Pro Gly Tyr Arg Arg Glu
Pro Ser Leu Ser Pro Lys Leu Thr 130 135 140Cys Leu Gln Asn Leu Lys
Trp Ser Thr Ala Val Glu Phe Cys Lys Lys145 150 155 160Lys Ser Cys
Pro Asn Pro Gly Glu Ile Arg Asn Gly Gln Ile Asp Val 165 170 175Pro
Gly Gly Ile Leu Phe Gly Ala Thr Ile Ser Phe Ser Cys Asn Thr 180 185
190Gly Tyr Lys Leu Phe Gly Ser Thr Ser Ser Phe Cys Leu Ile Ser Gly
195 200 205Ser Ser Val Gln Trp Ser Asp Pro Leu Pro Glu Cys Arg Glu
Ile Tyr 210 215 220Cys Pro Ala Pro Pro Gln Ile Asp Asn Gly Ile Ile
Gln Gly Glu Arg225 230 235 240Asp His Tyr Gly Tyr Arg Gln Ser Val
Thr Tyr Ala Cys Asn Lys Gly 245 250 255Phe Thr Met Ile Gly Glu His
Ser Ile Tyr Cys Thr Val Asn Asn Asp 260 265 270Glu Gly Glu Trp Ser
Gly Pro Pro Pro Glu Cys Arg Gly Lys Ser Leu 275 280 285Thr Ser Lys
Val Pro Pro Thr Val Gln Lys Pro Thr Thr Val Asn Val 290 295 300Pro
Thr Thr Glu Val Ser Pro Thr Ser Gln Lys Thr Thr Thr Lys Thr305 310
315 320Thr Thr Pro Asn Ala Gln Ala Thr Arg Ser Thr Pro Val Ser Arg
Thr 325 330 335Thr Lys His Phe His Glu Thr Thr Pro Asn Lys Gly Ser
Gly Thr Thr 340 345 350Ser Gly Thr Thr Arg Leu Leu Ser Gly His Thr
Cys Phe Thr Leu Thr 355 360 365Gly Leu Leu Gly Thr Leu Val Thr Met
Gly Leu Leu Thr 370 375 380422DNAArtificial SequenceSynthetic
4ctactccacc cgtcttgttt gt 22522DNAArtificial SequenceSynthetic
5tttgggggtt aaggatacag tc 22619DNAArtificial SequenceSynthetic
6caggtgtggc atttcaagg 19720DNAArtificial SequenceSynthetic
7accctggggt ttagtaacgc 20824DNAArtificial SequenceSynthetic
8aagtactaaa tatgcgcaaa gcag 24922DNAArtificial SequenceSynthetic
9atggtcctat caagaaacat cc 221023DNAArtificial SequenceSynthetic
10gttaccttct ttgtgtgtat gcc 231123DNAArtificial SequenceSynthetic
11gctgtgaata ccagtcatga aac 231222DNAArtificial SequenceSynthetic
12aacctggaga atttgaggaa ag 221322DNAArtificial SequenceSynthetic
13tgtgctaata ttcttaaggg gc 221424DNAArtificial SequenceSynthetic
14gcatttataa gcatctcttg ttgg 241520DNAArtificial SequenceSynthetic
15tcattgaatg tctgcaaccc 201622DNAArtificial SequenceSynthetic
16ctaggtgttt gtggggagag ag 221722DNAArtificial SequenceSynthetic
17tctggtgggt ttctgaagag tt 221820DNAArtificial SequenceSynthetic
18tttacgcaga gtccttcagc 201922DNAArtificial SequenceSynthetic
19ccatttaatc ctgcaatctt gg 222021DNAArtificial SequenceSynthetic
20tggaaatttg agttgctttc g 212120DNAArtificial SequenceSynthetic
21tctcccagga atatggattg 202221DNAArtificial SequenceSynthetic
22gcaccccaaa ttaactgatt c 212319DNAArtificial SequenceSynthetic
23atgtgattcc aggactgcc 1924100DNAHomo sapiens 24gtgactgtgg
ccttccccca gatgtaccta atgcccagcc agctttggaa ggccgtacaa 60gttttcccga
ggatactgta ataacgtaca aatgtgaaga 10025100DNAHomo sapiens
25gtgactgtgg ccttccccca gatgtaccta atgcccagcc agctttggcc ttggccgtac
60aagttttccc gaggatactg taataacgta caaatgtgaa 10026100PRTHomo
sapiens 26Met Thr Val Ala Arg Pro Ser Val Pro Ala Ala Leu Pro Leu
Leu Gly1 5 10 15Glu Leu Pro Arg Leu Leu Leu Leu Val Leu Leu Cys Leu
Pro Ala Val 20 25 30Trp Gly Asp Cys Gly Leu Pro Pro Asp Val Pro Asn
Ala Gln Pro Ala 35 40 45Leu Glu Gly Arg Thr Ser Phe Pro Glu Asp Thr
Val Ile Thr Tyr Lys 50 55 60Cys Glu Glu Ser Phe Val Lys Ile Pro Gly
Glu Lys Asp Ser Val Ile65 70 75 80Cys Leu Lys Gly Ser Gln Trp Ser
Asp Ile Glu Glu Phe Cys Asn Arg 85 90 95Ser Cys Glu Val
1002796PRTHomo sapiens 27Met Thr Val Ala Arg Pro Ser Val Pro Ala
Ala Leu Pro Leu Leu Gly1 5 10 15Glu Leu Pro Arg Leu Leu Leu Leu Val
Leu Leu Cys Leu Pro Ala Val 20 25 30Trp Gly Asp Cys Gly Leu Pro Pro
Asp Val Pro Asn Ala Gln Pro Ala 35 40 45Leu Ala Leu Ala Val Gln Val
Phe Pro Arg Ile Leu Arg Thr Asn Val 50 55 60Lys Lys Ala Leu Lys Phe
Leu Ala Arg Arg Thr Gln Ser Ala Leu Arg65 70 75 80Ala Val Asn Gly
Gln Ile Leu Lys Ser Ser Ala Ile Val Ala Ala Arg 85 90
9528100DNAHomo sapiens 28gtgactgtgg ccttccccca gatgtaccta
atgcccagcc agctttggaa ggccgtacaa 60gttttcccga ggatactgta ataacgtaca
aatgtgaaga 10029100DNAHomo sapiens 29gtgactgtgc cttcccccag
atgtacctaa tgcccagcca gctttggaag gccgtacaag 60ttttcccgag gatactgtaa
taacgtacaa atgtgaagaa 10030100PRTHomo sapiens 30Met Thr Val Ala Arg
Pro Ser Val Pro Ala Ala Leu Pro Leu Leu Gly1 5 10 15Glu Leu Pro Arg
Leu Leu Leu Leu Val Leu Leu Cys Leu Pro Ala Val 20 25 30Trp Gly Asp
Cys Gly Leu Pro Pro Asp Val Pro Asn Ala Gln Pro Ala 35 40 45Leu Glu
Gly Arg Thr Ser Phe Pro Glu Asp Thr Val Ile Thr Tyr Lys 50 55 60Cys
Glu Glu Ser Phe Val Lys Ile Pro Gly Glu Lys Asp Ser Val Ile65 70 75
80Cys Leu Lys Gly Ser Gln Trp Ser Asp Ile Glu Glu Phe Cys Asn Arg
85 90 95Ser Cys Glu Val 1003196PRTHomo sapiens 31Met Thr Val Ala
Arg Pro Ser Val Pro Ala Ala Leu Pro Leu Leu Gly1 5 10 15Glu Leu Pro
Arg Leu Leu Leu Leu Val Leu Leu Cys Leu Pro Ala Val 20 25 30Trp Gly
Asp Cys Ala Phe Pro Gln Met Tyr Leu Met Pro Ser Gln Leu 35 40 45Trp
Lys Ala Val Gln Val Phe Pro Arg Ile Leu Arg Thr Asn Val Lys 50 55
60Lys Ala Leu Lys Phe Leu Ala Arg Arg Thr Gln Ser Ala Leu Arg Ala65
70 75 80Val Asn Gly Gln Ile Leu Lys Ser Ser Ala Ile Val Ala Ala Arg
Cys 85 90 953230DNAHomo sapiens 32tttgttaata cttttaggta gctgcgaggt
303330DNAHomo sapiens 33tttgttaata cttttaagta gctgcgaggt
3034100DNAHomo sapiens 34gaataattca aggggaacgt gaccattatg
gatatagaca gtctgtaacg tatgcatgta 60ataaaggatt caccatgatt ggagagcact
ctatttattg 10035100DNAHomo sapiens 35gaataattca aggggaacgt
gaccattatg gatatagaca gtctgtaacg tatgcatgta 60ataaaggatt caccatgatt
ggagagcact ctatttattc 10036100PRTHomo sapiens 36Ser Ser Phe Cys Leu
Ile Ser Gly Ser Ser Val Gln Trp Ser Asp Pro1 5 10 15Leu Pro Glu Cys
Arg Glu Ile Tyr Cys Pro Ala Pro Pro Gln Ile Asp 20 25 30Asn Gly Ile
Ile Gln Gly Glu Arg Asp His Tyr Gly Tyr Arg Gln Ser 35 40 45Val Thr
Tyr Ala Cys Asn Lys Gly Phe Thr Met Ile Gly Glu His Ser 50 55 60Ile
Tyr Cys Thr Val Asn Asn Asp Glu Gly Glu Trp Ser Gly Pro Pro65 70 75
80Pro Glu Cys Arg Gly Lys Ser Leu Thr Ser Lys Val Pro Pro Thr Val
85 90 95Gln Lys Pro Thr 10037100PRTHomo sapiens 37Ser Ser Phe Cys
Leu Ile Ser Gly Ser Ser Val Gln Trp Ser Asp Pro1 5 10 15Leu Pro Glu
Cys Arg Glu Ile Tyr Cys Pro Ala Pro Pro Gln Ile Asp 20 25 30Asn Gly
Ile Ile Gln Gly Glu Arg Asp His Tyr Gly Tyr Arg Gln Ser 35 40 45Val
Thr Tyr Ala Cys Asn Lys Gly Phe Thr Met Ile Gly Glu His Ser 50 55
60Ile Tyr Ser Thr Val Asn Asn Asp Glu Gly Glu Trp Ser Gly Pro Pro65
70 75 80Pro Glu Cys Arg Gly Lys Ser Leu Thr Ser Lys Val Pro Pro Thr
Val 85 90 95Gln Lys Pro Thr 100
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