ANTI-INTEGRIN αVβ6 AUTOANTIBODIES ARE A NOVEL PREDICTIVE BIOMARKER IN ULCERATIVE COLITIS

Background
Aconitate decarboxylase 1 (ACOD1; also known as IRG-1) is the ubiquitous source of the metabolite itaconate, which dampens inflammasome activation by preventing HIF1α production of IL-1β and prevents TNF production through NRF2 activation. We reasoned that expression of ACOD1 is an inhibitory pathway within monocytes to curtail their inflammatory function, which could be manipulated in IBD therapy.

Methods
We performed single-cell RNA sequencing of monocytes from colonoscopic biopsies of treatment naïve IBD patients, as well as complementary analysis of DSS treated C57BL/6J (WT) mice, using single-cell protein-mRNA (Primeflow) technologies for validation. To determine the role of ACOD1 in colitis, Acod1^-/- mice were administered 2% DSS in drinking water for 6 days (acute colitis) or 4 days followed by 14 day recovery period (inflammation resolution) and assessed the colon myeloid compartment by multi-parameter flow cytometry. This was complemented with competitive bone marrow chimeric mice to assess the intrinsic role of ACOD1 controlling monocyte survival and proinflammatory status. Transcriptional profiling (Nanostring) was used to determine the molecular pathways influenced by ACOD1.

Results
We found that ACOD1/Acod1 represented an evolutionarily conserved of feature of inflammation-associated monocytes, with expression present in mucosal but not blood monocytes. Acod1^-/- mice demonstrated increased susceptibility to acute intestinal injury with DSS compared to co-housed WT controls, characterised by increased weight loss and colon shortening with significant accumulation of colonic neutrophils and CD64⁺Ly6C⁺ MHC-II^+/– monocytes. Consistent with Acod1 limiting inflammasome activation, Acod1^-/- monocytes demonstrated significantly greater IL-1b producing capabilities than WT controls.

To assess Acod1 deficient and sufficient haemopoietic cells in in the same environment, we generated competitive bone marrow chimeric mice. Acod1 deficiency conferred a significant advantage to monocyte recruitment to the colon, characterised by a 10fold increase in Ly6C⁺ MHC-II^–colon monocytes in colitis.

Transcriptional profiling of WT and Acod1^-/- colonic monocytes revealed significantly greater expression of molecules required for monocyte extravasation, including Sell (CD62L), Icam1, Ccr2 and Itgal (CD11a). In addition, expression of genes indicative of macrophage maturation such as Itgax (CD11c), Cd163 and Cx3cr1 were lower in the context of Acod1 deficiency, suggesting that normal maturation of these cells may be perturbed by loss of Acod1.

Conclusion
ACOD1/Acod1 represents an evolutionarily conserved, monocyte specific immuno-metabolic pathway that acts to limit monocyte recruitment, fate and pro-inflammatory function within the inflamed intestine.

Background: Better biomarkers for prediction of ulcerative colitis (UC) development and prognostication are needed. Anti-integrin αvβ6 autoantibodies (anti-αvβ6) have recently been described in adult and pediatric UC patients. Here, we tested for the presence of anti-αvβ6 autoantibodies in the pre-clinical phase of UC and studied their association with disease-related outcomes after diagnosis.

Methods:
Anti-αvβ6 autoantibodies were measured in 4 longitudinal serum samples collected from 82 subjects who later developed UC and 82 matched controls (HC) from a Department of Defense pre-clinical cohort (PREDICTS). The longitudinal samples were collected at the following timepoints: Sample A at the time of UC diagnosis, Sample B at a median of 2 years before Sample A, Sample C at a median of 4 years before Sample A and Sample D at a median of 10 years before Sample A. In a distinct, external validation cohort (GEM), we tested 12 pre-UC subjects and 49 matched controls. Further, anti-αvβ6 were measured in 2 incident UC cohorts (COMPASS n=55 and OSCCAR n=104) and associations between anti-αvβ6 and UC-related outcomes were defined using Cox proportional-hazards model.

Results:
Anti-αvβ6 autoantibodies were significantly higher among individuals who developed UC compared to controls up to 10 years before diagnosis in PREDICTS (Figure 1A), and this was validated in the GEM cohort in which samples were collected at a median of 4.2 years before diagnosis (Figure 1B). During the pre-clinical phase (Sample D to A), the proportion of anti-αvβ6 seropositive subjects increased from 12.2% (Sample D) to 20.7% (Sample C) to 30.5% (Sample B) to 52.4% (Sample A) of subjects who developed UC (Chi-square test for trend p<0.0001), compared with a mean of 2.7% in HC group across the 4 timepoints in the PREDICTS cohort (Figure 1C). Anti-αvβ6 predicted UC development with an AUC of at least 0.8 up to 10 years before diagnosis (Figure 1D). Finally, high levels of anti-αvβ6 were associated with a composite of adverse UC-outcomes including hospitalization, disease extension, colectomy, systemic steroid use and/or escalation to biologic therapy in both cohorts of recently diagnosed UC patients (Figure 1E).

Conclusion:
Anti-integrin αvβ6 autoantibodies precede the clinical diagnosis of UC by up to 10 years and are associated with adverse UC-related outcomes. The presence of anti-αvβ6 autoantibodies before UC diagnosis suggests that a pre-clinical phase, potentially amenable to therapeutic intervention may indeed predate UC diagnosis.