Preventive Azithromycin Treatment Reduces Noninfectious Lung Injury and Acute Graft- versus-Host Disease in a Murine Model of Allogeneic Hematopoietic.

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Preventive Azithromycin Treatment Reduces Noninfectious Lung Injury and Acute Graft- versus-Host Disease in a Murine Model of Allogeneic Hematopoietic Cell Transplantation Sabarinath Venniyil Radhakrishnan, Senthilnathan Palaniyandi, Gunnar Mueller, Sandra Miklos, Max Hager, Elena Spacenko, Fridrik J. Karlsson, Elisabeth Huber, Nicolai A. Kittan, Gerhard C. Hildebrandt Biology of Blood and Marrow Transplantation Volume 21, Issue 1, Pages 30-38 (January 2015) DOI: 10.1016/j.bbmt.2014.09.025 Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 1 Survival at week +6 and week +14 after allo-HCT. Animals underwent transplantation as described in Materials and Methods. (A) Survival at week +6 after HCT. Azithromycin was used at 1 mg/mL for the first 3 days starting on day +14 and then at .5 mg/mL until day 42. (syngeneic control: n = 5; allogeneic control: n = 10; azithromycin-treated allogeneic: n = 8) Survival by Wilcoxon test. (B) Clinical GVHD score at week +6 after HCT as described in Materials and Methods. (C) Survival at week +14 after HCT (syngeneic control: n = 8; allogeneic control: n = 17; azithromycin-treated allogeneic: n = 15). Azithromycin was used at 1 mg/mL for the first 3 days starting on day +14 and then at .5 mg/mL until day +98. (D) Survival at week +14 (syngeneic control: n = 5; syngeneic azithromycin-treated group: n = 4; allogeneic control: n = 13; azithromycin-treated allogeneic group: n = 14; survival by Wilcoxon test). Azithromycin was used at 3 mg/mL starting on day +14 until day +100. Biology of Blood and Marrow Transplantation 2015 21, 30-38DOI: (10.1016/j.bbmt.2014.09.025) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 2 Histopathology and pulmonary function at week +6 and week +14 after HCT. Animals underwent transplantation as described in Materials and Methods (A-C) Bronchoalveolar lavage (BAL) cell counts, CD4+ T cells, CD8+ T cells, and neutrophils by flow cytometry at week +6 after HCT. (D-F) Pulmonary function test at week +6 after HCT: FEV50, FVC, and compliance. (G-I) Pathology of the lung, gut, and liver by H&E staining at week +6 after HCT using scoring systems as described in Materials and Methods. (syngeneic control: n = 5; allogeneic control: n = 5; azithromycin-treated allogeneic: n = 8). (J,K) BAL cell counts CD4+ T cells and CD8+ T cells by flow cytometry at week +14 after HCT. (L-N) Pulmonary function test at week +14 after HCT: FEV50, FVC, and compliance. (O) H/E, CD3+ IHC (400x) and Trichrome (100x) in allogeneic control and allogeneic azithromycin-treated at week +14 after HCT. (P,Q) Lung pathology at week +14 by H&E staining scored using a semiquantitative scoring system as described in Materials and Method. (R) CD3+ cell quantification in the lung as cells per high power field at week +14. (S,T) Pathology of the gut and liver by H&E staining at week +14 after HCT using scoring systems as described in Materials and Methods. Results shown as mean ± SEM (syn control: n = 5; syn azithromycin: n = 4; allogeneic control: n = 7; allogeneic azithromycin: n = 11). For H/E and CD3+ IHC, Zeiss Axioskop 40 microscope at 400 x magnifications and for trichrome stain Nikon EclipseE400 microscope at 100 x magnification was used. Biology of Blood and Marrow Transplantation 2015 21, 30-38DOI: (10.1016/j.bbmt.2014.09.025) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 3 Tissue cytokine levels at week +6 and week +14 after allo-HCT. Animals underwent transplantation as described in Materials and Methods. (A-D) Cytokine concentration in the lung analyzed in the lung supernatant by ELISA at week +6 after HCT as described in Materials and Methods: IFN-γ, CXCL1, MIP2, and CXCL9 respectively in pg/mg total protein. (E-H) Cytokine concentration in the gut by ELISA at week +6 after HCT: IFN-γ, CCL-2, CXCL9, and TNF-α respectively in pg/mg total protein. (syngeneic control: n = 5; allogeneic control: n = 5; azithromycin-treated allogeneic: n = 8). Results shown as mean ± SEM. (I-P) Cytokine concentration in the lung at week +14 analyzed in the lung supernatant using Luminex technology as described in Materials and Methods: CXCL9, CXCL10, CCL5, IL-1β, IL-15, TNF-α, CCL3, and CXCL1 respectively in pg/mg total lung protein. Results shown as mean ± SEM (syngeneic control: n = 4; azithromycin-treated syngeneic: n = 3; allogeneic control: n = 4; azithromycin-treated allogeneic n = 6). Biology of Blood and Marrow Transplantation 2015 21, 30-38DOI: (10.1016/j.bbmt.2014.09.025) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 4 Azithromycin decreases T cell proliferation in response to alloantigen presented by APCs through the induction of regulatory T cells. Mixed lymphocytic reaction (MLR) using C57BL/6 T cells as responders and irradiated (A) B6D2F1 or (B) BALB/c splenocytes as stimulators at varying concentrations of azithromycin. (C) Anti-CD3/CD28 induced T cell proliferation using C57BL/6 as responders at varying concentrations of azithromycin. (D-E) Percentage of regulatory CD4+ Foxp3+ T cells (Tregs) of all CD4+ T cells was quantified by flow cytometry in (D) MLR and (E) Anti-CD3/CD28 activation. (F) In vitro T cell migration assay using CXCL9 at different concentrations of azithromycin compared to control as described in Material and Methods. Results shown as mean ± SEM; all experiments done in triplicates. Biology of Blood and Marrow Transplantation 2015 21, 30-38DOI: (10.1016/j.bbmt.2014.09.025) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 5 Azithromycin suppresses alloreactive splenic T cell proliferation in vivo at day +7 and day +56 after HCT and induces regulatory T cells. Animals underwent transplantation as described in Materials and Methods. (A,B) Splenic CD4+ T cell and CD8+ T cell proliferation in allogeneic controls and allogeneic azithromycin-treated animals expressed as cells/spleen. (C) Percentage of regulatory CD4+ Foxp3+ T cells of total cells in the spleen of allogeneic controls and allogeneic azithromycin recipients (n = 6 in both groups). (D,E) Splenic CD4+ T cell and CD8+ T cell proliferation in the allogeneic controls and azithromycin-treated animals expressed as cells per spleen. (F) Percentage of regulatory CD4+ Foxp3+ T cells of total cells in the spleen of allogeneic controls and allogeneic azithromycin recipients (G) MHC class II expression on CD11c+ dendritic cells in the control and azithromycin-treated recipients (control n = 9, azithromycin-treated n = 10). Results shown as mean ± SEM. Biology of Blood and Marrow Transplantation 2015 21, 30-38DOI: (10.1016/j.bbmt.2014.09.025) Copyright © 2015 American Society for Blood and Marrow Transplantation Terms and Conditions