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The Journal of Immunology, 2001, 166: 4141-4147.
Copyright © 2001 by The American Association of Immunologists

Functional IL-2 Receptor {beta} (CD122) and {gamma} (CD132) Chains Are Expressed by Fibroblast-Like Synoviocytes: Activation by IL-2 Stimulates Monocyte Chemoattractant Protein-1 Production1

Valerie M. Corrigall2, Mateen Arastu3, Shazia Khan3, Chandrabala Shah3, Mark Fife, Tom Smeets4, Paul-Peter Tak4 and Gabriel S. Panayi

Department of Rheumatology, Guy’s, King’s, and St. Thomas’s School of Medicine, Guy’s Hospital, London, United Kingdom


    Abstract
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The expression of the IL-2R {alpha}-, {beta}-, and {gamma}-chains, CD25, CD122, and CD132, respectively, was investigated on fibroblast-like synoviocytes (FLS) and dermal fibroblasts (DF). Both protein and mRNA for CD122 and CD132 were observed but there was no evidence of CD25 expression. Quantification of the Ag binding sites for CD122 showed that FLS expressed 4 times more receptor molecules than DF. The functional capability of these receptors was confirmed by the production of monocyte chemoattractant protein-1 (MCP-1) in direct response to stimulation by IL-2, which could be inhibited by neutralizing anti-CD122 mAb. Both rheumatoid arthritis (RA) and osteoarthritis (OA) FLS and DF spontaneously produced MCP-1 in culture over a similar range of concentrations. However, RA and OA FLS produced significantly greater levels of MCP-1 following stimulation by IL-2 and IL-1{beta}; RA FLS produced significantly more MCP-1 than OA FLS. Addition of exogenous IL-2 caused a slight, but significant, decrease in MCP-1 production by DF. The addition of neutralizing anti-CD122 mAb to FLS cultures partially, but significantly, reduced the IL-2-induced MCP-1 secretion, but did not effect either the spontaneous or IL-1{beta}-induced secretion of MCP-1. Increased tyrosine phosphorylation was observed in FLS lysates following 30-min incubation with IL-2. In conclusion, in the inflamed synovium, as activated T cells migrate through the sublining and lining layer, T cell-derived IL-2 may activate FLS to secrete MCP-1, thus recruiting macrophages into the rheumatoid synovium and perpetuating inflammation.


    Introduction
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Within the inflamed synovial membrane (SM)5 in rheumatoid arthritis (RA), activated T cells and mesenchymal cells, especially macrophages and fibroblast-like synoviocytes (FLS), interact through direct cell-to-cell contact. Macrophages contribute to the synovitis by the release of inflammatory cytokines, such as IL-1{beta} and TNF-{alpha} (1), while FLS are the main erosive agents through the release of matrix metalloproteinases. CD4+ T cells may influence the mesenchymal reaction by direct cell contact with FLS, leading to the release of matrix metalloproteinases (2), or with macrophages leading to secretion of monokines such as IL-1{beta} and TNF-{alpha}. Furthermore, CD4+ T cells, by the release of IFN-{gamma}, up-regulate HLA-DR expression on FLS (3). Although the quantitative role of IL-2 in the pathogenesis of RA has been questioned, its importance is supported by several lines of evidence: infusion of IL-2 into cancer patients with quiescent RA caused flare of the arthritis (4, 5), anti-CD4 Ab therapy improved disease activity (6, 7), there was a beneficial effect of cyclosporin A on RA disease activity (8), only a single or a small number of Ag-specific CD4+ T cells are needed to initiate cell-mediated immunity (9, 10), and, finally, IL-2 was directly demonstrated (11, 12) in the RA synovium by a variety of techniques.

Initial infiltration of mononuclear cells into the SM may be induced by TGF-{beta} and platelet-derived growth factor (13). However, additional chemotactic mediators are necessary to facilitate their entry into the SM. Among these factors are IL-15 (14), IL-16 (15), and the chemokines. Chemokines are a group of small peptide cytokines that have been characterized according to their ability to control leukocyte trafficking (16). A number of chemokines have been found in the rheumatoid joint (17), including monocyte chemoattractant protein-1 (MCP-1) (18), which is produced by chondrocytes (19) and by FLS stimulated with TNF-{alpha} (18, 20). Recent work has shown that in addition to being a chemoattractant for monocytes, MCP-1 also attracts CD4+CD45RO+ T cells (21). This is of particular interest because these two cell types are the major cells infiltrating the RA SM.

IL-2R is made up of three chains, {alpha} (CD25), {beta} (CD122), and {gamma} (CD132), of which only the {alpha}-chain is specific for IL-2. Signaling takes place mainly via CD122. Activated T cells express the high affinity receptor composed of all three chains (22). However, cells other than T cells, such as monocytes, express functional CD122 and CD132 and have the ability to signal following ligation of the intermediate affinity receptor consisting of the heterodimer formed by CD122 and CD132. Plaisance et al. (23) and Gruss et al. (24) have shown that CD25 and CD122 are expressed on human embryonic fibroblasts, with loss of the CD25 in adult cells. Keratinocytes also express the CD122, but with variable expression of CD132 (25). Despite this demonstration of the IL-2R on diverse cells, the biological functions of IL-2 beyond those of a receptor for T lymphocyte growth factor have not been fully explored. However, recently a range of biological activities on other cells, including down-regulation of ICAM-1 expression (25), inhibition of tumor cell growth (25), induction of IL-8 and IL-1{beta} production by monocytes (26), dendritic cell development from cord blood cells (27), and MCP-1 production by embryonic fibroblasts have been described (24).

Intrigued by these observations, we hypothesized that IL-2 found within the RA SM may have nonimmunological effects by ligating to mesenchymal cells and thus directly contributing to joint inflammation. Consequently, we have examined the cell surface expression of the three chains of the IL-2R by FLS and adult dermal fibroblasts (DF) as control cells, the effect of IL-1{beta}, TNF-{alpha}, and IL-2 stimulation on the expression of IL-2R chains and the effect of IL-2 stimulation of FLS and DF on the consequent production of MCP-1.


    Materials and Methods
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Cell culture

FLS and DF isolation. SMs and skin slivers obtained from patients with RA or osteoarthritis (OA) undergoing orthopedic surgery within Guys Hospital were minced with scissors and digested in DMEM (Sigma, Poole, U.K.) with 600 U/ml of collagenase type XI (Sigma) for 90 min at 37°C. Cells were washed in DMEM supplemented with 10% heat-inactivated FCS, tissue culture medium (TCM), and seeded into 25-cm2 tissue culture flasks. Confluent cultures of adherent FLS and DF were passaged at a 1:2 ratio into 175-cm2 flasks. Cells were gently detached from the flasks with 0.25% trypsin (Life Technologies, Paisley, U.K.). The cells used during the study were limited to between passages 3 and 8 (28). All cells were CD45 (clone 2D1) and CD14 (clone M{phi}P9; Becton Dickinson, Oxford, U.K.) negative and MHC class I (clone W6/32, American Type Culture Collection, Manassas, VA) positive as determined by flow cytometry (see below).

During the study it was noted that use of DMEM supplemented with FCS resulted in raised background levels of MCP-1 production from cells (data not shown). Following this observation, cells were cultured in defined TCM (dTCM; DMEM supplemented with 100 mg of BSA; Merck, Poole, U.K.), 300 µg of transferrin (Sigma, Poole, U.K.), 50 µl of lipids (Sigma), and 5 mg of water-soluble cholesterol (Sigma) in 100 ml during the 48 h of the experiment. Culture with dTCM reduced MCP-1 production to background levels (data not shown).

FLS and DF cultures with cytokines and mAbs. FLS or DF were cultured at 105 cells/well in 24-well plates (Corning Costar, High Wycombe, U.K.) in dTCM. The cells were allowed to adhere overnight following trypsinization. They were washed three times with fresh dTCM before the addition of IL-1{beta} (10 IU/ml; R&D Systems, Oxford, U.K.), TNF-{alpha} (50 ng/ml), or IL-2 (1, 10, 100, 300, or 900 ng/ml; 1.8, 18, 180, 540, or 1720 IU/ml; Chiron, Birmingham, U.K.). Anti-CD122 mAb (5 µg/ml; clone Mik-{beta}2, PharMingen, Oxford, U.K.) was added to the cultures 2 h before addition of cytokines.

Immunofluorescence

Analysis of CD25, CD122, and CD132 expression by FLS and DF. Before cell surface marker analysis FLS and DF were removed from their plastic flasks by addition of ice-cold PBS and gentle scrapping. The detached cells were washed twice and then used in single immunofluorescence as previously described (29). IL-2R{alpha} (CD25, clone M-A251), {beta} (CD122, clone Mik-{beta}2), and {gamma} (CD132, clone TUGh4) chain molecules were examined on the FLS and the DF cell surface using mAb directly conjugated to FITC or PE (all supplied by Becton Dickinson/PharMingen, Oxford, U.K.). Mouse IgG isotype controls, either FITC or PE conjugated (Becton Dickinson, Oxford, U.K.), were used in parallel throughout the experiments. Flow cytometry was performed using a FACScan (Becton Dickinson) with LYSIS II software. Cells were gated using forward and side light scatter parameters to access the required cell population.

Quantification of Ag binding sites/cell for FLS and DF. Quantification of the number of Ag binding sites per cell was investigated using the Quantum Simply Cellular kit (Sigma, Poole, U.K.) and analyzed according to the manufacturer’s instructions. Briefly, beads coated with five specified quantities of goat anti-mouse IgG binding sites were saturated with anti-CD122.FITC (BD PharMingen, Oxford, U.K.) and analyzed by flow cytometry as instructed. Using peak channel analysis from the beads and the manufacturer’s data, the number of binding sites on each group of beads can be determined. The peak channel expression for anti-CD122 in the FLS or DF cell population was then determined, and the number of binding sites per cell calculated using the beads as the standard.

RT-PCR

Total RNA was isolated from FLS (2 x 106) using an SV Total RNA Isolation kit (Promega, Southampton, U.K.) according to the manufacturer’s instructions. Purified resting and PHA (5 µg/ml) activated T cells were used as positive controls. RT-PCR was performed as previously described (30) using the following primers: for CD122: sense, 5'-CCGTGGCTCGGCCACCTC-3'; and antisense, 5'-TAGGGGTCGTAAGTAAAGTACACC-3'; and for CD132: sense, 5'-CCAGGACCCACGGGAACCCA3'; and antisense, 5'-GGTGGGAATTCGGGGCATCG-3'. The products were 437 and 493 bp, respectively. As a positive control GAPDH primers were used.

MCP-1 estimation

MCP-1 estimation was conducted by ELISA using mAb pairs (purified capture mAb, clone 10F7; biotinylated detection mAb, clone 5D3-F7) and a recombinant human MCP-1 protein control (all supplied by PharMingen). The mAb concentrations giving best results were investigated, and the standard used from 10 to 5000 pg/ml. Supernatants were aliquoted, stored at -70°C until used, and thawed only once.

Tyrosine phosphorylation

FLS (105/well/ml) were incubated for 30 min with or without IL-2 (300 ng/ml). The TCM was removed, and the cells were covered and lysed in 200 µl of ice-cold 50 mM Tris-HCl, pH 7.4, containing protease inhibitors (1 mM PMSF and aprotinin, leupeptin and pepstatin at 1 µg/ml each), sodium orthovanadate and sodium fluoride (both at 1 mM; all from Sigma), 1% Nonidet P-40, 1 mM EDTA, and 0.25% sodium deoxycholate. The samples were boiled with sample buffer containing SDS and 2-ME (10%, v/v) 5 x 104 cell/ml equivalent was loaded into individual wells on a 10% polyacrylamide gel. Broad spectrum markers (Bio-Rad, Hemel Hempstead, U.K.) were loaded in parallel. The proteins were blotted onto nitrocellulose and the membrane blocked with 3% BSA. Specific anti-phosphotyrosine (clone 4G10, TCS Biologicals, Buckingham, U.K.) was used at 1/5,000 dilution and anti-mouse IgG. HRP conjugate (Sigma) was used at 1/10,000 dilution. Enhanced chemiluminescence (Amersham) was used to visualize the reaction.

Immunohistology

Synovial tissue sections were cut by cryostat and T cell presence in the SM lining layer was detected using anti-CD3.HRP conjugate as previously described (31).

Statistics

FACScan data were expressed as percentage of cells positive within a defined population. Up-regulation of surface expression was analyzed by nonparametric paired Wilcoxon signed rank test. ELISA data were expressed as mean of duplicate samples of MCP-1 concentration, and the results were analyzed using a nonparametric paired Wilcoxon rank test or Mann Whitney U test.


    Results
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Immunofluorescence

Cell surface expression of CD122 and CD132 on FLS and DF. Low constitutive expression of CD122 (range, 3–13.3%) was displayed by resting FLS (six RA and eight OA) and eight DF, whereas intermittent expression of CD132 (range, 0–21%) was shown. Neither IL-1{beta}, TNF-{alpha}, nor IL-2 significantly up-regulated the expression of CD122 or CD132 on five RA, six OA FLS, or four DF (Table IGo) after 48-h culture. Fig. 1GoA shows a histogram representative of the FACScan analysis of the cell surface expression CD122 and CD132 on FLS and DF. There appeared to be little difference between expression on the FLS or DF cell surface. CD25 was not expressed by any of the eight DF or 14 FLS cultures studied either before or after stimulation by IL-2, IL-1{beta}, or TNF-{alpha} (results not shown).


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Table I. Cell surface expression of CD122 and CD132 by FLS and DF from RA and OA patientsa

 


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FIGURE 1. Expression and quantification of CD122 and CD132 on FLS and DF. A, Representative histograms of flow cytometric analysis of the expression of CD122 or CD132 on FLS or DF ({square}) compared with the isotype negative control ({blacksquare}). On the vertical axis is the number of events acquired, and on the horizontal axis is the fluorescence intensity. B, FAC Scan analysis of anti-CD122-stained Quantum Simply Cellular beads with five levels of Ag binding sites for anti-CD122 (M1 to M5) compared with that expressed by FLS and DF. C, The quantification of CD122 Ag binding sites on unstimulated fibroblasts (four FLS and two DF) obtained using Quantum Simply Cellular bead analysis

 
Quantification of the CD122 Ag binding sites. Quantification of the CD122 Ag binding sites on the FLS and DF cell surface is shown in Fig. 1GoB. The first histogram shows a representative sample of the Quantum Simply Cellular beads, saturated with anti-CD122.FITC. The five peaks for the five graded goat anti-mouse Ig binding sites are clearly indicated. This was compared with FLS and DF, saturated with anti-CD122.FITC, and analyzed by histogram using peak channel expression. Fig. 1GoC shows the difference in number of CD122 binding sites recorded between the four FLS and two DF studied (FLS, 29,005 ± 5,100; DF, 8,065 ± 583); FLS clearly express more CD122 on their cell surface.

RT-PCR for CD122 and CD132 mRNA

mRNA for CD122 was detected by RT-PCR in three of three FLS (one RA (Fig. 2Go, lane b) and two OA (Fig. 2Go, lanes a and c)) cultures (Fig. 2Go, lanes a–c). PHA-activated T cells were used as the positive control (Fig. 2Go, lane d). The presence of mRNA for CD132 was more variable and was found in only two of three FLS examined (lanes b, e, and f). This suggests differential control of the two receptor chains. All cultures showed a similar intensity for the housekeeping gene GAPDH.



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FIGURE 2. The presence of mRNA for CD122 and CD132 in FLS. The presence of mRNA for CD122 detected by RT-PCR (RA FLS, lane b; OA FLS, lanes a and c) and CD132 (RA FLS, lane b; OA FLS, lanes e and f; positive control, activated T cells, lane d). The CD122 product was 437 bp, the CD132 product was 493 bp, and the GAPDH product was 598 bp. GAPDH was used as the internal standard housekeeping gene.

 
Addition of IL-2 to FLS cultures induced MCP-1 production

To investigate the functional ability of the IL-2R {beta}- and {gamma}-chains, exogenous recombinant human IL-2 was added to FLS and DF cells over a range of concentrations (1–1000 ng/ml, 1.8–1900 IU/ml) for 24 h. IL-1{beta} (10 IU/ml) was used as a positive control.

Resting FLS (eight RA and eight OA) and DF (six RA) spontaneously produced low concentrations of MCP-1, but there was considerable variation between cultures. There appeared to be no difference in the range of concentration produced by OA or RA resting FLS (range, 11–750 pg/ml; mean ± SD, 184 ± 285 pg/ml) and RA DF (range, 21–755 pg/ml; mean ± SD, 212 ± 279 pg/ml).

In response to exogenous IL-1{beta} both RA and OA FLS produced significantly more MCP-1 (RA (n = 5): IL-1{beta}-induced MCP-1 production range, 590-6042 pg/ml; dTCM range, 16–123 pg/ml (p = 0.0097); OA (n = 7): IL-1{beta}-induced MCP-1 production range, 650-5800 pg/ml; dTCM range, 44–750 pg/ml (p = 0.023); DF (n = 6): fold increase (FI), 25.1 ± 21.4; range, 2.1–55.0; MCP-1: range, 420-9500 pg/ml (p = 0.03); Fig. 3GoA). To aid analysis the results were normalized and expressed as the FI (expressed as the mean ± SD) above the production of MCP-1 by resting cultures. Interestingly, RA FLS produced significantly greater amounts of MCP-1 in response to IL-1{beta}, as measured by FI, than OA FLS (RA FLS FI, 70.2 ± 51; range, 32–160; OA FLS FI, 26.8 ± 14.5; range, 7.7–45; p = 0.017; Fig. 3GoA).



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FIGURE 3. Production of MCP-1 following stimulation of FLS and DF with IL-2 and IL-1{beta}. Production of MCP-1 in supernatants that were collected after 24-h culture. The results are expressed as the mean ± SD of the FI in MCP-1 production (the production of MCP-1 after stimulation/the background production of MCP-1) in experiments with 14 FLS (eight RA and six OA) and six DF (RA). See text for absolute amounts of MCP-1 produced. A, Culture of FLS and DF with 10 IU/ml IL-1{beta}. B, A representative dose-response curve of MCP-1 production induced by IL-2. C, Seventeen FLS (nine RA and eight OA) or six DF were cultured with IL-2 (300 ng/ml) and compared with production of MCP-1 by resting FLS or DF, respectively.

 
A dose-dependent increase in MCP-1 production was seen when exogenous IL-2 was added to FLS over a range from 1–1000 ng/ml (Fig. 3GoB). Thereafter, a single dose of IL-2 was used. Exogenous IL-2 (300 ng/ml) significantly increased the production of MCP-1 by RA FLS compared with OA FLS (RA (n = 8) FI, 17.6 ± 24.9; FI range, 1.5–72.3; range, 43–18,170 pg/ml; OA (n = 6) FI, 3.7 ± 5.8; FI range, 1.1–15.7; range, 53–13,305 pg/ml (p = 0.029); Fig. 3GoC). However, addition of exogenous IL-2 (300 ng/ml) to DF caused a slight, but significant, inhibition in the production of MCP-1 (DF (n = 6) FI, 0.6 ± 0.26; FI range, 0.24–1.0; range, 12–752 pg/ml; dTCM range, 21–755 pg/ml (p = 0.036); Fig. 3GoC).

In a single matched pair of RA FLS and DF, the spontaneous release of MCP-1 by the cells was similar (FLS, 16 pg/ml; DF, 21 pg/ml); however, FLS produced much greater quantities of MCP-1 following stimulation by IL-2 and IL-1{beta} (IL-2-stimulated FLS, 65 pg/ml; DF, 21 pg/ml; IL-1{beta}-stimulated FLS, 2534 pg/ml; DF, 830 pg/ml). However, in each case the FLS produced a 3-fold increase in MCP-1 compared with DF after stimulation.

Blocking CD122 with a neutralizing Ab inhibits MCP-1 production by FLS

To investigate whether the ligation of IL-2R by IL-2 directly resulted in de novo production of MCP-1, neutralizing Ab to CD122 (5 µg/ml) was added to the FLS cultures 2 h before addition of IL-1{beta} or IL-2. Fig. 4Go shows that, as previously observed, addition of IL-2 significantly up-regulated MCP-1 production (mean ± SD; unstimulated FLS, 2062 ± 2511 pg/ml; IL-2-stimulated FLS, 4046 ± 6057 pg/ml; p = 0.015). This was partially inhibited by the prior addition of neutralizing anti-CD122 mAb (IL-2-stimulated FLS, 4046 ± 6057 pg/ml; IL-2- plus anti-CD122-treated FLS, 2191 ± 2768 pg/ml; p = 0.015). The addition of anti-CD122 to the cultures reduced MCP-1 production in the presence of IL-2 by 36 ± 24%. As before, the addition of IL-1{beta} significantly raised the production of MCP-1, but the addition of anti-CD122 affected neither these cultures nor the TCM cultures (IL-1{beta}-stimulated FLS, 6464 ± 6510 pg/ml; IL-1{beta}- plus anti-CD122-treated FLS, 6029 ± 6130 pg/ml). Furthermore, two additional experiments showed no inhibition of MCP-1 production by an irrelevant isotype control mAb (results not shown).



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FIGURE 4. Inhibition of MCP-1 production caused by blocking CD122. FLS were cultured with (+) and without (-) neutralizing anti-CD122 (5 µg/ml) in dTCM alone or with added IL-2 (300 ng/ml) or IL-1{beta} (10 IU/ml). mAb was added 2 h before addition of the cytokines, and the supernatants were collected after 24 h. The results are expressed as the mean ± SD of the FI and are from six experiments (three RA FLS and three OA FLS).

 
Tyrosine phosphorylation

Following the addition of IL-2 to FLS for 30 min (Fig. 5Go, lane B) there was increased intracellular phosphorylation of proteins at 110, 90 70, 68, 56, 50, and 46 kDa, which was not seen in the resting cells (Fig. 5Go, lane A). CD122 (75 kDa) and CD132 (64 kDa) fall within the area of intense phosphorylation seen poststimulation. This is a direct demonstration of the increased tyrosine phosphorylation of intracellular proteins in FLS by IL-2.



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FIGURE 5. Tyrosine phosphorylation of intracellular FLS proteins following IL-2 stimulation. Anti-phosphotyrosine Ab was used to detect phosphorylation of intracellular proteins in FLS either cultured alone (A) or with IL-2 (300 ng/ml; B). The proteins were separated by PAGE (10% gel), blotted onto nitrocellulose, and probed with anti-phosphotyrosine (5 x 10-3 dilution) and anti-mouse IgG.HRP (10-4 dilution). ECL was used to visualize Ag Ab interactions. The results shown are from a representative experiment of two performed using OA FLS.

 
Immunohistology

Proliferation of FLS in the synovial lining layer and infiltration of activated T cells into the synovium followed by migration across the lining layer result in direct contact between T cells and FLS. The tissue section shown in Fig. 6Go is of RA synovium and shows CD3+ T cells within the synovial lining layer in direct contact with FLS and macrophages.



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FIGURE 6. T lymphocytes in the SM lining layer. Synovial tissue showing CD3+ T cells (red) in close association with the intimal lining layer, consisting of FLS and intimal macrophages. Single staining was performed using the peroxidase technique; counterstaining was performed using with Mayer’s hemalum. Original magnification, x200.

 

    Discussion
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study of the function and expression of the three IL-2R chains, CD25, CD122, and CD132, has for the greater part been limited to their expression on T cells and other hematogenous cells, such as monocytes (32). The lack of expression of CD25 by both FLS and DF confirmed the previous findings for DF (23). However, this is the first time that the important observation has been made that CD122 is constitutively expressed by FLS and adult DF. CD132, the {gamma} common receptor chain, is expressed intermittently, and both protein and mRNA for CD132 may be detected in these cells. Neither CD122 nor CD132 was significantly up-regulated on either RA or OA FLS or DF following stimulation by IL-1{beta}, IL-2, or TNF-{alpha}, but combinations of these cytokines, which would be expected to be present in inflammatory lesions, were not studied. RT-PCR for CD122 and CD132 provided confirmation that this was de novo protein production by the FLS, with three of three FLS positive for CD122 and two of three positive for CD132. Similarly, CD132 mRNA expression was only demonstrated in a proportion of keratinocytes (25).

The combination of CD122 and CD132 on the FLS surface, forming an IL-2R of intermediate affinity, provides a channel for communication between mesenchymal cells and T cells. The increased production of MCP-1 following IL-2 stimulation of RA or OA FLS indicated that these receptors were fully functional. The increased tyrosine phosphorylation was a direct demonstration of IL-2 activation of the intracellular signaling pathways downstream from CD122. The proteins phosphorylated have molecular masses corresponding to those of JAK3 (110 kDa) and STAT5b (90 kDa), both of which are phosphorylated downstream in the IL-2R signaling cascade, although these were not formally identified. Addition of neutralizing mAb to CD122 caused specific inhibition of IL-2-stimulated MCP-1 production, demonstrated by the decrease in MCP-1 produced following IL-2, but not IL-1{beta}, stimulation in the presence of anti-CD122.

Previous immunohistologic studies have identified the synovial macrophages as the main producers of MCP-1 within the RA synovium. However, this study, showing that relatively low concentrations of IL-2, a Th1 cytokine, may activate FLS to secrete MCP-1, indicates that FLS may be able to regulate the local influx of monocytes into the RA SM. There is the additional possibility that other cytokines may act in conjunction with IL-1{beta} and TNF-{alpha} to cause synergistic production of MCP-1 in the RA synovium. Production of MCP-1 and -2 is greatly increased following stimulation by IL-1{beta} in the presence of IFN-{gamma} or -{beta}. The presence of IFN-{beta} within the synovium has been demonstrated and is known to prolong the viability of T cells in contact with FLS (33). The situation may be further complicated by the possibility that the types of chemokines produced may be dictated by the combination of cytokines produced locally, because many cytokines have the ability to regulate the MCP-1 gene (20, 34). Thus, in lung fibroblast cultures IFN-{gamma} synergized with TNF-{alpha} to produce RANTES, while IL-4 synergized with TNF-{alpha} to produce eotaxin (35).

During this study differences were noted between adult DF and RA or OA FLS. Analysis of the cell surface expression of CD122 demonstrated that the DF displayed fewer Ag binding sites per cell than FLS. However, this number of sites per cell was in accordance with the previously quantified number of low affinity sites recorded for embryonic fibroblasts (23). The number of receptors expressed may well influence or provide a threshold for the response following IL-2 stimulation. FLS could be up to 4 times more sensitive to the presence of IL-2. Indeed, although DF production of MCP-1 appeared to be down-regulated following IL-2 stimulation, IL-1{beta} activation induced increased MCP-1 secretion to a similar degree as in FLS. Because the background level of secreted MCP-1 by resting DF and FLS was similar, it could be inferred that the number of cell surface binding sites plays a critical role in the activation of these cells by IL-2. This is supported by the evidence that increasing exogenous IL-2 did not further up-regulate MCP-1 production by DF. Comparative analysis of RA and OA FLS showed a similar basal production of MCP-1, which was significantly increased on stimulation by either IL-1{beta} or IL-2. Quantification of the MCP-1 showed a significantly higher production by RA FLS than OA FLS following both IL-1{beta} (p = 0.017) and IL-2 (p = 0.029) stimulation. The greater responsiveness by RA FLS to IL-1{beta} and IL-2 may be caused by interaction between either IL-1{beta} or IL-2 with constitutively produced cytokines present in the cultures, such as IL-6 (36), IL-8 (37), and IL-15 (38). Because the latter cytokine shares two receptor chains with IL-2, the effect of IL-15 in this system is presently under investigation.

The inflamed SM in RA is a focus for cellular infiltration. Within this dynamic area cells are trafficking through the endothelium and tissue into the synovial cavity. During this event they come in close contact both with resident cells in the sublining layer of the SM and subsequently with the activated FLS in the lining layer. The intimal lining layer mainly consists of two cell types: FLS and macrophages. The FLS are especially found in the lower part of the lining layer next to the synovial sublining where T cells are found (39). Fig. 6Go shows the close relationship between CD3+ T cells and intimal lining cells. This is in line with the previously reported association between lymphocytes and FLS (40). Th1 cytokine receptors are known to be expressed on the FLS cell surface. IFN-{gamma}R ligation on the FLS cell surface is used in vitro to up-regulate HLA-DR (3). Similarly, ligands for T cell costimulatory molecules, CD40 and ICAM-1, are expressed by FLS postactivation or constitutively, respectively (28). Therefore, there is a precedent for communication between T cells and FLS, either via direct surface-bound receptor-ligand interactions or through soluble mediators. Immunohistologic studies have indicated that in the rabbit Ag-induced arthritis model (41) and in the human RA SM (41) MCP-1 is localized to the synovial lining and sublining layers as well as the perivascular region. These subsynovial and perivascular regions of the RA SM are areas in which IL-2-positive CD4+ T lymphocytes have been located (42). Despite the fact that only low concentrations of IL-2 have been demonstrated in the synovium, the physiological consequence of direct contact between a T cell and FLS may result in high local concentrations of IL-2 (43, 44) with ready access to the IL-2R. RA FLS are large cells (mean diameter, 15 µm) with multiple receptors, which are further up-regulated by IL-1{beta}. These receptors may provide competition for the relatively small amount of IL-2 produced within the inflamed synovium and may account for the low mitotic rate of RA synovial T cells (45, 46)

The importance of MCP-1 in the pathology of RA is indicated by the improvement seen in animal models of collagen arthritis following treatment with neutralizing anti-MCP-1 Ab (47) or MCP-1 receptor antagonist (48). Both significantly reduced the severity of the experimental arthritis. The experiments reported here support this concept as the MCP-1 produced by monocytes, memory T cells, and FLS will orchestrate the local cellular infiltrate, thus perpetuating inflammation.


    Acknowledgments
 
We thank the orthopedic surgeons of Guy’s and St. Thomas’ Hospital Trust, and Prof. F. Heatley, B. Polvsen, P. Earnshaw, and D. Nunn for collecting the synovial membranes and skin samples, without which this work would have been impossible. In addition, we thank S. Haynes for typing the manuscript.


    Footnotes
 
1 This work was supported by the Arthritis Research Campaign U.K. (Project Grant C0559 and Integrated Clinical Arthritis Centre Award Grant P0526) and Intercalated B.Sc. scholarships (to M.A. (1996) and S.K. (1997)). Back

2 Address correspondence and reprint requests to Dr. Valerie Corrigall, Department of Rheumatology, Guy’s, King’s, and St. Thomas’s School of Medicine, 5th Floor Thomas Guy House, Guy’s Hospital, London, U.K. SE1 9RT. Back

3 M.A., S.K., and C.S. contributed equally to this work. Back

4 Current address: Division of Clinical Immunology and Rheumatology, University of Amsterdam, P.O. Box 22700, 11100 DE Amsterdam, The Netherlands. Back

5 Abbreviations used in this paper: SM, synovial membrane; FLS, fibroblast-like synoviocytes; DF, dermal fibroblasts; MCP-1, monocyte chemoattractant protein-1; RA, rheumatoid arthritis; OA, osteoarthritis; TCM, tissue culture medium; dTCM, defined TCM; FI, fold increase. Back

Received for publication November 16, 1999. Accepted for publication January 5, 2001.


    References
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Firestein, G. S., J. M. Alvaro Garcia, R. Maki. 1990. Quantitative analysis of cytokine gene expression in rheumatoid arthritis. J. Immunol. 144:3347.[Abstract]
  2. Burger, D., R. Rezzonico, J.-M. Li, C. Modoux, R. A. Pierce, H. G. Welgus, J.-M. Dayer. 1998. Imbalance between interstitial collagenase and tissue inhibitor of metalloproteinase 1 in synoviocytes and fibroblasts upon direct contact with stimulated T lymphocytes. Arthritis Rheum. 41:1748.[Medline]
  3. Alvaro-Garcia, J. M., N. J. Zvaifler, G. S. Firestein. 1990. Cytokines in chronic arthritis. V. Mutual antagonism between interferon-{gamma} and tumor necrosis {alpha} on HLA-DR expression, proliferation, collagenase production and granulocyte macrophage colony-stimulating factor production by rheumatoid arthritis synoviocytes. J. Clin. Invest. 86:1790.
  4. Lavelle-Jones, M., A. Al-Hadrani, E. M. Spiers, F. C. Campbell, A. Cuschieri. 1990. Reactivation of rheumatoid arthritis during continuous infusion of interleukin-2: evidence of lymphocytic control of rheumatoid disease. Br. Med. J. 301:97.
  5. Massarotti, E. M., N. Y. Liu, J. Mier, M. B. Atkins. 1992. Chronic inflammatory arthritis after treatment with high dose-interleukin-2 for malignancy. Am. J. Med. 92:693.[Medline]
  6. Choy, E. H. S., D. J. A. Connolly, G. H. Kingsley, J. M. Johnson, G. S. Panayi. 1997. Effect of a humanised non-depleting anti-CD4 monoclonal antibody (mAb) on synovial fluid (SF) in rheumatoid arthritis. Arthritis Rheum. 40:130. (Abstr.).
  7. Schulze-Koops, H., L. S .Davis, P. Haverty, M. C. Wacholtz, P. Lipsky. 1997. Reduction of Th1 cell activity in patients with rheumatoid arthritis after treatment with a non-depleting monoclonal antibody to CD4. Arthritis Rheum. 40:963. (Abstr.).
  8. Tesser, J. R. P., C. Wiesenhutter, R. Levy, M. Schiff, J. Lipani, A. Solinger, B. MacDonald, M. Elliott, K. Singh. 1997. Treatment of rheumatoid arthritis with a primatised anti-CD4 monoclonal antibody, SB-210396 (IDEC-CD9.1) - results of an open label extension study in patients responding to induction therapy. Arthritis Rheum. 40:1160. (Abstr.).
  9. Marshall, G. M., G. Seman, G. Milan, P. Truffa-Bahi, V. Zilberfarb. 1982. Local adoptive transfer of skin delayed type hypersensitivity initiated by a single T lymphocyte. J. Immunol. 129:954.[Abstract]
  10. Steinman, L.. 1996. A few autoreactive cells in an autoimmune infiltrate control a vast population of non-specific cells: a tale of smart bombs and the infantry. Proc. Natl. Acad. Sci. USA 93:2253.[Abstract/Free Full Text]
  11. Howell, W. M., C. J. Warren, M. I. N .J. Cook, M. I. Cawley, J. L. Smith. 1991. Detection of IL-2 at mRNA and protein levels in synovial infiltrates from inflammatory arthropathies using biotinylated oligonucleotide probes in situ. Clin. Exp. Immunol. 86:393.[Medline]
  12. Nouri, A. M., G. S. Panayi, S. M. Goodman. 1984. Cytokines and the chronic inflammation of rheumatic disease. II. The presence of interleukin-2 in synovial fluids. Clin. Exp. Immunol. 58:402.[Medline]
  13. Renimers, E. F., H. Sano, R. Lafyatis, J. P. Case, G. K. Kumkumian, T. Ha, T. Macaig, R. L. Wilder. 1991. Production of platelet derived growth faction {beta} chain (PDGF-B/C-cis) mRNA and immunoreactive PDGR{beta}-like polypeptide by rheumatoid synovium. J. Rheumatol. 18:7.[Medline]
  14. Oppenheimer-Marks, N., R. I. Brezinschek, M. Mohamadzadeh, R. Vita, P. E. Lipsky. 1998. Interleukin 15 is produced by endothelial cells and increases the transendothelial migration of T cell in vitro and in the SCID mouse-human rheumatoid arthritis model in vivo. J. Clin. Invest. 101:1261.[Medline]
  15. Parada, N. A., W. W. Cruikshank, H. L. Davis, T. C. Ryan, D. M. Centre. 1996. IL-16 and other CD4 ligand-induced migration is dependent upon protein kinase C. Cell. Immunol. 168:100.[Medline]
  16. Epstein, F. H., A. D. Luster. 1998. Chemokines-chemotactic cytokines that mediate inflammation. N. Engl. J. Med. 338:436.[Free Full Text]
  17. Hosaka, S., T. Akahoshi, C. Wada, H. Kondo. 1994. Expression of the chemokine superfamily in rheumatoid arthritis. Clin. Exp. Immunol. 97:451.[Medline]
  18. Sato, M., T. Miyazaki, T. Nagaya, Y. Murata, N. Ida, H. Seo. 1996. Antioxidants inhibit tumor necrosis factor-{alpha} mediated stimulation of interleukin-8, monocyte chemoattractant protein-1, and collagenase expression in cultured human synovial cells. J. Rheumatol. 23:432.[Medline]
  19. Villiger, P. M., R. Terkeltaub, M. Lotz. 1992. Monocyte chemoattractant protein-1 (MCP-1) expression in human articular cartilage: induction by peptide regulatory factors and differential effects of dexamethasone and retinoic acid. J. Clin. Invest. 90:488.
  20. Hachica, M., P. Rathanaswami, T. J. Schall, S. R. McColl. 1993. Production of monocyte chemotactic protein-1 in human synoviocytes. Arthritis Rheum. 36:26.[Medline]
  21. Lietscher, P., M. Seitz, M. Baggiolini, B. Moser. 1996. Interleukin-2 regulates CC chemokine receptor expression and chemotactic responsiveness in T lymphocytes. J. Exp. Med. 184:569.[Abstract/Free Full Text]
  22. Miniami, Y., T. Kono, T. Miyazaki, T. Taniguchi. 1993. The IL-2 receptor complex: its structure, function and target genes. Annu. Rev. Immunol. 11:245.[Medline]
  23. Plaisance, S., E. Rubenstein, A. Alileche, Y. Sahraoui, P. Krief, Y. Augery-Bourget, C. Jasmin, H. Suarez, B. Azzarone. 1992. Expression of the interleukin-2 receptor on human fibroblasts and its biological significance. Int. Immunol. 4:739.[Abstract/Free Full Text]
  24. Gruss, H. J., C. Scott, B. J. Rollins, M. A. Brach, F. Herrmann. 1996. Human fibroblasts express functional IL-2 receptors formed by the IL-2R{alpha} and {beta} chain subunits. J. Immunol. 157:851.[Abstract]
  25. Yasumura, S., W. Lin, E. Weidmann, P. Hebda, T. L. Whiteside. 1994. Expression of interleukin-2 receptors in human carcinoma cell lines and tumour growth inhibition by interleukin 2. Int. J. Cancer 59:225.[Medline]
  26. Cluitmans, F. H., B. H. Esandam, J. E. Landegent, R. Willemze, J. H. Falkenburg. 1993. Regulatory effects of T cell lymphokines on cytokine gene expression in monocytes. Lymphokine Cytokine Res. 12:457.[Medline]
  27. Bykovskaja, S. N., M. J. Butto, M. Bunker, H. Zhang, A. Majors, M. Herbert, A. Loksin, M. J. Levitt, A. Jaja, D. Scalise, et al 1998. Interleukin 2 induces development of dendritic cells from cord blood CD34+ cells. J. Leukocyte Biol. 63:620.[Abstract]
  28. Tsai, C., Jr L. A. Diaz, N. G. Singer, L. L. Li, A. H. Kirsch, R. Mitra, B. J. Nickoloff, L. J. Crofford, D. A. Fox. 1996. Responsiveness of human T lymphocytes to bacterial superantigens presented by cultured rheumatoid arthritis synoviocytes. Arthritis Rheum. 39:125.[Medline]
  29. Iannone, F., V. M. Corrigall, G. S. Panayi. 1996. CD69 on synovial T cells in rheumatoid arthritis correlates with disease activity. J. Rheumatol. 35:397.
  30. Suminami, Y., Y. Kashii, J. C. Law, W. C. Liu, J. Stanson, T. E. Reichart, H. Rabinowich, T. L. Whiteside. 1998. Molecular analysis of the IL-2 receptor beta chain gene expressed in human tumor cells. Oncogene 16:1309.[Medline]
  31. Youssef, P. P., T. J. M. Smeets, B. Bresnihan, G. Cunnane, O. Fitzgerald, F. Breedveld, P. P. Tak. 1998. Microscopic measurement of cellular infiltration in the rheumatoid arthritis synovial membrane: a comparison of semiquantitative and quantitative analysis. Br. J. Rheumatol. 37:1003.[Abstract/Free Full Text]
  32. Bosco, M. C., I. E. Delgado, T. K. Rowe, M. G. Malabarba, D. L. Longo, L. Varesio. 1997. Functional role for the myeloid differentiation antigen CD14 in the activation of human monocytes by IL-2. J. Immunol. 159:2922.[Abstract]
  33. Pilling, D., A. N. Akbar, J. Girdlestone, C. H. Orteu, N. J. Borthwick, N. Ampft, D. Scheel-Toellner, C. D. Buckley, M. Salmon. 1998. Interferon {beta} mediates stromal cell rescue of T cells from apoptosis. Eur. J. Immunol. 29:1041.
  34. Palacios, I., M. J. Lopez-Armada, P. Hernandez, O. Sanchez-Pemaute, S. Gutierrez, R. Miguelez, J. Martinez, J. Egido, G. Herrero-Beaumont. 1998. Tenidap decreased IL-8 and monocyte chemotactic peptide-1 (MCP-1) mRNA expression in the synovial fluid of rabbits with antigen arthritis and in cultured synovial cells. Clin. Exp. Immunol. 111:588.[Medline]
  35. Teran, L. M., M. Mochizuki, J. Bartels, E. L. Valencia, T. Nakajima, K. Hirai, J. M. Schroder. 1999. Th1 and Th2 type cytokines regulate the expression and production of eotaxin and RANTES by human lung fibroblasts. Am. J. Resp. Cell Mol. Biol. 20:777.[Abstract/Free Full Text]
  36. Miyazawa, K., A. Mori, K. Yamaoto, H. Okudaira. 1998. Constitutive transcription of the human interleukin-6 gene by rheumatoid synoviocytes: spontaneous activation of NF-{kappa}B and CBF1. Am. J. Pathol. 152:793.[Abstract]
  37. Seitz, M., P. Loetscher, B. Dewald, H. Twbin, M. Ceska, M. Baggiolini. 1994. Production of interleukin-1 receptor antagonist, inflammatory chemotactic proteins, and prostaglandin E by rheumatoid and osteoarthritic synoviocytes: regulation by IFN-{gamma} and IL-4. J. Immunol. 152:2060.[Abstract]
  38. Harada, S., M. Yamamura, H. Okamoto, Y. Morita, M. Kawashima, T. Aita, H. Makino. 1999. Production of interleukin-7 and interleukin-15 by fibroblast-like synoviocytes from patients with rheumatoid arthritis. Arthritis Rheum. 42:1508.[Medline]
  39. Tak, P. P.. 2000. Examination of the synovium and synovial fluid. G. S. Firestein, and G. S. Panayi, and F. A. Wollheim, eds. Rheumatoid Arthritis: Frontiers in Pathogenesis and Treatment 55.-68. Oxford Press, New York.
  40. Ishikawa, H., M. Ziff. 1976. Electron microscopic observations of immunoreactive cells in rheumatoid synovial membrane. Arthritis Rheum. 19:1.[Medline]
  41. Harigai, M., M. Hara, T. Yoshimura, E. J. Leonard, K. Inone, S. Kashiwazaki. 1993. Monocyte chemotactic protein-1 (MCP-1) in inflammatory joint diseases and its involvement in the cytokine network of rheumatoid synovium. Clin. Immunol. Immunopathol. 69:83.[Medline]
  42. Steiner, G., M. Tohidast-Akrad, G. Witzman, M. Vesely, A. Studnicka-Beuke, A. Gal, M. Kunaver, P. Zeuz, J. S. Sinden. 1998. Cytokine production by synovial T cells in rheumatoid arthritis. Rheumatology 38:202.[Abstract/Free Full Text]
  43. Morita, Y., M. Yamamura, M. Kawashima, S. Harada, K. Tsuji, K. Shibuya, K. Maruyama, H. Makino. 1998. Flow cytometric single cell analysis of cytokine production by CD4+ T cells in the synovial tissue and peripheral blood from patients with rheumatoid arthritis. Arthritis Rheum. 41:1669.[Medline]
  44. Kaplan, D.. 1996. Autocrine secretion and physiological concentration of cytokines. Immunol. Today 17:303.[Medline]
  45. Bonvoisin, B., G. Cordier, J. P. Revillard, E. Lejeunne, M. Bouvier. 1984. Increased DNA and/or RNA content of synovial fluid cells in rheumatoid arthritis: a flow-cytometry study. Ann. Rheum Dis. 43:222.[Abstract/Free Full Text]
  46. Bergroth, V., Y. T. Kontinnen, P. Nykanen, R. Von Essen, K. Koota. 1985. Proliferating cells in the synovial fluid in rheumatic disease: an analysis with autoradiography-immunoperoxidase double staining. Scand J. Immunol. 22:383.[Medline]
  47. Ogato, H., M. Takeya, T. Yoshimra, K. Takagi, K. Takahashi. 1997. The role of monocyte chemoattractant protein-1 (MCP-1) in the pathogenesis of collagen-induced arthritis in rats. J. Pathol. 182:106.[Medline]
  48. Plater-Zyberk, C., A. J. Hoogewerf, A. E. Proudfoot, C. A. Power, T. N. Wells. 1997. Effect of a CC chemokine receptor antagonist on collagen induced arthritis in DBA/1 mice. Immunol. Lett. 57:117.[Medline]



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