Targeting Neutrophil Aging and the Microbiota for the Treatment of Sickle Cell Disease

Sickle cell disease (SCD) is a genetic blood disorder characterized by repeated episodes of vaso-occlusion, in which neutrophils play a primary function through their recruitment in inflamed venules and interactions with sickle red blood cells (sRBCs) via activated α_Mβ₂ integrin (Mac-1). Intravital microscopy analyses revealed considerable heterogeneity in Mac-1 activation on adherent neutrophils, suggesting that subsets of neutrophils differ markedly in their pro-inflammatory activity (Nat Med 2009; 15:384). Recently, we found that aged neutrophils, marked by CD62L^loCXCR4^hi, represented an overly active subset exhibiting enhanced Mac-1 activation (Blood 2013; 122:324). To further characterize aged neutrophils, we compared their transcriptome with control and in vivo-activated neutrophils. Gene set enrichment analyses revealed that aged neutrophils up-regulated several pathways that were also enhanced during activation, including integrin, leukocyte adhesion, toll-like receptor (TLR), and NFκB signalling pathways (P < 0.05), suggesting a contribution by exogenous inflammatory mediators. Based on the expression profile, we hypothesized that microbiota-derived signals may influence neutrophil aging in the circulation. To test this idea, we analyzed aged neutrophil numbers in antibiotics (ABX)-treated and germ-free (GF) mice, in which the gut microbiota was largely depleted or deficient, respectively. We found significant reductions of aged neutrophil numbers in both models, and the numbers could be significantly restored by either lipopolysaccharide (LPS) gavage or fecal transplantation (Ctrl / ABX / ABX+LPS: 98±14 / 36±11 / 107±25 cells per μl blood; SPF / GF / GF-FT: 56±12 / 4±1 / 15±4 cells per μl blood; P < 0.05). We next investigated whether microbiota-driven neutrophil aging was mediated by TLRs and Myd88 signalling using chimeric mice reconstituted with a mixture of WT and Myd88, TLR4 or TLR2-deficient hematopoietic cells. Interestingly, we observed significant reductions in the aged subset of Myd88, TLR4 or TLR2-deficient neutrophils compared to WT neutrophils in the same mice, and in their capacity to capture fluosphere beads that specifically bound to activated Mac-1 (WT / LysM-cre/Myd88-flox: 10.4±0.3 / 7.0±0.6 %, 1.0±0.1 / 0.4±0.1 bead per cell; WT / Tlr4^-/-: 10.3±0.2 / 6.0±0.2 %, 1.0±0.1 / 0.4±0.1 bead per cell; WT / Tlr2^-/-: 10.0±0.4 / 6.8±0.5 %, 1.3±0.2 / 0.8±0.1 bead per cell; P < 0.01). Analysis of SCD mice (BERK) revealed that the aged neutrophil population was significantly increased (by >10-fold) compared to hemizygous (SA) mice, and the expansion was completely abrogated by microbiota depletion (SA / SCD (SS)-Ctrl / SS-ABX: 71±11 / 981±261 / 124±27 cells per μl blood, P < 0.01). We then challenged SA, untreated and ABX-treated SCD mice with TNF-α to induce acute vaso-occlusion. SCD mice exhibited significant increases in neutrophil adhesion, Mac-1 integrin activation and heterotypic interactions with RBCs compared to SA mice, all of which were markedly reduced by microbiota depletion (SA / SS-Ctrl / SS-ABX: 6.4±0.6 / 18.1±1.0 / 11.2±1.0 adherent neutrophil per vessel; 0.5±0.1 / 1.0±0.2 / 0.3±0.1 bead per cell; 0.1±0.1 / 0.5±0.1 / 0.2±0.1 RBC interaction per vessel per min; P < 0.05), resulting in significantly enhanced blood flow and prolonged survival in ABX-treated SCD mice (P < 0.05). Most interestingly, the splenomegaly of SCD mice was significantly reduced, and liver damage including fibrosis, necrosis and inflammation was dramatically alleviated in ABX-treated SCD mice (P < 0.05). Finally, we evaluated whether the numbers of circulating aged neutrophils were altered in patients with SCD. As Penicillin V antibiotic prophylaxis therapy is recommended for children < 5 years or older patients with immune defects to prevent life-threatening infections, we determined aged neutrophil numbers in this patient population. We found that SCD patients exhibited a marked increase in the numbers of circulating aged neutrophils compared to healthy controls, which were significantly reduced in patients on Penicillin V prophylaxis (Ctrl / SS / SS-PV: 261±40 / 1175±205 / 439±87 cells per μl blood, P < 0.05). Our results raise the possibility that targeting neutrophil aging and the microbiota may have broad implications in our understanding of sickle cell disease pathogenesis and its management that should be further studied in clinical trials.