Loss of Central Tolerance in Monogenic Disease
The Autoimmune Regulator gene,
AIRE, regulates the ectopic expression of self-peptides within the thymus in order to expose naïve T cells to these peptides during development [
11]. Loss of function mutations in
AIRE (either recessive or dominantly inherited) cause autoimmune polyendocrine syndrome type 1 (APS1, also known as autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy, APECED) by reducing or removing this function of AIRE in the thymus [
12]. This allows high affinity autoreactive T cells to escape the thymus. Clinically, APS1 is highly variable but is usually characterised by chronic mucocutaneous candidiasis, adrenal insufficiency and autoimmune hypoparathyroidism. Approximately 13% of individuals develop autoimmune diabetes by 30 years of age [
13].
T1D Genetic Risk Loci Involved in Central Tolerance
Variation in the insulin gene (
INS) is linked to the development of T1D and is thought to result in a failure of central tolerance. The T1D-associated polymorphic variant is considered to be a variable number of tandem repeats (VNTR), located in the promoter of the
INS gene to which AIRE binds, regulating
INS RNA expression in the thymus [
14‐
19]. VNTR variants of smaller size (class I VNTRs) are associated with increased T1D risk and lower INS mRNA expression in the thymus, allowing escape of insulin autoreactive CD4 T cells into the periphery during T cell development due to fewer insulin peptide-HLA class II interactions. Conversely, insulin autoreactive T cells are predicted to be deleted in individuals carrying the protective
INS variants (Class III VNTRs) which drives higher levels of
INS expression in the thymus [
16]. In keeping with a failure in central tolerance, insulin autoreactive CD4 T cells are present at a higher frequency in the peripheral blood of T1D subjects carrying the
INS susceptibility variants, whereas individuals with protective alleles have barely detectable levels of insulin autoreactive CD4 T cells [
20].
A failure in central tolerance may also contribute to the association of
HLA class II genes to T1D. Although the mechanism is not completely understood, evidence points to low affinity interactions between class II DQ8 molecules and islet peptides, which may result in failed deletion of islet autoreactive CD4 T cells [
21,
22]. Another T1D-associated gene,
PTPN22, has been linked with failures in both central and peripheral tolerance of T and B cells [
23,
24]. A failure of B cell tolerance may be due in part to altered B cell receptor signalling in the presence of the risk variant p.R620W in
PTPN22, allowing autoreactive B cells to escape central and peripheral tolerance checkpoints [
25]. Although T1D is considered a T cell–mediated disease, B cell pancreatic infiltrate is present in many childhood onset T1D cases [
26,
27] and anti-CD20 B cell depleting therapy temporarily slowed disease progression in established T1D [
28], indicating a role for B cells in T1D pathogenesis.
Reduced Peripheral Tolerance in Monogenic Disease
Reduced function or number of Tregs has been implicated in the disease mechanism of several monogenic autoimmune disorders. Immunodysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome highlights the requirement of Tregs to restrain autoimmunity. IPEX syndrome, which often proves fatal in early life, results from hemizygous mutations in the
FOXP3 gene, a key regulator of Treg development [
33]. The syndrome typically presents in the neonatal period, with > 90% of affected boys having severe protein losing enteropathy and ~ 80% developing autoimmune diabetes. Additional autoimmune diseases can develop including severe atopic dermatitis (70%) and autoimmune hypothyroidism (35%) [
34].
Individuals with recessively inherited
IL2RA mutations develop immunodeficiency 31C syndrome [
35], which is similar to IPEX syndrome (enteropathy, hypothyroidism and severe eczema) and can include neonatal-onset autoimmune diabetes [
36].
IL2RA encodes CD25, a subunit of the IL-2 receptor which is constitutively and highly expressed on regulatory T cells facilitating their recruitment and suppressive ability. IL-2 is a key signalling molecule involved in regulating the immune system and induces
FOXP3 expression; therefore, loss of the IL-2 receptor on T cells reduces
FOXP3 expression and Treg development [
37]. As in IPEX, mutations that lead to a loss of CD25 expression result in a reduced Treg compartment, promoting autoimmunity through the failure of peripheral tolerance [
38].
Heterozygous mutations in
CTLA4 cause autoimmune lymphoproliferative syndrome which can include autoimmune diabetes [
39‐
41]. CTLA4 is constitutively expressed by Tregs and can also be expressed by CD4+ and CD8+ effector T cells where it functions as a potent suppressive receptor molecule, by preventing co-activation of T effector cells via CD28 [
42]. It mediates inhibition in effector T cells by competing with CD28 for binding to CD80/CD86 on antigen presenting cells (APC) but may also inhibit T cell receptor signalling [
31,
43,
44]. Tregs from individuals with dominantly inherited
CTLA4 mutations show reduced expression of CTLA4, FOXP3 and IL2RA [
39].
Recessively inherited mutations in
LRBA cause common variable immunodeficiency-8 (CVID8) with autoimmunity [
45]. This includes extremely young onset of haematological autoimmune disorders (80%), enteropathy (70%) and autoimmune diabetes (30%) [
46]. LRBA plays an essential role in the post-translational regulation and trafficking of CTLA4 (see above), whereby it prevents lysosomal degradation of CTLA4 containing vesicles [
47•]. Interestingly, studies have identified six individuals with LRBA mutations who had a reduced number of Tregs [
48] and an individual with normal cell-surface CTLA4 expression [
49]. In the latter patient, there was increased Th17 cell activity (measured by IL-17 production) suggesting that the disease could also be mediated through effector cells.
Gain of function (GOF) mutations in
STAT3, which links extracellular cytokine signals to gene expression, cause infancy-onset multiple autoimmune disease [
50]. These mutations cause haematological autoimmune disorders (70%), enteropathies (50%) and autoimmune diabetes in ~ 30% of individuals which often presents in the neonatal period. Some patients present with similar features to autoimmune lymphoproliferative syndrome (ALPS) [
51,
52]. STAT3 is involved in multiple signalling pathways that influence the fate of CD4 T cells, enhancing development of Th17 and T follicular helper cells, while blocking the development and survival of regulatory T cells. Tregs are numerically and functionally reduced in most individuals with GOF
STAT3 mutations, while Th17 cells may be normal, reduced or increased [
53].
T1D Genetic Risk Loci Involved in Peripheral Tolerance
Genetic variants in genes that function in the IL-2 pathway are associated with T1D, including
IL2RA (described above) and
PTPN2 which encodes a non-receptor tyrosine phosphatase that regulates IL-2 signalling [
2••,
54,
55]. The most highly associated
IL2RA single nucleotide polymorphism (SNP), rs61839660, is non-coding and located in an enhancer region in intron 1 of the gene. The enhancer binds multiple transcription factors and interacts with other regulatory elements in the locus in primary CD4 T cells, but only in response to T cell stimulation [
56••]. The presence of the T1D risk allele at the enhancer resulted in enhanced CD25 (IL2RA) upregulation in CD4 conventional T cells but not Tregs in a knock-in mouse model [
56••], indicating that this SNP primarily impacts CD4 conventional T cells.
Alternatively, several other
IL2RA SNPs have been associated with decreased CD25 expression on CD4 conventional T cells and Tregs, and increased levels of soluble CD25 with the risk alleles, revealing the complexity of the
IL2RA locus [
57‐
59]. Functionally, this correlates with reduced IL-2 signalling and diminished Treg fitness and suppressive function [
58,
59]. The T1D-associated SNPs in the
PTPN2 gene are also non-coding and have been correlated with decreased
PTPN2 RNA levels and reduced IL-2 signalling in genotyped healthy control subjects and longstanding T1D patients [
60,
61]. The
PTPN2 T1D risk allele was also associated with decreased FOXP3 expression in activated CD4 T cells [
60]. The effects of these
IL2RA and
PTPN2 T1D risk alleles on IL-2 signalling are independent but additive, both potentially contributing to reduced peripheral tolerance through effects on Tregs [
58]. An additional T1D-associated SNP is located in the
IL2-IL21 intergenic region, although the impact of this SNP has not been evaluated yet [
2••].
A non-coding SNP rs3087243 located 3′ of the
CTLA4 gene has been associated with T1D, as well as other autoimmune diseases [
2••] (Table
1). How the
CTLA4 rs3087243 SNP affects CTLA4 function is not completely understood. Initial studies indicated that the rs3087243 variant affected
CTLA4 alternative splicing, resulting in lower levels of a soluble CTLA4 isoform in CD4 T cells carrying the T1D susceptibility allele [
62]. However, this finding was not replicated in a subsequent study [
63]. More recently the rs3087243 SNP was shown to be in high linkage disequilibrium with an (AT)
n dinucleotide repeat in the 3′ untranslated region of
CTLA4, with the T1D susceptibility allele associated with longer (AT)
n repeat length compared with the non-risk allele [
64]. Human islet autoreactive T cell lines with longer (AT)
n repeats expressed lower levels of
CTLA4 RNA and protein relative to T cell lines with shorter repeats, and longer (AT)
n repeats destabilised a GFP reporter expressed in Jurkat T cells [
64]. Confirmation of these findings in rs3087243 genotyped peripheral blood CD4 T cells and elucidation of corresponding functional phenotypes will clarify the mechanism of the T1D association with
CTLA4.