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CTLA4 Alanine-17 Confers Genetic Susceptibility to Graves’ Disease and to Type 1 Diabetes Mellitus¹

Medical Department I, Division of Endocrinology, Center of Internal Medicine (H.D., H.R., J.B., J.H., K.H.U., K.B.), and the Department of Pediatrics, Klinikum of the J. W. Goethe University (J.H.), Frankfurt/Main; and the Medical Clinic, Endocrine Department, University Hospital Benjamin Franklin, Free University of Berlin (R.F.), Berlin, Germany; and the Division of Endocrinology and Metabolism and Head and Neck Oncology Program of Mount Sinai Hospital, University of Toronto Medical School, Samuel Lunenfeld Research Institute of Mount Sinai Hospital (P.G.W.), Toronto, Ontario, Canada M5G 1X5

Address all correspondence and requests for reprints to: PD Dr. K. Badenhoop, Medizinische Klinik I, Klinikum der J. W. Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany.

	Abstract

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The genetic susceptibility to Graves’ disease and type 1 (insulin-dependent) diabetes mellitus is conferred by genes in the human leukocyte antigen region on the short arm of chromosome 6, but several other genes are presumed to determine disease susceptibility. Among those candidate genes is the cytotoxic T lymphocyte antigen 4 (CTLA4) located on chromosome 2q33 in man. We investigated the distribution of the CTLA4 exon 1 polymorphism (49 A/G) in Graves’ disease and IDDM. This dimorphism at codon 17 results in an amino acid exchange (Thr/Ala) in the leader peptide of the expressed protein and was analyzed by PCR, single strand conformation polymorphism, and restriction fragment length polymorphism analysis in 305 patients with Graves’ disease, 293 patients with IDDM, and 325 controls. Patients with Graves’ disease had significantly more Ala alleles than controls, both as homozygotes (21% vs. 13%) and as heterozygotes (53% vs. 46%), and less Thr as homozygotes (26% vs. 42%; P < 2 x 10^-4). The phenotypic frequency of Ala-positive patients (73%) was significantly higher than of controls (58%; P = 10^-4; relative risk = 2). Patients with IDDM also had significantly more Ala alleles as homozygotes (19%) or heterozygotes (50%; P = 0.01). In conclusion, an alanine at codon 17 of CTLA4 is associated with genetic susceptibility to Graves’ disease as well as to IDDM.

	Introduction

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TYPE 1 (INSULIN-DEPENDENT) diabetes mellitus (IDDM) as well as Graves’ disease are organ-specific autoimmune diseases and share susceptibility as well as resistance alleles of major histocompatibility complex class II human leukocyte antigen (HLA) DQA1 and DQB1 genes (1). Whereas predisposing gene loci have been mapped through the entire human genome in IDDM (2, 3, 4), little is known about genes other than HLA in Graves’ disease. There is, however, sufficient evidence to suggest that genes in the vicinity of HLA loci (5) or even more distant genes are involved in the susceptibility to Graves’ disease (6, 7, 8). One family study found no evidence for linkage of HLA to Graves’ disease or Hashimoto’s thyroiditis (9). Recently, a microsatellite allele of the cytotoxic T lymphocyte antigen 4 (CTLA4) gene located on chromosome 2 has been reported to be associated with Graves’ disease (10). The CTLA4 gene is polymorphic in untranslated sequences in exon 3, with variant lengths of a dinucleotide (AT)n repeat (11). There is also another polymorphism in exon 1 at position 49 (A/G) that codes for threonine (Thr) or alanine (Ala), respectively (12, 13). The CTLA4 G (Ala) allele has been found to be associated with IDDM in Spanish and Italian families, providing evidence that this allele is related to the type 1 diabetes susceptibility marker locus IDDM2 (4, 12, 14, 15). We developed a PCR-based, single stranded conformation polymorphism (SSCP) assay of the CTLA4 exon 1 polymorphism and screened patients with IDDM, Graves’ disease, and healthy controls.

	Subjects and Methods

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Subjects

Altogether 923 Caucasian subjects were investigated. Patients with IDDM (n = 293) had an age of onset ranging from 2–33 yr (mean, 17.9). Patients with Graves’ disease (n = 305) were from Germany (n = 196; Frankfurt/Main and Berlin) as well as Canada (n = 109; Toronto). Random healthy controls were from Germany (n = 242; Frankfurt/Main and Berlin) and Canada (n = 83; Toronto). There was no family history of diabetes mellitus, Graves’ disease, or other autoimmune disorders. The study was approved by the local ethics committee, and the individuals studied gave informed consent.

Methods

The CTLA4 exon 1 position 49 (codon 17) polymorphism was defined, employing PCR with oligonucleotides forward (5'-GCTCTACTTCCTGAAGACCT-3') and reverse (5'-AGTCTCACTCACCTTTGCAG-3'), designed according to the published human CTLA4 complementary DNA sequence (13). PCR was performed using 0.2 µg genomic DNA, 1 U Taq polymerase (Life Technologies, Gaithersburg, MD), 20 pmol of each primer, and 8 mmol deoxy-NTPs under the following conditions: initial denaturation for 4 min at 94 C, annealing for 45 s at 58 C, extension for 45 s at 72 C, denaturation for 45 s at 94 C (30 cycles), and a final extension for 4 min at 72 C in a Biomed thermocycler (Thewes, Germany).

SSCP analysis of CTLA4 polymorphisms

PCR products were screened for variants by SSCP. Briefly, 2 µL of a PCR product were mixed with 2.3 µL deionized formamide, incubated for 5 min at 95 C, and loaded onto an 8% polyacrylamide gel. Gel electrophoresis was carried out at 10 milliamperes (10 watts; maximum, 1000 volts) for 2.5 h, keeping a constant temperature of 8 C on a Multiphor II apparatus and a Multitemp cooling system (LKB Pharmacia, Freiburg, Germany). Subsequent silver staining revealed variant mobilities of conformational fragments (Fig. 1), which corresponded to nucleotide substitutions as defined by restriction enzyme analysis.

View larger version (92K): [in this window] [in a new window]   Figure 1. Silver-stained polyacrylamide gel of CTLA4 PCR SSCP fragments. The upper band indicates a G, and the lower band indicates an A at position 49 of exon 1, whereas the third band is detected in all samples. Individuals in lanes 1 and 4 are homozygous A(Thr), those in lanes 2, 5, 6, and 7 are heterozygous A/G (Thr/Ala), and the one in lane 3 is homozygous G(Ala).

The restriction enzyme BbvI cut the sequence if a G was present at position 49, resulting in 88/74-bp fragments; if an A was present in position 49, no digestion of the 162-bp PCR fragment occurred (Fig. 2). DNA fragments were resolved in 2.0% agarose gels stained with SYBR Green I (Molecular Probes, Leiden, Netherlands).

View larger version (35K): [in this window] [in a new window]   Figure 2. SYBR Green I-stained agarose gel of CTLA4 PCR fragments digested with the restriction enzyme BbvI. The sequence with an A at position 49 was not cut by BbvI and left the 162-bp PCR fragment at its full length. The sequence with a G was digested and resulted in 88/74-bp fragments. Lanes 1 and 3, A/G (Thr/Ala); lane 2, A/A (Thr/Thr); lane 4, G/G (Ala/Ala).

Patients with Graves’ disease (n = 245) and controls (n = 240) were typed for HLA DQA1 and DQB1 alleles as described in our previous report (1), and data were compared with CTLA4 alleles.

Statistical analysis

Patients and controls homozygous for A (Thr) or G (Ala), or heterozygous A/G were compared by the ² test. Gene frequencies were determined by gene counting. Patients with Graves’ disease and controls positive or negative for HLA DQA1¹0501 were compared separately, and P values were corrected (p_c) for the number of DQA1 alleles tested. P < 0.05 was considered significant. Relative risks (RR) were calculated according to Woolf’s method.

	Results

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Using our SSCP and PCR product restriction approaches, the CTLA4 exon 1 polymorphism was unambiguously assigned in 293 patients with IDDM, 305 patients with Graves’ disease, and 325 controls. The distribution of CTLA4 alleles did not differ in the two regional control groups from Germany or Canada (Ala homozygosity, 14% vs. 10%; heterozygosity, 45% vs. 48%; Thr homozygosity, 41% vs. 42%; data not shown). Likewise, the distributions of alleles were similar in the two groups of patients with Graves’ disease. Furthermore, the distribution of homozygotes for each allele and heterozygotes was tested for Hardy-Weinberg equilibrium. There were no differences between observed and expected numbers in any of the three groups.

CTLA4 exon 1 polymorphisms in patients with Graves’ disease

There were significantly more patients with Ala in the homozygous (21% vs. 13% controls) or heterozygous state (53% vs. 46% controls) and fewer patients homozygous for Thr (26% vs. 42% controls; P < 2 x 10^-4; Table 1). Also, gene frequencies differed significantly in the group of patients; 47% contained Ala and 54% contained Thr alleles compared with 36% Ala and 64% Thr alleles in control subjects (P < 5 x 10^-5; Table 1). The phenotypic frequency of Ala-positive individuals was higher in patients (73%) vs. controls (58%; P = 10^-4; RR = 2), whereas the frequency of Thr-positive subjects was 79% in patients and 87% in controls (P < 0.01; RR = 0.6; Table 1).

The strong association of the allele HLA DQA1¹0501 with Graves’ disease and other autoimmune endocrine disorders has been described previously (1). Patients (n = 153) and controls (n = 102) positive for this susceptibility marker differed significantly for CTLA4 alleles; 26% of patients were homozygous for the alanine-coding allele compared with 11% of controls (p_c < 0.04). Also, 48% of patients were heterozygous (e.g. the Ala/Thr genotype) compared to 47% of controls (Table 2). Therefore, selecting for this HLA DQA1 allele did not alter CTLA4 allele distribution. Female patients differed less significantly from female controls (P = 0.05) than male patients from male controls (P < 0.002), possibly because of the smaller number of male patients.

CTLA4 exon 1 polymorphisms in patients with IDDM

Nineteen percent of patients with IDDM were homozygous for Ala, 50% were heterozygous Ala/Thr, and 31% were homozygous for Thr (P = 0.01 vs. controls). The frequency of genes coding for Ala was higher in patients (44%) than in controls (36%), whereas the gene frequency for Thr was less in patients (56%) than in controls (64%; P < 4 x 10^-3; Table 1). Sixty-nine percent of patients were Ala positive (58% of controls; P < 0.009; RR = 1.6; Table 2).

A strong susceptibility factor for IDDM is the presence of HLA DQB1¹0302 (16, 17, 18). Patients and controls selected for the predisposing allele HLA DQB1¹0302 also showed a similar CTLA4 allele distribution, as did individuals selected for the protective alleles HLA DQB1¹0301 and DQB1¹0602 (data not shown).

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Our results demonstrate an association of the CTLA4 Ala¹⁷ allele with Graves’ disease. CTLA4 Ala¹⁷ was present on at least one allele in 73% of patients compared with 58% of controls. This difference was not more pronounced in patients with the predisposing HLA DQA1¹0501 and implies that CTLA4 is a separate susceptibility factor in Graves’ disease. Subdividing patients and controls for sex and HLA DQ status revealed that the Ala-containing alleles were significantly associated with Graves’ disease in HLA DQA1¹0501+ patients. Furthermore, male patients showed a stronger association, but this may be due to the female preponderance and has to be reevaluated in a larger set of patients.

An earlier report of CTLA4 alleles in Graves’ disease was based on the detection of microsatellite polymorphisms (10) situated in the 3'-untranslated region of exon 3 (11, 19). The 106-bp microsatellite allele displayed a strong association with Graves’ disease (10), which refers to the same allele found to be preferentially transmitted in families with type 1 diabetes (15). A study of Chinese Graves’ disease patients from Hong Kong also found an increase in the CTLA4 Ala¹⁷ allele (15). Thus, to date three independent studies point to CTLA4 as a susceptibility locus in Graves’ disease.

Patients with IDDM also more often had alanine-containing alleles, but this difference was less significant than in Graves’ disease. This is in accordance with a case control study from Belgium that showed significantly more Ala-positive individuals among patients (67%) than controls (55%) (15). Also, the CTLA4 Ala¹⁷ allele predisposes to IDDM in Spanish and Italian families, although this difference does not appear to be significant in families from Sardinia, Britain, or the U.S. (15).

As both type 1 diabetes and Graves’ disease are T cell mediated, CTLA4 may be involved in the T cell activation process. CTLA4 transcription can normally only be detected in activated T lymphocytes (20), where it is involved in antigen-specific apoptosis (21). Any dysregulation of this process may affect the pathogenesis of autoimmune disorders such as Graves’ disease or IDDM. However, as the CTLA4 association is weaker in IDDM than in Graves’ disease, it may confer susceptibility to autoimmune ß-cell destruction by a different mechanism. Alternatively, the CTLA4-linked susceptibility locus in IDDM might be different from that in Graves’ disease. In that respect it is of interest that the gene coding for one of the IDDM autoantigens, namely IA-2 or tyrosine phosphatase, has been mapped to chromosome 2q35 in man (22).

In conclusion, our findings indicate that genetic variants of both the antigen-presenting as well as the costimulatory molecules for the T lymphocyte regulation pathway control susceptibility, but are independent from each other. Although it is premature to speculate on the functional consequences of CTLA4 polymorphism, the CTLA4 gene or a locus in its vicinity confers susceptibility to Graves’ disease and IDDM.

	Acknowledgments

 
We thank Dr. Judy Wade, Toronto Hospital, and Dr. Dharam Singal, McMaster University, both from Regional Histocompatibility Laboratories, for their kind assistance in providing regional control DNA from Canada.

	Footnotes

 
¹ This work was supported by the Deutsche Forschungsgemeinschaft (DFG Ba/2-3, to K.B.), the Mount Sinai Hospital Department of Medicine Research Fund, the W. Garfield Weston Foundation, the Saul A. Silverman Family Foundation, the Temmy Latner/Dynacare Fund, and the Meadowcroft Group (to P.G.W.).

Received June 26, 1996.

Revised August 14, 1996.

Accepted September 13, 1996.

	References

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1. Badenhoop K, Walfish PG, Rau H, et al. 1995 Susceptibility and resistance alleles of human leukocyte antigen (HLA) DQA1 and HLA DQB1 are shared in endocrine autoimmune disease. J Clin Endocrinol Metab. 80:2112–2117.[Abstract]
2. Davies JL, Kawaguchi Y, Bennett ST, et al. 1994 A genome-wide search for human type 1 diabetes susceptibility genes. Nature. 371:130–136.[CrossRef][Medline]
3. Hashimoto L, Habita C, Beressi JP, et al. 1994 Genetic mapping of a susceptibility locus for insulin-dependent diabetes mellitus on chromosome 11q. Nature. 371:161–164.[CrossRef][Medline]
4. Cordell HJ, Todd JA. 1995 Multifactorial inheritance in type 1 diabetes. Trends Genet. 11:499–504.[CrossRef][Medline]
5. Badenhoop K, Schwarz G, Schleusener H, et al. 1992 Tumor necrosis factor ß gene polymorphisms in Graves’ disease. J Clin Endocrinol Metab. 74:287–291.[Abstract]
6. Farid NR, Stenszky V. 1988 Graves’ disease. In: Farid NR, ed. Immunogenetics of endocrine disorders. New York: Liss; 223–266.
7. Davies TF. 1992 New thinking on the immunology of Graves’ disease. Thyroid Today. 15:1–11.
8. Payami H, Joe S, Farid NR, et al. 1989 Relative predispositional effects (RPEs) of marker alleles with disease: HLA-DR alleles and Graves’ disease. Am J Hum Genet. 45:541–546.[Medline]
9. Roman SH, Greenberg D, Rubinstein P, Wallenstein S, Davies TF. 1992 Genetics of autoimmune thyroid disease: lack of evidence for linkage to HLA within families. J Clin Endocrinol Metab. 74:496–503.[Abstract]
10. Yanagawa T, Hidaka Y, Guimaraes V, Soliman M, DeGroot LJ. 1995 CTLA-4 gene polymorphism associated with Graves’ disease in a Caucasian population. J Clin Endocrinol Metab. 80:41–45.[Abstract]
11. Polymeropoulos MH, Xiao H, Rath DS, Merril CR. 1991 Dinucleotide repeat polymorphism at the human CTLA4 gene. Nucleic Acids Res. 19:4018.[Free Full Text]
12. Buzzetti R, Nistico L, Pozzilli P, et al. 1995 The CTLA4 microsatellite identifies a new region on chromosome 2 linked to IDDM. Diabetologia. 38(Suppl 1):A29.
13. Harper K, Balzano C, Rouvier E, Mattei M-G, Luciani M-F, Golstein P. 1991 CTLA-4 and CD28 activated lymphocyte molecules are closely related in both mouse and human as to sequence, message expression, gene structure, and chromosomal location. J Immunol. 147:1037–1044.[Abstract]
14. Copeman JB, Cucca F, Hearne CM, et al. 1995 Linkage disequilibrium mapping of a type 1 diabetes susceptibility gene (IDDM7) to chromosome 2q31–q33. Nat Genet. 9:80–85.[CrossRef][Medline]
15. Nistico L, Buzzetti R, Pritchard LE, et al. 1996 The CTLA-4 gene region of chromosome 2q33 is linked to, and associated with, type 1 diabetes. Hum Mol Genet. 5:1075–1080.[Abstract/Free Full Text]
16. Nepom BS, Palmer J, Kim SJ, Hansen JA, Holbeck SL, Nepom GT. 1986 Specific genomic markers for the HLA-DQ subregion discriminate between DR4 insulin-dependent diabetes mellitus and DR4 seropositive juvenile rheumatoid arthritis. J Exp Med. 164:345–350.[Abstract/Free Full Text]
17. Todd JA, Bell JI, Mcdevitt HO. 1987 HLA-DQß gene contributes to susceptibility and resistance to insulin-dependent diabetes mellitus. Nature. 329:599–604.[CrossRef][Medline]
18. Badenhoop K, Schwarz G, Bingley P, et al. 1990 Restriction fragment length polymorphism (RFLP) analysis of HLA haplotypes in families with type I diabetes mellitus. Tissue Antigens. 35:32–39.[Medline]
19. Dariavach P, Mattei M-G, Golstein P, Lefranc M-P. 1988 Human Ig superfamily CTLA-4 gene: chromosomal localisation and identity of protein sequence between murine and human CTLA-4 cytoplasmic domains. Eur J Immunol. 18:1901–1905.[Medline]
20. Hune CH, Bluestone JA, Nadler LM, Thompson CB. 1994 The B7 and CD28 receptor families. Immunol Today. 15:321–331.[CrossRef][Medline]
21. Gribben JG, Freeman GJ, Boussiotis VA, et al. 1995 CTLA4 mediates antigen-specific apoptosis of human T cells. Proc Natl Acad Sci USA. 92:811–815.[Abstract/Free Full Text]
22. Lan MS, Modi WS, Xie H, Notkins AL. 1996 Assignment of the IA-2 gene encoding an autoantigen in IDDM to chromosome 2q35. Diabetologia. 39:1001–1002.[Medline]

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				Q.-Y. Chen, D. Nadell, X.-Y. Zhang, A. Kukreja, Y.-J. Huang, J. Wise, F. Svec, R. Richards, K. E. Friday, A. Vargas, et al. The Human Leukocyte Antigen HLA DRB3*0202/DQA1*0501 Haplotype Is Associated with Graves' Disease in African Americans J. Clin. Endocrinol. Metab., April 1, 2000; 85(4): 1545 - 1549. [Abstract] [Full Text]

				R. Nithiyananthan, J. M. Heward, A. Allahabadia, A. H. Barnett, J. A. Franklyn, and S. C. L. Gough A Heterozygous Deletion of the Autoimmune Regulator (AIRE1) Gene, Autoimmune Thyroid Disease, and Type 1 Diabetes: No Evidence for Association J. Clin. Endocrinol. Metab., March 1, 2000; 85(3): 1320 - 1322. [Abstract] [Full Text]

				B. Vaidya, H. Imrie, D. R. Geatch, P. Perros, S. G. Ball, P. H. Baylis, D. Carr, S. J. Hurel, R. A. James, W. F. Kelly, et al. Association Analysis of the Cytotoxic T Lymphocyte Antigen-4 (CTLA-4) and Autoimmune Regulator-1 (AIRE-1) Genes in Sporadic Autoimmune Addison's Disease J. Clin. Endocrinol. Metab., February 1, 2000; 85(2): 688 - 691. [Abstract] [Full Text]

				A. Barton, A. Myerscough, S. John, M. Gonzalez-Gay, W. Ollier, and J. Worthington A single nucleotide polymorphism in exon 1 of cytotoxic T-lymphocyte-associated-4 (CTLA-4) is not associated with rheumatoid arthritis Rheumatology, January 1, 2000; 39(1): 63 - 66. [Abstract] [Full Text] [PDF]

G. Gambelunghe, A. Falorni, M. Ghaderi, S. Laureti, C. Tortoioli, F. Santeusanio, P. Brunetti, and C. B. Sanjeevi Microsatellite Polymorphism of the MHC Class I Chain-Related (MIC-A and MIC-B) Genes Marks the Risk for Autoimmune Addison's Disease J. Clin. Endocrinol. Metab., October 1, 1999; 84(10): 3701 - 3707.