Version of Record: https://www.sciencedirect.

com/science/article/pii/S027252312200065X
Manuscript_9032898b1e884fe24998ef64837bd6e4
TITLE:

Update on Innate and Adaptive Immunity in Cystic Fibrosis

Authors:

Emanuela M. Bruscia* and Tracey L. Bonfield*

*Equal contributors and corresponding authors

Emanuela M. Bruscia, Ph.D.

Associate Professor

Department of Pediatrics; Section of Pulmonology, Allergy, Immunology and Sleep Medicine

Yale University School of Medicine; New Haven, CT

emanuela.bruscia@yale.edu

Tracey L. Bonfield, PhD, D (ABMLI)

Associate Professor

Department of Pediatrics; Division of Pulmonology, Allergy and Immunology

Case Western Reserve University School of Medicine; Cleveland, Ohio


Diplomate of the American Board of Medical Laboratory Immunologists

tracey.bonfield@case.edu

The authors have nothing to disclose.

KEYWORDS

Innate immunity; Adaptive immunity; Inflammation; Infections, Cystic fibrosis

KEY POINTS

1
© 2022 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
  Innate and adaptive immunity are dysregulated in cystic fibrosis (CF).

 Inherited and acquired factors contribute to immune dysregulation in CF.

 Therapies regulating immunity are required to attenuate CF lung disease.

SYNOPSIS

Cystic fibrosis (CF) pathophysiology is hallmarked by excessive inflammation and the inability to efficiently

resolve lung infections, contributing to morbidly and eventually the mortality of patients with this disease.

Paradoxically, despite a robust inflammatory response, and an elevated number of immune cells, CF lungs fail

to clear bacteria and are susceptible to infections, which may become chronic over time. While impaired

mucociliary transport, a central hub of CF pathophysiology, plays a critical role in the establishment of chronic

infection, the immune mechanisms contributing to the adaptation of bacteria to the lung microenvironment, and

the CF lung’s tolerance to persistent bacteria (e.g., infection is largely contained within the lungs, and CF

patients do not develop septicemia) are not well understood. The role of immunity in CF is multifaceted,

encompassing response to the unique microenvironmental cues in the CF lung, intrinsic changes resulting

from CFTR dysfunction, and the contribution of modifier genes. Here, we have summarized the current

understanding of immune dysregulation in CF, which contributes to hyper-inflammation and impaired host

defense.

1. IMMUNE BARRIER FUNCTION AND HOST DEFENSE IN CF LUNGS

The primary barrier between the external environment and internal structures is the airway epithelium. The

integrity of this barrier is disrupted in CF, playing a central role in the altered immune response to lung

infections.

1.1 Mucociliary clearance

Mucociliary clearance removes pathogens from the airways1. The airway mucus is composed of organized

gel-forming mucins secreted by both submucosal glands and secretory cells of the airway epithelium. An

optimal mucus viscosity is needed for efficient transport and release. Loss of the cystic fibrosis transmembrane

2
conductance regulator (CFTR) function leads to defective epithelial chloride and bicarbonate transport, causing

dehydration of the airway surface liquid (ASL), and abnormal mucin release and folding. As a consequence,

mucus secretions in CF airways are desiccated, adherent, and difficult to clear by periciliary transport and

cough. Airway mucus obstruction fosters a hypoxic environment that alters airway epithelial cell gene

expression, enhancing mucins production and activating airway macrophages (MФ) to secrete pro-

inflammatory mediators2, 3, 4. The reduced bicarbonate transport also typical of CF airways, creates an acidic

airway environment which alters mucus elasticity and adherence, impacting its release from the submucosal

gland ducts and impairing removal5. These stagnant secretions provide an optimal milieu for pathogen

colonization and retention, perpetuating lung inflammation in CF.

FDA drugs used to improve ASL hydration and mucociliary clearance include dornase alfa, hypertonic

saline, and inhaled mannitol6. OligoG, which decreases mucus thickness, was found to be safe in a recent

phase 2b clinical trial in adults with CF7. Modulation of alternative epithelial ion channel activity (e.g.,

TMEM16A and ENaC) may also be a strategy to improve mucociliary transport in CF8.

1.2 Airway surface liquid (ASL) and airway secretion composition in CF

ASL antimicrobial composition. The acidic pH of the CF ASL neutralizes the activity of several enzymes/

antimicrobial peptides (e.g., β-defensin-3 and cathelicidin) that normally protect against pathogens9. The iron

chelator, lactoferrin is lower in CF lungs relative to healthy individuals, altering efficient pathogen

management10, 11. Hypothiocyanite (OSCN-), a potent antimicrobial molecule on the airway mucosal surfaces12,

is also defective in CF. CF secretions have defective levels of the secreted protein Short Palate Lung and

Nasal epithelial Clone 1 (SPLUNC1), which contributes to the host response by binding bacterial products and

inhibiting sodium absorption13. The CF ASL also exhibits impaired antiviral activity against several enveloped

and encapsulated viruses (e.g., respiratory syncytial virus and influenza A)14. Therapeutically, a drug that

combines OSCN- and lactoferrin (ALX-009), a SPLUNC1 mimetic peptide (SPX-101), and formulations of

metal gallium to sequester iron, are under clinical evaluations15, 16, 17.

Protease activity. Lung neutrophilia is a hallmark of CF disease. In the normal lung, neutrophils migrate to

the airways in response to chemokines, followed by apoptosis and removal by MФs or expectoration. Elevated

neutrophil numbers increase the amount and activity of neutrophil elastase (NE)18, with concentrations

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correlating with CF lung damage and function19. NE remains active due to low pH, degrading structural airway

matrix proteins (e.g., collagen), cleaving plasma membrane (PM) proteins involved in immune signaling, and

altering the complement. Active neutrophil-derived cathepsin G18, cathepsin S20, and proteinase 321 are also

elevated in CF sputum, neutralizing antimicrobial protein function20. The zinc-metalloproteinase family (e.g.,

MMP-9), which normally promote tissue repair, are abundantly recovered in CF sputum. The combined activity

of MMPs and prolyn endopeptidases generates collagen products [e.g., proline-glycine-proline (PGP)] by

degrading lung collagen, which further promotes inflammation and neutrophil chemotaxis to the lungs22.

Longitudinal studies with CFTR modular therapies in CF suggest a lack of improvement in levels of sputum

NE23. Several drugs designed to block neutrophil proteases are being tested in people with CF24, 25, 26, 27.

Nitric oxide (NO) content. NO is produced from the amino acid L-arginine by the enzymatic action of nitric

oxide synthase proteins (NOS). NO is essential for controlling inflammation and infection, and for modulating

ciliary activity, vasodilatation, and bronchodilatation28. NO is decreased in the exhaled breath of CF patients

with severe disease. Low NO levels may be due to low expression of NOS and/or low availability of the NO

substrate’s arginine29, 30, 31

. Importantly, treatment with ivacaftor resulted in increased NO in CF airways32.

Clinical trials are ongoing to determine the safety and effectiveness of controlled inhalation of NO on lung

inflammation33.

Oxidative environment. The CF ASL contains high levels of reactive oxygen species (ROS) derived from

immune and airway epithelial cells. The increased oxidative stress is exacerbated by diminished antioxidant

activity, including reduced glutathione, vitamin E, carotenoids, and coenzyme Q-10, as well as blunted

antioxidant responses34. Oxidative stress exacerbates inflammation, tissue damage, and affects multiple

bioactive lipid metabolic pathways, which likely play a role in CF lung disease progression34, 35.

1.3 Abnormal cell-cell connections

The airway barrier function is maintained by cell junctions (tight, adherent, and gap), which provide airway

epithelial cells contact and adhesion36. Loss of CFTR results in altered levels and positioning of airway

epithelial junction proteins creating weak connections, compromising epithelial paracellular permeability to

ions, metabolites, immune mediators, and bacterial products. Thus, it contributes to altered ASL content and

inflammation37, 38, 39
. Further studies are required to correlate changes in epithelial paracellular permeability

4
observed in experimental models to CF disease. Interestingly, azithromycin, a macrolide-type antibiotic with anti-

inflammatory proprieties commonly used to treat infection in patients with CF, augments airway epithelial

integrity40.

In summary, defects in immune barriers in CF dysregulate immunity by:

 Altering ASL and fostering hyper-inflammation in early stages of the disease.

 Disrupting mucociliary clearance, which favors bacterial trapping and adaptation, perpetuating

inflammation.

 Increasing protease activity, inflammatory mediators, and ROS, which interfere with efficient bacterial

clearance and compromise CF lung tissue integrity.

2. ALTERED INNATE IMMUNE RESPONSES AND HYPER-INFLAMMATION IN CF

2.1 Pattern recognition receptor signaling

The innate immune system senses microorganisms through pattern recognition receptors (PRRs) (Table

1), which recognize specific pathogen-associated molecular patterns (PAMPs) and damage-associated

molecular patterns (DAMPs). PRRs are expressed on immune and structural cells, which include the airway

epithelium. Once activated, PRRs activate tightly regulated signal transduction mechanisms to initiate the

inflammatory response. This results in the production of inflammatory mediators that lead to pathogen

elimination, followed by a return to tissue homeostasis. Regulation of PRRs by abundance, location, turnover,

and signal transduction determines the quality, intensity, and duration of the immune response 41. PRRs in CF

cells are continuously activated by microorganisms and the CF lung milieu reach in DAMPs (e.g. ROS, PGP,

ATP, and HMGB1), perpetuating activation of pro-inflammatory pathways, and enhancing poor pathogen

management and lung damage42, 43, 44. Despite continuous activation of PRRs, interferon (IFN) signaling, a key
5
antiviral pathway downstream to activation of PRRs that sense viral PAMPs, is blunted in CF, increasing

susceptibility to viral infection45. Even in the context of impaired antiviral function in CF, SARS-CoV2 infections

are not more frequent or more severe in the CF population compared to the general population46, potentially

due to sustained isolation, mask-wearing, and handwashing. Therapeutics like long-term azithromycin

antibiotic therapy47 and decreased ACE2 expression due to lung damage may also minimize SARS-CoV2

susceptibility in CF48.

2.2 Dysregulated immune pathways

Dysfunctional control of mitochondrial metabolism in response to infection drives immune dysfunction in

CF-affected cells by increasing proinflammatory metabolites (e.g., succinate and itaconate) and activating the

inflammasome pathway44, 49
. Elevated Interleukin-1 (IL-1) following inflammasome activation further

augments mucin production and the Th17 response3, 50. Autophagy is also dysfunctional in CF, resulting in the

accumulation of damaged organelles and malformed, nonfunctional proteins in lysosomes. Inefficient

autophagy also contributes to the lack of efficient intracellular pathogen killing (e.g., Burkholderia cepacia,

Pseudomonas aeruginosa), perpetuating infections and inflammation51.

The altered lipid metabolism in CF also contributes to dysregulated immunity52. Pro-inflammatory lipid

metabolites, such as arachidonic acid, prostaglandins, and neutrophil chemoattractant leukotriene B 4 (LTB 4),

are elevated in CF. In contrast, levels of the anti-inflammatory omega-3 polyunsaturated fatty acid (e.g.

docosahexaenoic acid) and pro-resolving lipid mediators (e.g. lipoxin A4, 15-lipoxygenase 2), which are

necessary for the resolution of the inflammatory response, are reduced in CF53,54, 55
. The level and cellular

distribution of sphingolipids and cholesterol, key components of the cellular plasma membrane (PM), are also

altered in CF56, 57
. Changes in PM lipid composition impact the localization and activation of PM immune

receptors, with consequences on downstream immune signaling regulation42, 43.

2.3 Anti-inflammatory therapeutic development

The CF Foundation (CFF) therapeutic development pipeline has targeted the CF altered immune response.

High-dose ibuprofen is highly effective in attenuating inflammation, although dosing and side effects complicate

utilization in patients58. LAU-7b is considered due to the ability to normalize ceramide imbalance in CF cells59

6
and to inhibit the inflammasome/IL-1 pathway60. Boosting anti-inflammatory responses through stimulating NO

production via L-arginine administration61, increasing Nrf2 activity62, pro-resolving lipid mediator treatment53,

and the use of human mesenchymal stem cells have also been explored in CF63, 64. It is important to note that

recently approved CFTR modulator therapies, which improve mutation-specific function, may not suppress CF

hyper-inflammation long-term23 (see Chapter 6).

In summary:

 Pathways involved in recognition and killing of pathogens and promotion of inflammation resolution are

disrupted in CF, promoting hyper-inflammation.

 Treatment of infection and inflammation in CF may require a multi-tiered approach, integrating immune

balance for optimal inflammation and infection resolution.

3. PHAGOCYTE FUNCTION AND HOST DEFENSE IN CF

3.1 Neutrophils

Neutrophils are the most abundant immune cells recovered from the bronchoalveolar fluid (BALF) in the

sputum of CF patients (Figure 1). Excessive migration of neutrophils into CF lungs is attributed to a massive

increase in chemokines and chemoattractant molecules (e.g., IL-8, LTB4, CXCL10, IL-17, and PGP). Yet, the

elevated numbers of neutrophils do not efficiently clear infections and, at the same time, secrete high levels of

proteases, pro-inflammatory cytokines, ROS, and neutrophil extracellular traps (NETs), amplifying lung hyper-

inflammation and damage43. Dysregulated NETosis, a controlled release of nuclear DNA coated with proteases

that normally help to capture and kill bacteria, is a major contributor to the high DNA content observed in CF

lungs65. Enhanced neutrophil numbers, impaired degranulation, and delayed apoptosis contribute to NETs

accumulation in CF airways. The failure of neutrophils to phagocytize bacteria is augmented by the shielding

effect of the viscous mucus in the CF airways, and by Pseudomonas aeruginosa’s exopolysaccharide

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secretions and biofilm formation66. Loss of CFTR also directly contributes to neutrophil dysfunction by impairing

their ability to generate intraphagosomally hypochlorous acid67 and to efficiently release secondary and tertiary

granules68, which contain antimicrobial molecules. In addition, neutrophils from patients with CF acquire an

altered activated state when exposed to the CF lung microenvironment. They retain sustained viability, primary

granule exocytosis (release of proteases, ROS), and activation of the inflammasome, resulting in upregulation

of anabolic genes and increased secretion of IL-1β, while downregulating antimicrobial functions60, 69, 70.

Despite the clear contributions of neutrophils in CF lung disease progression, clinical interventions

targeting neutrophil recruitment have not provided clinical benefits. A study using an LTB4 inhibitor (BIIL4)

resulted in an increased incidence of pulmonary exacerbations, due to its excessive inhibitory anti-

inflammatory effects71. A clinical trial using a new LTB4 inhibitor (Acebilustat), shows that this drug, while safe,

does not improve lung function. However, a trend towards reduced pulmonary exacerbations in subjects with

an earlier stage of CF lung disease has been observed72.

3.2 Macrophages/monocytes

Macrophages (MΦs) and monocytes (MOs) are regulators of inflammation and host immunity. They are

instrumental for maintaining tissue homeostasis, and their dysfunction contributes to the pathogenesis of

several diseases, including CF.

Altered MΦ immune pathways in CF. Many key pathways are dysregulated in CF MΦ/MO leading to

failures in properly controlling inflammatory triggers, resolving inflammation, and clearing bacteria.

Uncontrolled activation of TLRs and PTEN-AKT immune signaling, autophagy, the unfolded protein response,

and inflammasome activation contribute to CF MΦ dysfunction. Current therapeutics aimed at controlling

inflammation or at restoring CFTR function modulate MΦ/MO function42, 43, 44, 73.

MO and MO-derived MФ in the chronically infected CF lung. The lung contains resident MΦs that can be

classified as alveolar MΦ (AMs), and interstitial MΦs (IMs). In response to infection or injury, lungs are

populated by circulating pro-inflammatory MOs, which acquire a tissue-resident phenotype upon interfacing

with the lung microenviroment74. MΦ numbers are elevated in the airways of fetuses and young CF children

before chronic infection, suggesting sterile inflammation in early CF75, 76. These MΦs display altered expression

of immune receptors (e.g., TLR4, TLR5, CD11b, and MHC class II) and of scavenger receptors involved in

8
phagocytosis42. A single-cell-RNAseq study on immune cells isolated from CF and non-CF airway secretions

has shown that most of the MΦs in the CF airways originate from circulating monocytes77. Increased numbers

of blood-derived MΦ/MO can impede the resolution of inflammation, promote pathogen colonization, and

participate in CF lung remodeling74.

Pro-inflammatory circulating MO in CF. MOs recruited into the infected CF lungs are pre-primed to respond

to the unique CF lung microenvironment. Chronic lung infections provide a constant presence of LPS in CF,

promoting a state of tolerance in circulating MOs78, 79. They also display altered adhesion and chemotaxis into

the lung in response to chemoattractants80. MO isolated from patients before and after starting CFTR

modulator therapy suggests that restoration of CFTR function causes increased expression of genes that

positively regulate the inflammatory response81. In disagreement with a “tolerance” state, MOs from CF

patients produce high IL-1 and IL-18 levels82 and have an active IFN/STAT1 signaling83, which is decreased

by CFTR modulators.

MΦ function is altered by the CF environment, enhancing the metabolic adaptation of microorganisms. As

with neutrophils, MΦ function is altered by the CF lung microenvironment, which impacts the ability to regulate

inflammation and infection. The elevated levels of proteases in CF lungs cleave MΦs phosphatidylserine

receptors84 and other PM-associated molecules85, decreasing effectiveness of MΦ/MO airway clearance of

apoptotic cells and impeding reestablishment of tissue homeostasis. Moreover, CF MΦ’s produces high levels

of succinate, itaconate, and ROS due to alteration of PTEN-PI3K-AKT signaling and mitochondrial metabolism.

Succinate favors Pseudomonas aeruginosa colonization, and itaconate perpetuates their conversion toward a

mucoid phenotype, promoting the persistence of the infection by evading host immunity44.

In summary:

 Inefficient neutrophil and MO/MФ functions contribute to the overall pathophysiology in CF.

 An effective treatment aimed to control inflammation, infection, and reduce lung tissue damage will

need to control pathologic responses of these immune cells.

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4. ADAPTIVE IMMUNITY IN CYSTIC FIBROSIS

4.1. Communication between the innate and adaptive immune systems

The immune system involves a collaborative interaction between major histocompatibility complex (MHC)

on MΦ, dendritic cells (DC), and T-cells. DCs as the primary antigen-presenting cells, are central to the

integration of innate and adaptive immunity and are located throughout the respiratory mucosa and alveolar

epithelium where they sense and process antigens. Peripheral blood DCs from CF patients have lower levels

of MHC Class II receptors when compared to healthy controls86 suggesting altered antigen presentation87. In

addition, DC maturation and function may be compromised by neutrophil elastase cleavage of CD86 in CF

airway fluids88.

4.2. T lymphocytes and adaptive immune activation in CF

CFTR-deficient T lymphocytes have aberrant cytokine secretion and are hyper-inflammatory due to altered

Ca2+ influx. They produce higher levels of IL-13 and IL-4 in response to Aspergillus Fumigatus infections, and

lower levels of IL-10 compared to non-CF controls89. Defective tryptophan catabolism may also contribute to

the abnormal T-cell phenotype in CF90. Pathogenic Th17 T-cells, with the production of high IL-17 levels91,

have both an early and late contribution to CF lung pathophysiology. Although Th17 T-cells are critically

important in host responses to infection, in CF they promote neutrophil recruitment into the lungs and induce

expression of mucin-producing genes from the epithelium92. Treatments aimed at neutralization of IL-17

signaling reduced neutrophil recruitment into lungs of CF mice challenged with Pseudomonas aeruginosa,

implicating IL-17 as a therapeutic target93. However, since IL-17 is central to controlling infections and

stimulating HCO3- transport at the airway mucosa94, attention to balancing immunity is required in CF.

Inflammation in CF may also be attributed to the defective activity of the anti-inflammatory regulatory T-cell

(Tregs)95, 96.

4.3. B cells, antibodies and autoantibodies in CF

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 The CF lung environment creates a unique milieu for B-cell development and maturation, as shown by

changes in the transcriptional profile of CF B-cells97. Patients with CF have increased lung neogenesis of

bronchial-associated lymphoid tissue (BALT) and B-cell-activating factor of tumor necrosis factor family

(BAFF), which regulates B-cell survival and maturation. CF patients infected with Pseudomonas aeruginosa

present with high levels of circulating IgG immunoglobulins (mostly IgG3 and IgG4), and increased levels of

IgA98. Although high levels of antibodies against Pseudomonas aeruginosa are produced, the antibodies are

not efficient, potentially due to inefficient bacterial opsonization and phagocytosis99.

Altered B-cell phenotype and elevated immune complexes can promote autoimmunity100 contributing to CF

lung damage, inefficient complement, and adaptive immune response101, 102. Autoimmunity is present in 2-3%

of CF patients including the presence of anti-neutrophil cytoplasmic autoantibodies, which correlates with the

efficiency in managing Pseudomonas aeruginosa infections and disease severity103, 104. Autoantibodies against

the bactericidal/permeability-increase protein (BPI) and the degraded form of SPLUNC1, important in the

management of infections, are elevated in CF. BPI autoantibodies correlate with platelet numbers, impacting

the inflammatory response to Pseudomonas aeruginosa, as well as efficient wound healing and clotting105, 106.

In summary:

 Inefficient anti-Pseudomonas aeruginosa neutralizing antibody isotypes highlight the defective adaptive

immune response to lung infections in people with CF.

 CF pathophysiology may promote exposure to self-proteins, potentially contributing to autoimmunity

and antibody mediated platelet accumulation and activation.

5. POTENTIAL NEW PLAYERS MODIFYING THE IMMUNE RESPONSE IN PATIENTS WITH CF

Innate lymphoid cells (ILCs) and innate-like lymphocytes. ILCs differentiate from lymphoid progenitors. In

contrast to B- and T- cells that express antigen receptors and undergo clonal selection and expansion when

stimulated, ILCs mature into cells with specific phenotypes when exposed to microenvironmental cues,

11
contributing to mucosal immune surveillance and DCs activation. The CF lung microenvironment drives trans-

differentiation of ILC precursors in specific types of ILCs (i.e., ILC2) that secrete high IL-17A levels as well as

contribute to mucin production and obstruction in CF airways107. Other innate-like lymphocytes such as

mucosal-associated invariant T (MAIT) cells,   T cells, and natural killer T (NKT) cells, which share features

with ILCs108, are also shown to be dysregulated in CF. MAITs are dramatically reduced in peripheral blood of

patients with CF, and their reduction positively correlated with Pseudomonas aeruginosa infection, pulmonary

exacerbation and increased severity lung disease109, 110

. Patients with CF infected with Pseudomonas

aeruginosa may have an increase in   T cells111 that contribute to IL-17A secretion in lung tissue, lymph

nodes and peripheral blood of patients with CF112. Finally, dysregulation of the invariant NKT population has

been shown to be involved in attracting MΦ and neutrophils to the CF lungs113.

Platelets. Growing scientific evidence identifies platelets as critical players in immune processes,

contributing to pulmonary inflammation and destruction in CF. Platelets isolated from patients with CF show an

increased level of activation, which correlates with the clinical and proinflammatory status of the patients 114.

CFTR modulator therapy can partially restore CF platelet dysfunction 115. Hyperactivity of platelets can also

enhance cardiovascular disease, as well as the incidence of neurological events such as stroke in CF116, 117.

Myeloid-Derived Suppressor Cells (MDSCs). MDSCs are a heterogeneous population of cells that derive

from a pathologic state of activation of monocytes (M-MDSCs) and neutrophils (G-MDSCs) and have the key

feature of inhibiting T-cell function. Studies using CF mice and samples from CF patients have shown that CF

lungs have increased MDSC number, specifically G-MDSCs, which mediate T-cell suppression and have a

detrimental impact on the adaptive immune response118, 119.

Cell-to-cell communications via extracellular vesicles (EVs). Different types of cells in the lung

communicate by the secretion and transfer of biological mediators (proteins, RNAs, lipids) through EVs and

exosomes. EVs can function by either promoting or inhibiting the immune responses defined by their contents.

In CF, EVs promote lung inflammation and tissue damage120, 121

. Although less characterized, EVs are also

abundantly secreted by neutrophils in CF lungs70. Bacterial-derived outer-membrane vesicles (OMVs) transport

virulence factors, antibiotic-degrading enzymes, surface adherence factors, proteases, and enzymes that are

important for nutrient acquisition and communication in the microbiome community. OMVs are also decoyed to

prevent host immune cell attack by transferring information from the bacteria to host cells, disarming normal
12
pathogen resolution strategies122. OMVs from Pseudomonas aeruginosa have been found to suppress MHC-

related molecules in human lung MΦs as a strategy to evade the host immune response123.

Mesenchymal stem cells. Human mesenchymal stem cells (hMSCs) have immune-modulatory activity

which may be beneficial in CF through their production of antimicrobial peptides, anti-inflammatory

cytokines124, 125
and extracellular vesicles (hMSC-EVs)64. hMSC and their products can be given as an

allogeneic source, with no requirements for immunosuppression, but hMSC donor selection is important for

optimizing potency and potential efficacy126, 127

. The advantage of hMSC therapeutics, over traditional anti-

cytokine therapeutics, is the combined anti-microbial and anti-inflammatory function. Anti-cytokine therapy is

counter indicated in scenarios of infection, which complicates dosage and applications in CF128.

In summary:

 Immune imbalance in CF is driven by many complementary mechanisms and diverse immune cell

populations, which requires further investigation.

 hMSC and hMSC-EVs hold promise as potential immune-modulatory therapeutic in CF.

6. IMMUNITY AND MODIFIER GENES IN CF

Although mutations at the CFTR gene are the causative factor for the CF pathophysiology, genome-wide

association studies (GWAS) have demonstrated that the severity of CF lung disease is influenced by gene

variants located on other loci in the genome129. Several single nucleotide polymorphisms (SNPs) associated

with the severity of CF lung disease are found at the human leukocyte antigen (HLA) class II locus129, 130
.

Although the precise mechanisms by which SNPs in this locus modify the immune response in CF are unclear

to date, the association between HLA-DR and CF lung disease severity is the most significant region in the

genome. Among other modifier genes, there are the Na/H exchanger (SLC9A3)131 and the Calcineurin Like EF-

Hand Protein 2 (CHP2), which help to ASL pH. Their differential expression due to SNPs may change the

antimicrobial responses132 and the mucociliary clearance efficiency in CF airways. Variation in expression of
13
the Angiotensin II Receptor Type 2 (AGTR2) may be involved in controlling the inflammatory response133.

Additional studies have also identified SNPs at the NLR Family Pyrin Domain Containing 3 (NLRP3), NLR

Family CARD Domain Containing 4 (NLRC4), surfactant protein-D (SFTPD), and mannose-binding lectin

(MBL). These genes are associated with increased Pseudomonas aeruginosa colonization and severity of lung

disease in CF134, 135

. SNPs in genes that encode for immune mediators (e.g. IL-10, C3, MIF, TGF-β, IFN-γ,

TNF-α) have also been shown to correlate with CF lung pathology136 (see also Chapter 2).

In summary:

 Gene variants, which modify the immune response, contribute to the unique CF pathophysiology and

the heterogeneity of disease severity in patients with the same CFTR mutations.

7. SUMMARY

Evidence suggests that CF patients have inherited and acquired factors that contribute to abnormal innate

and adaptive immune regulation, which support hyper-inflammation, defective bacterial clearance, and lung

disease progression (Figure 2). Effective, long-term therapies for CF will need to target and restore these

inefficiencies of the immune response. More studies need to be pursued to understand the causes of

dysregulated immunity in CF. Concurrent immune-supportive therapeutics with CFTR modulatory therapies,

promise to provide CF patients with an improved quality of life.

Acknowledgements: We would like to thank Morgan Sutton BS (Graduate Student, St. Jude Graduate

School of Biomedical Sciences, Memphis TN) for her edification and review of the manuscript.

Clinics Care Points

Figure 1: Cytospin of cells recovered from BAL fluid of a CF patient.

Figure 2: Multifactorial Immune Dysregulations in CF

14
Table 1. Extracellular pattern recognition receptors

Type of PRRs Cellular Location Major

PAMPs

Toll-like receptors (TLRs) Plasma or intracellular Lipopolysaccharide, flagellin, peptidoglycans, lipoteichoic

organelle membranes acid, glycosylphosphatidylinositol, microbial nucleic acids,

porins, N-formylmethionine, etc.

Nucleotide-binding domain and Cytosol Ligands present in the cytosol and induce

leucine-rich repeat containing the inflammasome

receptors (NLRs)

RIG-I-like receptors and Cytosol Nucleic acid sensors

cGAS/STING

8. REFERENCES

1. Knowles, M.R. & Boucher, R.C. Mucus clearance as a primary innate defense mechanism for

mammalian airways. J Clin Invest 109, 571-577 (2002).

2. Esther, C.R., Jr. et al. Mucus accumulation in the lungs precedes structural changes and infection in

children with cystic fibrosis. Sci Transl Med 11 (2019).

3. Chen, G. et al. IL-1beta dominates the promucin secretory cytokine profile in cystic fibrosis. J Clin

Invest 129, 4433-4450 (2019).

15
4. Montgomery, S.T., Mall, M.A., Kicic, A., Stick, S.M. & Arest, C.F. Hypoxia and sterile inflammation in

cystic fibrosis airways: mechanisms and potential therapies. Eur Respir J 49 (2017).

5. Hoegger, M.J. et al. Impaired mucus detachment disrupts mucociliary transport in a piglet model of

cystic fibrosis. Science 345, 818-822 (2014).

6. Tildy, B.E. & Rogers, D.F. Therapeutic options for hydrating airway mucus in cystic fibrosis.

Pharmacology 95, 117-132 (2015).

7. van Koningsbruggen-Rietschel, S. et al. Inhaled dry powder alginate oligosaccharide in cystic fibrosis: a

randomised, double-blind, placebo-controlled, crossover phase 2b study. ERJ Open Res 6 (2020).

8. Martin, S.L., Saint-Criq, V., Hwang, T.C. & Csanady, L. Ion channels as targets to treat cystic fibrosis

lung disease. J Cyst Fibros 17, S22-S27 (2018).

9. Abou Alaiwa, M.H. et al. pH modulates the activity and synergism of the airway surface liquid

antimicrobials beta-defensin-3 and LL-37. Proc Natl Acad Sci U S A 111, 18703-18708 (2014).

10. Rogan, M.P. et al. Loss of microbicidal activity and increased formation of biofilm due to decreased

lactoferrin activity in patients with cystic fibrosis. J Infect Dis 190, 1245-1253 (2004).

11. Ghio, A.J. et al. Iron accumulates in the lavage and explanted lungs of cystic fibrosis patients. J Cyst

Fibros 12, 390-398 (2013).

12. Moskwa, P. et al. A novel host defense system of airways is defective in cystic fibrosis. Am J Respir

Crit Care Med 175, 174-183 (2007).

16
13. Khanal, S. et al. SPLUNC1: a novel marker of cystic fibrosis exacerbations. Eur Respir J 58 (2021).

14. Berkebile, A.R. et al. Airway Surface Liquid Has Innate Antiviral Activity That Is Reduced in Cystic

Fibrosis. Am J Respir Cell Mol Biol 62, 104-111 (2020).

15. Tunney, M.M. et al. Activity of hypothiocyanite and lactoferrin (ALX-009) against respiratory cystic

fibrosis pathogens in sputum. J Antimicrob Chemother 73, 3391-3397 (2018).

16. Couroux, P. et al. First clinical trials of novel ENaC targeting therapy, SPX-101, in healthy volunteers

and adults with cystic fibrosis. Pulm Pharmacol Ther 58, 101819 (2019).

17. Goss, C.H. et al. Gallium disrupts bacterial iron metabolism and has therapeutic effects in mice and

humans with lung infections. Sci Transl Med 10 (2018).

18. Goldstein, W. & Doring, G. Lysosomal-Enzymes from Polymorphonuclear Leukocytes and Proteinase-

Inhibitors in Patients with Cystic-Fibrosis. American Review of Respiratory Disease 134, 49-56 (1986).

19. Sagel, S.D., Wagner, B.D., Anthony, M.M., Emmett, P. & Zemanick, E.T. Sputum biomarkers of

inflammation and lung function decline in children with cystic fibrosis. Am J Respir Crit Care Med 186,

857-865 (2012).

20. Weldon, S. et al. miR-31 dysregulation in cystic fibrosis airways contributes to increased pulmonary

cathepsin S production. Am J Respir Crit Care Med 190, 165-174 (2014).

21. Witko-Sarsat, V. et al. Proteinase 3, a potent secretagogue in airways, is present in cystic fibrosis

sputum. Am J Respir Cell Mol Biol 20, 729-736 (1999).

17
22. Garratt, L.W. et al. Matrix metalloproteinase activation by free neutrophil elastase contributes to

bronchiectasis progression in early cystic fibrosis. Eur Respir J 46, 384-394 (2015).

23. Harris, J.K. et al. Changes in Airway Microbiome and Inflammation with Ivacaftor Treatment in Patients

with Cystic Fibrosis and the G551D Mutation. Ann Am Thorac Soc 17, 212-220 (2020).

24. Chalmers, J.D. et al. Phase 2 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis. N Engl J Med

383, 2127-2137 (2020).

25. Shen, X.B., Chen, X., Zhang, Z.Y., Wu, F.F. & Liu, X.H. Cathepsin C inhibitors as anti-inflammatory

drug discovery: Challenges and opportunities. Eur J Med Chem 225, 113818 (2021).

26. Barth, P. et al. Single dose escalation studies with inhaled POL6014, a potent novel selective reversible

inhibitor of human neutrophil elastase, in healthy volunteers and subjects with cystic fibrosis. J Cyst

Fibros 19, 299-304 (2020).

27. Mejias, J.C. et al. Neutrophil-targeted, protease-activated pulmonary drug delivery blocks airway and

systemic inflammation. JCI Insight 4 (2019).

28. Bogdan, C. Nitric oxide and the immune response. Nat Immunol 2, 907-916 (2001).

29. Grasemann, H., Michler, E., Wallot, M. & Ratjen, F. Decreased concentration of exhaled nitric oxide

(NO) in patients with cystic fibrosis. Pediatr Pulmonol 24, 173-177 (1997).

30. Kelley, T.J. & Drumm, M.L. Inducible nitric oxide synthase expression is reduced in cystic fibrosis

murine and human airway epithelial cells. J Clin Invest 102, 1200-1207 (1998).

18
31. Grasemann, H., Schwiertz, R., Matthiesen, S., Racke, K. & Ratjen, F. Increased arginase activity in

cystic fibrosis airways. Am J Respir Crit Care Med 172, 1523-1528 (2005).

32. Grasemann, H. et al. Effect of ivacaftor therapy on exhaled nitric oxide in patients with cystic fibrosis. J

Cyst Fibros (2015).

33. Bentur, L. et al. Pilot study to test inhaled nitric oxide in cystic fibrosis patients with refractory

Mycobacterium abscessus lung infection. J Cyst Fibros 19, 225-231 (2020).

34. Galli, F. et al. Oxidative stress and antioxidant therapy in cystic fibrosis. Biochim Biophys Acta 1822,

690-713 (2012).

35. Veltman, M. et al. CFTR Correctors and Antioxidants Partially Normalize Lipid Imbalance but not

Abnormal Basal Inflammatory Cytokine Profile in CF Bronchial Epithelial Cells. Front Physiol 12,

619442 (2021).

36. Pohl, C. et al. Barrier functions and paracellular integrity in human cell culture models of the proximal

respiratory unit. Eur J Pharm Biopharm 72, 339-349 (2009).

37. Huang, S. et al. Src signaling links mediators of inflammation to Cx43 gap junction channels in primary

and transformed CFTR-expressing airway cells. Cell Commun Adhes 10, 279-285 (2003).

38. Molina, S.A. et al. Junctional abnormalities in human airway epithelial cells expressing F508del CFTR.

Am J Physiol Lung Cell Mol Physiol 309, L475-487 (2015).

39. Weiser, N. et al. Paracellular permeability of bronchial epithelium is controlled by CFTR. Cell Physiol

Biochem 28, 289-296 (2011).

19
40. Asgrimsson, V., Gudjonsson, T., Gudmundsson, G.H. & Baldursson, O. Novel effects of azithromycin

on tight junction proteins in human airway epithelia. Antimicrob Agents Chemother 50, 1805-1812

(2006).

41. Akira, S., Uematsu, S. & Takeuchi, O. Pathogen recognition and innate immunity. Cell 124, 783-801

(2006).

42. Bruscia, E.M. & Bonfield, T.L. Cystic Fibrosis Lung Immunity: The Role of the Macrophage. J Innate

Immun (2016).

43. Lara-Reyna, S., Holbrook, J., Jarosz-Griffiths, H.H., Peckham, D. & McDermott, M.F. Dysregulated

signalling pathways in innate immune cells with cystic fibrosis mutations. Cell Mol Life Sci 77, 4485-

4503 (2020).

44. Riquelme, S.A. & Prince, A. Pseudomonas aeruginosa Consumption of Airway Metabolites Promotes

Lung Infection. Pathogens 10 (2021).

45. Zheng, S. et al. Impaired innate host defense causes susceptibility to respiratory virus infections in

cystic fibrosis. Immunity 18, 619-630 (2003).

46. Stanton, B.A., Hampton, T.H. & Ashare, A. SARS-CoV-2 (COVID-19) and cystic fibrosis. Am J Physiol

Lung Cell Mol Physiol 319, L408-L415 (2020).

47. Cigana, C., Nicolis, E., Pasetto, M., Assael, B.M. & Melotti, P. Anti-inflammatory effects of azithromycin

in cystic fibrosis airway epithelial cells. Biochem Biophys Res Commun 350, 977-982 (2006).

48. Manti, S. et al. Looking beyond pulmonary disease in COVID-19: A lesson from patients with cystic

fibrosis. Med Hypotheses 147, 110481 (2021).

20
49. Iannitti, R.G. et al. IL-1 receptor antagonist ameliorates inflammasome-dependent inflammation in

murine and human cystic fibrosis. Nat Commun 7, 10791 (2016).

50. Deng, J., Yu, X.Q. & Wang, P.H. Inflammasome activation and Th17 responses. Mol Immunol 107,

142-164 (2019).

51. Flores-Vega, V. et al. Bacterial Subversion of Autophagy in Cystic Fibrosis. Front Cell Infect Microbiol

Oct 8;11:760922 (2021).

52. Freedman, S.D. et al. Association of cystic fibrosis with abnormalities in fatty acid metabolism. N Engl J

Med 350, 560-569 (2004).

53. Recchiuti, A., Mattoscio, D. & Isopi, E. Roles, Actions, and Therapeutic Potential of Specialized Pro-

resolving Lipid Mediators for the Treatment of Inflammation in Cystic Fibrosis. Frontiers in

pharmacology 10, 252 (2019).

54. Yang, J., Eiserich, J.P., Cross, C.E., Morrissey, B.M. & Hammock, B.D. Metabolomic profiling of

regulatory lipid mediators in sputum from adult cystic fibrosis patients. Free Radic Biol Med 53, 160-171

(2012).

55. Ringholz, F.C. et al. Reduced 15-lipoxygenase 2 and lipoxin A4/leukotriene B4 ratio in children with

cystic fibrosis. Eur Respir J 44, 394-404 (2014).

56. White, N.M. et al. Altered cholesterol homeostasis in cultured and in vivo models of cystic fibrosis. Am J

Physiol Lung Cell Mol Physiol 292, L476-486 (2007).

57. Worgall, T.S. Lipid metabolism in cystic fibrosis. Curr Opin Clin Nutr Metab Care 12, 105-109 (2009).

21
58. Konstan, M.W. et al. Association of High-Dose Ibuprofen Use, Lung Function Decline, and Long-Term

Survival in Children with Cystic Fibrosis. Ann Am Thorac Soc 15, 485-493 (2018).

59. Youssef, M. et al. Treatment of Allergic Asthma with Fenretinide Formulation (LAU-7b) Downregulates

ORMDL Sphingolipid Biosynthesis Regulator 3 (Ormdl3) Expression and Normalizes Ceramide

Imbalance. J Pharmacol Exp Ther 373, 476-487 (2020).

60. McElvaney, O.J. et al. Specific Inhibition of the NLRP3 Inflammasome as an Antiinflammatory Strategy

in Cystic Fibrosis. Am J Respir Crit Care Med 200, 1381-1391 (2019).

61. Grasemann, H. et al. Oral L-arginine supplementation in cystic fibrosis patients: a placebo-controlled

study. Eur Respir J 25, 62-68 (2005).

62. Nichols, D.P., Ziady, A.G., Shank, S.L., Eastman, J.F. & Davis, P.B. The triterpenoid CDDO limits

inflammation in preclinical models of cystic fibrosis lung disease. Am J Physiol Lung Cell Mol Physiol

297, L828-836 (2009).

63. Sutton, M.T. et al. Antimicrobial Properties of Mesenchymal Stem Cells: Therapeutic Potential for

Cystic Fibrosis Infection, and Treatment. Stem Cells Int 2016, 5303048 (2016).

64. Munshi, A. et al. A comprehensive proteomics profiling identifies NRP1 as a novel identity marker of

human bone marrow mesenchymal stromal cell-derived small extracellular vesicles. Stem Cell Res

Ther 10, 401 (2019).

65. Khan, M.A., Ali, Z.S., Sweezey, N., Grasemann, H. & Palaniyar, N. Progression of Cystic Fibrosis Lung

Disease from Childhood to Adulthood: Neutrophils, Neutrophil Extracellular Trap (NET) Formation, and

NET Degradation. Genes (Basel) 10 (2019).

22
66. Jennings, L.K. et al. Pseudomonas aeruginosa aggregates in cystic fibrosis sputum produce

exopolysaccharides that likely impede current therapies. Cell reports 34, 108782 (2021).

67. Painter, R.G. et al. CFTR Expression in human neutrophils and the phagolysosomal chlorination defect

in cystic fibrosis. Biochemistry 45, 10260-10269 (2006).

68. Pohl, K. et al. A neutrophil intrinsic impairment affecting Rab27a and degranulation in cystic fibrosis is

corrected by CFTR potentiator therapy. Blood 124, 999-1009 (2014).

69. Giacalone, V.D., Margaroli, C., Mall, M.A. & Tirouvanziam, R. Neutrophil Adaptations upon Recruitment

to the Lung: New Concepts and Implications for Homeostasis and Disease. Int J Mol Sci 21 (2020).

70. Margaroli, C. et al. Transcriptional firing represses bactericidal activity in cystic fibrosis airway

neutrophils. Cell Rep Med 2, 100239 (2021).

71. Konstan, M.W. et al. A randomized double blind, placebo controlled phase 2 trial of BIIL 284 BS (an

LTB4 receptor antagonist) for the treatment of lung disease in children and adults with cystic fibrosis. J

Cyst Fibros 13, 148-155 (2014).

72. Elborn, J.S. et al. Empire-CF study: A phase 2 clinical trial of leukotriene A4 hydrolase inhibitor

acebilustat in adult subjects with cystic fibrosis. J Cyst Fibros 20, 1026-1034 (2021).

73. Gillan, J.L., Davidson, D.J. & Gray, R.D. Targeting cystic fibrosis inflammation in the age of CFTR

modulators: focus on macrophages. Eur Respir J 57 (2021).

74. Morales-Nebreda, L., Misharin, A.V., Perlman, H. & Budinger, G.R. The heterogeneity of lung

macrophages in the susceptibility to disease. Eur Respir Rev 24, 505-509 (2015).

23
75. Hubeau, C., Puchelle, E. & Gaillard, D. Distinct pattern of immune cell population in the lung of human

fetuses with cystic fibrosis. J Allergy Clin Immunol 108, 524-529 (2001).

76. Brennan, S. et al. Alveolar macrophages and CC chemokines are increased in children with cystic

fibrosis. Eur Respir J 34, 655-661 (2009).

77. Schupp, J.C. et al. Single Cell Transcriptional Archetypes of Airway Inflammation in Cystic Fibrosis. Am

J Respir Crit Care Med (2020).

78. del Fresno, C. et al. Monocytes from cystic fibrosis patients are locked in an LPS tolerance state: down-

regulation of TREM-1 as putative underlying mechanism. PLoS ONE 3, e2667 (2008).

79. Avendano-Ortiz, J. et al. Pseudomonas aeruginosa colonization causes PD-L1 overexpression on

monocytes, impairing the adaptive immune response in patients with cystic fibrosis. J Cyst Fibros 18,

630-635 (2019).

80. Sorio, C. et al. Mutations of Cystic Fibrosis Transmembrane Conductance Regulator Gene Cause a

Monocyte-Selective Adhesion Deficiency. Am J Respir Crit Care Med 193, 1123-1133 (2016).

81. Hisert, K.B. et al. CFTR Modulator Therapy Enhances Peripheral Blood Monocyte Contributions to

Immune Responses in People With Cystic Fibrosis. Frontiers in pharmacology 11, 1219 (2020).

82. Jarosz-Griffiths, H.H. et al. Different CFTR modulator combinations downregulate inflammation

differently in cystic fibrosis. Elife 9 (2020).

83. Hisert, K.B. et al. Ivacaftor decreases monocyte sensitivity to interferon-gamma in people with cystic

fibrosis. ERJ Open Res 6 (2020).

24
84. Vandivier, R.W. et al. Elastase-mediated phosphatidylserine receptor cleavage impairs apoptotic cell

clearance in cystic fibrosis and bronchiectasis. J Clin Invest 109, 661-670 (2002).

85. Ma, J. et al. Neutrophil elastase-regulated macrophage sheddome/secretome and phagocytic failure.

Am J Physiol Lung Cell Mol Physiol 321, L555-L565 (2021).

86. Hofer, T.P. et al. Decreased expression of HLA-DQ and HLA-DR on cells of the monocytic lineage in

cystic fibrosis. J Mol Med (Berl) 92, 1293-1304 (2014).

87. Xu, Y., Krause, A., Limberis, M., Worgall, T.S. & Worgall, S. Low sphingosine-1-phosphate impairs lung

dendritic cells in cystic fibrosis. Am J Respir Cell Mol Biol 48, 250-257 (2013).

88. Roghanian, A., Drost, E.M., MacNee, W., Howie, S.E. & Sallenave, J.M. Inflammatory lung secretions

inhibit dendritic cell maturation and function via neutrophil elastase. Am J Respir Crit Care Med 174,

1189-1198 (2006).

89. Mueller, C. et al. Lack of cystic fibrosis transmembrane conductance regulator in CD3+ lymphocytes

leads to aberrant cytokine secretion and hyperinflammatory adaptive immune responses. Am J Respir

Cell Mol Biol 44, 922-929 (2011).

90. Iannitti, R.G. et al. Th17/Treg imbalance in murine cystic fibrosis is linked to indoleamine 2,3-

dioxygenase deficiency but corrected by kynurenines. Am J Respir Crit Care Med 187, 609-620 (2013).

91. Chan, Y.R. et al. Patients with cystic fibrosis have inducible IL-17+IL-22+ memory cells in lung draining

lymph nodes. J Allergy Clin Immunol 131, 1117-1129, 1129 e1111-1115 (2013).

25
92. Iwanaga, N. & Kolls, J.K. Updates on T helper type 17 immunity in respiratory disease. Immunology

156, 3-8 (2019).

93. Hsu, D. et al. Interleukin-17 Pathophysiology and Therapeutic Intervention in Cystic Fibrosis Lung

Infection and Inflammation. Infect Immun 84, 2410-2421 (2016).

94. Rehman, T. et al. Inflammatory cytokines TNF-alpha and IL-17 enhance the efficacy of cystic fibrosis

transmembrane conductance regulator modulators. J Clin Invest 131 (2021).

95. Hector, A. et al. Regulatory T-cell impairment in cystic fibrosis patients with chronic pseudomonas

infection. Am J Respir Crit Care Med 191, 914-923 (2015).

96. McGuire, J.K. Regulatory T cells in cystic fibrosis lung disease. More answers, more questions. Am J

Respir Crit Care Med 191, 866-868 (2015).

97. Ideozu, J.E. et al. Transcriptional consequences of impaired immune cell responses induced by cystic

fibrosis plasma characterized via dual RNA sequencing. BMC Med Genomics 12, 66 (2019).

98. Mauch, R.M. et al. Secretory IgA-mediated immune response in saliva and early detection of

Pseudomonas aeruginosa in the lower airways of pediatric cystic fibrosis patients. Med Microbiol

Immunol 208, 205-213 (2019).

99. Mauch, R.M. et al. Assessment of IgG antibodies to Pseudomonas aeruginosa in patients with cystic

fibrosis by an enzyme-linked immunosorbent assay (ELISA). Diagn Pathol 9, 158 (2014).

100. Kristiansen, T.A., Vanhee, S. & Yuan, J. The influence of developmental timing on B cell diversity. Curr

Opin Immunol 51, 7-13 (2018).

26
101. Moss, R.B. Mucosal humoral immunity in cystic fibrosis - a tangled web of failed proteostasis, infection

and adaptive immunity. EBioMedicine 60, 103035 (2020).

102. Theprungsirikul, J. et al. Dissociation of systemic and mucosal autoimmunity in cystic fibrosis. J Cyst

Fibros 19, 196-202 (2020).

103. Sposito, F., McNamara, P.S. & Hedrich, C.M. Vasculitis in Cystic Fibrosis. Front Pediatr 8, 585275

(2020).

104. Skopelja, S. et al. The role for neutrophil extracellular traps in cystic fibrosis autoimmunity. JCI Insight

1, e88912 (2016).

105. Hovold, G., Lindberg, U., Ljungberg, J.K., Shannon, O. & Pahlman, L.I. BPI-ANCA is expressed in the

airways of cystic fibrosis patients and correlates to platelet numbers and Pseudomonas aeruginosa

colonization. Respir Med 170, 105994 (2020).

106. Webster, M.J. et al. SPLUNC1 degradation by the cystic fibrosis mucosal environment drives airway

surface liquid dehydration. Eur Respir J 52 (2018).

107. Lewis, B.W. et al. The Innate Lymphoid System Is a Critical Player in the Manifestation of

Mucoinflammatory Airway Disease in Mice. J Immunol 205, 1695-1708 (2020).

108. Fan, X. & Rudensky, A.Y. Hallmarks of Tissue-Resident Lymphocytes. Cell 164, 1198-1211 (2016).

109. Smith, D.J., Hill, G.R., Bell, S.C. & Reid, D.W. Reduced mucosal associated invariant T-cells are

associated with increased disease severity and Pseudomonas aeruginosa infection in cystic fibrosis.

PLoS One 9, e109891 (2014).

27
110. Pincikova, T. et al. Severely Impaired Control of Bacterial Infections in a Patient With Cystic Fibrosis

Defective in Mucosal-Associated Invariant T Cells. Chest 153, e93-e96 (2018).

111. Raga, S. et al. Gammadelta T lymphocytes from cystic fibrosis patients and healthy donors are high

TNF-alpha and IFN-gamma-producers in response to Pseudomonas aeruginosa. Respir Res 4, 9

(2003).

112. Hagner, M. et al. IL-17A from innate and adaptive lymphocytes contributes to inflammation and damage

in cystic fibrosis lung disease. Eur Respir J 57 (2021).

113. Siegmann, N. et al. Invariant natural killer T (iNKT) cells prevent autoimmunity, but induce pulmonary

inflammation in cystic fibrosis. Cell Physiol Biochem 34, 56-70 (2014).

114. Lindberg, U., Svensson, L., Hellmark, T., Segelmark, M. & Shannon, O. Increased platelet activation

occurs in cystic fibrosis patients and correlates to clinical status. Thromb Res 162, 32-37 (2018).

115. Ortiz-Munoz, G. et al. Cystic fibrosis transmembrane conductance regulator dysfunction in platelets

drives lung hyperinflammation. J Clin Invest 130, 2041-2053 (2020).

116. Hoffman, M., Gerding, J.P. & Zuckerman, J.B. Stroke and myocardial infarction following bronchial

artery embolization in a cystic fibrosis patient. J Cyst Fibros 16, 161-162 (2017).

117. Ellis, S. et al. CNS imaging studies in cystic fibrosis patients presenting with sudden neurological

events. BMJ Open Respir Res 6, e000456 (2019).

118. Oz, H.H. et al. Pseudomonas aeruginosa Airway Infection Recruits and Modulates Neutrophilic

Myeloid-Derived Suppressor Cells. Front Cell Infect Microbiol 6, 167 (2016).

28
119. Tucker, S.L., Sarr, D. & Rada, B. Granulocytic Myeloid-Derived Suppressor Cells in Cystic Fibrosis.

Front Immunol 12, 745326 (2021).

120. Koeppen, K. et al. CF monocyte-derived macrophages have an attenuated response to extracellular

vesicles secreted by airway epithelial cells. Am J Physiol Lung Cell Mol Physiol 320, L530-L544 (2021).

121. Szul, T. et al. Toll-Like Receptor 4 Engagement Mediates Prolyl Endopeptidase Release from Airway

Epithelia via Exosomes. Am J Respir Cell Mol Biol 54, 359-369 (2016).

122. Schwechheimer, C. & Kuehn, M.J. Outer-membrane vesicles from Gram-negative bacteria: biogenesis

and functions. Nat Rev Microbiol 13, 605-619 (2015).

123. Armstrong, D.A. et al. Extracellular Vesicles from Pseudomonas aeruginosa Suppress MHC-Related

Molecules in Human Lung Macrophages. Immunohorizons 4, 508-519 (2020).

124. Sutton, M.T. et al. Mesenchymal Stem Cell Soluble Mediators and Cystic Fibrosis. J Stem Cell Res

Ther 7 (2017).

125. Zulueta, A. et al. Lung mesenchymal stem cells-derived extracellular vesicles attenuate the

inflammatory profile of Cystic Fibrosis epithelial cells. Cellular signalling 51, 110-118 (2018).

126. van Heeckeren, A.M. et al. Enhancing Cystic Fibrosis Immune Regulation. Frontiers in pharmacology

12, 573065 (2021).

127. Bonfield, T.L. et al. Donor-defined mesenchymal stem cell antimicrobial potency against

nontuberculous mycobacterium. Stem Cells Transl Med 10, 1202-1216 (2021).

29
128. Drutskaya, M.S., Efimov, G.A., Kruglov, A.A. & Nedospasov, S.A. Can we design a better anti-cytokine

therapy? J Leukoc Biol 102, 783-790 (2017).

129. Corvol, H. et al. Genome-wide association meta-analysis identifies five modifier loci of lung disease

severity in cystic fibrosis. Nat Commun 6, 8382 (2015).

130. Wright, F.A. et al. Genome-wide association and linkage identify modifier loci of lung disease severity in

cystic fibrosis at 11p13 and 20q13.2. Nat Genet 43, 539-546 (2011).

131. Dorfman, R. et al. Modulatory effect of the SLC9A3 gene on susceptibility to infections and pulmonary

function in children with cystic fibrosis. Pediatr Pulmonol 46, 385-392 (2011).

132. Namkoong, H. et al. Genome-wide association study in patients with pulmonary Mycobacterium avium

complex disease. Eur Respir J 58 (2021).

133. Darrah, R.J. et al. AGTR2 absence or antagonism prevents cystic fibrosis pulmonary manifestations. J

Cyst Fibros 18, 127-134 (2019).

134. Graustein, A.D. et al. Inflammasome Genetic Variants, Macrophage Function, and Clinical Outcomes in

Cystic Fibrosis. Am J Respir Cell Mol Biol 65, 157-166 (2021).

135. Nourkami-Tutdibi, N., Freitag, K., Zemlin, M. & Tutdibi, E. Genetic Association With Pseudomonas

aeruginosa Acquisition in Cystic Fibrosis: Influence of Surfactant Protein D and Mannose-Binding

Lectin. Front Immunol 12, 587313 (2021).

136. Weiler, C.A. & Drumm, M.L. Genetic influences on cystic fibrosis lung disease severity. Frontiers in

pharmacology 4, 40 (2013).

30