Reviewer #3 (Public review):
Summary:
Tanaka and colleagues addressed the role of the C-C chemokine receptor 4 (CCR4) in early atherosclerotic plaque development using ApoE-deficient mice on a standard chow diet as a model. Because several CD4+ T cell subsets express CCR4, they examined whether CCR4-deficiency alters the immune response mediated by CD4+ T cells. By histological analysis of aortic lesions, they demonstrated that the absence of CCR4 promoted the development of early atherosclerosis, with heightened inflammation linked to increased macrophages and pro-inflammatory CD4+ T cells, along with reduced collagen content. Flow cytometry and mRNA expression analysis for identifying CD4+ T cell subsets showed that CCR4 deficiency promoted higher proliferation of pro-inflammatory effector CD4+ T cells in peripheral lymphoid tissues and accumulation of Th1 cells in the atherosclerotic lesions. Interestingly, the increased pro-inflammatory CD4+ T cell response occurred despite the expansion of T CD4+ Foxp3+ regulatory cells (Tregs), found in higher numbers in lymphoid tissues of CCR4-deficient mice, suggesting that CCR4 deficiency interfered with Treg's regulatory actions. In addition, CCR4 deficiency induced an augmented Th1/Treg ratio in the aortic lesions. The CCR4-mediated mechanisms underlying the control of early inflammation and atherosclerosis development were not completely elucidated. In vitro studies suggest that CCR4 expression in Tregs plays a role in controlling DC activation and, in turn, the extent of CD4+T cell activation and proliferation. Dependence on CCR4 expression for Treg migration to the atherosclerotic aorta was not proved. The findings contrast with earlier studies in a murine model of advanced atherosclerosis, where CCR4 deficiency did not alter the development of the aortic lesions. The authors included a thoughtful discussion about hypothetical mechanisms explaining these contrasting results, including putative differences in the role played by the CCL17/CCL22-CCR4 axis along the stages of atherosclerosis development in this murine model.
Major strengths:
• Demonstration of CCR4 deficiency's impact on early atherosclerosis. CCR4 deficiency effects on the early atherosclerosis development in the Apoe-/-mice model were demonstrated by a quantitative analysis of the lesion area, inflammatory cell content and the expression profile of several pro- and anti-inflammatory markers.<br /> • Analysis of the T CD4+ response in various lymphoid tissues (peripheral and para-aortic lymph nodes and spleen) and the atherosclerotic aorta during the early phase of atherosclerosis in the Apoe-/-mice model. This analysis, combining flow cytometry and mRNA expression, showed that CCR4 deficiency enhanced T CD4+ cell activation, favouring the amplification of the typical biased Th1-mediated inflammatory response observed in the lymphoid tissues of hypercholesterolemic mice.<br /> • Treg transference experiments. Transference of Treg from Apoe-/- or Ccr4-/- Apoe-/- mice to Apoe-/- mice under a standard chow diet was useful for addressing the relevance of CCR4 expression on Tregs for the atheroprotective effect of this regulatory T cell subset during early atherosclerosis.
Major weaknesses:
• The effect of CCR4 deficiency on the Th1/Th17 balance was not evaluated. Although the role of Th17 cells in atherosclerosis remains controversial, RORγt+ cells constituted, on average, more than 10% of the effector TCD45+CD3+CD4+ lymphocytes in the aorta of Apoe-/- mice (Fig 4H). Changes in the Th1/Th17 balance in lymphoid tissues and aortic lesions may influence the type and functional properties of inflammatory cells recruited to the atherosclerotic aorta.
• Lack of in vivo evidence for Treg suppressive effects on DC activation. The proposed CCR4 requirement for the Treg suppressive activity on DC activation is supported by in vitro co-culture assays, in which CCR4-deficiency partially reverted Treg regulatory actions. Higher expression of CD86, a DC activation marker, was found in spleen DCs from Ccr4-/- Apoe-/- mice compared to Apoe-/- mice (Supplementary Fig 5), which would be worth commenting on and discussing.
• Methodological limitations. Controls in flow cytometry analysis were suboptimal (no viability and doublets were checked) which may have introduced artefacts, especially when measuring less-represented cell populations within complex samples. In addition, assessing Treg migration to the aorta in atherosclerotic mice faced methodological limitations that hindered statistical comparisons between Tregs from Apoe-/- and Ccr4-/- Apoe-/- mice, leading to inconclusive results. The dependence on CCR4 expression for Treg migration to the atherosclerotic aorta was not established.
• Treg transference experiments did not allow the detection of a reduction in the aortic lesion area by transferred CCR4 expressing Tregs (comparison between saline and Apoe-/- Tregs groups). Using Apoe-/- mice as recipients, the CCR4-dependent protective effect of Tregs was mostly evidenced by analysis of aortic inflammation, which was valuable. When using Ccr4-/- Apoe-/- mice as recipients, analysis of aortic inflammation was not mentioned.
Study limitations:
This investigation has some limitations. Current tools for single-cell characterization have revealed the phenotypic heterogeneity and dynamics of aortic leukocytes, including T cells, which are among the principal aortic leukocytes found in mouse and human atherosclerotic lesions (doi:10.1161/CIRCRESAHA.117.312513). The flow cytometry analysis applied in this study cannot distinguish the generation of particular phenotypes within T CD4+ subsets, including putative phenotypes of no-suppressive T cells expressing low levels of Foxp3, as seems could occur in other chronic inflammatory disorders (doi: 10.1038/nm.3432; doi: 10.1172/JCI79014). Limitations due to the use of a complete CCR4 knockout mouse and putative differences in CCR4-mediated mechanisms along atherosclerosis stages and in human atherosclerosis were commented on by the authors in the discussion.
Global Impact:
This work opens the way for a deeper analysis of the contribution of CCR4 and its ligands to the activation and differentiation of T CD4+ lymphocytes during atherosclerosis development, with these lymphocytes being fundamental players in the generation of pro-atherogenic and anti-atherogenic immune responses. Differences in the mechanisms mediated by the CCL17/CCL22-CCR4 axis among early and advanced atherosclerosis highlight the complex landscape to examine and validate in human samples and the need to achieve a deep knowledge for identifying genuine and safe targets capable of promoting protective anti-atherogenic immune responses.