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SLC11A1 has pleiotropic effects on macrophage function and remains a strong candidate for infectious disease susceptibility. 5' and/or 3' polymorphisms have been associated with tuberculosis, leprosy, and visceral leishmaniasis (VL). Most studies undertaken to date were under-powered, and none has been replicated within a population. Association with tuberculosis has replicated variably across populations. Here we investigate SLC11A1 and VL in India.
Nine polymorphisms (rs34448891, rs7573065, rs2276631, rs3731865, rs17221959, rs2279015, rs17235409, rs17235416, rs17229009) that tag linkage disequilibrium blocks across SLC11A1 were genotyped in primary family-based (313 cases; 176 families) and replication (941 cases; 992 controls) samples. Family- and population-based analyses were performed to look for association between SLC11A1 variants and VL. Quantitative RT/PCR was used to compare SLC11A1 expression in mRNA from paired splenic aspirates taken before and after treatment from 24 VL patients carrying different genotypes at the functional promoter GTn polymorphism (rs34448891).
No associations were observed between VL and polymorphisms at SLC11A1 that were either robust to correction for multiple testing or replicated across primary and replication samples. No differences in expression of SLC11A1 were observed when comparing pre- and post-treatment samples, or between individuals carrying different genotypes at the GTn repeat.
This is the first well-powered study of SLC11A1 as a candidate for VL, which we conclude does not have a major role in regulating VL susceptibility in India.
Visceral leishmaniasis (VL) is a debilitating vector borne disease caused by parasites of the Leishmania donovani complex. Prevalence is high in Bihar State in India, indicating a need to understand more about disease pathogenesis to facilitate disease control. Population based epidemiological surveys suggest that 80-90% of individuals infected with L. donovani show no clinical symptoms [1,2]. Familial clustering, and the range of clinical outcomes from asymptomatic to fatal disease within and between ethnic groups sharing similar risk factors in Brazil [3,4] and Sudan [5,6], support a contribution of host genotype to susceptibility. Candidate gene and genome-wide linkage studies have highlighted a number of genes/gene regions contributing to disease susceptibility (reviewed ). However, replication between study sites has not been observed possibly due to small samples size and limited statistical power.
Amongst the genes studied to date, the most compelling candidate for VL susceptibility is SLC11A1 (formerly NRAMP1). SLC11A1 encodes solute carrier family 11a member 1, a transporter that regulates divalent cation homeostasis in macrophages and has many pleiotropic effects on macrophage activation (reviewed [8,9]). The gene was first identified for its role in controlling Leishmania donovani (gene designation Lsh), Salmonella typhimurium (Ity) and Mycobacterium bovis (Bcg) infections in mice [8,9]. The positionally cloned  candidate for these 3 genes was designated as the natural resistance associated macrophage protein 1 (Nramp1) for a period before its specific function as a transporter was confirmed . In mice, susceptibility to infection is associated with a coding region mutation in transmembrane domain 4 of Slc11a1 . In humans, no functional coding region variants have been identified , but common alleles 2 [T(GT)5AC(GT)5AC(GT)10] and 3 [T(GT)5AC(GT)5AC(GT)9] of a functional  Z-DNA forming GTn repeat (rs34448891) in the promoter region have been associated with disease risk, or protection from, a number of autoimmune and infectious diseases (reviewed [8,14]). Amongst these associations, a common theme was risk of autoimmune disease with allele 3 which drives higher SLC11A1 expression and pro-inflammatory cytokine production by macrophages, while the lower expressing allele 2 was associated with anti-inflammatory cytokines and infectious disease susceptibility, including tuberculosis . In contrast, in Sudan the proinflammatory GTn repeat allele 3 is on a risk haplotype for VL caused by L. donovani that includes variants at single nucleotide polymorphisms (SNPs) designated 274C/T in exon 3 (rs2276631) and 469 + 14G/C in intron 4 (rs3731865) in the 5' region of the gene . This was interpreted in relation to VL pathology which is associated with a strong pro-inflammatory tumour necrosis factor alpha response . In some populations infectious disease association (listed in additional on-line tables in reference ) has been with 3' variants at SLC11A1 rather than, or in addition to, the 5' polymorphic loci, including two insertion/deletion (IN/DEL) polymorphisms TGTG/- (rs17235416) and CAAA/- (rs17229009) in the 3'UTR. The latter are potentially regulatory polymorphisms, although this has not been demonstrated experimentally. Here we report on well-powered two-stage primary family-based, followed by a replication population-based, genetic association study that fails to support either a role for polymorphism at SLC11A1 in determining susceptibility to VL caused by L. donovani in India, or for the GTn repeat polymorphism in determining mRNA expression levels of SLC11A1 in splenic aspirates from VL patients before or after chemotherapy.
The study was conducted in the district of Muzaffarpur in Bihar State, India, where VL is highly endemic. VL cases and family members or controls were from villages located within a radius of ~100 km from the city of Muzaffarpur covering the districts of Muzaffarpur, Vaishali, Samastipur, Saran, Sheohar, East Champaran and Sitamarhi. Initially, families with at least two siblings affected with clinical VL were ascertained from medical records held in the Kala-Azar Medical Research Centre (KAMRC) in Muzaffarpur, India . This was later extended to collection of singleton cases plus parent (trios) (see Table Table1A).1A). The replication study comprised 958 unrelated cases and 1015 unrelated controls. The controls had no history of VL, or a family history of VL among first-, second- or third-degree relatives. Patients and controls were matched for self-reported age, sex, religion, caste and geographic district of recruitment (see Table Table1B).1B). Diagnosis of VL was based on presence of typical clinical features of VL i.e. fever with rigors and chills, splenomegaly, weight loss and pancytopenia followed by demonstration of parasites by parasitological methods (light microscopy, in vitro culture) using splenic aspirates . Additional VL cases identified in the field were confirmed on the basis of proof of medical records of diagnosis and treatment issued from one of the local health clinics or private practice, and accompanied by demonstration of clinical response to anti-leishmanial treatment (typically with amphotericin B). An annual incidence rate of 2.49 clinical VL cases/1,000 persons has been reported in the region . L. donovani sensu strictu (zymodeme MON-2) was confirmed as the causative agent of VL in the study region, in accordance with other reports on clinical isolates from kala-azar patients in the state of Bihar [21-24]. Additional epidemiological and demographic details relating to the study site are described elsewhere . Informed written consent in Hindi was obtained from all participating individuals and from parents of children under 18 years old. Approval for the study was provided by the Ethical Committee of the Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Collection of families for the primary study was undertaken between 2004 and 2006. The replication study collection was undertaken during 2009-2010. For the family-based primary study DNA was prepared from buccal swabs by whole genome amplification as described , and SNPs genotyped using ABI predesigned Taqman assays (ABI, Mulgrave, Victoria, Australia). For the replication case-control study, genomic DNA was extracted from saliva using the Oragene technology (DNA Genotek, Ontario, Canada), and SNPs genotyped using Sequenom iPLEX platform (Sequenom, San Diego, CA). The GTn repeat and IN/DELS were genotyped for all samples using ABI fragment analysis processed on an ABI3130 (Australia) or ABI3730 (India) Genetic Analyser.
Family-based allelic association tests based on the TDT but generalized to allow analysis under additive and genotype-wise models of inheritance were performed within FBAT under the null hypothesis of "no linkage and no association" [26,27]. TDT power approximations  show that the 313 primary VL trios had ≥95% power to detect an odds ratio ≥2 at P = 0.01 for markers with MAF ≥ 0.1, but only 49% power for an odds ratio of 1.5. Nevertheless, our primary sample was well-powered to detect effect sizes (odds ratios ≥ 2) equivalent to those observed in the earlier study of SLC11A1 and VL in Sudan . Robust association tests were performed to take account of multiple trios within a pedigree. Association tests for the replication case-control sample were undertaken using logistic regression analysis performed in PLINK  or LOGIT (Stata) using an additive model and a genotypic test. The 941 cases and 992 controls which passed quality control (Hardy-Weinberg Equilibrium) had 100% power to detect associations with an odds ratio of 2 for markers with MAF ≥ 0.1 at P = 0.001, and 93.5% power for odds ratio 1.5; MAF ≥ 0.1, P = 0.01.
Splenic biopsies were taken as part of routine diagnostic procedure at the Kala Azar Medical Research Centre, Muzaffarpur, Bihar State, India. Since the spleen is a major focus for parasite growth inside macrophages, this afforded an important opportunity to analyse gene expression in a primary site of infection. Pre- and post- treated patient's splenic samples were collected in 5 × RNA Later (Ambion) during 2009-2010, transported to Varanasi at 4°C and stored at -80°C until RNA was isolated. Details regarding age and sex (15 males, median age 16, range 7 to 45 years; 9 females, median age 10, range 8 to 30 years) splenic parasites (21 confirmed positive; 3 not done) and drug administered (19 Miltefosine; 1 Miltefosine + Paramomycin; 1Ambisome + Paramomycin; 3Amphomul) were recorded for each patient. Total RNA was isolated using RNeasy tissue kit (Qiagen) according to the manufacturer's instructions and eluted in 30 ul of RNase free water. Sample quality and integrity was assessed by ND-2000 spectrophotometer (Thermo Fischer Scientific) and agarose (Sigma Aldrich) gel electrophoresis. 500 ng of RNA was reverse transcribed using the High Capacity cDNA synthesis kit (Applied Biosystems). Taqman predesigned gene expression assay (Hs00184453_m1) was used to perform expression studies (7500 HT Real Time PCR system, ABI, Foster City CA, USA) with 18S rRNA (P/N 4319413E) used as an endogenous control to normalize the expression data. Experiments were performed on 24 paired pre- and post-treatment splenic aspirates from VL patients with appropriate no RT and no template controls included in each plate. All samples were run in duplicate. Results were analysed by 7500 software v.2.0.1 and Graph pad prism 5. Paired Student's T tests was used to test for significant differences between pre (Day-0) and post (D-30) expression levels for each genotype, i.e. 3/3, 3/2 and 2/2. One way ANOVA was used to test for differences between 3/3 vs 3/2 vs 2/2 groups at either Day-0 or Day-30.
To undertake our study we initially genotyped 9 polymorphisms (Table (Table2)2) in 176 nuclear families (Table (Table1)1) used in our previous study  that contain 313 offspring with VL collected in the area of Muzaffarpur, Bihar State, India, where L. donovani is endemic. This included the putative functional 5' GTn repeat and 3'UTR TGTG/- and CAAA/- IN/DELs, as well as the exon 3 274C/T (rs2276631) and intron 4 469 + 14G/C (rs3731865) SNPs shown to be associated with VL in Sudan . Using the family-based association test (FBAT) [30,31] in this primary family dataset (Table (Table3)3) we found tentative evidence (nominal P-values ≤0.05) for associations between VL and 5' GTn repeat, and between VL and the 3'UTR CAAA/- IN/DEL. In particular (Table (Table3B),3B), homozygosity for the high expressing pro-inflammatory allele 3 at the GTn repeat was associated with disease (Z-score = +2.382; nominal P = 0.017), while homozygosity for allele 2 (the deletion) was associated with protection for the 3'UTR CAAA IN/DEL (Z-score = -2.332; nominal P = 0.019). Since these two markers are not in strong LD with each other (Additional Figure Figure1:1: D' = 0.52; r2 = 0.16), these associations are likely to be independent, if real. Neither association is robust to application of a strict Bonferroni correction for 9 SNPs genotyped, which requires a significance cut-off of P ≤ 0.006 (i.e. P = 0.05/9). Given that the 8 SNPs that passed quality control are not all independent (Additional Figure Figure1),1), this is over-conservative. A less stringent correction taking account of non-independence of markers provides a cut-off of P ≤ 0.017 (i.e. P = 0.05/3; 2 LD blocks plus 1 independent marker).
Suggestive evidence for an association between Indian VL and allele 3 at the functional promoter region GTn polymorphism at SLC11A1, which was consistent with data for VL from Sudan , prompted us to pursue two further avenues of investigation. First, we looked at expression levels of SLC11A1 in mRNA from splenic aspirates from patients carrying the 3 different genotypes at the GTn repeat (Figure (Figure1).1). This failed to show any significant differences in expression levels of SLC11A1 in splenic aspirates from VL patients carrying the three GTn genotypes, either before or after treatment, as determined using one way ANOVA. Nor were there differences in expression within each genotype when pre- and post-treatment values were compared using paired Student's T tests. This suggests that differences in expression levels driven by the GTn repeat in luciferase assays in vitro, especially under lipopolysaccharide and interferon-γ stimulation [13,32], do not necessarily translate into regulation of expression in VL infected spleens in vivo. Secondly, we carried out a comprehensive replication of the association study in a much larger population-based case-control sample from the same region of Bihar State in India (Table (Table4).4). This study failed to show association between VL and any of the 8 markers that passed quality control. The trend for genotypic association at the GTn was in the reverse direction (i.e. a3 was the risk allele in the primary sample, and the protective allele in the replication samples) to that seen in the primary analysis (Table (Table3).3). Analyses using caste, which we have shown to provide a good surrogate for population substructure in genome-wide analyses (unpublished data), or religion as covariates also failed to provide evidence for positive associations in the case-control analysis (data not shown).
Here we re-examined SLC11A1 as a candidate gene for susceptibility to VL in India. Despite preliminary evidence for a role for putative functional polymorphisms in the 5' promoter and 3'UTR regions, we were unable to find supporting evidence for this in functional studies or in a large, well-powered, replication sample for association analysis. We conclude that SLC11A1 does not play a major role in determining susceptibility to VL in India. These results also call into question the earlier association observed between VL and SLC11A1 in Sudan , which was based on a single small sample of families. Whilst this could represent genetic heterogeneity between human populations and/or the parasite, it is also possible that this first report of association in humans could be a case of beginner's curse. Results presented here suggest that associations observed in small-scale primary samples require validation to determine whether they remain true for the population in which they have been observed.
This is the first well-powered study of SLC11A1 as a candidate for VL, which we conclude does have a major role in regulating VL susceptibility in India.
The authors declare that they have no competing interests.
AM, MF and SM carried out the field collection and/or preparation of the samples. SM and JO performed the genotyping, and participated in the statistical analysis and interpretation of the data. SEJ trained SM in the laboratory for genotyping techniques, in database entry and use of the genetic database GenIE in Perth, and in genetic statistical analysis methods. MF cross-checked statistical analyses and carried out additional statistical tests. MR oversaw laboratory-based work in Varanasi. DSR and KT oversaw the Sequenom genotyping undertaken by SM in Hyderabad. MS and PT assisted with RNA preparation. SM designed and carried out the QRT/PCR. SS helped conceive the study, was responsible for clinical care of cases at the Kala Azar Medical Research Centre, Muzaffarpur, Bihar State, India, and provided the logistical support to make the study possible. SM prepared the first draft of the manuscript. JMB designed the study, conceived the specific hypothesis to be tested, made the final interpretation of the data, and prepared the final manuscript. All authors read and approved the final manuscript.
The pre-publication history for this paper can be accessed here:
Figure S1. Haploview analysis for D' and r2 pairwise measures of linkage disequilibrium between SLC11A1 polymorphisms in the control sample for the replication sample from India.
We would like to thank the families from the state of Bihar, northeast India for their participation in this study. The authors declare no conflict of interest. This research was funded by grants from The Wellcome Trust in the UK (grant numbers: 074196/Z/04/Z and 085475/Z/08/Z) and The National Institutes for Health in the USA (grant numbers: R01 AI076233-01 and 1P50AI074321-01).