A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine. Johannesburg, June 2017 / Introduction: Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease of unknown aetiology. There is growing evidence environmental factor(s) trigger the disease in the genetically susceptible host. Fragment crystallisable receptor (FCR) genes encode receptors that recognise the fragment crystallisable (Fc) portion of immunoglobulins (IgG) play an important role in the removal of antigen-antibody complexes from the circulation. Genes that code for these receptors have shown to be associated with susceptibility to SLE in various populations. The aim of the present study is to determine the role of single nucleotide polymorphisms (SNPs), allotypes and copy number variations of FC Gamma receptor genes IIIA and IIIB in susceptibility for the Black South Africans with SLE. Methods: DNA from 162 Black South African SLE patients and 155 matched controls were investigated using Taqman assays to determine SNP genotyping differences (FCGRIIIA) and copy number variation (CNV) number (FCGRIIIB). A PCR was optimised in order to determine the allotype differences (FCGRIIIB) via agarose gel electrophoresis. Statistical analyses were then performed on the data to see if the results displayed significance in susceptibility to SLE. Results: The minor allele of the allotypes (FCGRIIIB) and the rs396991 SNP (FCGRIIIA) were not statistically significant in conferring susceptibility to SLE in cases or controls. The rs10127393 SNP (FCGRIIIA) was shown to be monomorphic within both cases and controls for the T allele and is not associated with SLE. The cumulative percentage of copy numbers (FCGRIIIB) ≤2 copies were 0.6% larger in cases than seen in controls. Although this was not significant, this was what has been previously suggested in the literature. Almost half of the cases (43.8%) had lupus nephritis (LN). Upon investigation the NA1/NA2 alleles were found to confer susceptibility to LN (p=0.018), whereas the rs396991 G allele did not (p=0.643). Conclusion: In this study the allotypes, SNPs and CNV investigated were not found to confer susceptibility to SLE. However, subtle trends suggest that further studies are required with larger sample sizes to acquire more data. Almost half of the cases were diagnosed with LN and the NA2 allele was shown to be a risk factor in developing LN. / MT2017

B cells are normally regulated to prevent activation against self-proteins through tolerance mechanisms.  However, occasionally there is a break in tolerance and B cells can become self-reactive, which might lead to the development of autoimmune disease. The activation of self-reactive B cells is regulated by receptors on the B cell surface, such as Fc gamma receptor IIb (FcγRIIb), complement receptor type 1 (CR1), and CR type 2 (CR2). In this thesis I have studied the role of FcγRIIb, CR1 and CR2 on B cells in autoimmune arthritis. By using a model for rheumatoid arthritis, I discovered that the initial self-reactive B cell response in arthritis was associated with the splenic marginal zone B cell population. Marginal zone B cells express high levels of CR1/CR2 and FcγRIIb, suggesting that they normally require high regulation. Further, female mice deficient in CR1/CR2 displayed increased susceptibility to arthritis compared to CR1/CR2-sufficient female mice. When investigating whether sex hormones affected arthritis susceptibility, we found that ovariectomy, of the otherwise fairly resistant CR1/CR2-sufficient mice, reduced the expression of CR1 on B cells and rendered the mice more susceptible to arthritis. In humans, a significantly reduced CR1 and FcγRIIb expression was found on B cells in aging women, but not in men. This may contribute to the increased risk for women to develop autoimmune disease as reduced receptor expression may lead to the activation of self-reactive B cells. In agreement, lower CR1, CR2 and FcγRIIb expression was seen in patients with rheumatoid arthritis.   Finally, a soluble form of FcγRIIb was used to investigate FcγRIIb’s ability to bind self-reactive IgG in an attempt to treat autoimmune arthritis. Treatment of mice with established arthritis was associated with less self-reactive IgG antibodies and consequently less disease, suggesting that soluble FcγRIIb may be used as a novel treatment in arthritis.

Host defense against infection and disease relies on the reciprocal communication between the immune and neuroendocrine systems where sex hormones exert negative and positive feedback actions on immune functions. Indeed, sex hormones have been implicated in gender dimorphic immune response and in the potentiation of immune-related disorders. The female hormone estrogen plays a role as an immunomodulator and may exert immunosuppressive and immunostimulatory effects. Though many studies focus on estrogen’s role in immunity within the female reproductive tract and autoimmunity, the modulatory effects of estrogen on vaccine responses are largely unexplored. The insufficient efficacy of some vaccines in certain target populations, as for example the elderly population, is well recognized. Hormones fluctuate throughout an individual’s life, and females in particular undergo several necessary reproductive (pregnancy and menopause) and lifestyle (oral contraceptive use) changes which involve sex hormones. Vaccine efficacy might be influenced by endogenous estrogen levels or by exogenous estrogen administration. Therefore, in the pursuit of improved vaccine efficacy, it is necessary to consider such hormonal factors and their contribution to immune status. We have studied estrogen’s role in modulation of vaccine responses using a mouse ovariectomy model where exogenous estrogen delivery can be controlled. Our studies included two different types of vaccines, a bacterial toxoid formulation and a bacterial secreted protein formulation. Results from these studies indicate that estrogen enhances vaccine-specific antibody production by likely supporting a general TH2 pathway and also modulates expression of genes encoding molecules critical in innate immune signaling and required for development of proper adaptive immune responses and antigen clearance through antibody-mediated mechanisms. The level at which estrogen modulates antibody responses appears to be dependent on the route of vaccine administration. The enhancement of specific humoral responses may involve mechanisms involving TLR2 and antibody Fc receptor expression on macrophages, cells that link innate and adaptive immune responses. Advances in our understanding of the relationship between sex hormones and the immune system may provide new insights into the mechanisms by which hormones act and thus may be exploited to guide the design of future vaccine strategies.

Cancer, historically considered a genetic disease, is currently acknowledged to affect the whole body. Our immune system is one key player that can elicit a response against malignant cells but can also promote tumorigenesis. Tumors avoid immune recognition by creating a suppressive microenvironment and inducing tolerance. T-cells are regarded a major effector cell type in tumor immunotherapy. An important ”switch” needed for T-cell activation involves so-called costimulatory and coinhibitory receptors. In this thesis, experimental tumor models were used to investigate the potential of immunomodulatory antibodies to stimulate immune cells and subsequently eliminate tumors. First, systemic antibody blockade of two negative checkpoint regulators (CTLA-4 and PD-1) present on T-cells was evaluated in combination with local CpG therapy or standard BCG treatment. Indeed, this combinatorial therapy with CpG augmented anti-tumor effects with increased levels of tumor-directed T-cells and reduced tumor-infiltrating Tregs. Secondly, as these immunomodulatory antibodies elicit severe side effects in patients, a local low-dose delivery regimen was explored as an alternative to systemic bolus treatment. Our results demonstrated that an approximately seven times lower dose of aCTLA-4, compared to systemic delivery, could eradicate both primary and distant tumors. CD40-expressing APCs are another potential target in antibody-mediated cancer therapy. CD40-stimulated dendritic cells (DCs) have the capability to activate tumor-directed T-cells to kill tumor cells. We next sought to investigate agonistic CD40 antibody efficacy and in vivo biodistribution when delivered locally compared to the equivalent systemic dose. Anti-tumor effects were dependent on CD8+ T-cells, host CD40 expression and the presence of tumor antigen at the injection site. CD40 antibodies were cleared from the circulation and accumulated in lymphoid organs, where, upon repeated aCD40 dosing, target APC populations increased in numbers and upregulated their surface CD40 expression. Lastly, CD40 agonist antibodies were mixed with nanoparticles to enhance their stimulatory properties. B-cells demonstrated increased proliferative capacity and DCs became more activated when exposed to the cocktail. Further, this combination reduced serum levels of pro-inflammatory cytokines compared to plain antibodies.       The results herein advocate further exploratory studies of the delivery of monoclonal antibodies at the tumor site in order to improve anti-tumor effects and reduce toxicity.

A Artrite reumatóide (AR) é uma doença inflamatória crônica e sistêmica, de etiologia desconhecida, que pode dificultar ou impossibilitar as funções habituais das articulações devido à destruição da cartilagem, edema e dor. A patogênese da AR envolve uma complexa inter-relação de fatores imunológicos, ambientais e genéticos, dificultando assim a descoberta de terapias eficientes. Na AR, o influxo de neutrófilos para a cavidade sinovial é predominante e contínuo de tal forma que, os neutrófilos são as células mais abundantes no sítio inflamatório. Uma vez ativados, os neutrófilos são capazes de produzir espécies reativas de oxigênio que, juntamente com enzimas proteolíticas, podem estar envolvidos na lesão articular observada nos pacientes com AR. A ativação dos neutrófilos pode ser mediada por receptores para IgG (Fc?R) e para o complemento (CR) presentes nas membranas dessas células, através da interação com complexos imunes (ICs). Esses receptores são também importantes moduladores das reações inflamatórias mediadas por ICs. Entretanto, a função do sistema complemento e dos Fc?R, bem como a importância de cada um na manifestação da AR ainda não está clara. Assim, neste estudo avaliou-se o metabolismo oxidativo de neutrófilos estimulados através de receptores Fc?R e Fc?R/CR em ambos os grupos de pacientes com AR, ativa e inativa, e em controles saudáveis. Esta função celular foi avaliada por quimioluminescência (QL) dependente de luminol e de lucigenina. Os resultados mostraram que não houve diferenças na produção de QL, tanto dependente de luminol quanto de lucigenina, quando mediada por Fc?R ou pela cooperação Fc?R/CR, em ambos os grupos de pacientes com AR comparados entre si e comparados com neutrófilos de indivíduos saudáveis. No entanto, a comparação do padrão da resposta de QL dentro de ambos os grupos de pacientes com AR, mostrou que a resposta celular aos IC opsonizados por soro humano de pacientes com AR (IC-IgG/SHAR) não foi significativamente significantemente maior em relação à observada para os IC não opsonizados, refletindo uma ausência da cooperação Fc?R/CR nestas células. Vale ressaltar que a atividade hemolítica do complemento sérico, tanto da via clássica/lectina quanto da alternativa, não foi diferente entre os grupos estudados. Quanto à expressão dos CR, somente no grupo de pacientes com AR ativa observou-se diferenças, sendo que CR1 estava aumentado em relação ao grupo controle (p<0,05) e CR3 aumentado quando comparado ao grupo de pacientes com AR inativa (p<0,05). A expressão dos Fc?R, CD32 e CD16, não foi diferente entre os grupos estudados. Ainda, as análises de correlação da expressão dos diferentes receptores de membrana mostraram: (i) correlação positiva CD16 vs CR1 somente nos grupos com AR, ativa e inativa; (ii) correlação positiva CD16 vs CR3 no grupo com AR ativa; (iii) ausência de correlação entre a expressão de CD32 e o número de neutrófilos CD32+ no grupo com AR ativa; e (iv) correlação positiva entre a expressão de CR3 e o número de neutrófilos CR3+ no grupo com AR ativa. O conjunto de resultados sugere que estas diferenças ocorrem apenas durante a atividade da doença, reforçando a hipótese que estas alterações sejam uma característica adquirida da doença. Desta forma, este estudo pode contribuir para esclarecer mecanismos envolvidos na patogênese da AR, que possam ser alvos em potencial para o desenvolvimento de agentes terapêuticos específicos para esta doença. / Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease of unknown etiology that can impair the usual joint functions, due to cartilage damage, edema and pain. The RA pathogenesis involves multiple interacting immunological, environmental and genetic factors, making it difficult to find effective therapies. Neutrophils are the most abundant cells at AR inflammatory sites, since they migrate continuously to the synovial cavity. The activated neutrophils generate reactive oxygen species and release a variety of proteases that seem to be involved in the joint lesions of RA patients. Neutrophil activation can be mediated by membrane receptors for IgG (Fc?R) and for complement (CR) through interaction with immune complexes (IC). These receptors are also very important modulators of IC-mediated inflammatory reactions. However, the role of the complement system and Fc?R and the hierarchy of them in the manifestation of RA are still unclear. In this study, we evaluated the neutrophil oxidative burst induced by Fc?R and Fc?R/CR, from RA patients at active and inactive disease stages, and from healthy controls. This cellular function was assessed by luminol- and lucigenin-enhanced chemiluminescence (CL) systems. When neutrophils were stimulated via Fc?R or Fc?R/CR cooperation, we found that the cellular responses of active and inactive RA patients were not significantly different when compared to each other and to the healthy controls, by using both CL systems. However, the comparison between the active and inactive RA groups revealed that the CL responses triggered by IC opsonized with RA serum were not significantly higher than those observed for neutrophils stimulated only via Fc?R (IC-IgG), reflecting an absence of Fc?R/CR cooperation in these cells. In addition, the hemolytic activities of serum complement, classical/lectin and alternative pathways, were not different among the groups studied. With regard to the CR expression, only neutrophils from the active RA group showed an increased number of CR1 and CR3 on their surfaces when compared with the control (p<0.05) and the inactive RA groups (p<0.05), respectively. The Fc?R expressions, CD32 and CD16, were not different among the groups studied. In addition, correlation analysis of the expression among the different receptors showed: (i) a positive correlation CD16 vs CR1 in both RA groups, active and inactive; (ii) a positive correlation CD16 vs CR3 in the active RA group; (iii) an absence of correlation between the CD32/neutrophil expression and the number of this cell bearing CD32 in the active RA groups; and (iv) a positive correlation between the CR3/neutrophil expression and the number of this cell bearing CR3 in the active RA group. These results suggest that such differences could be occurring just during the activity of the RA, supporting once again an acquired characteristic of the disease. This study can contribute for the understanding of the mechanisms involved in the pathogenesis of the RA, which might become potential targets for the development of specific therapeutic agents for this disease.

A Artrite reumatóide (AR) é uma doença inflamatória crônica e sistêmica, de etiologia desconhecida, que pode dificultar ou impossibilitar as funções habituais das articulações devido à destruição da cartilagem, edema e dor. A patogênese da AR envolve uma complexa inter-relação de fatores imunológicos, ambientais e genéticos, dificultando assim a descoberta de terapias eficientes. Na AR, o influxo de neutrófilos para a cavidade sinovial é predominante e contínuo de tal forma que, os neutrófilos são as células mais abundantes no sítio inflamatório. Uma vez ativados, os neutrófilos são capazes de produzir espécies reativas de oxigênio que, juntamente com enzimas proteolíticas, podem estar envolvidos na lesão articular observada nos pacientes com AR. A ativação dos neutrófilos pode ser mediada por receptores para IgG (Fc?R) e para o complemento (CR) presentes nas membranas dessas células, através da interação com complexos imunes (ICs). Esses receptores são também importantes moduladores das reações inflamatórias mediadas por ICs. Entretanto, a função do sistema complemento e dos Fc?R, bem como a importância de cada um na manifestação da AR ainda não está clara. Assim, neste estudo avaliou-se o metabolismo oxidativo de neutrófilos estimulados através de receptores Fc?R e Fc?R/CR em ambos os grupos de pacientes com AR, ativa e inativa, e em controles saudáveis. Esta função celular foi avaliada por quimioluminescência (QL) dependente de luminol e de lucigenina. Os resultados mostraram que não houve diferenças na produção de QL, tanto dependente de luminol quanto de lucigenina, quando mediada por Fc?R ou pela cooperação Fc?R/CR, em ambos os grupos de pacientes com AR comparados entre si e comparados com neutrófilos de indivíduos saudáveis. No entanto, a comparação do padrão da resposta de QL dentro de ambos os grupos de pacientes com AR, mostrou que a resposta celular aos IC opsonizados por soro humano de pacientes com AR (IC-IgG/SHAR) não foi significativamente significantemente maior em relação à observada para os IC não opsonizados, refletindo uma ausência da cooperação Fc?R/CR nestas células. Vale ressaltar que a atividade hemolítica do complemento sérico, tanto da via clássica/lectina quanto da alternativa, não foi diferente entre os grupos estudados. Quanto à expressão dos CR, somente no grupo de pacientes com AR ativa observou-se diferenças, sendo que CR1 estava aumentado em relação ao grupo controle (p<0,05) e CR3 aumentado quando comparado ao grupo de pacientes com AR inativa (p<0,05). A expressão dos Fc?R, CD32 e CD16, não foi diferente entre os grupos estudados. Ainda, as análises de correlação da expressão dos diferentes receptores de membrana mostraram: (i) correlação positiva CD16 vs CR1 somente nos grupos com AR, ativa e inativa; (ii) correlação positiva CD16 vs CR3 no grupo com AR ativa; (iii) ausência de correlação entre a expressão de CD32 e o número de neutrófilos CD32+ no grupo com AR ativa; e (iv) correlação positiva entre a expressão de CR3 e o número de neutrófilos CR3+ no grupo com AR ativa. O conjunto de resultados sugere que estas diferenças ocorrem apenas durante a atividade da doença, reforçando a hipótese que estas alterações sejam uma característica adquirida da doença. Desta forma, este estudo pode contribuir para esclarecer mecanismos envolvidos na patogênese da AR, que possam ser alvos em potencial para o desenvolvimento de agentes terapêuticos específicos para esta doença. / Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease of unknown etiology that can impair the usual joint functions, due to cartilage damage, edema and pain. The RA pathogenesis involves multiple interacting immunological, environmental and genetic factors, making it difficult to find effective therapies. Neutrophils are the most abundant cells at AR inflammatory sites, since they migrate continuously to the synovial cavity. The activated neutrophils generate reactive oxygen species and release a variety of proteases that seem to be involved in the joint lesions of RA patients. Neutrophil activation can be mediated by membrane receptors for IgG (Fc?R) and for complement (CR) through interaction with immune complexes (IC). These receptors are also very important modulators of IC-mediated inflammatory reactions. However, the role of the complement system and Fc?R and the hierarchy of them in the manifestation of RA are still unclear. In this study, we evaluated the neutrophil oxidative burst induced by Fc?R and Fc?R/CR, from RA patients at active and inactive disease stages, and from healthy controls. This cellular function was assessed by luminol- and lucigenin-enhanced chemiluminescence (CL) systems. When neutrophils were stimulated via Fc?R or Fc?R/CR cooperation, we found that the cellular responses of active and inactive RA patients were not significantly different when compared to each other and to the healthy controls, by using both CL systems. However, the comparison between the active and inactive RA groups revealed that the CL responses triggered by IC opsonized with RA serum were not significantly higher than those observed for neutrophils stimulated only via Fc?R (IC-IgG), reflecting an absence of Fc?R/CR cooperation in these cells. In addition, the hemolytic activities of serum complement, classical/lectin and alternative pathways, were not different among the groups studied. With regard to the CR expression, only neutrophils from the active RA group showed an increased number of CR1 and CR3 on their surfaces when compared with the control (p<0.05) and the inactive RA groups (p<0.05), respectively. The Fc?R expressions, CD32 and CD16, were not different among the groups studied. In addition, correlation analysis of the expression among the different receptors showed: (i) a positive correlation CD16 vs CR1 in both RA groups, active and inactive; (ii) a positive correlation CD16 vs CR3 in the active RA group; (iii) an absence of correlation between the CD32/neutrophil expression and the number of this cell bearing CD32 in the active RA groups; and (iv) a positive correlation between the CR3/neutrophil expression and the number of this cell bearing CR3 in the active RA group. These results suggest that such differences could be occurring just during the activity of the RA, supporting once again an acquired characteristic of the disease. This study can contribute for the understanding of the mechanisms involved in the pathogenesis of the RA, which might become potential targets for the development of specific therapeutic agents for this disease.

B lymphocytes play a significant role in autoimmune arthritis, with their function stretching beyond autoantibody production to cytokine secretion and presentation of autoantigen. However, the involvement and activation of different B-cell subset in the autoimmune response is not fully clear. The main focus of this thesis has been to understand the contribution of marginal zone (MZ) B cells in the induction of collagen-induced arthritis (CIA), a mouse model for rheumatoid arthritis (RA). We show that MZ B cells in the spleen of naïve mice display a natural self-reactivity to collagen type II (CII), the autoantigen used for immunization of CIA. The CII-reactive MZ B cells expand rapidly following immunization with CII, and produce IgM and IgG antibodies to CII. They also very efficiently present CII to cognate T cells in vitro and in vivo. Moreover, absence of regulatory receptors such as CR1/2 or FcγRIIb on the MZ B cells increases their proliferation and cytokine production in response to toll-like receptor, but not B-cell receptor, activation. Further, FcγRIIb-deficient MZ B cells present CII to T cells more efficiently than wild-type MZ B cells. We additionally demonstrate for the first time the existence of a small population of nodal MZ B cells in mouse lymph nodes. Similar to splenic MZ B cells, the nodal MZ B cells expand after CIA induction, secrete IgM anti-CII antibodies and can present CII to cognate T cells. Finally, we show that mast cells, associated with ectopic B cell follicles in inflamed RA joints, in coculture with B cells promote their expansion, production of IgM and IgG antibodies as well as upregulation of CD19 and L-selectin. Coculture with mast cells further causes the B cells to upregulate costimulators and class II MHC, important molecules for antigen-presenting function. In summary, my findings suggest that splenic and nodal self-reactive MZ B cells participate in breaking T-cell tolerance to CII in CIA. B-cell intrinsic regulation is needed to keep such autoreactive B cells quiescent. Mast cells can potentiate B-cell responses locally in the arthritic joint, thus feeding the autoimmune reaction.

HIV/AIDS is raging and causing millions of deaths around the world. The major challenge in treating HIV/AIDS is the establishment of HIV reservoirs where the viruse escapes both drug and immune system attempts at eradication. Throughout the course of HIV/AIDS, productive HIV infection occurs primarily in the lymphoid follicles or germinal centers (GC) surrounding follicular dendritic cells (FDC). In the GCs, FDCs trap and maintain infectious HIV for years and provide these infectious viruses to the host cells. FDCs also attract B and T cells into the GCs and increase the ability of CD4+ T cells to be infected. Additionally, FDCs also mediate the increase of HIV replication in HIV-infected CD4+ T cells. Recently, several clinical cases and in vitro studies suggest that alpha-1-antitrypsin (AAT) might inhibit HIV infection and replication. Therefore, I hypothesized that AAT inhibited both the infection and replication of HIV in primary CD4+ T cells. I also postulated that AAT inhibited the FDC-mediated contributions that potentiate HIV infection and replication. To test whether AAT inhibited HIV infection in lymphocytes, CD4+ T cells were pretreated with AAT and then incubated with HIV to detect HIV infection. To exam whether AAT inhibited HIV replication, infected CD4+ T cells were cultured with AAT to detect the replication of HIV. To determine whether AAT blocked the FDC-mediated contributions to HIV pathogenesis, activated or resting FDCs were treated with AAT to detect the trapping and maintenance of HIV. The results suggested that AAT inhibited HIV entry into CD4+ T cells by directly interacting with gp41 and thereby inhibiting the interaction between HIV and CD4+ T cells. AAT also inhibited HIV replication in infected CD4+ T cells. Further study revealed that AAT interacted with low-density lipoprotein-receptor related protein to mediate the internalization of AAT through a clathrin-dependent endocytic process in CD4+ T cells. Subsequently, internalized AAT was transported from the endosome to the lysosome and then released into the cytosol. In the cytosol, AAT directly interacted with IκBα to block its polyubiquitinylation at lysine residue 48, which resulted in the accumulation of phosphorylated/ubiqutinylated IκBα in the cytosol. In turn, the dissociation of IκBα from NF-κB was blocked, which thereby inhibited the nuclear translocation and activation of NF-κB. Additionally, AAT also down-regulated FDC-CD32 and FDC-CD21 expression, which are regulated by NF-kB, thereby inhibiting the trapping and maintenance of HIV on FDCs. Hence, AAT not only suppresses HIV replication, but also blocks HIV replication in CD4+ T cells. Moreover, AAT also inhibits the activation of FDCs thereby affecting the trapping and maintenance of HIV.

Molecular dynamics (MD) simulations were used to investigate the structural basis for the functions of three proteins: Fc(gamma) receptor III (CD16), von Willebrand factor (VWF), and integrin. CD16, a heavily glycosylated protein expressed on human immune cells, plays a crucial role in immune defense by linking antibody-antigen complexes with cellular effector functions. Glycosylation of CD16 decreases its affinity for IgG. MD simulations were run for CD16-IgG Fc complexes with or without an N-glycan on CD16. The two simulated complexes show different conformations. Molecular Mechanics-Poisson Boltzmann Surface Area (MM-PBSA) approach was used to calculate the binding free energy of the CD16-IgG Fc complexes. The calculated binding free energy helped to identify critical residues. VWF, a multimeric multidomain glycoprotein, initiates platelet adhesion at the sites of vascular injury. A specific VWF metalloprotease, A Disintegrin And Metalloprotease with ThromboSpondin motifs member 13 (ADAMTS-13), cleaves the Tyr1605-Met1606 bond in the VWF A2 domain to generate the full spectrum of plasma VWF species. Shear stress or denaturants assist VWF cleavage by ADAMTS-13 due to the unfolding of A2. MD was used to simulate the unfolding processes of A2 under force or high temperature. The beta-strands of A2 were pulled out sequentially by force, during which the cleavage site changed in steps from the fully buried state to the fully exposed state. Thermal unfolding follows a very different pathway. Integrins are adhesion molecules mediating cell-cell, cell-extracellular matrix, and cell-pathogen interactions. Experiments suggest that integrins can undergo a large-scale change from a bent to an extended conformation, associating with a transition from low to high affinity states, i.e., integrin activation. Steered MD was utilized to simulate the bent-to-extended conformational transition in time of aVb3 integrin. The integrin was observed to change smoothly from the bent to the extended conformation. One major energy barrier was overcome, corresponding to the disruption of the interactions at Hybrid/EGF4/bTD interfaces. A partially extended conformation tends to bend back while a fully extended conformation is stabilized by the coordination of Asp457 with Ca2+ at alpha-genu. Unbending with separated legs overcomes more energy barriers.