Modeling corticotroph deficiency with pituitary organoids supports the functional role of NFKB2 in human pituitary differentiation

Reviewer #1 (Public Review):

Summary:
NFKB mutations are thought to be one of the causes of pituitary dysfunction, but until now they could not be reproduced in mice and their pathomechanism was unknown. The authors used the differentiation of hypothalamic-pituitary organoids from human pluripotent stem cells to recapitulate the disease in human iPS cells carrying the NFKB mutation.

Strengths:
The authors achieved their primary goal of recapitulating the disease in human cells. In particular, the differentiation of the pituitary gland is closely linked to the adjacent hypothalamus in embryology, and the authors have again shown that this method is useful when the hypothalamus is suspected to be involved in pituitary abnormalities caused by genetic mutations.

Weaknesses:
On the other hand, the pathomechanism is still not fully understood. This study provides some clues to the pathomechanism, but further analysis of NFKB expression and experiments investigating the relevant factors in more detail may help to clarify it further.

Reviewer #2 (Public Review):

Summary:
DAVID syndrome is a rare autosomal dominant disorder characterized by variable immune dysfunction and variable ACTH deficiency. Nine different families have been reported, and all have heterozygous mutations in NFKB2. The mechanism of NFKB2 action in the immune systems has been well-studied, but nothing is known about its role in the pituitary gland.

The DAVID mutations cluster in the C-terminus of the NFKB2 and interfere with cleavage and nuclear translocation. The mutations are likely dominant negative, by affecting dimer function. ACTH deficiency can be life-threatening in neonates and adults, thus, understanding the mechanism of NFKB2 action in pituitary development and/or function is important.

The authors use CRISPR/Cas gene editing of human iPSC-derived pituitary-hypothalamic organoids to assess the function of NFKB2 and TBX19 in pituitary development. Mutations in TBX19 are the most common, known cause of pituitary ACTH deficiency, and the mechanism of action has been studied in mice, which phenocopy the human condition. Thus, the TBX19 organoids can serve as a positive control. The Nfkb2 mouse model has a p.Y868* mutation that impairs cleavage of NFKB2 p100, and the immune phenotype mimics the patients with DAVID mutations, but no pituitary phenotype was evident. Thus, a human organoid model might be the only approach suitable to discover the etiology of the pituitary phenotype.

Overall, the authors have selected an important problem, and the results suggest that the pituitary insufficiency in DAVID syndrome is caused by a developmental defect rather than an autoimmune hypophysitis condition. The use of gene editing in human iPSC-derived hypothalamic-pituitary organoids is significant, as there is only one example of this previously, namely studies on OTX2. Only a few laboratories have demonstrated the ability to differentiate iPSC or ES cells to these organoids, and the authors have improved the efficiency of differentiation, which is also significant.

The strength of the evidence is excellent. However, the two ACTH-deficient organoid models use a single genetically engineered clone, and the potential for variability amongst clones makes the conclusions less compelling. Since the authors obtained two independent clones for NFKB2 it is not clear why only one clone was studied. Finally, the effect of TBX19 on early pituitary fate markers is somewhat surprising given the phenotype of the knockout mice and patients with mutations. Thus, the use of a single clone for that study is also worrisome.

Strengths:
The authors make mutations in TBX19 and NFKB2 that exist in affected patients. The TBX19 p.K146R mutation is recessive and causes isolated ACTH deficiency. Mutations in this gene account for 2/3 of isolated ACTH deficiency cases. The NFKB2 p.D865G mutation is heterozygous in a patient with recurrent infections and isolated ACTH deficiency. NFKB2 mutations are a rare cause of ACTH deficiency, and they can be associated with the loss of other pituitary hormones in some cases. However, all reported cases are heterozygous.

The developmental studies of organoid differentiation seem rigorous in that 200 organoids were generated for each hiPSC line, and 3-10 organoids were analyzed for each time point and genotype. Differentiation analysis relied on both RNA transcript measurements and immunohistochemistry of cleared organoids using light sheet microscopy. Multiple time points were examined, including seven times for gene expression at the RNA level and two times in the later stages of differentiation for IHC.
TBX19 deficient organoids exhibit reduced levels of PITX1, LHX3, and POMC (ACTH precursor) expression at the RNA and IHC level, and there are fewer corticotropes in the organoids, as ascertained by POMC IHC.

The NFKB2 deficient organoids have a normal expression of the early pituitary transcription factor HESX1, but reduced expression of PITX2, LHX3, and POMC. Because there is no immune component in the organoid, this shows that NFKB2 mutations can affect corticotrope differentiation to produce POMC. RNA sequencing analysis of the organoids reveals potential downstream targets of NFKB2 action, including a potential effect on epithelial-to-mesenchymal-like transition and selected pituitary and hypothalamic transcription factors and signaling pathways.

Weaknesses:
There could be variation between individual iPSC lines that is unrelated to the genetically engineered change. While the authors check for off-target effects of the guide RNA at predicted sites using WGS, a better control would be to have independently engineered clones or to correct the engineered clone to wild type and show that the phenotypic effects are reversed.

All NFKB2 patients are heterozygous for what appear to be dominant negative mutations that affect protein cleavage and nuclear localization of processed protein as homo or heterdimers. The organoids are homozygous for this mutation. Supplemental Figure 4 indicates that one heterozygous clone and two homozygous mutant clones were obtained. Analysis of these additional clones would give more strength to the conclusions, showing reproducibility and the effect of mutant gene dosage.

Reviewer #3 (Public Review):

Summary:
This manuscript by Mac et al addresses the causes of pituitary dysfunction in patients with DAVID syndrome which is caused by mutations in the NFKB2 gene and leads to ACTH deficiency. The authors seek to determine whether the mutation directly leads to altered pituitary development, as opposed to an autoimmune defect, by using mutating human iPSCs and then establishing organoids that differentiate into pituitary tissue. They first seek to validate the system using a well-characterised mutation of the transcription factor TBX19, which also results in ACTH deficiency in patients. Then they characterise altered pituitary cell differentiation in mutant NFKB2 organoids and show that these lack corticotrophs, which would lead to ACTH deficiency.

Strengths:
The conclusion of the paper that ACTH deficiency in DAVID syndrome is independent of an autoimmune input is strong.

Weaknesses:
1. The authors correctly emphasise the importance of establishing the validity of an iPSC-based model in being able to recapitulate in vivo dysfunctional pituitary development through characterisation of a TBX19 knock-in mutation. Whilst this leads to the expected failure of functional corticotroph differentiation, other aspects of the normal pituitary differentiation pathway upstream of corticotroph commitment seem to have been affected in surprising ways. In particular, the loss of LHX3 and PITX1 in TBX19 mutant organoids compared with wild type requires explanation, especially as the mutant protein would only be expected to be expressed in a small proportion of anterior pituitary lineage cells. If the developmental expression profile of key transcription factors in mutant organoids does not recapitulate that which occurs in vivo, any interpretation of the relevance of expression differences in the NFKB2 organoids to the mechanism(s) leading to corticotroph function in vivo has to be questionable. It is notable that the manipulation of iPSC cells used to generate mutants through CRISPR/Cas9 editing is not applied to the control iPSC line. It is possible that these manipulations lead to changes to the iPSC cells that are independent of the mutations introduced and this may change the phenotype of the cells. A better control would have been an iPSC line with a benign knock-in (such as GFP into the ROSA26 locus).

2. In the results section of the manuscript the authors acknowledge that hypothalamic tissue in the NFKB2 mutant organoid may be having an effect on the development of pituitary tissue. However, in the discussion the emphasis is entirely on pituitary autonomous mechanisms such as pituitary HESX1 expression or POMC gene regulation; in the conclusion of the abstract, a direct role for NFKB2 in pituitary differentiation is described. Whilst the data here may suggest a non-immune mediated alteration in pituitary function in DAVID syndrome, if this is due to alteration of the developing hypothalamus then this is not direct. A fuller discussion of the potential hypothalamic contribution and/or further characterisation of this aspect is warranted.

3. qRT-PCR data presented in Figure 6A shows negligible alteration of HESX1 expression at all time points in NFKB2 mutant organoids. This is not consistent with the 2-fold increase in HESX1 expression described in day 48 organoids found by bulk RNA sequencing. How do the authors reconcile these results and why is one result focused on in the discussion where a potential mechanism for a blockade of normal pituitary cell differentiation is suggested? Further confirmation of HESX1 expression is required.

4. Throughout the authors focus on POMC gene expression and ACTH antibody immunopositive as being indicative of corticotroph cell identity. In the human fetal pituitary melanotrophs are present and most ACTH antibodies are unable to distinguish these cells from corticotrophs. Is the antibody used specifically for ACTH rather than other products of the POMC gene? It is unlikely that all the ACTH-positive cells are melanotrophs, nevertheless, it is important to know what the proportions of the 2 POMC-positive cell types are. This could be distinguished by looking for the expression of NeuroD1, which would also define whether corticotrophs are committed but not fully differentiated in the NFKB2 mutant organoids. In support of an effect on corticotrophs, it is notable that CRHR1 expression (which would be expected to be restricted to this cell type) is reduced by 84% in bulk RNAseq data (Table 1) and this may be an indicator of the loss of corticotrophs in the model.

5. Notwithstanding the caveats about whether the organoid model recapitulates in vivo pituitary differentiation (see 1 above) and whether the bulk RNAseq accurately reflects expression levels (see 3 above), there are potentially some extremely interesting changes in gene expression shown in Table 1 which warrant further discussion. For example, there is a 25-fold reduction in POU1F1 expression which may be expected to reflect a loss of somatotrophs in the organoid (and possibly lactotrophs) and highlights the importance of characterising the effect of NFKB2 on other anterior pituitary cell types within the organoid. If somatotrophs are affected, this may be relevant to the organoids as a model of DAVID syndrome as GH deficiency has been described in some individuals with NFKB2 mutations. The huge increase in CGA expression may reflect a switch in cell fate to gonadotrophs, as has been described with a loss of TPIT in the mouse. These are examples of the changes that warrant further characterisation and discussion.

6. How do the authors explain the lack of effect of NFKB2 mutation on global NFKB signalling?