J. Van Cleemput

RNA Profiling in Human and Murine Transplanted Hearts: Identification and Validation of Therapeutic Targets for Acute Cardiac and Renal Allograft Rejection

Acute cellular rejection (ACR) is the adverse response of the recipients immune system against the allogeneic graft. Using human surveillance endomyocardial biopsies (EMBs) manifesting ACR and murine allogeneic grafts, we profiled implicated microRNAs (miRs) and mRNAs. MiR profiling showed that miR‐21, ‐142‐3p, ‐142‐5p, ‐146a, ‐146b, ‐155, ‐222, ‐223, and ‐494 increased during ACR in humans and mice, whereas miR‐149‐5p decreased. mRNA profiling revealed 70 common differentially regulated transcripts, all involved in immune signaling and immune‐related diseases. Interestingly, 33 of 70 transcripts function downstream of IL‐6 and its transcription factor spleen focus forming virus proviral integration oncogene (SPI1), an established target of miR‐155, the most upregulated miR in human EMBs manifesting rejection. In a mouse model of cardiac transplantation, miR‐155 absence and pharmacological inhibition attenuated ACR, demonstrating the causal involvement and therapeutic potential of miRs. Finally, we corroborated our miR signature in acute cellular renal allograft rejection, suggesting a nonorgan specific signature of acute rejection. We concluded that miR and mRNA profiling in human and murine ACR revealed the shared significant dysregulation of immune genes. Inflammatory miRs, for example miR‐155, and transcripts, in particular those related to the IL‐6 pathway, are promising therapeutic targets to prevent acute allograft rejection.

Cost of 1-year left ventricular assist device destination therapy in chronic heart failure: a comparison with heart transplantation

Abstract Objective: To analyse overall cost involved with destination therapy (DT) in comparison to transplantation (HTX) and bridging to transplantation. Methods: Three groups of patients at one hospital were considered for this cost analysis: (1) patients included in the BENEMACS study starting May 2009 (n = 6); (2) all patients from May 2009 till May 2010 undergoing heart transplantation (n = 19); or (iii) undergoing Heartmate II implantation as a bridge to transplant (n = 13). Patients undergoing bridging were more sick (lower Intermacs class). DT patients were older (64±8 years). Cost was derived from actual hospital invoices, device, organ procurement and medical cost, and follow-up care during 1 year from implantation. Costs are presented in euro, by their mean values and standard deviation. Results: One-year survivals were 83, 84, and 77%, respectively, for DT, HTX, and bridging. Costs for initial and re-hospitalizations were not different between groups. Costs for medical follow-up and medication were significantly higher for transplanted patients. The 1-year total cost was €85 531±19 823 for HTX, €125 108±32 399 for bridging, and €137 068±29 007 for DT. As 42% of the transplanted patients were bridged, the cost of the medical pathway HTX was €138 076±19 823. Assuming a 5-year survival and a similar yearly follow-up cost, the average cost per year is €42 153 for HTX, €53 637 for transplantation including the bridging cost, and €47 487 for DT. Conclusion: Direct transplantation without bridging is the most cost-efficient treatment. The cost per patient per year for DT is similar to HTX considering its bridging activity.

Transplantation osteoporosis and corticosteroid-induced osteoporosis in autoimmune diseases: experience with alfacalcidol

Summary The effect of alfacalcidol therapy on bone mineral density at the spine and proximal femur was evaluated in 112 transplant recipients (59 heart, 26 liver and 27 lung); 45 transplant cases served as controls (included in a randomised way in a placebo group) and in 42 rheumatoid arthritis cases.¶ Liver and lung transplantation cases had before transplantation a lower bone density at the spine and femur compared to heart transplant cases. Heart transplant cases lost considerably more bone immediately after transplantation than liver and lung transplant recipients.¶ A positive effect of 2 years alfacalcidol treatment (0.5–1 μg/day) on bone loss was observed in all treated groups. Alfacalcidol was particularly effective against trabecular bone loss at the spine in rheumatoid arthritis patients and transplant recipients. There is a manifest difference in evolution between organ transplant groups and bone sites measured. Liver and lung transplant recipients respond better to therapy than cardiac recipients.

A probable primary HIV infection associated with acute non-specific myocarditis causing severe dilated cardiomyopathy.

A patient with a probable primary HIV infection and a biopsy proven non-specific myocarditis is reported. The patient developed a severe dilated cardiomyopathy and initially presented with global heartfailure and fever. The left ventricular function partially recovered. One week after discharge the patient was readmitted in a septic shock and died. Current hypotheses concerning the etiology of left ventricular dysfunction in HIV infection are discussed.

URINARY PROTEOMIC SIGNATURES ASSOCIATED WITH BETA-BLOCKADE AND HEART RATE IN HEART TRANSPLANT RECIPIENTS

Objective: Heart transplant (HTx) recipients have a high heart rate (HR), because of graft denervation and are frequently started on &bgr;-blockade (BB). We assessed whether BB and HR post HTx are associated with a specific urinary proteomic signature. Design and method: In 336 HTx patients (mean age, 56.8 years; 22.3% women), we analyzed cross-sectional data obtained 7.3 years (median) after HTx. We recorded medication use, measured HR during right heart catheterization, and applied capillary electrophoresis coupled with mass spectrometry to determine the multidimensional urinary classifiers HF1 and HF2 (known to be associated with left ventricular dysfunction), ACSP75 (acute coronary syndrome) and CKD273 (renal dysfunction) and 48 sequenced urinary peptides revealing the parental proteins. Results: In adjusted analyses, HF1, HF2 and CKD273 (p <  = 0.024) were higher in BB users than non-users with a similar trend for ACSP75 (p = 0.06). Patients started on BB within 1 year after HTx and non-users had similar HF1 and HF2 levels (p >  = 0.098), whereas starting BB later was associated with higher HF1 and HF2 compared with non-users (p <  = 0.014). There were no differences in the urinary biomarkers (p >  = 0.27) according to HR. BB use was associated with higher urinary levels of collagen II and III fragments and non-use with higher levels of collagen I fragments. Conclusions: BB use, but not HR, is associated with a urinary proteomic signature that is usually associated with worse outcome, because unhealthier conditions probably lead to initiation of BB. Starting BB early after HTx surgery might be beneficial.

AB0638 Cardiac transplant in systemic sclerosis-associated cardiomyopathy: monocentric experience of 3 cases

Background Cardiac involvement in systemic sclerosis (SSc) is a frequent complication, but end-stage cardiac failure remains uncommon and represents a poor prognosis. Heart-lung and lung transplant is an established treatment option for SSc-related pulmonary disease. Due to the limited published data, no recommendations exist for cardiac transplant in the context of SSc. Objectives We present our monocentric experience of 3 patients with SSc who underwent cardiac transplant for SSc-related end-stage heart disease (multiple hospitalisations due to failure of medical therapy and life-threatening complications). Results Case 1 is a 59-year-old male with limited cutaneous SSc. Antinuclear antibody (ANA) was negative. He had vascular (digital ulcers) and cardiac (heart failure (left ventricular ejection fraction (LVEF) 20%, NYHA class IV)) involvement, without major gastrointestinal or pulmonary involvement (no interstitial lung disease (ILD) or pulmonary arterial hypertension (PAH: assessed by right heart catheterization (RHC))). He underwent a cardiac transplant at the age of 51, after a disease duration of 6 years. Post-transplantation immunosuppressant therapy consists of tacrolimus and mycophenolic acid, initially associated with methylprednisolon, which is the standard immunosuppression protocol at our institution. Case 2 is a 55-year-old male with limited cutaneous SSc. ANA was positive, 1/320, speckled pattern, but no SSc-related autoantibody has been identified. He had gastrointestinal (upper gastrointestinal tract dysmotility), muscular (myositis) and cardiac (heart failure with secondary cardiac cirrhosis (LVEF 40%, NYHA class III)) involvement, without major pulmonary involvement (no ILD or PAH). He underwent a cardiac transplant at the age of 54, after a disease duration of 7 years. Standard immunosuppressants were initiated. Case 3 is a 50-year-old male with diffuse cutaneous SSc. ANA was negative. He had vascular (digital ulcers), gastrointestinal (upper gastrointestinal tract dysmotility) and cardiac (heart failure with secondary cardiac cirrhosis (LVEF 40%, NYHA class III)) involvement, without major pulmonary involvement (no ILD or PAH). He underwent a cardiac transplant at the age of 49, after a disease duration of 4 years. Standard immunosuppressants were initiated. At present, 1,5 years (case 2 and 3) and 8 years (case 1) after transplant, the donor hearts are still functioning well. No other SSc-related organ manifestations have occurred. Case 1 Case 2 Case 3 Sex, age Male, 59 years Male, 55 years Male, 50 years Type of SSc Limited Limited Diffuse Disease duration at Tx 6 years 7 years 4 years ANA Negative 1/320, speckled, no SSc-specific antibody Negative Pre-Tx NYHA class IV III III LVEF 20% 40% 40% RHC: mPAP in mmHg 26 20 31 RHC: PCWP in mmHg 20 14 28 Post-Tx NYHA class I I I LVEF 60% 55% 60% RHC: mPAP in mmHg 19 13 21 RHC: PCWP in mmHg 12 8 12 Tx: Transplant; mPAP: Mean pulmonary artery pressure; PCWP: Pulmonary capillary wedge pressure. Conclusions We present 3 patients with SSc who successfully underwent cardiac transplant for SSc-related end-stage heart disease. None had other major SSc-related organ involvement. This supports the limited published data that cardiac transplant is feasible and can be considered in end-stage SSc-related cardiomyopathy. Disclosure of Interest None declared

RADIATON INDUCED CARDIOVASCULAR DISEASE

A 46-year-old man who received thoracic radiotherapy in his early twenties for a Hodgkin lymphoma presented with increasing shortness of breath on minimal exertion, NYHA III. Clinically he suff ered from tachycardia, had an elevated jugular venous pressure, and dullness on percussion over his left lower lung base. Chest X-ray showed the presence of a left-sided pleural eff usion (Figure 1A, arrowhead) and several nodular opacities in the anterior mediastinum (Figure 1A, arrow), identifi ed as calcifi ed lymph-nodes on CT which further revealed widespread aortic, coronary and pericardial calcifi cation (Figure 1B) with extensive calcifi c penetration into the subepicardial infero-lateral myocardium up to six millimetres deep (Figure 1C, arrowhead), leading to constrictive haemodynamics. The carotid arteries were aff ected as well by calcifi ed, nonfl ow-limiting plaques (Figure 1D, arrows), while the coronary arteries showed several severe stenoses (Figure 1E, arrowheads). The non-coronary cusp of the aortic valve was diff usely calcifi ed while the other cusps only showed calcifi cation at the level of the commissures (Figure 1F), resulting in moderate aortic stenosis. After discussion between cardiologists and cardiac surgeons, it was decided to treat the coronary lesions percutaneously, since surgical graft insertion on these heavily calcifi ed vessels seemed virtually impossible. Moreover, considering the atherosclerotic changes in the other arteries, the quality of mammary artery grafts would be highly questionable. Bare metal stents were successfully implanted in the left anterior descending and circumfl ex artery. Six weeks later a sub-total pericardiectomy was performed during which a large bulk of calcifi c tissue was excised, and a mechanical aorticvalve prosthesis implanted. The patient made a good recovery and follow-up echocardiography showed proper function of the mechanical valve and moderate diastolic dysfunction without evidence of constriction. Radiation-induced cardiovascular disease (RICD) encompasses accelerated atherosclerosis in aff ected arteries and fi bro-calcifi c changes in pericardium, myocardium, valves and conduction system, resulting in a variety of clinical manifestations ranging from cardiac ischemia to pericardial constriction, restrictive cardiomyopathy, arrhythmias and valvular dysfunction (1, 2). RICD can remain silent for years and its occurrence is infl uenced by multiple factors including cumulative radiation-dose, concomitant chemotherapy and the use of protective cardiac shielding. Although several techniques have been developed to focus radiotherapy on the tumour thereby reducing irradiation of the surrounding tissues, the risk of RICD has not been extinguished (2).

Role of alfacalcidiol on bone quality and immunomodulation in autoimmune disease and organ transplantation

In autoimmune diseases, as well as in organ transplantation, corticosteroids are often an obligatory part of the treatment regimen. The deleterious effect of corticosteroids on bone metabolism is well known, although still controversial [1-3]. It is easier to maintain bone mass than to restore it. Although the treatment of choice for prevention of bone loss is hormone replacement therapy, it cannot always be applied, and for many reasons compliance is low over the world. Alternative strategies to prevent bone loss are now tried out in many centers. Calcitonin and bisphosphonates are well-known antiresorbing drugs, but costs and long-term efficiency for calcitonin and fear for bone toxicity for the bisphosphonates limits their use for prevention. An attractive strategy to prevent osteoporosis is the treatment with alfacalcidiol because it is a natural product with important effects on bone metabolism in physiological and pharmacological dosages. Calcium absorption from the gut and mineralization of the bone matrix are optimalized by alfacalcidiol. The purpose of this paper is to report on our experience with alfacalcidiol concerning bone mass and quality in corticosteroid-induced osteoporosis in experimental animals and on long-term bone quality in autoimmune diseases and organ transplantation. We have studied the effects of alfacalcidiol on bone mass and quality in ovariectomized animals with and without corticosteroids. In these fundamental studies we have found that alfacalcidiol had a profound protective and curative effect not only on bone mass but also on bone quality as tested by mechanical testing, namely, impact torsional loading test of whole bones. The combination of alfacalcidiol with estrogens was less effective than alfacalcidiol, but more effective than estrogens alone [4-6] (Fig. 1).