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Zhu XY, Klomjit N, Pawar AS, Puranik AS, Yang ZZ, Lutgens E, Eirin A, Lerman A, Textor SC, Lerman LO. Altered immune cell phenotypes within chronically ischemic human kidneys distal to occlusive renal artery disease. Am J Physiol Renal Physiol 2024; 326:F257-F264. [PMID: 38031731 DOI: 10.1152/ajprenal.00234.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023] Open
Abstract
Renal artery stenosis (RAS) is a major cause of ischemic kidney disease, which is largely mediated by inflammation. Mapping the immune cell composition in ischemic kidneys might provide useful insight into the disease pathogenesis and uncover therapeutic targets. We used mass cytometry (CyTOF) to explore the single-cell composition in a unique data set of human kidneys nephrectomized due to chronic occlusive vascular disease (RAS, n = 3), relatively healthy donor kidneys (n = 6), and unaffected sections of kidneys with renal cell carcinoma (RCC, n = 3). Renal fibrosis and certain macrophage populations were also evaluated in renal sections. Cytobank analysis showed in RAS kidneys decreased cell populations expressing epithelial markers (CD45-/CD13+) and increased CD45+ inflammatory cells, whereas scattered tubular-progenitor-like cells (CD45-/CD133+/CD24+) increased compared with kidney donors. Macrophages switched to proinflammatory phenotypes in RAS, and the numbers of IL-10-producing dendritic cells (DC) were also lower. Compared with kidney donors, RAS kidneys had decreased overall DC populations but increased plasmacytoid DC. Furthermore, senescent active T cells (CD45+/CD28+/CD57+), aged neutrophils (CD45+/CD15+/CD24+/CD11c+), and regulatory B cells (CD45+/CD14-/CD24+/CD44+) were increased in RAS. RCC kidneys showed a distribution of cell phenotypes comparable with RAS but less pronounced, accompanied by an increase in CD34+, CD370+, CD103+, and CD11c+/CD103+ cells. Histologically, RAS kidneys showed significantly increased fibrosis and decreased CD163+/CD141+ cells. The single-cell platform CyTOF enables the detection of significant changes in renal cells, especially in subsets of immune cells in ischemic human kidneys. Endogenous pro-repair cell types in RAS warrant future study for potential immune therapy.NEW & NOTEWORTHY The single-cell platform mass cytometry (CyTOF) enables detection of significant changes in one million of renal cells, especially in subsets of immune cells in ischemic human kidneys distal to renal artery stenosis (RAS). We found that pro-repair cell types such as scattered tubular-progenitor-like cells, aged neutrophils, and regulatory B cells show a compensatory increase in RAS. Immune cell phenotype changes may reflect ongoing inflammation and impaired immune defense capability in the kidneys.
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Affiliation(s)
- Xiang-Yang Zhu
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Nattawat Klomjit
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Aditya S Pawar
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Amrutesh S Puranik
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Zhi-Zhang Yang
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, United States
| | - Esther Lutgens
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Alfonso Eirin
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Stephen C Textor
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Lilach O Lerman
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
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Artyszuk Ł, Symonides B, Gaciong Z, Cienszkowska K, Ludwiczak M, Wrzaszczyk M, Szmigielski CA. A new threshold for kidney asymmetry improves association with abnormal renal-aortic ratio for diagnosis of renal artery stenosis. Vasc Med 2022; 27:551-556. [PMID: 36190768 DOI: 10.1177/1358863x221118604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Renal artery stenosis (RAS) reflects more widespread atherosclerosis deposition and is associated with high morbidity and mortality. According to the guidelines, a discrepancy in the size of the kidneys of over 15 mm found in an ultrasound should initiate the RAS diagnostic algorithm. This study aims to find the optimal threshold for renal asymmetry that better reflects the frequency of a significantly abnormal renal-aortic ratio (RAR), justifying further RAS diagnostic workup, than the currently used cut-off of 15 mm difference in renal diameters. METHODS The analysis included 1175 patients (mean age: 52 years, IQR: 38-66, men/women: 597/578) who underwent Doppler ultrasonography screening of renal arteries with recorded kidney size and RAR calculation. Ultrasound features of RAS were defined as a RAR greater than 3.5 or signs of renal artery occlusion. Receiver operating characteristic (ROC) curves were created and analyzed for absolute differences in kidney size and abnormal RAR. We calculated the area under the curve (AUC) and optimal cut-off values for sensitivity and specificity analysis. RESULTS The final analysis included 169 patients with a significant difference in renal dimension. RAS features were met in 61 patients. According to ROC curve analysis, the optimal index of renal asymmetry was 12 mm. The sensitivity and specificity for this method were 82.0% and 83.3%, respectively, and AUC was 86.3%. CONCLUSION Changing the definition of a significant difference in kidney size from 15 mm to 12 mm increases sensitivity and specificity for abnormal RAR and this finding may accelerate the diagnosis of RAS.
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Affiliation(s)
- Łukasz Artyszuk
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Cienszkowska
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Marta Ludwiczak
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Wrzaszczyk
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Cezary A Szmigielski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
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Klomjit N, Zhu XY, Massat AE, Pawar AS, Conley S, Puranik AS, Ferguson CM, Kim SR, Tang H, Jordan K, Saadiq I, Lerman A, Grande JP, Textor SC, Lerman LO. Microvascular remodeling and altered angiogenic signaling in human kidneys distal to occlusive atherosclerotic renal artery stenosis. Nephrol Dial Transplant 2022; 37:1844-1856. [PMID: 35451482 PMCID: PMC9494086 DOI: 10.1093/ndt/gfac156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal artery stenosis (RAS) is an important cause of chronic kidney disease and secondary hypertension. In animal models, renal ischemia leads to downregulation of growth-factor expression and loss of intrarenal microcirculation. However, little is known about the sequelae of large vessel occlusive disease on the microcirculation within human kidneys. METHOD This study included 5 patients who underwent nephrectomy due to renovascular occlusion, and 7 non-stenotic discarded donor kidneys (4 deceased donors). Micro-computed tomography was performed to assess microvascular spatial densities and tortuosity, an index of microvascular immaturity. Renal protein expression, gene expression, and histology were studied in-vitro using immunoblotting, polymerase-chain-reaction, and staining. RESULTS RAS demonstrated loss of medium-sized vessels (0.2-0.3mm) compared to donor kidneys (p = 0.037) and increased microvascular tortuosity. RAS kidneys had greater protein expression of angiopoietin-1, hypoxia-inducible factor (HIF)-1α, and thrombospondin (TSP)-1, but lower protein expression of vascular endothelial growth factor (VEGF) than donor kidneys. Renal fibrosis, loss of peritubular capillaries (PTC) and pericyte detachment were greater in RAS, yet they had more newly-formed PTC than donor kidneys. Therefore, our study quantified significant microvascular remodeling in the post-stenotic human kidney. RAS induced renal microvascular loss, vascular remodeling, and fibrosis. Despite downregulated VEGF, stenotic kidneys upregulated compensatory angiogenic pathways related to angiopoietin-1. CONCLUSIONS These observations underscore the nature of human RAS as a microvascular disease distal to main vessel stenosis, and support therapeutic strategies directly targeting the post-stenotic kidney microcirculation in patients with RAS.
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Affiliation(s)
- Nattawat Klomjit
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Xiang-Yang Zhu
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Aditya S Pawar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sabena Conley
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amrutesh S Puranik
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Seo Rin Kim
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Hui Tang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Kyra Jordan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Ishran Saadiq
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph P Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Lerman LO. Cell-based regenerative medicine for renovascular disease. Trends Mol Med 2021; 27:882-894. [PMID: 34183258 PMCID: PMC8403163 DOI: 10.1016/j.molmed.2021.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 12/25/2022]
Abstract
Renal artery stenosis (RAS) elicits the development of hypertension and post-stenotic kidney damage, which may become irresponsive to restoration of arterial patency. Rather than mere losses of blood flow or oxygen supply, irreversible intrarenal microvascular rarefaction, tubular injury, and interstitial fibrosis are now attributed to intrinsic pathways activated within the kidney, focusing attention on the kidney parenchyma as a therapeutic target. Several regenerative approaches involving the delivery of reparative cells or products have achieved kidney repair in experimental models of RAS and the delivery of mesenchymal stem/stromal cells (MSCs) has already been translated to human subjects with RAS with promising results. The ongoing development of innovative approaches in kidney disease awaits application, validation, and acceptance as routine clinical treatment to avert kidney damage in RAS.
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Affiliation(s)
- Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
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Zhou J, Jin F, Wu F. Clinical significance of changes in serum inflammatory factors in patients with chronic obstructive pulmonary disease and pulmonary infection. J Int Med Res 2021; 49:3000605211013275. [PMID: 34018839 PMCID: PMC8150426 DOI: 10.1177/03000605211013275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is often accompanied by pulmonary infection, inflammatory responses, decreased immunity, and decreased lung function. The relationships among the pulmonary inflammation index (PII), lung function, and immunity in COPD patients with pulmonary infection remain unclear. METHODS This retrospective observational study enrolled 234 participants (patients with COPD and pulmonary infection, patients with COPD without pulmonary infection, and healthy individuals) from January 2017 to December 2019. RESULTS Levels of interleukin (IL)-6 were lower and levels of IL-8 were higher in patients with COPD and pulmonary infection. Levels of white blood cells (WBCs), C-reactive protein (CRP), IL-6, IL-8, tumor necrosis factor (TNF)-α and CD8+ cells were higher, while levels of CD3+ and CD4+ cells, the CD4+/CD8+ ratio, forced expiratory volume in 1 s (FEV1), FEV1 % predicted (FEV1%pred), and FEV1/forced vital capacity (FVC) (FEV1%FVC) were lower in patients with COPD and pulmonary infection. Levels of WBCs, CRP, IL-6, IL-8, and TNF-α were negatively associated with FEV1, FEV1%pred and FEV1%FVC. CONCLUSIONS Patients with COPD and pulmonary infection have high PIIs, decreased immunity, and poor lung function. PII is closely related to lung function and may represent a useful biomarker for the assessment of patients with COPD and pulmonary infection.
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Affiliation(s)
- Jun Zhou
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Feng Jin
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Feng Wu
- Department of Respiratory Medicine, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
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Textor SC, Abumoawad A, Saad A, Ferguson C, Dietz A. Stem Cell Therapy for Microvascular Injury Associated with Ischemic Nephropathy. Cells 2021; 10:cells10040765. [PMID: 33807289 PMCID: PMC8066553 DOI: 10.3390/cells10040765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
Ischemic nephropathy reflects progressive loss of kidney function due to large vessel atherosclerotic occlusive disease. Recent studies indicate that this process is characterized by microvascular rarefaction, increased tissue hypoxia and activation of inflammatory processes of tissue injury. This review summarizes the rationale and application of functional MR imaging to evaluate tissue oxygenation in human subjects that defines the limits of renal adaptation to reduction in blood flow, development of increasingly severe tissue hypoxia and recruitment of inflammatory injury pathways in ischemic nephropathy. Human mesenchymal stromal/stem cells (MSC) are capable of modifying angiogenic pathways and immune responses, but the potency of these effects vary between individuals and various clinical characteristics including age and chronic kidney disease and levels of hypoxia. We summarize recently completed first-in-human studies applying intrarenal infusion of autologous adipose-derived MSC in human subjects with ischemic nephropathy that demonstrate a rise in blood flow and reduction in tissue hypoxia consistent with partial repair of microvascular injury, even without restoring main renal arterial blood flow. Inflammatory biomarkers in the renal vein of post-stenotic kidneys fell after MSC infusion. These changes were associated with modest but significant dose-related increments in kidney function. These data provide support a role for autologous MSC in repair of microvascular injury associated with tissue hypoxia.
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Affiliation(s)
- Stephen C. Textor
- Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN 55905, USA;
- Correspondence:
| | - Abdu Abumoawad
- Department of Medicine University of Missouri, Kansas, MO 64108, USA;
| | - Ahmed Saad
- Department of Medicine Creighton University School of Medicine, Omaha, NE 68124, USA;
| | | | - Allan Dietz
- Mayo Clinic, Human Cell Therapy Laboratory, Rochester, MN 55905, USA;
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Long X, Huang M, Hu H. Revascularization may accelerate renal dysfunction in hypertensive patients with moderate atherosclerotic stenosis of renal arteries. Med Hypotheses 2020; 144:110008. [DOI: 10.1016/j.mehy.2020.110008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
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Abstract
A gradually developing reduction in renal blood flow from atherosclerotic renovascular disease results in loss of kidney volume and a decrease in glomerular filtration rate that eventually becomes irreversible. Whether this process fundamentally reflects tissue hypoxia has been difficult to establish. Studies of human renovascular disease have indicated that reductions in blood flow of up to 30% to 40% can be tolerated with preservation of normal oxygenation and structural integrity. These observations are consistent with remarkable stability of poststenotic kidney function during sustained medical antihypertensive drug therapy in moderate renovascular disease. With more severe and sustained reductions, however, cortical oxygenation decreases and the magnitude of medullary hypoxia expands. These changes are associated with increasing renal venous levels of inflammatory cytokines, angiogenic markers, and infiltration of inflammatory cells, including tissue macrophages and T cells. Although restoring large-vessel blood flow can improve oxygenation, some of these processes reflect microvascular rarefication, remain activated, and do not depend on hemodynamic factors alone. Elucidation of tissue injury pathways associated with hypoxia opens the possibility of adjunctive therapeutic measures beyond renal revascularization. These include cell-based regeneration, mitochondrial protection, and/or angiogenic cytokine therapy to restore or preserve renal function in ischemic nephropathy.
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Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Chai D, Kong X, Lu S, Zhang J. CD4+/CD8+ ratio positively correlates with coronary plaque instability in unstable angina pectoris patients but fails to predict major adverse cardiovascular events. Ther Adv Chronic Dis 2020; 11:2040622320922020. [PMID: 32489573 PMCID: PMC7238310 DOI: 10.1177/2040622320922020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/30/2020] [Indexed: 01/28/2023] Open
Abstract
Background: The association between CD4+/CD8+ ratio and coronary plaque instability in
patients with unstable angina pectoris (UAP) has not been investigated. We
sought to elucidate the correlation between CD4+/CD8+ ratio and plaque
instability in this patient population. Methods: We enrolled 266 UAP patients who underwent pre-intervention optical coherence
tomography (OCT) examination and percutaneous coronary intervention in our
center from January 2016 to January 2018. Features of coronary plaques in
the culprit arteries were classified as unstable plaque and stable plaque.
Primary endpoint was occurrence of a major adverse cardiovascular event
(MACE). Receiver operating characteristic (ROC) analyses were used to
determine the predictive efficacy of the CD4+/CD8+ ratio for a group of
unstable plaque patients, and binary logistic regression analysis was
performed to evaluate potential independent predictors of plaque
instability. All-cause mortality and MACE between the two groups were
analyzed. Results: UAP patients with unstable plaque had a higher CD4/CD8 ratio compared with
stable plaque patients (p < 0.05). Results of binary
logistic regression analyses showed that CD4+/CD8+ ratio ⩾1.725 and prior
stroke were predictors and risk factors of plaque instability
(p < 0.05). ROC analyses showed that CD4+/CD8+ ratio
⩾1.725 was predictive of plaque instability in UAP patients. However, the
Kaplan–Meier estimate for MACE and all-cause mortality showed no statistical
significance. Conclusions: Higher CD4+/CD8+ ratio is associated with higher risk of plaque instability
in our cohort of UAP patients. However, CD4+/CD8+ ratio was not an
independent predictor of 1-year MACE or all-cause mortality.
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Affiliation(s)
- Dayang Chai
- Department of Cardiology, The First People's Hospital of Taicang, The Affiliated Taicang Hospital of Soochow University, Taicang, China
| | - Xiangquan Kong
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shu Lu
- Department of Cardiology, The First People's Hospital of Taicang, The Affiliated Taicang Hospital of Soochow University, No. 58 Changsheng Road, Taicang, 215400, China
| | - Junjie Zhang
- Department of Cardiology, Nanjing First Hospital, No. 68 Changle Road, Nanjing, 210006, China
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Vassallo D, Foley RN, Kalra PA. Design of a clinical risk calculator for major clinical outcomes in patients with atherosclerotic renovascular disease. Nephrol Dial Transplant 2019; 34:1377-1384. [PMID: 29939316 DOI: 10.1093/ndt/gfy157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/01/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Risk stratification in atherosclerotic renovascular disease (ARVD) can influence treatment decisions and facilitate patient selection for revascularization. In this study, we aim to use variables with the best predictive value to design a risk calculator that can assist clinicians with risk stratification and outcome prediction. METHODS Patients with a radiological diagnosis of ARVD referred to our tertiary renal centre were recruited into this prospective cohort study between 1986 and 2014. Primary clinical endpoints included: death, progression to end-stage kidney disease and cardiovascular events (CVE). A stepwise regression model was used to select variables with the most significant hazard ratio for each clinical endpoint. The risk calculator was designed using Hypertext Markup Language. Survival and CVE-free survival were estimated at 1, 5 and 10 years. RESULTS In total, 872 patients were recruited into the Salford ARVD study with a median follow-up period of 54.9 months (interquartile range 20.2-96.0). Only models predicting death and CVE showed good performance (C-index >0.80). Survival probabilities obtained from the risk calculator show that most patients with ARVD have reduced long-term survival. Revascularization improved outcomes in patients with higher baseline estimated glomerular filtration rate and lower proteinuria but not in those with co-existing comorbidities and higher levels of baseline proteinuria. CONCLUSIONS Although this risk calculator requires further independent validation in other ARVD cohorts, this study shows that a small number of easily obtained variables can help predict clinical outcomes and encourage a patient-specific therapeutic approach.
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Affiliation(s)
- Diana Vassallo
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
| | - Robert N Foley
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
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Affiliation(s)
- Alfonso Eirin
- From the Divisions of Nephrology and Hypertension (A.E., S.C.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Stephen C Textor
- From the Divisions of Nephrology and Hypertension (A.E., S.C.T., L.O.L.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- From the Divisions of Nephrology and Hypertension (A.E., S.C.T., L.O.L.), Mayo Clinic, Rochester, MN
- Department of Cardiovascular Diseases (L.O.L.), Mayo Clinic, Rochester, MN
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Abstract
PURPOSE OF REVIEW Atherosclerotic renovascular disease remains highly prevalent and presents an array of clinical syndromes. Recent prospective trials have dampened enthusiasm for revascularization generally, but clinicians recognize the need to identify patients likely to benefit from vascular intervention. RECENT FINDINGS This article highlights the inflammatory nature of vascular occlusive disease and the limits of the kidney to adapt to reduced blood flow. Although moderate reductions can be tolerated, severe impairment of renal perfusion leads to tissue hypoxia and activates inflammatory injury within the kidney. Hence, assessment of kidney viability and potential tools to modify mitochondrial and inflammatory damage may be important to identify patients for whom clinical intervention should be undertaken. SUMMARY Clinicians must recognize clinical syndromes that identify 'high-risk' groups and apply revascularization in those likely to benefit. Future efforts to protect the kidney (e.g., mitochondrial protection) or cell-based therapy may amplify clinical recovery when combined with restoring renal blood flow.
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Daloul R, Morrison AR. Approach to atherosclerotic renovascular disease: 2016. Clin Kidney J 2016; 9:713-21. [PMID: 27679718 PMCID: PMC5036906 DOI: 10.1093/ckj/sfw079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/20/2016] [Indexed: 12/20/2022] Open
Abstract
The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.
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Affiliation(s)
- Reem Daloul
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
| | - Aubrey R Morrison
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
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T-cell-mediated rejection of the kidney in the era of donor-specific antibodies: diagnostic challenges and clinical significance. Curr Opin Organ Transplant 2015; 20:325-32. [PMID: 25944230 DOI: 10.1097/mot.0000000000000189] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Burgeoning literature on antibody-mediated rejection (ABMR) has led to a perception that T-cell-mediated rejection (TCMR) is no longer a significant problem. This premise needs to be carefully appraised. RECENT FINDINGS A review of the literature indicates that TCMR remains an independent-risk factor for graft loss. Importantly, it can occur as a sensitizing event that triggers ABMR, and adversely affects its outcome. Moreover, T cells are regularly present in lesions used to diagnose ABMR, and these lesions can also develop in the absence of donor-specific antibodies (DSA). Conversely, patients with DSA are at risk for mixed ABMR-TCMR, which is quite common in many studies, and may require a combined anti-T-cell and anti-B-cell strategy for the best outcome. SUMMARY T-cell-based clinical monitoring and therapy is still relevant for prophylaxis of both cellular and humoral rejection, treatment of steroid refractory TCMR, which occurs in up to 20% of patients, and optimization of clinical outcome in mixed TCMR-ABMR, which is more frequently encountered than generally appreciated, and still associated with unacceptably high rates of graft loss.
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Kwon SH, Lerman LO. Atherosclerotic renal artery stenosis: current status. Adv Chronic Kidney Dis 2015; 22:224-31. [PMID: 25908472 DOI: 10.1053/j.ackd.2014.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/14/2014] [Accepted: 10/15/2014] [Indexed: 12/29/2022]
Abstract
Atherosclerotic renal artery stenosis (ARAS) remains a major cause of secondary hypertension and kidney failure. Randomized prospective trials show that medical treatment should constitute the main therapeutic approach in ARAS. Regardless of intensive treatment and adequate blood pressure control, however, renal and extrarenal complications are not uncommon. Yet, the precise mechanisms, accurate detection, and optimal treatment in ARAS remain elusive. Strategies oriented to early detection and targeting these pathogenic pathways might prevent development of clinical end points. Here, we review the results of recent clinical trials, current understanding of the pathogenic mechanisms, novel imaging techniques to assess kidney damage in ARAS, and treatment options.
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Juncos LI, Textor S. Current approaches to atherosclerotic obstructive renal artery stenosis. Ther Adv Cardiovasc Dis 2015; 9:153-7. [DOI: 10.1177/1753944715579143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Increased lifespan in the last few decades has substantially changed the scenario for renal artery stenosis. Indeed, because older populations show a higher prevalence of atherosclerotic disease, the incidence of atheromatous renal artery stenosis has also increased. Intuitively, one could surmise that stenosis removal should void both the hypertension and the kidney damage resulting from the obstructive stenosis. Surprisingly, a number of important clinical trials have failed to show the reversion seen in experimental models. The reasons for these differences may be linked to chronicity and inflammation associated with the atherosclerotic lesion. However, the failure to obtain a favorable response may also be related to abnormalities in the contralateral kidney. Indeed, this apparently normal kidney should work to compensate the hemodynamic effects of the ipsilateral stenosed kidney. Instead, structure and function in the contralateral kidney can be altered in renal artery stenosis to the point that this nonstenotic kidney may sustain both, hypertension and progressive kidney disease. Certainly, comparing the effects of clip removal in the Goldblatt model to angioplasty in clinical settings with atherosclerotic lesions may be totally inappropriate. Nevertheless, there remain certain clinical situations such as bilateral renal arterial disease, congestive heart failure, and progressive renal failure, where angioplasty may be an alternative. These approaches however are yet to be tested.
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Affiliation(s)
- Luis I. Juncos
- J Robert Cade Foundation, Pedro de Oñate 253 Cordoba, Cordoba 5003, Argentina
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Textor SC, Lerman LO. Paradigm Shifts in Atherosclerotic Renovascular Disease: Where Are We Now? J Am Soc Nephrol 2015; 26:2074-80. [PMID: 25868641 DOI: 10.1681/asn.2014121274] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Results of recent clinical trials and experimental studies indicate that whereas atherosclerotic renovascular disease can accelerate both systemic hypertension and tissue injury in the poststenotic kidney, restoring vessel patency alone is insufficient to recover kidney function for most subjects. Kidney injury in atherosclerotic renovascular disease reflects complex interactions among vascular rarefication, oxidative stress injury, and recruitment of inflammatory cellular elements that ultimately produce fibrosis. Classic paradigms for simply restoring blood flow are shifting to implementation of therapy targeting mitochondria and cell-based functions to allow regeneration of vascular, glomerular, and tubular structures sufficient to recover, or at least stabilize, renal function. These developments offer exciting possibilities of repair and regeneration of kidney tissue that may limit progressive CKD in atherosclerotic renovascular disease and may apply to other conditions in which inflammatory injury is a major common pathway.
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Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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van Dijk RA, Duinisveld AJF, Schaapherder AF, Mulder-Stapel A, Hamming JF, Kuiper J, de Boer OJ, van der Wal AC, Kolodgie FD, Virmani R, Lindeman JHN. A change in inflammatory footprint precedes plaque instability: a systematic evaluation of cellular aspects of the adaptive immune response in human atherosclerosis. J Am Heart Assoc 2015; 4:jah3876. [PMID: 25814626 PMCID: PMC4579929 DOI: 10.1161/jaha.114.001403] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Experimental studies characterize adaptive immune response as a critical factor in the progression and complications of atherosclerosis. Yet, it is unclear whether these observations translate to the human situation. This study systematically evaluates cellular components of the adaptive immune response in a biobank of human aortas covering the full spectrum of atherosclerotic disease. Methods and Results A systematic analysis was performed on 114 well‐characterized perirenal aortic specimens with immunostaining for T‐cell subsets (CD3/4/8/45RA/45RO/FoxP3) and the Th1/non‐Th1/Th17 ratio (CD4+T‐bet+/CD4+T‐bet−/CD4+/interleukin‐17+ double staining). CD20 and CD138 were used to identify B cells and plasma cells, while B‐cell maturation was evaluated by AID/CD21 staining and expression of lymphoid homeostatic CXCL13. Scattered CD4 and CD8 cells with a T memory subtype were found in normal aorta and early, nonprogressive lesions. The total number of T cells increases in progressive atherosclerotic lesions (≈1:5 CD4/CD8 T‐cell ratio). A further increase in medial and adventitial T cells is found upon progression to vulnerable lesions. This critical stage is further hallmarked by de novo formation of adventitial lymphoidlike structures containing B cells and plasma cells, a process accompanied by transient expression of CXCL13. A dramatic reduction of T‐cell subsets, disappearance of lymphoid structures, and loss of CXCL13 expression characterize postruptured lesions. FoxP3 and Th17 T cells were minimally present throughout the atherosclerotic process. Conclusions Transient CXCL13 expression, restricted presence of B cells in human atherosclerosis, along with formation of nonfunctional extranodal lymphoid structures in the phase preceding plaque rupture, indicates a “critical” change in the inflammatory footprint before and during plaque destabilization.
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Affiliation(s)
- R A van Dijk
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands (D., D., M.S., H., L.)
| | - A J F Duinisveld
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands (D., D., M.S., H., L.)
| | - A F Schaapherder
- Department of Transplantation Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.)
| | - A Mulder-Stapel
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands (D., D., M.S., H., L.)
| | - J F Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands (D., D., M.S., H., L.)
| | - J Kuiper
- Gorlaeus Laboratories, Division of Biopharmaceutics, Leiden Academic Centre for Drug Research, Leiden, The Netherlands (K.)
| | - O J de Boer
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands (B., W.)
| | - A C van der Wal
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands (B., W.)
| | - F D Kolodgie
- CVPath Institute Inc., Gaithersburg, MD (K., V.)
| | - R Virmani
- CVPath Institute Inc., Gaithersburg, MD (K., V.)
| | - J H N Lindeman
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands (D., D., M.S., H., L.)
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Renovascular hypertension: is there still a role for stent revascularization? Curr Opin Nephrol Hypertens 2014; 22:525-30. [PMID: 23917028 DOI: 10.1097/mnh.0b013e328363ffe0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Management of renovascular hypertension remains controversial and problematic, in part, due to failure of prospective trials to demonstrate added benefit to revascularization. RECENT FINDINGS Effective drug therapy often can achieve satisfactory blood pressure control, although concerns persist of the potential for progressive, delayed loss of kidney function beyond a stenotic lesion. Recent studies highlight benefits of renal artery stenting in subsets of patients including those with recurrent pulmonary edema and those intolerant to blockade of the renin-angiotensin system. Occasional patients with recent deterioration in renal function recover sufficient glomerular filtration rate after stenting to avoid requirements for renal replacement therapy. Emerging paradigms from both clinical and experimental studies suggest that hypoxic injury within the kidney activates inflammatory injury pathways and microvascular rarification that may not recover after technically successful revascularization alone. Initial data suggest that additional measures to repair the kidney, including the use of cell-based therapy, may offer the potential to recover kidney function in advanced renovascular disease. SUMMARY Specific patient groups benefit from renal revascularization. Nephrologists will increasingly be asked to manage complex renovascular patients, different from those in randomized trials, that require intensely individualized management.
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Eirin A, Zhang X, Zhu XY, Tang H, Jordan KL, Grande JP, Dietz AB, Lerman A, Textor SC, Lerman LO. Renal vein cytokine release as an index of renal parenchymal inflammation in chronic experimental renal artery stenosis. Nephrol Dial Transplant 2013; 29:274-82. [PMID: 24097799 DOI: 10.1093/ndt/gft305] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Renal parenchymal inflammation is a critical determinant of kidney injury in renal artery stenosis (RAS) but is difficult to assess in the single kidney without tissue samples. Whether renal vein (RV) levels of inflammatory markers reflect active parenchymal inflammation remains unknown. We evaluated the relationship between net RV cytokine release and tissue inflammation in the post-stenotic kidney. METHODS Pigs were studied after 10 weeks of RAS treated 4 weeks earlier with intra-renal vehicle or anti-inflammatory mesenchymal stem cells (MSCs) or normal control. Single-kidney renal blood flow was measured by fast computerized tomography. RV and inferior vena cava levels of tumor necrosis factor (TNF)-α, interferon (IF)-γ, monocyte chemoattractant protein (MCP-1) and interleukin (IL)-10 were measured by enzyme-linked immunosorbent assay, and their net release calculated. Renal expression of the same cytokines was correlated with their net release. RESULTS Net release of TNF-α, IF-γ and MCP-1 was higher in RAS compared with normal and to the contralateral kidney (all P<0.05), decreased in MSC-treated pigs as was their tissue expression. Contrarily, the release of the anti-inflammatory IL-10 was lower in RAS and normalized in RAS+MSC. The net release of TNF-α, MCP-1 and IL-10 directly correlated with their tissue expression. The ratio of inflammatory-to-reparative macrophages directly correlated with the release of MCP-1, but inversely with the release of IL-10. In vitro cultured MSCs also induced a shift in the macrophage phenotype from inflammatory (M1) to reparative (M2). CONCLUSIONS Our findings demonstrate that the release of inflammatory markers from the affected kidney provides an index of renal tissue inflammation in experimental RAS.
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Affiliation(s)
- Alfonso Eirin
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Satoh-Asahara N, Sasaki Y, Wada H, Tochiya M, Iguchi A, Nakagawachi R, Odori S, Kono S, Hasegawa K, Shimatsu A. A dipeptidyl peptidase-4 inhibitor, sitagliptin, exerts anti-inflammatory effects in type 2 diabetic patients. Metabolism 2013; 62:347-51. [PMID: 23062489 DOI: 10.1016/j.metabol.2012.09.004] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 09/06/2012] [Accepted: 09/06/2012] [Indexed: 12/28/2022]
Abstract
AIMS/HYPOTHESIS Glucagon-like peptide-1 (GLP-1) exerts beneficial effects on the cardiovascular system. Here, we examined the effect of sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, on systemic inflammation and pro-inflammatory (M1)/anti-inflammatory (M2)-like phenotypes of peripheral blood monocytes in diabetic patients. METHODS Forty-eight type 2 diabetic patients were divided into the following two groups: sitagliptin-treatment (50mg daily for 3months) (n=24) and untreated control (n=24) groups. Measurements were undertaken to assess changes in glucose-lipid metabolism, serum levels of inflammatory cytokines such as serum amyloid A-LDL (SAA-LDL), C-reactive protein (CRP), interleukin-6 (IL-6), IL-10 and tumor necrosis factor-α (TNF-α). Furthermore, the effects of sitagliptin treatment on M1/M2-like phenotypes in peripheral blood monocytes were examined. RESULTS Treatment with sitagliptin significantly decreased fasting plasma glucose, hemoglobin A1c (HbA1c), serum levels of inflammatory markers, such as SAA-LDL, CRP, and TNF-α. In contrast, sitagliptin increased serum IL-10, an anti-inflammatory cytokine, as well as plasma GLP-1. In addition, sitagliptin increased monocyte IL-10 expression and decreased monocyte TNF-α expression. Multivariate regression analysis revealed that the sitagliptin treatment was the only factor independently associated with an increase in monocyte IL-10 (β=0.499; R(2)=0.293, P<0.05). However, other factors including the improvement of glucose metabolism were not associated with the increase. CONCLUSIONS/INTERPRETATION This study is the first to show that a DPP-4 inhibitor, sitagliptin, reduces inflammatory cytokines and improves the unfavorable M1/M2-like phenotypes of peripheral blood monocytes in Japanese type 2 diabetic patients.
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Affiliation(s)
- Noriko Satoh-Asahara
- Division of Diabetic Research, Clinical Research Institute, National Hospital Organization, Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan.
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Textor SC, Lerman LO. Inflammatory cell markers as indicators of atherosclerotic renovascular disease. Clin J Am Soc Nephrol 2012; 7:193-5. [PMID: 22241820 DOI: 10.2215/cjn.12641211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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