Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Abdominal aortic aneurysm volume and relative intraluminal thrombus volume might be auxiliary predictors of rupture-an observational cross-sectional study

Objectives

The study aimed to identify differences and compare anatomical and biomechanical features between elective and ruptured abdominal aortic aneurysms (AAAs).

Methods

Data (clinical, anatomical, and biomechanical) of 98 patients with AAA, 75 (76.53%) asymptomatic (Group aAAA) and 23 (23.46%) ruptured AAA (Group rAAA), were prospectively collected and analyzed. Anatomical, morphological, and biomechanical imaging markers like peak wall stress (PWS) and rupture risk equivalent diameter (RRED), comorbid conditions, and demographics were compared between the groups. Biomechanical features were assessed by analysis of Digital Imaging and Communication in Medicine images by A4clinics (Vascops), and anatomical features were assessed by 3Surgery (Trimensio). Binary and multiple logistic regression analysis were used and adjusted for confounders. Accuracy was assessed using receiving operative characteristic (ROC) curve analysis.

Results

In a multivariable model, including gender and age as confounder variables, maximal aneurysm diameter [MAD, odds ratio (OR) = 1.063], relative intraluminal thrombus (rILT, OR = 1.039), and total aneurysm volume (TAV, OR = 1.006) continued to be significant predictors of AAA rupture with PWS (OR = 1.010) and RRED (OR = 1.031). Area under the ROC curve values and correct classification (cc) for the same parameters and the model that combines MAD, TAV, and rILT were measured: MAD (0.790, cc = 75%), PWS (0.713, cc = 73%), RRED (0.717, cc = 55%), TAV (0.756, cc = 79%), rILT (0.656, cc = 60%), and MAD + TAV + rILT (0.797, cc = 82%).

Conclusion

Based on our results, in addition to MAD, other important predictors of rupture that might be used during aneurysm surveillance are TAV and rILT. Biomechanical parameters (PWS, RRED) as valuable predictors should be assessed in prospective clinical trials. Similar studies on AAA smaller than 55 mm in diameter, even difficult to organize, would be of even greater clinical value.

Abstract 6245: 3D-models of pediatric bone sarcomas for personalized therapeutic screening

Osteosarcoma (OS) and Ewing sarcoma (ES) are the most common bone cancers in children. They are rare cancers and thus difficult to study due to scarcity of patient material, large genomic instability and a wide histological heterogeneity (in OS) or a lack of satisfactory transgenic animal model and availability of preclinical tests (in ES). There is a dire need for new models and novel therapeutic approaches. Although patient-derived xenografts (PDXs) may recapitulate human tumor biology and predict drug response, propagating PDXs in mice limits its use as a drug-testing platform.

We have established and standardized ES and OS spheroid culture and developed a semi-automated drug-screening platform in tumor spheroids. We established several robust techniques for spheroid formation, with clear pathophysiological gradients, but without central necroses at the onset of drug treatment. We performed RNA-seq comparing spheroid transcription profiles to 2D culture and observed dramatic changes in overall expression patterns. We observed upregulation of genes shown to correlate with poor prognosis in OS patients. We saw upregulation of processes associated with regulation of cell migration, negative regulation of proliferation and modulation of the extracellular matrix (ECM). In addition to ES spheroid models, we created bioprinted 3D-models of ES cell lines and of cells obtained from ES PDXs, using extrusion bioprinting techniques (where cells are encapsulated within the cross-linked polymers, thus allowing homogeneous distribution and high cell density). PDX-derived cells were kept in liquid culture and as 3D-bioprinted constructs, while their transcription profiles were compared with the initial PDX. The mevalonate pathway was the most overrepresented in all ES 3D-models, consistent with predominant upregulation of this metabolic pathway integral to tumor growth and progression. After 15 days in 3D-bioprinted culture, we observed pronounced upregulation of genes involved in ECM signaling, suggesting that the construct promoted in vivo-like tumor-ECM interactions, without further promoting main proliferation and cell survival pathways, which was observed in liquid culture. Furthermore, we showed potential for combinatorial treatment with statins and confirmed feasibility of drug testing in patient-derived 3D models.

Finally, as our spheroid models showed upregulation of many processes involved in metastasis (genes associated with invasion, migration, angiogenesis and hypoxia), we focused on lung as the most common site of metastasis in ES and OS patients. We are thus establishing mixed airway organoid/tumoroid cultures, to investigate further the lung metastatic niche, with a goal to provide proof of concept for patient-specific 3D-models of lung metastatic tumors to guide personalized drug selection for patients with advanced disease.

Citation Format: Branka Radic Sarikas, Mathias Ilg, Marica Markovic, Caterina Sturtzel, Eva Scheuringer, Justine Zulini, Martin Metzelder, Florian Halbritter, Martin Distel, Didier Surdez, Olivier Delattre, Aleksandr Ovsianikov, Heinrich Kovar. 3D-models of pediatric bone sarcomas for personalized therapeutic screening [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6245.

Employment status of patients with schizophrenia spectrum disorder treated with long acting injectable paliperidone palmitate: Real world mirror image study

Introduction

Schizophrenia spectrum disorders may severely limit ability to achieve and maintain gainful employment of affected working-age individuals.

Objectives

Assess the employment status in patients with schizophrenia spectrum disorders treated with long acting injectable paliperidone palmitate after the switch from oral antipsychotics.

Methods

A single centre mirror image design study of 115 patients with schizophrenia spectrum disorder was conducted in a tertiary level psychiatric hospital. Data were collected for period of 12 months prior toand 12 months after switching from oral antipsychotic to long acting injectable paliperidone.Employment status for 6 enrolled patients was missing.

Results

Mean age of enrolled patients was 38,4±11,6 years. Of the 109 patients analyzed for employment status, 44,4% remained employed for 12 months after switching to long acting injectable paliperidone while 4,6% patients changed their employment status from unemployed to employed after the switch. No patient changed their employment status from employed to unemployed after the switch. 9,2% patients were already retired at the beginning of study period and 5,5% of patients maintained their student status. 36,7% patients remained unemployed for the whole study period. The correlation between employment status of employed and unemployed patients and duration of illness was borderline significant with p=0,049.

Conclusions

The data from this study suggest that use of long acting injectable paliperidone contributed to preservation of working ability of working-age patients suffering from schizophrenia spectrum disorders.

Disclosure

No significant relationships.

Guiding cell migration in 3D with high-resolution photografting

Multi-photon lithography (MPL) has proven to be a suitable tool to precisely control the microenvironment of cells in terms of the biochemical and biophysical properties of the hydrogel matrix. In this work, we present a novel method, based on multi-photon photografting of 4,4′-diazido-2,2′-stilbenedisulfonic acid (DSSA), and its capabilities to induce cell alignment, directional cell migration and endothelial sprouting in a gelatin-based hydrogel matrix. DSSA-photografting allows for the fabrication of complex patterns at a high-resolution and is a biocompatible, universally applicable and straightforward process that is comparably fast. We have demonstrated the preferential orientation of human adipose-derived stem cells (hASCs) in response to a photografted pattern. Co-culture spheroids of hASCs and human umbilical vein endothelial cells (HUVECs) have been utilized to study the directional migration of hASCs into the modified regions. Subsequently, we have highlighted the dependence of endothelial sprouting on the presence of hASCs and demonstrated the potential of photografting to control the direction of the sprouts. MPL-induced DSSA-photografting has been established as a promising method to selectively alter the microenvironment of cells.

Gelatin methacryloyl as environment for chondrocytes and cell delivery to superficial cartilage defects

Cartilage damage typically starts at its surface, either due to wear or trauma. Treatment of these superficial defects is important in preventing degradation and osteoarthritis. Biomaterials currently used for deep cartilage defects lack appropriate properties for this application. Therefore, we investigated photo‐crosslinked gelatin methacryloyl (gelMA) as a candidate for treatment of surface defects. It allows for liquid application, filling of surface defects and forming a protective layer after UV‐crosslinking, thereby keeping therapeutic cells in place. gelMA and photo‐initiator lithium phenyl‐2,4,6‐trimethyl‐benzoylphosphinate (Li‐TPO) concentration were optimized for application as a carrier to create a favorable environment for human articular chondrocytes (hAC). Primary hAC were used in passages 3 and 5, encapsulated into two different gelMA concentrations (7.5 wt% (soft) and 10 wt% (stiff)) and cultivated for 3 weeks with TGF‐β3 (0, 1 and 10 ng/mL). Higher TGF‐β3 concentrations induced spherical cell morphology independent of gelMA stiffness, while low TGF‐β3 concentrations only induced rounded morphology in stiff gelMA. Gene expression did not vary across gel stiffnesses. As a functional model gelMA was loaded with two different cell types (hAC and/or human adipose‐derived stem cells [ASC/TERT1]) and applied to human osteochondral osteoarthritic plugs. GelMA attached to the cartilage, smoothened the surface and retained cells in place. Resistance against shear forces was tested using a tribometer, simulating normal human gait and revealing maintained cell viability. In conclusion gelMA is a versatile, biocompatible material with good bonding capabilities to cartilage matrix, allowing sealing and smoothening of superficial cartilage defects while simultaneously delivering therapeutic cells for tissue regeneration.

On-chip high-definition bioprinting of microvascular structures

'Organ-on-chip' devices which integrate three-dimensional (3D) cell culture techniques with microfluidic approaches have the capacity to overcome the limitations of classical 2D platforms. Although several different strategies have been developed to improve the angiogenesis within hydrogels, one of the main challenges in tissue engineering remains the lack of vascularization in the fabricated 3D models. The present work focuses on the high-definition (HD) bioprinting of microvascular structures directly on-chip using two-photon polymerization (2PP). 2PP is a nonlinear process, where the near-infrared laser irradiation will only lead to the polymerization of a very small volume pixel (voxel), allowing the fabrication of channels in the microvascular range (10-30 µm in diameter). Additionally, 2PP not only enables the fabrication of sub-micrometer resolution scaffolds but also allows the direct embedding of cells within the produced structure. The accuracy of the 2PP printing parameters were optimized in order to achieve high-throughput and HD production of microfluidic vessel-on-chip platforms. The spherical aberrations stemming from the refractive index mismatch and the focusing depth inside the sample were simulated and the effect of the voxel compensation as well as different printing modes were demonstrated. Different layer spacings and their dependency on the applied laser power were compared both in terms of accuracy and required printing time resulting in a 10-fold decrease in structuring time while yielding well-defined channels of small diameters. Finally, the capacity of 2PP to create vascular structures within a microfluidic chip was tested with two different settings, by direct embedding of a co-culture of endothelial- and supporting cells during the printing process and by creating a supporting, cell-containing vascular scaffold barrier where the endothelial cell spheroids can be seeded afterwards. The functionality of the formed vessels was demonstrated with immunostaining of vascular endothelial cadherin (VE-Cadherin) endothelial adhesion molecules in both static and perfused culture.

Mechanical dispersion is associated with clinical and subclinical coronary artery disease in patients on chronic renal replacement therapy with normal left ventricular ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since coronary artery disease (CAD) is the leading cause of mortality in patients with end-stage renal failure, early detection of CAD in these patients presenting with still normal left ventricular (LV) systolic function is of clinical importance.

Aim

To investigate the correlation between electrical and mechanical dispersion and CAD in dialysis patients with normal LV systolic function.

Material and methods: This prospective study included 78 dialysis patients who underwent a 12-channel electrocardiogram and echocardiographic examination to determine electrical and mechanical myocardial dispersion. A coronary calcium score using cardiac computed tomography was also assessed in a group of 20 patients without known CAD. Electrical dispersion was defined as the difference between the longest and shortest corrected QT interval (QTc). Mechanical dispersion (MD) was defined as either standard deviation of mechanical contraction duration of all LV segments (MD_SD) or the difference between the longest and shortest duration of mechanical contraction (MD_delta). The duration of mechanical contraction was determined by myocardial strain analysis.

Results

Previously known CAD was present in 11 (14%) patients, while pathologic Q wave was absent in all patients. No significant correlation was observed between QTc dispersion and both MD parameters (p &gt; 0.05 for both). Both MD parameters (p = 0.007 for MD_SD; p = 0.026 for MD_delta), but not electrical dispersion (p = 0.584), showed a discriminative power for detecting previously known CAD (Figure). In patients without known CAD, neither QTc dispersion nor MD_SD showed a correlation with coronary calcium score (p &gt; 0.05 for both). MD_delta showed a strong correlation with both total and coronary calcium score in the territory of the left anterior descending coronary artery (r = 0.62; p = 0.004) in patients without previously known CAD.

Conclusion

Mechanical dispersion is associated with known CAD in dialysis patients with normal LV systolic function. The range of mechanical myocardial contraction duration (MD_delta) correlates with subclinical coronary atherosclerosis.

Figure. Discriminative power of mechanical and electrical dispersion for the detection of coronary artery disease

Abstract Figure.

High-Resolution 3D Bioprinting of Photo-Cross-linkable Recombinant Collagen to Serve Tissue Engineering Applications

Various biopolymers, including gelatin, have already been applied to serve a plethora of tissue engineering purposes. However, substantial concerns have arisen related to the safety and the reproducibility of these materials due to their animal origin and the risk associated with pathogen transmission as well as batch-to-batch variations. Therefore, researchers have been focusing their attention toward recombinant materials that can be produced in a laboratory with full reproducibility and can be designed according to specific needs (e.g., by introducing additional RGD sequences). In the present study, a recombinant protein based on collagen type I (RCPhC1) was functionalized with photo-cross-linkable methacrylamide (RCPhC1-MA), norbornene (RCPhC1-NB), or thiol (RCPhC1-SH) functionalities to enable high-resolution 3D printing via two-photon polymerization (2PP). The results indicated a clear difference in 2PP processing capabilities between the chain-growth-polymerized RCPhC1-MA and the step-growth-polymerized RCPhC1-NB/SH. More specifically, reduced swelling-related deformations resulting in a superior CAD-CAM mimicry were obtained for the RCPhC1-NB/SH hydrogels. In addition, RCPhC1-NB/SH allowed the processing of the material in the presence of adipose tissue-derived stem cells that survived the encapsulation process and also were able to proliferate when embedded in the printed structures. As a consequence, it is the first time that successful HD bioprinting with cell encapsulation is reported for recombinant hydrogel bioinks. Therefore, these results can be a stepping stone toward various tissue engineering applications.

Support to responsive parenting through communication tools

Issue

Counselling unit for positive parenting “Halobeba” has been established at Institute of Public Health of Belgrade with support of UNICEF in order to enable continuum of mother and child health care. Availability of information on child care and development was noticed as significant factor for parental confidence and practice.

Description of the problem

Trained nurses provide responses to parental questions through 24/7 phone and e mail communication to assist in problem solving and offer emotional support. Nurses are skilled in active listening, proper questioning, counselling and effective encouragement. Free mob app on breastfeeding was developed as knowledge base for parents. New interactive mob app was recently launched as parenting tool for child health and development monitoring.

Results

Since 2002, more than 1,700,000 responses were provided through phone communication and over 20,000 via email and number of beneficiaries has increased over the years. Most common topics were about breastfeeding, introducing solid food, treatment of fever and respiratory infections, gastrointestinal problems, injuries, immunization, and developmental milestones. Less than 15% of cases were referred to pediatric clinic. Level of parental overall satisfaction was very high and availability and effectiveness of service were especially valued as well as nurses communication skills.

Lessons

Family centered service that corresponds to caregivers needs is effective approach to support nurturing care for young children. Personalized M-health tools make child care more accessible and build capacities of caregivers.

Key messages

Sending consistent and trusted messages through different communication channels contribute to enhancing users' knowledge and skills. Knowledgeable and responsive caregivers properly interpret child’s needs, respond appropriately, facilitate the child’s social and emotional development, and provide proper care.

Photo-crosslinkable recombinant collagen mimics for tissue engineering applications

Gelatin is frequently used in various biomedical applications. However, gelatin is generally extracted from an animal source, which can result in issues with reproducibility as well as pathogen transmittance. Therefore, we have investigated the potential of a recombinant peptide based on collagen I (RCPhC1) for tissue engineering applications and more specifically for adipose tissue regeneration. In the current paper, RCPhC1 was functionalized with photo-crosslinkable methacrylamide moieties to enable subsequent UV-induced crosslinking in the presence of a photo-initiator. The resulting biomaterial (RCPhC1-MA) was characterized by evaluating the crosslinking behaviour, the mechanical properties, the gel fraction, the swelling properties and the biocompatibility. The obtained results were compared with the data obtained for methacrylamide-modified gelatin (Gel-MA). The results indicated that the properties of RCPhC1-MA networks are comparable to those of animal-derived Gel-MA. RCPhC1-MA is thus an attractive synthetic alternative for animal-derived Gel-MA and is envisioned to be applicable for a wide range of tissue engineering purposes.

Thiol-Gelatin-Norbornene Bioink for Laser-Based High-Definition Bioprinting

Two-photon polymerization (2PP) is a lithography-based 3D printing method allowing the fabrication of 3D structures with sub-micrometer resolution. This work focuses on the characterization of gelatin-norbornene (Gel-NB) bioinks which enables the embedding of cells via 2PP. The high reactivity of the thiol-ene system allows 2PP processing of cell-containing materials at remarkably high scanning speeds (1000 mm s^-1 ) placing this technology in the domain of bioprinting. Atomic force microscopy results demonstrate that the indentation moduli of the produced hydrogel constructs can be adjusted in the 0.2-0.7 kPa range by controlling the 2PP processing parameters. Using this approach gradient 3D constructs are produced and the morphology of the embedded cells is observed in the course of 3 weeks. Furthermore, it is possible to tune the enzymatic degradation of the crosslinked bioink by varying the applied laser power. The 3D printed Gel-NB hydrogel constructs show exceptional biocompatibility, supported cell adhesion, and migration. Furthermore, cells maintain their proliferation capacity demonstrated by Ki-67 immunostaining. Moreover, the results demonstrate that direct embedding of cells provides uniform distribution and high cell loading independently of the pore size of the scaffold. The investigated photosensitive bioink enables high-definition bioprinting of well-defined constructs for long-term cell culture studies.

AB0207 CLINICAL IMPACT OF ANTI-CARP ANTIBODIES IN RHEUMATOID ARTHRITIS

Background:

Antibodies directed against carbamylated proteins (anti-CarP) have been recently introduced for the first time as a new biomarker in rheumatoid arthritis (RA) (1). Their presence is predictive for the development of RA (2). Anti-CarP antibodies are associated with the development of more severe forms of the disease in overall and anti-citrullinated peptide antibodies negative population of patients with RA (3). In the literature is still current the research which associate these antibodies with disease activity and functional status of patients.

Objectives:

This study investigated the incidence of anti-CarP positive findings in patients with RA on synthetic and biologic disease-modifying therapy (DMT) and the relationship between anti-CarP antibody status and both disability and disease activity.

Methods:

It was an open-label, observational, cross-sectional study. The trial included 70 patients with RA diagnosed on the basis of ACR 1987 and ACR / EULAR 2010 criteria, on treatment with synthetic and biological DMT, who attended the Clinic of Rheumatology, Military Medical Academy, from September to December 2018.The control group consisted of 18 healthy individuals. After approval of the institutional Ethical Committee and after patients have signed Informed Consent,the study was conducted. Disease activity score (DAS28) was determined for the assessment of RA activity, and the assessment of patients’ functional ability was performed using the Health assessment questionnaire disability index (HAQ-DI). Concentration of anti-CarP antibodies was determined by commercial ELISA anti-CarP quantitative sandwich immunoassay. The methods of descriptive and analytical statistics were used in statistical data processing.

Results:

Based on the cut-off value (5.9 ng / ml), no one in the control group had positive anti-CarP antibodies, while 34.7% of the subjects with RA were positive. The positive correlation was found between anti-CarP antibody concentration and DAS28 in all RA patients (p = 0.0003; Pearson r = 0.4829). The positive correlation was also found between anti-CarP antibody concentration and HAQ-DI in all RA patients (p = 0.0003; Pearson r = 0.4253).

Conclusion:

Anti-CarP antibodies were present in a significant number of patients with RA. This study demonstrated that patients with RA with higher concentrations of anti-CarP antibodies have higher disease activity and impaired functional status. It is undisputed that further and larger studies are needed to better determine the clinical significance of these antibodies.

References:

[1]Shi J, Knevel R et al. Autoantibodies recognizing carbamylated proteins are present in sera of patients with rheumatoid arthritis and predict joint damage. Proc Natl AcadSci U S A. 2011 Oct 18;108(42):17372-7.

[2]Yee A, Webb T et al. Anti-CarP antibodies as promising marker to measure joint damage and disease activity in patients with rheumatoid arthritis. Immunol Res. 2015 Feb;61(1-2):24-30.

[3]Brink M, Verheul MK et al. Anti-carbamylated protein antibodies in thepresymptomatic phase of rheumatoid arthritis, their relationship with multiple anticitrulline peptide antibodies and association with radiological damage. Arthritis Res Ther. 2015 Feb 7;17:25.

Graphs 1 and 2.

Correlation of anti-CarP antibody concentration with DAS28 and HAQ-DI in all RA patients

Disclosure of Interests:

None declared

Capacity Building in Nurturing Care in Serbia

Background

Training program for home visitors on early child development was developed and implemented within UNICEF supported projects involving 25 primary health centers. Training content was notably based on resource modules “Supporting Families for Nurturing Care”, adapted according to the local context. Health professionals are seen as the critical actors to support development of young children and their families. Family-centered approach that addresses social as well as medical dimensions of problems became priority in their practice with a special focus on working with children from socially deprived settings and children with disabilities.

Objectives

The main objective was to improve knowledge and practice of home visitors on early child development based on most recent scientific evidence. Broad spectrum of topics was covered including engaging fathers, early detection of postpartum depression, attachment, developmental monitoring, age-appropriate play, home safety, stigma and discrimination. Training were organized as interactive face to face sessions and online courses and attendees were actively engaged in reflection. Comprehensive check list with various assessment instruments was developed to provide guidance to home visitors in implementation of gained skills.

Results

Increase in knowledge of 150 home visitors was between 57.6% and 82.9%. Enhanced knowledge and skills have been applied in 14912 families of which socially deprived was 34.5% during 2-year period of implementation. Parent-child interactions, assessed by visiting nurses, were improved by 32.6%, responsive feeding practices by 27.4%, while age-appropriate play by 34.4% after interventions during home visits.

Conclusions

Well-developed monitoring system was crucial for implementation of gained knowledge and skills in practice of home visitors.

Key messages

Home visitors were empowered to take a strengths-based approach in their work with families. Developed tools facilitated prioritization of most vulnerable families and tailoring support according to needs.

Impact of Hydrogel Stiffness on Differentiation of Human Adipose-Derived Stem Cell Microspheroids

Hydrogels represent an attractive material platform for realization of three-dimensional (3D) tissue-engineered constructs, as they have tunable mechanical properties, are compatible with different types of cells, and resemble elements found in natural extracellular matrices. So far, numerous hydrogel-cartilage/bone tissue engineering (TE)-related studies were performed by utilizing a single cell encapsulation approach. Although multicellular spheroid cultures exhibit advantageous properties for cartilage or bone TE, the chondrogenic or osteogenic differentiation potential of stem cell microspheroids within hydrogels has not been investigated much. This study explores, for the first time, how stiffness of gelatin-based hydrogels (having a storage modulus of 538, 3584, or 7263 Pa) affects proliferation and differentiation of microspheroids formed from telomerase-immortalized human adipose-derived stem cells (hASC/hTERT). Confocal microscopy indicates that all tested hydrogels supported cell viability during their 3- to 5-week culture period in the control, chondrogenic, or osteogenic medium. Although in the softer hydrogels cells from neighboring microspheroids started outgrowing and interconnecting within a few days, their protrusion was slower or limited in stiffer hydrogels or those cultured in chondrogenic medium, respectively. High expressions of chondrogenic markers (SOX9, ACAN, COL2A1), detected in all tested hydrogels, proved that the chondrogenic differentiation of hASC/hTERT microspheroids was very successful, especially in the two softer hydrogels, where superior cartilage-specific properties were confirmed by Alcian blue staining. These chondrogenically induced samples also expressed COL10A1, a marker of chondrocyte hypertrophy. Interestingly, the hydrogel itself (with no differentiation medium) showed a slight chondrogenic induction. Regardless of the hydrogel stiffness, in the samples stimulated with osteogenic medium, the expression of selected markers RUNX2, BGLAP, ALPL, and COL1A1 was not conclusive. Nevertheless, the von Kossa staining confirmed the presence of calcium deposits in osteogenically stimulated samples in the two softer hydrogels, suggesting that these also favor osteogenesis. This observation was also confirmed by Alizarin red quantification assay, with which higher amounts of calcium were detected in the osteogenically induced hydrogels than in their controls. The presented data indicate that the encapsulation of adipose-derived stem cell microspheroids in gelatin-based hydrogels show promising potential for future applications in cartilage or bone TE. Impact Statement Osteochondral defects represent one of the leading causes of disability in the world. Although numerous tissue engineering (TE) approaches have shown success in cartilage and bone tissue regeneration, achieving native-like characteristics of these tissues remains challenging. This study demonstrates that in the presence of a corresponding differentiation medium, gelatin-based hydrogels support moderate osteogenic and excellent chondrogenic differentiation of photo-encapsulated human adipose-derived stem cell microspheroids, the extent of which depends on hydrogel stiffness. Because photosensitive hydrogels are a convenient material platform for creating stiffness gradients in three dimensions, the presented microspheroid-hydrogel encapsulation strategy holds promise for future strategies of cartilage or bone TE.

A Modular Approach to Sensitized Two-Photon Patterning of Photodegradable Hydrogels

Photodegradable hydrogels have emerged as useful platforms for research on cell function, tissue engineering, and cell delivery as their physical and chemical properties can be dynamically controlled by the use of light. The photo-induced degradation of such hydrogel systems is commonly based on the integration of photolabile o-nitrobenzyl derivatives to the hydrogel backbone, because such linkers can be cleaved by means of one- and two-photon absorption. Herein we describe a cytocompatible click-based hydrogel containing o-nitrobenzyl ester linkages between a hyaluronic acid backbone, which is photodegradable in the presence of cells. It is demonstrated for the first time that by using a cyclic benzylidene ketone-based small molecule as photosensitizer the efficiency of the two-photon degradation process can be improved significantly. Biocompatibility of both the improved two-photon micropatterning process as well as the hydrogel itself is confirmed by cell culture studies.

The efficacy of raw and concentrated bentonite clay in reducing the toxic effects of aflatoxin in broiler chicks

The objective of this study was to evaluate the efficacy of two adsorbents, a raw bentonite clay (RC) and a concentrated bentonite clay (CC), in ameliorating the toxic effects of aflatoxin B1 (AFB1). Results of the in vitro study (pH 3.0) indicated the CC adsorbed more AFB1 than RC (93.39 mg/g vs. 79.30 mg/g) suggesting that CC may be more effective than RC in reducing the toxic effects of AFB1. One hundred and eighty day-old straight run broiler chicks were assigned to 6 replicate pens of 5 chicks each and assigned to 6 dietary treatments from hatch to day 21. Dietary treatments included: 1) basal diet (BD) containing no AFB1 or adsorbents; 2) BD plus 0.50% RC; 3) BD plus 0.50% CC; 4) BD plus 2.0 mg AFB1/kg; 5) BD plus 2.0 mg AFB1/kg plus 0.50% RC; and 6) BD plus 2.0 mg AFB1/kg plus 0.50% CC. Dietary AFB1 concentrations were confirmed by analysis and diets were screened for other mycotoxins prior to the start of the experiment. The addition of AFB1 to the feed reduced (P < 0.05) growth performance and increased (P < 0.05) relative liver weight (RLW) and kidney weight (RKW) of chicks fed AFB1 compared to control chicks on day 21. These changes were ameliorated (P < 0.05) by the addition of RC and CC to the AFB1 diet. Mild to moderate lesions of aflatoxicosis (2.25) were observed in chicks fed AFB1 alone on day 21. The addition of both RC and CC to the AFB1 diet decreased (P < 0.05) but did not prevent liver lesions (0.92 and 1.42, respectively). Results indicate that both RC and CC were effective in reducing the toxic effects of AFB1, however the cost of processing of CC would make the RC a more economical product for reducing the effects of AFB1 in young broiler chicks.

Fabrication of biomimetic placental barrier structures within a microfluidic device utilizing two-photon polymerization

The placenta is a transient organ, essential for development and survival of the unborn fetus. It interfaces the body of the pregnant woman with the unborn child and secures transport of endogenous and exogenous substances. Maternal and fetal blood are thereby separated at any time, by the so-called placental barrier. Current in vitro approaches fail to model this multifaceted structure, therefore research in the field of placental biology is particularly challenging. The present study aimed at establishing a novel model, simulating placental transport and its implications on development, in a versatile but reproducible way. The basal membrane was replicated using a gelatin-based material, closely mimicking the composition and properties of the natural extracellular matrix. The microstructure was produced by using a high-resolution 3D printing method - the two-photon polymerization (2PP). In order to structure gelatin by 2PP, its primary amines and carboxylic acids are modified with methacrylamides and methacrylates (GelMOD-AEMA), respectively. High-resolution structures in the range of a few micrometers were produced within the intersection of a customized microfluidic device, separating the x-shaped chamber into two isolated cell culture compartments. Human umbilical-vein endothelial cells (HUVEC) seeded on one side of this membrane simulate the fetal compartment while human choriocarcinoma cells, isolated from placental tissue (BeWo B30) mimic the maternal syncytium. This barrier model in combination with native flow profiles can be used to mimic the microenvironment of the placenta, investigating different pharmaceutical, clinical and biological scenarios. As proof-of-principle, this bioengineered placental barrier was used for the investigation of transcellular transport processes. While high molecular weight substances did not permeate, smaller molecules in the size of glucose were able to diffuse through the barrier in a time-depended manner. We envision to apply this bioengineered placental barrier for pathophysiological research, where altered nutrient transport is associated with health risks for the fetus.

Calibration of colloidal probes with atomic force microscopy for micromechanical assessment

Mechanical assessment of biological materials and tissue-engineered scaffolds is increasingly focusing at lower length scale levels. Amongst other techniques, atomic force microscopy (AFM) has gained popularity as an instrument to interrogate material properties, such as the indentation modulus, at the microscale via cantilever-based indentation tests equipped with colloidal probes. Current analysis approaches of the indentation modulus from such tests require the size and shape of the colloidal probe as well as the spring constant of the cantilever. To make this technique reproducible, there still exist the challenge of proper calibration and validation of such mechanical assessment. Here, we present a method to (a) fabricate and characterize cantilevers with colloidal probes and (b) provide a guide for estimating the spring constant and the sphere diameter that should be used for a given sample to achieve the highest possible measurement sensitivity. We validated our method by testing agarose samples with indentation moduli ranging over three orders of magnitude via AFM and compared these results with bulk compression tests. Our results show that quantitative measurements of indentation modulus is achieved over three orders of magnitude ranging from 1 kPa to 1000 kPa via AFM cantilever-based microindentation experiments. Therefore, our approach could be used for quantitative micromechanical measurements without the need to perform further validation via bulk compression experiments.

Cross-Linkable Gelatins with Superior Mechanical Properties Through Carboxylic Acid Modification: Increasing the Two-Photon Polymerization Potential

The present work reports on the development of photo-cross-linkable gelatins sufficiently versatile to overcome current biopolymer two-photon polymerization (2PP) processing limitations. To this end, both the primary amines as well as the carboxylic acids of gelatin type B were functionalized with photo-cross-linkable moieties (up to 1 mmol/g) resulting in superior and tunable mechanical properties (G' from 5000 to 147000 Pa) enabling efficient 2PP processing. The materials were characterized in depth prior to and after photoinduced cross-linking using fully functionalized gelatin-methacrylamide (gel-MOD) as a benchmark to assess the effect of functionalization on the protein properties, cross-linking efficiency, and mechanical properties. In addition, preliminary experiments on hydrogel films indicated excellent in vitro biocompatibility (close to 100% viability) both in the presence of MC3T3 preosteoblasts and L929 fibroblasts. Moreover, 2PP processing of the novel derivative was superior in terms of applied laser power (≥40 vs ≥60 mW for gel-MOD at 100 mm/s) as well as post-production swelling (0-20% vs 75-100% for gel-MOD) compared to those of gel-MOD. The reported novel gelatin derivative (gel-MOD-AEMA) proves to be extremely suitable for direct laser writing as both superior mimicry of the applied computer-aided design (CAD) was obtained while maintaining the desired cellular interactivity of the biopolymer. It can be anticipated that the present work will also be applicable to alternative biopolymers mimicking the extracellular environment such as collagen, elastin, and glycosaminoglycans, thereby expanding current material-related processing limitations in the tissue engineering field.

A biocompatible macromolecular two-photon initiator based on hyaluronan

The possibility of the direct encapsulation of living cells via two-photon induced photopolymerization enables the microfabrication of hydrogel scaffolds with high initial cell loadings and intimate matrix-cell contact. While highly efficient water-soluble two-photon initiators based on benzylidene ketone dyes have been developed, they exhibit considerable cyto- and phototoxicity. To address the problem of photoinitiator migration from the extracellular matrix into the cytosol, a two-photon initiator bound to a polymeric hyaluronan backbone (HAPI) was synthesized in this work. HAPI exhibited a distinct improvement of cytocompatibility compared to a reference two-photon initiator. Basic photophysical investigations were performed to characterize the absorption and fluorescence behavior of HAPI. Laser scanning microscopy was used to visualize and confirm the hindered transmembrane migration behavior of HAPI. The performance of HAPI was tested in two-photon polymerization at exceedingly high printing speeds of 100 mm s-1 producing gelatin-based complex 3D hydrogel scaffolds with a water content of 85%. The photodamage of the structuring process was low and viable MC3T3 cells embedded in the gel were monitored for several days after structuring.

Hybrid Tissue Engineering Scaffolds by Combination of Three-Dimensional Printing and Cell Photoencapsulation

Three-dimensional (3D) printing offers versatile possibilities for adapting the structural parameters of tissue engineering scaffolds. However, it is also essential to develop procedures allowing efficient cell seeding independent of scaffold geometry and pore size. The aim of this study was to establish a method for seeding the scaffolds using photopolymerizable cell-laden hydrogels. The latter facilitates convenient preparation, and handling of cell suspension, while distributing the hydrogel precursor throughout the pores, before it is cross-linked with light. In addition, encapsulation of living cells within hydrogels can produce constructs with high initial cell loading and intimate cell-matrix contact, similar to that of the natural extra-cellular matrix (ECM). Three dimensional scaffolds were produced from poly(lactic) acid (PLA) by means of fused deposition modeling. A solution of methacrylamide-modified gelatin (Gel-MOD) in cell culture medium containing photoinitiator Li-TPO-L was used as a hydrogel precursor. Being an enzymatically degradable derivative of natural collagen, gelatin-based matrices are biomimetic and potentially support the process of cell-induced remodeling. Preosteoblast cells MC3T3-E1 at a density of 10 × 10⁶ cells per 1 mL were used for testing the seeding procedure and cell proliferation studies. Obtained results indicate that produced constructs support cell survival and proliferation over extended duration of our experiment. The established two-step approach for scaffold seeding with the cells is simple, rapid, and is shown to be highly reproducible. Furthermore, it enables precise control of the initial cell density, while yielding their uniform distribution throughout the scaffold. Such hybrid tissue engineering constructs merge the advantages of rigid 3D printed constructs with the soft hydrogel matrix, potentially mimicking the process of ECM remodeling.

Enzymatic synthesis of hyaluronic acid vinyl esters for two-photon microfabrication of biocompatible and biodegradable hydrogel constructs

A novel class of photopolymerizable hydrogel system based on hyaluronan vinyl esters has been developed for two-photon 3D microfabrication of biocompatible hydrogel constructs.