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Juul N, Ajalloueian F, Willacy O, Chamorro CI, Fossum M. Advancing autologous urothelial micrografting and composite tubular grafts for future single-staged urogenital reconstructions. Sci Rep 2023; 13:15584. [PMID: 37730755 PMCID: PMC10511703 DOI: 10.1038/s41598-023-42092-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023] Open
Abstract
Urogenital reconstructive surgery can be impeded by lack of tissue. Further developments within the discipline of tissue engineering may be part of a solution to improve clinical outcomes. In this study, we aimed to design an accessible and easily assembled tubular graft with autologous tissue, which could be constructed and implanted as a single-staged surgical procedure within the premises of an ordinary operating room. The ultimate goals would be to optimize current treatment-options for long-term urinary diversion. Therefore, we evaluated the optimal composition of a collagen-based scaffold with urothelial micrografts in vitro, and followingly implanted the construct in vivo as a bladder conduit. The scaffold was evaluated in relation to cell regeneration, permeability, and biomechanical properties. After establishing an optimized scaffold in vitro, consisting of high-density collagen with submerged autologous micrografts and reinforced with a mesh and stent, the construct was successfully implanted in an in vivo minipig model. The construct assemblance and surgical implantation proved feasible within the timeframe of a routine surgical intervention, and the animal quickly recovered postoperatively. Three weeks post-implantation, the conduit demonstrated good host-integration with a multilayered luminal urothelium. Our findings have encouraged us to support its use in more extensive preclinical large-animal studies.
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Affiliation(s)
- Nikolai Juul
- Laboratory of Tissue Engineering, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Division of Pediatric Surgery, Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Fatemeh Ajalloueian
- Department of Health Technology, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Oliver Willacy
- Laboratory of Tissue Engineering, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Division of Pediatric Surgery, Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Clara Ibel Chamorro
- Laboratory of Tissue Engineering, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Laboratory of Tissue Engineering, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Magdalena Fossum
- Laboratory of Tissue Engineering, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Division of Pediatric Surgery, Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
- Laboratory of Tissue Engineering, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Amesty MV, Chamorro CI, López-Pereira P, Martínez-Urrutia MJ, Sanz B, Rivas S, Lobato R, Fossum M. Creation of Tissue-Engineered Urethras for Large Urethral Defect Repair in a Rabbit Experimental Model. Front Pediatr 2021; 9:691131. [PMID: 34239850 PMCID: PMC8258112 DOI: 10.3389/fped.2021.691131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Tissue engineering is a potential source of urethral substitutes to treat severe urethral defects. Our aim was to create tissue-engineered urethras by harvesting autologous cells obtained by bladder washes and then using these cells to create a neourethra in a chronic large urethral defect in a rabbit model. Methods: A large urethral defect was first created in male New Zealand rabbits by resecting an elliptic defect (70 mm2) in the ventral penile urethra and then letting it settle down as a chronic defect for 5-6 weeks. Urothelial cells were harvested noninvasively by washing the bladder with saline and isolating urothelial cells. Neourethras were created by seeding urothelial cells on a commercially available decellularized intestinal submucosa matrix (Biodesign® Cook-Biotech®). Twenty-two rabbits were divided into three groups. Group-A (n = 2) is a control group (urethral defect unrepaired). Group-B (n = 10) and group-C (n = 10) underwent on-lay urethroplasty, with unseeded matrix (group-B) and urothelial cell-seeded matrix (group-C). Macroscopic appearance, radiology, and histology were assessed. Results: The chronic large urethral defect model was successfully created. Stratified urothelial cultures attached to the matrix were obtained. All group-A rabbits kept the urethral defect size unchanged (70 ± 2.5 mm2). All group-B rabbits presented urethroplasty dehiscence, with a median defect of 61 mm2 (range 34-70). In group-C, five presented complete correction and five almost total correction with fistula, with a median defect of 0.3 mm2 (range 0-12.5), demonstrating a significant better result (p = 7.85 × 10-5). Urethrography showed more fistulas in group-B (10/10, versus 5/10 in group-C) (p = 0.04). No strictures were found in any of the groups. Group-B histology identified the absence of ventral urethra in unrepaired areas, with squamous cell metaplasia in the edges toward the defect. In group-C repaired areas, ventral multilayer urothelium was identified with cells staining for urothelial cell marker cytokeratin-7. Conclusions: The importance of this study is that we used a chronic large urethral defect animal model and clearly found that cell-seeded transplants were superior to nonseeded. In addition, bladder washing was a feasible method for harvesting viable autologous cells in a noninvasive way. There is a place for considering tissue-engineered transplants in the surgical armamentarium for treating complex urethral defects and hypospadias cases.
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Affiliation(s)
| | - Clara Ibel Chamorro
- Department of Women's and Children's Health, Bioclinicum J10:20, Karolinska Institutet, Stockholm, Sweden
| | - Pedro López-Pereira
- Department of Pediatric Urology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Beatriz Sanz
- Department of Cell Culture, IdiPAZ Instituto de Investigación Hospital Universitario La Paz, Madrid, Spain
| | - Susana Rivas
- Department of Pediatric Urology, Hospital Universitario La Paz, Madrid, Spain
| | - Roberto Lobato
- Department of Pediatric Urology, Hospital Universitario La Paz, Madrid, Spain
| | - Magdalena Fossum
- Department of Women's and Children's Health, Bioclinicum J10:20, Karolinska Institutet, Stockholm, Sweden.,Division of Pediatric Surgery, Department of Surgical Gastroenterology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Health Sciences, Copenhagen University, Copenhagen, Denmark
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Chamorro CI, Asghar M, Ekblad Å, Färnert A, Götherström C, Fossum M. Urothelial cell senescence is not linked with telomere shortening. J Tissue Eng Regen Med 2019; 13:1518-1527. [PMID: 31117156 DOI: 10.1002/term.2900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 11/11/2022]
Abstract
The success of regenerative medicine relies in part on the quality of the cells implanted. Cell cultures from cells isolated from bladder washes have been successfully established, but molecular changes and cell characteristics have not been explored in detail. In this work, we analysed the role of telomere shortening in relation to the regenerative potential and senescence of cells isolated from bladder washes and expanded in culture. We also analysed whether bladder washes would be a potential source for attaining stem cells or promoting stem cell proliferation by using two different substrates to support their growth: a feeder layer of growth-arrested murine fibroblasts J2 3T3 cells and a xeno-free human recombinant laminin-coated surface. We found no association between telomere shortening and senescence in urothelial cells in vitro. Urothelial cells had a stable telomere length and expressed mesenchymal stem cells markers but failed to differentiate into bone or adipocytes. Feeder layer showed an advantage to laminin-coated surfaces in respect to proliferative capacity with the expense of risking that feeder layer cells could persist in later passages. This emphasizes the importance of using carefully controlled culture conditions and molecular quality controls before autotransplantation in future clinical settings. In conclusion, urothelial cells isolated by bladder washes show regenerative potential that need further understanding. Senescence in vitro might be due to cellular stress, and if so, further improvements in culture conditions may lead to longer cell life and higher proliferative capacity.
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Affiliation(s)
- Clara Ibel Chamorro
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Division of Pediatric Urology, Department of Highly Specialized Pediatric Surgery and Pediatric Medicine, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Pediatric Surgery, Faculty of Health Science, University of Copenhagen, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Muhammad Asghar
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Ekblad
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Magdalena Fossum
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Division of Pediatric Urology, Department of Highly Specialized Pediatric Surgery and Pediatric Medicine, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Pediatric Surgery, Faculty of Health Science, University of Copenhagen, Rigshospitalet, DK-2100 Copenhagen, Denmark
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Chamorro CI, Zeiai S, Reinfeldt Engberg G, Brodin D, Lundin J, Nordenskjöld A, Fossum M. Study on genetic stability in human urothelial cells
in vitro. J Tissue Eng Regen Med 2017; 12:e720-e726. [DOI: 10.1002/term.2354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/05/2016] [Accepted: 11/09/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Clara Ibel Chamorro
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
| | - Said Zeiai
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
- Department of Pediatric Surgery, Section of Urology, Astrid Lindgren Children's HospitalKarolinska University Hospital Stockholm Sweden
| | - Gisela Reinfeldt Engberg
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
- Department of Pediatric Surgery, Section of Urology, Astrid Lindgren Children's HospitalKarolinska University Hospital Stockholm Sweden
| | - David Brodin
- Department of Biosciences and NutritionKarolinska Institutet Stockholm Sweden
| | - Johanna Lundin
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
- Department of Pediatric Surgery, Section of Urology, Astrid Lindgren Children's HospitalKarolinska University Hospital Stockholm Sweden
| | - Magdalena Fossum
- Department of Women's and Children's Health and Center for Molecular MedicineKarolinska Institutet Stockholm Sweden
- Department of Pediatric Surgery, Section of Urology, Astrid Lindgren Children's HospitalKarolinska University Hospital Stockholm Sweden
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Chamorro CI, Zeiai S, Reinfeldt Engberg G, Brodin D, Nordenskjöld A, Fossum M. A Study on Proliferation and Gene Expression in Normal Human Urothelial Cells in Culture. Tissue Eng Part A 2015; 21:510-7. [DOI: 10.1089/ten.tea.2014.0175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Clara Ibel Chamorro
- Department of Women's and Children's Health, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Said Zeiai
- Department of Women's and Children's Health, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Urology Section, Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Gisela Reinfeldt Engberg
- Department of Women's and Children's Health, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Urology Section, Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - David Brodin
- Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Urology Section, Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Magdalena Fossum
- Department of Women's and Children's Health, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Urology Section, Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Weber G, Chamorro CI, Granath F, Liljegren A, Zreika S, Saidak Z, Sandstedt B, Rotstein S, Mentaverri R, Sánchez F, Pivarcsi A, Ståhle M. Human antimicrobial protein hCAP18/LL-37 promotes a metastatic phenotype in breast cancer. Breast Cancer Res 2009; 11:R6. [PMID: 19183447 PMCID: PMC2687709 DOI: 10.1186/bcr2221] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 01/16/2009] [Accepted: 01/30/2009] [Indexed: 12/14/2022] Open
Abstract
Introduction Human cathelicidin antimicrobial protein, hCAP18, and its C-terminal peptide LL-37 is a multifunctional protein. In addition to being important in antimicrobial defense, it induces chemotaxis, stimulates angiogenesis and promotes tissue repair. We previously showed that human breast cancer cells express high amounts of hCAP18, and hypothesised that hCAP18/LL-37 may be involved in tumour progression. Methods hCAP18 mRNA was quantified in 109 primary breast cancers and compared with clinical findings and ERBB2 mRNA expression. Effects of exogenous LL-37 and transgenic overexpression of hCAP18 on ErbB2 signalling were investigated by immunoblotting using extracts from breast cancer cell lines ZR75-1 and derivatives of MCF7. We further analysed the impact of hCAP18/LL-37 on the morphology of breast cancer cells grown in soft agar, on cell migration and on tumour development in severe combined immunodeficiency (SCID) mice. Results The expression of hCAP18 correlated closely with that of ERBB2 and with the presence of lymph node metastases in oestrogen receptor-positive tumours. hCAP18/LL-37 amplified Heregulin-induced mitogen-activated protein kinase (MAPK) signalling through ErbB2, identifying a functional association between hCAP18/LL-37 and ErbB2 in breast cancer. Treatment with LL-37 peptide significantly stimulated the migration of breast cancer cells and their colonies acquired a dispersed morphology indicative of increased metastatic potential. A truncated version of LL-37 competitively inhibited LL-37 induced MAPK phosphorylation and significantly reduced the number of altered cancer cell colonies induced by LL-37 as well as suppressed their migration. Transgenic overexpression of hCAP18 in a low malignant breast cancer cell line promoted the development of metastases in SCID mice, and analysis of hCAP18 transgenic tumours showed enhanced activation of MAPK signalling. Conclusions Our results provide evidence that hCAP18/LL-37 contributes to breast cancer metastasis.
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Affiliation(s)
- Günther Weber
- GICC, CNRS UMR 6239, Université François Rabelais, Avenue Monge, Tours, France.
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Sánchez-Soriano RM, Almenar L, Martínez-Dolz L, Reganon E, Martínez-Sales V, Chamorro CI, Vila V, Martín-Pastor J, Villa P, Salvador A. Diagnostic usefulness of inflammatory markers in acute cellular rejection after heart transplantation. Transplant Proc 2007; 38:2569-71. [PMID: 17098005 DOI: 10.1016/j.transproceed.2006.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Acute cellular rejection (ACR) affects early morbidity and mortality after heart transplantation. The diagnostic technique of choice is endomyocardial biopsy. Our aim was to evaluate the diagnostic usefulness of inflammatory markers as a noninvasive method to monitor cellular rejection. MATERIAL AND METHODS We prospectively analyzed 73 cardiac transplant patients by determining the serum levels of protein fibrinogen (fgpro), functional fibrinogen (fgfun), C-reactive protein (CRP), and sialic acid (SA) coinciding with an endomyocardial biopsy (5.1 revisions/patient). The statistical methods were chi(2), Student's t-test, and ROC curves. RESULTS Of the 373 controls, significant rejection was detected in 19%. Analysis of the relationship between ACR and the markers showed significantly elevated levels of fgpro (345 +/- 90 versus 307 +/- 74 mg/dL; P = .03), fgfun (361 +/- 101 versus 318 +/- 89 mg/dL; P = .04), and SA (74 +/- 22 versus 66 +/- 15 mg/dL; P = .02), but not CRP (19 +/- 29 versus 10 +/- 21 mg/dL; P = .07). SA displayed a better diagnostic utility (area under the curve 0.7; P < .01), 35% sensitivity, 85% specificity, and 82% negative predictive value for a cutoff point of 80 mg/dL. CONCLUSIONS Among the inflammatory markers increased in ACR, SA was the most useful noninvasive tool for screening.
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Affiliation(s)
- R M Sánchez-Soriano
- Cardiac Failure and Transplant Unit, La Fe University Hospital, Valencia, Spain.
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Chamorro CI, Almenar L, Martínez-Dolz L, Sánchez-Lacuesta E, Martín-Pastor J, Ten-Morro F, Sánchez-Soriano RM, Agüero J, Ortiz V, Moro JA, Salvador A. Do Cardiovascular Risk Factors Influence Cardiac Allograft Vasculopathy? Transplant Proc 2006; 38:2572-4. [PMID: 17098006 DOI: 10.1016/j.transproceed.2006.08.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the leading cause of heart transplant failure after the first year. The etiological factors involved are currently a controversial matter. Intravascular ultrasound (IVUS) is considered the diagnostic procedure of choice. We assessed the relationship of cardiovascular risk factors with CAV. MATERIALS We analyzed prospectively 22 patients. We conducted a first study with coronary angiography and IVUS at 36 +/- 3 days and a second at 598 +/- 49 days. We performed an average of 5.6 clinical revisions per patient, assessing the effect of the classic cardiovascular risk factors, the cause of heart failure, and the age of the patient and donor. The statistics used were chi(2), Fisher exact test, and Student t test. RESULTS CAV was found in 10 subjects (45.5%). Univariate analysis showed statistically significant differences in the assessment of the presence of diabetes and dyslipidemia posttransplantation, but not pretransplantation. Among the patients with CAV there was a higher percentage of diabetics (32.8% vs 12%, P < .01). The patients with CAV also had higher levels of total cholesterol (211 +/- 40 mg/dL vs 195 +/- 35 mg/dL, P = .02), triglycerides (172 +/- 108 mg/dL vs 136 +/- 66 mg/dL, P = .03), low-density lipoprotein (133 +/- 35 mg/dL vs 117 +/- 30 mg/dL, P = .01), and lower high-density lipoprotein levels (46 +/- 15 mg/dL vs 52 +/- 12 mg/dL, P = .03). CONCLUSIONS Only the diabetes and dyslipidemia present in the posttransplantation period were associated with CAV, which highlights the fact that it is a condition that both shares and has different features with atherosclerosis and probably requires a different diagnostic-therapeutic approach.
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Affiliation(s)
- C I Chamorro
- Cardiac Failure and Transplant Unit, La Fe University Hospital, Valencia, Spain.
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Chamorro CI, Almenar L, Martínez-Dolz L, Reganon E, Sánchez-Lacuesta E, Villa P, Ten F, Andrés L, Martínez-Sales V, Salvador A. Usefulness of von Willebrand Factor in Cardiac Allograft Vasculopathy: Preliminary Experience. Transplant Proc 2006; 38:2566-8. [PMID: 17098004 DOI: 10.1016/j.transproceed.2006.08.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a disease that significantly limits the survival of transplant patients intravascular ultrasound (IVUS) is considered the method of choice for its diagnosis. von Willebrand factor (vWf) has been used as a marker of endothelial malfunction. We sought to evaluate the usefulness of vWf as a CAV marker. MATERIALS AND METHODS We prospectively analyzed 22 cardiac transplant subjects, on whom we performed a first study using coronary angiography and IVUS at 36 +/- 3 days and a second study at 598 +/- 49 days. During the follow-up period, five vWf serum controls were performed per patient. We analyzed the results with the repeated-measures ANOVA test and a ROC curve. RESULTS CAV was detected in 10 (45.5%) of the 22 patients. Although vWf levels tended to diminish progressively during evolution, this trend was not statistically significant (P = .3). However, differences were appreciated based on the presence versus absence of CAV (298 +/- 139 mg/dL versus 212 +/- 105 mg/dL, P = .02). The ROC curve showed a sensitivity of 40%, a specificity of 83%, and a negative predictive value of 82% with a cutoff point of 300 mg/dL. CONCLUSIONS Subjects with CAV showed significantly higher vWf serum concentrations, particularly during the preliminary phases of cardiac transplantation decreasing during its evolution. This marker could be useful for early screening of CAV.
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Affiliation(s)
- C I Chamorro
- Cardiac Failure and Transplant Unit, La Fe University Hospital, Valencia, Spain.
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