side effects: grundlagenforschung zur cni-nephrotoxizität
TRANSCRIPT
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Side effects:
Grundlagenforschung zur CNI-Nephrotoxizität
S. Bachmann, Anatomie
DFG FOR 667
DFG FOR 1368
DFG SFB 1365
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3 signals to rejection
TCR: Allopeptide on MHC of an APC reacts with TCR of a receptor TC
IL-2: Costimulating molecules of the APC bind to their TC counterpart
(CD80/86 to CD28); activation of CALCINEURIN PHOSPHATASE
->CBM-complex/NFkB, NFAT -> IL2
TC proliferation: IL2/IL2R binding -> mTOR, TC proliferation, clonal proliferation
-> TC mediated rejection
-> TC stimulate BC -> antibody-mediated rejection
B. Rudolph, 2018
C4d
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Ca++ and calmodulin -> activation of Cn
Ca2+/Calmodulin-dependent S/T phosphatase
Heterodimer with catalytic subunit isoforms
CnB chain + CnAα, CnAβ, CnAγ
Inhibitors: Cyclosporine A and Tacrolimus/FK506
Immunophilins: (Cyclophilin A,B and FKBP12)
Calcineurin
Immunophilin bound to FK506
(Chaperone; cis/trans isomerase)
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Since 1983: CNI
CsA,Tacrolimus,
Immunophilins
Williams & Gooch Exp Rev Mol Med 2012,
Kang CB Neurosignals 2008
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CNI and immunophilins
CsA,Tacrolimus,
Immunophilins
Immunophilin
Chaperones
cis/trans Isomerase
Williams & Gooch Exp Rev Mol Med 2012,
Kang CB Neurosignals 2008
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Calcineurin has multiple substrates!
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CNI – side effects, nephrotoxicity - Pathology
CNI: Short term outcome very good, Risk: early application of high doses-> acute damage
CNI: Long term graft survival suboptimal
1. Functional/ acute arteriolopathy (hyalinosis; 92%)
2. Thrombotic microangiopathy
3. Toxic tubulopathy
4. Interstitial/striped fibrosis
5. Glomerulosclerosis; FGS, FSGS; proteinuria
Mihatsch 2011: CNI sind nephrotoxisch, aber es gibt keine
spezifischen histologischen Läsionen!
Terminus CAN = Chronic Allograft Nephropathy
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CNI – side effects, acute nephrotoxicity: Pathology
Transplanted of own kidney:
Afferent constriction
Arteriolar vacuolization of muscular wall
A.A. thrombosis and loop collapse
Isometric tubular vacuolization (ER)
Thrombotic microangiopathy (rare)
Naesens 2018, Leal R et al., KI 2018
M. Thomson, IVA; Figs. a-c GSP
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CNI – side effects, chronic nephrotoxicity: Pathology
Late-onset graft dysfunction (grades I to IV):
Arteriolar („beaded“) hyalinisation, subendothelial and media
Leal R et al., KI 2018
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Vanhove T and Kuypers D, Transplantation 2017
Pathology – fibrosis and point of no return
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Venk, Kriz, Bidani JASN 2015
Pathology: on the origin of fibrosis and its spreading upon AKI
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Towards function: adverse effects of CNIs
Cyclosporine and tacrolimus may cause... • Hypertension
• Hyperkalemia
• Hypercalciuria
• Mild metabolic acidosis
• Calcium wasting
• ECM accumulation
• TGF-ß overproduction
• increased apoptosis
• elevated serum creatinine levels
CsA i.v. directly after transplantation: Switch fom diuresis to oliguria
"Between arteriolar constriction and renal scarring"
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Morozumi & Mihatsch Transplant Proc 2004
CNI nephrotoxicity – structural vs. functional
View from 2004
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Mortensen et al., FIM 2017
View from 2017
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Eigene Arbeiten, Berlin
Treating rats, mice, zebrafish, cultured cells
with tacrolimus, CsA
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Blankenstein et al. AJP 2017
J. Hu 2018
Juxtaglomerular apparatus
+CNI JG cells Renin
-CNI COX2 +CNI
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A reason for COX-2
Höcherl et al. KI 2004
Daily Na excretion
mVal/d x kg b.w.
200
50
Basal Furosemide
Vehicle
Cyclosporine A
Rofecoxib
Cyclosporine A
+ rofecoxib
CsA likely attenuates the natriuretic action of loop diuretics
by inhibition of renal COX-2 expression
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A reason for RAAS and CNI (rats, 35 d 15 mg CsA/kg)
Pichler RH… and Johnson R, JASN 1994
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ACEI and ARBs – combined with CNI?
TGFß und endothelin levels decrease, creatinine clearance worsened
Unclear, whether co-treatment with ARBs is able to slow the progression of CNI
nephrotoxicity in a human setting
Long term studies: lisinopril and nifedipin have similar beneficial effects,
but also: nifedipin and not lisinopril improved graft function (Naesens)
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Na-K-2Cl cotransporter NKCC2
Na-Cl cotransporter NCC
Renal salt handling, extracellular volume
and blood pressure control
Distal nephron and CNI-induced hypertension
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CnA isoforms and cyclophilins distributed differentially
FKBP12
CyPA
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K+
ROMK
Mg2+ Ca2+
NH4+
Blood
Na+
K+
Na,K-
ATPase
Calcineurin
Urine
P
P
P
Na+,K+,Cl-
Cl-
WNK
Ca2+
Ca2+
Ca2+
Ca2+
SPAK/
OSR1 P P
Cation-coupled chloride cotransporters: NKCC2
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K+
ROMK
Mg2+ Ca2+
NH4+
Na+
K+
Na,K-
ATPase
Calcineurin
P
P
P
Cl-
WNK
Ca2+
SPAK/
OSR1 P P CnI Iph.
Na+,K+,Cl-
Blood
Urine
Cation-coupled chloride cotransporters: NKCC2
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ΔIs
c,
μA
/cm
²
25µm
*
1
0
-200
-400
-600
-800
-1000
-1200
vehicle cyclosporine A
NKCC2
pT96/pT101-NKCC2
GAPDH
0
100
200
300
*
NKCC2 pNKCC2
CyA
vehicle
*
CyA + furosemide
vehicle + furosemide
GAPDH
pN
KC
C2
sig
na
l, %
isolated perfused TAL
Borschewski A K et al. J Am Soc Nephrol. 2015
Effects of cyclosporine A in rats: NKCC2 activity
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0
2
4
6
8
0
20
40
60
80
100
120
140
Na e
xcre
tion
, m
M/k
g b
.w.
BP, m
m H
g
Salt retention Increased Blood Pressure
*
*
CyA
vehicle
10d CyA in rats
Effects of cyclosporine A in rats: volume aspects
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CsA stimulates Na,K,2Cl-cotransport
Wu & Vandewalle KI 2000
86Rb+ influx,
nmol.min-1
.mg protein-1
Early findings
in subcultured
mouse mTAL
cells
Conclusion: TAL activated NaCl transport -
a component in CsA – induced hypertension
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Bachmann S., Kidney Int 2018
Calcineurin and late distal tubule
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Hypertension is salt-sensitive
Tac causes K retention
Hoorn E et al.
Nat Med 7:1304-9, 2011
Effects of tacrolimus in mice: animal physiology
Tac causes Hypertension
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Tac increases pNCC Tac increases thiazide-
sensitivity
NCC ablation abrogates
Tac effects
Hoorn E et al.
Nat Med 7:1304-9, 2011
Tacrolimus activates NCC to cause hypertension
Conclusion: DCT activated NaCl transport -
a component in Tacrolimus – associated hypertension
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Cn Cn
Calcineurin Inhibitors (cyclosporine A or tacrolimus)
Renal salt retention -> hypertension, electrolyte disorders
Controlling CNI hypertension with diuretics?
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Since Schlöndorff et al. JASN 2008: 256 pubmed hits on UPR in the kidney!
SFB C04: Do CNI affect proteostasis (ER stress)?
7 Sites in the UPR for potential intervention
Design: Junda Hu, 2018
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ER stress
UPR
Cytoprotective:
↑protein folding
↓protein translation
↑autophagy
Calcineurin Inhibitors
Maladaptive:
↑proapoptotic factors
Toxic tubulopathy 24% in CNI-NT: to study role of UPR
Lhotak AJP F 2012
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Lab members and collaborators
Bachmann Lab
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Good reviews in the field
are rare, this one is excellent, but needs update!
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Naesens Nat Rev Nephrol 2016
CNI & immunosuppressant choice
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Basic view in 2006: calcineurin function
Gooch j J, AJP F, 2006
IL-2 to -4 and TNFa
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NATURE 1992
IL-2 - The original paper
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Venk, Kriz, Bidani JASN 2015
Pathology: on the origin of fibrosis and its spreading upon AKI
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CyA; Dr. Rudolph