Estudio de heparinas y heparinoide de bajo peso molecular, pentasacárido y heparina no fraccionada en un modelo de trombosis "in vitro". Efecto sobre el depósito de plaquetas y la formación de fibrina

[spa] La heparina es una familia de cadenas de glicosaminoglicanos (GAGs) formados por residuos de glucosamina y ácido urónico, cuya eficacia y seguridad en la profilaxis y tratamiento de las enfermedades trombóticas están bien establecidas.El descubrimiento de que parecía posible desdoblar el efecto inhibidor del factor Xa de la inhibición de la trombina, con las fracciones de bajo peso molecular de la heparina despertó grandes expectativas y condujo a la introducción en terapéutica de las heparinas y heparinoides de bajo peso molecular. Debido a los distintos procedimientos de obtención y a las diferentes unidades utilizadas por los fabricantes para expresar la actividad de sus productos, las comparaciones entre los distintos preparados eran complicadas.Esta situación indujo a la realización de la presente tesis en la que se comparó el efecto de distintos GAGs sobre la hemostasia en un modelo de trombosis in vitro.Los productos estudiados fueron: Fragmin® (Kabi) y Fraxiparinc® (Sanofi), dos heparinas de bajo peso molecular que se obtienen a partir de la heparina por despolimerización y purificación; Lomoparán® (Organon) un hiparinoide de bajo peso molecular que se produce directamente de mucosa intestinal porcina; Org 31550 es un derivado sintético del pentasacárido natural de unión a la ATIII y está exento de toda acción inhibidora de la trombina; la heparina no fraccionada estudiada (HNF, Laboratorios Rovi) es la disponible comercialmente y se obtiene de mucosa intestinal porcina.Debido a las distintas unidades empleadas por los fabricantes, en primer lugar hubo que seleccionar la concentración óptima que sería utilizada en las perfusiones, para cada uno de los productos. De forma arbitraria se decidió utilizar la mínima necesaria que inhibiera la formación de trombina en sangre mantenida en reposo a temperatura ambiente. Como indicador de la formación de trombina se determinó la concentración de fibrinopéptido A (FPA).A continuación se estudió el efecto de los GAGs sobre el funcionalismo plaquetario a las dosis seleccionadas. Para ello se realizaron perfusiones en las que se cuantificó el depósito de plaquetas sobre la superficie expuesta al flujo y se evaluó la formación de microagregados plaquetarios.Las perfusiones se realizaron en una cámara de perfusión desarrollada por Sakariassen. La superficie adhesiva era matriz extracelular (MEC) de células endoteliales (CE) cultivadas in vitro. Expuesta al flujo esta matriz induce la adhesión plaquetaria, pero no la formación de trombos. Para obtener una matriz trombogénica que permitiera estudiar la formación de fibrina y trombos plaquetarios, las células fueron estimuladas con un éster de forbol que induce en las CE la síntesis y depósito de factor tisular en la MEC que activará la cascada de la coagulación que conducirá a la producción de trombina.En la evaluación en face de la adhesión plaquetaria se cuantificó la superficie cubierta (SC) por plaquetas. Los trombos plaquetarios se evaluaron en sección transversal que permite cuantificar la superficie cubierta por trombos de diferentes alturas. Al finalizar las perfusiones se midió la formación de microagregados (SPD) realizando recuentos en EDTA y en glutaraldehído en un contador automático fijando la ventana de recuento entre 3,2 y 16 fl. La idea es que los microagregados formados durante la perfusión se deshacen al colocarlos en una EDTA, y por el contrario son fijados en glutaraldehído y no son valorados por el contador.El siguiente paso consistió en encontrar un método fiable que permitiera cuantificar la fibrina depositada sobre la matriz. En primer lugar se comparó la técnica que se pensaba utilizar, que es la del Fg-PO con la del Fg marcado con iodo 125 que se considera el patrón pero que tiene el inconveniente de que obliga a trabajar con material radioactivo. Para el estudio comparativo se realizaron perfusiones sobre matriz trombogénica en las que la fibrina se midió con las dos técnicas a la vez.Una vez establecida la técnica a utilizar se estudió el efecto de los glicosaminoglicanos y de las condiciones de flujo sobre la formación de fibrina, utilizando las mismas condiciones de perfusiones que antes.RESULTADOSSe observa que Fragmin y Fraxiparine son casi igualmente efectivas inhibiendo la formación de trombina en la sangre en reposo en términos de molaridad (33,2 Y 36,8 nmol/ml aunque difieren considerablemente cuando se expresan en las U del fabricante (20 y 40 U/mi). Mucha mayor cantidad se requiere de Lomoparan (146,4 nmol/ml) y del pentasacárido 31550 (95,2 nmol/ml) posiblemente debido a su menor actividad inhibidora de la trombina. Como cabía esperar por su actividad anti-trombina mucha menor cantidad de HNF fue necesaria (1,9 nmol/ml).Con la sangre anticoagulada con Lomoparan, la SC por plaquetas es significativamente mayor a los otros GAGs. Respecto al SPD la cifra de Lomoparan es menor aunque sólo es estadísticamente significativa comparada con la obtenida con Fragmin. Al estudiar la relación entre SC y SPD en cada una de las perfusiones realizadas, se observa que presentan una correlación lineal inversa estadísticamente significativa. Parece probable que la mayor SC observada con Lomoparan sea debido a su menor capacidad de formación de microagregados.Cuando se estudió el efecto sobre la formación de agregados, sólo en la superficie cubierta por agregados mayores de 10 milimicras se observaron diferencias, siendo menor para heparina no fraccionada y Lomoparan que para Fragmin y Fraxiparine. Sabemos que la formación de trombos plaquetarios en estas condiciones es un proceso trombina dependiente. Por lo tanto las diferencias observadas en los agregados de mayor tamaño posiblemente sea debida a diferencias en la cantidad de trombina formada. Presentando la HNF la mayor capacidad de inhibición, y tras ella Lomoparan, Fragmin y Fraxiparine.Tras realizar los estudios comparativos se decidió utilizar el marcaje con yodo pues a pesar de que la manipulación del material radioactivo es más engorrosa, proporciona unos resultados fiables.Una vez seleccionada la técnica a utilizar, se estudió el efecto de los glicosaminoglicanos y del flujo sobre el depósito de fibrina.La cantidad de fibrina depositada en las perfusiones realizadas con sangre anticoagulada con la HNF, a ambos coeficientes de cizalladura es casi inexistente. Ni la microscopía óptica ni la electrónica, mostraron fibrina en absoluto; estas cifras probablemente muestran los valores de fondo correspondientes al Fg-Yodo asociado a la MEC y/o a las plaquetas.Por el contrario, la fibrina formada con los otros GAGs varió considerablemente dependiendo del tipo de anticoagulante y el coeficiente de cizalladura. A 300 s(-1) el pentasacárido Org 31550 proporcionó las cantidades mayores de fibrina formada, seguido por Fraxiparine y Fragmin. Lomoparan inhibió el depósito de fibrina en mayor proporción.Cuando el coeficiente de cizalladura se aumentó a 1.300 s(-1) la cantidad de fibrina disminuyó. Para el pentasacárido y la HNF, la reducción no alcanzó significación estadística. Sí lo fue para Fraxiparine, Fragmin y Lomoparán, en los que rondó alrededor del 80%.La generación del FPA siguió el mismo patrón que la fibrina, es decir el menor aument o correspondió a la HNF, ya continuación Lornoparan, Fragmin y Fraxiparine y el mayor al pentasacárido. El aumento en los niveles de fibrinopéptido A se detuvo al fmalizar la perfusión en todos los GAGs excepto para el pentasacárido. En este caso, a los 15' de acabar la perfusión los niveles de FPA habían crecido aproximadamente un 30%. Esto probablemente indica que una vez se ha formado trombina escapa a los mecanismos de inhibición y continua ejerciendo su acción en la fase líquida.Entre los GAGs de bajo peso molecular Lomoparán posee un efecto antitrombina mayor que Fragmin y Fraxiparine. Este mayor potencial antitrombólico podría deberse a la presencia de dermatán sulfato, pues recientemente se ha demostrado que los complejos de dermatán sulfato-cofactor JI de la heparina son capaces de inhibir a la trombina unida a la fibrina mientras que los complejos de antitrombina III-heparina no lo son. El perfil de acción de Fragmin y Fraxiparine es más o menos igual con una tendencia de Fraxiparine hacia un menor efecto antitrombótico.Las diferencias observadas en la generación de FPA comparando los dos coeficientes de cizalladura no fueron estadísticamente significativas. Esto sugiere que la menor cantidad de fibrina depositada a alto coeficiente de cizalladura posiblemente se debe a una menor polimerización de los monómeros de fibrina inducida por el flujo que a un defecto en la formación de trombina.[eng] Low molecular weight heparin(oid)s (LMWH) differ markedly in terms of molecular composition and activity. In order lo gel more insight into the effect on platelets and fibrin deposition we have compared Fragmin® (KabiVitrum, FA), Fraxiparine® (Choay Laboratories, FP), Lornoparan®, a LMW heparinoid (Organon, LO), a synthetic derivative of rhe natural pentasaccharide, Organon 31550 (PE) and unfractionated heparin (Rovi Laboratories, UH) in a perfusion systern. The concentration selected for perfusion studies was the lowest which inhibited thrombin generation (measured as increase in fibrinopeptide A, FPA) in blood stored for 3 hours at room temperature. Blood from healthy donors was anticoagulated with FA 20 U/ml, FP 40 U/ml, LO 15 U/ml, PE 200 U/ml and UH 5 U/ml. Perfusions were carried out in a rectangular chamber at a shear rate of 300 and 1300 s(-1) for 5 minutes. The extracellular matrices (ECM) used as adhesive surface were obtained from cultured human umbilical vein endothelial cells. A part of these cells were stimulated with phorbol myristate acetate for 16 hours to induce tissue factor synthesis and thrombin formation in the ECM.The extent of platelet aggregation during perfusion was measured as single platelet disappearance (SPD) by comparing platelet counts in EDTA and glutaraldehyde. Fibrin deposition was measured with IUI-fibrinogen. FPA generation during perfusion was assessed with a RIA kit. In the perfusions performed al 1300 s(-1)' for 5 min, over non stimulated ECM, LO showed a significantly higher platelet adhesion than the other heparins. This correlated with a significantly lower SPD during perfusion. In perfusions carried out at 300 s(-1) over stimulated ECM, all LMWH's and PE gave significantly more fibrin deposition than UH. LO gave less fibrin than the others LMWH's. When the shear rate was increased to 1,300 s(-1) the amount of fibrin deposited on !he ECM decreased, with no changes in the amount of FPA generated, indicating that probably it was due to a defect on fibrin polymerisation more than to a impairment of thrombin formation. In conclusion: in this experimental model, LO exerts less effect on platelets than the other heparins studied. All LMWH's tested and PE, but not UH, a1low local thrombin generation and fibrin deposition on subendothelium. LO inhibited fibrin deposition to a larger extent than the other LMWH's

The role of red blood cell exchange for severe imported malaria in the artesunate era: a retrospective cohort study in a referral centre

BACKGROUND: Intravenous artesunate has replaced quinine as the first-line therapy for severe imported malaria, given its anti-malarial superiority shown in clinical trials conducted in endemic countries. Evidence for red blood cell (RBC) exchange in patients with severe malaria treated with artesunate is lacking. This retrospective cohort study describes the experience at Hospital Clinic of Barcelona with the use of artesunate for severe malaria and the joint use of RBC exchange in selected cases. METHODS: Patients treated for severe malaria at Hospital Clinic of Barcelona between August 2013 and January 2015 were included in this retrospective study. Severe malaria was defined according to WHO criteria. Data were extracted from electronic hospital records. A log-linear mixed model approach was used to estimate parasite clearance times. RESULTS: Within the study period, 42 patients were diagnosed of malaria at this centre, of which 38 had Plasmodium falciparum (90.5 %). Sixteen patients (42 %) had severe malaria cases and were treated with intravenous artesunate. Four patients underwent RBC exchange within a period of 15 h after the first dose of artesunate (range 9-21 h). The procedure lasted a median of 2 h (IQR 1.8-2 h), using a median of 12 (IQR 11-14) units of packed RBCs to replace a median of 3794 ml (IQR 2977-4343). The technique was well-tolerated without haemodynamic complications. There were no deaths. The regression model showed an estimated time to 95 % decay of 21.6 h (95 % CI 17.3-28.8). When assessing effect modification by RBC exchange, there was no difference in the parasite elimination rate (p = 0.286). DISCUSSION AND CONCLUSION: In this study RBC exchange failed to show benefits in terms of parasite clearance probably due to the small number of patients analysed. The evidence for exchange transfusion remains limited

Rituximab, plasma exchange and immunoglobulins: an ineffective treatment for chronic active antibody-mediated rejection

BACKGROUND: Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants. METHODS: To determine the efficacy and safety of combined therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF'17 classification, was identified. RESULTS: We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively. CONCLUSIONS: Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications

Aerosol lidar intercomparison in the framework of SPALINET- the SPAnish LIdar NETwork: methodology and results

A group of eight Spanish lidars was formed in order to extend the European Aerosol Research Lidar Network-Advanced Sustainable Observation System (EARLINET-ASOS) project. This study presents intercomparisons at the hardware and software levels. Results of the system intercomparisons are based on range-square-corrected signals in cases where the lidars viewed the same atmospheres. Comparisons were also made for aerosol backscatter coefficients at 1064 nm (2 systems) and 532 nm (all systems), and for extinction coefficients at 532 nm (2 systems). In total, three field campaigns were carried out between 2006 and 2007. Comparisons were limited to the highest layer found before the free troposphere, i.e., either the atmospheric boundary layer or the aerosol layer just above it. Some groups did not pass the quality assurance criterion on the first attempt. Following modification and improvement to these systems, all systems met the quality criterion. The backscatter algorithm intercomparison consisted of processing lidar signal profiles simulated for two types of atmospheric conditions. Three stages with increasing knowledge of the input parameters were considered. The results showed that all algorithms work well when all inputs are known. They also showed the necessity to perform, when possible, additional measurements to attain better estimation of the lidar ratio, which is the most critical unknown in the elastic lidar inversion

Extreme, wintertime Saharan dust intrusion in the Iberian Peninsula: Lidar monitoring and evaluation of dust forecast models during the February 2017 event

The research leading to these results has received funding from the H2020 program from the European Union (grant agreement no. 654109, 778349) and also from the Spanish Ministry of Industry, Economy and Competitiviness (MINECO, ref. CGL2013-45410-R, CGL2016-81092-R, CGL2017-85344-R, TEC2015-63832-P), the Spanish Ministry of Science, Innovation and Universities (ref. CGL2017-90884-REDT); the CommSensLab "Maria de Maeztu" Unity of Excellence (ref. MDM-2016-0600) financed by the Spanish Agencia Estatal de Investigación. Co-funding was also provided by the European Union through the European Regional Development Fund (ref. POCI-01-0145-FEDER-007690, ALT20-03-0145-FEDER-000004, ALT20-03-0145-FEDER-000011); by the Andalusia Regional Government (ref. P12-RNM-2409); by the Madrid Regional Government (projects TIGAS-CM, ref. Y2018/EMT-5177 and AIRTEC-CM, ref. P2018/EMT4329); by the University of Granada through “Plan Propio. Programa 9 Convocatoria 2013” and by the Portuguese Foundation for Science and Technology and national funding (ref. SFRH/BSAB/143164/2019). The BSC-DREAM8b and NNMB/BSC-Dust (now NMMB-MONARCH) model simulations were performed by the Mare Nostrum supercomputer hosted by the Barcelona Supercomputer Center (BSC). S. Basart acknowledges the AXA Research Fund for supporting aerosol research at the BSC through the AXA Chair on Sand and Dust Storms Fund, as well as the InDust project (COST Action CA16202). The authors gratefully acknowledge the NOAA Air Resources Laboratory (ARL) for the provision of the HYSPLIT transport and dispersion model and/or READY website (http://www.ready.noaa.gov) used in this publication.An unprecedented extreme Saharan dust event was registered in winter time from 20 to 23 February 2017 over the Iberian Peninsula (IP). We report on aerosol optical properties observed under this extreme dust intrusion through passive and active remote sensing techniques. For that, AERONET (AErosol RObotic NETwork) and EARLINET (European Aerosol Research LIdar NETwork) databases are used. The sites considered are: Barcelona (41.38°N, 2.17°E), Burjassot (39.51°N, 0.42°W), Cabo da Roca (38.78°N, 9.50°W), Évora (38.57°N, 7.91°W), Granada (37.16°N, 3.61°W) and Madrid (40.45°N, 3.72°W). Large aerosol optical depths (AOD) and low Ångström exponents (AE) are observed. An AOD of 2.0 at 675 nm is reached in several stations. A maximum peak of 2.5 is registered in Évora. During and around the peak of AOD, AEs close to 0 and even slightly negative are measured. With regard to vertically-resolved aerosol optical properties, particle backscatter coefficients as high as 15 Mm−1 sr−1 at 355 nm are recorded at the lidar stations. Layer-mean lidar ratios are found in the range 40–55 sr at 355 nm and 34–61 sr at 532 nm during the event. The particle depolarization ratios are found to be constant inside the dust layer, and consistent from one site to another. Layer-mean values vary in the range 0.19–0.31. Another remarkable aspect of the event is the limited vertical distribution of the dust plume which never exceeds 5 km. The extreme aspect of the event also presented a nice case for testing the ability of two dust forecast models, BSC-DREAM8b and NMMB/BSC-Dust, to reproduce the arrival, the vertical distribution and the intensity of the dust plume over a long-range transport region. In the particular case of the February 2017 dust event, we found a large underestimation in the forecast of the extinction coefficient provided by BSC-DREAM8b at all heights independently of the site. In contrast NMMB/BSC-Dust forecasts presented a better agreement with the observations, especially in southwestern part of the IP. With regard to the forecast skill as a function of lead time, no clear degradation of the prognostic is appreciated at 24, 48 and 72 h for Évora and Granada stations (South). However the prognostic does degrade (bias increases and/or correlation decreases) for Barcelona (North), which is attributed to the fact that Barcelona is at a greater distance from the source region and to the singularity of the event.Funding from the H2020 program from the European Union (grant agreement no. 654109, 778349)Spanish Ministry of Industry, Economy and Competitiviness (MINECO, ref. CGL2013-45410-R, CGL2016-81092-R, CGL2017-85344-R, TEC2015-63832-P)Spanish Ministry of Science, Innovation and Universities (ref. CGL2017-90884-REDT)CommSensLab "Maria de Maeztu" Unity of Excellence (ref. MDM-2016-0600) financed by the Spanish Agencia Estatal de InvestigaciónCo-funding was also provided by the European Union through the European Regional Development Fund (ref. POCI-01-0145-FEDER-007690, ALT20-03-0145-FEDER-000004, ALT20-03-0145-FEDER-000011)Andalusia Regional Government (ref. P12-RNM-2409); by the Madrid Regional Government (projects TIGAS-CM, ref. Y2018/EMT-5177 and AIRTEC-CM, ref. P2018/EMT4329)Portuguese Foundation for Science and Technology and national funding (ref. SFRH/BSAB/143164/2019

Immune Tolerance in Multiple Sclerosis and Neuromyelitis Optica with Peptide-Loaded Tolerogenic Dendritic Cells in a Phase 1b Trial

There are adaptive T-cell and antibody autoimmune responses to myelin-derived peptides in multiple sclerosis (MS) and to aquaporin-4 (AQP4) in neuromyelitis optica spectrum disorders (NMOSDs). Strategies aimed at antigen-specific tolerance to these autoantigens are thus indicated for these diseases. One approach involves induction of tolerance with engineered dendritic cells (tolDCs) loaded with specific antigens. We conducted an in-human phase 1b clinical trial testing increasing concentrations of autologous tolDCs loaded with peptides from various myelin proteins and from AQP4. We tested this approach in 12 patients, 8 with MS and 4 with NMOSD. The primary end point was the safety and tolerability, while secondary end points were clinical outcomes (relapses and disability), imaging (MRI and optical coherence tomography), and immunological responses. Therapy with tolDCs was well tolerated, without serious adverse events and with no therapy-related reactions. Patients remained stable clinically in terms of relapse, disability, and in various measurements using imaging. We observed a significant increase in the production of IL-10 levels in PBMCs stimulated with the peptides as well as an increase in the frequency of a regulatory T cell, known as Tr1, by week 12 of follow-up. In this phase 1b trial, we concluded that the i.v. administration of peptide-loaded dendritic cells is safe and feasible. Elicitation of specific IL-10 production by peptide-specific T cells in MS and NMOSD patients indicates that a key element in antigen specific tolerance is activated with this approach. The results warrant further clinical testing in larger trials

Rituximab, plasma exchange and immunoglobulins: an ineffective treatment for chronic active antibody-mediated rejection

BACKGROUND: Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants. METHODS: To determine the efficacy and safety of combined therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF'17 classification, was identified. RESULTS: We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively. CONCLUSIONS: Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications

SPALINET: Red Española de lidares de aerosoles

Postprint (published version