Avaliação de mediadores inflamatórios de prognóstico e preditivos de rejeição subclínica no transplante renal
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Data
2018-02-22
Autores
Gouveia, Ericson Cavalcanti [UNIFESP]
Orientadores
Pestana, Jose Osmar Medina de Abreu [UNIFESP]
Tipo
Tese de doutorado
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Considera-se rejeição subclínica os achados histológicos de rejeição do enxerto, em biópsia de rotina, na ausência de alteração da função renal. Apesar dos avanços no conhecimento imunológico e na imunossupressão do transplante renal, a rejeição aguda ainda é uma importante causa de disfunção e perda do enxerto. O objetivo do estudo foi avaliar mediadores inflamatórios como fatores de prognóstico e preditivos de rejeição subclínica. Foi um estudo de coorte prospectivo e exploratório com 126 pacientes submetidos a transplante renal, distribuídos em grupos: sem rejeição subclínica (n=52), borderline (n=18) e com rejeição subclínica (n=18). Os controles foram constituídos de 20 indivíduos (18 a 65 anos). As concentrações séricas de IL2, IL-4, IL-6, IL-17A, IFN-γ, TNF-α e IL-10 foram detectadas pela técnica de Cytometric Bead Array por citometria de fluxo, e das formas solúveis de CD40 (sCD40), PD1 (sPD1) e PDL1 (sPDL1) por enzyme linked immunosorbentassay. A coleta de sangue para a dosagem desses marcadores foi realizada no pré-transplante e após 90 dias após o transplante. Testes de Mann-Whitney e Kruskal-Wallis foram usados para análise de medianas entre dois e três grupos, respectivamente e de Wilcoxon na analise pareada. Foi utilizado o teste t e ANOVA para a comparação das médias entre dois e três grupos, respectivamente. Foi considerado significante p<0.05. Foi realizado análise de curva Receiver Operating Characteristic (ROC) para determinar o melhor valor de acurácia de cada marcador estudado e a ocorrência de rejeição subclínica. A análise estatística foi realizada no programa GraphPadPrism v6.0. Os grupos foram homogêneos com relação aos principais fatores de risco para rejeição aguda. Os níveis de IL2, IL-4, IFN-γ e TNF-α foram indetectáveis nos três grupos. Não houve diferença estatística significante nos níveis séricos de IL-6, IL-10, sPD-1 e sPDL-1 entre os três grupos. Os níveis séricos de IL17A foram mais elevados no grupo sem rejeição subclínica comparados aos do grupo borderline e com rejeição subclínica, no pré e pós-tranplante. No pré-transplante, as concentrações séricas de sCD40 (pg/mL) foram elevadas no grupo sem rejeição subclínica (1714±710) comparadas aos borderline (1001±344, p=0,0007) e com rejeição subclínica (893±261, p=0,0003). No pós-transplante, as concentrações séricas de sCD40 (pg/mL) foram elevadas no grupo sem rejeição subclínica (395,7±106) comparadas aos borderline (284,2±57, p=0,0006) e com rejeição subclínica (893±261, p=0,0008). Foi encontrada uma baixa sensibilidade e especificidades de IL-6, IL-10, IL-17A, sPD-1,sPD-L1 para a ocorrência de rejeição subclínica. Os níveis de sCD40 que estabeleceram uma ponte de corte para a ocorrência de rejeição subclínica foram de 1150 pg/mL, no pré-transplante, com sensibilidade de 92% e especificidade de 75% (AUC- 0,82, IC a 95% de 0,70 a 0,95, p=0,0008) e de 335pg/mL, no pós-transplante, com sensibilidade de 92% e especificidade de 76% (AUC- 0,85, IC a 95% de 0,73 a 0,97, p=0,0004). O sCD40 funciona como inibidor natural da ligação CD40-CD40L entre as células que é uma via importante de coestimulação da ativação de linfócito T e B. Esse estudo mostra que sCD40 tem potencial como possível biomarcador preditivo de rejeição subclínica.
Subclinical rejection is considered when histological findings of acute graft rejection is found, in the absence of altered renal function, on a routine biopsy. Despite advances in the knowledge of transplant immunology and improvements in immunosuppression, acute rejection is still an important cause of dysfunction and graft loss. The aim of the study was to evaluate inflammatory mediators as prognostic and predictors factors of subclinical rejection. A prospective and exploratory cohort study was conducted with 126 patients, divided into groups: no subclinical rejection (n=52), borderline (n=18) and subclinical rejection (n=18). The control group consisted of 20 individuals (18 to 65 years). Serum concentrations of IL2, IL-6, IL17A, IFN-γ, TNF-α and IL-10 were detected by the Cytometric Bead Array technique by flow cytometry, and the soluble forms of CD40 (sCD40), PD-1 (sPD-1) and PD-L1 (sPD-L1) by enzyme linked immunosorbent assay. Blood collection for the determination of these markers was performed on the pre-transplant and after 90 days after transplantation. Mann-Whitney and Kruskal-Wallis tests were used for analysis of medians between two and three groups, respectively and Wilcoxon in paired analyses. The t-test and ANOVA were used to compare means between two and three groups, respectively. Values of p <0.05 were considered significant. Receiver Operating Characteristic (ROC) curve analysis was performed to determine the best accuracy value of each marker studied and the occurrence of subclinical rejection. Statistical analysis was performed in the GraphPadPrism v6.0 program. The groups were homogeneous in relation to the main risk factors for acute rejection. Levels of IL2, IL-4, IFN-γ and TNF-α were undetectable in all three groups. There was no statistically significant difference in serum levels of IL-6, IL-10, sPD-1 and sPDL-1 among the three groups. Pre-transplant sCD40 (pg/mL) levels were elevated in the group without subclinical rejection (1714±710) compared to borderline group (1001± 344, p=0.0007) and to subclinical rejection group (893±261, p=0.0003). Posttransplantat sCD40 (pg/mL) were elevated in the group without subclinical rejection (395.7±106) compared to borderline group (284.2±57, p=0.0006) and to subclinical rejection (893±261, p=0.0008). IL-6, IL-10, IL-17A, sPD-1 and sPD-L1 have low sensitivity and specificities for the occurrence of subclinical rejection. The cut-off level of sCD40 for subclinical rejection was 1150pg/mL in pre-transplant, with sensitivity of 92% and specificity of 75% (AUC-0.82, 95% CI 0,70 to 0.95, p=0.0008) and 335pg/mL in post-transplant, with sensitivity of 92% and specificity of 76% (AUC0.85, 95% CI 0.73 to 0.97, p=0.0004). SCD40 functions as a natural inhibitor of CD40-CD40L that is an important co-stimulatory pathway for T and B lymphocyteaactivation. This study shows that sCD40 has potential as a possible predictive biomarker for subclinical rejection.
Subclinical rejection is considered when histological findings of acute graft rejection is found, in the absence of altered renal function, on a routine biopsy. Despite advances in the knowledge of transplant immunology and improvements in immunosuppression, acute rejection is still an important cause of dysfunction and graft loss. The aim of the study was to evaluate inflammatory mediators as prognostic and predictors factors of subclinical rejection. A prospective and exploratory cohort study was conducted with 126 patients, divided into groups: no subclinical rejection (n=52), borderline (n=18) and subclinical rejection (n=18). The control group consisted of 20 individuals (18 to 65 years). Serum concentrations of IL2, IL-6, IL17A, IFN-γ, TNF-α and IL-10 were detected by the Cytometric Bead Array technique by flow cytometry, and the soluble forms of CD40 (sCD40), PD-1 (sPD-1) and PD-L1 (sPD-L1) by enzyme linked immunosorbent assay. Blood collection for the determination of these markers was performed on the pre-transplant and after 90 days after transplantation. Mann-Whitney and Kruskal-Wallis tests were used for analysis of medians between two and three groups, respectively and Wilcoxon in paired analyses. The t-test and ANOVA were used to compare means between two and three groups, respectively. Values of p <0.05 were considered significant. Receiver Operating Characteristic (ROC) curve analysis was performed to determine the best accuracy value of each marker studied and the occurrence of subclinical rejection. Statistical analysis was performed in the GraphPadPrism v6.0 program. The groups were homogeneous in relation to the main risk factors for acute rejection. Levels of IL2, IL-4, IFN-γ and TNF-α were undetectable in all three groups. There was no statistically significant difference in serum levels of IL-6, IL-10, sPD-1 and sPDL-1 among the three groups. Pre-transplant sCD40 (pg/mL) levels were elevated in the group without subclinical rejection (1714±710) compared to borderline group (1001± 344, p=0.0007) and to subclinical rejection group (893±261, p=0.0003). Posttransplantat sCD40 (pg/mL) were elevated in the group without subclinical rejection (395.7±106) compared to borderline group (284.2±57, p=0.0006) and to subclinical rejection (893±261, p=0.0008). IL-6, IL-10, IL-17A, sPD-1 and sPD-L1 have low sensitivity and specificities for the occurrence of subclinical rejection. The cut-off level of sCD40 for subclinical rejection was 1150pg/mL in pre-transplant, with sensitivity of 92% and specificity of 75% (AUC-0.82, 95% CI 0,70 to 0.95, p=0.0008) and 335pg/mL in post-transplant, with sensitivity of 92% and specificity of 76% (AUC0.85, 95% CI 0.73 to 0.97, p=0.0004). SCD40 functions as a natural inhibitor of CD40-CD40L that is an important co-stimulatory pathway for T and B lymphocyteaactivation. This study shows that sCD40 has potential as a possible predictive biomarker for subclinical rejection.
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Citação
GOUVEIA, Ericson Cavalcanti. Avaliação de mediadores inflamatórios de prognóstico e preditivos de rejeição subclínica no transplante renal. 2017. [96] p. Tese (Doutorado em Medicina translacional) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2017.