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The microvasculature:

Small blood vessel behaviour in shock


& Acute Kidney Injury,
a translational approach

Matijs van Meurs, MD. PhD.

Dept. Critical Care, UMCG


&
Laboratory for Endothelial Biomedicine & Vascular Drug Targeting
Research
m.van.meurs@umcg.nl
Thank you for the invitation

Marco Harmsen Patrick van Rijn


Interactive

er School 2018
Wednesday

VAREM Summay
Tuesday
Monday 11 july 2018

l Prog ra m C A Sunday
9 july 2018
10 july 2018

Educationa
Saturday Breakfast
8 july 2018
Frid
7 july 2018 Breakfast
Thursday 2018 6 july Breakfast
Wednesday Breakfast
5 july 2018 (A)
Breakfast - room 3111.0017
A. Deusinglaan 1
Tuesday 4 july 2018 Breakfast
Monday
Sunday 3 july 2018 Breakfast
2/Jul/18 Breakfast
1/Jul/18 Breakfast
Time Breakfast (A)
- room 3111.0017
8:00
Arrival A. Deusinglaan 1
Patrick van Rijn:
Biomaterials
Breakfast Maarten van der
Laan
9.00-10.00h Group Assignment
9:00 ase s
Large vessel dise Marco Harmsen
/ Final Presentation
arrival 9.00-10.00h
Janette Burgess: to the panel
Marie-Jose Gouman
s: Patrick van Rijn:
cal
t and stem From Organotypi Nanotechnology
Cardiac developmen Marcel Ruiters:
culturing & 10.-11.00j
Guido Krenning: cells Valorisation &
Marco Harmsen: continued 9.00-11.00h 3D BioPrinting to p
entrepreneurshi
Opening & course 10-10.30h Tissue Engineering
10:00
overview Menno de Jong: 9.00-12.00h
ls
Hydrogel materia Inge Zuhorn:
10.00-11.00h Nanomedicine &
Herman Sillje: targeting
Lunch
Patients experie
nce Cardiac disease Lunch
10.30-12.00h Ruud Bank: Lunch
~10.30-12.00h Collagen
11.00-12.00h Lunch
11:00 Alumni
Lunch up 5 Closure and
up 4 Journal Club Gro
Lunch Journal Club Gro
Lunch
Lunch Lunch up 3
12:00 Journal Club Gro Travel
Ruud Bank:
up 2 ction
Journal Club Gro Foreign Body Rea Inge Zuhorn:
up 1
13:30 Matijs van Meurs: Journal Club Gro 13.30-14.30h Nanomedicine &
Sepsis - a microva
scular Excursion to targeting
icine in g
disease Regenerative med Bax bier Schiermonnikoo
13.30-14 .30h 3D perspective
ple Janette Burgess: group assignment:
ends on peo rix
14:00 Bike course - dep Extracellular Mat
arriving 14.00-15.00h preparation of
Guido Krenning: presentation
ment,
Vascular develop
stem cells and Group Assignment
dysfunction
15:00
14.30-15.30h Group Assignment
Group Assignment Group Assignment

16:00 City tour Free night 10 euro


BBQ 10 euro per
Group Assignment
participants

17:00 Group Assignment

18:00
me
BBQ with SSG + The
party
19:00
5 euro
Bowling , O'Mally
euro, quiz 5 Free night 10 euro
Pakhuis dinner 9
Pannekoekeschip euro
20:00 ks
dinner SSG drin
Free night

21:00
Who is he ?

• Matijs van Meurs


• 44 years
• Atheneum,
• Medicine (Groningen)
• Anesthesiologist
• Intensivist
• PhD Research Medical Bilology lab, Promotor Prof Dr Ingrid Molema : the
endotheelcel in shock
• 2010 : 6 months Research in Boston, Harvard Medical School
• Patient Care and translational research
Ø Translational Shock Research Group
Ø Tutor of clinical and pre clinical researchers
• Teaching BSc, MSc students (medicine, biology), MD in training, MD-PhD
students (JSM), high school students , kids University
Translational Shock Research :
Bridging the gap

In vitro laboratory In vivo anim al studies: Ex vivo kidney biopsies Critically-ill Patient
techniques SHOCK m odels Blood/plasm a

Defining m echanism s, Translation of new data


targets & therapeutic Proof of concept into the clinic, controlled
strategies studies, leading to
effective care
Today’s CAVAREM Summerschool lecture
• The Patient & The Disease & The ICU

• Multiple Organ Dysfunction Syndrome (MODS) and AKI (Acute Kidney Injury)
are bad

• Septic shock, also a microvascular disease


– Therapeutic options
– Microvascular endothelial behaviour
– Vasculocentric view of sepsis

• The Angiopietin/ Tie2 system as an example of a novel vascular target in AKI


(Acute Kidney Injury)
– Introduction
– Ang/Tie2: MODS biomarker ?
– Ang/Tie2: MODS mediator ?
– Ang/Tie2: MODS novel therapy ?
The Patient & The Disease & The ICU
The Patient
Severe Septic shock (blood poisoning)
• 17-yr healty male
• 2 days fever, this morning blue spots
• ICU referring Hospital: antibiotics, Fluid and
vasopressors
• Admission UMCG:
– Sedated , machine ventilated

• Swollen, 130 (90) kg; low BP (RR 80/40


mmHg), rapid hart beat (pulse 140/min), does
not urinate anymore for days ! (anuria)

– trombocytes 41x109/l; Hb 4.7 mmol/l


– kreatinine 779 µmol/l ureum 59.9 mmol/l
Septic Shock with multiple organ failure (MODS)

• Culture blood and skin:

Neisseria meningitidis
(meningo coccus)
The Disease
Sepsis kills

Editorial NEJM 2002:966


http://www.survivingsepsis.org
Sepsis and HS leads to Multiple organ dysfunction: MODS
Shock MODS

• Systemic reduction in tissue • Respiratory:


perfusion ARDS mortality 40%
• Decreased tissue oxygen • Renal:
and nutrient delivery dialyses, mortality 60%
• Cardiovascular
• Hepatic
• Gastrointestinal
• Haematological
• Central nervous systems

NEJM 359:7, july 3, 2008


Chest. 2008 May;133(5):1120-7
It is lethal and it is common: action
It is lethal and it is common: action, but how

• 72 Randomised clinical trials > 50 patients in


sepsis
• In these trials 53.705 patients
• Different interventions as :” The intervention”
• 285 lives saved (NS)
• Number of lives saved per trial 4 (CI -4 to +12)
• Mortality
• “Control” 37,4%
• “Intervention” 37,3 % (NS)

Opsina-Tascon, Crit Care Med 2008; 36:1311-1322


The ICU
Hospitals in The Netherlands
Groningen

• 8 UMC’s
– 120 hospitals Amsterdam
• UMCG Leiden
– 1339 beds Utrecht
– 28.779 Rotterdam
inpatients/year Nijmegen

– 500.000
outpatients/year
– large referral area
Maastricht
The Adult Division provides services in
specialized units: 44 beds

> 3000 patients yearly are cared for in ICU


Every day post operative patients are treated on
ICUs world wide with failing organs

ICV UMCG, picture H Delwig


Summary: The Patient & The Disease & The ICU
• Previously healthy persons are dying in our ICU´s
because of multiple organ failure
– It starts with major insults: shock
• Sepis
– Mechanisms are largely unknown
In and after shock organs become dysfunctional

http://sketchymedicine.com/category/internal-med/nephro/ AND
Multiple organ failure : Concepts

Pathologic Process Manifestations

Tissue Hypoxia Increased lactate

Uncontrolled infection Nosocomial ICU-infection

Systemic inflammation Cytokines (TNF,IL6,IL8); Leucocytose

Immune paralysis Increased anti-inflammatory cytokines (IL10)

Endothelial activation Leucocyte adherence, increased capillary


permeability
Dysregulated apoptosis Decreased neutrophil apoptosis

Gut-liver axis Increased infection, Kupffer cell activation


Microvascular function in septic shock and
hemorrhagic shock , molecular control thereof
Prevention and therapy of multiple organ failure
(MODS)

Severe septic shock

S o u rc e
A n tib io tic s
c o n tro l

B lo c k a d e
S u p p o rtiv e o f th e
th e ra p y “m e d ia to r
soup’

NO SPECIFIC mediator
therapies are available

http://www.survivingsepsis.org/
Treatment for septic shock:

Negative or Not Evaluated

Russell N Engl J Med 2006;355(16):1699-1713


Acute Kidney Injury (AKI) in Critically Ill patients
• Acute Kidney Injury (AKI) is a devastating complication in ICU patients. Sepsis
is related to the development of AKI.
(Hu & Moe,2012 Nat. Rev. Nephrol.)

• AKI Incidence on the ICU in UMCG 38 % and World Wide 57 %


(Koeze et al, 2017 BMC Nephrology )
(Hoste 2015, Intensive Care Med

• After RRT Mortality is high (50%) in adult patients.


(Bellomo R, 2009 N.Engl.J.Med.)

• If the patient survives, the long-term outcome of AKI varies from complete
recovery, incomplete recovery with progression to Chronic Kidney Disease
(CKD), or End-stage renal disease (ESRD).
(Coca SG. 2012 Kidney Int.)
• Nothing to offer AKI patients once in the ICU except renal replacement
therapy and supportive care
Multiple mechanisms of
Acute Kidney Injury (AKI) in Critically Ill patients

Ferenbach DA et al, Nat Rev Nephrol 2015


Why look at microvascular blood vessels as
therapeutic target in AKI

• Hypotension • Diminished vascular


• Vascular Leakage contractility
• Leucocyte influx • Increased vascular
permeability
• Endothelial pro
inflammatory activation

Conduit conduit
vessels vessels

Resistance vessels

capillaries
The micro vascular endothelial cell in sepsis

INPUT OUTPUT

Sepsis induced
stress • Hypotension
• Hypoxia • Vascular Leakage
• Inflammation • Leucocyte influx
• Blood flow
endothelial cell
protein membrane
signal
transduction

RNA translation
nuclear
membrane
DNA

mRNA
gene transcription
The smallest blood vessels in the kidney:
molecular regulation of vascular inflammation and
leakage – road to therapies

Leukocyte

The endothelial cell:


Leukocyte recruitement
Vascular leakage
Why look at microvascular blood vessels as
drug target in AKI:

Hypothesis
The microvasculature of the kidney is an active player in
the development of Acute Kidney Injury during and after
Critical Illness
and endothelial cells are key mediators in the underlying
pathophysiological processes.
Angiopoietin-1 protects the adult vasculature
against plasma leakage

Thurston G et al Nature Medicine 2000


Angiopoietin-1 protects the adult
vasculature against plasma leakage
Current concept: Ang/Tie2 signaling
links inflammation and vascular leakage
Ang-1 Ang-2
Leukocyte
Influx Vascular
Tie-2 Leakage
Adhesion
molecules Receptor Ang-2
Bloodstream

Leukocyte recruitment Weibel-Palade-bodies

Rho
kinase Ca²+
Stabilisation of
cell-cell junctions

NFκB
PI3K/Akt
Ca²+

Blood vessel
Survival Anti-Inflammatory
Ang-1 stabilization

Endothelial cell

Pericyte
van Meurs , Kümpers et al Crit Care. 2009;
Translational research :
Bridging the gap between basic research and clinical practice
In vitro laboratory In vivo anim al studies: Ex vivo kidney biopsies Critically-ill Patient
techniques SHOCK m odels Blood/plasm a

Defining m echanism s, Proof of concept Translation of new data


targets & therapeutic into the clinic, controlled
strategies
AKI studies, leading to
effective care
• Biomarkers ?
• Mediators ?
• Novel therapeutic strategies ?
Biomarkers: sepsis leads to Ang2 release related
to disease severity in sepsis

Kümpers P, et al. Crit Care. 2008


Biomarkers: Ang2 is increased in CPB
patients with postoperative AKI

AKI

Jongman et al, Plos One 2015


Biomarkers: most studies unchanged, Ang1
is decreased in septic Surinam neonates

Ang1 Unchanged Ang1 decreased

van Meurs , Kümpers et al Crit Care. 2009; Zonneveld R et al, Shock 2017
Shock conditions induce loss of Tie2 mRNA
and protein in the kidney

LPS/endotoxemia (0,5 µg/g) Hemorrhagic shock


*
0.008 0.015 *

relative to GAPDH
Tie-2 mRNA level
relative to GAPDH
Tie-2 mRNA level
0.006
0.010
A: Tie2 mRNA 0.004
0.005
0.002

0.000 0.000
0 4 8 24 0 4 8 24
Time after LPS administration (hours) Time after HS/resuscitation (hours)

*
10 10
*

pg Tie-2/ug total protein


pg Tie-2/ug total protein

8 8

6 6
B: Tie2 protein 4
4

2 2

0 0
0 4 8 24 0 4 24
Time after HS/resuscitation (hours)
Time after LPS administration (hours)

Van Meurs, Kurniati, et al Am J Physiol Renal Physiol. 2009


Soluble Tie2 is increased in plasma in sepsis
and in AKI patients (biomarker?)

40

30

sTie2 (ng/mL)
20

10

0
control AKI

David Lab Hannover accepted CCM Koeze, Jongman et al


SHOCK Group UMCG unpublished
In CPB rats,
Ang/Tie2 system is deranged in the kidney
(biomarker?/mediator?)
Ang1 Ang2

mRNA level relative to GAPDH

mRNA level relative to GAPDH


0.025 0.010

0.020 0.008

0.015 0.006

0.010 0.004

0.005 0.002

0.000 0.000

PB
l
tro

PB
l
tro
C
on

C
on
C

C
mRNA level relative to GAPDH Tie2
0.03

0.02

VUMC - Dekker, Boer,


0.01 van den Brom –
Accepted BJA
0.00
PB
l
tro

C
on
C
In AKI patients who died in the ICU,
Ang/Tie2 system is deranged in the kidney
(biomarker?/mediator?)
Ang1 Ang2

mRNA level relative to GAPDH


mRNA level relative to GAPDH
0.08 0.010

0.008
0.06
0.006
0.04
0.004
0.02
0.002

0.00 0.000

I
l

l
tro

AK

tro

AK
on

on
C

C
Ang1/Ang2 ratio Tie2
mRNA level relative to GAPDH

mRNA level relative to GAPDH


15 0.5

0.4
10
0.3

0.2
5
0.1

0 0.0
I
l

I
l
tro

AK

Aslan A et al. Crit Care. 2014

tro

AK
on

on
C

C
Ang2 mediates vascular leakage and
hypotension

Ziegler et al JCI 2013


Renal Ang/Tie2 reponses can be
mimicked by exposure of EC flow changes
in vitro (mediator)

Ang2

Tie2

Li R et al Shock. 2014
Disturbed EC behaviour in human AKI
leads to immune cell invasion in the
kidney

Figure 1 controls sepsis controls sepsis

A B
C
neutrophils

D E
macrophages

Aslan et al et Crit Care under revision


Translational research :
The Ang/Tie2 system is deranged in plasma & the Kidney

In vitro laboratory In vivo anim al studies: Ex vivo kidney biopsies Critically-ill Patient
techniques SHOCK m odels Blood/plasm a

• critical illness leads to Ang2 release


• in CPB patients with postoperative AKI, plasma Ang2 is increased
• In CPB rats, mRNA of the Ang/Tie2 system is deranged in the kidney
• In AKI patients, mRNA of the Ang/Tie2 system is deranged in the kidney,
which is paralleled by immune cell influx in the glomerulus and the
peritubular space.
• Ang/Tie2 system is a MEDIATOR of vascular leakage, vascular
inflammation and mortality in cell/animal models and is flow sensitive.
Ang1 mimetic Vasculotide improves
survival in a murine sepsis model
(therapy)
LPS 15 mg/kg
2 h later Ang1 mimetic Vasculotide 500 ng/ mouse

David S et al. Am J Physiol Lung Cell Mol Physiol 2011


Does restoring the Ang/Tie2 balance prevents
AKI in CPB or Hemorrhagic Shock ?

N Dekker, M Trieu, C.E. van den Brom


Ang1 mimetic Vasculotide improves
cremaster perfusion in a rat hemorrhagic
shock model (therapy), AKI markers work in
progress

Perfused vessels

Continuously perfused vessels


15

(vessels/recording)
SHOCK
10 SHOCK+VT
Sham

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tio
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M Trieu et al , Anesthesiology 2018


Translational research :
The Ang/Tie2 system is deranged in AKI

Ang-1 Ang-2

Adhesion Tie-2
molecules Receptor A
Bloodstream

Leukocyte recruitment Weibel-Palade-bodies


• Ang/Tie2: AKI biomarker
Rho
• Ang/Tie2: AKI mediator
kinase Ca²+
Stabilisation of
• Ang/Tie2: AKI novel therapy ? cell-cell junctions

NFκB
Future therapeutic options

Saharinen P et al. , Nature Reviews. Drug Discovery, 2017


Patients on ICUs world wide have failing organs:
Research to prevent death and renal disease
From Biomarker to mediator and novel therapy

Translation ?
In sepsis Negative or Not Evaluated

Russell N Engl J Med 2006;355(16):1699-1713


From Bedside to Bench to Bedside:
LEARN “microvascular endothelial behaviour” in the kidney

Ang-1 Ang-2

Adhesion Tie-2
molecules Receptor Ang-2
Bloodstream

(adapted from Aird – 2005) Leukocyte recruitment

Rho
Weibel-Palade-bodies

kinase Ca²+
Stabilisation of
cell-cell junctions

NFκB
PI3K/Akt
Ca²+

Blood vessel
Survival Anti-Inflammatory
Ang-1 stabilization

Endothelial cell

Pericyte
Take home message

• The vasculature is not a plumbing device


• The patient: critically ill
– The disease: Shock
• Septic shock
• Hemorrhagic shock
– The ICU
• Microvascular function in septic shock and
hemorrhagic shock
• Endothelial inflammation
• Vascular integrity and vascular leakage

• ICV and medical biology join expertise to explore,


understand (and treat ?) these patients
Take home message

• Translational research
– Learn
• Individual
• Local group
• Critical Care/vascular biology community
– Social
• Local
• National
• International
– Teach

– Eduction & Science & better patient care & Fun

m.van.meurs@umcg.nl
Acknowledgements
SHOCK GROUP CSO UMCG Anesthesiology UMCG
Medical Biology UMCG (Ingrid Molema) Jack Ligtenberg Thomas Scheeren
ICV UMCG (Jill Moser & Jan Zijlstra) Vincent Quinten Tony Absalom
Hans de Vries
Michel Struys

Nephrology UMCG
Coen Stegeman

Funding
NVA
Nierstichting China
Scholarship Council
(R. Li, R Yan)
www.ebvdt.nl
Pamgene ‘s Hertogenbosch
Rob Ruitenbeek
VU MC Amsterdam International
Anesthesiology and Physiology Paul van Slyke (Toronto Canada)
Christa Boer Sascha David (Hannover, Germany)
Charissa van den Brom, Philipp Kuempers (Muenster, Germany)
Nick Koning Gregor Theilmeijer (Oldenburg, Germany)
Michelle Trieu & Nicole Dekker