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Increased production of reactive oxygen species in pharmacologically-immunosuppressed patients
ELSEVIER SCIENCE IRELAND
xjcol
Chemico-Biological Interactions 91 (1994) 159-164
Increased production of reactive oxygen species in pharmacologically-immunosuppressed patients Michel de Lorgeril *a, Marie-Jeanne Richard b, Josiane A r n a u d b, Pascale B o i s s o n n a t a, Jeannine Guidollet c, Georges D u r e a u a, Serge R e n a u d a, A l a i n Favier b alnstitut National pour la Sante et la Recherche M~dicale U.63, 22 Avenue du Doyen L~pine, Case 18, 69675 Bron Cedex, France hLaboratory of Biochemistry C, CHRUG, Grenoble, France "Laboratory of Biochemistry, H6pital Cardiologique, Bron, France
(Received 11 July 1993; accepted 10 November 1993)
Abstract HIV-infected patients and transplanted patients share similar immunosuppressed status. Recent insights gained through the field of heart transplantation may help to clarify the role of reactive oxygen species in HIV-infected patients. Key words." Transplantation; Cyclosporin; Immunosuppression; Reactive oxygen species;
Antioxidant
1. Introduction HIV infection seems to be associated with increased production of reactive oxygen species (ROS), the cause of which is unknown [1]. HIV-infected patients and cyclosporin-treated transplant recipients share a similar immune status whereas in HIV infection, immunosuppression is virus-dependent and after transplantation, it is the essential pharmacological intervention which induces major inhibition of CIM T-lymphocytes. In both conditions, however, the monocyte-macrophage system is stimulated in response to foreign antigen, opportunistic infection and/or HIV infection itself. CD4 cell inhibition and stimulation of monocyte-macrophage result in striking changes in the cytokine cascade regulation, as recently discussed [2]. Whether immunosuppression is responsible for the increased production of ROS in * Corresponding author. 0009-2797/94/$07.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDI 0009-2797(94)03267-C
160
M. de Lorgeril et al. /Chem.-BioL Interact. 91 (1994) 159-164
heart and kidney transplant recipients, as discussed below, is unknown. Nevertheless, data obtained in transplant recipients may shed light on what occurs in HIVinfected patients and clarify the role of ROS in HIV pathogenesis. We have recently shown that heart transplantation (HT) is associated with several biological (platelet function) and biochemical (lipid peroxidation) anomalies suggesting that immunosuppression and/or subclinical chronic rejection may result in major systemic perturbations. Most of these perturbations being reproducible in immunosuppressed animals in the absence of graft [3], are likely to be the immunosuppressive state and/or the immunosuppressive drugs which are responsible for the anomalies described below.
2. Biochemical profile of heart transplant recipients Table 1 is a biochemical summary of 200 non-transplanted coronary patients and 200 HT recipients. Patients with coronary artery disease, but who did not undergo transplantation, served as a control group since the ultimate goal of our investigations was to identify factor(s) responsible for the acceleration of arteriosclerosis in the grafted heart in comparison with the usual course of the disease in nontransplanted coronary patients. As expected in these cyclosporin-treated patients, blood creatinine (cyclosporin is nephrotoxic) and uric acid are increased. It is noteworthy, however, that both creatinine [4] and uric acid [5] have been found positively correlated with serum markers of lipid peroxidation. This suggests that cyclosporin nephrotoxicity whose molecular mechanism(s) is still unexplained could result from a process that involves ROS production [6]. The elevated bilirubin, alkalin phosphatase and gamma glutamyl transferase are likely related to immunosuppressive drug liver toxicity (azathioprine and cyclosporin). The significantly lower level of ferritin, in association with a normal seric iron level was unexpected and remains unexplained. Further studies are required to explore the relationships between ROS production and ferritin in transplant recipients. As shown on Table 1, serum albumin is significantly lower in HT recipients than Table 1
Glucose (mmol/1) Creatinine (#mol/l) A l b u m i n (g/l) Uric acid (#mol/I) Seric iron (#mol/l) Ferritin (/~g/I) Bilirubin (/zmol/l) G a m m a GT(IU/I) Alkaline p h o s p h a t a s e (IU/I) Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
5.6 152 46.4 364 16 90 14 76.1 81
5.7 ± 109 ± 47.4 • 344 ~ 16 + 133 ± 10.9 446.2 + 64.6 +
N.S. 0.0001 0.01 0.04 N.S. 0.0001
± 4+ ~ + ± ± 4±
3.7 55 4.5 121 6 92 6.5 96 37
1.5 27 3.2 74 5 107 3.8 40 20
0.0001 0.0001 0.0001
M. de Lorgeril et al. /Chem.-Biol. Interact. 91 (1994) 159-164
161
in controls. This is an unexpected and major finding because albumin has been shown to be predictive of mortality from cancer and other causes [7]; and cancer is a major cause of morbidity and mortality in both HIV-infected and transplanted patients. Albumin participates in the ant±oxidant system, in particular, by virtue of its role in the transport of zinc. As a matter of fact, zinc has been found low in HT recipients [5]. In the same study, zinc and albumin were positively and significantly correlated [5]. Using multivariate analysis, zinc was found to be a significant predictor of ROS production in these patients. This further suggests important roles for zinc and albumin in immunosuppressed patients. Similar studies could be conducted in HIV-infected patients with the hope that correction of any deficit in zinc (or albumin, for instance, secondary to malnutrition) may help to prevent or slow AIDS complication. Table 2 provides a lipid summary of the two groups of patients described above. The data are comparable to those published by others for cardiac and renal transplant recipients. They are important to be considered because in most studies, lipid peroxides have been shown to be related to seric lipids [4,5]. In fact, our coronary patients and HT recipients appeared to have a similar lipidic profile. In particular, the total cholesterol ratio over HDL, an index of atherogenicity, is equivalent in both groups. In contrast, lipoprotein a, a major risk factor of premature coronary heart disease was lower in HT recipients. This is not surprising since only half of our HT recipients were transplanted secondary to an infarction-related heart failure. The quantitative data shown in Table 2 do not exclude that qualitative lipid anomalies may exist. For instance, investigating platelet lipid composition, we found lower level of stearic acid (18:0) whereas that of (n-9) and (n-3) series were in general higher. The levels of the (n-6) fatty acids, one of the main target of peroxidation, were similar in both groups [8]. In addition, Chancerelle et al. have reported high concentration of Schiff bases, the endproduct of lipid peroxidation, in HT recipients [4]. Moreover, HT patients had higher levels of immunoglobulins with antibody-like specificity for Schiff bases in their plasma which confirmed that the increased production of ROS actually occurred in vivo and not during the process of samplingfreezing-storage [4]. De Lorgeril et al., using the method of Heath et al. [9], have Table 2
Cholesterol (mmol/I) Triglycerides (retool/I) LDL cholesterol (mmol/l) VLDL cholesterol (mmol/l) HDL cholesterol (mmol/l) Apoprotein B (g/l) Apoprotein AI (g/l) Lipoprotein (a) (g/l) Cholesterol/HDL chol Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
7.2 2.3 4.9 0.9 1.5 1.6 1.4 0.18 5.4
6.4 2.0 4.5 0.8 1.2 1.4 1.3 0.28 5.6
0.0001 0.01 0.003 0.01 0.0001 0.007 0.0001 0.0001 N.S.
+ 1.7 ± 1.5 ± 1.5 ± 0.6 ± 0.5 ± 0.5 a- 0.4 q- 0.22 ± 2.2
± q± ± ± ± ± ± ±
1.2 1.1 1.1 0.4 0.3 0.3 0.2 0.33 1.5
162
M. de Lorgeril et al. ~Chem.-Biol. Interact. 91 (1994) 159-164
also shown that malondialdehyde levels are elevated in HT recipients in comparison with controls [5]. Seric lipids, uric acid and zinc were the main contributors to ROS production variability [5]. Superoxide dismutase and glutathione peroxidase activities, which are major enzymatic scavengers of ROS, were not significantly reduced in these cyclosporin-treated patients [5]. Finally, a relative deficiency in alphatocopherol has been shown in HT recipients [8]. However, there has been no attempt to correlate that measurement with a marker of ROS production. In kidney transplant recipients treated with cyclosporin, Taylor et al. reported similar data recently: plasma malondialdehyde levels were higher and plasma thiols (mainly albumin thiols) were lower in transplanted when compared with controls [10]. Interestingly, superoxide dismutase was slightly, but not significantly, elevated in the transplanted patients which confirmed that increased ROS production in cyclosporin-treated patients was likely not related to a deficit in enzymatic scavengers [5,10].
3. Hematological profile of heart transplant recipients As shown on Table 3, significant lower hemoglobin and hematocrit were found in HT recipients whereas platelet and leukocyte counts were similar. This can be explained by the relative bone marrow toxicity of immunosuppressive drugs. Lymphopenia was also a consequence of cyclosporin treatment. Unexpected was the significantly higher neutrophile count in HT recipients. This is a major finding for several reasons: first, neutrophile count has been shown to be a predictor of all cause and cancer mortality in large epidemiological studies [11]; second, during the response to injury and chronic inflammation, ROS are produced by phagocytic cells [12]. Is there any relationship between the increased neutrophile count and ROS production in HT recipients? As a matter of fact, Taylor et al. have reported increased ROS production and neutrophile aggregability (reactivity) in kidney transplant recipients treated with cyclosporin [10]. Finally, in pharmacologically immunosuppressed patients, there is a large amount of literature showing a high rate of thrombo-embolic complications in cyclosporin- or non-cyclosporin-treated patients (for review, see refs. 8 and 10). It is noteworthy that in these patients, aspirin, the major antiplatelet agent, is not clinically efficient [8]. We have shown that aspirin Table 3
Hemoglobin (g/l) Hematocrit (%) Leucocytes (109/1) Neutrophiles (109/1) Lymphocytes (109/1) Platelets (109/1) Platelet volume (/~3) Platelet mass (#3 × 109/i) Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
131 39 6.2 4.8 1.0 215 8.0 1804
144 43 6.3 3.7 1.8 217 8.3 1720
0.0001 0.0001 N.S. 0.01 0.0001 N.S. 0.002 N.S.
± ± ± ± ± + ± 4-
17 5 1.9 5.8 0.7 63 1.0 463
± 12 4- 4 ~= 1.6 4- 1.2 4- 0.6 4- 64 4- 0.9 4- 473
M. de Lorgeril et al. /Chem.-Biol. Interact. 91 (1994) 159-164
163
does not reduce platelet aggregation in immunosuppressed patients as it did in usual coronary patients [13]. Enhanced platelet aggregation (also observed in kidney transplant recipients [10]) is directly related to the occurrence o f c o r o n a r y artery thrombosis in H T recipients [14]. Aspirin works essentially by blocking cyclooxygenase, the key-enzyme o f the prostaglandin pathway in platelets as well as endothelial cells. The production o f thromboxane, the major endproduct o f the prostaglandin pathway in platelets, and the production of prostacyclin, its counterpart in endothelial cells, have been shown to be decreased in H T recipients [15]. Both pathways are associated with R O S production and are mainly regulated by the levels of ROS. Consequently, it is speculated that the high production o f R O S in these patients may inhibit prostaglandin pathway, which may explain the lack of efficiency of aspirin. On the other hand, R O S may stimulate platelet aggregation by damaging the membrane, i.e. by a way independent o f cyclooxygenase. As a matter o f fact, antioxidant supplementation (500 mg a-tocopherol, for 2 months) actually reduced platelet aggregation in H T recipients (paper submitted) which suggests a causal relationship between R O S production, platelet aggregation and thrombotic complications. Thromboembolisms are not unfrequent in HIV-infected patients [2] which suggests that similar intrications between prostaglandin metabolism, the coagulation system, platelet function, ROS production and the immune system may be seen in HIV-infected patients and contribute, at least partly, to the occurrence o f the many complications associated with AIDS.
4. References 1 B. Halliwell and C.E. Cross, Reactive oxygen species, antioxidants, and acquired immunodeficiency syndrome. Sense or speculation?, Arch. Intern. Med., 151 (1991) 29-31. 2 M. De Lorgeril, P. Boissonnat, G. Dureau and S. Renaud, HIV infection and immune system in genesis of coronary lesions, Lancet, 340 (1992) 1226-1227. 3 P. Desseigne, M. de Lorgeril, M. Ciavatti, P. Boissonnat, G. Dureau, S. Renaud and J. Delaye, Steroid-free immunosuppressive treatment increases platelet aggregation in rats, J. Am. Coll. Cardiol., (1993) 21 (1993) 37A. 4 Y. Chancerelle, M. de Lorgeril, R. Viret, B. Chiron, G. Dureau, S. Renaud and J.F. Kergonou, Increased lipid peroxidation in cyclosporin-treated heart transplant recipients, Am. J. Cardiol., 68 (1991) 813-816. 5 M. De Lorgeril, M.J. Richard, J. Arnaud, P. Boissonnat, J. Guidollet, G. Dureau, S. Renaud and A. Favier, Lipid peroxides and antioxidant defenses in accelerated transplantation-associated coronary arteriosclerosis, Am. Heart J., 125 (1993) 974-980. 6 G. lnselmann, M. Blank and K. Baumann, Cyclosporin A induces lipid peroxidation in microsomes and effect on active and passive glucose transport by brush border membrane vesicles of rat kidney, Res. Commun. Chem. Pathol. Pharmacol., 62 (1988) 207-220. 7 A. Phillips, A.G. Shaper and P.H. Whincup, Association between serum albumin and mortality from cardiovascular disease, cancer and other causes, Lancet, 334 (1989) 1434-1436. 8 M. De Lorgeril, G. Dureau, P. Boissonnat, J. Guidollet, I. Juhan-Vague, C. Bizollon and S. Renaud, Platelet function and composition in heart transplant recipients compared with non-transplanted coronary patients, Arteriosclerosis Thrombosis, 12 (1992) 222-230. 9 R.L. Heath and A.L. Tappel, A new sensitive assay for measurements of hydroperoxides, Anal. Biochem., 76 (1976) 184-191. 10 J.E. Taylor, N. Scott, A. Hill, A. Bridges, I.S. Henderson, W.K. Stewart and J.J.F. Belch, Oxygen free radicals and platelet and granulocyte aggregabilityin renal transplant patients, Transplantation, 55 (1993) 500-504.
164
11 12 13
14
15
M. de Lorgeril et aL ~Chem.-Biol. Interact. 91 (1994) 159-164
J.B. Zalokar, J.L. Richard and J.R. Claude, Leucocyte count, smoking and myocardial infarction, N. Engl. J. Med., 304 (1991) 465. P.A. Southorn and G. Powis, Free radicals in medicine: 1. Chemical nature and biological reactions, Mayo Clin. Proc., 63 (1988) 381. M. De Lorgeril, G. Dureau, P. Boissonnat, M. Ovize, C. Monnez, I. Monjaud, P. Salen and S. Renaud, Increased platelet aggregation after heart transplantation: influence of aspirin, J. Heart Lung Transplant., 10 ( 1991 ) 600-603. M. De Lorgeril, R. Loire, J. Guidollet, P. Boissonnat, G. Dureau and S. Renaud, Accelerated coronary artery disease after heart transplantation: the role of enhanced platelet aggregation and thrombosis, J. Intern. Med. 233 (1993) 343-350. J.C. Bordet, M. de Lorgeril, P. Boissonnat et al., Systemic but not renal production of prostacyclin is highly reduced in cyclosporin-treated heart transplant recipients, Am. J. Cardiol., 72 (1993) 486-487.
xjcol
Chemico-Biological Interactions 91 (1994) 159-164
Increased production of reactive oxygen species in pharmacologically-immunosuppressed patients Michel de Lorgeril *a, Marie-Jeanne Richard b, Josiane A r n a u d b, Pascale B o i s s o n n a t a, Jeannine Guidollet c, Georges D u r e a u a, Serge R e n a u d a, A l a i n Favier b alnstitut National pour la Sante et la Recherche M~dicale U.63, 22 Avenue du Doyen L~pine, Case 18, 69675 Bron Cedex, France hLaboratory of Biochemistry C, CHRUG, Grenoble, France "Laboratory of Biochemistry, H6pital Cardiologique, Bron, France
(Received 11 July 1993; accepted 10 November 1993)
Abstract HIV-infected patients and transplanted patients share similar immunosuppressed status. Recent insights gained through the field of heart transplantation may help to clarify the role of reactive oxygen species in HIV-infected patients. Key words." Transplantation; Cyclosporin; Immunosuppression; Reactive oxygen species;
Antioxidant
1. Introduction HIV infection seems to be associated with increased production of reactive oxygen species (ROS), the cause of which is unknown [1]. HIV-infected patients and cyclosporin-treated transplant recipients share a similar immune status whereas in HIV infection, immunosuppression is virus-dependent and after transplantation, it is the essential pharmacological intervention which induces major inhibition of CIM T-lymphocytes. In both conditions, however, the monocyte-macrophage system is stimulated in response to foreign antigen, opportunistic infection and/or HIV infection itself. CD4 cell inhibition and stimulation of monocyte-macrophage result in striking changes in the cytokine cascade regulation, as recently discussed [2]. Whether immunosuppression is responsible for the increased production of ROS in * Corresponding author. 0009-2797/94/$07.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDI 0009-2797(94)03267-C
160
M. de Lorgeril et al. /Chem.-BioL Interact. 91 (1994) 159-164
heart and kidney transplant recipients, as discussed below, is unknown. Nevertheless, data obtained in transplant recipients may shed light on what occurs in HIVinfected patients and clarify the role of ROS in HIV pathogenesis. We have recently shown that heart transplantation (HT) is associated with several biological (platelet function) and biochemical (lipid peroxidation) anomalies suggesting that immunosuppression and/or subclinical chronic rejection may result in major systemic perturbations. Most of these perturbations being reproducible in immunosuppressed animals in the absence of graft [3], are likely to be the immunosuppressive state and/or the immunosuppressive drugs which are responsible for the anomalies described below.
2. Biochemical profile of heart transplant recipients Table 1 is a biochemical summary of 200 non-transplanted coronary patients and 200 HT recipients. Patients with coronary artery disease, but who did not undergo transplantation, served as a control group since the ultimate goal of our investigations was to identify factor(s) responsible for the acceleration of arteriosclerosis in the grafted heart in comparison with the usual course of the disease in nontransplanted coronary patients. As expected in these cyclosporin-treated patients, blood creatinine (cyclosporin is nephrotoxic) and uric acid are increased. It is noteworthy, however, that both creatinine [4] and uric acid [5] have been found positively correlated with serum markers of lipid peroxidation. This suggests that cyclosporin nephrotoxicity whose molecular mechanism(s) is still unexplained could result from a process that involves ROS production [6]. The elevated bilirubin, alkalin phosphatase and gamma glutamyl transferase are likely related to immunosuppressive drug liver toxicity (azathioprine and cyclosporin). The significantly lower level of ferritin, in association with a normal seric iron level was unexpected and remains unexplained. Further studies are required to explore the relationships between ROS production and ferritin in transplant recipients. As shown on Table 1, serum albumin is significantly lower in HT recipients than Table 1
Glucose (mmol/1) Creatinine (#mol/l) A l b u m i n (g/l) Uric acid (#mol/I) Seric iron (#mol/l) Ferritin (/~g/I) Bilirubin (/zmol/l) G a m m a GT(IU/I) Alkaline p h o s p h a t a s e (IU/I) Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
5.6 152 46.4 364 16 90 14 76.1 81
5.7 ± 109 ± 47.4 • 344 ~ 16 + 133 ± 10.9 446.2 + 64.6 +
N.S. 0.0001 0.01 0.04 N.S. 0.0001
± 4+ ~ + ± ± 4±
3.7 55 4.5 121 6 92 6.5 96 37
1.5 27 3.2 74 5 107 3.8 40 20
0.0001 0.0001 0.0001
M. de Lorgeril et al. /Chem.-Biol. Interact. 91 (1994) 159-164
161
in controls. This is an unexpected and major finding because albumin has been shown to be predictive of mortality from cancer and other causes [7]; and cancer is a major cause of morbidity and mortality in both HIV-infected and transplanted patients. Albumin participates in the ant±oxidant system, in particular, by virtue of its role in the transport of zinc. As a matter of fact, zinc has been found low in HT recipients [5]. In the same study, zinc and albumin were positively and significantly correlated [5]. Using multivariate analysis, zinc was found to be a significant predictor of ROS production in these patients. This further suggests important roles for zinc and albumin in immunosuppressed patients. Similar studies could be conducted in HIV-infected patients with the hope that correction of any deficit in zinc (or albumin, for instance, secondary to malnutrition) may help to prevent or slow AIDS complication. Table 2 provides a lipid summary of the two groups of patients described above. The data are comparable to those published by others for cardiac and renal transplant recipients. They are important to be considered because in most studies, lipid peroxides have been shown to be related to seric lipids [4,5]. In fact, our coronary patients and HT recipients appeared to have a similar lipidic profile. In particular, the total cholesterol ratio over HDL, an index of atherogenicity, is equivalent in both groups. In contrast, lipoprotein a, a major risk factor of premature coronary heart disease was lower in HT recipients. This is not surprising since only half of our HT recipients were transplanted secondary to an infarction-related heart failure. The quantitative data shown in Table 2 do not exclude that qualitative lipid anomalies may exist. For instance, investigating platelet lipid composition, we found lower level of stearic acid (18:0) whereas that of (n-9) and (n-3) series were in general higher. The levels of the (n-6) fatty acids, one of the main target of peroxidation, were similar in both groups [8]. In addition, Chancerelle et al. have reported high concentration of Schiff bases, the endproduct of lipid peroxidation, in HT recipients [4]. Moreover, HT patients had higher levels of immunoglobulins with antibody-like specificity for Schiff bases in their plasma which confirmed that the increased production of ROS actually occurred in vivo and not during the process of samplingfreezing-storage [4]. De Lorgeril et al., using the method of Heath et al. [9], have Table 2
Cholesterol (mmol/I) Triglycerides (retool/I) LDL cholesterol (mmol/l) VLDL cholesterol (mmol/l) HDL cholesterol (mmol/l) Apoprotein B (g/l) Apoprotein AI (g/l) Lipoprotein (a) (g/l) Cholesterol/HDL chol Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
7.2 2.3 4.9 0.9 1.5 1.6 1.4 0.18 5.4
6.4 2.0 4.5 0.8 1.2 1.4 1.3 0.28 5.6
0.0001 0.01 0.003 0.01 0.0001 0.007 0.0001 0.0001 N.S.
+ 1.7 ± 1.5 ± 1.5 ± 0.6 ± 0.5 ± 0.5 a- 0.4 q- 0.22 ± 2.2
± q± ± ± ± ± ± ±
1.2 1.1 1.1 0.4 0.3 0.3 0.2 0.33 1.5
162
M. de Lorgeril et al. ~Chem.-Biol. Interact. 91 (1994) 159-164
also shown that malondialdehyde levels are elevated in HT recipients in comparison with controls [5]. Seric lipids, uric acid and zinc were the main contributors to ROS production variability [5]. Superoxide dismutase and glutathione peroxidase activities, which are major enzymatic scavengers of ROS, were not significantly reduced in these cyclosporin-treated patients [5]. Finally, a relative deficiency in alphatocopherol has been shown in HT recipients [8]. However, there has been no attempt to correlate that measurement with a marker of ROS production. In kidney transplant recipients treated with cyclosporin, Taylor et al. reported similar data recently: plasma malondialdehyde levels were higher and plasma thiols (mainly albumin thiols) were lower in transplanted when compared with controls [10]. Interestingly, superoxide dismutase was slightly, but not significantly, elevated in the transplanted patients which confirmed that increased ROS production in cyclosporin-treated patients was likely not related to a deficit in enzymatic scavengers [5,10].
3. Hematological profile of heart transplant recipients As shown on Table 3, significant lower hemoglobin and hematocrit were found in HT recipients whereas platelet and leukocyte counts were similar. This can be explained by the relative bone marrow toxicity of immunosuppressive drugs. Lymphopenia was also a consequence of cyclosporin treatment. Unexpected was the significantly higher neutrophile count in HT recipients. This is a major finding for several reasons: first, neutrophile count has been shown to be a predictor of all cause and cancer mortality in large epidemiological studies [11]; second, during the response to injury and chronic inflammation, ROS are produced by phagocytic cells [12]. Is there any relationship between the increased neutrophile count and ROS production in HT recipients? As a matter of fact, Taylor et al. have reported increased ROS production and neutrophile aggregability (reactivity) in kidney transplant recipients treated with cyclosporin [10]. Finally, in pharmacologically immunosuppressed patients, there is a large amount of literature showing a high rate of thrombo-embolic complications in cyclosporin- or non-cyclosporin-treated patients (for review, see refs. 8 and 10). It is noteworthy that in these patients, aspirin, the major antiplatelet agent, is not clinically efficient [8]. We have shown that aspirin Table 3
Hemoglobin (g/l) Hematocrit (%) Leucocytes (109/1) Neutrophiles (109/1) Lymphocytes (109/1) Platelets (109/1) Platelet volume (/~3) Platelet mass (#3 × 109/i) Mean ± S.D.
Transplanted (n = 200)
Controls (n = 200)
P
131 39 6.2 4.8 1.0 215 8.0 1804
144 43 6.3 3.7 1.8 217 8.3 1720
0.0001 0.0001 N.S. 0.01 0.0001 N.S. 0.002 N.S.
± ± ± ± ± + ± 4-
17 5 1.9 5.8 0.7 63 1.0 463
± 12 4- 4 ~= 1.6 4- 1.2 4- 0.6 4- 64 4- 0.9 4- 473
M. de Lorgeril et al. /Chem.-Biol. Interact. 91 (1994) 159-164
163
does not reduce platelet aggregation in immunosuppressed patients as it did in usual coronary patients [13]. Enhanced platelet aggregation (also observed in kidney transplant recipients [10]) is directly related to the occurrence o f c o r o n a r y artery thrombosis in H T recipients [14]. Aspirin works essentially by blocking cyclooxygenase, the key-enzyme o f the prostaglandin pathway in platelets as well as endothelial cells. The production o f thromboxane, the major endproduct o f the prostaglandin pathway in platelets, and the production of prostacyclin, its counterpart in endothelial cells, have been shown to be decreased in H T recipients [15]. Both pathways are associated with R O S production and are mainly regulated by the levels of ROS. Consequently, it is speculated that the high production o f R O S in these patients may inhibit prostaglandin pathway, which may explain the lack of efficiency of aspirin. On the other hand, R O S may stimulate platelet aggregation by damaging the membrane, i.e. by a way independent o f cyclooxygenase. As a matter o f fact, antioxidant supplementation (500 mg a-tocopherol, for 2 months) actually reduced platelet aggregation in H T recipients (paper submitted) which suggests a causal relationship between R O S production, platelet aggregation and thrombotic complications. Thromboembolisms are not unfrequent in HIV-infected patients [2] which suggests that similar intrications between prostaglandin metabolism, the coagulation system, platelet function, ROS production and the immune system may be seen in HIV-infected patients and contribute, at least partly, to the occurrence o f the many complications associated with AIDS.
4. References 1 B. Halliwell and C.E. Cross, Reactive oxygen species, antioxidants, and acquired immunodeficiency syndrome. Sense or speculation?, Arch. Intern. Med., 151 (1991) 29-31. 2 M. De Lorgeril, P. Boissonnat, G. Dureau and S. Renaud, HIV infection and immune system in genesis of coronary lesions, Lancet, 340 (1992) 1226-1227. 3 P. Desseigne, M. de Lorgeril, M. Ciavatti, P. Boissonnat, G. Dureau, S. Renaud and J. Delaye, Steroid-free immunosuppressive treatment increases platelet aggregation in rats, J. Am. Coll. Cardiol., (1993) 21 (1993) 37A. 4 Y. Chancerelle, M. de Lorgeril, R. Viret, B. Chiron, G. Dureau, S. Renaud and J.F. Kergonou, Increased lipid peroxidation in cyclosporin-treated heart transplant recipients, Am. J. Cardiol., 68 (1991) 813-816. 5 M. De Lorgeril, M.J. Richard, J. Arnaud, P. Boissonnat, J. Guidollet, G. Dureau, S. Renaud and A. Favier, Lipid peroxides and antioxidant defenses in accelerated transplantation-associated coronary arteriosclerosis, Am. Heart J., 125 (1993) 974-980. 6 G. lnselmann, M. Blank and K. Baumann, Cyclosporin A induces lipid peroxidation in microsomes and effect on active and passive glucose transport by brush border membrane vesicles of rat kidney, Res. Commun. Chem. Pathol. Pharmacol., 62 (1988) 207-220. 7 A. Phillips, A.G. Shaper and P.H. Whincup, Association between serum albumin and mortality from cardiovascular disease, cancer and other causes, Lancet, 334 (1989) 1434-1436. 8 M. De Lorgeril, G. Dureau, P. Boissonnat, J. Guidollet, I. Juhan-Vague, C. Bizollon and S. Renaud, Platelet function and composition in heart transplant recipients compared with non-transplanted coronary patients, Arteriosclerosis Thrombosis, 12 (1992) 222-230. 9 R.L. Heath and A.L. Tappel, A new sensitive assay for measurements of hydroperoxides, Anal. Biochem., 76 (1976) 184-191. 10 J.E. Taylor, N. Scott, A. Hill, A. Bridges, I.S. Henderson, W.K. Stewart and J.J.F. Belch, Oxygen free radicals and platelet and granulocyte aggregabilityin renal transplant patients, Transplantation, 55 (1993) 500-504.
164
11 12 13
14
15
M. de Lorgeril et aL ~Chem.-Biol. Interact. 91 (1994) 159-164
J.B. Zalokar, J.L. Richard and J.R. Claude, Leucocyte count, smoking and myocardial infarction, N. Engl. J. Med., 304 (1991) 465. P.A. Southorn and G. Powis, Free radicals in medicine: 1. Chemical nature and biological reactions, Mayo Clin. Proc., 63 (1988) 381. M. De Lorgeril, G. Dureau, P. Boissonnat, M. Ovize, C. Monnez, I. Monjaud, P. Salen and S. Renaud, Increased platelet aggregation after heart transplantation: influence of aspirin, J. Heart Lung Transplant., 10 ( 1991 ) 600-603. M. De Lorgeril, R. Loire, J. Guidollet, P. Boissonnat, G. Dureau and S. Renaud, Accelerated coronary artery disease after heart transplantation: the role of enhanced platelet aggregation and thrombosis, J. Intern. Med. 233 (1993) 343-350. J.C. Bordet, M. de Lorgeril, P. Boissonnat et al., Systemic but not renal production of prostacyclin is highly reduced in cyclosporin-treated heart transplant recipients, Am. J. Cardiol., 72 (1993) 486-487.