La transplantation hépatique est une technique chirurgicale maîtrisée, mais le devenir à long terme du greffon et de l’hôte doit encore être amélioré. L’étude pharmacogénétique des inhibiteurs de la calcineurine (CNI) devrait permettre de comprendre la variabilité de leurs effets thérapeutiques et toxiques. Dans un premier temps, nous avons réalisé une revue de la littérature concernant la pharmacogénétique des CNI en greffe d’organe et surtout hépatique en particulier les trois polymorphismes les plus impliqués dans la pharmacocinétique des CNI (CYP3A4*22, CYP3A5*3 et ABCB1 exons 12, 21, 26) et leurs éventuelles associations avec le devenir clinique du patient. L’état actuel des connaissances valide l’intérêt du génotype CYP3A5*3 pour adapter au mieux la posologie précoce de tacrolimus seulement en greffe rénale. Dans un second temps, nous avons mené une étude de cohorte rétrospective visant à étudier la pertinence et l’intérêt des génotypes du donneur et du receveur d’organe mentionnés précédemment, intervenant dans le métabolisme (CYP3A4*22, CYP3A5*3) et le transport membranaire (ABCB1 exons 12, 21 et 26) de la cyclosporine et du tacrolimus en transplantation hépatique. 170 patients avec un suivi de plus de 10 ans en moyenne ont été inclus. Les principaux résultats montrent que : l’allèle CYP3A5 *1 du receveur était associé significativement à un risque plus élevé de perte de greffon à long terme comparé à l’allèle CYP3A5 *3 ; l’allèle TT de l’exon 12 d’ABCB1 du receveur était associé à un risque moins élevé de rejet chronique ; et l’exposition à des doses élevées de CNI, la valeur initiale de la fonction rénale et l’âge du receveur étaient également indépendamment associés au risque d’altération de la fonction rénale. La caractérisation de ces marqueurs pharmacogénétiques en transplantation hépatique pourrait permettre d’adapter les traitements immunosuppresseurs pour chaque patient transplanté. D’autres voies de recherche (pharmacogénétique de la voie calcineurine, biomarqueurs précoces des lésions du greffon, ...) seront nécessaires pour identifier un profil personnalisé pour chaque greffé afin d’adapter au mieux la stratégie thérapeutique à long terme. / Liver transplantation is now a well mastered surgery with standardized procedures, but the long-term clinical outcomes of the graft and the patient remain uncertain. The pharmacogenetic study of the calcineurin inhibitors (CNI) cyclosporine and tacrolimus should help to understand the variability of their pharmacokinetics and therapeutic or side effects. In the first part of this work, we reviewed the main pharmacogenetic studies of CNI in liver transplantation, focusing on the three polymorphisms mostly involved in CNI pharmacokinetics (CYP3A4*22, CYP3A5*3 et ABCB1 exons 12, 21, 26) and their possible associations with clinical outcomes. To date, the only pharmacogenetic test consensually recommended in organ transplantation is the CYP3A5*3 variant for a better selection of the initial tacrolimus dose in kidney transplantation. The second part of this work was a retrospective cohort study in liver transplantation to investigate the influence of the above mentioned donor’s and recipient’s genotypes, involved in the metabolism (CYP3A4*22, CYP3A5*3) and the membrane transport (ABCB1 exons 12, 21 and 26) of cyclosporine and tacrolimus. 170 patients were enrolled in this study with a mean follow-up of more than ten years. Our main results are that: the recipient CYP3A5*1 allele was associated with a higher risk of graft loss than the CYP3A5*3 allele; the recipient ABCB1 exon 12 TT genotype was associated with a lower risk of chronic rejection than the CC genotype; overexposure to CNI, initial renal function and recipient age were associated with a higher risk of post-transplantation renal dysfunction. No genetic factor was associated with patient survival, acute rejection, liver function tests, recurrence of viral or other initial liver disease, or nephrotoxicity. Prospective characterization of both recipient and donor CYP3A4, CYP3A5 and ABCB1 polymorphisms could help to optimize immunosuppressive therapy for each candidate to liver transplantation. Further studies (pharmacogenetics of calcineurin pathway, early biomarkers of graft dysfunction, ...), should help to define a personalized profile for each transplant patient in order to best adapt the immunosuppressive strategy on the long term.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This work examined the effectiveness of Cu pre-exposition on biochemical and behavioral changes induced by Hg exposure in young rats treated subcutaneously with saline or CuCl2.2H2O (Cu 2.6 mg/kg/day) from 3 to 7 days old and with saline or HgCl2 (Hg 3.7 mg/kg/day) from 8 to 12 days old. Tissue samples from animals killed 24 h or 21 days after the end of mercury exposure (13 or 33 days old) were used to analyze of blood, liver, kidney and cerebrum δ-aminolevulinic acid dehydratase (δ-ALA-D) activity; cerebrum and cerebellum acetylcholinesterase (AChE) activity; biochemical parameters indicative of hepatic and renal toxicity; and to determination of hepatic and renal metallothionein and metal levels (Hg, Cu, Zn, Fe e Mg) in all tissues studied. The animals also were submitted to behavioral tasks: negative geotaxis task (3, 5. 7, 9, 11 and 13 days old), tail immersion (13, 20 and 27 days old), rotarod tests (25 and 30 days old) and beaker test (17 to 20 days old). Mercury exposure reduced body and cerebrum and increased kidney weight; inhibited the hepatic and renal δ-ALA-D, cerebellum AChE and serum LDH activity; and increased serum urea and creatinine and hepatic MT levels at 13 days. The Hg effect persisted on body and renal weight, renal δ-ALA-D activity and urea levels checked after 33 days. Still, Hg exposure caused accumulation of this metal in all tissues analyzed; increased hepatic Zn and Fe levels; and decreased renal Fe and increased Cu levels at 13 days. The effect persisted on hepatic Hg levels; and renal Hg and Fe levels. In addition, a decrease in the liver weight and renal Mg levels; and increase in the cerebrum and cerebellum Zn levels were observed only at 33 days. In behavioral tasks, rats exposed to Hg presented impartment in motor function and muscular strength verified in the negative geotaxis task and beaker test. The Cu effectiveness as preventive treatment was immediate on parameters such as cerebellum AChE activity, serum creatinine levels, Hg content and homeostasis of hepatic Fe levels. The prevention of altered parameters as body, Kidney and liver weight, renal δ-ALA-D activity, serum urea levels and homeostasis of renal Fe and Mg levels were verified at 33 days. Behavioral changes were completely prevented by Cu pre-exposure. Moreover, Cu pre-exposure caused an important redistribution of Hg decreasing hepatic and sanguine Hg levels and increasing renal levels of 13-day-old rats. This effect occurred in parallel with an increase in MT levels in liver and kidney, suggesting that hepatic MT can bind to Hg and transporting this metal to the kidney in order to be excreted. The results of the present study suggest that Cu can be considered as potential preventive therapeutic agent against Hg toxicity, even when were evaluated later. / Este trabalho investigou o efeito preventivo do cobre contra as alterações bioquímicas e comportamentais induzidas pelo mercúrio em ratos tratados subcutaneamente com salina ou CuCl2.2H2O (Cu 2,6 mg/kg/dia) do 3o ao 7o e com salina ou HgCl2 (Hg 3,7 mg/kg/dia) do 8o ao 12o dia de idade. Amostras teciduais de animais mortos 24 h ou 21 dias após o término da exposição ao mercúrio (13 ou 33 dias de idade) foram utilizadas para a análise da atividade das enzimas δ-aminolevulinato desidratase (δ-ALA-D) de sangue, fígado, rim e cérebro; acetilcolinesterase (AChE) de cérebro e cerebelo; parâmetros bioquímicos indicativos de toxicidade hepática e renal; e para a quantificação dos níveis de metalotioneínas (MT) hepática e renal e de metais (Hg, Cu, Zn, Fe e Mg) nos diferentes tecidos. Os animais foram submetidos às tarefas comportamentais: geotactismo negativo (3, 5, 7, 9, 11 e 13 dias de idade), imersão da cauda (13, 20 e 27 dias de idade), teste do béquer (17 aos 20 dias de idade) e locomoção forçada em cilindro giratório (25 e 30 dias de idade). A exposição ao mercúrio reduziu o peso corporal e cerebral e aumentou o peso renal; inibiu a atividade das enzimas δ-ALA-D hepática e renal, AChE de cerebelo e LDH sérica; e aumentou os níveis de uréia e creatinina sérica e MT hepática aos 13 dias. O efeito do mercúrio persistiu sobre o peso corporal e renal, a atividade da δ-ALA-D renal e níveis de uréia verificados aos 33 dias. Ainda, a exposição ao mercúrio causou um acúmulo deste metal em todos os tecidos analisados; aumentou os níveis de Zn e Fe hepático; e diminuiu os níveis de Fe e aumentou os níveis de Cu renal aos 13 dias. O efeito persistiu sobre os níveis de Hg hepático e sobre os níveis de Hg e Fe renal. Além disso, um decréscimo no peso de fígado e nos níveis de Mg renal e um aumento nos níveis de Zn em cérebro e cerebelo foram observados somente aos 33 dias. Em relação às tarefas comportamentais, ratos expostos ao Hg apresentaram prejuízo na função motora e força muscular verificados nos testes do geotactismo negativo e teste do béquer. A eficiência do cobre como tratamento preventivo foi imediata em parâmetros como atividade da AChE de cerebelo, níveis de creatinina sérica, conteúdo de Hg e homeostase dos níveis de Fe hepático. A prevenção das alterações sobre o peso corporal, renal e hepático, atividade da -ALA-D renal, níveis de ureia sérica e homeostase dos níveis renais de Fe e Mg foram observados aos 33 dias. Alterações comportamentais foram totalmente prevenidas. Além disso, a pré-exposição ao cobre causou uma redistribuição do mercúrio, decrescendo os níveis de Hg hepático e sanguíneos e aumentando os níveis renais aos 13 dias. Este efeito ocorreu em paralelo a um aumento dos níveis de MT hepática e renal, sugerindo que a MT hepática pode ligar-se ao Hg e transportar o metal tóxico para o rim a fim de ser excretado. Os resultados do presente estudo sugerem que o cobre pode ser considerado um potencial agente terapêutico em casos de intoxicação por mercúrio, mesmo quando avaliado tardiamente.

Le chloroacétaldéhyde (CAA), un des principaux produits du métabolisme hépatique de l’ifosfamide (IFO), est considéré comme responsable de la néphrotoxicité de ce médicament. Les mécanismes exacts de cette néphrotoxicité ne sont pas complètement élucidés. Dans la première partie de cette étude, nous avons essayé de préciser les mécanismes physiopathologiques de la toxicité du CAA sur un modèle de tranches de cortex rénal de rat, puis, dans la deuxième partie, nous avons recherché un effet anticancéreux éventuel du CAA sur des cellules de cancer du sein humain (MCF-7). La néphrotoxicité du CAA, utilisé à des concentrations proches de celles mesurées chez les patients traités par l’IFO, soit 0 - 75 µM, s’est manifestée par une chute d’ATP et du glutathion ainsi que par une inhibition du métabolisme du lactate. Certaines enzymes de la néoglucogenèse, notamment la glyceraldéhyde 3-phosphate déshydrogénase, ont été inhibées par le CAA. Le complexe I de la chaîne respiratoire mitochondriale ainsi que l’oxydation du lactate ont été également inhibées par le toxique. D’autre part, le CAA (10 et 25 µM) a inhibé la prolifération des cellules MCF-7 sans que cette inhibition soit accompagnée d’une chute d’ATP cellulaire. Le transport cellulaire et le métabolisme du glucose ainsi que certaines enzymes de la glycolyse ont été également inhibés par le CAA. Parmi celles-ci, l’hexokinase semble être l’enzyme qui catalyse l’étape limitante de la voie de la glycolyse. En conclusion, le CAA est bien impliqué dans les mécanismes de la néphrotoxicité de l’IFO, mais de plus, il pourrait, via l’inhibition de la glycolyse, contribuer à l’effet thérapeutique de l’IFO. / Chloroacetaldehyde (CAA), one of the main products of ifosfamide (IFO) hepatic metabolism, is considered as responsible of IFO nephrotoxicity. The mechanisms of this nephrotoxicity are not completely known. In the first part of this study, we tried to clarify the pathophysiological mechanisms of CAA toxicity using precision-cut rat renal cortical slices, then, in the second part, we looked for a possible anticancerous effect of CAA on human breast cancer cells (MCF-7). Using clinically-relevant concentrations (0-75 µM), CAA nephrotoxicity was demonstrated by the depletion of ATP and glutathione and by the inhibition of lactate metabolism. Some of the gluconeogenic enzymes, mainly glyceraldehyde 3-phosphate dehydrogenase, were inhibited by CAA. The complex I of the mitochondrial respiratory chain as well as lactate oxidation were also inhibited by CAA. On the other hand, CAA (10 and 25 µM) inhibited MCF-7 cell proliferation which was not accompanied by cellular ATP depletion. Glucose transport and metabolism as well as some of the glycolytic enzymes were also inhibited by CAA. Hexokinase seems to be the rate-limiting enzyme of glycolysis. In conclusion, CAA is implied in the mechanisms of IFO-induced nephrotoxicity; furthermore, it could, via the inhibition of the glycolytic pathway, contribute to the therapeutic effect of IFO.

Cette enquête épidémiologique porte sur l'impact sanitaire de la décharge de Mbeubeuss, réceptacle de l'ensemble des déchets ménagers et industriels de Dakar (Sénégal), sur la population résidant à proximité. Les déchets, stockés sans être recouverts, sont source de pollution atmosphérique et des sols, notamment par le plomb et le cadmium. Les répercussions sanitaires sont d'autant plus préoccupantes que de nombreux riverains de cette décharge sont directement ou indirectement exposés. L'objectif de cette étude était de déterminer, après caractérisation chimique des échantillons de sol et de particules atmosphériques, l'imprégnation de la population (enfants et adultes) à ces deux métaux et de rechercher leur éventuel impact sur la fonction rénale. Nos résultats ont mis en évidence des teneurs atmosphériques et telluriques en plomb et en cadmium plus élevées sur le site de la décharge (teneurs 20 à 80 fois plus élevées que celles de la zone témoin). L'imprégnation saturnine, déterminée au travers des plombémies, plomburies et des marqueurs biologiques d'effet (PPZ, AlaU), de même que les teneurs sanguines et urinaires en cadmium étaient significativement plus importantes chez les individus résidant au voisinage de la décharge. La production excessive d'espèces réactives de l'oxygène induite par cette imprégnation s'est traduit par une diminution du système de défenses antioxydantes (SOD, GPx, Sélénium, GSH) et une peroxydation lipidique (MDA) accrue chez les sujets exposés. En outre, les variations de certains des marqueurs sensibles et spécifiques de néphrotoxicité (concentrations urinaires élevées en protéines totales, en RBP et en CC16 ; et augmentation des activités GSTα et LDH) suggèrent l'apparition de signes discrets et précoces d'altération de la fonction rénale chez les individus résidant à proximité de la décharge. L'exposition aux émissions de la décharge de Mbeubeuss constitue donc une véritable source de risques pour l'environnement et la santé des populations environnantes. Cette étude pourrait sans doute contribuer à conscientiser les acteurs de la santé sur les risques liés à cette décharge et à placer ces problèmes environnementaux, qui constituent un nouveau défi pour les pays pauvres, au cœur des futurs programmes de développement. / This case-control study dealt with adverse health effects on the population living near Mbeubeuss landfill in Dakar (Senegal). All household and industrial waste arising from Dakar are stored in this open landfill without being covered and are therefore possible sources of air pollution and soil contamination by heavy metals, especially Pb and Cd. Health impacts are of particular concern since many of the neighboring residents of this discharge are directly or indirectly exposed. The objective of this study was to determine Pb and Cd concentrations in both environment and humans, and to evaluate possible renal function alteration within the adult and child populations. Our results showed that lead and cadmium concentrations of soils and atmosphere were higher in the landfill (20 to 80 times) than those of the control area. The lead impregnation, evaluated through the blood and urine lead levals, and the biomarkers of exposure (PPZ, ALAU) as well as blood and urine cadmiums levels, were significantly higher in the subjects neighboring the landfill. Excessive production of reactive oxygen species induced by the metal impregnation conducted in exposed subjects to a decrease in antioxidant defense system (SOD, GPx, Selenium, GSH) and an increase in lipid peroxidation (MDA). Moreover, changes in several sensitive and specific markers of nephrotoxicity (high urinary concentrations of total protein, RBP and CC16, as well as GSTα and increased activities) suggested the occurence of discrete and early signs of impaired renal function for the landfill neighboring population. Exposure to emissions from the Mbeubeuss landfill is therefore a source of risk for the environment and the health of people who live and/or work within it. This study could undoubtedly help to raise awareness of landfill-related health risks amoung stakeholders, and to place these environmental problems, wich constitute a new challenge for poor countries, at the heart of future development programs.

Massenspektrometrisches Imaging (MSI) ist unverzichtbar für die Untersuchung der räumlichen Verteilung von Molekülen in einer Vielzahl von biologischen Proben. Seit seiner Einführung hat sich MALDI zu einer dominierenden Bildgebungsmethode entwickelt, die sich als nützlich erwiesen hat, um die Komplexität von Lipidstrukturen in biologischen Geweben zu bestimmen. Einerseits ist die Rolle von Cisplatin bei der Behandlung von menschlichen malignen Erkrankungen gut etabliert, jedoch ist Nephrotoxizität eine limitierende Nebenwirkung, die Veränderungen des renalen Lipidprofils beinhaltet. Dies führte zu der Motivation, die Lipidzusammensetzung des Nierengewebes in mit Cisplatin behandelten Ratten zu untersuchen, um die involvierten Lipid-Signalwege aufzuklären. Es wurde eine Methode zur Kartierung der Lipidzusammensetzung in Nierenschnitten unter Verwendung von MALDI MSI entwickelt. Die Verteilung von Nierenlipiden in Cisplatin-behandelten Proben zeigte deutliche Unterschiede in Bezug auf die Kontrollgruppen. Darüber hinaus wurde die Beurteilung der Ionenbilder von Lipiden in Cisplatin-behandelten Nieren meist als qualitative Aspekte betrachtet. Relative quantitative Vergleiche wurden durch den variablen Einfluss von experimentellen und instrumentellen Bedingungen begrenzt. Daher bestand die Notwendigkeit, ein Normalisierungsverfahren zu entwickeln, das einen Vergleich der Lipidintensität verschiedener Proben ermöglicht. Das Verfahren verwendete einen Tintenstrahldrucker, um eine Mischung der MALDI-Matrix und der internen internen Lipid-Metall-Standards aufzubringen. Unter Verwendung von ICP-MS erlaubte der interne Metallstandard, die Konsistenz der Matrix und der internen Standards zu bestätigen. Die Anwendung der Methode zur Normalisierung von Ionenintensitäten von Nierenlipiden zeigte eine ausgezeichnete Bildkorrektur und ermöglichte einen relativen quantitativen Vergleich von Lipidbildern in Cisplatin-behandelten Proben. / Mass spectrometry imaging is indispensable for studying the spatial distribution of molecules within a diverse range of biological samples. Since its introduction, MALDI has become a dominant imaging method, which proved useful to sort out the complexity of lipid structures in biological tissues. The role of cisplatin in the treatment of human malignancies is well-established. However, nephrotoxicity is a limiting side effect that involves an acute injury of the proximal tubule and alterations in the renal lipid profile. This evolved the motivation to study the spatial distribution of lipids in the kidney tissue of cisplatin-treated rats to shed light on the lipid signaling pathways involved. A method for mapping of lipid distributions in kidney sections using MALDI-LTQ-Orbitrap was developed, utilizing the high performance of orbitrap detection. The distribution of kidney lipids in cisplatin-treated samples revealed clear differences with respect to control group, which could be correlated to the proximal tubule injury. The findings highlight the usefulness of MALDI MSI as complementary tool for clinical diagnostics. Furthermore, assessment of the ion images of lipids in cisplatin-treated kidney mostly considered qualitative aspects. Relative quantitative comparisons were limited by the variable influence of experimental and instrumental conditions. Hence, the necessity developed to establish a normalization method allowing comparison of lipid intensity in MALDI imaging measurements of different samples. The method employed an inkjet printer to apply a mixture of the MALDI matrix and dual lipid-metal internal standards. Using ICP-MS, the metal internal standard allowed to confirm the consistency of the matrix and internal standards application. Applying the method to normalize ion intensities of kidney lipids demonstrated excellent image correction and successfully enabled relative quantitative comparison of lipid images in control and cisplatin-treated samples.

Made available in DSpace on 2014-07-29T16:11:52Z (GMT). No. of bitstreams: 1 dissertacao guilherme.pdf: 2090110 bytes, checksum: a1c991816c551ebd8ad069c1df1f9f72 (MD5) Previous issue date: 2008-09-25 / The araticum (Annona coriacea Mart.) is a typical fruit of the brazilian cerrado used popularly to overcome inflammatory processes. The family Annonaceae presents as the main constituents acetogenins, a class of substances with great cytotoxic and genotoxic potential, and cited as responsible for a disease similar to parkinson in a Caribbean population that used the fruit as much as food and for medicinal purposes. The aim of this study was to evaluate the putative activity of crude ethanolic extract of seeds of A. coriacea on the cerebral cortex of mice exposed at doses of 12.5, 25, 50 and 100 mg / kg, and evaluate its activity on different areas of the brain, the liver and kidneys. We used 30 adult male Swiss mice divided into groups control, solvent and treated (12.5, 25, 50 and 100 mg / kg). The extract was administered orally for four days. The target organs were extirpated, fixed in 70% ethanol (v / v) and processed for histological method - hematoxylin and eosin. The analysis of the slides was performed by image processing system for counting cells and other morphometric analysis. The morphological studies showed no significant changes to the brain in different areas, just as no changes were detected in the kidneys. On the other hand, was found a reduction on the frequency of cells per area of the liver, like as an reduction on the consumption of food, water and production of excreta. We conclude with this work a possible hepatotoxic activity induced by exposure to crude ethanol extract of seeds of A. Coriacea Mart., observed by the decrease in frequency of cells per area of the liver, correlated with reductions in consumption of food / water and production of excreta by animals. / O Araticum (Annona coriacea Mart.) é um fruto típico do cerrado brasileiro utilizado popularmente para remediar processos inflamatórios. A família Annonaceae apresenta como principais constituintes as acetogeninas, uma classe de substâncias com grande potencial citotóxico, genotóxico e ainda citado como o responsável por uma doença similar ao parkinsonismo em uma população caribenha que utilizava o fruto tanto como alimento quanto para fins medicinais. O objetivo deste estudo foi avaliar a putativa atividade do extrato bruto etanólico das sementes da A. coriacea sobre o córtex cerebral de camundongos expostos nas doses de 12,5; 25; 50 e 100 mg/kg, além de avaliar sua atividade sobre diferentes áreas do encéfalo, sobre o fígado e rins. Foram utilizados 30 camundongos Swiss machos adultos divididos em grupos controle, solvente e tratados (12,5; 25; 50 e 100 mg/kg). O extrato foi administrado por via oral durante quatro dias. Os órgãos-alvo foram extirpados, fixados em etanol 70% (v/v) e processados para método histológico - hematoxilina e eosina. A análise das lâminas foi executada via sistema de processamento de imagens para a contagem das células e demais análises morfométricas. Os estudos morfológicos não demonstraram alterações significativas para o cérebro em suas diferentes áreas, da mesma forma que não foram detectadas alterações nos rins. Por outro lado, foi detectado uma redução da freqüência de células por área do fígado, assim como verificamos uma diminiução no consumo de ração, água e produção de excreta. Concluimos com este trabalho uma possível atividade hepatotóxica induzida pela exposição ao extrato bruto etanólico das sementes da A. Coriacea Mart., observada pela diminuição da freqüência de células por área do fígado, correlacionado com reduções de consumo de ração/água e produção de excretas pelos animais.

L’insuffisance rénale chronique (IRC) est un problème majeur fréquemment rencontré chez les greffés cardiaques. Les inhibiteurs de la calcineurine, pierre angulaire de l’immunosuppression en transplantation d’organes solides, sont considérés comme une des principales causes de dysfonction rénale postgreffe. Plusieurs autres éléments tels que les caractéristiques démographiques, cliniques et génétiques du receveur contribuent également au phénomène, mais il demeure plutôt difficile de déterminer quels sont les patients les plus à risque de développer une IRC après la transplantation. Ainsi, la découverte de nouveaux marqueurs génétiques de dysfonction rénale pourrait un jour mener à l’individualisation de la thérapie immunosuppressive selon le profil génétique de chaque patient. Or, on ne connaît pas les opinions des greffés à l’égard des tests pharmacogénomiques et l’on ne sait pas si celles-ci diffèrent des opinions exprimées par les individus en bonne santé. Cette thèse de doctorat a donc pour objectifs : 1- De décrire l’évolution de la fonction rénale à très long terme après la transplantation et d’identifier les marqueurs démographiques et phénotypiques associés à l’IRC postgreffe cardiaque; 2- D’identifier les marqueurs génétiques associés à la néphrotoxicité induite par les inhibiteurs de la calcineurine; 3- D’évaluer et de comparer les attitudes des patients et des individus en bonne santé par rapport à l’intégration clinique potentielle des marqueurs pharmacogénomiques. Trois projets ont été réalisés pour répondre à ces questions. Le premier repose sur une analyse rétrospective de l’évolution de la fonction rénale chez les patients greffés au sein de notre établissement entre 1983 et 2008. Nous y avons découvert que le déclin de la fonction rénale se poursuit jusqu’à 20 ans après la transplantation cardiaque et que les facteurs de risque d’IRC incluent entre autres l’âge avancé, le sexe féminin, la dysfonction rénale prégreffe, l’hypertension, l’hyperglycémie et l’utilisation de la prednisone. Le deuxième projet est une étude pharmacogénomique s’intéressant aux déterminants génétiques de la néphrotoxicité induite par les inhibiteurs de la calcineurine. Elle nous a permis d’illustrer pour la première fois qu’un polymorphisme génétique lié à PRKCB (gène codant pour la protéine kinase C-β) est associé avec la fonction rénale des patients greffés cardiaques, alors que cela n’est probablement pas le cas pour les polymorphismes de TGFB1 (gène codant pour le transforming growth factor-β1). La troisième section de cette thèse rapporte les résultats d’un questionnaire dont le but était de comparer les attitudes envers les tests pharmacogénomiques parmi un groupe de personnes en bonne santé, de patients greffés cardiaques et de patients souffrant d’insuffisance cardiaque. Cette étude a démontré que, bien que l’enthousiasme pour la pharmacogénomique soit partagé par tous ces individus, les craintes liées à la confidentialité et aux répercussions potentielles sur l’emploi et les assurances sont plus prononcées chez les personnes en bonne santé. En résumé, les travaux issus de cette thèse ont révélé que l’identification précoce des patients greffés cardiaques les plus susceptibles de présenter une détérioration de la fonction rénale ainsi que l’adoption d’une approche thérapeutique individualisée reposant notamment sur les applications cliniques de la pharmacogénomique pourraient éventuellement permettre de freiner cette complication postgreffe. / Chronic kidney disease (CKD) is a major problem frequently observed in cardiac transplant recipients. Calcineurin inhibitors, which have become the cornerstone of immunosuppressive treatments in solid organ transplantation, are considered a major cause of post-transplant renal dysfunction. Several other factors such as recipients’ demographic, clinical and genetic characteristics also contribute to this phenomenon, but it remains rather difficult to determine which patients present the highest risk of CKD after transplantation. Discovery of new genetic markers of renal dysfunction could one day lead to individualization of immunosuppressive therapy according to each patient’s genetic profile. However, transplant patients’ opinions towards pharmacogenomic testing remain unknown, and it is unclear whether these differ from healthy individuals’ opinions. This doctoral thesis thus aims: 1- To describe the very long-term evolution of renal function after transplantation and to identify demographic and phenotypic markers associated with postheart transplant CKD; 2- To identify genetic markers associated with calcineurin inhibitor-induced nephrotoxicity; 3- To assess and to compare the attitudes of patients and healthy individuals concerning the potential integration of pharmacogenomic markers in clinical practice. Three projects have been conducted to answer these questions. The first one relies on a retrospective analysis of the evolution of renal function in patients who received a heart transplantation at our institution between 1983 and 2008. We discovered that deterioration of renal function continues up to 20 years after transplant and that risk factors of CKD include, among others, advanced age, female gender, pretransplant renal dysfunction, hypertension, hyperglycemia and use of prednisone. The second project is a pharmacogenomic study looking at genetic determinants of calcineurin inhibitor-induced nephrotoxicity. We were able to illustrate for the first time that a genetic polymorphism related to PRKCB (gene encoding protein kinase C-β) is associated with renal function in heart transplant patients, whereas it is probably not the case for polymorphisms in TGFB1 (gene encoding transforming growth factor-β1). The third section of this thesis reports the results of a questionnaire whose purpose was to compare the attitudes towards pharmacogenomic testing in a group of healthy volunteers, cardiac transplant recipients and heart failure patients. This study demonstrated that, although enthusiasm regarding pharmacogenomics is shared equally among these individuals, preoccupations related to confidentiality and potential impacts on employment and insurance are more important in healthy volunteers. In summary, the work presented in this thesis showed that early identification of heart transplant patients who are most likely to develop renal dysfunction as well as adoption of an individualized therapeutic approach involving clinical applications of pharmacogenomics could potentially help to prevent this post-transplant complication.

Made available in DSpace on 2016-01-26T12:51:42Z (GMT). No. of bitstreams: 1 rosasoubhia_tese.pdf: 792706 bytes, checksum: bba71696e22270729d09c3130cc047eb (MD5) Previous issue date: 2005-05-25 / Introduction: Tacrolimus (FK 506) is a potent immunosuppressive drug that may cause nephrotoxicity decreasing the renal blood flow (RBF) and glomerular filtration rate (GFR). Conventional non-steroidal anti-inflammatory drugs (NSAIDs) may cause nephrotoxicity, interfering with renal hemodynamics and fluid and eletrolyte homeostasis. Recently, new selective COX-2 inhibitors have been developed producing less side effects (gastric, cardiac and renal) related to COX-1 inhibition. The increasing use of FK 506 and the intensive use of NSAIDs with analgesic or ani-inflammatory purposes, increases the possibility of a drug combination, potentiating the nephrotoxic risk of the two drugs. Objective : Compare the renal function of rats receiving combination therapy with FK and a non-selective COX inhibitor, sodium diclofenac (SD) with those receiving FK and a selective COX-2 inhibitor, rofecoxib (RO). Material and Methods : Male Munich-Wistar rats receiving a low sodium diet (0.06%) for 7 days and gavage treatment for 7 days with FK (2 mg/kg/day), SD (10 mg/kg/day), RO (3 mg/kg/day), FK+SD, FK+RO and vehicle (control) were used. Glomerular filtration rate (GFR, inulin clearance, ml/min/100g); renal blood flow (RBF, Doppler ultrasound, ml/min); mean blood pressure (MBP, intracarotid probe, mmHg); renal vascular resistence ( RVR, mmHg/ml/min); hematocrit (Htc); urinary volume ( UV, &#956;l/min); solute clearance; renal histology; animal weight (g) and FK serum concentration (SCFK, ng/ml) were assessed. Results are presented as a mean±standart deviation and compared by ANOVA followed by Student-Neuman-Keuls test. Results : The GRF of the SD group was 0.98±0.03, RO 1.06±0.04 and FK 0.99±0.06 similar to control values (1.10±0.05). GRF values decreased in the FK+RO (0.86±0.06;p<0.05 vs RO and Control) and FK+SD (0.63±0.06;p<0.001 vs control, FK and SD groups and p<0.01 vs FK+RO) groups. RBF, MBP, RVR and Htc values were similar in all groups. Diuresis was lower in the groups with drug combination, but there was a statistically significant difference only between FK+SD and RO groups (8.38±0.46 vs 12.99±1.22;p<0.05). There were no significant histological chan ges in the treatment groups. The FK+SD group showed statistically significant weigth changes (-18±5) when compared to the Control and RO groups (6±2 and 5±2, respectively; p<0.001) and to the SD an FK+RO groups (0.2±4 and 1±2, respectively; p<0.01). SCFK was significantly decreased (p<0.05) for FK+SD and FK+RO (1.7±0.3 and 1.8±0.4) groups when compared to the FK group (3.2±0.4. Conclusions: The combination of FK and a non-selective COX inhibitor significantly decreased GFR regardless of a RBF decrease or RVR increase, and is probably a result of Kf decrease. The trend to antidiuresis was similar for the combination of FK with both classes of NSAIDs. FK combined to a non-selective COX inhibitor caused a mild systemic toxicity when compared with the COX-2 selective inhibitor. Serum FK concentrations were significantly lower in NSAIDs treated animals. / Introdução: O tacrolimus (FK 506) é uma potente droga imunossupressora, pode causar nefrotoxicidade aguda com diminuição do fluxo sanguíneo renal (FSR) e ritmo de filtração glomerular (RFG). Os antiinflamatórios não-hormonais (AINHs) convencionais podem causar nefrotoxicidade, interferindo na hemodinâmica renal e na homeostase de fluidos e eletrólitos. Recentemente surgiram novas drogas do grupo coxib que são inibidores seletivos da COX-2, e portanto teriam menos efeitos colaterais relacionados à inibição da COX-1 (gástricos, cardíacos e renais). O crescente uso do FK 506 e o intenso uso de AINHs com finalidade analgésica e ou antiinflamatória aumenta a possibilidade de utilização em conjunto, potencializando o risco de nefrotoxicidade das duas drogas. Objetivo: Comparar a função renal de ratos sob os efeitos do uso simultâneo do FK e de um inibidor não-seletivo da COX, o diclofenaco sódico (DS) e do FK e de um inibidor seletivo da COX-2, o rofecoxib (RO). Materiais e Método: Utilizaram-se ratos Munich-Wistar machos em dieta hipossódica (0,06%) por 7 dias e tratamento por gavagem por 7 dias com FK (2 mg/kg/dia), DS (l0mg/kg/dia), RO (3mg/kg/dia), FK+DS, FK+RO e veículo (Contr). Aferidos ritmo de filtração glomerular (RFG, depuração de inulina, ml/min/l00g); o fluxo sanguíneo renal (FSR, ultrasom Doppler, ml/min); a pressão arterial média (PAM, probe intracarotídeo, mmHg); a resistência vascular renal (RVR, mmHg/ml/min); hematócríto (Ht); o volume urinário (VU, pl/min); a depuração de solutos; a histologia renal; o peso dos animais (g) e a concentração sanguínea de FK CSFK, ng/ml). Os resultados são apresentados com médiaserro padrão da média e comparados por ANOVA seguido do teste Student-Neuman-Keuls. Resultados: O RFG do grupo DS foi 0,980,03, do RO foi 1,060,04 e do FK 0,990,06 similares ao controle (1,100,05). Houve queda do RFG nos grupos FK+RO (0,860,06;p<0,Os vs RO e Contr) e FK+DS (0,630,06;p<0,001 vs Contr,DS, RO e FK; p<0,01 vs FK+RO) Nota de Resumo O FSR, a PAM, a RVR e o Ht foram semelhantes em todos os grupos. A diurese foi menor nos grupos com associação de drogas, mas houve diferença estatisticamente significante apenas entre os grupos FK+DS e RO (8,380,46 vs l299l,22;p<0,05). Não ocorreram modificações histológicas significativas nos grupos estudados. O grupo FK+DS apresentou variação de peso (-185) estatisticamente significante em relação aos grupos Contr 62 e RO 52 (p<0,001) e DS 0,24 e FK+RO -12 (p<0,01). A CSFK diminuiu significativamente (p<0,05) para os grupos FK+DS e FK+RO (1,70,3 e 1,80,4) em relação ao grupo FK (3,20,4). Conclusões: A associação do FK com um inibidor não-seletivo da COX causou diminuição mais acentuada do RFG independentemente da diminuição do FSR ou aumento da RVR, sendo provavelmente decorrente da diminuição do Kf. A tendência à antidiurese foi similar para a associação do FK com as duas classes de AINHs. O FK associado com um inibidor não-seletivo da COX causou discreta toxicidade sistêmica quando comparado com inibidor seletivo da COX-2. Nos animais tratados com AINHs, as concentrações sanguíneas do FK foram significativamente menores.