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Tese (doutorado)—Universidade de Brasília, Faculdade de Medicina, Programa de Pós-graduação em Medicina Tropical, 2015. / Submitted by Patrícia Nunes da Silva (patricia@bce.unb.br) on 2015-11-17T19:48:43Z No. of bitstreams: 1 2015_ HenryMaiaPeixoto_Parcial.pdf: 3442470 bytes, checksum: b84b03e2ddc7d08569743a7d466360fa (MD5) / Approved for entry into archive by Guimaraes Jacqueline(jacqueline.guimaraes@bce.unb.br) on 2015-11-19T11:18:55Z (GMT) No. of bitstreams: 1 2015_ HenryMaiaPeixoto_Parcial.pdf: 3442470 bytes, checksum: b84b03e2ddc7d08569743a7d466360fa (MD5) / Made available in DSpace on 2015-11-19T11:18:55Z (GMT). No. of bitstreams: 1 2015_ HenryMaiaPeixoto_Parcial.pdf: 3442470 bytes, checksum: b84b03e2ddc7d08569743a7d466360fa (MD5) / Introdução: A deficiência da enzima G6PD (dG6PD) é causada por mutações no gene G6PD, ligado ao cromossomo X, que exerce um importante papel na proteção da hemácia contra agentes oxidantes, podendo acometer ambos os sexos. As manifestações clinicamente relevantes, no entanto, como a anemia hemolítica aguda, ocorrem, predominantemente, em homens. A primaquina, uma 8-aminoquinolina utilizada no tratamento radical da malária vivax, representa o principal fator desencadeador de complicações associadas à dG6PD em áreas endêmicas de malária. Nesse sentido, a utilização de um teste para detecção da dG6PD antes da indicação da primaquina poderá prover uma maior segurança aos portadores da deficiência. Objetivo: Avaliar a eficiência da introdução de teste diagnóstico rápido (TR) para detectar a dG6PD em indivíduos do sexo masculino com malária vivax na Amazônia Brasileira. Método: Foi realizada uma análise econômica na perspectiva do Sistema Único de Saúde (SUS). O estudo foi subdividido em análise de custos, análise de custo-efetividade e análise de impacto orçamentário. Foram estimados custos diretos da dG6PD para os anos 2009, 2010 e 2011 na Amazônia Brasileira, considerando os custos com o diagnóstico do P. vivax, com o seu tratamento e com as hospitalizações associadas ao uso da primaquina. A análise de custo efetividade, desenvolvida para o ano de 2013, considerou os desfechos: caso diagnosticado adequadamente, hospitalização evitada e cura da malária vivax. Foram comparadas, por meio de árvores de decisão, a rotina preconizada no Brasil que não inclui o diagnóstico da dG6PD (estratégia Rotina) e duas estratégias diagnósticas com TR para dG6PD em indivíduos do sexo masculino infectados com P. vivax antes da indicação da primaquina. A primeira estratégia considerou o uso combinado do TR BinaxNOW® G6PD (BX-G6PD) nos municípios com mais de 100 mil habitantes e a rotina para os demais municípios. A segunda estratégia considerou o uso do TR CareStartTM G6PD (CS-G6PD) em 100% dos municípios. A análise de impacto orçamentário, desenvolvida para os anos de 2013, 2014 e 2015, comparou a rotina adotada no Brasil com a estratégia baseada no uso do CS-G6PD, considerando uma expectativa de difusão na Amazônia Brasileira de 30% no primeiro ano, de 70% no segundo ano e de 100% no terceiro ano. Resultados: As estimativas de custos da dG6PD no âmbito da malária vivax indicam um custo médio correspondente a R$ 10.066.338,31, variando de acordo com a análise de sensibilidade entre R$7.981.552,46 e R$ 12.048.660,00. Na análise de custo-efetividade para o desfecho caso diagnosticado adequadamente, ao comparar as estratégias baseadas em TR com a Rotina, a estratégia com CS-G6PD foi a mais custo efetiva e a estratégia com o BX-G6PD foi dominada de forma estendida; considerando o desfecho hospitalização evitada, a estratégia que usou o CS-G6PD dominou as demais. Para o desfecho cura da malária vivax, embora a Rotina tenha sido a mais custo-efetiva, a estratégia CS-G6PD apresentou um menor custo, além de não apresentar uma diferença importante quanto à efetividade. Na análise de impacto orçamentário, quando comparados os cenários constituídos pela Rotina e o CS-G6PD, o impacto orçamentário incremental foi negativo nos três anos avaliados. Conclusão: A pesquisa estima que a estratégia baseada CS-G6PD é a estratégia mais custo-efetiva para diagnosticar a dG6PD e evitar a hospitalização, além de apresentar impactos orçamentários incrementais que indicam um melhor uso dos recursos públicos. / Introduction: The Deficiency of the enzyme G6PD (G6PDd) is caused by mutations in the gene G6PD, which plays an important role in protecting the red blood cell against oxidizing agents; it is linked to the chromosome X, and it may affect both sexes. The clinically relevant manifestations, such as acute haemolytic anaemia, mainly occur in men, however. The 8-aminoquinoline primaquine, which is the medication used in the radical treatment of malaria caused by Plasmodium vivax, represents the main factor that triggers complications associated with G6PDd in malaria endemic areas. In this sense, the usage of a test for the detection of the G6PDd before the indication of primaquine will be able to provide increased security to the carriers of G6PDd. Objective: To evaluate the efficiency of the introduction of rapid diagnostic testing (RDT) to detect the G6PDd in male individuals with vivax malaria in the Brazilian Amazon. Method: An economic analysis was performed in the perspective of the Brazilian Public Health System (SistemaÚnico de Saúde - SUS). The study was subdivided into cost analysis, cost-effectiveness analysis and budget impact analysis. Direct costs from the G6PDd for the years 2009, 2010 and 2011 in the Brazilian Amazon were estimated considering the cost of the diagnosis of P. vivax, with its treatment and with hospitalizations associated with the use of primaquine. The analysis of cost-effectiveness, developed for the year 2013, considered the outcomes: properly diagnosed cases, avoided hospitalizations and cure of vivax malaria. By means of decision trees, the routine recommended in Brazil, which does not include the diagnosis of the G6PDd (Routine strategy), and two diagnostic strategies with RDT for the G6PDd in male individuals infected with P vivax before the indication of primaquine were compared. The first strategy considered the combined use of the RDT BinaxNOW® G6PD (BX-G6PD) in municipalities with more than 100,000 inhabitants and the routine to the other municipalities. The second strategy considered the use of the RDT CareStartTM G6PD (CS-G6PD) in 100% of the municipalities. The analysis of budget impact, developed for the years 2013, 2014 and 2015, compared the routine adopted in Brazil with the strategy based on the use of the CS-G6PD considering an expectation of diffusion in the Brazilian Amazon of 30% in the first year, of 70% in the second year and of 100% in the third year. Results: The cost estimations of the G6PDd in the framework of vivax malaria indicate an average cost equivalent to R$ 10,066,338.31, varying according to the analysis of sensitivity between R$ 7,981,552.46 and R$ 12,048,660.00. In the analysis of cost-effectiveness for the outcome properly diagnosed cases, when comparing the strategies based on RDT with the Routine, the strategy with CS-G6PD was the most cost-effective and the strategy with the BX-G6PD was dominated in extended form; considering the outcome avoided hospitalizations, the strategy that used the CS-G6PD dominated the others. For the outcome cure of vivax malaria, though the Routine was the most cost-effective, the CS-G6PD strategy presented a lower cost, besides not presenting an important difference regarding the effectiveness. In the analysis of budget impact, when compared to the scenarios constituted by the Routine and the CS-G6PD, the incremental budgeting impact was negative in the three years evaluated. Conclusion: The study estimates that the CS-G6PD based strategy is the most cost-effective one for diagnosing the G6PDd and avoiding hospitalization, besides presenting incremental budgeting impacts that indicate a better use of public resources.

Les Leucémies Aigües Myéloïdes (LAM) sont des hémopathies malignes hétérogènes de mauvais pronostic qui se caractérisent par une expansion clonale de progéniteurs immatures. De nombreuses dérégulations de voies de signalisation sont retrouvées dans les cellules leucémiques et leur confèrent un avantage de prolifération et de survie. La voie de signalisation mTORC1, qui contrôle la traduction protéique, l’autophagie et plusieurs voies métaboliques, est ainsi constitutivement activée dans les cellules leucémiques. La reprogrammation métabolique notamment via « l’effet Warburg » est un phénomène bien décrit dans les cellules cancéreuses. L’augmentation de l’utilisation de la glycolyse, confère aux cellules tumorales un avantage de survie en favorisant une production rapide d’ATP et d’intermédiaires métaboliques nécessaires pour les biosynthèses de nucléotides, d’acides-aminés et de lipides. C’est donc dans ce contexte que j’ai étudié le métabolisme du glucose dans les cellules de LAM et l’implication de la voie de signalisation mTORC1 dans la dérégulation de ce métabolisme. J’ai tout d’abord identifié par une étude transcriptomique dans la lignée leucémique MOLM-14 que la signalisation mTORC1 contrôle plusieurs voies métaboliques notamment celles permettant l’utilisation du glucose. Ceci a été vérifié dans plusieurs lignées de LAM puisque l’inhibition ou la sur-activation de mTORC1 entrainent respectivement une diminution ou une augmentation de la consommation de glucose et de la production de lactate. De façon intéressante, le niveau d’activation de la voie mTORC1 détermine la sensibilité des cellules leucémiques à l’inhibition de la glycolyse. En effet, lorsque mTORC1 est activé, le blocage de la glycolyse induit de l’autophagie et l’apoptose des cellules leucémiques. A l’inverse, le blocage de mTORC1 induit une reprogrammation métabolique des cellules leucémiques qui utilisent alors principalement la phosphorylation oxydative pour produire l’ATP dont elles ont besoin. Leur survie devient alors indépendante du glucose. A l’inverse des cellules primaires de LAM, les cellules hématopoïétiques immatures normales CD34+ sont moins sensibles au blocage de la glycolyse. Le ciblage du métabolisme du glucose pourrait donc constituer une stratégie thérapeutique intéressante dans les LAM. Je me suis ensuite intéressée aux effets anti-leucémiques induits par l’inhibition de la voie des pentoses phosphates (PP) et plus particulièrement au ciblage de la G6PD (glucose-6-phosphate déshydrogénase) par le composé le 6-aminonicotinamide (6-AN). En effet, une étude de flux métabolique a permis de mettre en évidence qu’une proportion importante de glucose est dirigé vers la voie des PP, laissant suggérer que l’addiction des cellules leucémiques au glucose pourrait être liée à une utilisation augmentée de cette voie annexe. J’ai alors observé que le 6-AN induit une cytotoxicité in-vitro y compris dans les cellules primaires de patients, sans avoir d’effets sur les cellules hématopoïétiques normales et in-vivo dans un modèle de xénogreffe de la lignée MOLM-14 chez la souris NUDE. Cette étude a donc permis de montrer que l’activation constitutive de mTORC1 rend la survie des cellules de LAM dépendante de la glycolyse et crée une sensibilité spécifique à l’inhibition de la G6PD. La dérégulation de la signalisation mTORC1 étant quasi-constante dans les LAM, cibler la G6PD pourrait donc représenter une stratégie thérapeutique intéressante. / Acute Myeloid Leukemia (AML) are heterogeneous hematological diseases with poor prognosis characterized by a clonal expansion of immature progenitors. Many deregulation of signaling pathways are found in leukemic cells and give them an advantage of proliferation and survival. The MTORC1 signaling pathway, which controls protein translation, autophagy and several metabolic pathways, is constitutively activated in leukemic cells. Metabolic reprogramming in particular the "Warburg effect" is a phenomenon well described in cancer cells. High rate of glycolysis has been considered to give tumour cells advantages through rapid production of ATP and intermediates for the synthesis of nucleotides, amino acids, and lipids. In this context, I studied glucose metabolism in AML cells and the involvement of the mTORC1 signaling pathway in the deregulation of this metabolism. First, I identified by a transcriptomic analysis in the MOLM-14 cell line that mTORC1 signaling controls several metabolic pathways including those for glucose utilization. This has been verified in several AML cell lines, since inhibition or over-activation of mTORC1 respectively induces a decrease or an increase in glucose consumption and lactate production. Interestingly, the level of activation of the mTORC1 signaling pathway determines the sensitivity of AML cells to the inhibition of glycolysis. Indeed, when mTORC1 is activated, the blockade of glycolysis induces autophagy and apoptosis of leukemic cells. Conversely, blocking mTORC1 induces metabolic reprogramming of leukemic cells, which then mainly use oxidative phosphorylation to produce ATP for their needs. AML cell survival become independent of glucose. Unlike primary AML cells, survival of normal immature hematopoietic cells CD34+ is only barely affected by the blockade of glycolysis. Thus, targeting the glucose metabolism may constitute an attractive therapeutic strategy in AML. I then investigated the anti-leukemic activity induced by the inhibition of the pentose phosphate pathway (PPP) and more particularly by the specific blockade of G6PD (glucose 6-phosphate dehydrogenase) with the 6-aminonicotinamide (6- AN) compound. Indeed, a metabolic flux analysis demonstrated that a significant proportion of glucose was directed towards the PPP. This result suggested that the addiction of leukemic cells toward glucose might be related to an increased use of PPP. I then observed that the 6-AN induced in vitro cytotoxicity including in primary AML cells from patients without effect on normal immature hematopoietic cells CD34+ and in vivo in a xenograft model of MOLM-14 cell line in the NUDE mouse. This study therefore demonstrated that the constitutive activation of mTORC1 makes AML cells survival dependent on glycolysis, and creates a specific vulnerability to the inhibition of G6PD. Given that deregulation of the mTORC1 signaling pathway is almost constant in AML, targeting G6PD may therefore represent an interesting therapeutic strategy.

Malária, causada por parasitas Plasmodium spp., ainda contribui com cerca de 400 mil mortes anuais sendo uma das mais vastas doenças de nosso tempo. Plasmodium falciparum, que causa a malária tropical, leva a forma mais severa da doença. Não obstante, há alguns grupos com resistência nativa conhecidas como, por exemplo, a siclemia ou enzimopatias como no caso da deficiência da glicose 6-fosfato desidrogenase. Apesar dos anos de pesquisa, até hoje os exatos mecanismos que conferem proteção, permanecem desconhecidos. Contudo, várias hipóteses, como o aumento da resposta imune inata ou a resposta melhorada contra os danos oxidativos dentro dos eritrócitos são discutidos. Este trabalho foca nos sistemas de defesa contra danos oxidativos em Plasmodium falciparum usando parasitas geneticamente modificados em células sanguíneas vermelhas anormais. O aumento de diferentes sistemas antioxidantes deveria fornecer um olhar aprofundado dos mecanismos de proteção destes eritrócitos modificados. Neste trabalho demonstramos a importância da Glutationa-S-Transferase para a sobrevivência do parasita em eritrócitos com a deficiência da glicose 6-fosfato desidrogenase. Isso leva a hipótese de que níveis aumentados de ROS nas células vermelhas geram uma alta quantidade de xenobióticos no parasita, resultando na morte da célula. / Malaria, caused by Plasmodium spp., remains with more than 400.000 deaths annually one of the vastest diseases of our time. Plasmodium falciparum, is the most dangerous species leading to severe malaria. Nevertheless, there are some native resistances known like sickle cell trait or enzymopathies such as glucose-6-phosphate dehydrogenase deficiency. However, the protection mechanism is still unknown. Hypotheses like a better innate immune response or the increased oxidative stress inside the altered erythrocytes are discussed. This work is focusing on the oxidative defence system of P. falciparum using transgenically modified parasites cultured in wild-type and abnormal red blood cells. Elevated expression levels of different anti-oxidative systems in P. falciparum should give a deeper insight of the protection mechanism of the altered erythrocytes. In this work, we show the importance of the Glutathione-S-Transferase (GST) for the proliferation of the malaria pathogen in erythrocytes with glucose-6-phosphate dehydrogenase deficiency. This leads to the hypothesis that the increased ROS level in these red blood cells generating a high amount of xenobiotics within the parasite which results in cell death.

Glucose-6-phosphate dehydrogenase (G6PD) is a cytoplasmic enzyme with an important function in cell oxidative damage prevention. Erythrocytes have a predisposition towards oxidized environments due to their lack of mitochondria, giving G6PD a major role in its stability. G6PD deficiency (G6PDd) is the most common enzyme deficiency in humans; it affects approximately 400 million individuals worldwide. The overall G6PDd allele frequency across malaria endemic countries is estimated to be 8%, corresponding to approximately 220 million males and 133 million females. However, there are no reports on the prevalence of G6PDd in Andean communities where bartonellosis is prevalent.

Orientador: Paulo Eduardo Martins Ribolla / Resumo: A deficiência da enzima Glicose-6-Fosfato Desidrogenase (G6PD) é uma anormalidade genética de alta prevalência populacional que resulta em uma menor reatividade do sistema de óxido-redução eritrocitário, geralmente sem repercussões clínicas; estima-se que mais de 300 milhões de pessoas são portadoras dessa alteração. A enzima é expressa em todos os tecidos e catalisa a primeira etapa da Via das Pentoses. Nas hemácias, essa via é de fundamental importância na manutenção do equilíbrio de seu estado redox e a deficiência dessa enzima pode favorecer eventos hemolíticos agudos e crônicos; e em recém nascidos, pode contribuir para o agravamento da icterícia neonatal. O diagnóstico da deficiência baseia-se na atividade enzimática, identificada através de testes quantitativos e qualitativos. Os testes qualitativos limitam-se a agrupar indivíduos em “deficientes” e “não deficientes”, já os métodos quantitativos são mais precisos na inferência dessa atividade. Estas técnicas podem necessitar de repetições dos testes para confirmação de resultados incongruentes. Por outro lado, a variante genética responsável pela deficiência pode ser precisamente reconhecida através de testes de diagnóstico molecular. O presente projeto tem como objetivo desenvolver uma metodologia de identificação molecular da variante G202A, frequentemente encontrada na população brasileira, e realizar uma comparação do custo-benefício com a metodologia de sequenciamento de Sanger. Ao todo, foram analisadas 107 amost... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Glucose-6-phosphate dehydrogenase deficiency is a metabolic enzymatic defect affecting 300 million people worldwide. The enzyme is present in all tissues and catalyses the first reaction in the Pentose Phosphate pathway responsible for maintaining the redox equilibrium in red blood cell. Deficient enzyme may lead to acute and chronic haemolytic anaemia and neonatal jaundice. Diagnosis for G6PD deficiency is based on biochemical quantitative or qualitative tests. Qualitative tests only classifies subjects as “deficient” or “non-deficient”, while quantitative tests are more precise, however both biochemical approches need a confirmative assay to confirm ambiguous results. On the other hand molecular identification for the molecular variants are more accurate and precise. We developed a new molecular assay to identify the G202A molecular variant present at high frequency on Brazilian population and comparer it to Sanger sequencing. One hundred and seven peripheral blood sample were collected on filter paper. DNA extraction were performed followed by G6PD exon 4 amplification and sequencing. On-line tool “Primer1” generated allele-specific primers for TETRA-ARMS genotyping. Twenty two subjects were deficient homozygote, eighty four wild homozygote and one heterozygote. All subjects genotype were confirmed by Sanger sequencing. TETRA-ARMS costs per reaction is three times lower than Sanger sequencing. We conclude that TETRA-ARMS is a suitable protocol to detect G202A mutation on h... (Complete abstract click electronic access below) / Mestre

Regulation of Glucose metabolism is known to play an important role in pathogenesis of many diseases. Primarily because deregulation of this metabolic pathway can lead to either apoptosis or extended life span of the cells involved. Viruses are parasitic in nature, they utilize the host cellular pathways to support their own progeny; hence it is expected that viruses would regulate the central glucose metabolism of infected host cells. Human immunodeficiency virus type 1 (HIV-1) causes acquired immune deficiency syndrome, and it uniquely infects both activated CD4+ T cells and terminally differentiated macrophages during the course of HIV-1 pathogenesis. While HIV-1 infection of CD4+ T cells induces G2 arrest and cell death within 2-3 days, HIV-1 infection of macrophages results in longer survival of infected cells and low constitutive viral production, generating viral reservoirs. Our studies show that HIV-1 infection lead to significant changes in the glycolytic pathway of infected cells by altering the enzymatic activity and protein expression of various glycolytic components. The data suggests that the two HIV-1 target cell types exhibit very different metabolic outcomes. During viral replication in monocyte/macrophage lineage cells we observe increase in glycolytic protein expression and the same proteins show no modulation in T-cell lines post viral replication. Similar differential regulation is observed in case of enzymatic activity of glycolytic enzymes as well. We also conducted proteomic studies in collaboration with the proteomics core. HIV-1 encoded viral protein Vpr is essential for infection of macrophages by HIV-1. Vpr is known to cause cell cycle block in infected cell and bring about cell death. However, macrophages are resistant to cell death and are viral reservoir, even Vpr over expression does not cause apoptosis in these cell types. The goal of the study was to use a stable-isotope labeling by amino acids in cell culture (SILAC) coupled with mass spectrometry-based proteomics approach to characterize the Vpr response in macrophages. More than 600 proteins were quantified in SILAC coupled with LC-MS/MS approach, among which 136 were significantly altered upon Vpr overexpression in macrophages. The proteomic data illustrating increase in abundance of enzymes in the glycolytic pathway (pentose phosphate and pyruvate metabolism) was further validated by western blot analysis. We observed that HIV-1 hijacks the macrophage glucose metabolism pathway via the Vpr-hypoxia inducible factor 1 alpha (HIF-1 alpha) axis to induce expression of hexokinase (HK), glucose-6-phosphate dehydrogenase (G6PD) and pyruvate kinase muscle type 2 (PKM2) that facilitates viral replication and biogenesis, and long-term survival of macrophages. We then focused on infected monocyte macrophages to identify if glycolytic components such as HK and G6PD were regulated by HIV-1 infection/replication. We report that Hexokinase-1 (HK-1) enzyme expression increases post infection of PBMCs where as the enzymatic activity of HK decreases. Similar effect is seen with HIV-1 replication in latently infected monocyte cell lines U1. The G6PD enzyme activity and expression both increases in infected PBMCs and in U1 cells post induction of viral replication with PMA. We also found that HK-1 translocate to the mitochondria of U1 cells post induction of HIV-1. It is known that the product of HK activity, Glucose 6-phosphate (G6P) releases HKI from the outer leaflet of mitochondria. Hence we conclude that the viral infection decreases HK activity to have less G6P produced in cell and increases G6PD enzyme activity ensuring the remaining G6P is quickly used up, supporting the adherence of outer mitochondrial membrane bound HK1. This sequence of cellular events ensures longer survival of infected cells supporting the viral progeny to propagate in the cell. We further show that suppressing the Pentose phosphate pathway (PPP) by blocking G6PD activity is not only detrimental to the survival of the infected cells it also suppresses viral replication and promoter level transactivation of the viral LTR. Next we sought to identify if glycolytic enzyme PKM2, that is also known to play a nonmetabolic dual role as a protein kinase regulating gene transcription has any effect on the transcription of HIV-LTR. Our study demonstrates upregulation of pyruvate kinase isoform M2 (PKM2) expression in whole cell extracts and nuclear extracts of HIV-1JRFL infected PBMCs and during reactivation of HIV-1 in chronically infected U1 cells. We then focused on understanding the potential role of PKM2 on HIV-1 LTR transactivation. Our studies demonstrate that over expression of PKM2 leads to transactivation of the HIV-1 LTR reporter construct. Using various deletions constructs of HIV-1 LTR, we mapped the region spanning between -120 bp to -80 bp to be essential for PKM2 mediated transactivation. This region contains the NFKB DNA binding site and mutation of NFKB binding site attenuated PKM2 mediated transactivation of HIV-LTR. Chromatin immune-precipitation (ChIP) analysis confirmed interaction of PKM2 with HIV-1 LTR. Our studies suggest that PKM2 is a transcriptional co-activator of HIV-1 LTR. Hence it opens up another possible target to curb HIV-1 replication at transcriptional level. This study sheds light on the regulation of glycolytic pathway of host cells by HIV-1 infection and its consequences for the virus, opening up new avenues to target viral replication and identify glycolytic markers of HIV-1 pathogenesis. / Biology

A icterícia neonatal é geralmente benigna, mas desfechos desfavoráveis podem ocorrer e a identificação dos casos de maior risco seria muito útil. Alguns fatores de risco já conhecidos são prematuridade, desidratação, aleitamento materno, deficiência de G6PD e incompatibilidade sanguínea. As alterações na conjugação hepática de bilirrubina devido a polimorfismos da UGT1A1 também podem contribuir para esse maior risco. O objetivo deste estudo foi estimar a freqüência da deficiência de G6PD e/ou das variantes polimórficas da UGT1A1 como fatores de risco para hiperbilirrubinemia grave em neonatos com mais de 35 semanas de idade gestacional e peso superior a 2000g em uma Unidade Neonatal do Sul do Brasil. Estudo prospectivo, observacional, de casos e controles, que incluiu 243 recémnascidos admitidos para fototerapia no HCPA e 247 controles, entre março e dezembro de 2007. Foi realizada dosagem da atividade da G6PD e análises genético-moleculares do respectivo gene. Foi também realizado PCR para a UGT1A1 com eletroforese capilar em analisador genético ABI 3130xl e análise no programa GeneMapper®. Foram detectados genótipos polimórficos da UGT1A1 em 16% dos pacientes, com prevalência nos ictéricos de 13,5% e nos normais de 18,2%, diferença não significativa. Identificada maior prevalência dos polimorfismos em negros e pardos (25%) em relação aos brancos (13%) (p=0,014). A prevalência da deficiência de G6PD foi 4,6%, sem mostrar correlação com a icterícia. Concluímos que nesta amostra de recém-nascidos do sul do Brasil nem as variantes da UGT1A1, nem a deficiência de G6PD foram associadas à hiperbilirrubinemia grave, com prevalências semelhantes às verificadas em outras populações. Considerando a grande miscigenação presente nessa região, outros fatores e interações gênicas devem ser procurados, incluindo possivelmente o estudo de outros polimorfismos, identificando fatores de risco para explicar a doença, um importante problema de saúde a merecer a atenção dos pesquisadores. / Neonatal jaundice is usually benign, but unfavorable outcomes may happen; therefore, the identification of high-risk cases would be very useful. Some risk factors already known are prematurity, dehydration, breastfeeding, G6PD deficiency and blood incompatibility. Alterations in the hepatic conjugation of bilirubin due to UGT1A1 polymorphisms may also contribute to this higher risk. The objective of this study was to estimate the frequency of G6PD deficiency and the promoter region of UGT1A1 gene variants as risk factors to severe hyperbilirubinemia in newborns of over 35 weeks of gestational age and weighing above 2,000g in a Neonatal Service in Southern Brazil. This is a prospective and observational study of cases and controls which included 243 newborns admitted for phototherapy at HCPA and 247 controls, between March and December, 2007. G6PD activity was determined and the deficient cases were investigated by genetic analysis. PCR for the UGT1A1 variants was also performed, followed by capillary electrophoresis in genetic analyzer ABI 3130xl and the analysis in GeneMapper® program. Polymorphic genotypes were detected in 16% of the patients, prevalence in icteric patients was 13,5% and in normal individuals was 18,2%, a difference which was not significant. A higher prevalence of polymorphisms in blacks and mulattos (25%) was identified when compared to whites (13%) (p=0,014). A prevalence of 4,6% of G6PD deficiency was found, without association to jaundice. We concluded that in this sample of newborns from the South of Brazil, polymorphic variants of UGT1A1 were not associated to severe hyperbilirubinemia as well as G6PD deficiency; being the prevalence similar to those found in other populations. Considering the high miscegenation that occurs in this area of Brazil, perhaps other factors and genic interactions should be sought in order to identify genetic risk factors, possibly including the study of further polymorphisms, as neonatal jaundice remains an important health problem to be approached by investigators.

Made available in DSpace on 2014-06-11T19:32:14Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-08-28Bitstream added on 2014-06-13T20:03:26Z : No. of bitstreams: 1 ondei_ls_dr_sjrp_parcial.pdf: 292639 bytes, checksum: 9c76afbfba65412651952af8454cb31d (MD5) Bitstreams deleted on 2015-01-16T10:37:50Z: ondei_ls_dr_sjrp_parcial.pdf,Bitstream added on 2015-01-16T10:38:34Z : No. of bitstreams: 1 000603676.pdf: 889558 bytes, checksum: df390d92da0411515e31635f99e1d76d (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Ministério da Saúde / Na talassemia beta, o acúmulo das cadeias alfa livres, bem como a liberação do grupo heme e do ferro durante o processo hemolítico, ocasionam aumento de danos oxidativos que podem resultar em lipoperoxidação de membranas celulares, desnaturação de proteínas e oxidação da hemoglobina. Na deficiência de glicose- 6-fosfato desidrogenase (G6PD), esse aumento é decorrente da diminuição da produção de nicotinamida adenina dinucleotídeo fosfato reduzido (NADPH) que pode resultar em hemólise intravascular. Diante da possibilidade de estresse oxidativo nos portadores de beta talassemia heterozigota e nos indivíduos com deficiência de G6PD, neste trabalho avaliou-se a expressão fenotípica das afecções genéticas por meio da identificação das mutações e análise de marcadores para estresse oxidativo. Para o estabelecimento dos grupos controle e com deficiência de G6PD foram avaliadas 544 amostras de sangue periférico de indivíduos da região Noroeste do Estado de São Paulo, sendo 426 doadores de sangue e 118 indivíduos de uma instituição de ensino superior. Para a composição do grupo com talassemia beta heterozigota foram avaliadas 46 amostras de sangue de indivíduos com diagnóstico clínico de talassemia beta da cidade de São Carlos/SP. Foram realizados métodos de triagem e confirmatórios para a identificação da talassemia beta heterozigota e da deficiência de G6PD, e dosagens bioquímicas para quantificação das espécies reativas ao ácido tiobarbitúrico (TBARS), utilizado como marcador de estresse oxidativo, e para a determinação da capacidade antioxidante em equivalência ao Trolox (TEAC). Os polimorfismos da glutationa S-transferase (GST) GSTM1 e GSTT1 foram avaliados por PCR multiplex o de GSTP1 por PCR/RFLP. No grupo com talassemia beta heterozigota foram encontradas 18 (39%) amostras com a mutação CD39; 22 (48%) com a mutação... / In beta thalassemia, the excess of unpaired alpha chains, as well as the heme group and iron released during the hemolytic process increase the oxidative damage. In G6PD deficiency, this increase is caused by a reduced production of NADPH that results in an intravascular hemolysis. Thus, facing the oxidative stress possibility in beta thalassemia carriers and G6PD deficiency individuals, it was aimed to evaluate the fenotypic expression of this genetic disorders through the mutation identification, as well as the oxidative stress marker analysis. We used 544 peripheral blood samples of individuals from São Paulo’s northwestern to control group and to G6PD deficiency group establishment. For beta thalassemia heterozygote group were evaluated 48 blood samples of São Carlos/SP city. Tests were carried out aiming the screening and confirmation of beta thalassemia and G6PD deficiency, as well as the analysis of lipid peroxidation products measured as thiobarbituric acid reactive species (TBARS) and Trolox equivalent antioxidant capacity (TEAC). Were determined the frequencies of GSTM1, GSTT1 and GSTP1 polymorphisms. The analysis with beta thalassemia carriers allowed to establish in the study group a frequency of 39% for CD39 mutation, 48% for IVS-I-110 mutation and 2% for IVS-I-6 mutation. For G6PD deficiency was founded a frequency of 3.86%. The beta thalassemic group evaluation showed an increase of TBARS and TEAC values, when compared to the control group. There was a tendency to increase lipid peroxidation in beta0 CD39 mutants compared to beta+ IVS-I-110 mutants, because there is more free chains amount in beta0 thalassemia than beta+ thalassemia. In the G6PD deficiency analysis was found a lower G6PD activity in men than in women, but there was no interference of gender in the TBARS and TEAC assays results. The comparison between the control group and the G6PD deficiency group... (Complete abstract click electronic access below)

A icterícia neonatal é geralmente benigna, mas desfechos desfavoráveis podem ocorrer e a identificação dos casos de maior risco seria muito útil. Alguns fatores de risco já conhecidos são prematuridade, desidratação, aleitamento materno, deficiência de G6PD e incompatibilidade sanguínea. As alterações na conjugação hepática de bilirrubina devido a polimorfismos da UGT1A1 também podem contribuir para esse maior risco. O objetivo deste estudo foi estimar a freqüência da deficiência de G6PD e/ou das variantes polimórficas da UGT1A1 como fatores de risco para hiperbilirrubinemia grave em neonatos com mais de 35 semanas de idade gestacional e peso superior a 2000g em uma Unidade Neonatal do Sul do Brasil. Estudo prospectivo, observacional, de casos e controles, que incluiu 243 recémnascidos admitidos para fototerapia no HCPA e 247 controles, entre março e dezembro de 2007. Foi realizada dosagem da atividade da G6PD e análises genético-moleculares do respectivo gene. Foi também realizado PCR para a UGT1A1 com eletroforese capilar em analisador genético ABI 3130xl e análise no programa GeneMapper®. Foram detectados genótipos polimórficos da UGT1A1 em 16% dos pacientes, com prevalência nos ictéricos de 13,5% e nos normais de 18,2%, diferença não significativa. Identificada maior prevalência dos polimorfismos em negros e pardos (25%) em relação aos brancos (13%) (p=0,014). A prevalência da deficiência de G6PD foi 4,6%, sem mostrar correlação com a icterícia. Concluímos que nesta amostra de recém-nascidos do sul do Brasil nem as variantes da UGT1A1, nem a deficiência de G6PD foram associadas à hiperbilirrubinemia grave, com prevalências semelhantes às verificadas em outras populações. Considerando a grande miscigenação presente nessa região, outros fatores e interações gênicas devem ser procurados, incluindo possivelmente o estudo de outros polimorfismos, identificando fatores de risco para explicar a doença, um importante problema de saúde a merecer a atenção dos pesquisadores. / Neonatal jaundice is usually benign, but unfavorable outcomes may happen; therefore, the identification of high-risk cases would be very useful. Some risk factors already known are prematurity, dehydration, breastfeeding, G6PD deficiency and blood incompatibility. Alterations in the hepatic conjugation of bilirubin due to UGT1A1 polymorphisms may also contribute to this higher risk. The objective of this study was to estimate the frequency of G6PD deficiency and the promoter region of UGT1A1 gene variants as risk factors to severe hyperbilirubinemia in newborns of over 35 weeks of gestational age and weighing above 2,000g in a Neonatal Service in Southern Brazil. This is a prospective and observational study of cases and controls which included 243 newborns admitted for phototherapy at HCPA and 247 controls, between March and December, 2007. G6PD activity was determined and the deficient cases were investigated by genetic analysis. PCR for the UGT1A1 variants was also performed, followed by capillary electrophoresis in genetic analyzer ABI 3130xl and the analysis in GeneMapper® program. Polymorphic genotypes were detected in 16% of the patients, prevalence in icteric patients was 13,5% and in normal individuals was 18,2%, a difference which was not significant. A higher prevalence of polymorphisms in blacks and mulattos (25%) was identified when compared to whites (13%) (p=0,014). A prevalence of 4,6% of G6PD deficiency was found, without association to jaundice. We concluded that in this sample of newborns from the South of Brazil, polymorphic variants of UGT1A1 were not associated to severe hyperbilirubinemia as well as G6PD deficiency; being the prevalence similar to those found in other populations. Considering the high miscegenation that occurs in this area of Brazil, perhaps other factors and genic interactions should be sought in order to identify genetic risk factors, possibly including the study of further polymorphisms, as neonatal jaundice remains an important health problem to be approached by investigators.