Orientador: Maria Helena de Melo Lima / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Enfermagem / Made available in DSpace on 2018-08-25T10:33:22Z (GMT). No. of bitstreams: 1 Trevisan_DaniloDonizetti_M.pdf: 1847455 bytes, checksum: 8d96bd8d4a5dd1d09a10c926f760691d (MD5) Previous issue date: 2014 / Resumo: Introdução: No âmbito do transplante de células-tronco hematopoiéticas - TCTH, as interações medicamentosas potenciais (IMp) podem causar impacto clínico relevante no paciente. Poucos são os estudos para elucidar esse fenômeno nestes pacientes. O enfermeiro, juntamente com sua equipe de enfermagem, são os profissionais mais envolvidos, diretamente, no processo de preparo e administração de medicamentos bem como acompanhamento integral ao paciente, o que justifica a importância da realização de pesquisas sobre o tema. Objetivo: Determinar a prevalência de Interações Medicamentosas Potenciais em pacientes submetidos a transplante de células-tronco hematopoiéticas no dia da infusão das células-tronco hematopoiéticas. Método: Estudo transversal realizado na Unidade de Transplante de Medula Óssea (TMO) do Hospital de Clínicas da Universidade Estadual de Campinas. Prescrições de medicamentos de pacientes submetidos a TCTH (alogênico ou autólogo) com idade igual ou superior a 18 anos foram inclusos neste estudo. Para traçar o perfil terapêutico dos medicamentos utilizou-se a classificação Anatomical Therapeutic Chemical (ATC) da Organização Mundial da Saúde (OMS). As IMp foram analisadas por meio da base de dados Micromedex® 2.0. Para a presente pesquisa foram de interesse as interações entre medicamentos bem como nível de gravidade, nível de evidência científica, tempo de início dos efeitos e o impacto clínico potencial. Utilizou-se análise descritiva para variáveis qualitativas e quantitativas, sendo realizado frequências absoluta e relativa, cálculo de média e desvio padrão. Os dados foram analisados pelo software estatístico SAS (Statistical Analysis System) versão 9.2. Resultados: Quarenta pacientes submetidos a TCTH foram incluídos neste estudo; 33 (82,5%) pacientes foram expostos a pelo menos uma IMp maior e uma contraindicada concomitantes. A totalidade dos pacientes expostos às IMp, tiveram risco aumentado de cardiotoxicidade. A maioria das IMp foi de gravidade maior (80,9%), com início de efeito não especificado (61,9%) e com documentação boa e excelente (52,4%). Conclusão: Pacientes de TCTH são altamente expostos às IMp clinicamente significantes. A ameaça à vida foi certa, ainda que a literatura limite-se a apontar os desfechos clínicos de apenas uma dupla de medicamentos. O manejo da IMp requer ações que incluem testes bioquímicos, instalação de monitores cardíacos e realização periódica de eletrocardiograma, implantação de prescrições eletrônicas com sistema de alerta para IMp e disponibilidade de bases de dados sobre IMp. É importante considerar o risco-benefício da combinação de medicamentos / Abstract: Introduction: In the context of hematopoietic stem cell transplantation - HSCT, potential drug-drug interactions (PDDI) can cause significant clinical impact on the patient. Few studies to elucidate this phenomenon in these patients. Nurses, along with his team of nursing professionals are more involved directly in the preparation and administration of medications and integral patient, which justifies the importance of conducting research on the topic tracking process. Objective: To determine the prevalence of Potential Drug Interactions in patients undergoing transplantation of hematopoietic stem cells on the day of infusion of hematopoietic stem cells. Method: Cross-sectional study conducted at the Bone Marrow Transplantation (BMT) of the Clinical Hospital of the State University of Campinas. Drug prescriptions for patients undergoing HSCT (allogeneic or autologous) aged over 18 years were included in this study. To trace the therapeutic profile of drugs used the Anatomical Therapeutic Chemical classification (ATC) of the World Health Organization (WHO). The PDDI were analyzed using the base Micromedex ® 2.0 data. In this research of interest were the interactions between drugs and level of severity, level of evidence, time of onset of effects and potential clinical impact. Descriptive analysis was used for qualitative and quantitative variables, being held absolute and relative frequencies, calculation of mean and standard deviation. Data were analyzed using SAS (Statistical Analysis System) version 9.2 statistical software. Results: Forty patients undergoing HSCT were included in this study; 33 (82.5%) patients were exposed to at least one PDDI major and contraindicated. All patients exposed to PDDI, had an increased risk of cardiotoxicity. Most PDDI was major severe (80.9%), with onset of effect unspecified (61.9%) with excellent e good documentation (52.4%). Conclusion: Patients HSCT are highly exposed to PDDI clinically significant. The threat to life was right, although the literature is pointing out the clinical outcomes of only a couple of drugs. The management of PDDI requires actions that include biochemical tests, installation of cardiac monitors and perform periodic electrocardiograms, implementation of electronic prescriptions with warning system for PDDI and availability of databases on PDDI. It is important to consider the risk-benefit of the drug combination / Mestrado / Enfermagem e Trabalho / Mestre em Ciências da Saúde

Orientador: Cármino Antonio de Souza / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas. / Made available in DSpace on 2018-08-18T19:05:15Z (GMT). No. of bitstreams: 1 Bom_ElianeAparecida_M.pdf: 1448559 bytes, checksum: 25012b57d1d19d99fb859ba48f6615c3 (MD5) Previous issue date: 2011 / Resumo: A fisioterapia respiratória (FR) como prevenção e/ou tratamento de complicações respiratórias integra o arsenal de cuidados ao paciente submetido ao transplante de células progenitoras hematopoéticas (TCPH). As complicações pulmonares ocorrem em 40 a 60% dos pacientes submetidos ao TCPH e estão associadas à morbidade e mortalidade significativas. Este é um estudo piloto, prospectivo e randomizado realizado entre abril de 2005 a dezembro de 2007, na Enfermaria de Transplante de Medula Óssea do Hospital das Clínicas da Universidade Estadual de Campinas. Os objetivos foram investigar a ação da fisioterapia respiratória, e caracterizar a influência desta na evolução do padrão respiratório e da função respiratória dos pacientes submetidos ao TCPH mieloablativo. Sessenta e sete pacientes foram incluídos no estudo, sendo que, trinta e nove pacientes foram randomizados em 2 grupos: grupo A (estudo) e grupo B (controle). Os dados foram coletados à beira do leito com monitores manipulados pelo fisioterapeuta pesquisador. O protocolo de coleta foi realizado sequencialmente no dia anterior ao TCPH (D-1) - valores de controle do estudo -, e nos dias (D+2 e D+7), pós TCPH - valores de estudo - sendo estes colhidos após a aplicação do protocolo de fisioterapia. Duas intervenções diferentes de fisioterapia foram aplicadas no período de D-1 até D+7, visando a reexpansão pulmonar, desobstrução brônquica e o fortalecimento e/ou manutenção da força muscular dos pacientes. No grupo A foi aplicado um protocolo de fisioterapia pré-estabelecido com os seguintes exercícios: respiração diafragmática, padrão ventilatório com inspiração fracionada, padrão ventilatório com expiração abreviada, inspirômetro de incentivo - Respiron®, exercícios com o Shaker®, treinamento da musculatura respiratória com Threshold® IMT, tosse espontânea e/ou tosse assistida. No grupo B aplicou-se somente a estimulação inspiratória com o inspirômetro de incentivo, Respiron®. As variáveis escolhidas para avaliação da evolução do padrão respiratório e da função respiratória foram: volume corrente (VC), volume minuto (VM), pressão inspiratória máxima (PImáx), pressão expiratória máxima (PEmáx), saturação periférica de oxigênio (SpO2), frequência respiratória (f) e frequência cardíaca (FC). A análise dos dados comparou as variáveis do D-1, D+2 e D+7, respectivamente entre os grupos A e B. No grupo A houve diferença favorável e significativa das condições respiratórias para as seguintes variáveis: VC no D+2 (p = 0,007) e D+7 (p = 0,004); PImáx no D+7 (p = 0,035) e PEmáx em D+7 (p = 0,033). Através dos resultados, concluiu-se que o uso do protocolo de fisioterapia respiratória aplicado neste estudo modificou algumas das variáveis analisadas demonstrando melhora do padrão respiratório e da função respiratória de forma eficiente / Abstract: The chest physiotherapy (CP) as prevention or treatment of respiratory complications integrates the armory of cares to patients submitted to the hematopoietic stem cell transplantation (HSCT). These complications are present in 40 to 60% of transplanted patients and are associated with significant morbidity and mortality. This is a pilot study, randomized and prospective carried out from April 2005 to December 2007 in the Bone Marrow Transplant Unity from University of Campinas. The objective was to investigate the effectiveness of CP based in clinical evidence and analyzing the respiratory and ventilatory functions obtained; to characterize the influence of CP on breathing pattern and respiratory function evolution of these patients. Sixty seven patients submitted to mieloablative HSCT were included. Among these, thirty nine were evaluated and randomized in two groups: A (study) and B (control). The data was collected at bedside by the investigator physiotherapist. The collection protocol was sequentially performed from the day before HSCT (D-1) - control data - to the second and seventh days after the HSCT (D+2 and D+7) - study data. These last ones were collected after the CP protocol. Two different CP protocols previously established were applied from D-1 to D+7. The group A had diaphragmatic proprioceptive stimulation, breathing exercises, incentive spirometry utilization with Respiron®, inspiratory muscle training with Threshold® IMT device, bronchial hygienization with Shaker® and cough stimulation or assistance. The group B realized a protocol only with the use of incentive spirometry. To analyze of breathing pattern and respiratory function evolution were observed the following variables: tidal volume (VT), minute volume (MV), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), oxygen saturation (SpO2), respiratory frequency (f) and heart rate (HR). The data analysis showed a significant difference in the period from D-1 to D+7 for the variables: VT at D+2 (p=0.007) and D+7 (p=0.004), MIP (p=0.035) and MEP (p=0.033) at D+7. The authors conclude that the protocol for CP applied in this study resulted in the improvement of the breathing pattern and respiratory functions of patients submitted to HSCT / Mestrado / Ciencias Basicas / Mestre em Clinica Medica

Orientadores: João Palermo Neto, Antonio Armario Garcia / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T19:54:17Z (GMT). No. of bitstreams: 1 Queiroz_JuliadeSouza_D.pdf: 6420413 bytes, checksum: 5de0fbd4bbb6451ff5729cbdc2fc74ce (MD5) Previous issue date: 2012 / Resumo: A exposição do organismo a estressores psicossociais e ambientais altera de forma significativa o funcionamento do sistema imune. Os efeitos do estresse sobre a resposta imune têm sido atribuídos, principalmente, à ativação do eixo hipotálamo-pituitária-adrenal (HPA) com consequente aumento nos níveis de ACTH e glicocorticóides e à ativação do sistema nervoso autônomo simpático (SNAS), com liberação de catecolaminas. Nos últimos anos, a alga Chlorella vulgaris (CV) tem despertado o interesse da comunidade científica pelos seus efeitos moduladores sobre as defesas do hospedeiro imunossuprimido. Em estudos anteriores mostramos que o restabelecimento da geração de granulócitos-macrófagos nos órgãos hematopoéticos e a ativação das funções efetoras de fagócitos e linfócitos são cruciais na expressão da atividade imunomoduladora da alga. No entanto, nada se sabe sobre os efeitos da CV no sistema nervoso central em situações de estresse. Sendo assim, neste trabalho realizamos estudos pioneiros com relação ao efeito do tratamento com a alga sobre: 1) a ativação neuronal (c-fos) no córtex pré-frontal, septum lateral, núcleo da Rafe e lócus coeruleus; 2) a ativação do eixo HPA através da expressão do gen de hnCRF na região parvocelular do núcleo paraventricular do hipotálamo, mpdPVN, liberação de ACTH e de corticosterona e, 3) avaliação indireta da atividade do SNAS através dos níveis de glicose no plasma de animais estressados. Considerando-se a medula óssea ser o sítio de origem das células pluripotenciais das quais se originam as células do sistema hematopoético, e que este sistema é totalmente vulnerável ao controle neuroendócrino, avaliamos os efeitos do tratamento com CV sobre a hematopoese de animais estressados através dos 4) crescimento e diferenciação de precursores para granulócitos e macrófagos (CFU-GM); 5) presença de fatores estimuladores da formação de colônias do soro (colony stimulating activity - CSA); 6) quantificação de populações de células maduras e imaturas e 7) morte celular na população de células tronco. A regulação da produção de células hematopoéticas pelas células do estroma da medula óssea em camundongos estressados foi avaliada pela técnica de cultura líquida de longa duração de células da medula óssea (LTBMC), que consiste em um modelo ex vivo para o estudo das interações entre as células progenitoras hematopoéticas e as células do estroma. Nela avaliamos 8) o CFU-GM, níveis de IL-1? / IL-6 e quantificamos uma população madura e uma imatura. Nossos resultados mostraram que a aplicação do estressor produziu um aumento na expressão de c-fos em todas as áreas cerebrais avaliadas, assim como na expressão do gen de hnCRF na região mpdPVN. Os níveis de ACTH e corticosterona também estavam aumentados após o estresse, assim como os níveis de glicose. Na medula óssea observamos que a aplicação do estressor reduziu o número de CFU-GM, e aumentou os níveis de CSA no plasma. Houve um aumento na morte celular e redução no número de precursores hematopoéticos e de células maduras. Na LTBMC, um prejuízo na atividade funcional do estroma medular foi observado através: da redução do CFU-GM, dos níveis de IL-1? / IL-6 e do número de células imaturas e maduras. O aumento na expressão de c-fos após o estresse foi prevenida pelo tratamento com CV em todas as áreas avaliadas, com exceção da região magnocelular do PVN. O resultado mais acentuado do tratamento com CV foi observado na redução da expressão de c-fos no núcleo da Rafe e do gen para hnCRF no mpdPVN, que se encontrou em níveis semelhantes aos observados no grupo controle após o estresse. Todas as alterações hematopoéticas causadas pelo estresse foram prevenidas pelo tratamento com CV. Tomados em seu conjunto, nossos resultados mostraram que o efeito protetor da hematopoese pode ser devido a uma prevenção na ativação neuronal de áreas cerebrais relacionadas à decodificação do estressor do tipo emocional, reduzindo a amplitude de ativação do eixo HPA e do SNAS / Abstract: The exposition of the organism to psychosocial and environmental stressful stimuli alters the functioning of the immune system in a significant way. The effects of stress on the immune response are mainly attributed to the activation of the hypothalamic-pituitary axis (HPA) with consequent increment on ACTH and glucocorticoids levels and, to the activation of the autonomic nervous system, with the incremented levels of cathecholamines. In the last years, increasing interests about the algae Chlorella vulgaris (CV) has been demonstrated by the scientific community, due to its modulatory effects on the defenses of the immunosuppressed host. In previous studies we demonstrated that the reestablishment of the generation of granulocytes and macrophages in bone marrow and, the activation of effectors functions of phagocytes and lymphocytes, are crucial features about the immunomodulatory activity from the algae. However, nothing is known about the activity of CV in the central nervous system. Thus, pioneer investigation was made in this work about the effect of treatment with the CV on: 1) neuronal activation (c-fos) in pre-frontal cortex, lateral septum, Rafe nucleus and locus coeruleus; 2) activation of the HPA axis by analysis of expression of the gen to hnCRF in the parvocelular region from the paraventricular nucleus of the hypothalamus -mpdPVN and the release of ACTH and corticosterone) and, 3) glucose levels, as an indirect indicator of autonomic nervous system activity. Considering that the bone marrow is the site of origin from pluripotent cells from which all cells from the hematopoietic system are originated, and also that this system is vulnerable to the neuroendocrine control, we evaluated the effects of the treatment with CV on the hematopoiesis of stressed animals through 4) growing and differentiation of precursors to granulocytes and macrophages (CFU-GM); 5) colony stimulating activity from the serum (CSA); 6) quantification of population of mature and immature populations and 7) cell death. The interaction between stromal cells and hematopoietic progenitors in stressed mice was evaluated by the technique of long term bone marrow culture (LTBMC). In the culture we evaluated 8) the CFU-GM, levels of IL-1? / IL-6 and quantification of mature and immature population. The application of the stressor produced an increase in the expression of c-fos in all brain areas evaluated and in the expression of the gen to hnCRF in mpdPVN. Increased levels of ACTH, corticosterone and glucose found in stressed animals corroborate these findings. Reduced numbers of CFU-GM in the bone marrow and increase in plasma CSA, increased cell death in stem cell population (LSK) and decreased numbers of hematopoietic precursors and of mature cells was also observed in stressed group. In LTBMC we observed impairment on the functional activity from medullar stroma, which was observed by reduction of: CFU-GM, IL-1? / IL-6 levels and number of immature and mature cells. Treatment with CV partially prevented increase in c-fos activation caused by stress in the brain except in the magnocelular region from PVN. The more accentuated result from treatment with CV of stressed animals was observed in the expression of c-fos in the Raphe nucleus and in the expression of the gen to hnCRF in mpdPVN, where levels were similar to that observed in control group. All hematopoietic alterations observed after stress were prevented by the treatment with CV. Taken together, our results demonstrate that the protective effect of the treatment with CV on hematopoiesis of stressed animals may be due to a prevention of the neuronal activation in areas related to the decodification of the emotional stressful stimuli, reducing the amplitude of HPA axis and autonomic nervous system activity / Doutorado / Farmacologia / Doutora em Farmacologia

O saco vitelino é o único anexo embrionário presente em todas as espécies dos embriões vertebrados, répteis, aves e mamíferos. Em mamíferos domésticos o saco vitelino é inicialmente grande, pois nestas espécies ele é transitório. Após a implantação, surge no mesênquima lateral à notocorda agrupamentos de células, denominados ilhotas sanguíneas, que representam os progenitores dos sistemas vascular e hematopoético: os hemangioblastos. Os hemangioblastos centrais das ilhas sanguíneas formam as primeiras células-tronco hematopoéticas, enquanto os hemangioblastos periféricos se diferenciam em angioblastos, os precursores dos vasos sanguíneos. O desenvolvimento inicial da atividade hematopoética no saco vitelino conduz a hipótese de que esse tecido é o local primário de desenvolvimento hematopoético e que as células-tronco derivadas dele semeiam os outros sítios intraembriônicos. Foi possível observar nas análises microscópicas que realmente existe uma relação entre ambas linhagens. Nas análises de expressão gênica, alguns genes expressos pelo hemangioblasto apresentaram alta expressão nas análises D+0 e outros genes também específicos do hemangioblasto, porém em estágios secundários de diferenciação como os encontrados na região aórtica, a nível de endotélio hemogênico apresentaram altos níveis de expressão após 3 dias em cultivo. Concluímos portanto, que o saco vitelino por ser o local primário de formação das células sanguíneas e endoteliais nos estágios iniciais da embriogênese, por serem primitivas e, portanto não expressarem marcadores de células maduras na sua superfície, tornam estas células uma importante fonte de células-tronco relevante para a Terapia Celular para hemofilia e muitas outras doenças humanas. / The yolk sac is the single attachment embryo present in all species of vertebrate embryos, reptiles, birds and mammals. In domestic mammals the yolk sac is initially large, since these species it is transient. After implantation, appears in the lateral mesenchyme to the notochord cell clusters, called \"blood islands\" that represent the progenitors of vascular and hematopoietic systems: the hemangioblasts. The central islands hemangioblasts form the first blood hematopoietic stem cells, while peripheral hemangioblasts, the angioblastic differentiate into the precursors of blood vessels. The initial development of the yolk sac hematopoietic activity leads to the hypothesis that this tissue is the primary site of development and that hematopoietic stem cells derived from them sow other intraembryos sites. It was observed in the microscopic analysis that there is indeed a relationship between the two lineages. In the analysis of gene expression, some genes expressed by hemangioblasts showed high expression in D+0 and other specific genes also hemangioblasts, but in secondary stages of differentiation as found in the aortic region, the level of hemogenic endothelium showed high levels of expression after 3 days in culture. We therefore conclude that the yolk sac to be the primary site of formation of blood and endothelial cells in the early stages of embryogenesis, for its cells be primitive and therefore do not express markers of mature cells on the surface, these cells become an important source of cells relevant to stem cell therapy for hemophilia and many other human diseases.

La greffe de cellules souches hématopoïétiques est parfois le seul traitement curatif dans certaines pathologies pédiatriques telles que les leucémies, les sarcomes, les dédicits immunitaires ou les thalassémies. Le busulfan, un alkylant myéloablatif, fait partie de nombreux protocoles de conditionnement de greffe. C'est un médicament à marge thérapeutique étroite doté d'une forte variabilité pharmacocinétique, qui fait souvent l'objet d'un suivi thérapeutique pharmacologique afin d'optimiser la prise de greffe et d'éviter les risques de maladie veino-occlusive, principale toxicité du busulfan et responsable d'une morbidité et d'une mortalité importante. L'aire sous la courbe, dont il existe un intervalle cible recommandé, est aujourd'hui le paramètre pharmacocinétique utlisé pour effectuer le suivi thérapeutique du busulfan et l'adaptation posologique pendant le conditionnement.L'objectif de notre travail est d'étudier les relations entre la pharmacocinétique du busulfan et ses effets thérapeutiques et toxiques, en particulier la maladie veino-occlusive, et de développer des méthodes d'adaptation posologique pour optimiser l'usage de ce médicament chez l'enfant. Nos travaux ont conduit à plusieurs innovations méthodologiques, avec le développement et la validation d'un modèle pharmacocinétique de population non-paramétrique pour l'adaptation Bayésienne des posologies de busulfan en pédiatrie, et le développement d'une nouvelle méthode de détermination de la dose initiale maximisant la probabilité d'atteindre un intervalle cible d'exposition. Sur le plan clinique, nous avons pu mettre en évidence l'absence de bénéfice clinique de l'utilisation d'un intervalle cible d'exposition plus restreint que celui recommandé. Par ailleurs, nous avons identifié que la survenue de la MVO était liée à la concentration maximale de busulfan, et non à l'aire sous la courbe des concentrations en fonction du temps.L'ensemble de ces résultats est une contribution à l'amélioration de l'utilisation et du suivi thérapeutique pharmacologique du busulfan en onco-hématologie pédiatrique / Hematopoietic stem cell transplantation remains the only curative treatment in many pediatric diseases as leukemia, sarcoma, immunodeficiencies or thalassemia. Busulfan, a myeloablative alkylant, is the cornerstone of pre-transplant conditioning. It has a narrow therapeutic index and a large pharmacokinetic variability. For these reasons, therapeutic drug monitoring is required in order to optimize engraftment and avoid veno-occlusive disease, the main toxicity of busulfan which is responsible of significant morbidity and mortality. Today, the area under the curve, of which there is a target range recommended, is the pharmacokinetic parameter used to carry out therapeutic drug monitoring and dose adjustment during conditioning. Our objective is to investigate relationships between busulfan PK and clinical outcomes, especially veno-occlusive disease, and to develop methods of dose adjustment in order to optimize the use of this medication in children.Our work leaded to several methodological innovations, with the development and the validation of a non-parametric pharmacokinetic model for Bayesian dose adjustment of busulfan in pediatrics, and the development of a new method for the first dose determination maximizing the probability of achieving an exposure target range. From a clinical point a view, we highlighted the lack of clinical benefit in using an exposure target range narrower than those recommended. Furthermore, we identified that veno-occlusive incidence was correlated to the maximal concentration of busulfan, contrary to the area under the concentration-time curve.All of these results contribute to improving use and therapeutic monitoring of busulfan in pediatric onco-hematology

L’hématopoïèse est assurée par une population de cellules souches hématopoïétiques (CSH) générées au cours du développement embryonnaire. L’objectif de ma thèse a été de comprendre les mécanismes qui régulent l’émergence des CSH dans la niche hématopoïétique intra-embryonnaire. Nous avons démontré la présence dans cette région d’un Système Rénine- Angiotensine local et fonctionnel qui agit via la production de l’Angiotensine II sur les précurseurs pré-hématopoïétiques et les CSH émergentes. Egalement, nous avons mis en évidence la présence d’une accumulation de macrophages d’origine vitelline et démontré que ces cellules ont un rôle crucial dans l’émergence de l’hématopoïèse définitive en permettant la migration des précurseurs pré-hématopoïétiques. Une étude moléculaire nous a permis de démontrer que l’ACE - un marqueur des précurseurs pré-hématopoïétiques et CSH humaines - est une cible du facteur de transcription CDX2 qui en régule l’expression. Ces travaux contribuent à une meilleure compréhension de la mise en place du système hématopoïétique au cours du développement et sont prometteurs pour des fins thérapeutiques. / The continuous generation of blood cells throughout life relies on the existence of hematopoietic stem cells (HSC) generated during embryogenesis. The aim of my thesis was to understand the mechanisms underlying HSC emergence in the intra-embryonic hematopoietic niche. Many effectors have been detected in this region, including a functional and local Renin- Angiotensin System which acts directly on pre-HSC precursors and HSC emergence through the production of Angiotensin II . We have also observed an accumulation of yolk sac-derived macrophages in the same region and demonstrated that these cells have a crucial role in the establishment of definitive hematopoiesis, allowing the migration of the pre-HSC precursors in the mesenchyme. In addition, by a molecular study, we have demonstrated that ACE - a cell surface marker of human HSC also expressed on pre-hematopoietic cells - is a transcriptional target of the CDX2 homeoprotein. All these results contribute to a better understanding of the hematopoietic system during development and are promising for therapeutic purposes.

A l’origine de l’hématopoïèse se trouve les cellules souches hématopoïétiques (CSH). Elles constituent un pool de cellules rares présentes dans la moelle osseuse aux niveaux de zones particulières de l’os appelées niche. Les cellules de la niche produisent des cytokines, telles que la thrombopoïétine (TPO), qui régulent les CSH en contrôlant leur quiescence et leur auto-renouvellement. Peu de choses sont connues sur les mécanismes mis en place par la CSH et son environnement pour faire face aux dommages de l’ADN, notamment induits lors de radio- ou chimio-thérapies. Durant cette étude, nous avons mis en évidence un nouveau rôle de la TPO et de son récepteur Mpl dans la réparation de l’ADN des CSH en réponse à des stress génotoxiques. Les CSH déficientes ou haplo-insuffisantes pour Mpl, ou les CSH sauvages et cultivées en absence de TPO, présentent un défaut de réparation et une instabilité génomique. En réponse à l’irradiation, la TPO potentialise l’activation de la voie NF-kB qui permet l’induction du gène précoce Iex-1. La TPO est également l’activateur majeur de la voie ERK dans les CSH. IEX-1 et pERK forment un complexe tripartite avec DNA-PK, une protéine clé de la voie Non Homologous End Joining (NHEJ). La DNA-PK est fortement activée par la TPO, ce qui augmente la fidélité et l’efficacité de la voie NHEJ et permet d’améliorer l’intégrité génomique des CSH. Par ailleurs, nous montrons qu’une simple injection de TPO ou de son agoniste Romiplostim, avant irradiation ou injection de doxorubicine, limite la mutagénèse des CSH et leur perte de fonction associée. Cet effet est spécifique de la TPO, d’autres cytokines comme le SCF et le Flt3-L, n’ont aucun effet sur la réparation. Ces résultats montrent que la TPO contrôle directement les voies de signalisation aboutissant à la réparation de l’ADN des CSH. Ils ouvrent des perspectives nouvelles pour l’utilisation des agonistes de la TPO comme adjuvant protecteur avant radio- ou chimiothérapie pour minimiser les risques de développement de leucémies aigües myéloïdes secondaires. L’expression de Mpl étant haploinsuffisante pour la fonction de réparation de l’ADN, ces résultats suggèrent que Mpl pourrait être tumeur suppresseur en réponse aux traitements chimio-ou radio-thérapeutiques. / Hematopoietic stem cells (HSC) are at the beginning of hematopoeisis. They constitute a pool of rare cells in bone marrow in specifics zones of bones called niche. Niche’s cells produce cytokines, like thrombopoietin (TPO). These cytokines regulates HSC by controlling quiescence and self-renewal. Few are known about mechanism used by HSC and its environment to prevent DNA damage, and especially those induced by radio- or chemo-therapies. In this study, we discover a new role of TPO and its receptor Mpl in DNA repair of HSC in response to genotoxic stress. HSC without Mpl, or wild type HSC cultured without TPO, show an important defect of DNA repair and genomic instability. In response to irradiation, TPO increases activation of NF-KB pathway that increases induction of IEX-1 early gene. TPO is also the major activator of ERK pathway in HSC. IEX-1 and p-ERK can form a tripartite complex with DNA-PK, a key protein of Non homologous end joining pathway (NHEJ). DNA-PK is fully activated by TPO which increase fidelity and efficacy of NHEJ pathway leading to better genomic integrity of HSC. We also show in this study that a simple injection of TPO or Romiplostim before irradiation or Doxorubicin injection, decrease mutagenesis of HSC and their loss of function associated. This effect of TPO is specific of TPO because other cytokines like SCF or Flt3-L have no effect on the DNA repair. These results show that TPO can directly control signaling pathway leading to repair of HSC’s DNA and open new avenues for TPO agonist using. They can be used to protect HSC before radio- or chemo-therapies and to minimize development of secondary acute myeloid leukemia. Expression of Mpl being haplo-insufficient for DNA repair functions, this result suggests that Mpl could be a tumor suppressor in response to radio- or chemo-therapies treatments.

Les propriétés centrales des cellules souches sont la pluripotence et la capacité d'auto-renouvellement. Les cellules souches hématopoïétiques (CSHs) sont dotées de ces caractéristiques qui leur permettent de générer toutes les cellules du compartiment hématopoïétique, tout en maintenant en parallèle leur compartiment. Nous menons des approches visant à amplifier ex vivo les CSHs en les activant par HOXB4 exogène (CSHs humaines) ou via la signalisation Notch/DLL-4 (CSHs murines). Or deux analyses transcriptomiques indépendantes de ces deux modes d'activation ont de manière étonnante convergé sur une augmentation de l'expression de deux gènes jamais identifiés auparavant comme étant impliqués dans le maintien des CSHs : Pumilio1 (Pum1) et Pumilio2 (Pum2). Pum1 et Pum2 sont des régulateurs post-transcriptionnels appartenant à la famille Pumilio-FBF (PUF) des protéines liant l'ARN. Bien qu'il ait été établi que le rôle princeps de ces protéines PUF est de soutenir la prolifération des cellules souches chez les Invertébrés, jusqu'à présent on ne sait rien du rôle de Pum1 et Pum2 dans les CSH humaines et murines.Pour toutes ces raisons, nous avons étudié le rôle et les mécanismes d'action de Pum1 et Pum2 dans les CSH murines et humaines en utilisant l'interférence ARN (ARNi). L'invalidation de Pum1 ou de Pum2 dans les CSHs murines conduit à une réduction de l'expansion et du potentiel clonogénique ex vivo, associée à une apoptose accrue et l'arrêt du cycle cellulaire en phase G0/G1. L'invalidation concomitante de Pum1 et Pum2 majore ces effets ce qui suggère un effet coopératif entre les deux protéines. L'expansion et le potentiel clonogénique des CSH invalidées pour Pum1 sont restaurés suite à l'expression forcée de Pum1 (insensible au shRNA utilisé), validant ainsi la spécificité de nos shRNAs. Par contre la surexpression de Pum1 dans les CSHs invalidées pour Pum2 ne restaure pas leurs fonctions, soulignant le rôle non redondant de chaque protéine. En outre, lorsque les CSHs invalidées pour Pum1 ou Pum2 sont inoculées à des souris irradiées létalement de suivre le potentiel hématopoïétique à long terme, seules quelques rares cellules de la moelle osseuse issues des CSH KD pour Pum1 ou Pum2 sont mises en évidence après 4 mois de reconstitution, contrairement aux CSH contrôles. Des résultats identiques ont été obtenus en invalidant Pum1 ou Pum2 dans les CSH humaines.En conclusion, nos résultats démontrent l'implication des facteurs Pumilio dans le maintien du potentiel souche, l'expansion et la survie des CSHs murines et humaines. L'identification des facteurs Pumilio et de leurs cibles comme nouveaux régulateurs des CSHs permettra d'envisager de nouveaux outils en vue de perspectives thérapeutiques. / The central properties of stem cells are the pluripotency and the capacity of self-renewal. Hematopoietic stem cells (HSCs) posses such common features that allows them to generate all the cells of the hematopoietic compartments, maintaining in the same time the HSC pool. We develop approaches focused on ex vivo HSC expansion through activation by exogenous HOXB4 (human HSCs) or Notch/Dll-4 ligand (murine HSCs). Two independent transcriptomic analyses surprisingly converged toward an increased expression of two genes never identified sofar as crucial for HSC functions: Pumilio1 (Pum1) and Pumilio2 (Pum2). Pum1 and Pum2 are posttranscriptional regulators belonging to the Pumilio-FBF (PUF) family of RNA-binding proteins. Although it was established that the primordial role of PUF proteins is to sustain mitotic proliferation of stem cells in Invertebrates, so far nothing is known about the role of Pum1 and Pum2 in human and murine HSCs.For these reasons, we have investigated the roles and mechanisms of action of Pum1 and Pum2 in murine and human HSCs through shRNA strategy. Pum1 and Pum2 knockdown (KD) in murine HSCs led to a decreased HSC expansion and clonogenic potential ex vivo, associated with an increased apoptosis and a cell cycle arrest in G0/G1 phase. KD of both Pum1 and Pum2 enhanced these effects, suggesting a cooperative effect. Expansion and clonogenic potential of KD Pum1 HSCs were rescued by enforced expression of Pum1 (insensitive to our shRNA), thus validating the specificity of our shRNA. Enforced expression of Pum1 could not rescue the functions of Pum2 KD HSCs, highlighting the non-redundant role of these proteins. Furthermore, when Pum1 or Pum2 KD HSCs were inoculated into lethally irradiated mice to follow the long-term hematopoietic potential, only rare bone marrow cells derived from Pum1 and Pum2 KD HSCs were evidenced after 4 months, contrary to control HSCs. Identical results were obtained with human Pum1 or Pum2 KD HSCs.In conclusion, our results demonstrate the involvement of Pumilio factors in stemness maintenance, expansion and survival of murine and human HSCs. Identification of Pumilio factors and their targets as new regulators of HSCs expansion will allow consider them as new tools for therapeutic perspectives.

Les cellules souches hématopoïétiques (CSH) possèdent deux propriétés fondamentales : l'auto-renouvellement et la capacité de se différencier en lignées hématopoïétiques de tout type. Les CSH se maintiennent dans la moelle osseuse et se renouvellent par division asymétrique. En revanche, les divisions symétriques caractérisent les cellules qui s'engagent dans la différenciation. L'environnement pauvre en oxygène de la moelle osseuse favorise la glycolyse anaérobique et l'oxydation des acides gras, préservant, respectivement, la quiescence et les divisions asymétriques. Que l'engagement des CSH vers la différenciation lymphoïde, myéloïde ou érythroïde dépende ou entraîne une reprogrammation métabolique n'est toujours pas connu. En effet, de nombreuses études ont montré que cytokines et contacts cellulaires sont indispensables pour l'engagement des CSH vers une lignée donnée, alors que l'impact potentiel des nutriments et du métabolisme sur ce processus reste très peu étudié. La différenciation est associée à une prolifération qui nécessite des besoins métaboliques accrus pouvant être supportés par diverses sources d'énergie, telles que le glucose, les acides gras, le lactate ou la glutamine. Le glucose et la glutamine sont des précurseurs de l'ATP, des lipides et des nucléotides. Toutefois, leurs contributions relatives aux voies métaboliques contrôlant l'engagement des CSH n'ont pas été évaluées. Pour autant, nos études ainsi que celles menées par d'autres laboratoires ont montré que l'expression du transporteur de glucose Glut1 n'augmente qu'au cours des dernières étapes de la différenciation érythroïde, suggérant l'implication potentiel d'autres nutriments dans la régulation des étapes précoces de l'engagement vers la voie érythroïde. Ainsi, mon travail de thèse a consisté à déterminer si la disponibilité et l'utilisation des nutriments régulent la différenciation des CSH vers la lignée érythroïde. De fait, j'ai montré que le transporteur de glutamine ASCT2 est hautement exprimé dans les CSH et que la répression d'ASCT2 ou le blocage du métabolisme de la glutamine empêche la différenciation érythroïde des CSH, les détournant vers la voie myéloïde, même en présence d'érythropoïétine. Dans ces conditions, nous avons montré que la différenciation érythroïde ne pouvait pas être restaurée par l'ajout d'intermédiaires du cycle de Krebs, alors que qu'elle était dépendante de la biosynthèse de novo de nucléotides. Étonnamment, le 2-désoxyglucose (2-DG), un analogue du glucose inhibant la glycolyse, accélérait l'érythropoïèse. Nous avons aussi mis en évidence in vivo, en condition de stress érythropoïétique, des influences différentes du catabolisme de la glutamine et celui du glucose dans la modulation de l'érythropoïèse. Afin de mieux élucider les mécanismes par lesquels la glutamine module la différenciation érythroïde des CSH, nous avons étudié les voies métaboliques qu'elle emprunte. Des expériences de suivi de la glutamine marquée ont montré que l'entrée de la glutamine dans le cycle de Krebs est requise pour une érythropoïèse efficace. Par contre, nous avons montré que la synthèse de novo des nucléotides était l'étape limitante de la différenciation érythroïde. De plus, nous avons observé que la différenciation érythroïde accélérée en présence du 2-DG était associée à une augmentation importante du niveau des pentoses phosphates, précurseurs des nucléotides. Ainsi, l'utilisation de la voie des pentoses phosphates par le glucose, plutôt que la glycolyse, était essentielle pour l'érythropoïèse. En conclusion, mon travail de thèse a montré que la production de nucléotides via le métabolisme coordonné du glucose et de la glutamine est la condition sine qua non pour l'engagement des CSH vers la lignée érythroïde. / Hematopoietic stem cells (HSCs) possess two fundamental characteristics; self-renewal capacity and the ability to give rise to all blood cell lineages. Before their commitment to a specific lineage, these cells are maintained in a quiescent state in the bone marrow. Asymmetric division is essential for the maintenance of the stem cell compartment while symmetric division results in HSC differentiation. The hypoxic environment of the bone marrow is conducive to anaerobic glycolysis and fatty acid oxidation, preserving stem cell quiescence and asymmetric division, respectively. However, it is not known whether the commitment of an HSC to a lymphoid, myeloid or erythroid lineage fate, is regulated by a metabolic switch. Indeed, while much research has shown a critical role for cytokines and cell-cell contacts in the commitment of HSCs to distinct hematopoietic lineages, the possibility that nutrient entry and metabolism may contribute to this process was not considered until very recently. Cell differentiation is associated with proliferation resulting in increased metabolic requirements that can be met by energy sources such as glucose, fatty acids, lactate, or glutamine, amongst others. While glucose and glutamine are both precursors for the production of ATP, lipids and nucleotides, their relative contributions to metabolic pathways driving HSC lineage commitment have not been evaluated. Interestingly, we and others previously found that the Glut1 glucose transporter is highly upregulated only during the final mitoses of HSC-driven erythroid differentiation, suggesting that other nutrients may regulate early stages of erythroid lineage commitment. During my PhD, I was interested in determining whether nutrient availability and utilization regulate HSC differentiation to the erythroid lineage. Interestingly, I found that the ASCT2 glutamine transporter is expressed at high levels on HSCs. Downregulation of ASCT2 or blocking glutamine metabolism abrogated erythroid differentiation of HSCs and diverted erythropoietin-signaled HSCs towards a myeloid fate. Under conditions where glutamine utilization was blocked, erythroid differentiation was not restored by directly replenishing the tricarboxylic acid cycle but rather, was dependent on de novo nucleotide biosynthesis. Surprisingly, 2-deoxyglucose, a glucose analogue that inhibits glycolysis, enhanced erythropoiesis. Glutamine and glucose catabolism also differentially modulated erythropoiesis in vivo, under stress conditions. To better elucidate the mechanism(s) via which glutamine supports the erythroid lineage specification of HSCs, we evaluated the metabolic pathways fueled by glutamine. Carbon/nitrogen-labeled glutamine tracing experiments showed that the rate-limiting step in EPO-induced erythroid differentiation is glutamine-dependent de novo nucleotide biosynthesis while glutamine entry into the TCA cycle (anaplerosis) is not required. Furthermore, the accelerated erythroid differentiation in the presence of 2-DG was associated with a striking increase in pentose phosphates, precursors of nucleotides. Notably, the shunting of glucose into the pentose phosphate pathway (PPP), rather than glycolysis, was essential for erythropoiesis. In conclusion, my research shows that the coordinated redirection of glucose and glutamine into the production of nucleotides is the sine qua non condition for the erythroid differentiation of HSCs.

Orientadores: Cármino Antonio de Souza, Afonso Celso Vigorito / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T14:24:56Z (GMT). No. of bitstreams: 1 Colella_MarcosPaulo_M.pdf: 4664560 bytes, checksum: ce76d7ca7d69ede5a86dc9fe14e7bbca (MD5) Previous issue date: 2014 / Resumo: O Transplante de Células Tronco Hematopoiéticas (TCTH) Alogênico representa uma possibilidade de cura para pacientes portadores de doenças hematológicas malignas e benignas. Porém, como qualquer modalidade de tratamento, apresenta efeitos adversos que podem ser graves, inclusive causando a morte. Com o intuito de se avaliar a influência que as comorbidades teriam na mortalidade não relacionada à recidiva (MNRR), foi criada uma ferramenta, o Índice de Comorbidade específico do Transplante de Células Tronco Hematopoiéticas (Hematopoietic Cell Transplant Specific Comorbidity Index - HCT-CI). Nossos objetivos, portanto, foram validar o HCT-CI na população de pacientes submetidos a TCTH Alogênico em nossa instituição, no período de 1993 a 2010, e avaliar outros fatores de riscos envolvidos na MNRR e na Sobrevida Global (SG). Os prontuários de 457 pacientes foram revistos e as informações referentes às comorbidades contidas no HCT-CI foram registradas. A maioria dos pacientes (59%) recebeu o índice 0, seguido de 30% de pacientes com índice de 1-2 e 11% com índice ? 3. Na análise univariada, os pacientes com HCT-CI igual a zero, comparados aos com HCT-CI ?1, apresentaram uma MNRR de 33% vs. 45% (p=0.01) e SG de 53% vs. 35% (p=0.001); nos pacientes que ao transplante apresentavam doença de baixo risco, comparados aos com doença de alto risco, a MNRR foi de 30% vs. 50% (p<0.0001) e SG de 57% vs. 27% (p<0.0001); o tipo de enxerto (medula óssea vs. sangue periférico) apresentou MNRR de 29% vs. 49% (p<0.0001) e SG de 56% vs. 34% (p<0.0001). A análise multivariada confirmou a influência do HCT-CI na MNRR e na SG, do risco da doença sobre a SG e do tipo de enxerto na MNRR. O tipo de condicionamento (baixa dose vs. alta dose) não teve influência na MNRR e SG, tanto na análise univariada quanto na multivariada. Quanto o grupo foi estratificado pelo HCT-CI (0 e ?1) o risco da doença ao transplante e o tipo de enxerto tiveram influência na MNRR e na SG, na análise univariada e multivariada, tanto nos pacientes com HCT-CI 0 e ?1. Não houve influência do tipo de condicionamento. O HCT-CI foi validado na nossa população de pacientes submetidos ao TCTH alogênico e identificamos outros fatores de risco que tiveram influência na MNRR e na SG. O HCT-CI, portanto, deve ser utilizado como guia no planejamento da estratégia terapêutica em pacientes portadores de comorbidades / Abstract: Allogeneic hematopoietic stem cell transplant is an important modality of treatment for patients bearing malignant and benign hematologic diseases, representing a chance of cure. As every treatment, it has a treatment-related mortality, possibly influenced by comorbidities. To better evaluate the influence of comorbidities on Non-Relapse Mortality (NRM) and Overall Survival (OS), the Hematopoietic Cell Transplant Specific Comorbidity Index (HCT-CI) was developed. Our objective was to apply the HCT-CI and to find risk factors for NRM and OS in patients who underwent an allogeneic hematopoietic stem cell transplant in our institution, between 1993 and 2010. Medical charts from 457 patients were reviewed. Most patients (59%) were classified in score 0, followed by 30% of cases with score 1-2 and 11% score 3-7. In a univariate analysis, patients with comorbidity score 0, compared with score ?1 had a NRM of 33% vs. 45% (p=0.01) and OS at 5 years of 53% vs. 35% (p=0.001); patients with low risk disease at transplant, compared with high risk disease, had a NRM of 30% vs. 50% (p<0.0001) and OS of 57% vs. 27% (p<0.0001); graft source (bone marrow vs. peripheral blood) had a NRM of 29% vs. 49% (p<0.0001) and OS 56% vs. 34% (p<0.0001). The multivariate analysis confirmed the influence of HCT-CI score on NRM and OS, disease risk at transplant on OS and graft source on NRM. The conditioning type (low dose vs. high dose) did not influence the NRM and OS in both univariate and multivariate analysis. When stratified by comorbidity (0 and ?1), disease status at transplant and graft source influenced NRM and OS in univariate and multivariate analysis, either in the group of patients with HCT-CI 0 and ?1. The conditioning type had no impact. Based on our data, we were able to validate de HCT-CI in our institution and to identify other risk factors with influence on NRM and OS. The HCT-CI, therefore, could be used to guide the treatment strategy of patients with comorbidities / Mestrado / Clinica Medica / Mestre em Clinica Medica