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Wang X, Niu X, Wang Y, Liu Y, Yang C, Chen X, Qi Z. C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 pathway as a therapeutic target and regulatory mechanism for spinal cord injury. Neural Regen Res 2025; 20:2231-2244. [PMID: 39104168 DOI: 10.4103/nrr.nrr-d-24-00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/07/2024] [Indexed: 08/07/2024] Open
Abstract
Spinal cord injury involves non-reversible damage to the central nervous system that is characterized by limited regenerative capacity and secondary inflammatory damage. The expression of the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis exhibits significant differences before and after injury. Recent studies have revealed that the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis is closely associated with secondary inflammatory responses and the recruitment of immune cells following spinal cord injury, suggesting that this axis is a novel target and regulatory control point for treatment. This review comprehensively examines the therapeutic strategies targeting the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis, along with the regenerative and repair mechanisms linking the axis to spinal cord injury. Additionally, we summarize the upstream and downstream inflammatory signaling pathways associated with spinal cord injury and the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis. This review primarily elaborates on therapeutic strategies that target the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis and the latest progress of research on antagonistic drugs, along with the approaches used to exploit new therapeutic targets within the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis and the development of targeted drugs. Nevertheless, there are presently no clinical studies relating to spinal cord injury that are focusing on the C-C motif chemokine ligand 2/C-C motif chemokine receptor 2 axis. This review aims to provide new ideas and therapeutic strategies for the future treatment of spinal cord injury.
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Affiliation(s)
- Xiangzi Wang
- School of Medicine, Guangxi University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xiaofei Niu
- Graduate School of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingkai Wang
- School of Medicine, Guangxi University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Yang Liu
- School of Medicine, Guangxi University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Cheng Yang
- Characteristic Medical Center of People's Armed Police Forces, Tianjin, China
| | - Xuyi Chen
- Characteristic Medical Center of People's Armed Police Forces, Tianjin, China
| | - Zhongquan Qi
- School of Medicine, Guangxi University, Nanning, Guangxi Zhuang Autonomous Region, China
- Fujian Maternity and Child Health Hospital, Fuzhou, Fujian Province, China
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Zhang J, Huang S, Zhu Z, Gatt A, Liu J. E-selectin in vascular pathophysiology. Front Immunol 2024; 15:1401399. [PMID: 39100681 PMCID: PMC11294169 DOI: 10.3389/fimmu.2024.1401399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/05/2024] [Indexed: 08/06/2024] Open
Abstract
Selectins are a group of Ca2+-dependent, transmembrane type I glycoproteins which attract cell adhesion and migration. E-selectin is exclusively expressed in endothelial cells, and its expression is strongly enhanced upon activation by pro-inflammatory cytokines. The interaction of E-selectin with its ligands on circulating leukocytes captures and slows them down, further facilitating integrin activation, firm adhesion to endothelial cells and transmigration to tissues. Oxidative stress induces endothelial cell injury, leading to aberrant expression of E-selectin. In addition, the elevated level of E-selectin is positively related to high risk of inflammation. Dysregulation of E-selectin has been found in several pathological conditions including acute kidney injury (AKI), pulmonary diseases, hepatic pathology, Venous thromboembolism (VTE). Deletion of the E-selectin gene in mice somewhat ameliorates these complications. In this review, we describe the mechanisms regulating E-selectin expression, the interaction of E-selectin with its ligands, the E-selectin physiological and pathophysiological roles, and the therapeutical potential of targeting E-selectin.
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Affiliation(s)
- Jinjin Zhang
- Department of Laboratory Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
- Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
| | - Shengshi Huang
- Institute of Microvascular Medicine, Medical Research Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Key Medical and Health Laboratory of Translational Medicine in Microvascular Aging, Jinan, China
| | - Zhiying Zhu
- Department of Laboratory Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
- Haematology Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Ju Liu
- Department of Laboratory Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
- Institute of Microvascular Medicine, Medical Research Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Key Medical and Health Laboratory of Translational Medicine in Microvascular Aging, Jinan, China
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Fattakhov N, Ngo A, Torices S, Joseph JA, Okoro A, Moore C, Naranjo O, Becker S, Toborek M. Cenicriviroc prevents dysregulation of astrocyte/endothelial cross talk induced by ischemia and HIV-1 via inhibiting the NLRP3 inflammasome and pyroptosis. Am J Physiol Cell Physiol 2024; 326:C487-C504. [PMID: 38145295 PMCID: PMC11192487 DOI: 10.1152/ajpcell.00600.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023]
Abstract
Blood-brain barrier (BBB) breakdown is one of the pathophysiological characteristics of ischemic stroke, which may contribute to the progression of brain tissue damage and subsequent neurological impairment. Human immunodeficiency virus (HIV)-infected individuals are at greater risk for ischemic stroke due to diminished immune function and HIV-associated vasculopathy. Studies have shown that astrocytes are involved in maintaining BBB integrity and facilitating HIV-1 infection in the brain. The present study investigated whether targeting astrocyte-endothelial cell signaling with cenicriviroc (CVC), a dual chemokine receptor (CCR)2 and CCR5 antagonist, may protect against dysregulation of cross talk between these cells after oxygen-glucose deprivation/reoxygenation (OGD/R) combined with HIV-1 infection. Permeability assay with 10 kDa fluorescein isothiocyanate (FITC)-dextran demonstrated that CVC alleviated endothelial barrier disruption in noncontact coculture of human brain microvascular endothelial cells (HBMECs) with HIV-1-infected human astrocytes, and reversed downregulation of tight junction protein claudin-5 induced by OGD/R- and HIV-1. Moreover, CVC attenuated OGD/R- and HIV-1-triggered upregulation of the NOD-like receptor protein-3 (NLRP3) inflammasome and IL-1β secretion. Treatment with CVC also suppressed astrocyte pyroptosis by attenuating cleaved caspase-1 levels and the formation of cleaved N-terminal GSDMD (N-GSDMD). Secretome profiling revealed that CVC ameliorated secretion levels of chemokine CC chemokine ligand 17 (CCL17), adhesion molecule intercellular adhesion molecule-1 (ICAM-1), and T cell activation modulator T cell immunoglobulin and mucin domain 3 (TIM-3) by astrocytes synergistically induced by OGD/R and HIV-1. Overall, these results suggest that CVC contributes to restoring astrocyte-endothelial cross interactions in an astrocyte-dependent manner via protection against NLRP3 activation and pyroptosis.NEW & NOTEWORTHY The present study reveals the role of astrocytic NOD-like receptor protein-3 (NLRP3) inflammasome in dysfunctional astrocyte-endothelial cross interactions triggered in response to oxygen/glucose deprivation injury associated with human immunodeficiency virus type 1 (HIV-1) infection. Our results suggest that blocking NLRP3 inflammasome activation and pyroptosis-mediated inflammation with cenicriviroc (CVC) may constitute a potentially effective therapeutic strategy for blood-brain barrier (BBB) protection during HIV-1-associated ischemic stroke.
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Affiliation(s)
- Nikolai Fattakhov
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Alex Ngo
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Silvia Torices
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Joelle-Ann Joseph
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Adesuwa Okoro
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Cameron Moore
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Oandy Naranjo
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Sarah Becker
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Michal Toborek
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, Florida, United States
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Sun H, Wang XK, Li JR, Tang M, Li H, Lei L, Li HY, Jiang J, Li JY, Dong B, Jiang JD, Peng ZG. Establishment and application of a high-throughput screening model for cell adhesion inhibitors. Front Pharmacol 2023; 14:1140163. [PMID: 36909195 PMCID: PMC9995855 DOI: 10.3389/fphar.2023.1140163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
The cell adhesion between leukocytes and endothelial cells plays an important balanced role in the pathophysiological function, while excessive adhesion caused by etiological agents is associated with the occurrence and development of many acute and chronic diseases. Cell adhesion inhibitors have been shown to have a potential therapeutic effect on these diseases, therefore, efficient and specific inhibitors against cell adhesion are highly desirable. Here, using lipopolysaccharide-induced human umbilical vein endothelial cells (HUVECs) and calcein-AM-labeled human monocytic cell THP-1, we established a high-throughput screening model for cell adhesion inhibitors with excellent model evaluation parameters. Using the drug repurposing strategy, we screened out lifitegrast, a potent cell adhesion inhibitor, which inhibited cell adhesion between HUVEC and THP-1 cells by directly interrupting the adhesion interaction between HUVEC and THP-1 cells and showed a strong therapeutic effect on the mouse acute liver injury induced by poly (I:C)/D-GalN. Therefore, the screening model is suitable for screening and validating cell adhesion inhibitors, which will promote the research and development of inhibitors for the treatment of diseases caused by excessive cell adhesion.
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Affiliation(s)
- Han Sun
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Kai Wang
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Rui Li
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mei Tang
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hu Li
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Biotechnology of Antibiotics, The National Health and Family Planning Commission (NHFPC), Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Lei
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Ying Li
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jiang
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia-Yu Li
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Biao Dong
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Biotechnology of Antibiotics, The National Health and Family Planning Commission (NHFPC), Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Dong Jiang
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Biotechnology of Antibiotics, The National Health and Family Planning Commission (NHFPC), Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zong-Gen Peng
- CAMS Key Laboratory of Antiviral Drug Research, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Biotechnology of Antibiotics, The National Health and Family Planning Commission (NHFPC), Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ma J, Luo J, Sun Y, Zhao Z. Cytokines associated with immune response in atherosclerosis. Am J Transl Res 2022; 14:6424-6444. [PMID: 36247305 PMCID: PMC9556506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/25/2022] [Indexed: 06/16/2023]
Abstract
Inflammation is an essential mechanism of immune response that involves a large number of different immune cells. Atherosclerosis is essentially an inflammatory disease caused by inappropriate activities of immune cells. During this process, various cytokines activate immune cells, regulate and transmit immune cell signals, and stimulate a local inflammatory environment. In this study, we reviewed the cytokines associated with immune activity in atherosclerosis, including their roles in immune cell activation and mediating immune cell chemotaxis. The findings give important insights into inflammatory immune microenvironment, including basic mechanisms and interactions, providing new ideas and options for clinical detection and treatment of this disease.
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Affiliation(s)
- Jiqing Ma
- Department of Vascular Surgery, Changhai Hospital, Naval Medical UniversityShanghai 200433, China
| | - Jianhua Luo
- National Key Laboratory of Medical Immunology & Institute of Immunology, Naval Medical UniversityShanghai 200433, China
| | - Yudong Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing UniversityNanjing 210002, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Naval Medical UniversityShanghai 200433, China
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Files DC, Tacke F, O’Sullivan A, Dorr P, Ferguson WG, Powderly WG. Rationale of using the dual chemokine receptor CCR2/CCR5 inhibitor cenicriviroc for the treatment of COVID-19. PLoS Pathog 2022; 18:e1010547. [PMID: 35749425 PMCID: PMC9231801 DOI: 10.1371/journal.ppat.1010547] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has created a global pandemic infecting over 230 million people and costing millions of lives. Therapies to attenuate severe disease are desperately needed. Cenicriviroc (CVC), a C-C chemokine receptor type 5 (CCR5) and C-C chemokine receptor type 2 (CCR2) antagonist, an agent previously studied in advanced clinical trials for patients with HIV or nonalcoholic steatohepatitis (NASH), may have the potential to reduce respiratory and cardiovascular organ failures related to COVID-19. Inhibiting the CCR2 and CCR5 pathways could attenuate or prevent inflammation or fibrosis in both early and late stages of the disease and improve outcomes of COVID-19. Clinical trials using CVC either in addition to standard of care (SoC; e.g., dexamethasone) or in combination with other investigational agents in patients with COVID-19 are currently ongoing. These trials intend to leverage the anti-inflammatory actions of CVC for ameliorating the clinical course of COVID-19 and prevent complications. This article reviews the literature surrounding the CCR2 and CCR5 pathways, their proposed role in COVID-19, and the potential role of CVC to improve outcomes.
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Affiliation(s)
- Daniel Clark Files
- Department of Internal Medicine, Pulmonary, Critical Care, Allergy and Immunology Section, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Frank Tacke
- Medical Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | | | - Patrick Dorr
- AbbVie Inc., North Chicago, Illinois, United States of America
| | | | - William G. Powderly
- John T. Milliken Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine in St Louis, St Louis, Missouri, United States of America
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Bull BS, Hay KL, Herrmann PC. Fibrin Strands Will Grow from Soluble Fibrin and Hang Up in an In Vitro Microcirculatory Viscoelastic Model: Is This a Major Cause of COVID-19 Associated Coagulopathy? J Clin Med 2022; 11:jcm11082084. [PMID: 35456177 PMCID: PMC9031993 DOI: 10.3390/jcm11082084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/04/2022] Open
Abstract
Viscoelastic testing (VET) by both TEG and ROTEM has demonstrated hypercoagulability early in corona virus disease 2019 (COVID-19) associated coagulopathy (CAC). Additional VET studies demonstrated fibrinolytic shutdown late in a majority of severely ill COVID-19 patients with an associated elevation of d-dimer. Elevated d-dimer confirms that coagulation, followed by fibrinolysis, has occurred. These findings imply that, during CAC, three enzymes—thrombin, Factor XIIIa and plasmin—must have acted in sequence. However, limitations in standard VET analyses preclude exploration of the earliest phases of clot induction, as well as clot formation and clot dissolution in flowing blood. Herein, we describe a novel method illuminating aspects of this unexplored area. In addition, we created an in vitro blood flow model in which the interactions of thrombin, Factor XIII and plasmin with fibrinogen can be studied, allowing the determination of soluble fibrin (SF), the highly unstable form of fibrin that precedes the appearance of a visible clot. This model allows the determination of the SF level at which fibrin microclots begin to form.
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Zeng Z, Lan T, Wei Y, Wei X. CCL5/CCR5 axis in human diseases and related treatments. Genes Dis 2022; 9:12-27. [PMID: 34514075 PMCID: PMC8423937 DOI: 10.1016/j.gendis.2021.08.004] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/08/2021] [Accepted: 08/12/2021] [Indexed: 02/05/2023] Open
Abstract
To defense harmful stimuli or maintain the immune homeostasis, the body produces and recruits a superfamily of cytokines such as interleukins, interferons, chemokines etc. Among them, chemokines act as crucial regulators in defense systems. CCL5/CCR5 combination is known for facilitating inflammatory responses, as well as inducing the adhesion and migration of different T cell subsets in immune responses. In addition, recent studies have shown that the interaction between CCL5 and CCR5 is involved in various pathological processes including inflammation, chronic diseases, cancers as well as the infection of COVID-19. This review focuses on how CCL5/CCR5 axis participates in the pathological processes of different diseases and their relevant signaling pathways for the regulation of the axis. Moreover, we highlighted the gene therapy and chemotherapy studies for treating CCR5-related diseases, including the ongoing clinical trials. The barriers and perspectives for future application and translational research were also summarized.
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Affiliation(s)
- Zhen Zeng
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, Chengdu, Sichuan 610041, PR China
| | - Tianxia Lan
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, Chengdu, Sichuan 610041, PR China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, Chengdu, Sichuan 610041, PR China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 17, Block 3, Southern Renmin Road, Chengdu, Sichuan 610041, PR China
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Maggi P, Ricci E, Messina V, Salzillo A, Simeone F, Iodice A, Socio GV. Dangerous liaisons? The role of inflammation and comorbidities in HIV and SARS-CoV-2 infection. Expert Rev Clin Immunol 2021; 17:201-208. [PMID: 33538189 DOI: 10.1080/1744666x.2021.1886080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION In people living with HIV (PLWH), immune activation and inflammation levels are high even when viral suppression is maintained, potentially contributing to several comorbidities, and hampering the immune response to infections such as the recent SARS-CoV-2 disease 2019 (COVID-19). AREAS COVERED Immune activation and inflammation play a role in SARS-CoV-2 infection. Severe COVID-19 patients may experience cytokine release syndrome (CRS), leading to alveolar damage, pulmonary fibrinolysis, dysregulated coagulation, and pulmonary injury. Into the systemic circulation, cytokines in excess might leak out of pulmonary circulation, causing systemic symptoms and possibly a multiple-organ dysfunction syndrome. Preexisting comorbidities are also linked to worse COVID-19 outcome: studies suggest that diabetes and hypertension are linked to higher mortality rates. Such comorbidities are more frequent in PLWH, but it is unclear if they have worse outcomes in the case of COVID-19. The literature was searched in PubMed/MEDLINE and EMBASE, and manually in COVID-19 resources. EXPERT OPINION A body of evidence shows that HIV and SARS-CoV-2 are able to activate inflammatory pathways, acute in the case of SARS-CoV-2, chronic in the case of HIV, while the comorbidities seem to represent, in the first case, a contributory cause, in the second an effect of the virus-induced damage.
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Affiliation(s)
- Paolo Maggi
- Department of Infectious Disease, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Elena Ricci
- Fondazione A.S.I.A. Onlus, Buccinasco, Milan, Italy
| | - Vincenzo Messina
- Infectious and Tropical Diseases Clinic, AORN S.Anna and S.Sebastiano, Caserta, Italy
| | - Angela Salzillo
- Infectious and Tropical Diseases Clinic, AORN S.Anna and S.Sebastiano, Caserta, Italy
| | - Filomena Simeone
- Infectious and Tropical Diseases Clinic, AORN S.Anna and S.Sebastiano, Caserta, Italy
| | - Angelo Iodice
- Infectious and Tropical Diseases Clinic, AORN S.Anna and S.Sebastiano, Caserta, Italy
| | - Giuseppe Vittorio Socio
- Department of Medicine 2, Infectious Diseases Clinic, Azienda Ospedaliera Di Perugia and University of Perugia, Santa Maria Hospital, Perugia, Italy
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10
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Ng TI, Dorr PK, Krishnan P, Cohen DE, Rhee S, Wang SX, Ruzek MC, Mensa FJ, Kati WM. Biomarkers for the clinical development of antiviral therapies. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2021; 100:19-32. [PMID: 34542933 DOI: 10.1002/cyto.b.21974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/23/2020] [Accepted: 11/17/2020] [Indexed: 06/13/2023]
Abstract
With the morbidity and mortality associated with the COVID-19 pandemic that we are witnessing this year, the risks posed by emerging viral diseases to global health are all too obvious. This pandemic highlights the importance of antiviral drug discovery, which targets emerging viral pathogens, as well as existing pathogenic viruses that undergo continuous evolution. Drug discovery and development is a long and resource intensive process; however, the use of biomarkers can accelerate clinical development of antivirals by providing information regarding diagnosis of specific viral infections, status of infection, potential safety parameters, and antiviral responses. In clinical practice, many of the biomarkers initially utilized to support clinical development are also used for patient care. While viral load is a standard and essential biomarker used to detect the desired viral suppression induced by an antiviral agent, it has become apparent that additional biomarkers, whether related to the virus, the host or as a consequence of the drug's mechanistic effects, are also important for monitoring clinical outcomes associated with an antiviral therapy. This review summarizes the biomarkers used in the clinical development (as well as in clinical practice, where appropriate) of antiviral therapies for hepatitis C virus, hepatitis B virus, human immunodeficiency virus, and severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Teresa I Ng
- Virology Drug Discovery, AbbVie Inc., North Chicago, Illinois, USA
| | - Patrick K Dorr
- General Medicine and Virology, AbbVie Inc., North Chicago, Illinois, USA
| | - Preethi Krishnan
- Virology Drug Discovery, AbbVie Inc., North Chicago, Illinois, USA
| | - Daniel E Cohen
- General Medicine and Virology, AbbVie Inc., North Chicago, Illinois, USA
| | - Susan Rhee
- General Medicine and Virology, AbbVie Inc., North Chicago, Illinois, USA
| | - Stanley X Wang
- General Medicine and Virology, AbbVie Inc., North Chicago, Illinois, USA
| | - Melanie C Ruzek
- Translational Immunology, AbbVie Inc., Worcester, Massachusetts, USA
| | - Federico J Mensa
- General Medicine and Virology, AbbVie Inc., North Chicago, Illinois, USA
| | - Warren M Kati
- Virology Drug Discovery, AbbVie Inc., North Chicago, Illinois, USA
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11
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Yu H, Li C, Wang X, Duan J, Yang N, Xie L, Yuan Y, Li S, Bi C, Yang B, Li Y. Techniques and Strategies for Potential Protein Target Discovery and Active Pharmaceutical Molecule Screening in a Pandemic. J Proteome Res 2020; 19:4242-4258. [PMID: 32957788 PMCID: PMC7640955 DOI: 10.1021/acs.jproteome.0c00372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/12/2022]
Abstract
Viruses remain a major challenge in the fierce fight against diseases. There have been many pandemics caused by various viruses throughout the world over the years. Recently, the global outbreak of COVID-19 has had a catastrophic impact on human health and the world economy. Antiviral drug treatment has become another essential means to overcome pandemics in addition to vaccine development. How to quickly find effective drugs that can control the development of a pandemic is a hot issue that still needs to be resolved in medical research today. To accelerate the development of drugs, it is necessary to target the key target proteins in the development of the pandemic, screen active molecules, and develop reliable methods for the identification and characterization of target proteins based on the active ingredients of drugs. This article discusses key target proteins and their biological mechanisms in the progression of COVID-19 and other major epidemics. We propose a model based on these foundations, which includes identifying potential core targets, screening potential active molecules of core targets, and verifying active molecules. This article summarizes the related innovative technologies and methods. We hope to provide a reference for the screening of drugs related to pandemics and the development of new drugs.
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Affiliation(s)
| | | | | | - Jingyi Duan
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Na Yang
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Lijuan Xie
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Yu Yuan
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Shanze Li
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Chenghao Bi
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Bin Yang
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
| | - Yubo Li
- Tianjin University of Traditional
Chinese Medicine, No. 10, Poyang Lake Road, West Zone, Tuanbo New City, Jinghai District, Tianjin, 301617, China
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12
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Tincati C, Mondatore D, Bai F, d'Arminio Monforte A, Marchetti G. Do Combination Antiretroviral Therapy Regimens for HIV Infection Feature Diverse T-Cell Phenotypes and Inflammatory Profiles? Open Forum Infect Dis 2020; 7:ofaa340. [PMID: 33005694 PMCID: PMC7513927 DOI: 10.1093/ofid/ofaa340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/06/2020] [Indexed: 12/19/2022] Open
Abstract
Immune abnormalities featuring HIV infection persist despite the use of effective combination antiretroviral therapy (cART) and may be linked to the development of noninfectious comorbidities. The aim of the present narrative, nonsystematic literature review is to understand whether cART regimens account for qualitative differences in immune reconstitution. Many studies have reported differences in T-cell homeostasis, inflammation, coagulation, and microbial translocation parameters across cART classes and in the course of triple vs dual regimens, yet such evidence is conflicting and not consistent. Possible reasons for discrepant results in the literature are the paucity of randomized controlled clinical trials, the relatively short follow-up of observational studies, the lack of clinical validation of the numerous inflammatory biomarkers utilized, and the absence of research on the effects of cART in tissues. We are currently thus unable to establish if cART classes and regimens are truly accountable for the differences observed in immune/inflammation parameters in different clinical settings. Questions still remain as to whether an early introduction of cART, specifically in the acute stage of disease, or newer drugs and novel dual drug regimens are able to significantly impact the quality of immune reconstitution and the risk of disease progression in HIV-infected subjects.
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Affiliation(s)
- Camilla Tincati
- Department of Health Sciences, Clinic of Infectious Diseases, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Debora Mondatore
- Department of Health Sciences, Clinic of Infectious Diseases, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Francesca Bai
- Department of Health Sciences, Clinic of Infectious Diseases, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Antonella d'Arminio Monforte
- Department of Health Sciences, Clinic of Infectious Diseases, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giulia Marchetti
- Department of Health Sciences, Clinic of Infectious Diseases, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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13
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Gabuzda D, Jamieson BD, Collman RG, Lederman MM, Burdo TH, Deeks SG, Dittmer DP, Fox HS, Funderburg NT, Pahwa SG, Pandrea I, Wilson CC, Hunt PW. Pathogenesis of Aging and Age-related Comorbidities in People with HIV: Highlights from the HIV ACTION Workshop. Pathog Immun 2020; 5:143-174. [PMID: 32856008 PMCID: PMC7449259 DOI: 10.20411/pai.v5i1.365] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/12/2022] Open
Abstract
People with HIV (PWH) experience accentuated biological aging, as defined by markers of inflammation, immune dysfunction, and the epigenetic clock. They also have an elevated risk of multiple age-associated comorbidities. To discuss current knowledge, research gaps, and priorities in aging and age-related comorbidities in treated HIV infection, the NIH program staff organized a workshop held in Bethesda, Maryland in September 2019. This review article describes highlights of discussions led by the Pathogenesis/Basic Science Research working group that focused on three high priority topics: immunopathogenesis; the microbiome/virome; and aging and senescence. We summarize knowledge in these fields and describe key questions for research on the pathogenesis of aging and age-related comorbidities in PWH. Understanding the drivers and mechanisms underlying accentuated biological aging is a high priority that will help identify potential therapeutic targets to improve healthspan in older PWH.
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Affiliation(s)
- Dana Gabuzda
- Department of Cancer Immunology and Virology; Dana-Farber Cancer Institute; Boston, Massachusetts; Department of Neurology; Harvard Medical School; Boston, Massachusetts
| | - Beth D Jamieson
- Department of Medicine; David Geffen School of Medicine; University of California; Los Angeles, California
| | - Ronald G Collman
- Department of Medicine; University of Pennsylvania School of Medicine; Philadelphia, Pennsylvania
| | - Michael M Lederman
- Department of Medicine; Case Western Reserve University School of Medicine; Cleveland, Ohio
| | - Tricia H Burdo
- Department of Neuroscience; Lewis Katz School of Medicine; Temple University; Philadelphia, Pennsylvania
| | - Steven G Deeks
- Department of Medicine; University of California; San Francisco, California
| | - Dirk P Dittmer
- Department of Microbiology and Immunology; University of North Carolina School of Medicine; Chapel Hill, North Carolina
| | - Howard S Fox
- Department of Pharmacology and Experimental Neuroscience; University of Nebraska Medical Center; Omaha, Nebraska
| | - Nicholas T Funderburg
- Division of Medical Laboratory Science; School of Health and Rehabilitation Sciences; Ohio State University College of Medicine; Columbus, Ohio
| | - Savita G Pahwa
- Department of Microbiology and Immunology; University of Miami Miller School of Medicine; Miami, Florida
| | - Ivona Pandrea
- Department of Microbiology and Molecular Genetics; School of Medicine; University of Pittsburgh; Pittsburgh, Pennsylvania
| | - Cara C Wilson
- Department of Medicine; Division of Infectious Diseases; University of Colorado Anschutz Medical Campus; Aurora, Colorado
| | - Peter W Hunt
- Department of Medicine; University of California; San Francisco, California
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14
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Bowler S, Siriwardhana C, Mitchell BI, D'Antoni ML, Ogata-Arakaki D, Souza S, Yee R, Gangcuangco LMA, Chow DC, Ndhlovu LC, Shikuma C. Cenicriviroc, a dual CCR2 and CCR5 antagonist leads to a reduction in plasma fibrotic biomarkers in persons living with HIV on antiretroviral therapy. HIV Res Clin Pract 2020; 20:123-129. [PMID: 32013805 DOI: 10.1080/25787489.2020.1719319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Chronic HIV is associated with increased inflammation and tissue fibrosis despite suppressive antiretroviral therapy (ART). Monocytes and macrophages have been implicated in the pathogenesis of fibrosis, facilitated by chemokine receptor interactions.Methods: We assessed systemic fibrotic biomarkers (transforming growth factor beta-1 [TGF-β1], thrombospondin-1 [TSP-1], C-terminal pro-peptide of collagen type I [CICP], and IL-11) in banked plasma from a previously published 24-week open-label trial of cenicriviroc (CVC), a dual CCR2/CCR5 antagonist, among persons living with HIV (PLWH) on stable ART with undetectable plasma HIV RNA (<50 copies/mL). Fibrotic markers were assessed by ELISA and Luminex. Untreated HIV-seronegative individuals (n = 6) of similar age and demographics served as a comparator group.Results: Median age of PLWH was 55 years. At baseline, PLWH had higher median TGF-β1 (2.11 vs 1.62 ng/mL, p = 0.01), TSP-1 (236.74 vs 83.29 ng/mL, p < 0.0001), and CICP (200.46 vs 111.28 ng/mL, p = 0.01), but lower IL-11 (36.00 vs 53.74 pg/mL, p = 0.01) compared to HIV-uninfected individuals. Over 24 weeks, median TGF-β1 (-0.74 ng/mL, p = 0.006), TSP-1 (-52.12 ng/mL, p < 0.0001), and CICP (-28.12 ng/mL, p < 0.0001) decreased and IL-11 (28.98 pg/mL, p < 0.0001) increased in PLWH. At week 24, TGF-β1, CICP, and IL-11 were similar between the two groups (p > 0.05), while TSP-1 remained elevated in PLWH (p = 0.009) compared to controls.Conclusions: PLWH had higher levels of the plasma fibrotic markers TGF-β1, TSP-1, and CICP. After 24 weeks of CVC, fibrotic markers generally returned to levels comparable to HIV-uninfected controls. Dual CCR2 and CCR5 blockade may ameliorate the detrimental fibrotic events that persist in treated HIV.
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Affiliation(s)
- S Bowler
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - C Siriwardhana
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - B I Mitchell
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - M L D'Antoni
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - D Ogata-Arakaki
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - S Souza
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA.,Queen's Medical Center, Honolulu, Hawaii, USA
| | - R Yee
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - L M A Gangcuangco
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA.,Queen's Medical Center, Honolulu, Hawaii, USA
| | - D C Chow
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA.,Queen's Medical Center, Honolulu, Hawaii, USA
| | - L C Ndhlovu
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - C Shikuma
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
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15
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Chilunda V, Calderon TM, Martinez-Aguado P, Berman JW. The impact of substance abuse on HIV-mediated neuropathogenesis in the current ART era. Brain Res 2019; 1724:146426. [PMID: 31473221 PMCID: PMC6889827 DOI: 10.1016/j.brainres.2019.146426] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/16/2019] [Accepted: 08/28/2019] [Indexed: 12/21/2022]
Abstract
Approximately 37 million people worldwide are infected with human immunodeficiency virus (HIV). One highly significant complication of HIV infection is the development of HIV-associated neurocognitive disorders (HAND) in 15-55% of people living with HIV (PLWH), that persists even in the antiretroviral therapy (ART) era. The entry of HIV into the central nervous system (CNS) occurs within 4-8 days after peripheral infection. This establishes viral reservoirs that may persist even in the presence of ART. Once in the CNS, HIV infects resident macrophages, microglia, and at low levels, astrocytes. In response to chronic infection and cell activation within the CNS, viral proteins, inflammatory mediators, and host and viral neurotoxic factors produced over extended periods of time result in neuronal injury and loss, cognitive deficits and HAND. Substance abuse is a common comorbidity in PLWH and has been shown to increase neuroinflammation and cognitive disorders. Additionally, it has been associated with poor ART adherence, and increased viral load in the cerebrospinal fluid (CSF), that may also contribute to increased neuroinflammation and neuronal injury. Studies have examined mechanisms that contribute to neuroinflammation and neuronal damage in PLWH, and how substances of abuse exacerbate these effects. This review will focus on how substances of abuse, with an emphasis on methamphetamine (meth), cocaine, and opioids, impact blood brain barrier (BBB) integrity and transmigration of HIV-infected and uninfected monocytes across the BBB, as well as their effects on monocytes/macrophages, microglia, and astrocytes within the CNS. We will also address how these substances of abuse may contribute to HIV-mediated neuropathogenesis in the context of suppressive ART. Additionally, we will review the effects of extracellular dopamine, a neurotransmitter that is increased in the CNS by substances of abuse, on HIV neuropathogenesis and how this may contribute to neuroinflammation, neuronal insult, and HAND in PLWH with active substance use. Lastly, we will discuss some potential therapies to limit CNS inflammation and damage in HIV-infected substance abusers.
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Affiliation(s)
- Vanessa Chilunda
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, USA
| | - Tina M Calderon
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, USA
| | - Pablo Martinez-Aguado
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, USA
| | - Joan W Berman
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, USA; Department of Microbiology and Immunology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, USA.
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16
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Gutierrez MDM, Mateo MG, Vidal F, Domingo P. Does choice of antiretroviral drugs matter for inflammation? Expert Rev Clin Pharmacol 2019; 12:389-396. [PMID: 31017494 DOI: 10.1080/17512433.2019.1605902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The massive implementation of combination antiretroviral therapy (cART) has forever changed the landscape of HIV infection. This unprecedented success has turned HIV infection into a manageable chronic disease. The increased survival of people living with HIV is, however, shadowed by a high burden of aging-related comorbidities. The pathogenic basis underlying this excess of co-morbid conditions is most likely a persistent inflammatory and immune activation state, despite an optimal control of HIV replication, which in turn has largely been attributed to bacterial or bacterial products translocation from the gut. Area covered: This review is focused on the relationship between cART and the chronic inflammatory and immune activation status in otherwise virologically well-controlled people living with HIV (PLWH). Particular focus will be placed on the differences, if any, between distinct cART modalities, with emphasis on less-drug cART regimens, and especially on dual therapies. Expert opinion: Research to address the increased inflammatory and immune activation status of cART-treated, HIV-infected patients, should focus on adjuvant means of therapy, rather than on the cART regime itself. With current antiretrovirals, no difference between dual and triple regimens has been demonstrated, provided that virological and immunological outcomes be non-inferior.
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Affiliation(s)
- María Del Mar Gutierrez
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - María Gracia Mateo
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - Francesc Vidal
- b HIV Unit, Department of Internal Medicine , Hospital Universitari Joan XXIII, Universitat Rovira I Virgili, Institut de Recerca Rovira I Virgili , Tarragona , Spain
| | - Pere Domingo
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
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