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Shi C, Mammadova-Bach E, Li C, Liu D, Anders HJ. Pathophysiology and targeted treatment of cholesterol crystal embolism and the related thrombotic angiopathy. FASEB J 2023; 37:e23179. [PMID: 37676696 DOI: 10.1096/fj.202301316r] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
Cholesterol crystal (CC) embolism is a complication of advanced atherosclerotic plaques located in the major arteries. This pathological condition is primarily induced by interventional and surgical procedures or occurs spontaneously. CC can induce a wide range of tissue injuries including CC embolism syndrome, a spontaneous or intervention-induced complication of advanced atherosclerosis, while treatment of CC embolism has remained empiric. Vascular occlusions caused by CC embolism may exceed the ischemia tolerance of many tissues, particularly when small arteries are affected. The main approach to CC embolism is primary prophylaxis in patients at risk by stabilizing atherosclerotic plaques and avoiding unnecessary catheter interventions. During CC embolism, the use of platelet inhibitors to avoid abnormal activation and aggregation and anticoagulants may reduce the risk of vascular occlusions and tissue ischemia. This probably explains the relatively low prevalence of clinical manifestations of CC embolism, which are frequently found in autopsy studies. In this review, we summarized the current knowledge on the pathophysiology of CC embolism syndrome deriving from clinical observations and experimental mouse models. Furthermore, we described the risk factors of CC embolism in humans as well as the experimental studies based on empiric treatments. We also discuss potential therapeutic interventions based on recent experimental data and emerging drug options evolving from other research domains. Given the substantial unmet medical need to improve the outcomes of CC embolism, the identification of effective treatment strategies is urgently needed.
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Affiliation(s)
- Chongxu Shi
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Elmina Mammadova-Bach
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
- Walther-Straub-Institute for Pharmacology and Toxicology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Cong Li
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
| | - Dong Liu
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
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Shi C, Kim T, Steiger S, Mulay SR, Klinkhammer BM, Bäuerle T, Melica ME, Romagnani P, Möckel D, Baues M, Yang L, Brouns SLN, Heemskerk JWM, Braun A, Lammers T, Boor P, Anders HJ. Crystal Clots as Therapeutic Target in Cholesterol Crystal Embolism. Circ Res 2020; 126:e37-e52. [PMID: 32089086 DOI: 10.1161/circresaha.119.315625] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE Cholesterol crystal embolism can be a life-threatening complication of advanced atherosclerosis. Pathophysiology and molecular targets for treatment are largely unknown. OBJECTIVE We aimed to develop a new animal model of cholesterol crystal embolism to dissect the molecular mechanisms of cholesterol crystal (CC)-driven arterial occlusion, tissue infarction, and organ failure. METHODS AND RESULTS C57BL/6J mice were injected with CC into the left kidney artery. Primary end point was glomerular filtration rate (GFR). CC caused crystal clots occluding intrarenal arteries and a dose-dependent drop in GFR, followed by GFR recovery within 4 weeks, that is, acute kidney disease. In contrast, the extent of kidney infarction was more variable. Blocking necroptosis using mixed lineage kinase domain-like deficient mice or necrostatin-1s treatment protected from kidney infarction but not from GFR loss because arterial obstructions persisted, identifying crystal clots as a primary target to prevent organ failure. CC involved platelets, neutrophils, fibrin, and extracellular DNA. Neutrophil depletion or inhibition of the release of neutrophil extracellular traps had little effects, but platelet P2Y12 receptor antagonism with clopidogrel, fibrinolysis with urokinase, or DNA digestion with recombinant DNase I all prevented arterial occlusions, GFR loss, and kidney infarction. The window-of-opportunity was <3 hours after CC injection. However, combining Nec-1s (necrostatin-1s) prophylaxis given 1 hour before and DNase I 3 hours after CC injection completely prevented kidney failure and infarcts. In vitro, CC did not directly induce plasmatic coagulation but induced neutrophil extracellular trap formation and DNA release mainly from kidney endothelial cells, neutrophils, and few from platelets. CC induced ATP release from aggregating platelets, which increased fibrin formation in a DNase-dependent manner. CONCLUSIONS CC embolism causes arterial obstructions and organ failure via the formation of crystal clots with fibrin, platelets, and extracellular DNA as critical components. Therefore, our model enables to unravel the pathogenesis of the CC embolism syndrome as a basis for both prophylaxis and targeted therapy.
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Affiliation(s)
- Chongxu Shi
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
| | - Tehyung Kim
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
| | - Stefanie Steiger
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
| | - Shrikant R Mulay
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
| | - Barbara M Klinkhammer
- Department of Nephrology, Institute of Pathology (B.M.K, P.B.), RWTH Aachen University Hospital, Germany
| | - Tobias Bäuerle
- Preclinical Imaging Platform Erlangen, Institute of Radiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (T.B.)
| | - Maria Elena Melica
- Excellence Centre for Research, Transfer and High Education for the development of DE NOVO Therapies (M.E.M., P.R.), University of Florence, Italy.,Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (M.E.M., P.R.), University of Florence, Italy
| | - Paola Romagnani
- Excellence Centre for Research, Transfer and High Education for the development of DE NOVO Therapies (M.E.M., P.R.), University of Florence, Italy.,Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (M.E.M., P.R.), University of Florence, Italy.,Nephrology and Dialysis Unit, Meyer Children's University Hospital, Florence, Italy (P.R.)
| | - Diana Möckel
- Institute for Experimental Molecular Imaging (D.M., M.B., T.L.), RWTH Aachen University Hospital, Germany
| | - Maike Baues
- Institute for Experimental Molecular Imaging (D.M., M.B., T.L.), RWTH Aachen University Hospital, Germany
| | - Luying Yang
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
| | - Sanne L N Brouns
- Department of Biochemistry, CARIM, Maastricht University, The Netherlands (S.L.N.B., J.W.M.H.)
| | - Johan W M Heemskerk
- Department of Biochemistry, CARIM, Maastricht University, The Netherlands (S.L.N.B., J.W.M.H.)
| | - Attila Braun
- Walther-Straub-Institute for Pharmacology and Toxicology, Ludwig-Maximilians University Munich, German Center for Lung Research, Germany (A.B.)
| | - Twan Lammers
- Institute for Experimental Molecular Imaging (D.M., M.B., T.L.), RWTH Aachen University Hospital, Germany
| | - Peter Boor
- Department of Nephrology, Institute of Pathology (B.M.K, P.B.), RWTH Aachen University Hospital, Germany
| | - Hans-Joachim Anders
- From the Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU München, Germany (C.S., T.K., S.S., S.R.M., L.Y., H.-J.A.)
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