Circulation最新文献

Malnutrition can affect patients with various acute cardiovascular disease conditions, including acute coronary syndromes, arrhythmias, or valvular disease; however, most of the literature has focused on patients with heart failure. Malnutrition prevalence estimates range from 20% to 60% for hospitalized patients. Use of Global Leadership Initiative on Malnutrition criteria for malnutrition diagnosis for patients with cardiovascular disease has confirmed prognostic value, correlating with poorer physical function and higher mortality. Nutritional support plays a key role for inpatients, particularly in the cardiac intensive care unit, and includes initiation of feeding within 48 hours of hospitalization, preferably through enteral nutrition. Enteral nutrition is more cost-effective compared with parenteral nutrition and can decrease mortality and shorten lengths of stay. Parenteral nutrition is reserved for patients with severe gastrointestinal dysfunction or to supplement nutrition when enteral nutrition is contraindicated, for example, during high pressor doses that preclude adequate intestinal perfusion or when achieving <70% of nutritional targets after the first week. The optimal protein intake for patients with cardiogenic shock is an area of ongoing research, with higher protein approaches not appearing beneficial in recent critical care trials.

Background: The entrance of naive T cells into lymph nodes (LNs) is a crucial step for induction of heart transplant acceptance under costimulatory blockade. Specialized blood vessels within the LN known as high endothelial venules (HEVs) mediate this process. HEVs express a key glycoprotein containing 6-sulfo sialyl Lewis X, the binding site for L-selectin on the membrane of naive T cells. The proper formation of this carbohydrate requires sulfation by N-acetylglucosamine 6-O-sulfotransferases, particularly CHST4. Given the critical role of CHST4 in HEVs and transplant immunity, we aimed to develop a first-in-class antibody-drug conjugate (ADC) targeting the CHST4/HEV axis to deliver immunoregulatory molecules to LNs and promote long-term cardiac transplant survival.

Methods: We used CHST4 knockout mice and inducible diphtheria toxin receptor mouse models to investigate the role of CHST4 in HEV function during heart allograft transplantation. To assess the impact of CHST4 deficiency on heart transplant outcomes, we used fully major histocompatibility complex-mismatched and single major histocompatibility complex class II-mismatched models to study acute and chronic heart transplant rejection, respectively. We developed a first-in-class, dual-payload antibody-drug conjugate aimed at promoting regulatory T cells by conjugating rapamycin and tubastatin A to the HEV-targeting MHA112 antibody. The efficacy of this ADC was tested in murine heart allograft models.

Results: Loss of CHST4 expression by HEVs impaired the entry of naive T cells into LNs and consequently reduced regulatory T cell formation, thereby disrupting cardiac transplant acceptance under costimulatory blockade. Treatment with the HEV-targeted ADC carrying rapamycin and tubastatin A prolonged murine heart allograft survival and suppressed chronic rejection, a major barrier to long-term graft success. Mechanistically, this ADC enhanced regulatory T cell induction, reduced proinflammatory T cells within lymph nodes, and decreased immune cell infiltration in cardiac allografts, achieving these effects with substantially lower doses of rapamycin and tubastatin A compared with administration of the free drugs.

Conclusions: Our findings uncover a key mechanistic role for CHST4 in HEVs in facilitating the regulatory T cell generation within the LN and promoting heart transplant acceptance. Moreover, we introduce a promising CHST4-based, HEV-targeted ADC therapy as a potential strategy to suppress heart transplant rejection.