Angelo Avogaro Università degli Studi di Padova La carenza di cellule endoteliali progenitrici: un passaggio chiave nell’ambito della patologia cardiovascolare del malato di diabete. Universa Universis Patavina Libertas

Fibrinolysis Platelets aggregation CoagulationPermeabilityAdhesiveness Infiammation PAI-1 t-PA NO PGI 2 TXA 2 Fibrinogen Thrombomodulin vWF TF RAGE MCP-1 P-selectin ICAM-1 VCAM-1 NO PGI 2 EDHF TXA 2 ET-1 VEGF PDGF TGF-β Vasodilatation Vasocostriction Proliferation

Causes of endothelial dysfunction in Diabetes 1. Impaired ROS PKC Polyols AGE Hexosamines L-arginine L-citrulline NOS3 NO  ADMA  BH4  Vasodilatation ROS Glycated proteins  Glucose NAD(P)H Oxidase

Changes in Coronary segment diameters expressed as percentage of baseline in response to Acetylcholine (Adapted from Nitenberg et al. Diabetes 1993) P<0.01P<0.001 n.sC vs. D

Postprandial Myocardial Perfusion is impaired in Type 2 Diabetic Patients (Scognamiglio et al. 2005) BaselinePostprandial Myocardial Blood Flow

Changes in Coronary segment diameters expressed as percentage of baseline in response to Acetylcholine (Adapted from Nitenberg et al. Diabetes 1993) P<0.01P<0.001 n.sC vs. D

Circulating Endothelial Cells in Cardiovascular Disease (Boos et al. 2006) Blood Vessel CEC CD 133+ CD 146- RF

Endothelial Precursor Cells: a novel approach to assess vascular integrity 0.1% to 3.0% of endothelial cells proliferate daily Endothelial cell division may reach 50% of the cells in and around the injured sites Ingram et al. Blood 2005

Circulating endothelial cells are elevated in patients with type 2 diabetes mellitus independently of HbA 1 c (McClung et al. 2005)

Lamalice, L. et al. Circ Res 2007;100: Major steps of endothelial cell migration

Risk factors Apoptosis Regeneration EPC Endothelial cell apoptosis and -regeneration

Bone Marrow ↔ Circulating Progenitor Cells Bone marrow cells Peripheral blood CD34 + cell pool Endothelial progenitor cells (KDR + ) Cardiomyocyte progenitor cells (c-met + /CXCR4 + ) Smooth muscle progenitor cells (  -actin + )

Apoptosis Other CD34+ derived phenotypes EPCs HSCs Injured endothelium Repair VSMCs migration From BONE MARROW New vessel growth Differentiation ? IschemiaVEGFSDF-1PlGFFGFEPO Defective mobilization Decreased survival Increased homing Deranged differentiation Low EPCs Mechanisms of Progenitor Cell Decrease Fadini et al. Curr Diabetes Rev 2005

Bone marrow and peripheral blood progenitor cells r = 0.51 p = r = 0.51 p = Bone marrow and peripheral blood sampled during open heart surgery

Diabetes Mellitus and EPCs (Tepper et al. Circulation 2002; Loomans et al. Diabetes 2004; Fadini et al. JACC 2005) Diabetes Mellitus and EPCs (Tepper et al. Circulation 2002; Loomans et al. Diabetes 2004; Fadini et al. JACC 2005) CTRL DM2 Culture Adhesion HbA1c (%) EPC count HbA1c (%) EPC count

Krankel, N. et al. Arterioscler Thromb Vasc Biol 2005;25: The quantitative analysis revealed a significant decrease in the CPC amount after culture in HG medium (A)

The clinical significance of EPCs (Fadini et al. ATVB 2006) The clinical significance of EPCs (Fadini et al. ATVB 2006) PAD: Disease Stage of RuthefordCCA plaque obstruction

The clinical significance of EPCs Disease Marker – Prediabetes (Fadini et al Diabetologia 2007) The clinical significance of EPCs Disease Marker – Prediabetes (Fadini et al Diabetologia 2007)

Reduced survival Federici et al. Diabetes 2006 Federici et al. Diabetes 2006 Seeger et al. Circulation 2005 Seeger et al. Circulation 2005 ** ** ** ** Glucose P38inhib--+ Glucose P38inhib EPC / high power field

Impaired mobilization (Fadini et al. Diabetologia 2006) G-CSF 50 mg/kg + SCF 200 mg/kg 5 days

adjusted observed adjusted observed Progressive progenitor cell decline N = 425 Adjusted for age, sex, plasma glucose, HbA1c, BMI, smoke, blood pressure, lipid profile, diabetic complications and CVD, medications NGTIFGIGT DM new DM <10 DM DM >20 CD34+ Cell count

CD34+ progenitor cells metabolic components Synergistic reduction of CD34+ progenitors at clustering cardiometabolic risk factors Correlation between CD34+ cells and HOMA, a measure of insulin resistance Synergistic reduction of CD34+ progenitors at clustering cardiometabolic risk factors Correlation between CD34+ cells and HOMA, a measure of insulin resistance Fadini et al. Eur Heart J 2006

All events CV events Death All events CV events Death Progenitor Cells and Outcomes in MetSyn Patients After correction for age, sex, lipid profile, blood pressure, family history, smoking habit, obesity, CRP, plasma glucose, renal function, baseline CVD, metabolic syndrome, 10-yr Italian risk score. * * n = 214 Atherosclerosis in press

The bone marrow connection Bone marrow defect Endothelial progenitor cells Cardiomyocyte progenitor cells Smooth muscle progenitor cells CD34+ Sca-1+ c-kit+ CARDIOVASCULAR COMPLICATIONS DIABETES MELLITUS

AcknowledgmentsAcknowledgments PADOVA EPC Study Group METABOLIC DIVISION Gianpaolo Fadini Saula de Kreutzenberg GENERAL PATHOLOGY Saverio Sartore Mattia Albiero Stefano Schiaffino CLINICAL IMMUNOLOGY Carlo Agostini Elisa Boscaro Partly supported by the Heart Repair consortium PADOVA EPC Study Group METABOLIC DIVISION Gianpaolo Fadini Saula de Kreutzenberg GENERAL PATHOLOGY Saverio Sartore Mattia Albiero Stefano Schiaffino CLINICAL IMMUNOLOGY Carlo Agostini Elisa Boscaro Partly supported by the Heart Repair consortium