Mycophenolate mofetil attenuates plaque inflammation in patients with symptomatic carotid artery stenosis

doi:10.1016/j.atherosclerosis.2010.01.043

Atherosclerosis

Volume 211, Issue 1, July 2010, Pages 231-236

https://doi.org/10.1016/j.atherosclerosis.2010.01.043 Get rights and content

Abstract

Atherosclerosis as well as the subsequent progression towards cardiovascular events are considered to, at least partially, be a consequence of chronic inflammatory activity. Therefore, we decided to evaluate the impact of short-term immunosuppressive treatment on plaque characteristics in patients with symptomatic carotid artery stenosis.

Twenty-one patients were randomized to receive either 1000 mg. Mycophenolate mofetil (MMF) BD or placebo for at least 2 weeks prior to undergoing carotid endarterectomy (CEA). The serial sections of the CEA specimens were immunostained for activated T-cells (CD3⁺CD69⁺), regulatory T-cells (CD3⁺FOXP3⁺) and macrophages (CD68). In addition, gene expression profiling was performed by Illumina gene-array.

Immunostaining revealed a reduction of activated T-cells in nine MMF-treated patients compared to 11 placebo-treated control patients (19.7% vs. 28.1%; p < 0.05) as well as an increase of regulatory T-cells (3.8% vs. 1.8%; p = 0.05). Microarray analyses confirmed beneficial changes to plaque phenotype, showing reduced expression of pro-inflammatory genes. Significantly reduced expression of metalloproteinases and osteopontin was observed in three out of nine MMF-treated patients compared to nil out of 11 in the placebo group.

In the present study we show that immunosuppressive treatment for two-and-a-half weeks prior to CEA elicits changes in the plaque phenotype of symptomatic patients. These changes include reduced inflammatory cell presence with a concomitant decrease in pro-inflammatory gene expression.

Introduction

Atherosclerotic vascular disease can be regarded as a disproportionate inflammatory response directed against the deposition of oxidized lipids in the arterial wall [1]. Therefore, the cornerstone of prevention and treatment of atherosclerosis consists of reducing the low-density lipoprotein cholesterol (LDL) levels by means of statin therapy [2]. The additive impact of C-reactive protein (CRP)-lowering on top of LDL lowering [3] has emphasized the promise of dedicated anti-inflammatory strategies as a means to further reduce cardiovascular disease burden. In support, a variety of experimental studies has corroborated that the attenuation of leukocyte invasion into the arterial wall reduces the formation of atherosclerotic lesions [4]. In humans, data are cumulating to show that accelerated atherosclerosis is a hallmark of chronic inflammatory disease states [5], whereas suppression of inflammatory activity attenuates this association. To date, however, no data are available demonstrating the direct anti-atherosclerotic effect of immune-modulating interventions in humans.

Mycophenolate mofetil (MMF) is an inhibitor of the enzyme inosine monophosphate dehydroxygenase (IMPDH) and has a strong cytostatic effect on T-cells by interfering with DNA synthesis in activated T-cells [6]. Since T-cells are of pivotal importance in the pathophysiology of atherosclerosis [1], MMF may exert beneficial effects on the progression of atherosclerosis [7]. In this proof-of-concept, we evaluated whether short-term treatment with MMF in symptomatic patients scheduled for carotid endarterectomy was associated with altered cellular infiltration and/or changes in plaque inflammatory activity, as assessed with mRNA expression profiling.

Section snippets

Methods

Consecutive patients with a carotid artery stenosis (>70% diameter stenosis on angiography) as defined by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria combined with an ipsilateral vascular event (transient ischemic attack and/or cerebrovascular attack) were prospectively included at the Outpatient Department of Vascular Surgery at the Sint Antonius Hospital in Nieuwegein, the Netherlands. Patients were randomized to receive either MMF 1000 mg BD or a placebo and

Baseline characteristics

A total of 21 patients participated in this study, 9 of whom were randomly assigned to MMF treatment and 12 to placebo treatment. One patient of the placebo group was excluded because of technical difficulties obtaining a specimen of the atherosclerotic plaque. Table 1 summarizes the demographic characteristics of both groups. During the short-term treatment period hematological parameters remained stable and none of the patients developed opportunistic infections (data not shown). One patient

Discussion

In the present study we show that immunosuppressive therapy with MMF in patients with manifest cardiovascular disease leads to a reduced number of activated T-cells with a concomitant increase of regulatory T-cells in the carotid plaques. This anti-inflammatory profile was further supported by the profoundly reduced expression of inflammatory cell type marker genes as well as reductions of metalloproteinase genes, including osteopontin and MMP9, in a subgroup of MMF-treated patients. These

Conclusions

This study provides first proof-of-concept for the fact that the inflammatory process in the atherosclerotic plaque in humans can be modified by immunomodulatory therapy. Considering the chronic nature of the atherosclerotic plaque a 2-week period may look short for the observed changes in this study. However, rHDL infusion in 10 patients with claudication for 5–7 days prior to atherectomy showed acute changes in lipid content of the atherosclerotic plaque [31]. Together with our observations

Sources of funding

This study was partly funded by a research grant from Aspreva Pharmaceuticals.

Disclosures

None.

Acknowledgments

All medication was kindly provided by Aspreva Pharmaceuticals with special thanks to Helen Philips.

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^☆: Trial registration: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=841 (ISRCTN84092396).

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Mycophenolate mofetil attenuates plaque inflammation in patients with symptomatic carotid artery stenosis☆

Abstract

Introduction

Section snippets

Methods

Baseline characteristics

Discussion

Conclusions

Sources of funding

Disclosures

Acknowledgments

Atherosclerosis

Blood

Int Immunopharmacol

Inflammation in atherosclerosis

Nature

Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines

Circulation

Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein

N Engl J Med

Immunomodulation of the inflammatory response in atherosclerosis

Curr Opin Lipidol

Atherogenesis in rheumatology

Lupus

Mechanisms of action of mycophenolate mofetil

Lupus

Mycophenolate mofetil (MMF): firing at the atherosclerotic plaque from different angles?

Cardiovasc Res

A Bayesian framework for the analysis of microarray expression data: regularized t-test and statistical inferences of gene changes

Bioinformatics

Gene set enrichment analysis: a knowledge-based approach for interpreting genome-wide expression profiles

Proc Natl Acad Sci USA

Interleukin-15 mediates T cell-dependent regulation of tumor necrosis factor-alpha production in rheumatoid arthritis

Nat Med

Low numbers of FOXP3 positive regulatory T cells are present in all developmental stages of human atherosclerotic lesions

PLoS One

Natural regulatory T cells control the development of atherosclerosis in mice

Nat Med