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The German Centre for Cardiovascular Research (DZHK) is one of the German Centres for Health Research and aims to conduct early and guideline-relevant studies to develop new therapies and diagnostics that impact the lives of people with cardiovascular disease. Therefore, DZHK members designed a collaboratively organised and integrated research platform connecting all sites and partners. The overarching objectives of the research platform are the standardisation of prospective data and biological sample collections among all studies and the development of a sustainable centrally standardised storage in compliance with general legal regulations and the FAIR principles. The main elements of the DZHK infrastructure are web-based and central units for data management, LIMS, IDMS, and transfer office, embedded in a framework consisting of the DZHK Use and Access Policy, and the Ethics and Data Protection Concept. This framework is characterised by a modular design allowing a high standardisation across all studies. For studies that require even tighter criteria additional quality levels are defined. In addition, the Public Open Data strategy is an important focus of DZHK. The DZHK operates as one legal entity holding all rights of data and biological sample usage, according to the DZHK Use and Access Policy. All DZHK studies collect a basic set of data and biosamples, accompanied by specific clinical and imaging data and biobanking. The DZHK infrastructure was constructed by scientists with the focus on the needs of scientists conducting clinical studies. Through this, the DZHK enables the interdisciplinary and multiple use of data and biological samples by scientists inside and outside the DZHK. So far, 27 DZHK studies recruited well over 11,200 participants suffering from major cardiovascular disorders such as myocardial infarction or heart failure. Currently, data and samples of five DZHK studies of the DZHK Heart Bank can be applied for.
Abstract
Aims
Treating patients with acute decompensated heart failure (ADHF) presenting with volume overload is a common task. However, optimal guidance of decongesting therapy and treatment targets are not well defined. The inferior vena cava (IVC) diameter and its collapsibility can be used to estimate right atrial pressure, which is a measure of right‐sided haemodynamic congestion. The CAVA‐ADHF‐DZHK10 trial is designed to test the hypothesis that ultrasound assessment of the IVC in addition to clinical assessment improves decongestion as compared with clinical assessment alone.
Methods and results
CAVA‐ADHF‐DZHK10 is a randomized, controlled, patient‐blinded, multicentre, parallel‐group trial randomly assigning 388 patients with ADHF to either decongesting therapy guided by ultrasound assessment of the IVC in addition to clinical assessment or clinical assessment alone. IVC ultrasound will be performed daily between baseline and hospital discharge in all patients. However, ultrasound results will only be reported to treating physicians in the intervention group. Treatment target is relief of congestion‐related signs and symptoms in both groups with the additional goal to reduce the IVC diameter ≤21 mm and increase IVC collapsibility >50% in the intervention group. The primary endpoint is change in N‐terminal pro‐brain natriuretic peptide from baseline to hospital discharge. Secondary endpoints evaluate feasibility, efficacy of decongestion on other scales, and the impact of the intervention on clinical endpoints.
Conclusions
CAVA‐ADHF‐DZHK10 will investigate whether IVC ultrasound supplementing clinical assessment improves decongestion in patients admitted for ADHF.
Viral diseases are a threat to bacteria and enormous animals alike. Vaccines are available against several viruses. However, for some viruses, like ASFV, we still lack vaccines, while for others, like IAV, they are not as effective as we need them to be. To a large extent, this is because we do not fully understand the mechanisms conferring antiviral immunity. To improve our understanding of antiviral immunity, we used a model species that is in many immunological aspects closer to humans than the widely used laboratory mice, pigs. In this thesis, pigs were investigated as a potential biomedical model species for viral respiratory infections in humans and as a natural host for viral infections. Both approaches provide valuable insights into aspects of porcine immunology that can either be used as the foundation for translational research or for the design of targeted therapeutics and vaccines for pigs.
Insights into fundamental characteristics of the porcine immune system form the basis for translational studies. Paper I pioneered a detailed characterization of porcine iNKT cells. To make pigs and porcine iNKT cells more available for scientific investigations, we established multicolor flow cytometry analysis platforms that allow for a more detailed investigation of these cells than previously possible. We found porcine iNKT cells circulating in peripheral blood to be a rare population among CD3+ lymphocytes that displays a pre-activated effector state and can be divided into at least three functional subsets. Upon antigenic activation, they proliferated rapidly, secreted pro-inflammatory cytokines, and exerted cytotoxicity. Moreover, we provided first evidence for a role of iNKT cells in porcine IAV and ASFV infections, which we investigated in more detail in paper IV. Central characteristics, i.e., phenotype and functional properties, exhibit a high degree of similarity between humans and pigs. Moreover, differences between human and murine iNKT cells are more pronounced than between humans and pigs.
Based on the results obtained in paper II, the established biomedical model could be used for further studies of infectious respiratory diseases. IAV infections pave the way for secondary co-infections with increased morbidity and lethality. These bactoviral co-infections are a threat to both pigs and humans. The shared susceptibility as well as homologies on the physiological and immunological level make pigs exceptionally suitable animal models for studies of these infections. Paper I and II can also be interpreted under translational aspects. Activation of iNKT cells in porcine vaccination studies showed promising results. Based on these and our findings, this might be a suitable approach for humans as well. Along with other studies, our results suggest that pigs might be a well-suited large animal model for research in infectious diseases. This is true especially for respiratory infections, such as seasonal IAV infections, for which pigs are natural hosts and contribute to viral spread and emergence as “mixing vessels”, which can result in pandemic strains like H1N1pdm09. We could show that porcine iNKT cells as well as the antiviral responses of cTC against H1N1pdm09 in pigs are comparable to human cells and processes. The increased implementation of pigs in basic and applied research might enable an improved translation of scientific knowledge to human and veterinary medicine.
In two further studies, papers III and IV, we investigated T-cell responses during a viral infection, ASF, for which pigs are the only natural hosts. Immune responses were similar after highly and moderately virulent ASFV infection in domestic pigs and wild boar, respectively. However, they differed between both species. Antiviral immunity in domestic pigs was predominantly exerted by αβ T cells, CD8α+ and DP αβ T cells, while the response in wild boar was dominated by γδ T cells, mainly CD8α+ effector cells. Since wild boar show a higher disease severity and lethality, even during infection with moderately virulent ASFV “Estonia2014”, a shift to γδ T cells seems to be detrimental. In contrast, domestic pigs survive infections with moderately virulent ASFV “Estonia2014”, which indicates that CD8α+ or DP αβ T cells confer protection at least in infections with non-highly virulent ASFV strains. Interestingly, in paper V we found higher and prolonged inflammation in domestic pigs, correlating with increased T-cell influx. However, histopathological analyses revealed no direct explanation for the differences in disease progression and lethality in domestic pigs and wild boar. These findings require further studies to elucidate the underlying mechanisms.
The lack of basic data about immunological differences between domestic pigs and wild boar hampers attempts to understand immunity against ASFV. We found differences between both suid subspecies already at steady state and even more prominent during ASFV infections in papers III-V. Most apparently, T-cell responses in wild boar were heavily biased towards γδ T cells, while immune responses in domestic pigs were based on αβ T cells. However, information about even basic characteristics, like the composition, phenotypes, and functional qualities of wild boar’s immune system, is missing. Therefore, essential baseline data must be obtained in order to adequately assess changes in future studies.
Analyses like these reveal major advantages of pigs as a biomedical model. On the one hand, similar to conventional model species, researchers can investigate every tissue at any desired time. Tissue from human patients is often scarce or not at all available, so models that can be investigated at specific times after infection are needed. On the other hand, results obtained in pigs are more comparable to humans than data from murine studies. Moreover, pigs are susceptible to similar pathogens as humans and experimental infections can be investigated without the need for major genetic manipulations. However, there are also limitations of the porcine model system. Analysis tools are not as advanced as they are for mice, especially in terms of availability of mAbs or genetically modified organisms. Still, given the major advantages that become more and more obvious, efforts should be made to make pigs more applicable for basic and translational research. In addition, findings derived from pigs can be used for the species itself. Pigs are a major livestock species and new treatments, or vaccines could also be used for them. Therefore, this research could eventually also improve animal welfare.
In summary, the presented thesis significantly enhanced our knowledge of porcine immune processes for cTC in general and iNKT cells in particular. Results were obtained both at steady state and in the context of IAV and ASFV infections, and thus, made pigs more available as a model for future research. The use of multicolor flow cytometry provided a broad overview of the ongoing immune reactions and enables further, more wide-ranging studies that can also address open questions in even more complex infection scenarios.