Telomerós, Envejecimiento y Prevención

Dr. Arturo Fernández- Cruz

Health demographic change and wellbeing

The economic crisis

Incidencia de IAM en población

de 25 a 74 años por sexos

1200 millones OMS

PREVEND

8074

JIM

Nov 2013

La medicina de las 4 Ps

•PREDICTIVA

•PREVENTIVA

•PERSONALIZADA

•PARTICIPATORIA

La detección temprana 90% de supervivencia

La detección tardía 10% de supervivencia

NEJM Modelo matemático 1980-2000 Reducción de los FRs Nuevos tratamientos Solo el 7% debido CABG o STENTs NEJM enero 2013

Progress in science

depends on new techniques,

new discoveries, and new

ideas probably in that order

Sydney Brenner

Tecnologías que crecen exponencialmente

Test genéticos a bajo coste Test de medición de Telomeros

Computadores-Bio-informática, Historia y archivos electrónicos

Técnicas de imagen TAC, RM (Colonoscopia virtual), “IPad”

Conexión por Internet, medicina on-line (visitas virtuales)

Redes Sociales

Mi tecnología favorita es el iPhone “digital medicine”

NUEVAS TECNOLOGÍAS

“senescent” cells

healthy

cell

50-70 divisions

healthy cells

are MORTAL

cancer

cell

cancer cells are

IMMORTAL unlimited divisions

Henrietta

Lacks

telomere telomere

Chromosome

(parent cell)

Telomeres are lost everytime that a cell divides

“the end-replication problem”

DNA is lost from the ends

Chromosome

(daughter cell #1)

Chromosome

(daughter cell #2)

An embryonary gene known as telomerase is able to elongate

telomeres to compensate excessive telomere loss during embryo

development.

This gene, telomerase, is silenced after birth … however …

Cancer cells manage to reactivate telomerase, thus escaping the mortal

fate of adult cells and becoming immortal.

TTAGGG TTAGGG

AATCCC AATCCC

genes telomeres

TTAGGG TTAGGG

AATCCC AATCCC

TTAGGG TTAGGG

AATCCC AATCCC

cell death

cell senescence

aging

TTAGGG TTAGGG

AATCCC AATCCC

genes telomeres

cancer

TTAGGG TTAGGG

AATCCC AATCCC

TTAGGG TTAGGG

AATCCC AATCCC

TTAGGG TTAGGG

AATCCC AATCCC

TTAGGG TTAGGG

AATCCC AATCCC

TTAGGG TTAGGG

AATCCC AATCCC

Telomere length as a biomarker of biological age & health status

Canela et al., PNAS (2007)

Telomere length predicts age & cognitive impairment Telomere length decreases with age

HT

Q

FIS

H

cancer (> 95% of cancers

activate telomerase)

high

Telo

mere

len

gth

disease

health

age

Telomeres, telomerase and aging

Human pathologies due to telomerase defects

dysqueratosis congenita (DKC1, Terc)

aplastic anemia (Terc, Tert)

idiophatic pulmonary fibrosis (Terc, Tert)

loss of the regenerative capacity of the skin

lungs, bone marrow…

Telomere length=Biomarker of aging?

Lower percentiles of telomere length=

higher risk of diseases (cardiovascular,

neurodegenerative, death by infections)

Telomere length measurements for individuals

Life Length´s partnership with:

Page 20 © 2014 Life Length. All rights reserved. Reproduction of this document or any portion thereof without prior written consent is prohibited.

Telomere Measurements for individuals

Your median telomere length is estimated to be normal compared to Life Length´s database population.

1. Your telomere length

Median Telomere Length: 9.2 Kb

< 7.8 78 – 8.5 8.2 – 13.7 13.7 – 15.3 > 15.3

VERY SHORT SHORT NORMAL LONG VERY LONG

Median Telomere Length (MTL) = 9.2 ± 0.3 Kb

You: 9.2 Kb

The adjacent graph shows a comparative analysis of the median telomere length in your sample compared with the control database.

Each line represents a specific percentage of our database.

For example, falling in the 75th percentile means that 25% of people of your age have a longer median telomere length than you.

It is therefore best if your sample falls into one of the higher bands.

2. Median telomere length – Comparison by age band and percentiles

20 30 40 50 60 70 80 90

Chronological age (years)

Me

dia

n t

elo

me

re

len

gth

(K

b)

16

15

14

13

12

11

9

8

95

90

75

50

25

10

05

%

3. Your estimated biological age

Estimated Biological Age: 55 years old Chronological Age: 50 years old

Value ± SD

Biological age based on chronological age and telomere length

Comparison of MTL per age group

Comparison of MTL against entire database (to find severe outliers)

Extract from actual evaluation

0

50

100

150

200

250

300

350

400

450

500

0 5 10 15 20 25 30 35 40

0

50

100

150

200

250

300

350

400

450

500

0 5 10 15 20 25 30 35 40

0

50

100

150

200

250

300

350

400

450

500

0 5 10 15 20 25 30 35 40

0

100

200

300

400

500

600

700

800

0 5 10 15 20 25 30 35 40

0

50

100

150

200

250

300

0 5 10 15 20 25 30 35 40

telo

me

re le

ngth

, kb

telomere length, kb

samples

Subject 49- Male 02/02/78 healthy

Subject 50- Male 22/09/77 medular aplasia, TERC mut

Subject 51- Male 17/05/78 healthy

Subject 52- Male 06/06/78 healthy

frequency

telomere length, kb

telomere length, kb

telomere length, kb

telomere length, kb

frequency

frequency

frequency

frequency

Subject 49

9.49 ± 2.81 kb

n=1951

Subject 50

5.7 ± 2.01 kb

n=1685

Subject 51

10.46 ± 3.28 kb

n=2796

Subject 52

10.06 ± 3.34 kb

n=4811

L5178Y-S

10.06 ± 3.34 kb

n=1408

0

5

10

15

20

subject 49 subject 50 subject 51 subject 52 L5178Y-S

% t

elo

me

res <

8 k

b

samples

n=1951

n=1685

n=2796 n=4811

n=1408

***

0

10

20

30

40

50

60

70

80

90

100

subject 49 subject 50 subject 51 subject 52 L5178Y-S

***

Telomere length as a diagnosis tool

Hospital

Vall d´Hebrón

Canela et al., unpublished

0 10 20 30 40 50 60 700

5

10

15

20

Mea

n t

elo

mer

e le

ngt

h (K

b)

Age (years)

0 10 20 30 40 50 60 700

10

20

30

40

50

60

% s

ho

rt t

elo

me

res

(<3

kb)

Age (years)

Telomere length measurements for individuals

% short telomeres detect more differences between individuals than average length

% short telomeres show higher dispersion as we age

% short telomeres are likely to reflect “way of living” (environment) or biological age

Bioactive food components can influence genetic and epigenetic events

associated with a host of disease processes

Trujillo E et al. J Am Diet Assoc 2006;106:403-413

Trujillo E et al. J Am Diet Assoc 2006;106:403-413

Dietary factors and the regulation of DNA methylation “CpG sites” 28 millones

S Horvad clock-watcher Nature April

2014 Nature 508,22:2014

Methylation

status

353 CpG sites

algorithm

Genetic tests: genes as risk factors for disease

INHERITED

Telomere tests: indication of the degree of aging

INHERITED ENVIRONMENT

MORE POWERFUL PREDICTIONS

OF RISKS AND TIME OF ONSET

# aging is the highest risk factor for all diseases

# telomere length integrates both inheritance & environmental factors EPIGENETICS

DEVELOPMENT OF

NEW TREATMENTS TO

PREVENT DISEASE

A NEW ERA in medicine?: Personalized & preventive medicine

Virus

Inflamación crónica

Factores genéticos

Envejecimiento celular – Estrés oxidativo: Integridad del telómero

Patogenia del cáncer

Inmortalización celular

Fallo en los mecanismos de

control

Telomere length and Cancer

The Association of Telomeres length and Cancer: a Meta-analysis

S A Savage et al Cancer Epidemiology Biomarkers Prev 20:1238,2011

Short Telomeres are associated with excess Cancer Incidence and mortality

A L Kamaroff JAMA 2010 july 7 P Willet JAMA 304:69, 2010

Fifteen year follow up of association between Telomere length and

incidence Cancer and Cancer mortality

JAMA 306:42,2011

Breast cancer: Familial breast cancer

BRCA1/BRCA2

BRCA1

Age (years)

Re

lati

ve

Te

lom

ere

len

gth

BRCA2

Age (years)

Re

lati

ve

Te

lom

ere

len

gth

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

10 20 30 40 50 60 70 80

BRCAX

Age (years)

Re

lati

ve

Te

lom

ere

len

gth

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

10 20 30 40 50 60 70 80

Sporadic BC

Age (years)

Re

lati

ve

Te

lom

ere

len

gth

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

10 20 30 40 50 60 70 80

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

10 20 30 40 50 60 70 80

A C

B D

More powerfull tools to predict risk factors and develop new treatments

Javier Benitez (CNIO)

MEDICINA PREDICTIVA

• BCR Gail mama BCRAs • BRACAPRO mama ovario • BOADICEA mama, ovario,

prostata, melanoma • PREMM colon • PULMON

Cancer genograma

Diabetes FINDRISK SCORE

Cribados

Telomeros

Genes

Can telomerase delay

aging pathologies?

Telomerase as an anti-cancer target (Imetelstat)

Phase II

Clinical trials

(breast, lung, prostate etc)

ratones

K5-mTert

No telomerase

Less

aging

Less

cancer

More cancer Premature aging

La telomerasa se expresa específicamente en células madre

telomerase

Telomere length

Tg telomerase

(epithelia)

Gonzalez-Suarez et al., Oncogene (2004)

Super p53

Super p16

Super p19ARF

Cancer

suppressors

+

SUPER-M

Linear regression:

WT: Slope=-7.03 ± 1.24 kb/year

R2=0.31 (Quadratic: R2=0.34)

p<0.0001

TgTERT: Slope=-7.05 ± 1.60 kb/year

R2=0.22 (Quadratic: R2=0.30)

p<0.0001

0.0 0.5 1.0 1.5 2.0 2.5 0

10

20

30

40

50

60

70

80

Age (years)

Me

an

te

lom

ere

len

gth

(kb)

Vera et al., Cell Reports, 2012

Mouse telomeres shorten 100-times faster than human telomeres

Humans: 70 bps/year

Mice: 7 Kb/year

Incre

ase

in t

he

% o

f

sh

ort

te

lom

ere

s (

pe

r m

on

th)

The increase in the % of short telomeres predicts individual mouse longevity

0 50 100 150 200-0.5

0.0

0.5

1.0

1.5

Lifespan (weeks)

WT: Slope=-0.005022 ± 0.002550

R2=0.2

p=0.06

TgTERT: Slope=-0.01267 ± 0.005604

R2=0.3

p=0.04

WT

TgTERT

WT

TgTERT

telomerase-deficient

wild-type

Blasco et al., Science (1995)

Blasco et al., Cell (1997)

Lee, Blasco, et al., Nature (1998)

González-Suarez et al., Nat Genet (2000)

González-Suarez et al., EMBO J. (2001)

Flores et al., Science (2005)

Telomerase-deficient mice (Terc-/-):

decreased regenerative capacity

due to stem cell dysfunction

less cancer

Super-telomerase mice (K5-Tert):

better tissue fitness

slightly more cancer

The role of telomerase in chromosome stability, cancer & aging

Tomás-Loba et al, Cell (2008)

SUPER Wild-type

Defeating aging with increased telomerase + tumor suppression

Increased “health span” & longevity in SUPER mice

Cancer-free survival Overall survival

0

20

40

60

80

100

0 60 80 100 120 140 160 180

Sp53 (n=25) SUPER (p=0.003; n=6)

su

rviv

al (%

)

age (weeks)

+50%

normales (n=25)

0

20

40

60

80

100

0 60 80 100 120 140 160 180

Sp53 (n=49)

SUPER (p<0.001; n=12)

su

rviv

al (%

)

age (weeks)

+40%

normal (n=49)

0

20

40

60

n=25

n=6

p=0.003

0

20

40

60

n=49

n=12

p<0.001

normal SUPER

Su

rviv

al

at

3 y

ea

rs (

%)

normal SUPER

Su

rviv

al

at

3 y

ea

rs (

%)

Tomás-Loba et al., Cell (2008)

He

alth

sp

an

Improved neuromuscular fitness

25000

30000

35000

40000

45000

glu

co

se

to

lera

nce

(A

UC

)

**

30-76 weeks

Glu

co

se

to

lera

nc

e (

AU

C)

n=5

n=3

wildtype SUPER

p=0.02

Improved glucose tolerance

0

25

50

75

100

125

Su

cc

es

s r

ate

(%

)

n=11

n=9

wildtype

p=0.02

n=8 n=10

SUPER

p=1

young (5-20 weeks) old (116-160 weeks)

Improved health late in life in SUPER mice

Tomás-Loba et al., Cell (2008)

SUPER-M wildtype

young (5-12 weeks)

old (123-165 weeks)

wildtype

Su

bc

uta

ne

ou

s f

at

laye

r (

m)

0

20

40

60

80

100

120

n=19

n=24

SUPER-M

n=11

n=61

Less skin aging in SUPER-M mice

Subcutaneous fat

old (123-165 weeks)

Tomás et al., Cell (2008)

Telomere length and ATHEROSCLEROSIS

Critical values of replicative senescence the “hayflic limit” vascular age

Circ Res 2006

Family History of CHD Heart 2008

European Atherosclerosis Reseach Study II J Mol Med July 2008

White cell telomere lenght and risk of premature AMI Atherosclerosis

Thromb Vasc Biol 2003 Lancet 2001 the WOSCOP study Lancet 2007

Tromboembolism

RY Zee… P Ridker Int J of Clinical Chemistry 2009; 406:148

Telomere length and preclinical ATHEROSCLEROSIS

Framingham Heart Study Arterioesclerosis Thromb Vac Biol May 2011

ASKLEPIOS STUDY European Heart Journal 2009 Obese man

Heart 2008 Carotid Atherosclerosis Hypertension 2004:43;182

Coronary Artery Disease Arterioesclerosis Thromb Vasc Biol 2004:24, 546

Calcium Score Atherosclerosis 2009

Vascular thrombosis RY Zee ..P Ridker 2013

Leukocyte and plaque telomere length in cases and controls.

Huzen J et al. Arterioscler Thromb Vasc Biol. 2011;31:1219-1225

Copyright © American Heart Association, Inc. All rights reserved.

X

LAD

ligation

Aging is not a disease…but there are many aging-associated diseases

preclinical model for cardiovascular disease

Normal heart

Failing heart

Failing heart Normal heart

PET – FDG uptake

Histopathology

AAV9-TERT

AAV9-empty

AAV9-TERT treatment protects 20% of the mice from death by infact

Bruno Bernardes de Jesus

Christian Bär

0 10 20 30 4040

60

80

100

AAV9-empty

AAV9-mTERT:

2x1012vg/m

No virus

Pe

rcen

t su

rviv

al

Hea

rt infa

rct

Days after myocardial infarction

n=35

n=37

n=21

p=0,07

74%

57%

FVB/N

0.0

0.5

1.0

1.5

0.0

0.5

1.0

1.5

Lo

ng

itu

din

al th

ickn

ess

(mm

)

Tra

nsvers

al th

ickn

ess

(mm

)

1 week

p=0.02 p=0.01

p=0.5

n=4

n=13

n=5 n=4

n=13

n=5

p=0.03 p=0.01

p=0.7

1 week

AAV9-empty

AAV9-mTERT:

2x1012vg/m

Sham (no myocardial infarction)

Echocardiography

Myocardial Infaction

AAV9-empty

SHAM

AAV9-mTERT: 2x1012vg/m

An AAV9-TERT treatment reduces scar formation upon infaction

Bruno Bernardes de Jesus

Christian Bär

Masson trichrome

Scar size/LV size, %

Nu

mb

er

of

mic

e

0

5

10

15

20

Mild Severe

Extremely severe

AAV9-

eGFP

AAV9-

mTERT

0

10

20

30

40

% o

f are

a

AAV9-

eGFP

AAV9-

mTERT

n=10

n=7

p=0.14

MI

AAV9-empty

AAV9-mTERT:

2x1012vg/m

0

50

100

150

200

me

an

sp

ot

inte

ns

ity /

nu

cle

us

(a

.u.)

mean 52.33 a.u.

(1850 nuclei) mean 64.98 a.u.

(1968 nuclei)

124% of AAV9 empty

p<0.0001

0

50

100

150

me

an

sp

ot

inte

ns

ity /

nu

cle

us

(a

.u.)

mean 40.08 a.u.

(2455 nuclei) mean 44.85 a.u.

(3096 nuclei)

112% of AAV9 empty

p<0.0001

AAV9-empty (n=4)

AAV9-mTERT (n=4)

(2x1012vg/m)

cardiomyocytes fibroblasts (infarct area)

AAV9-TERT treated mice show longer telomeres in heart after infaction

Bruno Bernardes de Jesus

Christian Bär

Telomere length and Diabetes

Association of Telomere shortening with IGT and DM2 macroangiopathy

Atherosclerosis Nov 2007

Accelerated senescence in the kidneys of patients with DM2 nephropathy

American J of Physiology 2008 DM2

Microalbuminuria Diabetes Care 2007;30:2909 Diabetologia 2006

Leukocyte Telomere shortening in elderly type 2 DM with previous AMI

Atherosclñerosis 2009

Association of Telomere length with type 2 DM oxidative stress and

UCP2 gene variation Atherosclerosis 2010

DNA damage. Diabetes Care 2006

Challenge: Individualized Risk Assessment

in Low- and Intermediate Risk Individuals

Algorithms

Neural

Network

MSCT, MRT, PET

Telomeres

And

Genes of

clinical

relevance

Lp(a) PLA2

CRP, BNP

Apo A-, HDL 2b

ApoB

Phytosterols

Metabolic syndrome

Other

CONFIDENTIAL

Rupture-Prone Plaques may not be Severely Stenosed

but are Inflamed with Thin Fibrous Caps

Early Plaque

with Lipid Pool

Thick Cap with Small

Necrotic Lipid Core

“Stable Plaque”

Thin Cap

“Rupture-Prone”

Plaque

Ruptured Plaque

with Thrombus

in Lumen

Adapted from Kolodgie F, et al. Arterioscler Thromb Vasc Biol 2006.

CARE PATHWAY FOR CARDIOVASCULAR RISK CLINIC

Cardiology REFERRAL

General Practice

05

1015202530

Ave Patient

10

yr

CV

D r

isk

Genetic CRF

CLINIC VISIT

Retest

Genetics

Telomeros

Results

RISK SCORE

Clinical Chem

T-Chol/HDL/TG

Lp(a)? etc?

Results

RISK SCORE + BMI/BP/Smoke

Carotid Coronaries

ACTION PLAN

Blood Pressure

Lowering

Lipid

Lowering

Smoking

Cessation

Weight

Loss

GPs -Specialist

Referral

Cardiology

Referral

Patient Appointment

Saliva sample request + Informed consent

Monitoring other effects than LDL: where do we stand ?

Statin may reduce the rate at which Telomeres shorten

Lancet 2001 2007 Jan 13

Omega-3 fatty acid supplementation reduces Telomere shortening in the cognitively

impaired J of Nutrition October 22 2013

Omega-3 fatty acids, oxidative stress and leukocyte Telomere length- A randomized

controlled trial E, Balackburn et al Brain Behavior Immunity Sept 2012

Longitudinal association of Telomere length and Obesity indices in an Intervention Study

with Mediterranean Diet the PREDIMED-NAVARRA trial S Garcia-Calzon International

Journal of Obesity 2014, 38:177

Paula Martínez, Gonzalo Gómez-López, Fernando García, Evi Mercken, Sarah Mitchell,

Juana M. Flores, Rafael de Cabo, Maria A. Blasco. RAP1 Protects from Obesity through

Its Extratelomeric Role Regulating Gene Expression. Cell Reports, 2013; DOI: 1-

Metabolic Syndrome PREVEND study JIM Nov 2013

The association between Physical Activity in Leisure time and leukocite Telomere

lenght

LF Cherkas Arch Intern Med 2008;168:154. Lancet oncology Sep 2013

Stress can shorten Telomere in chilhood Nature 17 may2011

Telomere length and Aging related to Depression?

Molecular Psychiatry Nov 12 2013 Biol Psychiatry 2012 ;15:294

CORRELATION BETWEEN IMT AND EPC LEVELS IN PATIENTS WITH METABOLIC SYNDROME

0

1

2

3

4

5

6

7

8

9

0,2 0,4 0,6 0,8 1 1,2

GIM

EP

Cs

Ta

rdía

s (

%)

CD

34

+/V

E-c

ad

he

rin

a+

(%

) r = - 0,169

P = 0,017

IMT (mm)

Telomerase activation

(with smal molecules)

Telomerase activation with a nutritional supplement

Infancy/youth/adulthood aging

cancer cardiovascular

diabetes

renal disease

immunosenescence

neurodegeneration

etc…

telomere loss

consequences

Interventions

(ie, TERT)

aging

cancer cardiovascular

diabetes

renal disease

immunosenescence

neurodegeneration

etc…

Infancy/youth/adulthood

Understanding the molecular basis of aging to prevent disease

genetic &

environmental

Everything will be alright in

the end

and if it’s not alright

it’s not the END

Muchas Gracias

Gastamos mas en armamentos que en la Prevención