Connecting the dots: Gouty arthritis, clonal haematopoiesis and myeloid activation, in a unified inflammation model for atherosclerosis progression.

Clonal hematopoiesis (CH) of indeterminate potential (CHIP) is a risk factor for cardiovascular disease. The relationship between CHIP and coronary microvascular dysfunction (CMD) is unknown. The current study examines the association between CHIP and CH with CMD and the potential relationships in risk for adverse cardiovascular outcomes. In this retrospective observational study, targeted next-generation sequencing was performed for 177 participants with no coronary artery disease who presented with chest pain and underwent routine coronary functional angiogram. Patients with somatic mutations in leukemia-associated driver genes in hematopoietic stem and progenitor cells were examined; CHIP was considered at a variant allele fraction ≥2%; CH was considered at a variant allele fraction ≥1%. CMD was defined as coronary flow reserve to intracoronary adenosine of ≤2. Major adverse cardiovascular events considered were myocardial infarction, coronary revascularization, or stroke. A total of 177 participants were examined. Mean follow-up was 12±7 years. A total of 17 patients had CHIP and 28 had CH. Cases with CMD (n=19) were compared with controls with no CMD (n=158). Cases were 56±9 years, were 68% women, and had more CHIP (27%; P=0.028) and CH (42%; P=0.001) than controls. CMD was associated with independent risk for major adverse cardiovascular events (hazard ratio, 3.89 [95% CI, 1.21-12.56]; P=0.023), and 32% of this risk was mediated by CH. The risk mediated by CH was ≈0.5× as large as the direct effect of CMD on major adverse cardiovascular events. In humans, we observe patients with CMD are more likely to have CHIP, and nearly one-third of major adverse cardiovascular events in CMD are mediated by CH.

TET2-mutant clonal hematopoiesis and risk of gout

Introduction: Patients with chronic kidney disease (CKD) are at substantially increased risk of dementia. Clonal hematopoiesis of indeterminate potential (CHIP), caused by clonal expansion of blood cells with somatic mutations in certain driver genes, is an established risk factor for cardiovascular diseases, including cerebral vascular disease. In contrast, CHIP was recently shown to be associated with a decreased risk of Alzheimer’s disease. Given emerging evidence of a key role of vascular compared to neurodegenerative mechanisms in CKD-related dementia, the relation of CHIP with cognitive decline in CKD patients needs clarity. We investigated the prospective associations of CHIP with cognitive impairment in a cohort of patients with CKD. Methods: Our study included 1989 participants aged 65 years or older from the Chronic Renal Insufficiency Cohort. Participants underwent high-depth targeted gene sequencing to ascertain CHIP status. Cognitive function was assessed by four cognitive tests (see Table ). For each test, incident cognitive impairment was defined as a test score one standard deviation worse than the baseline group mean. Sequential Cox proportional hazards models tested associations between CHIP and cognitive impairment after adjusting for demographics (model 1), clinical measures (model 2), and APOE genotype in a subset with available data (model 3). Results: CHIP carriers were significantly less likely to experience impairment in attention (Trails A) and executive function (Trails B) in our fully adjusted models ( Table ). There were no significant associations between CHIP and impairment in global cognition (3MS) or verbal memory (Buschke). There were no differences in the associations of CHIP with cognitive impairment across sex or race groups (data not shown). Conclusions: In patients with CKD, we observed markedly reduced risks of impairment in cognitive domains of attention and executive function. Further studies are needed to confirm our findings and evaluate mechanisms of these relations.

Monosodium urate (MSU) crystals increase gout associated coronary heart disease (CHD) risk through the activation of NLRP3 inflammasome

Background. Patients (pts) with metastatic triple negative breast cancer (mTNBC) receive serial cytotoxic chemotherapy regimens, often with cumulative myelosuppressive effects, impairing treatment tolerance. Clonal hematopoiesis of indeterminate potential (CHIP) refers to the detection of somatic mutations in genes recurrently mutated in hematologic malignancies in the blood of adults with no evident hematologic abnormalities. Little is known about the natural history of CHIP after breast cancer treatment. We sought to characterize CHIP in pts undergoing treatment for mTNBC. Methods. In this retrospective cohort study we identified 149 pts with biopsy-proven mTNBC at a single tertiary care institution with at least one blood sample collected within six months of metastatic diagnosis. We performed targeted sequencing of cryopreserved peripheral blood mononuclear cell (PBMC)-derived genomic DNA and defined CHIP as the presence of at least one pathogenic somatic mutation present at variant allelic fraction (VAF) of 0.02-0.35. We assessed the relationship between CHIP status and overall survival (OS), demographics, clinicopathologic features, germline mutation status, and type and timing of therapy. Results. We identified 27 unique CHIP variants across 22/149 pts (15%) within six months of metastatic diagnosis. Frequency of mutated genes were as follows: DNMT3A (n=15), PPM1D (n=4), TP53 (n=3), TET2 (n=2), SRCAP (n=1), ZBTB33 (n=1), ZNF318 (n=1). Median follow-up in the cohort was 37.9 months (IQR: 23.9-Not reached). The median age at time of blood draw was 55 years (IQR: 8.5) for pts with CHIP vs. 51 years (IQR: 16.5) for pts without CHIP. Ten (45%) pts with CHIP and 47 (37%) pts without CHIP were current or former smokers. Two (9%) pts with CHIP and 10 (7.9%) pts without CHIP were known germline mutation carriers of BRCA1, BRCA2 or PALB2. Twenty-two (100%) pts with CHIP and 124 (98%) pts without CHIP had received systemic chemotherapy for mTNBC prior to blood draw. There were no significant differences in type of chemotherapy regimen received between patients with or without CHIP. Twenty (90.9%) pts with CHIP vs. 96 (75.6%) of pts without CHIP had received radiation therapy prior to blood draw. Pts with CHIP had similar OS to those without CHIP (median OS 7.75 [2.20-31.7] vs. 9.33 [8.02-11.73] months). No pts developed therapy-related myeloid neoplasms (t-MN) or died of complications of cardiac disease. Conclusions. Pts with mTNBC had a higher frequency of CHIP than previously reported in age-matched healthy populations, but similar CHIP prevalence to what has been seen in cohorts of pts with solid tumors. Our study assessed for the presence of CHIP at only a single time point early in the metastatic course, but serial blood sampling later in treatment might reveal additional cases of CHIP. Though this cohort of patients with life-limiting mTNBC was small, presence of CHIP in the first six months of metastatic diagnosis was not associated with worse survival. Citation Format: Katheryn Santos, Qingchun Jin, Peter G. Miller, Ashka Patel, Gregory J. Kirkner, Janet L. Files, Melissa E. Hughes, Samantha M. Stokes, Nabihah Tayob, Daniel G. Stover, Christopher J. Gibson, Eric P. Winer, Nancy U. Lin, Judy E. Garber, Heather A. Parsons. Clonal hematopoiesis of indeterminate potential (CHIP) in metastatic triple negative breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-08-01.

Introduction: Clonal hematopoiesis of indeterminate potential (CHIP) is an age-related disorder associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). Mechanistic studies of CHIP implicate inflammatory pathways underlying this relationship. Although inflammation is a well-established component of chronic kidney disease (CKD), linked to both CKD progression and ASCVD in CKD patients, CHIP has not been investigated in a CKD setting. Objective: To estimate the prevalence of CHIP in patients with CKD and to examine the cross-sectional associations between CHIP and biomarkers that were previously related to CKD progression and ASCVD among CKD patients. Methods: The current study was conducted among 598 Chronic Renal Insufficiency Cohort (CRIC) study participants with whole-exome sequencing data and baseline measures of fibrinogen, interleukin (IL)-6, serum albumin, and tumor necrosis factor-α. CHIP was detected from sequencing data using MuTect2. CHIP was defined as the presence of a somatic hematologic malignancy-associated mutation with a variant allele frequency (VAF) of at least 2%. CHIP was also categorized ordinally by clone size as no CHIP, small CHIP clone (VAF<10%), and large CHIP clone (VAF ≥10%). Ordinal logistic regression was used to test associations of CHIP with each biomarker in age- and multivariable-adjusted models. Multivariable models adjusted for age, sex, ancestry, body mass index, estimated glomerular filtration rate, systolic blood pressure, low-density lipoprotein cholesterol, fasting plasma glucose, and blood pressure, lipid, and glucose lowering medications. Results: CHIP was detected in a total of 28 individuals from the WES study (4.7%). Among those 70 years of age and older, we detected a CHIP prevalence of nearly 16%. As expected, participants with CHIP were older than those without CHIP (mean age: 67 and 58 years, respectively; P<0.0001). Other demographic and clinical variables were similar between groups . Age-adjusted models showed strong associations between CHIP and both fibrinogen and IL-6 with odds ratios of 2.49 (95% CI: 1.09, 5.71) and 2.45 (95% CI: 1.05, 5.72), respectively. After multivariable adjustment, only fibrinogen remained associated with CHIP with an odds ratio of 4.70 (95% CI: 1.69, 13.0). Consistent with these findings, there was a strong dose-dependent association between CHIP clone size and fibrinogen in multivariable adjusted analyses (P for linear trend=0.009). Compared to those without CHIP, odds ratios for higher fibrinogen tertile were 3.0 (95% CI: 0.84, 11.3) and 4.7 (95% CI: 1.29, 16.7) among those with small and large CHIP clone sizes, respectively. Conclusions: CHIP prevalence was higher among CKD patients in the current study compared to previous estimates from the general population. Furthermore, a strong, dose-dependent association between CHIP and fibrinogen was identified.

Clonal hematopoiesis (CH) of indeterminate potential (CHIP), driven by somatic mutations in leukemia-associated genes, confers increased risk of hematologic malignancies, cardiovascular disease, and all-cause mortality. In blood of healthy individuals, small CH clones can expand over time to reach 2% variant allele frequency (VAF), the current threshold for CHIP. Nevertheless, reliable detection of low-VAF CHIP mutations is challenging, often relying on deep targeted sequencing. Here, we present UNISOM, a streamlined workflow for enhancing CHIP detection from whole-genome and whole-exome sequencing data that are underpowered, especially for low VAFs. UNISOM utilizes a meta-caller for variant detection, in couple with machine learning models which classify variants into CHIP, germline, and artifact. In whole-exome sequencing data, UNISOM recovered nearly 80% of the CHIP mutations identified via deep targeted sequencing in the same cohort. Applied to whole-genome sequencing data from Mayo Clinic Biobank, it recapitulated the patterns previously established in much larger cohorts, including the most frequently mutated CHIP genes and predominant mutation types and signatures, as well as strong associations of CHIP with age and smoking status. Notably, 30% of the identified CHIP mutations had < 5% VAFs, demonstrating its high sensitivity toward small mutant clones. This workflow is applicable to CHIP screening in population genomic studies. The UNISOM pipeline is freely available at https://github.com/shulanmayo/UNISOM and https://ngdc.cncb.ac.cn/biocode/tool/7816.

Gouty arthritis is a common metabolic disorder characterized by the deposition of monosodium urate (MSU) crystals in joints. Aberrant activation of the NLRP3 inflammasome is a key driver of MSU-induced joint inflammation, making it a promising therapeutic target for gouty arthritis. Gnetum montanum Markgr. has long been used in traditional medicine in parts of Asia to treat gout; however, its effects on gout-specific inflammatory responses have not been fully elucidated. In this study, we used two cell models, including MSU-stimulated mouse primary peritoneal and THP1 derived macrophages, in combination with western blot analysis, enzymatic activity assays, ELISA method, and flow cytometry analysis to evaluate the protective effect of G. montanum extract (GME) against MSU-driven inflammation. A mouse model of MSU-induced paw edema was then employed to validate the in vivo anti-inflammatory efficacy. We found that GME alleviated gouty inflammation by inhibiting NLRP3 inflammasome activation in mouse peritoneal and human THP-1 macrophages. GME also protected macrophages from MSU-induced pyroptosis, a pro-inflammatory form of programmed cell death. Mechanistically, GME suppressed xanthine oxidase (XO) activation triggered by MSU crystals, resulting in decreased reactive oxygen species (ROS) production. This reduction in ROS prevented the upregulation of thioredoxin-interacting protein (TXNIP), a key mediator that binds to and activates NLRP3. Furthermore, oral administration of GME in mice attenuated MSU-induced paw inflammation, likely through downregulation of XO-driven oxidative stress and NLRP3 inflammasome signaling. These findings suggest that GME effectively modulates gout-specific inflammatory pathways and warrants further investigation of GME as a potential therapeutic candidate for gouty arthritis.

Gouty arthritis (GA) is an inflammatory arthritic disorder that is characterized by intense, acute inflammatory responses, such as synovitis and arthritis that occur due to articular deposition of monosodium urate (MSU) crystals. This study has compared the therapeutic potentials of either Berberine (BERB) or Paracetamol (Para) on MSU-induced inflammation in rat model of Gouty arthritis (GA). GA was induced by “intra-articular” injection of MSU suspension (20 mg/ml) inside the knee joint of the rat’s right limb. Circumference was measured at 48 h after MSU injection and 14 days post-treatment with BERB or Para. Gait assessment was conducted. Histopathological alterations of knee and paw (ankle) joint tissue were investigated. Serum levels of Malondialdehyde (MDA), monocyte chemotactic protein 1 (MCP-1), Vascular endothelial growth factor (VEGF), and prostaglandin E2 (PGE2) were estimated. Molecular analysis of Elastase, Cyclooxygenase-2 (COX-2), Matrix metalloproteinase-9 (MMP-9), and Myeloperoxidase (MPO) was evaluated. In addition, DNA fragmentation assay was performed. Our results revealed that deposition of MSU crystals in the articular joints provoked an inflammatory response, oxidative stress, and DNA fragmentation (apoptosis). However, the oral treatment of MSU-induced rats with either BERB (50 mg/kg/day) or Para (50 mg/kg/day) for 14 days mitigated MSU-stimulated inflammation and arthritis as represented by the behavioral, histopathological, biochemical, and molecular levels. Treatment of MSU-induced arthritic rats with BERB or Para attenuated oedema and alleviated histological signs of acute inflammation. In addition, treatment decreased chemokine levels and reduced MDA levels. These results indicated that BERB and Para exerted strong anti-inflammatory, anti-oxidative, and anti-apoptotic activities against GA.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-16622-0.

Premature menopause is an independent risk factor for cardiovascular disease in women, but mechanisms underlying this association remain unclear. Clonal hematopoiesis of indeterminate potential (CHIP), the age-related expansion of hematopoietic cells with leukemogenic mutations without detectable malignancy, is associated with accelerated atherosclerosis. Whether premature menopause is associated with CHIP is unknown. We included postmenopausal women from the UK Biobank (n=11 495) aged 40 to 70 years with whole exome sequences and from the Women's Health Initiative (n=8111) aged 50 to 79 years with whole genome sequences. Premature menopause was defined as natural or surgical menopause occurring before age 40 years. Co-primary outcomes were the presence of any CHIP and CHIP with variant allele frequency >0.1. Logistic regression tested the association of premature menopause with CHIP, adjusted for age, race, the first 10 principal components of ancestry, smoking, diabetes, and hormone therapy use. Secondary analyses considered natural versus surgical premature menopause and gene-specific CHIP subtypes. Multivariable-adjusted Cox models tested the association between CHIP and incident coronary artery disease. The sample included 19 606 women, including 418 (2.1%) with natural premature menopause and 887 (4.5%) with surgical premature menopause. Across cohorts, CHIP prevalence in postmenopausal women with versus without a history of premature menopause was 8.8% versus 5.5% (P<0.001), respectively. After multivariable adjustment, premature menopause was independently associated with CHIP (all CHIP: odds ratio, 1.36 [95% 1.10-1.68]; P=0.004; CHIP with variant allele frequency >0.1: odds ratio, 1.40 [95% CI, 1.10-1.79]; P=0.007). Associations were larger for natural premature menopause (all CHIP: odds ratio, 1.73 [95% CI, 1.23-2.44]; P=0.001; CHIP with variant allele frequency >0.1: odds ratio, 1.91 [95% CI, 1.30-2.80]; P<0.001) but smaller and nonsignificant for surgical premature menopause. In gene-specific analyses, only DNMT3A CHIP was significantly associated with premature menopause. Among postmenopausal middle-aged women, CHIP was independently associated with incident coronary artery disease (hazard ratio associated with all CHIP: 1.36 [95% CI, 1.07-1.73]; P=0.012; hazard ratio associated with CHIP with variant allele frequency >0.1: 1.48 [95% CI, 1.13-1.94]; P=0.005). Premature menopause, especially natural premature menopause, is independently associated with CHIP among postmenopausal women. Natural premature menopause may serve as a risk signal for predilection to develop CHIP and CHIP-associated cardiovascular disease.

Clonal hematopoiesis of indeterminate potential (CHIP) is defined by the age-dependent accumulation of somatic leukemia-associated driver mutations in hematopoietic stem cells, in individuals with normal blood counts and with absence of an underlying myeloid neoplasm (MN).1, 2 CHIP is associated with an increased risk of developing MN and an increased all-cause mortality, largely due to cardiovascular disease.3 The presence of CHIP prior to receiving chemotherapy and radiation has been associated with therapy related MN (T-MN), such as myelodysplastic syndromes (MDS) and acute myeloid leukemia.4 Autologous stem cell transplantation (ASCT) is an effective treatment modality for managing higher-risk patients with non-Hodgkin's lymphoma (NHL) and multiple myeloma (MM). In a seminal NHL study, 30% of patients were found to have CHIP at the time of ASCT, with the presence of CHIP being associated with an increased rate of T-MN (10-year cumulative incidence of 14.1% vs 4.3%) and an inferior overall survival (10 year OS 30.4% vs 60.9%).5 In MM, targeted sequencing of 629 patients prior to ASCT detected CHIP in 21.6% of patients, with the presence of CHIP strongly associating with inferior OS (HR 1.34, p = .02) and an inferior progression-free survival (PFS, HR 1.45, p < .001). Interestingly, in this study, adverse CHIP-associations were apparently overcome by lenalidomide maintenance therapy.6 Unlike in NHL, CHIP in MM was not associated with T-MN; while lenalidomide maintenance therapy, independent of the presence or absence of CHIP, was associated with T-MN (p = .047) and second primary malignancies (SPM).6 We carried out this study to assess the prevalence and prognostic impact of CHIP in a relatively uniform cohort of MM patients at the time of ASCT, with all patients going on to receive lenalidomide maintenance therapy. Successive MM patients who consented to have their pre-ASCT bone marrow (BM) sample collected and who underwent first ASCT at Mayo Clinic, followed by lenalidomide maintenance therapy, were included in the study. The BM mononuclear cell DNA from pre-ASCT samples was extracted after excluding CD38/CD138+ (negative selection) plasma cells and then subjected to targeted NGS testing (42-myeloid related genes) by previously described methods.7 All patients were closely followed for the development of T-MN as defined by the 2016 WHO criteria, arterial and venous thromboembolism (VTE) and SPM.8, 9 Response to therapy was assessed using the international myeloma working group (IMWG) consensus criteria 2016.10 Statistical methods are highlighted in the supplemental material. Clonal hematopoiesis was detectable in 23 (23%) of 101 MM patients assessed in the study (Table S1, Figure S1). Clinical characteristics, MM risk stratification, median number of prior therapies, response to therapy, ASCT conditioning regimens, engraftment data, day +100 post ASCT outcomes and median duration of lenalidomide maintenance are outlined in Table 1. Except for a higher median age at MM diagnosis in MM patient with CHIP (p = .002), there were no other significant differences between the two groups (Figure S2). Ten (43.5%) patients in the MM CHIP group and 30 (38.0%) in the MM no CHIP group, received alkylatingagent-based induction therapy prior to ASCT (p = .66). Melphalan 200 mg/m2 conditioning was used in 87.1% of patients (95.7% in the CHIP vs 84.6% in the no CHIP group, p = .45), while the remainder received melphalan 140 mg/m2 conditioning. The median duration of lenalidomide maintenance therapy was 21 months (10–36); 16 months in MM patients with CHIP and 22 months in MM patients without CHIP (p = .76), with the median lenalidomide dose being 15 mg (range 10–15 mg; 10 mg in the CHIP group and 15 mg in the no CHIP group, p = .08). The most frequent CHIP mutations encountered included DNMT3A [52%; median variant allele frequency (VAF) 9.0%, range 2.0%–29.2%], TET2 (26%; median VAF 3.0%, range 2.0%–4.8%), followed by TP53, PPM1D and BRAF (10.0% each), respectively (Figures 1(A) and S1). Sixteen patients (69.6%) had one mutation, while seven (30.4%) had >1 mutation and two patients had four mutations each (Figure 1(B)). Eight (66.6%) of 12 patients with DNMT3A mutations had nonsynonymous missense mutations, while four had deletion variants: with no patient harboring the commonly mutated DNMT3A R882 hot spot. There were no statistically significant differences in CHIP mutation distribution, including TP53 and PPM1D mutations, between MM CHIP patients that received alkylating-agent based induction therapy prior to ASCT, vs MM CHIP patients that did not (Figure 1(C)). At last follow up, 70 (69.3%) relapses after ASCT and 41 (40.6%) deaths were documented. Twenty-nine patients (28.7%) were on salvage therapy whereas 13 (12.9%) were on lenalidomide maintenance and 14 (13.8%) were on observation alone, with no statistically significant differences between MM patients with CHIP vs MM without CHIP. Rates of VTE were similar between MM patients with CHIP (30%) and those without CHIP (24%), with similar rates of provoked thromboses (33% vs 29%, p = .4). Thromboses were diagnosed in typical locations in individuals with CHIP including seven lower extremity deep vein thromboses (DVT) and two pulmonary emboli (PE). In contrast, a variety of VTE locations were diagnosed in those without CHIP, including 10 lower extremity DVT, three PE, one DVT with PE, two upper extremity DVT and one portal vein thrombosis. There was a distinction in VTE timing with regards to lenalidomide use between MM patients with CHIP and those without CHIP. For MM patients with CHIP, 2/9 (22.2%) VTE occurred while on lenalidomide, 2/9 (22.2%) occurred prior to lenalidomide and 4/9 (44.4%) occurred at least 3 months after discontinuation of lenalidomide therapy. For MM patients without CHIP, majority (13/17, 76.5%) of VTE occurred while on lenalidomide, with a minority (11%) occurring either before or at least 3 months after discontinuation of lenalidomide. While lenalidomide is a known risk factor for thrombosis in MM, the fact that 44% of VTE in MM with CHIP occurred >3 months after discontinuing lenalidomide, suggests that CHIP might increase VTE risk in this setting (P = .04). Median OS from the time of diagnosis of the entire cohort was 124.6 months (95%CI 97.5-N/A months) with a corresponding 5 year OS of 82.0% (95% CI 74.8%–89.9%). There was no difference in median OS between MM with CHIP vs those without CHIP (100.2 months; 95%CI 76.2-NA months vs 135.6 months; 95%CI 106.3-N/A months, p = .27) (Figure 1(D)), including assessments with individual CHIP-mutations. The median EFS after ASCT was 36.4 months (95%CI 30.5–48.5 months), with there being no difference in median PFS between MM CHIP (36.4 months, 95%CI 24.1–58.5 months) patients vs MM patients without CHIP (36.4 months, 95%CI 29.9–52.4 months) (p = .34) (Figure 1(E)), including TP53 mutations (Figure S3). There were also no differences between the two groups with regards to non-relapse mortality (Figure S4), cumulative incidence of relapse after ASCT (Figure S5) and time to next treatment. Nineteen (18.8%) SPM were documented, 7 (30.4%) in MM CHIP group vs 12 (15.3%) in the MM no CHIP group (Figure 1(F), p = .13), with corresponding 5-year cumulative incidence rates of 22% and 13%, respectively. These SPM included five (4.9%) hematological malignancies (two in MM CHIP vs three in MM no CHIP), seven (6.9%) skin cancers (three in MM CHIP vs four in MM no CHIP) and seven visceral malignancies (two in MM CHIP vs five in MM no CHIP) (Table S2, Figure S6). The two MM CHIP patients who developed T-MN/MDS had TP53 and PPM1D mutations, respectively. In the MM no CHIP group, there was one patient with B-acute lymphoblastic leukemia and two patients with T-MDS with monosomal karyotypes. In summary, we define the CHIP landscape in MM patients at the time of ASCT, with mutations in epigenetic regulator genes being most common (57%), followed by tumor suppressor genes (17%). Unlike in NHL, presence of CHIP at time of ASCT in MM did not impact OS, PFS and incidence of T-MN; a finding potentially attributable to immunomodulatory properties of lenalidomide, or to the use of maintenance therapy in general.6, 11 While the presence of CHIP and lenalidomide therapy have individually been associated with increased risk of thromboses,1-3, 9 we did not see synergy in MM patients with CHIP, although the timing and patterns of thromboses suggest that CHIP might negatively influence thrombotic risk. While SPM have been well described with lenalidomide maintenance therapy,9 we did not see any differences in SPM and hematological malignancies between the two groups. The findings of this study independently confirm a prior observation on the potential ability of lenalidomide maintenance to mitigate the expected adverse effects of CHIP on OS and PFS in MM patients' post-ASCT6; an important consideration given that approximately 13 000 MM patients undergo ASCT in the US annually, with lenalidomide maintenance considered as standard of care.12, 13 Given the smaller sample size and the inherent flaws of a retrospective analysis, future clinical trials evaluating therapies in MM patients' post-ASCT should consider accounting for the presence of CHIP and its impact on outcomes. The authors would like to acknowledge the “Henry Predolin Leukemia Foundation”, Mayo Clinic, Rochester, MN, USA. Mrinal Patnaik has served on the advisory board of Kura Oncology. A Keith Stewart has served on the advisory board for Celgene. Rafael Fonseca has the following disclosures: Consulting: Amgen, BMS, Celgene, Takeda, Bayer, Janssen, Novartis, Pharmacyclics, Sanofi, Karyopharm, Merck, Juno, Kite, Aduro, OncoTracker, Oncopeptides, GSK, AbbVie. Scientific Advisory Board: Adaptive Biotechnologies, Caris Life Sciences and OncoTracker. Gene mutations annotated in the study have been provided in the supplementary material. Raw sequencing data can be made available on request. Appendix S1 Supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Accumulation of somatic hematopoietic stem cell mutations with aging has been revealed by the recent genome-wide analysis. Clonal expansion, known as clonal hematopoiesis of indeterminate potential (CHIP), is a premalignant condition of hematological cancers. It is defined as the absence of definitive morphological evidence of a hematological neoplasm and occurrence of ≥2% of mutant allele fraction in the peripheral blood. In CHIP, the most frequently mutated genes are epigenetic regulators such as DNMT3A, TET2, and ASXL1. CHIP induces inflammation. CHIP is shown to be associated with not only hematological malignancy but also non-malignant disorders such as atherosclerosis, cardiovascular diseases and chronic liver disease. In addition, recent several large clinical trials have shown that CHIP is also the risk factor for developing chronic kidney disease (CKD). In this review article, we proposed novel findings about CHIP and CHIP related kidney disease based on the recent basic and clinical research. The possible mechanism of the kidney injury in CHIP is supposed to be due to the clonal expansion in both myeloid and lymphoid cell lines. In myeloid cell lines, the mutated macrophages increase the inflammatory cytokine level and induce chronic inflammation. It leads to epigenetic downregulation of kidney and macrophage klotho level. In lymphoid cell lines, CHIP might be related to monoclonal gammopathy of renal significance (MGRS). It describes any B cell or plasma cell clonal disorder that does not fulfill the criteria for cancer yet produces a nephrotoxic monoclonal immunoglobulin that leads to kidney injury or disease. MGRS causes M-protein related nephropathy frequently observed among aged CKD patients. It is important to consider the CHIP-related complications such as hematological malignancy, cardiovascular diseases and metabolic disorders in managing the elderly CKD patients. There are no established therapies for CHIP and CHIP-related CKD yet. However, recent studies have supported the development of effective CHIP therapies, such as blocking the expansion of aberrant HSCs and inhibiting chronic inflammation. In addition, drugs targeting the epigenetic regulation of Klotho in the kidney and macrophages might be therapeutic targets of CHIP in the kidney.

Emerging evidence on the role of clonal hematopoiesis of indeterminate potential in chronic kidney disease

Background and Aims Asymptomatic hyperuricemia (HU) is common among patients with chronic kidney disease (CKD) but the causative role of HU on CKD progression remains controversial. Two large multi-center randomized controlled trials (RCTs), the CKD-FIX and the PERL study, have now disproven a causal relation. On the other hand, a causative role of persistent HU exists with gouty arthritis but a rapid correction of HU with urate lowering therapy can also elicit acute gout attacks. This suggests a more complex role of HU in this context. Hence, we hypothesized that soluble uric acid (sUA) has immunomodulatory effects on leukocyte function during the immune response to monosodium urate (MSU) crystals. Method Alb-creERT2;Glut9lox/lox and Glut9lox/lox control mice were injected with tamoxifen and placed either on a chow or high-fat diet with inosine to induce HU with or without CKD. After two weeks, MSU crystals or vehicle were injected into air pouches or postcapillary venules in the cremaster muscle of transgenic mice. Leukocyte infiltration and the extent of inflammation were assessed by flow cytometry, intravital microscopy, ELISA, and colorimetric assays. Human blood neutrophils and CD14+ monocytes were isolated from CKD stage G2-4 (n=10) and CKD stage G5 (n=18) patients or healthy individuals (n=15). Neutrophil transwell migration assays were performed and the number of migrated human neutrophils towards chemoattractants determined by flow cytometry. Human blood CD14+ monocytes were treated with MSU crystals or lipopolysaccharide ex vivo, and the expression of inflammatory mediators determined by RT-PCR and flow cytometry. Results We found that the presence of HU impaired leukocyte recruitment into MSU crystal-injected air pouches of mice with or without CKD. Intravital microscopy revealed that HU specifically reduced leukocyte adhesion, extravasation, and leukocyte-related tissue inflammation. The CKD-mediated attenuation of MSU crystal-induced inflammation was fully reversible by treating HU with urate lowering therapy such as rasburicase. In blood neutrophils isolated from healthy individuals, sUA diminished β2 integrin activation and expression, and hence impaired neutrophil migration ex vivo. An impaired migratory capability was also observed in neutrophils from CKD stage G2-4 or G5D patients. Moreover, sUA attenuated Toll-like and TNFα receptor-induced human monocyte activation, a process depending on the intracellular uptake of sUA via the urate transporter SLC2A9 (GLUT9), the only urate transporter expressed by these immune cells. Conclusion We identify sUA as an endogenous modulator of innate immunity. HU modulates neutrophil migration by altering efficient β2 integrin activation and suppresses pattern recognition receptor-driven monocyte activation via SLC2A9 in gouty arthritis related or unrelated to CKD (see Figure). This process provides a molecular explanation for several previously unexplained clinical phenomena in the context of gouty arthritis and renal failure.

Clonal hematopoiesis of indeterminate potential (CHIP) is an emerging risk factor for cardiovascular diseases. Genetic IL (interleukin)-6 signaling deficiency reduced cardiovascular disease risk in CHIP carriers. However, the association between CHIP and incident abdominal aortic aneurysm (AAA) and whether IL-6 signaling inhibition attenuates AAA risk among individuals with CHIP remained unclear. Participants without prevalent AAA from the UK Biobank were included. The associations of any CHIP (variant allele fraction, ≥2%), large CHIP (variant allele fraction, ≥10%), and gene-specific CHIP subtypes with incident AAA were investigated. The protection role of IL6R p.Asp358Ala, a genetic proxy for IL-6 deficiency, was tested after stratification by CHIP status. Furthermore, the interaction and joint effects of CHIP and genetic susceptibility on AAA risk were tested. This study included 425 211 participants. Any CHIP and large CHIP was identified in 13 768 (3.2%) and 8576 (2.0%) participants, respectively. CHIP was associated with an increased risk of incident AAA (hazard ratio [HR], 1.21 [95% CI, 1.01-1.44]; P=0.034), with large CHIP clones exhibiting greater effect size (HR, 1.35 [95% CI, 1.10-1.66]; P=0.0045). Driver gene-specific analyses revealed that ASXL1-mediated CHIP exerted the strongest effect size on AAA risk (HR, 2.10 [95% CI, 1.54-2.88]; P<0.001). The presence of 2 IL6R p.Asp358Ala alleles attenuated the risk of AAA in large CHIP carriers (HR, 0.48 [95% CI, 0.23-0.99]; P=0.046). In the joint analysis, participants with CHIP and high genetic risk had a higher risk of developing AAA than those without CHIP and with low genetic risk (HR, 2.15 [95% CI, 1.63-2.85]; P<0.001). CHIP is associated with an increased risk of AAA. Genetic IL-6 signaling deficiency attenuates the risk of AAA in large CHIP carriers. CHIP may serve as an attractive target for the prevention and treatment of AAA.