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Cai Z, Wu X, Song Z, Sun S, Su Y, Wang T, Cheng X, Yu Y, Yu C, Chen E, Chen W, Yu Y, Linkermann A, Min J, Wang F. Metformin potentiates nephrotoxicity by promoting NETosis in response to renal ferroptosis. Cell Discov 2023; 9:104. [PMID: 37848438 PMCID: PMC10582023 DOI: 10.1038/s41421-023-00595-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/16/2023] [Indexed: 10/19/2023] Open
Abstract
Given the rapidly aging population, aging-related diseases are becoming an excessive burden on the global healthcare system. Metformin has been shown to be beneficial to many age-related disorders, as well as increase lifespan in preclinical animal models. During the aging process, kidney function progressively declines. Currently, whether and how metformin protects the kidney remains unclear. In this study, among longevity drugs, including metformin, nicotinamide, resveratrol, rapamycin, and senolytics, we unexpectedly found that metformin, even at low doses, exacerbated experimentally-induced acute kidney injury (AKI) and increased mortality in mice. By single-cell transcriptomics analysis, we found that death of renal parenchymal cells together with an expansion of neutrophils occurs upon metformin treatment after AKI. We identified programmed cell death by ferroptosis in renal parenchymal cells and blocking ferroptosis, or depleting neutrophils protects against metformin-induced nephrotoxicity. Mechanistically, upon induction of AKI, ferroptosis in renal parenchymal cells initiates the migration of neutrophils to the site of injury via the surface receptor CXCR4-bound to metformin-iron-NGAL complex, which results in NETosis aggravated AKI. Finally, we demonstrated that reducing iron showed protective effects on kidney injury, which supports the notion that iron plays an important role in metformin-triggered AKI. Taken together, these findings delineate a novel mechanism underlying metformin-aggravated nephropathy and highlight the mechanistic relationship between iron, ferroptosis, and NETosis in the resulting AKI.
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Affiliation(s)
- Zhaoxian Cai
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- The First Affiliated Hospital, Basic Medical Sciences, School of Public Health, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Xiaotian Wu
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zijun Song
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shumin Sun
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yunxing Su
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tianyi Wang
- The First Affiliated Hospital, Basic Medical Sciences, School of Public Health, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Xihao Cheng
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingying Yu
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chao Yu
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - En Chen
- College of Pharmaceutical Science, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wenteng Chen
- College of Pharmaceutical Science, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yongping Yu
- College of Pharmaceutical Science, Zhejiang University, Hangzhou, Zhejiang, China
| | - Andreas Linkermann
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Junxia Min
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Fudi Wang
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- The First Affiliated Hospital, Basic Medical Sciences, School of Public Health, Hengyang Medical School, University of South China, Hengyang, Hunan, China.
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Molitch ME, Tripputi M, Levey AS, Crandall JP, Dabelea D, Herman WH, Knowler WC, Orchard TJ, Schroeder EB, Srikanthan P, Temprosa M, White NH, Nathan DM. Effects of metformin and intensive lifestyle interventions on the incidence of kidney disease in adults in the DPP/DPPOS. J Diabetes Complications 2023; 37:108556. [PMID: 37607422 PMCID: PMC11017540 DOI: 10.1016/j.jdiacomp.2023.108556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
AIMS We analyzed the incidence of kidney disease in the Diabetes Prevention Program Outcomes Study (DPPOS) by originally randomized treatment group assignment: Intensive Lifestyle (ILS), Metformin (MET) or Placebo (PLB). METHODS The current analyses used a time-to-event approach in which the primary outcome was kidney disease, ascertained as urine albumin-to-creatinine ratio (ACR) ≥ 3.39 mg/mmol (30 mg/g) or eGFR <45 mL/min/1.73m2, with confirmation required at the next visit, or adjudicated end-stage kidney disease (ESKD). RESULTS At a median of 21 years following randomization in DPP, diabetes development was reduced in both the ILS (HR 0.73 [95%CI = 0.62, 0.85]) and MET groups (HR 0.85 [0.73, 0.99]) compared to the PLB group. Although risk for developing the primary kidney disease outcome was higher among those with incident diabetes compared to those without (HR 1.81 [1.43, 2.30]), it did not differ by intervention groups (ILS vs. PLB 1.02 (0.81, 1.29); MET vs. PLB 1.08 (0.86, 1.35). There was a non-significant metformin by age interaction (p = 0.057), with metformin being beneficial for kidney disease in the younger but potentially harmful in the older participants. CONCLUSIONS Development of kidney disease was increased in participants who developed diabetes but did not differ by original treatment group assignment. CLINICAL TRIAL REGISTRATIONS Diabetes Prevention Program (DPP) Clinical trial reg. no. NCT00004992 DPP Outcomes Study (DPPOS) Clinical trial reg. no. NCT0038727.
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Affiliation(s)
- Mark E Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Mark Tripputi
- DPP/DPPOS Coordinating Center, Biostatistics Center, The George Washington University, Rockville, MD, United States of America
| | - Andrew S Levey
- Tufts Medical Center, Boston, MA, United States of America
| | - Jill P Crandall
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Dana Dabelea
- Colorado School of Public Health, University of Colorado, Denver, CO, United States of America
| | - William H Herman
- Schools of Medicine and Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - William C Knowler
- DPP/DPPOS Coordinating Center, Biostatistics Center (Consultant), The George Washington University, Rockville, MD, United States of America
| | - Trevor J Orchard
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States of America
| | - Emily B Schroeder
- Division of Endocrinology, Parkview Health, Fort Wayne, IN, United States of America
| | - Preethi Srikanthan
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Marinella Temprosa
- DPP/DPPOS Coordinating Center, Biostatistics Center, The George Washington University, Rockville, MD, United States of America.
| | - Neil H White
- Washington University School of Medicine, St. Louis, MO, United States of America
| | - David M Nathan
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA, United States of America
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Chen J, Lee C, Lee M, Huang P, Yen T, Lee M, Tsai C, Wang J, Lee J. Bisphosphonate Use Is Not Associated with Tuberculosis Risk Among Patients With Osteoporosis: A Nationwide Cohort Study. J Clin Pharmacol 2022; 62:1412-1418. [DOI: 10.1002/jcph.2090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/23/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Jin‐Hua Chen
- Biostatistics Center College of Management Taipei Medical University Taipei Taiwan
- Graduate Institute of DataScience College of Management Taipei Medical University Taipei Taiwan
- Department of Medical Education and Research Wanfang Hospital Taipei Medical University Taipei Taiwan
| | - Chih‐Hsin Lee
- Division of Pulmonary Medicine Department of Internal Medicine Wan Fang Hospital Taipei Medical University Taipei Taiwan
- Division of Pulmonary Medicine Department of Internal Medicine School of Medicine College of Medicine Taipei Medical University Taipei Taiwan
| | - Meng‐Rui Lee
- Department of Internal Medicine National Taiwan University Hospital Hsin‐Chu Branch Hsin‐Chu Taiwan
- Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan
- Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan
| | - Pei‐Yu Huang
- School of Pharmacy College of Pharmacy Taipei Medical University Taipei Taiwan
| | - Tzu‐Hsin Yen
- School of Pharmacy College of Pharmacy Taipei Medical University Taipei Taiwan
| | - Ming‐Chia Lee
- School of Pharmacy College of Pharmacy Taipei Medical University Taipei Taiwan
- Department of Pharmacy New Taipei City Hospital New Taipei City Taiwan
- Department of Nursing Cardinal Tien College of Healthcare and Management Taipei Taiwan
| | - Ching‐Wen Tsai
- Health Data Analytics and Statistics Center Office Of Data Science Taipei Medical University Taipei Taiwan
| | - Jann‐Yuan Wang
- Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan
| | - Jen‐Ai Lee
- School of Pharmacy College of Pharmacy Taipei Medical University Taipei Taiwan
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Kim MH, Oh HJ, Kwon SH, Jeon JS, Noh H, Han DC, Kim H, Ryu DR. Metformin use and cardiovascular outcomes in patients with diabetes and chronic kidney disease: a nationwide cohort study. Kidney Res Clin Pract 2021; 40:660-672. [PMID: 34922433 PMCID: PMC8685353 DOI: 10.23876/j.krcp.20.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Metformin has recently been shown not to increase the risk of lactic acidosis in patients with chronic kidney disease (CKD). Thus, the criteria for metformin use in this population has expanded. However, the relationship between metformin use and clinical outcomes in CKD remains controversial. METHODS This study considered data from 97,713 diabetes patients with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), and the secondary outcomes were all-cause mortality and incident end-stage renal disease (ESRD). RESULTS Metformin users had a significantly higher risk of MACCE than non-users (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.14-1.26; p < 0.001). However, metformin users had a lower risk of all-cause mortality (HR, 0.78; 95% CI, 0.74-0.81; p < 0.001) and ESRD (HR, 0.44; 95% CI, 0.42-0.47; p < 0.001) during follow-up than non-users did. The relationships between metformin use and clinical outcomes remained consistent in propensity score matching analyses and subgroup analyses of patients with adequate adherence to anti-diabetes medication. CONCLUSION Treatment with metformin was associated with an increased risk of MACCE in patients with diabetes and CKD. However, metformin users had a lower risk of all-cause mortality and ESRD during follow-up than non-users did. Therefore, metformin needs to be carefully used in patients with CKD.
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Affiliation(s)
- Min-Ho Kim
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hyung Jung Oh
- Department of Nephrology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, UAE
| | - Soon Hyo Kwon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jin Seok Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyunjin Noh
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong Cheol Han
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.,Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Drzewoski J, Hanefeld M. The Current and Potential Therapeutic Use of Metformin-The Good Old Drug. Pharmaceuticals (Basel) 2021; 14:122. [PMID: 33562458 PMCID: PMC7915435 DOI: 10.3390/ph14020122] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin, one of the oldest oral antidiabetic agents and still recommended by almost all current guidelines as the first-line treatment for type 2 diabetes mellitus (T2DM), has become the medication with steadily increasing potential therapeutic indications. A broad spectrum of experimental and clinical studies showed that metformin has a pleiotropic activity and favorable effect in different pathological conditions, including prediabetes, type 1 diabetes mellitus (T1DM) and gestational diabetes mellitus (GDM). Moreover, there are numerous studies, meta-analyses and population studies indicating that metformin is safe and well tolerated and may be associated with cardioprotective and nephroprotective effect. Recently, it has also been reported in some studies, but not all, that metformin, besides improvement of glucose homeostasis, may possibly reduce the risk of cancer development, inhibit the incidence of neurodegenerative disease and prolong the lifespan. This paper presents some arguments supporting the initiation of metformin in patients with newly diagnosed T2DM, especially those without cardiovascular risk factors or without established cardiovascular disease or advanced kidney insufficiency at the time of new guidelines favoring new drugs with pleotropic effects complimentary to glucose control. Moreover, it focuses on the potential beneficial effects of metformin in patients with T2DM and coexisting chronic diseases.
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Affiliation(s)
- Józef Drzewoski
- Central Teaching Hospital of Medical University of Lodz, 92-213 Lodz, Poland
| | - Markolf Hanefeld
- Medical Clinic III, Department of Medicine Technical University Dresden, 01307 Dresden, Germany;
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