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Tawengi M, Al-Dali Y, Tawengi A, Benter IF, Akhtar S. Targeting the epidermal growth factor receptor (EGFR/ErbB) for the potential treatment of renal pathologies. Front Pharmacol 2024; 15:1394997. [PMID: 39234105 PMCID: PMC11373609 DOI: 10.3389/fphar.2024.1394997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 07/29/2024] [Indexed: 09/06/2024] Open
Abstract
Epidermal growth factor receptor (EGFR), which is referred to as ErbB1/HER1, is the prototype of the EGFR family of receptor tyrosine kinases which also comprises ErbB2 (Neu, HER2), ErbB3 (HER3), and ErbB4 (HER4). EGFR, along with other ErbBs, is expressed in the kidney tubules and is physiologically involved in nephrogenesis and tissue repair, mainly following acute kidney injury. However, its sustained activation is linked to several kidney pathologies, including diabetic nephropathy, hypertensive nephropathy, glomerulonephritis, chronic kidney disease, and renal fibrosis. This review aims to provide a summary of the recent findings regarding the consequences of EGFR activation in several key renal pathologies. We also discuss the potential interplay between EGFR and the reno-protective angiotensin-(1-7) (Ang-(1-7), a heptapeptide member of the renin-angiotensin-aldosterone system that counter-regulates the actions of angiotensin II. Ang-(1-7)-mediated inhibition of EGFR transactivation might represent a potential mechanism of action for its renoprotection. Our review suggests that there is a significant body of evidence supporting the potential inhibition of EGFR/ErbB, and/or administration of Ang-(1-7), as potential novel therapeutic strategies in the treatment of renal pathologies. Thus, EGFR inhibitors such as Gefitinib and Erlinotib that have an acceptable safety profile and have been clinically used in cancer chemotherapy since their FDA approval in the early 2000s, might be considered for repurposing in the treatment of renal pathologies.
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Affiliation(s)
- Mohamed Tawengi
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Yazan Al-Dali
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Ibrahim F Benter
- Faculty of Pharmacy, Final International University, Kyrenia, Cyprus
| | - Saghir Akhtar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
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Magalhaes GS, Gregorio JF, Beltrami VA, Felix FB, Oliveira-Campos L, Bonilha CS, Righetti RF, Tibério IDFLC, De Sousa FB, Rezende BM, Teixeira-Carvalho A, Santos RA, Campagnole-Santos MJ, Rodrigues-Machado MDG, Teixeira MM, Pinho V. A single dose of angiotensin-(1-7) resolves eosinophilic inflammation and protects the lungs from a secondary inflammatory challenge. Inflamm Res 2024; 73:1019-1031. [PMID: 38656426 DOI: 10.1007/s00011-024-01880-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Angiotensin-(1-7) [Ang-(1-7)] is a pro-resolving mediator. It is not known whether the pro-resolving effects of Ang-(1-7) are sustained and protect the lung from a subsequent inflammatory challenge. This study sought to investigate the impact of treatment in face of a second allergic or lipopolysaccharide (LPS) challenge. METHODS Mice, sensitized and challenged with ovalbumin (OVA), received a single Ang-(1-7) dose at the peak of eosinophilic inflammation, 24 h after the final OVA challenge. Subsequently, mice were euthanized at 48, 72, 96, and 120 h following the OVA challenge, and cellular infiltrate, inflammatory mediators, lung histopathology, and macrophage-mediated efferocytic activity were evaluated. The secondary inflammatory stimulus (OVA or LPS) was administered 120 h after the last OVA challenge, and subsequent inflammatory analyses were performed. RESULTS Treatment with Ang-(1-7) resulted in elevated levels of IL-10, CD4+Foxp3+, Mres in the lungs and enhanced macrophage-mediated efferocytic capacity. Moreover, in allergic mice treated with Ang-(1-7) and then subjected to a secondary OVA challenge, inflammation was also reduced. Similarly, in mice exposed to LPS, Ang-(1-7) effectively prevented the lung inflammation. CONCLUSION A single dose of Ang-(1-7) resolves lung inflammation and protect the lung from a subsequent inflammatory challenge highlighting its potential therapeutic for individuals with asthma.
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Affiliation(s)
| | - Juliana Fabiana Gregorio
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vinicius Amorim Beltrami
- Department of Morphology, Biological Sciences Institute, Federal University of Minas Gerais, Av Antonio Carlos, 6627-ICB, Belo Horizonte, MG, 31270-901, Brazil
| | - Franciel Batista Felix
- Department of Morphology, Biological Sciences Institute, Federal University of Minas Gerais, Av Antonio Carlos, 6627-ICB, Belo Horizonte, MG, 31270-901, Brazil
| | - Livia Oliveira-Campos
- Medical Sciences Faculty of Minas Gerais, Post-Graduate Program in Health Sciences, Alameda Ezequiel Dias, 275, Belo Horizonte, MG, 30130-110, Brazil
| | - Caio Santos Bonilha
- Center for Research in Inflammatory Diseases, University of São Paulo, São Paulo, SP, Brazil
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, G12 8TA, UK
| | - Renato Fraga Righetti
- Faculty of Medicine FMUSP, University of São Paulo, São Paulo, SP, Brazil
- Rehabilitation Service, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Frederico B De Sousa
- Laboratory of Polymeric and Supramolecular Systems, Institute of Physics and Chemistry, Federal University of Itajuba, Itajubá, MG, Brazil
| | - Barbara Maximino Rezende
- Department of Basic Nursing, School of Nursing, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Robson As Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria José Campagnole-Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria da Gloria Rodrigues-Machado
- Medical Sciences Faculty of Minas Gerais, Post-Graduate Program in Health Sciences, Alameda Ezequiel Dias, 275, Belo Horizonte, MG, 30130-110, Brazil.
| | - Mauro Martins Teixeira
- Department of Biochemistry and Immunology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vanessa Pinho
- Department of Morphology, Biological Sciences Institute, Federal University of Minas Gerais, Av Antonio Carlos, 6627-ICB, Belo Horizonte, MG, 31270-901, Brazil.
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Lee MMY, Kondo T, Campbell RT, Petrie MC, Sattar N, Solomon SD, Vaduganathan M, Jhund PS, McMurray JJV. Effects of renin-angiotensin system blockers on outcomes from COVID-19: a systematic review and meta-analysis of randomized controlled trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:68-80. [PMID: 37740450 PMCID: PMC10766905 DOI: 10.1093/ehjcvp/pvad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Randomized controlled trials (RCTs) have assessed the effects of renin-angiotensin system (RAS) blockers in adults with coronavirus disease 2019 (COVID-19). This meta-analysis provides estimates of the safety and efficacy of treatment with (vs. without) RAS blockers from these trials. METHODS PubMed, Web of Science, and ClinicalTrials.gov were searched (1 March-12 April 2023). Event/patient numbers were extracted, comparing angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB) treatment with no treatment, for the outcomes: intensive care unit (ICU) admission, mechanical ventilation, vasopressor use, acute kidney injury (AKI), renal replacement therapy (RRT), acute myocardial infarction, stroke/transient ischaemic attack, heart failure, thromboembolic events, and all-cause death. Fixed-effects meta-analysis estimates were pooled. RESULTS Sixteen RCTs including 3492 patients were analysed. Compared with discontinuation of RAS blockers, continuation was not associated with increased risk of ICU [risk ratio (RR) 0.96, 0.66-1.41], ventilation (RR 0.77, 0.55-1.09), vasopressors (RR 0.92, 0.58-1.44), AKI (RR 1.01, 0.40-2.56), RRT (RR 1.01, 0.46-2.21), or thromboembolic events (RR 1.07, 0.36-3.19). RAS blocker initiation was not associated with increased risk of ICU (RR 0.71, 0.47-1.08), ventilation (RR 1.12, 0.91-1.38), AKI (RR 1.28, 0.89-1.86), RRT (RR 1.66, 0.89-3.12), or thromboembolic events (RR 1.20, 0.06-23.70), although vasopressor use increased (RR 1.27, 1.02-1.57). The RR for all-cause death in the continuation/discontinuation trials was 1.24 (0.80-1.92), and 1.22 (0.96-1.55) in the initiation trials. In patients with severe/critical COVID-19, RAS blocker initiation increased the risk of all-cause death (RR 1.31, 1.01-1.72). CONCLUSION ACE inhibitors and ARBs may be continued in non-severe COVID-19 infection, where indicated. Conversely, initiation of RAS blockers may be harmful in critically ill patients.PROSPERO registration number: CRD42023408926.
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Affiliation(s)
- Matthew M Y Lee
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
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Xu J, Yu Z, Liu X. Angiotensin-(1-7) suppresses airway inflammation and airway remodeling via inhibiting ATG5 in allergic asthma. BMC Pulm Med 2023; 23:422. [PMID: 37919667 PMCID: PMC10623740 DOI: 10.1186/s12890-023-02719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Angiotensin (Ang)-(1-7) can reduce airway inflammation and airway remodeling in allergic asthma. Autophagy-related 5 (ATG5) has attracted wide attentions in asthma. However, the effects of Ang-(1-7) on ATG5-mediated autophagy in allergic asthma are unclear. METHODS In this study, human bronchial epithelial cell (BEAS-2B) and human bronchial smooth muscle cell (HBSMC) were treated with different dose of Ang-(1-7) to observe changes of cell viability. Changes of ATG5 protein expression were measured in 10 ng/mL of interleukin (IL)-13-treated cells. Transfection of ATG5 small interference RNA (siRNA) or ATG5 cDNA in cells was used to analyze the effects of ATG5 on secretion of cytokines in the IL-13-treated cells. The effects of Ang-(1-7) were compared to the effects of ATG5 siRNA transfection or ATG5 cDNA transfection in the IL-13-treated cells. In wild-type (WT) mice and ATG5 knockout (ATG5-/-) mice, ovalbumin (OVA)-induced airway inflammation, fibrosis and autophagy were observed. In the OVA-induced WT mice, Ang-(1-7) treatment was performed to observe its effects on airway inflammation, fibrosis and autophagy. RESULTS The results showed that ATG5 protein level was decreased with Ang-(1-7) dose administration in the IL-13-treated BEAS-2B and IL13-treated HBSMC. Ang-(1-7) played similar results to ATG5 siRNA that it suppressed the secretion of IL-25 and IL-13 in the IL-13-treated BEAS-2B cells, and inhibited the expression of transforming growth factor (TGF)-β1 and α-smooth muscle actin (α-SMA) protein in the IL-13-treated HBSMC cells. ATG5 cDNA treatment significantly increased the secretion of IL-25 and IL-13 and expression of TGF-β1 and α-SMA protein in IL-13-treated cells. Ang-(1-7) treatment suppressed the effects of ATG5 cDNA in the IL-13-treated cells. In OVA-induced WT mice, Ang-(1-7) treatment suppressed airway inflammation, remodeling and autophagy. ATG5 knockout also suppressed the airway inflammation, remodeling and autophagy. CONCLUSIONS Ang-(1-7) treatment suppressed airway inflammation and remodeling in allergic asthma through inhibiting ATG5, providing an underlying mechanism of Ang-(1-7) for allergic asthma treatment.
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Affiliation(s)
- Jianfeng Xu
- Department of Pulmonary and Critical Care Medicine, Yantai Yuhuangding Hospital, No.20, Yuhuangding East Road, Zhifu District, Yantai, 264001, China
| | - Zhenyu Yu
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, 246001, China
| | - Xueping Liu
- Department of Pulmonary and Critical Care Medicine, Yantai Yuhuangding Hospital, No.20, Yuhuangding East Road, Zhifu District, Yantai, 264001, China.
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Chiba Y, Ito M, Ando Y, Ueda C, Yamashita M, Suto W, Ishizaka S, Torizuka A, Watanabe C, Takenoya F, Hanazaki M, Sakai H. Altered renin-angiotensin system gene expression in airways of antigen-challenged mice: ACE2 downregulation and unexpected increase in angiotensin 1-7. Respir Physiol Neurobiol 2023; 316:104137. [PMID: 37595771 DOI: 10.1016/j.resp.2023.104137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/29/2023] [Accepted: 08/11/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE Evidence suggest that the renin-angiotensin system (RAS) is activated in people with asthma, although its pathophysiological role is unclear. Angiotensin-converting enzyme 2 (ACE2) is the major enzyme that converts angiotensin II to angiotensin 1-7 (Ang-1-7), and is also known as a receptor of SARS-CoV-2. The current study was conducted to identify the change in RAS-related gene expression in airways of a murine asthma model. METHODS The ovalbumin (OA)-sensitized mice were repeatedly challenged with aerosolized OA to induce asthmatic reaction. Twenty-four hours after the last antigen challenge, the main bronchial smooth muscle (BSM) tissues were isolated. RESULTS The KEGG pathway analysis of differentially expressed genes in our published microarray data revealed a significant change in the RAS pathway in the antigen-challenged mice. Quantitative RT-PCR analyses showed significant increases in the angiotensin II-generating enzymes (Klk1, Klk1b3 and Klk1b8) and a significant decrease in Ace2. Surprisingly, ELISA analyses revealed a significant increase in Ang-1-7 levels in bronchoalveolar lavage (BAL) fluids of the antigen-challenged animals, while no significant change in angiotensin II was observed. Application of Ang-1-7 to the isolated BSMs had no effect on their isometrical tension. CONCLUSION The expression of Ace2 was downregulated in the BSMs of OA-challenged mice, while Klk1, Klk1b3 and Klk1b8 were upregulated. Despite the downregulation of ACE2, the level of its enzymatic product, Ang-1-7, was increased in the inflamed airways, suggesting the existence of an unknown ACE2-independent pathway for Ang-1-7 production. The functional role of Ang-1-7 in the airways remains unclear.
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Affiliation(s)
- Yoshihiko Chiba
- Laboratory of Molecular Biology and Physiology, Hoshi University School of Pharmacy, Tokyo, Japan.
| | - Mana Ito
- Laboratory of Molecular Biology and Physiology, Hoshi University School of Pharmacy, Tokyo, Japan
| | - Yusuke Ando
- Laboratory of Clinical Pathology, Faculty of Pharmacy, Josai University, Saitama, Japan
| | - Chihiro Ueda
- Laboratory of Molecular Biology and Physiology, Hoshi University School of Pharmacy, Tokyo, Japan
| | - Michio Yamashita
- Laboratory of Sports Sciences, Hoshi University School of Pharmacy, Tokyo, Japan
| | - Wataru Suto
- Laboratory of Molecular Biology and Physiology, Hoshi University School of Pharmacy, Tokyo, Japan
| | - Shota Ishizaka
- Laboratory of Clinical Pathology, Faculty of Pharmacy, Josai University, Saitama, Japan
| | - Ai Torizuka
- Laboratory of Clinical Pathology, Faculty of Pharmacy, Josai University, Saitama, Japan
| | - Chie Watanabe
- Laboratory of Clinical Pathology, Faculty of Pharmacy, Josai University, Saitama, Japan
| | - Fumiko Takenoya
- Laboratory of Sports Sciences, Hoshi University School of Pharmacy, Tokyo, Japan
| | - Motohiko Hanazaki
- Laboratory of Molecular Biology and Physiology, Hoshi University School of Pharmacy, Tokyo, Japan; Department of Anesthesiology and Intensive Care Medicine, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Hiroyasu Sakai
- Laboratory of Biomolecular Pharmacology, Hoshi University School of Pharmacy, Tokyo, Japan
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Gan PXL, Liao W, Linke KM, Mei D, Wu XD, Wong WSF. Targeting the renin angiotensin system for respiratory diseases. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2023; 98:111-144. [PMID: 37524485 DOI: 10.1016/bs.apha.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Renin-angiotensin system (RAS) plays an indispensable role in regulating blood pressure through its effects on fluid and electrolyte balance. As an aside, cumulative evidence from experimental to clinical studies supports the notion that dysregulation of RAS contributes to the pro-inflammatory, pro-oxidative, and pro-fibrotic processes that occur in pulmonary diseases like asthma, chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and acute lung injury (ALI). Pharmacological intervention of the various RAS components can be a novel therapeutic strategy for the treatment of these respiratory diseases. In this chapter, we first give a recent update on the RAS, and then compile, review, and analyse recent reports on targeting RAS components as treatments for respiratory diseases. Inhibition of the pro-inflammatory renin, angiotensin-converting enzyme (ACE), angiotensin (Ang) II, and Ang II type 1 receptor (AT1R) axis, and activation of the protective ACE2, AT2R, Ang (1-7), and Mas receptor axis have demonstrated varying degrees of efficacies in experimental respiratory disease models or in human trials. The newly identified alamandine/Mas-related G-protein-coupled receptor member D pathway has shown some therapeutic promise as well. However, our understanding of the RAS ligand-and-receptor interactions is still inconclusive, and the modes of action and signaling cascade mediating the newly identified RAS receptors remain to be better characterized. Clinical data are obviously lacking behind the promising pre-clinical findings of certain well-established molecules targeting at different pathways of the RAS in respiratory diseases. Translational human studies should be the focus for RAS drug development in lung diseases in the next decade.
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Affiliation(s)
- Phyllis X L Gan
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore
| | - W Liao
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore; Singapore-HUJ Alliance for Research Enterprise, National University of Singapore, Singapore, Singapore
| | - Kira M Linke
- Department of Pharmacology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - D Mei
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - X D Wu
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - W S Fred Wong
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore; Singapore-HUJ Alliance for Research Enterprise, National University of Singapore, Singapore, Singapore; Drug Discovery and Optimization Platform, National University Health System, Singapore, Singapore.
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Akhtar S, Babiker F, Akhtar UA, Benter IF. Mitigating Cardiotoxicity of Dendrimers: Angiotensin-(1-7) via Its Mas Receptor Ameliorates PAMAM-Induced Cardiac Dysfunction in the Isolated Mammalian Heart. Pharmaceutics 2022; 14:pharmaceutics14122673. [PMID: 36559167 PMCID: PMC9781033 DOI: 10.3390/pharmaceutics14122673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
AIM The influence of the physiochemical properties of dendrimer nanoparticles on cardiac contractility and hemodynamics are not known. Herein, we investigated (a) the effect of polyamidoamine (PAMAM) dendrimer generation (G7, G6, G5, G4 and G3) and surface chemistry (-NH2, -COOH and -OH) on cardiac function in mammalian hearts following ischemia-reperfusion (I/R) injury, and (b) determined if any PAMAM-induced cardiotoxicity could be mitigated by Angiotensin-(1-7) (Ang-(1-7), a cardioprotective agent. METHODS Hearts isolated from male Wistar rats underwent regional I/R and/or treatment with different PAMAM dendrimers, Ang-(1-7) or its MAS receptors antagonists. Thirty minutes of regional ischemia through ligation of the left anterior descending coronary artery was followed by 30 min of reperfusion. All treatments were initiated 5 min prior to reperfusion and maintained during the first 10 min of reperfusion. Cardiac function parameters for left ventricular contractility, hemodynamics and vascular dynamics data were acquired digitally, whereas cardiac enzymes and infarct size were used as measures of cardiac injury. RESULTS Treatment of isolated hearts with increasing doses of G7 PAMAM dendrimer progressively exacerbated recovery of cardiac contractility and hemodynamic parameters post-I/R injury. Impairment of cardiac function was progressively less on decreasing dendrimer generation with G3 exhibiting little or no cardiotoxicity. Cationic PAMAMs (-NH2) were more toxic than anionic (-COOH), with neutral PAMAMs (-OH) exhibiting the least cardiotoxicity. Cationic G7 PAMAM-induced cardiac dysfunction was significantly reversed by Ang-(1-7) administration. These cardioprotective effects of Ang-(1-7) were significantly revoked by administration of the MAS receptor antagonists, A779 and D-Pro7-Ang-(1-7). CONCLUSIONS PAMAM dendrimers can impair the recovery of hearts from I/R injury in a dose-, dendrimer-generation-(size) and surface-charge dependent manner. Importantly, PAMAM-induced cardiotoxicity could be mitigated by Ang-(1-7) acting through its MAS receptor. Thus, this study highlights the activation of Ang-(1-7)/Mas receptor axis as a novel strategy to overcome dendrimer-induced cardiotoxicity.
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Affiliation(s)
- Saghir Akhtar
- College of Medicine, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
- Correspondence: (S.A.); (F.B.)
| | - Fawzi Babiker
- Departments of Physiology, Faculty of Medicine, Health Science Center, Kuwait University, Safat P.O. Box 24923, Kuwait
- Correspondence: (S.A.); (F.B.)
| | - Usman A. Akhtar
- Department of Mechanical and Chemical Engineering, College of Engineering, Qatar University, Doha P.O. Box 2713, Qatar
| | - Ibrahim F. Benter
- Faculty of Medicine, Eastern Mediterranean University, Famagusta 99628, North Cyprus, Turkey
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Krenn K, Tretter V, Kraft F, Ullrich R. The Renin-Angiotensin System as a Component of Biotrauma in Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:806062. [PMID: 35498160 PMCID: PMC9043684 DOI: 10.3389/fphys.2021.806062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major concern in critical care medicine with a high mortality of over 30%. Injury to the lungs is caused not only by underlying pathological conditions such as pneumonia, sepsis, or trauma, but also by ventilator-induced lung injury (VILI) resulting from high positive pressure levels and a high inspiratory oxygen fraction. Apart from mechanical factors that stress the lungs with a specific physical power and cause volutrauma and barotrauma, it is increasingly recognized that lung injury is further aggravated by biological mediators. The COVID-19 pandemic has led to increased interest in the role of the renin-angiotensin system (RAS) in the context of ARDS, as the RAS enzyme angiotensin-converting enzyme 2 serves as the primary cell entry receptor for severe acute respiratory syndrome (SARS) coronavirus (CoV)-2. Even before this pandemic, studies have documented the involvement of the RAS in VILI and its dysregulation in clinical ARDS. In recent years, analytical tools for RAS investigation have made major advances based on the optimized precision and detail of mass spectrometry. Given that many clinical trials with pharmacological interventions in ARDS were negative, RAS-modifying drugs may represent an interesting starting point for novel therapeutic approaches. Results from animal models have highlighted the potential of RAS-modifying drugs to prevent VILI or treat ARDS. While these drugs have beneficial pulmonary effects, the best targets and application forms for intervention still have to be determined to avoid negative effects on the circulation in clinical settings.
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Gregório JF, Magalhães GS, Rodrigues-Machado MG, Gonzaga KER, Motta-Santos D, Cassini-Vieira P, Barcelos LS, Vieira MAR, Santos RAS, Campagnole-Santos MJ. Angiotensin-(1-7)/Mas receptor modulates anti-inflammatory effects of exercise training in a model of chronic allergic lung inflammation. Life Sci 2021; 282:119792. [PMID: 34229006 DOI: 10.1016/j.lfs.2021.119792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/20/2022]
Abstract
AIMS Exercise training increases circulating and tissue levels of angiotensin-(1-7) [Ang-(1-7)], which was shown to attenuate inflammation and fibrosis in different diseases. Here, we evaluated whether Ang-(1-7)/Mas receptor is involved in the beneficial effects of aerobic training in a chronic model of asthma. MATERIAL AND METHODS BALB/c mice were subjected to a protocol of asthma induced by ovalbumin sensitization (OVA; 4 i.p. injections) and OVA challenge (3 times/week for 4 weeks). Simultaneously to the challenge period, part of the animals was continuously treated with Mas receptor antagonist (A779, 1 μg/h; for 28 days) and trained in a treadmill (TRE; 60% of the maximal capacity, 1 h/day, 5 days/week during 4 weeks). PGC1-α mRNA expression (qRT-PCR), plasma IgE and lung cytokines (ELISA), inflammatory cells infiltration (enzymatic activity assay) and airway remodeling (by histology) were evaluated. KEY FINDINGS Blocking the Mas receptor with A779 increased IgE and IL-13 levels and prevented the reduction in extracellular matrix deposition in airways in OVA-TRE mice. Mas receptor blockade prevented the reduction of myeloperoxidase activity, as well as, prevented exercise-induced IL-10 increase. These data show that activation of Ang-(1-7)/Mas receptor pathway is involved in the anti-inflammatory and anti-fibrotic effects of aerobic training in an experimental model of chronic asthma. SIGNIFICANCE Our results support exercise training as a non-pharmacological tool to defeat lung remodeling induced by chronic pulmonary inflammation. Further, our result also supports development of new therapy based on Ang-(1-7) or Mas agonists as important tool for asthma treatment in those patients that cannot perform aerobic training.
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Affiliation(s)
- Juliana Fabiana Gregório
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Giselle Santos Magalhães
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Post-Graduate Program in Healthy Sciences of Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Kézia Emanoeli Ramos Gonzaga
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Post-Graduate Program in Healthy Sciences of Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Daisy Motta-Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Sports Department, School of Physical Education, Physiotherapy and Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Puebla Cassini-Vieira
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Lucíola Silva Barcelos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria Aparecida Ribeiro Vieira
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Robson Augusto Souza Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria Jose Campagnole-Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology in Nanobiopharmaceutics (INCT-Nanobiofar), Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
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10
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Gregório JF, Rodrigues-Machado MDG, Santos RAS, Carvalho Ribeiro IA, Nunes OM, Aguiar Oliveira IF, Vasconcelos AV, Campagnole-Santos MJ, Magalhães GS. ASTHMA: ROLE OF THE ANGIOTENSIN-(1-7)/MAS PATHWAY IN PATHOPHYSIOLOGY AND THERAPY. Br J Pharmacol 2021; 178:4428-4439. [PMID: 34235725 DOI: 10.1111/bph.15619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/06/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022] Open
Abstract
The incidence of asthma is a global health problem, requiring studies aimed at developing new treatments to improve clinical management, thereby reducing personal and economic burdens on the health system. Therefore, the discovery of mediators that promote anti-inflammatory and pro-resolutive events are highly desirable to improve lung function and quality of life in asthmatic patients. In that regard, experimental studies have shown that the Angiotensin-(1-7)/Mas receptor of the renin-angiotensin system (RAS) is a potential candidate for the treatment of asthma. Therefore, we reviewed findings related to the function of the Angiotensin-(1-7)/Mas pathway in regulating the processes associated with inflammation and exacerbations in asthma, including leukocyte influx, fibrogenesis, pulmonary dysfunction and resolution of inflammation. Thus, knowledge of the role of the Angiotensin-(1-7)/Mas can help pave the way for the development of new treatments for this disease with high morbidity and mortality through new experimental and clinical trials.
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Affiliation(s)
- Juliana Fabiana Gregório
- Department of Physiology and Biophysics, National Institute of Science and Technology - INCT-Nanobiopharmaceutical, Biological Sciences Institute, Federal University of Minas Gerais
| | | | - Robson A S Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology - INCT-Nanobiopharmaceutical, Biological Sciences Institute, Federal University of Minas Gerais
| | | | - Olivia Mendonça Nunes
- Medical Sciences Faculty of Minas Gerais, Post-Graduation Program in Health Sciences, Belo Horizonte, Brazil
| | | | - Ana Victoria Vasconcelos
- Medical Sciences Faculty of Minas Gerais, Post-Graduation Program in Health Sciences, Belo Horizonte, Brazil
| | - Maria José Campagnole-Santos
- Department of Physiology and Biophysics, National Institute of Science and Technology - INCT-Nanobiopharmaceutical, Biological Sciences Institute, Federal University of Minas Gerais
| | - Giselle Santos Magalhães
- Department of Physiology and Biophysics, National Institute of Science and Technology - INCT-Nanobiopharmaceutical, Biological Sciences Institute, Federal University of Minas Gerais.,Medical Sciences Faculty of Minas Gerais, Post-Graduation Program in Health Sciences, Belo Horizonte, Brazil
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11
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Hong L, Wang Q, Chen M, Shi J, Guo Y, Liu S, Pan R, Yuan X, Jiang S. Mas receptor activation attenuates allergic airway inflammation via inhibiting JNK/CCL2-induced macrophage recruitment. Biomed Pharmacother 2021; 137:111365. [PMID: 33588264 DOI: 10.1016/j.biopha.2021.111365] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Defective absorption of acute allergic airway inflammation is involved in the initiation and development of chronic asthma. After allergen exposure, there is a rapid recruitment of macrophages around the airways, which promote acute inflammatory responses. The Ang-(1-7)/Mas receptor axis reportedly plays protective roles in various tissue inflammation and remodeling processes in vivo. However, the exact role of Mas receptor and their underlying mechanisms during the pathology of acute allergic airway inflammation remains unclear. OBJECTIVE We investigated the role of Mas receptor in acute allergic asthma and explored its underlying mechanisms in vitro, aiming to find critical molecules and signal pathways. METHODS Mas receptor expression was assessed in ovalbumin (OVA)-induced acute asthmatic murine model. Then we estimated the anti-inflammatory role of Mas receptor in vivo and explored expressions of several known inflammatory cytokines as well as phosphorylation levels of MAPK pathways. Mas receptor functions and underlying mechanisms were studied further in the human bronchial epithelial cell line (16HBE). RESULTS Mas receptor expression decreased in acute allergic airway inflammation. Multiplex immunofluorescence co-localized Mas receptor and EpCAM, indicated that Mas receptor may function in the bronchial epithelium. Activating Mas receptor through AVE0991 significantly alleviated macrophage infiltration in airway inflammation, accompanied with down-regulation of CCL2 and phosphorylation levels of MAPK pathways. Further studies in 16HBE showed that AVE0991 pre-treatment inhibited LPS-induced or anisomycin-induced CCL2 increase and THP-1 macrophages migration via JNK pathways. CONCLUSION Our findings suggested that Mas receptor activation significantly attenuated CCL2 dependent macrophage recruitments in acute allergic airway inflammation through JNK pathways, which indicated that Mas receptor, CCL2 and phospho-JNK could be potential targets against allergic airway inflammation.
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Affiliation(s)
- Luna Hong
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qiujie Wang
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ming Chen
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianting Shi
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yimin Guo
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shanying Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Research Center of Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ruijian Pan
- Departments of Electric Power Engineering, South China University of Technology, Guangzhou, China
| | - Xiaoqing Yuan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
| | - Shanping Jiang
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Institute of Pulmonary Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China.
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12
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Sriram K, Loomba R, Insel PA. Targeting the renin-angiotensin signaling pathway in COVID-19: Unanswered questions, opportunities, and challenges. Proc Natl Acad Sci U S A 2020; 117:29274-29282. [PMID: 33203679 PMCID: PMC7703541 DOI: 10.1073/pnas.2009875117] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of the renin-angiotensin signaling (RAS) pathway in COVID-19 has received much attention. A central mechanism for COVID-19 pathophysiology has been proposed: imbalance of angiotensin converting enzymes (ACE)1 and ACE2 (ACE2 being the severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] virus "receptor") that results in tissue injury from angiotensin II (Ang II)-mediated signaling. This mechanism provides a rationale for multiple therapeutic approaches. In parallel, clinical data from retrospective analysis of COVID-19 cohorts has revealed that ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may be beneficial in COVID-19. These findings have led to the initiation of clinical trials using approved drugs that target the generation (ACEIs) and actions (ARBs) of Ang II. However, treatment of COVID-19 with ACEIs/ARBs poses several challenges. These include choosing appropriate inclusion and exclusion criteria, dose optimization, risk of adverse effects and drug interactions, and verification of target engagement. Other approaches related to the RAS pathway might be considered, for example, inhalational administration of ACEIs/ARBs (to deliver drugs directly to the lungs) and use of compounds with other actions (e.g., activation of ACE2, agonism of MAS1 receptors, β-arrestin-based Angiotensin receptor agonists, and administration of soluble ACE2 or ACE2 peptides). Studies with animal models could test such approaches and assess therapeutic benefit. This Perspective highlights questions whose answers could advance RAS-targeting agents as mechanism-driven ways to blunt tissue injury, morbidity, and mortality of COVID-19.
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Affiliation(s)
- Krishna Sriram
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92093
| | - Rohit Loomba
- Department of Medicine, University of California San Diego, La Jolla, CA 92093
| | - Paul A Insel
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92093;
- Department of Medicine, University of California San Diego, La Jolla, CA 92093
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13
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Copaifera spp. oleoresins impair Toxoplasma gondii infection in both human trophoblastic cells and human placental explants. Sci Rep 2020; 10:15158. [PMID: 32938966 PMCID: PMC7495442 DOI: 10.1038/s41598-020-72230-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/27/2020] [Indexed: 12/11/2022] Open
Abstract
The combination of pyrimethamine and sulfadiazine is the standard care in cases of congenital toxoplasmosis. However, therapy with these drugs is associated with severe and sometimes life-threatening side effects. The investigation of phytotherapeutic alternatives to treat parasitic diseases without acute toxicity is essential for the advancement of current therapeutic practices. The present study investigates the antiparasitic effects of oleoresins from different species of Copaifera genus against T. gondii. Oleoresins from C. reticulata, C. duckei, C. paupera, and C. pubiflora were used to treat human trophoblastic cells (BeWo cells) and human villous explants infected with T. gondii. Our results demonstrated that oleoresins were able to reduce T. gondii intracellular proliferation, adhesion, and invasion. We observed an irreversible concentration-dependent antiparasitic action in infected BeWo cells, as well as parasite cell cycle arrest in the S/M phase. The oleoresins altered the host cell environment by modulation of ROS, IL-6, and MIF production in BeWo cells. Also, Copaifera oleoresins reduced parasite replication and TNF-α release in villous explants. Anti-T. gondii effects triggered by the oleoresins are associated with immunomodulation of the host cells, as well as, direct action on parasites.
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14
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Akhtar S, Benter IF, Danjuma MI, Doi SAR, Hasan SS, Habib AM. Pharmacotherapy in COVID-19 patients: a review of ACE2-raising drugs and their clinical safety. J Drug Target 2020; 28:683-699. [PMID: 32700580 DOI: 10.1080/1061186x.2020.1797754] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic is caused by the severe acute-respiratory-syndrome-coronavirus-2 that uses ACE2 as its receptor. Drugs that raise serum/tissue ACE2 levels include ACE inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs) that are commonly used in patients with hypertension, cardiovascular disease and/or diabetes. These comorbidities have adverse outcomes in COVID-19 patients that might result from pharmacotherapy. Increasing ACE2 could potentially increase the risk of infection, severity or mortality in COVID-19 or it might be protective as it forms angiotensin-(1-7) which exhibits anti-inflammatory/anti-oxidative effects and prevents diabetes- and/or hypertension-induced end-organ damage. Thus, there existed clinical uncertainty. Here, we review studies implicating 15 classes of drugs in increasing ACE2 levels in vivo and the available literature on the clinical safety of these drugs in COVID-19 patients. Further, in a re-analysis of clinical data from a meta-analysis of 9 studies, we show that ACEIs/ARBs usage was not associated with an increased risk of all-cause mortality. Literature suggests that ACEIs/ARBs usage generally appears to be clinically safe though their use in severe COVID-19 patients might increase the risk of acute renal injury. For definitive clarity, further clinical and mechanistic studies are needed in assessing the safety of all classes of ACE2 raising medications.
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Affiliation(s)
- Saghir Akhtar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Ibrahim F Benter
- Faculty of Medicine, Eastern Mediterranean University, Famagusta, North Cyprus
| | - Mohammed I Danjuma
- College of Medicine, QU Health, Qatar University, Doha, Qatar.,Division of Internal Medicine, Hamad Medical Corporation Hospital, Doha, Qatar
| | - Suhail A R Doi
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Syed S Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Abdella M Habib
- College of Medicine, QU Health, Qatar University, Doha, Qatar
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