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Bignamini AA, Chebil A, Gambaro G, Matuška J. Sulodexide for Diabetic-Induced Disabilities: A Systematic Review and Meta-Analysis. Adv Ther 2021; 38:1483-1513. [PMID: 33502688 PMCID: PMC7932977 DOI: 10.1007/s12325-021-01620-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Micro- and macrovascular complications of diabetes are leading morbidities in the world population. They are responsible not only for increased mortality but also severe disabilities, which jeopardize quality of life (e.g., blindness, walking limitations, and renal failure requiring dialysis). The new antidiabetic agents (e.g., glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter inhibitors) are increasingly recognized as breakthrough agents in the treatment of diabetes and prevention of diabetic complications. However, drugs effective in preventing and treating diabetic disabilities are still needed and sulodexide could be one of those able to address the unmet clinical needs of the new antidiabetic agents. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal. We also manually searched potentially relevant journals, conference proceedings, and journal supplements. Any study monitoring any effect of sulodexide in subjects with diabetes, in relation to renal, vascular, and ocular complication, was considered. Treatment effects were estimated using standardized mean differences (SMDs), mean differences (MDs), and risk ratios (RRs), as appropriate. We calculated 95% confidence interval (CIs) and heterogeneity (Q, tau, and I2). RESULTS The search found 45 studies with 2817 participants (mean age 57 years; 63% male). The 26 randomized controlled studies included 2074 participants (mean age 58.8 years; 66% male). Sulodexide reduced the impact of diabetic retinopathy; increased the pain-free and maximal walking distance in peripheral arterial disease; accelerated the healing of diabetes-associated trophic ulcers; and decreased the rate of albumin excretion in subjects with nephropathy. The risk of adverse events (AEs) was not different between sulodexide and controls. CONCLUSION Sulodexide has a beneficial effect on the ocular, peripheral arterial disease, trophic ulcers, and renal complications of diabetes without increasing the risk of AEs.
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Affiliation(s)
- Angelo A Bignamini
- School of Specialisation in Hospital Pharmacy, Department of Pharmaceutical Sciences, University of Milan, Milan, Italy.
| | - Ahmed Chebil
- Department B of Ophthalmology, Hedi Rais Institute of Ophthalmology, Faculty of Medicine of Tunis, University of El Manar, Tunis, Tunisia
| | - Giovanni Gambaro
- Division of Nephrology and Dialysis, Ospedale Maggiore, University of Verona, Verona, Italy
| | - Jiří Matuška
- MATMED S.R.O., Private Angiology Facility, Hodonin, Czech Republic
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Abstract
Recent advances in the field of glycobiology have exposed a multitude of biological processes that are controlled or influenced by proteoglycans, in both physiological and pathological conditions ranging from early embryonic development, inflammation, and fibrosis to tumor invasion and metastasis. The first part of this article reviews the biosynthesis of proteoglycans and their multifunctional roles in health and disease; the second part of this review focuses on their putative roles in peritoneal homeostasis and peritoneal inflammation and fibrosis in the context of chronic peritoneal dialysis and peritonitis.
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Affiliation(s)
- Susan Yung
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Hong Kong
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The Heparanase Inhibitor (Sulodexide) Decreases Urine Glycosaminoglycan Excretion and Mitigates Functional and Histological Renal Damages in Diabetic Rats. ACTA MEDICA BULGARICA 2019. [DOI: 10.2478/amb-2019-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background/objectives: Recent data suggest a role for heparanase in several proteinuric conditions. An increased glomerular heparanase expression is associated with loss of heparan sulfate in the glomerular basement membrane (GBM). The aim of the present study was to investigate the renal effects of heparanase inhibition in a diabetic experimental model.
Methods: Fifteen male Wistar rats (230 ± 20 g) were divided into three groups: 1) controls, 2) diabetics (STZ, 50 mg/kg, dissolved in saline, ip), 3) diabetics + heparanase inhibitor (Sulodexide 1/5 mg/kg per day, gavage). The treatment started on the 21st day, for 21 consecutive days. The rats were kept individually in a metabolic cage (8 AM-2 PM) and urine samples were collected on the 21st and 42nd day. At study end blood, urine and tissue samples were collected for biochemical (blood BUN and Cr, urine GAG and Protein) and histological analyses.
Results: The results of this study showed that the heparanase inhibitor (sulodexide) significantly decreased urine GAG and protein excretion, urine protein/creatinine ratio and serum BUN and Cr in streptozotocin-induced DN in the rats. Pathological changes were significantly alleviated in the DN rats having received the heparanase inhibitor (sulodexide).
Conclusion: Our data suggest that the heparanase inhibitor (sulodexide) is able to protect against functional and histopathological injury in DN.
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Chan GC, Tang SC. Diabetic nephropathy: landmark clinical trials and tribulations. Nephrol Dial Transplant 2016; 31:359-368. [DOI: 10.1093/ndt/gfu411] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Li R, Xing J, Mu X, Wang H, Zhang L, Zhao Y, Zhang Y. Sulodexide therapy for the treatment of diabetic nephropathy, a meta-analysis and literature review. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:6275-83. [PMID: 26664049 PMCID: PMC4671764 DOI: 10.2147/dddt.s87973] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Sulodexide is a heterogeneous group of sulfated glycosaminoglycans (GAGs) that is mainly composed of low-molecular-weight heparin. Clinical studies have demonstrated that sulodexide is capable of reducing urinary albumin excretion rates in patients with type 1 and type 2 diabetes, suggesting that sulodexide has renal protection. However, this efficacy remains inconclusive. In this article, we used meta-analysis to summarize the clinical results of all prospective clinical studies in order to determine the clinical efficacy and safety of sulodexide in diabetic patients with nephropathy. Overall, sulodexide therapy was associated with a significant reduction in urinary protein excretion. In the sulodexide group, 220 (17.7%) achieved at least a 50% decrease in albumin excretion rate compared with only 141 (11.5%) in the placebo. The odds ratio comparing proportions of patients with therapeutic success between the sulodexide and placebo groups was 3.28 (95% confidence interval, 1.34-8.06; P=0.01). These data suggest a renoprotective benefit of sulodexide in patients with diabetes and micro- and macroalbuminuria, which will provide important information for clinical use of this drug as a potential modality for diabetic nephropathy, specifically, the prevention of end-stage renal disease that is often caused by diabetes.
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Affiliation(s)
- Rui Li
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Jing Xing
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Xaojing Mu
- Dalian Hospital of Traditional Chinese Medicine, Dalian, People's Republic of China
| | - Hui Wang
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Lei Zhang
- Intensive Care Unit, Tianjin First Central Hospital, People's Republic of China
| | - Yu Zhao
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Yu Zhang
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
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Satirapoj B, Kaewput W, Supasyndh O, Ruangkanchanasetr P. Effect of sulodexide on urinary biomarkers of kidney injury in normoalbuminuric type 2 diabetes: a randomized controlled trial. J Diabetes Res 2015; 2015:172038. [PMID: 25918727 PMCID: PMC4396730 DOI: 10.1155/2015/172038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 01/05/2023] Open
Abstract
Glycosaminoglycans or sulodexide has shown benefits in early experimental diabetic nephropathy (DN) models, but its efficacy in patients with early stage of DN is unknown. Methods. Twenty patients were randomly assigned to the placebo group and another 20 patients were randomly assigned to receive sulodexide 100 mg/day for 14 weeks. Primary outcome was a change of urinary TGF-beta1, albuminuria, and glomerular filtration rate (GFR). All patients had stable metabolic profiles for at least 90 days before randomization. Results. Urinary TGF-beta1 increased significantly in the placebo group but did not change significantly in the sulodexide group. Additionally, the mean change of urine TGF-beta1 in the placebo group was significantly higher than that in the sulodexide group (8.44 ± 9.21 versus 2.17 ± 6.96 pg/mg Cr, P = 0.02). Mean changes of urinary albumin were 15.05 ± 30.09 μg/mg Cr (P = 0.038) in the placebo group and 13.89 ± 32.25 μg/mg Cr (P = 0.069) in the sulodexide group. No consistent patterns of side effects were observed. Conclusion. In this 14-week trial, benefits of sulodexide in preventing the increase of urinary TGF-beta1 were observed in patients with normoalbuminuric type 2 diabetes. The study suggests that sulodexide treatment may provide additional renoprotection in early stage DN. This trial is registered with TCTR20140806001.
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Affiliation(s)
- Bancha Satirapoj
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
- *Bancha Satirapoj:
| | - Wisit Kaewput
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Ouppatham Supasyndh
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Prajej Ruangkanchanasetr
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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Abstract
Diabetic nephropathy is currently the most common cause of end stage renal disease not only in the Western hemisphere but also in the developing nations. While the available therapeutic options remain not very effective, there is a strong ongoing effort to understand the pathogenesis better and develop more useful biomarkers. As the pathogenic mediators and signaling pathways get better defined, the scope of novel pharmaceutical agents to address such mediating factors as therapeutic targets is advancing. This review provides, in addition to a brief synopsis of currently used strategies, a comprehensive review of potential therapies that have been evolving in the past decade with a specific focus on the promising agents.
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Affiliation(s)
- Harneet Kaur
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sharma Prabhakar
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Abstract
Diabetes mellitus contributes greatly to morbidity, mortality, and overall health care costs. In major part, these outcomes derive from the high incidence of progressive kidney dysfunction in patients with diabetes making diabetic nephropathy a leading cause of end-stage renal disease. A better understanding of the molecular mechanism involved and of the early dysfunctions observed in the diabetic kidney may permit the development of new strategies to prevent diabetic nephropathy. Here we review the pathophysiological changes that occur in the kidney in response to hyperglycemia, including the cellular responses to high glucose and the responses in vascular, glomerular, podocyte, and tubular function. The molecular basis, characteristics, and consequences of the unique growth phenotypes observed in the diabetic kidney, including glomerular structures and tubular segments, are outlined. We delineate mechanisms of early diabetic glomerular hyperfiltration including primary vascular events as well as the primary role of tubular growth, hyperreabsorption, and tubuloglomerular communication as part of a "tubulocentric" concept of early diabetic kidney function. The latter also explains the "salt paradox" of the early diabetic kidney, that is, a unique and inverse relationship between glomerular filtration rate and dietary salt intake. The mechanisms and consequences of the intrarenal activation of the renin-angiotensin system and of diabetes-induced tubular glycogen accumulation are discussed. Moreover, we aim to link the changes that occur early in the diabetic kidney including the growth phenotype, oxidative stress, hypoxia, and formation of advanced glycation end products to mechanisms involved in progressive kidney disease.
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Affiliation(s)
- Volker Vallon
- Department of Medicine, University of California San Diego & VA San Diego Healthcare System, San Diego, California, USA.
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Boels MGS, Lee DH, van den Berg BM, Dane MJC, van der Vlag J, Rabelink TJ. The endothelial glycocalyx as a potential modifier of the hemolytic uremic syndrome. Eur J Intern Med 2013; 24:503-9. [PMID: 23357408 DOI: 10.1016/j.ejim.2012.12.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 12/19/2012] [Accepted: 12/20/2012] [Indexed: 12/22/2022]
Abstract
Atypical hemolytic uremic syndrome (HUS) is a renal disease due to complement dysregulation. Many of the known causes of atypical HUS originate from genetic mutations of complement regulatory proteins, such as complement factor H (CFH) and thrombomodulin. However, atypical HUS has only a genetic penetrance of 40-50% of the cases and usually appears in adulthood. We introduce a novel factor that may be involved in the onset and development of atypical HUS, i.e. the endothelial surface glycocalyx. The glycocalyx is a highly interactive matrix covering the luminal side of vascular endothelial cells and consists of glycosaminoglycans, proteoglycans and glycoproteins, which has an important role in maintaining homeostasis of the vasculature. The surface-bound glycocalyx glycosaminoglycan constituent heparan sulfate is crucial for CFH binding and function, both in recognition of host tissue and prevention of spontaneous complement activation via the alternative pathway. Most of the clinically relevant genetic mutations in CFH result in incorrect binding to heparan sulfate. In addition, a role between proper function of thrombomodulin and the endothelial glycocalyx has also been observed. We suggest that not only changes in binding properties of the complement regulatory proteins play a role but also changes in the endothelial glycocalyx are involved in increased risk of clinical manifestation of atypical HUS. Finally, vascular glycocalyx heterogeneity in turn could dictate the specific vulnerability of the glomerular vascular bed in atypical HUS and may provide new therapeutic targets to intervene with endothelial cell activation and local complement pathway regulation.
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Affiliation(s)
- Margien G S Boels
- Department of Nephrology, Einthoven Laboratory for Vascular Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Yung S, Chau MKM, Zhang Q, Zhang CZ, Chan TM. Sulodexide decreases albuminuria and regulates matrix protein accumulation in C57BL/6 mice with streptozotocin-induced type I diabetic nephropathy. PLoS One 2013; 8:e54501. [PMID: 23349910 PMCID: PMC3551764 DOI: 10.1371/journal.pone.0054501] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 12/12/2012] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Sulodexide is a mixture of glycosaminoglycans that may reduce proteinuria in diabetic nephropathy (DN), but its mechanism of action and effect on renal histology is not known. We investigated the effect of sulodexide on disease manifestations in a murine model of type I DN. METHODS Male C57BL/6 mice were rendered diabetic with streptozotocin. After the onset of proteinuria, mice were randomized to receive sulodexide (1 mg/kg/day) or saline for up to 12 weeks and renal function, histology and fibrosis were examined. The effect of sulodexide on fibrogenesis in murine mesangial cells (MMC) was also investigated. RESULTS Mice with DN showed progressive albuminuria and renal deterioration over time, accompanied by mesangial expansion, PKC and ERK activation, increased renal expression of TGF-β1, fibronectin and collagen type I, III and IV, but decreased glomerular perlecan expression. Sulodexide treatment significantly reduced albuminuria, improved renal function, increased glomerular perlecan expression and reduced collagen type I and IV expression and ERK activation. Intra-glomerular PKC-α activation was not affected by sulodexide treatment whereas glomerular expression of fibronectin and collagen type III was increased. MMC stimulated with 30 mM D-glucose showed increased PKC and ERK mediated fibronectin and collagen type III synthesis. Sulodexide alone significantly increased fibronectin and collagen type III synthesis in a dose-dependent manner in MMC and this increase was further enhanced in the presence of 30 mM D-glucose. Sulodexide showed a dose-dependent inhibition of 30 mM D-glucose-induced PKC-βII and ERK phosphorylation, but had no effect on PKC-α or PKC-βI phosphorylation. CONCLUSIONS Our data demonstrated that while sulodexide treatment reduced proteinuria and improved renal function, it had differential effects on signaling pathways and matrix protein synthesis in the kidney of C57BL/6 mice with DN.
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Affiliation(s)
- Susan Yung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Yang BY, Lee HS, Song SH, Kwak IS, Lee SB, Lee DW, Seong EY. Use of low-dose sulodexide in IgA nephropathy patients on renin–angiotensin system blockades. Kidney Res Clin Pract 2012; 31:163-9. [PMID: 26894022 PMCID: PMC4716093 DOI: 10.1016/j.krcp.2012.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/26/2012] [Accepted: 06/11/2012] [Indexed: 11/18/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Byeong Yun Yang
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hee Seon Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sang Heon Song
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Corresponding author. Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 602–739, Korea.
| | - Ihm Soo Kwak
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Soo Bong Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Dong Won Lee
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Eun Young Seong
- Division of Nephrology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Reeves WB, Rawal BB, Abdel-Rahman EM, Awad AS. Therapeutic Modalities in Diabetic Nephropathy: Future Approaches. OPEN JOURNAL OF NEPHROLOGY 2012; 2:5-18. [PMID: 23293752 PMCID: PMC3534956 DOI: 10.4236/ojneph.2012.22002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Several therapeutic interventions for the treatment of diabetic nephropathy have been developed and implemented over the past few decades with some degree of success. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are therefore urgently needed. Recently, several novel therapeutic strategies have been explored in treating DN patients including Islet cell transplant, Aldose reductase inhibitors, Sulodexide (GAC), Protein Kinase C (PKC) inhibitors, Connective tissue growth factor (CTGF) inhibitors, Transforming growth factor-beta (TGF-β) inhibitors and bardoxolone. The benefits and risks of these agents are still under investigation. This review aims to summarize the utility of these novel therapeutic approaches.
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Affiliation(s)
- William Brian Reeves
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
| | - Bishal B. Rawal
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
| | - Emaad M. Abdel-Rahman
- Department of Medicine, Division of Nephrology, University of Virginia, Charlottesville, USA
| | - Alaa S. Awad
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
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Packham DK, Wolfe R, Reutens AT, Berl T, Heerspink HL, Rohde R, Ivory S, Lewis J, Raz I, Wiegmann TB, Chan JCN, de Zeeuw D, Lewis EJ, Atkins RC. Sulodexide fails to demonstrate renoprotection in overt type 2 diabetic nephropathy. J Am Soc Nephrol 2012; 23:123-30. [PMID: 22034636 PMCID: PMC3269919 DOI: 10.1681/asn.2011040378] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 08/14/2011] [Indexed: 12/19/2022] Open
Abstract
Sulodexide, a mixture of naturally occurring glycosaminoglycan polysaccharide components, has been reported to reduce albuminuria in patients with diabetes, but it is unknown whether it is renoprotective. This study reports the results from the randomized, double-blind, placebo-controlled, sulodexide macroalbuminuria (Sun-MACRO) trial, which evaluated the renoprotective effects of sulodexide in patients with type 2 diabetes, renal impairment, and significant proteinuria (>900 mg/d) already receiving maximal therapy with angiotensin II receptor blockers. The primary end point was a composite of a doubling of baseline serum creatinine, development of ESRD, or serum creatinine ≥6.0 mg/dl. We planned to enroll 2240 patients over approximately 24 months but terminated the study after enrolling 1248 patients. After 1029 person-years of follow-up, we did not detect any significant differences between sulodexide and placebo; the primary composite end point occurred in 26 and 30 patients in the sulodexide and placebo groups, respectively. Side effect profiles were similar for both groups. In conclusion, these data do not suggest a renoprotective benefit of sulodexide in patients with type 2 diabetes, renal impairment, and macroalbuminuria.
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Affiliation(s)
- David K Packham
- Melbourne Renal Research Group, 73-75 Pine Street, Reservoir, Melbourne, Victoria 3073, Australia.
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Lewis EJ, Lewis JB, Greene T, Hunsicker LG, Berl T, Pohl MA, de Zeeuw D, Heerspink HL, Rohde RD, Atkins RC, Reutens AT, Packham DK, Raz I. Sulodexide for kidney protection in type 2 diabetes patients with microalbuminuria: a randomized controlled trial. Am J Kidney Dis 2011; 58:729-36. [PMID: 21872376 DOI: 10.1053/j.ajkd.2011.06.020] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/10/2011] [Indexed: 01/28/2023]
Abstract
BACKGROUND Sulodexide, a heterogenous group of sulfated glycosaminoglycans, includes low-molecular-weight heparin (~80% ± 8%), high-molecular-weight heparin (~5% ± 3%), and dermatan (~20% ± 8%), with a mean molecular weight of ~9 kDa. The drug is absorbed orally and has no anticoagulant effect in the doses used. Small preliminary studies consistently showed sulodexide to be associated with decreased albuminuria in patients with diabetes. STUDY DESIGN We conducted a multicenter placebo-controlled double-blinded study to determine the effect of sulodexide on urine albumin excretion in patients with type 2 diabetic nephropathy. SETTING & PARTICIPANTS Patients with type 2 diabetes and urine albumin-creatinine ratios (ACRs) of 35-200 mg/g in men and 45-200 mg/g in women were enrolled. Serum creatinine level was <1.5 mg/dL. Blood pressure goal was 130/80 mm Hg. A maximum US Food and Drug Administration-approved dose of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for a minimum of 4 months before randomization was required. INTERVENTION The study drug was sulodexide, 200 mg/d. OUTCOME & MEASUREMENTS The primary end point was normoalbuminuria (ACR <20 mg/g and a decrease >25%) or 50% decrease in baseline ACR. RESULTS In 1,056 randomly assigned patients with a mean baseline ACR of 107.8 ± 83.7 mg/g, comparing the sulodexide versus placebo groups, the primary end point was achieved in 16.5% versus 18.4%; normoalbuminuria, in 7.9% versus 6.1%; and a 50% decrease in albuminuria, in 15.4% versus 17.6%. The relative probability of any given change in albuminuria was identical in both groups. LIMITATIONS We were unable to determine whether the administered sulodexide was absorbed from the gastrointestinal tract. CONCLUSION Sulodexide failed to decrease urine albumin excretion in patients with type 2 diabetic nephropathy and microalbuminuria.
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Bang K, Chin HJ, Chae DW, Joo KW, Kim YS, Kim S, Ju KD, Kim H, Ahn C, Oh KH. Anti-proteinuric effect of sulodexide in immunoglobulin a nephropathy. Yonsei Med J 2011; 52:588-94. [PMID: 21623600 PMCID: PMC3104455 DOI: 10.3349/ymj.2011.52.4.588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We conducted a multi-center randomized double-blind study to determine the effects of 6-month therapy with sulodexide on urinary protein excretion in patients with idiopathic Immunoglobulin A (IgA) nephropathy. MATERIALS AND METHODS A total of seventy-seven patients participated in the study. They were randomly allocated to one of three groups: sulodexide 75 mg or 150 mg daily or the placebo for 6 months. The primary end point was the achievement, at 6 months, of at least 50% reduction in urine protein/creatinine ratio (UPCR) from the baseline value. RESULTS At 6 months, the primary end point was achieved by 12.5% of the patients assigned to the placebo, 4.0% of the patients assigned to sulodexide 75 mg daily and 21.4% of those assigned to 150 mg (p=0.308). Treatment with sulodexide 150 mg daily for 6 months significantly reduced log UPCR from 6.38±0.77 at baseline to 5.98±0.94 at 6 months (p=0.045), while treatment with sulodexide 75 mg daily and placebo did not. CONCLUSION A 6-month treatment with sulodexide did not achieve 50% reduction of urinary protein excretion in IgA nephropathy patients, but showed a tendency to increase the time-dependent anti-proteinuric effect. Therefore, long-term clinical trials on a larger scale are warranted to elucidate the hypothesis that sulodexide affords renal protection in IgA nephropathy patients.
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Affiliation(s)
- Kitae Bang
- Department of Internal Medicine, Eulji University of Medicine, Daejeon, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Suhnggwon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Don Ju
- Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Hwajung Kim
- Transplantation Research Institute, Seoul National University, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Transplantation Research Institute, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Transplantation Research Institute, Seoul, Korea
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Cicero AF, Ertek S. Preclinical and clinical evidence of nephro- and cardiovascular protective effects of glycosaminoglycans. Arch Med Sci 2010; 6:469-77. [PMID: 22371788 PMCID: PMC3284059 DOI: 10.5114/aoms.2010.14456] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 06/15/2009] [Accepted: 10/17/2009] [Indexed: 01/27/2023] Open
Abstract
Despite advances in pharmacological treatment, diabetic nephropathy is still the leading cause of end-stage renal disease and an important cause of morbidity and mortality in diabetics. Glycosaminoglycans are long, unbranched mucopolysaccharides that play an important role in establishing a charge-selective barrier that restricts the passage of negatively charged molecules, such as albumin and other proteins, at the level of the glomerular basal membrane. Their loss is associated with loss of selectivity and proteinuria. Extensive preclinical evidence and some clinical trials suggest that glycosaminoglycans replacement is associated with improvement of glomerular selectivity and of proteinuria. Sulodexide could also have some other effects, potentially useful to reduce the renal damage and the cardiovascular disease associated with proteinuria, such as improvement of haemorheological and blood lipid parameters, an endothelium protective effect and anti-inflammatory action. This review will discuss the evidence supporting the potential nephroprotective effects of sulodexide and other glycosaminoglycans.
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Affiliation(s)
- Arrigo F. Cicero
- Hypertension Research Unit, Internal Medicine, Aging and Kidney Diseases Department, Alma Mater Studiorum University of Bologna, Italy
| | - Sibel Ertek
- Endocrinology and Metabolic Diseases Department, Ufuk University, Ankara, Turkey
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Gaddi AV, Cicero AF, Gambaro G. Nephroprotective action of glycosaminoglycans: why the pharmacological properties of sulodexide might be reconsidered. Int J Nephrol Renovasc Dis 2010; 3:99-105. [PMID: 21694935 PMCID: PMC3108767 DOI: 10.2147/ijnrd.s5943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Indexed: 12/13/2022] Open
Abstract
A relatively large body of evidence supports the notion that glomerular capillary wall and mesangial alterations in diabetic nephropathy involve biochemical alterations of glycoproteins in these structures. Evidence in experimental animals rendered diabetic reveals that the administration of heparin and other anionic glycoproteins can effectively prevent the biochemical alterations that promote albuminuria. Moreover, angiotensin II inhibits heparan sulfate synthesis, while heparins modulate angiotensin II signaling in glomerular cells, inhibiting aldosterone synthesis and lowering proteinuria in diabetes patients. Sulodexide, a mixture of heparin and dermatan sulfate, appears to be a promising treatment for diabetic proteinuria partially resistant to renin-angiotensin system blocking agents. Sulodexide prevents heparan sulfate degradation, thus allowing reconstruction of heparan sulfate content and restoration of glomerular basement membrane ionic permselectivity. The antiproteinuric effect appears to be mainly related to the basal proteinuria and consequently to the duration of treatment in a relatively large number of small clinical trials. On the other hand, several sulodexide pharmacodynamic properties could improve the prognosis of chronic kidney disease patients, also independently from its antiproteinuric effect. However, sulodexide development as an antiproteinuric drug needs to be continued, in order to define which kind of patients could better respond to this treatment.
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Affiliation(s)
- Antonio V Gaddi
- Atherosclerosis and Metabolic disease Research Unit, Internal Medicine, Aging and Kidney diseases Dept., University of Bologna, Italy.
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Agrawal V, Kizilbash SH, McCullough PA. New therapeutic agents for diabetic kidney disease. ACTA ACUST UNITED AC 2008. [DOI: 10.2217/14750708.5.4.553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lewis EJ, Xu X. Abnormal glomerular permeability characteristics in diabetic nephropathy: implications for the therapeutic use of low-molecular weight heparin. Diabetes Care 2008; 31 Suppl 2:S202-7. [PMID: 18227486 DOI: 10.2337/dc08-s251] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The physicochemical characteristics of the glomerular capillary filtration membrane restrict the passage of macromolecules on the basis of molecular weight, charge, and shape. The proposed ionic charge permselectivity characteristics of the glomerular basement membrane (GBM) are determined by its chemical composition, primarily the highly sulfated glycosaminoglycan heparan. In diabetic nephropathy, the heparan sulfate content of the GBM is diminished. It has been proposed that decreased GBM heparan sulfate content causes decreased permselectivity to negatively charged macromolecules such as albumin, allowing this protein to leak into the urinary space. One possible explanation for decreased GBM heparan sulfate content in diabetic nephropathy is the observation that heparanase, an enzyme capable of degrading heparan sulfate, is upregulated in the glomerular epithelial cell (GEC) in response to increased glucose. Increased GEC heparanase activity has been demonstrated in glomeruli in diabetic kidneys, and increased urine heparanase has been observed in diabetic nephropathy. In vitro studies have shown that GEC heparanase activity depends on the glucose concentration of the culture medium. GEC heparanase activity can be inhibited by heparin compounds. Sulodexide, an orally active low-molecular weight heparin, has been shown to lower urine albumin excretion. The working hypothesis that has emerged is that sulodexide may be an in vivo heparanase inhibitor that reaches the glomerular capillary wall and prevents heparan sulfate degradation, thus allowing reconstruction of heparan sulfate content and restoration of GBM ionic permselectivity. Two clinical trials are currently being carried out to determine whether sulodexide is renoprotective in diabetic nephropathy.
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Affiliation(s)
- Edmund J Lewis
- Department of Medicine, Section of Nephrology, Collaborative Study Group, Rush University Medical Center, Chicago, Illinois 60607, USA.
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Wijnhoven TJM, van den Hoven MJW, Ding H, van Kuppevelt TH, van der Vlag J, Berden JHM, Prinz RA, Lewis EJ, Schwartz M, Xu X. Heparanase induces a differential loss of heparan sulphate domains in overt diabetic nephropathy. Diabetologia 2008; 51:372-82. [PMID: 18058084 DOI: 10.1007/s00125-007-0879-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 10/08/2007] [Indexed: 01/11/2023]
Abstract
AIMS/HYPOTHESIS Recent studies suggest that loss of heparan sulphate in the glomerular basement membrane (GBM) of the kidney with diabetic nephropathy is due to the increased production of heparanase, a heparan sulphate-degrading endoglycosidase. Our present study addresses whether heparan sulphate with different modifications is differentially reduced in the GBM and whether heparanase selectively cleaves heparan sulphate with different domain specificities. METHODS The heparan sulphate content of renal biopsies (14 diabetic nephropathy, five normal) were analysed by immunofluorescence staining with four anti-heparan sulphate antibodies: JM403, a monoclonal antibody (mAb) recognising N-unsubstituted glucosamine residues; two phage display-derived single chain antibodies HS4C3 and EW3D10, defining sulphated heparan sulphate domains; and anti-K5 antibody, an mAb recognising unmodified heparan sulphate domains. RESULTS We found that modified heparan sulphate domains (JM403, HS4C3 and EW3D10), but not unmodified domains (anti-K5) and agrin core protein were reduced in the GBM of kidneys from patients with diabetic nephropathy, compared with controls. Glomerular heparanase levels were increased in diabetic nephropathy kidneys and inversely correlated with the amounts of modified heparan sulphate domains. Increased heparanase production and loss of JM403 staining in the GBM correlated with the severity of proteinuria. Loss of modified heparan sulphate in the GBM as a result of degradation by heparanase was confirmed by heparan sulphate staining of heparanase-treated normal kidney biopsy specimens. CONCLUSIONS/INTERPRETATION Our data suggest that loss of modified heparan sulphate in the GBM is mediated by an increased heparanase presence and may play a role in the pathogenesis of diabetes-induced proteinuria.
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Affiliation(s)
- T J M Wijnhoven
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Lambers Heerspink HJ, Fowler MJ, Volgi J, Reutens AT, Klein I, Herskovits TA, Packham DK, Fraser IR, Schwartz SL, Abaterusso C, Lewis J. Rationale for and study design of the sulodexide trials in Type 2 diabetic, hypertensive patients with microalbuminuria or overt nephropathy. Diabet Med 2007; 24:1290-5. [PMID: 17956455 DOI: 10.1111/j.1464-5491.2007.02249.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with Type 2 diabetes and albuminuria are at high risk to progress to end-stage renal disease (ESRD). Although angiotensin receptor blockers confer renoprotection, many diabetic patients still develop overt nephropathy and reach ESRD. Glycosaminoglycans belong to the same family as heparin and heparinoids. Pilot studies with sulodexide, a glycosaminoglycan, have shown that sulodexide can reduce urinary albumin excretion rates in diabetic patients. No hard renal end-point data are available. METHODS Two multicentre, double-masked, randomized placebo controlled trials were designed to study the renoprotective potential of sulodexide. The Sulodexide Microalbuminuria Trial examined the efficacy of sulodexide given over 26 weeks in 1000 patients with Type 2 diabetes, hypertension and microalbuminuria. The Sulodexide Overt Nephropathy Trial examined the efficacy of sulodexide in 2240 patients with Type 2 diabetes, hypertension and proteinuria > or = 900 mg/24 h. RESULTS The primary outcome of The Sulodexide Microalbuminuria Trial was (i) conversion to normoalbuminuria and at least a 25% decrease in the urinary albumin creatinine ratio (UACR), or (ii) at least a 50% reduction in UACR. The primary outcome of The Sulodexide Overt Nephropathy Trial was time to a composite end point of doubling of serum creatinine or ESRD. CONCLUSIONS The sulodexide nephropathy programme will document whether therapy with sulodexide confers renal protection in Type 2 diabetes and nephropathy.
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Affiliation(s)
- H J Lambers Heerspink
- Department of Clinical Pharmacology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Wijnhoven TJ, van de Westerlo EM, Smits NC, Lensen JF, Rops AL, van der Vlag J, Berden JH, van den Heuvel LP, van Kuppevelt TH. Characterization of anticoagulant heparinoids by immunoprofiling. Glycoconj J 2007; 25:177-85. [PMID: 17909966 PMCID: PMC2234449 DOI: 10.1007/s10719-007-9070-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 08/20/2007] [Accepted: 08/28/2007] [Indexed: 11/29/2022]
Abstract
Heparinoids are used in the clinic as anticoagulants. A specific pentasaccharide in heparinoids activates antithrombin III, resulting in inactivation of factor Xa and–when additional saccharides are present–inactivation of factor IIa. Structural and functional analysis of the heterogeneous heparinoids generally requires advanced equipment, is time consuming, and needs (extensive) sample preparation. In this study, a novel and fast method for the characterization of heparinoids is introduced based on reactivity with nine unique anti-heparin antibodies. Eight heparinoids were biochemically analyzed by electrophoresis and their reactivity with domain-specific anti-heparin antibodies was established by ELISA. Each heparinoid displayed a distinct immunoprofile matching its structural characteristics. The immunoprofile could also be linked to biological characteristics, such as the anti-Xa/anti-IIa ratio, which was reflected by reactivity of the heparinoids with antibodies HS4C3 (indicative for 3-O-sulfates) and HS4E4 (indicative for domains allowing anti-factor IIa activity). In addition, the immunoprofile could be indicative for heparinoid-induced side-effects, such as heparin-induced thrombocytopenia, as illustrated by reactivity with antibody NS4F5, which defines a very high sulfated domain. In conclusion, immunoprofiling provides a novel, fast, and simple methodology for the characterization of heparinoids, and allows high-throughput screening of (new) heparinoids for defined structural and biological characteristics.
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Affiliation(s)
- Tessa J. Wijnhoven
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Department of Pediatric Nephrology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Els M. van de Westerlo
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Nicole C. Smits
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Joost F. Lensen
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Angelique L. Rops
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Johan van der Vlag
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jo H. Berden
- Nephrology Research Laboratory, Division of Nephrology, Nijmegen Centre for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Lambert P. van den Heuvel
- Department of Pediatric Nephrology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Toin H. van Kuppevelt
- Department of Matrix Biochemistry, Nijmegen Centre for Molecular Life Sciences, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Wijnhoven TJM, Lensen JFM, Rops ALWMM, van der Vlag J, Kolset SO, Bangstad HJ, Pfeffer P, van den Hoven MJW, Berden JHM, van den Heuvel LPWJ, van Kuppevelt TH. Aberrant heparan sulfate profile in the human diabetic kidney offers new clues for therapeutic glycomimetics. Am J Kidney Dis 2006; 48:250-61. [PMID: 16860191 DOI: 10.1053/j.ajkd.2006.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 05/02/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diabetic nephropathy poses an increasing health problem in the Western world, and research to new leads for diagnosis and therapy therefore is warranted. In this respect, heparan sulfates (HSs) offer new possibilities because crude mixtures of these polysaccharides are capable of ameliorating proteinuria. The aim of this study is to immuno(histo)chemically profile HSs from microalbuminuric kidneys from patients with type 1 diabetes and identify specific structural HS alterations associated with early diabetic nephropathy. METHODS Renal cryosections of control subjects and patients with type 1 diabetes were analyzed immunohistochemically by using a set of 10 unique phage display-derived anti-HS antibodies. HS structures defined by relevant antibodies were characterized chemically by means of enzyme-linked immunosorbent assay and probed for growth factor binding and presence in HS/heparin-containing drugs. RESULTS In all patients, HS structure defined by the antibody LKIV69 consistently increased in basement membranes of proximal tubules. This structure contained N- and 2-O-sulfates and was involved in fibroblast growth factor 2 binding. It was present in HS/heparin-containing drugs shown to decrease albuminuria in patients with diabetes. The HS structure defined by the antibody HS4C3 increased in the renal mesangium of some patients, especially those who developed macroalbuminuria within 8 to 10 years. This structure contained N- and 6-O-sulfates. For 8 other antibodies, no major differences were observed. CONCLUSION Specific structural alterations in HSs are associated with early diabetic nephropathy and may offer new leads for early diagnosis and the rational design of therapeutic glycomimetics.
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Affiliation(s)
- Tessa J M Wijnhoven
- Department of Matrix Biochemistry and Nephrology Research Laboratory, Nijmegen Centre for Molecular Life Sciences, The Netherlands.
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Abaterusso C, Gambaro G. The Role of Glycosaminoglycans and Sulodexide in the Treatment of Diabetic Nephropathy. ACTA ACUST UNITED AC 2006; 5:211-22. [PMID: 16879000 DOI: 10.2165/00024677-200605040-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Diabetic nephropathy occurs in 20-40% of diabetic patients, making it one of the most important causes of end-stage renal disease (ESRD). It has a large impact in terms of associated morbidity and mortality for the individual patient and in terms of costs for healthcare. Several studies have demonstrated that micro- and macroalbuminuria predict cardiovascular morbidity and mortality in patients with diabetes mellitus.Current nephroprotective therapies for diabetic nephropathy include the pursuit of normoglycemia and normotension, and a consensus is emerging that there is a necessity to also achieve as low a level of albuminuria as possible. However, the search for innovative and ancillary approaches to the prevention and treatment of this diabetic complication is warranted since strict metabolic control can be difficult, and sometimes dangerous, to achieve and even diabetic patients responding to ACE inhibitors (ACEIs) or angiotensin II receptor antagonists (angiotensin receptor blockers; ARBs) and metabolic control show progressive renal damage and eventually ESRD. A number of drugs are currently being investigated; glycosaminoglycans are particularly interesting since, in theory, they target the generalized endothelial dysfunction and metabolic defect in matrix and basement membrane synthesis which, according to the Steno hypothesis, are responsible for diabetic nephropathy and macroangiopathy.Treatment with glycosaminoglycans, and with sulodexide in particular, significantly improves albuminuria in type 1 and type 2 diabetic patients with micro- or macroalbuminuria. The albuminuria-lowering effect of sulodexide enhances the effect of ACEI/ARB therapy. Most studies have shown that the effect of sulodexide on albuminuria is sustained, strongly suggesting that favorable chemical and anatomic remodeling is induced by exogenous glycosaminoglycans in renal tisues, as observed in the experimental model.
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Affiliation(s)
- Cataldo Abaterusso
- Department of Biomedical and Surgical Sciences, Division of Nephrology, University of Verona, Verona, Italy
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Abstract
Despite the worldwide epidemic of chronic kidney disease complicating diabetes mellitus, current therapies directed against nephroprogression are limited to angiotensin conversion or receptor blockade. Nonetheless, additional therapeutic possibilities are slowly emerging. The diversity of therapies currently in development reflects the pathogenic complexity of diabetic nephropathy. The three most important candidate drugs currently in development include a glycosaminoglycan, a protein kinase C (PKC) inhibitor and an inhibitor of advanced glycation. In targeting primary mechanisms by which hyperglycaemia contributes to diabetic complications, these drugs could provide risk reduction complementary to the partial reduction proven for ACE inhibitors and angiotensin II receptor antagonists (angiotensin receptor blockers). Glycosaminoglycans act to restore glycoproteins present in reduced amounts in the glomerular basement membrane and mesangium of diabetic animal models. Components of the drug sulodexide prevent pathological changes and proteinuria in diabetic rats. Reductions in albuminuria, a hallmark of early diabetic kidney disease, have been reported in initial human trials. In the US, a multicentre phase II study has been completed, with an interim analysis indicating reduction in urinary albumin losses. Pivotal phase II trials have begun in patients with type 2 diabetes. A second metabolic pathway of diabetic complications is overexpression of PKC. Several activators of this family of intracellular kinases have been identified and PKC activation may result in tissue damage through a variety of mechanisms. In animal models, the inhibitor ruboxistaurin reduces albuminuria, diabetic histological changes and kidney injury. Like sulodexide, drug development of ruboxistaurin has reached completion of a phase II evaluation with mixed results. The third metabolic target is the nonenzymatic formulation of advanced glycation end-products (AGEs) through well described biochemical pathways. Multiple pathways lead to AGE accumulation in tissues in diabetes and diverse AGE products are formed. AGE deposition has been implicated in animal models of diabetic nephropathy. The leading AGE inhibitor currently in development is pyridoxamine, which has multiple actions that inhibit glycation. Pyridoxamine is an efficient AGE inhibitor in experimental diabetes. A phase II study in diabetic patients with nephropathy reported mixed efficacy results and a favourable safety profile. Phase III evaluation of pyridoxamine has not begun. These three classes of potential therapies, if successfully developed, will confirm that diabetic kidney disease has entered the era of biochemical treatments.
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Affiliation(s)
- Mark E Williams
- Renal Unit, The Joslin Diabetes Center, Boston, Massachusetts 02215, USA.
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Errichi BM, Cesarone MR, Belcaro G, Marinucci R, Ricci A, Ippolito A, Brandolini R, Vinciguerra G, Dugall M, Felicita A, Pellegrini L, Gizzi G, Ruffini M, Acerbi G, Bavera P, Renzo AD, Corsi M, Scoccianti M, Hosoi M, Lania M. Prevention of recurrent deep venous thrombosis with sulodexide: the SanVal registry. Angiology 2004; 55:243-9. [PMID: 15156256 DOI: 10.1177/000331970405500302] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate the prevention of recurrent deep vein thrombosis (R-DVT) with an oral antithrombotic agent (sulodexide) in moderate to high-risk subjects. A group of 405 patients was included into the multicenter registry. Both compression and an exercise program were used as well as a risk-factors control plan. After diagnosis of DVT, patients were treated with oral anticoagulants for 6 months. At the end of this period a coagulation study was made and patients started treatment with oral sulodexide capsules for a period of 24 months. The femoral, popliteal, tibial, and superficial veins were scanned with high-resolution ultrasound at inclusion;scans were repeated at 6, 12, 18, and 24 months. Of the 405 subjects included into the registry 178 in the control group (mean age 52.2; SD 11; M:F=90:88) and 189 in the treatment group (mean age 53.2; SD 10.3; M:F=93:96) completed the analysis period of 24 months. At 6 and 12 months the incidence of R-DVT was lower (p<0.05) in the treatment group. At 24 months the global incidence of R-DVT was 17.9% in the control group and 7.4% in the sulodexide group (p<0.05), 2.42 times lower than in controls. The 2 groups were comparable for age and sex distribution and for the localization of the thrombi at inclusion. Also the 2 groups of dropouts were comparable. In the control group there were 32 recurrent DVTs and 24 subjects lost to follow-up (total of 56) of 202 included subjects (27.7%) in comparison with 28 failures (14 recurrent DVTs and 14 lost subjects) of 203 subjects (13.8%) in the treatment group. This difference was statistically significant. In this analysis the incidence of DVT in controls was 2.07 times higher than in the treatment group subjects. In conclusion sulodexide was effective in reducing recurrent thrombotic events in high-risk subjects.
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Affiliation(s)
- B M Errichi
- General Surgery Osp. Guardiagrele (Ch), University of Milan, Italy
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Gambaro G, Kinalska I, Oksa A, Pont'uch P, Hertlová M, Olsovsky J, Manitius J, Fedele D, Czekalski S, Perusicová J, Skrha J, Taton J, Grzeszczak W, Crepaldi G. Oral sulodexide reduces albuminuria in microalbuminuric and macroalbuminuric type 1 and type 2 diabetic patients: the Di.N.A.S. randomized trial. J Am Soc Nephrol 2002; 13:1615-25. [PMID: 12039991 DOI: 10.1097/01.asn.0000014254.87188.e5] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Diabetic nephropathy may be effectively prevented and treated by controlling glycemia and administering angiotensin-converting enzyme (ACE) inhibitors. However, strict metabolic control can be difficult, and ACE inhibitors may be poorly tolerated and only partially effective, particularly in diabetes mellitus type 2 (DM2), warranting the search for ancillary treatment. Sulodexide is a glycosaminoglycan, a new class of drug that has demonstrated nephroprotective activity in experimental investigations. The Di.N.A.S. study was a randomized, double-blind, placebo-controlled, multicenter, dose-range finding trial to evaluate the extent and duration of the hypoalbuminuric effect of oral sulodexide in diabetic patients. A total of 223 microalbuminuric and macroalbuminuric DM1 and DM2 patients with serum creatinine < or =150 micromol/L and stable BP and metabolic control were recruited. They were randomly allocated to one of four groups: 50 mg/d, 100 mg/d, or 200 mg/d sulodexide daily or placebo for 4 mo (T0 to T4), with 4 mo of follow-up after drug suspension (T4 to T8). Treatment with 200 mg/d sulodexide for 4 mo significantly reduced log albumin excretion rate (logAER) from 5.25 +/- 0.18 at T0 to 3.98 +/- 0.11 at T4 (P < 0.05), which was maintained till T8 (4.11 +/- 0.13; P < 0.05 versus T0). Moreover, the sulodexide-induced percent reductions in AER at T4 were significantly different from the placebo value at T4 and approximately linear to dose increments (30% [confidence limits, 4 to 49%], P = 0.03; 49% [30 to 63%], P = 0.0001; and 74% [64 to 81%], P = 0.0001 in the sulodexide 50, 100, and 200 mg/d groups, respectively. At T8, the sulodexide 200 mg/d group maintained a 62% (45 to 73%) AER significant reduction versus placebo (P = 0.0001). Subanalysis by type of diabetes (DM1 versus DM2, microalbuminuric versus macroalbuminuric, or on concomitant ACE inhibitors versus not on ACE inhibitors) demonstrated similar findings. These effects were obtained without any significant variation in metabolic control and BP or serum creatinine. Very few adverse events were reported; none were serious. In conclusion, a 4-mo course of high doses of sulodexide significantly and dose-dependently improves albuminuria in DM1 and DM2 patients and micro- or macroalbuminuric patients with or without concomitant ACE inhibition. The effect on albuminuria is long-lasting and seemingly additive to the ACE inhibitory effect.
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Affiliation(s)
- Giovanni Gambaro
- Department of Medical and Surgical Science, Division of Nephrology, University of Padua, Padua, Italy.
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Weigert C, Brodbeck K, Häring HU, Gambaro G, Schleicher ED. Low-molecular-weight heparin prevents high glucose- and phorbol ester-induced TGF-beta 1 gene activation. Kidney Int 2001; 60:935-43. [PMID: 11532088 DOI: 10.1046/j.1523-1755.2001.060003935.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hyperglycemia-induced overexpression of prosclerotic transforming growth factor-beta 1 (TGF-beta 1) has been implicated in the pathogenesis of diabetic nephropathy. Since previous in vivo studies demonstrated a renoprotective effect of low-molecular-weight (LMW) heparin in experimental animals, and recent in vitro data showed an interaction of this drug with the overactivated TGF-beta 1 cascade in high glucose- and phorbol ester-stimulated mesangial cells, we studied the molecular mechanism of these effects on TGF-beta 1 gene expression. METHODS Mesangial cells were stimulated with 30 mmol/L glucose or with 0.5 micromol/L phorbol ester [phorbol myristate acetate (PMA)] in the absence or presence of LMW heparin. TGF-beta 1 promoter activity was determined in promoter-reporter luciferase assays. The effect of LMW heparin on the binding of nuclear proteins to a regulatory activator protein-1 (AP-1) site, which mediates the high glucose and PMA responsiveness of the TGF-beta 1 promoter, was studied by electrophoretic mobility shift assays. RESULTS The presence of LMW heparin completely prevented TGF-beta 1 gene activation in both high glucose- and PMA-stimulated cells. Preincubation of the cells with LMW heparin and subsequent stimulation of the cells with both stimuli yielded the same result. Furthermore, treatment with LMW heparin prevented the enhanced binding of nuclear proteins to the regulatory AP-1 site, while binding to a Sp1 site was unaffected. Basal promoter activity and basal AP-1 binding also was reduced by LMW heparin. The LMW heparin effect on basal promoter activity was abolished by mutation of the regulatory AP-1 box B and by deletion of this AP-1 binding site. CONCLUSIONS LMW heparin prevents high glucose- and PMA-mediated TGF-beta 1 expression by inhibiting the activation of the TGF-beta 1 promoter and by preventing the enhanced binding of nuclear proteins to the regulatory AP-1 site.
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Affiliation(s)
- C Weigert
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Pathobio-chemistry, University of Tübingen, Tübingen, Germany
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Ceol M, Gambaro G, Sauer U, Baggio B, Anglani F, Forino M, Facchin S, Bordin L, Weigert C, Nerlich A, Schleicher ED. Glycosaminoglycan therapy prevents TGF-beta1 overexpression and pathologic changes in renal tissue of long-term diabetic rats. J Am Soc Nephrol 2000; 11:2324-2336. [PMID: 11095655 DOI: 10.1681/asn.v11122324] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic induction of the prosclerotic cytokine transforming growth factor beta (TGF-beta) has been implicated in the pathogenesis of diabetic nephropathy. In a rat model of diabetes mellitus-induced glomerulosclerosis, daily administration of a modified heparin (mH) glycosaminoglycan (GAG) preparation with low anticoagulant activity prevented glomerular and tubular matrix accumulation, as well as overexpression of TGF-beta1 mRNA and albuminuria, without obvious side effects. To elucidate the molecular mechanisms of GAG/mH inhibitory actions on TGF-beta1, studies using cultured mesangial cells were also performed. In these cells, high glucose-induced, dose-dependent increases in TGF-beta1 mRNA and bioactive TGF-beta protein expression were inhibited by GAG/mH treatment, whereas basal TGF-beta1 expression was not affected. Both the heparin-derived GAG and dermatan sulfate were effective, indicating that the heparin chemical structure is not necessary for inhibitory activity. Coincubation of GAG with active TGF-beta1 demonstrated no inhibitory effect on TGF-beta1 bioactivity, excluding a neutralizing effect of GAG on TGF-beta1 a the protein level. Furthermore, it was demonstrated that GAG inhibited phorbol myristate acetate-induced translocation of protein kinase C-alpha (PKC-alpha) and -beta1 and activation of PKC-alpha, as well as high glucose-induced activation of PKC-alpha. These results suggest that GAG inhibit TGF-beta1 overexpression at the transcriptional level, possibly via inhibition of high glucose-activated PKC. The findings indicate the potential of GAG therapy for the prevention of diabetic glomerulosclerosis by the inhibition of chronic disease-induced TGF-beta1 mRNA overexpression.
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Affiliation(s)
- Monica Ceol
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Pathobiochemistry, University of Tübingen, Tübingen, Germany
| | - Giovanni Gambaro
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
| | - Ulrich Sauer
- Institute of Pathology, University of Munich, Munich, Germany
| | - Bruno Baggio
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
| | - Franca Anglani
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
| | - Monica Forino
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
| | - Sonia Facchin
- Institute of Internal Medicine, Division of Nephrology, University of Padova, Padova, Italy
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Pathobiochemistry, University of Tübingen, Tübingen, Germany
| | - Luciana Bordin
- Department of Biochemistry, University of Padova, Padova, Italy
| | - Cora Weigert
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Pathobiochemistry, University of Tübingen, Tübingen, Germany
| | - Andreas Nerlich
- Institute of Pathology, University of Munich, Munich, Germany
| | - Erwin D Schleicher
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Pathobiochemistry, University of Tübingen, Tübingen, Germany
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Gambaro G, VAN DER Woude FJ. Glycosaminoglycans: use in treatment of diabetic nephropathy. J Am Soc Nephrol 2000; 11:359-368. [PMID: 10665944 DOI: 10.1681/asn.v112359] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Giovanni Gambaro
- Dipartimento di Scienze Mediche e Chirurgiche, Divisione di Nefrologia, Policlinico Universitario, Università di Padova, Padova, Italy
| | - Fokko J VAN DER Woude
- Vth Medical University Clinic, Klinikum Mannheim, Ruperto Carola University Heidelberg, Mannheim, Germany
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