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Heitman K, Alexander MS, Faul C. Skeletal Muscle Injury in Chronic Kidney Disease-From Histologic Changes to Molecular Mechanisms and to Novel Therapies. Int J Mol Sci 2024; 25:5117. [PMID: 38791164 PMCID: PMC11121428 DOI: 10.3390/ijms25105117] [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: 04/09/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic kidney disease (CKD) is associated with significant reductions in lean body mass and in the mass of various tissues, including skeletal muscle, which causes fatigue and contributes to high mortality rates. In CKD, the cellular protein turnover is imbalanced, with protein degradation outweighing protein synthesis, leading to a loss of protein and cell mass, which impairs tissue function. As CKD itself, skeletal muscle wasting, or sarcopenia, can have various origins and causes, and both CKD and sarcopenia share common risk factors, such as diabetes, obesity, and age. While these pathologies together with reduced physical performance and malnutrition contribute to muscle loss, they cannot explain all features of CKD-associated sarcopenia. Metabolic acidosis, systemic inflammation, insulin resistance and the accumulation of uremic toxins have been identified as additional factors that occur in CKD and that can contribute to sarcopenia. Here, we discuss the elevation of systemic phosphate levels, also called hyperphosphatemia, and the imbalance in the endocrine regulators of phosphate metabolism as another CKD-associated pathology that can directly and indirectly harm skeletal muscle tissue. To identify causes, affected cell types, and the mechanisms of sarcopenia and thereby novel targets for therapeutic interventions, it is important to first characterize the precise pathologic changes on molecular, cellular, and histologic levels, and to do so in CKD patients as well as in animal models of CKD, which we describe here in detail. We also discuss the currently known pathomechanisms and therapeutic approaches of CKD-associated sarcopenia, as well as the effects of hyperphosphatemia and the novel drug targets it could provide to protect skeletal muscle in CKD.
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Affiliation(s)
- Kylie Heitman
- Division of Nephrology and Section of Mineral Metabolism, Department of Medicine, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Matthew S. Alexander
- Division of Neurology, Department of Pediatrics, The University of Alabama at Birmingham and Children’s of Alabama, Birmingham, AL 35294, USA
- Center for Exercise Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
- Department of Genetics, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
- Civitan International Research Center, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
- Center for Neurodegeneration and Experimental Therapeutics, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Christian Faul
- Division of Nephrology and Section of Mineral Metabolism, Department of Medicine, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA;
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2
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Kim K, Fazzone B, Cort TA, Kunz EM, Alvarez S, Moerschel J, Palzkill VR, Dong G, Anderson EM, O'Malley KA, Berceli SA, Ryan TE, Scali ST. Mitochondrial targeted catalase improves muscle strength following arteriovenous fistula creation in mice with chronic kidney disease. Sci Rep 2024; 14:8288. [PMID: 38594299 PMCID: PMC11004135 DOI: 10.1038/s41598-024-58805-1] [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: 11/21/2023] [Accepted: 04/03/2024] [Indexed: 04/11/2024] Open
Abstract
Hand dysfunction is a common observation after arteriovenous fistula (AVF) creation for hemodialysis access and has a variable clinical phenotype; however, the underlying mechanism responsible is unclear. Grip strength changes are a common metric used to assess AVF-associated hand disability but has previously been found to poorly correlate with the hemodynamic perturbations post-AVF placement implicating other tissue-level factors as drivers of hand outcomes. In this study, we sought to test if expression of a mitochondrial targeted catalase (mCAT) in skeletal muscle could reduce AVF-related limb dysfunction in mice with chronic kidney disease (CKD). Male and female C57BL/6J mice were fed an adenine-supplemented diet to induce CKD prior to placement of an AVF in the iliac vascular bundle. Adeno-associated virus was used to drive expression of either a green fluorescent protein (control) or mCAT using the muscle-specific human skeletal actin (HSA) gene promoter prior to AVF creation. As expected, the muscle-specific AAV-HSA-mCAT treatment did not impact blood urea nitrogen levels (P = 0.72), body weight (P = 0.84), or central hemodynamics including infrarenal aorta and inferior vena cava diameters (P > 0.18) or velocities (P > 0.38). Hindlimb perfusion recovery and muscle capillary densities were also unaffected by AAV-HSA-mCAT treatment. In contrast to muscle mass and myofiber size which were not different between groups, both absolute and specific muscle contractile forces measured via a nerve-mediated in-situ preparation were significantly greater in AAV-HSA-mCAT treated mice (P = 0.0012 and P = 0.0002). Morphological analysis of the post-synaptic neuromuscular junction uncovered greater acetylcholine receptor cluster areas (P = 0.0094) and lower fragmentation (P = 0.0010) in AAV-HSA-mCAT treated mice. Muscle mitochondrial oxidative phosphorylation was not different between groups, but AAV-HSA-mCAT treated mice had lower succinate-fueled mitochondrial hydrogen peroxide emission compared to AAV-HSA-GFP mice (P < 0.001). In summary, muscle-specific scavenging of mitochondrial hydrogen peroxide significantly improves neuromotor function in mice with CKD following AVF creation.
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Affiliation(s)
- Kyoungrae Kim
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, P.O. Box 100128, Gainesville, FL, 32610, USA
- Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, USA
| | - Tomas A Cort
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Eric M Kunz
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Samuel Alvarez
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Jack Moerschel
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Victoria R Palzkill
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Gengfu Dong
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, P.O. Box 100128, Gainesville, FL, 32610, USA
- Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, USA
| | - Kerri A O'Malley
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, P.O. Box 100128, Gainesville, FL, 32610, USA
- Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, USA
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, P.O. Box 100128, Gainesville, FL, 32610, USA
- Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, USA
| | - Terence E Ryan
- Department of Applied Physiology and Kinesiology, University of Florida, 1864 Stadium Rd, Gainesville, FL, 32611, USA.
- Center for Exercise Science, University of Florida, Gainesville, FL, USA.
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, P.O. Box 100128, Gainesville, FL, 32610, USA.
- Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, USA.
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3
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Gollie JM, Ryan AS, Sen S, Patel SS, Kokkinos PF, Harris-Love MO, Scholten JD, Blackman MR. Exercise for patients with chronic kidney disease: from cells to systems to function. Am J Physiol Renal Physiol 2024; 326:F420-F437. [PMID: 38205546 DOI: 10.1152/ajprenal.00302.2023] [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: 09/25/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
Chronic kidney disease (CKD) is among the leading causes of death and disability, affecting an estimated 800 million adults globally. The underlying pathophysiology of CKD is complex creating challenges to its management. Primary risk factors for the development and progression of CKD include diabetes mellitus, hypertension, age, obesity, diet, inflammation, and physical inactivity. The high prevalence of diabetes and hypertension in patients with CKD increases the risk for secondary consequences such as cardiovascular disease and peripheral neuropathy. Moreover, the increased prevalence of obesity and chronic levels of systemic inflammation in CKD have downstream effects on critical cellular functions regulating homeostasis. The combination of these factors results in the deterioration of health and functional capacity in those living with CKD. Exercise offers protective benefits for the maintenance of health and function with age, even in the presence of CKD. Despite accumulating data supporting the implementation of exercise for the promotion of health and function in patients with CKD, a thorough description of the responses and adaptations to exercise at the cellular, system, and whole body levels is currently lacking. Therefore, the purpose of this review is to provide an up-to-date comprehensive review of the effects of exercise training on vascular endothelial progenitor cells at the cellular level; cardiovascular, musculoskeletal, and neural factors at the system level; and physical function, frailty, and fatigability at the whole body level in patients with CKD.
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Affiliation(s)
- Jared M Gollie
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Health, Human Function, and Rehabilitation Sciences, The George Washington University, Washington, District of Columbia, United States
| | - Alice S Ryan
- Department of Medicine, University of Maryland, Baltimore, Maryland, United States
- Division of Geriatrics and Palliative Medicine, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, United States
| | - Sabyasachi Sen
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
| | - Samir S Patel
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
| | - Peter F Kokkinos
- Division of Cardiology, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
| | - Michael O Harris-Love
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Geriatric Research Education and Clinical Center, Eastern Colorado Veterans Affairs Health Care System, Denver, Colorado, United States
| | - Joel D Scholten
- Physical Medicine and Rehabilitation Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
| | - Marc R Blackman
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, United States
- Department of Medicine, Washington DC Veterans Affairs, Medical Center, Washington, District of Columbia, United States
- Department of Medicine, The George Washington University, Washington, District of Columbia, United States
- Department of Medicine, Georgetown University, Washington, District of Columbia, United States
- Department of Rehabilitation Medicine, Georgetown University, Washington, District of Columbia, United States
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Kim K, Cort TA, Kunz EM, Moerschel J, Palzkill VR, Dong G, Moparthy CN, Anderson EM, Fazzone B, O'Malley KA, Robinson ST, Berceli SA, Ryan TE, Scali ST. N-acetylcysteine treatment attenuates hemodialysis access-related limb pathophysiology in mice with chronic kidney disease. Am J Physiol Renal Physiol 2023; 325:F271-F282. [PMID: 37439200 PMCID: PMC10511162 DOI: 10.1152/ajprenal.00083.2023] [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: 04/03/2023] [Revised: 06/20/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
The objective of the present study was to determine if treatment with N-acetylcysteine (NAC) could reduce access-related limb dysfunction in mice. Male and female C57BL6J mice were fed an adenine-supplemented diet to induce chronic kidney disease (CKD) prior to the surgical creation of an arteriovenous fistula (AVF) in the iliac vascular bundle. AVF creation significantly increased peak aortic and infrarenal vena cava blood flow velocities, but NAC treatment had no significant impact, indicating that fistula maturation was not impacted by NAC treatment. Hindlimb muscle and paw perfusion recovery and muscle capillary density in the AVF limb were unaffected by NAC treatment. However, NAC treatment significantly increased the mass of the tibialis anterior (P = 0.0120) and soleus (P = 0.0452) muscles post-AVF. There was a significant main effect of NAC treatment on hindlimb grip strength at postoperative day 12 (POD 12) (P = 0.0003), driven by significantly higher grip strength in both male (P = 0.0273) and female (P = 0.0031) mice treated with NAC. There was also a significant main effect of NAC treatment on the walking speed at postoperative day 12 (P = 0.0447), and post hoc testing revealed an improvement in NAC-treated male mice (P = 0.0091). The area of postsynaptic acetylcholine receptors (P = 0.0263) and motor endplates (P = 0.0240) was also increased by NAC treatment. Interestingly, hindlimb skeletal muscle mitochondrial oxidative phosphorylation trended higher in NAC-treated female mice but was not statistically significant (P = 0.0973). Muscle glutathione levels and redox status were not significantly impacted by NAC treatment in either sex. In summary, NAC treatment attenuated some aspects of neuromotor pathology in mice with chronic kidney disease following AVF creation.NEW & NOTEWORTHY Hemodialysis via autogenous arteriovenous fistula (AVF) is the preferred first-line modality for renal replacement therapy in patients with end-stage kidney disease. However, patients undergoing AVF surgery frequently experience a spectrum of hand disability symptoms postsurgery including weakness and neuromotor dysfunction. Unfortunately, no treatment is currently available to prevent or mitigate these symptoms. Here, we provide evidence that daily N-acetylcysteine supplementation can attenuate some aspects of limb neuromotor function in a preclinical mouse model of AVF.
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Affiliation(s)
- Kyoungrae Kim
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Tomas A Cort
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Eric M Kunz
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Jack Moerschel
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Victoria R Palzkill
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Gengfu Dong
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Chatick N Moparthy
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
| | - Kerri A O'Malley
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
| | - Scott T Robinson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
| | - Terence E Ryan
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, United States
- Center for Exercise Science, University of Florida, Gainesville, Florida, United States
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, United States
- Malcom Randall Veteran Affairs Medical Center, University of Florida, Gainesville, Florida, United States
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5
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Nahas PC, de Branco FMS, Azeredo CM, Rinaldi AEM, de Oliveira EP. Serum uric acid is not associated with appendicular muscle mass index in young and middle-aged adults: Results from NHANES 2011-2012. Clin Nutr ESPEN 2022; 52:262-269. [PMID: 36513464 DOI: 10.1016/j.clnesp.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/25/2022] [Accepted: 08/31/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Recent studies have evaluated the association between uric acid (UA) and muscle mass in older adults; however, little is known about this relationship in young and middle-aged individuals. Our aim was to investigate whether serum UA is associated with appendicular muscle mass index (AMMI) in young and middle-aged individuals. We also aimed to evaluate whether this association is sex-specific. METHODS A cross-sectional study was performed with young and middle-aged individuals aged from 20 to 59 years from National Health and Nutrition Examination Survey (NHANES) 2011-2012. A total of 2255 individuals (1440 young and 815 middle-aged individuals; 1167 men and 1088 women) were evaluated. Body composition was assessed by Dual Energy X-ray absorptiometry (DXA) and AMMI was calculated using the arms plus legs lean mass divided by the height squared. UA levels were measured by colorimetric method. Regression analyzes were performed to evaluate whether AMMI is associated with the tertiles of UA levels after adjustments for potential confounders. RESULTS In the unadjusted analyzes, serum UA was positively associated with AMMI for total sample, young, and middle-aged individuals of both sexes. However, after adjustments for confounders, UA levels were no longer associated with AMMI independent of the age-rage and sex. CONCLUSION Serum UA is not associated with AMMI in young or middle-aged individuals independent of the sex.
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Affiliation(s)
- Paula C Nahas
- Laboratory of Nutrition, Exercise and Health (LaNES), School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Flávia M S de Branco
- Laboratory of Nutrition, Exercise and Health (LaNES), School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Catarina M Azeredo
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Ana Elisa M Rinaldi
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Erick P de Oliveira
- Laboratory of Nutrition, Exercise and Health (LaNES), School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil.
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Aranda-Rivera AK, Cruz-Gregorio A, Pedraza-Chaverri J, Scholze A. Nrf2 Activation in Chronic Kidney Disease: Promises and Pitfalls. Antioxidants (Basel) 2022; 11:antiox11061112. [PMID: 35740009 PMCID: PMC9220138 DOI: 10.3390/antiox11061112] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
The nuclear factor erythroid 2-related factor 2 (Nrf2) protects the cell against oxidative damage. The Nrf2 system comprises a complex network that functions to ensure adequate responses to redox perturbations, but also metabolic demands and cellular stresses. It must be kept within a physiologic activity range. Oxidative stress and alterations in Nrf2-system activity are central for chronic-kidney-disease (CKD) progression and CKD-related morbidity. Activation of the Nrf2 system in CKD is in multiple ways related to inflammation, kidney fibrosis, and mitochondrial and metabolic effects. In human CKD, both endogenous Nrf2 activation and repression exist. The state of the Nrf2 system varies with the cause of kidney disease, comorbidities, stage of CKD, and severity of uremic toxin accumulation and inflammation. An earlier CKD stage, rapid progression of kidney disease, and inflammatory processes are associated with more robust Nrf2-system activation. Advanced CKD is associated with stronger Nrf2-system repression. Nrf2 activation is related to oxidative stress and moderate uremic toxin and nuclear factor kappa B (NF-κB) elevations. Nrf2 repression relates to high uremic toxin and NF-κB concentrations, and may be related to Kelch-like ECH-associated protein 1 (Keap1)-independent Nrf2 degradation. Furthermore, we review the effects of pharmacological Nrf2 activation by bardoxolone methyl, curcumin, and resveratrol in human CKD and outline strategies for how to adapt future Nrf2-targeted therapies to the requirements of patients with CKD.
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Affiliation(s)
- Ana Karina Aranda-Rivera
- Laboratory F-315, Department of Biology, Faculty of Chemistry, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.K.A.-R.); (A.C.-G.); (J.P.-C.)
| | - Alfredo Cruz-Gregorio
- Laboratory F-315, Department of Biology, Faculty of Chemistry, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.K.A.-R.); (A.C.-G.); (J.P.-C.)
| | - José Pedraza-Chaverri
- Laboratory F-315, Department of Biology, Faculty of Chemistry, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.K.A.-R.); (A.C.-G.); (J.P.-C.)
| | - Alexandra Scholze
- Department of Nephrology, Odense University Hospital, 5000 Odense C, Denmark
- Institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark
- Correspondence:
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7
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Brightwell CR, Kulkarni AS, Paredes W, Zhang K, Perkins JB, Gatlin KJ, Custodio M, Farooq H, Zaidi B, Pai R, Buttar RS, Tang Y, Melamed ML, Hostetter TH, Pessin JE, Hawkins M, Fry CS, Abramowitz MK. Muscle fibrosis and maladaptation occur progressively in CKD and are rescued by dialysis. JCI Insight 2021; 6:150112. [PMID: 34784301 PMCID: PMC8783691 DOI: 10.1172/jci.insight.150112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Skeletal muscle maladaptation accompanies chronic kidney disease (CKD) and negatively impacts physical function. Emphasis in CKD has historically been placed on muscle fiber intrinsic deficits, such as altered protein metabolism and atrophy. However, targeted treatment of fiber intrinsic dysfunction has produced limited improvement, whereas alterations within the fiber extrinsic environment have scarcely been examined. METHODS We investigated alterations to the skeletal muscle interstitial environment with deep cellular phenotyping of biopsies from patients with CKD compared to age-matched control participants and performed transcriptome profiling to define the molecular underpinnings of CKD-associated muscle impairments. We further examined changes in the observed muscle maladaptation following initiation of dialysis therapy for kidney failure. RESULTS Patients with CKD exhibited a progressive fibrotic muscle phenotype, which was associated with impaired regenerative capacity and lower vascular density. The severity of these deficits was strongly associated with the degree of kidney dysfunction. Consistent with these profound deficits, CKD was associated with broad alterations to the muscle transcriptome, including altered extracellular matrix organization, downregulated angiogenesis, and altered expression of pathways related to stem cell self-renewal. Remarkably, despite the seemingly advanced nature of this fibrotic transformation, dialysis treatment rescued these deficits, restoring a healthier muscle phenotype. Furthermore, after accounting for muscle atrophy, strength and endurance improved after dialysis initiation. CONCLUSION These data identify a dialysis-responsive muscle fibrotic phenotype in CKD and suggest that the early dialysis window presents a unique opportunity of improved muscle regenerative capacity during which targeted interventions may achieve maximal impact. TRIAL REGISTRATION NCT01452412FUNDING. NIH.
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Affiliation(s)
- Camille R Brightwell
- Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, United States of America
| | - Ameya S Kulkarni
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - William Paredes
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Kehao Zhang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Jaclyn B Perkins
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, United States of America
| | - Knubian J Gatlin
- Department of Nutrition and Metabolism, The University of Texas Medical Branch, Galveston, United States of America
| | - Matthew Custodio
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Hina Farooq
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Bushra Zaidi
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Rima Pai
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Rupinder S Buttar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Yan Tang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Michal L Melamed
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Thomas H Hostetter
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, United States of America
| | - Jeffrey E Pessin
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | - Meredith Hawkins
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
| | | | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, United States of America
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8
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Thaler A, Omer N, Giladi N, Gurevich T, Bar-Shira A, Gana-Weisz M, Goldstein O, Kestenbaum M, Shirvan JC, Cedarbaum JM, Orr-Urtreger A, Regev K, Shenhar-Tsarfaty S, Mirelman A. Mutations in GBA and LRRK2 Are Not Associated with Increased Inflammatory Markers. JOURNAL OF PARKINSONS DISEASE 2021; 11:1285-1296. [PMID: 33998549 PMCID: PMC8461659 DOI: 10.3233/jpd-212624] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Inflammation is an integral part of neurodegeneration including in Parkinson’s disease (PD). Ashkenazi Jews have high rates of genetic PD with divergent phenotypes among GBA-PD and LRRK2-PD. The role of inflammation in the prodromal phase of PD and the association with disease phenotype has yet to be elucidated. Objective: To assess central and peripheral cytokines among PD patients with mutations in the LRRK2 and GBA genes and among non-manifesting carriers (NMC) of these mutations in order to determine the role of inflammation in genetic PD. Methods: The following cytokines were assessed from peripheral blood and cerebrospinal fluid (CSF): TNF-α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10 and INF- γ. A comprehensive intake including general medical conditions, use of anti-inflammatory treatments, motor and cognitive assessments and additional laboratory measures were recorded, enabling the construction of the MDS probable prodromal score. Results: Data from 362 participants was collected: 31 idiopathic PD (iPD), 30 LRRK2-PD, 77 GBA-PD, 3 homozygote GBA-PD, 3 GBA-LRRK2-PD, 67 LRRK2-NMC, 105 GBA-NMC, 14 LRRK2-GBA-NMC, and 32 healthy controls. No between-group differences in peripheral or CSF cytokines were detected. No correlation between disease characteristics or risk for prodromal PD could be associated with any inflammatory measure. Conclusion: In this study, we could not detect any evidence on dysregulated immune response among GBA and LRRK2 PD patients and non-manifesting mutation carriers.
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Affiliation(s)
- Avner Thaler
- Movement Disorders Unit, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel.,Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Nurit Omer
- Movement Disorders Unit, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Nir Giladi
- Movement Disorders Unit, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Tanya Gurevich
- Movement Disorders Unit, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Bar-Shira
- Genetic Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Mali Gana-Weisz
- Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Orly Goldstein
- Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Meir Kestenbaum
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Neurology Department, Meir Hospital, Kfar-Saba, Israel
| | | | - Jesse M Cedarbaum
- Biogen Inc, Cambridge, MA, USA.,Coeruleus Clinical Sciences LLC, Woodbridge, CT, USA
| | - Avi Orr-Urtreger
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel.,Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Keren Regev
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Neuroimmunology Unit, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Shani Shenhar-Tsarfaty
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Internal Medicine "C", "D", and "E", Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Anat Mirelman
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel.,Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, Tel-Aviv, Israel
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9
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Juul-Nielsen C, Shen J, Stenvinkel P, Scholze A. Systematic review of the nuclear factor erythroid 2-related factor 2 (NRF2) system in human chronic kidney disease: alterations, interventions, and relation to morbidity. Nephrol Dial Transplant 2021; 37:904-916. [PMID: 33547785 DOI: 10.1093/ndt/gfab031] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND NRF2 and its effectors NAD(P)H:quinoneoxidoreductase 1 (NQO1) and heme oxygenase 1 (HO-1) are of interest in kidney disease. We therefore reviewed studies about their status in patients with chronic kidney disease (CKD). METHODS We undertook systematic searches of PubMed and EMBASE databases. Alterations of NRF2, NQO1 and HO-1 in CKD, their responses to interventions and their relation to clinically relevant parameters were reported. RESULTS We identified 1373 articles, of which 32 studies met the inclusion criteria. NRF2 levels were decreased in the majority of analyses of CKD patients. Half of the analyses showed a similar or increased NQO1 level vs. control, whereas NQO1 was decreased in half of the analyses. Most of the studies reported either an increased or similar HO-1 level in CKD patients compared to controls. For patients with CKD stages 1-4, studies reported positive correlations to markers of kidney disease severity. Also, positive associations of NQO1/HO-1 levels to inflammation and comorbidities were reported. One third of the studies showed discordant changes between gene expression and protein level of NRF2 system components. Two thirds of intervention studies (50% dietary, such as using resistant starch) reported an increase of NRF2, NQO1, or HO-1. CONCLUSIONS In patients with CKD, NRF2 expression was downregulated, while NQO1 and HO-1 showed varying alterations related to inflammation, comorbidities, and severity of kidney damage. Interventions that increased NRF2 system components were described, but their effectiveness and clinical relevance require further clinical studies of high quality. Research on gene expression together with protein analyses is indispensable to understand NRF2 system alterations in CKD.
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Affiliation(s)
| | - Jianlin Shen
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University
| | - Peter Stenvinkel
- Department of Renal Medicine, Karolinska University Hospital at Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Scholze
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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10
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Thaler A, Omer N, Giladi N, Gurevich T, Bar-Shira A, Gana-Weisz M, Goldstein O, Kestenbaum M, Cedarbaum JM, Orr-Urtreger A, Shenhar-Tsarfaty S, Mirelman A. Biochemical markers for severity and risk in GBA and LRRK2 Parkinson's disease. J Neurol 2021; 268:1517-1525. [PMID: 33388928 DOI: 10.1007/s00415-020-10325-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The phenotype of Parkinson's disease (PD) is variable with mutations in genes such as LRRK2 and GBA explaining part of this heterogeneity. Additional genetic and environmental factors contribute to disease variability. OBJECTIVE To assess the association between biochemical markers, PD severity and probability score for prodromal PD, among GBA and LRRK2 mutation carriers. METHODS Levels of uric acid, vitamin D, C-reactive protein, microalbumin/creatinine ratio (ACR), white blood count (WBC), hemoglobin, platelets, neutrophil/lymphocyte ratio and estimated glomerular filtration rate (eGFR) were assessed from patients with PD and non-manifesting carriers (NMC) of mutations in GBA and LRRK2, together with disease related questionnaires enabling the construction of the MDS prodromal probability score. RESULT A total of 241 patients with PD: 105 idiopathic PD (iPD), 49 LRRK2-PD and 87 GBA-PD and 412 non-manifesting subjects; 74 LRRK2-NMC, 118 GBA-NMC and 220 non-manifesting non-carriers (NMNC), participated in this study. No significant differences in biochemical measures were detected among patients with PD or non-manifesting carriers. Among GBA-PD patients, worse motor performance was associated with ACR (B = 4.68, 95% CI (1.779-7.559); p = 0.002). The probability score for prodromal PD among all non-manifesting participants was associated with eGFR; NMNC (B = - 0.531 95% CI (- 0.879 to - 0.182); p < 0.001, LRRK2-NMC (B = - 1.014 95% CI (- 1.663 to - 0.366); p < 0.001) and GBA-NMC (B = - 0.686 95% CI (1.300 to - 0.071); p = 0.029). CONCLUSION Sub-clinical renal impairment is associated with increased likelihood for prodromal PD regardless of genetic status. While the mechanism behind this finding needs further elucidation, it suggests that kidney function might play a role in PD pathogenesis.
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Affiliation(s)
- Avner Thaler
- Movement Disorder Unit, Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, 6 Weizmann Street, 64239, Tel-Aviv, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
- Sagol School of Neuroscience, Tel-Aviv University, Tel Aviv, Israel.
- Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, Tel Aviv, Israel.
| | - Nurit Omer
- Movement Disorder Unit, Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, 6 Weizmann Street, 64239, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Nir Giladi
- Movement Disorder Unit, Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, 6 Weizmann Street, 64239, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel Aviv, Israel
| | - Tanya Gurevich
- Movement Disorder Unit, Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, 6 Weizmann Street, 64239, Tel-Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Bar-Shira
- Genetic Institute, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Mali Gana-Weisz
- Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Orly Goldstein
- Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Meir Kestenbaum
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Neurology Department, Meir Medical Center, Kfar Saba, Israel
| | - Jesse M Cedarbaum
- Biogen Inc., Cambridge, MA, USA
- Coeruleus Clinical Sciences LLC, Woodbridge, CT, USA
| | - Avi Orr-Urtreger
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Genomic Research Laboratory for Neurodegeneration, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Shani Shenhar-Tsarfaty
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Internal Medicine "C", "D", and "E", Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Anat Mirelman
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel Aviv, Israel
- Laboratory of Early Markers of Neurodegeneration, Neurological Institute, Tel-Aviv Medical Center, Tel Aviv, Israel
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11
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Ikizler TA. Dialysis: learning dialysis through computation, experimentation, and implementation. Kidney Int 2020; 98:246-250. [PMID: 32709282 DOI: 10.1016/j.kint.2020.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/19/2022]
Affiliation(s)
- T Alp Ikizler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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12
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A Systematic Review of the Acute Effects of Hemodialysis on Skeletal Muscle Perfusion, Metabolism, and Function. Kidney Int Rep 2019; 5:307-317. [PMID: 32154452 PMCID: PMC7056853 DOI: 10.1016/j.ekir.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/16/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction The underlying mechanisms of skeletal muscle wasting in hemodialysis patients are complex. We performed a systematic review to summarize evidence on whether hemodialysis has acute effects on skeletal muscle perfusion, metabolism, and function. Methods The protocol was registered on PROSPERO (Registration number CRD42018103682). A systematic search was performed in MEDLINE, PubMed, Cochrane, Embase, Scopus, and Web of Science. Citation, reference list, and gray literature searches were also performed. Studies were selected in 2 stages: title and abstract review, then full-text review. Results A total of 65 full-text articles were reviewed, and 14 studies were eligible for inclusion. No studies were identified that assessed muscle perfusion during dialysis. Two studies used near-infrared spectroscopy to indirectly measure skeletal muscle oxygen consumption, which increased during dialysis in 1 study but only in patients with diabetes in the second. Metabolism was examined in 9 studies. A number of acute metabolic changes were reported (e.g., caspase-3 activity, polyubiquitin, and interleukin-6 protein increased in response to hemodialysis) as was a net negative protein balance over the dialysis session. Three studies examining muscle function did not produce consistent findings. Conclusion Gaps remain in understanding the acute effects of hemodialysis on skeletal muscle, particularly for changes in perfusion and function, although there does appear to be an acute effect on muscle metabolism.
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13
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Ksiazek K, Buraczynska M. Association between Monocyte Chemoattractant Protein-1 -2518 (A/G) Single Nucleotide Polymorphism and Chronic Periodontitis in End-stage Renal Disease Patients - A Case-control Study. Immunol Invest 2019; 49:897-906. [PMID: 31847640 DOI: 10.1080/08820139.2019.1702052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Monocyte chemoattractant protein 1 (MCP-1) plays an important role in the development of periodontitis. The purpose of this investigation was to evaluate association of the MCP-1 gene polymorphism with chronic periodontitis in patients with end-stage renal disease (ESRD). One hundred fifty ESRD patients with chronic periodontitis (CP), 100 without CP and 190 healthy controls were included in this study. Genomic DNA from all participants was genotyped for the -2518 (A/G) polymorphism by a polymerase chain reaction - restriction fragment length polymorphism (PCR--RFLP) assay. Significant differences were observed in the genotype and allele frequencies between patients with ESRD and CP and controls. The G allele frequency was significantly higher in patients than in control subjects, with odds ratio 1.77 (95 % CI 1.2-2.5), p = 0.0014. For the GG genotype the OR was 3.63 (95 % CI 1.5-8.76), p = 0.041. No significant differences in the polymorphism distribution were observed between ESRD patients without CP and control subjects. Comparison of the MCP-1 gene polymorphism distribution in ESRD patients with various primary diseases leading to ESRD did not show any significant differences. The mean MCP-1 serum levels were compared between subgroups. They were significantly higher in ESRD patients with CP (582 ± 112 pg/ml) than in patients without CP (309 ± 103 pg/ml) and controls (265 ± 85 pg/ml). Our results suggest that the MCP-1-2518 A/G polymorphism might be a novel risk factor for developing chronic periodontitis in patients with ESRD.
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Affiliation(s)
- Katarzyna Ksiazek
- Department of Paedodontics, Medical University of Lublin , Lublin, Poland
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14
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Ksiazek K, Blaszczak J, Buraczynska M. IL4 gene VNTR polymorphism in chronic periodontitis in end-stage renal disease patients. Oral Dis 2018; 25:258-264. [PMID: 30194905 DOI: 10.1111/odi.12974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/18/2018] [Accepted: 09/02/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Interleukin-4 gene polymorphisms were found to be associated with periodontitis. The purpose of this case-control study was to evaluate association of IL4 VNTR polymorphism with periodontitis in patients with end-stage renal disease (ESRD). SUBJECTS AND METHODS We examined 180 ESRD patients with chronic periodontitis, 82 without CP and 180 healthy controls. Genomic DNA from all subjects was genotyped for the IL4 VNTR polymorphism by polymerase chain reaction (PCR). RESULTS Genotype distribution in all groups followed Hardy-Weinberg equilibrium. Significant differences in genotype and allele frequencies were observed between groups. The patient group had higher frequency of P1 allele than controls, with odds ratio for P1 allele 1.6 (95% CI 1.1-2.3) and P1P1 genotype 2.73 (95% CI 1.06-7.5). There were no differences in polymorphism distribution between ESRD patients without CP and controls. Periodontal disease was more severe in older patients (≥50 years). Similarly, patients with T2DM had more severe manifestation of CP than patients without diabetes (p = 0.01 for plaque index, p = 0.004 for bleeding index and p = 0.03 for gingival index). CONCLUSION Our findings suggest that VNTR polymorphism in IL4 gene might be a risk factor for chronic periodontitis in patients with ESRD.
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Affiliation(s)
- Katarzyna Ksiazek
- Department of Paedodontics, Medical University of Lublin, Lublin, Poland
| | - Jerzy Blaszczak
- Department of Jaw Orthopaedics, Medical University of Lublin, Lublin, Poland
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15
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Abramowitz MK, Paredes W, Zhang K, Brightwell CR, Newsom JN, Kwon HJ, Custodio M, Buttar RS, Farooq H, Zaidi B, Pai R, Pessin JE, Hawkins M, Fry CS. Skeletal muscle fibrosis is associated with decreased muscle inflammation and weakness in patients with chronic kidney disease. Am J Physiol Renal Physiol 2018; 315:F1658-F1669. [PMID: 30280599 DOI: 10.1152/ajprenal.00314.2018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Muscle dysfunction is an important cause of morbidity among patients with chronic kidney disease (CKD). Although muscle fibrosis is present in a CKD rodent model, its existence in humans and its impact on physical function are currently unknown. We examined isometric leg extension strength and measures of skeletal muscle fibrosis and inflammation in vastus lateralis muscle from CKD patients ( n = 10) and healthy, sedentary controls ( n = 10). Histochemistry and immunohistochemistry were used to assess muscle collagen and macrophage and fibro/adipogenic progenitor (FAP) cell populations, and RT-qPCR was used to assess muscle-specific inflammatory marker expression. Muscle collagen content was significantly greater in CKD compared with control (18.8 ± 2.1 vs. 11.7 ± 0.7% collagen area, P = 0.008), as was staining for collagen I, pro-collagen I, and a novel collagen-hybridizing peptide that binds remodeling collagen. Muscle collagen was inversely associated with leg extension strength in CKD ( r = -0.74, P = 0.01). FAP abundance was increased in CKD, was highly correlated with muscle collagen ( r = 0.84, P < 0.001), and was inversely associated with TNF-α expression ( r = -0.65, P = 0.003). TNF-α, CD68, CCL2, and CCL5 mRNA were significantly lower in CKD than control, despite higher serum TNF-α and IL-6. Immunohistochemistry confirmed fewer CD68+ and CD11b+ macrophages in CKD muscle. In conclusion, skeletal muscle collagen content is increased in humans with CKD and is associated with functional parameters. Muscle fibrosis correlated with increased FAP abundance, which may be due to insufficient macrophage-mediated TNF-α secretion. These data provide a foundation for future research elucidating the mechanisms responsible for this newly identified human muscle pathology.
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Affiliation(s)
| | - William Paredes
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Kehao Zhang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Camille R Brightwell
- Department of Nutrition and Metabolism, University of Texas Medical Branch , Galveston, Texas
| | - Julia N Newsom
- Department of Nutrition and Metabolism, University of Texas Medical Branch , Galveston, Texas
| | - Hyok-Joon Kwon
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers-The State University of New Jersey , New Brunswick, New Jersey
| | - Matthew Custodio
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rupinder S Buttar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Hina Farooq
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Bushra Zaidi
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rima Pai
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey E Pessin
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.,Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, New York
| | - Meredith Hawkins
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Christopher S Fry
- Department of Nutrition and Metabolism, University of Texas Medical Branch , Galveston, Texas
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16
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De Moraes WMAM, de Souza PRM, da Paixão NA, de Sousa LGO, Ribeiro DA, Marshall AG, Prestes J, Irigoyen MC, Brum PC, Medeiros A. Aerobic exercise training rescues protein quality control disruption on white skeletal muscle induced by chronic kidney disease in rats. J Cell Mol Med 2017; 22:1452-1463. [PMID: 29265674 PMCID: PMC5824409 DOI: 10.1111/jcmm.13374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
We tested whether aerobic exercise training (AET) would modulate the skeletal muscle protein quality control (PQC) in a model of chronic kidney disease (CKD) in rats. Adult Wistar rats were evaluated in four groups: control (CS) or trained (CE), and 5/6 nephrectomy sedentary (5/6NxS) or trained (5/6NxE). Exercised rats were submitted to treadmill exercise (60 min., five times/wk for 2 months). We evaluated motor performance (tolerance to exercise on the treadmill and rotarod), cross-sectional area (CSA), gene and protein levels related to the unfolded protein response (UPR), protein synthesis/survive and apoptosis signalling, accumulated misfolded proteins, chymotrypsin-like proteasome activity (UPS activity), redox balance and heat-shock protein (HSP) levels in the tibialis anterior. 5/6NxS presented a trend towards to atrophy, with a reduction in motor performance, down-regulation of protein synthesis and up-regulation of apoptosis signalling; increases in UPS activity, misfolded proteins, GRP78, derlin, HSP27 and HSP70 protein levels, ATF4 and GRP78 genes; and increase in oxidative damage compared to CS group. In 5/6NxE, we observed a restoration in exercise tolerance, accumulated misfolded proteins, UPS activity, protein synthesis/apoptosis signalling, derlin, HSPs protein levels as well as increase in ATF4, GRP78 genes and ATF6α protein levels accompanied by a decrease in oxidative damage and increased catalase and glutathione peroxidase activities. The results suggest a disruption of PQC in white muscle fibres of CKD rats previous to the atrophy. AET can rescue this disruption for the UPR, prevent accumulated misfolded proteins and reduce oxidative damage, HSPs protein levels and exercise tolerance.
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Affiliation(s)
- Wilson Max Almeida Monteiro De Moraes
- Biosciences Department, Federal University of Sao Paulo, Santos, Brazil.,Post-Graduation Program on Physical Education, Catholic University of Brasilia (UCB), Brasilia, Federal District, Brazil
| | | | | | | | | | - Andrea G Marshall
- Department of Neurobiology, Physiology and Behavior, University of California Davis, Davis, CA, USA
| | - Jonato Prestes
- Post-Graduation Program on Physical Education, Catholic University of Brasilia (UCB), Brasilia, Federal District, Brazil
| | - Maria Claudia Irigoyen
- Hypertension Unit, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Patricia Chakur Brum
- Department of Post-graduation in Medicine, Nove de Julho University (UNINOVE), Sao Paulo, Brazil
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17
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Obayashi K, Saeki K, Maegawa T, Sakai T, Kitagawa M, Otaki N, Kataoka H, Kurumatani N. Association of Serum Asymmetric Dimethylarginine With Muscle Strength and Gait Speed: A Cross-Sectional Study of the HEIJO-KYO Cohort. J Bone Miner Res 2016; 31:1107-13. [PMID: 26704561 DOI: 10.1002/jbmr.2773] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 12/25/2022]
Abstract
Muscle strength and gait speed are related with functional limitations and disabilities and also predict cardiovascular and all-cause mortality. Nitric oxide (NO) plays an important role in regulating physiological process in skeletal muscles; however, the association between serum asymmetric dimethylarginine (ADMA) level, an endogenous competitive inhibitor of NO synthesis, and physical performance has not yet been studied. We investigated the associations of serum ADMA level with muscle strength and usual gait speed in a cross-sectional study of 550 elderly individuals (mean age, 71.2 ± 6.6 years). Mean ADMA level was 0.45 ± 0.06 µmol/L; mean grip and quadriceps strengths were 27.7 ± 8.4 kg and 165.1 ± 81.6 Nm, respectively; and mean gait speed was 1.37 ± 0.30 m/s. In multivariate linear regression analysis adjusted for potential confounding factors (age, gender, body weight, smoking and drinking status, household income, hypertension, diabetes, renal function, and physical activity), higher serum ADMA level was significantly associated with lower grip and quadriceps strengths and slower gait speed (grip strength: β, -1.257; 95% confidence interval [CI], -1.990 to -0.525; p = 0.001; quadriceps strength: β, -11.730; 95% CI, -20.924 to -2.536; p = 0.012; gait speed: β, -0.065; 95% CI, -0.108 to -0.022; p = 0.003). Our findings indicate the significant association between serum ADMA level and physical performance among elderly individuals, which was independent of the important potential confounders. © 2015 American Society for Bone and Mineral Research.
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Affiliation(s)
- Kenji Obayashi
- Department of Community Health and Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Keigo Saeki
- Department of Community Health and Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | | | | | | | - Naoto Otaki
- Department of Dietary Life and Food Science, Mukogawa Women's University, Hyogo, Japan
| | - Hiroshi Kataoka
- Department of Neurology, Nara Medical University School of Medicine, Nara, Japan
| | - Norio Kurumatani
- Department of Community Health and Epidemiology, Nara Medical University School of Medicine, Nara, Japan
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18
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Amdur RL, Mukherjee M, Go A, Barrows IR, Ramezani A, Shoji J, Reilly MP, Gnanaraj J, Deo R, Roas S, Keane M, Master S, Teal V, Soliman EZ, Yang P, Feldman H, Kusek JW, Tracy CM, Raj DS. Interleukin-6 Is a Risk Factor for Atrial Fibrillation in Chronic Kidney Disease: Findings from the CRIC Study. PLoS One 2016; 11:e0148189. [PMID: 26840403 PMCID: PMC4739587 DOI: 10.1371/journal.pone.0148189] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/14/2016] [Indexed: 01/08/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with chronic kidney disease (CKD). In this study, we examined the association between inflammation and AF in 3,762 adults with CKD, enrolled in the Chronic Renal Insufficiency Cohort (CRIC) study. AF was determined at baseline by self-report and electrocardiogram (ECG). Plasma concentrations of interleukin(IL)-1, IL-1 Receptor antagonist, IL-6, tumor necrosis factor (TNF)-α, transforming growth factor-β, high sensitivity C-Reactive protein, and fibrinogen, measured at baseline. At baseline, 642 subjects had history of AF, but only 44 had AF in ECG recording. During a mean follow-up of 3.7 years, 108 subjects developed new-onset AF. There was no significant association between inflammatory biomarkers and past history of AF. After adjustment for demographic characteristics, comorbid conditions, laboratory values, echocardiographic variables, and medication use, plasma IL-6 level was significantly associated with presence of AF at baseline (Odds ratio [OR], 1.61; 95% confidence interval [CI], 1.21 to 2.14; P = 0.001) and new-onset AF (OR, 1.25; 95% CI, 1.02 to 1.53; P = 0.03). To summarize, plasma IL-6 level is an independent and consistent predictor of AF in patients with CKD.
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Affiliation(s)
- Richard L. Amdur
- Biostatistics core, George Washington University Medical Faculty Associates, Washington, DC, United States of America
- George Washington University School of Medicine, Washington, DC, United States of America
| | - Monica Mukherjee
- Division of cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Alan Go
- Kaiser Permanente Division of Research, Oakland, CA, United States of America
| | - Ian R. Barrows
- George Washington University School of Medicine, Washington, DC, United States of America
| | - Ali Ramezani
- Division of Renal diseases and Hypertension, George Washington University School of Medicine, Washington, DC, United States of America
| | - Jun Shoji
- Division of Renal diseases and Hypertension, George Washington University School of Medicine, Washington, DC, United States of America
| | - Muredach P. Reilly
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Joseph Gnanaraj
- Bridgeport Hospital, Bridgeport, CT, United States of America
| | - Raj Deo
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Sylvia Roas
- Harvard Medical School, Joslin Diabetes Center, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Martin Keane
- Temple Heart and Vascular Center, Philadelphia, PA, United States of America
| | - Steve Master
- Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Valerie Teal
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Elsayed Z. Soliman
- Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Peter Yang
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Harold Feldman
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - John W. Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Division of Kidney, Urologic and Hematologic Diseases, Bethesda, MD, United States of America
| | - Cynthia M. Tracy
- Division of Cardiology, George Washington University School of Medicine, Washington, DC, United States of America
| | - Dominic S. Raj
- Division of Renal diseases and Hypertension, George Washington University School of Medicine, Washington, DC, United States of America
- * E-mail:
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Fanti P, Giustarini D, Rossi R, Cunningham SED, Folli F, Khazim K, Cornell J, Matteucci E, Bansal S. Dietary Intake of Proteins and Calories Is Inversely Associated With The Oxidation State of Plasma Thiols in End-Stage Renal Disease Patients. J Ren Nutr 2015; 25:494-503. [PMID: 26235932 DOI: 10.1053/j.jrn.2015.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/18/2015] [Accepted: 06/09/2015] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Oxidative stress contributes to the pathogenesis of protein-energy wasting in maintenance hemodialysis (MHD) patients, but knowledge of specific effectors and mechanisms remains fragmented. Aim of the study was to define whether and how food intake is involved in the causal relationship between oxidative stress and protein-energy wasting. METHODS Seventy-one adult MHD patients and 24 healthy subjects (control) were studied cross-sectionally with analyses of diet record and of oxidative stress, as measured by a battery of plasma thiols including the protein sulfhydryl (-SH) group (PSH) levels (a marker of total protein-SH reducing capacity), the protein thiolation index (PTI, the ratio between disulfide, i.e., oxidized and reduced -SH groups in proteins), low molecular mass (LMM) thiols, LMM disulfides, and mixed LMM-protein disulfides. In addition, interleukin-6 (IL-6), albumin, C-reactive protein, and neutrophil gelatinase-associated lipocalin (NGAL) were measured as markers of inflammation. RESULTS The patients showed low energy (22.0 ± 8.4 kcal/kg/day) and adequate protein (1.0 ± 0.4 g/kg/day) intakes, high levels of cystine (CySS; patients vs. CONTROL 113.5 [90.9-132.8] vs. 68.2 [56.2-75.7] μM), cysteinylated proteins (CySSP; 216.0 [182.8-254.0] vs. 163.5 [150.0-195.5] μM), and high PTI (0.76 [0.61-0.88] vs. 0.43 [0.40-0.54]; P < .001 in all comparisons). In patients, variation of CySSP was explained by a standard regression model (R = 0.775; P = .00001) that included significant contributions of protein intake (β = -0.361), NGAL (β = 0.387), age (β = 0.295), and albumin (β = 0.457). In the same model, variation of PTI (R = 0.624; P = .01) was explained by protein intake (β = -0.384) and age (β = 0.326) and NGAL (β = 0.311). However, when PSH was entered as dependent variable (R = 0.730; P = .0001), only serum albumin (β = 0.495) and age (β = -0.280), but not dietary intake or NGAL, contributed to the model. CONCLUSIONS In MHD, markers of thiol oxidation including CySSP and PTI show independent association with dietary intake and NGAL, whereas PSH, a marker of thiol-reducing capacity, did not associate with these same variables. The mechanism(s) responsible for inverse association between oxidative stress and food intake in MHD remain undefined.
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Affiliation(s)
- Paolo Fanti
- Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Renal Section Medicine Service, South Texas Veteran Health Care System, San Antonio, Texas.
| | - Daniela Giustarini
- Department of Life Sciences, Laboratory of Pharmacology and Toxicology, University of Siena, Siena, Italy
| | - Ranieri Rossi
- Department of Life Sciences, Laboratory of Pharmacology and Toxicology, University of Siena, Siena, Italy
| | - Sue E D Cunningham
- School of Health Professions, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Franco Folli
- Division of Diabetes, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Khaled Khazim
- Nephrology and Hypertension Unit, Western Galilee Hospital, Nahariya, Israel
| | - John Cornell
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Shweta Bansal
- Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Hwang JH, Ryu J, An JN, Kim CT, Kim H, Yang J, Ha J, Chae DW, Ahn C, Jung IM, Oh YK, Lim CS, Han DJ, Park SK, Kim YS, Kim YH, Lee JP. Pretransplant malnutrition, inflammation, and atherosclerosis affect cardiovascular outcomes after kidney transplantation. BMC Nephrol 2015; 16:109. [PMID: 26194096 PMCID: PMC4508766 DOI: 10.1186/s12882-015-0108-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/06/2015] [Indexed: 12/11/2022] Open
Abstract
Background Malnutrition, inflammation, and atherosclerosis (MIA) syndrome is associated with a high mortality rate in patients with end-stage renal disease. However, the clinical relevance of MIA syndrome in kidney transplantation (KT) recipients remains unknown. Methods We enrolled 1348 adult KT recipients. Recipients were assessed based on serum albumin, cholesterol, or body mass index for the malnutrition factor and C-reactive protein level for the inflammation factor. Any history of cardiovascular (CV), cerebrovascular, or peripheral vascular disease satisfied the atherosclerosis factor. Each MIA factors were assessed by univariate analysis and we calculated an overall risk score by summing up scores for each independent variable. The enrolled patients were divided into 4 groups depending on the MIA score (0, 2–4, 6, 8–10). Results The patients with higher MIA score showed worse outcome of fatal/non-fatal acute coronary syndrome (ACS) (p < 0.001) and composite outcomes of ACS and all-cause mortality (p < 0.001) than with the lower MIA score. In multivariate analysis, ACS showed significantly higher incidence in the MIA score 8-10 group than in the MIA score 0 group (Hazard ratio 6.12 95 % Confidence interval 1.84–20.32 p = 0.003). Conclusions The presence of MIA factors before KT is an independent predictor of post-transplant CV outcomes.
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Affiliation(s)
- Jin Ho Hwang
- Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea.
| | - Jiwon Ryu
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea.
| | - Jung Nam An
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Clara Tammy Kim
- Graduate School of Public Health, Seoul National University, Seoul, South Korea.
| | - Hyosang Kim
- Department of Internal Medicine, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea.
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea.
| | - Jongwon Ha
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea.
| | - Dong Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Curie Ahn
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - In Mok Jung
- Department of Surgery, Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Duck-Jong Han
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea.
| | - Su-Kil Park
- Department of Internal Medicine, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea.
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea.
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea.
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Imamaki H, Ishii A, Yokoi H, Kasahara M, Kuwabara T, Mori KP, Kato Y, Kuwahara T, Satoh M, Nakatani K, Saito Y, Tomosugi N, Sugawara A, Nakao K, Mukoyama M, Yanagita M, Mori K. Low Serum Neutrophil Gelatinase-associated Lipocalin Level as a Marker of Malnutrition in Maintenance Hemodialysis Patients. PLoS One 2015; 10:e0132539. [PMID: 26161663 PMCID: PMC4498679 DOI: 10.1371/journal.pone.0132539] [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] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 06/17/2015] [Indexed: 11/29/2022] Open
Abstract
Background Neutrophil gelatinase-associated lipocalin (NGAL or LCN2) is an iron-transporting factor which possesses various activities such as amelioration of kidney injury and host defense against pathogens. Its circulating concentrations are elevated in acute and chronic kidney diseases and show a positive correlation with poor renal outcome and mortality, but its clinical significance in maintenance hemodialysis (HD) patients remains elusive. Methods Serum NGAL levels were determined by enzyme-linked immunosorbent assay in out-patient, Japanese HD subjects. Their correlation to laboratory findings and morbidity (as development of severe infection or serum albumin reduction) was investigated using linear regression analysis and χ2 test. Results Pre-dialysis serum NGAL levels in HD patients were elevated by 13-fold compared to healthy subjects (n=8, P<0.001). In a cross-sectional study of 139 cases, serum NGAL concentrations were determined independently by % creatinine generation rate (an indicator of muscle mass, standardized coefficient β=0.40, P<0.001), peripheral blood neutrophil count (β=0.38, P<0.001) and anion gap (which likely reflects dietary protein intake, β=0.16, P<0.05). Iron administration to anemic HD patients caused marked elevation of peripheral blood hemoglobin, serum ferritin and iron-regulatory hormone hepcidin-25 levels, but NGAL levels were not affected. In a prospective study of 87 cases, increase in serum albumin levels a year later was positively associated to baseline NGAL levels by univariate analysis (r=0.36, P<0.01). Furthermore, within a year, patients with the lowest NGAL tertile showed significantly increased risk for marked decline in serum albumin levels (≥0.4 g/dl; odds ratio 5.5, 95% confidence interval 1.5–20.3, P<0.05) and tendency of increased occurrence of severe infection requiring admission (odds ratio 3.1, not significant) compared to the middle and highest tertiles. Conclusion Low serum NGAL levels appear to be associated with current malnutrition and also its progressive worsening in maintenance HD patients.
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Affiliation(s)
- Hirotaka Imamaki
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Ishii
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideki Yokoi
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masato Kasahara
- Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Takashige Kuwabara
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Keita P. Mori
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukiko Kato
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Kuwahara
- Department of Nephrology, Saiseikai Ibaraki Hospital, Osaka, Japan
| | | | - Kimihiko Nakatani
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yoshihiko Saito
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Naohisa Tomosugi
- Division of Advanced Medicine, Medical Research Institute, Kanazawa Medical University, Kanazawa, Japan
| | - Akira Sugawara
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Kazuwa Nakao
- TK Project, Medical Innovation Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- TMK Project, Medical Innovation Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kiyoshi Mori
- TMK Project, Medical Innovation Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
- * E-mail:
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22
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Gupta J, Dominic EA, Fink JC, Ojo AO, Barrows IR, Reilly MP, Townsend RR, Joffe MM, Rosas SE, Wolman M, Patel SS, Keane MG, Feldman HI, Kusek JW, Raj DS. Association between Inflammation and Cardiac Geometry in Chronic Kidney Disease: Findings from the CRIC Study. PLoS One 2015; 10:e0124772. [PMID: 25909952 PMCID: PMC4409366 DOI: 10.1371/journal.pone.0124772] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/08/2015] [Indexed: 01/27/2023] Open
Abstract
Background Left ventricular hypertrophy (LVH) and myocardial contractile dysfunction are independent predictors of mortality in patients with chronic kidney disease (CKD). The association between inflammatory biomarkers and cardiac geometry has not yet been studied in a large cohort of CKD patients with a wide range of kidney function. Methods Plasma levels of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), IL-6, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β, high-sensitivity C-Reactive protein (hs-CRP), fibrinogen and serum albumin were measured in 3,939 Chronic Renal Insufficiency Cohort study participants. Echocardiography was performed according to the recommendations of the American Society of Echocardiography and interpreted at a centralized core laboratory. Results LVH, systolic dysfunction and diastolic dysfunction were present in 52.3%, 11.8% and 76.3% of the study subjects, respectively. In logistic regression analysis adjusted for age, sex, race/ethnicity, diabetic status, current smoking status, systolic blood pressure, urinary albumin- creatinine ratio and estimated glomerular filtration rate, hs-CRP (OR 1.26 [95% CI 1.16, 1.37], p<0.001), IL-1RA (1.23 [1.13, 1.34], p<0.0001), IL-6 (1.25 [1.14, 1.36], p<0.001) and TNF-α (1.14 [1.04, 1.25], p = 0.004) were associated with LVH. The odds for systolic dysfunction were greater for subjects with elevated levels of hs-CRP (1.32 [1.18, 1.48], p<0.001) and IL-6 (1.34 [1.21, 1.49], p<0.001). Only hs-CRP was associated with diastolic dysfunction (1.14 [1.04, 1.26], p = 0.005). Conclusion In patients with CKD, elevated plasma levels of hs-CRP and IL-6 are associated with LVH and systolic dysfunction.
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Affiliation(s)
- Jayanta Gupta
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center, El Paso, Texas, United States of America
| | - Elizabeth A. Dominic
- The George Washington University School of Medicine, Washington, DC, United States of America
| | - Jeffrey C. Fink
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Akinlolu O. Ojo
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ian R. Barrows
- The George Washington University School of Medicine, Washington, DC, United States of America
| | - Muredach P. Reilly
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Raymond R. Townsend
- Renal and Electrolyte Division, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Marshall M. Joffe
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sylvia E. Rosas
- Joslyn Diabetic Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Melanie Wolman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Samir S. Patel
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, United States of America
| | - Martin G. Keane
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Harold I. Feldman
- Renal and Electrolyte Division, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - John W. Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, United States of America
| | - Dominic S. Raj
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, United States of America
- * E-mail:
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Prasad GVR. Metabolic syndrome and chronic kidney disease: Current status and future directions. World J Nephrol 2014; 3:210-219. [PMID: 25374814 PMCID: PMC4220353 DOI: 10.5527/wjn.v3.i4.210] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/26/2014] [Accepted: 09/24/2014] [Indexed: 02/06/2023] Open
Abstract
Metabolic syndrome (MetS) is a term used to denote a combination of selected, widely prevalent cardiovascular disease (CVD)-related risk factors. Despite the ambiguous definition of MetS, it has been clearly associated with chronic kidney disease markers including reduced glomerular filtration rate, proteinuria and/or microalbuminuria, and histopathological markers such as tubular atrophy and interstitial fibrosis. However, the etiological role of MetS in chronic kidney disease (CKD) is less clear. The relationship between MetS and CKD is complex and bidirectional, and so is best understood when CKD is viewed as a common progressive illness along the course of which MetS, another common disease, may intervene and contribute. Possible mechanisms of renal injury include insulin resistance and oxidative stress, increased proinflammatory cytokine production, increased connective tissue growth and profibrotic factor production, increased microvascular injury, and renal ischemia. MetS also portends a higher CVD risk at all stages of CKD from early renal insufficiency to end-stage renal disease. Clinical interventions for MetS in the presence of CKD should include a combination of weight reduction, appropriate dietary modification and increase physical activity, plus targeting of individual CVD-related risk factors such as dysglycemia, hypertension, and dyslipidemia while conforming to relevant national societal guidelines.
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Kazancioglu R, Buyukaydin B, Cinar A, Soysal P, Gorcin B, Isik A. Malnutrition in elderly patients with renal failure: Importance of pre-dialysis period. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2014.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ramezani A, Barrows IR, Raj DS. Electroacupuncture therapy for muscle atrophy in CKD: is there a needle in the haystack? J Am Soc Nephrol 2014; 26:510-2. [PMID: 25228360 DOI: 10.1681/asn.2014080781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Ali Ramezani
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC, and
| | - Ian R Barrows
- George Washington University School of Medicine, Washington, DC
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC, and
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26
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Wing MR, Yang W, Teal V, Navaneethan S, Tao K, Ojo A, Guzman NN, Reilly M, Wolman M, Rosas SE, Cuevas M, Fischer M, Lustigova E, Master SR, Xie D, Appleby D, Joffe M, Kusek J, Feldman HI, Raj DS. Race modifies the association between adiposity and inflammation in patients with chronic kidney disease: findings from the chronic renal insufficiency cohort study. Obesity (Silver Spring) 2014; 22:1359-66. [PMID: 24415732 PMCID: PMC4327849 DOI: 10.1002/oby.20692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 11/14/2013] [Accepted: 12/29/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The race-specific association of inflammation with adiposity and muscle mass in subjects with chronic kidney disease (CKD) was examined. METHODS Plasma concentration of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), IL-6, IL-10, tumor necrosis factor (TNF)-α, TGF-β, high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and serum albumin was measured in 3,939 Chronic Renal Insufficiency Cohort study participants. Bioelectric impedance analysis was used to determine body fat mass (BFM) and fat-free mass (FFM). RESULTS Plasma levels of hs-CRP, fibrinogen, IL-1RA, IL-6, and TNF-α increased and serum albumin decreased across the quartiles of body mass index. In multivariable analysis, BFM and FFM were positively associated with hs-CRP, fibrinogen, IL-1β, IL-1RA, and IL-6. One standard deviation (SD) increase in BFM and FFM was associated with 0.36 (95% confidence interval [CI] = 0.33, 0.39) and 0.26 (95% CI = 0.22, 0.30) SD increase in log-transformed hs-CRP, respectively (P < 0.001). Race stratified analysis showed that the association between biomarkers and BFM and FFM differed by race, with Caucasians, demonstrating a stronger association with markers of inflammation than African Americans. CONCLUSIONS BFA and FFM are positively associated with markers of inflammation in patients with CKD. Race stratified analysis showed that Caucasians have a stronger association with markers of inflammation compared to African Americans.
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Affiliation(s)
- Maria R Wing
- Division of Renal Disease and Hypertension, The George Washington University, Washington, DC
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Wang IK, Lin CL, Wu YY, Chou CY, Lin SY, Liu JH, Yen TH, Huang CC, Sung FC. Increased risk of Parkinson's disease in patients with end-stage renal disease: a retrospective cohort study. Neuroepidemiology 2014; 42:204-210. [PMID: 24751820 DOI: 10.1159/000358921] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/20/2014] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Studies on dyskinesia and Parkinson's syndrome associated with chronic kidney disease or end-stage renal disease (ESRD) have been mainly limited to case reports or case series studies. This population-based study investigated the risk of Parkinson's disease in patients with ESRD. METHODS From a universal insurance claims database of Taiwan, we established a cohort of 8,325 adults with newly diagnosed ESRD from 1997 to 2010 without a history of Parkinson's disease. A control cohort of 33,382 insured subjects without a history of kidney disease or Parkinson's disease was also selected, with frequency matched for age, sex and index date of the patients with ESRD. Both cohorts were followed up until the end of 2010. RESULTS The Parkinson's disease incidence was 1.55-fold higher in the cohort with ESRD than in the comparison cohort (48.8 vs. 31.7 per 10,000 person-years) with an adjusted hazard ratio of 1.73 (95% confidence interval, 1.39-2.15). Sex-specific and age-specific analysis showed a higher relative risk for women and younger patients with ESRD compared to the control cohort. CONCLUSIONS ESRD is significantly associated with an increased risk of Parkinson's disease. Close surveillance for Parkinson's disease should be considered for patients with ESRD.
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Affiliation(s)
- I-Kuan Wang
- Institute of Clinical Medical Science, China Medical University College of Medicine, Taichung, Taiwan
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Foster TL, Ferrantelli E, van Wier-van der Schaaf T, Beelen RHJ. European Training and Research in Peritoneal Dialysis: scientific objectives, training, implementation and impact of the programme. J Ren Care 2013; 40:34-9. [PMID: 24325343 DOI: 10.1002/jorc.12041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) offers many advantages over hospital-based haemodialysis, including better quality of life. Despite this, there is a general under-utilisation of PD in Europe, which, to some extent, can be attributed to a lack of knowledge and education amongst renal clinicians and nurses. OBJECTIVES The specific aim of the European Training and Research in Peritoneal Dialysis (EuTRiPD) programme is to address this lack of knowledge, to develop a minimum of five biomarkers that allow the prediction of outcome in PD and three therapeutic treatments to improve outcome in PD. APPROACH EuTRiPD is a EU-wide consortium with clinical, academic and commercial partners set up to address this knowledge gap. By training through research and close collaboration between academic and commercial entities we hope to improve the outcome and uptake of PD. It is the goal of EuTRiPD to improve the currently hampered diagnostic therapeutic developments in renal replacement therapy (RRT) and structure existing high-quality PD-related research across Europe. CONCLUSION It is hoped that EuTRiPD can and will have a significant impact on socio-economic and scientific aspects of PD. It is the aim for EuTRiPD to boost the uptake of PD throughout Europe by making PD the obvious choice for patients.
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Affiliation(s)
- Tom L Foster
- Department of Molecular Cell Biology and Immunology, VU University Medical Center (VUMC), Amsterdam, The Netherlands
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29
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Lauritzen HP, Brandauer J, Schjerling P, Koh HJ, Treebak JT, Hirshman MF, Galbo H, Goodyear LJ. Contraction and AICAR stimulate IL-6 vesicle depletion from skeletal muscle fibers in vivo. Diabetes 2013; 62:3081-92. [PMID: 23761105 PMCID: PMC3749330 DOI: 10.2337/db12-1261] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Recent studies suggest that interleukin 6 (IL-6) is released from contracting skeletal muscles; however, the cellular origin, secretion kinetics, and signaling mechanisms regulating IL-6 secretion are unknown. To address these questions, we developed imaging methodology to study IL-6 in fixed mouse muscle fibers and in live animals in vivo. Using confocal imaging to visualize endogenous IL-6 protein in fixed muscle fibers, we found IL-6 in small vesicle structures distributed throughout the fibers under basal (resting) conditions. To determine the kinetics of IL-6 secretion, intact quadriceps muscles were transfected with enhanced green fluorescent protein (EGFP)-tagged IL-6 (IL-6-EGFP), and 5 days later anesthetized mice were imaged before and after muscle contractions in situ. Contractions decreased IL-6-EGFP-containing vesicles and protein by 62% (P < 0.05), occurring rapidly and progressively over 25 min of contraction. However, contraction-mediated IL-6-EGFP reduction was normal in muscle-specific AMP-activated protein kinase (AMPK) α2-inactive transgenic mice. In contrast, the AMPK activator AICAR decreased IL-6-EGFP vesicles, an effect that was inhibited in the transgenic mice. In conclusion, resting skeletal muscles contain IL-6-positive vesicles that are expressed throughout myofibers. Contractions stimulate the rapid reduction of IL-6 in myofibers, occurring through an AMPKα2-independent mechanism. This novel imaging methodology clearly establishes IL-6 as a contraction-stimulated myokine and can be used to characterize the secretion kinetics of other putative myokines.
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Affiliation(s)
- Hans P.M.M. Lauritzen
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
| | - Josef Brandauer
- Department of Health Sciences, Gettysburg College, Gettysburg, Pennsylvania
| | - Peter Schjerling
- Department of Orthopedic Surgery M, Institute of Sports Medicine, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ho-Jin Koh
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
| | - Jonas T. Treebak
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael F. Hirshman
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
| | - Henrik Galbo
- Department of Rheumatology and Institute of Inflammation Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Laurie J. Goodyear
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
- Corresponding author: Laurie J. Goodyear,
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Farquharson C, Ahmed SF. Inflammation and linear bone growth: the inhibitory role of SOCS2 on GH/IGF-1 signaling. Pediatr Nephrol 2013; 28:547-56. [PMID: 22886280 DOI: 10.1007/s00467-012-2271-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/16/2012] [Accepted: 07/11/2012] [Indexed: 12/29/2022]
Abstract
Linear bone growth is widely recognized to be adversely affected in children with chronic kidney disease (CKD) and other chronic inflammatory disorders. The growth hormone (GH)/insulin-like growth factor-1 (IGF-1) pathway is anabolic to the skeleton and inflammatory cytokines compromise bone growth through a number of different mechanisms, which include interference with the systemic as well as the tissue-level GH/IGF-1 axis. Despite attempts to promote growth and control disease, there are an increasing number of reports of the persistence of poor growth in a substantial proportion of patients receiving rhGH and/or drugs that block cytokine action. Thus, there is an urgent need to consider better and alternative forms of therapy that are directed specifically at the mechanism of the insult which leads to abnormal bone health. Suppressor of cytokine signaling 2 (SOCS2) expression is increased in inflammatory conditions including CKD, and is a recognized inhibitor of GH signaling. Therefore, in this review, we will focus on the premise that SOCS2 signaling represents a critical pathway in growth plate chondrocytes through which pro-inflammatory cytokines alter both GH/IGF-1 signaling and cellular function.
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Affiliation(s)
- Colin Farquharson
- Division of Developmental Biology, The Roslin Institute and Royal (Dick) School of Veterinary Studies, The University of Edinburgh, Easter Bush, Midlothian, EH25 9RG, UK.
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Kim JC, Kalantar-Zadeh K, Kopple JD. Frailty and protein-energy wasting in elderly patients with end stage kidney disease. J Am Soc Nephrol 2012; 24:337-51. [PMID: 23264684 DOI: 10.1681/asn.2012010047] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Older people constitute an increasingly greater proportion of patients with advanced CKD, including those patients undergoing maintenance dialysis treatment. Frailty is a biologic syndrome of decreased reserve and resistance to stressors that results from cumulative declines across multiple physiologic systems and causes vulnerability to adverse outcomes. Frailty is common in elderly CKD patients, and it may be associated with protein-energy wasting (PEW), sarcopenia, dynapenia, and other complications of CKD. Causes of frailty with or without PEW in the elderly with CKD can be classified into three categories: causes primarily caused by aging per se, advanced CKD per se, or a combination of both conditions. Frailty and PEW in elderly CKD patients are associated with impaired physical performance, disability, poorer quality of life, and reduced survival. Prevention and treatment of these conditions in the elderly CKD patients often require a multifaceted approach. Here, we examine the causes and consequences of these conditions and examine the interplay between frailty and PEW in elderly CKD patients.
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Affiliation(s)
- Jun Chul Kim
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90502, USA
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Rattanasompattikul M, Molnar MZ, Zaritsky JJ, Hatamizadeh P, Jing J, Norris KC, Kovesdy CP, Kalantar-Zadeh K. Association of malnutrition-inflammation complex and responsiveness to erythropoiesis-stimulating agents in long-term hemodialysis patients. Nephrol Dial Transplant 2012; 28:1936-45. [PMID: 23045431 DOI: 10.1093/ndt/gfs368] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Protein-energy wasting, inflammation and refractory anemia are common in long-term hemodialysis patients. A decreased responsiveness to erythropoiesis-stimulating agents (ESA) is often the cause of the refractory anemia. We hypothesized that the malnutrition-inflammation complex is an independent predictor of decreased responsiveness to ESAs in hemodialysis patients. METHODS This cohort study of 754 hemodialysis patients was examined for an association between inflammatory and nutritional markers, including the malnutrition-inflammation score (MIS) and responsiveness to ESA. Cubic spline models were fitted to verify found associations. RESULTS The mean (±SD) age of patients was 54 ± 15 years, 53% were diabetic and 32% blacks. MIS was worse in the highest quartile of ESAs responsiveness index (ERI, ESA dose divided by hemoglobin) when compared with 1st quartile (6.5 ± 4.5 versus 4.4 ± 3.4; P < 0.001). Both C-reactive protein (log CRP) (β = 0.19) and interleukin-6 (log IL-6) (β = 0.32) were strong and independent predictors of ERI using multivariate linear regression. Serum albumin (β = -0.30) and prealbumin levels (β = -0.14) were inversely associated with ERI. Each 1 SD higher MIS, higher CRP and lower albumin were associated with 86, 44 and 97% higher likelihood of having highest versus three lowest ERI quartiles in fully adjusted models [odds ratio (and 95% confidence interval) of 1.86 (1.31-2.85), 1.44 (1.08-1.92) and 1.97 (1.41-2.78)], respectively. Cubic splines confirmed the continuous and incremental nature of these associations. CONCLUSIONS Malnutrition-inflammation complex is an incremental predictor of poor responsiveness to ESAs in hemodialysis patients. Further studies are needed to assess whether modulating inflammatory or nutritional processes can improve anemia management.
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Affiliation(s)
- Manoch Rattanasompattikul
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
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Braosi APR, de Souza CM, Luczyszyn SM, Dirschnabel AJ, Claudino M, Olandoski M, Probst CM, Garlet GP, Pecoits-Filho R, Trevilatto PC. Analysis of IL1 gene polymorphisms and transcript levels in periodontal and chronic kidney disease. Cytokine 2012; 60:76-82. [PMID: 22795294 DOI: 10.1016/j.cyto.2012.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 06/03/2012] [Accepted: 06/04/2012] [Indexed: 01/03/2023]
Abstract
UNLABELLED Chronic kidney disease (CKD) and periodontitis (PD) are complex inflammatory disturbances, influenced by genetic factors. Interleukin (IL)-1 genes code for inflammatory mediators involved in the physiopathogenesis of both diseases. Functional polymorphisms in IL1 genes modulate cytokine levels and have been associated with susceptibility to immune-inflammatory conditions. OBJECTIVES The aim of this study was investigate the association of functional IL1 gene polymorphisms and transcript levels with susceptibility to CKD and PD. DESIGN The sample consisted of 246 individuals, mean age 44.8 years, divided into: group 1 (64 patients without CKD and without PD), group 2 (58 without CKD and with PD), group 3 (52 with CKD and without PD) and group 4 (72 with CKD and with PD). DNA was obtained from cells of oral mucosa and polymorphisms IL1AC-889T, IL1BC-511T, IL1BC+3954T and IL1RN (intron 2) were analyzed by PCR-RFLP. Transcript levels from gingival tissues were analyzed by real-time PCR. RESULTS IL1RN(*)1 allele was associated with almost 4-fold increased risk for CKD (OR 3.92 95% CI=1.6-9.4, p=0.002). IL1RN(*)2 allele was associated with 3-fold increased risk for PD in CKD patients (OR 3.08 95% CI=1.2-7.9, p=0.019). Allele T for polymorphism IL1B+3954 was associated with CKD in PD patients (OR 2.28 95% CI=1.1-4.7, p=0.019). Significantly increased levels of transcripts of IL1A, IL1B and IL1RN genes were found in PD patients. CONCLUSIONS It was observed an evidence for association of IL1B and IL1RN alleles with susceptibility to CKD and PD. Higher levels of IL1 gene transcripts were found in PD patients.
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Affiliation(s)
- Ana Paula Ribeiro Braosi
- Health and Biosciences School, Pontifícia Universidade Católica do Paraná (PUCPR), Imaculada Conceição Street 1155, CEP 80215-901, Curitiba, PR, Brazil
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Sterling KA, Eftekhari P, Girndt M, Kimmel PL, Raj DS. The immunoregulatory function of vitamin D: implications in chronic kidney disease. Nat Rev Nephrol 2012; 8:403-12. [PMID: 22614789 DOI: 10.1038/nrneph.2012.93] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiovascular and infectious diseases remain the most common causes of death among patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Basic science and epidemiological studies indicate that vitamin D has importance not only for cardiovascular health, but also for the immune response. Vitamin D signaling pathways regulate both innate and adaptive immunity, maintaining the associated inflammatory response within physiological limits. Levels of both the inactive as well as active form of vitamin D (25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, respectively) are decreased in patients with CKD and ESRD. It is reasonable to hypothesize, therefore, that the immune dysfunction associated with vitamin D deficiency in patients with CKD and ESRD in part explains the misdirected inflammatory response and increased susceptibility to infection seen in this population. Indeed, observational studies show that vitamin D deficiency in patients with ESRD is associated with increased mortality, and treatment with vitamin D is associated with a decreased risk of infection, as well as reduced all-cause mortality. However, whether different vitamin D preparations have differential effects on physiological function and clinical outcomes is still unclear. A proper understanding of the immune regulatory function of vitamin D is important for the development of future therapeutic strategies.
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Affiliation(s)
- Kevin A Sterling
- Division of Renal Diseases and Hypertension, Department of Medicine, The George Washington University School of Medicine, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA
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Kim Y, Molnar MZ, Rattanasompattikul M, Hatamizadeh P, Benner D, Kopple JD, Kovesdy CP, Kalantar-Zadeh K. Relative contributions of inflammation and inadequate protein intake to hypoalbuminemia in patients on maintenance hemodialysis. Int Urol Nephrol 2012; 45:215-27. [PMID: 22528583 DOI: 10.1007/s11255-012-0170-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 03/26/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Serum albumin is one of the strongest mortality predictors in maintenance hemodialysis (MHD) patients. Yet, the degree to which serum albumin represents dietary protein intake or an inflammatory state, among others, is not clear. We hypothesize that these inadequate protein intake and inflammation contribute somewhat equally to hypoalbuminemia. METHODS In a cross-sectional analysis, we examined correlates of low serum albumin, <3.8 g/dL, in 812 MHD patients in whom interleukin-6 (IL-6) and normalized protein nitrogen appearance (nPNA), also known as normalized protein catabolic rate (nPCR), were also measured. Logistic regression estimated odds ratios were employed, and spline models were plotted to examine the likelihood of relatively low serum albumin <3.8 g/dL. RESULTS Mean age (±SD) of patients was 54 ± 15 years; 53 % of patients were men, 50 % Hispanic, 31 % African-American, and 55 % diabetic. The mean dialysis vintage was 31 ± 34 months (median: 19, inter-quartile range: 7-44 months). The baseline serum albumin, averaged over a 3-month period (mean ± SD), was 3.88 ± 0.38 g/mL. The unadjusted correlation coefficients of l IL-6 and nPNA with serum albumin were -0.36 and +0.20, respectively (p < 0.001 for each comparison). The likelihood for an albumin <3.8 gr/dL increased linearly with decreasing nPNA and rising serum IL-6. This trend was steeper with increasing serum IL-6 up to a concentration of 30 ng/mL. CONCLUSIONS Both low protein intakes and a high state of inflammation are associated with low serum albumin in MHD patients.
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Affiliation(s)
- Youngmee Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Torrance, CA, USA
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Sarcopenia: a major challenge in elderly patients with end-stage renal disease. J Aging Res 2012; 2012:754739. [PMID: 22536505 PMCID: PMC3321443 DOI: 10.1155/2012/754739] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/22/2011] [Accepted: 12/30/2011] [Indexed: 11/17/2022] Open
Abstract
Sarcopenia is a condition of multifaceted etiology arising in many elderly people. In patients with chronic kidney, the loss of muscle mass is much more intensive and the first signs of sarcopenia are observed in younger patients than it is expected. It is associated with the whole-body protein-energy deficiency called protein-energy wasting (PEW). It seems to be one of the major factors limiting patient's autonomy as well as decreasing the quality of life. If it cannot be treated with the simple methods requiring some knowledge and devotion, we will fail to save patients who die due to cardiovascular disease and infection, despite proper conduction of renal replacement therapy. Many factors influencing the risk of sarcopenia development have been evaluated in number of studies. Many studies also were conducted to assess the efficacy of different therapeutic strategies (diet, physical activity, hormones). Nevertheless, there is still no consensus on treatment the patients with PEW. Therefore, in the paper we present the reasons and pathophysiology of sarcopenia as an important element of protein energy wasting (PEW) in elderly patients suffering from chronic kidney disease. We also analyze possible options for treatment according to up-to-date knowledge.
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Ujszaszi A, Czira ME, Fornadi K, Novak M, Mucsi I, Molnar MZ. Quality of life and protein-energy wasting in kidney transplant recipients. Int Urol Nephrol 2012; 44:1257-68. [PMID: 22246594 DOI: 10.1007/s11255-012-0122-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 01/05/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE Chronic kidney disease has profound effects on the health-related quality of life (HRQoL) of patients, with serious physiological, psychological and socio-economic implications. The co-occurrence of protein-energy wasting and inflammation in end-stage renal disease patients is associated with worse HRQoL and increased mortality. We designed this study to examine the relationship between nutritional and inflammatory status and HRQoL in kidney transplant recipients. METHODS Data from 100 randomly selected kidney transplant patients were analyzed in a cross-sectional survey. Socio-demographic parameters, laboratory results, transplantation-related data, comorbidities, medication and malnutrition-inflammation score (MIS) (Kalantar Score) were tabulated at baseline. Patients completed the Kidney Disease Quality of Life-SF (KDQoL-SF™) self-administered questionnaire. RESULTS Mean age was 51 ± 13 years, median (interquartile range, IQR) time since transplantation 66 (83) months, 57% were men, and 19% had diabetes. The median (IQR) MIS was 3 (3). The MIS significantly and negatively correlated with almost all HRQoL domains analyzed, and this association remained significant in multivariate linear regression analysis for the log-transformed scores on energy/fatigue (β = -0.059 P < 0.001), bodily pain (β = -0.056 P = 0.004), physical functioning (β = -0.029, P = 0.022) and symptoms/problems (β = -0.023 P = 0.005) domains after statistical correction for age, gender, eGFR, dialysis vintage, Charlson Comorbidity Index and occupational status. Additionally, cubic spline analyses revealed linearly increasing, "dose-response" relationship between almost all domains of KDQoL-SF™ and the MIS. CONCLUSIONS Malnutrition-inflammation score is independently associated with different dimensions of HRQoL in kidney transplant recipients.
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Affiliation(s)
- Akos Ujszaszi
- Institute of Pathophysiology, Semmelweis University, Nagyvarad ter 4, 1089 Budapest, Hungary
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Kandavelu S, Somasundar PC. Effect of Dialysis on Heme Oxygenase-1 (HO-1) Expression in Peripheral Blood Leukocytes of End Staged Renal Diseased Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.3923/ajb.2011.416.425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Molnar MZ, Czira ME, Rudas A, Ujszaszi A, Lindner A, Fornadi K, Kiss I, Remport A, Novak M, Kennedy SH, Rosivall L, Kovesdy CP, Mucsi I. Association of the Malnutrition-Inflammation Score With Clinical Outcomes in Kidney Transplant Recipients. Am J Kidney Dis 2011; 58:101-8. [DOI: 10.1053/j.ajkd.2010.11.027] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 11/17/2010] [Indexed: 01/28/2023]
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El-Wakil HS, Abou-Zeid AA, El-Gohary IE, Abou El-Seoud NA, Abou El-Yazeed MA, El-Leithy MA. Effect of high flux versus low flux hemodialysis on serum beta-2 microglobulin, advanced oxidation protein products and protein carbonyl. ALEXANDRIA JOURNAL OF MEDICINE 2011. [DOI: 10.1016/j.ajme.2011.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hala S. El-Wakil
- Department of Internal Medicine , Faculty of Medicine, Alexandria University, Egypt
| | - Abla A. Abou-Zeid
- Department of Clinical Pathology, Faculty of Medicine, Alexandria University, Egypt
| | - Iman E. El-Gohary
- Department of Internal Medicine , Faculty of Medicine, Alexandria University, Egypt
| | | | | | - Maha A. El-Leithy
- Alexandria, Sixth Year Students, Faculty of Medicine, Alexandria University, Egypt
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Carrero JJ, Stenvinkel P. Inflammation in End-Stage Renal Disease-What Have We Learned in 10 Years? Semin Dial 2010; 23:498-509. [DOI: 10.1111/j.1525-139x.2010.00784.x] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Dwivedi RS, Herman JG, McCaffrey TA, Raj DSC. Beyond genetics: epigenetic code in chronic kidney disease. Kidney Int 2010; 79:23-32. [PMID: 20881938 DOI: 10.1038/ki.2010.335] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Epigenetics refers to a heritable change in the pattern of gene expression that is mediated by a mechanism specifically not due to alterations in the primary nucleotide sequence. Well-known epigenetic mechanisms encompass DNA methylation, chromatin remodeling (histone modifications), and RNA interference. Functionally, epigenetics provides an extra layer of transcriptional control and plays a crucial role in normal physiological development, as well as in pathological conditions. Aberrant DNA methylation is implicated in immune dysfunction, inflammation, and insulin resistance. Epigenetic changes may be responsible for 'metabolic memory' and development of micro- and macrovascular complications of diabetes. MicroRNAs are critical in the maintenance of glomerular homeostasis and hence RNA interference may be important in the progression of renal disease. Recent studies have shown that epigenetic modifications orchestrate the epithelial-mesenchymal transition and eventually fibrosis of the renal tissue. Oxidative stress, inflammation, hyperhomocysteinemia, and uremic toxins could induce epimutations in chronic kidney disease. Epigenetic alterations are associated with inflammation and cardiovascular disease in patients with chronic kidney disease. Reversible nature of the epigenetic changes gives a unique opportunity to halt or even reverse the disease process through targeted therapeutic strategies.
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Affiliation(s)
- Rama S Dwivedi
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, District of Columbia 20037, USA
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Guarnieri G, Zanetti M, Vinci P, Cattin MR, Pirulli A, Barazzoni R. Metabolic Syndrome and Chronic Kidney Disease. J Ren Nutr 2010; 20:S19-23. [DOI: 10.1053/j.jrn.2010.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Molnar MZ, Keszei A, Czira ME, Rudas A, Ujszaszi A, Haromszeki B, Kosa JP, Lakatos P, Sarvary E, Beko G, Fornadi K, Kiss I, Remport A, Novak M, Kalantar-Zadeh K, Kovesdy CP, Mucsi I. Evaluation of the Malnutrition-Inflammation Score in Kidney Transplant Recipients. Am J Kidney Dis 2010; 56:102-11. [DOI: 10.1053/j.ajkd.2010.02.350] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 02/25/2010] [Indexed: 11/11/2022]
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Guebre-Egziabher F, Juillard L, Kalbacher E, Bachetta J, Fouque D. [Inflammation and insulin resistance: chronic renal disease features]. Nephrol Ther 2010; 6 Suppl 1:S7-12. [PMID: 20172498 DOI: 10.1016/s1769-7255(10)70005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Chronic renal disease is a state of microinflammation and insulin resistance. They both impact on the patient's outcome with an increased cardiovascular morbi-mortality and malnutrition. Current evidence suggests that there is a link between these two abnormal conditions. Recent data show a multiple organ regulatory pathway with a key role of bone, adipose tissue, immune system and central nervous system in energy balance control and glucose homeostasis. Thus, in searching for effective therapies, we should use an integrated approach aimed at modifying integrated outcomes rather than targeting single molecules.
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Schaefer F. Daily online haemodiafiltration: the perfect 'stimulus package' to induce growth? Nephrol Dial Transplant 2010; 25:658-60. [PMID: 20083477 DOI: 10.1093/ndt/gfp769] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Yeh SS, Marandi M, Thode HC, Levine DM, Parker T, Dixon T, Schuster MW. Report of a Pilot, Double-Blind, Placebo-Controlled Study of Megestrol Acetate in Elderly Dialysis Patients With Cachexia. J Ren Nutr 2010; 20:52-62. [DOI: 10.1053/j.jrn.2009.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Indexed: 11/11/2022] Open
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Ikemoto T, Hojo Y, Kondo H, Takahashi N, Hirose M, Nishimura Y, Katsuki T, Shimada K. Plasma granzyme B as a predicting factor of coronary artery disease--clinical significance in patients with chronic renal failure. J Cardiol 2009; 54:409-15. [PMID: 19944316 DOI: 10.1016/j.jjcc.2009.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 06/16/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To elucidate the role of granzyme B in coronary artery disease (CAD) in patients with chronic kidney disease (CKD). We hypothesized that granzyme B plays an important role in the formation of coronary artery lesions in patients with CKD. PATIENTS AND METHODS We studied 141 patients (116 men and 25 women; mean age, 64.2±9.6 years) and 16 control subjects. Diagnosis of CAD was confirmed by selective coronary angiography. CKD was defined as a sustained decrease in the estimated glomerular filtration (eGFR) rate less than 60 mL/min/1.73 m(2) over 3 months. We assigned patients to three groups: CAD without CKD (CAD group, n=46), CKD without CAD (CKD group, n=18), and CAD with CKD (CAD/CKD group, n=77). Plasma granzyme B was measured by enzyme-linked immunosorbent assay. Factors contributing to the severity of CAD were analyzed by multiple regression analysis in patients with CAD. RESULTS Plasma levels of high-sensitivity CRP (hs-CRP) and granzyme B in the CAD/CKD group were significantly higher than in other groups. A significant positive correlation was observed between plasma hs-CRP and granzyme B levels. A significant negative correlation was observed between eGFR and granzyme B levels. Multiple regression analysis revealed that granzyme B and hs-CRP levels were independent predicting variables of the number of stenoses in major coronary arteries. CONCLUSIONS These results indicate that granzyme B might be a novel risk factor for the formation of coronary atherosclerosis by inducing apoptosis of vascular tissues in patients with CKD.
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Affiliation(s)
- Tomokazu Ikemoto
- Department of Cardiology, Jichi Medical University, 3311 Yakushiji, Shimotsuke-City, Tochigi 329-0498, Japan
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Guarnieri G, Zanetti M, Vinci P, Cattin MR, Barazzoni R. Insulin resistance in chronic uremia. J Ren Nutr 2009; 19:20-4. [PMID: 19121765 DOI: 10.1053/j.jrn.2008.11.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Insulin resistance often characterizes chronic uremia, and is associated with enhanced morbidity and mortality, because it may contribute to protein-energy wasting (in turn, an independent predictor of reduced survival), atherosclerosis, and cardiovascular death. Causes of insulin resistance in chronic uremia are complex and multifactorial. Obesity is emerging as an independent risk factor for chronic kidney disease, and an expected rise in number of obese uremic patients because of the ongoing worldwide obesity epidemic is likely to increase the prevalence of insulin resistance in chronic uremia in the near future. Similar to the general population, reported associations between obesity and insulin resistance in chronic uremia support a role of adipose tissue and altered adipokine profiles in insulin resistance in obese chronic kidney disease patients. Hormonal imbalances, chronic acidosis, and systemic inflammation and oxidative stress are uremia-associated relevant causes of insulin resistance in nonobese individuals. A further understanding of the causes of insulin resistance in chronic uremia represents a potential important tool in the design of more effective therapeutic strategies to reduce uremia-associated morbidity and mortality.
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Affiliation(s)
- Gianfranco Guarnieri
- Department of Clinical, Morphological, and Technological Sciences, Clinica Medica, University of Trieste, Trieste, Italy.
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