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Aristizábal-Colorado D, Ocampo-Posada M, Rivera-Martínez WA, Corredor-Rengifo D, Rico-Fontalvo J, Gómez-Mesa JE, Duque-Ossman JJ, Abreu-Lomba A. SGLT2 Inhibitors and How They Work Beyond the Glucosuric Effect. State of the Art. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00673-1. [PMID: 39179723 DOI: 10.1007/s40256-024-00673-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2024] [Indexed: 08/26/2024]
Abstract
Type 2 diabetes mellitus (T2DM) is associated with a heightened risk of cardiovascular and renal complications. While glycemic control remains essential, newer therapeutic options, such as SGLT2 inhibitors, offer additional benefits beyond glucose reduction. This review delves into the mechanisms underlying the cardio-renal protective effects of SGLT2 inhibitors. By inducing relative hypoglycemia, these agents promote ketogenesis, optimize myocardial energy metabolism, and reduce lipotoxicity. Additionally, SGLT2 inhibitors exert renoprotective actions by enhancing renal perfusion, attenuating inflammation, and improving iron metabolism. These pleiotropic effects, including modulation of blood pressure, reduction of uric acid, and improved endothelial function, collectively contribute to the cardiovascular and renal benefits observed with SGLT2 inhibitor therapy. This review will provide clinicians with essential knowledge, understanding, and a clear recollection of this pharmacological group's mechanism of action.
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Affiliation(s)
- David Aristizábal-Colorado
- Department of Internal Medicine, Universidad Libre, Cali, Colombia
- Internal Medicine Research Group, Universidad Libre, Cali, Colombia
- Interamerican Society of Cardiology (SIAC), Mexico City, Mexico
| | - Martín Ocampo-Posada
- Department of Internal Medicine, Universidad Libre, Cali, Colombia
- Internal Medicine Research Group, Universidad Libre, Cali, Colombia
- Faculty of Health, Pontificia Universidad Javeriana, Cali, Colombia
- Grupo de Investigación en Ciencias Básicas y Clínicas de la Salud, Universidad Javeriana, Cali, Colombia
| | - Wilfredo Antonio Rivera-Martínez
- Internal Medicine Research Group, Universidad Libre, Cali, Colombia
- Department of Endocrinology, Faculty of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - David Corredor-Rengifo
- Department of Internal Medicine, Universidad Libre, Cali, Colombia
- Internal Medicine Research Group, Universidad Libre, Cali, Colombia
| | - Jorge Rico-Fontalvo
- Department of Nephrology. Faculty of Medicine, Universidad Simón Bolívar, Barranquilla, Colombia
- Latin American Society of Nephrology and Arterial Hypertension (SLANH), Panama City, Panamá
| | - Juan Esteban Gómez-Mesa
- Interamerican Society of Cardiology (SIAC), Mexico City, Mexico.
- Cardiology Department, Fundación Valle del Lili, Cali, Colombia.
- Department of Health Sciences, Universidad Icesi, Cali, Colombia.
| | - John Jairo Duque-Ossman
- Universidad Del Quindío, Armenia, Colombia
- Latin American Federation of Endocrinology (FELAEN), Armenia, Colombia
| | - Alin Abreu-Lomba
- Internal Medicine Research Group, Universidad Libre, Cali, Colombia
- Endocrinology Department, Clínica Imbanaco, Cali, Colombia
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2
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Kakzanov Y, Sevilya Z, Goldman A, Cipok M, Hershkovitz V, Bryk G, Lev EI. The Effect of SGLT2 Inhibitor Therapy on Endothelial Progenitor Cell Function in Patients With Heart Failure. J Cardiovasc Pharmacol 2024; 84:220-226. [PMID: 38922584 DOI: 10.1097/fjc.0000000000001581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/03/2024] [Indexed: 06/27/2024]
Abstract
ABSTRACT Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to reduce the risk of cardiovascular mortality and hospitalizations in patients with heart failure (HF) with preserved or reduced ejection fraction (HFpEF or HFrEF). The mechanism for this benefit is not clear. Endothelial progenitor cells (EPCs) are bone marrow-derived cells able to differentiate into functional endothelial cells and participate in endothelial repair. The aim of this study was to evaluate the effect of SGLT-2 inhibitors on the level and function of EPCs in patients with HF. We enrolled 20 patients with symptomatic HF, 12 with HFrEF and 8 with HFpEF (aged 73.3 ± 10.2 years, 95% men). Blood samples were drawn at 2 time points: baseline and ≥3 months after initiation of SGLT-2 inhibitor therapy. Circulating EPC levels were evaluated by expression of vascular endothelial growth factor receptor-2 (VEGFR-2), CD34, and CD133 by flow cytometry. EPC colony forming units (CFUs) were quantified after 7 days in culture. The proportion of cells that coexpressed VEGFR-2 and CD34 or VEGFR-2 and CD133 was higher following 3 months of SGLT-2 inhibitors [0.26% (interquartile range, IQR 0.10-0.33) versus 0.55% (IQR 0.28-0.91), P = 0.002; 0.12% (IQR 0.07-0.15) versus 0.24% (IQR 0.15-0.39), P = 0.001, respectively]. EPC CFUs were also increased following SGLT-2 inhibitor treatment [23 (IQR 3.7-37.8) versus 79.4 (IQR 25.1-110.25) colonies/10 6 cells, P = 0.0039]. In patients with symptomatic HF, both HFpEF and HFrEF, treatment with SGLT-2 inhibitors is associated with an increase in the level and function of circulating EPCs. This augmentation in EPCs may be a contributing mechanism to the clinical benefit of SGLT-2 inhibitors in patients with HF.
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Affiliation(s)
- Yana Kakzanov
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Ziv Sevilya
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Alexander Goldman
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Michal Cipok
- Hematology Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel; and
| | - Vera Hershkovitz
- Hematology Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel; and
| | - Gabriel Bryk
- Biochemistry Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Eli I Lev
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
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3
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Cignarella A, Peterson CD. Mechanistic Chronopharmacology: Preclinical Modeling of an SGLT2 Inhibitor in Preventing Painful Diabetic Neuropathy. J Pharmacol Exp Ther 2024; 390:174-176. [PMID: 39025653 DOI: 10.1124/jpet.124.002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 07/20/2024] Open
Affiliation(s)
- Andrea Cignarella
- University of Padova Medical School, Department of Medicine, Padova, Italy (A.C.); and Departments of Pharmaceutics and Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota (C.D.P.)
| | - Cristina D Peterson
- University of Padova Medical School, Department of Medicine, Padova, Italy (A.C.); and Departments of Pharmaceutics and Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota (C.D.P.)
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4
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Terenzi DC, Bakbak E, Teoh H, Krishnaraj A, Puar P, Rotstein OD, Cosentino F, Goldenberg RM, Verma S, Hess DA. Restoration of blood vessel regeneration in the era of combination SGLT2i and GLP-1RA therapy for diabetes and obesity. Cardiovasc Res 2024; 119:2858-2874. [PMID: 38367275 DOI: 10.1093/cvr/cvae016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 02/19/2024] Open
Abstract
Ischaemic cardiovascular diseases, including peripheral and coronary artery disease, myocardial infarction, and stroke, remain major comorbidities for individuals with type 2 diabetes (T2D) and obesity. During cardiometabolic chronic disease (CMCD), hyperglycaemia and excess adiposity elevate oxidative stress and promote endothelial damage, alongside an imbalance in circulating pro-vascular progenitor cells that mediate vascular repair. Individuals with CMCD demonstrate pro-vascular 'regenerative cell exhaustion' (RCE) characterized by excess pro-inflammatory granulocyte precursor mobilization into the circulation, monocyte polarization towards pro-inflammatory vs. anti-inflammatory phenotype, and decreased pro-vascular progenitor cell content, impairing the capacity for vessel repair. Remarkably, targeted treatment with the sodium-glucose cotransporter-2 inhibitor (SGLT2i) empagliflozin in subjects with T2D and coronary artery disease, and gastric bypass surgery in subjects with severe obesity, has been shown to partially reverse these RCE phenotypes. SGLT2is and glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the management of individuals with T2D and comorbid obesity. In addition to glucose-lowering action, both drug classes have been shown to induce weight loss and reduce mortality and adverse cardiovascular outcomes in landmark clinical trials. Furthermore, both drug families also act to reduce systemic oxidative stress through altered activity of overlapping oxidase and antioxidant pathways, providing a putative mechanism to augment circulating pro-vascular progenitor cell content. As SGLT2i and GLP-1RA combination therapies are emerging as a novel therapeutic opportunity for individuals with poorly controlled hyperglycaemia, potential additive effects in the reduction of oxidative stress may also enhance vascular repair and further reduce the ischaemic cardiovascular comorbidities associated with T2D and obesity.
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Affiliation(s)
- Daniella C Terenzi
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4 D04 V1W8, Ireland
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ehab Bakbak
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Hwee Teoh
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Division of Endocrinology and Metabolism, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Aishwarya Krishnaraj
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Pankaj Puar
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ori D Rotstein
- Division of General Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Surgery, University of Toronto, Stewart Building, 149 College Street, 5th floor, Toronto, ON M5T 1P5, Canada
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Solnavagen 1, 171 77 Solna, Sweden
| | | | - Subodh Verma
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
- Department of Surgery, University of Toronto, Stewart Building, 149 College Street, 5th floor, Toronto, ON M5T 1P5, Canada
| | - David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
- Molecular Medicine Research Laboratories, Krembil Centre for Stem Cells Biology, Robarts Research Institute, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada
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5
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Bendotti G, Montefusco L, Pastore I, Lazzaroni E, Lunati ME, Fiorina P. The anti-inflammatory and immunological properties of SGLT-2 inhibitors. J Endocrinol Invest 2023; 46:2445-2452. [PMID: 37535237 DOI: 10.1007/s40618-023-02162-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are antidiabetic oral drugs that act on proximal renal tubules promoting renal glucose excretion. Although SGLT-2i belong to the class of hypoglycemic agents, in the last years great interest has emerged in studying their pleiotropic effects, beyond their ability to lower glucose levels. PURPOSE In this review we are describing the anti-inflammatory and immunological properties of SGLT-2i; furthermore, we are addressing how the mechanisms associated with the aforementioned anti-inflammatory properties may contribute to the beneficial effects of SGLT-2i in diabetes. METHODS A systematic search was undertaken for studies related the properties of SGLT-2i in reducing the inflammatory milieu of acute and chronic disease by acting on the immune system, independently by glycemia. RESULTS Recently, some data described the anti-inflammatory and immunological properties of SGLT-2 in both pre-clinical and clinical studies. Numerous data confirmed the cardio- and -renal protective effects of SGLT-2i in patients with heart failure and kidney diseases, with or without diabetes. CONCLUSIONS SGLT-2i are promising drugs with anti-inflammatory and immunological properties. Despite the mechanism of action of SGLT-2i is not fully understood, these drugs demonstrated anti-inflammatory effects, which may help in keeping under control the variety of complications associated with diabetes.
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Affiliation(s)
- G Bendotti
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
- Endocrinology and Metabolic Diseases Unit, AO S.S. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - L Montefusco
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - I Pastore
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - E Lazzaroni
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - M E Lunati
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - P Fiorina
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, Milan, Italy.
- International Center for T1D, Pediatric Clinical Research Center "Romeo ed Enrica Invernizzi", Department of Biomedical and Clinical Science L. Sacco, University of Milan, Milan, Italy.
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave. Enders Building 5th floor En511, Boston, MA, 02115, USA.
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Altabas V, Marinković Radošević J, Špoljarec L, Uremović S, Bulum T. The Impact of Modern Anti-Diabetic Treatment on Endothelial Progenitor Cells. Biomedicines 2023; 11:3051. [PMID: 38002051 PMCID: PMC10669792 DOI: 10.3390/biomedicines11113051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Diabetes is one of the leading chronic diseases globally with a significant impact on mortality. This condition is associated with chronic microvascular and macrovascular complications caused by vascular damage. Recently, endothelial progenitor cells (EPCs) raised interest due to their regenerative properties. EPCs are mononuclear cells that are derived from different tissues. Circulating EPCs contribute to regenerating the vessel's intima and restoring vascular function. The ability of EPCs to repair vascular damage depends on their number and functionality. Diabetic patients have a decreased circulating EPC count and impaired EPC function. This may at least partially explain the increased risk of diabetic complications, including the increased cardiovascular risk in these patients. Recent studies have confirmed that many currently available drugs with proven cardiovascular benefits have beneficial effects on EPC count and function. Among these drugs are also medications used to treat different types of diabetes. This manuscript aims to critically review currently available evidence about the ways anti-diabetic treatment affects EPC biology and to provide a broader context considering cardiovascular complications. The therapies that will be discussed include lifestyle adjustments, metformin, sulphonylureas, gut glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor analogs, sodium-glucose transporter 2 inhibitors, and insulin.
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Affiliation(s)
- Velimir Altabas
- Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre Milosrdnice University Clinical Hospital, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jelena Marinković Radošević
- Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre Milosrdnice University Clinical Hospital, 10000 Zagreb, Croatia
| | - Lucija Špoljarec
- Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre Milosrdnice University Clinical Hospital, 10000 Zagreb, Croatia
| | | | - Tomislav Bulum
- Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre Milosrdnice University Clinical Hospital, 10000 Zagreb, Croatia
- Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, 10000 Zagreb, Croatia
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7
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Benítez-Camacho J, Ballesteros A, Beltrán-Camacho L, Rojas-Torres M, Rosal-Vela A, Jimenez-Palomares M, Sanchez-Gomar I, Durán-Ruiz MC. Endothelial progenitor cells as biomarkers of diabetes-related cardiovascular complications. Stem Cell Res Ther 2023; 14:324. [PMID: 37950274 PMCID: PMC10636846 DOI: 10.1186/s13287-023-03537-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/13/2023] [Indexed: 11/12/2023] Open
Abstract
Diabetes mellitus (DM) constitutes a chronic metabolic disease characterized by elevated levels of blood glucose which can also lead to the so-called diabetic vascular complications (DVCs), responsible for most of the morbidity, hospitalizations and death registered in these patients. Currently, different approaches to prevent or reduce DM and its DVCs have focused on reducing blood sugar levels, cholesterol management or even changes in lifestyle habits. However, even the strictest glycaemic control strategies are not always sufficient to prevent the development of DVCs, which reflects the need to identify reliable biomarkers capable of predicting further vascular complications in diabetic patients. Endothelial progenitor cells (EPCs), widely known for their potential applications in cell therapy due to their regenerative properties, may be used as differential markers in DVCs, considering that the number and functionality of these cells are affected under the pathological environments related to DM. Besides, drugs commonly used with DM patients may influence the level or behaviour of EPCs as a pleiotropic effect that could finally be decisive in the prognosis of the disease. In the current review, we have analysed the relationship between diabetes and DVCs, focusing on the potential use of EPCs as biomarkers of diabetes progression towards the development of major vascular complications. Moreover, the effects of different drugs on the number and function of EPCs have been also addressed.
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Affiliation(s)
- Josefa Benítez-Camacho
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
| | - Antonio Ballesteros
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Lucía Beltrán-Camacho
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
- Cell Biology, Physiology and Immunology Department, Córdoba University, Córdoba, Spain
| | - Marta Rojas-Torres
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
| | - Antonio Rosal-Vela
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
| | - Margarita Jimenez-Palomares
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
| | - Ismael Sanchez-Gomar
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain
| | - Mª Carmen Durán-Ruiz
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University, Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, 11519, Cádiz, Spain.
- Biomedical Research and Innovation Institute of Cadiz (INIBICA), Cádiz, Spain.
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8
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Bakbak E, Verma S, Krishnaraj A, Quan A, Wang CH, Pan Y, Puar P, Mason T, Verma R, Terenzi DC, Rotstein OD, Yan AT, Connelly KA, Teoh H, Mazer CD, Hess DA. Empagliflozin improves circulating vascular regenerative cell content in people without diabetes with risk factors for adverse cardiac remodeling. Am J Physiol Heart Circ Physiol 2023; 325:H1210-H1222. [PMID: 37773589 DOI: 10.1152/ajpheart.00141.2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023]
Abstract
Sodium glucose-cotransporter 2 (SGLT2) inhibitors have been reported to reduce cardiovascular events and heart failure in people with and without diabetes. These medications have been shown to counter regenerative cell exhaustion in the context of prevalent diabetes. This study sought to determine if empagliflozin attenuates regenerative cell exhaustion in people without diabetes. Peripheral blood mononuclear cells were collected at the baseline and 6-mo visits from individuals randomized to receive empagliflozin (10 mg/day) or placebo who were participating in the EMPA-HEART 2 CardioLink-7 trial. Precursor cell phenotypes were characterized by flow cytometry for cell-surface markers combined with high aldehyde dehydrogenase activity to identify precursor cell subsets with progenitor (ALDHhi) versus mature effector (ALDHlow) cell attributes. Samples from individuals assigned to empagliflozin (n = 25) and placebo (n = 21) were analyzed. At baseline, overall frequencies of primitive progenitor cells (ALDHhiSSClow), monocyte (ALDHhiSSCmid), and granulocyte (ALDHhiSSChi) precursor cells in both groups were similar. At 6 mo, participants randomized to empagliflozin demonstrated increased ALDHhiSSClowCD133+CD34+ proangiogenic cells (P = 0.048), elevated ALDHhiSSCmidCD163+ regenerative monocyte precursors (P = 0.012), and decreased ALDHhiSSCmidCD86 + CD163- proinflammatory monocyte (P = 0.011) polarization compared with placebo. Empagliflozin promoted the recovery of multiple circulating provascular cell subsets in people without diabetes suggesting that the cardiovascular benefits of SGLT2 inhibitors may be attributed in part to the attenuation of vascular regenerative cell exhaustion that is independent of diabetes status.NEW & NOTEWORTHY Using an aldehyde dehydrogenase (ALDH) activity-based flow cytometry assay, we found that empagliflozin treatment for 6 mo was associated with parallel increases in circulating vascular regenerative ALDHhi-CD34/CD133-coexpressing progenitors and decreased proinflammatory ALDHhi-CD14/CD86-coexpressing monocyte precursors in individuals without diabetes but with cardiovascular risk factors. The rejuvenation of the vascular regenerative cell reservoir may represent a mechanism via which sodium glucose-cotransporter 2 (SGLT2) inhibitors limit maladaptive repair and delay the development and progression of cardiovascular diseases.
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Affiliation(s)
- Ehab Bakbak
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Subodh Verma
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aishwarya Krishnaraj
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Chao-Hung Wang
- Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi Pan
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Pankaj Puar
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tamique Mason
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Raj Verma
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Ori D Rotstein
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, St Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, St Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Molecular Medicine Research Laboratories, Robarts Research Institute, London, Ontario, Canada
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9
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Luo L, Dong B, Zhang J, Qiu Y, Liu X, Zhou Z, He J, Zhang X, Chen L, Xia W. Dapagliflozin restores diabetes-associated decline in vasculogenic capacity of endothelial progenitor cells via activating AMPK-mediated inhibition of inflammation and oxidative stress. Biochem Biophys Res Commun 2023; 671:205-214. [PMID: 37302296 DOI: 10.1016/j.bbrc.2023.05.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) provide added vascular protection beyond glucose lowering to patients with type 2 diabetes mellitus (T2DM). Endothelial progenitor cells (EPCs) are an important endogenous repair mechanism for diabetic vascular complications. Yet, whether SGLT2i protect vessels in diabetic patients by improving the function of EPCs remains to be elucidated. Here we enrolled Sixty-three T2DM patients and 60 healthy participants and 15 of T2DM group took dapagliflozin for 3 months. Retinal capillary density (RCD) was examined before and after meditation. Moreover, vasculogenic capacity of EPCs cocultured with or without dapagliflozin in vitro and in vivo (hind limb ischemia model) were assessed. Mechanically, genes related to inflammation/oxidative stress, and the AMPK signaling of EPCs were determined. Our results found T2DM demonstrated a declined RCD and a decreased number of circulating EPCs compared with healthy controls. Compared with the EPCs from healthy individuals, vasculogenic capacity of T2DM EPCs was significantly impaired, which could be restored by dapagliflozin meditation or dapagliflozin coculture. Increased expression of inflammation correlative genes and decreased anti-oxidative stress related genes expression were found in EPCs form T2DM, which were accompanied with reduced phosphorylation level of AMPK. Dapagliflozin treatment activated AMPK signaling, decreased the level of inflammation and oxidative stress, and rescued vasculogenic capacity of EPCs from T2DM. Furthermore, AMPK inhibitor pretreatment diminished the enhancement vasculogenic capacity of diabetic EPCs from dapagliflozin treatment. This study demonstrates for the first time that dapagliflozin restores vasculogenic capacity of EPCs via activating AMPK-mediated inhibition of inflammation and oxidative stress in T2DM.
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Affiliation(s)
- Lifang Luo
- Department of dermatology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
| | - Bing Dong
- Department of Hypertension and Vascular Disease, The Eight Affiliated Hospital of Sun Yat-Sen University, Shenzhen, 518033, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Jianning Zhang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Yumin Qiu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Xiaolin Liu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Zhe Zhou
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Jiang He
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China
| | - Xiaoyu Zhang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China.
| | - Long Chen
- The Geriatrics Department, Shenzhen Hospital of Southern Medical University, Shenzhen, 510086, China.
| | - Wenhao Xia
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China; Key Laboratory on Assisted Circulation Ministry of Health, Guangzhou, 510080, China.
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10
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Role of Endothelial Progenitor Cells in Frailty. Int J Mol Sci 2023; 24:ijms24032139. [PMID: 36768461 PMCID: PMC9916666 DOI: 10.3390/ijms24032139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Frailty is a clinical condition closely related to aging which is characterized by a multidimensional decline in biological reserves, a failure of physiological mechanisms and vulnerability to minor stressors. Chronic inflammation, the impairment of endothelial function, age-related endocrine system modifications and immunosenescence are important mechanisms in the pathophysiology of frailty. Endothelial progenitor cells (EPCs) are considered important contributors of the endothelium homeostasis and turn-over. In the elderly, EPCs are impaired in terms of function, number and survival. In addition, the modification of EPCs' level and function has been widely demonstrated in atherosclerosis, hypertension and diabetes mellitus, which are the most common age-related diseases. The purpose of this review is to illustrate the role of EPCs in frailty. Initially, we describe the endothelial dysfunction in frailty, the response of EPCs to the endothelial dysfunction associated with frailty and, finally, interventions which may restore the EPCs expression and function in frail people.
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11
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Li J, Zhou L, Gong H. New insights and advances of sodium-glucose cotransporter 2 inhibitors in heart failure. Front Cardiovasc Med 2022; 9:903902. [PMID: 36186974 PMCID: PMC9520058 DOI: 10.3389/fcvm.2022.903902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are newly emerging insulin-independent anti-hyperglycemic agents that work independently of β-cells. Quite a few large-scale clinical trials have proven the cardiovascular protective function of SGLT2is in both diabetic and non-diabetic patients. By searching all relevant terms related to our topics over the previous 3 years, including all the names of agents and their brands in PubMed, here we review the mechanisms underlying the improvement of heart failure. We also discuss the interaction of various mechanisms proposed by diverse works of literature, including corresponding and opposing viewpoints to support each subtopic. The regulation of diuresis, sodium excretion, weight loss, better blood pressure control, stimulation of hematocrit and erythropoietin, metabolism remodeling, protection from structural dysregulation, and other potential mechanisms of SGLT2i contributing to heart failure improvement have all been discussed in this manuscript. Although some remain debatable or even contradictory, those newly emerging agents hold great promise for the future in cardiology-related therapies, and more research needs to be conducted to confirm their functionality, particularly in metabolism, Na+-H+ exchange protein, and myeloid angiogenic cells.
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Affiliation(s)
- Juexing Li
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hui Gong
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
- *Correspondence: Hui Gong
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12
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Bonora BM, Cappellari R, Grasso M, Mazzucato M, D'Anna M, Avogaro A, Fadini GP. Glycaemic Control Achieves Sustained Increases of Circulating Endothelial Progenitor Cells in Patients Hospitalized for Decompensated Diabetes: An Observational Study. Diabetes Ther 2022; 13:1327-1337. [PMID: 35676613 PMCID: PMC9240124 DOI: 10.1007/s13300-022-01273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/12/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND AIM Diabetes reduces the levels of circulating endothelial progenitor cells (EPCs), which contribute to vascular homeostasis. In turn, low EPCs levels predict progression of chronic complications. Several studies have shown that hyperglycaemia exerts detrimental effects on EPCs. Improvement in glucose control with glucose-lowering medications is associated with an increase of EPCs, but only after a long time of good glycaemic control. In the present study, we examined the effect of a rapid glycaemic amelioration on EPC levels in subjects hospitalized for decompensated diabetes. METHODS We used flow cytometry to quantify EPCs (CD34+/CD133+KDR+) in patients hospitalized for/with decompensated diabetes at admission, at discharge, and 2 months after the discharge. During hospitalization, all patients received intensive insulin therapy. RESULTS Thirty-nine patients with type 1 or type 2 diabetes were enrolled. Average (± SEM) fasting glucose decreased from 409.2 ± 25.9 mg/dl at admission to 190.4 ± 12.0 mg/dl at discharge and to 169.0 ± 10.3 at 2 months (both p < 0.001). EPCs (per million blood cells) significantly increased from hospital admission (13.1 ± 1.4) to discharge (16.4 ± 1.1; p = 0.022) and remained stable after 2 months (15.5 ± 1.7; p = 0.023 versus baseline). EPCs increased significantly more in participants with newly-diagnosed diabetes than in those with pre-existing diabetes. The increase in EPCs was significant in type 1 but not in type 2 diabetes and in those without chronic complications. CONCLUSION In individuals hospitalized for decompensated diabetes, insulin therapy rapidly increases EPC levels for up to 2 months. EPC defect, reflecting impaired vascular repair capacity, may be reversible in the early diabetes stages.
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Affiliation(s)
- Benedetta Maria Bonora
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
- Venetian Institute of Molecular Medicine, 35128, Padua, Italy
| | | | - Marco Grasso
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Marta Mazzucato
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Marianna D'Anna
- Venetian Institute of Molecular Medicine, 35128, Padua, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
- Venetian Institute of Molecular Medicine, 35128, Padua, Italy.
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13
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Hess DA, Verma S, Bhatt D, Bakbak E, Terenzi DC, Puar P, Cosentino F. Vascular repair and regeneration in cardiometabolic diseases. Eur Heart J 2021; 43:450-459. [PMID: 34849704 DOI: 10.1093/eurheartj/ehab758] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/27/2021] [Accepted: 10/21/2021] [Indexed: 12/24/2022] Open
Abstract
Chronic cardiometabolic assaults during type 2 diabetes (T2D) and obesity induce a progenitor cell imbalance in the circulation characterized by overproduction and release of pro-inflammatory monocytes and granulocytes from the bone marrow alongside aberrant differentiation and mobilization of pro-vascular progenitor cells that generate downstream progeny for the coordination of blood vessel repair. This imbalance can be detected in the peripheral blood of individuals with established T2D and severe obesity using multiparametric flow cytometry analyses to discern pro-inflammatory vs. pro-angiogenic progenitor cell subsets identified by high aldehyde dehydrogenase activity, a conserved progenitor cell protective function, combined with lineage-restricted cell surface marker analyses. Recent evidence suggests that progenitor cell imbalance can be reversed by treatment with pharmacological agents or surgical interventions that reduce hyperglycaemia or excess adiposity. In this state-of-the-art review, we present current strategies to assess the progression of pro-vascular regenerative cell depletion in peripheral blood samples of individuals with T2D and obesity and we summarize novel clinical data that intervention using sodium-glucose co-transporter 2 inhibition or gastric bypass surgery can efficiently restore cell-mediated vascular repair mechanisms associated with profound cardiovascular benefits in recent outcome trials. Collectively, this thesis generates a compelling argument for early intervention using current pharmacological agents to prevent or restore imbalanced circulating progenitor content and maintain vascular regenerative cell trafficking to sites of ischaemic damage. This conceptual advancement may lead to the design of novel therapeutic approaches to prevent or reverse the devastating cardiovascular comorbidities currently associated with T2D and obesity.
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Affiliation(s)
- David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada.,Division of Vascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Molecular Medicine Research Laboratories, Krembil Centre for Stem Cells Biology, Robarts Research Institute, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada.,Department of Physiology and Pharmacology, University of Western Ontario, 1151 Richmond Street North, London, ON N6H 0E8, Canada
| | - Subodh Verma
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada.,Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Institute of Medical Sciences, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada.,Department of Surgery, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Deepak Bhatt
- Department of Cardiovascular Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Ehab Bakbak
- Department of Pharmacology and Toxicology, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada.,Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Daniella C Terenzi
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Institute of Medical Sciences, University of Toronto, 27 King's College Circle, Toronto, ON M5S 3J3, Canada
| | - Pankaj Puar
- Division of Cardiovascular Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm SE171 77, Sweden
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14
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Durante W, Behnammanesh G, Peyton KJ. Effects of Sodium-Glucose Co-Transporter 2 Inhibitors on Vascular Cell Function and Arterial Remodeling. Int J Mol Sci 2021; 22:ijms22168786. [PMID: 34445519 PMCID: PMC8396183 DOI: 10.3390/ijms22168786] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in diabetes. Recent clinical studies indicate that sodium-glucose co-transporter 2 (SGLT2) inhibitors improve cardiovascular outcomes in patients with diabetes. The mechanism underlying the beneficial effect of SGLT2 inhibitors is not completely clear but may involve direct actions on vascular cells. SGLT2 inhibitors increase the bioavailability of endothelium-derived nitric oxide and thereby restore endothelium-dependent vasodilation in diabetes. In addition, SGLT2 inhibitors favorably regulate the proliferation, migration, differentiation, survival, and senescence of endothelial cells (ECs). Moreover, they exert potent antioxidant and anti-inflammatory effects in ECs. SGLT2 inhibitors also inhibit the contraction of vascular smooth muscle cells and block the proliferation and migration of these cells. Furthermore, studies demonstrate that SGLT2 inhibitors prevent postangioplasty restenosis, maladaptive remodeling of the vasculature in pulmonary arterial hypertension, the formation of abdominal aortic aneurysms, and the acceleration of arterial stiffness in diabetes. However, the role of SGLT2 in mediating the vascular actions of these drugs remains to be established as important off-target effects of SGLT2 inhibitors have been identified. Future studies distinguishing drug- versus class-specific effects may optimize the selection of specific SGLT2 inhibitors in patients with distinct cardiovascular pathologies.
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15
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Albiero M, Tedesco S, Amendolagine FI, D'Anna M, Migliozzi L, Zuccolotto G, Rosato A, Cappellari R, Avogaro A, Fadini GP. Inhibition of SGLT2 Rescues Bone Marrow Cell Traffic for Vascular Repair: Role of Glucose Control and Ketogenesis. Diabetes 2021; 70:1767-1779. [PMID: 33903150 DOI: 10.2337/db20-1045] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/21/2021] [Indexed: 11/13/2022]
Abstract
The mechanisms by which sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in people with diabetes are incompletely understood. Recent studies show that SGLT2i may increase the levels of circulating cells with vascular regenerative capacity, at least in part by lowering glycemia. In this study, we used mice with streptozotocin-induced diabetes treated with the SGLT2i dapagliflozin at a dose that reduced glucose levels by 20%. Dapagliflozin improved the diabetes-associated defect of hematopoietic stem cell mobilization after stimulation with granulocyte colony-stimulating factor. Dapagliflozin rescued the traffic of bone marrow (BM)-derived cells to injured carotid arteries and improved endothelial healing in diabetic mice. Defective homing of CD49d+ granulocytes was causally linked with impaired endothelial repair and was reversed by dapagliflozin. The effects of dapagliflozin were mimicked by a similar extent of glucose reduction achieved with insulin therapy and by a ketone drink that artificially elevated β-hydroxybutyrate. Inhibition of endothelial repair by resident cells using the CXCR4 antagonist AMD3100 did not abolish the vascular effect of dapagliflozin, indirectly supporting that endothelial healing by dapagliflozin was mediated by recruitment of circulating cells. In summary, we show that dapagliflozin improved the traffic of BM-derived hematopoietic cells to the site of vascular injury, providing a hitherto unappreciated mechanism of vascular protection.
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Affiliation(s)
- Mattia Albiero
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Serena Tedesco
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | | | - Marianna D'Anna
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Ludovica Migliozzi
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Gaia Zuccolotto
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Istituto Oncologico Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padova, Italy
| | - Antonio Rosato
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
- Istituto Oncologico Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padova, Italy
| | - Roberta Cappellari
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
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16
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Tripaldi R, Lanuti P, Simeone PG, Liani R, Bologna G, Ciotti S, Simeone P, Di Castelnuovo A, Marchisio M, Cipollone F, Santilli F. Endogenous PCSK9 may influence circulating CD45 neg/CD34 bright and CD45 neg/CD34 bright/CD146 neg cells in patients with type 2 diabetes mellitus. Sci Rep 2021; 11:9659. [PMID: 33958634 PMCID: PMC8102605 DOI: 10.1038/s41598-021-88941-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/05/2021] [Indexed: 12/22/2022] Open
Abstract
Protease proprotein convertase subtilisin/kexin type 9 (PCSK9) is a regulator of LDL cholesterol clearance and has been associated with cardiovascular risk. PCSK9 inhibitors increase in vivo circulating endothelial progenitor cells (EPCs), a subtype of immature cells involved in ongoing endothelial repair. We hypothesized that the effect of PCSK9 on vascular homeostasis may be mediated by EPCs in patients with or without type 2 diabetes mellitus (T2DM). Eighty-two patients (45 with, 37 without T2DM) at high cardiovascular risk were enrolled in this observational study. Statin treatment was associated with higher circulating levels of PCSK9 in patients with and without T2DM (p < 0.001 and p = 0.036) and with reduced CD45neg/CD34bright (total EPC compartment) (p = 0.016) and CD45neg/CD34bright/CD146neg (early EPC) (p = 0.040) only among patients with T2DM. In the whole group of patients, statin treatment was the only independent predictor of low number of CD45neg/CD34bright (β = - 0.230; p = 0.038, adjusted R2 = 0.041). Among T2DM patients, PCSK9 circulating levels were inversely related and predicted both the number of CD45neg/CD34bright (β = - 0.438; p = 0.003, adjusted R2 = 0.173), and CD45neg/CD34bright/CD146neg (β = - 0.458; p = 0.002, adjusted R2 = 0.191) independently of age, gender, BMI and statin treatment. In high-risk T2DM patients, high endogenous levels of PCSK9 may have a detrimental effect on EPCs by reducing the endothelial repair and worsening the progression of atherothrombosis.
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Affiliation(s)
- Romina Tripaldi
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Paola Lanuti
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Paola Giustina Simeone
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Rossella Liani
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Giuseppina Bologna
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Sonia Ciotti
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Pasquale Simeone
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | | | - Marco Marchisio
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy
| | - Francesca Santilli
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST), Via Luigi Polacchi, Chieti, Italy.
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Sodium/glucose cotransporter 2 inhibitors in chronic kidney disease and heart failure: ready for prime time in patients without diabetes. Curr Opin Nephrol Hypertens 2021; 30:361-368. [PMID: 33767064 DOI: 10.1097/mnh.0000000000000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The benefits of sodium/glucose cotransporter 2 (SGLT2) inhibitors seem to extend beyond glycemic control. We review recent randomized trial evidence evaluating SGLT2 inhibition in nondiabetic settings, including in patients with chronic kidney disease (CKD) and heart failure (HF). RECENT FINDINGS DAPA-CKD, DAPA-HF and EMPEROR-Reduced compared SGLT2 inhibitors to placebo, enrolling 5868 patients without diabetes. In DAPA-CKD, patients with an estimated glomerular filtration rate (eGFR) of 25-75 ml/min/1.73 m2 and macroalbuminuria irrespective of kidney disease aetiology had improved cardiovascular and kidney outcomes if randomized to receive SGLT2 inhibitors (primary composite endpoint: hazard ratio [HR] 0.61, 95% CI 0.51-0.72; absolute risk reduction [ARR] 5.3%). In DAPA-HF and EMPEROR-Reduced, participants with reduced ejection fraction (HFrEF) had improved cardiovascular outcomes when an SGLT2 inhibitor was added to guideline-directed medical therapy, mainly through a reduction in HF hospitalizations (HR 0.70, 95% CI 0.59-0.83; ARR 3.7% and HR 0.69, 95% CI 0.59-0.81; ARR 5.1% with dapagliflozin and empagliflozin, respectively). In all 3 trials, the benefits were not modified by diabetes, baseline eGFR or proteinuria. SUMMARY SGLT2 inhibitors improve kidney and HF outcomes in patients with high-risk CKD and HFrEF, irrespective of diabetes. Clinicians should become more comfortable prescribing these medications as we await studies that may further broaden their indications.
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18
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Endothelial function and dysfunction: Impact of sodium-glucose cotransporter 2 inhibitors. Pharmacol Ther 2021; 224:107832. [PMID: 33662450 DOI: 10.1016/j.pharmthera.2021.107832] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Diabetes mellitus is associated with endothelial dysfunction that leads to cardiovascular complications. Sodium-glucose cotransporter 2 (SGLT2) inhibitors demonstrated efficacy in glycemic control in type 2 diabetes patients with positive cardiovascular outcome. Recent research revealed a link between SGLT2 inhibition and improved macro- and microvascular endothelial functions. Mechanisms underlying this phenomenon could be due to the role of SLGT2 in the regulation of endothelial physiology. In this review, current knowledge and hypothesis on the link between SGLT2 and endothelial function were critically appraised and the impact of SGLT2 inhibitors on endothelial dysfunction in pre-clinical and clinical studies was discussed.
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19
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Nandula SR, Kundu N, Awal HB, Brichacek B, Fakhri M, Aimalla N, Elzarki A, Amdur RL, Sen S. Role of Canagliflozin on function of CD34+ve endothelial progenitor cells (EPC) in patients with type 2 diabetes. Cardiovasc Diabetol 2021; 20:44. [PMID: 33581737 PMCID: PMC7881606 DOI: 10.1186/s12933-021-01235-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/01/2021] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Endothelial progenitor cells (EPCs) has been shown to be dysfunctional in both type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) leading to poor regeneration of endothelium and renal perfusion. EPCs have been shown to be a robust cardiovascular disease (CVD) risk indicator. Effect of sodium glucose channel inhibitors (SGLT2i) such as Canagliflozin (CG) on a cellular biomarker such as CD34+ve progenitor cells, which may help predict CVD risk, in patients with T2DM with established CKD has not been explored. METHODS This is a pilot study where 29 subjects taking metformin and/or Insulin were enrolled in a 16 week, double blind, randomized placebo matched trial, with a low dose 100 mg CG as the intervention group compared to matched placebo. Type 2 diabetes subjects (30-70 years old), with hemoglobin A1c (HbA1c) of 7-10%, were enrolled. CD34+ve cell number, migratory function, gene expression along with vascular parameters such as arterial stiffness, serum biochemistry pertaining to cardio-metabolic health, resting energy expenditure and body composition were measured. Data were collected at week 0, 8 and 16. A mixed model regression analysis was done and p value less than 0.05 was considered statistically significant. RESULTS A significant expression of CXCR4 receptor with a concomittant increase in migratory function of CD34+ve cells was observed in CG treated group as compared to placebo group. Gene expression analysis of CD34+ve cells showed an increase in expression of antioxidants (superoxide dismutase 2 or SOD2, Catalase and Glutathione Peroxidase or GPX) and notable endothelial markers (PECAM1, VEGF-A, and NOS3). A significant reduction in glucose and HbA1c levels were observed along with improved systolic and diastolic blood pressure in the CG group. A significant increase in adiponectin (p = 0.006) was also noted in treatment group. Urinary exosomal protein leak in urine, examining podocyte health (podocalyxin, Wilm's tumor and nephrin) showed reduction with CG CONCLUSION: Low dose Canagliflozin has a beneficial effect on CD34+ cell function, serum biochemistry and urinary podocyte specific exosomes in type 2 diabetes.
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Affiliation(s)
- Seshagiri Rao Nandula
- Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA.,Department of Medicine and Endocrinology, Veterans Affairs Medical Center, Washington, DC, USA
| | - Nabanita Kundu
- Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA
| | - Hassan B Awal
- The GW Medical Faculty Associates, Washington, DC, USA
| | - Beda Brichacek
- Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA
| | - Mona Fakhri
- Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA
| | - Nikhila Aimalla
- Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA
| | - Adrian Elzarki
- The GW Medical Faculty Associates, Washington, DC, USA.,Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA
| | | | - Sabyasachi Sen
- The GW Medical Faculty Associates, Washington, DC, USA. .,Department of Medicine, The George Washington University, 2300 Eye Street, SMHS, Room 462,, Washington, DC, 20037, USA. .,Department of Medicine and Endocrinology, Veterans Affairs Medical Center, Washington, DC, USA.
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20
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Albiero M, Bonora BM, Fadini GP. Diabetes pharmacotherapy and circulating stem/progenitor cells. State of the art and evidence gaps. Curr Opin Pharmacol 2020; 55:151-156. [PMID: 33271409 DOI: 10.1016/j.coph.2020.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/13/2022]
Abstract
Diabetes is burdened with the development of several end-organ complications leading to excess mortality. Though the causes of such organ damage are far from being clarified, diabetes has been redefined as a disease of impaired damage control, wherein ongoing damage is not adequately compensated by activation of repair processes. Bone marrow-derived hematopoietic stem/progenitor cells (HSPCs) and their descendants endothelial progenitor cells (EPCs) have been extensively studied as major players in tissue homeostasis as well as biomarkers of diabetic complication risk. Thus, strategies to raise the levels of circulating HSPCs/EPCs have attracted interest for their potential to modify the future risk of complications. We herein discuss state-of-the-art of the effects exerted by diabetes pharmacotherapy on such cell populations. Further, we highlight which outstanding questions remain to be addressed for a more comprehensive understanding of this topic.
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Affiliation(s)
- Mattia Albiero
- Department of Medicine, University of Padova, 35128 Padova, Italy; Veneto Institute of Molecular Medicine, 35128 Padova, Italy
| | - Benedetta Maria Bonora
- Department of Medicine, University of Padova, 35128 Padova, Italy; Veneto Institute of Molecular Medicine, 35128 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, 35128 Padova, Italy; Veneto Institute of Molecular Medicine, 35128 Padova, Italy.
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21
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Fadini GP, Mehta A, Dhindsa DS, Bonora BM, Sreejit G, Nagareddy P, Quyyumi AA. Circulating stem cells and cardiovascular outcomes: from basic science to the clinic. Eur Heart J 2020; 41:4271-4282. [PMID: 31891403 PMCID: PMC7825095 DOI: 10.1093/eurheartj/ehz923] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/19/2019] [Accepted: 12/05/2019] [Indexed: 02/06/2023] Open
Abstract
The cardiovascular and haematopoietic systems have fundamental inter-relationships during development, as well as in health and disease of the adult organism. Although haematopoietic stem cells (HSCs) emerge from a specialized haemogenic endothelium in the embryo, persistence of haemangioblasts in adulthood is debated. Rather, the vast majority of circulating stem cells (CSCs) is composed of bone marrow-derived HSCs and the downstream haematopoietic stem/progenitors (HSPCs). A fraction of these cells, known as endothelial progenitor cells (EPCs), has endothelial specification and vascular tropism. In general, the levels of HSCs, HSPCs, and EPCs are considered indicative of the endogenous regenerative capacity of the organism as a whole and, particularly, of the cardiovascular system. In the last two decades, the research on CSCs has focused on their physiologic role in tissue/organ homoeostasis, their potential application in cell therapies, and their use as clinical biomarkers. In this review, we provide background information on the biology of CSCs and discuss in detail the clinical implications of changing CSC levels in patients with cardiovascular risk factors or established cardiovascular disease. Of particular interest is the mounting evidence available in the literature on the close relationships between reduced levels of CSCs and adverse cardiovascular outcomes in different cohorts of patients. We also discuss potential mechanisms that explain this association. Beyond CSCs' ability to participate in cardiovascular repair, levels of CSCs need to be interpreted in the context of the broader connections between haematopoiesis and cardiovascular function, including the role of clonal haematopoiesis and inflammatory myelopoiesis.
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Affiliation(s)
- Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Anurag Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Devinder Singh Dhindsa
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
| | | | - Gopalkrishna Sreejit
- Division of Cardiac Surgery, Department of Surgery, Ohio State University, Columbus, OH 43210, USA
| | - Prabhakara Nagareddy
- Division of Cardiac Surgery, Department of Surgery, Ohio State University, Columbus, OH 43210, USA
| | - Arshed Ali Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
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22
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Cowie MR, Fisher M. SGLT2 inhibitors: mechanisms of cardiovascular benefit beyond glycaemic control. Nat Rev Cardiol 2020; 17:761-772. [PMID: 32665641 DOI: 10.1038/s41569-020-0406-8] [Citation(s) in RCA: 380] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/06/2023]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective antidiabetic therapies in patients with type 2 diabetes mellitus and are associated with improved glycaemic control as well as with reductions in body mass and blood pressure. In large cardiovascular outcome trials in patients with diabetes, SGLT2 inhibitors improve cardiovascular and renal outcomes, including hospitalization for heart failure, with this benefit extending to patients without diabetes who have heart failure with reduced ejection fraction. The possible mechanisms of benefit are being extensively investigated because they are unlikely to be related to improved glycaemic control. Early natriuresis with a reduction in plasma volume, a consequent rise in haematocrit, improved vascular function, a reduction in blood pressure and changes in tissue sodium handling are all likely to have a role. Additional mechanisms of SGLT2 inhibitors that might be beneficial include a reduction in adipose tissue-mediated inflammation and pro-inflammatory cytokine production, a shift towards ketone bodies as the metabolic substrate for the heart and kidneys, reduced oxidative stress, lowered serum uric acid level, reduced glomerular hyperfiltration and albuminuria, and suppression of advanced glycation end-product signalling. Further outcome trials and mechanistic studies, including in patients with heart failure with preserved ejection fraction or non-diabetic kidney disease, might identify other possible mechanisms of benefit of SGLT2-inhibitor therapy.
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Affiliation(s)
- Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK. .,Royal Brompton Hospital, London, UK.
| | - Miles Fisher
- Department of Diabetes, Endocrinology and Clinical Pharmacology, Glasgow Royal Infirmary, Glasgow, UK.,University of Glasgow, Glasgow, UK
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23
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Jain R, Awal H, Sen S. Using adult stem cells to monitor endothelial dysfunction in diabetes mellitus. J Diabetes Complications 2020; 34:107588. [PMID: 32345465 DOI: 10.1016/j.jdiacomp.2020.107588] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/24/2022]
Abstract
Diabetes affects approximately 10.5% of adults in the United States and this is projected to nearly double by 2025. Both type 2 diabetes (T2DM) and obesity are associated with endothelial dysfunction, oxidative stress, endothelial cell inflammation, cardiovascular pro-thrombotic states and are the most common causes of endothelial dysfunction, chronic kidney disease (CKD) and cardiovascular disease (CVD). Lately several new diabetes medications have come to clinical use that claim CVD risk improvement, however modalities used to test and monitor CVD risk are not cell based, which bring into question the reproducibility of these studies. Our review is designed to highlight cardiovascular risk reduction with novel diabetes medications while emphasizing cellular outcomes as a biomarker of cardiovascular risk. We are going to highlight studies that comment on peripheral blood derived CD34+ hematopoietic progenitor cells, as biomarkers of endothelial function. CD34+ cells have been extensively investigated by us and several other laboratories for the last two decades, as a viable cardiovascular function biomarker. In this context we will also discuss relevant CVD risk reduction trials that used novel diabetes medications.
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Affiliation(s)
- Rohit Jain
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA
| | - Hassan Awal
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA
| | - Sabyasachi Sen
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA.
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24
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Hess DA, Terenzi DC, Verma S. SGLT-2 Inhibitors and Regenerative Cell Exhaustion. Cell Metab 2020; 31:884-885. [PMID: 32302528 DOI: 10.1016/j.cmet.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/20/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
Abstract
In response to the Letter by Fadini, Hess et al. discuss the interpretation of their data and the details of the multiparametric analyses employed to measure the changes in circulating provascular cell content in patients with type 2 diabetes receiving empagliflozin compared to placebo treatment.
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Affiliation(s)
- David A Hess
- Division of Vascular Surgery, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada; Molecular Medicine Research Laboratories, Robarts Research Institute, London, ON, Canada; Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Daniella C Terenzi
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada; Insitute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada; Insitute of Medical Sciences, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
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25
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Fadini GP. SGLT-2 Inhibitors and Circulating Progenitor Cells in Diabetes. Cell Metab 2020; 31:883. [PMID: 32302526 DOI: 10.1016/j.cmet.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/22/2019] [Accepted: 03/30/2020] [Indexed: 11/26/2022]
Abstract
Hess et al. recently hypothesized that shifts in circulating progenitor cell populations may drive cardiovascular protection by SGLT-2 inhibitors in patients with type 2 diabetes. In this Letter, Fadini challenges that interpretation and discusses previous findings from an independent randomized placebo-controlled trial indicating that cardiovascular protection by SGLT-2 inhibitors may not directly involve circulating stem/progenitor cells.
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Affiliation(s)
- Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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26
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Sodium-glucose cotransporter 2 inhibitors antagonize lipotoxicity in human myeloid angiogenic cells and ADP-dependent activation in human platelets: potential relevance to prevention of cardiovascular events. Cardiovasc Diabetol 2020; 19:46. [PMID: 32264868 PMCID: PMC7140327 DOI: 10.1186/s12933-020-01016-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/17/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The clear evidence of cardiovascular benefits in cardiovascular outcome trials of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in type 2 diabetes might suggest an effect on atherosclerotic plaque vulnerability and/or thrombosis, in which myeloid angiogenic cells (MAC) and platelets (PLT) are implicated. We tested the effects of SGLT2i on inflammation and oxidant stress in a model of stearic acid (SA)-induced lipotoxicity in MAC and on PLT activation. The possible involvement of the Na+/H+ exchanger (NHE) was also explored. METHOD MAC and PLT were isolated from peripheral blood of healthy subjects and incubated with/without SGLT2i [empagliflozin (EMPA) and dapagliflozin (DAPA) 1-100 μM] to assess their effects on SA (100 μM)-induced readouts of inflammation, oxidant stress and apoptosis in MAC and on expression of PLT activation markers by flow-cytometry after ADP-stimulation. Potential NHE involvement was tested with amiloride (aspecific NHE inhibitor) or cariporide (NHE1 inhibitor). Differences among culture conditions were identified using one-way ANOVA or Friedman test. RESULTS NHE isoforms (1,5-9), but not SGLT2 expression, were expressed in MAC and PLT. EMPA and DAPA (100 μM) significantly reduced SA-induced inflammation (IL1β, TNFα, MCP1), oxidant stress (SOD2, TXN, HO1), but not apoptosis in MAC. EMPA and DAPA (both 1 μM) reduced PLT activation (CD62p and PAC1 expression). SGLT2i effects were mimicked by amiloride, and only partially by cariporide, in MAC, and by both inhibitors in PLT. CONCLUSIONS EMPA and DAPA ameliorated lipotoxic damage in stearate-treated MAC, and reduced ADP-stimulated PLT activation, potentially via NHE-inhibition, thereby pointing to plaque stabilization and/or thrombosis inhibition as potential mechanism(s) involved in SGLT2i-mediated cardiovascular protection.
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27
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Bonora BM, Avogaro A, Fadini GP. Extraglycemic Effects of SGLT2 Inhibitors: A Review of the Evidence. Diabetes Metab Syndr Obes 2020; 13:161-174. [PMID: 32021362 PMCID: PMC6982447 DOI: 10.2147/dmso.s233538] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/24/2019] [Indexed: 12/13/2022] Open
Abstract
Patients with type 2 diabetes (T2D) are often overweight/obese and affected by arterial hypertension, dyslipidaemia, and have high serum levels of uric acid. Moreover, T2D patient have a higher risk of developing cardiovascular or renal complications, which are leading causes of morbidity and mortality in this population. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a new class of glucose-lowering medications that block the reabsorption of glucose in the kidney, thereby increasing urinary glucose excretion, and lowering blood glucose levels. The beneficial effects of SGLT2 inhibition extend beyond glycaemic control, and include improvement in blood pressure, body weight, uric acid concentrations, liver steatosis, oxidative stress, and inflammation. In dedicated cardiovascular outcome trials, SGLT2i treatment was associated with a significant reduction in the rate of cardiovascular events and renal endpoints. In this review, we summarize the evidence for extra-glycemic effects of SGLT2i and the potential mechanisms driving cardiorenal protection exerted by this class of medications.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova35128, Italy
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28
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Hess DA, Terenzi DC, Trac JZ, Quan A, Mason T, Al-Omran M, Bhatt DL, Dhingra N, Rotstein OD, Leiter LA, Zinman B, Sabongui S, Yan AT, Teoh H, Mazer CD, Connelly KA, Verma S. SGLT2 Inhibition with Empagliflozin Increases Circulating Provascular Progenitor Cells in People with Type 2 Diabetes Mellitus. Cell Metab 2019; 30:609-613. [PMID: 31477497 DOI: 10.1016/j.cmet.2019.08.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
Hess et al. quantified circulating aldehyde dehydrogenase-expressing (ALDHhi) cell subsets in people with T2DM given either empagliflozin (EMPA) or placebo. EMPA treatment increased circulating pro-angiogenic CD133+ progenitor cells, decreased pro-inflammatory ALDHhi granulocyte precursors, and increased ALDHhi monocytes with M2 polarization. EMPA treatment improved T2DM-associated "regenerative cell depletion" contributing to enhanced vascular health.
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Affiliation(s)
- David A Hess
- Division of Vascular Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Molecular Medicine Research Laboratories, Robarts Research Institute, London, ON, Canada; Department of Physiology and Pharmacology, Western University, London, ON, Canada.
| | - Daniella C Terenzi
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Justin Z Trac
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Tamique Mason
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Natasha Dhingra
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Ori D Rotstein
- Division of General Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sandra Sabongui
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew T Yan
- Division of Cardiology, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Division of Cardiology, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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29
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Murray CE, Coleman CM. Impact of Diabetes Mellitus on Bone Health. Int J Mol Sci 2019; 20:ijms20194873. [PMID: 31575077 PMCID: PMC6801685 DOI: 10.3390/ijms20194873] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 12/21/2022] Open
Abstract
Long-term exposure to a diabetic environment leads to changes in bone metabolism and impaired bone micro-architecture through a variety of mechanisms on molecular and structural levels. These changes predispose the bone to an increased fracture risk and impaired osseus healing. In a clinical practice, adequate control of diabetes mellitus is essential for preventing detrimental effects on bone health. Alternative fracture risk assessment tools may be needed to accurately determine fracture risk in patients living with diabetes mellitus. Currently, there is no conclusive model explaining the mechanism of action of diabetes mellitus on bone health, particularly in view of progenitor cells. In this review, the best available literature on the impact of diabetes mellitus on bone health in vitro and in vivo is summarised with an emphasis on future translational research opportunities in this field.
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Affiliation(s)
- Cliodhna E Murray
- Regenerative Medicine Institute, National University of Ireland, Galway, Biomedical Sciences Building, Dangan, Newcastle Road, Galway City, County Galway, H91W2TY, Ireland.
| | - Cynthia M Coleman
- Regenerative Medicine Institute, National University of Ireland, Galway, Biomedical Sciences Building, Dangan, Newcastle Road, Galway City, County Galway, H91W2TY, Ireland.
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30
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Fadini GP, Spinetti G, Santopaolo M, Madeddu P. Impaired Regeneration Contributes to Poor Outcomes in Diabetic Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2019; 40:34-44. [PMID: 31510789 DOI: 10.1161/atvbaha.119.312863] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Diabetes mellitus increases the risk and accelerates the course of peripheral artery disease, making patients more susceptible to ischemic events and infections and delaying tissue healing. Current understanding of pathogenic mechanisms is mainly based on the negative influence of diabetes mellitus on atherosclerotic disease and inflammation. In recent years, the novel concept that diabetes mellitus can impinge on endogenous regenerative processes has been introduced. Diabetes mellitus affects regeneration at the local level, disturbing proper angiogenesis, collateral artery formation, and muscle repair. Recent evidence indicates that an impairment in vascular mural cells, alias pericytes, may participate in diabetic peripheral vasculopathy. Moreover, the bone marrow undergoes a global remodeling, consisting of microvessels and sensory neurons rarefaction and fat accumulation, which creates a hostile microenvironment for resident stem cells. Bone marrow remodeling is also responsible for detrimental systemic effects. In particular, the aid of reparative cells from the bone marrow is compromised: these elements are released in an improper manner and become harmful vectors of inflammatory and antiangiogenic molecules and noncoding RNAs. This new understanding of impaired regeneration is inspiring new therapeutic options for the treatment of ischemic complications in people with diabetes mellitus.
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Affiliation(s)
- Gian Paolo Fadini
- From the Department of Medicine, University of Padova, Italy (G.P.F.).,Veneto Institute of Molecular Medicine, Padova, Italy (G.P.F.)
| | - Gaia Spinetti
- Laboratory of Cardiovascular Research, IRCCS MultiMedica, Milan, Italy (G.S.)
| | - Marianna Santopaolo
- Experimental Cardiovascular Medicine, University of Bristol, United Kingdom (M.S., P.M.)
| | - Paolo Madeddu
- Experimental Cardiovascular Medicine, University of Bristol, United Kingdom (M.S., P.M.)
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31
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De Ciuceis C, Agabiti-Rosei C, Rossini C, Caletti S, Coschignano MA, Ferrari-Toninelli G, Ragni G, Cappelli C, Cerudelli B, Airò P, Scarsi M, Tincani A, Porteri E, Rizzoni D. Microvascular Density and Circulating Endothelial Progenitor Cells Before and After Treatment with Incretin Mimetics in Diabetic Patients. High Blood Press Cardiovasc Prev 2018; 25:369-378. [PMID: 30203268 DOI: 10.1007/s40292-018-0279-7] [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: 08/22/2018] [Accepted: 09/03/2018] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Glucagon-like peptide 1-receptor agonists (incretin mimetics) and dipeptidyl peptidase-4 inhibitors (incretin enhancers) have been recently introduced in the treatment of diabetes mellitus. In particular, incretin mimetics seems to have ancillary antioxidant/antinflammatory properties that might be involved in endothelial protection. AIM To investigate the effect of incretin mimetic therapy (liraglutide, exenatide) given to 11 patients with type 2 diabetes mellitus, on circulating endothelial progenitor cells (EPCs) (bone marrow-derived cells possibly participating in neovascularization and endothelial protection and repair) and capillary density. METHODS Four diabetic patients were treated with exenatide (5 μg twice daily for 4 weeks and then 10 μg twice daily for 3 weeks) and 7 with liraglutide (0.6 mg per day for 1 week and then 1.2 mg per day for 3 weeks). Peripheral venous blood samples were obtained before treatment (basal) and after 4 week in patients treated with liraglutide, and after 4 and 7 weeks in patients treated with exenatide, since drug titration is usually longer. EPCs were evaluated by flow cytometry as CD34+/KDR+ cells. Capillary density was evaluated by videomicroscopy, before and after venous congestion, in the dorsum of the 4th finger. RESULTS Patients treated with liraglutide (6 males 1 female, age 54 ± 12 years) showed a decrease in body mass index and blood pressure during treatment, while patients treated with exenatide (3 males 1 female, age 57 ± 6 years) did not show any relevant change. EPCs were significantly increased after treatment with exenatide, but not after treatment with liraglutide. Capillary density was slightly increased only after 4 weeks of treatment with exenatide, however the increase was no longer present at the final evaluation. CONCLUSIONS Treatment with exenatide, but not with liraglutide, was able to increase the number of circulating EPCs, possibly through an antioxidative/antiinflammatory effect.
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Affiliation(s)
- Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Claudia Agabiti-Rosei
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Claudia Rossini
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Stefano Caletti
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Maria Antonietta Coschignano
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | | | - Giorgio Ragni
- Division of Medicine, Spedali Civili di Brescia, Gardone Val Trompia, Italy
| | - Carlo Cappelli
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Bruno Cerudelli
- Division of Medicine, Spedali Civili di Brescia, Gardone Val Trompia, Italy
| | - Paolo Airò
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Mirko Scarsi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enzo Porteri
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, c/o 2ª Medicina, Spedali Civili, 25100, Brescia, Italy.
- Division of Medicine, Istituto Clinico Città di Brescia, Brescia, Italy.
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