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Costa BP, Nassr MT, Diz FM, Carlessi LP, Fernandes KHA, Nunes FB, Branchini G, de Oliveira JR. Fructose-1,6-bisphosphate induces generation of reactive oxygen species and activation of p53-dependent cell death in human endometrial cancer cells. J Appl Toxicol 2020; 41:1050-1062. [PMID: 33078453 DOI: 10.1002/jat.4091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 11/11/2022]
Abstract
Fructose-1,6-bisphosphate (F1,6BP), an intermediate of the glycolytic pathway, has been found to play a promising anticancer effect; nevertheless, the mechanisms involved remain poorly understood. The present study aimed to evaluate the effect and mechanisms of F1,6BP in a human endometrial cancer cell line (Ishikawa). F1,6BP showed an antiproliferative and non-cytotoxic effect on endometrial cancer cells. These effects are related to the increase in reactive oxygen species (ROS) levels and mitochondrial membrane potential (ΔΨm). These harmful stimuli trigger the upregulation of the expression of pro-apoptotic genes (p53 and Bax), leading to the reduction of cell proliferation through inducing programmed cell death by apoptosis. Furthermore, F1,6BP-treated cells had the formation of autophagosomes induced, as well as a decrease in their proliferative capacity after withdrawing the treatment. Our results demonstrate that F1,6BP acts as an anticancer agent through the generation of mitochondrial instability, loss of cell function, and p53-dependent cell death. Thus, F1,6BP proves to be a potential molecule for use in the treatment against endometrial cancer.
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Affiliation(s)
- Bruna Pasqualotto Costa
- Laboratory of Cellular Biophysics and Inflammation, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Marcella Tornquist Nassr
- Laboratory of Cellular Biophysics and Inflammation, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Fernando Mendonça Diz
- Program in Materials Engineering and Technology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Leonardo Pfeiff Carlessi
- Laboratory of Cellular Biophysics and Inflammation, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Krist Helen Antunes Fernandes
- Laboratory of Clinical and Experimental Immunology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Fernanda Bordignon Nunes
- Laboratory of Cellular Biophysics and Inflammation, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.,Laboratory of Cellular, Molecular and Computational Biophysics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Gisele Branchini
- Laboratory of Cellular, Molecular and Computational Biophysics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Jarbas Rodrigues de Oliveira
- Laboratory of Cellular Biophysics and Inflammation, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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Dias HB, Krause GC, Squizani ED, Lima KG, Schuster AD, Pedrazza L, Basso BDS, Martha BA, de Mesquita FC, Nunes FB, Donadio MVF, de Oliveira JR. Fructose-1,6-bisphosphate reverts iron-induced phenotype of hepatic stellate cells by chelating ferrous ions. Biometals 2017. [DOI: 10.1007/s10534-017-0025-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Krause GC, Lima KG, Haute GV, Schuster AD, Dias HB, Mesquita FC, Pedrazza L, Marczak ES, Basso BS, Velasque AC, Martha BA, Nunes FB, Donadio MVF, de Oliveira JR. Fructose-1,6-bisphosphate decreases IL-8 levels and increases the activity of pro-apoptotic proteins in HepG2 cells. Biomed Pharmacother 2017; 89:358-365. [DOI: 10.1016/j.biopha.2017.01.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 02/07/2023] Open
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Al-Maghrebi M, Renno WM. Altered expression profile of glycolytic enzymes during testicular ischemia reperfusion injury is associated with the p53/TIGAR pathway: effect of fructose 1,6-diphosphate. PeerJ 2016; 4:e2195. [PMID: 27441124 PMCID: PMC4941766 DOI: 10.7717/peerj.2195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 06/08/2016] [Indexed: 12/21/2022] Open
Abstract
Background. Testicular ischemia reperfusion injury (tIRI) is considered the mechanism underlying the pathology of testicular torsion and detorsion. Left untreated, tIRI can induce testis dysfunction, damage to spermatogenesis and possible infertility. In this study, we aimed to assess the activities and expression of glycolytic enzymes (GEs) in the testis and their possible modulation during tIRI. The effect of fructose 1,6-diphosphate (FDP), a glycolytic intermediate, on tIRI was also investigated. Methods. Male Sprague-Dawley rats were divided into three groups: sham, unilateral tIRI, and tIRI + FDP (2 mg/kg). tIRI was induced by occlusion of the testicular artery for 1 h followed by 4 h of reperfusion. FDP was injected peritoneally 30 min prior to reperfusion. Histological and biochemical analyses were used to assess damage to spermatogenesis, activities of major GEs, and energy and oxidative stress markers. The relative mRNA expression of GEs was evaluated by real-time PCR. ELISA and immunohistochemistry were used to evaluate the expression of p53 and TP53-induced glycolysis and apoptosis regulator (TIGAR). Results. Histological analysis revealed tIRI-induced spermatogenic damage as represented by a significant decrease in the Johnsen biopsy score. In addition, tIRI reduced the activities of hexokinase 1, phosphofructokinase-1, glyceraldehyde 3-phosphate dehydrogenase, and lactate dehydrogenase C. However, mRNA expression downregulation was detected only for hexokinase 1, phosphoglycerate kinase 2, and lactate dehydrogenase C. ATP and NADPH depletion was also induced by tIRI and was accompanied by an increased Malondialdehyde concentration, reduced glutathione level, and reduced superoxide dismutase and catalase enzyme activities. The immunoexpression of p53 and TIGAR was markedly increased after tIRI. The above tIRI-induced alterations were attenuated by FDP treatment. Discussion. Our findings indicate that tIRI-induced spermatogenic damage is associated with dysregulation of GE activity and gene expression, which were associated with activation of the TIGAR/p53 pathway. FDP treatment had a beneficial effect on alleviating the damaging effects of tIRI. This study further emphasizes the importance of metabolic regulation for proper spermatogenesis.
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Affiliation(s)
- May Al-Maghrebi
- Faculty of Medicine—Department of Biochemistry, Kuwait University, Jabriyah, Kuwait
| | - Waleed M. Renno
- Faculty of Medicine—Department of Anatomy, Kuwait University, Jabriyah, Kuwait
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Hammad N, Rosas-Lemus M, Uribe-Carvajal S, Rigoulet M, Devin A. The Crabtree and Warburg effects: Do metabolite-induced regulations participate in their induction? Biochim Biophys Acta 2016; 1857:1139-46. [PMID: 27066942 DOI: 10.1016/j.bbabio.2016.03.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 11/22/2022]
Abstract
The Crabtree and Warburg effects are two well-known deviations of cell energy metabolism that will be described herein. A number of hypotheses have been formulated regarding the molecular mechanisms leading to these cellular energy metabolism deviations. In this review, we will focus on the emerging notion that metabolite-induced regulations participate in the induction of these effects. All throughout this review, it should be kept in mind that no regulatory mechanism is exclusive and that it may vary in cancer cells owing to different cell types or oncogenic background. This article is part of a Special Issue entitled 'EBEC 2016: 19th European Bioenergetics Conference, Riva del Garda, Italy, July 2-6, 2016', edited by Prof. Paolo Bernardi.
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de Mesquita FC, Bitencourt S, Caberlon E, da Silva GV, Basso BS, Schmid J, Ferreira GA, de Oliveira FDS, de Oliveira JR. Fructose-1,6-bisphosphate induces phenotypic reversion of activated hepatic stellate cell. Eur J Pharmacol 2013; 720:320-5. [DOI: 10.1016/j.ejphar.2013.09.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 09/13/2013] [Accepted: 09/29/2013] [Indexed: 12/27/2022]
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Bochi GV, Torbitz VD, Cargnin LP, Sangoi MB, Santos RCV, Gomes P, Moresco RN. Fructose-1,6-bisphosphate and N-acetylcysteine attenuate the formation of advanced oxidation protein products, a new class of inflammatory mediators, in vitro. Inflammation 2013; 35:1786-92. [PMID: 22777066 DOI: 10.1007/s10753-012-9498-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The accumulation of advanced oxidation protein products (AOPP) has been linked to several pathological conditions. Previous studies have identified AOPP as a novel biomarker of oxidative damage to proteins and a novel class of mediator of inflammation. The aim of this study was to determine the effects of fructose-1,6-bisphosphate (FBP) and N-acetylcysteine (NAC) as well as the synergistic effect of both treatments on the formation of AOPP in vitro. For this purpose, we incubated the human serum albumin (HSA) with various hypochlorous acid (HOCl) concentrations to produce albumin-advanced oxidation protein products (HSA-AOPP). Both FBP and NAC were capable of inhibiting the formation of HOCl-induced AOPP in a concentration-dependent manner. The synergistic effect promoted by the association of these drugs showed to be more effective than when tested alone. Thus, both FBP and NAC may be good candidates to mitigate and neutralize pro-inflammatory and pro-oxidant effects of AOPP in several diseases.
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Affiliation(s)
- Guilherme Vargas Bochi
- Laboratório de Bioquímica Clínica, Departamento de Análises Clínicas e Toxicológicas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Avenida Roraima 1000, Prédio 26, Sala 1401, Camobi, 97105-900 Santa Maria, Rio Grande do Sul, Brazil
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Alva N, Cruz D, Sanchez S, Valentín JM, Bermudez J, Carbonell T. Nitric oxide as a mediator of fructose 1,6-bisphosphate protection in galactosamine-induced hepatotoxicity in rats. Nitric Oxide 2012; 28:17-23. [PMID: 23032643 DOI: 10.1016/j.niox.2012.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 09/21/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
Abstract
Fructose 1,6-bisphosphate (F1,6BP) has been widely used as a therapeutic agent for different harmful conditions in a variety of tissues. The hypothesis of the present work was that the increase in nitric oxide production and the prevention of oxidative stress induced by exogenous F1,6BP mediate its protective effect against the hepatotoxic action of GalN. Experimental groups used were sham, F1,6BP (2g/kg bw i.p.), GalN (0.4g/kg bw i.p), l-NAME (10mg/kg bw i.v.), F1,6BP+GalN, l-NAME+GalN and l-NAME+F1,6BP+GalN. Animals were killed after 24h of bolus administration. F1,6BP induced an increase in NO and the redox ratio (GSH/GSSG) in liver. Western blot assays pointed to overexpression of liver eNOS in F1,6BP-treated rats. The hepatic injury induced by GalN increased transaminases in plasma and decreased the reduced/oxidized glutathione ratio in liver. The concomitant administration of F1,6BP reversed this damage, while the addition of l-NAME worsened the liver injury. We provided evidence that this F1,6BP-induced protection may be related to the increase in NO production through the positive modulation of eNOS, and the increase in intracellular reduced glutathione, thus providing a higher reducing capacity.
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Affiliation(s)
- Norma Alva
- Departament de Fisiologia i Immunologia (Biologia), Universitat de Barcelona, Barcelona, Spain
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Abstract
Earlier studies by our group showed that fructose-1,6-bisphosphate (FBP) enhances the hypothermic preservation of rat cardiac myocytes and the functional recovery of animal hearts after hypothermic storage. However, the mechanisms involved were not clear. We extended the cardiomyocyte studies by testing whether the FBP effects were due to chelation of extracellular calcium, leading to lower intracellular levels. We also tested effects of 2,3-butanedione monoxime (BDM), pyruvate, and adenine nucleotide precursors. Cardiomyocytes were incubated in ischemic suspension at 3°C, and aliquots examined over 48 to 72 hours for retention of rod-shaped morphology, a measure of viability. Cytosolic Ca2+ levels were measured in some experiments. FBP at 5 mM reduced the death rate even when added after one or two days of incubation. It caused cytosolic calcium levels that were 33% lower than controls in freshly-isolated cells and 70% lower after one day of incubation. EGTA protected against cell death similarly to FBP. These results indicated that one of the mechanisms by which FBP exerts protective effects is through chelation of extracellular calcium. BDM was strongly protective and reduced cytosolic calcium by 30% after one day of incubation. As with FBP, BDM was effective when added after one or two days of incubation. BDM may be useful in combination with FBP in preserving heart tissue. Pyruvate, adenine, and ribose provided little or no protection during hypothermia.
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Affiliation(s)
- Thomas J. Wheeler
- Department of Biochemistry and Molecular Biology, University of Louisville School of Medicine, Louisville, Kentucky, United States of America
| | - Sufan Chien
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, United States of America
- * E-mail:
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George N, Kumar TP, Antony S, Jayanarayanan S, Paulose CS. Effect of vitamin D3 in reducing metabolic and oxidative stress in the liver of streptozotocin-induced diabetic rats. Br J Nutr 2012; 108:1410-8. [PMID: 22221397 DOI: 10.1017/S0007114511006830] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Diabetes mellitus is a growing health problem worldwide and is associated with severe liver complications. The aim of the present study is to analyse the status of metabolic and free-radical-scavenging enzymes and second messengers in the liver of streptozotocin (STZ)-induced diabetic rats, and to determine the hepatoprotective role of vitamin D(3). All studies were performed using the liver of adult male Wistar rats. Gene expression studies were carried out using real-time PCR with specific probes. Second messenger levels were determined using (3)H-labelled Biotrak assay kits, and glucose uptake assay with D-[(14)C]glucose. The present results show that there was a decrease in hepatic glucose uptake, malate dehydrogenase activity, glycogen content, inositol triphosphate (IP(3)) and cyclic GMP levels, and superoxide dismutase, glutathione peroxidase, phospholipase C, cyclic AMP-responsive element-binding protein, vitamin D receptor (VDR) and insulin receptor (INSR) gene expression in the diabetic rats when compared with the controls (all P < 0·05), while cyclic AMP levels and GLUT2 expression were increased (P < 0·05). Treatment of the diabetic rats with vitamin D(3) and insulin reversed the altered parameters to near control values. In conclusion, the data suggest a novel role of vitamin D(3) in restoring impaired liver metabolism in STZ-induced diabetic rats by regulating glucose uptake, storage and metabolism. We demonstrated that the restoring effect of vitamin D(3) is mediated through VDR modulation, thereby improving signal transduction and controlling free radicals in the liver of diabetic rats. These data suggest a potential role for vitamin D(3) in the treatment of diabetes-associated hepatic complications.
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Alva N, Carbonell T, Roig T, Bermúdez J, Palomeque J. Fructose 1,6 biphosphate administration to rats prevents metabolic acidosis and oxidative stress induced by deep hypothermia and rewarming. Eur J Pharmacol 2011; 659:259-64. [PMID: 21463624 DOI: 10.1016/j.ejphar.2011.03.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 02/16/2011] [Accepted: 03/09/2011] [Indexed: 11/17/2022]
Abstract
Fructose 1,6 biphosphate (F1,6BP) exerts a protective effect in several in vitro models of induced injury and in isolated organs; however, few studies have been performed using in vivo hypothermia. Here we studied the effects of deep hypothermia (21ºC) and rewarming in anaesthetised rats after F1,6BP administration (2 g/kg body weight). Acid-base and oxidative stress parameters (plasma malondialdehyde and glutathione, and erythrocyte antioxidant enzymes) were evaluated. Erythrocyte and leukocyte numbers in blood and plasma nitric oxide were also measured 3 h after F1,6BP administration in normothermia animals. In the absence of F1,6BP metabolic acidosis developed after rewarming. Oxidative stress was also evident after rewarming, as shown by a decrease in thiol groups and in erythrocyte superoxide dismutase, catalase and GSH-peroxidase, which corresponded to an increase in AST in rewarmed animals. These effects were reverted in rats treated with F1,6BP. Blood samples of F1,6BP-treated animals showed a significant increase in plasma nitric oxide 3 h after administration, coinciding with a significant rise in leukocyte number. F1,6BP protection may be due to the decrease in oxidative stress and to the preservation of the antioxidant pool. In addition, we propose that the reduction in extracellular acidosis may be due to improved tissue perfusion during rewarming and that nitric oxide may play a central role.
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Affiliation(s)
- Norma Alva
- Departament de Fisiologia (Biologia), Universitat de Barcelona, Barcelona, Spain.
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Bajić A, Zakrzewska J, Godjevac D, Andjus P, Jones DR, Spasić M, Spasojević I. Relevance of the ability of fructose 1,6-bis(phosphate) to sequester ferrous but not ferric ions. Carbohydr Res 2010; 346:416-20. [PMID: 21232735 DOI: 10.1016/j.carres.2010.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/06/2010] [Accepted: 12/08/2010] [Indexed: 12/27/2022]
Abstract
The cytoprotective activity of F16BP has been documented in severe conditions such as convulsions, reperfusion injury, septic shock, diabetic complications, hypothermia-induced injury, UV-provoked skin damage and in other processes including apoptosis and excitotoxicity. F16BP shows very efficient cytoprotective activity in astroglial cells exposed to H(2)O(2)-provoked oxidative stress and during neuronal injury caused by hypoxic conditions. As most of the aforementioned processes involve iron activity-related conditions, we investigated the ferric and ferrous iron binding properties of F16BP under physiological conditions using (31)P NMR and EPR spectroscopy. Our results indicate that cytoprotective F16BP activity is predominantly based on ferrous iron sequestration. (31)P NMR spectroscopy of F16BP employing paramagnetic properties of iron clearly showed that F16BP forms stabile complexes with Fe(2+) which was verified by EPR of another divalent cation-Mn(2+). On the other hand, F16BP does not sequester ferric iron nor does it increase its redox activity as shown by (31)P NMR and EPR spin-trapping. Therefore, F16BP may be beneficial in neurodegenerative and other conditions that are characterised by ferric iron stores and deposits.
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Affiliation(s)
- Aleksandar Bajić
- Center for Laser Microscopy, Faculty of Biology, University of Belgrade, Serbia
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Abdelmalek MF, Suzuki A, Guy C, Unalp-Arida A, Colvin R, Johnson RJ, Diehl AM. Increased fructose consumption is associated with fibrosis severity in patients with nonalcoholic fatty liver disease. Hepatology 2010; 51:1961-71. [PMID: 20301112 PMCID: PMC2922495 DOI: 10.1002/hep.23535] [Citation(s) in RCA: 530] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED The rising incidence of obesity and diabetes coincides with a marked increase in fructose consumption. Fructose consumption is higher in individuals with nonalcoholic fatty liver disease (NAFLD) than in age-matched and body mass index (BMI)-matched controls. Because fructose elicits metabolic perturbations that may be hepatotoxic, we investigated the relationship between fructose consumption and disease severity in NAFLD. We studied 427 adults enrolled in the NASH Clinical Research Network for whom Block food questionnaire data were collected within 3 months of a liver biopsy. Fructose consumption was estimated based on reporting (frequency x amount) of Kool-aid, fruit juices, and nondietary soda intake, expressed as servings per week, and classified into none, minimum to moderate (<7 servings/week), and daily (> or =7 servings/week). The association of fructose intake with metabolic and histological features of NAFLD was analyzed using multiple linear and ordinal logistic regression analyses with and without controlling for other confounding factors. Increased fructose consumption was univariately associated with decreased age (P < 0.0001), male sex (P < 0.0001), hypertriglyceridemia (P < 0.04), low high-density lipoprotein (HDL) cholesterol (<0.0001), decreased serum glucose (P < 0.001), increased calorie intake (P < 0.0001), and hyperuricemia (P < 0.0001). After controlling for age, sex, BMI, and total calorie intake, daily fructose consumption was associated with lower steatosis grade and higher fibrosis stage (P < 0.05 for each). In older adults (age > or = 48 years), daily fructose consumption was associated with increased hepatic inflammation (P < 0.05) and hepatocyte ballooning (P = 0.05). CONCLUSION In patients with NAFLD, daily fructose ingestion is associated with reduced hepatic steatosis but increased fibrosis. These results identify a readily modifiable environmental risk factor that may ameliorate disease progression in patients with NAFLD.
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Affiliation(s)
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, NC
| | - Cynthia Guy
- Department of Pathology, Duke University, Durham, NC
| | - Aynur Unalp-Arida
- NASH CRN Data Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ryan Colvin
- NASH CRN Data Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Richard J. Johnson
- Division of Renal Diseases and Hypertension at the University of Colorado, Denver, CO
| | - Anna Mae Diehl
- Division of Gastroenterology, Duke University, Durham, NC
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