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Bertonha AF, Silva CCL, Shirakawa KT, Trindade DM, Dessen A. Penicillin-binding protein (PBP) inhibitor development: A 10-year chemical perspective. Exp Biol Med (Maywood) 2023; 248:1657-1670. [PMID: 38030964 PMCID: PMC10723023 DOI: 10.1177/15353702231208407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Bacterial cell wall formation is essential for cellular survival and morphogenesis. The peptidoglycan (PG), a heteropolymer that surrounds the bacterial membrane, is a key component of the cell wall, and its multistep biosynthetic process is an attractive antibacterial development target. Penicillin-binding proteins (PBPs) are responsible for cross-linking PG stem peptides, and their central role in bacterial cell wall synthesis has made them the target of successful antibiotics, including β-lactams, that have been used worldwide for decades. Following the discovery of penicillin, several other compounds with antibiotic activity have been discovered and, since then, have saved millions of lives. However, since pathogens inevitably become resistant to antibiotics, the search for new active compounds is continuous. The present review highlights the ongoing development of inhibitors acting mainly in the transpeptidase domain of PBPs with potential therapeutic applications for the development of new antibiotic agents. Both the critical aspects of the strategy, design, and structure-activity relationships (SAR) are discussed, covering the main published articles over the last 10 years. Some of the molecules described display activities against main bacterial pathogens and could open avenues toward the development of new, efficient antibacterial drugs.
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Affiliation(s)
- Ariane F Bertonha
- Brazilian Biosciences National Laboratory (LNBio), CNPEM, Campinas 13084-971, Brazil
| | - Caio C L Silva
- Brazilian Biosciences National Laboratory (LNBio), CNPEM, Campinas 13084-971, Brazil
| | - Karina T Shirakawa
- Brazilian Biosciences National Laboratory (LNBio), CNPEM, Campinas 13084-971, Brazil
- Departamento de Genética, Evolução, Microbiologia e Imunologia, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-862, Brazil
| | - Daniel M Trindade
- Brazilian Biosciences National Laboratory (LNBio), CNPEM, Campinas 13084-971, Brazil
| | - Andréa Dessen
- Brazilian Biosciences National Laboratory (LNBio), CNPEM, Campinas 13084-971, Brazil
- Univ. Grenoble Alpes, CNRS, CEA, Institut de Biologie Structurale (IBS), F-38044 Grenoble, France
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Assis LHP, Silva-Junior RMP, Dolce LG, Alborghetti MR, Honorato RV, Nascimento AFZ, Melo-Hanchuk TD, Trindade DM, Tonoli CCC, Santos CT, Oliveira PSL, Larson RE, Kobarg J, Espreafico EM, Giuseppe PO, Murakami MT. The molecular motor Myosin Va interacts with the cilia-centrosomal protein RPGRIP1L. Sci Rep 2017; 7:43692. [PMID: 28266547 PMCID: PMC5339802 DOI: 10.1038/srep43692] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/30/2017] [Indexed: 12/31/2022] Open
Abstract
Myosin Va (MyoVa) is an actin-based molecular motor abundantly found at the centrosome. However, the role of MyoVa at this organelle has been elusive due to the lack of evidence on interacting partners or functional data. Herein, we combined yeast two-hybrid screen, biochemical studies and cellular assays to demonstrate that MyoVa interacts with RPGRIP1L, a cilia-centrosomal protein that controls ciliary signaling and positioning. MyoVa binds to the C2 domains of RPGRIP1L via residues located near or in the Rab11a-binding site, a conserved site in the globular tail domain (GTD) from class V myosins. According to proximity ligation assays, MyoVa and RPGRIP1L can interact near the cilium base in ciliated RPE cells. Furthermore, we showed that RPE cells expressing dominant-negative constructs of MyoVa are mostly unciliated, providing the first experimental evidence about a possible link between this molecular motor and cilia-related processes.
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Affiliation(s)
- L H P Assis
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil.,Graduate Program in Functional and Molecular Biology, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - R M P Silva-Junior
- Department of Cell and Molecular Biology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - L G Dolce
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil.,Graduate Program in Functional and Molecular Biology, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - M R Alborghetti
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - R V Honorato
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - A F Z Nascimento
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil.,Graduate Program in Functional and Molecular Biology, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - T D Melo-Hanchuk
- Department of Biochemistry and Tissue Biology, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - D M Trindade
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - C C C Tonoli
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - C T Santos
- Department of Cell and Molecular Biology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - P S L Oliveira
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - R E Larson
- Department of Cell and Molecular Biology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - J Kobarg
- Department of Biochemistry and Tissue Biology, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - E M Espreafico
- Department of Cell and Molecular Biology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - P O Giuseppe
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
| | - M T Murakami
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, SP, Brazil
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Nascimento AFZ, Trindade DM, Tonoli CCC, de Giuseppe PO, Assis LHP, Honorato RV, de Oliveira PSL, Mahajan P, Burgess-Brown NA, von Delft F, Larson RE, Murakami MT. Structural insights into functional overlapping and differentiation among myosin V motors. J Biol Chem 2013; 288:34131-34145. [PMID: 24097982 PMCID: PMC3837155 DOI: 10.1074/jbc.m113.507202] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/27/2013] [Indexed: 11/06/2022] Open
Abstract
Myosin V (MyoV) motors have been implicated in the intracellular transport of diverse cargoes including vesicles, organelles, RNA-protein complexes, and regulatory proteins. Here, we have solved the cargo-binding domain (CBD) structures of the three human MyoV paralogs (Va, Vb, and Vc), revealing subtle structural changes that drive functional differentiation and a novel redox mechanism controlling the CBD dimerization process, which is unique for the MyoVc subclass. Moreover, the cargo- and motor-binding sites were structurally assigned, indicating the conservation of residues involved in the recognition of adaptors for peroxisome transport and providing high resolution insights into motor domain inhibition by CBD. These results contribute to understanding the structural requirements for cargo transport, autoinhibition, and regulatory mechanisms in myosin V motors.
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Affiliation(s)
- Andrey F Z Nascimento
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Daniel M Trindade
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Celisa C C Tonoli
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Priscila O de Giuseppe
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Leandro H P Assis
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Rodrigo V Honorato
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Paulo S L de Oliveira
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil
| | - Pravin Mahajan
- Structural Genomics Consortium, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | | | - Frank von Delft
- Structural Genomics Consortium, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | - Roy E Larson
- Department of Cellular & Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, São Paulo 14049-900, Brazil
| | - Mario T Murakami
- Brazilian Biosciences National Laboratory, National Center for Research in Energy and Materials, Campinas, São Paulo 13083-100, Brazil.
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Souza TACB, Trindade DM, Tonoli CCC, Santos CR, Ward RJ, Arni RK, Oliveira AHC, Murakami MT. Molecular adaptability of nucleoside diphosphate kinase b from trypanosomatid parasites: stability, oligomerization and structural determinants of nucleotide binding. Mol Biosyst 2011; 7:2189-95. [PMID: 21528129 DOI: 10.1039/c0mb00307g] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Nucleoside diphosphate kinases play a crucial role in the purine-salvage pathway of trypanosomatid protozoa and have been found in the secretome of Leishmania sp., suggesting a function related to host-cell integrity for the benefit of the parasite. Due to their importance for housekeeping functions in the parasite and by prolonging the life of host cells in infection, they become an attractive target for drug discovery and design. In this work, we describe the first structural characterization of nucleoside diphosphate kinases b from trypanosomatid parasites (tNDKbs) providing insights into their oligomerization, stability and structural determinants for nucleotide binding. Crystallographic studies of LmNDKb when complexed with phosphate, AMP and ADP showed that the crucial hydrogen-bonding residues involved in the nucleotide interaction are fully conserved in tNDKbs. Depending on the nature of the ligand, the nucleotide-binding pocket undergoes conformational changes, which leads to different cavity volumes. SAXS experiments showed that tNDKbs, like other eukaryotic NDKs, form a hexamer in solution and their oligomeric state does not rely on the presence of nucleotides or mimetics. Fluorescence-based thermal-shift assays demonstrated slightly higher stability of tNDKbs compared to human NDKb (HsNDKb), which is in agreement with the fact that tNDKbs are secreted and subjected to variations of temperature in the host cells during infection and disease development. Moreover, tNDKbs were stabilized upon nucleotide binding, whereas HsNDKb was not influenced. Contrasts on the surface electrostatic potential around the nucleotide-binding pocket might be a determinant for nucleotide affinity and protein stability differentiation. All these together demonstrated the molecular adaptation of parasite NDKbs in order to exert their biological functions intra-parasite and when secreted by regulating ATP levels of host cells.
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Affiliation(s)
- Tatiana A C B Souza
- Laboratório Nacional de Biociências, Laboratório Nacional de Luz Síncrotron, Centro Nacional de Pesquisa em Energia e Materiais, Campinas, SP, Brazil.
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Santos CR, Tonoli CCC, Trindade DM, Betzel C, Takata H, Kuriki T, Kanai T, Imanaka T, Arni RK, Murakami MT. Structural basis for branching-enzyme activity of glycoside hydrolase family 57: Structure and stability studies of a novel branching enzyme from the hyperthermophilic archaeon Thermococcus Kodakaraensis KOD1. Proteins 2010; 79:547-57. [DOI: 10.1002/prot.22902] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Trindade DM, Silva JC, Navarro MS, Torriani ICL, Kobarg J. Low-resolution structural studies of human Stanniocalcin-1. BMC Struct Biol 2009; 9:57. [PMID: 19712479 PMCID: PMC2744999 DOI: 10.1186/1472-6807-9-57] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 08/27/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stanniocalcins (STCs) represent small glycoprotein hormones, found in all vertebrates, which have been functionally implicated in Calcium homeostasis. However, recent data from mammalian systems indicated that they may be also involved in embryogenesis, tumorigenesis and in the context of the latter especially in angiogenesis. Human STC1 is a 247 amino acids protein with a predicted molecular mass of 27 kDa, but preliminary data suggested its di- or multimerization. The latter in conjunction with alternative splicing and/or post-translational modification gives rise to forms described as STC50 and "big STC", which molecular weights range from 56 to 135 kDa. RESULTS In this study we performed a biochemical and structural analysis of STC1 with the aim of obtaining low resolution structural information about the human STC1, since structural information in this protein family is scarce. We expressed STC1 in both E. coli and insect cells using the baculo virus system with a C-terminal 6 x His fusion tag. From the latter we obtained reasonable amounts of soluble protein. Circular dichroism analysis showed STC1 as a well structured protein with 52% of alpha-helical content. Mass spectroscopy analysis of the recombinant protein allowed to assign the five intramolecular disulfide bridges as well as the dimerization Cys202, thereby confirming the conservation of the disulfide pattern previously described for fish STC1. SAXS data also clearly demonstrated that STC1 adopts a dimeric, slightly elongated structure in solution. CONCLUSION Our data reveal the first low resolution, structural information for human STC1. Theoretical predictions and circular dichroism spectroscopy both suggested that STC1 has a high content of alpha-helices and SAXS experiments revealed that STC1 is a dimer of slightly elongated shape in solution. The dimerization was confirmed by mass spectrometry as was the highly conserved disulfide pattern, which is identical to that found in fish STC1.
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Affiliation(s)
- Daniel M Trindade
- Centro de Biologia Molecular Estrutural (CEBIME), Campinas, SP, Brazil
- Instituto de Biologia, Departamento de Bioquímica, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Júlio C Silva
- Instituto de Física "Gleb Wataghin", Universidade Estadual de Campinas, Campinas, SP, Brazil
- Laboratório Nacional de Luz Síncrotron (LNLS), Campinas, SP, Brazil
| | | | - Iris CL Torriani
- Instituto de Física "Gleb Wataghin", Universidade Estadual de Campinas, Campinas, SP, Brazil
- Laboratório Nacional de Luz Síncrotron (LNLS), Campinas, SP, Brazil
| | - Jörg Kobarg
- Centro de Biologia Molecular Estrutural (CEBIME), Campinas, SP, Brazil
- Instituto de Biologia, Departamento de Bioquímica, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Lanza DCF, Trindade DM, Assmann EM, Kobarg J. Over-expression of GFP-FEZ1 causes generation of multi-lobulated nuclei mediated by microtubules in HEK293 cells. Exp Cell Res 2008; 314:2028-39. [PMID: 18439996 DOI: 10.1016/j.yexcr.2008.02.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 02/20/2008] [Accepted: 02/26/2008] [Indexed: 12/17/2022]
Abstract
FEZ1 (Fasciculation and elongation protein zeta 1) is an ortholog of the Caenorhabditis elegans protein UNC-76, involved in neuronal development and axon outgrowth, in that worm. Mammalian FEZ1 has already been reported to cooperate with PKC-zeta in the differentiation and polarization of PC12 neuronal cells. Furthermore, FEZ1 is associated with kinesin 1 and JIP1 to form a cargo-complex responsible for microtubule based transport of mitochondria along axons. FEZ1 can also be classified as a hub protein, since it was reported to interact with over 40 different proteins in yeast two-hybrid screens, including at least nine nuclear proteins. Here, we transiently over-expressed GFP-FEZ1full in human HEK293 and HeLa cells in order to study the sub-cellular localization of GFP-FEZ1. We observed that over 40% of transiently transfected cells at 3 days post-transfection develop multi-lobulated nuclei, which are also called flower-like nuclei. We further demonstrated that GFP-FEZ1 localizes either to the cytoplasm or the nuclear fraction, and that the appearance of the flower-like nuclei depends on intact microtubule function. Finally, we show that FEZ1 co-localizes with both, alpha- and especially with gamma-tubulin, which localizes as a centrosome like structure at the center of the multiple lobules. In summary, our data suggest that FEZ1 has an important centrosomal function and supply new mechanistic insights to the formation of flower-like nuclei, which are a phenotypical hallmark of human leukemia cells.
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Affiliation(s)
- Daniel C F Lanza
- Laboratório Nacional de Luz Síncrotron, Campinas SP, Brazil; Instituto de Biologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Souza DRS, Nakachima L, Biagioni RB, Nakazone MA, Pinhel MAS, Trindade DM, Mafra VT, Tácito LHB, Martin JFV, Pinheiro Júnior S, Brandão AC. Relevance of apolipoprotein E4 for the lipid profile of Brazilian patients with coronary artery disease. ACTA ACUST UNITED AC 2008; 40:189-97. [PMID: 17273655 DOI: 10.1590/s0100-879x2007000200005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Accepted: 11/06/2006] [Indexed: 11/22/2022]
Abstract
Apolipoprotein E (apoE - e2, e3, e4 alleles) plays a role in the regulation of lipid metabolism, with the e4 considered to be a risk factor for coronary artery disease (CAD). We aimed to evaluate the apoE polymorphisms in Brazilians with CAD and their influence on the lipid profile and other risk factors (hypertension, diabetes mellitus, smoking). Two hundred individuals were examined: 100 patients with atherosclerosis confirmed by coronary angiography and 100 controls. Blood samples were drawn to determine apoE polymorphisms and lipid profile. As expected, the e3 allele was prevalent in the CAD (0.87) and non-CAD groups (0.81; P = 0.099), followed by the e4 allele (0.09 and 0.14, respectively; P = 0.158). The e3/3 (76 and 78%) and e3/4 (16 and 23%) were the most common genotypes for patients and controls, respectively. The lipid profile was altered in patients compared to controls (P < 0.05), independently of the e4 allele. However, in the controls this allele was prevalent in individuals with elevated LDL-cholesterol levels only (odds ratio = 2.531; 95% CI = 1.028-6.232). The frequency of risk factors was higher in the CAD group (P < 0.05), but their association with the lipid profile was not demonstrable in e4 carriers. In conclusion, the e4 allele is not associated with CAD or lipid profile in patients with atherosclerosis. However, its frequency in the non-CAD group is associated with increased levels of LDL-cholesterol, suggesting an independent effect of the e4 allele on lipid profile when the low frequency of other risk factors in this group is taken into account.
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Affiliation(s)
- D R S Souza
- Departamento de Biologia Molecular, Faculdade de Medicina de São José do Rio Preto, Avenida Brigadeiro Faria Lima 5416, 15090-000 São José do Rio Preto, SP, Brazil.
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Brandão AC, Trindade DM, Hotta J, Pinhel MA, Anacleto AM, Godoy JMP, Godoy MF, Santos JE, Souza DRS. Polimorfismo genético do fibrinogênio na doença arterial periférica. Rev Bras Hematol Hemoter 2004. [DOI: 10.1590/s1516-84842004000300010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Souza DRS, Campos BF, Arruda EFD, Yamamoto LJ, Trindade DM, Tognola WA. Influence of the polymorphism of apolipoprotein E in cerebral vascular disease. Arq Neuropsiquiatr 2003; 61:7-13. [PMID: 12715012 DOI: 10.1590/s0004-282x2003000100002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
UNLABELLED The genetic heterogeneity of apolipoprotein E (apo E) has been associated with lipid profile and atherothrombotic stroke, however this association remains inconclusive. OBJECTIVE To evaluate the relationship between the isoforms of apo E and atherothrombotic stroke, by ascertaining the frequency of its alleles and genotypes associated with the lipid profile in patients with stroke. METHOD A total of 207 individuals were divided into two groups, consisting of 107 patients with stroke and 100 individuals without clinical symptoms of the disease. Blood samples were taken from patients and controls for molecular investigation of the apo E (epsilon2, epsilon3 and epsilon4 alleles) for the analysis of the lipid profile. RESULTS The epsilon3 allele was the most common and its prevalence was significantly higher in patients (0.93) compared to the controls (0.86; p=0.024). The epsilon2 allele was rarely seen specifically in patients (0.02 versus 0.05 in controls, p=0.191). The epsilon4 allele was not associated with stroke showing a reduced frequency in patients (0.05) when compared to controls (0.09; p=0.011). Although higher average levels of lipid profile were found in patients when compared to controls, with statistical significance for the values of total cholesterol (TC) (203.6 mg/dL +/- 57.98 and 181.9 mg/dL +/- 68.47 respectively; p=0.003) and low-density lipoprotein cholesterol (LDLc) (131.4mg/dL +/- 52.60 and 116 mg/dL +/- 56.38, respectively; p=0.014), these were independent of the presence of the epsilon4 allele. In control group the higher TC and LDLc values occurred in the absence of the epsilon4 allele, confirming the conflicting effect of the alleles of apo E on the plasmatic lipids and atherothrombotic stroke. CONCLUSION The isoforms of apo E cannot be regarded as an isolated risk factor for stroke and do not show association with lipid profile in this study.
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Affiliation(s)
- Dorotéia R S Souza
- Departamento de Biologia Molecular, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brasil.
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