Autosomal dominant ApoA4 mutations present as tubulointerstitial kidney disease with medullary amyloidosis

Sporadic cases of apolipoprotein A-IV medullary amyloidosis have been reported. Here we describe five families found to have autosomal dominant medullary amyloidosis due to two different pathogenic APOA4 variants. A large family with autosomal dominant chronic kidney disease (CKD) and bland urinary sediment underwent whole genome sequencing with identification of a chr11:116692578 G>C (hg19) variant encoding the missense mutation p.L66V of the ApoA4 protein. We identified two other distantly related families from our registry with the same variant and two other distantly related families with a chr11:116693454 C>T (hg19) variant encoding the missense mutation p.D33N. Both mutations are unique to affected families, evolutionarily conserved and predicted to expand the amyloidogenic hotspot in the ApoA4 structure. Clinically affected individuals suffered from CKD with a bland urinary sediment and a mean age for kidney failure of 64.5 years. Genotyping identified 48 genetically affected individuals; 44 individuals had an estimated glomerular filtration rate (eGFR) under 60 ml/min/1.73 m2, including all 25 individuals with kidney failure. Significantly, 11 of 14 genetically unaffected individuals had an eGFR over 60 ml/min/1.73 m2. Fifteen genetically affected individuals presented with higher plasma ApoA4 concentrations. Kidney pathologic specimens from four individuals revealed amyloid deposits limited to the medulla, with the mutated ApoA4 identified by mass-spectrometry as the predominant amyloid constituent in all three available biopsies. Thus, ApoA4 mutations can cause autosomal dominant medullary amyloidosis, with marked amyloid deposition limited to the kidney medulla and presenting with autosomal dominant CKD with a bland urinary sediment. Diagnosis relies on a careful family history, APOA4 sequencing and pathologic studies.

Distinctive Clinical Correlates of Small Intestinal Bacterial Overgrowth with Methanogens

BACKGROUND AND AIMS

Most patients with small intestinal bacterial overgrowth (SIBO) produce hydrogen by fermentation of dietary carbohydrates; however, ∼30% of patients with SIBO are colonized with Archaea, anaerobic organisms that produce methane. SIBO is associated with a plethora of symptoms and conditions, but their diagnostic significance is unclear. We aimed to determine if specific symptoms and conditions are associated with methanogenic SIBO.

METHODS

This study received institutional review board approval (IRB00059873). In this retrospective cross-sectional study, we queried a database of glucose breath tests conducted for suspected SIBO at our tertiary care medical center, which included data on the presence or absence of gastrointestinal symptoms and conditions often associated with SIBO. All patients had undergone a standardized breath testing protocol.

RESULTS

In a cohort of 1461 patients, 33.1% were SIBO positive; of these, 49.8% produced only hydrogen, 38.8% produced only methane, and 11.4% produced both gases. The following factors distinguished patients with hydrogen-producing SIBO, but not methanogenic SIBO, from SIBO-negative patients: vitamin B₁₂ deficiency (odds ratio, 1.44; confidence interval [CI], 1.01-2.06; P = .046), Roux-en-Y gastric bypass (odds ratio, 2.14; CI, 1.09-4.18; P = .027), cholecystectomy (odds ratio, 1.42; CI, 1.06-1.91; P = .020), and diabetes (odds ratio, 1.59; CI, 1.13-2.24; P = .008). The absence of vitamin B₁₂ deficiency was the sole discriminating factor between methanogenic and hydrogenic SIBO (odds ratio, 0.57; CI, 0.34-0.97; P = .038).

CONCLUSIONS

Patients with SIBO caused by methane-producing Archaea display a different spectrum of associated symptoms and clinical conditions compared with patients with SIBO caused by hydrogen-producing bacteria, particularly a lower incidence of vitamin B₁₂ deficiency.

The Impact of a Mediterranean Diet on the Gut Microbiome in Healthy Human Subjects: A Pilot Study

BACKGROUND AND AIMS

Despite the reported salutary benefits of a Mediterranean diet (MD) on a wide variety of health conditions, the specific microbial changes associated with an MD within the gastrointestinal (GI) tract are not well studied. Specifically, although population and survey-based studies have shown microbial changes, there are no published data on how an MD alters the gut flora in a controlled setting.

METHODS

We recruited 10 healthy subjects, each of whom gave a stool sample at baseline and then was provided with prepared meals of a "typical" American diet; after 2 weeks, a second stool sample was collected. All subjects were then provided with prepared meals based on the MD for another 2 weeks, followed by a final stool sample collection. Stool samples were batch analyzed with DNA extraction, and sequencing libraries were generated. Measures of bacterial diversity, species richness, and enterotypes were performed.

RESULTS

All ten subjects tolerated the diets well. Bacterial diversity increased with an MD, as measured by alpha diversity via the Simpson index. Furthermore, there were significant differences in 5 bacterial genera between the 2 diets.

CONCLUSION

This small pilot study of controlled diets demonstrates that the MD can rapidly alter the gut microbiome in healthy subjects at the level of global microbial diversity and individual genera. These data confirm the findings of previous observational studies and establish the feasibility of conducting longer term studies on the impact of the MD on the flora of the GI tract and its relationship to digestive diseases.

Ensuring respect for persons in COMPASS: a cluster randomised pragmatic clinical trial

Cluster randomised clinical trials present unique challenges in meeting ethical obligations to those who are treated at a randomised site. Obtaining informed consent for research within the context of clinical care is one such challenge. In order to solve this problem it is important that an informed consent process be effective and efficient, and that it does not impede the research or the healthcare. The innovative approach to informed consent employed in the COMPASS study demonstrates the feasibility of upholding ethical standards without imposing undue burden on clinical workflows, staff members or patients who may participate in the research by virtue of their presence in a cluster randomised facility. The COMPASS study included 40 randomised sites and compared the effectiveness of a postacute stroke intervention with standard care. Each site provided either the comprehensive postacute stroke intervention or standard care according to the randomisation assignment. Working together, the study team, institutional review board and members of the community designed an ethically appropriate and operationally reasonable consent process which was carried out successfully at all randomised sites. This achievement is noteworthy because it demonstrates how to effectively conduct appropriate informed consent in cluster randomised trials, and because it provides a model that can easily be adapted for other pragmatic studies. With this innovative approach to informed consent, patients have access to the information they need about research occurring where they are seeking care, and medical researchers can conduct their studies without ethical concerns or unreasonable logistical impediments.

TRIAL REGISTRATION NUMBER

NCT02588664, recruiting. This article covers the development of consent process that is currentlty being employed in the study.

Very Low Density Lipoprotein Assembly Is Required for cAMP-responsive Element-binding Protein H Processing and Hepatic Apolipoprotein A-IV Expression

Hepatic apolipoprotein A-IV (apoA-IV) expression is correlated with hepatic triglyceride (TG) content in mouse models of chronic hepatosteatosis, and steatosis-induced hepatic apoA-IV gene expression is regulated by nuclear transcription factor cAMP-responsive element-binding protein H (CREBH) processing. To define what aspects of TG homeostasis regulate hepatic CREBH processing and apoA-IV gene expression, several mouse models of attenuated VLDL particle assembly were subjected to acute hepatosteatosis induced by an overnight fast or short term ketogenic diet feeding. Compared with chow-fed C57BL/6 mice, fasted or ketogenic diet-fed mice displayed increased hepatic TG content, which was highly correlated (r² = 0.95) with apoA-IV gene expression, and secretion of larger, TG-enriched VLDL, despite a lower rate of TG secretion and a similar or reduced rate of apoB100 secretion. When VLDL particle assembly and secretion was inhibited by hepatic shRNA-induced apoB silencing or genetic or pharmacologic reduction in microsomal triglyceride transfer protein (MTP) activity, hepatic TG content increased dramatically; however, CREBH processing and apoA-IV gene expression were attenuated compared with controls. Adenovirus-mediated reconstitution of MTP expression proportionately restored CREBH processing and apoA-IV expression in liver-specific MTP knock-out mice. These results reveal that hepatic TG content, per se, does not regulate CREBH processing. Instead, TG mobilization into the endoplasmic reticulum for nascent VLDL particle assembly activates CREBH processing and enhances apoA-IV gene expression in the setting of acute steatosis. We conclude that VLDL assembly and CREBH activation play key roles in the response to hepatic steatosis by up-regulating apoA-IV and promoting assembly and secretion of larger, more TG-enriched VLDL particles.

Abstract 540: Very Low Density Lipoprotein Assembly is Required for cAMP Responsive Element-binding Protein H Processing and Hepatic Apolipoprotein A-IV Expression in Mouse Models of Acute Steatosis

Background: Our previous studies have demonstrated that hepatic expression of apolipoprotein A-IV (apoA-IV) is increased in mouse models of chronic steatosis and is closely correlated with hepatic triglyceride (TG) content. We have also shown that steatosis-induced hepatic apoA-IV gene expression is regulated by processing of the nuclear transcription factor cAMP responsive element-binding protein H (CREBH). Herein, we explored the mechanisms that mediate steatosis-induced CREBH processing.

Methods: We measured hepatic CREBH processing, apoA-IV gene expression, and lipid content in several mouse models of attenuated or enhanced VLDL assembly that were subjected to acute steatosis induced by a 16 hour overnight fast or by feeding a ketogenic diet for 6 days.

Results: Both fasting and the ketogenic diet induced acute hepatic TG accumulation associated with increased CREBH processing and apoA-IV gene expression, which were associated with hepatic TG content in C57BL/6 mice. All mouse models of attenuated VLDL secretion (shRNA-induced apoB knock down, liver specific microsomal triglyceride transfer protein (MTP) knockout, treatment with the MTP inhibitor BMS212122, and comparative gene identification-58 (CGI-58) deficiency) had increased hepatic TG accumulation, but displayed repressed CREBH processing and reduced apoA-IV gene expression compared to controls. When deficient VLDL assembly in liver-specific MTP knockout mice was reconstituted by adenoviral infection with a human MTP transgene, steatosis-induced CREBH processing and apoA-IV expression were restored. In a mouse model of enhanced VLDL assembly (transgenic overexpression of human MTP), apoA-IV gene expression correlated with bulk hepatic TG accumulation, but not with VLDL secretion rate, indicating that other steatosis-related factors participate in apoA-IV gene regulation.

Conclusions: Taken together, these data provide compelling evidence that VLDL assembly and secretion is required for hepatic CREBH processing and enhanced apoA-IV gene expression in the setting of acute steatosis. These data further suggest that CREBH and apoA-IV play central roles in VLDL-mediated hepatic lipid efflux.

Abstract 4: Apolipoprotein A-IV Confers Protection Against Oxidant Stress and Adipose Tissue Inflammation in Mouse Models of Obesity

Background: Increased lipid oxidation may initiate the chronic inflammatory state which characterizes adipose tissue in obesity. Apo A-IV is a potent in vitro antioxidant, and has been reported to confer protection against multiple inflammatory stimuli in vivo. Apo A-IV may be an especially effective antioxidant in peripheral tissues, as its labile affinity for lipoproteins results in relatively high concentrations in interstitial fluid.

Hypothesis: Apo A-IV attenuates lipid peroxidation and adipose tissue inflammation in mouse models of obesity.

Methods: Double heterozygote A4+/- x Ob+/- mice on a C57BL6 background were bred to generate wild type (WT), apo A-IV knockout (A4KO), Ob/Ob, and double knockout (DKO) mice. Groups of age-matched male littermates were fed pro-inflammatory high fat (HF, 42% fat, 0.2% cholesterol) or high fat/high cholesterol (HFHC, 38% fat, 1.25% cholesterol) diets; fasting plasma apo A-IV levels were measured by immunoblotting; plasma total F2 isoprostane levels (a biomarker of global lipid peroxidation) were measured by GC-MS; and expression of genes for pro-inflammatory mediators in adipose tissue was measured in WT and A4KO mice by RT-PCR.

Results: Baseline plasma apo A-IV levels were higher in the Ob/Ob mice, but increased ~2-fold after 8 weeks on the HF diet. After 12 weeks on the HFHC diet, plasma total F2 isoprostane levels were elevated in Ob/Ob mice, but were highest in DKO mice, indicating that free radical lipid peroxidation in peripheral tissues was increased in the absence of intestinal apo A-IV synthesis. All mice gained weight, but DKO mice gained less than Ob/Ob mice. Adipose tissue expression of the genes for MCP1, IL6, and IL1b was elevated 2-3 fold in A4KO mice.

Conclusions: These data indicate that plasma apo A-IV levels are chronically elevated by a high fat intake, and that apo A-IV expression attenuates the pro-oxidant/pro-inflammatory state in diet-induced and genetic obesity, which may thereby modulate energy balance.

Acyl chain length, saturation, and hydrophobicity modulate the efficiency of dietary fatty acid absorption in adult humans

Intestinal fat absorption is known to be, overall, a highly efficient process, but much less is known about the efficiency with which individual dietary fatty acids (FA) are absorbed by the adult small intestine. We therefore measured the absorption efficiency of the major dietary FA using sucrose polybehenate (SPB) as a nonabsorbable marker and analyzed how it is modulated by acyl chain physicochemical properties and polymorphisms of proteins involved in chylomicron assembly. Dietary FA absorption efficiency was measured in 44 healthy subjects fed a standard diet containing 35% fat and 5% SPB. FA and behenic acid (BA) were measured in homogenized diets and stool samples by gas chromatography-mass spectroscopy, and coefficients of absorption for each FA were calculated as 1 - [(FA/BA)feces/(FA/BA)diet]. Absorption coefficients for saturated FA decreased with increasing chain length and hydrophobicity (mean ± SE) and ranged from 0.95 ± 0.02 for myristate (14:0), 0.80 ± 0.03 for stearate (18:0), to 0.26 ± 0.02 for arachidate (20:0). Absorption coefficients for unsaturated FA increased with increasing desaturation from 0.79 ± 0.03 for elaidic acid (18:1t), 0.96 ± 0.01 for linoleate (18:2), to near complete absorption for eicosapentaenoic (20:5) and docosahexaenoic (22:6) acids. Of several common genetic polymorphisms in key proteins involved in the chylomicron assembly pathway, only the intestinal fatty acid-binding protein-2 A54T allele (rs1799883) had any impact on FA absorption. We conclude that acyl chain length, saturation, and hydrophobicity are the major determinants of the efficiency with which dietary FA are absorbed by the adult small intestine.

Abstract 299: Intestinal Apolipoprotein A-IV Expression Conserves Visceral Adiposity in Mice Subjected to Cyclical Feeding and Fasting

Background. We recently observed that although C57BL6 and apo A-IV knockout (A4KO) mice had similar weight gain on rodent chow, C56BL6 mice gained more weight and had greater adiposity when fed a high fat diet for 12 weeks (J Lipid Res 52:1984-1994, 2011). As food intake and intestinal fat absorption were the same in both groups, these data suggest that intestinal apo A-IV expression increases the efficiency of dietary energy storage. Here we have investigated whether apo A-IV could conserve adiposity in the setting of energy deprivation.

Methods. Four month old male C56BL6 and A4KO mice (n=5) weighing ∼30-35 gm were subjected to repeated 3 day cycles of free access to a high fat (40%) diet alternating with access to only water. Intra-abdominal fat, fat free mass (FFM), and hepatic fat were measured at baseline and after 8 weeks by CT scanning. At the end of the study, livers and epidydimal fat pads were collected and weighed.

Results. After 8 weeks on the feed-fast regimen, C57BL6 and A4KO mice had lost similar amounts of total weight, 4.4 ± 0.7 vs 5.2 ± 0.5 g (mean ± SE) and fat free mass, 3.0 ± 0.5 vs 3.0 ± 0.4 g; however, C57BL6 mice had lost less fat than A4KO mice, 1.4 ± 0.3 vs 2.2 ± 0.2 g (p=0.05). C57BL6 mice displayed a smaller decrease in adiposity than A4KO mice, 13.8 ± 1.1 to 10.9 ± 1.1 % vs 13.1 ± 0.5 to 7.9 ± 0.8 % (p=0.02 for the difference in the decrease between groups). There was a trend towards lower hepatic fat content (estimated from CT Hounsfield units) in C57BL6 mice, but liver (1.4 ± 0.2 vs 1.7 ± 0.2 g) and fat pad (1.3 ± 0.7 vs 1.1 ± 0.7 g) weights were not significantly different between the strains, suggesting that cyclical fasting affected mainly visceral fat.

Conclusions. These data establish that intestinal apo A-IV expression conserves visceral adipose tissue during cyclical fasting. Because apo A-IV is a uniquely mammalian apolipoprotein which appeared at the time of the divergence of mammals from the avian-reptile lineages, and as the mammalian survival paradigm requires that sufficient stores of lipid energy are available to support thermogenesis, internal gestation, and lactation, these data suggest that a major role of apo A-IV is to promote energy storage during times of dietary energy surfeit and conserve lipid energy stores during periods of prolonged energy deprivation.

Bitter taster status predicts susceptibility to vection-induced motion sickness and nausea

BACKGROUND

Sensitivity to bitter taste and susceptibility to nausea are both protective mechanisms that guard against toxin ingestion, and both these traits vary within and between populations. Thus, we postulated that they may have co-evolved, such that they are associated.

METHODS

Bitter taster status was determined in 40 subjects (13 men, 27 women) by measuring the differential perceived taste intensity between salt and n-propylthiouracil using a labeled magnitude scale; susceptibility to vection-induced motion sickness and nausea was assessed using an optokinetic drum, a validated multi-symptom scoring scale, and electrogastrography.

KEY RESULTS

Taster status distribution was 25% non-tasters (NT), 40% tasters (T), and 35% supertasters (ST). Gender had no impact on this distribution, but females had a higher mean maximum symptom score than males (12.4 ± 1.4 vs 7.3 ± 2.0). Non-tasters displayed a faster and larger increase in mean symptom scores, had a higher percentage of subjects with high maximum symptom scores, and had a higher mean maximum score than T or ST, (14.8 ± 2.6 vs 7.1 ± 1.8, vs 9.8 ± 2.0). Taster status did not affect the gastric myoelectric frequency response to vection.

CONCLUSIONS & INFERENCES

Non-tasters are more susceptible to vection-induced motion sickness and nausea than T or ST, suggesting these two traits may have co-evolved in a reciprocal manner: in environments where the NT trait conferred an evolutionary advantage by enabling intake of fruits and vegetables containing bitter, yet beneficial, phytonutrients, increased nausea susceptibility may have arisen to maintain protection against ingested toxins.

ApoA-IV modulates the secretory trafficking of apoB and the size of triglyceride-rich lipoproteins

Although the evidence linking apoA-IV expression and triglyceride (TG)-rich lipoprotein assembly and secretion is compelling, the intracellular mechanisms by which apoA-IV could modulate these processes remain poorly understood. We therefore examined the functional impact of apoA-IV expression on endogenous apoB, TG, and VLDL secretion in stably transfected McA-RH7777 rat hepatoma cells. Expression of apoA-IV modified with the endoplasmic reticulum (ER) retention signal KDEL (apoA-IV-KDEL) dramatically decreased both the rate and efficiency of endogenous apoB secretion, suggesting a presecretory interaction between apoA-IV-KDEL and apoB or apoB-containing lipoproteins. Expression of native apoA-IV using either a constitutive or tetracycline-inducible promoter delayed the initial rate of apoB secretion and reduced the final secretion efficiency by ∼40%. However, whereas apoA-IV-KDEL reduced TG secretion by 75%, expression of native apoA-IV caused a 20-35% increase in TG secretion, accompanied by a ∼55% increase in VLDL-associated apoB, an increase in the TG:phospholipid ratio of secreted d < 1.006 lipoproteins, and a 10.1 nm increase in peak VLDL(1) particle diameter. Native apoA-IV expression had a negligible impact on expression of the MTP gene. These data suggest that by interacting with apoB in the secretory pathway, apoA-IV alters the trafficking kinetics of apoB-containing TG-rich lipoproteins through cellular lipidation compartments, which in turn, enhances particle expansion and increases TG secretion.

Impact of murine intestinal apolipoprotein A-IV expression on regional lipid absorption, gene expression, and growth

Apolipoprotein A-IV (apoA-IV) is synthesized by intestinal enterocytes during lipid absorption and secreted into lymph on the surface of nascent chylomicrons. A compelling body of evidence supports a central role of apoA-IV in facilitating intestinal lipid absorption and in regulating satiety, yet a longstanding conundrum is that no abnormalities in fat absorption, feeding behavior, or weight gain were observed in chow-fed apoA-IV knockout (A4KO) mice. Herein we reevaluated the impact of apoA-IV expression in C57BL6 and A4KO mice fed a high-fat diet. Fat balance and lymph cannulation studies found no effect of intestinal apoA-IV gene expression on the efficiency of fatty acid absorption, but gut sac transport studies revealed that apoA-IV differentially modulates lipid transport and the number and size of secreted triglyceride-rich lipoproteins in different anatomic regions of the small bowel. ApoA-IV gene deletion increased expression of other genes involved in chylomicron assembly, impaired the ability of A4KO mice to gain weight and increase adipose tissue mass, and increased the distal gut hormone response to a high-fat diet. Together these findings suggest that apoA-IV may play a unique role in integrating feeding behavior, intestinal lipid absorption, and energy storage.

Biogenesis of apolipoprotein A-V and its impact on VLDL triglyceride secretion

Apolipoprotein A-V (apoA-V) is a potent regulator of intravascular triglyceride (TG) metabolism, yet its plasma concentration is very low compared with that of other apolipoproteins. To examine the basis for its low plasma concentration, the secretion efficiency of apoA-V was measured in stably transfected McA-RH7777 rat hepatoma cells. Pulse-chase experiments revealed that only ∼20% of newly synthesized apoA-V is secreted into culture medium within 3 h postsynthesis and that ∼65% undergoes presecretory turnover; similar results were obtained with transfected nonhepatic Chinese hamster ovary cells. ApoA-V secreted by McA-RH7777 cells was not associated with cell surface heparin-competable binding sites. When stably transfected McA-RH7777 cells were treated with oleic acid, the resulting increase in TG synthesis caused a reduction in apoA-V secretion, a reciprocal increase in cell-associated apoA-V, and movement of apoA-V onto cytosolic lipid droplets. In a stably transfected doxycycline-inducible McA-RH7777 cell line, apoA-V expression inhibited TG secretion by ∼50%, increased cellular TG, and reduced Z-average VLDL(1) particle diameter from 81 to 67 nm; however, no impact on apoB secretion was observed. These data demonstrate that apoA-V inefficiently traffics within the secretory pathway, that its intracellular itinerary can be regulated by changes in cellular TG accumulation, and that apoA-V synthesis can modulate VLDL TG mobilization and secretion.