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Martin B, Gabris-Weber BA, Reddy R, Romero G, Chattopadhyay A, Salama G. Relaxin reverses inflammatory and immune signals in aged hearts. PLoS One 2018; 13:e0190935. [PMID: 29346407 PMCID: PMC5773192 DOI: 10.1371/journal.pone.0190935] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/22/2017] [Indexed: 02/06/2023] Open
Abstract
Background ‘Healthy’ aging drives structural and functional changes in the heart including maladaptive electrical remodeling, fibrosis and inflammation, which lower the threshold for cardiovascular diseases such as heart failure (HF) and atrial fibrillation (AF). Despite mixed results in recent clinical trials, Relaxin-therapy for 2-days could reduce mortality by 37% at 180-days post-treatment, in patients with acute decompensated HF. Relaxin’s short life-span (hours) but long-lasting protective actions led us to test the hypothesis that relaxin acts at a genomic level to reverse maladaptive remodeling in aging and HF. Methods and results Young (9-month) and aged (24-month), male and female F-344/Brown Norway rats were treated with relaxin (0.4 mg/kg/day) for 2-weeks delivered by subcutaneous osmotic mini-pumps or with sodium acetate (controls). The genomic effects of aging and relaxin were evaluated by extracting RNA from the left ventricles and analyzing genomic changes by RNA-sequencing, Ingenuity Pathway Analysis, MetaCore and tissue immunohistochemistry. We found that aging promotes a native inflammatory response with distinct sex-differences and relaxin suppresses transcription of multiple genes and signaling pathways associated with inflammation and HF in both genders. In addition, aging significantly increased: macrophage infiltration and atrial natriuretic peptide levels in female ventricles, and activation of the complement cascade, whereas relaxin reversed these age-related effects. Conclusion These data support the hypothesis that relaxin alters gene transcription and suppresses inflammatory pathways and genes associated with HF and aging. Relaxin’s suppression of inflammation and fibrosis supports its potential as a therapy for cardiovascular and inflammation-related diseases, such as HF, AF and diabetes.
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Affiliation(s)
- Brian Martin
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Beth Ann Gabris-Weber
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Rajiv Reddy
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Guillermo Romero
- Department of Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Ansuman Chattopadhyay
- Molecular Biology Information Service, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Guy Salama
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
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Beiert T, Knappe V, Tiyerili V, Stöckigt F, Effelsberg V, Linhart M, Steinmetz M, Klein S, Schierwagen R, Trebicka J, Roell W, Nickenig G, Schrickel JW, Andrié RP. Chronic lower-dose relaxin administration protects from arrhythmia in experimental myocardial infarction due to anti-inflammatory and anti-fibrotic properties. Int J Cardiol 2018; 250:21-28. [DOI: 10.1016/j.ijcard.2017.09.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/30/2017] [Accepted: 09/06/2017] [Indexed: 12/11/2022]
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Yandrapalli S, Jolly G, Biswas M, Rochlani Y, Harikrishnan P, Aronow WS, Lanier GM. Newer hormonal pharmacotherapies for heart failure. Expert Rev Endocrinol Metab 2018; 13:35-49. [PMID: 30063443 DOI: 10.1080/17446651.2018.1406799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. AREAS COVERED A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. EXPERT COMMENTARY A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.
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Affiliation(s)
- Srikanth Yandrapalli
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - George Jolly
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Medha Biswas
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Yogita Rochlani
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Prakash Harikrishnan
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Gregg M Lanier
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
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Zoet GA, van Rijn BB, Rehfeldt M, Franx A, Maas AHEM. Similar pro-NT and pro-RLX2 levels after preeclampsia and after uncomplicated pregnancy. Maturitas 2017; 106:87-91. [PMID: 29150171 DOI: 10.1016/j.maturitas.2017.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/28/2017] [Accepted: 09/20/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Women are at increased risk of developing cardiovascular disease (CVD) after preeclampsia. Proneurotensin 1-117 (pro-NT) and prorelaxin 2 connecting peptide (pro-RLX2) have recently emerged as potential biomarkers for CVD risk in women. We assessed pro-NT and pro-RLX2 levels in women with and without a history of preeclampsia. STUDY DESIGN 339 women with a history of early-onset preeclampsia and 327 women with an uncomplicated pregnancy underwent cardiovascular screening 10 years after delivery (the Preeclampsia Risk EValuation in FEMales (PREVFEM) cohort). MAIN OUTCOME MEASURES Pro-NT, a stable fragment of the neurotensin precursor, was assessed in the whole cohort. Pro-RLX2, the stable connecting peptide of the relaxin 2 prohormone, was assessed in a subset of this cohort, consisting of 27 women with a history of preeclampsia and 23 healthy controls. Associations between biomarker levels and traditional CVD risk factors in the preeclampsia and control group were assessed by Pearson's correlation coefficient. RESULTS We found no differences in pro-NT and pro-RLX2 levels between the preeclampsia and control group. Pro-NT levels were associated with higher HbA1c levels (r=0.113, p-value 0.045) and with BMI (r=0.124, p-value 0.027), but only in the control group. Pro-RLX2 was related to current smoking and triglyceride levels in women with a history of preeclampsia and related to LDL-cholesterol in women with an uncomplicated pregnancy. CONCLUSIONS Pro-NT and pro-RLX2 levels were comparable in women 10 years after preeclampsia and women with an uncomplicated pregnancy. The role of pro-NT and pro-RLX2 in CVD development after preeclampsia should be further investigated.
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Affiliation(s)
- G A Zoet
- Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Lundlaan 6, PO Box 85090, 3508 AB, Utrecht, The Netherlands.
| | - B B van Rijn
- Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Lundlaan 6, PO Box 85090, 3508 AB, Utrecht, The Netherlands; Academic Unit of Human Development and Health, University of Southampton, Princess Anne Hospital, Coxford Road, Southampton SO16 5YA, United Kingdom
| | | | - A Franx
- Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Lundlaan 6, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - A H E M Maas
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Han L, Luo J, Bai S, Jia Y, Chen X, Zhao Y, Chen L, Zhu X, Li Y, Jiang Y, Li X, Yang M, Li D, Teng X, Qi Y. Combined Assessment of Relaxin and B-Type Natriuretic Peptide Improves Diagnostic Value in Patients With Congestive Heart Failure. Am J Med Sci 2017; 354:480-485. [PMID: 29173360 DOI: 10.1016/j.amjms.2017.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/07/2017] [Accepted: 07/07/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND To improve the poor prognosis of congestive heart failure (CHF), early and accurate diagnosis is necessary. Relaxin is an endogenous cardiovascular peptide, and its plasma level is usually increased in patients with CHF. In this pilot study, we aimed to determine the diagnostic value of relaxin and B-type natriuretic peptide (BNP) in patients with and without CHF. MATERIALS AND METHODS The plasma level of relaxin was measured by enzyme-linked immunosorbent assay and plasma level of BNP by fluorescence immunoassay. The area under the receiver operating characteristic curve was used to assess the diagnostic value of relaxin and BNP. RESULTS We included 81 patients with decompenstated CHF and 36 controls. Plasma levels of relaxin and BNP were both higher in CHF patients than in controls. The correlation between plasma levels of relaxin and BNP and between relaxin or BNP and cardiac function was nonlinear. Relaxin had medium diagnostic value, and BNP had higher value for cardiac function and CHF. At a cutoff of 39.76pg/mL relaxin, sensitivity was 82.7%, specificity 55.6%, sum of the highest positive predictive value 80.5% and negative predictive value 58.8%. Although the diagnostic value was not better for relaxin than BNP, their combined assessment improved the sensitivity and specificity of diagnosis for CHF as compared with BNP alone. CONCLUSIONS Combined assessment of relaxin and BNP may improve the diagnosis of decompensated CHF, which may have potential application in the clinic.
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Affiliation(s)
- Ling Han
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Jingguang Luo
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Shanshan Bai
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Ye Jia
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xin Chen
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Yan Zhao
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Liwei Chen
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xiaogang Zhu
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Ying Li
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Jiang
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xiaohong Li
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Ming Yang
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Dongxia Li
- Department of Cardiology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xu Teng
- Hebei Key Laboratory of Laboratory Animal Science, Hebei Medical University, Shijiazhuang, China.
| | - Yongfen Qi
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China.
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Bhamidipati CM, Mokadam NA. You spin me right round. J Thorac Cardiovasc Surg 2017. [PMID: 28645816 DOI: 10.1016/j.jtcvs.2017.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Nahush A Mokadam
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, Wash.
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Abstract
Myocardial injury, mechanical stress, neurohormonal activation, inflammation, and/or aging all lead to cardiac remodeling, which is responsible for cardiac dysfunction and arrhythmogenesis. Of the key histological components of cardiac remodeling, fibrosis either in the form of interstitial, patchy, or dense scars, constitutes a key histological substrate of arrhythmias. Here we discuss current research findings focusing on the role of fibrosis, in arrhythmogenesis. Numerous studies have convincingly shown that patchy or interstitial fibrosis interferes with myocardial electrophysiology by slowing down action potential propagation, initiating reentry, promoting after-depolarizations, and increasing ectopic automaticity. Meanwhile, there has been increasing appreciation of direct involvement of myofibroblasts, the activated form of fibroblasts, in arrhythmogenesis. Myofibroblasts undergo phenotypic changes with expression of gap-junctions and ion channels thereby forming direct electrical coupling with cardiomyocytes, which potentially results in profound disturbances of electrophysiology. There is strong evidence that systemic and regional inflammatory processes contribute to fibrogenesis (i.e., structural remodeling) and dysfunction of ion channels and Ca2+ homeostasis (i.e., electrical remodeling). Recognizing the pivotal role of fibrosis in the arrhythmogenesis has promoted clinical research on characterizing fibrosis by means of cardiac imaging or fibrosis biomarkers for clinical stratification of patients at higher risk of lethal arrhythmia, as well as preclinical research on the development of antifibrotic therapies. At the end of this review, we discuss remaining key questions in this area and propose new research approaches. © 2017 American Physiological Society. Compr Physiol 7:1009-1049, 2017.
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Affiliation(s)
- My-Nhan Nguyen
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Helen Kiriazis
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Xiao-Ming Gao
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Xiao-Jun Du
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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ML290 is a biased allosteric agonist at the relaxin receptor RXFP1. Sci Rep 2017; 7:2968. [PMID: 28592882 PMCID: PMC5462828 DOI: 10.1038/s41598-017-02916-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/20/2017] [Indexed: 01/02/2023] Open
Abstract
Activation of the relaxin receptor RXFP1 has been associated with improved survival in acute heart failure. ML290 is a small molecule RXFP1 agonist with simple structure, long half-life and high stability. Here we demonstrate that ML290 is a biased agonist in human cells expressing RXFP1 with long-term beneficial actions on markers of fibrosis in human cardiac fibroblasts (HCFs). ML290 did not directly compete with orthosteric relaxin binding and did not affect binding kinetics, but did increase binding to RXFP1. In HEK-RXFP1 cells, ML290 stimulated cAMP accumulation and p38MAPK phosphorylation but not cGMP accumulation or ERK1/2 phosphorylation although prior addition of ML290 increased p-ERK1/2 responses to relaxin. In human primary vascular endothelial and smooth muscle cells that endogenously express RXFP1, ML290 increased both cAMP and cGMP accumulation but not p-ERK1/2. In HCFs, ML290 increased cGMP accumulation but did not affect p-ERK1/2 and given chronically activated MMP-2 expression and inhibited TGF-β1-induced Smad2 and Smad3 phosphorylation. In vascular cells, ML290 was 10x more potent for cGMP accumulation and p-p38MAPK than for cAMP accumulation. ML290 caused strong coupling of RXFP1 to Gαs and GαoB but weak coupling to Gαi3. ML290 exhibited signalling bias at RXFP1 possessing a signalling profile indicative of vasodilator and anti-fibrotic properties.
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59
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Vestri A, Pierucci F, Frati A, Monaco L, Meacci E. Sphingosine 1-Phosphate Receptors: Do They Have a Therapeutic Potential in Cardiac Fibrosis? Front Pharmacol 2017. [PMID: 28626422 PMCID: PMC5454082 DOI: 10.3389/fphar.2017.00296] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Sphingosine 1-phosphate (S1P) is a bioactive lipid that is characterized by a peculiar mechanism of action. In fact, S1P, which is produced inside the cell, can act as an intracellular mediator, whereas after its export outside the cell, it can act as ligand of specific G-protein coupled receptors, which were initially named endothelial differentiation gene (Edg) and eventually renamed sphingosine 1-phosphate receptors (S1PRs). Among the five S1PR subtypes, S1PR1, S1PR2 and S1PR3 isoforms show broad tissue gene expression, while S1PR4 is primarily expressed in immune system cells, and S1PR5 is expressed in the central nervous system. There is accumulating evidence for the important role of S1P as a mediator of many processes, such as angiogenesis, carcinogenesis and immunity, and, ultimately, fibrosis. After a tissue injury, the imbalance between the production of extracellular matrix (ECM) and its degradation, which occurs due to chronic inflammatory conditions, leads to an accumulation of ECM and, consequential, organ dysfunction. In these pathological conditions, many factors have been described to act as pro- and anti-fibrotic agents, including S1P. This bioactive lipid exhibits both pro- and anti-fibrotic effects, depending on its site of action. In this review, after a brief description of sphingolipid metabolism and signaling, we emphasize the involvement of the S1P/S1PR axis and the downstream signaling pathways in the development of fibrosis. The current knowledge of the therapeutic potential of S1PR subtype modulators in the treatment of the cardiac functions and fibrinogenesis are also examined.
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Affiliation(s)
- Ambra Vestri
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Molecular and Applied Biology Research Unit, University of FlorenceFlorence, Italy
| | - Federica Pierucci
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Molecular and Applied Biology Research Unit, University of FlorenceFlorence, Italy.,Interuniversity Institutes of MyologyFirenze, Italy
| | - Alessia Frati
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Molecular and Applied Biology Research Unit, University of FlorenceFlorence, Italy
| | - Lucia Monaco
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of RomeRome, Italy
| | - Elisabetta Meacci
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Molecular and Applied Biology Research Unit, University of FlorenceFlorence, Italy.,Interuniversity Institutes of MyologyFirenze, Italy
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Ebrahimi B. In vivo reprogramming for heart regeneration: A glance at efficiency, environmental impacts, challenges and future directions. J Mol Cell Cardiol 2017; 108:61-72. [PMID: 28502796 DOI: 10.1016/j.yjmcc.2017.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/08/2017] [Indexed: 02/08/2023]
Abstract
Replacing dying or diseased cells of a tissue with new ones that are converted from patient's own cells is an attractive strategy in regenerative medicine. In vivo reprogramming is a novel strategy that can circumvent the hurdles of autologous/allogeneic cell injection therapies. Interestingly, studies have demonstrated that direct injection of cardiac transcription factors or specific miRNAs into the infarct border zone of murine hearts following myocardial infarction converts resident cardiac fibroblasts into functional cardiomyocytes. Moreover, in vivo cardiac reprogramming not only drives cardiac tissue regeneration, but also improves cardiac function and survival rate after myocardial infarction. Thanks to the influence of cardiac microenvironment and the same developmental origin, cardiac fibroblasts seem to be more amenable to reprogramming toward cardiomyocyte fate than other cell sources (e.g. skin fibroblasts). Thus, reprogramming of cardiac fibroblasts to functional induced cardiomyocytes in the cardiac environment holds great promises for induced regeneration and potential clinical purposes. Application of small molecules in future studies may represent a major advancement in this arena and pharmacological reprogramming would convey reprogramming technology to the translational medicine paradigm. This study reviews accomplishments in the field of in vitro and in vivo mouse cardiac reprogramming and then deals with strategies for the enhancement of the efficiency and quality of the process. Furthermore, it discusses challenges ahead and provides suggestions for future research. Human cardiac reprogramming is also addressed as a foundation for possible application of in vivo cardiac reprogramming for human heart regeneration in the future.
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Affiliation(s)
- Behnam Ebrahimi
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
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61
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Samuel CS, Royce SG, Hewitson TD, Denton KM, Cooney TE, Bennett RG. Anti-fibrotic actions of relaxin. Br J Pharmacol 2017; 174:962-976. [PMID: 27250825 PMCID: PMC5406285 DOI: 10.1111/bph.13529] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/19/2016] [Accepted: 05/23/2016] [Indexed: 12/19/2022] Open
Abstract
Fibrosis refers to the hardening or scarring of tissues that usually results from aberrant wound healing in response to organ injury, and its manifestations in various organs have collectively been estimated to contribute to around 45-50% of deaths in the Western world. Despite this, there is currently no effective cure for the tissue structural and functional damage induced by fibrosis-related disorders. Relaxin meets several criteria of an effective anti-fibrotic based on its specific ability to inhibit pro-fibrotic cytokine and/or growth factor-mediated, but not normal/unstimulated, fibroblast proliferation, differentiation and matrix production. Furthermore, relaxin augments matrix degradation through its ability to up-regulate the release and activation of various matrix-degrading matrix metalloproteinases and/or being able to down-regulate tissue inhibitor of metalloproteinase activity. Relaxin can also indirectly suppress fibrosis through its other well-known (anti-inflammatory, antioxidant, anti-hypertrophic, anti-apoptotic, angiogenic, wound healing and vasodilator) properties. This review will outline the organ-specific and general anti-fibrotic significance of exogenously administered relaxin and its mechanisms of action that have been documented in various non-reproductive organs such as the cardiovascular system, kidney, lung, liver, skin and tendons. In addition, it will outline the influence of sex on relaxin's anti-fibrotic actions, highlighting its potential as an emerging anti-fibrotic therapeutic. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Affiliation(s)
- C S Samuel
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of PharmacologyMonash UniversityMelbourneVic.Australia
| | - S G Royce
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of PharmacologyMonash UniversityMelbourneVic.Australia
| | - T D Hewitson
- Department of NephrologyRoyal Melbourne HospitalMelbourneVic.Australia
| | - K M Denton
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of PhysiologyMonash UniversityMelbourneVic.Australia
| | - T E Cooney
- University of Pittsburgh Medical Centre (UPMC) HamotEriePAUSA
| | - R G Bennett
- Research Service 151VA Nebraska‐Western Iowa Health Care SystemOmahaNEUSA
- Department of Internal MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
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Teerlink JR, Voors AA, Ponikowski P, Pang PS, Greenberg BH, Filippatos G, Felker GM, Davison BA, Cotter G, Gimpelewicz C, Boer-Martins L, Wernsing M, Hua TA, Severin T, Metra M. Serelaxin in addition to standard therapy in acute heart failure: rationale and design of the RELAX-AHF-2 study. Eur J Heart Fail 2017; 19:800-809. [PMID: 28452195 PMCID: PMC5488179 DOI: 10.1002/ejhf.830] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/27/2017] [Accepted: 03/07/2017] [Indexed: 12/28/2022] Open
Abstract
Patients admitted for acute heart failure (AHF) experience high rates of in-hospital and post-discharge morbidity and mortality despite current therapies. Serelaxin is recombinant human relaxin-2, a hormone with vasodilatory and end-organ protective effects believed to play a central role in the cardiovascular and renal adaptations of human pregnancy. In the phase 3 RELAX-AHF trial, serelaxin met its primary endpoint of improving dyspnoea through day 5 in patients admitted for AHF. Compared to placebo, serelaxin also reduced worsening heart failure (WHF) by 47% through day 5 and both all-cause and cardiovascular mortality by 37% through day 180. RELAX-AHF-2 ( ClinicalTrials.gov NCT01870778) is designed to confirm serelaxin's effect on these clinical outcomes. RELAX-AHF-2 is a multicentre, randomized, double-blind, placebo-controlled, event-driven, phase 3 trial enrolling ∼6800 patients hospitalized for AHF with dyspnoea, congestion on chest radiograph, increased natriuretic peptide levels, mild-to-moderate renal insufficiency, and systolic blood pressure ≥125 mmHg. Patients are randomized within 16 h of presentation to 48 h intravenous infusions of serelaxin (30 µg/kg/day) or placebo, both in addition to standard of care treatments. The primary objectives are to demonstrate that serelaxin is superior to placebo in reducing: (i) 180 day cardiovascular death, and (ii) occurrence of WHF through day 5. Key secondary endpoints include 180 day all-cause mortality, composite of 180 day combined cardiovascular mortality or heart failure/renal failure rehospitalization, and in-hospital length of stay during index AHF. The results from RELAX-AHF-2 will provide data on the potential beneficial effect of serelaxin on cardiovascular mortality and WHF in selected patients with AHF.
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Affiliation(s)
- John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | - Peter S Pang
- Indiana University School of Medicine, Department of Emergency Medicine and the Regenstrief Institute, Indianapolis, IN, USA
| | - Barry H Greenberg
- Division of Cardiology, University of California, San Diego, CA, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | - Gad Cotter
- Momentum Research, Inc., Durham, NC, USA
| | | | | | | | - Tsushung A Hua
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Unemori E. Serelaxin in clinical development: past, present and future. Br J Pharmacol 2017; 174:921-932. [PMID: 28009437 DOI: 10.1111/bph.13695] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/18/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
The availability of highly purified recombinant human relaxin, serelaxin, has allowed clinical trials to be conducted in several indications and the elucidation of its pharmacology in human subjects. These studies have demonstrated that serelaxin has unique haemodynamic properties that are likely to contribute to organ protection and long-term outcome benefits in acute heart failure. Clinical observations support its consideration for therapeutic use in other patient populations, including those with chronic heart failure, coronary artery disease, portal hypertension and acute renal failure. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Patil NA, Rosengren KJ, Separovic F, Wade JD, Bathgate RAD, Hossain MA. Relaxin family peptides: structure-activity relationship studies. Br J Pharmacol 2017; 174:950-961. [PMID: 27922185 DOI: 10.1111/bph.13684] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 12/21/2022] Open
Abstract
The human relaxin peptide family consists of seven cystine-rich peptides, four of which are known to signal through relaxin family peptide receptors, RXFP1-4. As these peptides play a vital role physiologically and in various diseases, they are of considerable importance for drug discovery and development. Detailed structure-activity relationship (SAR) studies towards understanding the role of important residues in each of these peptides have been reported over the years and utilized for the design of antagonists and minimized agonist variants. This review summarizes the current knowledge of the SAR of human relaxin 2 (H2 relaxin), human relaxin 3 (H3 relaxin), human insulin-like peptide 3 (INSL3) and human insulin-like peptide 5 (INSL5). LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Affiliation(s)
- Nitin A Patil
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,School of Chemistry, University of Melbourne, Parkville, VIC, Australia
| | - K Johan Rosengren
- Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, VIC, Australia
| | - Frances Separovic
- School of Chemistry, University of Melbourne, Parkville, VIC, Australia
| | - John D Wade
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,School of Chemistry, University of Melbourne, Parkville, VIC, Australia
| | - Ross A D Bathgate
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, VIC, Australia
| | - Mohammed Akhter Hossain
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,School of Chemistry, University of Melbourne, Parkville, VIC, Australia
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Pintalhao M, Castro‐Chaves P, Vasques‐Novoa F, Gonçalves F, Mendonça L, Fontes‐Carvalho R, Lourenço P, Almeida P, Leite‐Moreira A, Bettencourt P. Relaxin serum levels in acute heart failure are associated with pulmonary hypertension and right heart overload. Eur J Heart Fail 2016; 19:218-225. [DOI: 10.1002/ejhf.611] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/24/2016] [Accepted: 06/10/2016] [Indexed: 01/05/2023] Open
Affiliation(s)
- Mariana Pintalhao
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Paulo Castro‐Chaves
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Francisco Vasques‐Novoa
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Francisco Gonçalves
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
| | - Luís Mendonça
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Ricardo Fontes‐Carvalho
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
- Cardiology DepartmentGaia Hospital Centre Gaia Portugal
| | - Patrícia Lourenço
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Pedro Almeida
- Cardiology DepartmentSão João Hospital Centre Porto Portugal
| | - Adelino Leite‐Moreira
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
- Cardiothoracic Surgery DepartmentSão João Hospital Centre Porto Portugal
| | - Paulo Bettencourt
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
- Department of Medicine, Faculty of MedicineUniversity of Porto Portugal
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Lee YS, Choi JW, Oh JE, Yun CO, Kim SW. Human relaxin gene expression delivered by bioreducible dendrimer polymer for post-infarct cardiac remodeling in rats. Biomaterials 2016; 97:164-75. [PMID: 27174688 PMCID: PMC5448559 DOI: 10.1016/j.biomaterials.2016.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/12/2016] [Accepted: 04/21/2016] [Indexed: 02/06/2023]
Abstract
In consensus, myocardial infarction (MI) is defined as irreversible cell death secondary to prolonged ischemia in heart. The aim of our study was to evaluate the therapeutic potential of anti-fibrotic human Relaxin-expressing plasmid DNA with hypoxia response element (HRE) 12 copies (HR1) delivered by a dendrimer type PAM-ABP polymer G0 (HR1/G0) after MI on functional, hemodynamic, geometric, and cardiac extracellular matrix (ECM) remodeling in rats. HR1/G0 demonstrated significantly improved LV systolic function, hemodynamic parameters, and geometry on 1 wk and 4 wks after MI in rats, compared with I/R group. The resolution of regional wall motional abnormalities and the increased blood flow of infarct-related coronary artery supported functional improvements of HR1/G0. Furthermore, HR1/G0 polyplex showed favorable post-infarct cardiac ECM remodeling reflected on the favorable cardiac ECM compositions. Overall, this is the first study, which presented an advanced platform for the gene therapy that reverses adverse cardiac remodeling after MI with a HR1 gene delivered by a bioreducible dendrimer polymer in the cardiac ECM.
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Affiliation(s)
- Young Sook Lee
- Center for Controlled Chemical Delivery, Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112, USA
| | - Joung-Woo Choi
- Center for Controlled Chemical Delivery, Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112, USA
| | - Jung-Eun Oh
- Department of Bioengineering, College of Engineering, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, Republic of Korea
| | - Chae-Ok Yun
- Department of Bioengineering, College of Engineering, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, Republic of Korea.
| | - Sung Wan Kim
- Center for Controlled Chemical Delivery, Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112, USA; Department of Bioengineering, College of Engineering, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 133-791, Republic of Korea
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67
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Antifibrotic Actions of Serelaxin – New Roles for an Old Player. Trends Pharmacol Sci 2016; 37:485-497. [DOI: 10.1016/j.tips.2016.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 12/25/2022]
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Zhou H, Qu X, Gao Z, Zheng G, Lin J, Su L, Huang Z, Li H, Huang W. Relaxin Level in Patients With Atrial Fibrillation and Association with Heart Failure Occurrence: A STROBE Compliant Article. Medicine (Baltimore) 2016; 95:e3664. [PMID: 27227926 PMCID: PMC4902350 DOI: 10.1097/md.0000000000003664] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia requiring medical treatment and has been associated with enhanced atrial fibrosis and heart failure (HF). Relaxin (RLX), an antifibrosis and antiinflammatory peptide hormone, may be used to evaluate atrial fibrosis and is associated with HF occurrence in AF. We aimed to clarify the clinical significance of RLX level in patients with AF.We measured circulating levels of RLX and other fibrosis-related factors in 311 patients with sinus rhythm (SR; n = 116) or AF (n = 195). All discharged AF patients were followed up for the occurrence of HF for a mean of 6 months.Circulating levels of RLX were significantly different in patients with AF as compared with SR (P < 0.001), and in the subgroup analysis of AF. RLX level was correlated with left atrial diameter (LAD; R = 0.358, P < 0.001). Among followed up AF patients, on Kaplan-Meier curve analysis, patients with the third RLX tertile (T3) had a significantly higher HF rate than those with the 1st tertile (T1) (P = 0.002) and the cut-off value was 294.8 ng/L (area under the ROC curve [AUC] = 0.723). On multivariable analysis, HF occurrence with AF was associated with increased tertile of serum RLX level (odds ratio [OR] 2.659; confidence interval [95% CI] 1.434-4.930; P = 0.002).RLX is associated with fibrosis-related biomarkers and significantly elevated in AF. RLX was related to the HF occurrence in patients with AF.
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Affiliation(s)
- Hao Zhou
- From the Department of Cardiovascular Medicine, the First Affiliated Hospital of Wenzhou Medical University; The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
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69
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Abstract
Outcomes for patients with acute heart failure remain suboptimal and treatments principally target improvement of symptoms. To date there has been no therapy approved for acute heart failure shown to improve mortality or readmission risk post-discharge. Serelaxin, a recombinant form of the naturally occurring polypeptide hormone relaxin, has demonstrated promise in preclinical and early clinical trials as a potentially novel therapy for acute heart failure. It is postulated through its anti-fibrotic and vasodilatory effects that this agent can improve outcomes in both the short and long term in these patients. Randomized clinical data has suggested that the medication is safe and well tolerated. However, definitive outcomes data is currently being assessed in a large multi-center trial.
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Affiliation(s)
- Danyaal S Moin
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Michelle W Bloom
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Lampros Papadimitriou
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Javed Butler
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
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70
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Carillon J, Gauthier A, Barial S, Tournier M, Gayrard N, Lajoix AD, Jover B. Relaxin and atrial natriuretic peptide pathways participate in the anti-fibrotic effect of a melon concentrate in spontaneously hypertensive rats. Food Nutr Res 2016; 60:30985. [PMID: 27079780 PMCID: PMC4832218 DOI: 10.3402/fnr.v60.30985] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/04/2016] [Accepted: 03/17/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In spontaneously hypertensive rats (SHR), a model of human essential hypertension, oxidative stress is involved in the development of cardiac hypertrophy and fibrosis associated with hypertension. Dietary supplementation with agents exhibiting antioxidant properties could have a beneficial effect in remodeling of the heart. We previously demonstrated a potent anti-hypertrophic effect of a specific melon (Cucumis melo L.) concentrate with antioxidant properties in spontaneously hypertensive rats. Relaxin and atrial natriuretic peptide (ANP) were reported to reduce collagen deposition and fibrosis progression in various experimental models. OBJECTIVE The aim of the present investigation was to test the hypothesis that, beside reduction in oxidative stress, the melon concentrate may act through relaxin, its receptor (relaxin/insulin-like family peptide receptor 1, RXFP1), and ANP in SHR. DESIGN AND RESULTS The melon concentrate, given orally during 4 days, reduced cardiomyocyte size (by 25%) and totally reversed cardiac collagen content (Sirius red staining) in SHR but not in their normotensive controls. Treatment with the melon concentrate lowered cardiac nitrotyrosine-stained area (by 45%) and increased by 17-19% the cardiac expression (Western blot) of superoxide dismutase (SOD) and glutathione peroxidase. In addition, plasma relaxin concentration was normalized while cardiac relaxin (Western blot) was lowered in treated SHR. Cardiac relaxin receptor level determined by immunohistochemical analysis increased only in treated SHR. Similarly, the melon concentrate reversed the reduction of plasma ANP concentration and lowered its cardiac expression. CONCLUSIONS The present results demonstrate that reversal of cardiac fibrosis by the melon concentrate involves antioxidant defenses, as well as relaxin and ANP pathways restoration. It is suggested that dietary SOD supplementation could be a useful additional strategy against cardiac hypertrophy and fibrosis.
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Affiliation(s)
- Julie Carillon
- EA7288 Université de Montpellier, Montpellier, France.,Bionov Research, Montpellier, France
| | | | - Sandy Barial
- EA7288 Université de Montpellier, Montpellier, France
| | | | | | | | - Bernard Jover
- EA7288 Université de Montpellier, Montpellier, France;
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71
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Organ protection possibilities in acute heart failure. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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72
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Horn MA, Trafford AW. Aging and the cardiac collagen matrix: Novel mediators of fibrotic remodelling. J Mol Cell Cardiol 2016; 93:175-85. [PMID: 26578393 PMCID: PMC4945757 DOI: 10.1016/j.yjmcc.2015.11.005] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/02/2015] [Accepted: 11/04/2015] [Indexed: 01/05/2023]
Abstract
Cardiovascular disease is a leading cause of death worldwide and there is a pressing need for new therapeutic strategies to treat such conditions. The risk of developing cardiovascular disease increases dramatically with age, yet the majority of experimental research is executed using young animals. The cardiac extracellular matrix (ECM), consisting predominantly of fibrillar collagen, preserves myocardial integrity, provides a means of force transmission and supports myocyte geometry. Disruptions to the finely balanced control of collagen synthesis, post-synthetic deposition, post-translational modification and degradation may have detrimental effects on myocardial functionality. It is now well established that the aged heart is characterized by fibrotic remodelling, but the mechanisms responsible for this are incompletely understood. Furthermore, studies using aged animal models suggest that interstitial remodelling with disease may be age-dependent. Thus with the identification of new therapeutic strategies targeting fibrotic remodelling, it may be necessary to consider age-dependent mechanisms. In this review, we discuss remodelling of the cardiac collagen matrix as a function of age, whilst highlighting potential novel mediators of age-dependent fibrotic pathways.
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Affiliation(s)
- Margaux A Horn
- Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, 3.06 Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, United Kingdom.
| | - Andrew W Trafford
- Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, 3.06 Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, United Kingdom
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73
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Frati A, Ricci B, Pierucci F, Nistri S, Bani D, Meacci E. Role of sphingosine kinase/S1P axis in ECM remodeling of cardiac cells elicited by relaxin. Mol Endocrinol 2016; 29:53-67. [PMID: 25415609 DOI: 10.1210/me.2014-1201] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The initiation and progression of heart failure is linked to adverse cardiac remodeling of the extracellular matrix (ECM) during disease mainly through the deregulation of myocardial metalloproteinases (MMPs). Relaxin (RLX), a peptide hormone acting as a physiological cardiac effector, is a key regulator of ECM remodeling in reproductive and nonreproductive tissues. Studying primary cultures of mouse cardiac muscle cells and rat H9c2 cardiomyoblasts, we have obtained evidence for a new signaling pathway activated by RLX to induce ECM remodeling that involves the bioactive sphingolipids sphingosine-1-phosphate (S1P) and ceramide. In both cell populations, recombinant human RLX increased sphingosine kinase activity and S1P formation, whereas sphingomyelin and ceramide content were decreased in [(3)H]serine-labeled cells. According to the literature, RLX promoted MMP-2 and MMP-9 expression/release. Pharmacological inhibition of sphingolipid metabolism and silencing of sphingosine kinase 1, the enzyme responsible for S1P formation, were able to prevent MMP expression/release elicited by the hormone and induce the expression of tissue inhibitor of MMPs. In addition, we found that sphingolipid signaling is required for the regulation of connective tissue growth factor, a member of the CCN 1-3 family of genes that are involved in cell proliferation and differentiation. Finally, the induction of cardiomyoblast maturation induced by RLX was also found to be counteracted by inhibition of S1P formation. In conclusion, these findings provide a novel mechanism by which RLX acts on cardiac ECM remodeling and cardiac cell differentiation and offer interesting therapeutic options to prevent heart fibrosis and to favor myocardial regeneration.
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Affiliation(s)
- Alessia Frati
- Department of Biomedical, Experimental, and Clinical Sciences (A.F., B.R., F.P., E.M.), Research Unit of Biochemistry, and Department of Experimental and Clinical Medicine (S.N., D.B.), Research Unit of Histology and Embryology, University of Florence, 50134 Florence, Italy
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74
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Montero-Pérez-Barquero M, Morales-Rull JL. Organ protection possibilities in acute heart failure. Rev Clin Esp 2016; 216:157-64. [PMID: 26896381 DOI: 10.1016/j.rce.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Unlike chronic heart failure (HF), the treatment for acute HF has not changed over the last decade. The drugs employed have shown their ability to control symptoms but have not achieved organ protection or managed to reduce medium to long-term morbidity and mortality. Advances in our understanding of the pathophysiology of acute HF suggest that treatment should be directed not only towards correcting the haemodynamic disorders and achieving symptomatic relief but also towards preventing organ damage, thereby counteracting myocardial remodelling and cardiac and extracardiac disorders. Compounds that exert vasodilatory and anti-inflammatory action in the acute phase of HF and can stop cell death, thereby boosting repair mechanisms, could have an essential role in organ protection.
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Affiliation(s)
- M Montero-Pérez-Barquero
- Servicio de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Reina Sofía, Universidad de Córdoba, Córdoba, España.
| | - J L Morales-Rull
- Unidad de Insuficiencia Cardiaca, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Región Sanitaria de Lleida, Lleida, España
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75
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Human Mesenchymal Stem Cell Delivery System Modulates Ischemic Cardiac Remodeling With an Increase of Coronary Artery Blood Flow. Mol Ther 2016; 24:805-11. [PMID: 26782638 DOI: 10.1038/mt.2016.22] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/10/2016] [Indexed: 12/25/2022] Open
Abstract
Ways for extending the longevity of stem cells are imperative to attain diverse expected therapeutic effects. Here, we constructed a three-dimentional (3D) scaffold system for human mesenchymal stem cell (hMSC) delivery. Intramyocardial injections of porous PEI1.8k blended with poly(lactic-co-glycolic acid) (PLGA) (PLGA/PEI1.8k) (PPP) microparticles by physical electrostatic conjugation and structural entrapment of hMSCs demonstrated enhanced functional and geometric improvements on post-infarct cardiac remodeling in rats. In the hMSC-loaded PPP delivery, increases of coronary artery blood flow rate and in vivo engraftment rate as well as time-dependent functional, geometric, and pathologic findings reversing post-infarct cardiac remodeling account for improved left ventricular (LV) systolic function up to the level of sham thoracotomy group. This study expands our understanding by proving that increase of coronary artery blood flow augmented functional recovery of hMSC-loaded PPP delivery system after myocardial infarction (MI).
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76
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Abstract
Although the period from 1953 to 2001 resulted in the approval of more than 30 medications currently used to treat heart failure (HF), few novel drugs have been approved in the last decade. However, the investigational pipeline for HF medications once again appears promising. In patients with chronic heart failure with reduced ejection fraction (HFrEF), ivabradine and valsartan/sucubitril (LCZ696) were recently approved by the US Food and Drug Administration. Both agents have been shown to reduce the risk of cardiovascular death and HF hospitalization. In the treatment of acute HF, serelaxin and ularitide are the farthest along in development. Both agents have demonstrated favorable effects on surrogate end points and preliminary data suggest a possible mortality benefit with serelaxin. Consequently, phase 3 trials are ongoing to evaluate the effect of serelaxin and ularitide on clinical outcomes. Given the poor history of recent investigational acute HF drugs that have advanced to phase 3/4 studies, enthusiasm for both serelaxin and ularitide must be tempered until these trials are completed.
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Affiliation(s)
- Sarah Hanigan
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert J. DiDomenico
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
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Bonanno A, Riccobono L, Bonsignore MR, Lo Bue A, Salvaggio A, Insalaco G, Marrone O. Relaxin in Obstructive Sleep Apnea: Relationship with Blood Pressure and Inflammatory Mediators. Respiration 2016; 91:56-62. [PMID: 26731435 DOI: 10.1159/000443182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with nocturnal intermittent hypoxia, which may be responsible for increased circulating levels of vascular endothelial growth factor (VEGF) and inflammatory mediators, such as metalloproteinases (MMPs), and which contributes to the pathogenesis of systemic hypertension. Why some OSA patients remain normotensive is poorly understood. Relaxin-2, a pregnancy hormone, may sometimes circulate in men and could increase in hypoxic conditions. It exerts a vasodilatory activity and can modulate the release of molecules, such as MMPs and VEGF. OBJECTIVES The objective of this study was to explore if circulating relaxin-2 in male OSA subjects may be related to OSA severity, to circulating levels of MMPs, of their inhibitors (tissue inhibitors of metalloproteinases; TIMPs), and of VEGF, and if it may protect from hypertension. PATIENTS AND METHODS Fifty untreated male subjects with suspected OSA were recruited. After nocturnal polysomnography, a morning venous blood sample was withdrawn. Then, 24-hour ambulatory blood pressure (BP) monitoring was performed. RESULTS The respiratory disturbance index in the sample was 30.4 [interquartile range (IQR) 15.6-55.2]. Relaxin-2 was detectable in 20 subjects. These subjects did not differ in OSA severity or diurnal and nocturnal BP from subjects with undetectable relaxin-2, but they showed lower TIMP-1 (126.8 ± 29.1 vs. 156.9 ± 41.7 pg/ml, respectively; p = 0.007) and a marginally higher MMP-9/TIMP-1 molar ratio [0.58 (IQR 0.23-1.35) vs. 0.25 (IQR 0.15-0.56); p = 0.052]. CONCLUSIONS Relaxin-2 in male subjects was not related to OSA severity, but it was associated with lower TIMP-1. As it was often undetectable, even when BP values were normal, it is unlikely that it plays a role as a major factor protecting from hypertension in OSA.
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Affiliation(s)
- Anna Bonanno
- National Research Council, Institute of Biomedicine and Molecular Immunology x2018;A. Monroy', Palermo, Italy
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78
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Abstract
With the total cases and economic burden of heart failure continuing to rise, there is an overwhelming need for novel therapies. Several drugs for heart failure have succeeded in preclinical and early-phase clinical trials, but most of them failed to show the real benefit in pivotal clinical trials. Meanwhile, the US Food and Drug Administration recently approved two promising new drugs to treat heart failure: ivabradine and sacubitril/valsartan. Furthermore, some of the newer agents in testing offer the potential for significant progress in addition to these drugs. Patiromer and zirconium cyclosilicate are attractive agents that are expected to prevent hyperkalemia during renin-angiotensin-aldosterone system inhibition, and serelaxin and urodilatin are promising drugs in the treatment of acute heart failure. Future clinical trials with more appropriate study designs, optimal clinical endpoints, and proper patient selection are mandatory to assess the true efficacy of these attractive compounds in clinical practice.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wh Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, USA
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79
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Díez J, Ruilope LM. Serelaxin for the treatment of acute heart failure: a review with a focus on end-organ protection. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:119-30. [PMID: 27418970 PMCID: PMC4853824 DOI: 10.1093/ehjcvp/pvv046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/26/2015] [Indexed: 12/15/2022]
Abstract
Acute heart failure (AHF) is a complex clinical syndrome characterized by fluid overload and haemodynamic abnormalities (short-term clinical consequences) and the development of end-organ damage (long-term consequences). Current therapies for the treatment of AHF, such as loop diuretics and vasodilators, help to relieve haemodynamic imbalance and congestion, but have not been shown to prevent (and may even contribute to) end-organ damage, or to provide long-term clinical benefit. Serelaxin is the recombinant form of human relaxin-2, a naturally occurring hormone involved in mediating haemodynamic changes during pregnancy. Preclinical and clinical studies have investigated the effects mediated by serelaxin and the suitability of this agent for the treatment of patients with AHF. Data suggest that serelaxin acts via multiple pathways to improve haemodynamics at the vascular, cardiac, and renal level and provide effective congestion relief. In addition, this novel agent may protect the heart, kidneys, and liver from damage by inhibiting inflammation, oxidative stress, cell death, and tissue fibrosis, and stimulating angiogenesis. Serelaxin may therefore improve both short- and long-term outcomes in patients with AHF. In this review, we examine the unique mechanisms underlying the potential benefits of serelaxin for the treatment of AHF, in particular, those involved in mediating end-organ protection.
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Affiliation(s)
- Javier Díez
- Program of Cardiovascular Diseases, Centre for Applied Medical Research and Department of Cardiology and Cardiac Surgery, University of Navarra Clinic, University of Navarra, Av. Pío XII 55, Pamplona 31008, Spain
| | - Luis M Ruilope
- Research Institute, Hypertension Unit, Hospital 12 de Octubre and Department of Public Health and Preventive Medicine, University Autónoma, Madrid, Spain
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80
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Tietjens J, Teerlink JR. Serelaxin and acute heart failure. Heart 2015; 102:95-9. [DOI: 10.1136/heartjnl-2014-306786] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/02/2015] [Indexed: 01/11/2023] Open
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Raleigh JMV, Toldo S, Das A, Abbate A, Salloum FN. Relaxin' the Heart: A Novel Therapeutic Modality. J Cardiovasc Pharmacol Ther 2015; 21:353-62. [PMID: 26589290 DOI: 10.1177/1074248415617851] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/22/2015] [Indexed: 12/20/2022]
Abstract
The peptide hormone relaxin has traditionally been linked to the maternal adaptation of the cardiovascular system during the first trimester of pregnancy. By promoting nitric oxide formation through different molecular signaling events, relaxin has been proposed as a pleiotropic and cardioprotective hormone in the setting of many cardiovascular diseases. In fact, preclinical studies were able to demonstrate that relaxin promotes vasodilatation and angiogenesis, ameliorates ischemia/reperfusion injury, and regulates extracellular matrix turnover and remodeling. In the RELAX-AHF phase 3 clinical trial, serelaxin (recombinant human relaxin) was shown to be safe, and it exerted survival benefits in patients with acute heart failure. RELAX-AHF-2 is currently ongoing, and it aims to address a larger population and evaluate harder clinical outcomes. Besides heart failure, acute myocardial infarction, peripheral arterial disease, and stable coronary disease could be target diseases for treatment with serelaxin in future clinical trials.
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Affiliation(s)
- Juan M Valle Raleigh
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Stefano Toldo
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Anindita Das
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Fadi N Salloum
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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82
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Dahlke M, Halabi A, Canadi J, Tsubouchi C, Machineni S, Pang Y. Pharmacokinetics of serelaxin in patients with severe renal impairment or end-stage renal disease requiring hemodialysis: A single-dose, open-label, parallel-group study. J Clin Pharmacol 2015; 56:474-83. [PMID: 26239266 PMCID: PMC5063144 DOI: 10.1002/jcph.607] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/31/2015] [Indexed: 11/08/2022]
Abstract
Serelaxin, a recombinant human relaxin-2 hormone, is in clinical development for treating acute heart failure. This open-label, parallel-group study investigated serelaxin pharmacokinetics (PK) after a single 4-hour intravenous infusion (10 µg/kg) in patients with severe renal impairment (n = 6) or end-stage renal disease (ESRD) requiring hemodialysis (PK on the day of dialysis [n = 6] or during dialysis-free interval [n = 6]), compared with matched healthy subjects (n = 18). In all participants, serum serelaxin concentration peaked at the end of infusion and subsequently declined with mean terminal elimination half-life of 6.5-8.8 hours. Compared with healthy subjects, a moderate decrease in serelaxin systemic clearance (37%-52%) and increase in its exposure (30%-115%) were observed in all patients. During the 4-hour hemodialysis in ESRD patients, 30% serelaxin was removed, with hemodialysis clearance constituting approximately 52% of total systemic clearance. Serelaxin was well tolerated with no deaths, serious adverse events (AE), or AE-related discontinuations. Antiserelaxin antibodies were not detected in any participant. Given the shallow dose-response relationship observed with serelaxin in clinical studies and its wide therapeutic window, the observed PK differences in patients with severe renal impairment compared with healthy subjects are unlikely to pose a safety risk and do not warrant a predefined dosage adjustment in such patients.
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Affiliation(s)
| | - Atef Halabi
- Clinical Research Services GmbH, Kiel, Germany
| | | | | | | | - Yinuo Pang
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
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83
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Halls ML, Bathgate RAD, Sutton SW, Dschietzig TB, Summers RJ. International Union of Basic and Clinical Pharmacology. XCV. Recent advances in the understanding of the pharmacology and biological roles of relaxin family peptide receptors 1-4, the receptors for relaxin family peptides. Pharmacol Rev 2015; 67:389-440. [PMID: 25761609 DOI: 10.1124/pr.114.009472] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Relaxin, insulin-like peptide 3 (INSL3), relaxin-3, and INSL5 are the cognate ligands for the relaxin family peptide (RXFP) receptors 1-4, respectively. RXFP1 activates pleiotropic signaling pathways including the signalosome protein complex that facilitates high-sensitivity signaling; coupling to Gα(s), Gα(i), and Gα(o) proteins; interaction with glucocorticoid receptors; and the formation of hetero-oligomers with distinctive pharmacological properties. In addition to relaxin-related ligands, RXFP1 is activated by Clq-tumor necrosis factor-related protein 8 and by small-molecular-weight agonists, such as ML290 [2-isopropoxy-N-(2-(3-(trifluoromethylsulfonyl)phenylcarbamoyl)phenyl)benzamide], that act allosterically. RXFP2 activates only the Gα(s)- and Gα(o)-coupled pathways. Relaxin-3 is primarily a neuropeptide, and its cognate receptor RXFP3 is a target for the treatment of depression, anxiety, and autism. A variety of peptide agonists, antagonists, biased agonists, and an allosteric modulator target RXFP3. Both RXFP3 and the related RXFP4 couple to Gα(i)/Gα(o) proteins. INSL5 has the properties of an incretin; it is secreted from the gut and is orexigenic. The expression of RXFP4 in gut, adipose tissue, and β-islets together with compromised glucose tolerance in INSL5 or RXFP4 knockout mice suggests a metabolic role. This review focuses on the many advances in our understanding of RXFP receptors in the last 5 years, their signal transduction mechanisms, the development of novel compounds that target RXFP1-4, the challenges facing the field, and current prospects for new therapeutics.
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Affiliation(s)
- Michelle L Halls
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Ross A D Bathgate
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Steve W Sutton
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Thomas B Dschietzig
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Roger J Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
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84
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Pai P. Cardiorenal syndrome. Int J Organ Transplant Med 2015. [DOI: 10.1016/j.hkjn.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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85
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Abstract
Heart failure (HF) can rightfully be called the epidemic of the 21(st) century. Historically, the only available medical treatment options for HF have been diuretics and digoxin, but the capacity of these agents to alter outcomes has been brought into question by the scrutiny of modern clinical trials. In the past 4 decades, neurohormonal blockers have been introduced into clinical practice, leading to marked reductions in morbidity and mortality in chronic HF with reduced left ventricular ejection fraction (LVEF). Despite these major advances in pharmacotherapy, our understanding of the underlying disease mechanisms of HF from epidemiological, clinical, pathophysiological, molecular, and genetic standpoints remains incomplete. This knowledge gap is particularly evident with respect to acute decompensated HF and HF with normal (preserved) LVEF. For these clinical phenotypes, no drug has been shown to reduce long-term clinical event rates substantially. Ongoing developments in the pharmacotherapy of HF are likely to challenge our current best-practice algorithms. Novel agents for HF therapy include dual-acting neurohormonal modulators, contractility-enhancing agents, vasoactive and anti-inflammatory peptides, and myocardial protectants. These novel compounds have the potential to enhance our armamentarium of HF therapeutics.
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Affiliation(s)
- Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital Ullevål, 0407 Oslo, Norway
| | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
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86
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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87
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Nistri S, Di Cesare Mannelli L, Ghelardini C, Zanardelli M, Bani D, Failli P. Pretreatment with Relaxin Does Not Restore NO-Mediated Modulation of Calcium Signal in Coronary Endothelial Cells Isolated from Spontaneously Hypertensive Rats. Molecules 2015; 20:9524-35. [PMID: 26016544 PMCID: PMC6272299 DOI: 10.3390/molecules20069524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 11/16/2022] Open
Abstract
We demonstrated that in coronary endothelial cells (RCEs) from normotensive Wistar Kyoto rats (WKY), the hormone relaxin (RLX) increases NO production and reduces calcium transients by a NO-related mechanism. Since an impairment of the NO pathway has been described in spontaneously hypertensive rats (SHR), the present study was aimed at exploring RLX effects on RCEs from SHR, hypothesizing that RLX could restore calcium responsiveness to NO. RCEs were isolated from WKY and SHR. Calcium transients were evaluated by image analysis after the administration of angiotensin II or α-thrombin. Angiotensin II (1 µM) caused a prompt rise of [Ca2+]i in WKY and SHR RCEs and a rapid decrease, being the decay time higher in SHR than in WKY. NOS inhibition increased calcium transient in WKY, but not in SHR RCEs. Whereas RLX pretreatment (24 h, 60 ng/mL) was ineffective in SHR, it strongly reduced calcium transient in WKY in a NO-dependent way. A similar behavior was measured using 30 U/mL α-thrombin. The current study offers evidence that RLX cannot restore NO responsiveness in SHR, suggesting an accurate selection of patients eligible for RLX treatment of cardiovascular diseases.
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Affiliation(s)
- Silvia Nistri
- Departments of Clinical & Experimental Medicine, Research Unit of Histology & Embryology University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
| | - Lorenzo Di Cesare Mannelli
- NEUROFARBA, Section of Pharmacology & Toxicology, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
| | - Carla Ghelardini
- NEUROFARBA, Section of Pharmacology & Toxicology, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
| | - Matteo Zanardelli
- NEUROFARBA, Section of Pharmacology & Toxicology, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
| | - Daniele Bani
- Departments of Clinical & Experimental Medicine, Research Unit of Histology & Embryology University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
| | - Paola Failli
- NEUROFARBA, Section of Pharmacology & Toxicology, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy.
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88
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Sato N, Takahashi W, Hirayama A, Ajioka M, Takahashi N, Okishige K, Wang X, Maki A, Maruyama H, Ebinger U, Yamaguchi M, Pang Y, Matsumoto H, Kawana M. Multicenter, Randomized, Double-Blinded, Placebo-Controlled Phase II Study of Serelaxin in Japanese Patients With Acute Heart Failure. Circ J 2015; 79:1237-47. [PMID: 25912697 DOI: 10.1253/circj.cj-15-0227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Serelaxin, a recombinant form of human relaxin-2, is in development for treating acute heart failure (AHF) and a Phase II study in Japanese AHF patients was conducted. METHODS AND RESULTS A randomized, double-blind, placebo-controlled study of serelaxin at 10 and 30 µg·kg(-1)·day(-1)continuous intravenous infusion for up to 48 h, added to standard care for Japanese AHF patients. Primary endpoints were adverse events (AEs) through Day 5, serious AEs (SAEs) through Day 14, and serelaxin pharmacokinetics. Secondary endpoints included changes in systolic blood pressure (SBP) and cardiorenal biomarkers. A total of 46 patients received the study drug and were followed for 60 days. The observed AE profile was comparable between the groups, with no AEs of concern. Dose-dependent increase in the serum concentration of serelaxin was observed across the 2 dose rates of serelaxin. A greater reduction in SBP was observed with serelaxin 30 µg·kg(-1)·day(-1)vs. placebo (-7.7 [-16.4, 1.0] mmHg). A greater reduction in NT-proBNP was noted with serelaxin (-50.8% and -54.9% for 10 and 30 µg·kg(-1)·day(-1), respectively at Day 2). CONCLUSIONS Serelaxin was well tolerated in this study with Japanese AHF patients, with no AEs of concern and favorable beneficial trends on efficacy. These findings support further evaluation of serelaxin 30 µg·kg(-1)·day(-1)in this patient population.
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Affiliation(s)
- Naoki Sato
- Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital
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89
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Schmieder RE, Mitrovic V, Hengstenberg C. Renal impairment and worsening of renal function in acute heart failure: can new therapies help? The potential role of serelaxin. Clin Res Cardiol 2015; 104:621-31. [PMID: 25787721 DOI: 10.1007/s00392-015-0839-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/04/2015] [Indexed: 12/29/2022]
Abstract
Renal dysfunction is a frequent finding in patients with acute heart failure (AHF) and an important prognostic factor for adverse outcomes. Worsening of renal function occurs in 30-50% of patients hospitalised for AHF, and is associated with increased mortality, prolonged hospital stay and increased risk of readmission. Likely mechanisms involved in the decrease in renal function include impaired haemodynamics and activation of neurohormonal factors, such as the renin-angiotensin-aldosterone system, the sympathetic nervous system and the arginine-vasopressin system. Additionally, many drugs currently used to treat AHF have a detrimental effect on renal function. Therefore, pharmacotherapy for AHF should carefully take into account any potential complications related to renal function. Serelaxin, currently in clinical development for the treatment of AHF is a recombinant form of human relaxin-2, identical in structure to the naturally occurring human relaxin-2 peptide hormone that mediates cardiac and renal adaptations during pregnancy. Data from both pre-clinical and clinical studies indicate a potentially beneficial effect of serelaxin on kidney function. In this review, we discuss the mechanisms and impact of impairment of renal function in AHF, and the potential benefits of new therapies, such as serelaxin, in this context.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital of the University Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany,
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90
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Wilson SS, Ayaz SI, Levy PD. Relaxin: A Novel Agent for the Treatment of Acute Heart Failure. Pharmacotherapy 2015; 35:315-27. [DOI: 10.1002/phar.1548] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Suprat S. Wilson
- Department of Pharmacy; Detroit Receiving Hospital; Detroit Michigan
| | - Syed I. Ayaz
- Department of Emergency Medicine; Wayne State University School of Medicine; Detroit Michigan
| | - Phillip D. Levy
- Department of Emergency Medicine; Cardiovascular Research Institute; Wayne State University School of Medicine; Detroit Michigan
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91
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Abstract
PURPOSE Relaxin, a new drug for heart failure therapy, exerts its cardiac actions through relaxin family peptide receptor 1 (RXFP1). Factors regulating RXFP1 expression remain unknown. We have investigated effects of activation of adrenoceptors (AR), an important modulator in the development and prognosis of heart failure, on expression of RXFP1 in rat cardiomyocytes and mouse left ventricles (LV). METHODS Expression of RXFP1 at mRNA (real-time PCR) and protein levels (immunoblotting) was measured in cardiomyocytes treated with α- and β-AR agonists or antagonists. RXFP1 expression was also determined in the LV of transgenic mouse strains with cardiac-restricted overexpression of α1A-, α1B- or β2-AR. Specific inhibitors were used to explore signal pathways involved in α1-AR mediated regulation of RXFP1 in cardiomyocytes. RESULTS In cultured cardiomyocytes, α1-AR stimulation resulted in 2-3 fold increase in RXFP1 mRNA (P < 0.001), which was blocked by specific inhibitors for protein kinase C (PKC) or mitogen-activated protein kinases/extracellular signal-regulated kinases (MAPK/ERK). Activation of β1-, but not β2-AR, significantly inhibited RXFP1 expression (P < 0.001). Relative to respective wild-type controls, RXFP1 mRNA levels in the LV of mice overexpressing α1A- or α1B-AR were increased by 3- or 10-fold, respectively, but unchanged in β2-AR transgenic hearts. Upregulation by α1-AR stimulation RXFP1 expression was confirmed at protein levels both in vitro and in vivo. CONCLUSIONS Expression of RXFP1 was up-regulated by α1-AR but suppressed by β-AR, mainly β1-AR subtype, in cardiomyocytes. Future studies are warranted to characterize the functional significance of such regulation, especially in the setting of heart failure.
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92
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Synthetic covalently linked dimeric form of H2 relaxin retains native RXFP1 activity and has improved in vitro serum stability. BIOMED RESEARCH INTERNATIONAL 2015; 2015:731852. [PMID: 25685807 PMCID: PMC4317577 DOI: 10.1155/2015/731852] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/11/2014] [Indexed: 11/18/2022]
Abstract
Human (H2) relaxin is a two-chain peptide member of the insulin superfamily and possesses potent pleiotropic roles including regulation of connective tissue remodeling and systemic and renal vasodilation. These effects are mediated through interaction with its cognate G-protein-coupled receptor, RXFP1. H2 relaxin recently passed Phase III clinical trials for the treatment of congestive heart failure. However, its in vivo half-life is short due to its susceptibility to proteolytic degradation and renal clearance. To increase its residence time, a covalent dimer of H2 relaxin was designed and assembled through solid phase synthesis of the two chains, including a judiciously monoalkyne sited B-chain, followed by their combination through regioselective disulfide bond formation. Use of a bisazido PEG7 linker and "click" chemistry afforded a dimeric H2 relaxin with its active site structurally unhindered. The resulting peptide possessed a similar secondary structure to the native monomeric H2 relaxin and bound to and activated RXFP1 equally well. It had fewer propensities to activate RXFP2, the receptor for the related insulin-like peptide 3. In human serum, the dimer had a modestly increased half-life compared to the monomeric H2 relaxin suggesting that additional oligomerization may be a viable strategy for producing longer acting variants of H2 relaxin.
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93
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Foster SR, Roura E, Molenaar P, Thomas WG. G protein-coupled receptors in cardiac biology: old and new receptors. Biophys Rev 2015; 7:77-89. [PMID: 28509979 DOI: 10.1007/s12551-014-0154-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/25/2014] [Indexed: 12/21/2022] Open
Abstract
G protein-coupled receptors (GPCRs) are seven-transmembrane-spanning proteins that mediate cellular and physiological responses. They are critical for cardiovascular function and are targeted for the treatment of hypertension and heart failure. Nevertheless, current therapies only target a small fraction of the cardiac GPCR repertoire, indicating that there are many opportunities to investigate unappreciated aspects of heart biology. Here, we offer an update on the contemporary view of GPCRs and the complexities of their signalling, and review the roles of the 'classical' GPCRs in cardiovascular physiology and disease. We then provide insights into other GPCRs that have been less extensively studied in the heart, including orphan, odorant and taste receptors. We contend that these novel cardiac GPCRs contribute to heart function in health and disease and thereby offer exciting opportunities to therapeutically modulate heart function.
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Affiliation(s)
- Simon R Foster
- School of Biomedical Sciences, University of Queensland, St Lucia Campus, 4072, Brisbane, Australia
| | - Eugeni Roura
- School of Biomedical Sciences, University of Queensland, St Lucia Campus, 4072, Brisbane, Australia.,Centre for Nutrition & Food Sciences, Queensland Alliance for Agriculture and Food Innovation, University of Queensland, St Lucia Campus, Brisbane, Australia
| | - Peter Molenaar
- Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, St Lucia Campus, Brisbane, Australia.,School of Medicine, University of Queensland, St Lucia Campus, Brisbane, Australia
| | - Walter G Thomas
- School of Biomedical Sciences, University of Queensland, St Lucia Campus, 4072, Brisbane, Australia.
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94
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Bathula SR, Akondi SM, Mainkar PS, Chandrasekhar S. “Pruning of biomolecules and natural products (PBNP)”: an innovative paradigm in drug discovery. Org Biomol Chem 2015; 13:6432-48. [DOI: 10.1039/c5ob00403a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Smart Schneider: ‘Nature’ is the most intelligent tailor with an ability to utilize the resources. Researchers are still at an infant stage learning this art. The present review highlights some of the man made pruning of bio-molecules and NPs (PBNP) in finding chemicals with a better therapeutic index.
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Affiliation(s)
- Surendar Reddy Bathula
- Division of Natural Products Chemistry CSIR-Indian Institute of Chemical Technology
- Hyderabad
- 500007 India
| | - Srirama Murthy Akondi
- Division of Natural Products Chemistry CSIR-Indian Institute of Chemical Technology
- Hyderabad
- 500007 India
| | - Prathama S. Mainkar
- Division of Natural Products Chemistry CSIR-Indian Institute of Chemical Technology
- Hyderabad
- 500007 India
| | - Srivari Chandrasekhar
- Division of Natural Products Chemistry CSIR-Indian Institute of Chemical Technology
- Hyderabad
- 500007 India
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95
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Abstract
Heart failure is a complex clinical syndrome responsible for high morbidity and mortality in the world. Despite advances in the management of heart failure, the prognosis of these patients remains poor and there is a critical need for new treatment strategies improving the clinical outcomes. New approaches in heart failure therapies target cellular mechanisms, as well as mechanical and structural aspects of heart failure that are not addressed by recent therapies. These include abnormalities in molecular mechanisms, electrical conduction and ventricular remodeling. This review presents the pathophysiological basis, mechanisms of action and available clinical efficacy and safety data of drugs and mechanical therapies that are currently under development.
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96
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Abstract
Acute heart failure (AHF) is characterized by high morbidity and mortality and high costs. Although the treatment of AHF has not changed substantially in recent decades, it is becoming clear that treatment strategies for AHF need to address both the immediate hemodynamic abnormalities giving rise to congestion as well as prevent organ damage that can influence long-term prognosis. Serelaxin, the recombinant form of human relaxin-2, a naturally occurring peptide hormone, has been found to significantly improve symptoms and signs of AHF, prevent in-hospital worsening heart failure, as well as significantly improve 180-day cardiovascular and all-cause mortality after a 48-h infusion commenced within 16 h of presentation (RELAX-AHF study). Available data suggest that the clinical benefits may be attributable to a potential combination of multiple actions of serelaxin, including improving systemic, cardiac, and renal hemodynamics, and protecting cells and organs from damage via anti-inflammatory, anti-cell death, anti-fibrotic, anti-hypertrophic, and pro-angiogenic effects. This manuscript describes the short- and long-term effects of serelaxin in AHF patients, analyzing how these effects can be explained by taking into account the range of hemodynamic and non-hemodynamic actions of serelaxin. In addition, this paper also addresses several aspects related to the role of serelaxin in the therapy of AHF that remain to be clarified and warrant further investigation.
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97
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Fernández-Alfonso MS, Ruilope LM. One Step Forward for Serelaxin as a Promising Therapy in Cardiac Fibrosis. Hypertension 2014; 64:229-30. [DOI: 10.1161/hypertensionaha.114.03642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- María S. Fernández-Alfonso
- From the Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain (M.S.F.-A.); and Unidad de Hipertensión, Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain (L.M.R.)
| | - Luis Miguel Ruilope
- From the Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain (M.S.F.-A.); and Unidad de Hipertensión, Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain (L.M.R.)
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98
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Roubille F, Morena M, Leray-Moragues H, Canaud B, Cristol JP, Klouche K. Pharmacologic Therapies for Chronic and Acute Decompensated Heart Failure: Specific Insights on Cardiorenal Syndromes. Blood Purif 2014; 37 Suppl 2:20-33. [DOI: 10.1159/000361061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Orso F, Fabbri G, Baldasseroni S, Maggioni AP. Newest additions to heart failure treatment. Expert Opin Pharmacother 2014; 15:1849-61. [PMID: 24989872 DOI: 10.1517/14656566.2014.934812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Despite the improvement in heart failure (HF) therapy in the last 30 years, this condition remains a major public health concern with high hospitalization and mortality rates, and related costs. Recently, new pharmacological approaches are under evaluation. AREAS COVERED For chronic HF with reduced ejection fraction (EF) direct renin inhibitors, neprilysin-angiotensin II receptor inhibitors and aldosterone synthase inhibitors have been tested. For HF with preserved EF, no therapy has been demonstrated up to now to be able to improve patients' outcomes and it remains a substantial unmet need. In acute HF (AHF) new inotropes and vasodilators have been developed and are currently investigated in trials. In this review, mechanism of action and clinical efficacy of new pharmacological approaches on acute and chronic HF will be discussed. EXPERT OPINION In patients with HF, some unmet needs remain to be challenged in the near future. For patients with chronic HF, the management of comorbidities, a better definition and treatment of patients with preserved EF are the major issues to be solved. The treatment of patients admitted for AHF is even more compelling. Several hypotheses of research focused on these issues are tested in ongoing trials.
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Affiliation(s)
- Francesco Orso
- Azienda Ospedaliero-Universitaria Careggi, Department of Heart and Vessel, Section of Geriatric Medicine and Cardiology , Florence , Italy
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Affiliation(s)
- Klaas Poelstra
- Department of Pharmacokinetics, Toxicology & Targeting, University of Groningen, The Netherlands
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