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Venglovecz V, Hegyi P. GPR30 is a potential player between islet cells and ductal HCO 3- secretion. Cell Calcium 2024; 123:102922. [PMID: 38924880 DOI: 10.1016/j.ceca.2024.102922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
The primary role of pancreatic ductal HCO3- secretion is to prevent premature activation of digestive enzymes and to provide a vehicle for the delivery of enzymes to the duodenum. In addition, HCO3-is responsible for the neutralization of gastric juice and protect against the formation of protein plugs and viscous mucus. Due to this multifaceted role of HCO3- in the pancreas, its altered functioning can greatly contribute to the development of various exocrine diseases. It is well known that the exocrine and endocrine pancreas interact lively with each other, but not all details of this relationship are known. An interesting finding of a recent study by Jo-Watanabe et al. is that the G protein-coupled oestrogen receptor, GPR30, which is expressed in the endocrine pancreas, can be also activated by HCO3-. This raises the possibility that ductal cells play a key role not only in the exocrine pancreas, but presumably also in endocrine function through HCO3- secretion.
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Affiliation(s)
- Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary; Translational Pancreatology Research Group, Interdisciplinary Center of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary; Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Translational Pancreatology Research Group, Interdisciplinary Center of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary; Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute for Pancreatic Disorders, Semmelweis University, Budapest, Hungary.
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2
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Folz J, Culver RN, Morales JM, Grembi J, Triadafilopoulos G, Relman DA, Huang KC, Shalon D, Fiehn O. Human metabolome variation along the upper intestinal tract. Nat Metab 2023; 5:777-788. [PMID: 37165176 PMCID: PMC10229427 DOI: 10.1038/s42255-023-00777-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/03/2023] [Indexed: 05/12/2023]
Abstract
Most processing of the human diet occurs in the small intestine. Metabolites in the small intestine originate from host secretions, plus the ingested exposome1 and microbial transformations. Here we probe the spatiotemporal variation of upper intestinal luminal contents during routine daily digestion in 15 healthy male and female participants. For this, we use a non-invasive, ingestible sampling device to collect and analyse 274 intestinal samples and 60 corresponding stool homogenates by combining five mass spectrometry assays2,3 and 16S rRNA sequencing. We identify 1,909 metabolites, including sulfonolipids and fatty acid esters of hydroxy fatty acids (FAHFA) lipids. We observe that stool and intestinal metabolomes differ dramatically. Food metabolites display trends in dietary biomarkers, unexpected increases in dicarboxylic acids along the intestinal tract and a positive association between luminal keto acids and fruit intake. Diet-derived and microbially linked metabolites account for the largest inter-individual differences. Notably, two individuals who had taken antibiotics within 6 months before sampling show large variation in levels of bioactive FAHFAs and sulfonolipids and other microbially related metabolites. From inter-individual variation, we identify Blautia species as a candidate to be involved in FAHFA metabolism. In conclusion, non-invasive, in vivo sampling of the human small intestine and ascending colon under physiological conditions reveals links between diet, host and microbial metabolism.
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Affiliation(s)
- Jacob Folz
- West Coast Metabolomics Center, University of California, Davis, CA, USA
| | - Rebecca Neal Culver
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jessica Grembi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - David A Relman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Kerwyn Casey Huang
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | | | - Oliver Fiehn
- West Coast Metabolomics Center, University of California, Davis, CA, USA.
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3
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Hegyi P, Seidler U, Kunzelmann K. CFTR-beyond the airways: Recent findings on the role of the CFTR channel in the pancreas, the intestine and the kidneys. J Cyst Fibros 2023; 22 Suppl 1:S17-S22. [PMID: 36621373 DOI: 10.1016/j.jcf.2022.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/31/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
With increased longevity of patients suffering from cystic fibrosis, and widespread lung transplantation facilities, the sequelae of defective CFTR in other organs than the airways come to the fore. This minireview highlights recent scientific progress in the understanding of CFTR function in the pancreas, the intestine and the kidney, and explores potential therapeutic strategies to combat defective CFTR function in these organs.
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Affiliation(s)
- Peter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; Center for Translational Medicine and Institute of Pancreatic Diseases, Semmelweis University, 1085 Budapest, Hungary; Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, 6725 Szeged, Hungary
| | - Ursula Seidler
- Department of Gastroenterology, Hannover Medical School, 30625 Hannover, Germany.
| | - Karl Kunzelmann
- Institute of Physiology, Regensburg University, 93040 Regensburg, Germany
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4
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Effects of immediate or early oral feeding on acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:175-184. [PMID: 34876385 DOI: 10.1016/j.pan.2021.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The timing of oral refeeding can affect length of stay (LOS) and recovery of acute pancreatitis (AP). However, the optimal timing for oral refeeding is still controversial for AP. This meta-analysis investigated the effects of immediate or early versus delayed oral feeding on mild and moderate AP, regardless of improvement in clinical signs or laboratory indicators. METHODS This systematic review and meta-analysis of randomized controlled trials (RCTs) based on data from Embase, Cochrane Library, PubMed, Web of science, and CBM before August 2021. Two researchers independently used Stata16 to extract and analyse study data. Random effect model was performed for meta-analysis to calculate the risk ratio (RR) and standardized mean difference (SMD). RESULTS 8 RCTs were selected, including 748 patients with mild to moderate AP. Patients in IOR (Immediate or early Oral Refeeding) group had less costs [SMD -0.83, 95%CI (-1.17, -0.5), P < 0.001] and shorter LOS [SMD -1.01, 95%CI (-1.17, -0.85), P < 0.001] than the DOR (Delayed Oral Refeeding) group patients. However, there was no difference in mortality [RR 0.54, 95%CI (0.11, 2.62), P = 0.44], pain relapse rate [RR 0.58, 95%CI (0.25, 1.35), P = 0.27], feeding intolerance rate [RR 0.61, 95%CI (0.28, 1.3), P = 0.2], AP progression rate [RR 0.21, 95%CI (0.04, 1.07), P = 0.06] and overall complications rate [RR 0.41, 95%CI (0.17, 1.01), P = 0.05] between the IOR and DOR groups. CONCLUSIONS Limited data suggest that IOR could reduce LOS and costs without increasing adverse events in mild to moderate AP.
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5
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Angyal D, Bijvelds MJC, Bruno MJ, Peppelenbosch MP, de Jonge HR. Bicarbonate Transport in Cystic Fibrosis and Pancreatitis. Cells 2021; 11:cells11010054. [PMID: 35011616 PMCID: PMC8750324 DOI: 10.3390/cells11010054] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022] Open
Abstract
CFTR, the cystic fibrosis (CF) gene-encoded epithelial anion channel, has a prominent role in driving chloride, bicarbonate and fluid secretion in the ductal cells of the exocrine pancreas. Whereas severe mutations in CFTR cause fibrosis of the pancreas in utero, CFTR mutants with residual function, or CFTR variants with a normal chloride but defective bicarbonate permeability (CFTRBD), are associated with an enhanced risk of pancreatitis. Recent studies indicate that CFTR function is not only compromised in genetic but also in selected patients with an acquired form of pancreatitis induced by alcohol, bile salts or smoking. In this review, we summarize recent insights into the mechanism and regulation of CFTR-mediated and modulated bicarbonate secretion in the pancreatic duct, including the role of the osmotic stress/chloride sensor WNK1 and the scaffolding protein IRBIT, and current knowledge about the role of CFTR in genetic and acquired forms of pancreatitis. Furthermore, we discuss the perspectives for CFTR modulator therapy in the treatment of exocrine pancreatic insufficiency and pancreatitis and introduce pancreatic organoids as a promising model system to study CFTR function in the human pancreas, its role in the pathology of pancreatitis and its sensitivity to CFTR modulators on a personalized basis.
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6
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Fűr G, Bálint ER, Orján EM, Balla Z, Kormányos ES, Czira B, Szűcs A, Kovács DP, Pallagi P, Maléth J, Venglovecz V, Hegyi P, Kiss L, Rakonczay Z. Mislocalization of CFTR expression in acute pancreatitis and the beneficial effect of VX-661 + VX-770 treatment on disease severity. J Physiol 2021; 599:4955-4971. [PMID: 34587656 DOI: 10.1113/jp281765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/24/2021] [Indexed: 01/15/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) has an essential role in maintaining pancreatic ductal function. Impaired CFTR function can trigger acute pancreatitis (AP) and exacerbate disease severity. We aimed to investigate the localization and expression of CFTR during AP, and determined the effects of a CFTR corrector (VX-661) and potentiator (VX-770) on disease severity. AP was induced in FVB/n mice by 6-10 hourly intraperitoneal injections of 50 μg/kg cerulein. Some mice were pre-treated with five to six daily injections of 2 mg/kg VX-661 + VX-770. Control animals were administered physiological saline instead of cerulein and dimethyl sulfoxide instead of VX compounds. AP severity was determined by measuring laboratory and histological parameters; CFTR and CK19 expression was measured. Activity of ion transporters was followed by intracellular pH or fluid secretion measurement of isolated pancreatic intra-/interlobular ducts. Cerulein-induced AP severity was greatest between 12 and 24 h. CFTR mRNA expression was significantly increased 24 h after AP induction. Immunohistochemistry demonstrated disturbed staining morphology of CFTR and CK19 proteins in AP. Mislocalization of CFTR protein was observed from 6 h, while expression increased at 24 h compared to control. Ductal HCO3 - transport activity was significantly increased 6 h after AP induction. AP mice pre-treatment with VX-661 + VX-770 significantly reduced the extent of tissue damage by about 20-30%, but other parameters were unchanged. Interestingly, VX-661 + VX-770 in vitro administration significantly increased the fluid secretion of ducts derived from AP animals. This study described the course of the CFTR expression and mislocalization in cerulein-induced AP. Our results suggest that the beneficial effects of CFTR correctors and potentiators should be further investigated in AP. KEY POINTS: Cystic fibrosis transmembrane conductance regulator (CFTR) is an important ion channel in epithelial cells. Its malfunction has several serious consequences, like developing or aggravating acute pancreatitis (AP). Here, the localization and expression of CFTR during cerulein-induced AP in mice were investigated and the effects of CFTR corrector (VX-661) and a potentiator (VX-770) on disease severity were determined. CFTR mRNA expression was significantly increased and mislocalization of CFTR protein was observed in AP compared to the control group. Interestingly, pre-treatment of AP mice with VX-661 + VX-770 significantly reduced the extent of pancreatic tissue damage by 20-30%. In vitro administration of VX-661 + VX-770 significantly increased the fluid secretion of ducts derived from AP animals. Based on these results, the utilization of CFTR correctors and potentiators should be further investigated in AP.
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Affiliation(s)
- Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Erik Márk Orján
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Zsolt Balla
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | | | - Beáta Czira
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Attila Szűcs
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | | | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs, Hungary.,Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
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7
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Sharma V, Aggarwal A, Jacob J, Sahni D. Myeloid-derived suppressor cells: Bridging the gap between inflammation and pancreatic adenocarcinoma. Scand J Immunol 2021; 93:e13021. [PMID: 33455004 DOI: 10.1111/sji.13021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 12/29/2022]
Abstract
Pancreatic cancer has been identified as one of the deadliest malignancies because it remains asymptomatic and usually presents in the advanced stage. Tumour immune evasion is a well-known mechanism of tumorigenesis in various forms of human malignancies. Chronic inflammation via complex networking of various inflammatory cytokines in the local tissue microenvironment dysregulates the immune system and support tumour development. Pro-inflammatory mediators present in the tumour microenvironment increase the tumour burden by causing immune suppression through the generation of myeloid-derived suppressor cells (MDSCs) and T regulatory cells. These cells, along-with myofibroblasts, create a highly immunosuppressive and resistant tumour microenvironment and are thus considered as one of the culprits for the failure of anti-cancer chemotherapies in pancreatic adenocarcinoma patients. Targeting these MDSCs using various combinatorial approaches might have the potential for abrogating the resistance and suppressive nature of the pancreatic tumour microenvironment. Therefore, there is more curiosity in studying the crosstalk of MDSCs with other immune cells during pathological conditions and the underlying mechanisms of immunosuppression in the current scenario. In this article, the possible role of MDSCs in inflammation-mediated tumour progression of pancreatic adenocarcinoma has been discussed.
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Affiliation(s)
- Vinit Sharma
- Department of Anatomy, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anjali Aggarwal
- Department of Anatomy, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Justin Jacob
- Department of Anatomy, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Daisy Sahni
- Department of Anatomy, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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8
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Becskeházi E, Korsós MM, Erőss B, Hegyi P, Venglovecz V. OEsophageal Ion Transport Mechanisms and Significance Under Pathological Conditions. Front Physiol 2020; 11:855. [PMID: 32765303 PMCID: PMC7379034 DOI: 10.3389/fphys.2020.00855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022] Open
Abstract
Ion transporters play an important role in several physiological functions, such as cell volume regulation, pH homeostasis and secretion. In the oesophagus, ion transport proteins are part of the epithelial resistance, a mechanism which protects the oesophagus against reflux-induced damage. A change in the function or expression of ion transporters has significance in the development or neoplastic progression of Barrett’s oesophagus (BO). In this review, we discuss the physiological and pathophysiological roles of ion transporters in the oesophagus, highlighting transport proteins which serve as therapeutic targets or prognostic markers in eosinophilic oesophagitis, BO and esophageal cancer. We believe that this review highlights important relationships which might contribute to a better understanding of the pathomechanisms of esophageal diseases.
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Affiliation(s)
- Eszter Becskeházi
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | | | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary.,Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
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9
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Pallagi P, Madácsy T, Varga Á, Maléth J. Intracellular Ca 2+ Signalling in the Pathogenesis of Acute Pancreatitis: Recent Advances and Translational Perspectives. Int J Mol Sci 2020; 21:ijms21114005. [PMID: 32503336 PMCID: PMC7312053 DOI: 10.3390/ijms21114005] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Intracellular Ca2+ signalling is a major signal transductional pathway in non-excitable cells, responsible for the regulation of a variety of physiological functions. In the secretory epithelial cells of the exocrine pancreas, such as acinar and ductal cells, intracellular Ca2+ elevation regulates digestive enzyme secretion in acini or fluid and ion secretion in ductal cells. Although Ca2+ is a uniquely versatile orchestrator of epithelial physiology, unregulated global elevation of the intracellular Ca2+ concentration is an early trigger for the development of acute pancreatitis (AP). Regardless of the aetiology, different forms of AP all exhibit sustained intracellular Ca2+ elevation as a common hallmark. The release of endoplasmic reticulum (ER) Ca2+ stores by toxins (such as bile acids or fatty acid ethyl esters (FAEEs)) or increased intrapancreatic pressure activates the influx of extracellular Ca2+ via the Orai1 Ca2+ channel, a process known as store-operated Ca2+ entry (SOCE). Intracellular Ca2+ overload can lead to premature activation of trypsinogen in pancreatic acinar cells and impaired fluid and HCO3- secretion in ductal cells. Increased and unbalanced reactive oxygen species (ROS) production caused by sustained Ca2+ elevation further contributes to cell dysfunction, leading to mitochondrial damage and cell death. Translational studies of AP identified several potential target molecules that can be modified to prevent intracellular Ca2+ overload. One of the most promising drugs, a selective inhibitor of the Orai1 channel that has been shown to inhibit extracellular Ca2+ influx and protect cells from injury, is currently being tested in clinical trials. In this review, we will summarise the recent advances in the field, with a special focus on the translational aspects of the basic findings.
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Affiliation(s)
- Petra Pallagi
- First Department of Medicine, University of Szeged, H6720 Szeged, Hungary; (P.P.); (T.M.); (Á.V.)
- HAS-USZ Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, H6720 Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, H6720 Szeged, Hungary
| | - Tamara Madácsy
- First Department of Medicine, University of Szeged, H6720 Szeged, Hungary; (P.P.); (T.M.); (Á.V.)
- HAS-USZ Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, H6720 Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, H6720 Szeged, Hungary
| | - Árpád Varga
- First Department of Medicine, University of Szeged, H6720 Szeged, Hungary; (P.P.); (T.M.); (Á.V.)
- HAS-USZ Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, H6720 Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, H6720 Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, H6720 Szeged, Hungary; (P.P.); (T.M.); (Á.V.)
- HAS-USZ Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, H6720 Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, H6720 Szeged, Hungary
- Correspondence: or ; Tel.: +36-(62)-342-877 or +36-70-41-66500
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10
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Zádori N, Gede N, Antal J, Szentesi A, Alizadeh H, Vincze Á, Izbéki F, Papp M, Czakó L, Varga M, de-Madaria E, Petersen OH, Singh VP, Mayerle J, Faluhelyi N, Miseta A, Reiber I, Hegyi P. EarLy Elimination of Fatty Acids iN hypertriglyceridemia-induced acuTe pancreatitis (ELEFANT trial): Protocol of an open-label, multicenter, adaptive randomized clinical trial. Pancreatology 2020; 20:369-376. [PMID: 31959416 DOI: 10.1016/j.pan.2019.12.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/03/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acute pancreatitis (AP) is a life-threatening inflammatory disease, with no specific pharmacological treatment. However, concerning some etiologies, early specific intervention (such as ERCP in biliary AP) has proven to be remarkably beneficial. Hypertriglyceridemia (HTG) induces severe pancreatic damage by several direct (cellular damage) and indirect (deterioration of microcirculation) mechanisms. Published data suggest that early removal of triglycerides (TGs) and toxic free fatty acids (FFAs) may be advantageous; however, high-quality evidence is still missing in the literature. METHODS Design: ELEFANT is a randomized controlled, multicenter, international trial testing the concept that early elimination of TGs and FFAs from the blood is beneficial in HTG-AP. The study will be performed with the adaptive "drop-the-loser" design, which supports the possibility of dropping the inferior treatment arm, based on the results of the interim analysis. Patients with HTG-AP defined by TG level over 11.3 mmol/l (1000 mg/dL) are randomized into three groups: (A) patients who undergo plasmapheresis and receive aggressive fluid resuscitation; (B) patients who receive insulin and heparin treatment with aggressive fluid resuscitation; and (C) patients with aggressive fluid resuscitation. Please note that all intervention must be started within 48 h from the onset of abdominal pain. Exclusion criteria are designed logically to decrease the possibility of any distorting effects of other diseases. The composite primary endpoint will include both severity and mortality. RESULTS Our null hypothesis is that early elimination of HTG and FFAs reduces the risk of mortality and severity of AP. Sample size calculation suggests that 495 patients will need to be enrolled in order to confirm or reject the hypothesis with a 10% dropout, 80% power and 95% significance level. The general safety and quality checks required for high-quality evidence will be adhered to. The study will be organized between February 2020 and December 2025. CONCLUSION Our study would provide the first direct evidence for or against early intervention in HTG-induced AP.
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Affiliation(s)
- Noémi Zádori
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary. http://www.tm-centre.org
| | - Noémi Gede
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary.
| | - Judit Antal
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary.
| | - Andrea Szentesi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Translational Multidisciplinary Research Group, Szeged, Hungary.
| | - Hussain Alizadeh
- Division of Hematology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary.
| | - Áron Vincze
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary.
| | - Ferenc Izbéki
- Division of Gastroenterology, Fejér County Saint George Teaching Hospital of the University of Pécs, Székesfehérvár, Hungary.
| | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - László Czakó
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary.
| | - Márta Varga
- Dr. Réthy Pál Hospital, Békéscsaba, Hungary.
| | - Enrique de-Madaria
- Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.
| | | | - Vijay P Singh
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA.
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, München, Germany.
| | | | - Attila Miseta
- Department of Laboratory Medicine, University of Pécs, Pécs, Hungary.
| | - István Reiber
- Division of Gastroenterology, Fejér County Saint George Teaching Hospital of the University of Pécs, Székesfehérvár, Hungary.
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Translational Multidisciplinary Research Group, Szeged, Hungary. http://www.tm-centre.org
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11
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Relationship of pancreas volume to tobacco smoking and alcohol consumption following pancreatitis. Pancreatology 2020; 20:60-67. [PMID: 31708473 DOI: 10.1016/j.pan.2019.10.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/02/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tobacco smoking and alcohol consumption are established risk factors for diseases of the pancreas. With the recent advances in imaging modalities (such as magnetic resonance (MR) imaging), opportunities have arisen to study pancreas size, in both health and disease. Studies investigating the relationship between tobacco smoking, alcohol consumption, and total pancreas volume (TPV) - a holistic measure of pancreatic exocrine reserve - are lacking. The aim of the present study was to investigate the associations between MR-derived TPV and tobacco smoking/alcohol consumption. METHODS This cross-sectional study recruited individuals with a history of pancreatitis and healthy controls. A validated questionnaire was used to ascertain current and lifetime tobacco smoking and alcohol consumption. TPV was quantified using MR images by two independent raters. Generalized additive models and linear regression analyses were conducted and adjusted for demographic, metabolic, and pancreatitis-related factors. RESULTS A total of 107 individuals following pancreatitis and 38 healthy controls were included. There was no statistically significant difference in TPV between any of the tobacco smoking/alcohol consumption categories of individuals following pancreatitis and healthy controls, in both unadjusted and adjusted analyses. In individuals following pancreatitis, multivariate linear regression found no association between TPV and 7 smoking- and alcohol-related variables. Sensitivity analyses constrained to individuals who did not abstain from either smoking or drinking following their first attack of pancreatitis did not yield statistical significance with TPV. In post-hoc analysis, age was significantly inversely associated with TPV in the most adjusted model (p = 0.016). CONCLUSIONS This is the first study to investigate the association between tobacco smoking, alcohol consumption, and MR-derived TPV following pancreatitis. It appears that age, but not tobacco smoking or alcohol consumption, is associated with a significantly reduced TPV.
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Tóth E, Maléth J, Závogyán N, Fanczal J, Grassalkovich A, Erdős R, Pallagi P, Horváth G, Tretter L, Bálint ER, Rakonczay Z, Venglovecz V, Hegyi P. Novel mitochondrial transition pore inhibitor N-methyl-4-isoleucine cyclosporin is a new therapeutic option in acute pancreatitis. J Physiol 2019; 597:5879-5898. [PMID: 31631343 DOI: 10.1113/jp278517] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/11/2019] [Indexed: 12/26/2022] Open
Abstract
KEY POINTS •Bile acids, ethanol and fatty acids affect pancreatic ductal fluid and bicarbonate secretion via mitochondrial damage, ATP depletion and calcium overload. •Pancreatitis-inducing factors open the membrane transition pore (mPTP) channel via cyclophilin D activation in acinar cells, causing calcium overload and cell death; genetic or pharmacological inhibition of mPTP improves the outcome of acute pancreatitis in animal models. •Here we show that genetic and pharmacological inhibition of mPTP protects mitochondrial homeostasis and cell function evoked by pancreatitis-inducing factors in pancreatic ductal cells. •The results also show that the novel cyclosporin A derivative NIM811 protects mitochondrial function in acinar and ductal cells, and it preserves bicarbonate transport mechanisms in pancreatic ductal cells. •We found that NIM811 is highly effective in different experimental pancreatitis models and has no side-effects. NIM811 is a highly suitable compound to be tested in clinical trials. ABSTRACT Mitochondrial dysfunction plays a crucial role in the development of acute pancreatitis (AP); however, no compound is currently available with clinically acceptable effectiveness and safety. In this study, we investigated the effects of a novel mitochondrial transition pore inhibitor, N-methyl-4-isoleucine cyclosporin (NIM811), in AP. Pancreatic ductal and acinar cells were isolated by enzymatic digestion from Bl/6 mice. In vitro measurements were performed by confocal microscopy and microfluorometry. Preventative effects of pharmacological [cylosporin A (2 µm), NIM811 (2 µm)] or genetic (Ppif-/- /Cyp D KO) inhibition of the mitochondrial transition pore (mPTP) during the administration of either bile acids (BA) or ethanol + fatty acids (EtOH+FA) were examined. Toxicity of mPTP inhibition was investigated by detecting apoptosis and necrosis. In vivo effects of the most promising compound, NIM811 (5 or 10 mg kg-1 per os), were checked in three different AP models induced by either caerulein (10 × 50 µg kg-1 ), EtOH+FA (1.75 g kg-1 ethanol and 750 mg kg-1 palmitic acid) or 4% taurocholic acid (2 ml kg-1 ). Both genetic and pharmacological inhibition of Cyp D significantly prevented the toxic effects of BA and EtOH+FA by restoring mitochondrial membrane potential (Δψ) and preventing the loss of mitochondrial mass. In vivo experiments revealed that per os administration of NIM811 has a protective effect in AP by reducing oedema, necrosis, leukocyte infiltration and serum amylase level in AP models. Administration of NIM811 had no toxic effects. The novel mitochondrial transition pore inhibitor NIM811 thus seems to be an exceptionally good candidate compound for clinical trials in AP.
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Affiliation(s)
- Emese Tóth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Noémi Závogyán
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Júlia Fanczal
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Anna Grassalkovich
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Réka Erdős
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Epithelial Cell Signalling and Secretion Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary
| | - Gergő Horváth
- Department of Medical Biochemistry, Semmelweis University, Budapest, Hungary
| | - László Tretter
- Department of Medical Biochemistry, Semmelweis University, Budapest, Hungary
| | - Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged, Szeged, Hungary.,Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
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13
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Gál E, Dolenšek J, Stožer A, Pohorec V, Ébert A, Venglovecz V. A Novel in situ Approach to Studying Pancreatic Ducts in Mice. Front Physiol 2019; 10:938. [PMID: 31396104 PMCID: PMC6668154 DOI: 10.3389/fphys.2019.00938] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/09/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction: The tissue slice technique offers several benefits compared to isolated cells and cell clusters that help us understand the (patho)physiology of several organs in situ. The most prominent features are preserved architecture and function, with intact homotypic and heterotypic interactions between cells in slices. In the pancreas, this technique has been utilized successfully to study acinar and endocrine islet cells. However, it has never been used to investigate ductal function. Since pancreatic ductal epithelial cells (PDECs) play an essential role in the physiology of the pancreas, our aim was to use this technique to study PDEC structure and function in situ. Materials and methods: Eight- to sixteen weeks old C57BL/6 mice were used for preparation of pancreas tissue slices. Low melting point agarose was injected into the common bile duct and the whole organ was extracted. For morphological studies, pieces of tissue were embedded in agarose and cryosectioned to obtain 15 μm thick slices. In order to visualize pancreatic ducts, (i) the Giemsa dye was added to the agarose and visualized using light microscopy or (ii) immunostaining for the cystic fibrosis transmembrane conductance regulator (CFTR) was performed. For functional characterization, agarose-embedded tissue was immediately cut to 140 μm thick tissue slices that were loaded with the cell permeant form of the Oregon Green 488 BAPTA-1 dye and used for confocal calcium imaging. Results: Giemsa staining has shown that the injected agarose reaches the head and body of the pancreas to a greater extent than the tail, without disrupting the tissue architecture. Strong CFTR expression was detected at the apical membranes of PDECs and acinar cells, whereas islet cells were completely negative for CFTR. Stimulation with chenodeoxycholic acid (CDCA, 1 mM) resulted in a robust transient increase in intracellular calcium concentration that was readily visible in >40 ductal cells per slice. Conclusion: Our results confirm that the acutely-isolated pancreas tissue slice technique is suitable for structural and functional investigation of PDECs and their relationship with other cell types, such as acini and endocrine cells in situ. In combination with different genetic, pharmacological or dietary approaches it could become a method of choice in the foreseeable future.
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Affiliation(s)
- Eleonóra Gál
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Jurij Dolenšek
- Faculty of Medicine, University of Maribor, Maribor, Slovenia.,Faculty of Natural Sciences and Mathematics, University of Maribor, Maribor, Slovenia
| | - Andraž Stožer
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Viljem Pohorec
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Attila Ébert
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
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14
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Márta K, Hegyi P. Uncommon appearance of concurrent liver cirrhosis and chronic pancreatitis: The alcohol metabolism theory. Dig Liver Dis 2019; 51:559-560. [PMID: 30691775 DOI: 10.1016/j.dld.2018.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Katalin Márta
- Institute for Translational Medicine, University of Pécs, Medical School, János Szentágothai Research Centre, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Medical School, János Szentágothai Research Centre, Pécs, Hungary; Momentum Gastroenterology Multidisciplinary Research Group, Hungarian Academy of Sciences University of Szeged, Szeged, Hungary.
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15
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Madácsy T, Pallagi P, Maleth J. Cystic Fibrosis of the Pancreas: The Role of CFTR Channel in the Regulation of Intracellular Ca 2+ Signaling and Mitochondrial Function in the Exocrine Pancreas. Front Physiol 2018; 9:1585. [PMID: 30618777 PMCID: PMC6306458 DOI: 10.3389/fphys.2018.01585] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/23/2018] [Indexed: 12/26/2022] Open
Abstract
Cystic fibrosis (CF) is the most common genetic disorder that causes a significant damage in secretory epithelial cells due to the defective ion flux across the cystic fibrosis transmembrane conductance regulator (CFTR) Cl- channel. Pancreas is one of the organs most frequently damaged by the disease leading to pancreatic insufficiency, abdominal pain and an increased risk of acute pancreatitis in CF patients causing a significant decrease in the quality of life. CFTR plays a central role in the pancreatic ductal secretory functions by carrying Cl- and HCO3 - ions across the apical membrane. Therefore pathophysiological studies in CF mostly focused on the effects of impaired ion secretion by pancreatic ductal epithelial cells leading to exocrine pancreatic damage. However, several studies indicated that CFTR has a central role in the regulation of intracellular signaling processes and is now more widely considered as a signaling hub in epithelial cells. In contrast, elevated intracellular Ca2+ level was observed in the lack of functional CFTR in different cell types including airway epithelial cells. In addition, impaired CFTR expression has been correlated with damaged mitochondrial function in epithelial cells. These alterations of intracellular signaling in CF are not well characterized in the exocrine pancreas yet. Therefore in this review we would like to summarize the complex role of CFTR in the exocrine pancreas with a special focus on the intracellular signaling and mitochondrial function.
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Affiliation(s)
- Tamara Madácsy
- First Department of Medicine, University of Szeged, Szeged, Hungary.,HAS-USZ Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary
| | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Jozsef Maleth
- First Department of Medicine, University of Szeged, Szeged, Hungary.,HAS-USZ Momentum Epithel Cell Signalling and Secretion Research Group, Szeged, Hungary.,Department of Public Health, University of Szeged, Szeged, Hungary
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16
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Kiss L, Fűr G, Mátrai P, Hegyi P, Ivány E, Cazacu IM, Szabó I, Habon T, Alizadeh H, Gyöngyi Z, Vigh É, Erőss B, Erős A, Ottoffy M, Czakó L, Rakonczay Z. The effect of serum triglyceride concentration on the outcome of acute pancreatitis: systematic review and meta-analysis. Sci Rep 2018; 8:14096. [PMID: 30237456 PMCID: PMC6147944 DOI: 10.1038/s41598-018-32337-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/05/2018] [Indexed: 12/16/2022] Open
Abstract
Elevated serum triglyceride concentration (seTG, >1.7 mM or >150 mg/dL) or in other words hypertriglyceridemia (HTG) is common in the populations of developed countries. This condition is accompanied by an increased risk for various diseases, such as acute pancreatitis (AP). It has been proposed that HTG could also worsen the course of AP. Therefore, in this meta-analysis, we aimed to compare the effects of various seTGs on the severity, mortality, local and systemic complications of AP, and on intensive care unit admission. 16 eligible studies, including 11,965 patients were retrieved from PubMed and Embase. The results showed that HTG significantly elevated the odds ratio (OR = 1.72) for severe AP when compared to patients with normal seTG (<1.7 mM). Furthermore, a significantly higher occurrence of pancreatic necrosis, persistent organ failure and renal failure was observed in groups with HTG. The rates of complications and mortality for AP were significantly increased in patients with seTG >5.6 mM or >11.3 mM versus <5.6 mM or <11.3 mM, respectively. We conclude that the presence of HTG worsens the course and outcome of AP, but we found no significant difference in AP severity based on the extent of HTG.
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Affiliation(s)
- Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Péter Mátrai
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
- MTASZTE Translational Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Emese Ivány
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Irina Mihaela Cazacu
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás Habon
- Department of Cardiology and Angiology, First Department of Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Hussain Alizadeh
- Department of Haematology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Éva Vigh
- Department of Radiology, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Adrienn Erős
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Máté Ottoffy
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary.
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17
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Venglovecz V, Pallagi P, Kemény LV, Balázs A, Balla Z, Becskeházi E, Gál E, Tóth E, Zvara Á, Puskás LG, Borka K, Sendler M, Lerch MM, Mayerle J, Kühn JP, Rakonczay Z, Hegyi P. The Importance of Aquaporin 1 in Pancreatitis and Its Relation to the CFTR Cl - Channel. Front Physiol 2018; 9:854. [PMID: 30050452 PMCID: PMC6052342 DOI: 10.3389/fphys.2018.00854] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/15/2018] [Indexed: 12/17/2022] Open
Abstract
Aquaporins (AQPs) facilitate the transepithelial water flow involved in epithelial fluid secretion in numerous tissues; however, their function in the pancreas is less characterized. Acute pancreatitis (AP) is a serious disorder in which specific treatment is still not possible. Accumulating evidence indicate that decreased pancreatic ductal fluid secretion plays an essential role in AP; therefore, the aim of this study was to investigate the physiological and pathophysiological role of AQPs in the pancreas. Expression and localization of AQPs were investigated by real-time PCR and immunocytochemistry, whereas osmotic transmembrane water permeability was estimated by the dye dilution technique, in Capan-1 cells. The presence of AQP1 and CFTR in the mice and human pancreas were investigated by immunohistochemistry. Pancreatic ductal HCO3- and fluid secretion were studied on pancreatic ducts isolated from wild-type (WT) and AQP1 knock out (KO) mice using microfluorometry and videomicroscopy, respectively. In vivo pancreatic fluid secretion was estimated by magnetic resonance imaging. AP was induced by intraperitoneal injection of cerulein and disease severity was assessed by measuring biochemical and histological parameters. In the mice, the presence of AQP1 was detected throughout the whole plasma membrane of the ductal cells and its expression highly depends on the presence of CFTR Cl- channel. In contrast, the expression of AQP1 is mainly localized to the apical membrane of ductal cells in the human pancreas. Bile acid treatment dose- and time-dependently decreased mRNA and protein expression of AQP1 and reduced expression of this channel was also demonstrated in patients suffering from acute and chronic pancreatitis. HCO3- and fluid secretion significantly decreased in AQP1 KO versus WT mice and the absence of AQP1 also worsened the severity of pancreatitis. Our results suggest that AQP1 plays an essential role in pancreatic ductal fluid and HCO3- secretion and decreased expression of the channel alters fluid secretion which probably contribute to increased susceptibility of the pancreas to inflammation.
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Affiliation(s)
- Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Lajos V Kemény
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Balla
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Eszter Becskeházi
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Eleonóra Gál
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Emese Tóth
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ágnes Zvara
- Laboratory of Functional Genomics, Biological Research Centre, Hungarian Academy of Sciences, Szeged, Hungary
| | - László G Puskás
- Laboratory of Functional Genomics, Biological Research Centre, Hungarian Academy of Sciences, Szeged, Hungary
| | - Katalin Borka
- Second Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Matthias Sendler
- Department of Medicine A, University Medicine Greifswald, University of Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, University of Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Department of Medicine A, University Medicine Greifswald, University of Greifswald, Greifswald, Germany.,Department of Medicine II, Klinikum Grosshadern, Universitätsklinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jens-Peter Kühn
- Institute of Radiology, University Medicine Greifswald, University of Greifswald, Greifswald, Germany.,Institute and Policlinic of Radiology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,MTA-SZTE Translational Gastroenterology Research Group, University of Szeged, Szeged, Hungary.,Institute for Translational Medicine and First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
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18
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TRO40303 Ameliorates Alcohol-Induced Pancreatitis Through Reduction of Fatty Acid Ethyl Ester-Induced Mitochondrial Injury and Necrotic Cell Death. Pancreas 2018; 47:18-24. [PMID: 29200128 PMCID: PMC5753827 DOI: 10.1097/mpa.0000000000000953] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Mitochondrial permeability transition pore inhibition is a promising approach to treat acute pancreatitis (AP). We sought to determine (i) the effects of the mitochondrial permeability transition pore inhibitor 3,5-seco-4-nor-cholestan-5-one oxime-3-ol (TRO40303) on murine and human pancreatic acinar cell (PAC) injury induced by fatty acid ethyl esters (FAEEs) or taurolithocholic acid-3-sulfate and (ii) TRO40303 pharmacokinetics and efficacy in experimental alcoholic AP (FAEE-AP). METHODS Changes in mitochondrial membrane potential (Δψm), cytosolic Ca ([Ca]c), and cell fate were examined in freshly isolated murine or human PACs by confocal microscopy. TRO40303 pharmacokinetics were assessed in cerulein-induced AP and therapeutic efficacy in FAEE-AP induced with palmitoleic acid and ethanol. Severity of AP was assessed by standard biomarkers and blinded histopathology. RESULTS TRO40303 prevented loss of Δψm and necrosis induced by 100 μM palmitoleic acid ethyl ester or 500 μM taurolithocholic acid-3-sulfate in murine and human PACs. Pharmacokinetic analysis found TRO40303 accumulated in the pancreas. A single dose of 3 mg/kg TRO40303 significantly reduced serum amylase (P = 0.043), pancreatic trypsin (P = 0.018), and histopathology scores (P = 0.0058) in FAEE-AP. CONCLUSIONS TRO40303 protects mitochondria and prevents necrotic cell death pathway activation in murine and human PACs, ameliorates the severity of FAEE-AP, and is a candidate drug for human AP.
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19
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Maléth J, Hegyi P. Ca2+ toxicity and mitochondrial damage in acute pancreatitis: translational overview. Philos Trans R Soc Lond B Biol Sci 2017; 371:rstb.2015.0425. [PMID: 27377719 PMCID: PMC4938025 DOI: 10.1098/rstb.2015.0425] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2016] [Indexed: 12/23/2022] Open
Abstract
Acute pancreatitis (AP) is a leading cause of hospitalization among non-malignant gastrointestinal disorders. The mortality of severe AP can reach 30-50%, which is most probably owing to the lack of specific treatment. Therefore, AP is a major healthcare problem, which urges researchers to identify novel drug targets. Studies from the last decades highlighted that the toxic cellular Ca(2+) overload and mitochondrial damage are key pathogenic steps in the disease development affecting both acinar and ductal cell functions. Moreover, recent observations showed that modifying the cellular Ca(2+) signalling might be beneficial in AP. The inhibition of Ca(2+) release from the endoplasmic reticulum or the activity of plasma membrane Ca(2+) influx channels decreased the severity of AP in experimental models. Similarly, inhibition of mitochondrial permeability transition pore (MPTP) opening also seems to improve the outcome of AP in in vivo animal models. At the moment MPTP blockers are under detailed clinical investigation to test whether interventions in MPTP openings and/or Ca(2+) homeostasis of the cells can be specific targets in prevention or treatment of cell damage in AP.This article is part of the themed issue 'Evolution brings Ca(2+) and ATP together to control life and death'.
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Affiliation(s)
- József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary MTA-SZTE Momentum Translational Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary MTA-SZTE Momentum Translational Gastroenterology Research Group, University of Szeged, Szeged, Hungary Institute for Translational Medicine, University of Pécs, Pécs, Hungary
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20
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Márta K, Szabó AN, Pécsi D, Varjú P, Bajor J, Gódi S, Sarlós P, Mikó A, Szemes K, Papp M, Tornai T, Vincze Á, Márton Z, Vincze PA, Lankó E, Szentesi A, Molnár T, Hágendorn R, Faluhelyi N, Battyáni I, Kelemen D, Papp R, Miseta A, Verzár Z, Lerch MM, Neoptolemos JP, Sahin-Tóth M, Petersen OH, Hegyi P. High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial. BMJ Open 2017; 7:e015874. [PMID: 28912191 PMCID: PMC5722094 DOI: 10.1136/bmjopen-2017-015874] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP. METHODS/DESIGN This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to. ETHICS AND DISSEMINATION The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors. TRIAL REGISTRATION The trial has been registered at the ISRCTN (ISRTCN 63827758).
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Affiliation(s)
- Katalin Márta
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Anikó N Szabó
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Judit Bajor
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Kata Szemes
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Mária Papp
- 2nd Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Tornai
- 2nd Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Áron Vincze
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Zsolt Márton
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia A Vincze
- Department of Pharmaceutics and Central Clinical Pharmacy, University of Pécs, Pécs, Hungary
| | - Erzsébet Lankó
- Department of Pharmaceutics and Central Clinical Pharmacy, University of Pécs, Pécs, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
| | - Tímea Molnár
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Roland Hágendorn
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | | | | | | | - Róbert Papp
- Surgery Clinic, University of Pécs, Pécs, Hungary
| | - Attila Miseta
- Department of Laboratory Medicine, University of Pécs, Pécs, Hungary
| | - Zsófia Verzár
- Department of Emergency Medicine, University of Pécs, Pécs, Hungary
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Miklós Sahin-Tóth
- Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Ole H Petersen
- Medical Research Council Group, Cardiff School of Biosciences, Cardiff University, Cardiff, UK
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
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Yang A, Sun Y, Mao C, Yang S, Huang M, Deng M, Ding N, Yang X, Zhang M, Jin S, Jiang Y, Huang Y. Folate Protects Hepatocytes of Hyperhomocysteinemia Mice From Apoptosis via Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)-Activated Endoplasmic Reticulum Stress. J Cell Biochem 2017; 118:2921-2932. [PMID: 28230279 DOI: 10.1002/jcb.25946] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/21/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Anning Yang
- Department of Pathophysiology; West China College of Preclinical and Forensic Medical Sciences; Sichuan University; Chengdu China
| | - Yue Sun
- State Key Laboratory of Biotherapy; Sichuan University; Chengdu China
| | - Caiyan Mao
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Songhao Yang
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Min Huang
- Department of Pathophysiology; West China College of Preclinical and Forensic Medical Sciences; Sichuan University; Chengdu China
| | - Mei Deng
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Ning Ding
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Xiaoling Yang
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Minghao Zhang
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Shaoju Jin
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Yideng Jiang
- Department of Physiology and Pathophysiology; School of Basic Medical Sciences; Ningxia Medical University; Yinchuan China
| | - Ying Huang
- Department of Pathophysiology; West China College of Preclinical and Forensic Medical Sciences; Sichuan University; Chengdu China
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22
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Mosztbacher D, Farkas N, Solymár M, Pár G, Bajor J, Szűcs &A, Czimmer J, Márta K, Mikó A, Rumbus Z, Varjú P, Hegyi P, Párniczky A. Restoration of energy level in the early phase of acute pediatric pancreatitis. World J Gastroenterol 2017; 23:957-963. [PMID: 28246469 PMCID: PMC5311105 DOI: 10.3748/wjg.v23.i6.957] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/21/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a serious inflammatory disease with rising incidence both in the adult and pediatric populations. It has been shown that mitochondrial injury and energy depletion are the earliest intracellular events in the early phase of AP. Moreover, it has been revealed that restoration of intracellular ATP level restores cellular functions and defends the cells from death. We have recently shown in a systematic review and meta-analysis that early enteral feeding is beneficial in adults; however, no reviews are available concerning the effect of early enteral feeding in pediatric AP. In this minireview, our aim was to systematically analyse the literature on the treatment of acute pediatric pancreatitis. The preferred reporting items for systematic review (PRISMA-P) were followed, and the question was drafted based on participants, intervention, comparison and outcomes: P: patients under the age of twenty-one suffering from acute pancreatitis; I: early enteral nutrition (per os and nasogastric- or nasojejunal tube started within 48 h); C: nil per os therapy; O: length of hospitalization, need for treatment at an intensive care unit, development of severe AP, lung injury (including lung oedema and pleural effusion), white blood cell count and pain score on admission. Altogether, 632 articles (PubMed: 131; EMBASE: 501) were found. After detailed screening of eligible papers, five of them met inclusion criteria. Only retrospective clinical trials were available. Due to insufficient information from the authors, it was only possible to address length of hospitalization as an outcome of the study. Our mini-meta-analysis showed that early enteral nutrition significantly (SD = 0.806, P = 0.034) decreases length of hospitalization compared with nil per os diet in acute pediatric pancreatitis. In this minireview, we clearly show that early enteral nutrition, started within 24-48 h, is beneficial in acute pediatric pancreatitis. Prospective studies and better presentation of research are crucially needed to achieve a higher level of evidence.
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23
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Meta-Analysis of Early Nutrition: The Benefits of Enteral Feeding Compared to a Nil Per Os Diet Not Only in Severe, but Also in Mild and Moderate Acute Pancreatitis. Int J Mol Sci 2016; 17:ijms17101691. [PMID: 27775609 PMCID: PMC5085723 DOI: 10.3390/ijms17101691] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/10/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022] Open
Abstract
The recently published guidelines for acute pancreatitis (AP) suggest that enteral nutrition (EN) should be the primary therapy in patients suffering from severe acute pancreatitis (SAP); however, none of the guidelines have recommendations on mild and moderate AP (MAP). A meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). The following PICO (problem, intervention, comparison, outcome) was applied: P: nutrition in AP; I: enteral nutrition (EN); C: nil per os diet (NPO); and O: outcome. There were 717 articles found in Embase, 831 in PubMed, and 10 in the Cochrane database. Altogether, seven SAP and six MAP articles were suitable for analyses. In SAP, forest plots were used to illustrate three primary endpoints (mortality, multiorgan failure, and intervention). In MAP, 14 additional secondary endpoints were analyzed (such as CRP (C-reactive protein), WCC (white cell count), complications, etc.). After pooling the data, the Mann-Whitney U test was used to detect significant differences. Funnel plots were created for testing heterogeneity. All of the primary endpoints investigated showed that EN is beneficial vs. NPO in SAP. In MAP, all of the six articles found merit in EN. Analyses of the primary endpoints did not show significant differences between the groups; however, analyzing the 17 endpoints together showed a significant difference in favor of EN vs. NPO. EN is beneficial compared to a nil per os diet not only in severe, but also in mild and moderate AP.
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24
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Saint-Criq V, Gray MA. Role of CFTR in epithelial physiology. Cell Mol Life Sci 2016; 74:93-115. [PMID: 27714410 PMCID: PMC5209439 DOI: 10.1007/s00018-016-2391-y] [Citation(s) in RCA: 252] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 12/20/2022]
Abstract
Salt and fluid absorption and secretion are two processes that are fundamental to epithelial function and whole body fluid homeostasis, and as such are tightly regulated in epithelial tissues. The CFTR anion channel plays a major role in regulating both secretion and absorption in a diverse range of epithelial tissues, including the airways, the GI and reproductive tracts, sweat and salivary glands. It is not surprising then that defects in CFTR function are linked to disease, including life-threatening secretory diarrhoeas, such as cholera, as well as the inherited disease, cystic fibrosis (CF), one of the most common life-limiting genetic diseases in Caucasian populations. More recently, CFTR dysfunction has also been implicated in the pathogenesis of acute pancreatitis, chronic obstructive pulmonary disease (COPD), and the hyper-responsiveness in asthma, underscoring its fundamental role in whole body health and disease. CFTR regulates many mechanisms in epithelial physiology, such as maintaining epithelial surface hydration and regulating luminal pH. Indeed, recent studies have identified luminal pH as an important arbiter of epithelial barrier function and innate defence, particularly in the airways and GI tract. In this chapter, we will illustrate the different operational roles of CFTR in epithelial function by describing its characteristics in three different tissues: the airways, the pancreas, and the sweat gland.
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Affiliation(s)
- Vinciane Saint-Criq
- Epithelial Research Group, Institute for Cell and Molecular Biosciences, University Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Michael A. Gray
- Epithelial Research Group, Institute for Cell and Molecular Biosciences, University Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
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25
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Epithelial Anion Transport as Modulator of Chemokine Signaling. Mediators Inflamm 2016; 2016:7596531. [PMID: 27382190 PMCID: PMC4921137 DOI: 10.1155/2016/7596531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 12/16/2022] Open
Abstract
The pivotal role of epithelial cells is to secrete and absorb ions and water in order to allow the formation of a luminal fluid compartment that is fundamental for the epithelial function as a barrier against environmental factors. Importantly, epithelial cells also take part in the innate immune system. As a first line of defense they detect pathogens and react by secreting and responding to chemokines and cytokines, thus aggravating immune responses or resolving inflammatory states. Loss of epithelial anion transport is well documented in a variety of diseases including cystic fibrosis, chronic obstructive pulmonary disease, asthma, pancreatitis, and cholestatic liver disease. Here we review the effect of aberrant anion secretion with focus on the release of inflammatory mediators by epithelial cells and discuss putative mechanisms linking these transport defects to the augmented epithelial release of chemokines and cytokines. These mechanisms may contribute to the excessive and persistent inflammation in many respiratory and gastrointestinal diseases.
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26
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Criddle DN. Reactive oxygen species, Ca(2+) stores and acute pancreatitis; a step closer to therapy? Cell Calcium 2016; 60:180-9. [PMID: 27229361 DOI: 10.1016/j.ceca.2016.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/18/2022]
Abstract
Disruption of Ca(2+) homeostasis can lead to severe damage of the pancreas, resulting in premature activation of digestive enzymes, vacuolisation and necrotic cell death, features typical of acute pancreatitis (AP). Therefore a fine balance between Ca(2+) release from internal stores, Ca(2+) entry and extrusion mechanisms is necessary to avoid injury. Precipitants of AP induce Ca(2+) overload of the pancreatic acinar cell that causes mitochondrial dysfunction, via formation of the mitochondrial permeability transition pore (MPTP), loss of ATP production and consequent necrosis. Oxidative stress has been shown to occur in the development of AP and may modify Ca(2+) signalling events in the acinar cell. However, the precise pathophysiological involvement is currently unclear and antioxidant therapy in the clinic has largely proved ineffective. Possible reasons for this are discussed, including evidence that ROS generation may determine cell death patterns. In contrast, recent evidence has indicated the potential for AP therapy via the prevention of Ca(2+)-dependent mitochondrial damage. Multiple approaches are indicated from preclinical findings; 1) inhibition of Ca(2+) release by IP3R blockade, 2) inhibition of Ca(2+) entry through Orai1 blockade and 3) prevention of MPTP formation. Clinical trials of drugs which prevent mitochondrial dysfunction induced by Ca(2+) overload of pancreatic acinar cells are imminent and may provide patient benefit for a disease that currently lacks specific therapy.
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Affiliation(s)
- David N Criddle
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, and NIHR Liverpool Pancreas Biomedical Research Unit, University of Liverpool, L69 3BX, UK.
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27
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The adenosine A2B receptor is involved in anion secretion in human pancreatic duct Capan-1 epithelial cells. Pflugers Arch 2016; 468:1171-1181. [PMID: 26965147 PMCID: PMC4943985 DOI: 10.1007/s00424-016-1806-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 02/25/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
Abstract
Adenosine modulates a wide variety of biological processes via adenosine receptors. In the exocrine pancreas, adenosine regulates transepithelial anion secretion in duct cells and is considered to play a role in acini-to-duct signaling. To identify the functional adenosine receptors and Cl− channels important for anion secretion, we herein performed experiments on Capan-1, a human pancreatic duct cell line, using open-circuit Ussing chamber and gramicidin-perforated patch-clamp techniques. The luminal addition of adenosine increased the negative transepithelial potential difference (Vte) in Capan-1 monolayers with a half-maximal effective concentration value of approximately 10 μM, which corresponded to the value obtained on whole-cell Cl− currents in Capan-1 single cells. The effects of adenosine on Vte, an equivalent short-circuit current (Isc), and whole-cell Cl− currents were inhibited by CFTRinh-172, a cystic fibrosis transmembrane conductance regulator (CFTR) Cl− channel inhibitor. The adenosine A2B receptor agonist, BAY 60-6583, increased Isc and whole-cell Cl− currents through CFTR Cl− channels, whereas the A2A receptor agonist, CGS 21680, had negligible effects. The A2B receptor antagonist, PSB 603, inhibited the response of Isc to adenosine. Immunohistochemical analysis showed that the A2A and A2B receptors colocalized with Ezrin in the luminal membranes of Capan-1 monolayers and in rat pancreatic ducts. Adenosine elicited the whole-cell Cl− currents in guinea pig duct cells. These results demonstrate that luminal adenosine regulates anion secretion by activating CFTR Cl− channels via adenosine A2B receptors on the luminal membranes of Capan-1 cells. The present study endorses that purinergic signaling is important in the regulation of pancreatic secretion.
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28
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Hegyi P, Wilschanski M, Muallem S, Lukacs GL, Sahin-Tóth M, Uc A, Gray MA, Rakonczay Z, Maléth J. CFTR: A New Horizon in the Pathomechanism and Treatment of Pancreatitis. Rev Physiol Biochem Pharmacol 2016; 170:37-66. [PMID: 26856995 DOI: 10.1007/112_2015_5002] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) is an ion channel that conducts chloride and bicarbonate ions across epithelial cell membranes. Mutations in the CFTR gene diminish the ion channel function and lead to impaired epithelial fluid transport in multiple organs such as the lung and the pancreas resulting in cystic fibrosis. Heterozygous carriers of CFTR mutations do not develop cystic fibrosis but exhibit increased risk for pancreatitis and associated pancreatic damage characterized by elevated mucus levels, fibrosis, and cyst formation. Importantly, recent studies demonstrated that pancreatitis causing insults, such as alcohol, smoking, or bile acids, strongly inhibit CFTR function. Furthermore, human studies showed reduced levels of CFTR expression and function in all forms of pancreatitis. These findings indicate that impairment of CFTR is critical in the development of pancreatitis; therefore, correcting CFTR function could be the first specific therapy in pancreatitis. In this review, we summarize recent advances in the field and discuss new possibilities for the treatment of pancreatitis.
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Affiliation(s)
- Péter Hegyi
- Institute for Translational Medicine and 1st Department of Medicine, University of Pécs, Pécs, Hungary.
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary.
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Shmuel Muallem
- National Institute of Dental and Craniofacial Research, Bethesda, MD, USA
| | | | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
| | - Aliye Uc
- Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Michael A Gray
- Institute for Cell & Molecular Biosciences, University Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Zoltán Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
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29
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Abstract
The human exocrine pancreas consists of 2 main cell types: acinar and ductal cells. These exocrine cells interact closely to contribute to the secretion of pancreatic juice. The most important ion in terms of the pancreatic ductal secretion is HCO3. In fact, duct cells produce an alkaline fluid that may contain up to 140 mM NaHCO3, which is essential for normal digestion. This article provides an overview of the basics of pancreatic ductal physiology and pathophysiology. In the first part of the article, we discuss the ductal electrolyte and fluid transporters and their regulation. The central role of cystic fibrosis transmembrane conductance regulator (CFTR) is highlighted, which is much more than just a Cl channel. We also review the role of pancreatic ducts in severe debilitating diseases such as cystic fibrosis (caused by various genetic defects of cftr), pancreatitis, and diabetes mellitus. Stimulation of ductal secretion in cystic fibrosis and pancreatitis may have beneficial effects in their treatment.
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Abstract
The early phase of both acute and chronic pancreatitis can be characterized by disrupt level and function of the cystic fibrosis transmembrane conductance regulator (CFTR) Cl(-) channel, decreased bicarbonate secretion, intraductal acidosis, decrease of fluid secretion and elevation of mucoprotein levels. It is almost needless to say that these intrapancreatic changes are very similar to the pathophysiological changes observed in cystic fibrosis. The aim of this mini review is to describe the development of the above mentioned pathological observations in details, moreover highlight some future therapeutic opportunities in pancreatitis.
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Affiliation(s)
- Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Momentum Translational Gastroenterology Research Group, Szeged, Hungary.
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31
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Kondo S, Fujiki K, Ko SBH, Yamamoto A, Nakakuki M, Ito Y, Shcheynikov N, Kitagawa M, Naruse S, Ishiguro H. Functional characteristics of L1156F-CFTR associated with alcoholic chronic pancreatitis in Japanese. Am J Physiol Gastrointest Liver Physiol 2015; 309:G260-9. [PMID: 26089335 PMCID: PMC4537928 DOI: 10.1152/ajpgi.00015.2014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 06/09/2015] [Indexed: 01/31/2023]
Abstract
Although cystic fibrosis is rare in Japanese, measurement of sweat Cl(-) has suggested mild dysfunction of cystic fibrosis transmembrane conductance regulator (CFTR) in some patients with chronic pancreatitis. In the present study, we have investigated the association of CFTR variants and chronic pancreatitis in Japanese and the functional characteristics of a Japanese- and pancreatitis-specific CFTR variant, L1156F. Seventy patients with alcoholic chronic pancreatitis, 18 patients with idiopathic chronic pancreatitis, and 180 normal subjects participated. All exons and their boundaries and promoter region of the CFTR gene were sequenced. Human embryonic kidney-293 cells were transfected with three CFTR variants (M470V, L1156F, and M470V+L1156F), and the protein expression was examined. Xenopus laevis oocytes were injected with the CFTR variants, and bicarbonate (HCO3 (-)) transport activity was examined. CFPAC-1 cells were transfected with the CFTR variants and Cl(-)/HCO3 (-) exchange activity was examined. Six variants (E217G, I556V, M470V, L1156F, Q1352H, and R1453W) were identified in the coding region of the CFTR gene. Cystic fibrosis-causing mutations were not found. The allele frequencies of L1156F and Q1352H in alcoholic chronic pancreatitis (5.0 and 7.9%) were significantly (P < 0.01) higher than those in normal subjects (0.6 and 1.9%). L1156F was linked with a worldwide CFTR variant, M470V. Combination of M470V and L1156F significantly reduced CFTR expression to ∼60%, impaired CFTR-mediated HCO3 (-)/Cl(-) transport activity to 50-60%, and impaired CFTR-coupled Cl(-)/HCO3 (-) exchange activity to 20-30%. The data suggest that the Japanese-specific CFTR variant L1156F causes mild dysfunction of CFTR and increases the risk of alcoholic chronic pancreatitis in Japanese.
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Affiliation(s)
- Shiho Kondo
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kotoyo Fujiki
- Department of Nutrition, Nagoya University of Arts and Sciences, Nisshin, Japan
| | - Shigeru B H Ko
- Department of Systems Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Akiko Yamamoto
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Miyuki Nakakuki
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasutomo Ito
- Division for Medical Research Engineering, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nikolay Shcheynikov
- Epithelial Signaling and Transport Section, National Institute of Dental and Craniofacial Research, Bethesda, Maryland; and
| | - Motoji Kitagawa
- Department of Nutrition, Nagoya University of Arts and Sciences, Nisshin, Japan
| | | | - Hiroshi Ishiguro
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan;
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32
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Genetic susceptibility factors for alcohol-induced chronic pancreatitis. Pancreatology 2015; 15:S23-31. [PMID: 26149858 DOI: 10.1016/j.pan.2015.05.476] [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: 12/01/2014] [Revised: 04/10/2015] [Accepted: 05/27/2015] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis is a progressive inflammatory disease of the pancreas and frequently associated with immoderate alcohol consumption. Since only a small proportion of alcoholics eventually develop chronic pancreatitis genetic susceptibility factors have long been suspected to contribute to the pathogenesis of the disease. Smaller studies in ethnically defined populations have found that not only polymorphism in proteins involved in the metabolism of ethanol, such as Alcohol Dehydrogenase and Aldehyde Dehydrogenase, can confer a risk for developing chronic pancreatitis but also mutations that had previously been reported in association with idiopathic pancreatitis, such as SPINK1 mutations. In a much broader approach employing genome wide search strategies the NAPS study found that polymorphisms in the Trypsin locus (PRSS1 rs10273639), and the Claudin 2 locus (CLDN2-RIPPLY1-MORC4 locus rs7057398 and rs12688220) confer an increased risk of developing alcohol-induced pancreatitis. These results from North America have now been confirmed by a European consortium. In another genome wide approach polymorphisms in the genes encoding Fucosyltransferase 2 (FUT2) non-secretor status and blood group B were not only found in association with higher serum lipase levels in healthy volunteers but also to more than double the risk for developing alcohol-associated chronic pancreatitis. These novel genetic associations will allow to investigate the pathophysiological and biochemical basis of alcohol-induced chronic pancreatitis on a cellular level and in much more detail than previously possible.
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Hegyi P, Rakonczay Z. The role of pancreatic ducts in the pathogenesis of acute pancreatitis. Pancreatology 2015; 15:S13-7. [PMID: 25921231 DOI: 10.1016/j.pan.2015.03.010] [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: 12/13/2014] [Revised: 03/09/2015] [Accepted: 03/17/2015] [Indexed: 12/11/2022]
Abstract
Pancreatic ducts secrete 2.5 l of alkaline, HCO3(-)-rich fluid daily which greatly contributes to the homeostasis of the pancreas. Ducts are also important in the pathophysiology of the pancreas; alteration of ductal function can lead to severe diseases such as cystic fibrosis and chronic pancreatitis. The role of pancreatic ducts in the development of acute pancreatitis has only been uncovered recently. Pancreatitis inducing agents like bile acids and ethanol dose-dependently affect pancreatic ductal secretion; low concentrations stimulate, whereas high concentrations inhibit secretion. The majority of the review will focus on the central role of cystic fibrosis transmembrane conductance regulator (CFTR), a critical protein in the regulation of ductal secretion, in the pathogenesis of acute pancreatitis which is highlighted by numerous investigations. Downregulation of CFTR expression results in increased severity of acute pancreatitis in mice. Furthermore, human genetic studies have demonstrated statistically significant association of CFTR mutations with acute recurrent pancreatitis. Overall, the data support the involvement of pancreatic ducts in the pathogenesis of acute pancreatitis.
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Affiliation(s)
- Peter Hegyi
- University of Szeged, First Department of Medicine, Szeged, Hungary; MTA-SZTE Lendület Translational Gastroenterology Research Group, Szeged, Hungary
| | - Zoltan Rakonczay
- University of Szeged, First Department of Medicine, Szeged, Hungary.
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34
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Maléth J, Hegyi P, Rakonczay Z, Venglovecz V. Breakdown of bioenergetics evoked by mitochondrial damage in acute pancreatitis: Mechanisms and consequences. Pancreatology 2015; 15:S18-22. [PMID: 26162756 DOI: 10.1016/j.pan.2015.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is a severe inflammatory disease with unacceptably high mortality and without specific therapy. Clinical studies revealed that energy supplementation of patients via enteral feeding decreases systemic infections, multi-organ failure and mortality. These clinical observations have been supported by in vitro and in vivo experimental studies which showed that the most common pancreatitis inducing factors, such as bile acids, ethanol and non-oxidative ethanol metabolites induce intracellular ATP depletion and mitochondrial damage both in pancreatic acinar and ductal cells. Notably, the in vitro supplementation of ATP prevented the cellular damage and restored cell functions in both cell types. These observations suggest that either prevention of mitochondrial damage or restoration of intracellular ATP level might provide therapeutical benefits.
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Affiliation(s)
- József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Lendulet Translational Gastroenterology Research Group, Szeged, Hungary
| | - Zoltán Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary.
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Criddle DN. The role of fat and alcohol in acute pancreatitis: A dangerous liaison. Pancreatology 2015; 15:S6-S12. [PMID: 25845855 DOI: 10.1016/j.pan.2015.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 02/07/2023]
Abstract
Excessive alcohol consumption is a major trigger for severe acute pancreatitis which may lead to multi-organ dysfunction and premature death of the individual. Hyperlipidaemia is a risk factor for both acute and chronic pancreatitis and the role of fatty acids in mediating damage has received increasing attention in recent years. In the pancreas ethanol is metabolised by both oxidative and non-oxidative pathways. The latter, predominant route generates fatty acid ethyl esters (FAEEs) from fatty acid substrates via the action of diverse enzymes called FAEE synthases, including carboxylester lipase an enzyme synthesized and secreted by the acinar cells. Inhibition of the oxidative pathway promotes formation of FAEEs which induce sustained elevations of cytosolic calcium leading to inhibition of mitochondrial function, loss of ATP and necrosis of isolated pancreatic acinar cells. Furthermore, FAEEs undergo hydrolysis in the mitochondria releasing free fatty acids that exert toxic effects. Our recent work has shown that pharmacological inhibition of carboxylester lipase ameliorated detrimental effects of non-oxidative ethanol metabolism in isolated pancreatic acinar cells in vitro and in a new in vivo experimental model of alcoholic acute pancreatitis, revealing a specific enzyme target for ethanol-induced injury. Strategies that prevent FAEE synthesis, protect mitochondria, reduce calcium overload or sustain calcium homeostasis by ATP provision may provide promising therapeutic avenues for the treatment of alcoholic acute pancreatitis.
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Affiliation(s)
- David N Criddle
- Department of Cellular & Molecular Physiology & NIHR Liverpool Pancreas Biomedical Research Unit, RLBUHT, Institute of Translational Medicine, University of Liverpool, UK.
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Venglovecz V, Rakonczay Z, Gray MA, Hegyi P. Potassium channels in pancreatic duct epithelial cells: their role, function and pathophysiological relevance. Pflugers Arch 2014; 467:625-40. [PMID: 25074489 DOI: 10.1007/s00424-014-1585-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/09/2014] [Accepted: 07/18/2014] [Indexed: 12/14/2022]
Abstract
Pancreatic ductal epithelial cells play a fundamental role in HCO3 (-) secretion, a process which is essential for maintaining the integrity of the pancreas. Although several studies have implicated impaired HCO3 (-) and fluid secretion as a triggering factor in the development of pancreatitis, the mechanism and regulation of HCO3 (-) secretion is still not completely understood. To date, most studies on the ion transporters that orchestrate ductal HCO3 (-) secretion have focussed on the role of Cl(-)/HCO3 (-) exchangers and Cl(-) channels, whereas much less is known about the role of K(+) channels. However, there is growing evidence that many types of K(+) channels are present in ductal cells where they have an essential role in establishing and maintaining the electrochemical driving force for anion secretion. For this reason, strategies that increase K(+) channel function may help to restore impaired HCO3 (-) and fluid secretion, such as in pancreatitis, and therefore provide novel directions for future pancreatic therapy. In this review, our aims are to summarize the types of K(+) channels found in pancreatic ductal cells and to discuss their individual roles in ductal HCO3 (-) secretion. We will also describe how K(+) channels are involved in pathophysiological conditions and discuss how they could act as new molecular targets for the development of therapeutic approaches to treat pancreatic diseases.
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Affiliation(s)
- Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary,
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Kolodecik T, Shugrue C, Ashat M, Thrower EC. Risk factors for pancreatic cancer: underlying mechanisms and potential targets. Front Physiol 2014; 4:415. [PMID: 24474939 PMCID: PMC3893685 DOI: 10.3389/fphys.2013.00415] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 12/30/2013] [Indexed: 12/16/2022] Open
Abstract
PURPOSE OF THE REVIEW Pancreatic cancer is extremely aggressive, forming highly chemo-resistant tumors, and has one of the worst prognoses. The evolution of this cancer is multi-factorial. Repeated acute pancreatic injury and inflammation are important contributing factors in the development of pancreatic cancer. This article attempts to understand the common pathways linking pancreatitis to pancreatic cancer. RECENT FINDINGS Intracellular activation of both pancreatic enzymes and the transcription factor NF-κB are important mechanisms that induce acute pancreatitis (AP). Recurrent pancreatic injury due to genetic susceptibility, environmental factors such as smoking, alcohol intake, and conditions such as obesity lead to increases in oxidative stress, impaired autophagy and constitutive activation of inflammatory pathways. These processes can stimulate pancreatic stellate cells, thereby increasing fibrosis and encouraging chronic disease development. Activation of oncogenic Kras mutations through inflammation, coupled with altered levels of tumor suppressor proteins (p53 and p16) can ultimately lead to development of pancreatic cancer. SUMMARY Although our understanding of pancreatitis and pancreatic cancer has tremendously increased over many years, much remains to be elucidated in terms of common pathways linking these conditions.
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Affiliation(s)
- Thomas Kolodecik
- Digestive Diseases Section, Department of Internal Medicine, Yale UniversityNew Haven, CT, USA
- VA HealthcareWest Haven, CT, USA
| | - Christine Shugrue
- Digestive Diseases Section, Department of Internal Medicine, Yale UniversityNew Haven, CT, USA
- VA HealthcareWest Haven, CT, USA
| | - Munish Ashat
- Digestive Diseases Section, Department of Internal Medicine, Yale UniversityNew Haven, CT, USA
- VA HealthcareWest Haven, CT, USA
| | - Edwin C. Thrower
- Digestive Diseases Section, Department of Internal Medicine, Yale UniversityNew Haven, CT, USA
- VA HealthcareWest Haven, CT, USA
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