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Géza Pethő Á, Tapolyai M, Csongrádi É, Orosz P. Management of chronic kidney disease: The current novel and forgotten therapies. J Clin Transl Endocrinol 2024; 36:100354. [PMID: 38828402 PMCID: PMC11143912 DOI: 10.1016/j.jcte.2024.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
Chronic kidney disease (CKD) is a progressive and incurable condition that imposes a significant burden on an aging society. Although the exact prevalence of this disease is unknown, it is estimated to affect at least 800 million people worldwide. Patients with diabetes or hypertension are at a higher risk of developing chronic kidney damage. As the kidneys play a crucial role in vital physiological processes, damage to these organs can disrupt the balance of water and electrolytes, regulation of blood pressure, elimination of toxins, and metabolism of vitamin D. Early diagnosis is paramount to prevent potential complications. Treatment options such as dietary modifications and medications can help slow disease progression. In our narrative review, we have summarized the available therapeutic options to slow the progression of chronic kidney disease. Many new drug treatments have recently become available, offering a beacon of hope and optimism in CKD management. Nonetheless, disease prevention remains the most critical step in disease management. Given the significant impact of CKD on public health, there is a pressing need for further research. With the development of new technologies and advancements in medical knowledge, we hope to find more effective diagnostic tools and treatments for CKD patients.
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Affiliation(s)
- Ákos Géza Pethő
- Faculty of Medicine, Semmelweis University, Department of Internal Medicine and Oncology, Budapest, Hungary
| | - Mihály Tapolyai
- Medicine Service, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Nephrology, Szent Margit Kórhaz, Budapest, Hungary
| | - Éva Csongrádi
- Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Petronella Orosz
- Bethesda Children’s Hospital, 1146 Budapest, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
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Murck H, Karailiev P, Karailievova L, Puhova A, Jezova D. Treatment with Glycyrrhiza glabra Extract Induces Anxiolytic Effects Associated with Reduced Salt Preference and Changes in Barrier Protein Gene Expression. Nutrients 2024; 16:515. [PMID: 38398838 PMCID: PMC10893552 DOI: 10.3390/nu16040515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
We have previously identified that low responsiveness to antidepressive therapy is associated with higher aldosterone/cortisol ratio, lower systolic blood pressure, and higher salt preference. Glycyrrhiza glabra (GG) contains glycyrrhizin, an inhibitor of 11β-hydroxysteroid-dehydrogenase type-2 and antagonist of toll-like receptor 4. The primary hypothesis of this study is that food enrichment with GG extract results in decreased anxiety behavior and reduced salt preference under stress and non-stress conditions. The secondary hypothesis is that the mentioned changes are associated with altered gene expression of barrier proteins in the prefrontal cortex. Male Sprague-Dawley rats were exposed to chronic mild stress for five weeks. Both stressed and unstressed rats were fed a diet with or without an extract of GG roots for the last two weeks. GG induced anxiolytic effects in animals independent of stress exposure, as measured in elevated plus maze test. Salt preference and intake were significantly reduced by GG under control, but not stress conditions. The gene expression of the barrier protein claudin-11 in the prefrontal cortex was increased in control rats exposed to GG, whereas stress-induced rise was prevented. Exposure to GG-enriched diet resulted in reduced ZO-1 expression irrespective of stress conditions. In conclusion, the observed effects of GG are in line with a reduction in the activity of central mineralocorticoid receptors. The treatment with GG extract or its active components may, therefore, be a useful adjunct therapy for patients with subtypes of depression and anxiety disorders with heightened renin-angiotensin-aldosterone system and/or inflammatory activity.
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Affiliation(s)
- Harald Murck
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, 35039 Marburg, Germany
| | - Peter Karailiev
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia; (P.K.); (L.K.); (A.P.); (D.J.)
| | - Lucia Karailievova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia; (P.K.); (L.K.); (A.P.); (D.J.)
| | - Agnesa Puhova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia; (P.K.); (L.K.); (A.P.); (D.J.)
| | - Daniela Jezova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 845 05 Bratislava, Slovakia; (P.K.); (L.K.); (A.P.); (D.J.)
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Banerjee S, Baidya SK, Adhikari N, Ghosh B, Jha T. Glycyrrhizin as a promising kryptonite against SARS-CoV-2: Clinical, experimental, and theoretical evidences. J Mol Struct 2022; 1275:134642. [DOI: 10.1016/j.molstruc.2022.134642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/24/2022] [Accepted: 11/24/2022] [Indexed: 11/27/2022]
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Abbasi F, Adatorwovor R, Davarpanah MA, Mansoori Y, Hajiani M, Azodi F, Sefidbakht S, Davoudi S, Rezaei F, Mohammadmoradi S, Asadipooya K. A Randomized Trial of Combination Therapy, Sitagliptin and Spironolactone, in Hospitalized Adult Patients with COVID-19. J Endocr Soc 2022; 6:bvac017. [PMID: 35261932 PMCID: PMC8898039 DOI: 10.1210/jendso/bvac017] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
Context COVID-19 may cause respiratory distress syndrome and death. Treatment of COVID-19 to prevent complications remains a priority. Objective Our investigation sought to determine whether combination of spironolactone and sitagliptin could reduce mortality for inpatients with SARS-CoV-2 infection. Methods This single-blind, 4-arm, prospective randomized clinical trial was conducted at Shiraz and Bushehr University of Medical Sciences hospitals between December 2020 and April 2021. We randomized hospitalized adult patients with COVID-19 pneumonia into 4 groups: control, combination therapy, sitagliptin add-on, or spironolactone add-on. The primary outcome was the clinical improvement of the patients in the hospital as measured on an 8-point numerical scale. The secondary outcomes included intubation, ICU admission, end organ damages, CT findings, and paraclinical information. Results A total of 263 admitted patients were randomly assigned to control group (87 patients), combination group (60 patients), sitagliptin group (66 patients), and spironolactone group (50 patients). There were no significant differences in baseline characteristics, except for higher age in control group. The intervention groups, especially combination therapy, had better clinical outcomes (clinical score on fifth day of admission: 3.11 ± 2.45 for controls, 1.33 ± 0.50 for combination, 1.68 ± 1.02 for sitagliptin, and 1.64 ± 0.81 for spironolactone; P = 0.004). However, the mortality rate was lower in patients who received spironolactone (21.84% control, 13.33% combination, 13.64% sitagliptin, 10.00% spironolactone; P = 0.275). Our intervention reduced lung infiltration but not the area of involvement in lungs. Conclusion Sitagliptin and spironolactone can potentially improve clinical outcomes of hospitalized COVID-19 patients.
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Affiliation(s)
- Farhad Abbasi
- Department of Infectious Diseases, Bushehr University of Medical Sciences, Bushehr, Iran
| | | | | | | | | | - Farzan Azodi
- Faculty of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Sepideh Sefidbakht
- Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Shayan Mohammadmoradi
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, USA. Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Kamyar Asadipooya
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, USA
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Kai H, Kai M, Niiyama H, Okina N, Sasaki M, Maeda T, Katoh A. Overexpression of angiotensin-converting enzyme 2 by renin-angiotensin system inhibitors. Truth or myth? A systematic review of animal studies. Hypertens Res 2021; 44:955-968. [PMID: 33750913 PMCID: PMC7943405 DOI: 10.1038/s41440-021-00641-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/24/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
Angiotensin-converting enzyme 2 (ACE2) protects against organ damage in hypertension and cardiovascular diseases by counter regulating the renin-angiotensin system (RAS). ACE2 is also the receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Based on the claim that RAS inhibitors (RASIs) cause ACE2 overexpression in some animal experiments, concerns have arisen that RASIs may aggravate SARS-CoV-2 infection and coronavirus disease-2019 severity in RASI-treated patients. To achieve a comprehensive review, a systematic search of MEDLINE/PubMed was conducted regarding the effects of RASIs on tissue ACE2 mRNA/protein expression in healthy animals and animal models of human diseases. We identified 88 eligible articles involving 168 experiments in the heart, kidneys, lungs, and other organs. Three of 38 experiments involving healthy animals showed ACE2 expression greater than twice that of the control (overexpression). Among 102 disease models (130 experiments), baseline ACE2 was overexpressed in 16 models (18 experiments) and less than half the control level (repression) in 28 models (40 experiments). In 72 experiments, RASIs did not change ACE2 levels from the baseline levels of disease models. RASIs caused ACE2 overexpression compared to control levels in seven experiments, some of which were unsupported by other experiments under similar conditions. In 36 experiments, RASIs reversed or prevented disease-induced ACE2 repression, yielding no or marginal changes. Therefore, ACE2 overexpression appears to be a rare rather than common consequence of RASI treatment in healthy animals and disease models. Future studies should clarify the pathophysiological significance of RASI-induced reversal or prevention of ACE2 repression in disease models.
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Affiliation(s)
- Hisashi Kai
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan.
| | - Mamiko Kai
- Department of Pharmaceutical and Health Care Management, Faculty of Pharmaceutical Sciences, Fukuoka University, Fukuoka, Japan
| | - Hiroshi Niiyama
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan
| | - Norihito Okina
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan
| | - Motoki Sasaki
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan
| | - Takanobu Maeda
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan
| | - Atsushi Katoh
- Department of Cardiology, Kurume University Medical Center, Kurume, Japan
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Jezova D, Karailiev P, Karailievova L, Puhova A, Murck H. Food Enrichment with Glycyrrhiza glabra Extract Suppresses ACE2 mRNA and Protein Expression in Rats-Possible Implications for COVID-19. Nutrients 2021; 13:2321. [PMID: 34371831 PMCID: PMC8308790 DOI: 10.3390/nu13072321] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022] Open
Abstract
Angiotensin converting enzyme 2 (ACE2) is a key entry point of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus known to induce Coronavirus disease 2019 (COVID-19). We have recently outlined a concept to reduce ACE2 expression by the administration of glycyrrhizin, a component of Glycyrrhiza glabra extract, via its inhibitory activity on 11beta hydroxysteroid dehydrogenase type 2 (11betaHSD2) and resulting activation of mineralocorticoid receptor (MR). We hypothesized that in organs such as the ileum, which co-express 11betaHSD2, MR and ACE2, the expression of ACE2 would be suppressed. We studied organ tissues from an experiment originally designed to address the effects of Glycyrrhiza glabra extract on stress response. Male Sprague Dawley rats were left undisturbed or exposed to chronic mild stress for five weeks. For the last two weeks, animals continued with a placebo diet or received a diet containing extract of Glycyrrhiza glabra root at a dose of 150 mg/kg of body weight/day. Quantitative PCR measurements showed a significant decrease in gene expression of ACE2 in the small intestine of rats fed with diet containing Glycyrrhiza glabra extract. This effect was independent of the stress condition and failed to be observed in non-target tissues, namely the heart and the brain cortex. In the small intestine we also confirmed the reduction of ACE2 at the protein level. Present findings provide evidence to support the hypothesis that Glycyrrhiza glabra extract may reduce an entry point of SARS-CoV-2. Whether this phenomenon, when confirmed in additional studies, is linked to the susceptibility of cells to the virus requires further studies.
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Affiliation(s)
- Daniela Jezova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (D.J.); (P.K.); (L.K.); (A.P.)
| | - Peter Karailiev
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (D.J.); (P.K.); (L.K.); (A.P.)
| | - Lucia Karailievova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (D.J.); (P.K.); (L.K.); (A.P.)
| | - Agnesa Puhova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia; (D.J.); (P.K.); (L.K.); (A.P.)
| | - Harald Murck
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, 35039 Marburg, Germany
- Murck-Neuroscience, Westfield, NJ 07090, USA
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Oz M, Lorke DE, Kabbani N. A comprehensive guide to the pharmacologic regulation of angiotensin converting enzyme 2 (ACE2), the SARS-CoV-2 entry receptor. Pharmacol Ther 2021; 221:107750. [PMID: 33275999 PMCID: PMC7854082 DOI: 10.1016/j.pharmthera.2020.107750] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023]
Abstract
The recent emergence of coronavirus disease-2019 (COVID-19) as a global pandemic has prompted scientists to address an urgent need for defining mechanisms of disease pathology and treatment. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent for COVID-19, employs angiotensin converting enzyme 2 (ACE2) as its primary target for cell surface attachment and likely entry into the host cell. Thus, understanding factors that may regulate the expression and function of ACE2 in the healthy and diseased body is critical for clinical intervention. Over 66% of all adults in the United States are currently using a prescription drug and while earlier findings have focused on possible upregulation of ACE2 expression through the use of renin angiotensin system (RAS) inhibitors, mounting evidence suggests that various other widely administered drugs used in the treatment of hypertension, heart failure, diabetes mellitus, hyperlipidemias, coagulation disorders, and pulmonary disease may also present a varied risk for COVID-19. Specifically, we summarize mechanisms on how heparin, statins, steroids and phytochemicals, besides their established therapeutic effects, may also interfere with SARS-CoV-2 viral entry into cells. We also describe evidence on the effect of several vitamins, phytochemicals, and naturally occurring compounds on ACE2 expression and activity in various tissues and disease models. This comprehensive review aims to provide a timely compendium on the potential impact of commonly prescribed drugs and pharmacologically active compounds on COVID-19 pathology and risk through regulation of ACE2 and RAS signaling.
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Key Words
- adam17, a disintegrin and metalloprotease 17
- ace, angiotensin i converting enzyme
- ace-inh., angiotensin i converting enzyme inhibitor
- ampk, amp-activated protein kinase
- ang-ii, angiotensin ii
- arb, angiotensin ii type 1-receptor blocker
- ards, acute respiratory distress syndrome
- at1-r, angiotensin ii type 1-receptor
- βarb, β-adrenergic receptor blockers
- bk, bradykinin
- ccb, calcium channel blockers
- ch25h, cholesterol-25-hydroxylase
- copd, chronic obstructive lung disease
- cox, cyclooxygenase
- covid-19, coronavirus disease-2019
- dabk, [des-arg9]-bradykinin
- erk, extracellular signal-regulated kinase
- 25hc, 25-hydroxycholesterol
- hs, heparan sulfate
- hspg, heparan sulfate proteoglycan
- ibd, inflammatory bowel disease
- map, mitogen-activated protein
- mers, middle east respiratory syndrome
- mrb, mineralocorticoid receptor blocker
- nos, nitric oxide synthase
- nsaid, non-steroid anti-inflammatory drug
- ras, renin-angiotensin system
- sars-cov, severe acute respiratory syndrome coronavirus
- sh, spontaneously hypertensive
- s protein, spike protein
- sirt1, sirtuin 1
- t2dm, type 2 diabetes mellitus
- tcm, traditional chinese medicine
- tmprss2, transmembrane protease, serine 2
- tnf, tumor necrosis factor
- ufh, unfractionated heparin
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Affiliation(s)
- Murat Oz
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Safat 13110, Kuwait.
| | - Dietrich Ernst Lorke
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates; Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Nadine Kabbani
- School of Systems Biology, George Mason University, Fairfax, VA 22030, USA
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Kuriakose J, Montezano A, Touyz R. ACE2/Ang-(1-7)/Mas1 axis and the vascular system: vasoprotection to COVID-19-associated vascular disease. Clin Sci (Lond) 2021; 135:387-407. [PMID: 33511992 PMCID: PMC7846970 DOI: 10.1042/cs20200480] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 12/13/2022]
Abstract
The two axes of the renin-angiotensin system include the classical ACE/Ang II/AT1 axis and the counter-regulatory ACE2/Ang-(1-7)/Mas1 axis. ACE2 is a multifunctional monocarboxypeptidase responsible for generating Ang-(1-7) from Ang II. ACE2 is important in the vascular system where it is found in arterial and venous endothelial cells and arterial smooth muscle cells in many vascular beds. Among the best characterized functions of ACE2 is its role in regulating vascular tone. ACE2 through its effector peptide Ang-(1-7) and receptor Mas1 induces vasodilation and attenuates Ang II-induced vasoconstriction. In endothelial cells activation of the ACE2/Ang-(1-7)/Mas1 axis increases production of the vasodilator's nitric oxide and prostacyclin's and in vascular smooth muscle cells it inhibits pro-contractile and pro-inflammatory signaling. Endothelial ACE2 is cleaved by proteases, shed into the circulation and measured as soluble ACE2. Plasma ACE2 activity is increased in cardiovascular disease and may have prognostic significance in disease severity. In addition to its enzymatic function, ACE2 is the receptor for severe acute respiratory syndrome (SARS)-coronavirus (CoV) and SARS-Cov-2, which cause SARS and coronavirus disease-19 (COVID-19) respectively. ACE-2 is thus a double-edged sword: it promotes cardiovascular health while also facilitating the devastations caused by coronaviruses. COVID-19 is associated with cardiovascular disease as a risk factor and as a complication. Mechanisms linking COVID-19 and cardiovascular disease are unclear, but vascular ACE2 may be important. This review focuses on the vascular biology and (patho)physiology of ACE2 in cardiovascular health and disease and briefly discusses the role of vascular ACE2 as a potential mediator of vascular injury in COVID-19.
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Affiliation(s)
- Jithin Kuriakose
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Augusto C. Montezano
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Rhian M. Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
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Is Spironolactone the Preferred Renin-Angiotensin-Aldosterone Inhibitor for Protection Against COVID-19? J Cardiovasc Pharmacol 2020; 77:323-331. [PMID: 33278189 DOI: 10.1097/fjc.0000000000000960] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/14/2020] [Indexed: 12/13/2022]
Abstract
ABSTRACT The high mortality of specific groups from COVID-19 highlights the importance of host-viral interactions and the potential benefits from enhancing host defenses. SARS-CoV-2 requires angiotensin-converting enzyme (ACE) 2 as a receptor for cell entry and infection. Although both ACE inhibitors and spironolactone can upregulate tissue ACE2, there are important points of discrimination between these approaches. The virus requires proteolytic processing of its spike protein by transmembrane protease receptor serine type 2 (TMPRSS2) to enable binding to cellular ACE2. Because TMPRSS2 contains an androgen promoter, it may be downregulated by the antiandrogenic actions of spironolactone. Furin and plasmin also process the spike protein. They are inhibited by protease nexin 1 or serpin E2 (PN1) that is upregulated by angiotensin II but downregulated by aldosterone. Therefore, spironolactone should selectively downregulate furin and plasmin. Furin also promotes pulmonary edema, whereas plasmin promotes hemovascular dysfunction. Thus, a downregulation of furin and plasmin by PN1 could be a further benefit of MRAs beyond their well-established organ protection. We review the evidence that spironolactone may be the preferred RASSi to increase PN1 and decrease TMPRSS2, furin, and plasmin activities and thereby reduce viral cell binding, entry, infectivity, and bad outcomes. This hypothesis requires direct investigation.
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Biyashev D, Onay UV, Dalal P, Demczuk M, Evans S, Techner JM, Lu KQ. A novel treatment for skin repair using a combination of spironolactone and vitamin D3. Ann N Y Acad Sci 2020; 1480:170-182. [PMID: 32892377 PMCID: PMC7754145 DOI: 10.1111/nyas.14485] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/10/2020] [Accepted: 08/13/2020] [Indexed: 02/06/2023]
Abstract
Injury of the skin from exposure to toxic chemicals leads to the release of inflammatory mediators and the recruitment of immune cells. Nitrogen mustard (NM) and other alkylating agents cause severe cutaneous damage for which there are limited treatment options. Here, we show that combined treatment of vitamin D3 (VD3) and spironolactone (SP), a mineralocorticoid receptor antagonist, significantly improves the resolution of inflammation and accelerates wound healing after NM exposure. SP enhanced the inhibitory effect of VD3 on nuclear factor-kB activity. Combined treatment of NM-exposed mice with VD3 and SP synergistically inhibited the expression of iNOS in the skin and decreased the expression of matrix metallopeptidase-9, C-C motif chemokine ligand 2, interleukin (IL)-1α, and IL-1β. The combined treatment decreased the number of local proinflammatory M1 macrophages resulting in an increase in the M2/M1 ratio in the wound microenvironment. Apoptosis was also decreased in the skin after combined treatment. Together, this creates a proresolution state, resulting in more rapid wound closure. Combined VD3 and SP treatment is effective in modulating the immune response and activating anti-inflammatory pathways in macrophages to facilitate tissue repair. Altogether, these data demonstrate that VD3 and SP may constitute an effective treatment regimen to improve wound healing after NM or other skin chemical injury.
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Affiliation(s)
- Dauren Biyashev
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ummiye V Onay
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Prarthana Dalal
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael Demczuk
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Spencer Evans
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - José-Marc Techner
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kurt Q Lu
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Murck H. Symptomatic Protective Action of Glycyrrhizin (Licorice) in COVID-19 Infection? Front Immunol 2020; 11:1239. [PMID: 32574273 PMCID: PMC7270278 DOI: 10.3389/fimmu.2020.01239] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/18/2020] [Indexed: 01/22/2023] Open
Abstract
The role of the ACE2 enzyme in the COVID-19 infection is 2-fold, with opposing implications for the disease development. 1. The membrane bound angiotensin converting enzyme 2 (ACE2) serves as the entry point of COVID-19 2. Conversely, it supports an anti-inflammatory pathway. This led to the controversy of the impact of medications, which influence its expression. ACE2 is part of the wider renin-angiotensin-aldosterone system (RAAS) and is upregulated via compounds, which inhibits the classical ACE, thereby plasma aldosterone and aldosterone receptor (MR) activation. MR activation may therefore protect organs from binding the COVID-19 by reducing ACE2 expression. Glycyrrhizin (GL) is a frequent component in traditional Chinese medicines, which have been used to control COVID-19 infections. Its systemically active metabolite glycyrrhetinic acid (GA) inhibits 11beta hydroxysteroid dehydrogenase(11betaHSD2) and activates MR in organs, which express this enzyme, including the lungs. Does this affect the protective effect of ACE2? Importantly, GL has anti-inflammatory properties by itself via toll like receptor 4 (TLR4) antagonism and therefore compensates for the reduced protection of the downregulated ACE2. Finally, a direct effect of GL or GA to reduce virus transmission exists, which may involve reduced expression of type 2 transmembrane serine protease (TMPRSS2), which is required for virus uptake. Glycyrrhizin may reduce the severity of an infection with COVID-19 at the two stages of the COVID-19 induced disease process, 1. To block the number of entry points and 2. provide an ACE2 independent anti-inflammatory mechanism.
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Affiliation(s)
- Harald Murck
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany.,Murck-Neuroscience LLC, Westfield, NJ, United States
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Yang CT, Kor CT, Hsieh YP. Long-Term Effects of Spironolactone on Kidney Function and Hyperkalemia-Associated Hospitalization in Patients with Chronic Kidney Disease. J Clin Med 2018; 7:jcm7110459. [PMID: 30469400 PMCID: PMC6262621 DOI: 10.3390/jcm7110459] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 01/13/2023] Open
Abstract
Background: Spironolactone, a non-selective mineralocorticoid receptor antagonist, can protect against cardiac fibrosis and left ventricular dysfunction, and improve endothelial dysfunction and proteinuria. However, the safety and effects of spironolactone on patient-centered cardiovascular and renal endpoints remain unclear. Methods: We identified predialysis stage 3–4 chronic kidney disease (CKD) patients between 2000 and 2013 from the Longitudinal Health Insurance Database 2005 (LHID 2005). The outcomes of interest were end-stage renal disease (ESRD), major adverse cardiovascular events (MACE), hospitalization for heart failure (HHF), hyperkalemia-associated hospitalization (HKAH), all-cause mortality and cardiovascular mortality. The Fine and Gray sub-distribution hazards approach was adopted to adjust for the competing risk of death. Results: After the propensity score matching, 693 patients with stage 3–4 CKD were spironolactone users and 1386 were nonusers. During the follow-up period, spironolactone users had a lower incidence rate for ESRD than spironolactone non-users (39.2 vs. 53.69 per 1000 person-years) and a higher incidence rate for HKAH (54.79 vs. 18.57 per 1000 person-years). The adjusted hazard ratios for ESRD of spironolactone users versus non-users were 0.66 (95% CI, 0.51–0.84; p value < 0.001) and 3.17 (95% CI, 2.41–4.17; p value < 0.001) for HKAH. A dose-response relationship was found between spironolactone use and risk of ESRD and HKAH. There were no statistical differences in MACE, HHF, all-cause mortality and cardiovascular mortality between spironolactone users and non-users. Conclusion: Spironolactone represented a promising treatment option to retard CKD progression to ESRD amongst stage 3–4 CKD patients, but strategic treatments to prevent hyperkalemia should be enforced.
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Affiliation(s)
- Chen-Ta Yang
- Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan.
| | - Chew-Teng Kor
- Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan.
| | - Yao-Peng Hsieh
- Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan.
- School of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan.
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.
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13
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Spironolactone rescues renal dysfunction in obstructive jaundice rats by upregulating ACE2 expression. J Cell Commun Signal 2018; 13:17-26. [PMID: 29882088 DOI: 10.1007/s12079-018-0466-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/17/2018] [Indexed: 12/31/2022] Open
Abstract
Postoperative acute renal failure in patients with obstructive jaundice is still a serious clinically complication, yet the mechanisms remain unclear. Renin-angiotensin-aldosterone system (RAAS) plays a central role in renal disease progression. Several lines of evidence shows that angiotensin-converting-enzyme-2 (ACE2), a main effector of RAAS acts as a local regulator for renal protection. This study aims to investigate the role of ACE2 and the effect of spironolactone treatment in obstructive jaundice(OJ) rats with renal injury. The rats with obstructive jaundice were established by bile duct ligation. Total bilirubin (TBil), serum creatinine (Scr) and the expression of ACE2 in kidney tissue of obstructive jaundice rats were detected. Comparatively, the expression of ACE2, renin, angiotensin II (AngII), angiotensin-(1-7)[Ang-(1-7)], aldosterone and intercellular adhesion molecule 1 (ICAM-1) in kidney tissues after spironolactone administration were measured by ELISA. Renal necrosis, inflammation and fibrosis induced by OJ were also measured by HE staining and Masson staining. The correlation between the expression of ACE2 and TBil, also the Scr level were investigated. With the time of common bile duct ligation prolonged, the TBil and Scr concentration increased while the expression of ACE2 in OJ rats' kidney tissues decreased. However, after spironolactone intervention, the expressions of ACE2, renin, AngII, Ang-(1-7), aldosterone and ICAM-1 in kidney tissue were changed, moreover, necrotic, inflammatory and fibrotic condition was also decreased. The relationship between the mRNA expression of ACE2 and TBil/Scr was observed to be moderately negatively correlated (r = -0.516, R2 = 0.292, P < 0.01), (r = -0.576, R2 = 0.332, P < 0.01), respectively. RAAS exerted an important effect in the renal damage caused by OJ. Spironolactone intervention not only improved the degree of renal fibrosis induced by OJ, but also upregulated the ACE2 expression in the kidney of OJ rats and rescued the renal function.
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14
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Dougherty EJ, Elinoff JM, Ferreyra GA, Hou A, Cai R, Sun J, Blaine KP, Wang S, Danner RL. Mineralocorticoid Receptor (MR) trans-Activation of Inflammatory AP-1 Signaling: DEPENDENCE ON DNA SEQUENCE, MR CONFORMATION, AND AP-1 FAMILY MEMBER EXPRESSION. J Biol Chem 2016; 291:23628-23644. [PMID: 27650495 DOI: 10.1074/jbc.m116.732248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Indexed: 01/21/2023] Open
Abstract
Glucocorticoids are commonly used to treat inflammatory disorders. The glucocorticoid receptor (GR) can tether to inflammatory transcription factor complexes, such as NFκB and AP-1, and trans-repress the transcription of cytokines, chemokines, and adhesion molecules. In contrast, aldosterone and the mineralocorticoid receptor (MR) primarily promote cardiovascular inflammation by incompletely understood mechanisms. Although MR has been shown to weakly repress NFκB, its role in modulating AP-1 has not been established. Here, the effects of GR and MR on NFκB and AP-1 signaling were directly compared using a variety of ligands, two different AP-1 consensus sequences, GR and MR DNA-binding domain mutants, and siRNA knockdown or overexpression of core AP-1 family members. Both GR and MR repressed an NFκB reporter without influencing p65 or p50 binding to DNA. Likewise, neither GR nor MR affected AP-1 binding, but repression or activation of AP-1 reporters occurred in a ligand-, AP-1 consensus sequence-, and AP-1 family member-specific manner. Notably, aldosterone interactions with both GR and MR demonstrated a potential to activate AP-1. DNA-binding domain mutations that eliminated the ability of GR and MR to cis-activate a hormone response element-driven reporter variably affected the strength and polarity of these responses. Importantly, MR modulation of NFκB and AP-1 signaling was consistent with a trans-mechanism, and AP-1 effects were confirmed for specific gene targets in primary human cells. Steroid nuclear receptor trans-effects on inflammatory signaling are context-dependent and influenced by nuclear receptor conformation, DNA sequence, and the expression of heterologous binding partners. Aldosterone activation of AP-1 may contribute to its proinflammatory effects in the vasculature.
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Affiliation(s)
- Edward J Dougherty
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Jason M Elinoff
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Gabriela A Ferreyra
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Angela Hou
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Rongman Cai
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Junfeng Sun
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Kevin P Blaine
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Shuibang Wang
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
| | - Robert L Danner
- From the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
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15
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Lother A, Fürst D, Bergemann S, Gilsbach R, Grahammer F, Huber TB, Hilgendorf I, Bode C, Moser M, Hein L. Deoxycorticosterone Acetate/Salt–Induced Cardiac But Not Renal Injury Is Mediated By Endothelial Mineralocorticoid Receptors Independently From Blood Pressure. Hypertension 2016; 67:130-8. [DOI: 10.1161/hypertensionaha.115.06530] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/12/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Achim Lother
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - David Fürst
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Stella Bergemann
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Ralf Gilsbach
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Florian Grahammer
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Tobias B. Huber
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Ingo Hilgendorf
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Martin Moser
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
| | - Lutz Hein
- From the Department of Cardiology and Angiology I, Heart Center (A.L., I.H., C.B., M.M.), Institute of Experimental and Clinical Pharmacology and Toxicology (A.L., D.F., S.B., R.G., L.H.), Renal Division, Department of Medicine (F.G., T.B.H.), and BIOSS Centre for Biological Signaling Studies (T.B.H., L.H.), University of Freiburg, Freiburg, Germany
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16
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Brand S, Amann K, Mandel P, Zimnol A, Schupp N. Oxidative DNA damage in kidneys and heart of hypertensive mice is prevented by blocking angiotensin II and aldosterone receptors. PLoS One 2014; 9:e115715. [PMID: 25551569 PMCID: PMC4297153 DOI: 10.1371/journal.pone.0115715] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 11/28/2014] [Indexed: 12/24/2022] Open
Abstract
Introduction Recently, we could show that angiotensin II, the reactive peptide of the blood pressure-regulating renin-angiotensin-aldosterone-system, causes the formation of reactive oxygen species and DNA damage in kidneys and hearts of hypertensive mice. To further investigate on the one hand the mechanism of DNA damage caused by angiotensin II, and on the other hand possible intervention strategies against end-organ damage, the effects of substances interfering with the renin-angiotensin-aldosterone-system on angiotensin II-induced genomic damage were studied. Methods In C57BL/6-mice, hypertension was induced by infusion of 600 ng/kg • min angiotensin II. The animals were additionally treated with the angiotensin II type 1 receptor blocker candesartan, the mineralocorticoid receptor blocker eplerenone and the antioxidant tempol. DNA damage and the activation of transcription factors were studied by immunohistochemistry and protein expression analysis. Results Administration of angiotensin II led to a significant increase of blood pressure, decreased only by candesartan. In kidneys and hearts of angiotensin II-treated animals, significant oxidative stress could be detected (1.5-fold over control). The redox-sensitive transcription factors Nrf2 and NF-κB were activated in the kidney by angiotensin II-treatment (4- and 3-fold over control, respectively) and reduced by all interventions. In kidneys and hearts an increase of DNA damage (3- and 2-fold over control, respectively) and of DNA repair (3-fold over control) was found. These effects were ameliorated by all interventions in both organs. Consistently, candesartan and tempol were more effective than eplerenone. Conclusion Angiotensin II-induced DNA damage is caused by angiotensin II type 1 receptor-mediated formation of oxidative stress in vivo. The angiotensin II-mediated physiological increase of aldosterone adds to the DNA-damaging effects. Blocking angiotensin II and mineralocorticoid receptors therefore has beneficial effects on end-organ damage independent of blood pressure normalization.
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Affiliation(s)
- Susanne Brand
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Kerstin Amann
- Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Philipp Mandel
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Anna Zimnol
- Institute of Toxicology, University of Düsseldorf, Düsseldorf, Germany
| | - Nicole Schupp
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
- Institute of Toxicology, University of Düsseldorf, Düsseldorf, Germany
- * E-mail:
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17
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Bauersachs J, Jaisser F, Toto R. Mineralocorticoid receptor activation and mineralocorticoid receptor antagonist treatment in cardiac and renal diseases. Hypertension 2014; 65:257-63. [PMID: 25368026 DOI: 10.1161/hypertensionaha.114.04488] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Johann Bauersachs
- From the Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany (J.B.); Centre de Recherche des Cordeliers, Inserm U1138, Université Pierre et Marie Curie, Paris, France (F.J.); and Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas (R.T.).
| | - Frédéric Jaisser
- From the Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany (J.B.); Centre de Recherche des Cordeliers, Inserm U1138, Université Pierre et Marie Curie, Paris, France (F.J.); and Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas (R.T.)
| | - Robert Toto
- From the Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany (J.B.); Centre de Recherche des Cordeliers, Inserm U1138, Université Pierre et Marie Curie, Paris, France (F.J.); and Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas (R.T.)
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18
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Effect of alprostadil combined with Diammonium glycyrrhizinate on renal interstitial fibrosis in SD rats. ASIAN PAC J TROP MED 2014; 7:900-4. [DOI: 10.1016/s1995-7645(14)60157-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 09/10/2014] [Accepted: 10/15/2014] [Indexed: 11/22/2022] Open
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19
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Watanabe R, Azuma RW, Suzuki JI, Ogawa M, Itai A, Hirata Y, Komuro I, Isobe M. Inhibition of NF-κB activation by a novel IKK inhibitor reduces the severity of experimental autoimmune myocarditis via suppression of T-cell activation. Am J Physiol Heart Circ Physiol 2013; 305:H1761-71. [PMID: 24097428 DOI: 10.1152/ajpheart.00159.2013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
NF-κB, which is activated by the inhibitor of NF-κB kinase (IKK), is involved in the progression of inflammatory disease. However, the effect of IKK inhibition on the progression of myocarditis is unknown. We examined the effect of IKK inhibition on the progression of myocarditis. Lewis rats were immunized with porcine cardiac myosin to induce experimental autoimmune myocarditis (EAM). We administered the IKK inhibitor (IMD-0354; 15 mg·kg(-1)·day(-1)) or vehicle to EAM rats daily. Hearts were harvested 21 days after immunization. Although the untreated EAM group showed increased heart weight-to-body weight ratio, and severe myocardial damage, these changes were attenuated in the IKK inhibitor-treated group. Moreover, IKK inhibitor administration significantly reduced NF-κB activation and mRNA expression of IFN-γ, IL-2, and monocyte chemoattractant protein-1 in myocardium compared with vehicle administration. In vitro study showed that the IKK inhibitor treatment inhibited T-cell proliferation and Th1 cytokines production induced by myosin stimulation. The IKK inhibitor ameliorated EAM by suppressing inflammatory reactions via suppression of T-cell activation.
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Affiliation(s)
- Ryo Watanabe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Yushima, Bunkyo, Tokyo, Japan
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20
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Soler MJ, Wysocki J, Batlle D. ACE2 alterations in kidney disease. Nephrol Dial Transplant 2013; 28:2687-97. [PMID: 23956234 PMCID: PMC3811059 DOI: 10.1093/ndt/gft320] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/20/2013] [Indexed: 12/16/2022] Open
Abstract
Angiotensin-converting enzyme 2 (ACE2) is a monocarboxypeptidase that degrades angiotensin (Ang) II to Ang-(1-7). ACE2 is highly expressed within the kidneys, it is largely localized in tubular epithelial cells and less prominently in glomerular epithelial cells and in the renal vasculature. ACE2 activity has been shown to be altered in diabetic kidney disease, hypertensive renal disease and in different models of kidney injury. There is often a dissociation between tubular and glomerular ACE2 expression, particularly in diabetic kidney disease where ACE2 expression is increased at the tubular level but decreased at the glomerular level. In this review, we will discuss alterations in circulating and renal ACE2 recently described in different renal pathologies and disease models as well as their possible significance.
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Affiliation(s)
- María José Soler
- Department of Nephrology, Hospital del Mar-Fundació IMIM, Barcelona, Spain
| | - Jan Wysocki
- Division of Nephrology & Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Daniel Batlle
- Division of Nephrology & Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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21
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Salyer SA, Parks J, Barati MT, Lederer ED, Clark BJ, Klein JD, Khundmiri SJ. Aldosterone regulates Na(+), K(+) ATPase activity in human renal proximal tubule cells through mineralocorticoid receptor. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2013; 1833:2143-52. [PMID: 23684706 DOI: 10.1016/j.bbamcr.2013.05.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/15/2013] [Accepted: 05/08/2013] [Indexed: 12/21/2022]
Abstract
The mechanisms by which aldosterone increases Na(+), K(+) ATPase and sodium channel activity in cortical collecting duct and distal nephron have been extensively studied. Recent investigations demonstrate that aldosterone increases Na-H exchanger-3 (NHE-3) activity, bicarbonate transport, and H(+) ATPase in proximal tubules. However, the role of aldosterone in regulation of Na(+), K(+) ATPase in proximal tubules is unknown. We hypothesize that aldosterone increases Na(+), K(+) ATPase activity in proximal tubules through activation of the mineralocorticoid receptor (MR). Immunohistochemistry of kidney sections from human, rat, and mouse kidneys revealed that the MR is expressed in the cytosol of tubules staining positively for Lotus tetragonolobus agglutinin and type IIa sodium-phosphate cotransporter (NpT2a), confirming proximal tubule localization. Adrenalectomy in Sprague-Dawley rats decreased expression of MR, ENaC α, Na(+), K(+) ATPase α1, and NHE-1 in all tubules, while supplementation with aldosterone restored expression of above proteins. In human kidney proximal tubule (HKC11) cells, treatment with aldosterone resulted in translocation of MR to the nucleus and phosphorylation of SGK-1. Treatment with aldosterone also increased Na(+), K(+) ATPase-mediated (86)Rb uptake and expression of Na(+), K(+) ATPase α1 subunits in HKC11 cells. The effects of aldosterone on Na(+), K(+) ATPase-mediated (86)Rb uptake were prevented by spironolactone, a competitive inhibitor of aldosterone for the MR, and partially by Mifepristone, a glucocorticoid receptor (GR) inhibitor. These results suggest that aldosterone regulates Na(+), K(+) ATPase in renal proximal tubule cells through an MR-dependent mechanism.
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Affiliation(s)
- Sarah A Salyer
- Department of Medicine, Kidney Disease Program, University of Louisville, Louisville, KY, USA
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22
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Queisser N, Amann K, Hey V, Habib SL, Schupp N. Blood pressure has only minor influence on aldosterone-induced oxidative stress and DNA damage in vivo. Free Radic Biol Med 2013; 54:17-25. [PMID: 23104102 DOI: 10.1016/j.freeradbiomed.2012.10.549] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 10/16/2012] [Accepted: 10/16/2012] [Indexed: 01/22/2023]
Abstract
Epidemiological studies found an increased kidney cancer risk in hypertensive patients. These patients frequently present an increase in the mineralocorticoid aldosterone (Ald) due to a stimulated renin angiotensin aldosterone system (RAAS). Recently, we showed pro-oxidative and genotoxic effects of Ald in vitro. Here, we investigated the influence of blood pressure on aldosterone-induced oxidative damage. To distinguish whether effects in Sprague-Dawley rats treated with Ald were caused by Ald or by increased blood pressure, the mineralocorticoid receptor (MR) antagonist spironolactone was administered in a subtherapeutical dose, not lowering the blood pressure, and hydralazine, a RAAS-independent vasodilator, was given to normalize the pressure. With the antioxidant tempol, oxidative stress-dependent effects were demonstrated. Ald treatment caused kidney damage and oxidative and nitrative stress. Structural DNA damage and the mutagenic oxidative base modification 7,8-dihydro-8-oxoguanine were increased, as well as DNA repair activity and nuclear NF-κB translocation. Spironolactone and tempol decreased all markers significantly, whereas hydralazine had just slight effects. These data comprise the first report of essentially blood pressure-independent tissue- and DNA-damaging effects of Ald. A fully activated MR and the production of reactive oxygen and nitrogen species were crucial for these effects.
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Affiliation(s)
- Nina Queisser
- Institute of Pharmacology and Toxicology, University of Würzburg, 97078 Würzburg, Germany
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23
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Tanaka T, Ogawa M, Suzuki JI, Sekinishi A, Itai A, Hirata Y, Nagai R, Isobe M. Inhibition of IκB phosphorylation prevents load-induced cardiac dysfunction in mice. Am J Physiol Heart Circ Physiol 2012; 303:H1435-45. [DOI: 10.1152/ajpheart.00290.2012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pressure overload is known to be a cause of cardiac hypertrophy that often transits to heart failure. Although nuclear factor (NF)-κB is a key factor in the progression of cardiac hypertrophy, its pathophysiology is yet to be elucidated. Thus, we aimed to show that inhibition of NF-κB activation improves pressure overload-induced cardiac dysfunction. To assess the effect of inhibition on NF-κB activation in pressure overload cardiac hypertrophy, we used IMD-1041 in a murine thoracic aortic constriction (TAC) model. IMD-1041 inhibits the phosphorylation of IκB via inhibition of IκB kinase-β. IMD-1041 (100 mg·kg−1·day−1) or vehicle was administered orally into mice once a day, and mice were euthanized on day 42 after TAC. TAC resulted in left ventricular wall thickening, cardiac dysfunction, and increases of heart and lung weight, whereas IMD-1041 significantly suppressed the development of cardiac hypertropy 6 wk after TAC. Histologically, developed cardiac fibrosis and cardiomyocyte hypertrophy occurred in the vehicle-treated group, whereas IMD-1041 significantly attenuated these changes. IMD-1041 suppressed the expression of p65-positive cells and nuclear translocation of p65 induced by TAC compared with vehicle. Matrix metalloproteinase-2 activity increased in the vehicle + TAC-treated group; however, it was suppressed in the IMD-1041 + TAC-treated group. IMD-1041 treatment from day 28 to day 42 after TAC significantly attenuated the decrease in the percentage of fractional shortening and cardiac fibrosis without an antihypertrophic effect. In conclusion, IMD-1041 may be useful for preventing pressure overload-induced cardiac dysfunction and the transition of cardiac hypertrophy to contraction failure via suppression of NF-κB activation.
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Affiliation(s)
- Tetsu Tanaka
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masahito Ogawa
- Department of Advanced Clinical Science and Therapeutics, University of Tokyo, Tokya, Japan
| | - Jun-ichi Suzuki
- Department of Advanced Clinical Science and Therapeutics, University of Tokyo, Tokya, Japan
| | - Asuka Sekinishi
- Department of Periodontology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akiko Itai
- Institute of Medicinal Molecular Design, Tokyo, Japan; and
| | - Yasunobu Hirata
- Department of Advanced Clinical Science and Therapeutics, University of Tokyo, Tokya, Japan
| | - Ryozo Nagai
- Department of Cardiovascular Medicine, University of Tokyo, Tokyo, Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Lennikov A, Kitaichi N, Noda K, Ando R, Dong Z, Fukuhara J, Kinoshita S, Namba K, Mizutani M, Fujikawa T, Itai A, Ohno S, Ishida S. Amelioration of endotoxin-induced uveitis treated with an IκB kinase β inhibitor in rats. Mol Vis 2012; 18:2586-97. [PMID: 23112571 PMCID: PMC3482174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 11/18/2012] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Endotoxin-induced uveitis (EIU) is an animal model for acute ocular inflammation. Several substances play major roles in the development of inflammatory changes in EIU, including tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6. These inflammatory cytokines trigger the degradation of IκB by activating IκB kinases (IKKs). Released nuclear factor kappaB (NFκB) subsequently translocates to the nucleus, where NFκB expresses its proinflammatory function. IMD-0354, N-(3,5-Bis-trifluoromethylphenyl)-5-chloro-2-hydroxybenzamide, selectively inhibits IKKβ, particularly when induced by proinflammatory cytokines, such as TNF-α and IL-1β. In the present study, we examined whether IKKβ inhibition has therapeutic effects on EIU by using IMD-0354 and its prodrug IMD-1041. METHODS Six-week-old male Lewis rats were used. EIU was induced with subcutaneous injections of 200 μg of lipopolysaccharide (LPS) from Escherichia coli that had been diluted in 0.1 ml of phosphate-buffered saline. IMD-0354 was administered intraperitoneally at 30, 10, 3, or 0 mg/kg, suspended in 1.0 ml of 0.5% carboxymethyl cellulose sodium. The prodrug IMD-1041 (100 mg/kg) was also administered orally. The rats were euthanized 24 h after LPS injection, and EIU severity was evaluated histologically. The number of infiltrating cells and the protein, TNF-α, and monocyte chemoattractant protein-1 (MCP-1) concentrations in the aqueous humor were determined. TNF-α and MCP-1 concentrations were quantified with enzyme-linked immunosorbent assay. Eye sections were also stained with anti-NFκB and phosphorylated I-κBα antibodies. RESULTS The number of infiltrating cells in aqueous humor was 53.6±9.8×10(5), 72.5±17.0×10(5), 127.25±32.0×10(5), and 132.0±25.0×10(5) cells/ml in rats treated with 30, 10, 3, or 0 mg/kg of IMD-0354, respectively. The total protein concentrations of aqueous humor were 92.6±3.1 mg/ml, 101.5±6.8 mg/ml, 112.6±1.9 mg/ml, and 117.33±1.8 mg/ml in rats treated with 30, 10, 3, and 0 mg/kg of IMD-0354, respectively. Infiltrating cells and protein concentrations were significantly decreased by treatment with IMD-0354 (p<0.01). IMD-0354 treatment significantly reduced the concentration of TNF-α (p<0.05) and MCP-1 (p<0.01) in aqueous humor. The number of NFκB positive nuclei was reduced when treated with IMD-0354. Furthermore, IMD-0354-treated EIU rats showed only background levels of phosphorylated I-κBα; however, it was strongly expressed in the iris-ciliary body cell cytoplasm of the IMD-0354 untreated EIU rats. Oral administration of IMD-1041 also decreased the cell number (p<0.01) and protein concentration (p<0.05) of aqueous humor in EIU. CONCLUSIONS Acute uveitis was ameliorated by inhibition of IKKβ in rats. IMD-0354 and its prodrug IMD-1041 seem to be promising candidates for treating intraocular inflammation/uveitis.
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Affiliation(s)
- Anton Lennikov
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuyoshi Kitaichi
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan,Department of Ocular Inflammation and Immunology, Hokkaido University Graduate School of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan,Department of Ophthalmology, Health Sciences University of Hokkaido, Sapporo, Japan
| | - Kousuke Noda
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ryo Ando
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Zhenyu Dong
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Junichi Fukuhara
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Kinoshita
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kenichi Namba
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Miho Mizutani
- Institute of Medicinal Molecular Design (IMMD) Inc, Tokyo, Japan
| | | | - Akiko Itai
- Institute of Medicinal Molecular Design (IMMD) Inc, Tokyo, Japan
| | - Shigeaki Ohno
- Department of Ocular Inflammation and Immunology, Hokkaido University Graduate School of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Susumu Ishida
- Laboratory of Ocular Cell Biology and Visual Science, Department of Ophthalmology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Xue B, Zhang Z, Roncari CF, Guo F, Johnson AK. Aldosterone acting through the central nervous system sensitizes angiotensin II-induced hypertension. Hypertension 2012; 60:1023-30. [PMID: 22949534 DOI: 10.1161/hypertensionaha.112.196576] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Previous studies have shown that preconditioning rats with a nonpressor dose of angiotensin II (Ang II) sensitizes the pressor response produced by later treatment with a higher dose of Ang II and that Ang II and aldosterone (Aldo) can modulate each other's pressor effects through actions involving the central nervous system. The current studies tested whether Aldo can cross-sensitize the pressor actions of Ang II to enhance hypertension by employing an induction-delay-expression experimental design. Male rats were implanted for telemetered blood pressure recording. During induction, subpressor doses of either subcutaneous or intracerebroventricular Aldo were delivered for 1 week. Rats were then rested for 1 week (delay) to assure that any exogenous Aldo was metabolized. After this, Ang II was given subcutaneously for 2 weeks (expression). During induction and delay, Aldo had no sustained effect on blood pressure. However, during expression, Ang II-induced hypertension was greater in the groups receiving subcutaneous or intracerebroventricular Aldo during induction in comparison with those groups receiving vehicle. Central administration of mineralocorticoid receptor antagonist blocked sensitization. Brain tissue collected at the end of delay and expression showed increased mRNA expression of several renin-angiotensin-aldosterone system components in cardiovascular-related forebrain regions of cross-sensitized rats. Cultured subfornical organ neurons preincubated with Aldo displayed greater increases in [Ca2+]i after Ang II treatment, and there was a greater Fra-like immunoreactivity present at the end of expression in cardiovascular-related forebrain structures. Taken together, these results indicate that Aldo pretreatment cross-sensitizes the development of Ang II-induced hypertension probably by mechanisms that involve the central nervous system.
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Affiliation(s)
- Baojian Xue
- Department of Psychology, Cardiovascular Center, University of Iowa, 11 Seashore Hall E, Iowa City, IA 52242, USA
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Queisser N, Schupp N. Aldosterone, oxidative stress, and NF-κB activation in hypertension-related cardiovascular and renal diseases. Free Radic Biol Med 2012; 53:314-27. [PMID: 22609249 DOI: 10.1016/j.freeradbiomed.2012.05.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 05/07/2012] [Accepted: 05/07/2012] [Indexed: 02/07/2023]
Abstract
The mineralocorticoid aldosterone regulates electrolyte and fluid balance and is involved in blood pressure homoeostasis. Classically, it binds to its intracellular mineralocorticoid receptor to induce expression of proteins influencing the reabsorption of sodium and water in the distal nephron. Aldosterone gained special attention when large clinical studies showed that blocking its receptor in patients with cardiovascular diseases reduced their mortality. These patients present increased plasma aldosterone levels. The exact mechanisms of the potential toxic effects of aldosterone leading to cardiovascular damage are not known yet. The observation of reduced nitric oxide bioavailability in hyperaldosteronism implied the generation of oxidative stress by aldosterone. Subsequent studies confirmed the increase of oxidative stress markers in patients with chronic heart failure and in animal models of hyperaldosteronism. The effects of reactive oxygen species have been related to the activation of transcription factors, such as NF-κB. This review summarizes the present-day knowledge of aldosterone-induced oxidative stress and NF-κB activation in humans and different experimental models.
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Affiliation(s)
- Nina Queisser
- Institute of Pharmacology and Toxicology, University of Würzburg, Versbacher Str. 9, 97078 Würzburg, Germany
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Uota S, Zahidunnabi Dewan M, Saitoh Y, Muto S, Itai A, Utsunomiya A, Watanabe T, Yamamoto N, Yamaoka S. An IκB kinase 2 inhibitor IMD-0354 suppresses the survival of adult T-cell leukemia cells. Cancer Sci 2012; 103:100-6. [PMID: 21951590 PMCID: PMC11164137 DOI: 10.1111/j.1349-7006.2011.02110.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Adult T-cell leukemia (ATL) is a fatal T-cell malignancy associated with human T-cell leukemia virus type I infection. The aberrant expression of nuclear factor-κB (NF-κB) is considered to contribute to the malignant phenotype and chemo-resistance of ATL cells. Because of the poor prognosis of ATL, the development of new therapeutic strategies is direly needed. In the present study, we show that an IκB kinase 2 (IKK2) inhibitor, IMD-0354, efficiently inhibits the survival of CD4(+) CD25(+) primary ATL cells and prevents the growth of or induces apoptosis of patient-derived ATL cell lines. Assays of transcription with integrated forms of reporter genes revealed that IMD-0354 suppresses NF-κB-dependent transcriptional activity. Moreover, the daily administration of IMD-0354 prevents the growth of tumors in mice inoculated with ATL cells. Our results suggest that targeting IKK2 with a small molecule inhibitor, such as IMD-0354, is an attractive strategy for the treatment of ATL.
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Affiliation(s)
- Shin Uota
- Department of Molecular Virology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Bernardi S, Toffoli B, Zennaro C, Tikellis C, Monticone S, Losurdo P, Bellini G, Thomas MC, Fallo F, Veglio F, Johnston CI, Fabris B. High-salt diet increases glomerular ACE/ACE2 ratio leading to oxidative stress and kidney damage. Nephrol Dial Transplant 2011; 27:1793-800. [PMID: 22036945 DOI: 10.1093/ndt/gfr600] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Angiotensin II (AngII) contributes to salt-driven kidney damage. In this study, we aimed at investigating whether and how the renal damage associated with a high-salt diet could result from changes in the ratio between angiotensin-converting enzyme (ACE) and angiotensin-converting enzyme 2 (ACE2). METHODS Forty-eight rats randomly allocated to three different dietary contents of salt were studied for 4 weeks after undergoing a left uninephrectomy. We focussed on kidney functional, structural and molecular changes. At the same time, we studied kidney molecular changes in 20 weeks old Ace2-knockout mice (Ace2KO), with and without ACE inhibition. RESULTS A high salt content diet significantly increased the glomerular ACE/ACE2 ratio. This was associated with increased oxidative stress. To assess whether these events were related, we measured renal oxidative stress in Ace2KO, and found that the absence of ACE2 promoted oxidative stress, which could be prevented by ACE inhibition. CONCLUSION One of the mechanisms by which a high-salt diet leads to renal damage seems to be the modulation of the ACE/ACE2 ratio which in turn is critical for the cause of oxidative stress, through AngII.
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Affiliation(s)
- Stella Bernardi
- Department of Morphology and Embriology, University of Ferrara, Ferrara, Italy.
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