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Padoan F, Piccoli E, Pietrobelli A, Moreno LA, Piacentini G, Pecoraro L. The Role of Zinc in Developed Countries in Pediatric Patients: A 360-Degree View. Biomolecules 2024; 14:718. [PMID: 38927121 PMCID: PMC11201578 DOI: 10.3390/biom14060718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/09/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Zinc is an important trace element for growth and health at pediatric ages. Zinc is fundamental in inflammatory pathways, oxidative balance, and immune function. Zinc exhibits anti-inflammatory properties by modulating Nuclear Factor-kappa (NF-κB) activity and reducing histamine release from basophils, leukocytes, and mast cells. Furthermore, its antioxidant activity protects against oxidative damage and chronic diseases. Finally, zinc improves the ability to trigger effective immune responses against pathogens by contributing to the maturation of lymphocytes, the production of cytokines, and the regulation of apoptosis. Given these properties, zinc can be considered an adjunctive therapy in treating and preventing respiratory, nephrological, and gastrointestinal diseases, both acute and chronic. This review aims to deepen the role and metabolism of zinc, focusing on the role of supplementation in developed countries in pediatric diseases.
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Affiliation(s)
- Flavia Padoan
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics University of Verona, 37126 Verona, Italy
| | - Elena Piccoli
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics University of Verona, 37126 Verona, Italy
| | - Angelo Pietrobelli
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics University of Verona, 37126 Verona, Italy
| | - Luis A. Moreno
- Growth, Exercise, Nutrition and Development (GENUD), Research Group, Instituto Agroalimentario de Aragón (IA2), Instituto de Investigación Sanitaria Aragón (IIS Aragón), Universidad de Zaragoza, 50001 Zaragoza, Spain
| | - Giorgio Piacentini
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics University of Verona, 37126 Verona, Italy
| | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics University of Verona, 37126 Verona, Italy
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Kim J, Oh S, Yang DS, Rugg L, Mathur R, Kwak SS, Yoo S, Li S, Kanatzidis EE, Lee G, Yoon HJ, Huang Y, Ghaffari R, McColley SA, Rogers JA. A skin-interfaced, miniaturized platform for triggered induction, capture and colorimetric multicomponent analysis of microliter volumes of sweat. Biosens Bioelectron 2024; 253:116166. [PMID: 38428069 DOI: 10.1016/j.bios.2024.116166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
Eccrine sweat can serve as a source of biomarkers for assessing physiological health and nutritional balance, for tracking loss of essential species from the body and for evaluating exposure to hazardous substances. The growing interest in this relatively underexplored class of biofluid arises in part from its non-invasive ability for capture and analysis. The simplest devices, and the only ones that are commercially available, exploit soft microfluidic constructs and colorimetric assays with purely passive modes of operation. The most sophisticated platforms exploit batteries, electronic components and radio hardware for inducing sweat, for electrochemical evaluation of its content and for wireless transmission of this information. The work reported here introduces a technology that combines the advantages of these two different approaches, in the form of a cost-effective, easy-to-use device that supports on-demand evaluation of multiple biomarkers in sweat. This flexible, skin-interfaced, miniaturized system incorporates a hydrogel that contains an approved drug to activate eccrine sweat glands, electrodes and a simple circuit and battery to delivery this drug by iontophoresis through the surface of the skin, microfluidic channels and microreservoirs to capture the induced sweat, and multiple colorimetric assays to evaluate the concentrations of chloride, zinc, and iron. As demonstrated in healthy human participants monitored before and after a meal, such devices yield results that match those of traditional laboratory analysis techniques. Clinical studies that involve cystic fibrosis pediatric patients illustrate the use of this technology as a simple, painless, and reliable alternative to traditional hospital systems for measurements of sweat chloride.
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Affiliation(s)
- Joohee Kim
- Center for Bionics of Biomedical Research Division, Korea Institute of Science and Technology, Seoul, 02792, Republic of Korea; Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Precision Biology Research Center, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - Seyong Oh
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Division of Electrical Engineering, Hanyang University ERICA, Ansan, 15588, Republic of Korea
| | - Da Som Yang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA
| | - Larissa Rugg
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Radhika Mathur
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Sung Soo Kwak
- Center for Bionics of Biomedical Research Division, Korea Institute of Science and Technology, Seoul, 02792, Republic of Korea; Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA
| | - Seonggwang Yoo
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA
| | - Shupeng Li
- Department of Mechanical Engineering, Northwestern University, Evanston, IL, 60208, USA
| | - Evangelos E Kanatzidis
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA
| | - Geumbee Lee
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA
| | - Hong-Joon Yoon
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Department of Electronic Engineering, Gachon University, Seongnam-si, Gyeonggi-do 13120, Republic of Korea
| | - Yonggang Huang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Department of Mechanical Engineering, Northwestern University, Evanston, IL, 60208, USA
| | - Roozbeh Ghaffari
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Department of Biomedical Engineering, Northwestern University, Evanston, IL, 60208, USA; Epicore Biosystems Inc., Cambridge, MA, 02139, USA
| | - Susanna A McColley
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
| | - John A Rogers
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, 60208, USA; Department of Mechanical Engineering, Northwestern University, Evanston, IL, 60208, USA; Department of Biomedical Engineering, Northwestern University, Evanston, IL, 60208, USA; Epicore Biosystems Inc., Cambridge, MA, 02139, USA; Department of Materials Science and Engineering, Northwestern University, Evanston, IL, 60208, USA; Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
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3
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Malikidogo KP, Isaac M, Uguen A, Morfin JF, Tircsó G, Tóth É, Bonnet CS. Gd 3+ Complexes for MRI Detection of Zn 2+ in the Presence of Human Serum Albumin: Structure-Activity Relationships. Inorg Chem 2023; 62:17207-17218. [PMID: 37815813 DOI: 10.1021/acs.inorgchem.3c02280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Zn2+-responsive magnetic resonance imaging (MRI) contrast agents are typically composed of a Gd chelate conjugated to a Zn2+-binding moiety via a linker. They allow for Zn2+ detection in the presence of human serum albumin (HSA). In order to decipher the key parameters that drive their Zn2+-dependent MRI response, we designed a pyridine-based ligand, PyAmC2mDPA, and compared the properties of GdPyAmC2mDPA to those of analogue complexes with varying Gd core, Zn-binding moiety, or linker sizes. The stability constants determined by pH potentiometry showed the good selectivity of PyAmC2mDPA for Gd3+ (log KGd = 16.27) versus Zn2+ (log KZn = 13.58), proving that our modified Zn2+-binding DPA moiety prevents the formation of previously observed dimeric species. Paramagnetic relaxation enhancement measurements indicated at least three sites that are available for GdPyAmC2mDPA binding on HSA, as well as a 2-fold affinity increase when Zn2+ is present (KD = 170 μM versus KDZn = 60 μM). Fluorescence competition experiments provided evidence of the higher affinity for site II vs site I, as well as the importance of both the Zn-binding part and the Gd core in generating enhanced HSA affinity in the presence of Zn2+. Finally, an analysis of nuclear magnetic relaxation dispersion (NMRD) data suggested a significantly increased rigidity for the Zn2+-bound system, which is responsible for the Zn2+-dependent relaxivity response.
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Affiliation(s)
- Kyangwi P Malikidogo
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
| | - Manon Isaac
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
| | - Adrien Uguen
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
| | - Jean-François Morfin
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
| | - Gyula Tircsó
- Department of Inorganic and Analytical Chemistry, University of Debrecen, Egyetem tér 1, 4010 Debrecen, Hungary
- Le Studium, Loire Valley Institute for Advanced Studies, 1 Rue Dupanloup, 45000 Orléans, France
| | - Éva Tóth
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
| | - Célia S Bonnet
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d'Orléans, Rue Charles Sadron, F-45071 Orléans CEDEX 2, France
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Ayats-Vidal R, Bosque-García M, Cordobilla B, Asensio-De la Cruz O, García-González M, Castro-Marrero J, López-Rico I, Domingo JC. Changes of Erythrocyte Fatty Acids after Supplementation with Highly Concentrated Docosahexaenoic Acid (DHA) in Pediatric Cystic Fibrosis: A Randomized Double-Blind Controlled Trial. J Clin Med 2023; 12:jcm12113704. [PMID: 37297899 DOI: 10.3390/jcm12113704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
We characterized the fatty acid profiles in the erythrocyte membrane of pediatric patients with cystic fibrosis (CF) receiving highly concentrated docosahexaenoic acid (DHA) supplementation (Tridocosahexanoin-AOX® 70%) at 50 mg/kg/day (n = 11) or matching placebo (n = 11) for 12 months. The mean age was 11.7 years. The DHA group showed a statistically significant improvement in n-3 polyunsaturated fatty acids (PUFAs), which was observed as early as 6 months and further increased at 12 months. Among the n-3 PUFAs, there was a significant increase in DHA and eicosapentaenoic acid (EPA). Additionally, a statistically significant decrease in n-6 PUFAs was found, primarily due to a decrease in arachidonic acid (AA) levels and elongase 5 activity. However, we did not observe any changes in linoleic acid levels. The long-term administration of DHA over one year was safe and well tolerated. In summary, the administration of a high-rich DHA supplement at a dose of 50 mg/kg/day for one year can correct erythrocyte AA/DHA imbalance and reduce fatty acid inflammatory markers. However, it is important to note that essential fatty acid alterations cannot be fully normalized with this treatment. These data provide timely information of essential fatty acid profile for future comparative research.
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Affiliation(s)
- Roser Ayats-Vidal
- Pediatric Allergies, Immunology and Pneumology Unit, Pediatric Medicine Service, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Taulí 1, E-08208 Sabadell, Spain
| | - Montserrat Bosque-García
- Pediatric Allergies, Immunology and Pneumology Unit, Pediatric Medicine Service, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Taulí 1, E-08208 Sabadell, Spain
| | - Begoña Cordobilla
- Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, University of Barcelona, E-08028 Barcelona, Spain
| | - Oscar Asensio-De la Cruz
- Pediatric Allergies, Immunology and Pneumology Unit, Pediatric Medicine Service, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Taulí 1, E-08208 Sabadell, Spain
| | - Miguel García-González
- Pediatric Allergies, Immunology and Pneumology Unit, Pediatric Medicine Service, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Taulí 1, E-08208 Sabadell, Spain
| | - Jesús Castro-Marrero
- ME/CFS Research Unit, Division of Rheumatology, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, E-08035 Barcelona, Spain
| | - Irene López-Rico
- Pharmacy Department, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA), Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, E-08208 Sabadell, Spain
| | - Joan Carles Domingo
- Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, University of Barcelona, E-08028 Barcelona, Spain
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Shrestha N, McCarron A, Rout-Pitt N, Donnelley M, Parsons DW, Hryciw DH. Essential Fatty Acid Deficiency in Cystic Fibrosis Disease Progression: Role of Genotype and Sex. Nutrients 2022; 14:nu14214666. [PMID: 36364928 PMCID: PMC9657825 DOI: 10.3390/nu14214666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Adequate intake of nutrients such as essential fatty acids (EFA) are critical in cystic fibrosis (CF). The clinical course of deterioration of lung function in people with CF has been shown to relate to nutrition. Independent of the higher energy consumption and malabsorption due to pancreatic insufficiency, EFA deficiency is closely associated with the risk of pulmonary infection, the most significant pathology in CF. This review will focus on the EFA deficiency identified in people with CF, as well as the limited progress made in deciphering the exact metabolic pathways that are dysfunctional in CF. Specifically, people with CF are deficient in linoleic acid, an omega 6 fatty acid, and the ratio of arachidonic acid (omega 6 metabolite) and docosahexaenoic acid (omega 3 metabolite) is increased. Analysis of the molecular pathways in bronchial cells has identified changes in the enzymes that metabolise EFA. However, fatty acid metabolism primarily occurs in the liver, with EFA metabolism in CF liver not yet investigated, indicating that further research is required. Despite limited understanding in this area, it is well known that adequate EFA concentrations are critical to normal membrane structure and function, and thus are important to consider in disease processes. Novel insights into the relationship between CF genotype and EFA phenotype will be discussed, in addition to sex differences in EFA concentrations in people with CF. Collectively, investigating the specific effects of genotype and sex on fatty acid metabolism may provide support for the management of people with CF via personalised genotype- and sex-specific nutritional therapies.
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Affiliation(s)
- Nirajan Shrestha
- School of Pharmacy and Medical Sciences, Griffith University, Southport, QLD 4222, Australia
| | - Alexandra McCarron
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5001, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5001, Australia
- Respiratory and Sleep Medicine, Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA 5006, Australia
| | - Nathan Rout-Pitt
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5001, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5001, Australia
- Respiratory and Sleep Medicine, Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA 5006, Australia
| | - Martin Donnelley
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5001, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5001, Australia
- Respiratory and Sleep Medicine, Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA 5006, Australia
| | - David W. Parsons
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5001, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5001, Australia
- Respiratory and Sleep Medicine, Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA 5006, Australia
| | - Deanne H. Hryciw
- School of Environment and Science, Griffith University, Nathan, QLD 4111, Australia
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3000, Australia
- Griffith Institute for Drug Discovery, Griffith University, Nathan, QLD 4111, Australia
- Correspondence: ; Tel.: +61-7-3735-3601
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Liu X, Ali MK, Dua K, Xu R. The Role of Zinc in the Pathogenesis of Lung Disease. Nutrients 2022; 14:nu14102115. [PMID: 35631256 PMCID: PMC9143957 DOI: 10.3390/nu14102115] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 12/26/2022] Open
Abstract
Lung diseases, such as asthma, chronic obstructive pulmonary diseases (COPD), and cystic fibrosis (CF), are among the leading causes of mortality and morbidity globally. They contribute to substantial economic burdens on society and individuals. Currently, only a few treatments are available to slow the development and progression of these diseases. Thus, there is an urgent unmet need to develop effective therapies to improve quality of life and limit healthcare costs. An increasing body of clinical and experimental evidence suggests that altered zinc and its regulatory protein levels in the systemic circulation and in the lungs are associated with these disease’s development and progression. Zinc plays a crucial role in human enzyme activity, making it an essential trace element. As a cofactor in metalloenzymes and metalloproteins, zinc involves a wide range of biological processes, such as gene transcription, translation, phagocytosis, and immunoglobulin and cytokine production in both health and disease. Zinc has gained considerable interest in these lung diseases because of its anti-inflammatory, antioxidant, immune, and metabolic modulatory properties. Here we highlight the role and mechanisms of zinc in the pathogenesis of asthma, COPD, CF, acute respiratory distress syndrome, idiopathic pulmonary fibrosis, and pulmonary hypertension.
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Affiliation(s)
- Xiaoying Liu
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang 110001, China;
| | - Md Khadem Ali
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Stanford University, Stanford, CA 94305, USA;
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA 94305, USA
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Sydney, NSW 2007, Australia;
- Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW 2007, Australia
- Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun 248007, India
| | - Ran Xu
- Department of Thoracic Surgery, Shengjing Hospital, China Medical University, Shenyang 110022, China
- Correspondence: ; Tel.: +86-189-4025-8514
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Escobedo Monge MF, Barrado E, Alonso Vicente C, Redondo Del Río MP, Marugán de Miguelsanz JM. Zinc Nutritional Status in Patients with Cystic Fibrosis. Nutrients 2019; 11:E150. [PMID: 30642010 PMCID: PMC6356838 DOI: 10.3390/nu11010150] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Zinc is an essential nutrient for all forms of life and its deficiency affects the normal growth and development of human beings. OBJECTIVE The main aim was to investigate zinc nutritional status by serum zinc concentration (SZC) and dietary zinc intake and their association in cystic fibrosis (CF) patients. METHODS A cross-sectional study was conducted in CF patients. Anthropometric measurements and respiratory and pancreatic tests were conducted. Hypozincemia was determined by SZC while using atomic absorption spectrophotometry and dietary zinc deficiency by prospective 72-h dietary surveys. RESULTS Mean SZC (87.2 ± 16.7 μg/dL) and dietary zinc intake (97 ± 26.9% Dietary Reference Intake) were normal. Three of 17 patients with CF (17.6%) had hypozincemia and four (23.5%) had a dietary zinc deficiency. No patient with dietary zinc deficiency had hypozincemia. A positive and significant association was observed between SZC and Z-score of BMI-for-age (p = 0.048) and weight-for-height (p = 0.012) and between dietary zinc intake and energy intake (EI, p = 0.036) and Z-score of weight-for-high (p = 0.029). CONCLUSION SZC was associated with the nutritional status, expressed as BMI (Body Mass Index) and weight-for-height Z score, and dietary zinc intake with EI and weight-for-height Z-score. No patient with hypozincemia had dietary zinc deficiency. This situation should alert us to a marginal zinc deficiency and it may explain why there were no overlapping cases between the two groups. We suggest that probably 41% of the cases in this study would be at elevated risk of zinc deficiency and a zinc supplementation may be considered.
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Affiliation(s)
| | - Enrique Barrado
- Department of Analytical Chemistry, Science Faculty, University of Valladolid, Campus Miguel Delibes, Calle Paseo de Belén, 7, 47011 Valladolid, Spain.
| | - Carmen Alonso Vicente
- Department of Paediatrics of the Faculty of Medicine, Valladolid University; Section of Gastroenterology and Pediatric Nutrition, University Clinical Hospital of Valladolid, Avenida Ramón y Cajal, 7, 47005Valladolid, Spain.
| | | | - José Manuel Marugán de Miguelsanz
- Department of Paediatrics of the Faculty of Medicine, Valladolid University; Section of Gastroenterology and Pediatric Nutrition, University Clinical Hospital of Valladolid, Avenida Ramón y Cajal, 7, 47005Valladolid, Spain.
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Kamei S, Fujikawa H, Nohara H, Ueno-Shuto K, Maruta K, Nakashima R, Kawakami T, Matsumoto C, Sakaguchi Y, Ono T, Suico MA, Boucher RC, Gruenert DC, Takeo T, Nakagata N, Li JD, Kai H, Shuto T. Zinc Deficiency via a Splice Switch in Zinc Importer ZIP2/SLC39A2 Causes Cystic Fibrosis-Associated MUC5AC Hypersecretion in Airway Epithelial Cells. EBioMedicine 2017; 27:304-316. [PMID: 29289532 PMCID: PMC5828551 DOI: 10.1016/j.ebiom.2017.12.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 12/15/2017] [Accepted: 12/19/2017] [Indexed: 01/02/2023] Open
Abstract
Airway mucus hyperproduction and fluid imbalance are important hallmarks of cystic fibrosis (CF), the most common life-shortening genetic disorder in Caucasians. Dysregulated expression and/or function of airway ion transporters, including cystic fibrosis transmembrane conductance regulator (CFTR) and epithelial sodium channel (ENaC), have been implicated as causes of CF-associated mucus hypersecretory phenotype. However, the contributory roles of other substances and transporters in the regulation of CF airway pathogenesis remain unelucidated. Here, we identified a novel connection between CFTR/ENaC expression and the intracellular Zn2 + concentration in the regulation of MUC5AC, a major secreted mucin that is highly expressed in CF airway. CFTR-defective and ENaC-hyperactive airway epithelial cells specifically and highly expressed a unique, alternative splice isoform of the zinc importer ZIP2/SLC39A2 (ΔC-ZIP2), which lacks the C-terminal domain. Importantly, ΔC-ZIP2 levels correlated inversely with wild-type ZIP2 and intracellular Zn2 + levels. Moreover, the splice switch to ΔC-ZIP2 as well as decreased expression of other ZIPs caused zinc deficiency, which is sufficient for induction of MUC5AC; while ΔC-ZIP2 expression per se induced ENaC expression and function. Thus, our findings demonstrate that the novel splicing switch contributes to CF lung pathology via the novel interplay of CFTR, ENaC, and ZIP2 transporters. Zinc deficiency is a common feature in both CFTR-defective (CF) and ENaC-hyperactive (CF-like) airway epithelial cells. A splice switch from WT-ZIP2 to ΔC-ZIP2 as well as other ZIPs down-regulation caused zinc deficiency in CF and CF-like cells. Lower intracellular Zn2 + levels contributed to CF-associated MUC5AC hypersecretion in airway epithelial cells.
The role of zinc in the pathogenesis of CF lung disease is not well understood. We utilized human CF patient-derived cell lines and primary cells as well as murine CF model, and identified zinc deficiency as a common characteristic in CF models. Down-regulation of several zinc importers (ZIPs) in CF cells caused zinc deficiency, which is sufficient for induction of MUC5AC, a major secreted mucin that exacerbates CF pathogenesis. Especially, strong contribution of ΔC-ZIP2, a novel ZIP2 splice isoform, in the regulation of CF-associated MUC5AC hypersecretion was clearly demonstrated. The study refined the importance of zinc in airway homeostasis.
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Affiliation(s)
- Shunsuke Kamei
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan; Program for Leading Graduate Schools "HIGO (Health life science: Interdisciplinary and Glocal Oriented) Program", Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Haruka Fujikawa
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan; Program for Leading Graduate Schools "HIGO (Health life science: Interdisciplinary and Glocal Oriented) Program", Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Hirofumi Nohara
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan; Program for Leading Graduate Schools "HIGO (Health life science: Interdisciplinary and Glocal Oriented) Program", Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Keiko Ueno-Shuto
- Laboratory of Pharmacology, Division of Life Science, Faculty of Pharmaceutical Sciences, Sojo University, 4-22-1 Ikeda, Nishi-ku, Kumamoto 860-0082, Japan
| | - Kasumi Maruta
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Ryunosuke Nakashima
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Taisei Kawakami
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Chizuru Matsumoto
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Yuki Sakaguchi
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Tomomi Ono
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Mary Ann Suico
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Richard C Boucher
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dieter C Gruenert
- Head and Neck Stem Cell Lab, University of California, San Francisco, 2340 Sutter St, Box 1330, N331, San Francisco, CA 94115, USA
| | - Toru Takeo
- Division of Reproductive Engineering, Center for Animal Resources and Development (CARD), Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto 860-0811, Japan
| | - Naomi Nakagata
- Division of Reproductive Engineering, Center for Animal Resources and Development (CARD), Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto 860-0811, Japan
| | - Jian-Dong Li
- Center for Inflammation, Immunity & Infection, Institute for Biomedical Sciences, Georgia State University, 714 Petit Science Center, 100 Piedmont Ave SE, Atlanta GA30303, USA
| | - Hirofumi Kai
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan.
| | - Tsuyoshi Shuto
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-Honmachi, Chuo-ku, Kumamoto 862-0973, Japan.
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Weiss G, Carver PL. Role of divalent metals in infectious disease susceptibility and outcome. Clin Microbiol Infect 2017; 24:16-23. [PMID: 28143784 DOI: 10.1016/j.cmi.2017.01.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/21/2017] [Accepted: 01/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Divalent metals play important roles in maintaining metabolism and cellular growth of both eukaryotic hosts and invading microbes. Both metal deficiency and overload can result in abnormal cellular function or damage. Given its central role in host-pathogen interactions, subtle alterations of divalent metal homeostasis can occur in the course of infectious diseases which aim, from the host perspective, either to reduce the availability of respective metals to microbes or to use toxic metal accumulation to eliminate pathogens. AIMS To provide the reader with background information and clinical data on divalent metal homeostasis in host-pathogen interactions, how this affects the course of infectious disease and whether correction of metal disturbances has shown benefit in infections. SOURCES An in-depth analysis of PubMed articles related to the topic of this review published in English between 1970 and 2016 was performed. CONTENT From the microbial perspective, divalent metals are essential for growth and pathogenicity and to mount effective protection against antimicrobial host responses, including toxic radical formation. Microbes have evolved multiple strategies to control their access to divalent metals. From the clinical perspective, alterations of divalent metal levels may result in increased or decreased susceptibility to infection and often occur in response to infections. However, keeping in mind the strategies underlying such alterations, for which the term 'nutritional immunity' was coined, the uncritical correction of such divalent metal imbalances may cause harm to patients. This review addresses the role of the divalent metals iron, selenium, zinc, manganese and copper in infectious diseases from a mechanistic and clinical perspective. IMPLICATIONS We point out areas of research needed to expand our limited knowledge, hoping to improve the clinical management of patients with infections and to identify promising new targets for treatment by modulation of host or microbe divalent metal metabolism.
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Affiliation(s)
- G Weiss
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria.
| | - P L Carver
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA.
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Lindkvist B, Phillips ME, Domínguez-Muñoz JE. Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: Prevalence and diagnostic use. Pancreatology 2015; 15:589-97. [PMID: 26243045 DOI: 10.1016/j.pan.2015.07.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 12/11/2022]
Abstract
Pancreatic exocrine insufficiency (PEI) frequently occurs secondary to exocrine pancreatic disease (e.g. chronic pancreatitis, cystic fibrosis, cancer) or pancreatic/gastrointestinal surgery, resulting in the maldigestion of nutrients and consequently malnutrition. Pancreatic enzyme replacement therapy (PERT) is the cornerstone of PEI management. Despite its clinical relevance, the diagnosis of PEI in clinical practice is challenging, as the current gold standard test is cumbersome, and alternatives have limited availability or accuracy. There is a need for accurate and easily applicable diagnostic modalities. We review the prevalence of clinical symptoms and changes in anthropometric measurements and laboratory nutritional markers indicative of malnutrition in patients with PEI, and the relevance of these findings in diagnosing PEI and monitoring PERT efficacy. Based on limited available evidence, assessment of clinical symptoms, body weight, body mass index and other anthropometric parameters are not sensitive methods for PEI diagnosis, owing to high variability and multiple confounding factors, but appear useful in monitoring PERT efficacy. Limited evidence precludes strong recommendations but suggests that serum levels of vitamin E, magnesium, and plasma proteins, notably retinol binding protein, albumin, and prealbumin, may have diagnostic utility in PEI. Studies show that assessment of changes in these and other nutritional parameters is helpful in monitoring PERT efficacy. Further research is needed to confirm the diagnostic accuracy of these parameters for PEI. Until such data are available, a nutritional evaluation including circulating vitamin E, magnesium, retinol binding protein, albumin, and prealbumin may be used to evaluate the probability of PEI in clinical practice when reliable pancreatic function tests are not available.
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Affiliation(s)
- Björn Lindkvist
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.
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12
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Kaur K, Gupta R, Saraf SA, Saraf SK. Zinc: The Metal of Life. Compr Rev Food Sci Food Saf 2014; 13:358-376. [PMID: 33412710 DOI: 10.1111/1541-4337.12067] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 02/05/2014] [Indexed: 01/15/2023]
Abstract
The importance of zinc was 1st reported for Aspergillus niger. It took over 75 y to realize that zinc is also an essential trace element for rats, and an additional 30 y went by before it was recognized that this was also true for humans. The adult body contains about 2 to 3 g of zinc. Zinc is found in organs, tissues, bones, fluids, and cells. It is essential for many physiological functions and plays a significant role in a number of enzyme actions in the living systems. Bioinformatics estimates report that 10% of the human proteome contains zinc-binding sites. Based on its role in such a plethora of cellular components, zinc has diverse biological functions from enzymatic catalysis to playing a crucial role in cellular neuronal systems. Thus, based on the various published studies and reports, it is pertinent to state that zinc is one of the most important essential trace metals in human nutrition and lifestyle. Its deficiency may severely affect the homeostasis of a biological system. This review compiles the role of zinc in prophylaxis/therapeutics and provides current information about its effect on living beings.
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Affiliation(s)
- Kuljeet Kaur
- Faculty of Pharmacy, Babu Banarasi Das Natl. Inst. of Technology and Management (BBD Univ.), Lucknow, India
| | - Rajiv Gupta
- Faculty of Pharmacy, Babu Banarasi Das Natl. Inst. of Technology and Management (BBD Univ.), Lucknow, India
| | - Shubhini A Saraf
- Dept. of Pharmaceutical Sciences, SB&BT, Babasaheb Bhimrao Ambedkar Univ., Lucknow, India
| | - Shailendra K Saraf
- Faculty of Pharmacy, Babu Banarasi Das Northern India Inst. of Technology, Lucknow, India
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13
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Lowe NM, Dykes FC, Skinner AL, Patel S, Warthon-Medina M, Decsi T, Fekete K, Souverein OW, Dullemeijer C, Cavelaars AE, Serra-Majem L, Nissensohn M, Bel S, Moreno LA, Hermoso M, Vollhardt C, Berti C, Cetin I, Gurinovic M, Novakovic R, Harvey LJ, Collings R, Hall-Moran V. EURRECA-Estimating zinc requirements for deriving dietary reference values. Crit Rev Food Sci Nutr 2014; 53:1110-23. [PMID: 23952091 DOI: 10.1080/10408398.2012.742863] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Zinc was selected as a priority micronutrient for EURRECA, because there is significant heterogeneity in the Dietary Reference Values (DRVs) across Europe. In addition, the prevalence of inadequate zinc intakes was thought to be high among all population groups worldwide, and the public health concern is considerable. In accordance with the EURRECA consortium principles and protocols, a series of literature reviews were undertaken in order to develop best practice guidelines for assessing dietary zinc intake and zinc status. These were incorporated into subsequent literature search strategies and protocols for studies investigating the relationships between zinc intake, status and health, as well as studies relating to the factorial approach (including bioavailability) for setting dietary recommendations. EMBASE (Ovid), Cochrane Library CENTRAL, and MEDLINE (Ovid) databases were searched for studies published up to February 2010 and collated into a series of Endnote databases that are available for the use of future DRV panels. Meta-analyses of data extracted from these publications were performed where possible in order to address specific questions relating to factors affecting dietary recommendations. This review has highlighted the need for more high quality studies to address gaps in current knowledge, in particular the continued search for a reliable biomarker of zinc status and the influence of genetic polymorphisms on individual dietary requirements. In addition, there is a need to further develop models of the effect of dietary inhibitors of zinc absorption and their impact on population dietary zinc requirements.
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Affiliation(s)
- Nicola M Lowe
- International Institute of Nutrition and Applied Food Safety Studies, University of Central Lancashire, Preston, United Kingdom.
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Damphousse V, Mailhot M, Berthiaume Y, Rabasa-Lhoret R, Mailhot G. Plasma zinc in adults with cystic fibrosis: correlations with clinical outcomes. J Trace Elem Med Biol 2014; 28:60-4. [PMID: 24268877 DOI: 10.1016/j.jtemb.2013.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/15/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Zinc status has been previously documented in cystic fibrosis (CF) infants, children and adolescents. However, despite the increasing life expectancy observed in CF populations, data regarding zinc status of CF adults are surprisingly lacking. The objectives of this study were to (1) characterize zinc status and (2) explore associations between zinc status and clinical outcomes of CF adult patients. METHODS A retrospective chart review was performed for patients who had their plasma zinc measured between 2009 and 2012. Data included demographics, clinical characteristics, biochemical parameters and co-morbid conditions. RESULTS A total of 304 CF patients were included in the study. These patients displayed a good nutritional status (mean BMI±SD: 22.7±3.5) and moderate lung disease (mean FEV1±SD: 66.3±22.2). Low plasma zinc concentration (<9.2μmol/L) was found in 68 out of 304 CF patients (22.4%). Compared to patients with normal zinc, those with low zinc had significantly lower forced vital capacity and forced expiratory volume in one second. 72% of CF adults with low zinc suffered from bone disease (vs 49% with normal zinc, p=0.037) and 79% had impaired glycemic status (vs 58%, p=0.016). Accordingly, negative correlations were found between plasma zinc and glucose (r=-0.139, p=0.0001), HbA1c (r=-0.237, p=0.0001) and fructosamine (r=-0.134, p=0.034). In multiple linear regression, albumin and glycemic status were significant predictors of plasma zinc. CONCLUSION Our data indicated that nearly one quarter of CF adults with good nutritional status and moderate lung disease had low plasma zinc concentration and that low zinc status was associated with worse clinical outcomes.
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Affiliation(s)
- Veronic Damphousse
- Department of Nutrition, University of Montreal, Montreal, Quebec, Canada H3C 3J7
| | - Marjolaine Mailhot
- Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM) - Hôtel-Dieu, Montréal, Québec, Canada H2W 1T8
| | - Yves Berthiaume
- Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM) - Hôtel-Dieu, Montréal, Québec, Canada H2W 1T8; Institut de Recherches Cliniques de Montréal, Platform for Research on Obesity, Metabolism, and Diabetes (PROMD), Montréal, Québec, Canada H2W 1R7
| | - Remi Rabasa-Lhoret
- Department of Nutrition, University of Montreal, Montreal, Quebec, Canada H3C 3J7; Cystic Fibrosis Clinic, Centre hospitalier de l'Université de Montréal (CHUM) - Hôtel-Dieu, Montréal, Québec, Canada H2W 1T8; Institut de Recherches Cliniques de Montréal, Platform for Research on Obesity, Metabolism, and Diabetes (PROMD), Montréal, Québec, Canada H2W 1R7
| | - Genevieve Mailhot
- Department of Nutrition, University of Montreal, Montreal, Quebec, Canada H3C 3J7; Gastroenterology, Hepatology and Nutrition Unit, CHU Sainte-Justine Research Center, Montréal, Québec, Canada H3T 1C5.
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Gong Y, Han G, Zhang Y, Pan Y, Li X, Xia Y, Wu Y. Antifungal activity and cytotoxicity of zinc, calcium, or copper alginate fibers. Biol Trace Elem Res 2012; 148:415-9. [PMID: 22426818 DOI: 10.1007/s12011-012-9388-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
The antifungal properties and cytotoxicity of alginate fibers were investigated to widen their application in tissue engineering. Calcium, zinc, and copper alginate fibers were separately prepared by replacing Na(+) with Ca(2+), Zn(2+), or Cu(2+). The antifungal properties of the three alginate fibers were studied after coming into contact with Candida albicans. Then, the fungal inhibitory rates were measured using the plate-count method following shake-flask test. Moreover, an inhibition-zone test and observation by scanning electron microscopy were carried out. The inhibitory rate of the calcium, copper, and zinc alginate fibers were, respectively, 49.1, 68.6, and 92.2 %. The results from inhibition-zone test and shake-flask test show that zinc alginate fibers have the most significant antifungal action and that copper alginate fibers have obvious inhibitory action, but the calcium alginate fibers have weak inhibitory effects. The scanning electron micrographs similarly illustrate that the fungal surfaces show most scraggly after the interaction between C. albicans and zinc alginate fibers. Moreover, the relative growth rates of zinc or calcium alginate fibers in human embryonic kidney cells and human fibroblast cells were more than 100 %. No significant results were obtained (P>0.05). The calcium alginate fibers in human fibroblast cells were not much different from the negative control group (P>0.05). However, zinc alginate fibers had a significant change (P<0.05). Therefore, the excellent antifungal property of zinc alginate fibers demonstrates potential application in skin tissue engineering comparing with calcium or copper alginate fibers.
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Affiliation(s)
- Ying Gong
- Shandong Provincial Key Laboratory of New Fiber Materials and Modern Textile, the Growing Base for State Key Laboratory, Qingdao University, Qingdao 266071, People's Republic of China
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Galli F, Battistoni A, Gambari R, Pompella A, Bragonzi A, Pilolli F, Iuliano L, Piroddi M, Dechecchi MC, Cabrini G. Oxidative stress and antioxidant therapy in cystic fibrosis. Biochim Biophys Acta Mol Basis Dis 2012; 1822:690-713. [DOI: 10.1016/j.bbadis.2011.12.012] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/16/2011] [Accepted: 12/17/2011] [Indexed: 01/07/2023]
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Van Biervliet S, Vande Velde S, Van Biervliet J, Robberecht E. The Effect of Zinc Supplements in Cystic Fibrosis Patients. ANNALS OF NUTRITION AND METABOLISM 2008; 52:152-6. [DOI: 10.1159/000129650] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Accepted: 11/06/2007] [Indexed: 12/16/2022]
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