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Jiang S, Guo T, Guo S, Gao J, Ni Y, Ma W, Zhao R. Chronic Variable Stress Induces Hepatic Fe(II) Deposition by Up-Regulating ZIP14 Expression via miR-181 Family Pathway in Rats. BIOLOGY 2021; 10:biology10070653. [PMID: 34356508 PMCID: PMC8301360 DOI: 10.3390/biology10070653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/25/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022]
Abstract
Simple Summary Modern intensive production methods attract accusations of poor animal welfare due to long-term exposure to stressors including high temperature, persistent humidity and overcrowding. Stress can be defined as any condition that threatens the physiological homoeostasis and hypothalamic-pituitary-adrenal (HPA) axis responses that tend to restore the prior stable status of the organism. Uncontrollable and unpredictable sources of stress can cause various forms of damage to the liver, which is the central mediator of systemic iron balance. Iron, notably, is an essential element for maintaining health in virtually all organisms. We found that chronic variable stress can cause weight loss and disorders of the liver iron metabolism in rats, thereby triggering liver oxidative damage. Our results also suggest that the miR-181 family is a potential target for treating iron overload-associated diseases. Abstract It is well-known that hepatic iron dysregulation, which is harmful to health, can be caused by stress. The aim of the study was to evaluate chronic variable stress (CVS) on liver damage, hepatic ferrous iron deposition and its molecular regulatory mechanism in rats. Sprague Dawley rats at seven weeks of age were randomly divided into two groups: a control group (Con) and a CVS group. CVS reduces body weight, but increases the liver-to-body weight ratio. The exposure of rats to CVS increased plasma aspartate aminotransferase (AST), alkaline phosphatase (ALP) and hepatic malondialdehyde (MDA) levels, but decreased glutathione peroxidase (GSH-Px) activity, resulting in liver damage. CVS lowered the total amount of hepatic iron content, but induced hepatic Fe(II) accumulation. CVS up-regulated the expression of transferrin receptor 1 (TFR1) and ZRT/IRT-like protein 14 (ZIP14), but down-regulated ferritin and miR-181 family members. In addition, miR-181 family expression was found to regulate ZIP14 expression in HEK-293T cells by the dual-luciferase reporter system. These results indicate that CVS results in liver damage and induces hepatic Fe(II) accumulation, which is closely associated with the up-regulation of ZIP14 expression via the miR-181 family pathway.
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Affiliation(s)
- Shuxia Jiang
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
| | - Taining Guo
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
| | - Shihui Guo
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
| | - Jiang Gao
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
| | - Yingdong Ni
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
| | - Wenqiang Ma
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
- Correspondence: ; Tel.: +86-25-8439-6413; Fax: +86-25-8439-8669
| | - Ruqian Zhao
- Key Laboratory of Animal Physiology and Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, China; (S.J.); (T.G.); (S.G.); (J.G.); (Y.N.); (R.Z.)
- MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, China
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Tang Y, Wang D, Zhang H, Zhang Y, Wang J, Qi R, Yang J, Shen H, Xu Y, Li M. Rapid responses of adipocytes to iron overload increase serum TG level by decreasing adiponectin. J Cell Physiol 2021; 236:7544-7553. [PMID: 33855731 DOI: 10.1002/jcp.30391] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/14/2021] [Accepted: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Iron overload is tightly connected with metabolic disorders. Excess iron in the adipose and its roles in dyslipidemia are of interest to be identified. In acute iron overload mice receiving intraperitoneal injection of 100 mg/kg/day dextran-iron for 5 days, the epididymis adipose showed a remarkable increase in iron. Serum triglyceride and low-density lipoprotein cholesterol (LDL-C) levels were increased and high-density lipoprotein cholesterol (HDL-C) level was decreased, while serum alkaline phosphatase, aspartate aminotransferase, glucose, and insulin were not affected. The serum-cytokine-microarray showed that adipocytokines, including adiponectin, leptin, and resistin were significantly decreased. Other serum cytokines, including pro-insulin cytokines, inflammatory cytokines, chemokines, and growth factors were not changed, except that ghrelin and chemokine RANTES were increased. Iron overload decreased expressions of adiponectin and leptin both in vivo and in vitro. Intraperitoneal injection of recombinant leptin at 1 μg/g in acute iron overload mice had no significant effects on serum levels of TC, TG, HDL-C, and LDL-C, while intraperitoneal injection of recombinant adiponectin at 3 μg/g partially restored serum TG level through improving activities of lipoprotein lipase and hepatic lipase, but abnormal serum LDL-C and HDL-C were not redressed, suggesting other mechanisms also existed. In conclusion, the adipose responds to iron overload at an early stage to interfere with lipid metabolism by secreting adipocytokines, which may further affect glucose metabolism, inflammation, and other iron overload-induced effects on the body.
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Affiliation(s)
- Yuxiao Tang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Dongyao Wang
- School of Pharmacy, Second Military Medical University, Shanghai, China.,Faculty of Pharmacy, Shanghai University, Shanghai, China
| | - Hongwei Zhang
- Department of Nutrition, Second Military Medical University, Shanghai, China.,Department of Clinical Nutrition, Zhumadian Second People's Hospital, Henan, China
| | - Yinyin Zhang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Jie Wang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Ruirui Qi
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Jianxin Yang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Hui Shen
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Yan Xu
- Institute of International Medical Science and Technology, Sanda University, Shanghai, China
| | - Min Li
- Department of Nutrition, Second Military Medical University, Shanghai, China.,Institute of International Medical Science and Technology, Sanda University, Shanghai, China
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Tang Y, Wang D, Niu X, Wu H, Yang J, Zhang Y, Song S, Lv D, Chai Y, Lu H, Shen H, Ling C, Li M. Mild iron overload induces TRIP12-mediated degradation of YY1 to trigger hepatic inflammation. Free Radic Biol Med 2020; 161:187-197. [PMID: 33080340 DOI: 10.1016/j.freeradbiomed.2020.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Increasing populations are found to bear mild hepatic iron overload (HIO) due to unhealthy lifestyles, metabolic diseases, etc., whether this mild but chronic HIO induces hepatic inflammation is unknown. In the present study, mice receiving a 12-months 0.3% dextran-iron diet show mild HIO with no detectable oxidative damages in the liver but have infiltrated macrophages and increased IL-6, TNFα, AST and ALT since 6-months. The HNF4α/miR-122/CCL2 pathway, identified by our previous studies to induce macrophages infiltration, is initiated by chronic mild HIO. After excluding the role of DNA methylation, a modified transcription factor microarray is applied to find that transcription factor YY1 is responsible for HIO-decreased HNF4α expression. Then the E3 ubiquitin ligase TRIP12 is identified by an immunoprecipitation coupled LC-MS/MS and proved to bind and ubiquitinate YY1, leading to its degradation. The overexpression or silence of YY1 in the liver regulates the HNF4α/miR-122/CCL2 pathway. More importantly, YY1 overexpression alleviates chronic mild HIO induced hepatic inflammatory responses. In conclusion, these results elucidate an oxidative-stress-independent, TRIP12/YY1/HNF4α/miR-122/CCL2 pathway of chronic mild HIO inducing hepatic inflammation, implying that effective measures in addition to antioxidants are needed for individuals at the risk of chronic mild HIO.
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Affiliation(s)
- Yuxiao Tang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Dongyao Wang
- School of Pharmacy, Second Military Medical University, Shanghai, China; Faculty of Pharmacy, Shanghai University, Shanghai, China
| | - Xiaowen Niu
- Shanghai Dermatology Hospital, Tongji University, Shanghai, China
| | - Huiwen Wu
- Department of Nutrition, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jianxin Yang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Yinyin Zhang
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Shangjin Song
- School of Traditional Chinese Medicine & Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Diya Lv
- School of Pharmacy, Second Military Medical University, Shanghai, China
| | - Yifeng Chai
- School of Pharmacy, Second Military Medical University, Shanghai, China
| | - Hongtao Lu
- Department of Nutrition, Second Military Medical University, Shanghai, China
| | - Hui Shen
- Department of Nutrition, Second Military Medical University, Shanghai, China.
| | - Chen Ling
- State Key Laboratory of Genetic Engineering, School of Life Sciences, Zhongshan Hospital, Fudan University, Shanghai, China; Division of Cellular and Molecular Therapy, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Min Li
- Department of Nutrition, Second Military Medical University, Shanghai, China; Institute of International Medical Science and Technology, Sanda University, Shanghai, China.
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Tang Y, Qi R, Wu H, Shi W, Xu Y, Li M. Reduction of hemoglobin, not iron, inhibited maturation of red blood cells in male rats exposed to high intensity endurance exercises. J Trace Elem Med Biol 2019; 52:263-269. [PMID: 30732892 DOI: 10.1016/j.jtemb.2019.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 12/31/2022]
Abstract
The existence of sports anemia, induced by strenuous or long-term exercise and characterized by decreases of red blood cells (RBCs), hemoglobin and iron content, remains to be doubtful. To observe the effects of endurance exercise on RBCs and explain the underlying reason, we designed this study by observing RBCs parameters and iron metabolism in 8-weeks training rats and effects of iron supplement or protein supplement on RBCs. Results showed that erythrocyte counts, hematocrit, mean corpuscular volume and hemoglobin content decreased while RBC distribution width increased in exercised rats at later stage during 8 weeks training. But the contents of serum iron and ferritin decreased only at 1-week and 2-week and returned to normal at 4-week and 8-week. Same as iron content, apparent iron absorption rate was declined at early stage but restored to normal level at 8-week, as well as serum adrenaline, cortisol and insulin levels. Instead, the contents of total protein and albumin in serum were decreased at later stage during 8-weeks training. Furthermore, we observed that protein supplement ameliorated RBCs parameters in rats exposed to 8 weeks swimming exercise, but iron supplement had no effects on RBCs, though it obviously increased iron content of serum and the liver. Based on these results, we drew a conclusion that transient changes of iron metabolism, which may be induced by stress hormone changes, was not the reason for RBCs decrease in endurance exercises but hemoglobin reduction, induced by defects in protein supplement, impeded development of RBCs.
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Affiliation(s)
- Yuxiao Tang
- Department of Naval Nutrition and Food Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Ruirui Qi
- Department of Naval Nutrition and Food Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Huiwen Wu
- Department of Naval Nutrition and Food Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Wencai Shi
- Department of Naval Nutrition and Food Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Yan Xu
- Institute of International Medical Science and Technology, Sanda University, Shanghai, 201209, China.
| | - Min Li
- Department of Naval Nutrition and Food Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China; Institute of International Medical Science and Technology, Sanda University, Shanghai, 201209, China.
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Li H, Zhang C, Shen H, Shen Z, Wu L, Mo F, Li M. Physiological stress-induced corticosterone increases heme uptake via KLF4-HCP1 signaling pathway in hippocampus neurons. Sci Rep 2017; 7:5745. [PMID: 28720846 PMCID: PMC5515979 DOI: 10.1038/s41598-017-06058-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/07/2017] [Indexed: 11/10/2022] Open
Abstract
Iron overload has attracted much attention because of its adverse effect in increasing the risk of developing several neurodegenerative disorders. Under various pathologic conditions, a lot of heme are released. The aggregation of heme is more neurotoxic than that of iron released from the heme breakdown. Our previous studies demonstrated that psychological stress (PS) is a risk factor of cerebral iron metabolism disorders, thus causing iron accumulation in rat brains. In the present study, we found PS could increase heme uptake via heme carrier protein 1 (HCP1) in rat brains. We demonstrated that Glucocorticoid (GC), which is largely secreted under stress, could up-regulate HCP1 expression, thus promoting heme uptake in neurons. We also ascertained that HCP1 expression can be induced by GC through a transcription factor, Krüppel-like factor 4 (KLF4). These results may gain new insights into the etiology of heme uptake and iron accumulation in PS rats, and find new therapeutic targets of iron accumulation in Parkinson’s disease or Alzheimer’s disease.
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Affiliation(s)
- Hongxia Li
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Caixia Zhang
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China.,Department of Nursing, People's Libration Army of 266 Hospital, Chengde City, Hubei, 067000, China
| | - Hui Shen
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Zhilei Shen
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Lusha Wu
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China
| | - Fengfeng Mo
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China.
| | - Min Li
- Department of Ship Hygiene, Faculty of Naval Medicine, Second Military Medical University, Shanghai, 200433, China.
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Abstract
Exposure to stress is known to cause hepatic iron dysregulation, but the relationship between prolonged stress and liver iron metabolism is not yet fully understood. Thirty 13-week-old female Sprague-Dawley rats were randomly divided into two groups, as follows: the control group (saline-injection) and the dexamethasone group (Dexamethasone (Dex)-injection 0.1 mg/kg/day). After the 21-day stress trial, the results showed that chronic Dex administration not only impaired serum corticosterone (p = 0.00) and interleukin-6 (IL-6) (p = 0.01) levels, but also decreased white blood cell counts (p = 0.00), and reduced blood lymphocyte counts (p = 0.00). The daily Dex-injection also significantly reduced body weight (p < 0.01) by inhibiting food intake. Consecutive Dex administration resulted in decreased iron intake (p = 0.00), enhanced serum iron levels (p = 0.01), and increased the serum souble transferrin receptor (sTfR) content (p = 0.00) in rats. Meanwhile, long-term Dex exposure down-regulated duodenal cytochrome b (DCYTB) (p = 0.00) and the divalent metal transporter 1 (DMT1) (p = 0.04) protein expression, but up-regulated ferroportin (FPN) protein expression (p = 0.04). Chronic Dex administration reduced liver iron concentration (p = 0.02) in rats. Hepatic transferrin receptor 1 (TFR1) expression was lowered at the protein level (p = 0.03), yet with uncoupled mRNA abundance in Dex-treated rats. Enhanced iron-regulatory protein (IRP)/iron-responsive element (IRE) binding activity was observed, but did not line up with lowered hepatic TFR1 protein expression. This study indicates that long-term Dex exposure reduces liver iron content, which is closely associated with down-regulated hepatic TFR1 protein expression.
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Nairz M, Schroll A, Demetz E, Tancevski I, Theurl I, Weiss G. 'Ride on the ferrous wheel'--the cycle of iron in macrophages in health and disease. Immunobiology 2014; 220:280-94. [PMID: 25240631 DOI: 10.1016/j.imbio.2014.09.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/20/2014] [Accepted: 09/05/2014] [Indexed: 12/16/2022]
Abstract
Iron homeostasis and macrophage biology are closely interconnected. On the one hand, iron exerts multiple effects on macrophage polarization and functionality. On the other hand, macrophages are central for mammalian iron homeostasis. The phagocytosis of senescent erythrocytes and their degradation by macrophages enable efficient recycling of iron and the maintenance of systemic iron balance. Macrophages express multiple molecules and proteins for the acquisition and utilization of iron and many of these pathways are affected by inflammatory signals. Of note, iron availability within macrophages has significant effects on immune effector functions and metabolic pathways within these cells. This review summarizes the physiological and pathophysiological aspects of macrophage iron metabolism and highlights its relevant consequences on immune function and in common diseases such as infection and atherosclerosis.
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Affiliation(s)
- Manfred Nairz
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria.
| | - Andrea Schroll
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Egon Demetz
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Ivan Tancevski
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Igor Theurl
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine VI, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria.
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Kupper N, Pelle AJ, Szabó BM, Denollet J. The relationship between Type D personality, affective symptoms and hemoglobin levels in chronic heart failure. PLoS One 2013; 8:e58370. [PMID: 23472188 PMCID: PMC3589413 DOI: 10.1371/journal.pone.0058370] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 02/03/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anemia is associated with poor prognosis in heart failure (HF) patients. Contributors to the risk of anemia in HF include hemodilution, renal dysfunction and inflammation. Hemoglobin levels may also be negatively affected by alterations in stress regulatory systems. Therefore, psychological distress characterized by such alterations may adversely affect hemoglobin in HF. The association between hemoglobin and Type D personality and affective symptomatology in the context of HF is poorly understood. AIM To examine the relationship between Type D personality and affective symptomatology with hemoglobin levels at inclusion and 12-month follow-up, controlling for relevant clinical factors. METHODS Plasma levels of hemoglobin and creatinine were assessed in 264 HF patients at inclusion and at 12-month follow-up. Type D personality and affective symptomatology were assessed at inclusion. RESULTS At inclusion, hemoglobin levels were similar for Type D and non-Type D HF patients (p = .23), and were moderately associated with affective symptomatology (r = -.14, p = .02). Multivariable regression showed that Type D personality (β = -.15; p = .02), was independently associated with future hemoglobin levels, while controlling for renal dysfunction, gender, NYHA class, time since diagnosis, BMI, the use of angiotensin-related medication, and levels of affective symptomatology. Change in renal function was associated with Type D personality (β = .20) and hemoglobin at 12 months (β = -.25). Sobel mediation analysis showed significant partial mediation of the Type D - hemoglobin association by renal function deterioration (p = .01). Anemia prevalence increased over time, especially in Type D patients. Female gender, poorer baseline renal function, deterioration of renal function and a longer HF history predicted the observed increase in anemia prevalence over time, while higher baseline hemoglobin was protective. CONCLUSION Type D personality, but not affective symptomatology, was associated with reduced future hemoglobin levels, independent of clinical factors. The relation between Type D personality and future hemoglobin levels was mediated by renal function deterioration.
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Affiliation(s)
- Nina Kupper
- Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, and Department of Cardiology, TweeSteden Hospital, Tilburg, The Netherlands.
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