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Zhang C, Wang G, Yin X, Gou L, Guo M, Suo F, Zhuang T, Yuan Z, Liu Y, Gu M, Yao R. Hepatic protein phosphatase 1 regulatory subunit 3G alleviates obesity and liver steatosis by regulating the gut microbiota and bile acid metabolism. J Pharm Anal 2024; 14:100976. [PMID: 39263354 PMCID: PMC11388703 DOI: 10.1016/j.jpha.2024.100976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 03/05/2024] [Accepted: 04/08/2024] [Indexed: 09/13/2024] Open
Abstract
Intestinal dysbiosis and disrupted bile acid (BA) homeostasis are associated with obesity, but the precise mechanisms remain insufficiently explored. Hepatic protein phosphatase 1 regulatory subunit 3G (PPP1R3G) plays a pivotal role in regulating glycolipid metabolism; nevertheless, its obesity-combatting potency remains unclear. In this study, a substantial reduction was observed in serum PPP1R3G levels in high-body mass index (BMI) and high-fat diet (HFD)-exposed mice, establishing a positive correlation between PPP1R3G and non-12α-hydroxylated (non-12-OH) BA content. Additionally, hepatocyte-specific overexpression of Ppp1r3g (PPP1R3G HOE) mitigated HFD-induced obesity as evidenced by reduced weight, fat mass, and an improved serum lipid profile; hepatic steatosis alleviation was confirmed by normalized liver enzymes and histology. PPP1R3G HOE considerably impacted systemic BA homeostasis, which notably increased the non-12-OH BAs ratio, particularly lithocholic acid (LCA). 16S ribosomal DNA (16S rDNA) sequencing assay indicated that PPP1R3G HOE reversed HFD-induced gut dysbiosis by reducing the Firmicutes/Bacteroidetes ratio and Lactobacillus population, and elevating the relative abundance of Blautia, which exhibited a positive correlation with serum LCA levels. A fecal microbiome transplantation test confirmed that the anti-obesity effect of hepatic PPP1R3G was gut microbiota-dependent. Mechanistically, PPP1R3G HOE markedly suppressed hepatic cholesterol 7α-hydroxylase (CYP7A1) and sterol-12α-hydroxylase (CYP8B1), and concurrently upregulated oxysterol 7-α hydroxylase and G protein-coupled BA receptor 5 (TGR5) expression under HFD conditions. Furthermore, LCA administration significantly mitigated the HFD-induced obesity phenotype and elevated non-12-OH BA levels. These findings emphasize the significance of hepatic PPP1R3G in ameliorating diet-induced adiposity and hepatic steatosis through the gut microbiota-BA axis, which may serve as potential therapeutic targets for obesity-related disorders.
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Affiliation(s)
- Chu Zhang
- Xuzhou Key Laboratory of Neurobiology, Department of Cell Biology and Neurobiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Gui Wang
- Xuzhou Key Laboratory of Neurobiology, Department of Cell Biology and Neurobiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Xin Yin
- Department of Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, 221009, China
| | - Lingshan Gou
- Department of Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, 221009, China
| | - Mengyuan Guo
- Department of Geriatrics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China
| | - Feng Suo
- Department of Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, 221009, China
| | - Tao Zhuang
- Xuzhou Key Laboratory of Neurobiology, Department of Cell Biology and Neurobiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Zhenya Yuan
- Department of Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, 221009, China
| | - Yanan Liu
- Xuzhou Key Laboratory of Neurobiology, Department of Cell Biology and Neurobiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Maosheng Gu
- Department of Genetic Medicine, Xuzhou Maternity and Child Health Care Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, 221009, China
| | - Ruiqin Yao
- Xuzhou Key Laboratory of Neurobiology, Department of Cell Biology and Neurobiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
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Watanabe Y, Fujisaka S, Morinaga Y, Watanabe S, Nawaz A, Hatta H, Kado T, Nishimura A, Bilal M, Aslam MR, Honda K, Nakagawa Y, Softic S, Hirabayashi K, Nakagawa T, Nagai Y, Tobe K. Isoxanthohumol improves obesity and glucose metabolism via inhibiting intestinal lipid absorption with a bloom of Akkermansia muciniphila in mice. Mol Metab 2023; 77:101797. [PMID: 37709134 PMCID: PMC10539672 DOI: 10.1016/j.molmet.2023.101797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Polyphenols have health-promoting effects, such as improving insulin resistance. Isoxanthohumol (IX), a prenylated flavonoid found in beer hops, has been suggested to reduce obesity and insulin resistance; however, the mechanism remains unknown. METHODS High-fat diet-fed mice were administered IX. We analyzed glucose metabolism, gene expression profiles and histology of liver, epididymal adipose tissue and colon. Lipase activity, fecal lipid profiles and plasma metabolomic analysis were assessed. Fecal 16s rRNA sequencing was obtained and selected bacterial species were used for in vitro studies. Fecal microbiota transplantation and monocolonization were conducted to antibiotic-treated or germ-free (GF) mice. RESULTS The administration of IX lowered weight gain, decreased steatohepatitis and improved glucose metabolism. Mechanistically, IX inhibited pancreatic lipase activity and lipid absorption by decreasing the expression of the fatty acid transporter CD36 in the small intestine, which was confirmed by increased lipid excretion in feces. IX administration increased markers of intestinal barrier function, including thickening the mucin layer and increasing caludin-1, a tight-junction related protein in the colon. In contrast, the effects of IX were nullified by antibiotics. As revealed using 16S rRNA sequencing, the microbial community structure changed with a significant increase in the abundance of Akkermansia muciniphila in the IX-treated group. An anaerobic chamber study showed that IX selectively promoted the growth of A. muciniphila while exhibiting antimicrobial activity against some Bacteroides and Clostridium species. To further explore the direct effect of A. muciniphila on lipid and glucose metabolism, we monocolonized either A. muciniphila or Bacteroides thetaiotaomicron to GF mice. A. muciniphila monocolonization decreased CD36 expression in the jejunum and improved glucose metabolism, with decreased levels of multiple classes of fatty acids determined using plasma metabolomic analysis. CONCLUSIONS Our study demonstrated that IX prevents obesity and enhances glucose metabolism by inhibiting dietary fat absorption. This mechanism is linked to suppressing pancreatic lipase activity and shifts in microbial composition, notably an increase in A. muciniphila. These highlight new treatment strategies for preventing metabolic syndrome by boosting the gut microbiota with food components.
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Affiliation(s)
- Yoshiyuki Watanabe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Shiho Fujisaka
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Yoshitomo Morinaga
- Department of Microbiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Shiro Watanabe
- Institute of Natural Medicine, University of Toyama, Toyama, Japan
| | - Allah Nawaz
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan; Section of Integrative Physiology and Metabolism, Joslin Diabetes Center and Harvard Medical School, Boston, MA, USA
| | - Hideki Hatta
- Department of Diagnostic Pathology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Tomonobu Kado
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Ayumi Nishimura
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Muhammad Bilal
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Muhammad Rahil Aslam
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Keiko Honda
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshimi Nakagawa
- Division of Complex Biosystem Research, Department of Research and Development, Institute of Natural Medicine, University of Toyama, Toyama, Japan
| | - Samir Softic
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kenichi Hirabayashi
- Department of Diagnostic Pathology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Takashi Nakagawa
- Department of Molecular and Medical Pharmacology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshinori Nagai
- Department of Pharmaceutical Engineering, Faculty of Engineering, Toyama Prefectural University, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan.
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Iannone V, Lok J, Babu AF, Gómez-Gallego C, Willman RM, Koistinen VM, Klåvus A, Kettunen MI, Kårlund A, Schwab U, Hanhineva K, Kolehmainen M, El-Nezami H. Associations of altered hepatic gene expression in American lifestyle-induced obesity syndrome diet-fed mice with metabolic changes during NAFLD development and progression. J Nutr Biochem 2023; 115:109307. [PMID: 36868506 DOI: 10.1016/j.jnutbio.2023.109307] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/20/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) pathogenesis remains poorly understood due to the complex metabolic and inflammatory changes in the liver. This study aimed to elucidate hepatic events related to inflammation and lipid metabolism and their linkage with metabolic alterations during NAFLD in American lifestyle-induced obesity syndrome (ALIOS) diet-fed mice. Forty-eight C57BL/6J male mice were fed with ALIOS diet (n=24) or control chow diet (n=24) for 8, 12, and 16 weeks. At the end of each timepoint, eight mice were sacrificed where plasma and liver were collected. Hepatic fat accumulation was followed using magnetic resonance imaging and confirmed with histology. Further, targeted gene expression and non-targeted metabolomics analysis were conducted. Our results showed higher hepatic steatosis, body weight, energy consumption, and liver mass in ALIOS diet-fed mice compared to control mice. ALIOS diet altered expression of genes related to inflammation (Tnfa and IL-6) and lipid metabolism (Cd36, Fasn, Scd1, Cpt1a, and Ppara). Metabolomics analysis indicated decrease of lipids containing polyunsaturated fatty acids such as LPE(20:5) and LPC(20:5) with increase of other lipid species such as LPI(16:0) and LPC(16:2) and peptides such as alanyl-phenylalanine and glutamyl-arginine. We further observed novel correlations between different metabolites including sphingolipid, lysophospholipids, peptides, and bile acid with inflammation, lipid uptake and synthesis. Together with the reduction of antioxidant metabolites and gut microbiota-derived metabolites contribute to NAFLD development and progression. The combination of non-targeted metabolomics with gene expression in future studies can further identify key metabolic routes during NAFLD which could be the targets of potential novel therapeutics.
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Affiliation(s)
- Valeria Iannone
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Johnson Lok
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Ambrin Farizah Babu
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Afekta Technologies Ltd., Kuopio, Finland
| | - Carlos Gómez-Gallego
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Roosa Maria Willman
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Department of Medicine, Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - Ville Mikael Koistinen
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Afekta Technologies Ltd., Kuopio, Finland; Department of Life technologies, Food Sciences Unit, University of Turku, Turku, Finland
| | | | - Mikko I Kettunen
- Kuopio Biomedical Imaging Unit, A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Anna Kårlund
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Ursula Schwab
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Department of Medicine, Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland
| | - Kati Hanhineva
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Afekta Technologies Ltd., Kuopio, Finland; Department of Life technologies, Food Sciences Unit, University of Turku, Turku, Finland.
| | - Marjukka Kolehmainen
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.
| | - Hani El-Nezami
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Molecular and Cell Biology Division, School of Biological Sciences, University of Hong Kong, Hong Kong China
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Fujisaka S, Watanabe Y, Tobe K. The gut microbiome: a core regulator of metabolism. J Endocrinol 2023; 256:e220111. [PMID: 36458804 PMCID: PMC9874984 DOI: 10.1530/joe-22-0111] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/02/2022] [Indexed: 12/03/2022]
Abstract
The human body is inhabited by numerous bacteria, fungi, and viruses, and each part has a unique microbial community structure. The gastrointestinal tract harbors approximately 100 trillion strains comprising more than 1000 bacterial species that maintain symbiotic relationships with the host. The gut microbiota consists mainly of the phyla Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria. Of these, Firmicutes and Bacteroidetes constitute 70-90% of the total abundance. Gut microbiota utilize nutrients ingested by the host, interact with other bacterial species, and help maintain healthy homeostasis in the host. In recent years, it has become increasingly clear that a breakdown of the microbial structure and its functions, known as dysbiosis, is associated with the development of allergies, autoimmune diseases, cancers, and arteriosclerosis, among others. Metabolic diseases, such as obesity and diabetes, also have a causal relationship with dysbiosis. The present review provides a brief overview of the general roles of the gut microbiota and their relationship with metabolic disorders.
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Affiliation(s)
- Shiho Fujisaka
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Sugitani, Toyama, Japan
| | - Yoshiyuki Watanabe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Sugitani, Toyama, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, Sugitani, Toyama, Japan
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Role of Food Antioxidants in Modulating Gut Microbial Communities: Novel Understandings in Intestinal Oxidative Stress Damage and Their Impact on Host Health. Antioxidants (Basel) 2021; 10:antiox10101563. [PMID: 34679698 PMCID: PMC8533511 DOI: 10.3390/antiox10101563] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/21/2021] [Accepted: 09/26/2021] [Indexed: 02/07/2023] Open
Abstract
Dietary components have an important role on the structure and function of host gut microbial communities. Even though, various dietary components, such as carbohydrates, fats, proteins, fibers, and vitamins, have been studied in depth for their effect on gut microbiomes, little attention has been paid regarding the impact of several food antioxidants on the gut microbiome. The long-term exposure to reactive oxygen species (ROS) can cause microbial dysbiosis which leads to numerous intestinal diseases such as microbiota dysbiosis, intestinal injury, colorectal cancers, enteric infections, and inflammatory bowel diseases. Recently, it has been shown that the food derived antioxidant compounds might protect the host from intestinal oxidative stress via modulating the composition of beneficial microbial species in the gut. The present review summarizes the impact of food antioxidants including antioxidant vitamins, dietary polyphenols, carotenoids, and bioactive peptides on the structure as well as function of host gut microbial communities. Several in vitro, animal model, and clinical studies indicates that food antioxidants might modify the host gut microbial communities and their health status. However, still further clarification is needed as to whether changes in certain microbial species caused by food additives may lead to changes in metabolism and immune function.
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Bilal M, Nawaz A, Kado T, Aslam MR, Igarashi Y, Nishimura A, Watanabe Y, Kuwano T, Liu J, Miwa H, Era T, Ikuta K, Imura J, Yagi K, Nakagawa T, Fujisaka S, Tobe K. Fate of adipocyte progenitors during adipogenesis in mice fed a high-fat diet. Mol Metab 2021; 54:101328. [PMID: 34562641 PMCID: PMC8495176 DOI: 10.1016/j.molmet.2021.101328] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Expansion of adipose tissue during obesity through the recruitment of newly generated adipocytes (hyperplasia) is metabolically healthy, whereas that through the enlargement of pre-existing adipocytes (hypertrophy) leads to metabolic complications. Accumulating evidence from genetic fate mapping studies suggests that in animal models receiving a high-fat diet (HFD), only adipocyte progenitors (APs) in gonadal white adipose tissue (gWAT) have proliferative potential. However, the proliferative potential and differentiating capacity of APs in the inguinal WAT (iWAT) of male mice remains controversial. The objective of this study was to investigate the proliferative and adipogenic potential of APs in the iWAT of HFD-fed male mice. Methods We generated PDGFRα-GFP-Cre-ERT2/tdTomato (KI/td) mice and traced PDGFRα-positive APs in male mice fed HFD for 8 weeks. We performed a comprehensive phenotypic analysis, including the histology, immunohistochemistry, flow cytometry, and gene expression analysis, of KI/td mice fed HFD. Results Contrary to the findings of others, we found an increased number of newly generated tdTomato+ adipocytes in the iWAT of male mice, which was smaller than that observed in the gWAT. We found that in male mice, the iWAT has more proliferating tdTomato+ APs than the gWAT. We also found that tdTomato+ APs showed a higher expression of Dpp4 and Pi16 than tdTomato− APs, and the expression of these genes was significantly higher in the iWAT than in the gWAT of mice fed HFD for 8 weeks. Collectively, our results reveal that HFD feeding induces the proliferation of tdTomato+ APs in the iWAT of male mice. Conclusion In male mice, compared with gWAT, iWAT undergoes hyperplasia in response to 8 weeks of HFD feeding through the recruitment of newly generated adipocytes due to an abundance of APs with a high potential for proliferation and differentiation. High-fat diet (HFD) increases proliferative APs in iWAT of male mice. HFD promotes the recruitment of smaller adipocytes in the iWAT of male mice. iWAT expands by recruiting newly-generated adipocytes (hyperplasia) in male mice. gWAT expands by enlargement of pre-existing adipocytes (hypertrophy) in male mice.
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Affiliation(s)
- Muhammad Bilal
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Allah Nawaz
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan; Department of Molecular and Medical Pharmacology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Tomonobu Kado
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Muhammad Rahil Aslam
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yoshiko Igarashi
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Ayumi Nishimura
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yoshiyuki Watanabe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Takahide Kuwano
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Jianhui Liu
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hiroyuki Miwa
- Department of Cell Modulation, Institute of Molecular Embryology and Genetics, Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto, 860-0811, Japan
| | - Takumi Era
- Department of Cell Modulation, Institute of Molecular Embryology and Genetics, Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto, 860-0811, Japan
| | - Koichi Ikuta
- Department of Virus Research, Laboratory of Immune Regulation, Institute of Frontier Life and Medical Sciences, Kyoto University, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Johji Imura
- Department of Diagnostic Pathology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kunimasa Yagi
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Takashi Nakagawa
- Department of Molecular and Medical Pharmacology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Shiho Fujisaka
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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