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Böhm EW, Buonfiglio F, Korb CA, Dauth A, Pfeiffer N, Bręborowicz A, Gericke A. Potential of Sulodexide in the Treatment of Diabetic Retinopathy and Retinal Vein Occlusion. Thromb Haemost 2024. [PMID: 39293483 DOI: 10.1055/s-0044-1791232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
Retinal vascular diseases, such as diabetic retinopathy or retinal vein occlusion, are common causes of severe vision loss. Central to the pathophysiology of these conditions are endothelial dysfunction, inflammation, capillary leakage, ischemia, and pathological neoangiogenesis. Capillary damage leads to leakage and the development of macular edema, which is associated with vision loss and requires complex treatment. Sulodexide, a glycosaminoglycan composed of heparan sulfate and dermatan sulfate with high oral bioavailability, exhibits several favorable pharmacologic properties, including antithrombotic, anti-inflammatory, and endothelium-protective effects. Additionally, treatment with sulodexide has been associated with the reduction of oxidative stress and decreased expression of angiogenic growth factors, such as vascular endothelial growth factor. This review aims to provide an overview of the pharmacological properties, mechanisms of action, and therapeutic effects of sulodexide. Furthermore, its potential for clinical application in venous and diabetic diseases, such as venous thromboembolism, chronic venous insufficiency, peripheral artery disease, or diabetic nephropathy, is summarized. We also present experimental and clinical studies evaluating the potential of sulodexide in ocular conditions and discuss its therapeutic implications for the treatment of retinal vascular diseases.
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Affiliation(s)
- Elsa Wilma Böhm
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Francesco Buonfiglio
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christina A Korb
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alice Dauth
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andrzej Bręborowicz
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
- Collegium Medicum, Zielona Góra University, Zielona Góra, Poland
| | - Adrian Gericke
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
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Afsar B, Afsar RE. The role of glycosaminoglycans in blood pressure regulation. Microcirculation 2023; 30:e12832. [PMID: 37794746 DOI: 10.1111/micc.12832] [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: 02/01/2023] [Revised: 05/06/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
Essential hypertension (HT) is the global health problem and is a major risk factor for the development of cardiovascular and kidney disease. High salt intake has been associated with HT and impaired kidney sodium excretion is considered to be a major mechanism for the development of HT. Although kidney has a very important role in regulation of BP, this traditional view of BP regulation was challenged by recent findings suggesting that nonosmotic tissue sodium deposition is very important for BP regulation. This new paradigm indicates that sodium can be stored and deposited nonosmotically in the interstitium without water retention and without increased BP. One of the major determinants of this deposition is glycosaminoglycans (GAGs). By binding to GAGs found in the endothelial surface layer (ESL) which contains glycocalyx, sodium is osmotically inactivated and not induce concurrent water retention. Thus, GAGs has important function for homeostatic BP and sodium regulation. In the current review, we summarized the role of GAGs in ESL and BP regulation.
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Affiliation(s)
- Baris Afsar
- School of Medicine, Department of Nephrology, Suleyman Demirel University, Isparta, Turkey
| | - Rengin Elsurer Afsar
- School of Medicine, Department of Nephrology, Suleyman Demirel University, Isparta, Turkey
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3
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Yu H, Song YY, Li XH. Early diabetic kidney disease: Focus on the glycocalyx. World J Diabetes 2023; 14:460-480. [PMID: 37273258 PMCID: PMC10236994 DOI: 10.4239/wjd.v14.i5.460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/10/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
The incidence of diabetic kidney disease (DKD) is sharply increasing worldwide. Microalbuminuria is the primary clinical marker used to identify DKD, and its initiating step in diabetes is glomerular endothelial cell dysfunction, particularly glycocalyx impairment. The glycocalyx found on the surface of glomerular endothelial cells, is a dynamic hydrated layer structure composed of pro-teoglycans, glycoproteins, and some adsorbed soluble components. It reinforces the negative charge barrier, transduces the shear stress, and mediates the interaction of blood corpuscles and podocytes with endothelial cells. In the high-glucose environment of diabetes, excessive reactive oxygen species and proinflammatory cytokines can damage the endothelial glycocalyx (EG) both directly and indirectly, which induces the production of microalbuminuria. Further research is required to elucidate the role of the podocyte glycocalyx, which may, together with endothelial cells, form a line of defense against albumin filtration. Interestingly, recent research has confirmed that the negative charge barrier function of the glycocalyx found in the glomerular basement membrane and its repulsion effect on albumin is limited. Therefore, to improve the early diagnosis and treatment of DKD, the potential mechanisms of EG degradation must be analyzed and more responsive and controllable targets must be explored. The content of this review will provide insights for future research.
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Affiliation(s)
- Hui Yu
- Department of Nephrology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yi-Yun Song
- Department of Nephrology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Xian-Hua Li
- Department of Nephrology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Knežević D, Ćurko-Cofek B, Batinac T, Laškarin G, Rakić M, Šoštarič M, Zdravković M, Šustić A, Sotošek V, Batičić L. Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications. J Cardiovasc Dev Dis 2023; 10:jcdd10050213. [PMID: 37233179 DOI: 10.3390/jcdd10050213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.
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Affiliation(s)
- Danijel Knežević
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Božena Ćurko-Cofek
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Tanja Batinac
- Department of Clinical Medical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia
| | - Gordana Laškarin
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Marijana Rakić
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Maja Šoštarič
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Reanimatology, Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
| | - Marko Zdravković
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| | - Alan Šustić
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Vlatka Sotošek
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Lara Batičić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
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Dauth A, Bręborowicz A, Ruan Y, Tang Q, Zadeh JK, Böhm EW, Pfeiffer N, Khedkar PH, Patzak A, Vujacic-Mirski K, Daiber A, Gericke A. Sulodexide Prevents Hyperglycemia-Induced Endothelial Dysfunction and Oxidative Stress in Porcine Retinal Arterioles. Antioxidants (Basel) 2023; 12:antiox12020388. [PMID: 36829947 PMCID: PMC9952154 DOI: 10.3390/antiox12020388] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
Diabetes mellitus may cause severe damage to retinal blood vessels. The central aim of this study was to test the hypothesis that sulodexide, a mixture of glycosaminoglycans, has a protective effect against hyperglycemia-induced endothelial dysfunction in the retina. Functional studies were performed in isolated porcine retinal arterioles. Vessels were cannulated and incubated with highly concentrated glucose solution (HG, 25 mM D-glucose) +/- sulodexide (50/5/0.5 μg/mL) or normally concentrated glucose solution (NG, 5.5 mM D-glucose) +/- sulodexide for two hours. Endothelium-dependent and endothelium-independent vasodilatation were measured by videomicroscopy. Reactive oxygen species (ROS) were quantified by dihydroethidium (DHE) fluorescence. Using high-pressure liquid chromatography (HPLC), the intrinsic antioxidant properties of sulodexide were investigated. Quantitative PCR was used to determine mRNA expression of regulatory, inflammatory, and redox genes in retinal arterioles, some of which were subsequently quantified at the protein level by immunofluorescence microscopy. Incubation of retinal arterioles with HG caused significant impairment of endothelium-dependent vasodilation, whereas endothelium-independent responses were not affected. In the HG group, ROS formation was markedly increased in the vascular wall. Strikingly, sulodexide had a protective effect against hyperglycemia-induced ROS formation in the vascular wall and had a concentration-dependent protective effect against endothelial dysfunction. Although sulodexide itself had only negligible antioxidant properties, it prevented hyperglycemia-induced overexpression of the pro-oxidant redox enzymes, NOX4 and NOX5. The data of the present study provide evidence that sulodexide has a protective effect against hyperglycemia-induced oxidative stress and endothelial dysfunction in porcine retinal arterioles, possibly by modulation of redox enzyme expression.
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Affiliation(s)
- Alice Dauth
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
- Correspondence:
| | - Andrzej Bręborowicz
- Department of Pathophysiology, Poznań University of Medical Sciences, 60-512 Poznań, Poland
| | - Yue Ruan
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Qi Tang
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Jenia K. Zadeh
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
- AbbVie Germany GmbH & Co. KG, 65189 Wiesbaden, Germany
| | - Elsa W. Böhm
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Pratik H. Khedkar
- Institute of Translational Physiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andreas Patzak
- Institute of Translational Physiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ksenija Vujacic-Mirski
- Department of Cardiology, Cardiology 1, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Andreas Daiber
- Department of Cardiology, Cardiology 1, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
- Partner Site Rhine-Main, German Center for Cardiovascular Research (DZHK), 55131 Mainz, Germany
| | - Adrian Gericke
- Department of Ophthalmology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany
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A Dietary Supplement Containing Fucoidan Preserves Endothelial Glycocalyx through ERK/MAPK Signaling and Protects against Damage Induced by CKD Serum. Int J Mol Sci 2022; 23:ijms232415520. [PMID: 36555160 PMCID: PMC9779516 DOI: 10.3390/ijms232415520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
(1) Damage to the endothelial glycocalyx (eGC), a protective layer lining the endothelial luminal surface, is associated with chronic kidney disease (CKD), which leads to a worsening of cardiovascular outcomes in these patients. Currently, there are no targeted therapeutic approaches. Whether the dietary supplement EndocalyxTM (ECX) protects against endothelial damage caused by uremic toxins is unknown. (2) We addressed this question by performing atomic force microscopy measurements on living endothelial cells. We examined the effect of ECX on eGC thickness at baseline and with pooled serum from hemodialysis patients. ECX was also successfully administered in vivo in mice, in which eGC was assessed using perfused boundary region measurements by intravital microscopy of cremasteric vessels. (3) Both ECX and fucoidan significantly improved baseline eGC thickness. Our data indicate that these effects are dependent on ERK/MAPK and PI3K signaling. After incubation with eGC damaging serum from dialysis patients, ECX increased eGC height. Intravital microscopy in mice revealed a relevant increase in baseline eGC dimensions after feeding with ECX. (4) We identified a dietary supplement containing glycocalyx substrates and fucoidan as potential mediators of eGC preservation in vitro and in vivo. Our findings suggest that fucoidan may be an essential component responsible for protecting the eGC in acute settings. Moreover, ECX might contribute to both protection and rebuilding of the eGC in the context of CKD.
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Saini S, Kumar V, Koteshwara P. Role of Diffusion Tensor Imaging in renal parenchymal changes. Indian J Radiol Imaging 2021; 28:175-181. [PMID: 30050240 PMCID: PMC6038220 DOI: 10.4103/ijri.ijri_128_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Context: Diffusion Tensor Imaging (DTI) is a reliable noninvasive tool to assess renal function with medullary Fractional Anisotropy (FA) values showing the most consistent results. Aims: Evaluation of FA, Apparent Diffusion Coefficient (ADC) for detecting diabetic nephropathy (DN) using 1.5-Tesla magnetic resonance imaging (MRI). To determine FA and ADC values in chronic kidney disease (CKD) patients and controls, and comparing these with estimated glomerular filtiration rate (eGFR) and categorizing the stage of CKD. Patients and Methods: Thirty nondiabetic volunteers underwent DTI. The study included 83 diabetics, 30 frank urine proteinuric, 30 micro-albuminuric, 23 normo-albuminuric with only raised blood sugar patients. Patients were stratified by eGFR into groups: eGFR <60 and eGFR>60ml/min. ADC and FA values in cortex and medulla were compared between controls and study groups. Statistical Analysis Used: Analysis of variance and Pearson correlation using SPSS 16 were performed. Results: There was significant difference of FA medulla in controls versus albuminuric and micro-albuminuric versus frank proteinuric patients (P < 0.001). Also, there was significant difference between cortical ADC values between normal, microalbuminuric/proteinuric groups (P = 0.010, P =0.000, respectively). Significant difference between medullary FA values of patients with eGFR >60 and eGFR < 60 versus normal controls (P < 0.001) was noted. With declining renal function from normal to CKD category 5, a negative correlation between medullary FA (r= −0.785, P = 0.001) and ADC cortex values (r= −0.436, P = 0.001) was noted. A strong positive correlation between medullary FA and cortex ADC with eGFR (r = 0.598 and 0.344, respectively) was noted. Conclusion: Medullary FA of diabetics with relatively intact kidney function were significantly lower than those of controls. Hence, drop in medullary FA values can be an indicator of early nephropathy/patients at risk where eGFR is in near normal range. Cortical ADC and medullary FA demonstrated a significant correlation with eGFR with the latter showing a stronger positive correlation.
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Affiliation(s)
- Shimona Saini
- Department of Radiodiagnosis and Imaging, KMC, Manipal, Karnataka, India
| | - Vikas Kumar
- Department of Radiodiagnosis, PGIMER Dr Ram Manohar Lohia Hospital, New Delhi, India
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Diabetic nephropathy: A twisted thread to unravel. Life Sci 2021; 278:119635. [PMID: 34015285 DOI: 10.1016/j.lfs.2021.119635] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
Diabetic nephropathy (DN), a persistent microvascular problem of diabetes mellitus is described as an elevated level of albumin excretion in urine and impaired renal activity. The morbidity and mortality of type-1 diabetics and type-2 diabetics due to end stage renal disease is also a result of the increased prevalence of DN. DN typically occurs as a consequence of an association among metabolic and hemodynamic variables, activating specific pathways leading to renal injury. According to current interventions, intensive glucose regulation decreases the threat of DN incidence and growth, and also suppressing the renin-angiotensin system (RAS) is a significant goal for hemodynamic and metabolism-related deformities in DN. However, the pathogenesis of DN is multifactorial so novel approaches other than glucose and blood pressure control are required for treatment. This review briefly summarizes the reported pathogenesis of DN, current interventions for its treatment, and possible novel interventions to unweave the thread of DN.
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Nordheim E, Geir Jenssen T. Chronic kidney disease in patients with diabetes mellitus. Endocr Connect 2021; 10:R151-R159. [PMID: 33830068 PMCID: PMC8111312 DOI: 10.1530/ec-21-0097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 12/15/2022]
Abstract
Chronic kidney disease is a common complication and concomitant condition of diabetes mellitus. The treatment of patients with diabetes and chronic kidney disease, including intensive control of blood sugar and blood pressure, has been very similar for type 1 and type 2 diabetes patients. New therapeutic targets have shown promising results and may lead to more specific treatment options for patients with type 1 and type 2 diabetes.
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Affiliation(s)
- Espen Nordheim
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Correspondence should be addressed to E Nordheim:
| | - Trond Geir Jenssen
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT- The Arctic University of Norway, Tromsø
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Bignamini AA, Chebil A, Gambaro G, Matuška J. Sulodexide for Diabetic-Induced Disabilities: A Systematic Review and Meta-Analysis. Adv Ther 2021; 38:1483-1513. [PMID: 33502688 PMCID: PMC7932977 DOI: 10.1007/s12325-021-01620-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Micro- and macrovascular complications of diabetes are leading morbidities in the world population. They are responsible not only for increased mortality but also severe disabilities, which jeopardize quality of life (e.g., blindness, walking limitations, and renal failure requiring dialysis). The new antidiabetic agents (e.g., glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter inhibitors) are increasingly recognized as breakthrough agents in the treatment of diabetes and prevention of diabetic complications. However, drugs effective in preventing and treating diabetic disabilities are still needed and sulodexide could be one of those able to address the unmet clinical needs of the new antidiabetic agents. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal. We also manually searched potentially relevant journals, conference proceedings, and journal supplements. Any study monitoring any effect of sulodexide in subjects with diabetes, in relation to renal, vascular, and ocular complication, was considered. Treatment effects were estimated using standardized mean differences (SMDs), mean differences (MDs), and risk ratios (RRs), as appropriate. We calculated 95% confidence interval (CIs) and heterogeneity (Q, tau, and I2). RESULTS The search found 45 studies with 2817 participants (mean age 57 years; 63% male). The 26 randomized controlled studies included 2074 participants (mean age 58.8 years; 66% male). Sulodexide reduced the impact of diabetic retinopathy; increased the pain-free and maximal walking distance in peripheral arterial disease; accelerated the healing of diabetes-associated trophic ulcers; and decreased the rate of albumin excretion in subjects with nephropathy. The risk of adverse events (AEs) was not different between sulodexide and controls. CONCLUSION Sulodexide has a beneficial effect on the ocular, peripheral arterial disease, trophic ulcers, and renal complications of diabetes without increasing the risk of AEs.
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Affiliation(s)
- Angelo A Bignamini
- School of Specialisation in Hospital Pharmacy, Department of Pharmaceutical Sciences, University of Milan, Milan, Italy.
| | - Ahmed Chebil
- Department B of Ophthalmology, Hedi Rais Institute of Ophthalmology, Faculty of Medicine of Tunis, University of El Manar, Tunis, Tunisia
| | - Giovanni Gambaro
- Division of Nephrology and Dialysis, Ospedale Maggiore, University of Verona, Verona, Italy
| | - Jiří Matuška
- MATMED S.R.O., Private Angiology Facility, Hodonin, Czech Republic
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Korakas E, Ikonomidis I, Markakis K, Raptis A, Dimitriadis G, Lambadiari V. The Endothelial Glycocalyx as a Key Mediator of Albumin Handling and the Development of Diabetic Nephropathy. Curr Vasc Pharmacol 2020; 18:619-631. [PMID: 31889495 DOI: 10.2174/1570161118666191224120242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023]
Abstract
The endothelial glycocalyx is a complex mesh of proteoglycans, glycoproteins and other soluble components, which cover the vascular endothelium. It plays an important role in many physiological processes including vascular permeability, transduction of shear stress and interaction of blood cells and other molecules with the vascular wall. Its complex structure makes its precise assessment challenging, and many different visualization techniques have been used with varying results. Diabetes, one of the main disease models where disorders of the glycocalyx are present, causes degradation of the glycocalyx through a variety of molecular pathways and especially through oxidative stress due to the action of reactive oxygen species. As the glycocalyx has been primarily studied in the glomerular endothelium, more evidence points towards a vital role in albumin handling and, consequently, in diabetic nephropathy. Therefore, the maintenance or restoration of the integrity of the glycocalyx seems a promising therapeutic target. In this review, we consider the structural and functional capacities of the endothelial glycocalyx, the available methods for its evaluation, the mechanisms through which diabetes leads to glycocalyx degradation and albuminuria, and possible treatment options targeting the glycocalyx.
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Affiliation(s)
- Emmanouil Korakas
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- Second Cardiology Department, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Markakis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Raptis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Dimitriadis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vaia Lambadiari
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Fracasso A, Baggio B, Masiero M, Bonfante L, Bazzato G, Feriani M, Gambaro G. Effect of Oral Treatment with the Glycosaminoglycan Sulodexide on Peritoneal Transport in CAPD Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302300615] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Agostino Fracasso
- Division of Nephrology, University Hospital, University of Padua, Italy
| | - Bruno Baggio
- Umberto I General Hospital, Mestre-Venice Division of Nephrology, University Hospital, University of Padua, Italy
| | - Mauro Masiero
- Department of Medical and Surgical Sciences Department of Laboratory Medicine University Hospital, University of Padua, Italy
| | - Luciana Bonfante
- Umberto I General Hospital, Mestre-Venice Division of Nephrology, University Hospital, University of Padua, Italy
| | - Giorgio Bazzato
- Division of Nephrology, University Hospital, University of Padua, Italy
| | - Mariano Feriani
- Division of Nephrology, University Hospital, University of Padua, Italy
| | - Giovanni Gambaro
- Umberto I General Hospital, Mestre-Venice Division of Nephrology, University Hospital, University of Padua, Italy
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13
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Effects of Sulodexide on Hemostatic Factors, Lipid Profile, and Inflammation in Chronic Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080702700415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Sulodexide, a standardized extractive glycosaminoglycan containing 80% “fast moving” heparin and 20% dermatan sulfate, decreased plasma D-dimer, a marker of intravascular coagulation, and fibrinogen levels in chronic peritoneal dialysis patients. Blood levels of von Willebrand factor, lipid, and high-sensitivity C-reactive protein were not significantly changed. No bleeding episodes were reported. These results suggest that sulodexide was effective in partially reversing the thrombogenic coagulation profile without increasing the risk of bleeding.
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Yongwatana K, Supasyndh O, Satirapoj B. Renal Effects of Sulodexide in Type 2 Diabetic Patients without Nephrotic Range Proteinuria. J Diabetes Res 2020; 2020:2984680. [PMID: 32851094 PMCID: PMC7439194 DOI: 10.1155/2020/2984680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/28/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Glycosaminoglycan plays an important role in the maintenance of glomerular charge selectivity of diabetic nephropathy. Sulodexide, a mixture of naturally occurring glycosaminoglycan polysaccharide components, has shown a nephroprotective effect in an experimental model of diabetic nephropathy. Although sulodexide reduced albuminuria in patients with type 1 and type 2 diabetes, long-term effects in patients with type 2 diabetes with significant proteinuria have not been established. OBJECTIVES The study was aimed at investigating the effects of sulodexide on proteinuria and renal function in patients with type 2 diabetes and nephropathy. METHODS Fifty-two patients with proteinuria between 500 and 3000 mg/day received sulodexide 200 mg/day for 12 months, while 56 matched patients with type 2 diabetes constituted the control group. All patients received standard metabolic and blood pressure controls. Primary outcome was evaluated as percentage of reduced proteinuria compared with the control group. Renal function was assessed using estimated glomerular filtration rate (GFR). RESULTS Proteinuria significantly increased in the control group [0.9 (IQR 0.3 to 1.78) to 1.16 (IQR 0.44 to 2.23) g/gCr, P = 0.001], whereas it remained stable in the sulodexide group [0.66 (IQR 0.23 to 0.67) to 0.67 (IQR 0.17 to 1.51) g/gCr, P = 0.108]. At 12 months, proteinuria was higher by 19.4% (IQR 10.3 to 37.6) in the control group while proteinuria was lower by -17.7% (IQR -53.1 to 3.2) in the sulodexide group with a significant difference between groups (P = 0.001). Renal function was noted as a change of estimated GFR, and serum creatinine decreased significantly during the study in both groups but did not significantly differ between groups. No significant changes in the blood pressure, fasting plasma glucose, and hemoglobin A1C were reported. CONCLUSION In addition to standard treatment, sulodexide is efficient in maintaining proteinuria in patients with type 2 diabetes with nonnephrotic range proteinuria, but it did not provide an additional benefit concerning renal disease progression.
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Affiliation(s)
- Kachonsak Yongwatana
- Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Ouppatham Supasyndh
- Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Bancha Satirapoj
- Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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15
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Anguiano Gómez L, Lei Y, Kumar Devarapu S, Anders HJ. The diabetes pandemic suggests unmet needs for 'CKD with diabetes' in addition to 'diabetic nephropathy'-implications for pre-clinical research and drug testing. Nephrol Dial Transplant 2019; 33:1292-1304. [PMID: 28992221 DOI: 10.1093/ndt/gfx219] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/21/2017] [Indexed: 12/12/2022] Open
Abstract
Curing 'diabetic nephropathy' is considered an unmet medical need of high priority. We propose to question the concept of 'diabetic nephropathy' that implies diabetes as the predominant cause of kidney disease, which may not apply to the majority of type 2 diabetics approaching end-stage kidney disease. With the onset of diabetes, hyperglycaemia/sodium-glucose co-transporter-2-driven glomerular hyperfiltration promotes nephron hypertrophy, which, however, on its own, causes proteinuria not before a decade later, probably because podocyte hypertrophy can usually accommodate an increase in the filtration surface. In contrast, precedent chronic kidney disease (CKD), that is, few nephrons per body mass, e.g. due to poor nephron endowment from birth, obesity, pregnancy, or renal ageing or injury-related nephron loss, usually precedes the onset of type 2 diabetes. This applies in particular in older adults, and each on its own, but especially in combination, further aggravates single nephron hyperfiltration and glomerular hypertrophy. Whenever this additional hyperglycaemia-driven enlargement of the glomerular filtration surface exceeds the capacity of podocytes for hypertrophy, podocytes detachment leads to glomerulosclerosis and nephron loss, i.e. CKD progression. Animal models of 'diabetic nephropathy' based only on hyperglycaemia do not mimic this aspect and therefore poorly predict outcomes of clinical trials usually performed on elderly CKD patients with type 2 diabetes. Thus, we advocate the use of renal mass (nephron) ablation in type 2 diabetic animals to better mimic the pathophysiology of 'CKD with diabetes' in the target patient population and the use of the glomerular filtration rate as a primary endpoint to more reliably predict trial outcomes.
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Affiliation(s)
- Lidia Anguiano Gómez
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.,Department of Nephrology, Hospital del Mar-IMIM, Barcelona, Spain
| | - Yutian Lei
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Satish Kumar Devarapu
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Hans-Joachim Anders
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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16
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Endothelin receptor-A mediates degradation of the glomerular endothelial surface layer via pathologic crosstalk between activated podocytes and glomerular endothelial cells. Kidney Int 2019; 96:957-970. [PMID: 31402170 DOI: 10.1016/j.kint.2019.05.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 04/08/2019] [Accepted: 05/02/2019] [Indexed: 12/15/2022]
Abstract
Emerging evidence of crosstalk between glomerular cells in pathological settings provides opportunities for novel therapeutic discovery. Here we investigated underlying mechanisms of early events leading to filtration barrier defects of podocyte and glomerular endothelial cell crosstalk in the mouse models of primary podocytopathy (podocyte specific transforming growth factor-β receptor 1 signaling activation) or Adriamycin nephropathy. We found that glomerular endothelial surface layer degradation and albuminuria preceded podocyte foot process effacement. These abnormalities were prevented by endothelin receptor-A antagonism and mitochondrial reactive oxygen species scavenging. Additional studies confirmed increased heparanase and hyaluronoglucosaminidase gene expression in glomerular endothelial cells in response to podocyte-released factors and to endothelin-1. Atomic force microscopy measurements showed a significant reduction in the endothelial surface layer by endothelin-1 and podocyte-released factors, which could be prevented by endothelin receptor-A but not endothelin receptor-B antagonism. Thus, our studies provide evidence of early crosstalk between activated podocytes and glomerular endothelial cells resulting in loss of endothelial surface layer, glomerular endothelial cell injury and albuminuria. Hence, activation of endothelin-1-endothelin receptor-A and mitochondrial reactive oxygen species contribute to the pathogenesis of primary podocytopathies in experimental focal segmental glomerulosclerosis.
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17
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Hu J, Du Y. Managing chronic kidney disease in diabetes patients with the latest chemical therapies. Expert Rev Clin Pharmacol 2018; 12:53-60. [DOI: 10.1080/17512433.2019.1552829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jingbo Hu
- College of Pharmaceutical Science, Zhejiang University, Hangzhou, China
- Institute of Drug Discovery Technology, Ningbo University, Ningbo, China
| | - Yongzhong Du
- College of Pharmaceutical Science, Zhejiang University, Hangzhou, China
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18
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El Beaino M, McCaskey MK, Eter E. Sulodexide Monotherapy in Chronic Idiopathic Subjective Tinnitus: A Randomized Controlled Trial. Otolaryngol Head Neck Surg 2018; 158:1107-1112. [PMID: 29712507 DOI: 10.1177/0194599818767618] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To report the therapeutic value of sulodexide monotherapy in the management of patients with chronic subjective idiopathic tinnitus. Study Design Randomized double-blinded controlled trial. Setting Single tertiary care institution. Subjects and Methods Observations from 124 patients who received either sulodexide or placebo were collected from the patients' medical records. Computer-generated tables were used to allocate treatments. Patients took 1 tablet of the drug or placebo each morning and evening for 40 consecutive days. The response was assessed by the Tinnitus Handicap Inventory and the Mini-Tinnitus Questionnaire. Results Between 2014 and 2017, 124 patients were divided into 2 treatment arms. The sulodexide group encompassed 63 patients, whereas the placebo arm contained 61 patients. Tinnitus Handicap Inventory and Mini-Tinnitus Questionnaire scores were more decreased in the sulodexide arm compared to the placebo group ( P = .03 and P < .01, respectively). Conclusions Sulodexide monotherapy decreases chronic subjective idiopathic tinnitus.
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Affiliation(s)
- Marc El Beaino
- 1 Department of Otorhinolaryngology Head and Neck Surgery, Saint Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Meghan K McCaskey
- 2 School of Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Elie Eter
- 1 Department of Otorhinolaryngology Head and Neck Surgery, Saint Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon
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19
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Waasdorp M, Duitman J, Florquin S, Spek CA. Vorapaxar treatment reduces mesangial expansion in streptozotocin-induced diabetic nephropathy in mice. Oncotarget 2018; 9:21655-21662. [PMID: 29774092 PMCID: PMC5955164 DOI: 10.18632/oncotarget.25069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/22/2018] [Indexed: 11/25/2022] Open
Abstract
Background Twenty years after the onset of diabetes, up to 40% of patients develop diabetic nephropathy. Protease-activated receptor-1 (PAR-1) has recently been shown to aggravate the development of experimental diabetic nephropathy. PAR-1 deficient mice develop less albuminuria and glomerular lesions and PAR-1 stimulation induces proliferation and fibronectin production in mesangial cells in vitro. Vorapaxar is a clinically available PAR-1 inhibitor which is currently used for secondary prevention of ischemic events. Objectives The aim of this study was to investigate in a preclinical setting whether vorapaxar treatment may be a novel strategy to reduce diabetes-induced kidney damage. Results While control treated diabetic mice developed significant albuminuria, mesangial expansion and glomerular fibronectin deposition, diabetic mice on vorapaxar treatment did not show any signs of kidney damage despite having similar levels of hyperglycemia. Conclusions These data show that PAR-1 inhibition by vorapaxar prevents the development of diabetic nephropathy in this preclinical animal model for type I diabetes and pinpoint PAR-1 as a novel therapeutic target to pursue in the setting of diabetic nephropathy. Materials and Methods 22 C57Bl/6 mice were made diabetic using multiple low-dose streptozotocin injections (50 mg/kg) and 22 littermates served as non-diabetic controls. Four weeks after the induction of diabetes, 11 mice of each group were assigned to control or vorapaxar treatment. Mice were sacrificed after 20 weeks of treatment and kidney damage was evaluated.
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Affiliation(s)
- Maaike Waasdorp
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - JanWillem Duitman
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Inserm UMR1152, Physiopathologie et Epidémiologie des maladies respiratoires, Medical School Xavier Bichat, Paris, France.,Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodeling) and LabEx Inflamex, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - C Arnold Spek
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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20
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Liew H, Roberts MA, MacGinley R, McMahon LP. Endothelial glycocalyx in health and kidney disease: Rising star or false Dawn? Nephrology (Carlton) 2017; 22:940-946. [DOI: 10.1111/nep.13161] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Hui Liew
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Matthew A Roberts
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Robert MacGinley
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
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21
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Pillinger NL, Kam P. Endothelial glycocalyx: basic science and clinical implications. Anaesth Intensive Care 2017; 45:295-307. [PMID: 28486888 DOI: 10.1177/0310057x1704500305] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
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Affiliation(s)
- N L Pillinger
- Staff Specialist Anaesthetist, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
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22
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Heparanase: roles in cell survival, extracellular matrix remodelling and the development of kidney disease. Nat Rev Nephrol 2017; 13:201-212. [PMID: 28163306 DOI: 10.1038/nrneph.2017.6] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heparanase has regulatory roles in various processes, including cell communication, gene transcription and autophagy. In addition, it is the only known mammalian endoglycosidase that is capable of degrading heparan sulfate (HS). HS chains are important constituents and organizers of the extracellular matrix (ECM), and have a key role in maintaining the integrity and function of the glomerular filtration barrier. In addition, HS chains regulate the activity of numerous bioactive molecules, such as cytokines and growth factors, at the cell surface and in the ECM. Given the functional diversity of HS, its degradation by heparanase profoundly affects important pathophysiological processes, including tumour development, neovascularization and inflammation, as well as progression of kidney disease. Heparanase-mediated degradation and subsequent remodelling of HS in the ECM of the glomerulus is a key mechanism in the development of glomerular disease, as exemplified by the complete resistance of heparanase-deficient animals to diabetes and immune-mediated kidney disease. This Review summarizes the role of heparanase in the development of kidney disease, and its potential as a therapeutic target.
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23
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Liu YN, Zhou J, Li T, Wu J, Xie SH, Liu HF, Liu Z, Park TS, Wang Y, Liu WJ. Sulodexide Protects Renal Tubular Epithelial Cells from Oxidative Stress-Induced Injury via Upregulating Klotho Expression at an Early Stage of Diabetic Kidney Disease. J Diabetes Res 2017; 2017:4989847. [PMID: 28929120 PMCID: PMC5591972 DOI: 10.1155/2017/4989847] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/06/2017] [Indexed: 12/11/2022] Open
Abstract
The hypoalbuminuric effect of sulodexide (SDX) on diabetic kidney disease (DKD) was suggested by some clinical trials but was denied by the Collaborative Study Group. In this study, the diabetic rats were treated with SDX either from week 0 to 24 or from week 13 to 24. We found that 24-week treatment significantly decreased the urinary protein and HAVCR1 excretion, inhibited the interstitial expansion, and downregulated the renal cell apoptosis and interstitial fibrosis. Renoprotection was also associated with a reduction in renocortical/urinary oxidative activity and the normalization of renal klotho expression. However, all of these actions were not observed when SDX was administered only at the late stage of diabetic nephropathy (from week 13 to 24). In vitro, advanced glycation end products (AGEs) dose-dependently enhanced the oxidative activity but lowered the klotho expression in cultured proximal tubule epithelial cells (PTECs). Also, H2O2 could downregulate the expression of klotho in a dose-dependent manner. However, overexpression of klotho reduced the HAVCR1 production and the cellular apoptosis level induced by AGEs or H2O2. Our study suggests that SDX may prevent the progression of DKD at the early stage by upregulating renal klotho expression, which inhibits the tubulointerstitial injury induced by oxidative stress.
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Affiliation(s)
- Yu Ning Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing and Renal Research Institution of Beijing University of Chinese Medicine, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jingwei Zhou
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing and Renal Research Institution of Beijing University of Chinese Medicine, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100700, China
| | - Tingting Li
- Institute of Nephrology, Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, Guangdong 524001, China
| | - Jing Wu
- Institute of Nephrology, Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, Guangdong 524001, China
| | - Shu Hua Xie
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing and Renal Research Institution of Beijing University of Chinese Medicine, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100700, China
| | - Hua-feng Liu
- Institute of Nephrology, Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, Guangdong 524001, China
| | - Zhangsuo Liu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tae Sun Park
- Chonbuk National University, Jeonju, Republic of Korea
| | - Yaoxian Wang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing and Renal Research Institution of Beijing University of Chinese Medicine, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100700, China
- *Yaoxian Wang: and
| | - Wei Jing Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing and Renal Research Institution of Beijing University of Chinese Medicine, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100700, China
- Institute of Nephrology, Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, Guangdong 524001, China
- *Wei Jing Liu:
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24
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Guedri Y, Damma KN, Toumi M, Sahtout W, Azzabi A, Mrabet S, Nouira S, Saidane D, Amor S, Belarbia A, Zellama D, Achour A. Effect of intraperitoneal injection of sulodexide on peritoneal function and albumin leakage in continuous ambulatory peritoneal dialysis patients. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2016; 27:1194-1199. [PMID: 27900965 DOI: 10.4103/1319-2442.194611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Peritoneal protein loss is one of the inevitable consequences during continuous ambulatory peritoneal dialysis (CAPD). Our objective was to study the effect of sulodexide on the protein loss and efficiency of dialysis. This study included six patients receiving CAPD treated with sulodexide at the dose of 600 IU/day given by intraperitoneal injection for 10 days. Clinical and biologic parameters were assessed before starting the treatment (D0 and after 10 days of treatment (D10. We also evaluated the benefit of therapy persisting 20 days after the end of treatment (D30. The sulodexide administration produced a significant improvement of the peritoneal function as determined by a significant increase in the following ratios measured at the 4 th h of dwell time on D0 and D30: dialysate-to plasma (D/P) creatinine from 0.63 ± 1.45 to 0.85 ± 0.073 (P = 0.028) and D/P urea from 0.63 ± 0.15 to 79 ± 0.2 (P = 0.048). A significant decrease of albumin leakage was observed, which was 0.90 ± 0.40 g/L at baseline, 0.67 ± 0.36 g/L on the 10 th day, and 0.43 ± 0.22g/L 20 days after the end of treatment. Within 10-day treatment period, use of sulodexide resulted in a reduction in the peritoneal loss of albumin, in addition to improvement of the quality of dialysis and the residual renal function among these patients.
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Affiliation(s)
- Yosra Guedri
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - K Najla Damma
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | | | - Wissal Sahtout
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Awatef Azzabi
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Sinda Mrabet
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Safa Nouira
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | | | - Samira Amor
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Anis Belarbia
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Dorsaf Zellama
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
| | - Abdellatif Achour
- Department of Nephrology, Dialysis and Transplantation, Sahloul Hospital, Sousse, Tunisia
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25
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Olde Engberink RH, Vogt L. The renoprotective effects of sulodexide. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:1233-4. [PMID: 27042014 PMCID: PMC4809327 DOI: 10.2147/dddt.s102814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Rik Hg Olde Engberink
- Department of Internal Medicine, Section of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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26
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Chan GC, Tang SC. Diabetic nephropathy: landmark clinical trials and tribulations. Nephrol Dial Transplant 2016; 31:359-368. [DOI: 10.1093/ndt/gfu411] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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27
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Li R, Xing J, Mu X, Wang H, Zhang L, Zhao Y, Zhang Y. Sulodexide therapy for the treatment of diabetic nephropathy, a meta-analysis and literature review. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:6275-83. [PMID: 26664049 PMCID: PMC4671764 DOI: 10.2147/dddt.s87973] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Sulodexide is a heterogeneous group of sulfated glycosaminoglycans (GAGs) that is mainly composed of low-molecular-weight heparin. Clinical studies have demonstrated that sulodexide is capable of reducing urinary albumin excretion rates in patients with type 1 and type 2 diabetes, suggesting that sulodexide has renal protection. However, this efficacy remains inconclusive. In this article, we used meta-analysis to summarize the clinical results of all prospective clinical studies in order to determine the clinical efficacy and safety of sulodexide in diabetic patients with nephropathy. Overall, sulodexide therapy was associated with a significant reduction in urinary protein excretion. In the sulodexide group, 220 (17.7%) achieved at least a 50% decrease in albumin excretion rate compared with only 141 (11.5%) in the placebo. The odds ratio comparing proportions of patients with therapeutic success between the sulodexide and placebo groups was 3.28 (95% confidence interval, 1.34-8.06; P=0.01). These data suggest a renoprotective benefit of sulodexide in patients with diabetes and micro- and macroalbuminuria, which will provide important information for clinical use of this drug as a potential modality for diabetic nephropathy, specifically, the prevention of end-stage renal disease that is often caused by diabetes.
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Affiliation(s)
- Rui Li
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Jing Xing
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Xaojing Mu
- Dalian Hospital of Traditional Chinese Medicine, Dalian, People's Republic of China
| | - Hui Wang
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Lei Zhang
- Intensive Care Unit, Tianjin First Central Hospital, People's Republic of China
| | - Yu Zhao
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - Yu Zhang
- Emergency Department, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
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Abstract
Diabetic nephropathy is rapidly becoming the major cause of end-stage renal disease and cardiovascular mortality worldwide. Standard of care therapies include strict glycemic control and blockade of the renin-angiotensin-aldosterone axis. While these treatments slow progression of diabetic nephropathy, they do not arrest or reverse it. Newer therapies targeting multiple molecular pathways involved in renal inflammation, fibrosis, and oxidative stress have shown promise in animal models. Subsequently, many of these agents have been investigated in clinical human trials with mixed results. In this review, we will discuss recent findings of novel agents used in the treatment of diabetic nephropathy.
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Affiliation(s)
- Sadaf S Khan
- Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, 303 East Superior Lurie Building, 10th Floor, Chicago, IL, 60611, USA.
| | - Susan E Quaggin
- Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, 303 East Superior Lurie Building, 10th Floor, Chicago, IL, 60611, USA
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29
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Rabelink TJ, de Zeeuw D. The glycocalyx--linking albuminuria with renal and cardiovascular disease. Nat Rev Nephrol 2015; 11:667-76. [PMID: 26460356 DOI: 10.1038/nrneph.2015.162] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Albuminuria is commonly used as a marker of kidney disease progression, but some evidence suggests that albuminuria also contributes to disease progression by inducing renal injury in specific disease conditions. Studies have confirmed that in patients with cardiovascular risk factors, such as diabetes and hypertension, endothelial damage drives progression of kidney disease and cardiovascular disease. A key mechanism that contributes to this process is the loss of the glycocalyx--a polysaccharide gel that lines the luminal endothelial surface and that normally acts as a barrier against albumin filtration. Degradation of the glycocalyx in response to endothelial activation can lead to albuminuria and subsequent renal and vascular inflammation, thus providing a pathophysiological framework for the clinical association of albuminuria with renal and cardiovascular disease progression. In this Review, we examine the likely mechanisms by which glycocalyx dysfunction contributes to kidney injury and explains the link between cardiovascular disease and albuminuria. Evidence suggests that glycocalyx dysfunction is reversible, suggesting that these mechanisms could be considered as therapeutic targets to prevent the progression of renal and cardiovascular disease. This possibility enables the use of existing drugs in new ways, provides an opportunity to develop novel therapies, and indicates that albuminuria should be reconsidered as an end point in clinical trials.
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Affiliation(s)
- Ton J Rabelink
- Department of Medicine, Division of Nephrology, Einthoven Laboratory for Experimental Vascular Medicine, LUMC, Leiden University Medical Centre, Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, Netherlands
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Abstract
Diabetic nephropathy (DN), a leading cause of end-stage renal disease (ESRD) affecting ∼20-30% diabetics, is associated with increased cardiovascular mortality. The progression of kidney disease in patients with diabetes can take many years. It occurs as a result of interaction between both genetic and environmental factors in individuals with both type 1 and type 2 diabetes. Hyperglycaemia, hypertension, and genetic pre-disposition are the main risk factors besides elevated serum lipids, smoking habits, and the amount of dietary proteins. Interventions such as glycaemic control, blood pressure control and inhibition of the renin-angiotensin-aldosterone system have been shown to slow this progression. Despite the implementation of these strategies, the number of patients with diabetes that ultimately develop end-stage renal disease remains high. The treatment of DN, therefore, has posed a formidable challenge besides optimization of renin-angiotensin-aldosterone system blockade in patients with DN; additional investigation has focused on the potential of novel therapies that target various pathways upregulated by hyperglycaemia or other targets believed to promote the progression of DN such as oxidative stress, inflammation, endothelin system and vitamin D receptors. This review article addresses the pathogenesis and some of the well established principles regarding the progression and accepted management of DN, and also includes the perspectives of novel anti-DN agents and the future directions for the prevention of DN.
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Affiliation(s)
- Jamal Ahmad
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh 202002, India.
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Olde Engberink RHG, Rorije NMG, Lambers Heerspink HJ, De Zeeuw D, van den Born BJH, Vogt L. The blood pressure lowering potential of sulodexide--a systematic review and meta-analysis. Br J Clin Pharmacol 2015; 80:1245-53. [PMID: 26184982 DOI: 10.1111/bcp.12722] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 12/29/2022] Open
Abstract
AIMS Sulodexide is a highly purified mixture of glycosaminoglycans that has been studied for its anti-albuminuric potential. Considering the effects of glycosaminoglycans on endothelial function and sodium homeostasis, we hypothesized that sulodexide may lower blood pressure (BP). In this meta-analysis, we therefore investigated the antihypertensive effects of sulodexide treatment. METHODS We selected randomized controlled trials that investigated sulodexide treatment of at least 4 weeks and measured BP at baseline and after treatment. Two reviewers independently extracted data on study design, risk of bias, population characteristics and outcome measures. In addition, we contacted authors and pharmaceutical companies to provide missing data. RESULTS Eight studies, totalling 3019 subjects (mean follow-up 4.4 months) were included. Mean age was 61 years and mean baseline BP was 135/75 mmHg. Compared with control treatment, sulodexide resulted in a significant systolic (2.2 mmHg [95% CI 0.3, 4.1], P = 0.02) and diastolic BP reduction (1.7 mmHg [95% CI 0.6, 2.9], P = 0.004). Hypertensive patients displayed the largest systolic BP and diastolic BP reductions (10.2/5.4 mmHg, P < 0.001). Higher baseline systolic and diastolic BP were significantly associated with larger systolic (r(2)=0.83, P < 0.001) and diastolic BP (r(2)=0.41, P = 0.02) reductions after sulodexide treatment. In addition, systolic (r(2)=0.41, P = 0.03) and diastolic BP reductions (r(2)=0.60, P = 0.005) were significantly associated with albuminuria reduction. CONCLUSION Our data suggest that sulodexide treatment results in a significant BP reduction, especially in hypertensive subjects. This indicates that endothelial glycosaminoglycans might be an independent therapy target in cardiovascular disease. Future studies should further address the BP lowering potential of sulodexide.
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Affiliation(s)
| | - Nienke M G Rorije
- Division of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen
| | - Dick De Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen
| | - Bert-Jan H van den Born
- Division of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Liffert Vogt
- Division of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam
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Dounousi E, Duni A, Leivaditis K, Vaios V, Eleftheriadis T, Liakopoulos V. Improvements in the Management of Diabetic Nephropathy. Rev Diabet Stud 2015; 12:119-33. [PMID: 26676665 DOI: 10.1900/rds.2015.12.119] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The burden of diabetes mellitus is relentlessly increasing. Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) worldwide and a major cause of morbidity and mortality in patients with diabetes. The current standard therapy of diabetic nephropathy involves intensive treatment of hyperglycemia and strict blood pressure control, mainly via blockade of the renin-angiotensin system (RAS). Attention has been drawn to additional beneficial effects of oral hypoglycemic drugs and fibrates on other aspects of diabetic nephropathy. On the other hand, antiproteinuric effects of RAS combination therapy do not seem to enhance the prevention of renal disease progression, and it has been associated with an increased rate of serious adverse events. Novel agents, such as bardoxolone methyl, pentoxifylline, inhibitors of protein kinase C (PKC), sulodexide, pirfenidone, endothelin receptor antagonists, vitamin D supplements, and phosphate binders have been associated with controversial outcomes or significant side effects. Although new insights into the pathogenetic mechanisms have opened new horizons towards novel interventions, there is still a long way to go in the field of DN research. The aim of this review is to highlight the recent progress made in the field of diabetes management based on the existing evidence. The article also discusses novel targets of therapy, with a special focus on the major pathophysiologic mechanisms implicated in the initiation and progression of diabetic nephropathy.
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Affiliation(s)
- Evangelia Dounousi
- University of Ioannina, School of Health Siences, Department of Internal Medicine, Division of Nephrology, Ioannina, Greece
| | - Anila Duni
- University of Ioannina, School of Health Siences, Department of Internal Medicine, Division of Nephrology, Ioannina, Greece
| | - Konstantinos Leivaditis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Vaios
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Eleftheriadis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Jo H, Jung SH, Kang J, Yim HB, Kang KD. Sulodexide inhibits retinal neovascularization in a mouse model of oxygen-induced retinopathy. BMB Rep 2015; 47:637-42. [PMID: 24602608 PMCID: PMC4281343 DOI: 10.5483/bmbrep.2014.47.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Indexed: 01/19/2023] Open
Abstract
Sulodexide is a mixed glycosaminoglycan composed of heparin and dermatan sulfate. In this study, the anti-angiogenic effect of sulodexide was investigated using an oxygen-induced retinopathy (OIR) mouse model. The retinas of sham-injected OIR mice (P17) had a distinctive central area of nonperfusion, and this area was significantly decreased in sulodexide-injected mice. The number of neovascular tufts measured by SWIFT_NV and mean neovascular lumen number were significantly decreased in sulodexide-injected mice. Hyperbaric oxygen exposure resulted in increased levels of VEGF, MMP-2 and MMP-9, and when mice were treated with sulodexide, a dose-dependent reduction in VEGF, MMP-2 and MMP-9 levels was observed. Our results clearly demonstrate the anti-angiogenic effect of sulodexide and highlight sulodexide as a candidate supplementary substance to be used for the treatment of ocular pathologies that involve neovascularization. [BMB Reports 2014; 47(11): 637-642]
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Affiliation(s)
- Hyoung Jo
- Functional Food Center, Korea Institute of Science and Technology (KIST) Gangneung Institute, Gangneung 210-340, Korea
| | - Sang Hoon Jung
- Functional Food Center, Korea Institute of Science and Technology (KIST) Gangneung Institute, Gangneung 210-340, Korea
| | - Jun Kang
- Department of Pathology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon 403-720, Korea
| | - Hye Bin Yim
- Department of Ophthalmology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon 403-720, Korea
| | - Kui Dong Kang
- Department of Ophthalmology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon 403-720, Korea
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Toth-Manikowski S, Atta MG. Diabetic Kidney Disease: Pathophysiology and Therapeutic Targets. J Diabetes Res 2015; 2015:697010. [PMID: 26064987 PMCID: PMC4430644 DOI: 10.1155/2015/697010] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/17/2015] [Indexed: 12/13/2022] Open
Abstract
Diabetes is a worldwide epidemic that has led to a rise in diabetic kidney disease (DKD). Over the past two decades, there has been significant clarification of the various pathways implicated in the pathogenesis of DKD. Nonetheless, very little has changed in the way clinicians manage patients with this disorder. Indeed, treatment is primarily centered on controlling hyperglycemia and hypertension and inhibiting the renin-angiotensin system. The purpose of this review is to describe the current understanding of how the hemodynamic, metabolic, inflammatory, and alternative pathways are all entangled in pathogenesis of DKD and detail the various therapeutic targets that may one day play a role in quelling this epidemic.
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Affiliation(s)
- Stephanie Toth-Manikowski
- Division of Nephrology, Johns Hopkins University, 1830 E. Monument Street, Suite 416, Baltimore, MD 21287, USA
| | - Mohamed G. Atta
- Division of Nephrology, Johns Hopkins University, 1830 E. Monument Street, Suite 416, Baltimore, MD 21287, USA
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Satirapoj B, Kaewput W, Supasyndh O, Ruangkanchanasetr P. Effect of sulodexide on urinary biomarkers of kidney injury in normoalbuminuric type 2 diabetes: a randomized controlled trial. J Diabetes Res 2015; 2015:172038. [PMID: 25918727 PMCID: PMC4396730 DOI: 10.1155/2015/172038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 01/05/2023] Open
Abstract
Glycosaminoglycans or sulodexide has shown benefits in early experimental diabetic nephropathy (DN) models, but its efficacy in patients with early stage of DN is unknown. Methods. Twenty patients were randomly assigned to the placebo group and another 20 patients were randomly assigned to receive sulodexide 100 mg/day for 14 weeks. Primary outcome was a change of urinary TGF-beta1, albuminuria, and glomerular filtration rate (GFR). All patients had stable metabolic profiles for at least 90 days before randomization. Results. Urinary TGF-beta1 increased significantly in the placebo group but did not change significantly in the sulodexide group. Additionally, the mean change of urine TGF-beta1 in the placebo group was significantly higher than that in the sulodexide group (8.44 ± 9.21 versus 2.17 ± 6.96 pg/mg Cr, P = 0.02). Mean changes of urinary albumin were 15.05 ± 30.09 μg/mg Cr (P = 0.038) in the placebo group and 13.89 ± 32.25 μg/mg Cr (P = 0.069) in the sulodexide group. No consistent patterns of side effects were observed. Conclusion. In this 14-week trial, benefits of sulodexide in preventing the increase of urinary TGF-beta1 were observed in patients with normoalbuminuric type 2 diabetes. The study suggests that sulodexide treatment may provide additional renoprotection in early stage DN. This trial is registered with TCTR20140806001.
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Affiliation(s)
- Bancha Satirapoj
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
- *Bancha Satirapoj:
| | - Wisit Kaewput
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Ouppatham Supasyndh
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Prajej Ruangkanchanasetr
- Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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Gentile G, Mastroluca D, Ruggenenti P, Remuzzi G. Novel effective drugs for diabetic kidney disease? or not? Expert Opin Emerg Drugs 2014; 19:571-601. [PMID: 25376947 DOI: 10.1517/14728214.2014.979151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Diabetes mellitus is increasingly common worldwide and is expected to affect 592 million people by 2035. The kidney is often involved. A key goal in treating diabetes is to reduce the risk of development of kidney disease and, if kidney disease is already present, to delay the progression to end-stage renal disease (ESRD). This represents a social and ethical issue, as a significant proportion of patients reaching ESRD in developing countries do not have access to renal replacement therapy. AREAS COVERED The present review focuses on novel therapeutic approaches for diabetic nephropathy (DN), implemented on the basis of recent insights on its pathophysiology, which might complement the effects of single inhibition of the renin-angiotensin-aldosterone system (RAAS), the cornerstone of renoprotective interventions in diabetes, along with glycemic and blood pressure control. EXPERT OPINION Although a plethora of new treatment options has arisen from experimental studies, the number of novel renoprotective molecules successfully implemented in clinical practice over the last two decades is disappointingly low. Thus, new investigational strategies and diagnostic tools - including the appropriate choice of relevant renal end points and the study of urinary proteome of patients - will be as important as new therapeutic interventions to fight DN. Finally, in spite of huge financial interests in replacing the less expensive ACE inhibitors and angiotensin II receptor blockers with newer drugs, any future therapeutic approach has to be tested on top of - rather than instead of - optimal RAAS blockade.
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Affiliation(s)
- Giorgio Gentile
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò" , Villa Camozzi, Via Giambattista Camozzi 3, 24020, Ranica, Bergamo , Italy +39 03545351 ; +39 0354535371 ;
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Masola V, Zaza G, Gambaro G. Sulodexide and glycosaminoglycans in the progression of renal disease. Nephrol Dial Transplant 2014; 29 Suppl 1:i74-i79. [PMID: 24493873 DOI: 10.1093/ndt/gft389] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Experimental data in cell cultures and animal models suggest that sulodexide and glycosaminoglycans are potentially effective drugs to treat chronic kidney diseases and prevent progression to renal failure. However, no conclusive evidence support the use of them in human renal disease. In acute and chronic glomerulonephritis, only few studies have been performed. Sulodexide has been more intensely investigated in diabetic nephropathy (DN) where the body of data supports its effectiveness as an antialbuminuric agent in early stages. Unfortunately, there is no study in DN patients on the effect of sulodexide on clinical end points.
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Affiliation(s)
- Valentina Masola
- Division of Nephrology, Department of Biomedical and Surgical Sciences, University Hospital of Verona, Verona, Italy
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Abstract
Diabetic nephropathy is a significant cause of chronic kidney disease and end-stage renal failure globally. Much research has been conducted in both basic science and clinical therapeutics, which has enhanced understanding of the pathophysiology of diabetic nephropathy and expanded the potential therapies available. This review will examine the current concepts of diabetic nephropathy management in the context of some of the basic science and pathophysiology aspects relevant to the approaches taken in novel, investigative treatment strategies.
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Affiliation(s)
- Andy Kh Lim
- Department of Nephrology, Monash Medical Center, Monash Health, Clayton, VIC, Australia ; Department of General Medicine, Dandenong Hospital, Monash Health, Clayton, VIC, Australia ; Department of Medicine, Monash University, Clayton, VIC, Australia
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Olde Engberink RHG, Rorije NMG, Homan van der Heide JJ, van den Born BJH, Vogt L. Role of the vascular wall in sodium homeostasis and salt sensitivity. J Am Soc Nephrol 2014; 26:777-83. [PMID: 25294232 DOI: 10.1681/asn.2014050430] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Excessive sodium intake is associated with both hypertension and an increased risk of cardiovascular events, presumably because of an increase in extracellular volume. The extent to which sodium intake affects extracellular volume and BP varies considerably among individuals, discriminating subjects who are salt-sensitive from those who are salt-resistant. Recent experiments have shown that, other than regulation by the kidney, sodium homeostasis is also regulated by negatively charged glycosaminoglycans in the skin interstitium, where sodium is bound to glycosaminoglycans without commensurate effects on extracellular volume. The endothelial surface layer is a dynamic layer on the luminal side of the endothelium that is in continuous exchange with flowing blood. Because negatively charged glycosaminoglycans are abundantly present in this layer, it may act as an intravascular buffer compartment that allows sodium to be transiently stored. This review focuses on the putative role of the endothelial surface layer as a contributor to salt sensitivity, the consequences of a perturbed endothelial surface layer on sodium homeostasis, and the endothelial surface layer as a possible target for the treatment of hypertension and an expanded extracellular volume.
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Affiliation(s)
| | | | | | - Bert-Jan H van den Born
- Department of Internal Medicine, Vascular Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Divisions of Nephrology, and
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The protective role of fucosylated chondroitin sulfate, a distinct glycosaminoglycan, in a murine model of streptozotocin-induced diabetic nephropathy. PLoS One 2014; 9:e106929. [PMID: 25192337 PMCID: PMC4156394 DOI: 10.1371/journal.pone.0106929] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/03/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Heparanase-1 activation, albuminuria, and a decrease in glomerular heparan sulfate (HS) have been described in diabetic nephropathy (DN). Glycosaminoglycan (GAG)-based drugs have been shown to have renoprotective effects in this setting, although recent trials have questioned their clinical effectiveness. Here, we describe the effects of fucosylated chondroitin sulfate (FCS), a novel GAG extracted from a marine echinoderm, in experimentally induced DN compared to a widely used GAG, enoxaparin (ENX). METHODS Diabetes mellitus (DM) was induced by streptozotocin in male Wistar rats divided into three groups: DM (without treatment), FCS (8 mg/kg), and ENX (4 mg/kg), administered subcutaneously. After 12 weeks, we measured blood glucose, blood pressure, albuminuria, and renal function. The kidneys were evaluated for mesangial expansion and collagen content. Immunohistochemical quantifications of macrophages, TGF-β, nestin and immunofluorescence analysis of heparanase-1 and glomerular basement membrane (GBM) HS content was also performed. Gene expression of proteoglycan core proteins and enzymes involved in GAG assembly/degradation were analyzed by TaqMan real-time PCR. RESULTS Treatment with GAGs prevented albuminuria and did not affect the glucose level or other functional aspects. The DM group exhibited increased mesangial matrix deposition and tubulointerstitial expansion, and prevention was observed in both GAG groups. TGF-β expression and macrophage infiltration were prevented by the GAG treatments, and podocyte damage was halted. The diabetic milieu resulted in the down-regulation of agrin, perlecan and collagen XVIII mRNAs, along with the expression of enzymes involved in GAG biosynthesis. Treatment with FCS and ENX positively modulated such changes. Heparanase-1 expression was significantly reduced after GAG treatment without affecting the GBM HS content, which was uniformly reduced in all of the diabetic animals. CONCLUSIONS Our results demonstrate that the administration of FCS prevented several pathological features of ND in rats. This finding should stimulate further research on GAG treatment for this complication of diabetes.
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Abstract
SIGNIFICANCE Diabetes is a widespread disease with many clinical pathologies. Despite numerous pharmaceutical strategies for treatment, the incidence of diabetes continues to increase. Hyperglycemia, observed in diabetes, causes endothelial injury resulting in microvascular and macrovascular complications such as nephropathy, retinopathy, neuropathy, and increased atherosclerosis. RECENT ADVANCES Proteoglycans are chemically diverse macromolecules consisting of a protein core with glycosaminoglycans (GAGs) attached. Heparan sulfate proteoglycans are important compounds found on the endothelial cell membrane and in the extracellular matrix, which play an important role in growth regulation and serve as a reservoir for cytokines and other bioactive molecules. Endothelial cells are altered in hyperglycemia by a reduction in heparan sulfate and upregulation and secretion of heparanase, an enzyme that degrades heparan sulfate GAGs on proteoglycans. Reactive oxygen species, increased in diabetes, also destroy GAGs. CRITICAL ISSUES Preservation of heparan sulfate proteoglycans on endothelial cells may be a strategy to prevent angiopathy associated with diabetes. The use of GAGs and GAG-like compounds may increase endothelial heparan sulfate and prevent an increase in the heparanase enzyme. FUTURE DIRECTIONS Elucidating the mechanisms of GAG depletion and its significance in endothelial health may help to further understand, prevent, and treat cardiovascular complications associated with diabetes. Further studies examining the role of GAGs and GAG-like compounds in maintaining endothelial health, including their effect on heparanase, will determine the feasibility of these compounds in diabetes treatment. Preservation of heparan sulfate by decreasing heparanase may have important implications not only in diabetes, but also in cardiovascular disease and tumor biology.
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Affiliation(s)
- Linda M Hiebert
- 1 Department of Veterinary Biomedical Sciences, Western College of Veterinary Medicine, University of Saskatchewan , Saskatoon, Canada
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Effect of sulodexide in patients with non-proliferative diabetic retinopathy: diabetic retinopathy sulodexide study (DRESS). Graefes Arch Clin Exp Ophthalmol 2014; 253:829-37. [PMID: 25112845 PMCID: PMC4445329 DOI: 10.1007/s00417-014-2746-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 07/01/2014] [Accepted: 07/08/2014] [Indexed: 11/13/2022] Open
Abstract
Purpose To evaluate the effectiveness of sulodexide for the treatment of hard exudates (HE) in non-proliferative diabetic retinopathy (NPDR). Methods This was a randomized, placebo-controlled, multicenter trial involving 130 patients (65 for each group) who had mild-to-moderate NPDR with macular HE. Participants were given a daily dose of either 50 mg sulodexide or a matching dose of placebo orally for 12 months. Main outcome measure was an improvement in HE defined as a decrease in severity by at least two grades on a 10-grade severity scale. This was evaluated by fundus photography over 12-month period. Results The sulodexide group showed significantly greater improvement in HE severity than that shown by the placebo group (39.0 % vs. 19.3 %; chi square, P = 0.005). Logistic regression analysis yielded an odds ratio of 2.790 (95 % confidence interval, 1.155-6.743; P = 0.023) for the effect of treatment once adjustments were made for demographic, prognostic and disease confounders. Intention to treat and per-protocol analysis yielded similar results. Sulodexide’s safety was comparable to that of the placebo. Conclusions Oral sulodexide therapy over 12 months improved macular HE in patients with mild-to-moderate NPDR, without leading to detectable adverse events. The study protocol was registered on clinicaltrial.gov under identifier NCT01295775.
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Gueutin V, Gauthier M, Cazenave M, Izzedine H. Néphropathie diabétique : traitements émergents. Nephrol Ther 2014; 10:210-5. [DOI: 10.1016/j.nephro.2014.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 02/09/2014] [Accepted: 02/12/2014] [Indexed: 01/13/2023]
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Fekete A, Vannay Á. [Importance of diabetic nephropathy in childhood. Clinical findings and basic research in recent decades]. Orv Hetil 2014; 155:141-50. [PMID: 24440726 DOI: 10.1556/oh.2014.29814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past decades diabetes mellitus is becoming a global pandemic affecting more than 371 million people worldwide. Parallel with the increasing prevalence of type 1 diabetes, there is a growing number of type 2 diabetes cases among children and adolescents that poses new challenges to pediatricians. Diabetic nephropathy is one of the major causes of end stage renal disease, developing in approximately 30% of diabetic patients. However, overt nephropathy is rare in childhood; screening and ongoing assessment for the earliest manifestation of renal injury is extremely important in this young population, as well. Although in the past decades intensive research activity focused on understanding of the pathomechanism of diabetic nephropathy and invention of new therapeutic approaches, prevention and definitive care are still urgently needed. The clinical section of the article summarizes the present state of epidemiology, diagnosis and current therapies of childhood diabetic nephropathy. Then, the authors discuss the state of basic research and show a few promising targets for drug development.
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Affiliation(s)
- Andrea Fekete
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika, MTA-SE Lendület Diabétesz Kutatócsoport Budapest Bókay J. u. 53. 1083
| | - Ádám Vannay
- MTA-SE Gyermekgyógyászati és Nephrologiai Kutatócsoport Budapest
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Abstract
Despite improvements in glycaemic and blood pressure control, and the efficacy of renin-angiotensin system (RAS) blockade for proteinuria reduction, diabetic nephropathy is the most frequent cause of end-stage renal disease in developed countries. This finding is consistent with the hypothesis that key pathogenetic mechanisms leading to progression of renal disease are not modified or inactivated by current therapeutic approaches. Although extensive research has elucidated molecular signalling mechanisms that are involved in progression of diabetic kidney disease, a number of high-profile clinical trials of potentially nephroprotective agents have failed, highlighting an insufficient understanding of pathogenic pathways. These include trials of paricalcitol in early diabetic kidney disease and bardoxolone methyl in advanced-stage disease. Various strategies based on encouraging data from preclinical studies that showed renoprotective effects of receptor antagonists, neutralizing antibodies, kinase inhibitors, small compounds and peptide-based technologies are currently been tested in randomized controlled trials. Phase II clinical trials are investigating approaches targeting inflammation, fibrosis and signalling pathways. However, only one trial that aims to provide evidence for marketing approval of a potentially renoprotective drug (atrasentan) is underway-further research into the potential nephroprotective effects of novel glucose-lowering agents is required.
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Abstract
Diabetic nephropathy is currently the most common cause of end stage renal disease not only in the Western hemisphere but also in the developing nations. While the available therapeutic options remain not very effective, there is a strong ongoing effort to understand the pathogenesis better and develop more useful biomarkers. As the pathogenic mediators and signaling pathways get better defined, the scope of novel pharmaceutical agents to address such mediating factors as therapeutic targets is advancing. This review provides, in addition to a brief synopsis of currently used strategies, a comprehensive review of potential therapies that have been evolving in the past decade with a specific focus on the promising agents.
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Affiliation(s)
- Harneet Kaur
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sharma Prabhakar
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Frati Munari AC. Importancia médica del glucocáliz endotelial. Parte 2: su papel en enfermedades vasculares y complicaciones de la diabetes mellitus. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2014; 84:110-6. [DOI: 10.1016/j.acmx.2013.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 10/15/2013] [Accepted: 10/21/2013] [Indexed: 10/25/2022] Open
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Alicic RZ, Tuttle KR. Novel therapies for diabetic kidney disease. Adv Chronic Kidney Dis 2014; 21:121-33. [PMID: 24602462 DOI: 10.1053/j.ackd.2014.01.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/13/2014] [Accepted: 01/15/2014] [Indexed: 02/07/2023]
Abstract
The number of people diagnosed with diabetes is rising throughout the world, which in turn drives upward the global frequency of diabetic kidney disease (DKD). Individuals with DKD are at an increased risk for premature death, cardiovascular disease, and other severe illnesses that result in frequent hospitalizations and increased health-care utilization. Current treatments concentrate on controlling hyperglycemia and hypertension with the specific use of renin-angiotensin system inhibitors. Although such measures reduce the risk of progressive kidney disease, DKD remains the leading cause of ESRD and the major risk amplifier for death in this population. Therefore, novel therapeutic approaches are urgently needed. Ideas for novel targets for therapy are founded on recent advances in understanding DKD mechanisms that are based on experimental models and human observations. The purpose of this review is to describe the epidemiology and present knowledge of DKD pathophysiology as the basis for novel therapies including inhibitors of Janus kinases (JAK), protein kinase C, fibrosis, advanced glycation end products treatments, and endothelin.
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Early microvascular changes with loss of the glycocalyx in children with type 1 diabetes. J Pediatr 2014; 164:584-9.e1. [PMID: 24367980 DOI: 10.1016/j.jpeds.2013.11.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 10/07/2013] [Accepted: 11/07/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the microcirculation of children with type 1 diabetes mellitus who demonstrate no clinical signs of diabetic microangiopathy for the presence of microvascular alterations and glycocalyx perturbation. STUDY DESIGN Images of sublingual vessels were obtained in 14 children with diabetes (ages 12.8 ± 2.8 years, diabetes duration 6.7 ± 4.3 years) and 14 control patients (ages 11.8 ± 2.8 years) by the use of sidestream dark field imaging and analyzed for total vessel density, vessel surface coverage, vessel diameter distribution, mean flow index, and glycocalyx thickness. Wilcoxon rank sum test and Pearson correlation were used for statistical analysis. RESULTS We observed profound microcirculatory changes in children with diabetes compared with control patients, with a significant reduction of glycocalyx thickness (0.38 μm vs 0.60 μm; P = .013), which was inversely correlated with blood glucose levels (r = -0.55; P = .003). Furthermore, the percentage of large vessels (>20 μm diameter) was significantly increased (11% vs 6%; P = .023) at the expense of capillaries (<10 μm diameter) with consequent increase in total vessel surface coverage (30% vs 26.0%; P = .041). No differences were seen in total vessel density and mean flow index. CONCLUSIONS Microvascular alterations, including changes in microvessel distribution and loss of the glycocalyx, can be detected in children with type 1 diabetes mellitus before clinically apparent vascular complications. Our results disclose the glycocalyx as a possible monitoring measurement for earlier detection of diabetic microangiopathy and may provide a basis for new therapeutic strategies aiming at protection or restoration of the glycocalyx.
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Coccheri S, Mannello F. Development and use of sulodexide in vascular diseases: implications for treatment. Drug Des Devel Ther 2013; 8:49-65. [PMID: 24391440 PMCID: PMC3879015 DOI: 10.2147/dddt.s6762] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Sulodexide (SDX), a sulfated polysaccharide complex extracted from porcine intestinal mucosa, is a blend of two glycosaminoglycan (GAG) entities, namely a fast-moving heparin (HP) fraction and a dermatan sulfate (DS; 20%) component. The compound is unique among HP-like substances in that it is biologically active by both the parenteral and oral routes. A main feature of the agent is to undergo extensive absorption by the vascular endothelium. For this reason, in preclinical studies, SDX administered parenterally displays an antithrombotic action similar to that of HPs but associated with fewer alterations of the blood clotting mechanisms and tests, thus being much less conducive to bleeding risk than HPs. When given orally, SDX is associated with minimal changes in classic coagulation tests, but maintains a number of important effects on the structure and function of endothelial cells (EC), and the intercellular matrix. These activities include prevention or restoration of the integrity and permeability of EC, counteraction versus chemical, toxic or metabolic EC injury, regulation of EC-blood cell interactions, inhibition of microvascular inflammatory and proliferative changes, and other similar effects, thus allowing oral SDX to be considered as an endothelial-protecting agent. The best available clinical evidence of the efficacy of SDX administered orally with or without an initial parenteral phase is the following: alleviation of symptoms in chronic venous disease and especially acceleration of healing of venous leg ulcers; prevention of cardiovascular events in survivors after acute myocardial infarction; marked improvement of intermittent claudication in patients with peripheral occlusive arterial disease; and abatement of proteinuria in patients with diabetic nephropathy that may contribute to the amelioration or stabilization of kidney function. Although further clinical trials are warranted, SDX is presently widely accepted in many countries as an effective and safe long-term, endothelial-protecting drug.
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Affiliation(s)
- Sergio Coccheri
- Cardiovascular Medicine, University of Bologna, Bologna, Italy
| | - Ferdinando Mannello
- Department of Biomolecular Sciences (Section Clinical Biochemistry and Cell Biology), University ‘Carlo Bo’, Urbino, Italy
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