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Uvelius B, Andersson KE. Can Urinary Bladder Innervation Be Restored After Outlet Obstruction and Denervation? Int Neurourol J 2024; 28:75-82. [PMID: 38956767 PMCID: PMC11222827 DOI: 10.5213/inj.2448134.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024] Open
Abstract
Transurethral resection of the prostate, or other methods to decrease outlet resistance usually leads to relief of symptoms in patients with bladder outlet obstruction (BOO). If symptoms of underactivity persist after normalization of outflow conditions, treatment options are limited. In this review, we hypothesize, based on results from basic research, what might become treatment options for such patients in the future. The primary local treatment will still aim at reducing outlet obstruction. We speculate that local secondary treatment in the future might include transplantation of stem cells or mature bladder ganglion cells into the bladder wall. There has been some success in transplanting ganglion cells into the rat bladder. The ganglion cells will sprout into the surrounding tissue but functional connections between the axons of the transplanted neurons, and the detrusor smooth muscle have so far not been demonstrated. Neurotrophins or neurotrimin might be injected into the bladder wall to increase the sprouting of existing or transplanted neurons. Stem cell transplantation has been performed and improves detrusor function, but it has so far, been difficult to demonstrate transplanted stem cells. BOO, persisting detrusor underactivity, and decreased nerve density are often combined with inflammatory activity of the lower urinary tract. NLR family pyrin domain containing 3 (NLRP3) and its messenger RNA (mRNA) as well as cyclooxygenase-2 (Cox-2) mRNA are increased in obstructed bladders. Systemic treatment with the NLRP3 inhibitor glyburide normalized nerve density in rat bladder, and, to some extent, bladder function. It is unclear whether Cox-2 is involved in the decreased nerve density following obstruction, but Cox-2 mRNA increases 5-fold in obstructed bladder. Future therapy against bladder underactivity remaining following relief of obstruction includes either systemic treatment, perhaps by anti-inflammatory drugs, or local treatment by injection of stem cells, mature ganglion cells, and/or neurotrophins or neurotrimin into the bladder wall.
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Affiliation(s)
- Bengt Uvelius
- Department of Urology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Karl-Erik Andersson
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Wake Forest Institute for Regenerative Medicine, Winston Salem, NC, USA
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2
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Kodi T, Sankhe R, Gopinathan A, Nandakumar K, Kishore A. New Insights on NLRP3 Inflammasome: Mechanisms of Activation, Inhibition, and Epigenetic Regulation. J Neuroimmune Pharmacol 2024; 19:7. [PMID: 38421496 PMCID: PMC10904444 DOI: 10.1007/s11481-024-10101-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/06/2023] [Indexed: 03/02/2024]
Abstract
Inflammasomes are important modulators of inflammation. Dysregulation of inflammasomes can enhance vulnerability to conditions such as neurodegenerative diseases, autoinflammatory diseases, and metabolic disorders. Among various inflammasomes, Nucleotide-binding oligomerization domain leucine-rich repeat and pyrin domain-containing protein 3 (NLRP3) is the best-characterized inflammasome related to inflammatory and neurodegenerative diseases. NLRP3 is an intracellular sensor that recognizes pathogen-associated molecular patterns and damage-associated patterns resulting in the assembly and activation of NLRP3 inflammasome. The NLRP3 inflammasome includes sensor NLRP3, adaptor apoptosis-associated speck-like protein (ASC), and effector cysteine protease procaspase-1 that plays an imperative role in caspase-1 stimulation which further initiates a secondary inflammatory response. Regulation of NLRP3 inflammasome ameliorates NLRP3-mediated diseases. Much effort has been invested in studying the activation, and exploration of specific inhibitors and epigenetic mechanisms controlling NLRP3 inflammasome. This review gives an overview of the established NLRP3 inflammasome assembly, its brief molecular mechanistic activations as well as a current update on specific and non-specific NLRP3 inhibitors that could be used in NLRP3-mediated diseases. We also focused on the recently discovered epigenetic mechanisms mediated by DNA methylation, histone alterations, and microRNAs in regulating the activation and expression of NLRP3 inflammasome, which has resulted in a novel method of gaining insight into the mechanisms that modulate NLRP3 inflammasome activity and introducing potential therapeutic strategies for CNS disorders.
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Affiliation(s)
- Triveni Kodi
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Runali Sankhe
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Adarsh Gopinathan
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Krishnadas Nandakumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Anoop Kishore
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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3
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Kwon J, Kim DY, Cho KJ, Hashimoto M, Matsuoka K, Kamijo T, Wang Z, Karnup S, Robertson AM, Tyagi P, Yoshimura N. Pathophysiology of Overactive Bladder and Pharmacologic Treatments Including β3-Adrenoceptor Agonists -Basic Research Perspectives. Int Neurourol J 2024; 28:12-33. [PMID: 38461853 DOI: 10.5213/inj.2448002.001] [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: 12/31/2023] [Accepted: 01/10/2024] [Indexed: 03/12/2024] Open
Abstract
Overactive bladder (OAB) is a symptom-based syndrome defined by urinary urgency, frequency, and nocturia with or without urge incontinence. The causative pathology is diverse; including bladder outlet obstruction (BOO), bladder ischemia, aging, metabolic syndrome, psychological stress, affective disorder, urinary microbiome, localized and systemic inflammatory responses, etc. Several hypotheses have been suggested as mechanisms of OAB generation; among them, neurogenic, myogenic, and urothelial mechanisms are well-known hypotheses. Also, a series of local signals called autonomous myogenic contraction, micromotion, or afferent noises, which can occur during bladder filling, may be induced by the leak of acetylcholine (ACh) or urothelial release of adenosine triphosphate (ATP). They can be transmitted to the central nervous system through afferent fibers to trigger coordinated urgency-related detrusor contractions. Antimuscarinics, commonly known to induce smooth muscle relaxation by competitive blockage of muscarinic receptors in the parasympathetic postganglionic nerve, have a minimal effect on detrusor contraction within therapeutic doses. In fact, they have a predominant role in preventing signals in the afferent nerve transmission process. β3-adrenergic receptor (AR) agonists inhibit afferent signals by predominant inhibition of mechanosensitive Aδ-fibers in the normal bladder. However, in pathologic conditions such as spinal cord injury, it seems to inhibit capsaicin-sensitive C-fibers. Particularly, mirabegron, a β3-agonist, prevents ACh release in the BOO-induced detrusor overactivity model by parasympathetic prejunctional mechanisms. A recent study also revealed that vibegron may have 2 mechanisms of action: inhibition of ACh from cholinergic efferent nerves in the detrusor and afferent inhibition via urothelial β3-AR.
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Affiliation(s)
- Joonbeom Kwon
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Leaders Urology Clinic, Daegu, Korea
| | - Duk Yoon Kim
- Department of Urology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kang Jun Cho
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mamoru Hashimoto
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kanako Matsuoka
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tadanobu Kamijo
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhou Wang
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sergei Karnup
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne M Robertson
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh School of Bioengineering, Pittsburgh, PA, USA
| | - Pradeep Tyagi
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Naoki Yoshimura
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Yuan Z, Yu D, Gou T, Tang G, Guo C, Shi J. Research progress of NLRP3 inflammasome and its inhibitors with aging diseases. Eur J Pharmacol 2023; 957:175931. [PMID: 37495038 DOI: 10.1016/j.ejphar.2023.175931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
In recent years, a new target closely linked to a variety of diseases has appeared in the researchers' vision, which is the NLRP3 inflammasome. With the deepening of the study of NLRP3 inflammasome, it was found that it plays an extremely important role in a variety of physiological pathological processes, and NLRP3 inflammasome was also found to be associated with some age-related diseases. It is associated with the development of insulin resistance, Alzheimer's disease, Parkinson's, cardiovascular aging, hearing and vision loss. At present, the only clinical approach to the treatment of NLRP3 inflammasome-related diseases is to use anti-IL-1β antibodies, but NLRP3-specific inhibitors may be better than the IL-1β antibodies. This article reviews the relationship between NLRP3 inflammasome and aging diseases: summarizes some of the relevant experimental results reported in recent years, and introduces the biological signals or pathways closely related to the NLRP3 inflammasome in a variety of aging diseases, and also introduces some promising small molecule inhibitors of NLRP3 inflammasome for clinical treatment, such as: ZYIL1, DFV890 and OLT1177, they have excellent pharmacological effects and good pharmacokinetics.
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Affiliation(s)
- Zhuo Yuan
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Dongke Yu
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Tingting Gou
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Guoyuan Tang
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Chun Guo
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China; Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.
| | - Jianyou Shi
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.
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Hughes FM, Allkanjari A, Odom MR, Mulcrone JE, Jin H, Purves JT. Male Akita mice develop signs of bladder underactivity independent of NLRP3 as a result of a decrease in neurotransmitter release from efferent neurons. Am J Physiol Renal Physiol 2023; 325:F61-F72. [PMID: 37167271 PMCID: PMC10292983 DOI: 10.1152/ajprenal.00284.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023] Open
Abstract
Diabetic bladder dysfunction (DBD) is a prevalent diabetic complication that is recalcitrant to glucose control. Using the Akita mouse model (type 1) bred to be NLR family pyrin domain containing 3 (NLRP3)+/+ or NLRP3-/-, we have previously found that females (mild hyperglycemia) progress from an overactive to underactive bladder phenotype and that this progression was dependent on NLRP3-induced inflammation. Here, we examined DBD in the male Akita mouse (severe hyperglycemia) and found by urodynamics only a compensated underactive-like phenotype (increased void volume and decreased frequency but unchanged efficiency). Surprisingly, this phenotype was still present in the NLRP3-/- strain and so was not dependent on NLRP3 inflammasome-induced inflammation. To examine the cause of the compensated underactive-like phenotype, we assessed overall nerve bundle density and afferent nerve bundles (Aδ-fibers). Both were decreased in density during diabetes, but denervation was absent in the diabetic NLRP3-/- strain so it was deemed unlikely to cause the underactive-like symptoms. Changes in bladder smooth muscle contractility to cell depolarization and receptor activation were also not responsible as KCl (depolarizing agent), carbachol (muscarinic agonist), and α,β-methylene-ATP (purinergic agonist) elicited equivalent contractions in denuded bladder strips in all groups. However, electrical field stimulation revealed a diabetes-induced decrease in contractility that was not blocked in the NLRP3-/- strain, suggesting that the bladder compensated underactive-like phenotype in the male Akita mouse is likely through a decrease in efferent neurotransmitter release.NEW & NOTEWORTHY In this study, we show that diabetic bladder dysfunction (the most common diabetic complication) manifests through different mechanisms that may be related to severity of hyperglycemia and/or sex. Male Akita mice, which have severe hyperglycemia, develop bladder underactivity as a result of a decrease in efferent neurotransmitter release that is independent of inflammation. This contrasts with females, who have milder hyperglycemia, where diabetic bladder dysfunction progresses from overactivity to underactivity in an inflammation-dependent manner.
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Affiliation(s)
- Francis M Hughes
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - Armand Allkanjari
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - Michael R Odom
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - Jack E Mulcrone
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - Huixia Jin
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
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6
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Iguchi N, Dönmez Mİ, Malykhina AP, Wilcox DT. Anti-fibrotic effect of tocotrienols for bladder dysfunction due to partial bladder outlet obstruction. Investig Clin Urol 2023; 64:189-196. [PMID: 36882179 PMCID: PMC9995959 DOI: 10.4111/icu.20220328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023] Open
Abstract
PURPOSE To investigate potential beneficial effects of tocotrienols which have been suggested to inhibit hypoxia-inducible factor (HIF) pathway, on partial bladder outlet obstruction (PBOO)-induced bladder pathology. MATERIALS AND METHODS PBOO was surgically created in juvenile male mice. Sham-operated mice were used as controls. Animals received daily oral administration of either tocotrienols (T3) or soybean oil (SBO, vehicle) from day 0 to 13 post-surgery. Bladder function was examined in vivo by void spot assay. At 2 weeks post-surgery, the bladders were subjected to physiological evaluation of detrusor contractility in vitro using bladder strips, histology by H&E staining and collagen imaging, and gene expression analyses by quantitative PCR. RESULTS A significant increase in the number of small voids was observed after 1 week of PBOO compared to the control groups. At 2 weeks post-surgery, PBOO+SBO mice showed a further increase in the number of small voids, which was not observed in PBOO+T3 group. PBOO-induced decrease in detrusor contractility was similar between two treatments. PBOO induced bladder hypertrophy to the same degree in both SBO and T3 treatment groups, however, fibrosis in the bladder was significantly less prominent in the T3 group than the SBO group following PBOO (1.8- vs. 3.0-fold increase in collagen content compared to the control). Enhanced levels of HIF target genes in the bladders were observed in PBOO+SBO group, but not in PBOO+T3 group compared to the control. CONCLUSIONS Oral tocotrienol treatment reduced the progression of urinary frequency and bladder fibrosis by suppressing HIF pathways triggered by PBOO.
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Affiliation(s)
- Nao Iguchi
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - M İrfan Dönmez
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA.,Division of Pediatric Urology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Anna P Malykhina
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Duncan T Wilcox
- Division of Urology, Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA.,Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA.
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Chess-Williams R, Sellers DJ. Pathophysiological Mechanisms Involved in Overactive Bladder/Detrusor Overactivity. CURRENT BLADDER DYSFUNCTION REPORTS 2023. [DOI: 10.1007/s11884-023-00690-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Purpose of Review
To examine the latest published findings on the pathophysiological mechanisms involved in the development of overactive bladder (OAB) and detrusor overactivity (DO), and to identify common pathways linked to the risk factors associated with these conditions.
Recent Findings
Evidence is accumulating, both clinical and experimental, that many of the factors linked to the development of OAB/DO, including ageing, bladder outlet obstruction, psychological stress, and obesity are associated with reduced bladder blood flow. This induces local tissue inflammation with cytokine release and enhanced oxidative stress, ultimately resulting in altered detrusor sensitivity, detrusor hypertrophy and fibrosis, together with afferent hypersensitivity. These mechanisms would explain the symptoms of urgency and frequency observed in OAB patients. Although not a characteristic of OAB, undetected low level bacterial infections of the bladder have been proposed to explain the OAB symptoms in patients resistant to standard treatments. In this condition, inflammatory responses without reductions in perfusion activate the inflammatory pathways.
Summary
Evidence is mounting that poor bladder perfusion and local inflammatory responses are central mechanisms involved in the development of OAB/DO. As our understanding of these pathophysiological mechanisms advances, new avenues for drug development will be identified and ultimately treatment may become more individualized depending on the particular pathway involved and the drugs available.
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Hughes FM, Odom MR, Cervantes A, Livingston AJ, Purves JT. Why Are Some People with Lower Urinary Tract Symptoms (LUTS) Depressed? New Evidence That Peripheral Inflammation in the Bladder Causes Central Inflammation and Mood Disorders. Int J Mol Sci 2023; 24:2821. [PMID: 36769140 PMCID: PMC9917564 DOI: 10.3390/ijms24032821] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
Anecdotal evidence has long suggested that patients with lower urinary tract symptoms (LUTS) develop mood disorders, such as depression and anxiety, at a higher rate than the general population and recent prospective studies have confirmed this link. Breakthroughs in our understanding of the diseases underlying LUTS have shown that many have a substantial inflammatory component and great strides have been made recently in our understanding of how this inflammation is triggered. Meanwhile, studies on mood disorders have found that many are associated with central neuroinflammation, most notably in the hippocampus. Excitingly, work on other diseases characterized by peripheral inflammation has shown that they can trigger central neuroinflammation and mood disorders. In this review, we discuss the current evidence tying LUTS to mood disorders, its possible bidirectionally, and inflammation as a common mechanism. We also review modern theories of inflammation and depression. Finally, we discuss exciting new animal studies that directly tie two bladder conditions characterized by extensive bladder inflammation (cyclophosphamide-induced hemorrhagic cystitis and bladder outlet obstruction) to neuroinflammation and depression. We conclude with a discussion of possible mechanisms by which peripheral inflammation is translated into central neuroinflammation with the resulting psychiatric concerns.
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Affiliation(s)
- Francis M. Hughes
- Department Urology, Duke University Medical Center, P.O. Box 3831, Durham, NC 27710, USA
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9
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Odom MR, Hughes FM, Jin H, Purves JT. Diabetes causes NLRP3-dependent barrier dysfunction in mice with detrusor overactivity but not underactivity. Am J Physiol Renal Physiol 2022; 323:F616-F632. [PMID: 36135959 PMCID: PMC9705026 DOI: 10.1152/ajprenal.00047.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 02/08/2023] Open
Abstract
Approximately half of the patients with diabetes develop diabetic bladder dysfunction (DBD). The initiation and progression of DBD is largely attributed to inflammation due to dysregulated glucose and the production of toxic metabolites that activate the NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome. NLRP3 activation leads to the production and release of proinflammatory cytokines and causes urothelial pyroptosis, a form of programmed cell necrosis, which we hypothesize compromises urothelial barrier integrity. Here, we investigated how NLRP3-dependent inflammation impacts barrier function during the progression of diabetes using a type 1 diabetic female Akita mouse model that progresses from an early overactive to a late underactive detrusor phenotype at 15 and 30 wk, respectively. To determine the specific role of NLRP3, Akita mice were crossbred with mice lacking the NLRP3 gene. To determine barrier function, permeability to small molecules was assessed, ex vivo using Evans blue dye and in vivo using sulfo-NHS-biotin. Both ex vivo and in vivo permeabilities were increased in diabetic mice at 15 wk. Expression of uroplakin and tight junction components was also significantly downregulated at 15 wk. Interestingly, diabetic mice lacking the NLRP3 gene showed no evidence of barrier damage or downregulation of barrier genes and proteins. At the 30-wk time point, ex vivo and in vivo barrier damage as well as barrier component downregulation was no longer evident in diabetic mice, suggesting urothelial repair or remodeling occurs between the overactive and underactive stages of DBD. Collectively, these findings demonstrate the role of NLRP3-mediated inflammation in urothelial barrier damage associated with detrusor overactivity but not underactivity.NEW & NOTEWORTHY This is the first study to demonstrate that NLRP3-mediated inflammation is responsible for urothelial barrier damage in type 1 diabetic female Akita mice with an overactive bladder. Eliminating the NLRP3 gene in these diabetic mice prevented barrier damage as a result of diabetes. By the time female Akita mice develop an underactive phenotype, the urothelial barrier has been restored, suggesting that inflammation is a critical causative factor early in the development of diabetic bladder dysfunction.
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Affiliation(s)
- Michael R Odom
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Francis M Hughes
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Huixia Jin
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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10
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Hughes FM, Odom MR, Cervantes A, Purves J. Inflammation triggered by the NLRP3 inflammasome is a critical driver of diabetic bladder dysfunction. Front Physiol 2022; 13:920487. [PMID: 36505062 PMCID: PMC9733912 DOI: 10.3389/fphys.2022.920487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2022] Open
Abstract
Diabetes is a rapidly expanding epidemic projected to affect as many as 1 in 3 Americans by 2050. This disease is characterized by devastating complications brought about high glucose and metabolic derangement. The most common of these complications is diabetic bladder dysfunction (DBD) and estimates suggest that 50-80% of patients experience this disorder. Unfortunately, the Epidemiology of Diabetes Interventions and Complications Study suggests that strict glucose control does not decrease ones risk for incontinence, although it does decrease the risk of other complications such as retinopathy, nephropathy and neuropathy. Thus, there is a significant unmet need to better understand DBD in order to develop targeted therapies to alleviate patient suffering. Recently, the research community has come to understand that diabetes produces a systemic state of low-level inflammation known as meta-inflammation and attention has focused on a role for the sterile inflammation-inducing structure known as the NLRP3 inflammasome. In this review, we will examine the evidence that NLRP3 plays a central role in inducing DBD and driving its progression towards an underactive phenotype.
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Affiliation(s)
- Francis M. Hughes
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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11
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Hughes FM, Harper SN, Nosé BD, Allkanjari A, Zheng MT, Jin H, Purves JT. Specialized Pro-resolution Mediators in the bladder; Annexin-A1 normalizes inflammation and bladder dysfunction during bladder outlet obstruction. Am J Physiol Renal Physiol 2021; 321:F443-F454. [PMID: 34396790 DOI: 10.1152/ajprenal.00205.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Bladder Outlet Obstruction (BOO) is ultimately experienced by ≈90% of men, most commonly secondary to benign prostatic hyperplasia. Inflammation is a critical driver of BOO pathology in the bladder and can be divided into two critical steps; initiation and resolution. While great strides have been made toward understanding initiation of inflammation in the bladder (through the NLRP3 inflammasome), no studies have examined resolution. Resolution is controlled by 5 classes of compounds known as Specialized Pro-resolving Mediators (SPMs), all of which bind to one or more of 7 different receptors. Using immunocytochemistry, we show the presence of 6 of the known SPM receptors in the bladder of control and BOO rats; the 7th has no rodent homolog. The expression was predominantly localized to the urothelia, often with some expression in the smooth muscle, but little to none in the interstitial cells. We next examined the therapeutic potential of the Annexin-A1 resolution system, also present in control and BOO bladders. Using the peptide mimetic Ac2-26, we blocked inflammation-initiating pathways (NLRP3 activation), diminished BOO-induced inflammation (Evans blue dye extravasation), and normalized bladder dysfunction (urodynamics). Excitingly, Ac2-26 also promoted faster and more complete functional recovery after surgical de-obstruction. Together, the results demonstrate that the bladder expresses a wide variety of potential pro-resolving pathways and that modulation of just one of these pathways can alleviate many detrimental aspects of BOO and speed recovery after de-obstruction. This work establishes a precedent for future studies evaluating SPM effectiveness in resolving the many conditions associated with bladder inflammation.
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Affiliation(s)
- Francis M Hughes
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Shelby N Harper
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Brent D Nosé
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Armand Allkanjari
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Michael T Zheng
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Huixia Jin
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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12
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BOO induces fibrosis and EMT in urothelial cells which can be recapitulated in vitro through elevated storage and voiding pressure cycles. Int Urol Nephrol 2021; 53:2007-2018. [PMID: 34232473 DOI: 10.1007/s11255-021-02942-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine the unique contributions from elevated voiding and storage pressures in the development of fibrosis and the epithelial-to-mesenchymal transition (EMT) in urothelial cells, and how progressive BOO pressure cycling is an important mechanical cue leading to these pathological changes. MATERIALS AND METHODS Urothelial cells isolated from control, SHAM, 2 (acute)- or 6 (chronic)-week BOO rats treated with an inflammasome inhibitor or no drug. Total RNA was isolated and RT-PCR was conducted with custom primers for pro-fibrotic and EMT genes. In separate experiments, a rat urothelial cell line was exposed to cyclic pressure regimes characteristic of acute and chronic BOO in the presence or absence of an inflammasome inhibitor. Following exposure, RT-PCR was conducted, collagen content was determined and intracellular caspase-1 activity was measured. RESULTS Urothelial cells isolated from acute and chronic BOO rat models demonstrated expression of pro-fibrotic and EMT genes. Similarly, MYP3 rat urothelial cells subjected to pressure cycling regimes that reflect intravesical pressures in the acute or chronic BOO bladder also demonstrated increased expression of pro-fibrotic and EMT genes, along with elevated soluble collagen. Treatment with inflammasome inhibitors reduced expression of pro-fibrotic genes in the rat model and pressure cycling model but had a limited effect on EMT. CONCLUSION These results indicate that acute and chronic BOO pressure cycling are essential in the initiation and progression of fibrosis in the bladder via the NLRP3 inflammasome, but also provide new evidence that there is also an alternative NLRP3-independent pathway leading to EMT and fibrosis.
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Neurophysiological control of urinary bladder storage and voiding-functional changes through development and pathology. Pediatr Nephrol 2021; 36:1041-1052. [PMID: 32415328 DOI: 10.1007/s00467-020-04594-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
The effective storage of urine and its expulsion relies upon the coordinated activity of parasympathetic, sympathetic, and somatic innervations to the lower urinary tract (LUT). At birth, all mammalian neonates lack the ability to voluntary regulate bladder storage or voiding. The ability to control urinary bladder activity is established as connections to the central nervous system (CNS) form through development. The neural regulation of the LUT has been predominantly investigated in adult animal models where comparatively less is known about the neonatal and postnatal neurophysiological development that facilitate urinary continence. Furthermore, congenital neurological or anatomical defects can adversely affect both storage and voiding functions through postnatal development and into adulthood, leading to secondary conditions including vesicoureteral reflux, chronic urinary tract infections, and end-stage renal disease. Therefore, the aim of the review is to provide the current knowledge available on neurophysiological regulation of the LUT through pre- to postnatal development of human and animal models and the consequences of congenital anomalies that can affect LUT neural function.
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Chen L, Lv L, Zhang L, Gao Z, Liu Y, Wang S, Zhou N, Xia Y, Cui J, Jiang X, Zhang X, Li Y, Shi B. Metformin ameliorates bladder dysfunction in a rat model of partial bladder outlet obstruction. Am J Physiol Renal Physiol 2021; 320:F838-F858. [PMID: 33645317 DOI: 10.1152/ajprenal.00625.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/23/2021] [Indexed: 12/12/2022] Open
Abstract
Alteration of bladder morphology and function was the most important consequence of bladder outlet obstruction (BOO). Using a rat model of partial BOO (pBOO), we found that rats treated with metformin showed lower baseline pressures with a reduced inflammatory reaction in the early phase (2 wk) after pBOO. The NLR family pyrin domain containing 3 inflammasome pathway was inhibited in pBOO rat bladders with treatment of metformin in the early phase. Metformin reduced the activity of NLR family pyrin domain containing 3 in primary urothelial cells. In the chronic phase (9 wk after pBOO), metformin treatment ameliorated bladder fibrosis and improved the reduced compliance. Treatment with metformin suppressed the activation of Smad3 and compensated the diminished autophagy in 9-wk pBOO rat bladders. Autophagy was inhibited with upregulation of profibrotic proteins in primary fibroblasts from chronic pBOO bladders, which could be restored by administration of metformin. The antifibrotic effects of metformin on fibroblasts were diminished after silencing of AMP-activated protein kinase or light chain 3B. In summary, this study elucidates that oral administration of metformin relieves inflammation in the bladder during the early phase of pBOO. Long-term oral administration of metformin can prevent functional and histological changes in the pBOO rat bladder. The current study suggests that metformin might be used to prevent the development of bladder dysfunction secondary to BOO.NEW & NOTEWORTHY The present study in a rat model showed that oral administration of metformin alleviated inflammation following partial bladder outlet obstruction in the early phase and ameliorated bladder fibrosis as well as bladder dysfunction by long-term treatment. Our study indicated that metformin is a potential drug to inhibit bladder remodeling and alleviate bladder dysfunction. Clinical trials are needed to validate the effect of metformin on the bladder dysfunction and bladder fibrosis in the future.
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Affiliation(s)
- Lipeng Chen
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Linchen Lv
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Lekai Zhang
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Zhengdong Gao
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Yaxiao Liu
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
- Laboratory of Basic Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Jinan, China
| | - Shuai Wang
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Nan Zhou
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Yangyang Xia
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Jianfeng Cui
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Xuewen Jiang
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Xiulin Zhang
- Department of Urology, Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yan Li
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Key Laboratory of Urinary Precision Diagnosis and Treatment in Universities of Shandong, Jinan, China
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Keil Stietz KP, Kennedy CL, Sethi S, Valenzuela A, Nunez A, Wang K, Wang Z, Wang P, Spiegelhoff A, Puschner B, Bjorling DE, Lein PJ. In utero and lactational PCB exposure drives anatomic changes in the juvenile mouse bladder. Curr Res Toxicol 2021; 2:1-18. [PMID: 34337439 PMCID: PMC8317607 DOI: 10.1016/j.crtox.2021.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bladder dysfunction, including incontinence, difficulty emptying the bladder, or urgency to urinate is a pervasive health and quality of life concern. However, risk factors for developing these symptoms are not completely understood, and the influence of exposure to environmental chemicals, especially during development, on the formation and function of the bladder is understudied. Environmental contaminants such as polychlorinated biphenyls (PCBs) are known to pose a risk to the developing brain; however, their influence on the development of peripheral target organs, such as bladder, are unknown. To address this data gap, C57Bl/6J mouse dams were exposed to an environmentally-relevant PCB mixture at 0, 0.1, 1 or 6 mg/kg daily beginning two weeks prior to mating and continuing through gestation and lactation. Bladders were collected from offspring at postnatal days (P) 28-31. PCB concentrations were detected in bladders in a dose-dependent manner. PCB effects on the bladder were sex- and dose-dependent. Overall, PCB effects were observed in male, but not female, bladders. PCBs increased bladder volume and suburothelial βIII-tubulin-positive nerve density compared to vehicle control. A subset of these nerves were sensory peptidergic axons indicated by increased calcitonin gene-related protein (CGRP) positive nerve fibers in mice exposed to the highest PCB dose compared to the lowest PCB dose. PCB-induced increased nerve density was also positively correlated with the number of mast cells in the bladder, suggesting inflammation may be involved. There were no detectable changes in epithelial composition or apoptosis as indicated by expression of cleaved caspase 3, suggesting PCBs do not cause overt toxicity. Bladder volume changes were not accompanied by changes in bladder mass or epithelial thickness, indicating that obstruction was not likely involved. Together, these results are the first to suggest that following developmental exposure, PCBs can distribute to the bladder and alter neuroanatomic development and bladder volume in male mice.
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Affiliation(s)
- Kimberly P. Keil Stietz
- Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA,Department of Comparative Biosciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA,Corresponding author at: Department of Comparative Biosciences University of Wisconsin-Madison School of Veterinary Medicine, 2015 Linden Drive, Madison, WI 53706, USA.
| | - Conner L. Kennedy
- Department of Comparative Biosciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Sunjay Sethi
- Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Anthony Valenzuela
- Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Alexandra Nunez
- Department of Comparative Biosciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Kathy Wang
- Department of Comparative Biosciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Zunyi Wang
- Department of Surgical Sciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Peiqing Wang
- Department of Surgical Sciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Audrey Spiegelhoff
- Department of Comparative Biosciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Birgit Puschner
- Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Dale E. Bjorling
- Department of Surgical Sciences, University of Wisconsin-Madison, School of Veterinary Medicine, Madison, WI, USA
| | - Pamela J. Lein
- Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
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Hughes FM, Hirshman NA, Malick HA, White SW, Jin H, Harper SN, Purves JT. A possible mechanism underlying mood disorders associated with LUTS: Chronic bladder outlet obstruction causes NLRP3-dependent inflammation in the hippocampus and depressive behavior in rats. Neurourol Urodyn 2020; 39:1700-1707. [PMID: 32602164 DOI: 10.1002/nau.24448] [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: 03/24/2020] [Accepted: 06/16/2020] [Indexed: 01/04/2023]
Abstract
AIMS Reports link urinary dysfunction and mood disorders, such as depression, but a causative mechanism has never been postulated. Contemporary discoveries demonstrate a local inflammatory response in peripheral organs can trigger inflammation in the brain, particularly the hippocampus, mediated through the NLRP3 inflammasome. Critically, central inflammation causes depressive behavior. Since bladder outlet obstruction (BOO) evokes a local inflammatory response in the bladder, we hypothesize it will induce NLRP3-dependent inflammation in the hippocampus and depressive behavior. METHODS There were four groups of rats: control, sham, BOO, or BOO + glyburide (an NLRP3 inhibitor). BOO was created by urethral ligation over a 1 mm catheter. Sham was tied loosely. Glyburide was provided by slow-release pellet (subcutaneous 50 mg, 21 day, replaced as needed). Rats were analyzed 12 weeks post-op for: hippocampal inflammation, microglial density, neurogenesis, and depression symptoms (open field and sucrose preference). RESULTS BOO elicited hippocampal inflammation, accompanied by an increase in activated microglia (22%) and a decrease in neurogenesis (35%), which was blocked by glyburide. In addition, BOO rats displayed anxiety (57% decrease in exploratory behavior in the open field assay) and anhedonia (21% decrease in sucrose preference), two symptoms of depression. Like inflammation, these symptoms were diminished by glyburide to levels not statistically significantly different from controls. CONCLUSIONS BOO, a bladder-localized event, stimulates NLRP3-dependent inflammation in the rat hippocampus after 12 weeks and this inflammation causes depressive behavior. This is the first mechanistic explanation of the link between BOO and depression and provides evidence for a distinct bladder-brain axis.
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Affiliation(s)
- Francis M Hughes
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Bioengineering, Clemson University, Clemson, South Carolina
| | - Nathan A Hirshman
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hamza A Malick
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Simon W White
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Huixia Jin
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Shelby N Harper
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.,Department of Bioengineering, Clemson University, Clemson, South Carolina
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The Pharmacological Mechanism of Diabetes Mellitus-Associated Overactive Bladder and Its Treatment with Botulinum Toxin A. Toxins (Basel) 2020; 12:toxins12030186. [PMID: 32188046 PMCID: PMC7150832 DOI: 10.3390/toxins12030186] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/15/2020] [Indexed: 12/29/2022] Open
Abstract
Diabetes mellitus (DM) is an independent risk factor for overactive bladder (OAB). The pathophysiology of DM-associated OAB is multifactorial and time-dependent. Diabetic bladder dysfunction is highly associated with diabetic complications, mainly including diabetic neuropathy and atherosclerosis. Chronic systemic inflammation and bladder urothelial inflammation may contribute to the onset of OAB. Intravesical botulinum toxin A (BoNT-A) injection has proved to be a successful treatment for idiopathic and neurogenic OAB. BoNT-A can inhibit the efferent pathways of the bladder as well as the chronic inflammation and hypersensitivity via the afferent pathways. We conducted a review of the published literature in Pubmed using a combination of two keywords, namely “botulinum toxin A” (BoNT-A) and “overactive bladder”, with or without the additional keywords “detrusor overactivity”, “diabetes mellitus”, “inflammation”, and “urodynamic study”. We also reviewed the experience of our research teams, who have published several studies of the association between DM and OAB. Since limited data support the effectiveness and safety of BoNT-A for treating patients with DM-associated OAB, a comprehensive evaluation of diabetic complications and urodynamic study is needed before treatment. In the future, it is imperative to explore the clinical characteristics and inflammatory biomarkers of diabetes as determining predictors of the treatment efficacy.
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