1
|
Demko J, Saha B, Takagi E, Mannis A, Weber R, Pearce D. Coordinated Regulation of Renal Glucose Reabsorption and Gluconeogenesis by mTORC2 and Potassium. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.22.600201. [PMID: 38979219 PMCID: PMC11230149 DOI: 10.1101/2024.06.22.600201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Background The kidney proximal tubule is uniquely responsible for reabsorption of filtered glucose and gluconeogenesis (GNG). Insulin stimulates glucose transport and suppresses GNG in the proximal tubule, however, the signaling mechanisms and coordinated regulation of these processes remain poorly understood. The kinase complex mTORC2 is critical for regulation of growth, metabolism, solute transport, and electrolyte homeostasis in response to a wide array of inputs. Here we examined its role in the regulation of renal glucose reabsorption and GNG. Methods Rictor, an essential component of mTORC2, was knocked out using the Pax8-LC1 system to generate inducible tubule specific Rictor knockout (TRKO) mice. These animals were subjected to fasting, refeeding, and variation in dietary K + . Metabolic parameters including glucose homeostasis and renal function were assessed in balance cages. Kidneys and livers were also harvested for molecular analysis of gluconeogenic enzymes, mTORC2-regulated targets, and plasma membrane glucose transporters. Results On a normal chow diet, TRKO mice had marked glycosuria despite indistinguishable blood glucose relative to WT controls. Kidney plasma membrane showed lower SGLT2 and SGLT1 in the fed state, supporting reduced renal glucose reabsorption. Additional metabolic testing provided evidence for renal insulin resistance with elevated fasting insulin, impaired pyruvate tolerance, elevated hemoglobin A1c, and increased renal gluconeogenic enzymes in the fasted and fed states. These effects were correlated with reduced downstream phosphorylation of Akt and the transcription factor FOXO4, identifying a novel role of FOXO4 in the kidney. Interestingly, high dietary K + prevented glycosuria and excessive GNG in TRKO mice, despite persistent reduction in mTORC2 substrate phosphorylation. Conclusion Renal tubule mTORC2 is critical for coordinated regulation of sodium-glucose cotransport by SGLT2 and SGLT1 as well as renal GNG. Dietary K + promotes glucose reabsorption and suppresses GNG independently of insulin signaling and mTORC2, potentially providing an alternative signaling mechanism in states of insulin resistance. SIGNIFICANCE STATEMENT The kidney contributes to regulation of blood glucose through reabsorption of filtered glucose and gluconeogenesis. This study shows that mTORC2 and dietary potassium coordinate the regulation of sodium-glucose cotransport and glucose production in the kidney via independent mechanisms. New insights into the regulation of these processes in the kidney offer promising implications for diabetes mellitus management and treatment.
Collapse
|
2
|
Rauckhorst AJ, Vasquez Martinez G, Mayoral Andrade G, Wen H, Kim JY, Simoni A, Robles-Planells C, Mapuskar KA, Rastogi P, Steinbach EJ, McCormick ML, Allen BG, Pabla NS, Jackson AR, Coleman MC, Spitz DR, Taylor EB, Zepeda-Orozco D. Tubular mitochondrial pyruvate carrier disruption elicits redox adaptations that protect from acute kidney injury. Mol Metab 2024; 79:101849. [PMID: 38056691 PMCID: PMC10733108 DOI: 10.1016/j.molmet.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE Energy-intensive kidney reabsorption processes essential for normal whole-body function are maintained by tubular epithelial cell metabolism. Although tubular metabolism changes markedly following acute kidney injury (AKI), it remains unclear which metabolic alterations are beneficial or detrimental. By analyzing large-scale, publicly available datasets, we observed that AKI consistently leads to downregulation of the mitochondrial pyruvate carrier (MPC). This investigation aimed to understand the contribution of the tubular MPC to kidney function, metabolism, and acute injury severity. METHODS We generated tubular epithelial cell-specific Mpc1 knockout (MPC TubKO) mice and employed renal function tests, in vivo renal 13C-glucose tracing, mechanistic enzyme activity assays, and tests of injury and survival in an established rhabdomyolysis model of AKI. RESULTS MPC TubKO mice retained normal kidney function, displayed unchanged markers of kidney injury, but exhibited coordinately increased enzyme activities of the pentose phosphate pathway and the glutathione and thioredoxin oxidant defense systems. Following rhabdomyolysis-induced AKI, compared to WT control mice, MPC TubKO mice showed increased glycolysis, decreased kidney injury and oxidative stress markers, and strikingly increased survival. CONCLUSIONS Our findings suggest that decreased renal tubular mitochondrial pyruvate uptake hormetically upregulates oxidant defense systems before AKI and is a beneficial adaptive response after rhabdomyolysis-induced AKI. This raises the possibility of therapeutically modulating the MPC to attenuate AKI severity.
Collapse
Affiliation(s)
- Adam J Rauckhorst
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA; Fraternal Order of Eagles Diabetes Research Center (FOEDRC), University of Iowa, Iowa City, IA, USA; FOEDRC Metabolomics Core Research Facility, University of Iowa, Iowa City, IA, USA
| | - Gabriela Vasquez Martinez
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA
| | - Gabriel Mayoral Andrade
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA
| | - Hsiang Wen
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Ji Young Kim
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Aaron Simoni
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA
| | - Claudia Robles-Planells
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA
| | - Kranti A Mapuskar
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Prerna Rastogi
- Department of Pathology, University of Iowa, Iowa City, IA, USA
| | - Emily J Steinbach
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA; Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Michael L McCormick
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Bryan G Allen
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Navjot S Pabla
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Ashley R Jackson
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Mitchell C Coleman
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA; Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Douglas R Spitz
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Eric B Taylor
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA; Fraternal Order of Eagles Diabetes Research Center (FOEDRC), University of Iowa, Iowa City, IA, USA; FOEDRC Metabolomics Core Research Facility, University of Iowa, Iowa City, IA, USA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA; Pappajohn Biomedical Institute, University of Iowa, Iowa City, IA, USA.
| | - Diana Zepeda-Orozco
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus OH, USA; Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
| |
Collapse
|
3
|
Daza-Arnedo R, Rico-Fontalvo J, Aroca-Martínez G, Rodríguez-Yanez T, Martínez-Ávila MC, Almanza-Hurtado A, Cardona-Blanco M, Henao-Velásquez C, Fernández-Franco J, Unigarro-Palacios M, Osorio-Restrepo C, Uparella-Gulfo I. Insulin and the kidneys: a contemporary view on the molecular basis. FRONTIERS IN NEPHROLOGY 2023; 3:1133352. [PMID: 37675359 PMCID: PMC10479562 DOI: 10.3389/fneph.2023.1133352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 07/07/2023] [Indexed: 09/08/2023]
Abstract
Insulin is a hormone that is composed of 51 amino acids and structurally organized as a hexamer comprising three heterodimers. Insulin is the central hormone involved in the control of glucose and lipid metabolism, aiding in processes such as body homeostasis and cell growth. Insulin is synthesized as a large preprohormone and has a leader sequence or signal peptide that appears to be responsible for transport to the endoplasmic reticulum membranes. The interaction of insulin with the kidneys is a dynamic and multicenter process, as it acts in multiple sites throughout the nephron. Insulin acts on a range of tissues, from the glomerulus to the renal tubule, by modulating different functions such as glomerular filtration, gluconeogenesis, natriuresis, glucose uptake, regulation of ion transport, and the prevention of apoptosis. On the other hand, there is sufficient evidence showing the insulin receptor's involvement in renal functions and its responsibility for the regulation of glucose homeostasis, which enables us to understand its contribution to the insulin resistance phenomenon and its association with the progression of diabetic kidney disease.
Collapse
Affiliation(s)
- Rodrigo Daza-Arnedo
- Department of Nephrology, Colombian Association of Nephrology, Cartagena, Colombia
| | - Jorge Rico-Fontalvo
- Department of Nephrology, Colombian Association of Nephrology, Cartagena, Colombia
- Faculty of Medicine, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Gustavo Aroca-Martínez
- Department of Nephrology, Colombian Association of Nephrology, Cartagena, Colombia
- Faculty of Medicine, Universidad Simón Bolívar, Barranquilla, Colombia
| | | | | | | | - María Cardona-Blanco
- Department of Nephrology, Colombian Association of Nephrology, Cartagena, Colombia
| | | | - Jorge Fernández-Franco
- Department of Internal Medicine, Endocrinology Fellowship, Fundación Universitaria de Ciencias de la Salud—Hospital San José, Bogotá, Colombia
| | - Mario Unigarro-Palacios
- Department of Internal Medicine, Endocrinology Fellowship, Fundación Universitaria de Ciencias de la Salud—Hospital San José, Bogotá, Colombia
| | | | | |
Collapse
|
4
|
Sohail S, Akkawi G, Rechter T, Fluitt MB, Ecelbarger CM. Sex Modulates Response to Renal-Tubule-Targeted Insulin Receptor Deletion in Mice. Int J Mol Sci 2023; 24:8056. [PMID: 37175762 PMCID: PMC10178497 DOI: 10.3390/ijms24098056] [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: 02/28/2023] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Insulin facilitates renal sodium reabsorption and attenuates gluconeogenesis. Sex differences in this regulation have not been well characterized. Using tetracycline-inducible Cre-lox recombination, we knocked out (KO) the insulin receptor (InsR) from the renal tubule in adult male (M) and female (F) mice (C57Bl6 background) with a paired box 8 (PAX8) promoter. Body weights were not affected by the KO, but mean kidney weights were reduced in the KO mice (13 and 3%, in M and F, respectively, relative to wild-type (WT) mice). A microscopic analysis revealed 25 and 19% reductions in the proximal tubule (PT) and cortical collecting duct cell heights, respectively, in KOMs relative to WTMs. The reductions were 5 and 11% for KOFs. Western blotting of renal cortex homogenates showed decreased protein levels for the β and γ subunits of the epithelial sodium channel (ENaC) and the sodium-potassium-2-chloride cotransporter type 2 (NKCC2) in both sexes of KO mice; however, α-ENaC was upregulated in KOMs and downregulated in KOFs. Both sexes of KO mice cleared exogenously administered glucose faster than the WT mice and had lower semi-fasted, anesthetized blood glucose levels. However, KOMs (but not KOFs) demonstrated evidence of enhanced renal gluconeogenesis, including higher levels of renal glucose-6-phosphatase, the PT's production of glucose, post-prandial blood glucose, and plasma insulin, whereas KOFs exhibited downregulation of renal high-capacity sodium glucose cotransporter (SGLT2) and upregulation of SGLT1; these changes appeared to be absent in the KOM. Overall, these findings suggest a sex-differential reliance on intact renal tubular InsR signaling which may be translationally important in type 2 diabetes, obesity, or insulin resistance when renal insulin signaling is reduced.
Collapse
Affiliation(s)
- Soha Sohail
- Department of Medicine, Georgetown University, Washington, DC 20057, USA
| | - Gabriella Akkawi
- Department of Medicine, Georgetown University, Washington, DC 20057, USA
| | - Taylor Rechter
- Department of Medicine, Georgetown University, Washington, DC 20057, USA
| | - Maurice B. Fluitt
- Department of Medicine, Georgetown University, Washington, DC 20057, USA
- Department of Medicine, Howard University, Washington, DC 20059, USA
| | | |
Collapse
|
5
|
Rauckhorst AJ, Martinez GV, Andrade GM, Wen H, Kim JY, Simoni A, Mapuskar KA, Rastogi P, Steinbach EJ, McCormick ML, Allen BG, Pabla NS, Jackson AR, Coleman MC, Spitz DR, Taylor EB, Zepeda-Orozco D. Tubular Mitochondrial Pyruvate Carrier Disruption Elicits Redox Adaptations that Protect from Acute Kidney Injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.31.526492. [PMID: 36778297 PMCID: PMC9915694 DOI: 10.1101/2023.01.31.526492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Energy-intensive kidney reabsorption processes essential for normal whole-body function are maintained by tubular epithelial cell metabolism. Tubular metabolism changes markedly following acute kidney injury (AKI), but which changes are adaptive versus maladaptive remain poorly understood. In publicly available data sets, we noticed a consistent downregulation of the mitochondrial pyruvate carrier (MPC) after AKI, which we experimentally confirmed. To test the functional consequences of MPC downregulation, we generated novel tubular epithelial cell-specific Mpc1 knockout (MPC TubKO) mice. 13C-glucose tracing, steady-state metabolomic profiling, and enzymatic activity assays revealed that MPC TubKO coordinately increased activities of the pentose phosphate pathway and the glutathione and thioredoxin oxidant defense systems. Following rhabdomyolysis-induced AKI, MPC TubKO decreased markers of kidney injury and oxidative damage and strikingly increased survival. Our findings suggest that decreased mitochondrial pyruvate uptake is a central adaptive response following AKI and raise the possibility of therapeutically modulating the MPC to attenuate AKI severity.
Collapse
Affiliation(s)
- Adam J. Rauckhorst
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA
- Fraternal Order of Eagles Diabetes Research Center (FOEDRC), University of Iowa, Iowa City, IA, USA
- FOEDRC Metabolomics Core Research Facility, University of Iowa, Iowa City, IA, USA
| | - Gabriela Vasquez Martinez
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus OH, USA
| | - Gabriel Mayoral Andrade
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus OH, USA
| | - Hsiang Wen
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Ji Young Kim
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Aaron Simoni
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus OH, USA
| | - Kranti A. Mapuskar
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Prerna Rastogi
- Department of Pathology, University of Iowa, Iowa City, IA, USA
| | - Emily J Steinbach
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Michael L. McCormick
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Bryan G. Allen
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Navjot S. Pabla
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Ashley R. Jackson
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Mitchell C. Coleman
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Douglas R. Spitz
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Eric B. Taylor
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA
- Fraternal Order of Eagles Diabetes Research Center (FOEDRC), University of Iowa, Iowa City, IA, USA
- FOEDRC Metabolomics Core Research Facility, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Pappajohn Biomedical Institute, University of Iowa, Iowa City, IA, USA
| | - Diana Zepeda-Orozco
- Kidney and Urinary Tract Research Center, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus OH, USA
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
6
|
Yang J, Hall JE, Jose PA, Chen K, Zeng C. Comprehensive insights in GRK4 and hypertension: From mechanisms to potential therapeutics. Pharmacol Ther 2022; 239:108194. [DOI: 10.1016/j.pharmthera.2022.108194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/30/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022]
|
7
|
Insulin Resistance and High Blood Pressure: Mechanistic Insight on the Role of the Kidney. Biomedicines 2022; 10:biomedicines10102374. [PMID: 36289636 PMCID: PMC9598512 DOI: 10.3390/biomedicines10102374] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 12/03/2022] Open
Abstract
The metabolic effects of insulin predominate in skeletal muscle, fat, and liver where the hormone binds to its receptor, thereby priming a series of cell-specific and biochemically diverse intracellular mechanisms. In the presence of a good secretory reserve in the pancreatic islets, a decrease in insulin sensitivity in the metabolic target tissues leads to compensatory hyperinsulinemia. A large body of evidence obtained in clinical and experimental studies indicates that insulin resistance and the related hyperinsulinemia are causally involved in some forms of arterial hypertension. Much of this involvement can be ascribed to the impact of insulin on renal sodium transport, although additional mechanisms might be involved. Solid evidence indicates that insulin causes sodium and water retention, and both endogenous and exogenous hyperinsulinemia have been correlated to increased blood pressure. Although important information was gathered on the cellular mechanisms that are triggered by insulin in metabolic tissues and on their abnormalities, knowledge of the insulin-related mechanisms possibly involved in blood pressure regulation is limited. In this review, we summarize the current understanding of the cellular mechanisms that are involved in the pro-hypertensive actions of insulin, focusing on the contribution of insulin to the renal regulation of sodium balance and body fluids.
Collapse
|
8
|
Uijl E, Ye D, Ren L, Mirabito Colafella KM, van Veghel R, Garrelds IM, Lu HS, Daugherty A, Hoorn EJ, Nioi P, Foster D, Danser AHJ. Conventional Vasopressor and Vasopressor-Sparing Strategies to Counteract the Blood Pressure-Lowering Effect of Small Interfering RNA Targeting Angiotensinogen. J Am Heart Assoc 2022; 11:e026426. [PMID: 35876413 PMCID: PMC9375483 DOI: 10.1161/jaha.122.026426] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background A single dose of small interfering RNA (siRNA) targeting liver angiotensinogen eliminates hepatic angiotensinogen and lowers blood pressure. Angiotensinogen elimination raises concerns for clinical application because an angiotensin rise is needed to maintain perfusion pressure during hypovolemia. Here, we investigated whether conventional vasopressors can raise arterial pressure after angiotensinogen depletion. Methods and Results Spontaneously hypertensive rats on a low‐salt diet were treated with siRNA (10 mg/kg fortnightly) for 4 weeks, supplemented during the final 2 weeks with fludrocortisone (6 mg/kg per day), the α‐adrenergic agonist midodrine (4 mg/kg per day), or a high‐salt diet (all groups n=6–7). Pressor responsiveness to angiotensin II and norepinephrine was assessed before and after siRNA administration. Blood pressure was measured via radiotelemetry. Depletion of liver angiotensinogen by siRNA lowered plasma angiotensinogen concentrations by 99.2±0.1% and mean arterial pressure by 19 mm Hg. siRNA‐mediated blood pressure lowering was rapidly reversed by intravenous angiotensin II or norepinephrine, or gradually reversed by fludrocortisone or high salt intake. Midodrine had no effect. Unexpectedly, fludrocortisone partially restored plasma angiotensinogen concentrations in siRNA‐treated rats, and nearly abolished plasma renin concentrations. To investigate whether this angiotensinogen originated from nonhepatic sources, fludrocortisone was administered to mice lacking hepatic angiotensinogen. Fludrocortisone did not increase angiotensinogen in these mice, implying that the rise in angiotensinogen in the siRNA‐treated rats must have depended on the liver, most likely reflecting diminished cleavage by renin. Conclusions Intact pressor responsiveness to conventional vasopressors provides pharmacological means to regulate the blood pressure–lowering effect of angiotensinogen siRNA and may support future therapeutic implementation of siRNA.
Collapse
Affiliation(s)
- Estrellita Uijl
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Division of Nephrology and Transplantation, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Dien Ye
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Liwei Ren
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands.,Department of Pharmacy Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital Southern University of Science and Technology) Shenzhen China
| | - Katrina M Mirabito Colafella
- Cardiovascular Program, Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Australia
| | - Richard van Veghel
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Ingrid M Garrelds
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Hong S Lu
- Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Alan Daugherty
- Saha Cardiovascular Research Center and Department of Physiology University of Kentucky Lexington KY
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| | - Paul Nioi
- Alnylam Pharmaceuticals Cambridge MA
| | | | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine Erasmus MC, University Medical Center Rotterdam Rotterdam the Netherlands
| |
Collapse
|
9
|
Sharma R, Sahoo B, Srivastava A, Tiwari S. Reduced insulin signaling and high glucagon in early insulin resistance impaired fast-fed regulation of renal gluconeogenesis via insulin receptor substrate. J Cell Biochem 2022; 123:1327-1339. [PMID: 35644013 DOI: 10.1002/jcb.30294] [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: 10/28/2021] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/08/2022]
Abstract
Gluconeogenesis is one of the key processes through which the kidney contributes to glucose homeostasis. Urinary exosomes (uE) have been used to study renal gene regulation noninvasively in humans and rodents. Recently, we demonstrated fast-fed regulation of phosphoenolpyruvate carboxykinase (PEPCK), the rate-limiting enzyme for gluconeogenesis, in human uE. The regulation was impaired in subjects with early insulin resistance. Here, we studied primary human proximal tubule cells (hPT) and human uE to elucidate a potential link between insulin resistance and fast-fed regulation of renal PEPCK. We demonstrate that fasted hPTs had higher PEPCK and insulin receptor substrate-2 (IRS2) mRNA and protein levels, relative to fed cells. The fast-fed regulation was, however, attenuated in insulin receptor knockdown (IRKO) hPTs. The IRKO was confirmed by the blunted insulin-induced response on PEPCK, PGC1α, p-IR, and p-AKT expression in IRKO cells. Exosomes secreted by the wild-type or IRKO hPT showed similar regulation to the respective hPT. Similarly, in human uE, the relative abundance of IRS-2 mRNA (to IRS1) was higher in the fasted state relative to the fed condition. However, the fast-fed difference was absent in subjects with early insulin resistance. These subjects had higher circulating glucagon levels relative to subjects with optimal insulin sensitivity. Furthermore, in hPT cells, glucagon significantly induced PEPCK and IRS2 gene, and gluconeogenesis. IR knockdown in hPT cells further increased the gene expression levels. Together the data suggest that reduced insulin sensitivity and high glucagon in early insulin resistance may impair renal gluconeogenesis via IRS2 regulation.
Collapse
Affiliation(s)
- Rajni Sharma
- Department of Molecular Medicine & Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Biswajit Sahoo
- Department of Molecular Medicine & Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Aneesh Srivastava
- Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Swasti Tiwari
- Department of Molecular Medicine & Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
10
|
Culver SA, Akhtar S, Rountree-Jablin C, Keller SR, Cathro HP, Gildea JJ, Siragy HM. Knockout of Nephron ATP6AP2 Impairs Proximal Tubule Function and Prevents High-Fat Diet-Induced Obesity in Male Mice. Endocrinology 2021; 162:bqab200. [PMID: 34534267 PMCID: PMC8489432 DOI: 10.1210/endocr/bqab200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 12/24/2022]
Abstract
ATP6AP2 expression is increased in the nephron during high-fat diet (HFD) and its knockout (ATP6AP2 KO) reduces body weight (WT) in mice. We evaluated the contribution of ATP6AP2 to urinary glucose (UG) and albumin (Ualb) handling during HFD. We hypothesized that nephron ATP6AP2 KO increases UG and Ualb and minimizes HFD-induced obesity. Eight-week-old male C57BL/6J mice with inducible nephron-specific ATP6AP2 KO and noninduced controls were fed either normal diet (ND, 12% kcal fat) or HFD (45% kcal fat) for 6 months. ATP6AP2 KO mice on ND had 20% (P < 0.01) lower WT compared with controls. HFD-fed mice had 41% (P < 0.05) greater WT than ND-fed control mice. In contrast, ATP6AP2 KO abrogated the increase in WT induced by HFD by 40% (P < 0.05). Mice on HFD had less caloric intake compared with ND controls (P < 0.01). There were no significant differences in metabolic rate between all groups. UG and Ualb was significantly increased in ATP6AP2 KO mice on both ND and HFD. ATP6AP2 KO showed greater levels of proximal tubule apoptosis and histologic evidence of proximal tubule injury. In conclusion, our results demonstrate that nephron-specific ATP6AP2 KO is associated with glucosuria and albuminuria, most likely secondary to renal proximal tubule injury and/or dysfunction. Urinary loss of nutrients may have contributed to the reduced WT of knockout mice on ND and lack of WT gain in response to HFD. Future investigation should elucidate the mechanisms by which loss of renal ATP6AP2 causes proximal tubule injury and dysfunction.
Collapse
Affiliation(s)
- Silas A Culver
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Safia Akhtar
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Callie Rountree-Jablin
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Susanna R Keller
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Helen P Cathro
- Department of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - John J Gildea
- Department of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Helmy M Siragy
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| |
Collapse
|
11
|
Higashikawa T, Ito T, Mizuno T, Ishigami K, Kuroki K, Maekawa N, Usuda D, Morita T, Hamada K, Takagi S, Takeshima K, Yamada S, Sangen R, Izumida T, Mori H, Kiyosawa J, Saito A, Iguchi M, Nakahashi T, Kasamaki Y, Fukuda A, Kanda T, Okuro M. Effects of tofogliflozin on adrenocorticotropic hormone, renin and aldosterone, and cortisol levels in elderly patients with diabetes mellitus: A retrospective study of a patient cohort. Medicine (Baltimore) 2021; 100:e27638. [PMID: 34766565 PMCID: PMC8589243 DOI: 10.1097/md.0000000000027638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/09/2021] [Indexed: 02/07/2023] Open
Abstract
Adrenocorticotropic hormone (ACTH) and cortisol reportedly play a role in glycemic control in patients with type 2 diabetes mellitus (T2DM); however, the underlying mechanism remains controversial. We retrospectively investigated the effect of tofogliflozin on serum ACTH and cortisol levels in elderly patients with T2DM.Patients received 20 mg tofogliflozin daily for 3 months. Serum ACTH and cortisol levels were measured at baseline, as well as after 1 month and 3 months of tofogliflozin therapy.Serum ACTH levels were significantly reduced 3 months after tofogliflozin treatment (P < .01). Additionally, serum cortisol levels were reduced 3 months after tofogliflozin treatment, demonstrating borderline significance (P = .05). The higher body mass index (BMI; ≥25 kg/m2) group showed higher ACTH and cortisol levels than the lower BMI (<25 kg/m2) group, with borderline significance (P = .05). Renin levels were significantly increased 1 month after treatment (P < .05), maintaining serum aldosterone levels in parallel with the extracellular fluid.Our findings suggested that tofogliflozin decreased both serum ACTH and cortisol levels, with higher levels observed in the high BMI group. Tofogliflozin increased serum renin levels while maintaining serum aldosterone and extracellular fluid levels. Collectively, tofogliflozin could affect the hypothalamic-pituitary-adrenal pathway in patients with T2DM, especially in the low BMI group.
Collapse
Affiliation(s)
- Toshihiro Higashikawa
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | - Tomohiko Ito
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Takurou Mizuno
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Keiichirou Ishigami
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Kengo Kuroki
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Naoto Maekawa
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Daisuke Usuda
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Takuro Morita
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | - Kazu Hamada
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | - Susumu Takagi
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Kento Takeshima
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Shinya Yamada
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Ryusho Sangen
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Toshihide Izumida
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Hideyuki Mori
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Jun Kiyosawa
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Atsushi Saito
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Masaharu Iguchi
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Takeshi Nakahashi
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | - Yuji Kasamaki
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Akihiro Fukuda
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Tsugiyasu Kanda
- Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi, Toyama, Japan
| | - Masashi Okuro
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| |
Collapse
|
12
|
Mandal AK, Leask MP, Estiverne C, Choi HK, Merriman TR, Mount DB. Genetic and Physiological Effects of Insulin on Human Urate Homeostasis. Front Physiol 2021; 12:713710. [PMID: 34408667 PMCID: PMC8366499 DOI: 10.3389/fphys.2021.713710] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/02/2021] [Indexed: 12/19/2022] Open
Abstract
Insulin and hyperinsulinemia reduce renal fractional excretion of urate (FeU) and play a key role in the genesis of hyperuricemia and gout, via uncharacterized mechanisms. To explore this association further we studied the effects of genetic variation in insulin-associated pathways on serum urate (SU) levels and the physiological effects of insulin on urate transporters. We found that urate-associated variants in the human insulin (INS), insulin receptor (INSR), and insulin receptor substrate-1 (IRS1) loci associate with the expression of the insulin-like growth factor 2, IRS1, INSR, and ZNF358 genes; additionally, we found genetic interaction between SLC2A9 and the three loci, most evident in women. We also found that insulin stimulates the expression of GLUT9 and increases [14C]-urate uptake in human proximal tubular cells (PTC-05) and HEK293T cells, transport activity that was effectively abrogated by uricosurics or inhibitors of protein tyrosine kinase (PTK), PI3 kinase, MEK/ERK, or p38 MAPK. Heterologous expression of individual urate transporters in Xenopus oocytes revealed that the [14C]-urate transport activities of GLUT9a, GLUT9b, OAT10, OAT3, OAT1, NPT1 and ABCG2 are directly activated by insulin signaling, through PI3 kinase (PI3K)/Akt, MEK/ERK and/or p38 MAPK. Given that the high-capacity urate transporter GLUT9a is the exclusive basolateral exit pathway for reabsorbed urate from the renal proximal tubule into the blood, that insulin stimulates both GLUT9 expression and urate transport activity more than other urate transporters, and that SLC2A9 shows genetic interaction with urate-associated insulin-signaling loci, we postulate that the anti-uricosuric effect of insulin is primarily due to the enhanced expression and activation of GLUT9.
Collapse
Affiliation(s)
- Asim K. Mandal
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Megan P. Leask
- Biochemistry Department, University of Otago, Dunedin, New Zealand
- Division of Rheumatology and Clinical Immunology, University of Alabama, Birmingham, AL, United States
| | - Christopher Estiverne
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Hyon K. Choi
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tony R. Merriman
- Biochemistry Department, University of Otago, Dunedin, New Zealand
- Division of Rheumatology and Clinical Immunology, University of Alabama, Birmingham, AL, United States
| | - David B. Mount
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Renal Division, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
13
|
Bao H, Liu Y, Zhang M, Chen Z, Zhang W, Ge Y, Kang D, Gao F, Shen Y. Increased β-site APP cleaving enzyme 1-mediated insulin receptor cleavage in type 2 diabetes mellitus with cognitive impairment. Alzheimers Dement 2021; 17:1097-1108. [PMID: 33410588 DOI: 10.1002/alz.12276] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Patients with type 2 diabetes mellitus (T2DM) are at a high risk of cognitive impairment, with insulin resistance playing a pivotal role. β-site amyloid precursor protein cleaving enzyme 1 (BACE1) is considered a predictor of Alzheimer's disease. However, the potential roles of BACE1 in insulin resistance and the risk of cognitive impairment in T2DM remain unclear. METHODS We measured plasma BACE1 levels, BACE1 cleavage activities for Swedish mutant amyloid precursor protein (APPsw) and insulin receptor β subunit (INSR-β), and soluble INSR (sINSR) levels in a clinical cohort study. RESULTS T2DM patients with or without cognitive impairment exhibited elevated plasma BACE1 levels and BACE1 enzymatic activities for APPsw and INSR-β, and sINSR levels. Moreover, the glycemic status correlated with elevated BACE1 levels and BACE1-mediated INSR cleavage, which was associated with insulin resistance. DISCUSSION The elevated BACE1 levels in T2DM may contribute to increasing the cognitive impairment risk through both amyloidogenesis and insulin resistance.
Collapse
Affiliation(s)
- Hong Bao
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yiming Liu
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Mengguo Zhang
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zuolong Chen
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Weiwei Zhang
- Institute on Aging and Brain Disorders, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Yuhao Ge
- Institute on Aging and Brain Disorders, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Dongmei Kang
- Institute on Aging and Brain Disorders, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Feng Gao
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.,Institute on Aging and Brain Disorders, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Yong Shen
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.,Institute on Aging and Brain Disorders, First Affiliated Hospital of University of Science and Technology of China, Hefei, China.,Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| |
Collapse
|
14
|
Zeugswetter FK, Schwendenwein I. Basal glucose excretion in dogs: The impact of feeding, obesity, sex, and age. Vet Clin Pathol 2020; 49:428-435. [PMID: 32970348 PMCID: PMC7702102 DOI: 10.1111/vcp.12899] [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] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/20/2020] [Accepted: 03/11/2020] [Indexed: 11/28/2022]
Abstract
Background The urine glucose (UG) measurements are an integral part of urinalyses, especially in dogs with polyuria and polydipsia. A positive dipstick result is considered pathologic for disease. This paradigm has been challenged by new ultrasensitive tests, where the manufacturers recommend tolerating slightly positive results. It implies that, as in other species, basal urine glucose losses can exceed the lower limits of detection using ultrasensitive glucose dipsticks in healthy dogs. Objectives We aimed to determine whether glucose is routinely detectable using a sensitive quantitative wet chemistry method in the urine of nondiabetic, nonazotemic dogs, and investigate the impact of food intake, obesity, sex, castration status, and age. Methods Serial UG measurements were performed in healthy clinic‐owned Beagle dogs that were randomly fasted or fed. Glucose was measured in morning urine samples from normal‐weight healthy and obese dogs, and the university's electronic database was searched for quantitative UG measurements (Gluco‐quant Enzyme Kit/Roche Diagnostics). Results Small amounts of glucose were detected in 555 (99.1%) of 560 urine samples analyzed. All urine samples from the clinic‐owned Beagle dogs, as well as from privately owned obese and normal‐weight healthy dogs that tested positive for glucose. The median (range) UG concentration obtained from the university's electronic database was 0.39 (0‐1.55) mmol/L, and 2.2% of the samples tested negative. Feeding, obesity, gender, castration status, and age did not affect UG concentrations. Conclusions Studies, including a larger number of healthy dogs, are warranted to define a cut‐off between physiologic and pathologic glucosuria.
Collapse
Affiliation(s)
- Florian K Zeugswetter
- Clinical Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Ilse Schwendenwein
- Department of Pathobiology, Central Laboratory, University of Veterinary Medicine Vienna, Vienna, Austria
| |
Collapse
|
15
|
Hieshima K, Sugiyama S, Yoshida A, Kurinami N, Suzuki T, Ijima H, Miyamoto F, Kajiwara K, Jinnouchi K, Jinnouchi T, Jinnouchi H. Elevation of the renal threshold for glucose is associated with insulin resistance and higher glycated hemoglobin levels. J Diabetes Investig 2020; 11:617-625. [PMID: 31770476 PMCID: PMC7232275 DOI: 10.1111/jdi.13191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS/INTRODUCTION The renal threshold for glucose (RTg) corresponds to a blood glucose level of ~180 mg/dL; however, in hospitals, patients are often encountered who are hyperglycemic, but urine glucose test strip-negative, who remain negative for urine glucose even at blood glucose concentrations >180 mg/dL, implying a high RTg value. In this study, we aimed to identify factors determining high RTg in Japanese patients with type 2 diabetes mellitus. MATERIALS AND METHODS We estimated RTg (eRTg) using urinalysis data from 67 type 2 diabetes mellitus patients for whom the glucose infusion rate (GIR) was determined by hyperinsulinemic-euglycemic clamp. After allocating patients to two groups according to their baseline eRTg (<180 mg/dL or ≥180 mg/dL), we identified the factors affecting eRTg using simple and multiple linear regression analyses. RESULTS GIR, glycated hemoglobin (HbA1c), insulin use and dyslipidemia differed significantly between the groups. In simple regression analysis, GIR, HbA1c, body muscle-to-fat ratio and insulin use were significantly correlated with eRTg; and in multiple regression analysis, GIR and HbA1c remained independent negative and positive determinants, respectively, with the contribution of GIR being substantial. In receiver operating characteristic curve analysis, when GIR <5.7 was used as the insulin resistance threshold, the cut-off value of eRTg was 189 mg/dL (P = 0.0001). Furthermore, in receiver operating characteristic analysis using eRTg ≥189 mg/dL, the cut-off value for HbA1c was 8.0% (P = 0.0006). CONCLUSIONS High eRTg is associated with low GIR and high HbA1c, with GIR making a substantial contribution.
Collapse
Affiliation(s)
| | - Seigo Sugiyama
- Diabetes Care CenterJinnouchi HospitalKumamotoJapan
- Cardiovascular DivisionDiabetes Care CenterJinnouchi HospitalKumamotoJapan
| | | | | | | | - Hiroko Ijima
- Diabetes Care CenterJinnouchi HospitalKumamotoJapan
| | | | | | | | | | - Hideaki Jinnouchi
- Diabetes Care CenterJinnouchi HospitalKumamotoJapan
- Cardiovascular DivisionDiabetes Care CenterJinnouchi HospitalKumamotoJapan
- Division of Preventive CardiologyDepartment of Cardiovascular MedicineKumamoto University HospitalKumamotoJapan
| |
Collapse
|
16
|
Lytvyn Y, Bjornstad P, van Raalte DH, Heerspink HL, Cherney DZI. The New Biology of Diabetic Kidney Disease-Mechanisms and Therapeutic Implications. Endocr Rev 2020; 41:5601424. [PMID: 31633153 PMCID: PMC7156849 DOI: 10.1210/endrev/bnz010] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. Despite reductions in incidence rates of myocardial infarction and stroke in people with diabetes over the past 3 decades, the risk of diabetic kidney disease has remained unchanged, and may even be increasing in younger individuals afflicted with this disease. Accordingly, changes in public health policy have to be implemented to address the root causes of diabetic kidney disease, including the rise of obesity and diabetes, in addition to the use of safe and effective pharmacological agents to prevent cardiorenal complications in people with diabetes. The aim of this article is to review the mechanisms of pathogenesis and therapies that are either in clinical practice or that are emerging in clinical development programs for potential use to treat diabetic kidney disease.
Collapse
Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Petter Bjornstad
- Department of Medicine, Division of Nephrology, Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Netherlands
| | - Hiddo L Heerspink
- The George Institute for Global Health, Sydney, Australia.,Department of Clinical Pharmacology, University of Groningen, Groningen, Netherlands
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Oroojalian F, Charbgoo F, Hashemi M, Amani A, Yazdian-Robati R, Mokhtarzadeh A, Ramezani M, Hamblin MR. Recent advances in nanotechnology-based drug delivery systems for the kidney. J Control Release 2020; 321:442-462. [PMID: 32067996 DOI: 10.1016/j.jconrel.2020.02.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 12/24/2022]
Abstract
The application of nanotechnology in medicine has the potential to make a great impact on human health, ranging from prevention to diagnosis and treatment of disease. The kidneys are the main organ of the human urinary system, responsible for filtering the blood, and concentrating metabolic waste into urine by means of the renal glomerulus. The glomerular filtration apparatus presents a barrier against therapeutic agents based on charge and/or molecular size. Therefore, drug delivery to the kidneys faces significant difficulties resulting in treatment failure in several renal disorders. Accordingly, different strategies have recently being explored for enhancing the delivery of therapeutic agents across the filtration barrier of the glomerulus. Nanosystems with different physicochemical properties, including size, shape, surface, charge, and possessing biological features such as high cellular internalization, low cytotoxicity, controllable pharmacokinetics and biodistribution, have shown promising results for renal therapy. Different types of nanoparticles (NPs) have been used to deliver drugs to the kidney. In this review, we discuss nanotechnology-based drug delivery approaches for acute kidney injury, chronic kidney disease, renal fibrosis, renovascular hypertension and kidney cancer.
Collapse
Affiliation(s)
- Fatemeh Oroojalian
- Department of Advanced Sciences and Technologies, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Fahimeh Charbgoo
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany
| | - Maryam Hashemi
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Amani
- Department of Advanced Sciences and Technologies, North Khorasan University of Medical Sciences, Bojnurd, Iran; Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Rezvan Yazdian-Robati
- Molecular and Cell Biology Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mohammad Ramezani
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Michael R Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Dermatology, Harvard Medical School, Boston, MA 02115, USA; Laser Research Centre, Faculty of Health Science, University of Johannesburg, Doornfontein 2028, South Africa.
| |
Collapse
|
18
|
Sharma R, Kumari M, Prakash P, Gupta S, Tiwari S. Phosphoenolpyruvate carboxykinase in urine exosomes reflect impairment in renal gluconeogenesis in early insulin resistance and diabetes. Am J Physiol Renal Physiol 2020; 318:F720-F731. [PMID: 32036699 DOI: 10.1152/ajprenal.00507.2019] [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] [Indexed: 12/21/2022] Open
Abstract
Impaired insulin-induced suppression of renal gluconeogenesis could be a risk for hyperglycemia. Diabetes is associated with elevated renal gluconeogenesis; however, its regulation in early insulin resistance is unclear in humans. A noninvasive marker of renal gluconeogenesis would be helpful. Here, we show that human urine exosomes (uE) contain three gluconeogenic enzymes: phosphoenolpyruvate carboxykinase (PEPCK), fructose 1,6-bisphosphatase, and glucose 6-phosphatase. Their protein levels were positively associated with whole body insulin sensitivity. PEPCK protein in uE exhibited a meal-induced suppression. However, subjects with lower insulin sensitivity had blunted meal-induced suppression. Also, uE from subjects with prediabetes and diabetic rats had higher PEPCK relative to nondiabetic controls. Moreover, uE-PEPCK was higher in drug-naïve subjects with diabetes relative to drug-treated subjects with diabetes. To determine whether increased renal gluconeogenesis is associated with hyperglycemia or PEPCK expression in uE, acidosis was induced in rats by 0.28 M NH4Cl with 0.5% sucrose in drinking water. Control rats were maintained on 0.5% sucrose. At the seventh day posttreatment, gluconeogenic enzyme activity in the kidneys, but not in the liver, was higher in acidotic rats. These rats had elevated PEPCK in their uE and a significant rise in blood glucose relative to controls. The induction of gluconeogenesis in human proximal tubule cells increased PEPCK expression in both human proximal tubules and human proximal tubule-secreted exosomes in the media. Overall, gluconeogenic enzymes are detectable in human uE. Elevated PEPCK and its blunted meal-induced suppression in human urine exosomes are associated with diabetes and early insulin resistance.
Collapse
Affiliation(s)
- Rajni Sharma
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manju Kumari
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Prem Prakash
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sushil Gupta
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Swasti Tiwari
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
19
|
Pereira-Moreira R, Muscelli E. Effect of Insulin on Proximal Tubules Handling of Glucose: A Systematic Review. J Diabetes Res 2020; 2020:8492467. [PMID: 32377524 PMCID: PMC7180501 DOI: 10.1155/2020/8492467] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/18/2019] [Accepted: 12/27/2019] [Indexed: 02/06/2023] Open
Abstract
Renal proximal tubules reabsorb glucose from the glomerular filtrate and release it back into the circulation. Modulation of glomerular filtration and renal glucose disposal are some of the insulin actions, but little is known about a possible insulin effect on tubular glucose reabsorption. This review is aimed at synthesizing the current knowledge about insulin action on glucose handling by proximal tubules. Method. A systematic article selection from Medline (PubMed) and Embase between 2008 and 2019. 180 selected articles were clustered into topics (renal insulin handling, proximal tubule glucose transport, renal gluconeogenesis, and renal insulin resistance). Summary of Results. Insulin upregulates its renal uptake and degradation, and there is probably a renal site-specific insulin action and resistance; studies in diabetic animal models suggest that insulin increases renal SGLT2 protein content; in vivo human studies on glucose transport are few, and results of glucose transporter protein and mRNA contents are conflicting in human kidney biopsies; maximum renal glucose reabsorptive capacity is higher in diabetic patients than in healthy subjects; glucose stimulates SGLT1, SGLT2, and GLUT2 in renal cell cultures while insulin raises SGLT2 protein availability and activity and seems to directly inhibit the SGLT1 activity despite it activating this transporter indirectly. Besides, insulin regulates SGLT2 inhibitor bioavailability, inhibits renal gluconeogenesis, and interferes with Na+K+ATPase activity impacting on glucose transport. Conclusion. Available data points to an important insulin participation in renal glucose handling, including tubular glucose transport, but human studies with reproducible and comparable method are still needed.
Collapse
Affiliation(s)
- Ricardo Pereira-Moreira
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Zip Code: 13083-887, Brazil
| | - Elza Muscelli
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Zip Code: 13083-887, Brazil
| |
Collapse
|
20
|
Heyman SN, Bursztyn M, Szalat A, Muszkat M, Abassi Z. Fasting-Induced Natriuresis and SGLT: A New Hypothesis for an Old Enigma. Front Endocrinol (Lausanne) 2020; 11:217. [PMID: 32457696 PMCID: PMC7221140 DOI: 10.3389/fendo.2020.00217] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/26/2020] [Indexed: 11/17/2022] Open
Abstract
For years, physicians and scientists were enthralled by the enigmatic phenomenon of fasting-associated diuresis and natriuresis and their reversal by feeding. This abrupt response is most prominent in obese and hypertensive individuals, and if repeated once and again may lead to the attenuation of blood pressure and improve insulin sensitivity. The mechanisms involved in early natriuresis and diuresis remain speculative as the renin-angiotensin-aldosterone axis and natriuretic peptides are initially suppressed. Based on gained insight using sodium-glucose transporter 2 (SGLT-2) inhibitors, herein, we propose a role for enhanced post-prandial proximal tubular sodium uptake, mediated by increased glucose-sodium co-transport, as daily filtered glucose increases, and reduced sodium uptake when glucose reabsorption diminishes. This phenomenon might be more pronounced in diabetics due to prolonged post-prandial hyperglycemia and intense SGLT-driven transport. Our hypothesis may also provide a physiologic basis for fasting-related reduced blood pressure in hypertension. This theory deserves challenging by experimental and clinical studies.
Collapse
Affiliation(s)
- Samuel N. Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
- *Correspondence: Samuel N. Heyman
| | - Michael Bursztyn
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Auryan Szalat
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Zaid Abassi
- Department of Physiology and Biophysics, Ruth and Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
- Department of Laboratory Medicine, Rambam Health Care Campus, Haifa, Israel
- Zaid Abassi
| |
Collapse
|
21
|
Effects of Lactobacillus Plantarum and Lactobacillus Helveticus on Renal Insulin Signaling, Inflammatory Markers, and Glucose Transporters in High-Fructose-Fed Rats. ACTA ACUST UNITED AC 2019; 55:medicina55050207. [PMID: 31137715 PMCID: PMC6572085 DOI: 10.3390/medicina55050207] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The excess consumption of fructose in the diet may cause metabolic syndrome, which is associated with an increased risk of kidney disease. There is limited data on probiotic treatment in high-fructose-induced metabolic syndrome. The present study aims to investigate whether the supplementation of Lactobacillus plantarum (L. plantarum) and Lactobacillus helveticus (L. helveticus) could provide an improving effect on the renal insulin signaling effectors, inflammatory parameters, and glucose transporters in fructose-fed rats. Materials and Methods: The model of metabolic syndrome in male Wistar rats was produced by fructose, which was given as 20% solution in drinking water for 15 weeks. L. plantarum and L. helveticus supplementations were given by gastric gavage from 10 to 15 weeks of age. Results: High-fructose consumption in rats reduced renal protein expressions of insulin receptor substrate (IRS)-1, protein kinase B (AKT), and endothelial nitric oxide synthase (eNOS), which were improved by L. plantarum and partially by L. helveticus supplementations. Dietary fructose-induced elevations in renal tissue levels of tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-6, and IL-10, as well as expression of IL-6 mRNA, were attenuated, especially in L. plantarum treated rats. The increased renal expression of sodium-glucose cotransporter-2 (SGLT2), but not that of glucose transporter type-5 (GLUT5), was suppressed by the treatment with L. plantarum. Conclusion: Suppression in insulin signaling pathway together with the induction of inflammatory markers and upregulation of SGLT2 in fructose-fed rats were improved by L. plantarum supplementation. These findings may offer a new approach to the management of renal dysregulation induced by dietary high-fructose.
Collapse
|
22
|
Spires D, Manis AD, Staruschenko A. Ion channels and transporters in diabetic kidney disease. CURRENT TOPICS IN MEMBRANES 2019; 83:353-396. [PMID: 31196609 PMCID: PMC6815098 DOI: 10.1016/bs.ctm.2019.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Type 1 and 2 diabetes mellitus are major medical epidemics affecting millions of patients worldwide. Diabetes mellitus is the leading cause of diabetic kidney disease (DKD), which is the most common cause of end-stage renal disease (ESRD). DKD is associated with significant changes in renal hemodynamics and electrolyte transport. Alterations in renal ion transport triggered by pathophysiological conditions in diabetes can exacerbate hypertension, accelerate renal injury, and are integral to the development of DKD. Renal ion transporters and electrolyte homeostasis play a fundamental role in functional changes and injury to the kidney during DKD. With the large number of ion transporters involved in DKD, understanding the roles of individual transporters as well as the complex cascades through which they interact is essential in the development of effective treatments for patients suffering from this disease. This chapter aims to gather current knowledge of the major renal ion transporters with altered expression and activity under diabetic conditions, and provide a comprehensive overview of their interactions and collective functions in DKD.
Collapse
Affiliation(s)
- Denisha Spires
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Anna D Manis
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Alexander Staruschenko
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Clement J. Zablocki VA Medical Center, Milwaukee, WI, United States.
| |
Collapse
|
23
|
Chen J, Qiu SH, Guo HJ, Li W, Sun ZL. Associations of Insulin Levels and Insulin Resistance With Urine Glucose Excretion Independent of Blood Glucose in Chinese Adults With Prediabetes and Newly Diagnosed Diabetes. Front Physiol 2018; 9:1666. [PMID: 30519194 PMCID: PMC6258798 DOI: 10.3389/fphys.2018.01666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022] Open
Abstract
Several studies have demonstrated that renal glucose reabsorption is increased in patients with type 2 diabetes. However, the increased renal glucose reabsorption may contribute to the progression of hyperglycemia. Therefore, promoting urine glucose excretion (UGE) by suppression of renal glucose reabsorption is an attractive approach for the treatment of diabetes. Insulin resistance is identified as a major characteristic in the pathogenesis of type 2 diabetes. Thus, our aim was to evaluate the association of UGE with serum insulin levels and insulin resistance in subjects with glucose abnormalities, including prediabetes and newly diagnosed diabetes (NDD). The present study included 1129 subjects, 826 individuals with prediabetes and 303 individuals with NDD. Urine samples were collected within 2 h of oral glucose loading for the measurement of glucose. Fasting serum insulin was measured. Homeostatic model assessment of insulin resistance (HOMA-IR) was assessed. Multiple linear regression analysis and multivariate logistic regression analysis were performed to determine the association of UGE with insulin levels and HOMA-IR. A negative association between serum insulin levels and UGE was observed. The relationship remained significant after adjustment for potential confounders, including age, gender, blood pressure and glucose (β = -5.271, 95% CI: -9.775 to -0.767, p = 0.022). Furthermore, multivariable logistic regression model showed that increased insulin levels were associated with a decreased risk for high UGE after multivariable adjustment. In addition, similar correlation was also observed between HOMA-IR and UGE. HOMA-IR was negatively correlated with UGE after controlling for potential confounders. Moreover, an independent inverse relationship between HOMA-IR and the risk of high UGE was found (OR = 0.85, 95% CI: 0.78–0.93, p < 0.001). In conclusion, insulin levels and HOMA-IR were negatively correlated with UGE after adjusting for potential confounders. Subjects with increased insulin levels or IR were at a decreased risk of high UGE independent of blood glucose. The study suggests that insulin might affect UGE through other ways, in addition to the direct blood glucose-lowering effect, thereby resulting in reduced UGE.
Collapse
Affiliation(s)
- Juan Chen
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China
| | - Shan-Hu Qiu
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China
| | - Hai-Jian Guo
- Integrated Affairs Management Office, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Wei Li
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China
| | - Zi-Lin Sun
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China
| |
Collapse
|