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Van den Berghe G, Vanhorebeek I, Langouche L, Gunst J. Our Scientific Journey through the Ups and Downs of Blood Glucose Control in the ICU. Am J Respir Crit Care Med 2024; 209:497-506. [PMID: 37991900 DOI: 10.1164/rccm.202309-1696so] [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: 09/28/2023] [Accepted: 11/22/2023] [Indexed: 11/24/2023] Open
Abstract
This article tells the story of our long search for the answer to one question: Is stress hyperglycemia in critically ill patients adaptive or maladaptive? Our earlier work had suggested the lack of hepatic insulin effect and hyperglycemia as jointly predicting poor outcome. Therefore, we hypothesized that insulin infusion to reach normoglycemia, tight glucose control, improves outcome. In three randomized controlled trials (RCTs), we found morbidity and mortality benefit with tight glucose control. Moving from the bed to the bench, we attributed benefits to the prevention of glucose toxicity in cells taking up glucose in an insulin-independent, glucose concentration gradient-dependent manner, counteracted rather than synergized by insulin. Several subsequent RCTs did not confirm benefit, and the large Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation, or "NICE-SUGAR," trial found increased mortality with tight glucose control associated with severe hypoglycemia. Our subsequent clinical and mechanistic research revealed that early use of parenteral nutrition, the context of our initial RCTs, had been a confounder. Early parenteral nutrition (early-PN) aggravated hyperglycemia, suppressed vital cell damage removal, and hampered recovery. Therefore, in our next and largest "TGC-fast" RCT, we retested our hypothesis, without the use of early-PN and with a computer algorithm for tight glucose control that avoided severe hypoglycemia. In this trial, tight glucose control prevented kidney and liver damage, though with much smaller effect sizes than in our initial RCTs without affecting mortality. Our quest ends with the strong recommendation to omit early-PN for patients in the ICU, as this reduces need of blood glucose control and allows cellular housekeeping systems to play evolutionary selected roles in the recovery process. Once again, less is more in critical care.
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Affiliation(s)
- Greet Van den Berghe
- Clinical Division of Intensive Care Medicine, UZ Leuven, Leuven, Belgium; and
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Jan Gunst
- Clinical Division of Intensive Care Medicine, UZ Leuven, Leuven, Belgium; and
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Figueroa A, Maharaj A, Kang Y, Dillon KN, Martinez MA, Morita M, Nogimura D, Fischer SM. Combined Citrulline and Glutathione Supplementation Improves Endothelial Function and Blood Pressure Reactivity in Postmenopausal Women. Nutrients 2023; 15:nu15071557. [PMID: 37049398 PMCID: PMC10097312 DOI: 10.3390/nu15071557] [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: 02/16/2023] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Postmenopausal women (PMW) may experience endothelial dysfunction associated with arginine (ARG) deficiency relative to asymmetric dimethylarginine (ADMA) caused by oxidative stress. Endothelial dysfunction contributes to increased blood pressure (BP) responsiveness to sympathoexcitation induced by the cold pressor test (CPT). We investigated the effects of citrulline alone (CIT) and combined with the antioxidant glutathione (CIT+GSH) on vascular function. Forty-four healthy PMW were randomized to CIT (6 g), CIT+GSH (2 g + 200 mg: Setria®) or placebo (PL) for 4 weeks. Brachial artery flow-mediated dilation (FMD), aortic stiffness (pulse wave velocity, PWV), brachial and aortic BP reactivity to CPT, and serum fasting blood glucose (FBG), ARG, and ARG/ADMA ratio were measured. Baseline FBG was higher in CIT+GSH vs. PL. FMD increased after CIT+GSH vs. PL (p < 0.05). CIT and CIT+GSH increased ARG/ADMA (p < 0.05), but did not affect aortic PWV. CIT+GSH attenuated the brachial and aortic systolic BP and mean arterial pressure (MAP) responses to CPT vs. PL and CIT (p < 0.05). The improvements in FMD were related to baseline FMD (r = -0.39, p < 0.05) and aortic MAP response to CPT (r = -0.33, p < 0.05). This study showed that CIT+GSH improved FMD and attenuated systolic BP and MAP reactivity in PMW. Although CIT increased ARG/ADMA, it did not improve FMD in healthy PMW.
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Affiliation(s)
- Arturo Figueroa
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Arun Maharaj
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Yejin Kang
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Katherine N Dillon
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Mauricio A Martinez
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Masahiko Morita
- Research & Development Division, KIRIN Central Research Institute, Kirin Holdings Co., Ltd., 2-26-1, Muraoka-Higashi, Fujisawa 251-8555, Kanagawa, Japan
| | - Dai Nogimura
- Research & Development Division, KIRIN Central Research Institute, Kirin Holdings Co., Ltd., 2-26-1, Muraoka-Higashi, Fujisawa 251-8555, Kanagawa, Japan
| | - Stephen M Fischer
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
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Alipoor E, Mohammad Hosseinzadeh F, Hosseinzadeh-Attar MJ. Adipokines in critical illness: A review of the evidence and knowledge gaps. Biomed Pharmacother 2018; 108:1739-1750. [PMID: 30372877 DOI: 10.1016/j.biopha.2018.09.165] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/28/2022] Open
Abstract
Adipose tissue products or adipokines play a major role in chronic endocrine and metabolic disorders; however, little is known about critical conditions. In this article, the experimental and clinical evidence of alterations of adipokines, adiponectin, leptin, resistin, visfatin, asymmetric dimethylarginine (ADMA), and ghrelin in critical illness, their potential metabolic, diagnostic, and prognostic value, and the gaps in the field have been reviewed. The results showed considerable changes in the concentration of the adipokines; while the impact of adipokines on metabolic disorders such as insulin resistance and inflammation has not been well documented in critically ill patients. There is no consensus about the circulatory and functional changes of leptin and adiponectin. However, it seems that lower concentrations of adiponectin at admission with gradual consequent increase might be a useful pattern in determining better outcomes of critical illness. Some evidence has suggested the adverse effects of elevated resistin concentration, potential prognostic importance of visfatin, and therapeutic value of ghrelin. High ADMA levels and low arginine:ADMA ratio were also proposed as predictors of ICU mortality and morbidities. However, there is no consensus on these findings. Although primary data indicated the role of adipokines in critical illness, further studies are required to clarify whether the reason of these changes is pathophysiological or compensatory. The relationship of pathophysiological background, disease severity, baseline nutritional status and nutrition support during hospitalization, and variations in body fat percentage and distribution with adipokines, as well as the potential prognostic or therapeutic role of these peptides should be further investigated in critically ill patients.
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Affiliation(s)
- Elham Alipoor
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran; Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mohammad Hosseinzadeh
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Hosseinzadeh-Attar
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran; Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.
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Köster LS, Peda A, Fraites T, Sithole F. A preliminary investigation into the prognostic relevance of symmetric dimethylarginine in critically ill dogs. J Vet Emerg Crit Care (San Antonio) 2018; 28:527-531. [PMID: 30302896 DOI: 10.1111/vec.12780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 12/23/2016] [Accepted: 12/30/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine if there is an association between the concentration of symmetric dimethylarginine (SDMA) in dogs measured at the time of admission with the severity of critical illness and short-term mortality. DESIGN This prospective observational study recruited critically ill dogs with heterogeneous diagnoses and then classified their disease severity using the acute patient physiologic and laboratory evaluation complete score as having either a good (<30) or poor (≥30) prognosis. SETTING This study was conducted at Ross University Veterinary Clinic between January and November 2015. ANIMALS After exclusion of dogs diagnosed with acute kidney injury, 22 critically ill dogs and 7 control dogs were included in the study. INTERVENTIONS Each dog was assigned an acute patient physiologic and laboratory evaluation score calculated by the summation of individual scores allocated to selected clinical, focused assessment by sonography, hematological, and biochemistry results. Plasma SDMA concentrations were measured for all dogs at the time of admission. MEASUREMENT AND MAIN RESULTS There was no difference identified in SDMA concentrations between dogs with a severe category of disease as compared to mild to moderate category, or critically ill dogs compared to control dogs. There was also no difference identified in SDMA concentrations in survivors as compared to nonsurvivors. Similarly, SDMA concentration was not higher in nonsurvivors than in survivors (P = 0.968). In this population of dogs, SDMA was not a prognostic indicator. CONCLUSION Further work may be warranted in specific populations of animals but based upon this work SDMA is likely of little relevance.
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Affiliation(s)
- Liza Sally Köster
- Center for Integrative Mammalian Research, Clinical Sciences, Ross University School of Veterinary Medicine, Basseterre, St Kitts and Nevis, West Indies
| | - Andrea Peda
- Ross University Veterinary Clinic, Ross University School of Veterinary Medicine, Basseterre, St Kitts and Nevis, West Indies
| | - Trellor Fraites
- Laboratory Services, Ross University School of Veterinary Medicine, Basseterre, St Kitts and Nevis, West Indies
| | - Fortune Sithole
- One Health Center for Zoonosis and Tropical Veterinary Medicine, Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, St Kitts and Nevis, West Indies
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Asymmetric Dimethyl Arginine as a Biomarker of Atherosclerosis in Rheumatoid Arthritis. Mediators Inflamm 2018; 2018:3897295. [PMID: 29576746 PMCID: PMC5822828 DOI: 10.1155/2018/3897295] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease is the main cause of morbidity and mortality in rheumatoid arthritis (RA). Despite the advent on new drugs targeting the articular manifestations, the burden of cardiovascular disease is still an unmet need in the management of RA. The pathophysiology of accelerated atherosclerosis associated to RA is not yet fully understood, and reliable and specific markers of early cardiovascular involvement are still lacking. Asymmetric dimethylarginine is gaining attention for its implication in the pathogenesis of endothelial dysfunction and as biomarkers of subclinical atherosclerosis. Moreover, the metabolic pathway of methylarginines offers possible targets for therapeutic interventions to decrease the cardiovascular risk. The purpose of this review is to describe the main causes of increased methylarginine levels in RA, their implication in accelerated atherosclerosis, the possible role as biomarkers of cardiovascular risk, and finally the available data on current pharmacological treatment.
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Andrade F, López-Suárez O, Llarena M, Couce ML, Aldámiz-Echevarría L. Influence of phenylketonuria's diet on dimethylated arginines and methylation cycle. Medicine (Baltimore) 2017; 96:e7392. [PMID: 28682891 PMCID: PMC5502164 DOI: 10.1097/md.0000000000007392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Phenylketonuria's (PKU) treatment based on low natural protein diet may affect homocysteine (Hcys) metabolic pathway. Hcys alteration may be related to the methylation of arginine to asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which both modify nitric oxide production. The aim of this work is to evaluate the status of Hcys formation methylation cycle and ADMA and SDMA levels in patients with PKU in order to establish a potential relationship.Forty-two early diagnosed PKU patients under dietary treatment and good adherence to their diets were enrolled in this cross-sectional study. Their nutritional and biochemical profile, as well as Hcys synthesis status, ADMA and SDMA levels were analyzed and compared with a control group of 40 healthy volunteers. ADMA and SDMA were determined by high-performance liquid chromatography system coupled to triple quadrupole mass spectrometer.In this study, 23 classic PKU, 16 moderate PKU, and 3 mild HPA were enrolled. The median age was 10 years old. Median ADMA, SDMA, and Hcys concentration levels (5.1 μM [2.3-25.7], 0.35 μM [0.18-0.57], 0.43 μM [0.26-0.61], respectively) were lower in patients with PKU (P < .001 for ADMA and SDMA) whereas vitamin B12 and folate levels (616 pg/mL [218-1943] and 21 ng/mL [5-51], respectively) were higher comparing with controls. Statistically significant correlations were found between ADMA, and Phe (r = -0.504, P = .001) and Hcys (r = -0.458, P = .037) levels. Several nutrition biomarkers, such as prealbumin, 25-hydroxy vitamin D, selenium, and zinc, were below the normal range.Our study suggests that patients with PKU suffer from poor methylation capacity. Restriction of natural proteins in addition to high intake of vitamin B12 and folic acid supplementation in the dietary products, produce an impairment of methylation cycle that leads to low Hcys and ADMA levels. As a result, methylated compounds compete for methyl groups, and there is an impairment of methylation cycle due to low Hcys levels, which is related to the lack of protein quality, despite of elevated concentrations of cofactors.
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Affiliation(s)
- Fernando Andrade
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
| | - Olalla López-Suárez
- Metabolic Disorders Unit, Santiago de Compostela University Hospital, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Marta Llarena
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
| | - María L. Couce
- Metabolic Disorders Unit, Santiago de Compostela University Hospital, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Luis Aldámiz-Echevarría
- Unit of Metabolism, BioCruces Health Research Institute, CIBER de Enfermedades Raras (CIBERER), Barakaldo
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Ghashut RA, Blackwell S, Ryan S, Willox L, McMillan DC, Kinsella J, Talwar D. Assessment of asymmetrical dimethylarginine metabolism in patients with critical illness. Eur J Clin Invest 2017; 47:279-288. [PMID: 27930821 DOI: 10.1111/eci.12710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 12/01/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Critically ill patients experience metabolic disorders including hypercatabolic state and hyperglycaemia, and these are associated with poor outcome. Hyperglycaemia and asymmetrical dimethylarginine (ADMA) are reported to have significant influences on endothelial dysfunction. The aim of this study was to examine the relationship between plasma ADMA and related arginine metabolism in patients with critical illness. MATERIALS AND METHOSDS Two venous blood samples (EDTA) (104 patients), on admission and follow-up sample in the last day in intensive care unit (ICU) (died or discharge sample median 7, interquartile range (IQR) 6-8, range 5-15). Plasma ADMA, arginine, homoarginine and SDMA were measured by high-performance liquid chromatography (HPLC). RESULT ADMA (P < 0·01) and SDMA (P < 0·05) were elevated, and homoarginine was decreased (P < 0·05) in nonsurvivors and was directly associated with predicted mortality rate (P < 0·05 and P < 0·001), Sequential Organ Failure Assessment (SOFA) (P < 0·05, P < 0·001), ICU stay (P < 0·05, P < 0·001) and mortality (P < 0·01, P < 0·05). ADMA was directly associated with SDMA (P < 0·001), albumin (P < 0·05), ICU stay and mortality (P < 0·01). SDMA was directly associated with creatinine (P < 0·001) and Acute physiology and Chronic Health Evaluation II score (P < 0·001). In the follow-up measurements, there was a significant decrease in SOFA score (P < 0·01), homoarginine (P < 0·01), aminotransferase (P < 0·01), Laboratory Glucose (P < 0·01) and albumin (P < 0·01). In contrast, there was an increase in arginine (P < 0·01), ADMA (P < 0·01), ADMA:SDMA ratio (P < 0·01) and the norepinephrine administration (P < 0·01). CONCLUSION In the present longitudinal study, ADMA metabolism was altered in patients with critical illness and was associated with disease severity and mortality.
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Affiliation(s)
- Rawia A Ghashut
- Academic Unit of Anaesthesia, College of Medical, Veterinary and Life of Sciences - University of Glasgow, Royal Infirmary, Glasgow, UK.,Academic Unit of Surgery, College of Medical, Veterinary and Life of Sciences - University of Glasgow, Royal Infirmary, Glasgow, UK
| | - Scott Blackwell
- Department of Biochemistry, The Scottish Trace Element and Micronutrient Reference Laboratory, Royal Infirmary, Glasgow, UK
| | - Sylvia Ryan
- Department of Biochemistry, The Scottish Trace Element and Micronutrient Reference Laboratory, Royal Infirmary, Glasgow, UK
| | - Laura Willox
- Department of Biochemistry, The Scottish Trace Element and Micronutrient Reference Laboratory, Royal Infirmary, Glasgow, UK
| | - Donald C McMillan
- Academic Unit of Surgery, College of Medical, Veterinary and Life of Sciences - University of Glasgow, Royal Infirmary, Glasgow, UK
| | - John Kinsella
- Academic Unit of Anaesthesia, College of Medical, Veterinary and Life of Sciences - University of Glasgow, Royal Infirmary, Glasgow, UK
| | - Dinesh Talwar
- Department of Biochemistry, The Scottish Trace Element and Micronutrient Reference Laboratory, Royal Infirmary, Glasgow, UK
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Poniedziałek-Czajkowska E, Mierzyński R, Szymula D, Leszczyńska-Gorzelak B, Oleszczuk J. Intercellular Adhesion Molecule and Endogenous NOS Inhibitor: Asymmetric Dimethylarginine in Pregnant Women with Gestational Diabetes Mellitus. J Diabetes Res 2016; 2016:1342643. [PMID: 26981539 PMCID: PMC4766337 DOI: 10.1155/2016/1342643] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/08/2016] [Accepted: 01/13/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aim of the study was to evaluate the concentrations of soluble intercellular adhesion molecule-1 (s-ICAM-1) and endogenous NOS inhibitor, asymmetric dimethylarginine (ADMA), as markers of endothelium dysfunction in patients with gestational diabetes mellitus (GDM). PATIENTS AND METHODS The levels of s-ICAM-1 and ADMA were analysed in the group of 56 patients with GDM and compared to 25 healthy pregnant women. The concentrations of s-ICAM-1 and ADMA were measured in serum using ELISA tests. RESULTS The groups did not differ by baseline descriptors: age (30.75 ± 6.32 versus 28.50 ± 4.95 years, NS) and gestational age (28.96 ± 2.85 versus 29.12 ± 2.96 hbd, NS). The patients with GDM were more obese (BMI 27.93 ± 7.02 versus 22.34 ± 4.21 kg/m(2), p = 0.032) and had higher concentration of C-reactive protein (6.46 ± 6.03 versus 3.18 ± 3.83 mg/L, p = 0.029). In the GDM group the level of ADMA was lower (0.38 ± 0.17 versus 0.60 ± 0.28 μmol/L, p = 0.001) and the level of s-ICAM-1 was significantly higher (289.95 ± 118.12 versus 232.56 ± 43.31 ng/mL, p = 0.036) compared to controls. CONCLUSIONS The pregnant women with GDM are characterized by higher concentration of s-ICAM-1 that reflects the activation and dysfunction of the endothelial cells. The decreased ADMA level in GDM patients seems to be preventive in the limitation of NO synthesis caused by the impaired insulin action and the endothelial dysfunction.
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Affiliation(s)
| | - Radzisław Mierzyński
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- *Radzisław Mierzyński:
| | - Dariusz Szymula
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Bożena Leszczyńska-Gorzelak
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Jan Oleszczuk
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
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The l-arginine/NO pathway, homoarginine, and nitrite-dependent renal carbonic anhydrase activity in young people with type 1 diabetes mellitus. Amino Acids 2015; 47:1865-74. [DOI: 10.1007/s00726-015-2027-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/10/2015] [Indexed: 02/05/2023]
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Takaya J, Tanabe Y, Kuroyanagi Y, Kaneko K. Asymmetric dimethylarginine is negatively correlated with hyperglycemia in children. Endocr J 2015; 62:551-6. [PMID: 25903645 DOI: 10.1507/endocrj.ej14-0521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Asymmetric dimethylarginine (ADMA) is a nonselective nitric oxide (NO) synthase inhibitor associated with cardiovascular and metabolic disorders. In several prospective and cross-sectional studies, ADMA has evolved as a marker of cardiovascular risk. However, there is limited information on this serum marker in young people, particularly in those with obesity, type 1 diabetes (DM1) and type 2 diabetes (DM2). We investigated ADMA concentrations in children and adolescents with hyperglycemia as compared with healthy age- and sex-matched individuals. The subjects were 21 simple obesity [male 13, female 8; aged 11.7±4.3 years], 18 with DM1 [male 4, female 14; aged 12.9±4.2 years, duration of disease 3.4±2.1 years], 10 with DM2 [male 5, female 5; aged 13.9±3.4 years, duration of disease 2.8±1.4 years] and 21 controls [male 12, female 9; aged 11.1±2.7 years]. ADMA levels were analyzed in a cross-sectional study. Concentrations of serum ADMA were determined using an enzyme-linked immunosorbent assay. Circulating levels of ADMA were significantly lower in subjects with DM1, DM2 or obesity. In all subjects, ADMA levels were inversely correlated with glycated hemoglobin A1c concentrations (r=-0.401, p=0.0003) and serum glucose levels (r=-0.341, p=0.0023). Low circulating ADMA levels are directly associated with glucose levels, suggesting that ADMA production is suppressed in childhood in order to compensate and protect vasculopathy due to hyperglycemia.
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Affiliation(s)
- Junji Takaya
- Department of Pediatrics, Kawachi General Hospital, Higashi-Osaka 578-0954, Japan
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11
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Plasma arginine/ADMA ratio as a sensitive risk marker for atherosclerosis: Shimane CoHRE study. Atherosclerosis 2014; 239:61-6. [PMID: 25576847 DOI: 10.1016/j.atherosclerosis.2014.12.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/26/2014] [Accepted: 12/17/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Asymmetric dimethylarginine (ADMA), which acts an endogenous inhibitor of nitric oxide synthase (NOS), is involved in the pathogenesis of cardiovascular disease. Arginine (Arg) may regulate vascular endothelial function, since Arg is the substrate of NO competing with ADMA. In our previous study, low Arg/ADMA ratio is an independent risk for microangiopathy-related cerebral damage. PURPOSE Here, we performed a cross-sectional study to evaluate the association between the Arg/ADMA ratio and the maximal intima-media thickness (IMT) in the carotid artery. SUBJECTS AND METHODS Participants were 785 community-dwelling Japanese people without any severe disorders. Plasma concentration of Arg and ADMA in fasting blood sample was determined using HPLC. IMT was measured in the bilateral carotid artery by ultrasonography. RESULTS Among quartiles stratified by the Arg/ADMA ratio, ANOVA showed a significant difference in IMT and the IMT in Q1 (the lowest quartile) was significantly higher than that in Q4 (the highest quartile). In multiple linear regression analysis, age, the male gender, lower BMI, the presence of hypertension and lower Arg/ADMA ratio were independently correlated with IMT, while IMT was not correlated with Arg or ADMA alone. In addition, the Arg/ADMA ratio was associated with IMT independent of age, sex, BMI and the presence of hypertension with odds ratio 0.21 (95%CI: 0.05-0.88) in multiple logistic regression analysis for IMT 1.5 mm or more. CONCLUSION Imbalance of Arg and ADMA is independently involved in the progression of atherosclerosis, and the Arg/ADMA ratio may be a sensitive marker for atherosclerosis.
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12
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Claes KJ, Bammens B, Kuypers DR, Meijers B, Naesens M, Sprangers B, Vanrenterghem Y, Lerut E, de Loor H, Evenepoel P. Time course of asymmetric dimethylarginine and symmetric dimethylarginine levels after successful renal transplantation. Nephrol Dial Transplant 2014; 29:1965-72. [PMID: 24957811 DOI: 10.1093/ndt/gfu219] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although renal transplantation (Tx) improves the outcome of patients with renal disease, cardiovascular (CV) risk remains high. Recently, it was demonstrated that asymmetric dimethylarginine (ADMA) levels predict CV events and graft survival in renal transplant recipients (RTRs). Little is known about the impact of renal Tx on the plasma levels of ADMA and symmetric dimethylarginine (SDMA). The present study aimed to define the time course of ADMA and SDMA after Tx. METHODS We prospectively followed 167 incident RTRs with visits at the time of Tx and 3 and 12 months thereafter. At all visits, demographics and relevant biochemistry were recorded and blood was sampled for analysis of ADMA and SDMA (high-performance liquid chromatography). Eighty-four patients had an additional sampling in the immediate postoperative period. In a case-controlled substudy (n = 31), we compared ADMA and SDMA levels between RTRs and chronic kidney disease (CKD) patients, matched for glomerular filtration rate, gender, age, CV history and diabetes. RESULTS Overall, plasma ADMA and SDMA levels decreased after Tx. The decline of SDMA was more pronounced and paralleled the recovery of renal function. Interestingly, the decline of ADMA was preceded by an increase in the immediate postoperative period. In the case-controlled substudy, SDMA levels were similar, whereas ADMA levels were significantly higher in RTRs compared with the CKD counterparts (P = 0.003). CONCLUSION ADMA levels follow a biphasic pattern after successful renal Tx with a transient rise in the immediate postoperative period followed by a decline. Levels remain elevated compared with CKD patients, matched for age, gender, diabetes, CV history and renal function.
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Affiliation(s)
- Kathleen J Claes
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Bert Bammens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Dirk R Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Björn Meijers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Yves Vanrenterghem
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Henriette de Loor
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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Brinkmann SJH, de Boer MC, Buijs N, van Leeuwen PAM. Asymmetric dimethylarginine and critical illness. Curr Opin Clin Nutr Metab Care 2014; 17:90-7. [PMID: 24281375 DOI: 10.1097/mco.0000000000000020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Asymmetric dimethylarginine (ADMA) is an analog of arginine and functions as an endogenous inhibitor of the nitric oxide synthase, which forms nitric oxide. Nitric oxide is crucial for perfusion of vital organs and is an important signaling agent in the development of critical illness. The role of ADMA in the pathophysiological mechanisms underlying critical illness is widely studied in the last decades, and recently it has become clear that ADMA should not be overlooked by clinicians working at the ICU. The aim of this review is to describe new insights into the role of ADMA in critical illness and its clinical relevance. RECENT FINDINGS High levels of ADMA are found in critically ill patients, because of higher levels of protein methylation, increased rate of protein turnover, decreased activity of dimethylamine dimethylaminohydrolase, and impaired renal and hepatic clearance capacity. These high levels are an independent risk factor for cardiac dysfunction, organ failure, and ICU mortality. The arginine : ADMA ratio in particular is of clinical importance and the restoration of this ratio is expedient to restore several functions that are disturbed during critical illness. SUMMARY Elevated ADMA levels occur in critically ill patients, which is detrimental for morbidity and mortality. The arginine : ADMA ratio should be restored to maintain nitric oxide production and therewith improve the clinical outcome of the patient.
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Affiliation(s)
- Saskia J H Brinkmann
- aDepartment of Plastic and Reconstructive Surgery bDepartment of Surgery, VU University Medical Center, Amsterdam, the Netherlands
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Anderssohn M, McLachlan S, Lüneburg N, Robertson C, Schwedhelm E, Williamson RM, Strachan MWJ, Ajjan R, Grant PJ, Böger RH, Price JF. Genetic and environmental determinants of dimethylarginines and association with cardiovascular disease in patients with type 2 diabetes. Diabetes Care 2014; 37:846-54. [PMID: 24186881 DOI: 10.2337/dc13-0546] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate determinants of asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), including single nucleotide polymorphisms (SNPs), in the DDAH1, DDAH2, and AGXT2 genes and their associations with prevalent and incident cardiovascular disease (CVD) in older adults with type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS Prevalent CVD was assessed in men and women aged 60-75 years with type 2 diabetes as part of the Edinburgh Type 2 Diabetes Study (ET2DS), and the participants were prospectively followed up for 4 years for incident CVD. Dimethylarginines were measured in 783 of these subjects, and genotyping for tag SNPs in the DDAH1, DDAH2, and AGXT2 genes was performed in 935 subjects. RESULTS Plasma ADMA levels were significantly associated with SNPs in DDAH1 (top SNP rs1554597; P = 9.0E-09), while SDMA levels were associated with SNPs in AGXT2 (top SNP rs28305; P = 1.3E-04). Significant, independent determinants of plasma ADMA were sex, L-arginine, creatinine, fasting glucose, and rs1554597 (all P < 0.05; combined R(2) = 0.213). Determinants of SDMA were age, sex, creatinine, L-arginine, diabetes duration, prevalent CVD, and rs28305 (all P < 0.05; combined R(2) = 0.425). Neither dimethylarginine was associated with incident CVD. None of the investigated SNPs were associated with overall CVD, although subgroup analysis revealed a significant association of AGXT2 rs28305 with intermittent claudication. CONCLUSIONS Our study in a well-characterized population with type 2 diabetes does not support reported associations or causal relationship between ADMA and features of diabetes or CVD.
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Rochette L, Lorin J, Zeller M, Guilland JC, Lorgis L, Cottin Y, Vergely C. Nitric oxide synthase inhibition and oxidative stress in cardiovascular diseases: Possible therapeutic targets? Pharmacol Ther 2013; 140:239-57. [DOI: 10.1016/j.pharmthera.2013.07.004] [Citation(s) in RCA: 269] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/14/2013] [Indexed: 12/14/2022]
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Liu H, Bao F, Irwanto A, Fu X, Lu N, Yu G, Yu Y, Sun Y, Low H, Li Y, Liany H, Yuan C, Li J, Liu J, Chen M, Liu H, Wang N, You J, Ma S, Niu G, Zhou Y, Chu T, Tian H, Chen S, Zhang X, Liu J, Zhang F. An association study of TOLL and CARD with leprosy susceptibility in Chinese population. Hum Mol Genet 2013; 22:4430-7. [PMID: 23784377 PMCID: PMC3792694 DOI: 10.1093/hmg/ddt286] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Previous genome-wide association studies (GWASs) identified multiple susceptibility loci that have highlighted the important role of TLR (Toll-like receptor) and CARD (caspase recruitment domain) genes in leprosy. A large three-stage candidate gene-based association study of 30 TLR and 47 CARD genes was performed in the leprosy samples of Chinese Han. Of 4363 SNPs investigated, eight SNPs showed suggestive association (P < 0.01) in our previously published GWAS datasets (Stage 1). Of the eight SNPs, rs2735591 and rs4889841 showed significant association (P < 0.001) in an independent series of 1504 cases and 1502 controls (Stage 2), but only rs2735591 (next to BCL10) showed significant association in the second independent series of 938 cases and 5827 controls (Stage 3). Rs2735591 showed consistent association across the three stages (P > 0.05 for heterogeneity test), significant association in the combined validation samples (Pcorrected = 5.54 × 10−4 after correction for 4363 SNPs tested) and genome-wide significance in the whole GWAS and validation samples (P = 1.03 × 10−9, OR = 1.24). In addition, we demonstrated the lower expression of BCL10 in leprosy lesions than normal skins and a significant gene connection between BCL10 and the eight previously identified leprosy loci that are associated with NFκB, a major regulator of downstream inflammatory responses, which provides further biological evidence for the association. We have discovered a novel susceptibility locus on 1p22, which implicates BCL10 as a new susceptibility gene for leprosy. Our finding highlights the important role of both innate and adaptive immune responses in leprosy.
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Affiliation(s)
- Hong Liu
- Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, Shandong, China
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Mah E, Noh SK, Ballard KD, Park HJ, Volek JS, Bruno RS. Supplementation of a γ-tocopherol-rich mixture of tocopherols in healthy men protects against vascular endothelial dysfunction induced by postprandial hyperglycemia. J Nutr Biochem 2013; 24:196-203. [DOI: 10.1016/j.jnutbio.2012.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 04/25/2012] [Accepted: 04/27/2012] [Indexed: 12/21/2022]
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Chen XM, Hu CP, Li YJ, Jiang JL. Cardiovascular risk in autoimmune disorders: role of asymmetric dimethylarginine. Eur J Pharmacol 2012; 696:5-11. [PMID: 23026371 DOI: 10.1016/j.ejphar.2012.09.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 09/04/2012] [Accepted: 09/17/2012] [Indexed: 02/08/2023]
Abstract
Mounting evidence indicates that cardiovascular events are a main cause of excessive mortality of autoimmune disorders like type I diabetes mellitus and rheumatic diseases. Inflammation and endothelial dysfunction, independent predictors to cardiovascular disease, are hallmarks of autoimmunity. Asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor, can cause or contribute to the inflammatory syndrome and endothelial dysfunction. Recently, elevated ADMA levels have been demonstrated in many autoimmune diseases, suggesting that ADMA might play an important role for the associated manifestations of cardiovascular disease. In the review, we discuss the role of ADMA in the excessive cardiovascular morbidity and mortality associated with autoimmune diseases.
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Affiliation(s)
- Xu-Meng Chen
- Department of Pharmacology, School of Pharmaceutical Sciences, Central South University, Xiang-Ya Road #110, Changsha 410078, China
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Huemer M, Simma B, Mayr D, Möslinger D, Mühl A, Schmid I, Ulmer H, Bodamer OA. Free asymmetric dimethylarginine (ADMA) is low in children and adolescents with classical phenylketonuria (PKU). J Inherit Metab Dis 2012; 35:817-21. [PMID: 22290024 DOI: 10.1007/s10545-011-9448-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 12/27/2011] [Accepted: 12/29/2011] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Free asymmetric dimethylarginine (ADMA) is a competitive inhibitor of the nitric oxide synthases (NOS). Suppression of nitric oxide (NO) synthesis increases the risk of atherosclerosis. Nevertheless, in the condition of oxidative stress, NOS blockade by ADMA may exert protective effects. Protein metabolism is altered in patients with phenylketonuria (PKU) on dietary treatment and as shown recently, oxidative stress is high in PKU. Since free ADMA concentrations are determined by both protein metabolism and oxidative stress we hypothesized, that free ADMA levels may be elevated in PKU patients. DESIGN Sixteen patientswith PKU on dietary treatment (mean age 10.1 ± 5.2 yrs), and 91 healthy children (mean age 11.6 ± 3.7 yrs) participated in a cross sectional study. RESULTS ADMA, total homocysteine (tHcy) and blood glucose were lower and the L-arginine/ADMA ratio was higher in PKU patients compared to controls. No significant correlation was present between phenylalanine (Phe) concentrations, protein intake, and lipid profile, history of cardiovascular disease or ADMA. DISCUSSION In contrast to our hypothesis, ADMAwas lower and the L-arginine/ADMA ratio was higher in PKU patients. Therefore, in PKU patients, the regulating function of ADMA on NO synthesis is altered and may thus contribute to oxidative stress.
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Affiliation(s)
- M Huemer
- Department of Pediatrics, Landeskrankenhaus Bregenz, Carl Pedenz Str. 2, 6900 Bregenz, Austria.
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Fogarty RD, Abhary S, Javadiyan S, Kasmeridis N, Petrovsky N, Whiting MJ, Craig JE, Burdon KP. Relationship between DDAH gene variants and serum ADMA level in individuals with type 1 diabetes. J Diabetes Complications 2012; 26:195-8. [PMID: 22521321 DOI: 10.1016/j.jdiacomp.2012.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 03/09/2012] [Accepted: 03/21/2012] [Indexed: 10/28/2022]
Abstract
Asymmetric dimethylarginine (ADMA) levels are elevated in diabetes and likely contribute to diabetic complications such as retinopathy and nephropathy. The DDAH enzymes are primarily responsible for ADMA metabolism. Polymorphisms in the dimethylarginine dimethylaminohydrolase (DDAH) 1 and 2 genes have been previously associated with serum ADMA levels in type 2 diabetes (T2DM). We sought to determine whether they are also associated with ADMA levels in individuals with type 1 diabetes (T1DM). Serum ADMA concentrations were measured in 196 individuals with T1DM. Twenty-six tag SNPs in the DDAH1 gene and 10 in the DDAH2 gene were genotyped. One SNP in the DDAH1 gene (rs3738111) and one in the DDAH2 gene (rs805293) showed a correlation with serum ADMA levels; however, neither survived correction for multiple testing. We found limited evidence that genetic polymorphisms in DDAH genes influence serum ADMA levels in individuals with T1DM. This differs to findings in T2DM and may be due to underlying differences in the cohorts or to fundamental differences in the pathogenesis of the two types of diabetes.
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Affiliation(s)
- Rhys D Fogarty
- Department of Ophthalmology, Flinders Medical Centre and Flinders University, South Australia, Australia
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21
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Davids M, Richir MC, Visser M, Ellger B, van den Berghe G, van Leeuwen PAM, Teerlink T. Role of dimethylarginine dimethylaminohydrolase activity in regulation of tissue and plasma concentrations of asymmetric dimethylarginine in an animal model of prolonged critical illness. Metabolism 2012; 61:482-90. [PMID: 22000584 DOI: 10.1016/j.metabol.2011.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 08/16/2011] [Accepted: 08/18/2011] [Indexed: 12/26/2022]
Abstract
High plasma concentrations of asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor, are associated with adverse outcome in critically ill patients. Asymmetric dimethylarginine is released within cells during proteolysis of methylated proteins and is either degraded by dimethylarginine dimethylaminohydrolase (DDAH) or exported to the circulation via cationic amino acid transporters. We aimed to establish the role of DDAH activity in the regulation of tissue and plasma concentrations of ADMA. In 33 critically ill rabbits, we measured DDAH activity in kidney, liver, heart, and skeletal muscle and related these values to concentrations of ADMA in these tissues and in the circulation. Both DDAH activity and ADMA concentration were highest in kidney and lowest in skeletal muscle, with intermediate values for liver and heart. Whereas ADMA content was significantly correlated between tissues (r = 0.40-0.78), DDAH activity was not. Significant inverse associations between DDAH activity and ADMA content were only observed in heart and liver. Plasma ADMA was significantly associated with ADMA in the liver (r = 0.41), but not in the other tissues. In a multivariable regression model, DDAH activities in muscle, kidney, and liver, but not in heart, were negatively associated with plasma ADMA concentration, together explaining approximately 50% of its variation. In critical illness, plasma ADMA poorly reflects intracellular ADMA. Furthermore, tissue DDAH activity is a stronger predictor of plasma ADMA than of intracellular ADMA, indicating that, compared with DDAH activity, generation of ADMA and cationic amino acid transporter-mediated exchange may be more important regulators of intracellular ADMA.
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Affiliation(s)
- Mariska Davids
- Metabolic Laboratory, Department of Clinical Chemistry, VU University Medical Center, PO Box 7057, 1007MB Amsterdam, The Netherlands
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Hewett JN, Rodgers GW, Chase JG, Le Compte AJ, Pretty CG, Shaw GM. Assessment of SOFA Score as a Diagnostic Indicator in Intensive Care Medicine. ACTA ACUST UNITED AC 2012. [DOI: 10.3182/20120829-3-hu-2029.00035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Archer JRH, Misra S, Simmgen M, Jones PW, Baker EH. Phase II study of tight glycaemic control in COPD patients with exacerbations admitted to the acute medical unit. BMJ Open 2011; 1:e000210. [PMID: 22021788 PMCID: PMC3191583 DOI: 10.1136/bmjopen-2011-000210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Hyperglycaemia is associated with poor outcomes from exacerbations of chronic obstructive pulmonary disease (COPD). Glycaemic control could improve outcomes by reducing infection, inflammation and myopathy. Most patients with COPD are managed on the acute medical unit (AMU) outside intensive care (ICU). OBJECTIVE To determine the feasibility, safety and efficacy of tight glycaemic control in patients on an AMU. DESIGN Prospective, non-randomised, phase II, single-arm study of tight glycaemic control in COPD patients with acute exacerbations and hyperglycaemia admitted to the AMU. Participants received intravenous, then subcutaneous, insulin to control blood glucose to 4.4-6.5 mmol/l. Tight glycaemic control was evaluated: feasibility, protocol adherence; acceptability, patient questionnaire; safety, frequency of hypoglycaemia (capillary blood glucose (CBG) <2.2 mmol/l and 2.2-3.3 mmol/l); efficacy, median CBG, fasting CBG, proportion of measurements/time in target range, glycaemic variability. RESULTS were compared with 25 published ICU studies. Results 20 patients (10 females, age 71 ± 9 years; forced expiratory volume in 1 s: 41 ± 16% predicted) were recruited. Tight glycaemic control was feasible (78% CBG measurements and 89% of insulin-dose adjustments were adherent to protocol) and acceptable to patients. 0.2% CBG measurements were <2.2 mmol/l and 4.1% measurements 2.2-3.3 mmol/l. The study CBG and proportion of measurements/time in target range were similar to that of ICU studies, whereas the fasting CBG was lower, and the glycaemic variability was greater. CONCLUSIONS Tight glycaemic control is feasible and has similar safety and efficacy on AMU to ICU. However, as more recent ICU studies have shown no benefit and possible harm from tight glycaemic control, alternative strategies for blood glucose control in COPD exacerbations should now be explored. Trial registration number ISRCTN: 42412334. http://Clinical.Trials.gov NCT00764556.
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Affiliation(s)
- John R H Archer
- Division of Biomedical Science, St. George's, University of London, London, UK
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Ellahham S. Molecular mechanisms of hyperglycemia and cardiovascular-related events in critically ill patients: rationale for the clinical benefits of insulin therapy. Clin Epidemiol 2010; 2:281-8. [PMID: 21270967 PMCID: PMC3024895 DOI: 10.2147/clep.s15162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Newly recognized hyperglycemia frequently occurs with acute medical illness, especially among patients with cardiovascular disease (CVD). Hyperglycemia has been linked to increased morbidity and mortality in critically ill patients, especially when it is newly recognized. Increased rates of reinfarction, rehospitalization, major cardiovascular events, and death in CVD patients have also been found. An expanding body of literature describes the benefits of normalizing hyperglycemia with insulin therapy in hospitalized patients. This article reviews several underlying mechanisms thought to be responsible for the association between hyperglycemia and poor outcomes in critically ill patients and those with cardiovascular events, as well as the biologic rationale for the benefits of insulin therapy in these patients.
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Affiliation(s)
- Samer Ellahham
- Paragon Cardiovascular Foundation, Falls Church, VA, USA
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25
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Levy B, Collin S, Sennoun N, Ducrocq N, Kimmoun A, Asfar P, Perez P, Meziani F. Vascular hyporesponsiveness to vasopressors in septic shock: from bench to bedside. Intensive Care Med 2010; 36:2019-29. [PMID: 20862451 DOI: 10.1007/s00134-010-2045-8] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 08/24/2010] [Indexed: 01/20/2023]
Abstract
PURPOSE To delineate some of the characteristics of septic vascular hypotension, to assess the most commonly cited and reported underlying mechanisms of vascular hyporesponsiveness to vasoconstrictors in sepsis, and to briefly outline current therapeutic strategies and possible future approaches. METHODS Source data were obtained from a PubMed search of the medical literature with the following MeSH terms: Muscle, smooth, vascular/physiopathology; hypotension/etiology; shock/physiopathology; vasodilation/physiology; shock/therapy; vasoconstrictor agents. RESULTS Nitric oxide (NO) and peroxynitrite are crucial components implicated in vasoplegia and vascular hyporeactivity. Vascular ATP-sensitive and calcium-activated potassium channels are activated during shock and participate in hypotension. In addition, shock state is characterized by inappropriately low plasma glucocorticoid and vasopressin concentrations, a dysfunction and desensitization of alpha-receptors, and an inactivation of catecholamines by oxidation. Numerous other mechanisms have been individualized in animal models, the great majority of which involve NO: MEK1/2-ERK1/2 pathway, H(2)S, hyperglycemia, and cytoskeleton dysregulation associated with decreased actin expression. CONCLUSIONS Many therapeutic approaches have proven their efficiency in animal models, especially therapies directed against one particular compound, but have otherwise failed when used in human shock. Nevertheless, high doses of catecholamines, vasopressin and terlipressin, hydrocortisone, activated protein C, and non-specific shock treatment have demonstrated a partial efficiency in reversing sepsis-induced hypotension.
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Affiliation(s)
- B Levy
- Groupe Choc, Contrat Avenir INSERM 2006, Faculté de Médecine, Nancy Université, 9 Avenue de la Forêt de Haye, BP 184, Vandœuvre-lès-Nancy Cedex, 54505, France.
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26
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Chase JG, Pretty CG, Pfeifer L, Shaw GM, Preiser JC, Le Compte AJ, Lin J, Hewett D, Moorhead KT, Desaive T. Organ failure and tight glycemic control in the SPRINT study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R154. [PMID: 20704712 PMCID: PMC2945138 DOI: 10.1186/cc9224] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 06/30/2010] [Accepted: 08/12/2010] [Indexed: 02/06/2023]
Abstract
Introduction Intensive care unit mortality is strongly associated with organ failure rate and severity. The sequential organ failure assessment (SOFA) score is used to evaluate the impact of a successful tight glycemic control (TGC) intervention (SPRINT) on organ failure, morbidity, and thus mortality. Methods A retrospective analysis of 371 patients (3,356 days) on SPRINT (August 2005 - April 2007) and 413 retrospective patients (3,211 days) from two years prior, matched by Acute Physiology and Chronic Health Evaluation (APACHE) III. SOFA is calculated daily for each patient. The effect of the SPRINT TGC intervention is assessed by comparing the percentage of patients with SOFA ≤5 each day and its trends over time and cohort/group. Organ-failure free days (all SOFA components ≤2) and number of organ failures (SOFA components >2) are also compared. Cumulative time in 4.0 to 7.0 mmol/L band (cTIB) was evaluated daily to link tightness and consistency of TGC (cTIB ≥0.5) to SOFA ≤5 using conditional and joint probabilities. Results Admission and maximum SOFA scores were similar (P = 0.20; P = 0.76), with similar time to maximum (median: one day; IQR: [1,3] days; P = 0.99). Median length of stay was similar (4.1 days SPRINT and 3.8 days Pre-SPRINT; P = 0.94). The percentage of patients with SOFA ≤5 is different over the first 14 days (P = 0.016), rising to approximately 75% for Pre-SPRINT and approximately 85% for SPRINT, with clear separation after two days. Organ-failure-free days were different (SPRINT = 41.6%; Pre-SPRINT = 36.5%; P < 0.0001) as were the percent of total possible organ failures (SPRINT = 16.0%; Pre-SPRINT = 19.0%; P < 0.0001). By Day 3 over 90% of SPRINT patients had cTIB ≥0.5 (37% Pre-SPRINT) reaching 100% by Day 7 (50% Pre-SPRINT). Conditional and joint probabilities indicate tighter, more consistent TGC under SPRINT (cTIB ≥0.5) increased the likelihood SOFA ≤5. Conclusions SPRINT TGC resolved organ failure faster, and for more patients, from similar admission and maximum SOFA scores, than conventional control. These reductions mirror the reduced mortality with SPRINT. The cTIB ≥0.5 metric provides a first benchmark linking TGC quality to organ failure. These results support other physiological and clinical results indicating the role tight, consistent TGC can play in reducing organ failure, morbidity and mortality, and should be validated on data from randomised trials.
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Affiliation(s)
- J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, Private Bag, New Zealand.
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Anderssohn M, Schwedhelm E, Lüneburg N, Vasan RS, Böger RH. Asymmetric dimethylarginine as a mediator of vascular dysfunction and a marker of cardiovascular disease and mortality: an intriguing interaction with diabetes mellitus. Diab Vasc Dis Res 2010; 7:105-18. [PMID: 20382774 DOI: 10.1177/1479164110366053] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Asymmetric dimethylarginine (ADMA) has evolved as an important regulator of nitric oxide (NO) synthesis in recent years. Elevated levels of ADMA have been reported in many conditions associated with a high cardiovascular risk. Moreover, ADMA is a biomarker for major cardiovascular events and mortality in cohorts with high, intermediate and low overall cardiovascular risk. Discrepant data have been reported on cardiovascular risk in people with and without diabetes mellitus, and the association of ADMA with diabetes mellitus per se has also remained controversial, possibly relating to type and stage of diabetes. Clinical and experimental data suggest that there is a multifaceted link between ADMA and insulin metabolism and action on one hand, and ADMA and glucose utilisation on the other. This interplay may be regulated by the enzyme involved in the metabolic degradation of ADMA, dimethylarginine dimethylaminohydrolase (DDAH). Recent data from prospective clinical studies suggest that whilst ADMA may be a marker for total mortality in patients without diabetes, elevated ADMA may exert beneficial effects in patients with diabetes. In this respect, ADMA could serve as a re-coupling agent overcoming endothelial nitric oxide synthase (eNOS) uncoupling in patients with diabetes. Anticipated advances in clinical and experimental investigation will help us to better understand this complex interrelationship between diabetes, eNOS, DDAH and ADMA.
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Affiliation(s)
- Maike Anderssohn
- Clinical Pharmacology Unit, Institute of Experimental and Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Vanhorebeek I, Langouche L. Molecular mechanisms behind clinical benefits of intensive insulin therapy during critical illness: glucose versus insulin. Best Pract Res Clin Anaesthesiol 2010; 23:449-59. [PMID: 20108584 DOI: 10.1016/j.bpa.2009.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
High blood glucose levels have been associated with morbidity and poor outcome in critically ill patients, irrespective of underlying pathology. In a large, randomised, controlled study the use of insulin therapy to maintain normoglycaemia for at least a few days improved survival and reduced morbidity of patients who are in a surgical intensive care unit (ICU). Since the publication of this landmark study, several other investigators have provided support for, whereas others have questioned, the beneficial effects of intensive insulin therapy. In this review, we discuss the investigated potential molecular mechanisms behind the clinical benefits of intensive insulin therapy. We first describe the molecular origin of hyperglycaemia and the impact of the therapy on insulin sensitivity. Next, the molecular basis of glucose toxicity in critical illness and the impact of intensive insulin therapy hereon are described, as well as other non-glucose-toxicity-related metabolic effects of intensive insulin therapy.
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Affiliation(s)
- Ilse Vanhorebeek
- Department of Intensive Care Medicine, Katholieke Universiteit Leuven, B-3000 Leuven, Belgium.
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Abstract
Hyperglycemia is commonplace in the critically ill patient and is associated with worse outcomes. It occurs after severe stress (e.g., infection or injury) and results from a combination of increased secretion of catabolic hormones, increased hepatic gluconeogenesis, and resistance to the peripheral and hepatic actions of insulin. The use of carbohydrate-based feeds, glucose containing solutions, and drugs such as epinephrine may exacerbate the hyperglycemia. Mechanisms by which hyperglycemia cause harm are uncertain. Deranged osmolality and blood flow, intracellular acidosis, and enhanced superoxide production have all been implicated. The net result is derangement of endothelial, immune and coagulation function and an association with neuropathy and myopathy. These changes can be prevented, at least in part, by the use of insulin to maintain normoglycemia.
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Affiliation(s)
- David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
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Teerlink T, Luo Z, Palm F, Wilcox CS. Cellular ADMA: regulation and action. Pharmacol Res 2009; 60:448-60. [PMID: 19682580 DOI: 10.1016/j.phrs.2009.08.002] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 08/03/2009] [Accepted: 08/04/2009] [Indexed: 02/07/2023]
Abstract
Asymmetric (N(G),N(G)) dimethylarginine (ADMA) is present in plasma and cells. It can inhibit nitric oxide synthase (NOS) that generates nitric oxide (NO) and cationic amino acid transporters (CATs) that supply intracellular NOS with its substrate, l-arginine, from the plasma. Therefore, ADMA and its transport mechanisms are strategically placed to regulate endothelial function. This could have considerable clinical impact since endothelial dysfunction has been detected at the origin of hypertension and chronic kidney disease (CKD) in human subjects and may be a harbinger of large vessel disease and cardiovascular disease (CVD). Indeed, plasma levels of ADMA are increased in many studies of patients at risk for, or with overt CKD or CVD. However, the levels of ADMA measured in plasma of about 0.5micromol.l(-1) may be below those required to inhibit NOS whose substrate, l-arginine, is present in concentrations many fold above the Km for NOS. However, NOS activity may be partially inhibited by cellular ADMA. Therefore, the cellular production of ADMA by protein arginine methyltransferase (PRMT) and protein hydrolysis, its degradation by N(G),N(G)-dimethylarginine dimethylaminohydrolase (DDAH) and its transmembrane transport by CAT that determines intracellular levels of ADMA may also determine the state of activation of NOS. This is the focus of the review. It is concluded that cellular levels of ADMA can be 5- to 20-fold above those in plasma and in a range that could tonically inhibit NOS. The relative importance of PRMT, DDAH and CAT for determining the intracellular NOS substrate:inhibitor ratio (l-arginine:ADMA) may vary according to the pathophysiologic circumstance. An understanding of this important balance requires knowledge of these three processes that regulate the intracellular levels of ADMA and arginine.
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Affiliation(s)
- Tom Teerlink
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
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Effects of insulin resistance on endothelial progenitor cells and vascular repair. Clin Sci (Lond) 2009; 117:173-90. [PMID: 19630751 DOI: 10.1042/cs20080263] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Insulin resistance, a key feature of obesity, the metabolic syndrome and Type 2 diabetes mellitus, results in an array of metabolic and vascular phenomena which ultimately promote the development of atherosclerosis. Endothelial dysfunction is intricately related to insulin resistance through the parallel stimulatory effects of insulin on glucose disposal in metabolic tissues and NO production in the endothelium. Perturbations characteristic of insulin resistance, including dyslipidaemia, inflammation and oxidative stress, may jeopardize the structural or functional integrity of the endothelium. Recent evidence suggests that endothelial damage is mitigated by endogenous reparative processes which mediate endothelial regeneration. EPCs (endothelial progenitor cells) are circulating cells which have been identified as mediators of endothelial repair. Several of the abnormalities associated with insulin resistance, including reduced NO bioavailability, increased production of ROS (reactive oxygen species) and down-regulation of intracellular signalling pathways, have the potential to disrupt EPC function. Improvement in the number and function of EPCs may contribute to the protective actions of evidence-based therapies to reduce cardiometabolic risk. In the present article, we review the putative effects of insulin resistance on EPCs, discuss the underlying mechanisms and highlight potential therapeutic manoeuvres which could improve vascular repair in individuals with insulin resistance.
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Wadham C, Mangoni AA. Dimethylarginine dimethylaminohydrolase regulation: a novel therapeutic target in cardiovascular disease. Expert Opin Drug Metab Toxicol 2009; 5:303-19. [PMID: 19331593 DOI: 10.1517/17425250902785172] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Asymmetric dimethylarginine (ADMA), an endogenous methylated form of the amino acid L-arginine, inhibits the activity of the enzyme endothelial nitric oxide synthase, with consequent reduced synthesis of nitric oxide. ADMA is metabolised to L-citrulline and dimethylamine by the enzyme dimethylarginine dimethylaminohydrolase (DDAH). The modulation of DDAH activity and expression plays a pivotal role in regulating intracellular ADMA concentrations, with important effects on vascular homeostasis. For example, impairment in DDAH activity, resulting in elevated ADMA concentrations and reduced nitric oxide synthesis, can promote the onset and progression of atherosclerosis in experimental models. This review discusses the current role of ADMA and DDAH in vascular health and disease, the techniques used to assess DDAH activity and expression, and the results of recent studies on pharmacological and biological agents modulating DDAH activity and expression. Suggestions for future basic and clinical research directions are also discussed.
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Affiliation(s)
- Carol Wadham
- Flinders University, Flinders Medical Centre, Department of Clinical Pharmacology, Adelaide, Australia
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Tissue-specific glucose toxicity induces mitochondrial damage in a burn injury model of critical illness. Crit Care Med 2009; 37:1355-64. [PMID: 19242345 DOI: 10.1097/ccm.0b013e31819cec17] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE In critically ill patients, preventing hyperglycemia (HG) with insulin therapy partially prevented organ dysfunction and protected mitochondria. A study in a rabbit model of critical illness indicated that lower blood glucose level, rather than higher insulinemia, is a key factor in such organ protection. In this model, we now investigated the impact of blood glucose lowering vs. hyperinsulinemia (HI) on mitochondria in relation to organ damage. We assessed whether such effects on mitochondria are mediated indirectly via organ perfusion or directly via reducing cellular glucose toxicity. DESIGN Prospective, randomized laboratory investigation. SETTING University laboratory. SUBJECTS Three-month-old male rabbits. INTERVENTIONS After induction of critical illness by burn injury, followed by fluid-resuscitation and parenteral nutrition, rabbits were allocated to four groups, each a combination of normal or elevated blood glucose levels with normal or elevated insulin levels. This required alloxan administration, immediately followed by intravenous insulin and glucose infusions titrated to the respective targets. MEASUREMENTS AND MAIN RESULTS In liver, the reduced damage by glucose lowering was not explained by better perfusion/oxygen delivery. Abnormal mitochondrial ultrastructure and function was present in the two hyperglycemic groups, most pronounced with concomitant HI. Affected mitochondrial respiratory chain enzyme activities were reduced to 25% to 62% of values in healthy rabbits, in the presence of up to five-fold increased tissue levels of glucose. This was accompanied by elevated levels of dicarbonyls, which may mediate direct toxicity of cellular glucose overload and accelerated glycolysis. The abnormalities were also present in myocardium, although to a lesser extent, and absent in skeletal muscle. CONCLUSIONS In a rabbit model of critical illness, HG evokes cellular glucose overload in liver and myocardium inducing mitochondrial dysfunction, which explained the HG-induced organ damage. Maintenance of normoglycemia, but not HI, protects against such mitochondrial and organ damage.
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Vlasselaers D, Milants I, Desmet L, Wouters PJ, Vanhorebeek I, van den Heuvel I, Mesotten D, Casaer MP, Meyfroidt G, Ingels C, Muller J, Van Cromphaut S, Schetz M, Van den Berghe G. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet 2009; 373:547-56. [PMID: 19176240 DOI: 10.1016/s0140-6736(09)60044-1] [Citation(s) in RCA: 424] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Critically ill infants and children often develop hyperglycaemia, which is associated with adverse outcome; however, whether lowering blood glucose concentrations to age-adjusted normal fasting values improves outcome is unknown. We investigated the effect of targeting age-adjusted normoglycaemia with insulin infusion in critically ill infants and children on outcome. METHODS In a prospective, randomised controlled study, we enrolled 700 critically ill patients, 317 infants (aged <1 year) and 383 children (aged >or=1 year), who were admitted to the paediatric intensive care unit (PICU) of the University Hospital of Leuven, Belgium. Patients were randomly assigned by blinded envelopes to target blood glucose concentrations of 2.8-4.4 mmol/L in infants and 3.9-5.6 mmol/L in children with insulin infusion throughout PICU stay (intensive group [n=349]), or to insulin infusion only to prevent blood glucose from exceeding 11.9 mmol/L (conventional group [n=351]). Patients and laboratory staff were blinded to treatment allocation. Primary endpoints were duration of PICU stay and inflammation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00214916. FINDINGS Mean blood glucose concentrations were lower in the intensive group than in the conventional group (infants: 4.8 [SD 1.2] mmol/L vs 6.4 [1.2] mmol/L, p<0.0001; children: 5.3 [1.1] mmol/L vs 8.2 [3.3] mmol/L, p<0.0001). Hypoglycaemia (defined as blood glucose <or=2.2 mmol/L) occurred in 87 (25%) patients in the intensive group (p<0.0001) versus five (1%) patients in the conventional group; hypoglycaemia defined as blood glucose less than 1.7 mmol/L arose in 17 (5%) patients versus three (1%) (p=0.001). Duration of PICU stay was shortest in the intensively treated group (5.51 days [95% CI 4.65-6.37] vs 6.15 days [5.25-7.05], p=0.017). The inflammatory response was attenuated at day 5, as indicated by lower C-reactive protein in the intensive group compared with baseline (-9.75 mg/L [95% CI -19.93 to 0.43] vs 8.97 mg/L [-0.9 to 18.84], p=0.007). The number of patients with extended (>median) stay in PICU was 132 (38%) in the intensive group versus 165 (47%) in the conventional group (p=0.013). Nine (3%) patients died in the intensively treated group versus 20 (6%) in the conventional group (p=0.038). INTERPRETATION Targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome of patients in PICU. The effect on long-term survival, morbidity, and neurocognitive development needs to be investigated. FUNDING Research Foundation (Belgium); Research Fund of the University of Leuven (Belgium) and the EU Information Society Technologies Integrated project "CLINICIP"; and Institute for Science and Technology (Belgium).
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Affiliation(s)
- Dirk Vlasselaers
- Department of Intensive Care Medicine (Paediatric Intensive Care Unit), Catholic University Leuven, Leuven, Belgium
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Fleissner F, Thum T. The IGF-1 receptor as a therapeutic target to improve endothelial progenitor cell function. Mol Med 2008; 14:235-7. [PMID: 18385819 DOI: 10.2119/2008-00037.fleissner] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 03/26/2008] [Indexed: 01/01/2023] Open
Affiliation(s)
- Felix Fleissner
- Julius-Maximilians Universität, Medizinische Klinik I (Kardiologie), Würzburg, Germany
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