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Fensham NC, Govus AD, Peeling P, Burke LM, McKay AKA. Factors Influencing the Hepcidin Response to Exercise: An Individual Participant Data Meta-analysis. Sports Med 2023; 53:1931-1949. [PMID: 37347443 DOI: 10.1007/s40279-023-01874-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Hepcidin, the master iron regulatory hormone, has been shown to peak 3-6 h postexercise, and is likely a major contributor to the prevalence of iron deficiency in athletes. Although multiple studies have investigated the hepcidin response to exercise, small sample sizes preclude the generalizability of current research findings. OBJECTIVE The aim of this individual participant data meta-analysis was to identify key factors influencing the hepcidin-exercise response. METHODS Following a systematic review of the literature, a one-stage meta-analysis with mixed-effects linear regression, using a stepwise approach to select the best-fit model, was employed. RESULTS We show that exercise is associated with a 1.5-2.5-fold increase in hepcidin concentrations, with pre-exercise hepcidin concentration accounting for ~ 44% of the variance in 3 h postexercise hepcidin concentration. Although collectively accounting for only a further ~ 3% of the variance, absolute 3 h postexercise hepcidin concentrations appear higher in males with lower cardiorespiratory fitness and higher pre-exercise ferritin levels. On the other hand, a greater magnitude of change between the pre- and 3 h postexercise hepcidin concentration was largely attributable to exercise duration (~ 44% variance) with a much smaller contribution from VO2max, pre-exercise ferritin, sex, and postexercise interleukin-6 (~ 6% combined). Although females tended to have a lower absolute 3 h postexercise hepcidin concentration [1.4 nmol·L-1, (95% CI [- 2.6, - 0.3]), p = 0.02] and 30% less change (95% CI [-54.4, - 5.1]), p = 0.02) than males, with different explanatory variables being significant between sexes, sample size discrepancies and individual study design biases preclude definitive conclusions. CONCLUSION Our analysis reveals the complex interplay of characteristics of both athlete and exercise session in the hepcidin response to exercise and highlights the need for further investigation into unaccounted-for mediating factors.
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Affiliation(s)
- Nikita C Fensham
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
| | - Andrew D Govus
- Discipline of Sport and Exercise Science, La Trobe University, Melbourne, VIC, Australia
| | - Peter Peeling
- University of Western Australia, Crawley, WA, Australia
- Western Australia Institute of Sport, Mt Claremont, WA, Australia
| | - Louise M Burke
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Alannah K A McKay
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
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2
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Hayashi N, Nagastuka H, Sato M, Goto K. Effect of long-term carnosine/anserine supplementation on iron regulation after a prolonged running session. Phys Act Nutr 2023; 27:70-77. [PMID: 37583074 PMCID: PMC10440176 DOI: 10.20463/pan.2023.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/08/2023] [Accepted: 06/26/2023] [Indexed: 08/17/2023] Open
Abstract
PURPOSE Exercise-induced hemolysis, which is caused by metabolic and/or mechanical stress during exercise, is considered a potential factor for upregulating hepcidin. Intramuscular carnosine has multiple effects including antioxidant activity. Therefore, this study aimed to determine whether long-term carnosine/anserine supplementation modulates exercise-induced hemolysis and subsequent hepcidin elevation. METHODS Seventeen healthy male participants were allocated to two different groups: participants consuming 1,500 mg/day of carnosine/anserine supplements (n = 9, C+A group) and participants consuming placebo powder supplements (n = 8, PLA group). The participants consumed carnosine/anserine or placebo supplements daily for 30.7 ± 0.4 days. They performed an 80-running session at 70% VO2peak pre-and post-supplementation. Iron regulation and inflammation in response to exercise were evaluated. RESULTS Serum iron concentrations significantly increased after exercise (p < 0.01) and serum haptoglobin concentrations decreased after exercise in both groups (p < 0.01). No significant differences in these variables were observed between pre-and post-supplementation. Serum hepcidin concentration significantly increased 180 min after exercise in both groups (p < 0.01). The integrated area under the curve of hepcidin significantly decreased after supplementation (p = 0.011) but did not vary between the C+A and PLA groups. CONCLUSION Long-term carnosine/anserine supplementation does not affect iron metabolism after a single endurance exercise session.
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Affiliation(s)
- Nanako Hayashi
- Research Organization of Science and Technology, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Haruna Nagastuka
- Faculty of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Mikako Sato
- NH Foods Ltd. R&D Center, Midorigahara, Tsukuba, Ibaraki, Japan
| | - Kazushige Goto
- Faculty of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
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Ghazzawi HA, Hussain MA, Raziq KM, Alsendi KK, Alaamer RO, Jaradat M, Alobaidi S, Al Aqili R, Trabelsi K, Jahrami H. Exploring the Relationship between Micronutrients and Athletic Performance: A Comprehensive Scientific Systematic Review of the Literature in Sports Medicine. Sports (Basel) 2023; 11:109. [PMID: 37368559 DOI: 10.3390/sports11060109] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this systematic review is twofold: (i) to examine the effects of micronutrient intake on athletic performance and (ii) to determine the specific micronutrients, such as vitamins, minerals, and antioxidants, that offer the most significant enhancements in terms of athletic performance, with the goal of providing guidance to athletes and coaches in optimizing their nutritional strategies. The study conducted a systematic search of electronic databases (i.e., PubMed, Web of Science, Scopus) using keywords pertaining to micronutrients, athletic performance, and exercise. The search involved particular criteria of studies published in English between 1950 and 2023. The findings suggest that vitamins and minerals are crucial for an athlete's health and physical performance, and no single micronutrient is more important than others. Micronutrients are necessary for optimal metabolic body's functions such as energy production, muscle growth, and recovery, which are all important for sport performance. Meeting the daily intake requirement of micronutrients is essential for athletes, and while a balanced diet that includes healthy lean protein sources, whole grains, fruits, and vegetables is generally sufficient, athletes who are unable to meet their micronutrient needs due to malabsorption or specific deficiencies may benefit from taking multivitamin supplements. However, athletes should only take micronutrient supplements with the consultation of a specialized physician or nutritionist and avoid taking them without confirming a deficiency.
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Affiliation(s)
- Hadeel Ali Ghazzawi
- Department Nutrition and Food Technology, School of Agriculture, The University of Jordan, Amman 11942, Jordan
| | - Mariam Ali Hussain
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 323, Bahrain
| | - Khadija Majdy Raziq
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 323, Bahrain
| | - Khawla Khaled Alsendi
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 323, Bahrain
| | - Reem Osama Alaamer
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 323, Bahrain
| | - Manar Jaradat
- Department Nutrition and Food Technology, School of Agriculture, The University of Jordan, Amman 11942, Jordan
| | - Sondos Alobaidi
- Department Nutrition and Food Technology, School of Agriculture, The University of Jordan, Amman 11942, Jordan
| | - Raghad Al Aqili
- Department Nutrition and Food Technology, School of Agriculture, The University of Jordan, Amman 11942, Jordan
| | - Khaled Trabelsi
- High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax 3000, Tunisia
- Research Laboratory-Education, Motricity, Sport and Health, University of Sfax, Sfax 3000, Tunisia
| | - Haitham Jahrami
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 323, Bahrain
- Government Hospitals, Ministry of Health, Manama 323, Bahrain
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4
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Barney DE, Ippolito JR, Berryman CE, Hennigar SR. A Prolonged Bout of Running Increases Hepcidin and Decreases Dietary Iron Absorption in Trained Female and Male Runners. J Nutr 2022; 152:2039-2047. [PMID: 35661896 DOI: 10.1093/jn/nxac129] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/22/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Declines in iron status are frequently reported in those who regularly engage in strenuous physical activity. A possible reason is increases in the iron regulatory hormone hepcidin, which functions to inhibit dietary iron absorption and can be induced by the inflammatory cytokine interleukin-6 (IL-6). OBJECTIVES The current study aimed to determine the impact of a prolonged bout of running on hepcidin and dietary iron absorption in trained female and male runners. METHODS Trained female and male collegiate cross country runners (n = 28, age: 19.7 ± 1.2 y, maximal oxygen uptake: 66.1 ± 6.1 mL $\cdot$ kg -1$\cdot$ min-2, serum ferritin: 21.9 ± 13.3 ng/mL) performed a prolonged run (98.8 ± 14.7 min, 21.2 ± 3.8 km, 4.7 ± 0.3 min/km) during a team practice. Participants consumed a stable iron isotope with a standardized meal 2 h postrun and blood was collected 1 h later. The protocol was repeated 2 wk later except participants abstained from exercise (rest). RBCs were collected 15 d after exercise and rest to determine isotope enrichment. Differences between exercise and rest were assessed by paired t tests and Wilcoxon matched-pairs signed rank tests. Data are means ± SDs. RESULTS Plasma hepcidin increased 51% after exercise (45.8 ± 34.4 ng/mL) compared with rest (30.3 ± 27.2 ng/mL, P = 0.0010). Fractional iron absorption was reduced by 36% after exercise (11.8 ± 14.6 %) compared with rest (18.5 ± 14.4 %, P = 0.025). Plasma IL-6 was greater after exercise (0.660 ± 0.354 pg/mL) than after rest (0.457 ± 0.212 pg/mL, P < 0.0001). Exploratory analyses revealed that the increase in hepcidin with exercise may be driven by a response in males but not females. CONCLUSIONS A prolonged bout of running increases hepcidin and decreases dietary iron absorption compared with rest in trained runners with low iron stores. The current study supports that IL-6 contributes to the increase in hepcidin with prolonged physical activity, although future studies should explore potential sex differences in the hepcidin response.This trial was registered at Clinicaltrials.gov as NCT04079322.
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Affiliation(s)
- David E Barney
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - James R Ippolito
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - Claire E Berryman
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - Stephen R Hennigar
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
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5
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Barba-Moreno L, Alfaro-Magallanes VM, de Jonge XAKJ, Díaz AE, Cupeiro R, Peinado AB. Hepcidin and interleukin-6 responses to endurance exercise over the menstrual cycle. Eur J Sport Sci 2020; 22:218-226. [PMID: 33317411 DOI: 10.1080/17461391.2020.1853816] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The aim of the current study was to investigate iron metabolism in endurance trained women through the interleukin-6, hepcidin and iron responses to exercise along different endogenous hormonal states. Fifteen women performed 40 min treadmill running trials at 75% vVO2peak during three specific phases of the menstrual cycle: early follicular phase (day 3 ± 0.85), mid-follicular phase (day 8 ± 1.09) and luteal phase (day 21 ± 1.87). Venous blood samples were taken pre-, 0 h post- and 3 h post-exercise. Interleukin-6 reported a significant interaction for menstrual cycle phase and time (p=0.014), showing higher interleukin-6 levels at 3 h post-exercise during luteal phase compared to the early follicular phase (p=0.004) and the mid-follicular phase (p=0.002). Iron levels were significantly lower (p=0.009) during the early follicular phase compared to the mid-follicular phase. However, hepcidin levels were not different across menstrual cycle phases (p>0.05). The time-course for hepcidin and interleukin-6 responses to exercise was different from the literature, since hepcidin peak levels occurred at 0 h post-exercise, whereas the highest interleukin-6 levels occurred at 3 h post-exercise. We concluded that menstrual cycle phases may alter interleukin-6 production causing a higher inflammation when progesterone levels are elevated (days 19-21). Moreover, during the early follicular phase a significant reduction of iron levels is observed potentially due to a loss of haemoglobin through menses. According to our results, high intensity exercises should be carefully monitored in these phases in order not to further compromise iron stores.
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Affiliation(s)
- Laura Barba-Moreno
- Faculty of Sciences for Physical Activity and Sport (INEF), LFE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, Madrid, Spain
| | - Víctor M Alfaro-Magallanes
- Faculty of Sciences for Physical Activity and Sport (INEF), LFE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, Madrid, Spain
| | | | - Angel E Díaz
- AEPSAD, Clinical laboratory, National Center of Sport Medicine, Health and Sports Department, Madrid, Spain
| | - Rocío Cupeiro
- Faculty of Sciences for Physical Activity and Sport (INEF), LFE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, Madrid, Spain
| | - Ana B Peinado
- Faculty of Sciences for Physical Activity and Sport (INEF), LFE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, Madrid, Spain
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Rossi EM, Ávila RA, Carneiro MTWD, Almenara CCP, Dos Santos L. Chronic Iron Overload Restrains the Benefits of Aerobic Exercise to the Vasculature. Biol Trace Elem Res 2020; 198:521-534. [PMID: 32124228 DOI: 10.1007/s12011-020-02078-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
Physical exercise is a well-recognized effective non-pharmacological therapy for cardiovascular diseases. However, because iron is essential element in many physiological processes including hemoglobin and myoglobin synthesis, thereby playing a role on oxygen transport, many athletes use iron supplement to improve physical performance. Regarding this, iron overload is associated with oxidative stress and damage to various systems, including cardiovascular. Thus, we aimed to identify the vascular effects of aerobic exercise in a rat model of iron overload. Male Wistar rats were treated with 100 mg/kg/day iron-dextran, i.p., 5 days a week for 4 weeks, and then underwent aerobic exercise protocol on a treadmill at moderate intensity, 60 min/day, 5 days a week for 8 weeks. Exercise reduced vasoconstrictor response of isolated aortic rings by increasing participation of nitric oxide (NO) and reducing oxidative stress, but these benefits to the vasculature were not observed in rats previously subjected to iron overload. The reduced vasoconstriction in the exercised group was reversed by incubation with superoxide dismutase (SOD) inhibitor, suggesting that increased SOD activity by exercise was lost in iron overload rats. Iron overload groups increased serum levels of iron, transferrin saturation, and iron deposition in the liver, gastrocnemius muscle, and aorta, and the catalase was overexpressed in the aorta probably as a compensatory mechanism to the increased oxidative stress. In conclusion, despite the known beneficial effects of aerobic exercise on vasculature, our results indicate that previous iron overload impeded the anticontractile effect mediated by increased NO bioavailability and endogenous antioxidant response due to exercise protocol.
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Affiliation(s)
- Emilly Martinelli Rossi
- Department of Physiological Sciences, Federal University of Espirito Santo, Av. Marechal Campos, 1468, Vitoria, ES, 29040-091, Brazil
| | - Renata Andrade Ávila
- Department of Physiological Sciences, Federal University of Espirito Santo, Av. Marechal Campos, 1468, Vitoria, ES, 29040-091, Brazil
- Faculdades Integradas São Pedro (FAESA), Av. Vitória, 2220, Vitoria, ES, 29053-360, Brazil
| | - Maria Tereza W D Carneiro
- Department of Chemistry, Federal University of Espirito Santo, Av. Fernando Ferrari, 514, Vitoria, ES, 29075-910, Brazil
| | - Camila C P Almenara
- Department of Physiological Sciences, Federal University of Espirito Santo, Av. Marechal Campos, 1468, Vitoria, ES, 29040-091, Brazil
| | - Leonardo Dos Santos
- Department of Physiological Sciences, Federal University of Espirito Santo, Av. Marechal Campos, 1468, Vitoria, ES, 29040-091, Brazil.
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Hayashi N, Yatsutani H, Mori H, Ito H, Badenhorst CE, Goto K. No effect of supplemented heat stress during an acute endurance exercise session in hypoxia on hepcidin regulation. Eur J Appl Physiol 2020; 120:1331-1340. [PMID: 32303828 DOI: 10.1007/s00421-020-04365-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/04/2020] [Indexed: 12/21/2022]
Abstract
Hepcidin is a novel factor for iron deficiency in athletes, which is suggested to be regulated by interleukin-6 (IL-6) or erythropoietin (EPO). PURPOSE The purpose of the present study was to compare endurance exercise-induced hepcidin elevation among "normoxia", "hypoxia" and "combined heat and hypoxia". METHODS Twelve males (21.5 ± 0.3 years, 168.1 ± 1.2 cm, 63.6 ± 2.0 kg) participated in the present study. They performed 60 min of cycling at 60% of [Formula: see text] in either "heat and hypoxia" (HHYP; FiO2 14.5%, 32 °C), "hypoxia" (HYP; FiO2 14.5%, 23 °C) or "normoxia" (NOR; FiO2 20.9%, 23 °C). After completing the exercise, participants remained in the prescribed conditions for 3 h post-exercise. Blood samples were collected before, immediately and 3 h after exercise. RESULTS Plasma IL-6 level significantly increased immediately after exercise (P < 0.05), with no significant difference among the trials. A significant elevation in serum EPO was observed 3 h after exercise in hypoxic trials (HHYP and HYP, P < 0.05), with no significant difference between HHYP and HYP. Serum hepcidin level increased 3 h after exercise in all trials (NOR, before 18.3 ± 3.9 and post180 31.2 ± 6.3 ng/mL; HYP, before 13.5 ± 2.5 and post180 23.3 ± 3.6 ng/mL, HHYP; before 15.8 ± 3.3 and post180 31.4 ± 5.3 ng/mL, P < 0.05). However, there was no significant difference among the trials during post-exercise. CONCLUSION Endurance exercise in "combined heat and hypoxia" did not exacerbate exercise-induced hepcidin elevation compared with the same exercise in "hypoxia" or "normoxia".
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Affiliation(s)
- Nanako Hayashi
- Graduate School of Sport and Health Science, Ritsumeikan University, 1-1-1, Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Haruka Yatsutani
- Graduate School of Sport and Health Science, Ritsumeikan University, 1-1-1, Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Hisashi Mori
- School of Human Science and Environment, University of Hyogo, Himeji, Hyogo, Japan
| | - Hiroto Ito
- Graduate School of Sport and Health Science, Ritsumeikan University, 1-1-1, Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Claire E Badenhorst
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Kazushige Goto
- Graduate School of Sport and Health Science, Ritsumeikan University, 1-1-1, Noji-higashi, Kusatsu, Shiga, 525-8577, Japan.
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Goto K, Kojima C, Kasai N, Sumi D, Hayashi N, Hwang H. Resistance exercise causes greater serum hepcidin elevation than endurance (cycling) exercise. PLoS One 2020; 15:e0228766. [PMID: 32106271 PMCID: PMC7046260 DOI: 10.1371/journal.pone.0228766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hepcidin is an iron regulating hormone, and exercise-induced hepcidin elevation is suggested to increase the risk of iron deficiency among athletes. OBJECTIVE We compared serum hepcidin responses to resistance exercise and endurance (cycling) exercise. METHODS Ten males [mean ± standard error: 172 ± 2 cm, body weight: 70 ± 2 kg] performed three trials: a resistance exercise trial (RE), an endurance exercise trial (END), and a rest trial (REST). The RE consisted of 60 min of resistance exercise (3-5 sets × 12 repetitions, 8 exercises) at 65% of one repetition maximum, while 60 min of cycling exercise at 65% of [Formula: see text] was performed in the END. Blood samples were collected before exercise and during a 6-h post-exercise (0h, 1h, 2h, 3h, 6h after exercise). RESULTS Both RE and END significantly increased blood lactate levels, with significantly higher in the RE (P < 0.001). Serum iron levels were significantly elevated immediately after exercise (P < 0.001), with no significant difference between RE and END. Both the RE and END significantly increased serum growth hormone (GH), cortisol, and myoglobin levels (P < 0.01). However, exercise-induced elevations of GH and cortisol were significantly greater in the RE (trial × time: P < 0.001). Plasma interleukin-6 (IL-6) levels were significantly elevated after exercise (P = 0.003), with no significant difference between the trials. Plasma hepcidin levels were elevated after exercise (P < 0.001), with significantly greater in the RE (463 ± 125%) than in the END (137 ± 27%, P = 0.03). During the REST, serum hepcidin and plasma IL-6 levels did not change significantly. CONCLUSION Resistance exercise caused a greater exercise-induced elevation in hepcidin than did endurance (cycling) exercise. The present findings indicate that caution will be required to avoid iron deficiency even among athletes in strength (power) types of events who are regularly involved in resistance exercise.
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Affiliation(s)
- Kazushige Goto
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
- * E-mail:
| | | | | | - Daichi Sumi
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Nanako Hayashi
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Hyejung Hwang
- Physical Activity and Performance Institute, Konkuk University, Seoul, Republic of Korea
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9
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Zügel M, Treff G, Steinacker JM, Mayer B, Winkert K, Schumann U. Increased Hepcidin Levels During a Period of High Training Load Do Not Alter Iron Status in Male Elite Junior Rowers. Front Physiol 2020; 10:1577. [PMID: 32038278 PMCID: PMC6985289 DOI: 10.3389/fphys.2019.01577] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 12/16/2019] [Indexed: 12/21/2022] Open
Abstract
The liver-derived hormone hepcidin plays a key role in iron metabolism by mediating the degradation of the iron export protein ferroportin 1 (FPN1). Circulating levels of hepcidin and the iron storage protein ferritin are elevated during the recovery period after acute endurance exercise, which can be interpreted as an acute phase reaction to intense exercise with far-reaching consequences for iron metabolism and homeostasis. Since absolute and functional iron deficiency (ID) potentially lead to a loss of performance and well-being, it is surprising that the cumulative effects of training stress on hepcidin levels and its interplay with cellular iron availability are not well described. Therefore, the aim of this study was to determine serum levels of hepcidin at six time points during a 4-week training camp of junior world elite rowers preparing for the world championships and to relate the alterations in training load to overall iron status determined by serum ferritin, transferrin, iron, and soluble transferrin receptor (sTfR). Serum hepcidin levels increased significantly (p = 0.02) during the initial increase in training load (23.24 ± 2.43 ng/ml) at day 7 compared to the start of training camp (11.47 ± 3.92 ng/ml) and turned back on day 13 (09.51 ± 3.59 ng/ml) already, meeting well the entrance level of hepcidin at day 0. Serum ferritin was significantly higher at day 7 compared to all other timepoints with exception of the subsequent time point at day 13 reflecting well the time course pattern of hepcidin. Non-significant changes between training phases were found for serum iron, transferrin, and sTfR levels as well as for transferrin saturation, and ferritin-index (sTfR/log ferritin). Our findings indicate that hepcidin as well as ferritin, both representing acute phase proteins, are sensitive to initial increases in training load. Erythropoiesis was unaffected by iron compartmentalization through hepcidin. We conclude that hepcidin is sensitive to rigorous changes in training load in junior world elite rowers without causing short-term alterations in functional iron homeostasis.
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Affiliation(s)
- Martina Zügel
- Department of Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
| | - Gunnar Treff
- Department of Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
| | - Jürgen M Steinacker
- Department of Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Kay Winkert
- Department of Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
| | - Uwe Schumann
- Department of Internal Medicine, Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
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10
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Hayashi N, Ishibashi A, Goto K. Effects of diet before endurance exercise on hepcidin response in young untrained females. Phys Act Nutr 2018; 22:55-61. [PMID: 30661331 PMCID: PMC6343765 DOI: 10.20463/jenb.2018.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/14/2018] [Indexed: 11/22/2022] Open
Abstract
[Purpose] We examined the effects of diet before endurance exercise on hepcidin response in young untrained females. [Methods] Ten young untrained females [age: 20.6 ± 0.8 y, height: 157.5 ± 1.0 cm, weight: 54.4 ± 1.5 kg, and maximal oxygen uptake (VO2max): 35.9 ± 1.1 mL/kg/min] were involved in two experimental conditions with a crossover design. The two conditions were separated by approximately 1 month, and each condition was performed during the follicular phase. Subjects completed 60 min of pedaling at 65% of VO2max after consuming a meal (FED) or not consuming a meal (CON). Blood samples were collected before, immediately after, and 3 h after exercise. [Results] Serum ferritin levels before exercise did not differ between the two conditions (P > 0.05). Blood glucose and lactate levels were significantly elevated immediately after exercise only under the FED condition (P < 0.05). Serum iron levels were significantly elevated after exercise under both conditions. However, the plasma interleukin-6 and serum hepcidin levels were not significantly different 3 h after exercise under either condition (P > 0.05). [Conclusion] Consuming a meal before endurance exercise at moderate intensity did not affect exercise-induced hepcidin elevation in young untrained females.
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11
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Effects of an Acute Exercise Bout on Serum Hepcidin Levels. Nutrients 2018; 10:nu10020209. [PMID: 29443922 PMCID: PMC5852785 DOI: 10.3390/nu10020209] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/30/2018] [Accepted: 02/11/2018] [Indexed: 02/07/2023] Open
Abstract
Iron deficiency is a frequent and multifactorial disorder in the career of athletes, particularly in females. Exercise-induced disturbances in iron homeostasis produce deleterious effects on performance and adaptation to training; thus, the identification of strategies that restore or maintain iron homeostasis in athletes is required. Hepcidin is a liver-derived hormone that degrades the ferroportin transport channel, thus reducing the ability of macrophages to recycle damaged iron, and decreasing iron availability. Although it has been suggested that the circulating fraction of hepcidin increases during early post-exercise recovery (~3 h), it remains unknown how an acute exercise bout may modify the circulating expression of hepcidin. Therefore, the current review aims to determine the post-exercise expression of serum hepcidin in response to a single session of exercise. The review was carried out in the Dialnet, Elsevier, Medline, Pubmed, Scielo and SPORTDiscus databases, using hepcidin (and “exercise” or “sport” or “physical activity”) as a strategy of search. A total of 19 articles were included in the review after the application of the inclusion/exclusion criteria. This search found that a single session of endurance exercise (intervallic or continuous) at moderate or vigorous intensity (60–90% VO2peak) stimulates an increase in the circulating levels of hepcidin between 0 h and 6 h after the end of the exercise bout, peaking at ~3 h post-exercise. The magnitude of the response of hepcidin to exercise seems to be dependent on the pre-exercise status of iron (ferritin) and inflammation (IL-6). Moreover, oxygen disturbances and the activation of a hypoxia-induced factor during or after exercise may stimulate a reduction of hepcidin expression. Meanwhile, cranberry flavonoids supplementation promotes an anti-oxidant effect that may facilitate the post-exercise expression of hepcidin. Further studies are required to explore the effect of resistance exercise on hepcidin expression.
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Sarıkaya B, Dursun AD, Taylan Deveden EY, Pınar L. Interleukin-6 and hepcidin expression changes in cardiac tissue of long-term trained and untrained rats after exhaustive exercise. Turk J Med Sci 2017; 47:1940-1946. [PMID: 29306260 DOI: 10.3906/sag-1703-73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim: Exercise benefits the cardiovascular system, but strenuous exercise can cause cardiac damage and induce cytokine production, particularly that of interleukin-6 (IL-6). Hepcidin, which is primarily regulated by IL-6, increases after exercise. Hepcidin is a possible protective factor against the adverse effects of strenuous exercise such as oxidative stress. The aim of the study is to reveal that training increases hepcidin and attenuates increased levels of IL-6 in the hearts of exhaustively exercised rats by comparing the IL-6 and hepcidin mRNA expression levels in trained and untrained groups.Materials and methods: Thirty male Wistar albino rats were assigned to the following groups: sedentary controls (Con); untrained animals that acutely completed exhaustive exercise and were sacrificed immediately after exhaustion (UT-i) or 1 day after exhaustion (UT-1); and long-term trained animals that completed exhaustive exercise and were sacrificed immediately after exhaustion (T-i) or 1 day after exhaustion (T-1). mRNA levels were examined by reverse transcription PCR. Results: IL-6 levels significantly increased in the UT-i, T-i, and T-1 groups compared to the Con group (P = 0.000, P = 0.024, P = 0.001), with maximal IL-6 expression found in the UT-i group. Hepcidin levels significantly increased in the T-1 group (P = 0.000) compared to the control. Conclusion: Increased IL-6 levels in rats show that exhaustive exercise can cause cardiac inflammation. However, long-term training attenuated the severity of the inflammation. The possible protective effect of increased hepcidin in the trained groups can be explained by the antiinflammatory effects of IL-6 and long-term training.
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Goto K, Kasai N, Kojima C, Ishibashi A. Postexercise serum hepcidin response to repeated sprint exercise under normoxic and hypoxic conditions. Appl Physiol Nutr Metab 2017; 43:221-226. [PMID: 28961407 DOI: 10.1139/apnm-2017-0418] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We determined the effects of repeated sprint exercise under normoxic and hypoxic conditions on serum hepcidin levels. Ten male athletes (age: 20.9 ± 0.3 years; height: 175.7 ± 6.0 cm; weight: 67.3 ± 6.3 kg) performed 2 exercise trials under normoxic (NOR; fraction of inspiratory oxygen (FiO2): 20.9%) or hypoxic conditions (HYPO; FiO2: 14.5%). The exercise consisted of 3 sets of 5 × 6 s of maximal pedaling (30-s rest periods between sprints, 10-min rest periods between sets). Blood samples were collected before exercise, immediately after exercise, and 1 and 3 h after exercise. Serum hepcidin levels were significantly elevated after exercise in both trials (both P < 0.01), with no significant difference between the trials. The postexercise blood lactate levels were significantly higher in the HYPO than the NOR (P < 0.05). Both trials caused similar increases in plasma interleukin-6 and serum iron levels (P < 0.001), with no significant difference between the trials. A significant interaction (trial × time) was apparent in terms of serum erythropoietin (EPO) levels (P = 0.003). The EPO level was significantly higher in the HYPO than the NOR at 3 h after exercise (P < 0.05). In conclusion, repeated sprint exercise significantly increased serum hepcidin levels to similar extent in 2 trials, despite differences in the inspired oxygen concentrations during both the exercise and the 3-h postexercise period.
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Affiliation(s)
- Kazushige Goto
- a Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, 525-8577, Japan
| | - Nobukazu Kasai
- a Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, 525-8577, Japan
| | - Chihiro Kojima
- a Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, 525-8577, Japan
| | - Aya Ishibashi
- a Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, 525-8577, Japan.,b Department of Sports Science, Japan Institute of Sports Science, Kitaku, Tokyo, 525-8577, Japan
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Goto K, Sumi D, Kojima C, Ishibashi A. Post-exercise serum hepcidin levels were unaffected by hypoxic exposure during prolonged exercise sessions. PLoS One 2017; 12:e0183629. [PMID: 28829838 PMCID: PMC5567555 DOI: 10.1371/journal.pone.0183629] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/30/2017] [Indexed: 12/21/2022] Open
Abstract
The purpose of the present study was to determine the influence of hypoxic exposure during prolonged endurance exercise sessions (79 min in total) on post-exercise hepcidin levels in trained male endurance athletes. Ten endurance athletes (mean ± standard deviation; height: 169.8 ± 7.1 cm, weight: 57.1 ± 5.0 kg) conducted two endurance exercise sessions under either a normobaric hypoxic condition [inspired O2 fraction (FiO2) = 14.5%] or a normoxic condition (FiO2 = 20.9%). Exercise consisted of 10 × 3 min running on a treadmill at 95% of maximal oxygen uptake ([Formula: see text]) with 60s of active rest at 60% of [Formula: see text]. After 10 min of rest, they subsequently performed 30 min of continuous running at 85% of [Formula: see text]. Running velocities were significantly lower in the HYPO than in the NOR (P < 0.0001). Exercise-induced blood lactate elevation was significantly greater in the HYPO (P < 0.01). There were significant increases in plasma interleukin-6, serum iron, and blood glucose levels after exercise, with no significant difference between the trials [interaction (trial × time) or main effect for trial, P > 0.05]. Serum hepcidin levels increased significantly 120 min after exercise (HYPO: from 10.7 ± 9.4 ng/mL to 15.8 ± 11.2 ng/mL; NOR: from 7.9 ± 4.7 ng/mL to 13.2 ± 7.9 ng/mL, P < 0.05), and no difference was observed between the trials. In conclusion, endurance exercise at lower running velocity in hypoxic conditions resulted in similar post-exercise hepcidin elevations as higher running velocity in normoxic conditions.
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Affiliation(s)
- Kazushige Goto
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
- Faculty of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
- * E-mail:
| | - Daichi Sumi
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Chihiro Kojima
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Aya Ishibashi
- Graduate School of Sports and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
- Japan Institute of Sports Sciences, Kitaku, Tokyo, Japan
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15
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Reichert CO, da Cunha J, Levy D, Maselli LMF, Bydlowski SP, Spada C. Hepcidin: Homeostasis and Diseases Related to Iron Metabolism. Acta Haematol 2017; 137:220-236. [PMID: 28514781 DOI: 10.1159/000471838] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/20/2017] [Indexed: 12/14/2022]
Abstract
Iron is an essential metal for cell survival that is regulated by the peptide hormone hepcidin. However, its influence on certain diseases is directly related to iron metabolism or secondary to underlying diseases. Genetic alterations influence the serum hepcidin concentration, which can lead to an iron overload in tissues, as observed in haemochromatosis, in which serum hepcidin or defective hepcidin synthesis is observed. Another genetic imbalance of iron is iron-refractory anaemia, in which serum concentrations of hepcidin are increased, precluding the flow and efflux of extra- and intracellular iron. During the pathogenesis of certain diseases, the resulting oxidative stress, as well as the increase in inflammatory cytokines, influences the transcription of the HAMP gene to generate a secondary anaemia due to the increase in the serum concentration of hepcidin. To date, there is no available drug to inhibit or enhance hepcidin transcription, mostly due to the cytotoxicity described in the in vitro models. The proposed therapeutic targets are still in the early stages of clinical trials. Some candidates are promising, such as heparin derivatives and minihepcidins. This review describes the main pathways of systemic and genetic regulation of hepcidin, as well as its influence on the disorders related to iron metabolism.
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Affiliation(s)
- Cadiele Oliana Reichert
- Clinical Analysis Department, Health Sciences Center, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
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Hennigar SR, McClung JP, Pasiakos SM. Nutritional interventions and the IL-6 response to exercise. FASEB J 2017; 31:3719-3728. [PMID: 28507168 DOI: 10.1096/fj.201700080r] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/24/2017] [Indexed: 01/24/2023]
Abstract
IL-6 is a pleiotropic cytokine with a wide range of biologic effects. In response to prolonged exercise, IL-6 is synthesized by contracting skeletal muscle and released into circulation. Circulating IL-6 is thought to maintain energy status during exercise by acting as an energy sensor for contracting muscle and stimulating glucose production. If tissue damage occurs, immune cells infiltrate and secrete cytokines, including IL-6, to repair skeletal muscle damage. With adequate rest and nutrition, the IL-6 response to exercise is attenuated as skeletal muscle adapts to training. However, sustained elevations in IL-6 due to repeated bouts of unaccustomed activities or prolonged exercise with limited rest may result in untoward physiologic effects, such as accelerated muscle proteolysis and diminished nutrient absorption, and may impair normal adaptive responses to training. Recent intervention studies have explored the role of mixed meals or carbohydrate, protein, ω-3 fatty acid, or antioxidant supplementation in mitigating exercise-induced increases in IL-6. Emerging evidence suggests that sufficient energy intake before exercise is an important factor in attenuating exercise-induced IL-6 by maintaining muscle glycogen. We detail various nutritional interventions that may affect the IL-6 response to exercise in healthy human adults and provide recommendations for future research exploring the role of IL-6 in the adaptive response to exercise.-Hennigar, S. R., McClung, J. P., Pasiakos, S. M. Nutritional interventions and the IL-6 response to exercise.
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Affiliation(s)
- Stephen R Hennigar
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts, USA; .,Oak Ridge Institute for Science and Education, Belcamp, Maryland, USA
| | - James P McClung
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts, USA
| | - Stefan M Pasiakos
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts, USA
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Buyukyazi G, Ulman C, Çelik A, Çetinkaya C, Şişman AR, Çimrin D, Doğru Y, Kaya D. The effect of 8-week different-intensity walking exercises on serum hepcidin, IL-6, and iron metabolism in pre-menopausal women. Physiol Int 2017; 104:52-63. [DOI: 10.1556/2060.104.2017.1.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective
Hepcidin may be an important mediator in exercise-induced iron deficiency. Despite the studies investigating acute exercise effects on hepcidin and markers of iron metabolism, we found no studies examining the chronic effects of walking exercises (WE) on hepcidin and markers of iron metabolism in premenopausal women. The chronic effects of two 8-week different-intensity WE on hepcidin, interleukin 6 (IL-6), and markers of iron metabolism in pre-menopausal women were examined.
Methods
Exercise groups (EG) [moderate tempo walking group (MTWG), n = 11; brisk walking group (BWG), n = 11] walked 3 days/week, starting from 30 to 51 min. Control group (CG; n = 8) did not perform any exercises. BWG walked at ∼70%–75%; MTWG at ∼50%–55% of HRRmax. VO2max, hepcidin, IL-6, and iron metabolism markers were determined before and after the intervention.
Results
VO2max increased in both EGs, favoring the BWG. Hepcidin increased in the BWG (p < 0.01) and CG (p < 0.05). IL-6 decreased in the BWG and the MTWG (p < 0.05; p < 0.01). While iron, ferritin, transferrin, and transferrin saturation levels did not change in any group, total iron binding capacity (p < 0.05), red blood cells (p < 0.05), and hematocrit (p < 0.01) increased only in the BWG.
Conclusion
Both WE types may be useful to prevent inflammation. However, brisk walking is advisable due to the positive changes in VO2max and some iron metabolism parameters, which may contribute to prevent iron deficiency. The increase in hepcidin levels remains unclear and necessitates further studies.
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Affiliation(s)
- G Buyukyazi
- 1 School of Sport Sciences and Technology, Dokuz Eylül University, Izmir, Turkey
| | - C Ulman
- 2 Department of Biochemistry, Faculty of Medicine, Celal Bayar University, Manisa, Turkey
| | - A Çelik
- 1 School of Sport Sciences and Technology, Dokuz Eylül University, Izmir, Turkey
| | - C Çetinkaya
- 1 School of Sport Sciences and Technology, Dokuz Eylül University, Izmir, Turkey
| | - AR Şişman
- 3 Department of Biochemistry, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - D Çimrin
- 3 Department of Biochemistry, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Y Doğru
- 4 Department of Biochemistry, School of Physical Education and Sports, Ege University, Izmir, Turkey
| | - D Kaya
- 5 Department of Cardiology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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Gassmann M, Muckenthaler MU. Adaptation of iron requirement to hypoxic conditions at high altitude. J Appl Physiol (1985) 2015; 119:1432-40. [PMID: 26183475 DOI: 10.1152/japplphysiol.00248.2015] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/10/2015] [Indexed: 12/12/2022] Open
Abstract
Adequate acclimatization time to enable adjustment to hypoxic conditions is one of the most important aspects for mountaineers ascending to high altitude. Accordingly, most reviews emphasize mechanisms that cope with reduced oxygen supply. However, during sojourns to high altitude adjustment to elevated iron demand is equally critical. Thus in this review we focus on the interaction between oxygen and iron homeostasis. We review the role of iron 1) in the oxygen sensing process and erythropoietin (Epo) synthesis, 2) in gene expression control mediated by the hypoxia-inducible factor-2 (HIF-2), and 3) as an oxygen carrier in hemoglobin, myoglobin, and cytochromes. The blood hormone Epo that is abundantly expressed by the kidney under hypoxic conditions stimulates erythropoiesis in the bone marrow, a process requiring high iron levels. To ensure that sufficient iron is provided, Epo-controlled erythroferrone that is expressed in erythroid precursor cells acts in the liver to reduce expression of the iron hormone hepcidin. Consequently, suppression of hepcidin allows for elevated iron release from storage organs and enhanced absorption of dietary iron by enterocytes. As recently observed in sojourners at high altitude, however, iron uptake may be hampered by reduced appetite and gastrointestinal bleeding. Reduced iron availability, as observed in a hypoxic mountaineer, enhances hypoxia-induced pulmonary hypertension and may contribute to other hypoxia-related diseases. Overall, adequate systemic iron availability is an important prerequisite to adjust to high-altitude hypoxia and may have additional implications for disease-related hypoxic conditions.
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Affiliation(s)
- Max Gassmann
- Institute of Veterinary Physiology, Vetsuisse Faculty, and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland, and Universidad Peruana Cayetano Heredia, Lima, Peru; and
| | - Martina U Muckenthaler
- Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Molecular Medicine Partnership Unit, University of Heidelberg, Translational Lung Research Center Heidelberg, and German Center for Lung Research, Heidelberg, Germany
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