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Hannemann J, Thorarinnsdottir EH, Amaral AFS, Schwedhelm E, Schmidt-Hutten L, Stang H, Benediktsdottir B, Gunnarsdóttir I, Gislason T, Böger R. Biomarkers of the L-Arginine/Dimethylarginine/Nitric Oxide Pathway in People with Chronic Airflow Obstruction and Obstructive Sleep Apnoea. J Clin Med 2023; 12:5230. [PMID: 37629272 PMCID: PMC10455103 DOI: 10.3390/jcm12165230] [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: 07/05/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea (OSA) are common chronic diseases that are associated with chronic and intermittent hypoxemia, respectively. Patients affected by the overlap of COPD and OSA have a particularly unfavourable prognosis. The L-arginine/nitric oxide (NO) pathway plays an important role in regulating pulmonary vascular function. Asymmetric (ADMA) and symmetric dimethylarginine (SDMA) interfere with NO production. METHODS We analysed the serum concentrations of ADMA, SDMA, L-arginine, L-citrulline, and L-ornithine in a large sample of the Icelandic general population together with chronic airflow obstruction (CAO), a key physiological marker of COPD that was assessed by post-bronchodilator spirometry (FEV1/FVC < LLN). OSA risk was determined by the multivariable apnoea prediction (MAP) index. RESULTS 713 individuals were analysed, of whom 78 (10.9%) showed CAO and 215 (30%) had MAP > 0.5. SDMA was significantly higher in individuals with CAO (0.518 [0.461-0.616] vs. 0.494 [0.441-0.565] µmol/L; p = 0.005), but ADMA was not. However, ADMA was significantly associated with decreasing FEV1 percent predicted among those with CAO (p = 0.002). ADMA was 0.50 (0.44-0.56) µmol/L in MAP ≤ 0.5 versus 0.52 (0.46-0.58) µmol/L in MAP > 0.5 (p = 0.008). SDMA was 0.49 (0.44-0.56) µmol/L versus 0.51 (0.46-0.60) µmol/L, respectively (p = 0.004). The highest values for ADMA and SDMA were observed in individuals with overlap of CAO and MAP > 0.5, which was accompanied by lower L-citrulline levels. CONCLUSIONS The plasma concentrations of ADMA and SDMA are elevated in COPD patients with concomitant intermittent hypoxaemia. This may account for impaired pulmonary NO production, enhanced pulmonary vasoconstriction, and disease progression.
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Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (J.H.); (E.S.); (L.S.-H.); (H.S.)
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and Its Health Sequelae, 20246 Hamburg, Germany
| | - Elin H. Thorarinnsdottir
- Primary Health Care of the Capital Area, 103 Reykjavik, Iceland;
- Faculty of Medicine, University of Iceland, 102 Reykjavik, Iceland; (B.B.); (T.G.)
| | - André F. S. Amaral
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK;
- NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (J.H.); (E.S.); (L.S.-H.); (H.S.)
| | - Lena Schmidt-Hutten
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (J.H.); (E.S.); (L.S.-H.); (H.S.)
| | - Heike Stang
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (J.H.); (E.S.); (L.S.-H.); (H.S.)
| | - Bryndis Benediktsdottir
- Faculty of Medicine, University of Iceland, 102 Reykjavik, Iceland; (B.B.); (T.G.)
- Sleep Department, Landspitali University Hospital of Iceland, 105 Reykjavik, Iceland
| | - Ingibjörg Gunnarsdóttir
- Unit for Nutrition Research, Landspitali University Hospital & Faculty of Food Science and Nutrition, University of Iceland, 102 Reykjavik, Iceland;
| | - Thórarinn Gislason
- Faculty of Medicine, University of Iceland, 102 Reykjavik, Iceland; (B.B.); (T.G.)
- Sleep Department, Landspitali University Hospital of Iceland, 105 Reykjavik, Iceland
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (J.H.); (E.S.); (L.S.-H.); (H.S.)
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and Its Health Sequelae, 20246 Hamburg, Germany
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Asymmetric Dimethylarginine in COPD Exacerbation. SISLI ETFAL HASTANESI TIP BULTENI 2022; 56:536-542. [PMID: 36660388 PMCID: PMC9833347 DOI: 10.14744/semb.2022.23682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 01/22/2023]
Abstract
Objectives Chronic obstructive pulmonary disease (COPD) is a disease with progressive airway limitation. The asymmetric dimethylarginine (ADMA) molecule is known to be effective in airway inflammation and remodeling. We investigated the relationship between ADMA and COPD, and its role in the course of the disease in cases with exacerbation. Methods This single-center study performed in our patient clinic included 56 patients (57.1% of males) with median age 67 (41-88) presented with COPD exacerbation and 26 sex-matched healthy controls. ADMA, white blood cell count, eosinophil, neutrophil, lymphocyte, C-reactive protein, fibrinogen, oxygen saturation%, and pulmonary function test values were compared. Results ADMA values were significantly higher (516.93 vs. 320.05 median, p<0.05) in the COPD group compared to the control group. No significant difference was demonstrated in ADMA concentrations according to Global Initiative for Chronic Obstructive Lung Disease Stages (p>0.05). In the receiver operating characteristic analysis to estimate the predictive power of COPD, the cutoff ADMA concentration >301 ng/ml was found to be able to distinguish COPD patients in all cases. Conclusion ADMA levels increase with complex mechanisms in COPD. It can be a significant indicator of the disease. However, more extensive research is needed for its use as a biomarker in severity and progression of COPD.
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Reprogramming of Amino Acid Metabolism Differs between Community-Acquired Pneumonia and Infection-Associated Exacerbation of Chronic Obstructive Pulmonary Disease. Cells 2022; 11:cells11152283. [PMID: 35892580 PMCID: PMC9330610 DOI: 10.3390/cells11152283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 02/05/2023] Open
Abstract
Amino acids and their metabolites are key regulators of immune responses, and plasma levels may change profoundly during acute disease states. Using targeted metabolomics, we evaluated concentration changes in plasma amino acids and related metabolites in community-acquired pneumonia (CAP, n = 29; compared against healthy controls, n = 33) from presentation to hospital through convalescence. We further aimed to identify biomarkers for acute CAP vs. the clinically potentially similar infection-triggered COPD exacerbation (n = 13). Amino acid metabolism was globally dysregulated in both CAP and COPD. Levels of most amino acids were markedly depressed in acute CAP, and total amino acid concentrations on admission were an accurate biomarker for the differentiation from COPD (AUC = 0.93), as were reduced asparagine and threonine levels (both AUC = 0.92). Reduced tryptophan and histidine levels constituted the most accurate biomarkers for acute CAP vs. controls (AUC = 0.96, 0.94). Only kynurenine, symmetric dimethyl arginine, and phenylalanine levels were increased in acute CAP, and the kynurenine/tryptophan ratio correlated best with clinical recovery and resolution of inflammation. Several amino acids did not reach normal levels by the 6-week follow-up. Glutamate levels were reduced on admission but rose during convalescence to 1.7-fold above levels measured in healthy control. Our data suggest that dysregulated amino acid metabolism in CAP partially persists through clinical recovery and that amino acid metabolism constitutes a source of promising biomarkers for CAP. In particular, total amino acids, asparagine, and threonine may constitute plasma biomarker candidates for the differentiation between CAP and infection-triggered COPD exacerbation and, perhaps, the detection of pneumonia in COPD.
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Hannemann J, Böger R. Dysregulation of the Nitric Oxide/Dimethylarginine Pathway in Hypoxic Pulmonary Vasoconstriction—Molecular Mechanisms and Clinical Significance. Front Med (Lausanne) 2022; 9:835481. [PMID: 35252268 PMCID: PMC8891573 DOI: 10.3389/fmed.2022.835481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/27/2022] [Indexed: 12/21/2022] Open
Abstract
The pulmonary circulation responds to hypoxia with vasoconstriction, a mechanism that helps to adapt to short-lived hypoxic episodes. When sustained, hypoxic pulmonary vasoconstriction (HPV) may become deleterious, causing right ventricular hypertrophy and failure, and contributing to morbidity and mortality in the late stages of several chronic pulmonary diseases. Nitric oxide (NO) is an important endothelial vasodilator. Its release is regulated, amongst other mechanisms, by the presence of endogenous inhibitors like asymmetric dimethylarginine (ADMA). Evidence has accumulated in recent years that elevated ADMA may be implicated in the pathogenesis of HPV and in its clinical sequelae, like pulmonary arterial hypertension (PAH). PAH is one phenotypic trait in experimental models with disrupted ADMA metabolism. In high altitude, elevation of ADMA occurs during long-term exposure to chronic or chronic intermittent hypobaric hypoxia; ADMA is significantly associated with high altitude pulmonary hypertension. High ADMA concentration was also reported in patients with chronic obstructive lung disease, obstructive sleep apnoea syndrome, and overlap syndrome, suggesting a pathophysiological role for ADMA-mediated impairment of endothelium-dependent, NO-mediated pulmonary vasodilation in these clinically relevant conditions. Improved understanding of the molecular (dys-)regulation of pathways controlling ADMA concentration may help to dissect the pathophysiology and find novel therapeutic options for these diseases.
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Affiliation(s)
- Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute DECIPHER, German-Chilean Institute for Research on Pulmonary Hypoxia and its Health Sequelae, Hamburg, Germany
- *Correspondence: Rainer Böger
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Scott JA, Maarsingh H, Holguin F, Grasemann H. Arginine Therapy for Lung Diseases. Front Pharmacol 2021; 12:627503. [PMID: 33833679 PMCID: PMC8022134 DOI: 10.3389/fphar.2021.627503] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/04/2021] [Indexed: 12/15/2022] Open
Abstract
Nitric oxide (NO) is produced by a family of isoenzymes, nitric oxide synthases (NOSs), which all utilize L-arginine as substrate. The production of NO in the lung and airways can play a number of roles during lung development, regulates airway and vascular smooth muscle tone, and is involved in inflammatory processes and host defense. Altered L-arginine/NO homeostasis, due to the accumulation of endogenous NOS inhibitors and competition for substrate with the arginase enzymes, has been found to play a role in various conditions affecting the lung and in pulmonary diseases, such as asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, and bronchopulmonary dysplasia. Different therapeutic strategies to increase L-arginine levels or bioavailability are currently being explored in pre-clinical and clinical studies. These include supplementation of L-arginine or L-citrulline and inhibition of arginase.
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Affiliation(s)
- Jeremy A Scott
- Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Harm Maarsingh
- Department of Pharmaceutical Sciences, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, United States
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, CO, United States
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Department of Paediatrics and Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
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Csoma B, Bikov A, Nagy L, Tóth B, Tábi T, Szűcs G, Komlósi ZI, Müller V, Losonczy G, Lázár Z. Dysregulation of the endothelial nitric oxide pathway is associated with airway inflammation in COPD. Respir Res 2019; 20:156. [PMID: 31311549 PMCID: PMC6636120 DOI: 10.1186/s12931-019-1133-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is related to endothelial dysfunction and the impaired generation of nitric oxide (NO) from L-arginine by the endothelial NO synthase (eNOS). The relationship between eNOS dysfunctionality and airway inflammation is unknown. We assessed serum asymmetric and symmetric dimethylarginine (ADMA and SDMA) and nitrite/nitrate concentrations, indicators of eNOS function, in patients with COPD and correlated them with markers of inflammation. METHODS We recruited 15 control smokers, 29 patients with stable and 32 patients with exacerbated COPD requiring hospitalization (20 of them were measured both at admission and discharge). Serum L-arginine, ADMA, SDMA, nitrite and nitrate were measured and correlated with airway inflammatory markers (fractional exhaled nitric oxide concentration - FENO, sputum nitrite and nitrate, sputum cellularity), serum C-reactive protein - CRP, white blood cell count, lung function and blood gases. ANOVA, t-tests and Pearson correlation were used (mean ± SD or geometric mean ± geometric SD for nitrite/nitrate). RESULTS Serum L-arginine/ADMA, a marker of substrate availability for eNOS, was lower in stable (214 ± 58, p < 0.01) and exacerbated COPD (231 ± 68, p < 0.05) than in controls (287 ± 64). The serum concentration of SDMA, a competitor of L-arginine transport, was elevated during an exacerbation (0.78 ± 0.39 μM) compared to stable patients (0.53 ± 0.14 μM, p < 0.01) and controls (0.45 ± 0.14 μM, p < 0.001). ADMA correlated with blood neutrophil percentage (r = 0.36, p < 0.01), FENO (r = 0.42, p < 0.01) and a tendency for positive association was observed to sputum neutrophil count (r = 0.33, p = 0.07). SDMA correlated with total sputum inflammatory cell count (r = 0.61, p < 0.01) and sputum neutrophil count (r = 0.62, p < 0.01). Markers were not related to lung function, blood gases or CRP. L-arginine/ADMA was unchanged, but serum SDMA level decreased (0.57 ± 0.42 μM, p < 0.05) after systemic steroid treatment of the exacerbation. Serum nitrite level increased in stable and exacerbated disease (4.11 ± 2.12 and 4.03 ± 1.77 vs. control: 1.61 ± 1.84 μM, both p < 0.001). CONCLUSIONS Our data suggest impaired eNOS function in stable COPD, which is transiently aggravated during an exacerbation and partly reversed by systemic steroid treatment. Serum ADMA and SDMA correlate with airway inflammatory markers implying a possible effect of anti-inflammatory therapy on endothelial dysfunction. Serum nitrite can serve as a compensatory pool for impaired endothelial NO generation.
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Affiliation(s)
- Balázs Csoma
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
| | - András Bikov
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
- NIHR Clinical Research Facility, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT UK
| | - Lajos Nagy
- Department of Applied Chemistry, University of Debrecen, Egyetem tér 1, Debrecen, 4032 Hungary
| | - Bence Tóth
- Department of Applied Chemistry, University of Debrecen, Egyetem tér 1, Debrecen, 4032 Hungary
| | - Tamás Tábi
- Department of Pharmacodynamics, Semmelweis University, Nagyvárad tér 4, Budapest, 1089 Hungary
| | - Gergő Szűcs
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
| | - Zsolt István Komlósi
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Nagyvárad tér 4, Budapest, 1089 Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
| | - György Losonczy
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
| | - Zsófia Lázár
- Department of Pulmonology, Semmelweis University, Diós árok 1/c, Budapest, 1125 Hungary
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Systemic concentrations of asymmetric dimethylarginine (ADMA) in chronic obstructive pulmonary disease (COPD): state of the art. Amino Acids 2018; 50:1169-1176. [PMID: 29951704 DOI: 10.1007/s00726-018-2606-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/20/2018] [Indexed: 01/08/2023]
Abstract
Experimental evidence suggests that oxidative stress (OS) may increase the activity of arginine methylating enzymes that produce the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA). In addition, it is well documented that OS can significantly decrease the synthesis and/or activity of ADMA degrading enzymes, thus causing ADMA accumulation in biological fluids. Recent reports have focused on circulating methylated arginine concentrations in chronic obstructive pulmonary disease, a disease characterized by a significant increase in OS. This review discusses the results of these studies and the opportunities for further research in this area.
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van den Berg MP, Meurs H, Gosens R. Targeting arginase and nitric oxide metabolism in chronic airway diseases and their co-morbidities. Curr Opin Pharmacol 2018; 40:126-133. [PMID: 29729549 DOI: 10.1016/j.coph.2018.04.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 01/22/2023]
Abstract
In the airways, arginase and NOS compete for the common substrate l-arginine. In chronic airway diseases, such as asthma and COPD, elevated arginase expression contributes to airway contractility, hyperresponsiveness, inflammation and remodeling. The disrupted l-arginine homeostasis, through changes in arginase and NOS expression and activity, does not only play a central role in the development of various airways diseases such as asthma or COPD. It possibly also affects l-arginine homeostasis throughout the body contributing to the emergence of co-morbidities. This review focusses on the role of arginase, NOS and ADMA in co-morbidities of asthma and COPD and speculates on their possible connection.
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Affiliation(s)
- Mariska Pm van den Berg
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1 (XB10), 9713 AV Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Herman Meurs
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1 (XB10), 9713 AV Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1 (XB10), 9713 AV Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands.
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Papp C, Pak K, Erdei T, Juhasz B, Seres I, Szentpéteri A, Kardos L, Szilasi M, Gesztelyi R, Zsuga J. Alteration of the irisin-brain-derived neurotrophic factor axis contributes to disturbance of mood in COPD patients. Int J Chron Obstruct Pulmon Dis 2017; 12:2023-2033. [PMID: 28744117 PMCID: PMC5511021 DOI: 10.2147/copd.s135701] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
COPD is accompanied by limited physical activity, worse quality of life, and increased prevalence of depression. A possible link between COPD and depression may be irisin, a myokine, expression of which in the skeletal muscle and brain positively correlates with physical activity. Irisin enhances the synthesis of brain-derived neurotrophic factor (BDNF), a neurotrophin involved in reward-related processes. Thus, we hypothesized that mood disturbances accompanying COPD are reflected by the changes in the irisin–BDNF axis. Case history, routine laboratory parameters, serum irisin and BDNF levels, pulmonary function, and disease-specific quality of life, measured by St George’s Respiratory Questionnaire (SGRQ), were determined in a cohort of COPD patients (n=74). Simple and then multiple linear regression were used to evaluate the data. We found that mood disturbances are associated with lower serum irisin levels (SGRQ’s Impacts score and reciprocal of irisin showed a strong positive association; β: 419.97; 95% confidence interval [CI]: 204.31, 635.63; P<0.001). This association was even stronger among patients in the lower 50% of BDNF levels (β: 434.11; 95% CI: 166.17, 702.05; P=0.002), while it became weaker for patients in the higher 50% of BDNF concentrations (β: 373.49; 95% CI: −74.91, 821.88; P=0.1). These results suggest that irisin exerts beneficial effect on mood in COPD patients, possibly by inducing the expression of BDNF in brain areas associated with reward-related processes involved in by depression. Future interventional studies targeting the irisin–BDNF axis (eg, endurance training) are needed to further support this notion.
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Affiliation(s)
- Csaba Papp
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health
| | - Krisztian Pak
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine
| | - Tamas Erdei
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine
| | - Bela Juhasz
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine
| | - Ildiko Seres
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen
| | - Anita Szentpéteri
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen
| | - Laszlo Kardos
- Department of Clinical Pharmacology, Infectious Diseases and Allergology, Kenezy Gyula Teaching County Hospital and Outpatient Clinic
| | - Maria Szilasi
- Department of Pulmonology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rudolf Gesztelyi
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine
| | - Judit Zsuga
- Department of Health Systems Management and Quality Management for Health Care, Faculty of Public Health
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