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Zhao Z, Ma D, Qin Y, Xu Y, Li S, Liu H. Melatonin downregulates angiogenesis and lymphangiogenesis by regulating tumor-associated macrophages via NLRP3 inflammasomes in lung adenocarcinoma. Aging (Albany NY) 2024; 16:12225-12238. [PMID: 39230586 PMCID: PMC11424589 DOI: 10.18632/aging.206057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 07/11/2024] [Indexed: 09/05/2024]
Abstract
Tumor-associated macrophages (TAMs), present within the tumor microenvironment (TME), strictly modulate tumor angiogenesis and lymphangiogenesis. Nevertheless, the associated signaling networks and candidate drug targets for these events remains to be elucidated. Given its antioxidative activities, we speculated that melatonin may reduce pyroptosis, and thereby modulate both angiogenesis and lymphangiogenesis. We revealed that a co-culture of A549 cells and THP-1 macrophages strongly enhanced expressions of the NLRP3 inflammasome axis members, and augmented angiogenesis and lymphangiogenesis. Next, we overexpressed NLRP3 in the A549 cells, and demonstrated that excess NLRP3 expression substantially upregulated VEGF and CXCL cytokine expressions, and enhanced lymphatic endothelial cells (LECs) tube formation. In contrast, NLRP3 inhibition produced the opposite effect. In addition, relative to controls, melatonin administration strongly inhibited the NLRP3 inflammasome axis, as well as angiogenesis and lymphangiogenesis in the co-culture system. Subsequent animal experiments using a Lewis Lung Carcinoma (LLC) subcutaneous tumor model in mice corroborate these findings. Melatonin treatment and NLRP3 knockdown significantly inhibit tumor growth and downregulate NLRP3 and IL-1β expression in tumor tissues. Furthermore, melatonin downregulates the expression of angiogenic and lymphangiogenic markers in tumor tissues. Taken together, the evidence suggested that a THP-1 macrophage and A549 cell co-culture stimulates angiogenesis and lymphangiogenesis via the NLRP3 axis. Melatonin protected against the TAMs- and NLRP3 axis-associated promotion of the aforementioned events in vitro and in vivo. Hence, melatonin is a promising candidate for managing for tumor-related angiogenesis and lymphangiogenesis in lung adenocarcinoma.
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Affiliation(s)
- Zhewei Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yuan Xu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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2
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Wu J, Shyy M, Shyy JYJ, Xiao H. Role of inflammasomes in endothelial dysfunction. Br J Pharmacol 2024. [PMID: 38952037 DOI: 10.1111/bph.16479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/14/2024] [Accepted: 05/04/2024] [Indexed: 07/03/2024] Open
Abstract
The vascular endothelium dynamically responds to environmental cues and plays a pivotal role in maintaining vascular homeostasis by regulating vasomotor tone, blood cell trafficking, permeability and immune responses. However, endothelial dysfunction results in various pathological conditions. Inflammasomes are large intracellular multimeric complexes activated by pathogens or cellular damage. Inflammasomes in vascular endothelial cells (ECs) initiate innate immune responses, which have emerged as significant mediators in endothelial dysfunction, contributing to the pathophysiology of an array of diseases. This review summarizes the mechanisms and ramifications of inflammasomes in ECs and related vascular diseases such as atherosclerosis, abdominal aortic aneurysm, stroke, and lung and kidney diseases. We also discuss potential drugs targeting EC inflammasomes and their applications in treating vascular diseases.
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Affiliation(s)
- Jimin Wu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
- Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
- Research Unit of Medical Science Research Management/Basic and Clinical Research of Metabolic Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Haihe Laboratory of Cell Ecosystem, Beijing, China
| | - Melody Shyy
- Biological Sciences, University of California, Santa Barbara, Santa Barbara, California, USA
| | - John Y-J Shyy
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Han Xiao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China
- Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
- Research Unit of Medical Science Research Management/Basic and Clinical Research of Metabolic Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Haihe Laboratory of Cell Ecosystem, Beijing, China
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3
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Sun Y, Li F, Liu Y, Qiao D, Yao X, Liu GS, Li D, Xiao C, Wang T, Chi W. Targeting inflammasomes and pyroptosis in retinal diseases-molecular mechanisms and future perspectives. Prog Retin Eye Res 2024; 101:101263. [PMID: 38657834 DOI: 10.1016/j.preteyeres.2024.101263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024]
Abstract
Retinal diseases encompass various conditions associated with sight-threatening immune responses and are leading causes of blindness worldwide. These diseases include age-related macular degeneration, diabetic retinopathy, glaucoma and uveitis. Emerging evidence underscores the vital role of the innate immune response in retinal diseases, beyond the previously emphasized T-cell-driven processes of the adaptive immune system. In particular, pyroptosis, a newly discovered programmed cell death process involving inflammasome formation, has been implicated in the loss of membrane integrity and the release of inflammatory cytokines. Several disease-relevant animal models have provided evidence that the formation of inflammasomes and the induction of pyroptosis in innate immune cells contribute to inflammation in various retinal diseases. In this review article, we summarize current knowledge about the innate immune system and pyroptosis in retinal diseases. We also provide insights into translational targeting approaches, including novel drugs countering pyroptosis, to improve the diagnosis and treatment of retinal diseases.
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Affiliation(s)
- Yimeng Sun
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
| | - Fan Li
- Eye Center, Zhongshan City People's Hospital, Zhongshan, 528403, China
| | - Yunfei Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
| | - Dijie Qiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
| | - Xinyu Yao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
| | - Guei-Sheung Liu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia; Ophthalmology, Department of Surgery, University of Melbourne, East Melbourne, VIC, 3002, Australia
| | - Dequan Li
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Chuanle Xiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
| | - Tao Wang
- Institute of Infectious Diseases, Shenzhen Bay Laboratory, Guangming District, Shenzhen, 518132, China; School of Basic Medical Sciences, Capital Medical University, 10 Xitoutiao You'anMen Street, Beijing, 100069, China
| | - Wei Chi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China.
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4
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Xu C, Li H, Xu Q, Zhao K, Hao M, Lin W, Ma X, Gao X, Kuang H. Dapagliflozin ameliorated retinal vascular permeability in diabetic retinopathy rats by suppressing inflammatory factors. J Diabetes Complications 2024; 38:108631. [PMID: 38340519 DOI: 10.1016/j.jdiacomp.2023.108631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Diabetic retinopathy is a common microvascular complication of diabetes and one of the major causes of blindness in the working-age population. Emerging evidence has elucidated that inflammation drives the key mechanism of diabetes-mediated retinal disturbance. As a new therapeutic drug targeting diabetes, whether dapagliflozin could improve vascular permeability from the perspective of anti-inflammatory effect need to be further explored. METHODS Type 2 diabetic retinopathy rat model was established and confirmed by fundus fluorescein angiography (FFA). ELISA detected level of plasma inflammatory factors and C-peptide. HE staining, immunohistochemistry and western blot detected histopathology changes of retina, expression of retinal inflammatory factors and tight junction proteins. RESULTS Dapagliflozin exhibited hypoglycemic effect comparable to insulin, but did not affect body weight. By inhibiting expression of inflammatory factors (NLRP3, Caspase-1, IL-18, NF-κB) in diabetic retina and plasma, dapagliflozin reduced damage of retinal tight junction proteins and improved retinal vascular permeability. The anti-inflammatory effect of dapagliflozin was superior to insulin. CONCLUSIONS Dapagliflozin improved retinal vascular permeability by reducing diabetic retinal and plasma inflammatory factors. The anti-inflammatory mechanism of dapagliflozin is independent of hypoglycemic effect and superior to insulin.
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Affiliation(s)
- Chengye Xu
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongxue Li
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qian Xu
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kangqi Zhao
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ming Hao
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wenjian Lin
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuefei Ma
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinyuan Gao
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongyu Kuang
- The Department of Endocrinology, The First Affiliated Hospital of Harbin Medical University, Harbin, China.
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5
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Gayatri V, Krishna Prasad M, Mohandas S, Nagarajan S, Kumaran K, Ramkumar KM. Crosstalk between inflammasomes, inflammation, and Nrf2: Implications for gestational diabetes mellitus pathogenesis and therapeutics. Eur J Pharmacol 2024; 963:176241. [PMID: 38043778 DOI: 10.1016/j.ejphar.2023.176241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
The role of inflammasomes in gestational diabetes mellitus (GDM) has emerged as a critical area of research in recent years. Inflammasomes, key components of the innate immune system, are now recognized for their involvement in the pathogenesis of GDM. Activation of inflammasomes in response to various triggers during pregnancy can produce pro-inflammatory cytokines, such as interleukin-1β (IL-1β) and interleukin-18 (IL-18), contributing to systemic inflammation and insulin resistance. This dysregulation not only impacts maternal health but also poses significant risks to fetal development and long-term health outcomes. Understanding the intricate interplay between inflammasomes and GDM holds promise for developing novel therapeutic strategies and interventions to mitigate the adverse effects of this condition on both mothers and their offspring. Researchers have elucidated that targeting inflammasomes using anti-inflammatory drugs and compounds can effectively reduce inflammation in GDM. Furthermore, the addition of nuclear factor erythroid 2-related factor 2 (Nrf2) to this complex mechanism opens novel avenues for therapeutics. The antioxidant properties of Nrf2 may potentially suppress inflammasome activation in GDM. This comprehensive review investigates the intricate relationship between inflammasomes and GDM, emphasizing the pivotal role of inflammation in its pathogenesis. It also sheds light on potential therapeutic strategies targeting inflammasome activation and explores the role of Nrf2 in mitigating inflammation in GDM.
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Affiliation(s)
- Vijaya Gayatri
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India
| | - Murali Krishna Prasad
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India
| | - Sundhar Mohandas
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India
| | - Sanjushree Nagarajan
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India
| | - Kriya Kumaran
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India
| | - Kunka Mohanram Ramkumar
- Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur 603 203, Tamil Nadu, India.
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6
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Xiang XH, Wei J, Wang XF, Xu Q, Yu CL, He CL, Long T, Guo MS, Chen X, Zhou XG, Wu JM, Qin DL, Wu AG, Tang Y, Lv HB. Lychee seed polyphenol ameliorates DR via inhibiting inflammasome/apoptosis and angiogenesis in hRECs and db/db mice. Biomed Pharmacother 2023; 167:115478. [PMID: 37703661 DOI: 10.1016/j.biopha.2023.115478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023] Open
Abstract
Blood retinal barrier (BRB) damage is an important pathogenesis of diabetic retinopathy, and alleviating BRB damage has become a key target for DR treatment. We previously found that Lycopene seed polyphenols (LSP) maintained BRB integrity by inhibiting NLRP3 inflammasome-mediated inflammation. However, it is still unknown whether LSP inhibits retinal neovascularization with abnormal capillaries and its mechanism of action. Here, we employed db/db mice and hRECs to find that LSP increases the level of glycolipid metabolism, maintains the morphology of retinal endothelial cells and inhibits acellular capillary neogenesis. Mechanistic studies revealed that LSP inhibits the NLRP3 inflammasome, reduces cell apoptosis in retinal tissue, increases tight junction protein (TJ) expression, and reduces vascular endothelial growth factor (VEGF) and Ve-Cadherin in vivo and in vitro. Collectively, this study finds that LSP inhibits inflammation and angiogenesis to improve BRB function to ameliorate DR.
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Affiliation(s)
- Xiao-Hong Xiang
- Department of Ophthalmology in the Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jing Wei
- Department of Ophthalmology in the Affiliated Hospital of Southwest Medical University, Luzhou, China; Eye School and Key Laboratory of Sichuan Province Ophthalmopathy Prevention & Cure and Visual Function Protection of Chengdu University of TCM, Chengdu, China.
| | - Xiao-Fang Wang
- Department of Human Anatomy School of Preclinical Medicine Southwest Medical University, Luzhou, China.
| | - Qin Xu
- Department of Ophthalmology in the Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Chong-Lin Yu
- Department of Human Anatomy School of Preclinical Medicine Southwest Medical University, Luzhou, China.
| | - Chang-Long He
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Tao Long
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Ming-Song Guo
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Xue Chen
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Xiao-Gang Zhou
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Jian-Ming Wu
- Department of Human Anatomy School of Preclinical Medicine Southwest Medical University, Luzhou, China.
| | - Da-Lian Qin
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - An-Guo Wu
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China.
| | - Yong Tang
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica of Southwest Medical University, Luzhou, China; State Key Laboratory of Quality Research in Chinese Medicine of Macau University of Science and Technology, Macau, China.
| | - Hong-Bin Lv
- Department of Ophthalmology in the Affiliated Hospital of Southwest Medical University, Luzhou, China.
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7
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Shadab A, Mahjoor M, Abbasi-Kolli M, Afkhami H, Moeinian P, Safdarian AR. Divergent functions of NLRP3 inflammasomes in cancer: a review. Cell Commun Signal 2023; 21:232. [PMID: 37715239 PMCID: PMC10503066 DOI: 10.1186/s12964-023-01235-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/17/2023] [Indexed: 09/17/2023] Open
Abstract
The cancer is a serious health problem, which is The cancer death rate (cancer mortality) is 158.3 per 100,000 men and women per year (based on 2013-2017 deaths). Both clinical and translational studies have demonstrated that chronic inflammation is associated with Cancer progression. However, the precise mechanisms of inflammasome, and the pathways that mediate this phenomenon are not fully characterized. One of the most recently identified signaling pathways, whose activation seems to affect many metabolic disorders, is the "inflammasome" a multiprotein complex composed of NLRP3 (nucleotide-binding domain and leucine-rich repeat protein 3), ASC (apoptosis associated speck-like protein containing a CARD), and procaspase-1. NLRP3 inflammasome activation leads to the processing and secretion of the proinflammatory cytokines interleukin-1β (IL-1β) and IL-18. The goal of this paper is to review new insights on the effects of the NLRP3 inflammasome activation in the complex mechanisms of crosstalk between different organs, for a better understanding of the role of chronic inflammation in cancer pathogenesis. We will provide here a perspective on the current research on NLRP3 inflammasome, which may represent an innovative therapeutic target to reverse the malignancy condition consequences of the inflammation. Video Abstract.
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Affiliation(s)
- Alireza Shadab
- Department of Immunology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
- Iran University of Medical Sciences, Deputy of Health, Tehran, Iran
| | - Mohamad Mahjoor
- Cellular and Molecular Research Center, Qom University of Medical Sciences, Qom, Iran
- Department of Immunology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abbasi-Kolli
- Iran University of Medical Sciences, Deputy of Health, Tehran, Iran
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Hamed Afkhami
- Cellular and Molecular Research Center, Qom University of Medical Sciences, Qom, Iran
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
- Department of Medical Microbiology, Faculty of Medicine, Shahed University, Tehran, Iran
| | - Parisa Moeinian
- Department of Medical Genetics and Molecular Biology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir-Reza Safdarian
- Immunology Board for Transplantation and Cell-Based Therapeutics (Immuno TACT), Universal Scientific Education and Research Network (USERN) Chicago, Chicago, IL, USA.
- Department of Immunology and Microbiology, Faculty of Veterinary Medicine, Tehran University, Tehran, Iran.
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8
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Chen C, Ding P, Yan W, Wang Z, Lan Y, Yan X, Li T, Han J. Pharmacological roles of lncRNAs in diabetic retinopathy with a focus on oxidative stress and inflammation. Biochem Pharmacol 2023; 214:115643. [PMID: 37315816 DOI: 10.1016/j.bcp.2023.115643] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/03/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
Diabetic retinopathy (DR) is a complication caused by abnormal glucose metabolism, which affects the vision and quality of life of patients and severely impacts the society at large.DR has a complex pathogenic process. Evidence from multiple studies have shown that oxidative stress and inflammation play pivotal roles in DR.Additionally, with the rapid development of various genetic detection methods, the abnormal expression of long non-coding RNAs (lncRNAs) have been confirmed to promote the development of DR.Research has demonstrated the potential of lncRNAs as ideal biomarkers and theranostic targets in DR. In this narrative review, we will focus on the research results on mechanisms underlying DR, list lncRNAs confirmed to be closely related to these mechanisms, and discuss their potential clinical application value and limitations.
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Affiliation(s)
- Chengming Chen
- Department of Ophthalmology, Tangdu Hospital, The Air Force Military Medical University, Xi'an 710038, China; Department of Ophthalmology, The 900th Hospital of Joint Logistic Support Force, PLA (Clinical Medical College of Fujian Medical University, Dongfang Hospital Affiliated to Xiamen University), Fuzhou 350025, China
| | - Peng Ding
- Department of Thoracic Surgery, Tangdu Hospital, The Air Force Military Medical University, Xi'an 710038, China
| | - Weiming Yan
- Department of Ophthalmology, The 900th Hospital of Joint Logistic Support Force, PLA (Clinical Medical College of Fujian Medical University, Dongfang Hospital Affiliated to Xiamen University), Fuzhou 350025, China
| | - Zhaoyang Wang
- Department of Thoracic Surgery, Tangdu Hospital, The Air Force Military Medical University, Xi'an 710038, China
| | - Yanyan Lan
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou 350122, China
| | - Xiaolong Yan
- Department of Thoracic Surgery, Tangdu Hospital, The Air Force Military Medical University, Xi'an 710038, China.
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi'an 710032, China.
| | - Jing Han
- Department of Ophthalmology, Tangdu Hospital, The Air Force Military Medical University, Xi'an 710038, China.
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9
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Yang Y, Jiang G, Huang R, Liu Y, Chang X, Fu S. Targeting the NLRP3 inflammasome in diabetic retinopathy: From Pathogenesis to Therapeutic Strategies. Biochem Pharmacol 2023; 212:115569. [PMID: 37100255 DOI: 10.1016/j.bcp.2023.115569] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
Diabetic retinopathy (DR) is a common diabetic microvascular complication and the main cause of vision loss in working-aged people. The NLRP3 inflammasome is a cytosolic multimeric complex that plays a significant role in innate immunity. After sensing injury, the NLRP3 inflammasome induces inflammatory mediator secretion and triggers a form of inflammatory cell death known as pyroptosis. Studies over the past five years have shown increased expression of NLRP3 and related inflammatory mediators in vitreous samples from DR patients at different clinical stages. Many NLRP3-targeted inhibitors have shown great antiangiogenic and anti-inflammatory effects in diabetes mellitus models, suggesting that the NLRP3 inflammasome is involved in the progression of DR. This review covers the molecular mechanisms of NLRP3 inflammasome activation. Furthermore, we discuss the implications of the NLRP3 inflammasome in DR, including the induction of pyroptosis and inflammation and the promotion of microangiopathy and retinal neurodegeneration. We also summarize the research progress on targeting the NLRP3 inflammasome in DR therapeutics with the expectation of providing new insights into DR progression and treatment.
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Affiliation(s)
- Yuxuan Yang
- The First Clinical Medical College, Lanzhou University, Lanzhou, The People's Republic of China, 730000
| | - Gengchen Jiang
- The First Clinical Medical College, Lanzhou University, Lanzhou, The People's Republic of China, 730000
| | - Runchun Huang
- The First Clinical Medical College, Lanzhou University, Lanzhou, The People's Republic of China, 730000
| | - Yi Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, The People's Republic of China, 730000
| | - Xingyu Chang
- The First Clinical Medical College, Lanzhou University, Lanzhou, The People's Republic of China, 730000
| | - Songbo Fu
- Department of Endocrinology, First Hospital of Lanzhou University, Lanzhou, Gansu, The People's Republic of China, 730000; Gansu Province Clinical Research Center for Endocrine Disease, Gansu, The People's Republic of China, 730000.
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10
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Wan J, Jiang Z, Liu D, Pan S, Zhou S, Liu Z. Inhibition of the glycogen synthase kinase 3β-hypoxia-inducible factor 1α pathway alleviates NLRP3-mediated pyroptosis induced by high glucose in renal tubular epithelial cells. Exp Physiol 2022; 107:1493-1506. [PMID: 36056793 DOI: 10.1113/ep090685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Abstract
NEW FINDINGS What is the central question of this study? Activation of the glycogen synthase kinase 3 β (GSK-3β)-hypoxia-inducible factor 1 α (HIF-1α) pathway results in stimulation of pyroptosis under high glucose, and exerts actions in a number renal diseases: does this pathway have a role in renal tubular epithelial cells? What is the main finding and its importance? Down-regulation of GSK-3β can inhibit pyroptosis of renal tubular epithelial cells induced by high glucose and this may be related to down-regulation of HIF-1α. This role of the GSK-3β-HIF-1α pathway has not previously been reported and identifies a potential new therapeutic target in diabetic nephropathy. ABSTRACT Diabetic nephropathy (DN) is not only one of the main complications of diabetes, but also has a high incidence rate and a high mortality rate. Glycogen synthase kinase 3 β (GSK-3β) and hypoxia-inducible factor 1 α (HIF-1α) have been demonstrated to influence DN by regulating pyroptosis. This study aimed to investigate the effect of the GSK-3β-HIF-1α pathway on pyroptosis of high-glucose (HG)-induced renal tubular cells. Mouse renal proximal tubular epithelial cells (TKPT cells) were induced by HG to simulate DN cell and we transfected TKPT cells with GSK-3β knockdown lentivirus. Western blot analysis confirmed the transfection effects and detected the expression of GSK-3β, HIF-1α, Nod-like receptor protein 3 (NLRP3), cleaved-caspase-1, pro-caspase-1, gasdermin D (GSDMD) and GSDMD-N. The expression of GSDMD-N and HIF-1α were also verified by immunofluorescence. The levels of interleukin (IL)-1β and IL-18 were measured by enzyme linked immunosorbent assay. Flow cytometric analysis determined the apoptosis rate. Results showed that HIF-1α expression was increased in HG-induced TKPT cells, and GSK-3β knockdown could decrease the levels of NLRP3, cleaved-caspase-1, GSDMD-N and HIF-1α, verified by immunofluorescence. Moreover, GSK-3β knockdown suppressed the expression of IL-1β and IL-18, and reduced the apoptosis rate. Lithium chloride (LiCl) interference could cause the same changes as GSK-3β knockdown for HG-induced TKPT cells, and dimethyloxallyl glycine could reverse the effect of GSK-3β-knockdown interference. Our studies definitively demonstrate that the GSK-3β-HIF-1α signalling pathway mediates HG-stimulated pyroptosis in renal tubular epithelial cells and that down-regulation of GSK-3β inhibited HG-induced pyroptosis by inhibiting the expression of HIF-1α. These findings suggest a new potential target for the treatment of DN.
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Affiliation(s)
- Jiayi Wan
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
| | - Ziming Jiang
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
| | - Dongwei Liu
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
| | - Shaokang Pan
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
| | - Sijie Zhou
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
| | - Zhangsuo Liu
- Traditional Chinese Medicine Integrated Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.,Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.,Henan Province Research Center for Kidney Disease, Zhengzhou, P. R. China.,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
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11
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Feng Z, Fan Y, Xie J, Liu S, Duan C, Wang Q, Ye Y, Yin W. HIF-1α promotes the expression of syndecan-1 and inhibits the NLRP3 inflammasome pathway in vascular endothelial cells under hemorrhagic shock. Biochem Biophys Res Commun 2022; 637:83-92. [DOI: 10.1016/j.bbrc.2022.10.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/13/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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Xiaodong L, Xuejun X. GSDMD-mediated pyroptosis in retinal vascular inflammatory diseases: a review. Int Ophthalmol 2022; 43:1405-1411. [PMID: 36068399 DOI: 10.1007/s10792-022-02506-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pyroptosis is a newly discovered form of programmed pro-inflammatory cell death. The main signaling pathways include the classical scorch death pathway that depends on NLRP3 inflammatory vesicles and other activation caspase-1 and the non-classical scorch death pathway that depends on caspase-4 /5/11. The substrate of all inflammatory caspases is GSDMD; a large number of studies have confirmed that pyroptosis is associated with certain infectious diseases, atherosclerotic diseases, metabolic diseases, and aseptic inflammatory diseases of important organs. In recent years, pyroptosis has been studied partially in the ocular field. So, this article reviews the recent literature intending to help readers understand the main mechanisms of cellular scorch death and the progress of GSDMD-mediated cellular scorch death in retinal vascular inflammatory diseases. METHOD A detailed review of the literature related to pyroptosis and inflammatory diseases of the retinal vasculature is presented. The following 6 electronic databases were searched: CNKI, Wanfang, VIP, PubMed, The Cochrane Library, and Embase Databases, and the search period was from the database to May 2022. The main search keywords include "Pyroptosis," " GSDMD," "Retinal Vascular Inflammatory Disease," "Diabetic retinopathy," "Retinal vasculitis." The discovery of pyroptosis, the main molecular mechanisms, key proteins, and their pathogenesis and therapeutic prospects in retinal vasculitis diseases are extensively studied and summarized. RESULT The mechanisms of gasdermin D-mediated pyroptosis are elaborated and analyzed, with particular emphasis on their key role and potential in the pathogenesis and treatment of inflammatory retinal vascular lesions. CONCLUSION Gasdermin D-mediated pyroptosis is a well-studied form of programmed pro-inflammatory cell death, which has a bidirectional regulatory effect on a variety of immune and inflammatory diseases. The literature reveals that pyroptosis is closely related to the pathogenesis of retinal vascular inflammatory diseases, and it may be an important therapeutic target for diabetic retinopathy and other retinal vasculitis eye diseases in the future.
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Affiliation(s)
- Li Xiaodong
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, Sichuan, China
| | - Xie Xuejun
- Department of Ophthalmology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan, People's Republic of China.
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Wrublewsky S, Speer T, Nalbach L, Boewe AS, Pack M, Alansary D, Roma LP, Hoffmann MDA, Schmitt BM, Weinzierl A, Menger MD, Laschke MW, Ampofo E. Targeting Pancreatic Islet NLRP3 Improves Islet Graft Revascularization. Diabetes 2022; 71:1706-1720. [PMID: 35622000 DOI: 10.2337/db21-0851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/21/2022] [Indexed: 11/13/2022]
Abstract
Hypoxia-induced islet cell death, caused by an insufficient revascularization of the grafts, is a major obstacle for successful pancreatic islet transplantation. Recently, it has been reported that the nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome is expressed in pancreatic islets and that its loss protects against hypoxia-induced cell death. Therefore, we hypothesized that the inhibition of NLRP3 in islets improves the survival and endocrine function of the grafts. The transplantation of Nlrp3-/- islets or wild-type (WT) islets exposed to the NLRP3 inhibitor CY-09 into mouse dorsal skinfold chambers resulted in an improved revascularization compared with controls. An increased insulin release after NLRP3 inhibition caused the enhanced angiogenic response. Moreover, the inhibition of NLRP3 in hypoxic β-cells triggered insulin gene expression by inducing the shuttling of MafA and pancreatic and duodenal homeobox-1 into the nucleus. This was mediated by a reduced interaction of NLRP3 with the thioredoxin-interacting protein (TXNIP). Transplantation of Nlrp3-/- islets or WT islets exposed to CY-09 under the kidney capsule of diabetic mice markedly improved the restoration of normoglycemia. These findings indicate that the inhibition of NLRP3 in isolated islets represents a promising therapeutic strategy to improve engraftment and function of the islets.
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Affiliation(s)
- Selina Wrublewsky
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Thimoteus Speer
- Department of Internal Medicine IV (Nephrology and Hypertension) and Translational Cardio-Renal Medicine, Saarland University, Homburg/Saar, Germany
| | - Lisa Nalbach
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Anne S Boewe
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Mandy Pack
- Medical Biochemistry and Molecular Biology, Saarland University, Homburg/Saar, Germany
| | - Dalia Alansary
- Biophysics Department, Center for Human and Molecular Biology, Saarland University, Homburg/Saar, Germany
| | - Leticia P Roma
- Biophysics Department, Center for Human and Molecular Biology, Saarland University, Homburg/Saar, Germany
| | - Markus D A Hoffmann
- Biophysics Department, Center for Human and Molecular Biology, Saarland University, Homburg/Saar, Germany
| | - Beate M Schmitt
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Andrea Weinzierl
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
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Yan L, Vaghari-Tabari M, Malakoti F, Moein S, Qujeq D, Yousefi B, Asemi Z. Quercetin: an effective polyphenol in alleviating diabetes and diabetic complications. Crit Rev Food Sci Nutr 2022; 63:9163-9186. [PMID: 35468007 DOI: 10.1080/10408398.2022.2067825] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Various studies, especially in recent years, have shown that quercetin has beneficial therapeutic effects in various human diseases, including diabetes. Quercetin has significant anti-diabetic effects and may be helpful in lowering blood sugar and increasing insulin sensitivity. Quercetin appears to affect many factors and signaling pathways involved in insulin resistance and the pathogenesis of type 2 of diabetes. TNFα, NFKB, AMPK, AKT, and NRF2 are among the factors that are affected by quercetin. In addition, quercetin can be effective in preventing and ameliorating the diabetic complications, including diabetic nephropathy, cardiovascular complications, neuropathy, delayed wound healing, and retinopathy, and affects the key mechanisms involved in the pathogenesis of these complications. These positive effects of quercetin may be related to its anti-inflammatory and anti-oxidant properties. In this article, after a brief review of the pathogenesis of insulin resistance and type 2 diabetes, we will review the latest findings on the anti-diabetic effects of quercetin with a molecular perspective. Then we will review the effects of quercetin on the key mechanisms of pathogenesis of diabetes complications including nephropathy, cardiovascular complications, neuropathy, delayed wound healing, and retinopathy. Finally, clinical trials investigating the effect of quercetin on diabetes and diabetes complications will be reviewed.
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Affiliation(s)
- Lei Yan
- Clinical Experimental Centre, Xi'an International Medical Center Hospital, Xi'an, China
- Department of Pre-Clinical Sciences, Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Kajang, Malaysia
| | - Mostafa Vaghari-Tabari
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Clinical Biochemistry and Laboratory Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faezeh Malakoti
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Soheila Moein
- Medicinal Plants Processing Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Durdi Qujeq
- Cellular and Molecular Biology Research Center (CMBRC), Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Bahman Yousefi
- Molecular Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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Zhu Z, Hu R, Li J, Xing X, Chen J, Zhou Q, Sun J. Alpinetin exerts anti-inflammatory, anti-oxidative and anti-angiogenic effects through activating the Nrf2 pathway and inhibiting NLRP3 pathway in carbon tetrachloride-induced liver fibrosis. Int Immunopharmacol 2021; 96:107660. [PMID: 33862553 DOI: 10.1016/j.intimp.2021.107660] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/23/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022]
Abstract
Alpinetin is the major active ingredient of Alpiniakatsumadai Hayata. As a kind of novel plant-derived flavonoid, alpinetin has shown potent hepatoprotective effect against many liver diseases such as non-alcoholic fatty liver and lipopolysaccharide/d-Galactosamine-induced liver injury. However, its roles in liver fibrosis remain to be determined. The aim of the current study was to investigate the effect of alpinetin in mice with carbon tetrachloride (CCl4)-induced liver fibrosis, and to elucidate the underlying mechanisms of action. Alpinetin ameliorated the CCl4-induced liver injury and fibrosis in mice, as shown by decreased collagen deposition and the decreased expression of liver fibrosis marker proteins. Alpinetin suppressed the inflammation and oxidative stress in fibrotic livers of mice, as evidenced by decreased levels of proinflammatory factors, the decreased reactive oxygen species (ROS) and malondialdehyde (MDA) levels, and the increased activities of antioxidant enzymes. In addition, alpinetin attenuated the angiogenesis in fibrotic livers of the test animals. Mechanistically, alpinetin inhibited the CCl4-induced expression of NLRP3, ASC, cleaved caspase-1, mature (cleaved-) IL-1β, and IL-18 in livers of mice. Furthermore, alpinetin resulted in an increased in the nuclear expression and a decrease in the cytoplasmic expression of Nrf2, as well as increased protein expression of downstream target enzymes, GCLC, HO-1, NQO1, and GCLM, thus exerting the antioxidant effect. Overall, these findings suggested that the anti-fibrotic effect of alpinetin can be attributed to the inhibition of NLRP3-mediated anti-inflammatory activities and Nrf2-mediated anti-oxidative activities, in addition to the decrement of hepatic angiogenesis.
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Affiliation(s)
- Zhiheng Zhu
- Department of General Surgery, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China
| | - Renyue Hu
- Medical School of Nantong University, 19 Qixiu Road, Nantong 226001, China
| | - Jidan Li
- Department of General Surgery, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China
| | - Xiaoxiao Xing
- Department of General Surgery, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China
| | - Jianxin Chen
- Department of General Surgery, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China
| | - Qi Zhou
- Department of Operating Room, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China.
| | - Jingjun Sun
- Department of General Surgery, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong 226018, China.
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