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Acen EL, Worodria W, Kateete DP, Olum R, Joloba ML, Akintola A, Bbuye M, Andia IB. Association of circulating serum free bioavailable and total vitamin D with cathelicidin levels among active TB patients and household contacts. Sci Rep 2023; 13:5365. [PMID: 37005478 PMCID: PMC10067953 DOI: 10.1038/s41598-023-32543-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/29/2023] [Indexed: 04/04/2023] Open
Abstract
The free hormone hypothesis postulates that the estimation of free circulating 25 (OH)D may be a better marker of vitamin D status and is of clinical importance compared to total vitamin D fraction. The unbound fraction is involved in biological activities since it is able to penetrate into the cell. Studies have shown that cathelicidin/LL-37 inhibits the growth of Mycobacterium tuberculosis in a vitamin D-dependent manner and therefore adequate vitamin D is required for its expression. The study aimed to determine the association between serum bioavailable and total vitamin D with LL-37 levels in ATB patients, LTBI, and individuals with no TB infection. This was a cross-sectional study in which bioavailable vitamin D and LL-37 levels were measured using competitive ELISA kits and total vitamin D was measured using electrochemilumiscence and consequently determined their association. The mean (SD) bioavailable vitamin D levels of the study participants were 3.8 ng/mL (2.6) and the median (IQR) of LL-37 levels were 320 ng/mL (160, 550 ng/mL). The mean (SD) of total vitamin D levels was 19.0 ng/mL (8.3) ng/mL. Similar weak correlations were observed between the bioavailable and total vitamin D with LL-37 levels, therefore, deviating from our hypothesis.
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Affiliation(s)
- Ester Lilian Acen
- Department of Physiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - William Worodria
- Pulmonary Division, Department of Internal Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - David Patrick Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Olum
- Department of Internal Medicine, School of Medicine, College of Health Sciences Unit, Makerere University, Kampala, Uganda
| | - Moses L Joloba
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ashraf Akintola
- Department of Biomedical Convergence Science and Technology, School of Industrial Technology Advances, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Mudarshiru Bbuye
- Makerere Lung Institute College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Biraro Andia
- Department of Internal Medicine, School of Medicine, College of Health Sciences Unit, Makerere University, Kampala, Uganda
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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Acen EL, Kateete DP, Worodria W, Olum R, Joloba ML, Bbuye M, Biraro IA. Evaluation of circulating serum cathelicidin levels as a potential biomarker to discriminate between active and latent tuberculosis in Uganda. PLoS One 2022; 17:e0272788. [PMID: 36018845 PMCID: PMC9416991 DOI: 10.1371/journal.pone.0272788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/26/2022] [Indexed: 01/08/2023] Open
Abstract
Background
Tuberculosis remains a major public health problem worldwide accounting for 1.4 million deaths annually. LL-37 is an effector molecule involved in immunity with both antimicrobial and immunomodulatory properties. The purpose of this study was to compare LL-37 circulatory levels among participants with active and latent tuberculosis and to determine its ability to discriminate between the two infectious states.
Methods
A cross-sectional study was performed among 56 active tuberculosis patients, 49 latent tuberculosis individuals, and 43 individuals without tuberculosis infection. The enzyme-linked immunosorbent assay was used to assess LL-37 levels. Data analysis was performed using STATA software and Graph pad Prism version 8. Mann-Whitney U test was used for correlation between variables with two categories and the Kruskal-Wallis test for three or more categories.
Results
The study had more female participants than males, with similar median ages across the three groups, 29.5, 25.0, and 23.0 years respectively. Active tuberculosis patients had significantly higher LL-37 levels compared to those with latent tuberculosis and without tuberculosis. The median/interquartile ranges were 318.8 ng/ml (157.9–547.1), 242.2 ng/ml (136.2–579.3), 170.9 ng/ml (129.3–228.3); p = 0.002 respectively. Higher LL-37 was found in the male participant with median/interquartile range, 424.8 ng/ml (226.2–666.8) compared to the females 237.7 ng/ml (129.6–466.6); p = 0.045. LL-37 had better discriminatory potential between active tuberculosis and no tuberculosis (AUC = 0.71, sensitivity 71.4% specificity = 69.8%) than with latent tuberculosis (AUC = 0.55, sensitivity = 71.4%, specificity = 44.9%). There was moderate differentiation between latent tuberculosis and no tuberculosis (AUC = 0.63, sensitivity = 44.9% specificity = 90.7%).
Conclusion
Significantly higher LL-37 levels were observed among active tuberculosis patients than those without tuberculosis infection and were, therefore able to discriminate between active tuberculosis and other tuberculosis infectious states, especially with no tuberculosis. Further assessment of this biomarker as a screening tool to exclude tuberculosis is required.
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Affiliation(s)
- Ester Lilian Acen
- Department of Physiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - David Patrick Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Worodria
- Pulmonary Division, Department of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Ronald Olum
- Department of Medicine, School of Medicine, College of Health Sciences Unit, Makerere University, Kampala, Uganda
| | - Moses L. Joloba
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mudarshiru Bbuye
- Makerere Lung Institute College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia Biraro
- Department of Medicine, School of Medicine, College of Health Sciences Unit, Makerere University, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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Expression of Vitamin D Receptor (VDR) gene and VDR polymorphism rs11574113 in pulmonary tuberculosis patients and their household contacts. GENE REPORTS 2022. [DOI: 10.1016/j.genrep.2022.101581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Acen EL, Biraro IA, Worodria W, Joloba ML, Nkeeto B, Musaazi J, Kateete DP. Impact of vitamin D status and cathelicidin antimicrobial peptide on adults with active pulmonary TB globally: A systematic review and meta-analysis. PLoS One 2021; 16:e0252762. [PMID: 34115790 PMCID: PMC8195352 DOI: 10.1371/journal.pone.0252762] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 05/24/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Tuberculosis remains a global threat and a public health problem that has eluded attempts to eradicate it. Low vitamin D levels have been identified as a risk factor for tuberculosis infection and disease. The human cathelicidin LL-37 has both antimicrobial and immunomodulatory properties and is dependent on vitamin D status. This systematic review attempts to compare vitamin D andLL-37 levels among adult pulmonary tuberculosis patients to non-pulmonary TB individuals between 16-75 years globally and to determine the association between vitamin D and cathelicidin and any contributing factor among the two study groups. METHODS/DESIGN We performed a search, through PubMed, HINARI, Google Scholar, EBSCOhost, and databases. A narrative synthesis through evaluation of vitamin D and LL-37 levels, the association of vitamin D and LL-37, and other variables in individual primary studies were performed. A random-effect model was performed and weighted means were pooled at a 95% confidence interval. This protocol is registered under the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42019127232. RESULTS Of the 2507 articles selected12 studies were eligible for the systematic review and of these only nine were included in the meta-analysis for vitamin D levels and six for LL-37 levels. Eight studies were performed in Asia, three in Europe, and only one study in Africa. The mean age of the participants was 37.3±9.9 yrs. We found low vitamin D and high cathelicidin levels among the tuberculosis patients compared to non-tuberculosis individuals to non-tuberculosis. A significant difference was observed in both vitamin D and LL-37 levels among tuberculosis patients and non-tuberculosis individuals (p = < 0.001). CONCLUSION This study demonstrated that active pulmonary tuberculosis disease is associated with hypovitaminosis D and elevated circulatory cathelicidin levels with low local LL-37 expression. This confirms that vitamin D status has a protective role against tuberculosis disease.
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Affiliation(s)
- Ester Lilian Acen
- Department of Physiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia Biraro
- Department of Internal Medicine, School of Medicine, College of Health Sciences Unit Makerere University, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Worodria
- Pulmonary Division, Department of Internal Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Moses L. Joloba
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University Kampala, Uganda
| | - Bill Nkeeto
- Department of Policy and Development Economics, School of Economics, College of Business and Management Sciences Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David Patrick Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University Kampala, Uganda
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Meca AD, Ștefănescu S, Bogdan M, Turcu-Știolică A, Nițu FM, Matei M, Cioboată R, Bugă AM, Pisoschi CG. Crosstalk between vitamin D axis, inflammation and host immunity mechanisms: A prospective study. Exp Ther Med 2021; 21:608. [PMID: 33936265 PMCID: PMC8082620 DOI: 10.3892/etm.2021.10040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) remains a public health burden, after many years at attempts for its eradication. Vitamin D (VD) status has been suggested to be related to TB susceptibility because it has the ability to regulate multiple axes of the innate and adaptive host immune response. VD mediates cathelicidin (LL-37) synthesis, a cationic bactericidal peptide, through the expression of vitamin D receptor (VDR). Host innate defense mechanisms include autophagy and apoptosis of alveolar macrophages. The present study aimed to assess the relationship between VD status, inflammation and host defense mechanisms before and after two months of first-line anti-TB pharmacotherapy. The study included newly diagnosed individuals with pulmonary TB without co-morbidities (HIV infection, diabetes, cancer) and without VD supplementation or other therapies interfering with VD serum levels. We measured serum levels of 25-hydroxyvitamin D (25-(OH)-D), the major circulating form of vitamin D, VDR, LL-37, beclin-1 (an autophagy marker) and M30 (an apoptosis biomarker) before and after two months of anti-TB treatment. Individuals presented lower levels of 25-(OH)-D before receiving first-line anti-TB treatment (T0) in comparison with its plasmatic levels after two-months of therapy (T2). At T2, patients were divided in two subgroups according the results of sputum-culture conversion. After two-months of therapy, decreased values of LL-37, beclin-1 and M30 were observed in the culture-negative patients compared to the culture-positive patients. Control of anti-TB treatment outcome could be improved by appraisal of VD status and host defense mechanisms such as autophagy and apoptosis.
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Affiliation(s)
- Andreea-Daniela Meca
- Department of Pharmacology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Simona Ștefănescu
- Clinical Laboratory, Clinical Emergency County Hospital, 200642 Craiova, Romania
| | - Maria Bogdan
- Department of Pharmacology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Adina Turcu-Știolică
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Floarea Mimi Nițu
- Department of Pneumology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Marius Matei
- Department of Histology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ramona Cioboată
- Department of Pneumology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ana Maria Bugă
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Zhou A, Li L, Zhao G, Min L, Liu S, Zhu S, Guo Q, Liu C, Zhang S, Li P. Vitamin D3 Inhibits Helicobacter pylori Infection by Activating the VitD3/VDR-CAMP Pathway in Mice. Front Cell Infect Microbiol 2020; 10:566730. [PMID: 33194806 PMCID: PMC7646218 DOI: 10.3389/fcimb.2020.566730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/27/2020] [Indexed: 01/10/2023] Open
Abstract
Helicobacter pylori (H. pylori) infection is closely associated with the occurrence and development of gastric diseases. Therefore, eliminating H. pylori infection should help to prevent gastric diseases. Vitamin D3 (VitD3, 1,25(OH)2D3) was previously observed to exhibit anti-H. pylori infection activity in clinic, but these results were reported in heterogeneous in vivo studies without elucidation of the underlying mechanisms. In the present study, we established H. pylori infection models in both wild-type and VDR knockdown (VDR-KD) mice, which were used to demonstrate that VitD3 inhibits H. pylori infection by enhancing the expression of VitD receptor (VDR) and cathelicidin antimicrobial peptide (CAMP). Furthermore, VDR-KD mice that exhibited lower VDR expression were more susceptible to H. pylori infection. In cultured mouse primary gastric epithelial cells, we further demonstrated that the VitD3/VDR complex binds to the CAMP promoter region to increase its expression. These data provide a mechanistic explanation of the anti-H. pylori infection activity of VitD3 at the molecular level in mice and suggest a new avenue for the clinical management of H. pylori eradication therapy.
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Affiliation(s)
- Anni Zhou
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Li
- Department of Digestive Diseases, Affiliated Hospital for Wei Fang Medical University, Weifang, China
| | - Guiping Zhao
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Li Min
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Si Liu
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shengtao Zhu
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qingdong Guo
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chunjie Liu
- Institute of Biomedical Engineering, Academy of Military Medical Sciences of the Chinese PLA, Beijing, China
| | - Shutian Zhang
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Peng Li
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Department of Gastroenterology, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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7
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Maruthai K, Sankar S, Subramanian M. Methylation Status of VDR Gene and its Association with Vitamin D Status and VDR Gene Expression in Pediatric Tuberculosis Disease. Immunol Invest 2020; 51:73-87. [PMID: 32847384 DOI: 10.1080/08820139.2020.1810702] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Deficiency in circulatory vitamin D level and vitamin D receptor DNA methylation could be associated with weakened innate immune response and increased susceptibility to tuberculosis (TB) disease in children. Therefore, we aimed to study the effect of vitamin D receptor (VDR) gene methylation on plasma vitamin D level and the expression of the VDR gene in children with active-TB disease. A cross-sectional comparative study was conducted in 43 children with active-TB and 33 healthy control children (HC). The vitamin D level was measured in plasma, while the levels of VDR gene promoter methylation and VDR gene expression were measured in peripheral blood. Children with active-TB showed a significantly lower median vitamin D level than HC [Cases 17.18 ng/mL (IQR, 8.3-18.6 ng/mL); HC 41.34 ng/mL (IQR, 40.2-43.49 ng/mL) (p<0.0001)] and decreased mRNA expression level of VDR gene [Cases 0.51 (IQR, 0.40-0.70); HC 1.06 (IQR, 0.8-1.2) (p<0.0001)] and increased VDR DNA methylation [Cases 75% (IQR, 50-75%); HC 10% (IQR, 10-25%) (p<0.0001)]. The VDR hypermethylation is significantly associated with reduced vitamin D level and decreased expression level of VDR gene. Therefore this inverse association could be involved in the impairment in the VDR mediated cytolytic and antimicrobial effector cell response in pediatric TB disease.
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Affiliation(s)
- Kathirvel Maruthai
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Saranya Sankar
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Mahadevan Subramanian
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Chung C, Silwal P, Kim I, Modlin RL, Jo EK. Vitamin D-Cathelicidin Axis: at the Crossroads between Protective Immunity and Pathological Inflammation during Infection. Immune Netw 2020; 20:e12. [PMID: 32395364 PMCID: PMC7192829 DOI: 10.4110/in.2020.20.e12] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023] Open
Abstract
Vitamin D signaling plays an essential role in innate defense against intracellular microorganisms via the generation of the antimicrobial protein cathelicidin. In addition to directly binding to and killing a range of pathogens, cathelicidin acts as a secondary messenger driving vitamin D-mediated inflammation during infection. Recent studies have elucidated the biological and clinical functions of cathelicidin in the context of vitamin D signaling. The vitamin D-cathelicidin axis is involved in the activation of autophagy, which enhances antimicrobial effects against diverse pathogens. Vitamin D studies have also revealed positive and negative regulatory effects of cathelicidin on inflammatory responses to pathogenic stimuli. Diverse innate and adaptive immune signals crosstalk with functional vitamin D receptor signals to enhance the role of cathelicidin action in cell-autonomous effector systems. In this review, we discuss recent findings that demonstrate how the vitamin D-cathelicidin pathway regulates autophagy machinery, protective immune defenses, and inflammation, and contributes to immune cooperation between innate and adaptive immunity. Understanding how the vitamin D-cathelicidin axis operates in the host response to infection will create opportunities for the development of new therapeutic approaches against a variety of infectious diseases.
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Affiliation(s)
- Chaeuk Chung
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon 35015, Korea
| | - Prashanta Silwal
- Infection Control Convergence Research Center, Chungnam National University School of Medicine, Daejeon 35015, Korea.,Department of Microbiology, Chungnam National University School of Medicine, Daejeon 35015, Korea
| | - Insoo Kim
- Infection Control Convergence Research Center, Chungnam National University School of Medicine, Daejeon 35015, Korea.,Department of Microbiology, Chungnam National University School of Medicine, Daejeon 35015, Korea
| | - Robert L Modlin
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 90095, USA.,Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Eun-Kyeong Jo
- Infection Control Convergence Research Center, Chungnam National University School of Medicine, Daejeon 35015, Korea.,Department of Microbiology, Chungnam National University School of Medicine, Daejeon 35015, Korea.,Department of Medical Science, Chungnam National University School of Medicine, Daejeon 35015, Korea
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9
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Rao Muvva J, Parasa VR, Lerm M, Svensson M, Brighenti S. Polarization of Human Monocyte-Derived Cells With Vitamin D Promotes Control of Mycobacterium tuberculosis Infection. Front Immunol 2020; 10:3157. [PMID: 32038652 PMCID: PMC6987394 DOI: 10.3389/fimmu.2019.03157] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/31/2019] [Indexed: 12/13/2022] Open
Abstract
Background: Understanding macrophage behavior is key to decipher Mycobacterium tuberculosis (Mtb) pathogenesis. We studied the phenotype and ability of human monocyte-derived cells polarized with active vitamin D [1,25(OH)2D3] to control intracellular Mtb infection compared with polarization of conventional subsets, classical M1 or alternative M2. Methods: Human blood-derived monocytes were treated with active vitamin D or different cytokines to obtain 1,25(OH)2D3-polarized as well as M1- and M2-like cells or fully polarized M1 and M2 subsets. We used an in vitro macrophage Mtb infection model to assess both phenotype and functional markers i.e., inhibitory and scavenger receptors, costimulatory molecules, cytokines, chemokines, and effector molecules using flow cytometry and quantitative mRNA analysis. Intracellular uptake of bacilli and Mtb growth was monitored using flow cytometry and colony forming units. Results: Uninfected M1 subsets typically expressed higher levels of CCR7, TLR2, and CD86, while M2 subsets expressed higher CD163, CD200R, and CD206. Most of the investigated markers were up-regulated in all subsets after Mtb infection, generating a mixed M1/M2 phenotype, while the expression of CD206, HLADR, and CD80 was specifically up-regulated (P < 0.05) on 1,25(OH)2D3-polarized macrophages. Consistent with the pro-inflammatory features of M1 cells, Mtb uptake and intracellular Mtb growth was significantly (P < 0.01–0.001 and P < 0.05–0.01) lower in the M1 (19.3%) compared with the M2 (82.7%) subsets 4 h post-infection. However, infectivity rapidly and gradually increased in M1 cells at 24–72 h. 1,25(OH)2D3-polarized monocyte-derived cells was the most potent subset to inhibit Mtb growth at both 4 and 72 h (P < 0.05–0.01) post-Mtb infection. This ability was associated with high mRNA levels of pro-inflammatory cytokines and the antimicrobial peptide LL-37 but also anti-inflammatory IL-10, while expression of the immunosuppressive enzyme IDO (indoleamine 2,3-dioxygenase) remained low in Mtb-infected 1,25(OH)2D3-polarized cells compared with the other subsets. Conclusions: Mtb infection promoted a mixed M1/M2 macrophage activation, and 1,25(OH)2D3-polarized monocyte-derived cells expressing LL-37 but not IDO, were most effective to control intracellular Mtb growth. Macrophage polarization in the presence of vitamin D may provide the capacity to mount an antimicrobial response against Mtb and simultaneously prevent expression of inhibitory molecules that could accelerate local immunosuppression in the microenvironment of infected tissue.
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Affiliation(s)
- Jagadeeswara Rao Muvva
- Department of Medicine, Center for Infectious Medicine (CIM), ANA Futura, Karolinska Institutet, Stockholm, Sweden
| | | | - Maria Lerm
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mattias Svensson
- Department of Medicine, Center for Infectious Medicine (CIM), ANA Futura, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Brighenti
- Department of Medicine, Center for Infectious Medicine (CIM), ANA Futura, Karolinska Institutet, Stockholm, Sweden
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10
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Ferlita S, Yegiazaryan A, Noori N, Lal G, Nguyen T, To K, Venketaraman V. Type 2 Diabetes Mellitus and Altered Immune System Leading to Susceptibility to Pathogens, Especially Mycobacterium tuberculosis. J Clin Med 2019; 8:E2219. [PMID: 31888124 PMCID: PMC6947370 DOI: 10.3390/jcm8122219] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/10/2019] [Indexed: 12/25/2022] Open
Abstract
There has been an alarming increase in the incidence of Type 2 Diabetes Mellitus (T2DM) worldwide. Uncontrolled T2DM can lead to alterations in the immune system, increasing the risk of susceptibility to infections such as Mycobacterium tuberculosis (M. tb). Altered immune responses could be attributed to factors such as the elevated glucose concentration, leading to the production of Advanced Glycation End products (AGE) and the constant inflammation, associated with T2DM. This production of AGE leads to the generation of reactive oxygen species (ROS), the use of the reduced form of nicotinamide adenine dinucleotide phosphate (NADPH) via the Polyol pathway, and overall diminished levels of glutathione (GSH) and GSH-producing enzymes in T2DM patients, which alters the cytokine profile and changes the immune responses within these patients. Thus, an understanding of the intricate pathways responsible for the pathogenesis and complications in T2DM, and the development of strategies to enhance the immune system, are both urgently needed to prevent co-infections and co-morbidities in individuals with T2DM.
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Affiliation(s)
- Steve Ferlita
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (S.F.); (N.N.); (G.L.); (T.N.)
| | - Aram Yegiazaryan
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA 91766-1854, USA;
| | - Navid Noori
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (S.F.); (N.N.); (G.L.); (T.N.)
| | - Gagandeep Lal
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (S.F.); (N.N.); (G.L.); (T.N.)
| | - Timothy Nguyen
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (S.F.); (N.N.); (G.L.); (T.N.)
| | - Kimberly To
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA;
| | - Vishwanath Venketaraman
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA; (S.F.); (N.N.); (G.L.); (T.N.)
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA 91766-1854, USA;
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766-1854, USA;
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Padhi A, Pattnaik K, Biswas M, Jagadeb M, Behera A, Sonawane A. Mycobacterium tuberculosisLprE Suppresses TLR2-Dependent Cathelicidin and Autophagy Expression to Enhance Bacterial Survival in Macrophages. THE JOURNAL OF IMMUNOLOGY 2019; 203:2665-2678. [DOI: 10.4049/jimmunol.1801301] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/15/2019] [Indexed: 12/20/2022]
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12
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Circulating levels of free 25(OH)D increase at the onset of rheumatoid arthritis. PLoS One 2019; 14:e0219109. [PMID: 31557191 PMCID: PMC6763124 DOI: 10.1371/journal.pone.0219109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/03/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Epidemiological studies suggest vitamin D deficiency as a potential risk factor for rheumatoid arthritis (RA) development, a chronic autoimmune disorder highly prevalent in indigenous North American (INA) population. We therefore profiled the circulating levels of 25-hydroxyvitaminD [25(OH)D], an active metabolite of vitamin D, in a cohort of at-risk first-degree relatives (FDR) of INA RA patients, a subset of whom subsequently developed RA (progressors). METHODS 2007 onward, serum samples from INA RA patients and FDR were collected at the time of a structured baseline visit and stored at -20°C. Anti-citrullinated protein antibodies (ACPA), 25(OH)D, hs-CRP, vitamin-D binding protein (VDBP) and parathyroid hormone (PTH) levels were determined using ELISA and rheumatoid factor (RF) seropositivity was determined by nephelometry. RESULTS We demonstrate that 25 (OH) D concentrations were lower in winter than summer (P = 0.0538), and that serum 25(OH)D levels were higher in samples collected and stored after 2013 (P<0.0001). Analysis of samples obtained after 2013 demonstrated that 37.6% of study participants were 25(OH)D insufficient (<75nmol/L). Also, seropositive RA patients and FDR had lower 25(OH)D levels compared to ACPA-/FDR (P<0.05, P<0.01 respectively). Linear regression analysis showed 25(OH)D insufficiency was inversely associated with presence of RA autoantibodies. Longitudinal samples from 14 progressors demonstrated a consistent increase in 25(OH)D levels at the time they exhibited clinically detectable joint inflammation, without any significant change in VDBP or PTH levels. Spearman rank correlation analysis showed significant association between 25(OH)D and PTH levels, both in RA patients and progressors at RA onset time. CONCLUSION We demonstrate that 25(OH)D levels in serum increased at RA onset in progressors. The potential role that vitamin D metabolites and their downstream effects play in RA transition requires further investigation.
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Missailidis C, Sørensen N, Ashenafi S, Amogne W, Kassa E, Bekele A, Getachew M, Gebreselassie N, Aseffa A, Aderaye G, Andersson J, Brighenti S, Bergman P. Vitamin D and Phenylbutyrate Supplementation Does Not Modulate Gut Derived Immune Activation in HIV-1. Nutrients 2019; 11:nu11071675. [PMID: 31330899 PMCID: PMC6682943 DOI: 10.3390/nu11071675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022] Open
Abstract
Dysbiosis and a dysregulated gut immune barrier function contributes to chronic immune activation in HIV-1 infection. We investigated if nutritional supplementation with vitamin D and phenylbutyrate could improve gut-derived inflammation, selected microbial metabolites, and composition of the gut microbiota. Treatment-naïve HIV-1-infected individuals (n = 167) were included from a double-blind, randomized, and placebo-controlled trial of daily 5000 IU vitamin D and 500 mg phenylbutyrate for 16 weeks (Clinicaltrials.gov NCT01702974). Baseline and per-protocol plasma samples at week 16 were analysed for soluble CD14, the antimicrobial peptide LL-37, kynurenine/tryptophan-ratio, TMAO, choline, and betaine. Assessment of the gut microbiota involved 16S rRNA gene sequencing of colonic biopsies. Vitamin D + phenylbutyrate treatment significantly increased 25-hydroxyvitamin D levels (p < 0.001) but had no effects on sCD14, the kynurenine/tryptophan-ratio, TMAO, or choline levels. Subgroup-analyses of vitamin D insufficient subjects demonstrated a significant increase of LL-37 in the treatment group (p = 0.02), whereas treatment failed to significantly impact LL-37-levels in multiple regression analysis. Further, no effects on the microbiota was found in number of operational taxonomic units (p = 0.71), Shannon microbial diversity index (p = 0.82), or in principal component analyses (p = 0.83). Nutritional supplementation with vitamin D + phenylbutyrate did not modulate gut-derived inflammatory markers or microbial composition in treatment-naïve HIV-1 individuals with active viral replication.
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Affiliation(s)
- Catharina Missailidis
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, 14152 Stockholm, Sweden.
| | | | - Senait Ashenafi
- Center for Infectious Medicine (CIM), F59, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, 14152 Stockholm, Sweden
| | - Wondwossen Amogne
- Department of Internal Medicine, Faculty of Medicine, Black Lion University Hospital and Addis Ababa University, 1176 Addis Ababa, Ethiopia
| | - Endale Kassa
- Department of Internal Medicine, Faculty of Medicine, Black Lion University Hospital and Addis Ababa University, 1176 Addis Ababa, Ethiopia
| | - Amsalu Bekele
- Department of Internal Medicine, Faculty of Medicine, Black Lion University Hospital and Addis Ababa University, 1176 Addis Ababa, Ethiopia
| | - Meron Getachew
- Department of Internal Medicine, Faculty of Medicine, Black Lion University Hospital and Addis Ababa University, 1176 Addis Ababa, Ethiopia
| | | | - Abraham Aseffa
- Armauer Hansen Research Institute (AHRI), 1005 Addis Ababa, Ethiopia
| | - Getachew Aderaye
- Department of Internal Medicine, Faculty of Medicine, Black Lion University Hospital and Addis Ababa University, 1176 Addis Ababa, Ethiopia
| | - Jan Andersson
- Center for Infectious Medicine (CIM), F59, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, 14152 Stockholm, Sweden
- Department of Medicine, Division of Infectious Diseases, Karolinska University Hospital Huddinge, 14152 Stockholm, Sweden
| | - Susanna Brighenti
- Center for Infectious Medicine (CIM), F59, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, 14152 Stockholm, Sweden
| | - Peter Bergman
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, 14152 Stockholm, Sweden
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Olszowiec-Chlebna M, Koniarek-Maniecka A, Brzozowska A, Błauż A, Rychlik B, Stelmach I. Vitamin D inhibits pro-inflammatory cytokines in the airways of cystic fibrosis patients infected by Pseudomonas aeruginosa- pilot study. Ital J Pediatr 2019; 45:41. [PMID: 30922377 PMCID: PMC6440129 DOI: 10.1186/s13052-019-0634-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/15/2019] [Indexed: 12/19/2022] Open
Abstract
Background Vitamin D plays an important role in inflammatory responses after antigen exposure. Interleukin-23 (Il-23) promotes Il-17-dependent inflammation during Pseudomonas aeruginosa (P. aeruginosa) pulmonary infection. We aimed to compare the ability of calcitriol and cholecalciferol to modulate the inflammatory response of the CF airways infected with P. aeruginosa. Methods This was a randomized, placebo-controlled, double-blind, cross-over trial. Twenty-three patients with CF (aged 6–19), chronically infected by P. aeruginosa were randomly assigned to: calcitriol group receiving 1,25(OH)2D 0,5 mcg daily or cholecalciferol group receiving cholecalciferol 1000 IU daily for three months. The levels of Il-23 and Il-17A in the exhaled breath concentrate (EBC) were measured. Calcium-phosphorus balance was also evaluated (serum concentration of calcium, phosphorus, 25OHD, parathormone (PTH) and calcium/creatinine ratio in urine). Data were analyzed using means of Stata/Special Edition, release 14.2. A level of P < 0.05 was considered statistically significant. Results The level of Il-17A in EBC significantly decreased in calcitriol group from 0,475 pg/mL (± SD 0,515 pg/mL) to 0,384 pg/mL (± SD 0,429 pg/mL) (p = 0,008); there was no change in cholecalciferol group (p = 0,074). The level of Il-23 in EBC did not significantly change in calcitriol group (p = 0,086); there was significant decrease in cholecalciferol group from 8,90 pg/mL (± SD 4,07 pg/mL) to 7,33 pg/mL (± SD 3,88 pg/mL) (p = 0,001). In calcitriol group serum phosphorus and PTH significantly decreased (p = 0,021 and p = 0,019 respectively), the concentration of calcium significantly increased (p = 0,001); there were no changes in cholecalciferol group. Conclusions Both analogs of vitamin D revealed their anti-inflammatory effect and reduced the level of Il-17A and Il-23 in the airway of CF patients with chronic P. aeruginosa infection. We observed improvement in calcium-phosphorus metabolism after supplementation with calcitriol, without adverse effects. It is recommended to use vitamin D in CF patients.
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Affiliation(s)
- M Olszowiec-Chlebna
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Korczak Paediatric Center, Piłsudskiego 71 Str, 90-329, Lodz, Poland
| | - A Koniarek-Maniecka
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Korczak Paediatric Center, Piłsudskiego 71 Str, 90-329, Lodz, Poland
| | - A Brzozowska
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Korczak Paediatric Center, Piłsudskiego 71 Str, 90-329, Lodz, Poland
| | - A Błauż
- Laboratory of Cytometry, Department of Molecular Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - B Rychlik
- Laboratory of Cytometry, Department of Molecular Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - I Stelmach
- Department of Pediatrics and Allergy, Medical University of Lodz, Copernicus Memorial Hospital, Korczak Paediatric Center, Piłsudskiego 71 Str, 90-329, Lodz, Poland.
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Ahmed JH, Makonnen E, Fotoohi A, Yimer G, Seifu D, Assefa M, Tigeneh W, Aseffa A, Howe R, Aklillu E. Vitamin D Status and Association of VDR Genetic Polymorphism to Risk of Breast Cancer in Ethiopia. Nutrients 2019; 11:nu11020289. [PMID: 30699973 PMCID: PMC6412905 DOI: 10.3390/nu11020289] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Emerging evidence associates vitamin D deficiency and vitamin D receptor (VDR) genetic variations with risk for breast cancer. This study investigated the prevalence of vitamin D deficiency and its association with tumor characteristics and the implications of VDR genetic variations for risk of breast cancer in Ethiopia. This unmatched case–control study involved 392 female breast cancer patients and 193 controls. The plasma 25-hydroxyvitamin D (25(OH)D3) level was quantified in chemotherapy-naïve (N = 112) and tamoxifen-treated patients (N = 89). Genotyping for the VDR common variant alleles rs7975232 (ApaI), rs2228570 (FokI), and rs731236 (TaqI) was done. Eighty-six percent of the patients were vitamin D deficient (<50 nmol/L). Chemotherapy-naïve breast cancer patients had a higher prevalence of vitamin D deficiency (91.9% vs. 78.3%) compared to the tamoxifen-treated group (p < 0.001). The prevalence of severe vitamin D deficiency (<25 nmol/L) was significantly higher in chemotherapy-naïve (41.1%) than tamoxifen-treated (11.2%) patients. Vitamin D deficiency was not significantly associated with tumor characteristics or VDR genotype. The rs2228570 GG genotype was associated with increased risk of breast cancer (OR = 1.44, 95% confidence interval = 1.01−2.06). Our result indicates that rs2228570 might be a moderate risk factor for breast cancer development in the Ethiopian population. The high prevalence of severe vitamin D deficiency in treatment-naïve breast cancer patients indicates the need for nutritional supplementation of vitamin D at the time of chemotherapy initiation.
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Affiliation(s)
- Jemal Hussien Ahmed
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
- Department of Pharmacy, Jimma University, P.O. Box 378 Jimma, Ethiopia.
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden.
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
- Center for Innovative Drug Development and Therapeutic Trials, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
| | - Alan Fotoohi
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden.
- Division of Clinical Pharmacology, Department of Medicine, Karolinska Institutet, 171 76 Solna, Stockholm, Sweden.
| | - Getnet Yimer
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
- Ohio State Global One Health initiative, Office of international affairs, Ohio State University, Pobox 9842 Addis Ababa, Ethiopia.
| | - Daniel Seifu
- Department of Biochemistry, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
| | - Mathewos Assefa
- Radiotherapy center, Addis Ababa University, P.O. Box 9086 Addis Ababa, Ethiopia.
| | | | - Abraham Aseffa
- Armauer Hansen Research Institute, P.O. Box 1005 Addis Ababa, Ethiopia.
| | - Rawleigh Howe
- Armauer Hansen Research Institute, P.O. Box 1005 Addis Ababa, Ethiopia.
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden.
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Uysal P, Simsek G, Durmus S, Sozer V, Aksan H, Yurt S, Cuhadaroglu C, Kosar F, Gelisgen R, Uzun H. Evaluation of plasma antimicrobial peptide LL-37 and nuclear factor-kappaB levels in stable chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2019; 14:321-330. [PMID: 30774329 PMCID: PMC6354692 DOI: 10.2147/copd.s185602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Antimicrobial peptides are effectors of host defence against infection and inflammation and can encourage wound repair. Objectives The objectives of this study were to investigate the plasma antimicrobial peptide LL-37 and nuclear factor-kappaB (NF-κB) levels in patients with stable COPD compared with a control group and to highlight their importance in immune inflammation. Methods One hundred and thirty-eight stable COPD patients and 33 control subjects were enrolled in the study. The COPD patients were classified into four groups based on FEV1 (groups I-IV) and also divided into "low-risk and high-risk" groups (groups A-B [low risk], C-D [high risk]). Results Plasma LL-37 levels were significantly lower while plasma NF-κB levels of the COPD patients were significantly higher than those of the control subjects (P<0.001, both). LL-37 levels were significantly lower in group IV than in groups I, II, and III (P<0.01, all). NF-κB levels were significantly higher in groups III and IV than in groups I and II (P<0.05, both). There was a positive correlation between FEV1 and FEV1/FVC in all COPD patients (r=0.742, P<0.001) and in group D (r=0.741, P<0.001). Furthermore, there was an inverse correlation between LL-37 and NF-κB in both the groups C (r=-0.566, P<0.001) and D (r=-0.694, P<0.001) and group C+D combined (r=-0.593, P<0.001). Furthermore, in group C, LL-37 and FEV1 were positively correlated (r=0.633, P<0.001). Conclusion Our study indicated that plasma LL-37 and NF-κB may play an important role in chronic immune inflammation. Decreased LL-37 levels may be particularly high risk for patients in stage IV disease. The role of LL-37 as a target for treatment of the immune system and COPD must be widely evaluated.
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Affiliation(s)
- Pelin Uysal
- Department of Chest Diseases, Faculty of Medicine, Mehmet Ali Aydınlar University, Atakent Hospital, Istanbul, Turkey
| | - Gonul Simsek
- Department of Physiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sinem Durmus
- Department of Biochemistry, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey,
| | - Volkan Sozer
- Department of Biochemistry, Yildiz Technical University, Istanbul, Turkey
| | - Hulya Aksan
- Deparment of Biochemistry, Faculty of Medicine, Halic University, I˙stanbul, Turkey
| | - Sibel Yurt
- Clinic of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, I˙stanbul, Turkey
| | - Caglar Cuhadaroglu
- Department of Chest Diseases, Faculty of Medicine, Mehmet Ali Aydınlar University, Atakent Hospital, Istanbul, Turkey
| | - Filiz Kosar
- Clinic of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, I˙stanbul, Turkey
| | - Remise Gelisgen
- Department of Biochemistry, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey,
| | - Hafize Uzun
- Department of Biochemistry, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey,
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