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Merino A, Hoogduijn MJ, Molina-Molina M, Arias-Salgado EG, Korevaar SS, Baan CC, Montes-Worboys A. Membrane particles from mesenchymal stromal cells reduce the expression of fibrotic markers on pulmonary cells. PLoS One 2021; 16:e0248415. [PMID: 33730089 PMCID: PMC7968667 DOI: 10.1371/journal.pone.0248415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a devastating lung disease with limited treatment options in which the telomere shortening is a strong predictive factor of poor prognosis. Mesenchymal stromal cells (MSC) administration is probed in several experimental induced lung pathologies; however, MSC might stimulate fibrotic processes. A therapy that avoids MSC side effects of transformation would be an alternative to the use of living cells. Membranes particles (MP) are nanovesicles artificially generated from the membranes of MSC containing active enzymes involved in ECM regeneration. We aimed to investigate the anti-fibrotic role of MP derived from MSC in an in vitro model of pulmonary fibrosis. METHODS Epithelial cells (A549) and lung fibroblasts, from IPF patients with different telomere length, were co-cultured with MP and TGF-β for 48h and gene expression of major pro-fibrotic markers were analyzed. RESULTS About 90% of both types of cells effectively took up MP without cytotoxic effects. MP decreased the expression of profibrotic proteins such as Col1A1, Fibronectin and PAI-1, in A549 cells. In fibroblasts culture, there was a different response in the inhibitory effect of MP on some pro-fibrotic markers when comparing fibroblast from normal telomere length patients (FN) versus short telomere length (FS), but both types showed an inhibition of Col1A1, Tenascin-c, PAI-1 and MMP-1 gene expression after MP treatment. CONCLUSIONS MP conserve some of the properties attributed to the living MSC. This study shows that MP target lung cells, via which they may have a broad anti-fibrotic effect.
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Affiliation(s)
- Ana Merino
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Martin J. Hoogduijn
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maria Molina-Molina
- Unit of Interstitial Lung Diseases, Pulmonary Department, University Hospital of Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
- CIBER of Respiratory Diseases (CIBERES) Health Institute Carlos III, Madrid, Spain
| | | | - Sander S. Korevaar
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Carla C. Baan
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ana Montes-Worboys
- Unit of Interstitial Lung Diseases, Pulmonary Department, University Hospital of Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
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2
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Nardiello C, Morty RE. World health observances in September 2020: sepsis, the lung and heart, and pulmonary fibrosis in focus. Am J Physiol Lung Cell Mol Physiol 2020; 319:L513-L517. [PMID: 32783623 DOI: 10.1152/ajplung.00375.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Claudio Nardiello
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Rory E Morty
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
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3
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Hayton C, Terrington D, Wilson AM, Chaudhuri N, Leonard C, Fowler SJ. Breath biomarkers in idiopathic pulmonary fibrosis: a systematic review. Respir Res 2019; 20:7. [PMID: 30634961 PMCID: PMC6329167 DOI: 10.1186/s12931-019-0971-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/01/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Exhaled biomarkers may be related to disease processes in idiopathic pulmonary fibrosis (IPF) however their clinical role remains unclear. We performed a systematic review to investigate whether breath biomarkers discriminate between patients with IPF and healthy controls. We also assessed correlation with lung function, ability to distinguish diagnostic subgroups and change in response to treatment. METHODS MEDLINE, EMBASE and Web of Science databases were searched. Study selection was limited to adults with a diagnosis of IPF as per international guidelines. RESULTS Of 1014 studies screened, fourteen fulfilled selection criteria and included 257 IPF patients. Twenty individual biomarkers discriminated between IPF and controls and four showed correlation with lung function. Meta-analysis of three studies indicated mean (± SD) alveolar nitric oxide (CalvNO) levels were significantly higher in IPF (8.5 ± 5.5 ppb) than controls (4.4 ± 2.2 ppb). Markers of oxidative stress in exhaled breath condensate, such as hydrogen peroxide and 8-isoprostane, were also discriminatory. Two breathomic studies have isolated discriminative compounds using mass spectrometry. There was a lack of studies assessing relevant treatment and none assessed differences in diagnostic subgroups. CONCLUSIONS Evidence suggests CalvNO is higher in IPF, although studies were limited by small sample size. Further breathomic work may identify biomarkers with diagnostic and prognostic potential.
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Affiliation(s)
- Conal Hayton
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK.
| | | | - Andrew M Wilson
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nazia Chaudhuri
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Colm Leonard
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
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4
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Jiang S, Li T, Yang Z, Yi W, Di S, Sun Y, Wang D, Yang Y. AMPK orchestrates an elaborate cascade protecting tissue from fibrosis and aging. Ageing Res Rev 2017; 38:18-27. [PMID: 28709692 DOI: 10.1016/j.arr.2017.07.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 07/07/2017] [Accepted: 07/10/2017] [Indexed: 01/10/2023]
Abstract
Fibrosis is a common process characterized by excessive extracellular matrix (ECM) accumulation after inflammatory injury, which is also a crucial cause of aging. The process of fibrosis is involved in the pathogenesis of most diseases of the heart, liver, kidney, lung, and other organs/tissues. However, there are no effective therapies for this pathological alteration. Annually, fibrosis represents a huge financial burden for the USA and the world. 5'-AMP-activated protein kinase (AMPK) is a pivotal energy sensor that alleviates or delays the process of fibrogenesis. In this review, we first present basic background information on AMPK and fibrogenesis and describe the protective roles of AMPK in three fibrogenic phases. Second, we analyze the protective action of AMPK during fibrosis in myocardial, hepatic, renal, pulmonary, and other organs/tissues. Third, we present a comprehensive discussion of AMPK during fibrosis and draw a conclusion. This review highlights recent advances, vital for basic research and clinical drug design, in the regulation of AMPK during fibrosis.
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Affiliation(s)
- Shuai Jiang
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education. Faculty of Life Sciences, Northwest University, 229 Taibai North Road, Xi'an 710069, China; Department of Aerospace Medicine, The Fourth Military Medical University, 169 Changle West Road, Xi'an 710032, China
| | - Tian Li
- Department of Biomedical Engineering, The Fourth Military Medical University, 169 Changle West Road, Xi'an 710032, China
| | - Zhi Yang
- Department of Biomedical Engineering, The Fourth Military Medical University, 169 Changle West Road, Xi'an 710032, China
| | - Wei Yi
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an 710032, China
| | - Shouyin Di
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, 1 Xinsi Road, Xi'an 710038, China
| | - Yang Sun
- Department of Geriatrics, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an 710032, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, Jiangsu, China
| | - Yang Yang
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education. Faculty of Life Sciences, Northwest University, 229 Taibai North Road, Xi'an 710069, China; Department of Biomedical Engineering, The Fourth Military Medical University, 169 Changle West Road, Xi'an 710032, China.
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Bauer Y, White ES, de Bernard S, Cornelisse P, Leconte I, Morganti A, Roux S, Nayler O. MMP-7 is a predictive biomarker of disease progression in patients with idiopathic pulmonary fibrosis. ERJ Open Res 2017; 3:00074-2016. [PMID: 28435843 PMCID: PMC5395293 DOI: 10.1183/23120541.00074-2016] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/31/2016] [Indexed: 01/10/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with poor prognosis, which is characterised by destruction of normal lung architecture and excessive deposition of lung extracellular matrix. The heterogeneity of disease progression in patients with IPF poses significant obstacles to patient care and prevents efficient development of novel therapeutic interventions. Blood biomarkers, reflecting pathobiological processes in the lung, could provide objective evidence of the underlying disease. Longitudinally collected serum samples from the Bosentan Use in Interstitial Lung Disease (BUILD)-3 trial were used to measure four biomarkers (metalloproteinase-7 (MMP-7), Fas death receptor ligand, osteopontin and procollagen type I C-peptide), to assess their potential prognostic capabilities and to follow changes during disease progression in patients with IPF. In baseline BUILD-3 samples, only MMP-7 showed clearly elevated protein levels compared with samples from healthy controls, and further investigations demonstrated that MMP-7 levels also increased over time. Baseline levels of MMP-7 were able to predict patients who had higher risk of worsening and, notably, baseline levels of MMP-7 could predict changes in FVC as early as month 4. MMP-7 shows potential to be a reliable predictor of lung function decline and disease progression.
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Affiliation(s)
- Yasmina Bauer
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | | | | | | | | | - Sebastien Roux
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland.,These authors contributed equally to this research
| | - Oliver Nayler
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland.,These authors contributed equally to this research
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Protective Effect of Infliximab, a Tumor Necrosis Factor-Alfa Inhibitor, on Bleomycin-Induced Lung Fibrosis in Rats. Inflammation 2016; 39:65-78. [PMID: 26253295 DOI: 10.1007/s10753-015-0224-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We aimed to investigate the preventive effect of Infliximab (IFX), a tumor necrosis factor (TNF)-α inhibitor, on bleomycin (BLC)-induced lung fibrosis in rats. Rats were assigned into four groups as follows: I-BLC group, a single intra-tracheal BLC (2.5 mg/kg) was installed; II-control group, a single intra-tracheal saline was installed; III-IFX + BLC group, a single-dose IFX (7 mg/kg) was administered intraperitoneally (i.p.), 72 h before the intra-tracheal BLC installation; IV-IFX group, IFX (7 mg/kg) was administered alone i.p. on the same day with IFX + BLC group. All animals were sacrificed on the 14th day of BLC installation. Levels of tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β, interleukin (IL)-6, periostin, YKL-40, nitric oxide (NO) in rat serum were measured, as well as, myeloperoxidase (MPO), superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) activity, and reduced glutathione (GSH), hydroxyproline, malondialdehyde (MDA) content in lung homogenates. Lung tissues were stained with hematoxylin and eosin (H&E) for quantitative histological evaluation. The inducible nitric oxide synthase (iNOS) expression and cell apoptosis in the lung tissues were determined quantitatively by immunohistochemical staining (INOS) and by TUNNEL staining, respectively. BLC installation worsened antioxidant status (such as SOD, CAT, GPx, GSH, MPO), while it increased the serum TNF-α, TGF-β, IL-6, periostin, YKL-40, and lipid peroxidation, and collagen deposition, measured by MDA and hydroxyproline, respectively. IFX pretreatment improved antioxidant status as well as BLC-induced lung pathological changes, while it decreased the TNF-α, TGF-β, IL-6, periostin, YKL-40, lipid peroxidation and collagen deposition. Finally, histological, immunohistochemical, and TUNNEL evidence also supported the ability of IFX to prevent BLC-induced lung fibrosis. The results of the present study indicate that IFX pretreatment can attenuate BLC-induced pulmonary fibrosis.
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7
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Oh GS, Lee SB, Karna A, Kim HJ, Shen A, Pandit A, Lee S, Yang SH, So HS. Increased Cellular NAD + Level through NQO1 Enzymatic Action Has Protective Effects on Bleomycin-Induced Lung Fibrosis in Mice. Tuberc Respir Dis (Seoul) 2016; 79:257-266. [PMID: 27790277 PMCID: PMC5077729 DOI: 10.4046/trd.2016.79.4.257] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/16/2016] [Accepted: 05/26/2016] [Indexed: 01/13/2023] Open
Abstract
Background Idiopathic pulmonary fibrosis is a common interstitial lung disease; it is a chronic, progressive, and fatal lung disease of unknown etiology. Over the last two decades, knowledge about the underlying mechanisms of pulmonary fibrosis has improved markedly and facilitated the identification of potential targets for novel therapies. However, despite the large number of antifibrotic drugs being described in experimental pre-clinical studies, the translation of these findings into clinical practices has not been accomplished yet. NADH:quinone oxidoreductase 1 (NQO1) is a homodimeric enzyme that catalyzes the oxidation of NADH to NAD+ by various quinones and thereby elevates the intracellular NAD+ levels. In this study, we examined the effect of increase in cellular NAD+ levels on bleomycin-induced lung fibrosis in mice. Methods C57BL/6 mice were treated with intratracheal instillation of bleomycin. The mice were orally administered with β-lapachone from 3 days before exposure to bleomycin to 1-3 weeks after exposure to bleomycin. Bronchoalveolar lavage fluid (BALF) was collected for analyzing the infiltration of immune cells. In vitro, A549 cells were treated with transforming growth factor β1 (TGF-β1) and β-lapachone to analyze the extracellular matrix (ECM) and epithelial-mesenchymal transition (EMT). Results β-Lapachone strongly attenuated bleomycin-induced lung inflammation and fibrosis, characterized by histological staining, infiltrated immune cells in BALF, inflammatory cytokines, fibrotic score, and TGF-β1, α-smooth muscle actin accumulation. In addition, β-lapachone showed a protective role in TGF-β1–induced ECM expression and EMT in A549 cells. Conclusion Our results suggest that β-lapachone can protect against bleomycin-induced lung inflammation and fibrosis in mice and TGF-β1–induced EMT in vitro, by elevating the NAD+/NADH ratio through NQO1 activation.
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Affiliation(s)
- Gi-Su Oh
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - Su-Bin Lee
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - Anjani Karna
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyung-Jin Kim
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - AiHua Shen
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - Arpana Pandit
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - SeungHoon Lee
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
| | - Sei-Hoon Yang
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Hong-Seob So
- Department of Microbiology, Center for Metabolic Function Regulation, Wonkwang University School of Medicine, Iksan, Korea
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Yanai H, Shteinberg A, Porat Z, Budovsky A, Braiman A, Zeische R, Fraifeld VE. Cellular senescence-like features of lung fibroblasts derived from idiopathic pulmonary fibrosis patients. Aging (Albany NY) 2015; 7:664-72. [PMID: 26399448 PMCID: PMC4600624 DOI: 10.18632/aging.100807] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 09/12/2015] [Indexed: 12/18/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is an age-related fatal disease with unknown etiology and no effective treatment. In this study, we show that primary cultures of fibroblasts derived from lung biopsies of IPF patients exhibited (i) accelerated replicative cellular senescence (CS); (ii) high resistance to oxidative-stress-induced cytotoxicity or CS; (iii) a CS-like morphology (even at the proliferative phase); and (iv) rapid accumulation of senescent cells expressing the myofibroblast marker α-SMA. Our findings suggest that CS could serve as a bridge connecting lung aging and its quite frequent outcome -- pulmonary fibrosis, and be an important player in the disease progression. Consequently, targeting senescent cells offers the potential of being a promising therapeutic approach.
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Affiliation(s)
- Hagai Yanai
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel
| | - Albert Shteinberg
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel
| | - Ziv Porat
- Flow Cytometry Unit, Department of Biological services, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Arie Budovsky
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel
- Judea Regional Research and Development Center, Carmel 90404, Israel
| | - Alex Braiman
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel
| | - Rolf Zeische
- Division of Pulmonary Medicine, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Vadim E Fraifeld
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Center for Multidisciplinary Research on Aging, Ben-Gurion University of the Negev, POB 653, Beer Sheva 84105, Israel
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Yang H, Jiang T, Li P, Mao Q. The protection of glycyrrhetinic acid (GA) towards acetaminophen (APAP)-induced toxicity partially through fatty acids metabolic pathway. Afr Health Sci 2015; 15:1023-7. [PMID: 26957996 DOI: 10.4314/ahs.v15i3.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acetaminophen (APAP)-induced liver toxicity remains the key factor limiting the clinical application of APAP, and herbs are the important sources for isolation of compounds preventing APAP-induced toxicity. AIMS To investigate the protection mechanism of glycyrrhetinic acid towards APAP-induced liver damage using metabolomics method. METHODS APAP-induced liver toxicity model was made through intraperitoneal injection (i.p.) of APAP (400 mg/kg). Glycyrrhetinic acid was dissolved in corn oil, and intraperitoneal injection (i.p.) of glycyrrhetinic acid (500 mg/kg body weight) was performed for 20 days before the injection of APAP. UPLC-ESI-QTOF MS was employed to analyze the metabolomic profile of serum samples. RESULTS The pre-treatment of glycyrrhetinic acid significantly protected APAP-induced toxicity, indicated by the histology of liver, the activity of ALT and AST. Metabolomics showed that the level of palmtioylcarnitine and oleoylcarnitine significantly increased in serum of APAP-treated mice, and the pre-treatment with GA can prevent this elevation of these two fatty acid-carnitines. CONCLUSION Reversing the metabolism pathway of fatty acid is an important mechanism for the protection of glycyrrhetinic acid towards acetaminophen-induced liver toxicity.
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Affiliation(s)
- Hua Yang
- Respiratory Department, Yantai Hospital of Traditional Chinese Medicine, Xingfu Road No.39, Zhifu District, Yantai City, Shandong Province, China
| | - Tingshu Jiang
- Respiratory Department, Yantai Yuhuangding Hospital Affiliated to Qingdao University; Yuhuangding East Road No.20, Zhifu District, Yantai City, Shandong Province, China
| | - Ping Li
- Respiratory Department, Yantai Hospital of Traditional Chinese Medicine, Xingfu Road No.39, Zhifu District, Yantai City, Shandong Province, China
| | - Qishan Mao
- Respiratory Department, Yantai Yuhuangding Hospital Affiliated to Qingdao University; Yuhuangding East Road No.20, Zhifu District, Yantai City, Shandong Province, China
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