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Schwartz L, Salamon K, Simoni A, Eichler T, Jackson AR, Murtha M, Becknell B, Kauffman A, Linn-Peirano S, Holdsworth N, Tyagi V, Tang H, Rust S, Cortado H, Zabbarova I, Kanai A, Spencer JD. Insulin receptor signaling engages bladder urothelial defenses that limit urinary tract infection. Cell Rep 2024; 43:114007. [PMID: 38517889 DOI: 10.1016/j.celrep.2024.114007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/10/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024] Open
Abstract
Urinary tract infections (UTIs) commonly afflict people with diabetes. To better understand the mechanisms that predispose diabetics to UTIs, we employ diabetic mouse models and altered insulin signaling to show that insulin receptor (IR) shapes UTI defenses. Our findings are validated in human biosamples. We report that diabetic mice have suppressed IR expression and are more susceptible to UTIs caused by uropathogenic Escherichia coli (UPEC). Systemic IR inhibition increases UPEC susceptibility, while IR activation reduces UTIs. Localized IR deletion in bladder urothelium promotes UTI by increasing barrier permeability and suppressing antimicrobial peptides. Mechanistically, IR deletion reduces nuclear factor κB (NF-κB)-dependent programming that co-regulates urothelial tight junction integrity and antimicrobial peptides. Exfoliated urothelial cells or urine samples from diabetic youths show suppressed expression of IR, barrier genes, and antimicrobial peptides. These observations demonstrate that urothelial insulin signaling has a role in UTI prevention and link IR to urothelial barrier maintenance and antimicrobial peptide expression.
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Affiliation(s)
- Laura Schwartz
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH 43205, USA
| | - Kristin Salamon
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Aaron Simoni
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Tad Eichler
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Ashley R Jackson
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH 43205, USA
| | - Matthew Murtha
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Brian Becknell
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH 43205, USA
| | - Andrew Kauffman
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Tulane University, New Orleans, LA 70118, USA
| | - Sarah Linn-Peirano
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Department of Veterinary Biosciences, The Ohio State University College of Veterinary Medicine, Columbus, OH 43210, USA
| | - Natalie Holdsworth
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Ohio University Heritage College of Osteopathic Medicine, Athens, OH 45701, USA
| | - Vidhi Tyagi
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Hancong Tang
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Steve Rust
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Hanna Cortado
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA
| | - Irina Zabbarova
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Anthony Kanai
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - John David Spencer
- The Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH 43205, USA; Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH 43205, USA.
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van Ginkel C, Hurst RE, Janssen D. The urothelial barrier in interstitial cystitis/bladder pain syndrome: its form and function, an overview of preclinical models. Curr Opin Urol 2024; 34:77-83. [PMID: 37933666 PMCID: PMC10842656 DOI: 10.1097/mou.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Investigating bladder pain syndrome/interstitial cystitis (IC/BPS) preclinically is challenging. Various research models have been used to mimic the urothelial barrier closely and replicate the disease. The aim of this review is to discuss preclinical research related to the urothelial barrier in context of IC/BPS. RECENT FINDINGS In vivo models mimic IC/BPS mainly with toxic substances in the urine, with protaminesulfate and proteoglycan deglycolysation resembling a temporary impaired barrier as seen in IC/BPS. This temporary increased permeability has also been found in vitro models. Glycosaminoglycan replenishment therapy has been described, in vivo and in vitro, to protect and enhance recover properties of the urothelium. The roles of immune and neurogenic factors in the pathogenesis of IC/BPS remains relatively understudied. SUMMARY Preclinical studies provide opportunities to identify the involvement of specific pathologic pathways in IC/BPS. For further research is warranted to elucidate the primary or secondary role of permeability, together with inflammatory and neurogenic causes of the disease.
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Affiliation(s)
- Charlotte van Ginkel
- Department of Urology, Radboud university medical Center, Nijmegen, The Netherlands
| | | | - Dick Janssen
- Department of Urology, Radboud university medical Center, Nijmegen, The Netherlands
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Crocetto F, Balsamo R, Amicuzi U, De Luca L, Falcone A, Mirto BF, Giampaglia G, Ferretti G, Capone F, Machiella F, Varriale D, Sicignano E, Pagano G, Lombardi A, Lucarelli G, Lasorsa F, Busetto GM, Del Giudice F, Ferro M, Imbimbo C, Barone B. Novel Key Ingredients in Urinary Tract Health-The Role of D-mannose, Chondroitin Sulphate, Hyaluronic Acid, and N-acetylcysteine in Urinary Tract Infections (Uroial PLUS ®). Nutrients 2023; 15:3573. [PMID: 37630763 PMCID: PMC10459296 DOI: 10.3390/nu15163573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Urinary tract infections represent a common and significant health concern worldwide. The high rate of recurrence and the increasing antibiotic resistance of uropathogens are further worsening the current scenario. Nevertheless, novel key ingredients such as D-mannose, chondroitin sulphate, hyaluronic acid, and N-acetylcysteine could represent an important alternative or adjuvant to the prevention and treatment strategies of urinary tract infections. Several studies have indeed evaluated the efficacy and the potential use of these compounds in urinary tract health. In this review, we aimed to summarize the characteristics, the role, and the application of the previously reported compounds, alone and in combination, in urinary tract health, focusing on their potential role in urinary tract infections.
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Affiliation(s)
- Felice Crocetto
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Raffaele Balsamo
- Urology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Ugo Amicuzi
- Division of Urology, Department of Surgical Sciences, AORN Sant’Anna e San Sebastiano, 81100 Caserta, Italy;
| | - Luigi De Luca
- Division of Urology, Department of Surgical Multispecialty, AORN Antonio Cardarelli, 80131 Naples, Italy;
| | - Alfonso Falcone
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Benito Fabio Mirto
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Gaetano Giampaglia
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Gianpiero Ferretti
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Federico Capone
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Fabio Machiella
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Domenico Varriale
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Enrico Sicignano
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Giovanni Pagano
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Alessandro Lombardi
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Giuseppe Lucarelli
- Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy; (G.L.); (F.L.)
| | - Francesco Lasorsa
- Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy; (G.L.); (F.L.)
| | - Gian Maria Busetto
- Department of Urology and Organ Transplantation, University of Foggia, 71121 Foggia, Italy;
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, 00161 Rome, Italy;
| | - Matteo Ferro
- Department of Urology, IEO—European Institute of Oncology, IRCCS—Istituto di Ricovero e Cura a Carattere Scientifico, 20141 Milan, Italy;
| | - Ciro Imbimbo
- Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy; (F.C.); (A.F.); (B.F.M.); (G.G.); (G.F.); (F.C.); (F.M.); (D.V.); (E.S.); (G.P.); (A.L.); (C.I.)
| | - Biagio Barone
- Division of Urology, Department of Surgical Sciences, AORN Sant’Anna e San Sebastiano, 81100 Caserta, Italy;
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Odom MR, Hughes FM, Jin H, Purves JT. Diabetes causes NLRP3-dependent barrier dysfunction in mice with detrusor overactivity but not underactivity. Am J Physiol Renal Physiol 2022; 323:F616-F632. [PMID: 36135959 PMCID: PMC9705026 DOI: 10.1152/ajprenal.00047.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 02/08/2023] Open
Abstract
Approximately half of the patients with diabetes develop diabetic bladder dysfunction (DBD). The initiation and progression of DBD is largely attributed to inflammation due to dysregulated glucose and the production of toxic metabolites that activate the NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome. NLRP3 activation leads to the production and release of proinflammatory cytokines and causes urothelial pyroptosis, a form of programmed cell necrosis, which we hypothesize compromises urothelial barrier integrity. Here, we investigated how NLRP3-dependent inflammation impacts barrier function during the progression of diabetes using a type 1 diabetic female Akita mouse model that progresses from an early overactive to a late underactive detrusor phenotype at 15 and 30 wk, respectively. To determine the specific role of NLRP3, Akita mice were crossbred with mice lacking the NLRP3 gene. To determine barrier function, permeability to small molecules was assessed, ex vivo using Evans blue dye and in vivo using sulfo-NHS-biotin. Both ex vivo and in vivo permeabilities were increased in diabetic mice at 15 wk. Expression of uroplakin and tight junction components was also significantly downregulated at 15 wk. Interestingly, diabetic mice lacking the NLRP3 gene showed no evidence of barrier damage or downregulation of barrier genes and proteins. At the 30-wk time point, ex vivo and in vivo barrier damage as well as barrier component downregulation was no longer evident in diabetic mice, suggesting urothelial repair or remodeling occurs between the overactive and underactive stages of DBD. Collectively, these findings demonstrate the role of NLRP3-mediated inflammation in urothelial barrier damage associated with detrusor overactivity but not underactivity.NEW & NOTEWORTHY This is the first study to demonstrate that NLRP3-mediated inflammation is responsible for urothelial barrier damage in type 1 diabetic female Akita mice with an overactive bladder. Eliminating the NLRP3 gene in these diabetic mice prevented barrier damage as a result of diabetes. By the time female Akita mice develop an underactive phenotype, the urothelial barrier has been restored, suggesting that inflammation is a critical causative factor early in the development of diabetic bladder dysfunction.
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Affiliation(s)
- Michael R Odom
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Francis M Hughes
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Huixia Jin
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Mowbray CA, Shams S, Chung G, Stanton A, Aldridge P, Suchenko A, Pickard RS, Ali ASM, Hall J. High molecular weight hyaluronic acid: a two-pronged protectant against infection of the urogenital tract? Clin Transl Immunology 2018; 7:e1021. [PMID: 29928502 PMCID: PMC5993165 DOI: 10.1002/cti2.1021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Recurrent urinary tract infections are associated with uropathogenic Escherichia coli (UPEC) ascending and infecting the urinary tract. Antibiotics provide only symptomatic relief, not prevent recurrence. Clinical evidence suggests that intravesical glycosaminoglycan therapy, such as hyaluronic acid (HA), helps reduce UTI recurrence. This has been investigated here using in vitro systems modelling the urogenital tract tissues. METHODS RT4 bladder cells were preconditioned with high molecular weight HA (> 1500 kDa) at 2 mg mL-1 and challenged with UPEC to analyse barrier protection and bacterial adherence. Untreated and HA-preconditioned VK2 E6/E7 vaginal cells were challenged with E. coli flagellin (50 ng mL-1) to mimic bacterial challenge, and media analysed for lipocalin-2, human β-defensin 2 and interleukin-8 by ELISA. Experiments were repeated after siRNA knockdown of Toll-like receptors 2, 4 and 5, and CD44 to investigate signalling. RESULTS Microscopic analyses showed reduced bacterial adherence and urothelial disruption with HA, suggesting that HA functions as a barrier protecting the epithelium from bacterial infection. Cells treated with HA and flagellin simultaneously produced more of the host antimicrobial peptide LCN2 and pro-inflammatory IL-8 (P < 0.05) compared to the no HA/flagellin challenges. Increased gene expression of DEFB4 (P < 0.05), but not the hBD2 peptide, was observed in the HA/flagellin-challenged cells. CONCLUSION These data suggest that exogenous HA has potential to protect the urogenital epithelia from UPEC infection via a two-pronged approach that involves the physical enhancement of the epithelial barrier and augmentation of its innate immune response.
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Affiliation(s)
- Catherine A Mowbray
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Syema Shams
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
- Institute of Cellular MedicineMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Git Chung
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Anna Stanton
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Phillip Aldridge
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Andrejus Suchenko
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
| | - Robert S Pickard
- Institute of Cellular MedicineMedical SchoolNewcastle UniversityNewcastle upon TyneUK
- Department of UrologyNewcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Ased SM Ali
- Institute of Cellular MedicineMedical SchoolNewcastle UniversityNewcastle upon TyneUK
- Department of Urology and Regional Spinal Injuries UnitMid Yorkshire Hospitals NHS TrustNewcastle upon TyneUK
| | - Judith Hall
- Institute of Cell and Molecular BiosciencesMedical SchoolNewcastle UniversityNewcastle upon TyneUK
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Liu KM, Chuang SM, Long CY, Lee YL, Wang CC, Lu MC, Lin RJ, Lu JH, Jang MY, Wu WJ, Ho WT, Juan YS. Ketamine-induced ulcerative cystitis and bladder apoptosis involve oxidative stress mediated by mitochondria and the endoplasmic reticulum. Am J Physiol Renal Physiol 2015; 309:F318-31. [PMID: 26109091 DOI: 10.1152/ajprenal.00607.2014] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 06/16/2015] [Indexed: 12/29/2022] Open
Abstract
Ketamine abusers develop severe lower urinary tract symptoms. The major aims of the present study were to elucidate ketamine-induced ulcerative cystitis and bladder apoptosis in association with oxidative stress mediated by mitochondria and the endoplasmic reticulum (ER). Sprague-Dawley rats were distributed into three different groups, which received normal saline or ketamine for a period of 14 or 28 days, respectively. Double-labeled immunofluorescence experiments were performed to investigate tight junction proteins for urothelial barrier functions. A TUNEL assay was performed to evaluate the distribution of apoptotic cells. Western blot analysis was carried out to examine the expressions of urothelial tight junction proteins, ER stress markers, and apoptosis-associated proteins. Antioxidant enzymes, including SOD and catalase, were investigated by real-time PCR and immunofluorescence experiments. Ketamine-treated rats were found to display bladder hyperactivity. This bladder dysfunction was accompanied by disruptions of epithelial cadherin- and tight junction-associated proteins as well as increases in the expressions of apoptosis-associated proteins, which displayed features of mitochondria-dependent apoptotic signals and ER stress markers. Meanwhile, expressions of mitochondria respiratory subunit enzymes were significantly increased in ketamine-treated bladders. Conversely, mRNA expressions of the antioxidant enzymes Mn-SOD (SOD2), Cu/Zn-SOD (SOD1), and catalase were decreased after 28 days of ketamine treatment. These results demonstrate that ketamine enhanced the generation of oxidative stress mediated by mitochondria- and ER-dependent pathways and consequently contributed to bladder apoptosis and urothelial lining defects. Such oxidative stress-enhanced bladder cell apoptosis and urothelial barrier defects are potential factors that may play a crucial role in bladder overactivity and ulceration.
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Affiliation(s)
- Keh-Min Liu
- Department of Anatomy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Mien Chuang
- Translational Research Center, Cancer Center, Department of Medical Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yu Long
- Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Lun Lee
- Department of Urology, Chi-Shan Hospital, Department of Health, Executive Yuan, Kaohsiung, Taiwan; Graduate Institute of Medical Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Chuan Wang
- Department of Anatomy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Chin Lu
- National Museum of Marine Biology and Aquarium, Pingtung, Taiwan; Graduate Institute of Marine Biotechnology, National Dong Hwa University, Pingtung, Taiwan
| | - Rong-Jyh Lin
- Department of Parasitology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jian-He Lu
- Graduate Institute of Medical Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Yu Jang
- Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Wen-Jeng Wu
- Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan; Department of Urology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; and Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wan-Ting Ho
- Department of Urology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; and
| | - Yung-Shun Juan
- Graduate Institute of Medical Science, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan; Department of Urology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; and Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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