Blockade of the renin-angiotensin system as a therapeutic target of NAFLD: results of an experimental model of hypercholesterolemia

Background/Introduction

Non-alcoholic fatty liver disease (NAFLD) is often associated with metabolic syndrome (MS) and its components, including systemic arterial hypertension (SAH). In a recently published meta-analysis, the estimated prevalence of SAH in patients with NAFLD was 39.34%. Recently published observational studies have shown that the presence of NAFLD is independently associated with an increased risk of identifying SAH. Therefore, we can infer that we will often have to treat SAH in patients with NAFLD and that potential beneficial effects of the antihypertensive drug, in this context, may influence the choice of the respective drug.

Purpose

To evaluate the effects of olmesartan in an animal model of NAFLD (hypercholesterolemic rabbits).

Methods

34 rabbits divided into 3 groups: control group (CG) n=13, olmesartan group (OG) n=12 and normal control group (NCG) n=9. The NCG received standard chow for laboratory rabbits, the CG and OG received standard chow plus 1% cholesterol. The OG was medicated with olmesartan 1 mg/kg/day throughout the study period (8 weeks), and the three groups were euthanised in the eighth week. Serum levels of glucose, total cholesterol, triglycerides, creatinine, aspartate aminotransferase (AST) and alanine aminotransferase were evaluated at baseline and euthanasia, and liver tissue samples were taken in the euthanasia from the three groups. Haematoxylin-eosin stained slides were analysed based on the histological scoring system for NAFLD, Gomori,s trichrome stained slides were used for further evaluation of fibrosis, and immunostained slides with antibodies anti-nitric oxide synthase inducible (iNOS) for hepatic oxidative stress analysis.

Results

The steatosis (p=0.013), lobular inflammation (p<0.001), ballooning (p=0.039), and fibrosis (p=0.015) scores were significantly lower in the OG compared to the CG. Similarly, NAFLD activity scores were significantly lower in OG compared to CG. The hepatic expression of iNOS was significantly lower in OG than CG (P=0.001). The serum variables results suggest no direct effect of olmesartan in any of them.

Conclusion(s)

Olmesartan significantly attenuated hepatic oxidative stress, the development of steatosis, lobular inflammation, ballooning, fibrosis and steatohepatitis. Therefore, it suggests that olmesartan may be considered a potentially suitable option for hypertensive patients with NAFLD.

Funding Acknowledgement

Type of funding sources: None.

The postural orthostatic tachycardia syndrome: a potentially treatable cause of chronic fatigue, exercise intolerance, and cognitive impairment in adolescents

Head upright tilt table testing has become an accepted method to measure an individual's predisposition to autonomically mediated periods of hypotension and bradycardia severe enough to cause frank syncope. At the same time it has become increasingly apparent that less profound falls in blood pressure, while not sufficient to result in loss of consciousness, may cause symptoms such as near syncope, vertigo, and dizziness. We describe a subgroup of adolescents that have a mild form of autonomic dysfunction that exhibit disabling symptoms such as postural tachycardia and palpitations, extreme fatigue, lightheadedness, exercise intolerance, and cognitive impairment. During baseline tilt table testing at a 70 degrees angle, these patients demonstrated a heart rate increase of > or = 30 beats/min (or a maximum heart rate of > or = 120 beats/min) within the first 10 minutes upright (not associated with profound hypotension), which reproduced their clinical symptom complex. Similar observations have been made in the adult population and has been termed the postural orthostatic tachycardia syndrome (POTS). We report that POTS may also occur in adolescents and represents a mild, potentially treatable form of autonomic dysfunction that can be readily identified during head upright tilt table testing.

Preliminary observations on the use of midodrine hydrochloride in the treatment of refractory neurocardiogenic syncope

Recurrent episodes of neurocardiogenic syncope that occur without warning are a common cause of recurrent syncope that can be identified during head upright tilt table testing. While the use of beta blockers, theophyllines, fludrocortisone, disopyramide, and serotonin reuptake inhibitors can be useful in the prevention of episodes, some patients are either unresponsive to or poorly tolerant of these agents. We investigated the use of the peripheral alpha stimulating agent midodrine in preventing both tilt-induced and spontaneous neurocardiogenic syncope. Twenty-five patients (16 women, 9 men, mean age 30 +/- 23 years) with severe recurrent syncope and a positive head upright tilt table study (refractory to or intolerant of standard therapies) were placed on midodrine 5-10 mg orally three times per day, (two patients required 15 mg/day). Of these, twelve became asymptomatic and five had a marked reduction in symptoms. We conclude that midodrine may be an effective therapy in patients with recurrent neurocardiogenic syncope refractory to other forms of therapy.

Clinical disorders of the autonomic nervous system associated with orthostatic intolerance: an overview of classification, clinical evaluation, and management

The disorders of autonomic control associated with orthostatic intolerance are a diverse group of infirmities that can result in syncope and near syncope (as well as a host of other complaints). A basic understanding of these disorders is essential to both diagnosis and proper treatment. These infirmities are not new, what has changed is our ability to recognize them. It has been said that "the world undergoes change in the human consciousness. As this consciousness changes, so does the world." On going studies will continue to help better define the broad spectrum of these disorders, and to elaborate better diagnostic and treatment modalities.

Diagnosis and management of neurocardiogenic syncope

The medical term syncope is derived from the Greek word "synkoptein," the original meaning of which was "to cut short". Because it is both a symptom and a sign, the physician may often find the evaluation of syncope a difficult and frustrating endeavor. Over the course of the past decade it has become apparent that transient alterations in autonomic nervous system activity, resulting in hypotension and bradycardia, are common causes of syncope. At the same time it has become apparent that these are a heterogenous group of disorders which, while sharing some characteristics, are nonetheless distinct maladies. This article attempts to briefly review our current understanding of these disorders and suggests guidelines on their diagnosis and management.

Pyrophosphohydrolase activity and inorganic pyrophosphate content of cultured human skin fibroblasts. Elevated levels in some patients with calcium pyrophosphate dihydrate deposition disease

In calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, metabolic abnormalities favoring extracellular inorganic pyrophosphate (PPi) accumulation have been suspected. Elevations of intracellular PPi in cultured skin fibroblasts from a single French kindred with familial CPPD deposition (19) and elevated nucleoside triphosphate pyrophosphohydrolase activity (NTPPPH), which generates PPi in extracts of CPPD crystal-containing cartilages (14) favor this suspicion. To determine whether NTPPPH activity or PPi content of cells might be a disease marker expressed in extraarticular cells, human skin-derived fibroblasts were obtained from control donors and patients affected with the sporadic and familial varieties of CPPD (CPPD-S and CPPD-F) deposition. Intracellular PPi was elevated in both CPPD-S (P less than 0.05) and CPPD-F (P less than 0.01) fibroblasts compared with control fibroblasts. Ecto-NTPPPH activity was elevated in CPPD-S (P less than 0.01) but not CPPD-F. Intracellular PPi correlated with ecto-NTPPPH (P less than 0.01). Elevated PPi levels in skin fibroblasts may serve as a biochemical marker for patients with familial or sporadic CPPD crystal deposition disease; ecto-NTPPPH activity further separates the sporadic and familial disease types. Expression of these biochemical abnormalities in nonarticular cells implies a generalized metabolic abnormality.

Ecto-nucleoside triphosphate pyrophosphohydrolase activity and calcium pyrophosphate dihydrate crystal deposition disease

Articular cartilage contains any ectoenzyme activity, NTP-PPH, which is capable of generating PPi from NTP substrates. The PPi generated is from the cleavage of the alpha-beta pyrophosphate bond of NTP and does not result from the effects of NTP catabolites. NTP-PPH activity is expressed on human skin fibroblasts in culture and is significantly increased in subjects with CPPD deposition. In addition, cultured fibroblasts from subjects with CPPD disease have higher intracellular PPi concentrations compared to cells from normals and patients with OA. These results support the hypothesis that alterations in PPi metabolism provide the metabolic basis for CPPD deposition.

Cartilage nucleoside triphosphate pyrophosphohydrolase. II. Role in extracellular pyrophosphate generation and nucleotide metabolism

Extracellular generation of inorganic pyrophosphate (PPi) in cartilage organ culture is markedly augmented by ATP.ATP, not an ATP metabolite (ADP, AMP, adenosine) is necessary for this augmentation. Excess PPi production is effectively blocked by known inhibitors of nucleoside triphosphate (NTP) pyrophosphohydrolase (EDTA, EGTA, dithiothreitol). Excess 32P-PPi is generated directly from gamma 32P-ATP by cartilage, as substrate and product have similar specific activities. These findings strongly favor ecto-NTP pyrophosphohydrolase as the source of extracellular PPi generation in the presence of NTP. Additionally, active nucleotide and nucleoside catabolism is demonstrated in these cartilage organ cultures.

Selenium, zinc, and copper changes with valproic acid: possible relation to drug side effects

Side effects of treatment with the anticonvulsant valproic acid (VPA) suggested the possibility of alteration of trace metal status. Administration of VPA for 1 week produced significant depletion of zinc and selenium in plasma of rats and a one-third reduction of hepatic selenium. Patients who were treated chronically, with VPA as the sole anticonvulsant medication, had decreased plasma selenium levels. Most cases of VPA-associated hepatotoxicity occur in children. This could be due to decreased selenium concentrations when mechanisms for protection against peroxidative damage are not fully developed.

Cartilage nucleoside triphosphate (NTP) pyrophosphohydrolase. I. Identification as an ecto-enzyme

When 1 mM ATP was added to ambient media of canine cartilage in organ culture or canine chondrocytes in monolayer culture, PPi was generated linearly over 4 hours. The appearance of PPi was related to an ectoenzyme based upon its ability to act upon extracellular substrate, to generate extracellular products, failure to detect enzyme activity in supernatant media, failure to increase activity by cell disruption, and susceptibility to digestion by extracellular trypsin. The enzyme responsible for PPi generation is nucleoside triphosphate (NTP) pyrophosphohydrolase, which acts upon a number of purine and pyrimidine nucleoside triphosphates. This enzyme may play a role in generation of extracellular PPi which participates in calcium pyrophosphate dihydrate crystal formation.