Galen M. Pieper

Review of alterations in endothelial nitric oxide production in diabetes: protective role of arginine on endothelial dysfunction.

Nitric oxide release from the endothelium plays an important role in regulation of vascular tone, inhibition of both platelet and leukocyte aggregation and adhesion, and inhibition of cell proliferation. These properties suggest that the level of NO production by the endothelium may play a pivotal role in the regulation of vascular disease. Analysis using mass spectrometry has revealed that NO is produced by NOS from the terminal guanidino nitrogen of the precursor amino acid L-arginine. Thus, utilization of L-arginine and conversion to NO may establish a regulatory site in the development of endothelial dysfunction. Endothelial dysfunction is characterized by defective endothelium-dependent relaxation, and some reviews regarding endothelial dysfunction in diabetes have been published. These reviews have focused on factors that might contribute to defective relaxation, some of which will not be addressed in detail in this review. The purpose of the present review is to summarize evidence that specifically supports either decreased NO production by diabetic vascular endothelium and/or impaired NO-mediated endothelium-dependent relaxation. Second, this review provides reasonable alternatives to explain some of the controversies in this research area. Third, since there is growing evidence that arginine appears to have some benefits for diabetes-associated abnormalities, this review summarizes the current state of knowledge of effects of acute and chronic administration of L-arginine on diabetesinduced endothelial dysfunction and discusses potential NOdependent and -independent mechanisms whereby therapeutic intervention with L-arginine might benefit the diabetic endothelium.

Acute amelioration of diabetic endothelial dysfunction with a derivative of the nitric oxide synthase cofactor, tetrahydrobiopterin.

Tetrahydrobiopterin is a cofactor for nitric oxide synthase. In low concentrations of this cofactor, nitric oxide synthase is known to produce less nitric oxide and, correspondingly, enhanced quantities of the oxidant species, hydrogen peroxide. In this study, we tested the hypothesis that an exogenous tetrahydrobiopterin derivative might improve endothelial nitric oxide synthase activity in diabetic endothelium. Diabetes was induced in Sprague-Dawley rats with intravenous injections of streptozotocin. After 8 weeks, endothelium-dependent relaxation was assessed in aortic rings by using acetylcholine, whereas endothelium-independent relaxation was assessed by using nitroglycerin. Acetylcholine-induced relaxation was impaired in diabetic rings, whereas nitroglycerin-induced relaxation was unimpaired. Exposure of rings for 30 min with 100 microM of the pteridine derivative, 6-methyl-5,6,7,8-tetrahydropterin (in the presence of diethylenetriaminepentaacetic acid to inhibit oxidation), followed by washing and equilibration in control media, augmented relaxation induced by acetylcholine in diabetic rings but had no effect on relaxation in control rings. Pteridine exposure did not alter relaxation or sensitivity to nitroglycerin in control rings either with or without endothelium. In diabetic rings, pteridine exposure augmented maximal relaxation to nitroglycerin in rings with or without endothelium while increasing the sensitivity only in rings with endothelium but not in rings without endothelium. In contrast, there was no effect of pteridine exposure on relaxation or sensitivity to nitroglycerin in diabetic rings (with or without endothelium) that are pretreated with L-nitroarginine. In summary, tetrahydrobiopterin availability can play a key role in the regulation of nitric oxide production by diabetic endothelium.

Enhanced, unaltered and impaired nitric oxide-mediated endothelium-dependent relaxation in experimental diabetes mellitus: importance of disease duration

Summary Long-term diabetes mellitus is characterized by impaired endothelium-dependent relaxation. In contrast, there is limited information on endothelial function in the early stages of the disease. In this study, we evaluated endothelial function ex vivo at early, intermediate and later stages of streptozotocin (STZ)-induced diabetes mellitus. We also evaluated the contribution of various endothelium-derived vasoactive factors at these stages of disease. In aortic rings contracted with norepinephrine, endothelium-dependent relaxation to acetycholine was increased at 24 h following injection with streptozotocin compared with controls, normal after 1 and 2 weeks of disease or impaired at 8 weeks of disease. Endothelium-independent relaxation to nitroglycerin was unaltered at all stages. The enhanced relaxation at 24 h was mimicked in rings from alloxan-induced diabetic rats. Acute exposure of normal rings to streptozotocin in vitro caused no perturbation in acetylcholine-stimulated relaxation. Enhanced relaxation in diabetic rings at 24 h persisted in the presence of either indomethacin or tetraethylammonium. Acetylcholine-induced relaxation was blocked in both control and diabetic rings using l-nitroarginine but not by aminoguanidine. This suggests that the increased response was mediated by enhanced constitutive nitric oxide (NO). These studies show a triphasic response of increased, unaltered and impaired endothelium-dependent relaxation within the same model but dependent on the duration of disease. These studies could reconcile previous conflicting data in the literature and account for the observations of increases in tissue blood flow seen in early stages of experimental and human diabetes mellitus. [Diabetologia (1999) 42: 204–213]

Activation of Nuclear Factor-κb in Cultured Endothelial Cells by Increased Glucose Concentration: Prevention by Calphostin C

Nuclear factor kappaB (NFkappaB) plays a pivotal role in early gene responses by promoting messenger RNA (mRNA) synthesis for various cell-adhesion molecules and inducible nitric oxide synthase. In this study, we examined whether increases in glucose concentration enhance NFkappaB expression in nuclear fractions of endothelial cells by using electrophoretic mobility shift assay. Bovine aortic endothelial cells (BAECs) were incubated in media containing 5.5-35 mM glucose. NFkappaB activity was increased as early as 1 h (peak activation at 2-4 h) after incubation with 35 mM glucose compared with 5.5 mM. Similar increases at 2 h of incubation were observed by using 25 but not 15 mM glucose. Glucose-induced NFkappaB activation was blocked by inhibiting nuclear translocation by using a peptide (SN-50) containing the nuclear-localization sequence of NFkappaB p50 linked to a membrane-permeable motif of the sequence for Kaposi fibroblast growth factor. Co-incubation with a selective protein kinase C (PKC) inhibitor, calphostin C, produced a concentration-dependent inhibition of glucose-induced NFkappaB activation. Thus NFkappaB activation is an early event in response to elevations in glucose, which may elicit multiple pathways contributing to the origin of hyperglycemia- or diabetes-induced endothelial cell injury.

Diabetic-induced endothelial dysfunction in rat aorta: role of hydroxyl radicals

OBJECTIVE Previous studies suggest a role of superoxide anion radicals (.O2-) in impaired endothelium-dependent relaxation of diabetic blood vessels; however, the role of secondary reactive oxygen species remains unclear. In the present study, we investigated a role of various potential reactive oxygen species in diabetic endothelial dysfunction. METHODS Thoracic aortic rings from 8-week streptozotocin-induced diabetic and age-matched control rats were mounted in isolated tissue baths. Endothelium-dependent relaxation to acetylcholine (ACH) and endothelium-independent relaxation to nitroglycerin (NTG) were assessed in precontracted rings. RESULTS ACH-induced relaxation was impaired in diabetic compared to control rings and was not improved with either indomethacin or daltroban. ACH-induced relaxation in both control and diabetic rings was completely blocked with the nitric oxide synthase inhibitors, L-nitroarginine methyl ester or L-nitroarginine (L-NA). NTG-induced relaxation was insensitive to L-NA and was unaltered by diabetes. Pretreatment with superoxide dismutase (SOD) at activities which did not alter contractile tone failed to alter response to ACH in diabetic rings. Similar results were obtained using either catalase or mannitol. In contrast, the combination of SOD plus catalase or DETAPAC, an inhibitor of metal-facilitated hydroxyl radical (.OH) formation, markedly enhanced relaxation to ACH in diabetic but not in control rings. Neither the combination of SOD plus catalase nor DETAPAC altered the sensitivity or relaxation to NTG in control rings with or without endothelium. In diabetic rings with endothelium, both DETAPAC or SOD plus catalase increased sensitivity but not maximum relaxation to NTG. In diabetic rings without endothelium, relaxation and sensitivity to NTG were unaltered by either treatment. In L-NA-treated diabetic rings with endothelium, sensitivity and relaxation to NTG was unaltered by either DETAPAC or SOD plus catalase. CONCLUSION Diabetic endothelium produces increases in both .O2- and H2O2 leading to enhanced intracellular production of .OH. Thus, .OH are implicated in diabetes-induced endothelial dysfunction.

Amelioration by L-arginine of a dysfunctional arginine/nitric oxide pathway in diabetic endothelium

Summary Defective endothelium-dependent relaxation in diabetic blood vessels may be regulated at the site of synthesis. We tested the hypothesis that acute administration of L-arginine (L-Arg) as substrate for endothelium-derived relaxing factor (EDRF) would normalize defective relaxation to acetylcholine (ACh) in streptozotocininduced diabetic rat aortic rings. Plasma concentrations of basic amino acids (e.g., arginine, lysine, and histidine) were significantly reduced by diabetes, but variable results (increased, decreased, or no change) were observed in plasma concentrations of neutral amino acids. Endothelium-dependent relaxation to ACh (but not calcium ionophore A23187) was impaired in diabetic rings. Relaxation to nitroglycerin (NTG) was not altered. Pretreatment with L-nitroarginine methyl ester (L-NAME), a nitric oxide (NO) synthase inhibitor, blocked the relaxation to ACh and A23187 but not relaxation to NTG in both control and diabetic rings. Pretreatment with 3 mM L-Arg (but not D-Arg) potentiated the relaxation to ACh in diabetic rings. L-Arg had no effect on ACh-induced relaxation in control rings or on relaxation to NTG in control or diabetic rings. A mechanism for impaired endothelium-dependent relaxation to ACh in diabetic aorta may arise from a defect in utilization of L-Arg by NO synthase for production of EDRF/NO.

Peroxidative stress in diabetic blood vessels. Reversal by pancreatic islet transplantation.

Diabetic complications are believed to arise, in part, through an increase in oxidative stress. We characterized antioxidant status in vascular tissue in untreated diabetic rats and in diabetic rats rendered euglycemic by pancreatic islet transplantation. Three key endogenous antioxidant enzymes (e.g., superoxide dismutase, catalase, and glutathione peroxidase) were measured. Sprague-Dawley rats with streptozotocin-induced diabetes were killed after 8 weeks of untreated hyperglycemia and compared with age-matched controls. Eight weeks of untreated diabetes resulted in a significant increase of tissue catalase in aorta, iliac artery, and femoral artery as compared with controls. No significant changes in either superoxide dismutase or glutathione peroxidase were observed in aorta, iliac artery, or femoral artery of diabetic animals. This increase in catalase in diabetic vascular tissue suggests increased oxidative stress due to chronic exposure to H2O2 in vivo. To assess the impact of islet transplantation on oxidative stress in vascular tissue, inbred Lewis strain rats were rendered diabetic with streptozotocin. After 8 weeks of untreated diabetes, rats received an intraportal islet isograft and were monitored for 4 subsequent weeks of euglycemia. Islet transplantation improved weight gain and normalized blood glucose and total glycosylated hemoglobin. While catalase was significantly increased in aorta and iliac artery at 8 and 12 weeks of diabetes, vascular catalase was restored to normal by islet transplantation. These data suggest that islet transplantation is an effective treatment strategy to minimize increased oxidative stress in diabetic vasculature.

Evidence for a role of iron-catalyzed oxidants in functional and metabolic stunning in the canine heart.

Brief (15-mlnute) coronary occlusion and subsequent reperfusion lead to prolonged functional and metabolic abnormalities (stunned myocardium). Previous work suggests that one factor responsible for this phenomenon is oxygen-derived free radicals. The formation of the highly reactive hydroxyl radical requires the presence of metal ions, most importantly iron. In the present study, the effect of the iron-chelator deferoxamine on the recovery of segment shortening (%SS) in the stunned myocardium was compared with a control group in barbital anesthetized dogs. Deferoxamine (500 mg intra-atrially) was administered 15 minutes prior to and throughout 15 minutes of coronary occlusion. %SS, regional myocardial blood flow, hemodynamics, and myocardial high-energy phosphates were measured. Areas at risk, collateral blood flow, and all hemodynamic parameters were similar between control and deferoxamine-treated animals. While deferoxamine did not prevent the loss of systolic wall function that occurred during ischemia, deferoxamine significantly unproved the recovery of %SS at all times throughout reperfusion (3-hour %SS of pretreatment: control, 12 ± 11; deferoxamine, 65 ± 12), normalized endocardial ATP (percent of nonischemic area: control, 79 ± 3%, deferoxamine, 93 ± 6%), attenuated the reperfusion-induced rebound increase in phosphocreatine and prevented the increase in tissue edema at 3 hours after reperfusion. Thus, deferoxamine exhibited a cardioprotective action both metabolically and functionally in the stunned myocardium presumably by decreasing the redox cycling, and hence, the availability of catalytic iron for use in hydroxyl radical formation and for the initiation of lipid peroxidation. These data suggest a possible role for the hydroxyl radical as a mediator of postischemic abnormalities in reversibly injured tissue.

Oral administration of the antioxidant, N-acetylcysteine, abrogates diabetes-induced endothelial dysfunction.

Oxidative stress is believed to play an important role in the development of vascular complications associated with diabetes mellitus. In this study, we examined the efficacy of long-term treatment with the antioxidant, N-acetylcysteine, in preventing the development of defective endothelium-dependent relaxation in streptozotocin-induced, Sprague-Dawley diabetic rats. At 48 h after injection of streptozotocin, a portion of diabetic rats received 250 mg/L N-acetylcysteine in drinking water for a total duration of 8 weeks. Oral administration did not alter the increase in blood glucose or the reduction in serum insulin but did modestly reduce total glycosylated hemoglobin. In precontracted thoracic aortic rings suspended in isolated tissue baths, endothelium-dependent relaxation to acetylcholine was impaired in diabetic rings compared with control rings. Endothelium-independent relaxation to nitroglycerin was unaltered. Long-term oral administration of N-acetylcysteine did not alter responses to nitroglycerin but completely prevented the defective relaxation to acetylcholine. These studies indicate a dissociation between glycemic control and correction of endothelial dysfunction and suggest that long-term exposure to reactive oxygen subsequent to diabetes rather than hyperglycemia per se is responsible for the development of endothelial dysfunction in diabetes mellitus.

Cardioprotective effects of nicorandil.

The effects of nicorandil, a nicotinamide nitrate with K+-channel-opening activity, was investigated in several models of ischemia-reperfusion injury in conscious and anesthetized dogs or isolated buffer-perfused rat hearts. In several models of reversible ischemic injury (stunned myocardium) in dogs, nicorandil resulted in an enhanced recovery of regional systolic shortening during reperfusion after a single episode of coronary artery occlusion (10–15 min). These beneficial actions of nicorandil were not shared by the nitrovasodilator sodium ni-troprusside but were mimicked by the selective K+-channel opener EMD 52692. In a model of irreversible ischemia-reperfusion injury (i.e., 2 h of coronary occlusion followed by reperfusion) in anesthetized dogs, nicorandil produced a marked reduction of myocardial infarct size. An equihypotensive dose of the calcium antagonist nifedipine had no significant effect; however, EMD 52692 produced the same reduction in infarct size as had nicorandil. In isolated, perfused rat hearts subjected to 20 min of low-flow (1.0 ml/min) global ischemia followed by 30 min of reperfusion, nicorandil (7 μM) resulted in a significant improvement in the recovery of iso-volumic left ventricular minute work during reperfusion compared with untreated hearts. Finally, the results of in vitro experiments indicated that nicorandil (10−6 to 10−3 M) produced a concentration-dependent inhibition of superoxide anion free radical production by human and canine neutrophils. The K+-channel opener EMD 52692 also inhibited superoxide production in canine neutrophils. These results indicate that nicorandil is a highly efficacious myocardial protective agent in several animal models of reversible or irreversible ischemia-reperfusion injury. Its mechanism of action is unclear, but the results of the present study suggest that the beneficial effects observed are at least in part related to its K+-channel-opening activity.