Jochen Börgermann

Advanced glycation end products, diabetes and ageing.

Advanced glycation end products (AGEs) are formed in vivo by a non-enzymatic reaction of proteins with carbohydrates and accumulate in many tissues during ageing. They are discussed as being responsible for many age- and diabetes-related diseases. On the other hand, AGEs are formed by the heating of food and are taken up by the nutrition. The contribution of endogenously formed versus exogenous intake of AGEs to age-related diseases is still under discussion.ZusammenfassungFortgeschrittene Glykierungsendprodukte (AGEs) werden in vivo durch eine nicht-enzymatische chemische Reaktion von Proteinen mit Kohlenhydraten gebildet und reichern sich in vielen Geweben mit dem Alter an. Sie werden für die Auslösung von alters- und Diabetes-induzierten Erkrankungen mitverantwortlich gemacht. Andererseits entstehen AGEs durch die Erhitzung von Lebensmitteln, die mit der Nahrung aufgenommen werden. Inwieweit nun endogene oder exogen-aufgenommene AGEs die größere Rolle bei der Entstehung von degenerativen Erkrankungen ist noch nicht geklärt.

Vitamin D deficiency and mortality

Purpose of reviewTo summarize recent findings on vitamin D deficiency and mortality. The serum concentration of 25-hydroxyvitamin D [25(OH)D], the metabolic precursor of the vitamin D hormone calcitriol, is the standard for assessing vitamin D status. Deficient 25(OH)D concentrations (<25 nmol/l) are prevalent in Europe and North America. Recent findingsSeveral large nonrandomized studies indicate that different from adequate 25(OH)D concentrations (>75 nmol/l), deficient 25(OH)D concentrations are associated with excess mortality in the general population and in patients with increased cardiovascular disease risk. Results support an earlier meta-analysis of controlled trials that were not primarily designed to assess mortality showing a survival benefit of vitamin D supplementation over no supplementation in middle-aged and elderly persons. In patients with advanced chronic diseases such as end-stage heart failure, however, circulating calcitriol predicts mid-term mortality better than 25(OH)D does. Available data indicate that these patients may enter a vicious cycle of low calcitriol, increased inflammation markers, and renal impairment, which may be difficult to escape by simple vitamin D supplementation. SummaryAccumulating evidence suggests that vitamin D deficiency is linked to excess mortality. However, future studies should clarify to which extent vitamin D supplementation can improve survival in the aging population and in specific patient groups.

Depression of progenitor cell function by advanced glycation endproducts (AGEs): Potential relevance for impaired angiogenesis in advanced age and diabetes

Diabetes and ageing induce reduction and dysfunction of vascular progenitor cells. Advanced glycation endproducts (AGEs) accumulate in diabetes and ageing. We investigated the influence of AGEs on function of CD34 progenitor cells. CD34 cells were co-cultured with HUVECs in a three-dimensional spheroid assay. Sprout length growth and incorporation of CD34 cells into the sprouts were analyzed under 2, 20 or 200 microg/ml AGEs. AGE-receptor expression, MAP-kinase signal transduction and apoptosis were analyzed using PCR, Western blotting and flow cytometry. In the spheroid assay, AGEs concentration-dependently cause a reduction of sprout length growth by 6+/-6 to 32+/-6% and an attenuation of progenitor cells incorporation into the sprouting endothelium by up to 43+/-6%. This functional impairment is accompanied by activation of CD34 cell proliferation at lower concentrations (2 or 20 microg/ml) and by apoptosis activation under 200 microg/ml AGEs. The mRNA expression of the receptors for AGEs and the AGEs-induced activation of p38 and p44/42 MAP-kinases are demonstrable in CD34 cells. This AGEs-mediated impairment of progenitor cell function identifies a new pathophysiological mechanism of disturbed vascular adaptation in diabetes or ageing and suggests that lowering AGEs in recipients of progenitor cell therapy might be beneficial for the success of this therapy.

Detection and Localization of the Hydrophobic Surfactant Proteins B and C in Human Tear Fluid and the Human Lacrimal System

Purpose: To evaluate the expression and presence of the surfactant proteins (SP) B and C in the lacrimal apparatus at the ocular surface and in tear fluid. Methods: Expression of SP-B and SP-C was analyzed by RT-PCR in healthy lacrimal gland, conjunctiva, meibomian gland, accessory lacrimal glands, cornea, and nasolacrimal ducts. The deposition of the hydrophobic proteins SP-B and SP-C was determined by Western blot and immunohistochemistry in healthy tissues, tear fluid, and aqueous humor. Results: The presence of both SP-B and SP-C on mRNA and protein level was evidenced in healthy human lacrimal gland, conjunctiva, cornea, and nasolacrimal ducts. Moreover, both proteins were present in tear fluid but were absent in aqueous humor. Immunohistochemical investigations revealed production of both peptides by acinar epithelial cells of the lacrimal gland and additionally by accessory lacrimal glands of the eyelid as well as epithelial cells of the conjunctiva and nasolacrimal ducts. Immunohistochemically, healthy cornea and goblet cells revealed no reactivity. Conclusions: Besides the recently detected surfactant-associated proteins SP-A and SP-D, our results show that SP-B and SP-C are also peptides of the tear film, the ocular surface, and the lacrimal apparatus. Based on the current knowledge of lowering surface tension in alveolar lung cells, a similar effect of SP-B and SP-C may be assumed concerning the tear film.

The Role of Vitamin D in Dyslipidemia and Cardiovascular Disease

Dyslipidemia and vascular calcification are important predictors of cardiovascular disease (CVD). Vitamin D may have an influence on these two CVD risk markers. We performed a systematic review on vitamin D, dyslipidemia, statins, vascular calcification and CVD. The vast majority of intervention studies did not show an effect of vitamin D on serum cholesterol levels. There is however evidence for a triglyceride-lowering effect of vitamin D which primarily comes from studies with chronic kidney disease patients, a group with elevated triglyceride levels. The previously presumed influence of statins on circulating 25-hydroxyvitamin D levels and on cellular vitamin D actions remains obscure. Experimental studies on vascular calcification and CVD suggest a biphasic effect of vitamin D with harmful effects at both low and high vitamin D levels. Epidemiological studies on vitamin D and vascular calcification are inconsistent at present, but are probably biased by confounding. Prospective cohort studies consistently indicate an enhanced multivariable-adjusted CVD mortality risk when circulating 25-hydroxyvitamin D levels are below 25 nmol/l. Adequately designed randomised controlled trials investigating the dose-response effect of vitamin D on different CVD outcome parameters are now warranted.

Ischemic pre-conditioning of 5 minutes but not of 10 minutes improves lung function after warm ischemia in a canine model☆

BACKGROUND Protection from reperfusion injury by ischemic pre-conditioning (IPC) before prolonged ischemia has been proven for the heart and the liver. We now assess the efficacy of IPC to protect lungs from reperfusion injury. METHODS Eighteen foxhounds (25 to 30 kg) were anesthetized, intubated, and ventilated with a fraction of inspired oxygen of 0.3 at a volume-controlled mode to maintain arterial pCO2 of 30 to 40 mm Hg. After left thoracotomy, we performed warm ischemia for 3 hours by clamping the left hilus, and followed with 8 hours of reperfusion (control, n = 6). In the treated groups, IPC was performed either for 5 minutes followed by 15-minute reperfusion (n = 6, IPC-5), or by 2 successive cycles of 10-minute ischemia, followed by 10-minute reperfusion (n = 6, IPC-10) before prior to the 3-hours warm-ischemia period. Pulmonary compliance and gas exchange were determined separately for each lung, and we recorded pulmonary and systemic hemodynamics. We performed bronchoalveolar lavage (BAL) at the end of the experiment and determined total protein concentration as well as tumor necrosis factor alpha (TNF-alpha) mRNA expression in cell-free supernatant and in BAL cells, respectively. We also assessed the wet/dry ratio of the lung. RESULTS In the controls, on reperfusion, we encountered a progressive deterioration of gas exchange, especially of the reperfused left lung, which we could largely avoid using the IPC-5 protocol. Similarly, pulmonary compliance steadily declined but was much better in the ICP-5 group. Parallel to the improvement of gas exchange and lung mechanics, we found less total alveolar protein content and TNF-alpha mRNA expression in BAL cells in the IPC-5 than in the controls. However, we did not find IPC-10 to be paralleled by a significant improvement of lung function. Neither IPC-5 nor IPC-10 influenced the pulmonary vascular resistance index or the fluid accumulation in the lung. CONCLUSION The major finding of the present study was that 5 minutes of IPC improved lung function after 3 hours of warm ischemia of the lung.

Clampless Off-Pump Versus Conventional Coronary Artery Revascularization A Propensity Score Analysis of 788 Patients

Background— This study aimed to assess if clampless off-pump coronary artery bypass grafting (CABG) decreases risk-adjusted mortality, stroke rate, and morbidity in unselected patients in comparison to conventional CABG. Methods and Results— Between July 2009 and November 2010, data of 1282 consecutive patients undergoing isolated CABG were prospectively recorded. In 30.8% (n=395), clampless off-pump revascularization was used, either with the PAS-Port automated central venous anastomosis system (n=310) or as total arterial revascularization without central anastomoses (n=85). Propensity score (PS) matching was performed based on 15 preoperative risk variables to correct for selection bias. In-hospital mortality and stroke rate as primary end point, as well as major complications and follow-up outcome of clampless off-pump (lessOPCAB) and conventional CABG (cCABG) were compared in 394 matched patient pairs (total: 788 patients). The clampless off-pump technique decreased the in-hospital rate of death (odds ratio, 0.25; 95% confidence interval, 0.05–1.18, P=0.080) and stroke (odds ratio, 0.36; 95% confidence interval, 0.13–0.99, P=0.048) significantly. Complications such as low cardiac output syndrome, prolonged ventilation and rethoracotomy were also reduced by lessOPCAB. Over a 2-year follow-up period overall survival, cerebrovascular and major adverse event rate were significantly lower in the lessOPCAB group, while the repeat revascularization rate was comparable. Conclusions— In a retrospective PS-matched analysis, clampless off-pump CABG lowers mortality, stroke rate and other morbidity in an unselected group of patients with coronary artery disease.

Device landing zone calcification and its impact on residual regurgitation after transcatheter aortic valve implantation with different devices

AIMS Calcification of the device landing zone is linked to paravalvular regurgitation after transcatheter aortic valve implantation (TAVI). The mechanisms remain incompletely understood and the performance of next-generation transcatheter heart valves (THV) has not been investigated. We evaluated the impact of calcification patterns on residual aortic regurgitation (AR) after TAVI with different THV in patients with severe aortic stenosis. METHODS AND RESULTS TAVI was performed in 537 patients at two centres. Devices implanted were the Edwards Sapien XT (n = 254), Medtronic CoreValve (n = 123), JenaValve (n = 62), Medtronic Engager (n = 56), and Symetis Acurate (n = 42) prostheses. Calcification of the device landing zone was retrospectively assessed from contrast-enhanced multidetector computed tomography data and correlated with echocardiographic and clinical data. Calcium volumes of the aortic valve and left-ventricular outflow tract were associated with residual AR: No AR, 604 mm(3) (inter-quartile range, IQR 349-916); trace AR, 639 mm(3) (IQR 368-948); mild AR, 710 mm(3) (IQR 412-2078); ≥moderate AR, 1041 mm(3) (IQR 791-1417, P = 0.001). Device landing zone calcium, particularly if located in the left-ventricular outflow tract, and a low cover index were predictive of AR. Differences in the incidence of AR were observed with regard to THV type. Higher calcium volume was associated with the need for post-dilation (n = 134, median 852 [IQR 342-945] vs. 604 [IQR 542-1207] mm(3), P < 0.001). CONCLUSION Calcification of the device landing zone, particularly if located inferior to the annulus, was independently associated with residual AR after TAVI with all evaluated THV; however, the incidence of paravalvular leakage differed significantly between the devices implanted.

Safety Issues of Vitamin D Supplementation

Vitamin D deficiency is a re-emerging global health problem, which is primarily due to inadequate vitamin D synthesis in the skin. Supplement use is an effective measure to improve vitamin D status. However, some safety issues have to be considered, which are highlighted in this review article: The concept of vitamin D safety consists of two models, the safe tolerable upper intake level (UL) method, and the idea of adequate circulating 25-hydroxyvitamin D (25[OH]D) levels. Oral vitamin D intakes up to 250 μg/d have not been associated with harm. Hypercalcemia, the hallmark of vitamin D intoxication, may only occur if circulating 25(OH)D levels are consistently above 375-500 nmol/l. However, some observational studies indicate that already circulating 25(OH)D levels > 125 nmol/l are related to an increased morbidity and mortality risk. Therefore, the Institute of Medicine has set the UL for adults at 100 μg/d, and the adequate circulating 25(OH)D level at 50 to 125 nmol/l. In clinical practice, oral vitamin D dosing has to consider that the increment in circulating 25(OH)D depends on baseline 25(OH)D levels and the persons body weight. It is reasonable to assess 25(OH)D before and 3-6 months after initiation of oral vitamin D administration and to adjust the dose, if necessary. In future, two issues have to be clarified: First, would it be more appropriate to define instead of a fixed UL a variable UL, based on the individuals body weight? Second, what are the underlying mechanisms, if any, for potentially harmful vitamin D effects at circulating 25(OH)D levels between 125 and 375 nmol/l.

Paracrine effects of CD34 progenitor cells on angiogenic endothelial sprouting.

BACKGROUND Progenitor cells contribute to repair of ischemia-associated disturbances of microcirculations, but detailed mechanisms of paracrine angiogenic activation of endothelium by progenitor cells are unclear. The present study was designed to test whether progenitor cells maintain their activation pattern of cytokine secretion and capillary-like endothelial sprout attraction under conditions of hypoxia induced angiogenic activation. METHODS CD34 progenitor cells were kept separated together with spheroids of human umbilical vein endothelial cells (HUVEC) sharing a common medium supernatant to generate a paracrine diffusion gradient from CD34 cells to the endothelial cell spheroids. The expression of 27 cytokines was analyzed in the supernatant. The length and the direction of the capillary like sprouts were analyzed under 20% and 1% oxygen concentration. RESULTS Co-culture with CD34 cells increased sprout length of HUVEC spheroids by 18%, while reduction of oxygen concentration from 20% to 1% increased sprout length by 52%. Analysis of the direction of the sprout growth revealed a directed growth toward CD34 cells under normoxic as well as under hypoxic conditions. Paracrine induction of cytokine secretion by co-culture was similar in normoxia and in hypoxia with IL-8 (60-80-fold induction) >IL-6 and MIP-1beta (10-20-fold) >MIP-1alpha and MCP-1 (3-10-fold). CONCLUSIONS These data indicate that CD34 cell induced paracrine activation of cytokine secretion pattern and attraction of endothelial sprouting are well maintained under conditions of hypoxia induced endothelial cell sprout growth. This is a prerequisite for paracrine effectiveness of trapped progenitor cells in hypoperfused and hypooxygenated tissue areas.