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Hemodialysis (HD) is the most frequently used treatment for end-stage renal disease. Despite all efforts to improve the outcomes, the mortality of patients on HD is still high, and this especially is related to cardiovascular diseases (CVD). Glucose degradation products accumulate in plasma and tissue as a result of oxidative stress in these patients. Such accumulation is strongly related to the risk of developing CVD. Tissue deposits of advanced glycation end products (AGE) can be easily assessed by a skin autofluorescence (SAF) technique. SAF is one of the strongest prognostic markers of mortality in HD patients. The aim of this thesis is to examine whether intervention on HD treatment can reduce the load of AGE of these patients. The aim of the first study was to investigate whether changes in SAF appear after a single HD session and if they might be related to changes in plasma AF. Skin and plasma AF (PAF) were measured before and after HD in 35 patients on maintenance HD therapy. Median dialysis time was 4 h (range 3-5.5). SAF was measured noninvasively with an AGE Reader, and plasma AF was measured before and after HD. The HD patients had on average a 65% higher SAF value than age-matched healthy persons (P < 0.001). PAF was reduced by 14% (P < 0.001), whereas SAF was not changed after a single HD treatment. No significant influence of the reduced PAF on SAF levels was found. This suggests that the measurement of SAF can be performed during the whole dialysis period and is not directly influenced by the changes in plasma AF during HD. In study 2 different dialysis filters were compared to clarify whether using a high-flux (HF) dialyzer favors plasma or SAF removal compared to low-flux (LF) dialyzer. Twenty-eight patients were treated with either an HF-HD or LF-HD but otherwise unchanged conditions in a cross-over design. SAF was measured non-invasively with an AGE reader before and after HD. PAF was determined as total and non-protein-bound fractions. Corrections for hemoconcentrations by volume changes were made using the change in serum albumin. Paired and non-paired statistical analyses were used. The different treatments did not change SAF after LF- and HF-dialysis. Total, free, and protein-bound PAF were reduced after a single LF-HD by 21%, 28%, and 17%, respectively (P<.001). After HF-HD total and free PAF was reduced by 5% and 15%, respectively (P<.001), while protein-bound values were unchanged. The LF-HD resulted in a more pronounced reduction of PAF than did HF-HD (P<.001). Serum albumin correlated inversely with PAF in HF-HD. There was no significant change in SAF after dialysis, either with LF or with HF dialysis. Although only limited reductions in PAF were observed, these were more pronounced when performing LF dialysis. These data are not in overwhelming support of the use of HF dialysis in the setting used in this study. In the third study the effect on SAF was investigated using either glucose-containing or glucose-free dialysate. SAF and PAF were measured in patients on HD during standard treatment with a glucose-containing dialysate (n=24). After that, the patients were switched to a glucose-free dialysate for a 2 week period, and new measurements were performed on PAF and SAF. There was an increase of pre-dialysis SAF measured at the beginning of the study compared with the values one month later (as in study 4). By comparing pre- and post-dialysis values there was a significant decrease of SAF only when using glucose-free dialysate. Free PAF decreased independently whether glucose-containing or glucose-free dialysate was used. The important finding was that increase in SAF seemed possible to slow down using glucose-free dialysate. Study 4 was performed to investigate whether there are seasonal variations in SAF on a HD population. SAF was measured non-invasively with an AGE Reader in patients on HD at different seasonal periods during one year such as February-May (N=31), May–August (N=28), August–March (N=25). SAF was measured before HD. Paired statistical analyses were performed between each two periods.  Unexpectedly there was at a median 6% increase in SAF during the winter (p=0.004) and a 11% decrease from 4.0 to 3.5 arbitrary units of the SAF during the summer (p<0.001). The study concluded that SAF shows seasonal variation. The cause of these changes could not be clarified. A beneficial effect may be due to extended exposure to sunlight during the summer and/or to different dietary intakes during the seasons. In conclusion, these interventional studies confirmed that PAF is lowered by dialysis. SAF was only decreased by HD when using glucose-free dialysate. SAF was not influenced by a single HD, with glucose-containing dialysate, independent of using HF or LF filters. These data favor glucose-free dialysate as a possible measure to slow down the progress of tissue AGE compared to glucose-containing dialysate. Longitudinal studies will help to clarify this issue further.

Les pathologies cardio-vasculaires (CVD) représentent la principale cause de morbidité et demortalité dans le monde. Le risque de CVD augmente avec l’âge, le tabagisme, le diabète, les dyslipidémies, l’obésité et l’insuffisance rénale. L’incidence et la prévalence des CVD nécessitent le développement de stratégies de prévention et de traitement, et la recherche de nouveaux biomarqueurs. Le récepteur aux produits de glycation avancée (RAGE) est impliqué dans plusieurs pathologies métaboliques ou inflammatoires. L’activation du RAGE par ses multiples ligands, i.e. produits de glycation avancée (AGE), protéines de la famille S100 et amphotérine (HMGB1) induit une cascade pro-inflammatoire. La forme soluble du RAGE (sRAGE) a été proposée comme biomarqueur du risque vasculaire, de la sévérité et du devenir des CVD, particulièrement chez les patients diabétiques ou insuffisants rénaux. Cependant, les données sont contradictoires et des corrélations positives et négatives sont observées pour une même pathologie. L’importance de l’axe ligand-RAGE dans les processus pathologiques et le large éventail de molécules se liant au RAGE (des protéines proinflammatoires aux auto-anticorps), justifient le présent travail. Au cours du présent travail, dans un premier temps, nous avons d’abord étudié les effets des ligands du RAGE et des auto-anticorps anti-sRAGE récemment décrit, sur la quantification du sRAGE en ELISA. Nous supposons que l’interaction entre le sRAGE et ces molécules pourrait perturber le dosage du sRAGE. Dans un deuxième travail, nous avons évalué les variations du taux de sRAGE et des auto-anticorps anti-sRAGE après chirurgie bariatrique d’une obésité morbide. Les ligands du RAGE (Nε-carboxyméthyllysine, S100A6, S100A12, S100B, HMGB1 et peptide β-amyloïde) se fixent au sRAGE en différents sites et pourraient potentiellement interférer dans sa quantification par l’intermédiaire d’un masquage d’épitope. Nous avons incubé ces ligands, à des concentrations physiologiques et pathologiques, avec du sRAGE recombinant et du sérum pour évaluer leur effet sur le dosage du sRAGE. Des auto-anticorps anti-sRAGE ont été identifiés et purifiés et leur effet sur le dosage de sRAGE a été évalué. La présence des ligands ou d’autoanticorps anti-sRAGE ne modifie pas le dosage du sRAGE recombinant ou sérique. L’obésité favorise les dyslipidémies, les perturbations glycémiques et l’inflammation, conditions au cours desquelles le RAGE pourrait jouer un rôle important. Nous avons étudié les variations des taux sériques du sRAGE et de ses auto-anticorps et leur évolution avec l’amélioration métabolique des sujets obèses après chirurgie bariatrique. Les patients ont été sélectionnés au sein d’une cohorte déjà établie (Patient présentant une obésité morbide et candidat à une chirurgie de bypass gastrique, ABOS, Lille). Les patients présentant des facteurs pouvant modifier les niveaux de sRAGE, tels qu’un traitement par statines, une insuffisance rénale chronique ou une hypertension,ont été exclus. Comparé au groupe contrôle, les taux de sRAGE et d’auto-anticorps étaientsignificativement plus élevés chez les patients obèses avant la chirurgie. Parallèlement à la baisse de l’indice de masse corporelle, les taux de sRAGE et d’anti-sRAGE ont été significativement diminués un an après la chirurgie. La baisse d’anti-sRAGE a été corrélée à l’augmentation des taux de HDL. Nous démontrons que les variations des taux de sRAGE constatées dans la littérature ne sont, à priori, pas dues à l’interaction des ligands du RAGE avec le sRAGE. D’autres hypothèses, comme la régulation de la formation et de la clairance du sRAGE, sont discutées. Nous avons, pour la première fois, démontré la présence d’auto-anticorps anti-sRAGE chez les patients obèses, et la diminution du taux de ces auto-anticorps après une chirurgie de bariatrique. Ces résultats suggèrent que l’obésité pourrait être responsable d’une réaction auto-immune contre le sRAGE. / Cardiovascular diseases (CVDs) are the leading cause of mortality and morbidity in the world. The risk of CVDs increases with age, tobacco, diabetes, dyslipidemia, obesity and kidney dysfunction. The incidence and prevalence of CVDs demands the development of efficient strategies for prevention and treatment, as well as new biomarkers. The receptor for advanced glycation end-products (RAGE) is implicated in several metabolic and inflammatory disorders. RAGE activation by its multiple ligands, i.e. advanced glycation end-products (AGEs), S100 proteins and amphoterin (HMGB1) induces pro-inflammatory events upon RAGE engagement. The soluble circulating form of RAGE (sRAGE) has been proposed as a biomarker of vascular risk, disease severity and outcome, especially in individuals with diabetes or kidney dysfunction. However, data is controversial since positive and negative correlations are observed for a same disease. Nevertheless, the importance of the ligand-RAGE axis in pathological processes and the wide range of RAGE-binding molecules (from pro-inflammatory proteins to autoantibodies), appreciates the present study.In this thesis, we first investigated effects of RAGE ligands and the recently described anti-sRAGE autoantibodies on sRAGE quantification. We hypothesized that interactions between sRAGE and these molecules could impair sRAGE quantification. On the second part, we evaluated the value of sRAGE and anti-sRAGE autoantibodies as biomarkers of metabolic improvement after bariatric surgery for morbid obesity. Patients were selected from the established cohort ABOS (Lille). RAGE ligands (Nε-carboxymethyllysine, S100A6, S100A12, S100B, HMGB1 and amyloid beta peptide) bind sRAGE at different sites and could potentially impair its quantification through epitope masking. We tested this hypothesis by incubating these ligands, from physiological to pathological concentrations, with recombinant sRAGE and serum to evaluate their effects on sRAGE quantification. Anti-sRAGE autoantibodies were identified and further purified and their effects on sRAGE measurement evaluated. The presence of ligands or anti-sRAGE autoantibodies did not impair recombinant or serum sRAGE quantification. Obesity is a condition of dyslipidemia, glycemia deregulation and inflammation where RAGE is believed to play an important role. We aimed then to investigate the levels of sRAGE and its autoantibodies according to metabolic improvement in obese subjects submitted to weight loss surgery. Patients were highly selected from a well established cohort (morbidly obese patients eligible for gastric bypass, ABOS, Lille). Patients under statins treatment, with kidney dysfunction or hypertension, factors that could affect sRAGE levels, were excluded. In obese patients, significant higher levels of sRAGE and anti-sRAGE autoantibodies were observed before weight-loss surgery. In parallel to body-mass Index, both sRAGE and anti-sRAGE titers were significantly decreased one year after surgery.We demonstrate that the variations of sRAGE levels among the literature are, most likely, not due to an interaction between RAGE ligands and sRAGE. Other hypothesis like the regulation of sRAGE formation and clearance are further discussed. We have, for the first time demonstrated the presence of anti-sRAGE autoantibodies in obese subjects and that their levels decrease after bariatric surgery. Although our data suggest that morbid obese status leads to an autoimmune reactions against sRAGE. Together, our findings argue against sRAGE as a good biomarker but suggest that anti-sRAGE autoantibodies may have a potential implication to evaluate metabolic risk and autoimmunity associated to RAGE

A participação dos produtos de glicação avançada (AGEs) nas complicações crônicas relacionadas ao diabetes, têm sido muito investigadas. Entretanto, pouco se sabe sobre a participação direta dos AGEs em relação a homeostase glicêmica, na qual o transportador de glicose GLUT4 (proteína codificada pelo gene SLC2A4 ) desempenha um papel essencial. Portanto o objetivo do presente estudo é investigar o papel dos AGEs tanto in vivo quanto in vitro sobre a expressão do Slc2a4/GLUT4. Nos modelos in vivo e in vitro, os AGEs reduziram a expressão gênica/proteica do Slc2a4/GLUT4 e reduziram a sensibilidade insulínica no modelo in vivo, como também exarcebaram tanto a via inflamatória pelo NFKB quanto a via do estresse de retículo endoplasmático pelas chaperonas. Por fim, estes resultados sugerem os AGEs como um mecanismo repressor da expressão do Slc2a4/GLUT4 no músculo esquelético pelas vias de estresse de retículo e inflamatória. / The participation of advanced glycation end products (AGEs) in the diabetes-related chronic complications has been extensively investigated. However, little is known about AGEs participation in glycemic homeostasis, for which the glucose transporter GLUT4 (Slc2a4 gene) plays a key role. The aim of this study was indentify the effect of AGEs in an in vivo and in vitro models in Slc2a4/GLUT4 expression. In vivo and in vitro models showed decrease of Slc2a4/GLUT4 expression and insulin sensitivity (only on in vivo model). AGEs increase inflammatory and endoplasmic reticulum stress ways by NFKB and chaperones respectively. In sume, The results reveal that AGEs repress Slc2a4/GLUT4 expression in muscle, in a reticulum endoplasmic stress- and inflammatory-mediated way. This effect contributes to impair plasma glucose clearance, highlighting AGEs reduction/inhibition as a target to improve glycemic control in diabetes.

Diabetic symmetrical polyneuropathy is the most common secondary complication of diabetes, with no effective treatment, apart from maintaining tight glycemic control. It is therefore essential to understand the mechanisms underlying the pathogenesis of the disease in order to develop new therapeutic strategies. Biochemical and structural changes are observed in the extracellular matrix (ECM) of the peripheral nerve in diabetes: including increased endoneurial collagen; reduplication of basement membranes around endoneurial capillaries; a thickening of basal lamina; and accumulation of advanced glycation end-products (AGEs). In normal nerves, ischaemic or other damage to distal axons provokes a regenerative response; in diabetes this is abortive and failure of axonal regeneration is a hallmark of clinical and experimental diabetic neuropathy. Matrix metalloproteinases (MMPs) are a large family of zinc-dependent proteolytic enzymes that cleave the protein components of the ECM. MMP-2 and MMP-9 play a central role in Wallerian degeneration and regeneration following nerve injury. This thesis investigates whether MMP-2 and -9 expression and/or activity were altered in the peripheral nerve in diabetes, and could contribute to regenerative failure in diabetic neuropathy. Using an experimental model of diabetes, we have demonstrated that MMP-2, but not MMP-9, is upregulated at gene, protein and activity levels in the rat sciatic nerve 8 weeks post-streptozotocin (STZ). This upregulation was not maintained at later time-points of diabetes. In vitro sciatic nerve cryoculture studies showed that peripheral nerve from STZ-diabetic rats was less supportive for neurite outgrowth from dissociated adult rat sensory neurons than nerve obtained from age-matched control rats. Cyrocultures were pre-treated with either MMP-2 or chondroitinase ABC, remodelling the peripheral nerve ECM, via the removal of inhibitory chondroitin sulfate proteoglycans from the sciatic nerve, and significantly enhanced its ability to support axonal regeneration, and partially restored the diabetes-associated regenerative deficit. However, exogenous MMP-2 or MMP-9 did not directly affect neurite outgrowth of dissociated adult rat sensory neurons. Finally, we assessed the neuroprotective effects of the AGE inhibitors LR90 and pyridoxamine in experimental diabetes, using a number of electrophysiological, behavioural and biochemical endpoints. These inhibitors were effective at preventing the development of some of the functional deficits observed in STZ-diabetes. Sensory nerve conduction velocity deficits and lipid peroxidation in the sciatic nerve were prevented by both LR90 and pyridoxamine. These agents have potential for the treatment of diabetic neuropathy.

Cyclooxygenase (COX) is the rate limiting enzyme that catalyses the production of prostanoids, which are crucial to vascular homeostasis. Evidence suggests that endothelial dysfunction and inflammation play a role in vascular complications in aging and diabetes. Previous animal studies by our laboratory at RMIT University reported enhanced COX expression with aging in rat aortas, platelets and monocytes. Potentially, alteration in COX expression may result in an imbalanced prostanoid production favoring the synthesis of vasoconstrictors and hence increase the risk of cardiovascular events in the aging population. The regulation of altered COX expression in aging, however, is not clear. It has been suggested that histone hyperacetylation may be an important mechanism that regulates COX levels during the aging process as increased histone acetylation has been shown to occur with aging. Thus, we hypothesized that COX expression is modulated by histone hyperacetylati on. This was investigated by measuring COX expression in histone hyperacetylated cultured endothelial cells. In the case of diabetes, studies have reported that the development of diabetes and its complications is associated with persistent inflammatory activity, evident with increased inflammatory markers in the circulation. COX-mediated pathways may be involved in this inflammatory process in diabetes. Furthermore, the formation of advanced glycation end products (AGEs) is accelerated in diabetes. AGEs can bind to receptors for AGEs (RAGE), which has also been suggested to play a role in inflammation in diabetes. We hypothesized that COX- and RAGE-mediated pathways contribute to increased inflammation in diabetes and potentiate the development of diabetic vascular complications. This was investigated by measuring changes in COX-mediated pathways in both rat and human diabetic models. The current thesis reports: 1) in cultured endothelial cells, histone hyperacetylation was associated with increased COX expression; 2) an overall increase in inflammation was observed in diabetes involving COX- and RAGE-mediated pathways. This was supported by increased platelet COX-1 and monocyte COX-2 levels in Zucker rats, increased monocyte COX-2 in human Type 1 diabetes and elevated plasma TXB2 and PGE2 levels in both human Type 1 and Type 2 diabetic subjects. Up-regulation of RAGE expression was further found in platelets and monocytes in both human diabetes types. When treated with NSAIDs, plasma prostanoid levels, COX and RAGE expression were reduced significantly in both platelets and monocytes in human diabetic subjects. 3) It is unclear how COX and RAGE expression was regulated, but histone modifications may be one of the mechanisms. Data from cultured cells indicated that increased COX expression was associated with increased histone acetylation levels induced by TSA. Concurrent increases in histone acetylation and COX-2 levels were also observed in human Type 1 diabetes, but similar findings were not observed in human Type 2 diabetes. In addition, we failed to find an age-dependent increase in monocyte histone H4 acetylation in human Type 2 diabetes despite an age-dependent increase in monocyte COX-2 expression. Thus, whether histone hyperacetylation modulates COX expression and in what conditions require further investigation.

Methylglyoxal (MG) is a reactive dicarbonyl compound mainly formed during glucose and fructose metabolism. Diabetic patients have increased plasma levels of MG. Our laboratory has shown that treatment with MG induces insulin resistance and type II diabetes in male Sprague-Dawley rats. However, the increases in endogenous MG level attained in different organs and its contribution to the pathogenesis of diabetes following the administration of either high glucose or high fructose diet have not been addressed. The present study aims to investigate whether the harmful effects induced by increased consumption of glucose and/or fructose is linked to increased MG generation. In vitro studies have suggested that L-arginine is an effective MG scavenger. Accordingly, another goal is to determine whether L-arginine pretreatment would scavenge MG under in vivo setting and reduce the harmful effects of hyperglycemia. MG and reduced glutathione (GSH) levels were determined in plasma and urine and in different organs of male Sprague-Dawley rats after 12 weeks of treatment with either high fructose or high glucose diet. GSH plays an important role in the degradation of MG and bears an inverse relationship with the levels of MG. The key results obtained suggest that both diets significantly increased blood pressure and plasma MG levels. A high fructose but not a high glucose diet, increased the plasma total cholesterol, triglycerides levels and total cholesterol/HDL ratio in parallel with the increases in MG and GSH levels in the liver. Increased MG levels seen in both aorta and mesenteric artery induced by high glucose or fructose diet was attenuated by pretreatment with L-arginine. These findings suggest that elevated MG level induced by treatment with high carbohydrate diets in both conduit (aorta) and resistance type (mesneteric artery) vessels may be linked to endothelial dysfunction seen in hyerglycemic/diabetic states. High glucose but not high fructose diet significantly increased MG levels in the pancreas. This observation is consistent with the well-known glucotoxicity caused by hyperglycemia in the pancreas. Taken together, these data provide the first evidence that elevated MG levels in certain organs/tissues following consumption of high fructose and/or glucose diet(s) may play a critical role in contributing to the metabolic abnormalities and the endothelial dysfunction that precedes the onset of macro and microvascular complications in either hyperglycemic and/or type II diabetic states. Interestingly, quenching of elevated MG levels in tissues by pretreamtent with L-arginine overcomes MG-induced vascular damage and endothelial dysfunction caused by high fructose and high glucose diet regimens.

Pre-gestational diabetes increases the risk of congenital malformation in the offspring and both morbidity and mortality in the diabetic mother and her offspring. During pregnancy, high glucose levels act as a teratogen through several cellular and biochemical pathways and increased production of reactive oxygen species (ROS) has a central role in diabetic embryopathy. The aim of this work was to investigate the importance of genetic predisposition for congenital malformations and to study the genes involved in the teratogenic process of diabetic pregnancy. The crossbreeding of two rat strains, with both low and high incidence of diabetes-induced malformations, indicated that strain-specific maternal factors, such as disturbed serum levels of amino acids, triglycerides, and β-hydroxybutyrate, were associated with malformation. In addition, disturbed fetal expression of genes involved in ROS defense and development (Shh, Bmp4, Ret and Gdnf) in mandible and heart, and decreased activity of Gapdh and Aldose Reductase were associated with the teratogenic process, and the trans-generational heredity of the mother determined the type of malformations induced by maternal diabetes. In rat embryos, a diabetic environment in utero changed the expression of genes involved in ROS defense (Nrf2, Gpx1 and Cat), development of mandible and heart (Msx2, Shh, Bmp4, Ret and Gdnf), and neural tube closure and apoptosis (Pax3 and p53). The changes were divergent with tissue-specific alterations of gene expression in developing mandible, heart anlage, and whole embryo. Disruption of the Receptor for Advanced Glycation End products (RAGE) had a protective effect against diabetic embryopathy in mice, and the blockage of RAGE diminished ROS production in the offspring: this supported oxidative stress being a necessary etiological component in diabetic embryopathy. Maternal metabolic state and genetic susceptibility influence fetal outcome in experimental diabetic pregnancy. Disturbed protection against oxidative stress and tissue-specific derangements in the expression of developmental genes play pivotal roles in the teratogenic mechanism, and enhanced levels of Advanced Glycation End products (AGE) and RAGE-induced oxidative stress are involved in diabetic dysmorphogenesis.

Diabetes is associated with increased fracture risk, which leads to increased morbidity and eventual mortality with a substantial financial burden. Type 2 Diabetics also have increased fracture risk, despite having the same or higher BMD as non-diabetics with a low fracture risk. One hypothesis for this is increased modifications made to the extra-cellular matrix via non-enzymatic glycation (NEG) that can occur in a hyperglycemic environment, such as with diabetes. The accumulation of NEG products, known as advanced glycation endproducts (AGEs) can possibly lead to microdamage and eventual weakening of the bone itself. We developed a time-response model in order to induce a wide range of AGEs in a manner that would sustain the mineral integrity of the bone and could be applied to a variety of bone sample types. This was performed on 65 rat tibias, distributed amongst 8 groups (3,7,10, & 14 days) for both ribose and control. Secondly, the protocol was performed on human cortical beam samples cut from 10 donor tibias with 3,5 and 7 day time points for ribose and control groups. All samples were incubated in a 0.6 M ribose solution or 0.0 M ribose control solution. There was a 7, 4, and 5-fold increase in AGEs at the 7, 10, and 14 day time points respectively over controls in the rat tibia study. There was no significant variation in cortical porosity, however TTMD was significantly less dense in the 14-day ribose treated groups. There was a trend toward higher AGEs with time in the human cortical beam specimens, but no significant increase. The AGEs values in the human cortical beam specimens were much lower than expected based on previous trials and reports in the literature. We were able to establish a time-response model for AGE accumulation in bone. However, the effects of AGEs on bone material properties remains inconclusive.

Methylglyoxal (MG), a highly reactive dicarbonyl accumulates after myocardial infarction (MI), causing adverse remodelling and cardiac dysfunction. We hypothesized that therapy using bone marrow cells (BMCs) overexpressing glyoxalase1 (Glo1), the main enzyme that metabolizes MG, injected into mouse MI model would translate into better survival of transplanted cells and improve their therapeutic effect. We found that Glo1 expression is significantly reduced at 7 days post-MI. Glo1 BMCs exposed to MG in vitro displayed greater angiogenic potential and reduced reactive oxygen species production compared to wild type (WT) BMCs. However, in the mouse MI model, Glo1 BMCs did not improve cardiac function or vascularity or reduce scar formation compared to WT BMCs and saline treatments. In conclusion, Glo1 overexpression in BMCs does not confer superior therapeutic efficacy for treating MI under the conditions tested.