The body encounters an innumerable amount of foreign substances, termed xenobiotics, which it must remove in order to prevent damage to cells and organs. This system of removal is a collection of processes known as ADME (absorption, distribution, metabolism, and excretion). The dynamics of ADME ultimately determine the fate, or pharmacokinetics, of a xenobiotic in the body whether it be an administered pharmaceutical or a potentially harmful toxicant. The major cellular effectors of ADME are the drug metabolizing enzymes (DMEs) and transporters. DMEs function to transform xenobiotics into a metabolite that is more suitable for excretion, whereas drug transporters serve a two-fold function. They may facilitate the uptake of the xenobiotic into the cell so that it can be acted upon by DMEs, or they may function to actively secrete xenobiotics and metabolites from the cell, encouraging their removal from the body. Any perturbations in the expression or function of these critical cellular effectors can result in the diminished therapeutic effect of a pharmaceutical via accelerated removal from the body, or increased toxicity of a pharmaceutical or toxicant due to retention in the body and increased exposure.Perturbations in the ADME processes may result in adverse drug reactions (ADRs) which are an unintended response to a pharmaceutical when administered at the recommended dose. In the last reporting year, the USFDA documented 471,291 serious ADRs causing hospitalization or permanent disabilities, of which 82,724 resulted in death. ADRs can be categorized as two types: dose-related ADRs, and those that are generally unpredictable and mostly occur in susceptible individuals. The major factors that make a person susceptible to ADRs are genetics and disease; however, genetics account for only a small proportion. This dissertation is focused on the contribution of an environmentally-derived component, particularly liver disease, to the occurrence of ADRs. Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease of industrialized nations. It represents a spectrum of damage progressing to the severe stage of nonalcoholic steatohepatitis (NASH), and is closely related to obesity and type 2 diabetes. The following studies have determined the effect of NAFLD and NASH on DMEs and transporters, and demonstrated the propensity for NASH to result in serious ADRs.

The persistent and toxic perfluoroalkyl acids (PFAAs) are ubiquitously present in the environment and reach humans predominantly via food and drinking water. The aim of the present study was to investigate the effect of low-grade (<10 ng L-1 of single PFAAs) contaminated PFAAs drinking water on serum PFAA concentrations in a representative Swedish adolescent population, and to examine the influence of potential determinants on the variation of the PFAAs serum concentrations. This was done by using multivariate regression analysis on the possible determinants of blood serum PFAA concentrations in 479 Swedish adolescents, 10 to 21 years of age, who had left complete dietary and life style information in 2016-17 in the nation-wide food consumption survey Riksmaten Ungdom. Raw and drinking water samples (DW) from water treatment plants (WTPs) that delivered DW to participants schools were sampled in 2018, analysed for PFAAs, and used for assessing the participants DW PFAA exposure. Maternal education level and maternal birth country, consumption of fish, as well as age and sex were significantly associated with the participants PFAAs serum concentrations. DW concentrations as low as <1 ng L for PFOA and PFHxS, <0.45 ng L-1 for PFNA and <4 ng L-1 for PFOS were significantly associated with increased adolescent serum concentrations of the PFAAs in question, which suggests that low-grade contaminated drinking water is an important exposure route for Swedish adolescents. For risk assessment purposes, it was investigated whether parts of the adolescent population exceeded the serum PFOS and PFOA concentrations corresponding to the current health-based reference intakes as assessed by the European Food Safety Authority (EFSA) and the U.S. Agency for Toxic Substances and Disease Registry (ATSDR). Around 1.7% and 2.7% of participants had PFOS serum concentrations exceeding serum levels used to derive the tolerable daily intake (TDI) (EFSA) and the minimum risk level (MRL) (ATSDR), respectively and a cause for concern was consequently identified. However, the high serum concentrations of participants exceeding the TDI and MRL serum concentrations belong to participants suspected to have been previously exposed to highly contaminated drinking water and not from consuming foods and beverages containing background concentrations of PFAAs.

Familial hypercholesterolemia is a genetic disease affecting about 10 million people around the world. Those who carry the disease have a very high risk of developing cardiovascular diseases and commonly encounter myocardial infarction at the early age of 40. Therefore, a diagnosis and immediate treatment are very important for these patients. Despite many combinations of available drugs, there are many patients who still cannot reach the desired cholesterol levels. Mipomersen is a new lipid-lowering drug which inhibits the synthesis of apolipoprotein B, a common component of lipoproteins such as low-density lipoprotein. Inhibition of this protein leads to reduced production of these lipoproteins and reduces the risk of cardiovascular diseases. The drug is currently only indicated for treating patients with homozygous familial hypercholesterolemia.  Unfortunately, there have been many reports of adverse events in patients using mipomersen which has proven problematic.         The aim of this thesis is to analyze the efficacy and safety of mipomersen when treating patients with familial hypercholesterolemia. This has been done by searching for five clinical trials in the database Web of Science. The studies were required to include patients with familial hypercholesterolemia, use mipomersen as the study drug and analyze its effect and safety.   The studies showed that mipomersen has a very good effect in decreasing low-density lipoproteins as well as other lipoproteins in comparison to placebo. Many of the patients who were treated with mipomersen displayed several adverse events and the most common were injection-site reaction and influenza-like symptoms. Elevated levels of aminotransaminase and increased fat deposit in the liver were also common. Based on the five clinical trials analyzed in this thesis, mipomersen is an effective lipid-lowering drug which reduces low density lipoprotein cholesterol, apolipoprotein B and lipoprotein (a) in patients with familial hypercholesterolemia. Elevations in alanine aminotransferase and aspartate aminotransferase are common in patients treated with mipomersen. This could indicate a negative impact on the liver. To be more certain of its safety profile, more research could be needed. There are however, new treatments that combines statins and a proprotein convertase subtilisin/kexin 9 inhibitor, which could be the future of lipid-lowering treatments and mipomersen would then likely be substituted.

Nonalcoholic fatty liver disease (NAFLD) has become a worldwide, chronic liver disease of increasing clinical significance. It is closely associated with the rising epidemics of obesity and insulin resistance. Up to 17% of the United States population may progress from the disease stage characterized as simple, benign steatosis to the more severe, inflammatory stage of nonalcoholic steatohepatitis (NASH). This progression occurs through 2nd 'hits' of increased oxidative stress and inflammation to a liver that has been sensitized by lipotoxic stress. NASH is also characterized by increased collagen deposition resulting in fibrosis and architectural rearrangement of the liver. Progressive NAFLD is currently recognized as an important contributor to the development of cryptogenic cirrhosis and subsequent liver-related mortalities (estimated at 30-40% in these patients).The pathological progression of NAFLD, as described by the 'two hit' hypothesis, characterizes the different stages of liver injury. However, the mechanism(s) responsible for the progression to NASH are unknown. Profiling global gene expression and metabolite patterns in human liver samples representing the full spectrum of progressive human NAFLD may reveal potential mechanisms of progressive disease. Human liver samples representing each stage of NAFLD progression were analyzed by methodologies such as high-throughput microarrays, high resolution mass spectrometry, and protein immunoblot techniques. Bioinformatics tools and gene expression/regulation database software were utilized in several studies to characterize the altered hepatic profiles of these patients. Hepatic transcriptomic profiles of ADME (absorption, distribution, metabolism and elimination) and ER (endoplasmic reticulum) stress response genes exhibited initiated hepatoprotective responses in patients with NASH. The endogenous pathways of BA (bile acid) synthesis and BCAA (branched chain amino acid) metabolism also showed evidence of coordinately regulated alterations in response to disease-induced stress in NASH. The transcriptional regulation of the investigated pathways was confirmed by transcription factor binding sites enrichment analysis. The collective response to hepatic stress in human NAFLD, demonstrates a coordinated, hepatoprotective intent that may be utilized for future therapeutics in the battle against progressive liver disease.

Bladder cancer has been associated with chronic arsenic exposure. Monomethylarsonous acid [MMA(III)] is a metabolite of inorganic arsenic biotransformation and has been shown to transform an immortalized urothelial cell line (UROtsa) at a concentration 20-fold less than arsenite. MMA(III) was used as a model arsenical to examine the mechanisms of arsenical-induced transformation of the urothelium. A microarray analysis was performed to assess the transcriptional changes in UROtsa during the critical window of chronic MMA(III) exposure that leads to transformation at three months time. The analysis revealed only minor changes in gene expression at one and two months of exposure, contrasting with substantial changes observed at three months of exposure. The gene expression changes at three months were analyzed showing distinct alterations in biological processes and pathways such as a response to oxidative stress, enhanced cell proliferation, anti-apoptosis, MAPK signaling, as well as inflammation. To address the lack of information between two and three months of exposure -- the critical period of transformation -- the expression of selected pathway marker genes were measured by PCR array analysis on a weekly and monthly basis. A very similar pattern of altered expression of these genes was observed when compared to microarray results, and suggested early perturbations in cell signaling cascades, immunological pathways, cytokine expression, and MAPK pathway, are particularly important in driving malignant transformation. These results showed a strong association between the acquired phenotypic changes that occurred as early as one to two months of chronic MMA(III) exposure, and gene expression patterns that are indicative of the earliest stages in carcinogenesis. Additionally, studies on the effects of withdrawal of arsenical were also conducted and showed that phenotypic changes persisted even in the absence of arsenical; that gene expression patterns of pathway marker genes, those that showed significant alterations between 3 and 6 months of exposure, appeared to normalize after withdrawal of the arsenical.

Epigenetic dysfunction is a known contributor in carcinogenesis, and is emerging as a mechanism involved in toxicant-induced malignant transformation for environmental carcinogens such as arsenicals. In addition to aberrant DNA methylation of single genes, another manifestation of epigenetic dysfunction in cancer is agglomerative DNA methylation, which can participate in long-range epigenetic silencing that targets many neighboring genes and has been shown to occur in several types of clinical cancers. Using in vitro model systems of toxicant-induced malignant transformation, we found hundreds of aberrant DNA methylation events that emerge during malignant transformation, some of which occur in an agglomerative fashion. In an arsenite-transformed prostate epithelial cell line, the protocadherin (PCDH), HOXC and HOXD gene family clusters are targeted for agglomerative DNA methylation. Aberrant DNA methylation in general occurred more often within H3K27me3 stem cell domains. We found a striking association between enrichment of H3K9me3 stem cell domains and toxicant-induced agglomerative DNA methylation. Global gene expression profiling of the arsenite-transformed prostate epithelial cells showed that gene expression changes and DNA methylation changes were negatively correlated, but less than 10% of the hypermethylated genes were down-regulated. These studies confirm that a majority of the DNA hypermethylation events occur at transcriptionally repressed, H3K27me3 marked genes. In contrast to aberrant DNA methylation targeting H3K27me3 pre-marked silent genes, we found that actively expressed ZNF genes marked with H3K9me3 on their 3' ends, are preferred targets of DNA methylation linked gene silencing. H3K9me3 mediated gene silencing of ZNF genes was widespread, occurring at individual ZNF genes on multiple chromosomes and across ZNF gene family clusters. At ZNF gene promoters, H3K9me3 and DNA hypermethylation replaced H3K4me3, resulting in a widespread down-regulation of ZNF gene expression which accounted for 8% of all the down-regulated genes in the arsenical-transformed cells. In summary, these studies associate arsenical exposure with agglomerative DNA methylation of gene family clusters and widespread silencing of ZNF genes by DNA hypermethylation-linked H3K9me3 spreading, further implicating epigenetic dysfunction as a driver of arsenical-induced carcinogenesis.

The immune-reactive sperm are kept separate from the body by epithelial barriers such as the blood-testis barrier (BTB). While these barriers are beneficial for the protection of sperm from toxicants, they can make treating these areas difficult due to preventing the entry of pharmacological agents. This is especially an issue in the treatment of HIV and Ebola infection based on the ample evidence that these viruses are able to survive and spread from within the male genital tract (MGT), but only a few antiviral drugs are known to access the MGT. Transporters that line the epithelial barriers of the MGT, especially the BTB, are important for determining whether or not a drug is able to penetrate into the MGT through transepithelial transport. Several nucleoside analogs (NSA), which are used to treat HIV infection and leukemias, are known to be able to accumulate in seminal plasma, which makes them a useful tool for understanding transepithelial transport for the BTB. The purpose of these studies is to characterize the transport profile for the MGT, in particular the BTB, to gain a better understanding of how xenobiotics, especially ones based on nucleosides, can access the MGT. The chief finding of this work is the discovery of a transepithelial transport pathway expressed by Sertoli cells that allows for the entry of nucleosides (necessary for germ cell development) and NSA into the MGT. This pathway depends on equilibrative nucleoside transporter (ENT) 1 uptake and ENT2 efflux and occurs in both rats and humans. These studies provide the foundation for being able to predict the penetration of novel drugs into the MGT.

Epidemiology studies have established a strong link between chronic arsenic exposure and lung cancer. Currently, contribution of perturbed energy metabolism to carcinogenesis is an intensive area of research. In several human cell culture models (primary, immortal, malignant), we observed that non-cytotoxic exposure to arsenite increased extracellular acidification rate. Lactate accumulation caused by extracellular acidification, could be inhibited by 2-deoxy-D-glucose, a non-metabolized glucose analog. This established that arsenite induces aerobic glycolysis (the Warburg effect), a metabolic shift frequently observed in the acquisition of malignancy. Our studies in BEAS-2B, a non-malignant pulmonary epithelial cell line, found that the metabolic perturbation began early in the course of malignant transformation by arsenite (6 weeks). Correlated with the surge of glycolysis, we found elevated levels of HIF-1A and loss of E-Cadherin during chronic arsenite exposure. Our evidence suggests that this metabolic shift is sustained by HIF-1A (hypoxia-inducible factor 1A). We found that arsenite-exposed BEAS-2B accumulated HIF-1A protein, and underwent transcriptional up-regulation of HIF-1A-target genes. Overexpression of HIF-1A increases glycolysis 15% (vs. control), confirming that HIF-1A can modulate glycolysis in BEAS-2B. Coincident with induction of glycolysis, we observed a decrease in E-cadherin expression, indicating loss of epithelial identity. HIF-1A stable knockdown in BEAS-2B abrogated the arsenite induction of glycolysis, and indicated suppression in colony formation. These findings suggest that the hypoxia-mimetic effect of arsenite plays an important role in arsenite-induced malignant transformation. The significance of this study is that arsenite-induced alteration of energy metabolism represents the type of fundamental perturbation that could extend to many diverse effects caused by arsenic.

Inter-individual variability in drug response is a significant clinical concern and may lead to the development of adverse drug reactions, which are currently a top-ten cause of death in the United States. Recently, the manifestation of disease, which may alter normal physiological function, has gained increased attention for its role as a contributing factor in the development of inter-individual responses to drugs. One such disease, known as nonalcoholic fatty liver disease (NAFLD), is the most common chronic liver disease in Western society and represents a spectrum of clinical morbidities that range from the usually benign simple fatty liver to the more advanced nonalcoholic steatohepatitis (NASH). Prior investigations have identified liver-specific alterations in xenobiotic transporter and metabolizing enzymes in NASH, which lead to the functional disruption of drug disposition. To identify a useful model(s) that is representative of hepatic transporter expression profiles in humans with NASH, gene and protein expression profiles of liver membrane transporters were assayed across several commonly used experimental rodent models of the disease. NASH models that were representative of the human condition developed global, adaptive changes in transporter regulation in the liver, which was not present in models that failed to recapitulate human profiles. Specifically, decreased expression of hepatic uptake transporters was coupled with an induction of efflux transporters, which may serve as a hepatoprotective response by limiting hepatic exposure to potentially harmful substances during times of tissue stress. To link a possible molecular mechanism for these hepatic adaptations in NASH, the role of the oxidative stress-activated transcription factor, Nrf2, was investigated. A functional Nrf2 regulatory element was identified within the eighth intron of the human ABCC3 transporter gene, implicating Nrf2 activation in NASH as a contributor to the coordinated induction of hepatic efflux transporters in the disease. To further clarify the effects of NASH on renal membrane transporter regulation, a thorough analysis of gene and protein expression was conducted with the validated rodent models used previously. Following the manifestation of disease, a global induction of renal efflux was observed, suggesting a compensatory, coordinated response of membrane transporters in the kidney upon disease induction. The functional consequences of liver and kidney xenobiotic transporter dysregulation was shown to disrupt the disposition of the environmental toxicant, arsenic. Specifically, NASH results in increased excretion of arsenic into urine as well as altered hepatic and renal exposure. These findings are associated with hepatic and renal transporter dysregulation and demonstrate for the first time that NASH alters the disposition of environmental toxicants. In summary, these studies contribute novel findings that identify liver and kidney-specific adaptations in disease that may contribute to global alterations in xenobiotic disposition thereby increasing the likelihood of developing adverse drug reactions in patients with NASH.

Cyclin D1, a proto-oncogene, is required for progression from the G1 phase into the S phase of the cell cycle. Over-expression of cyclin D1 causes an increase in cell cycle progression and cell proliferation, implicating it in a variety of cancers including renal cell carcinoma (RCC). The rodent RCC cell model, QTRRE, and human RCC cell models, ACHN, 786-O and Caki-2, exhibit elevated levels of cyclin D1. Pentoxifylline (PTX), a non-specific phosphodiesterase inhibitor, is an FDA-approved hemorheologic agent used to treat intermittent claudication, stemming from peripheral vascular diseases, as well as other diseases involving defective locoregional blood flow. Treatment of QTRRE, ACHN, 786-O and Caki-2 with PTX caused a time- (0-24 hrs) and dose- (0-1.0 mg/mL) dependent decrease of cyclin D1 protein and p-Rb levels in whole cell lysate as well as cytosolic and nuclear fractions, albeit, to different extents within the models. Concomitant with cyclin D1 and p-Rb decrease, enhanced G1 phase cell cycle arrest was observed in the RCC models. Mechanistic studies in these RCC cell models were carried out to determine PTXs mechanism of action with regard to cyclin D1 protein level decrease. RT-PCR analysis showed no significant changes in cyclin D1 mRNA copy number in time- (0-24 hrs) and dose- (0-1.0 mg/mL) dependent PTX treatments. However, such treatments caused decrease in p-4EBP1 (Ser65), p-4EBP1 (Thr70), and p-4EBP1 (Thr37/46). Because PTX's ability to decrease cyclin D1 protein was prevented in the presence of the proteasome inhibitor, MG-132, studies were performed to determine whether cyclin D1 stability was decreased during PTX treatment. Cyclin D1 degradation is initiated by phosphorylation of residue Thr286 by GSK-3β. Inhibition of GSK-3β with LiCl or knockdown via siRNA in the presence of PTX failed to block cyclin D1 decrease. Moreover, PTX treatment in the presence of MG-132 revealed no significant increase in cyclin D1 p-Thr286 compared to control. Finally, using the protein synthesis inhibitor, CHX, PTX caused no significant decrease in cyclin D1 t₁/₂ (wt-HA and T286A-HA) compared to control. Sorafenib, a broad-spectrum (cRAF, bRAF, KIT, FLT-3, VEGFR-2, VEGFR-3, and PDGFR-β) kinase inhibitor, is FDA-approved for the treatment of RCC. Studies with sorafenib and PTX in the ACHN cell model were carried out to determine PTXs possible adjuvant role in inhibiting cell growth via cyclin D1 decrease and G1 phase arrest. MTS data showed PTX potentiates the anti-proliferative effects of sorafenib. PTX pre-treatment for 24 hrs was also lowered the effective dose of sorafenib from 50 μM to 5 μM. Further, ACHN xenograft tumor volumes from mice treated with PTX and sorafenib displayed significantly higher tumor growth inhibition compared to either drug treatment alone or vehicle. Finally, drug treated ACHN xenograft tissue displayed significantly lower cyclin D1, p-RB and p-4EBP1 levels. These results demonstrate a novel anti-cancer property of PTX and suggest its use as a possible adjuvant therapy in RCC treatment should be further explored.