Cholesterol and fatty acid homeostasis is maintained by a complex network of regulatory mechanisms that control the biosynthesis and deposition of lipids over diverse physiological conditions. However, these processes can become dysregulated and uncoupled from energy metabolism by metabolic stress such as a hyper-caloric diet and physical inactivity; eventually manifesting as risk factors associated with atherosclerotic cardiovascular disease (ASCVD), Type 2 diabetes (T2D), and/or non-alcoholic fatty liver disease (NAFLD). AMP-activated protein kinase (AMPK) is a sensor of cellular energy status that promotes metabolic homeostasis by mediating effects on multiple cellular processes including cholesterol and fatty acid synthesis biosynthesis. However, the mechanisms linking AMPK to lipid metabolism under normal and pathological conditions, remain undefined. In these studies, we identify a novel nutrient sensing mechanism whereby the coenzyme A (CoA) activated esters of long-chain fatty acids (LCFA-CoA) directly activate AMPK via specific interactions within the β1-regulatory subunit involving a Ser108 residue previously shown only with synthetic activators. We demonstrate the physiological relevance for this mechanism in an acute setting by showing that fatty acid oxidation was attenuated in mice harboring an AMPKβ1-S108A knock-in mutation compared to WT mice. We then demonstrated that β1-selctive AMPK activation is mimicked by the CoA conjugated form of bempedoic acid, a synthetic small molecule lipid synthesis inhibitor in clinical development for lowering elevated levels of low-density lipoprotein cholesterol (LDL-C). The importance of this mechanism was determined by assessing multiple disease outcomes in Ampkβ1-/-/Apoe-/- double knockout (DKO) mice fed a high fat-high cholesterol (HFHC) diet ± bempedoic acid. In these studies, bempedoic acid treatment reduced plasma LDL-C and atherosclerosis in both Apoe-/- and DKO mice, while no differences in disease outcomes was detected between the two genotypes in response to HFHC feeding. Further mechanistic investigations in rodent and primary human hepatocytes, revealed that the CoA conjugate of bempedoic acid suppressed lipid synthesis via competitive inhibition of ATP-citrate lyase (ACL), which promoted LDL receptor upregulation and associated reductions in LDL-C. We then integrate these findings with published literature in a written synthesis aimed to evaluate the role of ACL in metabolism, and its potential utility as a therapeutic target to treat ASCVD and metabolic disorders in humans. Although several questions remain regarding the metabolic role of AMPK activation by LCFA-CoAs, these studies have expanded our understanding of how cells acutely integrate lipid and energy signals to maintain lipid homeostasis, and identified ACL as a promising strategy to treat hypercholesterolemia, ASCVD, and associated metabolic disorders. / Thesis / Doctor of Philosophy (PhD) / The dysregulation of cholesterol and triglyceride metabolism can manifest as risk factors for life-threating diseases such as atherosclerotic cardiovascular diseases (ASCVD), Type-2 diabetes (T2D), and nonalcoholic fatty liver disease (NAFLD). However, the underlying mechanisms controlling lipid homeoastasis in health and disease are not completely understood. ATP-citrate lyase (ACL) and AMP-activated protein kinase (AMPK) are emerging as key nodes in metabolism that integrate lipid metabolism with signals of nutrient availability and cellular energy status, respectively. These strategic positions in metabolism suggest that both these enzymes could play an important role in the underlying pathophysiology of lipid-related diseases, and are therefore, prime candidates for therapeutic intervention. In these studies, we expand our understanding of the role of AMPK in metabolism beyond energy sensing by identifying specific lipid metabolites as direct allosteric activators of kinase activity. We also evaluate the therapeutic utility of targeting both AMPK and ACL in novel models of hypercholesterolemia and metabolic disease, and demonstrate that ACL inhibition offers a promising strategy to address multiple unmet medical needs.

The global prevalence of chronic kidney disease (CKD) has risen at an accelerating rate, increasing the global healthcare burden for long-term and chronic care costs. Multiple risk factors including hypertension, diabetes, and dyslipidemia synergistically induce the progression of CKD. Chief among these factors are dyslipidemia and obesity; increased free fatty acid uptake due to excess consumption of lipid-rich diets has been shown to promote intra-renal lipid accumulation in several in vivo models and in patients in various stages of CKD. Furthermore, patients with renal disease are also at a substantially higher risk for atherosclerotic cardiovascular disease (CVD). In the general population, as well as in patients with renal disease, circulating low-density lipoprotein cholesterol (LDLc) is a well-established driver of atherosclerotic lesion development and CVD progression. In 2003, the proprotein convertase subtilisin/kexin type-9 (PCSK9) was identified as the third locus of familial hypercholesterolemia and was further characterized for its ability to enhance the degradation of the low-density lipoprotein receptor (LDLR). Since this seminal discovery, the development of monoclonal antibodies targeted against PCSK9 demonstrated a significant reduction in LDLc and subsequent CVD risk, establishing the remarkable ‘bench to bedside’ transition. However, the inherent role of PCSK9 in regulating lipid homeostasis remained unknown in different pathological conditions. In the first chapter of my thesis, I demonstrate that PCSK9 regulates the LDLR as a feedback mechanism to protect against non-alcoholic steatohepatitis (NASH) progression induced by a high-fat diet (HFD) challenge. Since its seminal discovery, PCSK9 was also characterized to modulate a wide variety of receptors known to play a crucial role in lipid metabolism including the cluster of differentiation 36 (CD36), the very low-density lipoprotein receptor (VLDLR), and the apolipoprotein E receptor 2 (ApoER2). Previously, we have demonstrated that the absence of PCSK9 promotes diet-induced non-alcoholic steatohepatitis and liver injury through increased surface expression of CD36. Given that these same receptors are well-expressed on renal epithelia, the second chapter of my thesis demonstrates that PCSK9 is also able to modulate renal lipid metabolism by attenuating tubular lipid accumulation and subsequent renal injury. Furthermore, when PCSK9 was first characterized by Seidah and colleagues in 2003, in situ hybridization of murine PCSK9 demonstrated that it was primarily expressed in the liver, but also well-expressed in the kidney cortex, cerebellum, and small intestines. Despite its expression in a wide range of tissues, the secretion of PCSK9 was exclusive to the liver, thus, questioning what the intracellular role of PCSK9 may be. Hence, my last chapter of my masters studies lies in establishing the role of intracellular PCSK9 expression in a cellular process known as endoplasmic reticulum (ER) stress in the kidney. ER stress is a phenomena which primarily occurs due to increased accumulation of misfolded polypeptides, and has been implicated in numerous metabolic diseases including hepatic steatosis, CKD, and neurodegenerative pathologies. Previously, we have demonstrated that overexpressing wild-type and variants of PCSK9 in a Pcsk9-/- mouse does not induce the activation of the unfolded protein response (UPR) and attenuates hepatic ER stress. Using a well-established CKD model, I show that Pcsk9-/- mice exhibit increased renal ER stress and injury relative to wild-type controls. Overall, my findings demonstrate for the first time that both extracellular and intracellular PCSK9 has the ability to modulate renal injury using two distinct mechanism to protect against CKD progression. / Thesis / Master of Health Sciences (MSc)

Obesity and its comorbidities have emerged as serious healthcare concerns in the western world due to increased prevalence of nutritional overabundance and decreased physical activity. Due to the significant population affected and economic burden placed on national healthcare systems, there is a demonstrated need for effective weight management therapeutics. Obesity presents clinically diverse phenotypes that increase a person's susceptibility to comorbidities that commonly result in deteriorated health (cardiovascular disease, diabetes mellitus, hypertension, etc). A comorbidity of specific relevance is non-alcoholic fatty liver disease (NAFLD) and its advanced disease state known as non-alcoholic steatohepatitis (NASH), as it has had a documented rise in prevalence parallel to that observed with obesity. Currently there are no FDA approved therapeutics for NAFLD or NASH, with the majority in clinical development aiming to mitigate the effects caused by accumulation of adipose tissue in the liver known as steatosis. An alternative therapeutic approach is to use small molecules to uncouple oxidative phosphorylation in the mitochondria by passively shuttling protons from the mitochondrial inner membrane space into the mitochondrial matrix. Mitochondrial uncoupling results in the disruption of the proton motive force leading to an upregulation of metabolism (i.e., decrease in steatosis). Small molecule mitochondrial uncouplers have recently garnered great interest for their potential in treating the advanced disease state of NASH. In this study, we report the structure-activity relationship (SAR) profiling of a 6-amino-[1,2,5]oxadiazolo[3,4-b]pyrazin-5-ol core, which utilizes the hydroxy moiety as the proton transporter across the mitochondrial inner membrane. We demonstrated that a wide array of substituents are tolerated with this novel scaffold that increased cellular metabolic rates in vitro using changes in oxygen consumption rate as a read-out. In particular, compound SHS4121705 (2.12i) displayed an EC50 of 4.3 M in L6 myoblast cells and excellent oral bioavailability and liver exposure in mice. In the preclinical stelic animal model (STAM) mouse model of NASH, administration of 2.12i at 25 mg kg-1day-1 resulted in decreased liver triglyceride levels and improved liver enzymes, NAFLD activity score, and fibrosis without affecting body temperature or food intake. Overall, our initial studies showcased the promise of mitochondrial uncouplers toward the treatment of NASH. While initial results were promising, the lead compound 2.12i had reduced potency compared to the alkyl derivatives reported in the SAR, unfortunately alkyl derivatives suffered from poor physiochemical properties, possibly due to metabolism of the alkyl chain. We hypothesized that addressing metabolic liabilities of these compounds could lead to increased potency with maintained efficacy in the STAM mouse model of NASH. Herein, we detail the SAR profiling of a 6-amino-[1,2,5]oxadiazolo[3,4-b]pyrazin-5-ol core derivatized with 1,1'-biphenyl anilines capable of eliciting mild mitochondrial uncoupling. A wide array of substituents are tolerated, and demonstrated sustained and stable increases in ¬cellular oxygen consumption rates over a broad concentration range. In particular, compound SHS4091862 (3.9b) displayed an EC50 of 2.0 μM in L6 myoblast cells with a pharmacokinetic profile of Cmax = 46 μM and t1/2 = 4.7 h indicating excellent oral bioavailability. Administration of 3.9b at 60 mg kg-1 day-1 in the STAM mouse model of NASH decreased fibrosis, steatosis, and hepatocellular ballooning to result in a 1.9-point decrease in NAFLD activity score (NAS) compared to vehicle. No changes in food intake, body weight, alanine transaminase (ALT) or aspartate transaminase (AST) levels were observed with 3.9b. Positive control Resmetirom afforded a 1.2-point decrease in NAS score, but increased ALT levels. Cumulatively, our work demonstrates the therapeutic potential of small molecule mitochondrial uncouplers to address metabolic diseases, namely NAFLD. / Doctor of Philosophy / There has been a significant increase in the population suffering from metabolic diseases in the western world. Among the most concerning metabolic diseases are obesity and nonalcoholic fatty liver disease, which have been shown to arise from excessive consumption of calorie dense food and limited physical activity. A novel approach to combat these diseases is to use mitochondrial uncouplers that disrupt the body's natural process for ATP production, causing an increase in metabolism. This increase in the metabolic rate results in the reduction of fat mass including in organs such as the liver. This work describes the design, development, and biological study of mitochondrial uncouplers capable of producing an increase in metabolism; specifically, SHS4121705 (2.12i) and SHS4091862 (3.9b) were shown to be potent uncouplers in vitro and were active in mouse models of fatty liver disease.

Abstract : Pro-inflammatory cytokines play a key role in pathogenesis of obesity and non-alcoholic fatty liver disease (NAFLD). IL-15 is a pro-inflammatory cytokine, which signals through a receptor complex composed of the IL-15 receptor (IL-15R) alpha chain, the IL-2/IL-15R beta chain and the common gamma chain. The functions of IL-15 have been extensively described in immune cells but less is known about its functions in others tissues such as the liver. The aim of this thesis is to investigate the role of IL-15 in fatty liver disease. C57BL/6 wildtype (WT) and IL-15 knockout (Il15[superscript -/-]) mice were maintained on high fat diet (HFD) or normal control diet (NCD). After 16 weeks, body weight, liver mass, fat accumulation in the liver, serum lipid levels and gene expression in the liver were evaluated. Intrahepatic lymphocytes (IHL) were also analysed. Primary hepatocytes were stimulated with IL-15 and chemokines gene expression was studied. IHLs were examined in WT, Il15[superscript -/-] and Il15ra[superscript -/-], as well as in macrophage- and hepatocyte-specific Il15ra[superscript -/-] mice. We found that IL-15 deficiency prevents weight gain and accumulation of lipids in the liver. Circulating levels of cholesterol and non-esterified fatty acids were elevated in WT mice but not in Il15[superscript -/-] mice. Hepatic expression of chemokines such as Ccl2, Ccl5 and Cxcl10 was increased in WT mice under HFD, but not in Il15[superscript -/-] mice. The livers of Il15[superscript -/-] and Il15ra[superscript -/-] mice also showed decreased expression of Tnfa and iNOS, and macrophage markers Cd68 and F4/80. Accordingly, stimulation of primary hepatocytes with IL-15 induced chemokine gene expression in WT but not in Il15ra[superscript -/-] hepatocytes. Furthermore, hepatocyte-specific ablation of IL-15Rαreduced infiltration of NK and NKT cells in the liver, suggesting that IL15Rα expression in the hepatocytes is needed for the recruitment and/or maintenance of the NK cell population in the liver. In conclusion, IL-15 promotes fat accumulation in the liver, and this is associated with increased inflammatory response in the liver. Increased availability of IL-15 in obesity may stimulate hepatocytes to secrete chemokines that promote hepatic inflammation resulting in fatty liver disease. IL-15Rα expression in hepatocytes appears to play a role in the maintenance of NK, NKT and iNKT cells. // Résumé : Les cytokines pro-inflammatoires jouent un rôle important dans la pathogenèse de l’obésité et la stéatose hépatique. L'IL-15 est une cytokine pro-inflammatoire qui est trans-présentée par l'IL-15Rα aux chaines IL-2/IL-15Rβ et γc. La fonction de l'IL-15 a été largement décrite dans les cellules immunitaires, mais ses fonctions dans d'autres tissus sont moins connues. Le but de ce mémoire est d'élucider le rôle de l'IL-15 dans la stéatose hépatique. Les souris C57BL/6 de type sauvage (WT) et Il15[indice supérieur -/-] ont été soumises à un régimehyperlipidique (HFD) ou à un régime normal. Après 16 semaines, le poids corporel, lamasse hépatique, l'accumulation de lipides dans le foie, les taux de lipides sériques et l'expression des différents gènes reliés à l’inflammation et au métabolisme dans le foie ont été évalués. Les lymphocytes intra-hépatiques (IHL) ont été également étudiés. Des hépatocytes primaires ont été stimulés avec IL-15, et l'expression génique de chimiokines a été déterminée. Les populations de IHLs ont été également caractérisées chez les souris WT, Il15[indice supérieur -/-] et Il15ra[indice supérieur -/-], ainsi que chez des souris dont la déficience dans l’expression d’IL-15Rα est ciblée aux macrophages ou aux hépatocytes. Nos résultats montrent que la déficience en IL-15 empêche l'accumulation de lipides dans le foie. Les taux de cholestérol et d’acides gras non estérifiés dans le sang étaient élevés chez les souris WT, mais pas chez les souris Il15[indice supérieur -/-]. L'expression hépatique des chimiokines Ccl2, Ccl5, Cxcl10 et des marqueurs de macrophages était augmentée chez les souris WT sous HFD, mais pas chez les souris Il15[indice supérieur -/-]. La stimulation des hépatocytes primaires avec l'IL-15 induit l'expression des gènes des chimiokines chez les hépatocytes WT, mais pas chez les Il15ra[indice supérieur -/-]. En outre, nous avons trouvé une infiltration réduite des cellules NK et NKT dans le foie des souris déficientes en Il15ra[indice supérieur -/-] dans les hépatocytes, ce qui suggère que l'expression d’IL15Rα chez les hépatocytes est nécessaire aurecrutement des cellules NK, NKT et / ou à leur maintien. En conclusion, nous proposons que l’IL-15 favorise l'accumulation de lipides dans le foie, et que ceci est associée à une réponse inflammatoire accrue. La disponibilité accrue de l'IL-15 dans l'obésité pourrait stimuler les hépatocytes à secréter des chimiokines ce qui favorise l'inflammation hépatique et conduirait à la stéatose hépatique. L’expression de l'IL-15Rα dans les hépatocytes semble jouer un rôle principal dans l’infiltration des cellules NK, NKT et iNKT dans le foie.

La NAFLD (non alcoholic fatty liver disease) ou stéatopathie dysmétabolique est la manifestation hépatique du syndrome métabolique. Elle regroupe l’ensemble des lésions hépatiques liées à l’obésité en dehors de toute consommation d’alcool : la stéatose, la NASH (non alcoholic steatohepatitis), la fibrose, la cirrhose et le carcinome hépatocellulaire. Les systèmes immunitaires inné et adaptatif participent activement à la pathologie. J’ai étudié deux axes : l’axe du récepteur des glucocorticoïdes-GILZ dans les cellules de Kupffer et CXCR4-CXCL12 dans les lymphocytes T CD4+.Les cellules de Kupffer (CK) jouent un rôle clé dans la pathologie de la NASH. GILZ (glucocorticoid induced leucine zipper) est exprimé par les monocytes/macrophages et est sous le contrôle du récepteur aux glucocorticoïdes (GR). De plus, GILZ intervient dans l’inhibition des processus inflammatoires. J’ai montré que l’obésité entraîne une diminution de l’expression du GR et de GILZ dans les CK. En utilisant du RU486, un antagoniste spécifique du GR, j’ai prouvé que la diminution de l’expression du GR entraîne la diminution de l’expression de GILZ et sensibilise les CK au LPS. Ce mécanisme joue un rôle déterminant dans le développement de l’inflammation hépatique au cours de l’obésité, en modulant la réponse inflammatoire des CK. Le recrutement de cellules inflammatoires dans le foie est un élément clé de la progression de la NASH. Les lymphocytes T CD4+ issus de souris obèses ont des propriétés chimiotactiques accrues dépendantes de CXCR4. J’ai montré que la NASH augmente les propriétés migratoires dépendantes de CXCR4 des lymphocytes T CD4+ chez l’homme et la souris dans trois modèles murins de NASH. Le traitement de souris obèses par de l’AMD3100, un antagoniste de CXCR4, permet de diminuer le recrutement hépatique de lymphocytes. L’augmentation du chimiotactisme des lymphocytes T CD4+ n’était pas dû, ni à une augmentation de l’expression de CXCR4 et CXCR7, ni même de CXCL12 au niveau du foie. J’ai montré que ce mécanisme dépendait de l’augmentation de l’affinité de CXCR4 pour CXCL12.Ainsi, j’ai mis en évidence deux axes participant à l’inflammation hépatique au cours de l’obésité. Ces axes représentent de nouvelles cibles thérapeutiques potentielles. / NAFLD (non alcoholic fatty liver disease) is the hepatic manifestation of metabolic syndrome. It encompasses the entire spectrum of obesity-related liver lesions : steatosis, NASH (non alcoholic steatohepatitis), fibrosis, cirrhosis and hepatocellular carcinoma. Innate and adaptative immune systems participate actively to the pathophysiology.I studied two axis : the glucocorticoid receptor-GILZ axis in Kupffer cells and CXCR4-CXCL12 in CD4+ T lymphocytes.Kupffer cells (KC) play a key role in pathophysiology of NASH. GILZ (glucocorticoid induced leucine zipper) is expressed by monocytes/macrophages and is under the control of glucocorticoid receptor (GR). Moreover, GILZ takes part in inhibition of inflammatory processes. I showed that obesity induces a decreased expression of GR and GILZ in KC. Using RU486, a GR antagonist, I proved that decreased expression of GR induces the decreased expression of GILZ and sensitize KC to LPS. This mechanism plays a decisive role in initiation of liver inflammation in obesity, modulating inflammatory response of KC. In obese mice, recruitment of inflammatory cells into the liver is a key element in the progression of NASH. CD4+ T lymphocytes from obese mice have enhanced CXCR4-dependent chemotactic properties. I showed that NASH enhances CXCR4-dependent chemotactic properties of CD4+ T lymphocytes in patients and in three mouse models of NASH. Obese mice treatment with AMD3100, a CXCR4 antagonist, decreases lymphocytes recruitement into the liver. Enhanced chemotactic properties of CD4+ T lymphocytes were not due to increased expressions of nor CXCR4 and CXCR7, neither CXCL12 in the liver. I showed that this mechanism was dependent of an increased affinity of CXCR4 to CXCL12.Therefore, I highlighted two axis participating to obesity-related liver inflammation. These axis represent new potential therapeutic targets.

No description available.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / As associações entre obesidade, doença hepática gordurosa não alcoólica (NAFLD) e diabetes mellitus tipo 2 (DM2) são bem estabelecidas, e o sistema renina-angiotensina (SRA) pode proporcionar uma ligação entre eles. O bloqueio do SRA em diferentes níveis pode estar relacionado a respostas na resistência à insulina, remodelagem do pâncreas e do fígado em um modelo de obesidade induzida por dieta. Camundongos C57BL/6 foram alimentados com uma dieta hiperlipídica (HF) durante oito semanas e depois tratados com alisquireno (50 mg/kg/dia), enalapril (30 mg/kg/dia) ou losartana (10 mg/kg/dia) por um período adicional de seis semanas. As drogas foram incorporadas na dieta. Avaliou-se a massa corporal (MC), pressão arterial, consumo e gasto energético (GE), metabolismo da glicose e lipídico, histopatologia pancreática e hepática, análise hormonal, imunohistoquímica, perfil gênico e/ou proteico do SRA no pâncreas, gliconeogênese hepática, sinalização da insulina, oxidação e acúmulo lipídico. Todos os inibidores do SRA reduziram significativamente o aumento da pressão arterial nos camundongos alimentados com dieta HF. O tratamento com enalapril, mas não alisquireno ou losartana, reduziu o ganho de MC e a ingestão alimentar; aumentou o GE; amenizou a intolerância à glicose e resistência à insulina; melhorou a massa de células alfa e beta; impediu a redução da adiponectina plasmática e restaurou a sensibilidade à leptina. Além disso, o tratamento com enalapril melhorou a expressão proteica nas ilhotas pancreáticas de Pdx1, GLUT2, ECA2 e do receptor Mas. O tratamento com losartana apresentou uma elevação na expressão proteica de AT2R no pâncreas. No fígado, a administração de enalapril atenuou a esteatose hepática, o acúmulo de triglicerídeos e preveniu o aumento dos níveis de PEPCK, G6Pase e do GLUT2. Do mesmo modo, o enalapril melhorou a transdução dos sinais da insulina através da via IRS-1/Akt, bem como reduziu os níveis de expressão gênica e/ou proteica de PPAR-gama, SREBP-1c e FAS. Esses resultados sugerem que a inibição da ECA com enalapril atenuou muitos efeitos deletérios provocados pelo consumo da dieta HF, incluindo: normalização da morfologia e função das ilhotas pancreáticas, proteção contra a resistência à insulina e acúmulo de lipídios no fígado. Estes efeitos protetores do enalapril podem ser atribuídos, principalmente, à redução no ganho de MC e ingestão alimentar, aumento do GE, ativação do eixo ECA2/Ang(1-7)/receptor Mas e dos níveis de adiponectina, o que promove uma melhora na ação hepática da insulina e leptina, normalização da gliconeogênese, amenizando a NAFLD. / The associations between obesity, NAFLD (non-alcoholic fatty liver disease) and diabetes are well established, and the reninangiotensin system (RAS) may provide a link among them. . The blocking of the RAS at different levels may be related to responses on insulin resistance, remodeling of the pancreas and liver in a model of diet-induced obesity. Mice (C57BL/6) were fed on a high-fat (HF) diet for 8 weeks and then treated with aliskiren (50 mg/kg/day), enalapril (30 mg/kg/day) or losartan (10 mg/kg/day) for an additional 6 weeks. The drugs were incorporated into the diet. We assessed body mass (BM), blood pressure, energy intake and expenditure (EE), glucose and lipid metabolism, pancreatic and hepatic histopathology, hormonal analysis, immunohistochemistry, the expression profile of genes and/or proteins affecting pancreas RAS, hepatic gluconeogenesis, insulin signaling and lipid oxidation and accumulation. All RAS inhibitors significantly attenuated the increased blood pressure in mice fed a HF diet. Treatment with enalapril, but not aliskiren or losartan, significantly attenuated BM gain, increased EE, enhanced the glucose intolerance and insulin resistance; improved the alpha and beta cell mass; prevented the reduction of plasma adiponectin and restored leptin sensibility. Furthermore, enalapril treatment improved the protein expression of the pancreatic islet Pdx1, GLUT2, ACE2 and Mas receptors. Losartan treatment showed the greatest AT2R expression in the pancreas. In the liver, the enalapril administration improved hepatic steatosis, triglycerides and prevented the increase hepatic protein levels of PEPCK, G6Pase and GLUT2. Additionally, enalapril improved the deleterious effects on the HF diet by upregulating the signal transduction through the IRS-1/Akt pathway, as well as downregulatin the protein levels and mRNA expression of PPAR-gamma, SREBP-1c and FAS. Our findings indicate that ACE inhibition with enalapril attenuated several of the deleterious effects of the HF diet. In summary, enalapril appears to be responsible for the normalization of islet morphology and function, a protective role against hepatic insulin resistance and lipid accumulation in the liver. These protective effects of enalapril were attributed, primarily, to the reduction in body mass gain and food intake, increasing EE, the enhancement of the ACE2/Ang (1-7)/Mas receptor axis and adiponectin levels, enhancing hepatic insulin action, leptin and gluconeogenesis, and attenuating NAFLD.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / As associações entre obesidade, doença hepática gordurosa não alcoólica (NAFLD) e diabetes mellitus tipo 2 (DM2) são bem estabelecidas, e o sistema renina-angiotensina (SRA) pode proporcionar uma ligação entre eles. O bloqueio do SRA em diferentes níveis pode estar relacionado a respostas na resistência à insulina, remodelagem do pâncreas e do fígado em um modelo de obesidade induzida por dieta. Camundongos C57BL/6 foram alimentados com uma dieta hiperlipídica (HF) durante oito semanas e depois tratados com alisquireno (50 mg/kg/dia), enalapril (30 mg/kg/dia) ou losartana (10 mg/kg/dia) por um período adicional de seis semanas. As drogas foram incorporadas na dieta. Avaliou-se a massa corporal (MC), pressão arterial, consumo e gasto energético (GE), metabolismo da glicose e lipídico, histopatologia pancreática e hepática, análise hormonal, imunohistoquímica, perfil gênico e/ou proteico do SRA no pâncreas, gliconeogênese hepática, sinalização da insulina, oxidação e acúmulo lipídico. Todos os inibidores do SRA reduziram significativamente o aumento da pressão arterial nos camundongos alimentados com dieta HF. O tratamento com enalapril, mas não alisquireno ou losartana, reduziu o ganho de MC e a ingestão alimentar; aumentou o GE; amenizou a intolerância à glicose e resistência à insulina; melhorou a massa de células alfa e beta; impediu a redução da adiponectina plasmática e restaurou a sensibilidade à leptina. Além disso, o tratamento com enalapril melhorou a expressão proteica nas ilhotas pancreáticas de Pdx1, GLUT2, ECA2 e do receptor Mas. O tratamento com losartana apresentou uma elevação na expressão proteica de AT2R no pâncreas. No fígado, a administração de enalapril atenuou a esteatose hepática, o acúmulo de triglicerídeos e preveniu o aumento dos níveis de PEPCK, G6Pase e do GLUT2. Do mesmo modo, o enalapril melhorou a transdução dos sinais da insulina através da via IRS-1/Akt, bem como reduziu os níveis de expressão gênica e/ou proteica de PPAR-gama, SREBP-1c e FAS. Esses resultados sugerem que a inibição da ECA com enalapril atenuou muitos efeitos deletérios provocados pelo consumo da dieta HF, incluindo: normalização da morfologia e função das ilhotas pancreáticas, proteção contra a resistência à insulina e acúmulo de lipídios no fígado. Estes efeitos protetores do enalapril podem ser atribuídos, principalmente, à redução no ganho de MC e ingestão alimentar, aumento do GE, ativação do eixo ECA2/Ang(1-7)/receptor Mas e dos níveis de adiponectina, o que promove uma melhora na ação hepática da insulina e leptina, normalização da gliconeogênese, amenizando a NAFLD. / The associations between obesity, NAFLD (non-alcoholic fatty liver disease) and diabetes are well established, and the reninangiotensin system (RAS) may provide a link among them. . The blocking of the RAS at different levels may be related to responses on insulin resistance, remodeling of the pancreas and liver in a model of diet-induced obesity. Mice (C57BL/6) were fed on a high-fat (HF) diet for 8 weeks and then treated with aliskiren (50 mg/kg/day), enalapril (30 mg/kg/day) or losartan (10 mg/kg/day) for an additional 6 weeks. The drugs were incorporated into the diet. We assessed body mass (BM), blood pressure, energy intake and expenditure (EE), glucose and lipid metabolism, pancreatic and hepatic histopathology, hormonal analysis, immunohistochemistry, the expression profile of genes and/or proteins affecting pancreas RAS, hepatic gluconeogenesis, insulin signaling and lipid oxidation and accumulation. All RAS inhibitors significantly attenuated the increased blood pressure in mice fed a HF diet. Treatment with enalapril, but not aliskiren or losartan, significantly attenuated BM gain, increased EE, enhanced the glucose intolerance and insulin resistance; improved the alpha and beta cell mass; prevented the reduction of plasma adiponectin and restored leptin sensibility. Furthermore, enalapril treatment improved the protein expression of the pancreatic islet Pdx1, GLUT2, ACE2 and Mas receptors. Losartan treatment showed the greatest AT2R expression in the pancreas. In the liver, the enalapril administration improved hepatic steatosis, triglycerides and prevented the increase hepatic protein levels of PEPCK, G6Pase and GLUT2. Additionally, enalapril improved the deleterious effects on the HF diet by upregulating the signal transduction through the IRS-1/Akt pathway, as well as downregulatin the protein levels and mRNA expression of PPAR-gamma, SREBP-1c and FAS. Our findings indicate that ACE inhibition with enalapril attenuated several of the deleterious effects of the HF diet. In summary, enalapril appears to be responsible for the normalization of islet morphology and function, a protective role against hepatic insulin resistance and lipid accumulation in the liver. These protective effects of enalapril were attributed, primarily, to the reduction in body mass gain and food intake, increasing EE, the enhancement of the ACE2/Ang (1-7)/Mas receptor axis and adiponectin levels, enhancing hepatic insulin action, leptin and gluconeogenesis, and attenuating NAFLD.

An increasing prevalence of metabolic syndrome and obesity has been linked to the rise in transplant indication for cryptogenic cirrhosis and nonalcoholic fatty liver disease (NAFLD), creating a growing challenge to public health. NAFLD liver transplant (LT) candidates are listed with low priority, and their waiting mortality is high. The impact of community/geographic factors on donor risk models is unknown. The purpose of this study was to develop a parsimonious donor risk-adjusted model tailored to NAFLD recipients by assessing the impact of donor, recipient, transplant, and external factors on graft survival. The theoretical framework was the social ecological model. Secondary data were collected from 3,165 consecutive recipients from the Scientific Registry of Transplant Recipients and Community Health Scores, a proxy of community health disparities derived from the Robert Wood Johnson Foundation's community health rankings. Data were examined using univariate and multivariate analyses. The donor risk-adjusted model was developed using donor-only factors and supplemented with recipient and transplant factors, classifying donors as low, medium, and high risk. NAFLD residents in high-risk counties had increased likelihood of liver graft failure. Findings may be used to allocate high-risk donors to a subset of NAFLD with excellent outcomes, increasing the donor pool and decreasing mortality on the wait list.

Orientador: Antonio Carlos Caramori / Resumo: A obesidade representa um dos maiores problemas de saúde pública no mundo e cursa com inúmeras complicações e comorbidades. As medidas de mudanças no estilo de vida, embora sejam as terapias mais duradouras, não têm conseguido resolver muitos casos, principalmente em pacientes com obesidade mórbida, onde a cirurgia bariátrica passa a ser uma opção no tratamento capaz de impedir a progressão de comorbidades. A DHGNA, uma das complicações da obesidade, tornou-se também preocupante, pois tem alta prevalência, potencial de progressão para doença hepática grave e associação com diabetes mellitus tipo 2 (DM2), síndrome metabólica e doença cardíaca coronariana. O acompanhamento multiprofissional, principalmente nutricional, no pré e pós-operatório pode positivamente interferir sobre a ocorrência da DHGNA e suas complicações. O presente estudo avaliou a influência do acompanhamento com equipe multiprofissional sobre a evolução da DHGNA, com dados coletados dos prontuários de 76 pacientes do Ambulatório de Obesidade Mórbida do Hospital das Clínicas da Faculdade de Medicina de Botucatu (HCFMB). A DHGNA foi observada por ecografia e biópsia hepática (em graus variados) nos pacientes submetidos à cirurgia bariátrica, cuja intensidade e frequência tiveram melhora no pós-operatório. Qualitativamente os registros da equipe demonstraram um atendimento humanizado que busca estratégias de aconselhamento, auxiliando o paciente nas mudanças do estilo de vida, porém, a atuação da mesma no serviço... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Obesity represents one of the major public health issues in the world and has a wide range of complications and comorbidities. The measures of lifestyle changes, even though they are the most long-lasting therapies, have not been able to solve many cases, mainly in patients with morbid obesity, where bariatric surgery becomes an option in the treatment able to prevent the progression of comorbidities. NAFLD, one of the complications of obesity, has also become a concern, as it has a high prevalence, a potential for progression to severe liver disease and association with type 2 diabetes mellitus (DM2), metabolic syndrome, and coronary heart disease. The multi-professional, mainly nutritional monitoring, both in the pre-and postoperative periods can positively interfere with the occurrence of NAFLD and its complications. The present study evaluated the influence of follow-up with the multi-professional team on the evolution of NAFLD, with data collected from the medical reports of 76 patients from the Morbid Obesity Outpatient Clinic of the Hospital das Clínicas da Faculdade de Medicina de Botucatu (HCFMB). NAFLD was observed by echography and liver biopsy (to varying degrees) in patients undergoing bariatric surgery, whose intensity and frequency had improvement in the postoperative period. Qualitatively, the team records have shown a humanized service which seeks counseling strategies, assisting the patient in lifestyle changes. However, its performance in the studied servic... (Complete abstract click electronic access below) / Mestre