Sirtuin 6 Expression and Inflammatory Activity in Diabetic
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Diabetes Volume 64, April 2015 1395 Maria Luisa Balestrieri,1 Maria Rosaria Rizzo,2 Michelangela Barbieri,2 Pasquale Paolisso,2 Nunzia D’Onofrio,1 Alfonso Giovane,1 Mario Siniscalchi,3 Fabio Minicucci,3 Celestino Sardu,2 Davide D’Andrea,3 Ciro Mauro,3 Franca Ferraraccio,4 Luigi Servillo,1 Fabio Chirico,5 Pasquale Caiazzo,5 Giuseppe Paolisso,2 and Raffaele Marfella2 Sirtuin 6 Expression and Inflammatory Activity in Diabetic Atherosclerotic Plaques: Effects of Incretin Treatment Diabetes 2015;64:1395–1406 | DOI: 10.2337/db14-1149 The role of sirtuin 6 (SIRT6) in atherosclerotic pro- Cardiovascular disease represents the leading cause of gression of diabetic patients is unknown. We evaluated death in patients with type 2 diabetes (1). Diabetes leads SIRT6 expression and the effect of incretin-based to increased vulnerability for plaque disruption, and therapies in carotid plaques of asymptomatic diabetic mediates increased incidence and severity of clinical and nondiabetic patients. Plaques were obtained from fl events (2). In ammation, particularly in diabetes, plays COMPLICATIONS 52 type 2 diabetic and 30 nondiabetic patients undergo- a central role in the cascade of events that result in plaque ing carotid endarterectomy. Twenty-two diabetic patients erosion and fissuring (2). There is now increasing evi- were treated with drugs that work on the incretin system, dence that a number of transcription factors, including GLP-1 receptor agonists, and dipeptidyl peptidase-4 the Sir2 family of enzymes, namely sirtuins (SIRTs), reg- 6 inhibitors for 26 8 months before undergoing the end- ulate multiple genes whose products are putatively in- arterectomy. Compared with nondiabetic plaques, dia- volved in the regulation of inflammation and endothelial betic plaques had more inflammation and oxidative cell (EC) function (3). The Sir2 family consists of seven stress, along with a lesser SIRT6 expression and collagen enzymes (SIRT1 to SIRT7) that share a conserved core cat- content. Compared with non-GLP-1 therapy–treated alytic domain, but differ in their cellular localization and plaques, GLP-1 therapy–treated plaques presented greater tissue distribution (4). Among the SIRTs, SIRT6, a chromatin- SIRT6 expression and collagen content, and less in- associated deacetylase, is considered to have a leading flammation and oxidative stress, indicating a more stable plaque phenotype. These results were supported by in role in regulating genomic stability, cellular metabolism, – vitro observations on endothelial progenitor cells (EPCs) stress response, and aging (5 8). A recent study (9) in fl and endothelial cells (ECs). Indeed, both EPCs and ECs mice suggested a role for SIRT6 in in ammation. Moreover, treated with high glucose (25 mmol/L) in the presence of the knockdown of SIRT6 resulted in the increased expres- fl GLP-1 (100 nmol/L liraglutide) presented a greater SIRT6 sion of proin ammatory cytokines (interleukin [IL]-1b, and lower nuclear factor-kBexpressioncomparedwith IL-6, and IL-8), extracellular matrix remodeling enzymes cells treated only with high glucose. These findings es- (matrix metalloproteinase [MMP]-2, MMP-9, and plasmin- tablish the involvement of SIRT6 in the inflammatory ogen activator inhibitor 1), and intracellular adhesion pathways of diabetic atherosclerotic lesions and sug- molecule-1 (4). In ECs, the loss of SIRT6 was associated gest its possible positive modulation by incretin, the with an increased expression of nuclear factor-kB(NF-kB), effect of which is associated with morphological and whereas overexpression of SIRT6 was associated with de- compositional characteristics of a potential stable pla- creased NF-kB transcriptional activity (4), indicating that que phenotype. SIRT6 may be associated with the upregulation of genes 1Department of Biochemistry, Biophysics and General Pathology, Second Univer- Corresponding author: Raffaele Marfella, [email protected]. sity of Naples, Naples, Italy Received 25 July 2014 and accepted 2 October 2014. 2Department of Medical, Surgical, Neurological, Aging and Metabolic Sciences, This article contains Supplementary Data online at http://diabetes Second University of Naples, Naples, Italy .diabetesjournals.org/lookup/suppl/doi:10.2337/db14-1149/-/DC1. 3Department of Cardiology, Cardarelli Hospital, Naples, Italy 4Department of Clinical, Public and Preventive Medicine, Second University of © 2015 by the American Diabetes Association. Readers may use this article as Naples, Naples, Italy long as the work is properly cited, the use is educational and not for profit, and 5Department of Neurosurgery, Cardarelli Hospital, Naples, Italy the work is not altered. 1396 Atherosclerosis in Patients With Diabetes and Sirtuin 6 Diabetes Volume 64, April 2015 involved in inflammation, vascular remodeling, and an- peptidase-4 (DPP-4) inhibitors, were classified as “never giogenesis. However, the role of SIRT6 in human athero- incretin users.” The patients with diabetes who had al- sclerotic plaques has not yet been described. Although ready used GLP-1 agonists or DPP-4 inhibitors were clas- it has been demonstrated that diabetes may be impli- sified as “current incretin users.” Among the 52 diabetic cated in the regulation of SIRT6 expression in diabetes- patients enrolled in the study, 24 were current incretin induced neurodegeneration (10), still no evidence exists users, and 28 were never incretin users. The current about the potential role of SIRT6 in the evolution of incretin users were patients who had been treated with atherosclerotic plaques in diabetic patients. We hypothe- incretin for at least 6 months. Patients treated with sized that, by acting on SIRT6, diabetes may enhance the incretin for a period of ,6monthswereexcludedfrom inflammatory potential of atherosclerotic plaques, favoring the study. Information on the duration of treatment was their instability. Thus, this study was designed to identify available for all current users. The mean (6SD) duration differences in SIRT6 expression, as well as in inflamma- of incretin treatment was 26 6 8 months. No patients tory infiltration, between carotid plaques of asymptom- had clinical or laboratory evidence of heart failure, pre- atic diabetic and nondiabetic patients. Experimental vious stroke, valvular defects, malignant neoplasms, or studies suggest that in obese mice, GLP-1–based therapies secondary causes of hypertension. Carotid sonography may reduce inflammation (11–13) and enhance the pro- was performed on a single ultrasound machine (Aloka tein expression of SIRT1 (14). Moreover, human studies 5500). The study was approved by the local ethics com- showed that sitagliptin (15) and exenatide (16), even at mittee, and informed written consent was obtained for a single dose, exert a potent anti-inflammatory effect, and each patient. that many of these effects were persistent over a period of 12 weeks, thus suggesting that the anti-inflammatory Laboratory Analysis effects of GLP-1–based therapies could help to reduce After an overnight fast, plasma glucose, HbA1c, and serum atherogenesis. lipid levels were measured by enzymatic assays in the Here, we evaluated the effect of incretin therapy in hospital chemistry laboratory. GLP-1 levels (Active GLP-1 fi diabetic patients on SIRT6 expression in carotid plaques [7-36] Speci c ELISA Kit; Epitope Diagnostics) were mea- and early outgrown circulating endothelial progenitor sured after an overnight fast (at 8:00 A.M.) and after cells (EPCs). Furthermore, a set of in vitro experiments breakfast. A standardized breakfast contained 419 kcal in ECs and EPCs was designed to evaluate the effect (57% carbohydrate, 17% protein, and 26% fat). After of incretin on SIRT6 and NF-kB during high-glucose breakfast, blood samples for the measurement of GLP-1 treatment. were obtained every 30 min over a 2-h period. The mean of the four GLP-1 evaluations was defined as the post- RESEARCH DESIGN AND METHODS prandial GLP-1 value. The standardized meal tolerance Patients were recruited from the outpatient Department test and baseline evaluations were performed 7 days be- of Cardiology and Cardiovascular Surgery of the Cardarelli fore surgery. Thereafter, the patients were asked to self- Hospital, Naples, Italy, from January 2009 to June 2013. monitor their blood glucose level (fasting, postbreakfast, From among these patients, we selected 52 type 2 diabetic postmeal, and postdinner glucose levels) until the day and 30 nondiabetic patients (nondiabetic group) with of surgery. Levels of fasting blood glucose were eval- asymptomatic carotid stenosis (according to North Amer- uated before surgery. Fasting and postprandial plasma ican Symptomatic Carotid Endarterectomy Trial classifi- glucose data were obtained from the average of each cation), enlisted to undergo carotid endarterectomy for assessment. extracranial high-grade ( 70%) internal carotid artery Atherectomy Specimens stenosis (17). Asymptomatic patients underwent a base- After surgery, the specimens were cut perpendicular to line clinical examination, gave a medical history, and had the long axis into two halves. The first half was frozen in never developed neurologic symptoms or cerebral lesions liquid nitrogen for the following ELISA analysis. A assessed by computed tomography. All patients under- portion of the other half of the specimen was immedi- went computed tomography scanning or MRI. Diabetes ately immersion fixedin10%bufferedformalin.Sections was categorized according to the criteria of the American were serially cut at 5 mm, mounted on lysine-coated