\r\n\tThis cell has evolved an effective defense system to counteract the challenges as it is always in an oxygen-rich environment. The evolution of hemoglobin and deformability of erythrocyte membrane adapting to its function in circulation is especially striking. Erythrocyte aging and eryptosis strike a balance - the mixed population of cells and constant recycling every 120 days is a very distinct feature. Its metabolic shunt pathways and metabolites/enzymes alter and adapt with age and changes in the microenvironment.
\r\n
\r\n\tErythrocyte and its cytoskeleton responses to various situations such as infections, hypoxia, hypothermia, intrigues researchers and biologists alike. This book aims to throw light on the significance of erythrocyte and its characteristic nature and survival in different physiological situations as it plays a very crucial role.
\r\n
\r\n\tThis book hopes to bring different perspectives from various aspects and provide insights into the effective mechanisms evolved by erythrocytes, to counteract the challenges faced in its oxidation environment and the further research approaches.
",isbn:"978-1-80356-732-7",printIsbn:"978-1-80356-731-0",pdfIsbn:"978-1-80356-733-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"1b6073b9ff3f8f63004943bd263cd04e",bookSignature:"Dr. Vani Rajashekaraiah",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11725.jpg",keywords:"Erythrocyte, Hemoglobin, Erythrocyte Aging, Pathways, Metabolites, Deficiencies, Membrane Changes, Band 3, Deformability, Hemolysis, Disease Conditions, Free Radical Initiators",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 24th 2022",dateEndSecondStepPublish:"May 26th 2022",dateEndThirdStepPublish:"July 25th 2022",dateEndFourthStepPublish:"October 13th 2022",dateEndFifthStepPublish:"December 12th 2022",remainingDaysToSecondStep:"8 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Vani Rajashekaraiah, Associate Professor, JAIN (Deemed-to-be University), Bangalore has 20 years of research experience in Oxidative Stress Physiology and Hematology and 16 years of teaching experience. 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(Courses: Molecular Genetics, Molecular Biology and Genetic Engineering). \n Research Experience: 20 years in the field of Oxidative Stress Physiology and hematology.\n Current Research focus: Blood Storage (erythrocytes, platelets) and Drug-induced Thrombocytopenia\n Total publications in SCOPUS / Web of Science: 27 and International book chapters: 04.\n Research guidance: 3 PhD students (completed); 3 PhD students guiding currently.\n \t \n Six years of research experience as JRF (CSIR) and SRF (CSIR) in the field of High Altitude Physiology and Biochemistry, specialization in Oxidative Stress Physiology, from August 2002 to 2008. \no\tPursued research under the guidance of Dr. S. Asha Devi, Professor, Dept. of \n Zoology, Bangalore University, Bangalore-560056, towards Ph.D in Zoology.\n Title of the thesis- “Studies on Oxidative Stress in Erythrocytes of Rats Exposed to \n Intermittent Hypobaric Hypoxia”.",institutionString:"Jain University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Jain University",institutionURL:null,country:{name:"India"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"185543",firstName:"Maja",lastName:"Bozicevic",middleName:null,title:"Dr.",imageUrl:"https://mts.intechopen.com/storage/users/185543/images/4748_n.jpeg",email:"maja.b@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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1. Introduction
Lupus nephritis (LN) is the most common severe organ manifestation of systemic lupus erythematosus (SLE). It may be the presenting manifestation of SLE and usually arises within 5 years of diagnosis [1]. Approximately 40–70% of SLE patients will develop LN [2] with histopathological changes observed in most patients even among those without renal manifestations (known as “silent LN”; mostly with “milder” class I and II histologic lesions) [3, 4]. Clinical presentation of LN is highly variable, ranging from asymptomatic proteinuria with normal renal function to rapidly progressive renal failure.
Recent data demonstrates reduction in the temporal mortality trend among end stage renal disease (ESRD) LN patients [5]; however, the risk of progression to ESRD in LN remains unchanged [5, 6]. Despite significant improvement of outcome in this modern era, less than 50% of patients achieve complete clinical remission following immune suppression [7] with 10–20% of patients progressing to ESRD [8]. This chapter explores recent studies that have substantially contributed to our understanding of LN and provides new insights into the epidemiology, pathogenesis, classification criteria and management strategies of LN.
2. Epidemiology
The prevalence of SLE and LN varies based on age, gender, geographical location, socioeconomic status and ethnicity. There are also disproportionate differences in the incidence and prevalence, depending upon the validated classification criteria or methods of case ascertainment used.
2.1 Systemic lupus erythematosus (SLE)
In a large retrospective study performed in the United Kingdom (UK) involving more than 7,000 SLE cases between 1999 and 2012, the overall annual incidence of SLE was 4.9 cases per 100,000 population per year with overall prevalence of 97 per 100,000 population; highest in Afro-Caribbean ethnic subgroup (517 per 100,000), followed by the Indian subgroup (193 per 100,000) while Caucasian subgroup was 134 per 100,000 [9]. Other studies found similar estimates with annual incidence between 4 and 8 cases per 100,000 population per year. Expectedly, the worldwide prevalence of SLE also varies between 30 to 90 cases per 100,000 population, highest in the African populations, lowest in Caucasians, with Hispanic and Asian subgroups in between the two extremes [10, 11].
All studies worldwide have demonstrated marked predominance of women in SLE, between 6 and 9 times higher than men. In the United States (US) and UK, the peak incidence was in women aged between 40 and 59 [10, 12]; in contrast, a population based study in Taiwan involving almost 7000 SLE patients revealed earlier peak incidence in women aged between 20 and 29 [13], a consistent trend among other studies in the Asia-Pacific region [14].
2.2 Lupus nephritis (LN)
Renal involvement occurs in 25–50% of SLE patients at the time of diagnosis [15]. The cumulative incidence, again, varies according to ethnicities. In a US study involving three ethnic subgroups, the incidence of LN was found to be the highest among the African subgroup (69%) followed by Hispanics (61%) and Caucasians (29%) [16]. In the Asia-Pacific region, the cumulative incidence of LN varies between 30% and 82%, lowest in Australian and highest in Malaysian populations respectively [14].
Despite higher overall incidence of SLE in women than in men, strikingly, renal involvement was found to be 50% higher in SLE men in a meta-analysis involving nearly 12,000 SLE patients across multiple countries [17]. Left untreated, LN carries significant morbidity and mortality, with the mortality rate estimated to be 6 times higher than general population. However, with the current therapeutic options, the 10-year survival for patients with LN can exceed 98% [18].
3. Pathogenesis
The pathogenesis of LN is complex and achieving full understanding of its pathophysiologic mechanisms has proved challenging due to the molecular and phenotypic heterogeneity. Genetic predisposition, epigenetic dysregulation and environmental triggers are all likely to contribute to the disease expression [1, 19, 20]. Dysregulation of both innate and adaptive immune responses manifested by disturbance in apoptotic cell clearance, cytokines stimulation, B-cell immunity and T-cell function leads to glomerular and/or tubulointerstitial injury.
Production of autoantibodies targeting self-DNA, other self-nuclear antigens and non-nuclear materials results from loss of immune self-tolerance and autoimmunity in genetically predisposed individuals. Formation of immune complexes (ICs) may occur in circulation and deposits in various organ systems including the kidneys. Antibodies can also directly target in situ nephritogenic antigens at the major resident renal cells (mesangial cells, glomerular endothelial cells, tubular epithelial cells and podocytes) [21]. Co-stimulation by Fc receptors (FcRs) and endosomal Toll-like receptors (TLRs) leads to activation of the complement system and subsequent release of cytokines and chemokines leading to renal tissue injury [22, 23, 24, 25]. Anti-C1q antibodies, while not exclusive to LN, are strongly associated with renal inflammation and severe LN, amplifying complement activation in situ [26, 27].
Overactivation of 1) Interferon (IFN)-I signalling pathway, which is regulated by dendritic cells (DCs), interleukins (eg. IL 12/23), JAK1, TYK2 and various STAT proteins and 2) NFκB are both implicated early in the innate immune response and play major roles in the pathogenesis [28, 29]. Adaptive responses including persistent activation and interaction of aberrant polyclonal B and T cells involving multiple co-stimulatory molecules promote chronic inflammation and renal tissue damage. Studies have also uncovered that formation of long-lived memory T-cells and plasma cells that reside in survival niches in bone marrow and inflamed tissue render them resistant to conventional immunosuppression or B cell therapies [30].
B cell activation factor (BAFF)/B-lymphocyte stimulator (BLyS) promotes formation of tertiary lymphoid structures (TLSs) that contribute to lymphocyte priming and autoantibody production within the kidneys [31] while evidence in patients and animal models have demonstrated high levels of IL-17 producing T cells in LN [32]. Several other regulators of apoptosis have also been implicated in the development of LN including dysregulation of autophagy, BCL-2, phosphatase and tensin homologue (PTEN), mannose-binding lectin (MBL) and neutrophil extracellular traps (NETs) among several others [33, 34, 35, 36, 37, 38, 39, 40].
More than 10 genome-wide association studies (GWAS) have been conducted thus far with more than 50 genes implicated involving various pathogenic mechanisms in the pathogenesis of SLE, some associated with LN [2, 41]. These candidate genes are likely to undergo further evaluation and validation from deep sequencing and mechanistic studies. Mohan et al. have elegantly categorised the implicated genes into four functional groups; genes that influence 1) lymphocyte activation, particularly B cells (eg. BLK, STAT4, TNFSF4, HLA-DR) 2) innate immune signalling (notably NFκB and IFN-I; eg. IKZF1, IRF5, TLR9, TNFAIP3) 3) intra-renal signalling (eg. ACE, KLK) and 4) handling of apoptotic material, chromatin and ICs (eg. ATG5, ITGAM, FCGR2A/3A/3B); genetic interaction from multiple categories is required for severe LN to develop [2].
The TLR7 gene, which is located at chromosome X, has recently been the focus of considerable research in SLE and LN. Theories regarding the contribution of TLR7 gene have included 1) Enhanced TLR7 protein expression in renal DCs and macrophages which correlated with renal disease parameters in murine models [42] 2) Emerging evidence that TLR7 dosage is a key pathogenic factor to the pathogenesis of SLE: Dillon et al. assembled the largest group consisting of 316 men with SLE and found high prevalence of SLE in X chromosome aneuploides such as Klinefelter’s syndrome (KS; 47, XXY) and de la Chapelle’s syndrome (46, XX male) [43] while recently, Souyris and colleagues provided proof that TLR7gene evades X chromosome inactivation in immune cells in women and KS men, and proposed this as a mechanism for the elevated risk of SLE in women and KS [44], which may partially explain the high preponderance of SLE in females.
4. Diagnosis and classification
Current non-invasive SLE biomarkers such as proteinuria or active urine sediment, serum creatinine, anti dsDNA and hypocomplementemia could not reliably confirm the presence, severity and/or chronicity, or predict the outcome of LN. Many novel biomarkers are currently being explored in the management and as therapeutic target in LN; unfortunately, none so far had been utilised in daily clinical practice [45].
In patients suspected of LN, certain clinical and laboratory features may however predict the class of LN a patient may have. In a retrospective study analysing 297 renal biopsies of SLE patients with some degree of proteinuria, absence of malar rash, negative anti-dsDNA and urine leukocytes of <5/high power field under microscopy are independent predictors for class II LN. Class III or IV can independently be predicted by younger age at diagnosis (<32 years), musculoskeletal involvement, hypertension, presence of anti-dsDNA, elevated creatinine level, absence of nephrotic range proteinuria and presence of leucocytes and cellular cast in urine. Older age, malar rash and low C3 level may be predictive for class V LN [46].
4.1 Role of renal biopsy
Renal biopsy is the gold standard for the diagnosis and current classification of LN. The histological findings may assist physicians to optimise therapeutic strategies in individual patients, including assessing disease activity and/or chronicity for guidance to escalate or de-escalate immunosuppression accordingly. It is an invasive procedure with potential risks, most notably bleeding; however, given the lack of available biomarkers to identify disease activity, it remains an irreplaceable tool and mainstay of current management in LN.
Indication for a renal biopsy includes significant proteinuria of >0.5 g/day (or equivalent), certain unclear acute elevation of serum creatinine level, and in patients with severe disease relapse (Table 1) [47]. Biopsy is rarely done in patients with isolated haematuria or proteinuria of <0.5 g/day; hence, class I LN is rarely seen in the histology. Performed by either experienced nephrologist or interventional radiologist, adequate tissue is obtained in >95% of times.
Should biopsy
May biopsy
Proteinuria >0.5 g/24 hours Unexplained renal insufficiency Differentiating activity vs. chronicity Severe relapse
Isolated haematuria or pyuria Proteinuria less than 0.5 g/24 hours ‘Protocol’ biopsy during/after treatment Mild relapse
Table 1.
Possible indications for kidney biopsy in SLE patient.
Given the location of kidney where no direct compression can be performed post biopsy, bleeding (as detected by routine CT scan or ultrasound post biopsy) was found to be common, ranging in 57–91% of patients [48]; however, the actual incidence of clinically important bleeding is small. Meta-analysis of 34 relevant studies found low rates of macroscopic haematuria (3.5%) and blood transfusion (0.9%), with lower rates yielded in need for interventions (0.6%) such as catheter insertion for bladder obstruction (0.3%) and nephrectomy (0.01%) and death (0.02%) [49].
The bleeding risk increases in females, use of larger needle (14-G), elevated serum creatinine (>176 umol/L) or acute renal failure, uncontrolled systolic blood pressure (>170 mmHg) [49, 50] and in patients with coagulopathies or are on anticoagulation/antiplatelet agents. Most serious complications are detected within 4 hours of biopsy, and majority within 12 hours [51, 52]. Routine 1-hour post biopsy ultrasound for presence of haematoma to predict complication has not been shown to be clinically beneficial (positive predictive value of 43%; negative predictive value of 95%) [53].
The role of repeat renal biopsy in LN flares is controversial. In essence, a repeat biopsy is required if it may change management; for example, this is particularly true in a patient with stable renal function who developed sudden deterioration of creatinine associated with active urine sediment. This may reflect the possibility of crescentic glomerulonephritis (GN) that warrants stronger immunosuppression. During LN flare, histological transformation is more likely to occur if the initial histology revealed non-proliferative disease (initial class II); although, many would still have persistent active lesions in proliferative disease [54, 55].
Renal biopsy may also be considered to determine disease chronicity in patients with persistent proteinuria and lower glomerular filtration rate (GFR), which warrant de-escalation of immunosuppression. It is well documented that repeat biopsies lead to change to immunosuppression in more than half of the cases [55].
Decision to stop maintenance immunosuppression in LN is often challenging and some researchers perform ‘protocol biopsies’ after a period of complete clinical remission to guide withdrawal of treatment. Its’ value however is still debatable, as studies mostly looked at the prognosis based on the histological features [54]. In a study by De Rosa et al., 36 LN patients on immunosuppressive therapy for more than 3 years and in clinical remission (proteinuria <0.5 g/day) were re-biopsied. Regardless of the results of biopsy, the immunosuppressive medications were tapered down. Those patients with residual activity in histology had higher chance of relapses upon reducing therapy [56], which supports histology-based approach in treatment withdrawal.
4.2 Classification criteria
4.2.1 SLE and renal involvement
The revised American College of Rheumatology (ACR) 1997 criteria specifies that a patient can be diagnosed with SLE if 4 of 11 criteria are met at any interval of observation (Table 2). Renal involvement can be considered if patient developed proteinuria of >0.5/day or appearance of cellular cast (red cells, haemoglobin, granular, tubular or mixed) [57]. The 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria divided SLE features into 11 clinical and 6 immunologic criteria, where SLE can be fulfilled by a) biopsy-proven LN in presence of ANA or anti-DNA antibodies or b) meeting ≥4 of 17 criteria, with at least 1 criterion from each division [58].
ACR 1997
SLICC 2012
ACR 2019
4 out of 11 criteria
4 out of 17 criteria, with at least 1 from each domain
Fulfil the entry criterion, followed by 10 points in additive criteria
Clinical Domain Acute cutaneous lupus Chronic cutaneous lupus Oral ulcer Synovitis Non-scarring alopecia Serositis Renal Neurologic Haemolytic anaemia Leukopenia or lymphopenia Thrombocytopenia Immunologic Domain ANA Anti dsDNA Anti-Sm Antiphospholipid antibody Low complement Direct Coomb’s test
Entry criterion ANA positive Additive criteria Clinical domain Constitutional Fever (2) Haematologic Leukopenia (3) Thrombocytopenia (4) Autoimmune haemolysis (4) Neuropsychiatric Delirium (2) Psychosis (3) Seizure (5) Mucocutaneous Non-scarring alopecia (2) Oral ulcers (2) Subcutanoues OR discoid lupus (4) Acute cutaneous lupus (6) Serosal Pleural/Pericardial effusion (5) Acute pericarditis (6) Musculoskeletal Joint involvement (6) Renal Proteinuria > 0.5 g/24 h (4) Renal biopsy class II or V (8) Renal biopsy class III or IV (10) Immunology domain Antiphospholipid antibodies Anti-cardiolipin OR anti-B2GP1 antibodies OR lupus anticoagulant (2) Complement proteins Low C3 OR low C4 (3) Low C3 AND low C4 (4) SLE-specific antibodies Anti-dsDNA antibody OR anti-Smith antibody (6)
Table 2.
Criteria for SLE diagnosis based on different criteria.
European League Against Rheumatism (EULAR)/ACR published a new set of criteria for SLE diagnosis in 2019 [58]. It employs the strategy that ANA must be positive for the diagnosis to be considered, followed by 10 domains with different individual weightage; diagnosis can be made if total score reaches 10 points, again with renal involvement carrying a high weight between 4 and 10 depending on the renal manifestations (Table 2) [59].
4.3 Diagnosis of lupus nephritis
The clinical presentations of LN may differ ranging from asymptomatic haematuria to rapidly progressive GN. All patients with SLE should have urinalysis checked on regular basis to detect renal involvement. Presence of significant proteinuria would trigger the need for a renal biopsy, although many would perform biopsies for reasons such as persistent haematuria and elevated serum creatinine [54]. Biopsy is critical to distinguish between active nephritis, non-glomerular pathology of SLE (such as tubulointerstitial nephritis or thrombotic microangiopathy) and disease chronicity (such as interstitial fibrosis, tubular atrophy and glomerulosclerosis). Importantly, biopsy findings should be interpreted and correlated carefully with patients’ clinical features and serology.
In an analysis by Ishizaki et al. of 48 SLE patients who had renal biopsies but no urine abnormality, 36 patients were identified to have some morphologic changes. Although majority had class I/II (72%), six (17%) patients were found to have class III/IV LN [60]. LN has characteristic histological features that differ from other glomerular pathology and may involve lesions in the glomerular, vascular or tubulointerstitial structures. Analysis of 860 renal biopsies by Kudose S et al. confirmed 5 histopathological features of LN; 1) “full-house” staining by immunofluorescence (IF) 2) intense C1q staining 3) extraglomerular deposits 4) combined subendothelial and subepithelial deposits and 5) endothelial tubuloreticular inclusion [61].
The first published classification of glomerular changes in LN was formulated in 1974 under the auspices of the World Health Organisation (WHO; Table 3). It divides glomerular changes into five classes, which became the basis of today’s classification. Class I applies to biopsies with no detectable changes in glomeruli; class II for pure mesangial disease, class III and IV were defined as proliferative disease, with the former affecting <50% of glomeruli and latter >50%. Class V was for membranous changes. This was modified in 1982, which include replacement of “focal proliferative” term to “focal segmental” GN and addition of a new category, class VI, which denoted advanced sclerosing GN (Table 3) [62].
WHO 1974
ISN/RPS 2003
ISN/RPS 2018
Class I Normal glomeruli
Class I Minimal mesangial lupus nephritis
Class I Minimal mesangial lupus nephritis d
Class II Pure mesangial alteration
Class II Mesangial proliferative lupus nephritis
Class II Mesangial proliferative lupus nephritis d
Class III Focal proliferative glomerulonephritis
Class III Focal lupus nephritis a, b
Class III Focal lupus nephritis d
Class IV Diffuse proliferative glomerulonephritis
Class IV Diffuse segmental (IV-S) or global (IV-G) lupus nephritis a, b
Class IV Diffuse lupus nephritis d
Class V Membranous glomerulonephritis
Class V Membranous lupus nephritis c
Class V Membranous lupus nephritis c, d
Class VI Advanced sclerosing lupus nephritis
Class VI Advanced sclerosing lupus nephritis d
Table 3.
Lupus nephritis classification.
WHO: World Health Organisation; ISN/RPS: International Society of Nephrology/Renal Pathology Society; a: indicate the proportion of glomeruli with active and sclerotic lesions; b: indicate the proportion of glomeruli with fibrinoid necrosis and cellular crescents; c: may occur in combination with class III or IV; d: activity and chronicity indices (total scores of 24 for activity, 12 for chronicity).
Due to inconsistencies and ambiguities of the available classification criteria, under the auspices of International Society of Nephrology/Renal Pathology Society (ISN/RPS), a new classification of LN was proposed in 2003 [63]. While keeping the overall architecture of the 6 classes in LN, several significant changes were made and emphasis was given to standardisation of biopsy reports. Definition of class I was changed to normal glomeruli under light microscopy but with mesangial deposits under IF. There was also subdivision of class IV into diffuse segmental (IV-S) or diffuse global (IV-G), while terms active (A), chronic (C) or acute-on-chronic (A/C) lesions were also introduced.
The ISN/RPS classification for LN was revised in 2018; among the changes include elimination of the subdivisions of class IV into segmental (IV-S) or global (IV-G), replacement of previous denomination of active (A) and chronic (C) to the actual activity indices (maximum score for activity index is 24 and chronicity index is 12; Table 4), and preference for the term “hypercellularity” rather than “proliferation” [64]. The lack of classification for tubulointerstitial and vascular involvement in LN will be addressed and revised after the next (phase 2) international nephropathology working group evaluation and recommendations [64].
Items
Score
Comment
Activity Index
Endocapillary hypercellularity
0 to 3+
0 to 3+ based on % involvement of glomeruli or tubulointerstitium. 0 = none, 1+ = <25%, 2+ = 25–50%, 3+ = > 50%.
Neutrophils/karyorrhexis
0 to 3+
Fribrinoid necrosis
0 to 3+ (x2)
Hyaline deposits
0 to 3+
Cellular/fibrocellular crescents
0 to 3+ (x2)
Double weightage for fibrinoid necrosis and cellular/fibrocellular crescent.
Interstitial inflammation
0 to 3+
TOTAL
24
Chronicity Index
Total glomerulosclerosis score
0 to 3+
0 to 3+ based on % involvement of glomeruli or tubulointerstitium. 0 = none, 1+ = <25%, 2+ = 25–50%, 3+ = > 50%.
Fibrous crescent
0 to 3+
Tubular atrophy
0 to 3+
Interstitial fibrosis
0 to 3+
TOTAL
12
Table 4.
Modified NIH activity and chronicity scoring system (ISN/RPS 2018).
5. Management
5.1 Current management strategies
Early treatment in LN has been shown to improve outcome; however, effective management remains a challenge. It requires a multidisciplinary team approach (MDT), ideally by rheumatologists, nephrologists and nephropathologists. The cornerstone of treatment entails corticosteroids, antimalarial, and steroid-sparing agents (conventional immunomodulators and/or biological therapies) tailored to individual patients based upon histological class and severity to achieve rapid resolution of inflammation, proteinuria <0.5–0.7 g/day by 12 months (or up to 24 months in baseline nephrotic range proteinuria) [47] and prevention of relapsing episodes.
5.1.1 Induction phase
While there is little agreement for class II LN, in active proliferative class III, IV and pure membranous class V (with nephrotic range proteinuria or proteinuria >1 g/day despite optimal use of renin-angiotensin-aldosterone system (RAAS) blockers), the current recommendation for initial induction treatment options include either low-dose intravenous cyclophosphamide (CYCi; 500 mg fortnightly infusions for 3 months) or mycophenolate mofetil (MMF; 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) [47, 65, 66, 67, 68]. This is combined with high-dose pulsed intravenous methylprednisolone followed by oral corticosteroid taper. High-dose CYCi is reserved for patients with severe LN due to its’ various unfavourable side effects (mainly severe cytopenias and infection, cystitis, ovarian failure, cervical dysplasia and malignancy).
The use of calcineurin inhibitors (CNIs) namely tacrolimus (TAC) and cyclosporin (Cys) either as monotherapy or as part of a multitarget regimen therapy (with MMF/MPA and glucocorticoid) may have a favourable efficacy to induce remission. Meta-analysis in 2017 which included 45 induction trials of diverse participant background confirmed superior efficacy in induction by multitarget therapy compared to CYCi [69]; however, safety concern with its long term use mainly of chronic progressive irreversible nephrotoxicity remains an issue [70].
5.1.2 Maintenance phase
In the maintenance phase of treatment where less intensive therapy is required, MMF (1-2 g/day or MPA at equivalent dose) or azathioprine (AZA) are the drugs of choice [47, 71, 72] (with or without low dose <7.5 mg/day corticosteroid), depending on the induction regimen and plan for pregnancy. Hydroxychloroquine (HCQ) is recommended for all LN patients in the absence of contraindications [47]. Due to possible ocular toxicity, the dose should not exceed 5 mg/kg body weight and should be adjusted in patients with renal and liver disease, with regular ophthalmological screening.
5.1.3 Refractory lupus nephritis
Rituximab (RTX), although off-label, is not only indicated in patients refractory to conventional therapy or after great cumulative dose of CYCi, but also in patients of child bearing age [47, 73, 74]. Another B-cell targeting therapy which inhibits BlyS, Belimumab has recently been proven to be beneficial as add-on to the standard of care (SOC) therapy (mainly in the MMF subgroup) with primary efficacy renal response seen by week 24 and sustained through week 104 [75].
It is recommended not to discontinue immunosuppression too early as most renal flares occurs during this period. Treatment withrawal can be considered in patients with sustained complete remission for 3–5 years, with treatment deescalation prior to complete withrawal of therapy [47]. Close monitoring of patients and management of co-morbidities including blood pressure (BP) control, treatment of hyperlipidaemia with statins and proteinuria with RAAS blockers are important, while vaccination against influenza and Streptococcus pneumoniae are strongly recommended. Repeat renal biopsy may be considered to guide the duration of maintenance immunotherapy and may be required in patients with incomplete response or recurrent LN flares [47, 65].
5.2 Future novel therapeutic options
Developing more effective treatment strategies in LN remains a priority among clinicians and researchers across the globe; however, major challenges exist in its advancement due to the complex pathophysiology and heterogeneity, which directly impact on clinical trial design and overall outcome. Moreover, most trials are conducted with background therapy, which is difficult to control during the study and its subsequent analysis, as there is no clear definition in the SOC [76]. Notwithstanding this, extensive therapeutic strategies have emerged with wide array of novel treatments to improve patient outcomes. Major trend in current treatment landscape for LN focuses on reduction of steroid use.
There is gathering evidence, especially in more recent times, documenting the successful safe use of Belimumab, a monoclonal antibody (mAb) directed against BlyS as an add-on therapy in LN, especially in patients with low complement levels and high anti-DNA antibodies [75, 77]. It is the first targeted therapy and currently the only biological agent approved specifically for LN. There is also increasing interest in the sequential use of two B-cell targeting agents, RTX and Belimumab in active LN [78, 79] with a phase III trial already underway [80]. The rationale for this approach is due to the hypothesis that their co-administration may enhance depletion of circulating and tissue-resident autoreactive B cells.
Another potent BAFF-inhibitor, Blisibimod, was associated with reduction in steroid use, decreased proteinuria and biomarker responses in a multinational phase III trial [81]. Tabalumab, a selective mAb that neutralises both membrane and soluble BAFF, despite having the same therapeutic class, on the contrary did not yield the expected positive statistical significance results in two phase III studies involving SLE patients; however, only approximately 10% of patients in these studies had renal involvement [82, 83].
Voclosporin, a novel next generation CNIs (an analogue of cyclosporin) with enhanced calcineurin inhibition, better safety profile and consistent predictable dose response, despite initial safety concerns in the prior phase II study [84], has recently been demonstrated in a phase III trial to be highly effective for treatment of LN when combined with MMF, with acceptable safety profile, at least for the short term (52 weeks) [85]. More importantly, it has just received the approval by the United States’ Food and Drug Administration (FDA) on the 22nd of January 2021, making it the only second targeted therapy approved specifically for LN [86].
There is emerging theoretical evidence for targeting autoantibody-secreting long-lived plasma cells (PCs) that recide in dedicated survival niches in the bone marrow or inflammed tissues of LN patients. Bortezomib, a proteasome inhibitor has been shown to be effective in both animal models and real-world setting but is limited by treatment related toxicity [87, 88, 89]. Recently, Ostendorf and colleagues have demosntrated succesful use of Daratumumab, a mAb that targets CD38 and depletes PCs with acceptable safety profile in a patient with refractory LN [90]. The experience of its use however is still limited and more data will be required.
Obinutuzumab, a novel anti-CD20 mAb demonstrated encouraging sustained 18-months B-cell depletion and renal response in a phase II trial with further evaluation in phase III trial underway (can be accessed at ClinicalTrials.gov with identification number: NCT04221477) [91]. BI 655064 (anti CD40 mAb; NCT02770170) has recently completed a phase II trial as add-on therapy to SOC treatment in active LN and awaiting evaluation. Other biological agents currently undergoing clinical trials in the treatment of LN include Anifrolumab (Type I IFN receptor mAb; NCT02547922) in phase II, while Dapirolizumab (pegylated anti CD40 ligand; NCT04294667) and Secukinumab (anti-IL-17 mAb; NCT04181762) are both in phase III trials [92].
A pipeline of novel agents in LN are being developed or asssesed in clinical trials including Ravulizumab (novel anti complement C5 antibody; NCT04564339), Guselkumab (IL-23 inhibitor; NCT04376827), Itolizumab, (anti CD6 antibody; NCT04128579), KZR-616 (proteasome inhibitor; NCT03393013), Iguratimod (novel small molecule; NCT02936375), and BMS-986165 (novel tyrosine kinase 2 (TYK2) inhibitor; NCT03943147) among many others [92].
Targeting the JAK/STAT signalling pathway with Tofacitinib, or CP-690, 550 have been shown to be effective in murine LN model and may potentially serve as therapeutic target in LN [93, 94]. Successful Bruton’s Tyrosine Kinase (BTK) inhibition in several studies involving mice LN models supports Kong et al. finding of significantly upregulated BTK expression in glomerulus of LN patients and may potentially be a therapeutic target in LN [95, 96, 97].
Despite looking promising in SLE, a placebo-controlled phase II/III study to evaluate Atacicept (recombinant fusion protein that inhibits BAFF/BLyS or APRIL) in combination with MMF and corticosteroids in active LN patients was prematurely terminated due to unexpected substantial decline in serum IgG and serious pneumonia infections in Atacicept-treated patients [98, 99]. Abatacept, a recombinant fusion protein co-stimulation modulator, trialled as add on to SOC in LN failed the primary end point of a phase III trial despite demonstarating more rapid reduction of proteinuria and earlier sustained remission [100].
Newer treatment paradigms showing promising results include succesful use of autologous haematopoietic and allogeneic mesenchymal stem cell transplantations for LN in animal studies and among Asian patients [101, 102, 103, 104, 105, 106] while Yu et al. demonstrated in vitro the protective role by vitamin D in podocyte injury induced by autoantibodies from patients with LN and suggested possible role of vitamin D as a novel therapy target in LN [107].
6. Special considerations
6.1 Pregnancy and lupus nephritis
6.1.1 Pre-pregnancy
Women of childbearing age with LN should understand and be counselled about the potential risks of pregnancy, even if she is in complete remission. Age, previous pregnancy complication, duration from last LN relapse, medication exposure, treatment adherence, blood pressure (BP) control and current disease status are among the important factors that may determine the outcome of future pregnancy. Baseline complement levels, antibody status for dsDNA, SS-A and SS-B, presence of antiphospholipid antibodies (aPL; notably lupus anticoagulant antibody) and urinalysis for proteinuria should be obtained prior to pregnancy.
Possible maternal complications include flare of nephritis, uncontrolled hypertension, pre-eclampsia, risk of Caesarean section, worsening renal function and thrombosis. Foetal risks include prematurity, growth retardation, congenital heart block and intrauterine death [108]. Patients with active disease at conception, uncontrolled hypertension, proteinuria of >1 g/day and abnormal renal function have the highest risk for complications; therefore, good control of disease prior to pregnancy is critically important to optimise pregnancy outcome and ideally the pregnancy should be planned.
Patients on MMF should be transitioned to pregnancy-safe immunosuppressive drugs such as AZA or TAC, while HCQ should be continued throughout pregnancy. MMF exposure especially after the first trimester increases the risk of miscarriage and congenital malformation [109], and practically should be stopped at least 3–6 months prior to conception to ensure disease control is maintained with the new agent(s) [47]. CYC is also teratogenic, associated with premature ovarian failure and increases miscarriage rate [110].
RAAS blockers should ideally be stopped before conception due to possible teratogenicity risk [111]; however, later publications seemed to suggest that they may be safe to be used until pregnancy is confirmed [112]. This is important especially for those who have residual proteinuria as attempt to conceive may take months or even years of effort. Stopping RAAS blockers early on in these patients would essentially exclude them from its’ benefits.
6.1.2 During pregnancy
Multidisciplinary team approach is important during pregnancy and should ideally involve the obstetrician, neonatologist, nephrologist and rheumatologist. Majority of patients (80%) with quiescent LN would have successful pregnancies [113]; however, about a third may relapse during pregnancy [108]. Identification of patients who are at higher risk is important when pregnancy begins, as these patients will require closer observation to ensure good maternal and foetal outcomes (Table 5) [109, 114, 115, 116, 117, 118].
Miscarriage and embryopathy involving ear, mouth, finger and ocular malformation [109]
Table 5.
Baseline risk assessment during pregnancy.
IUGR: Intra-uterine growth retardation.
During early pregnancy, BP would usually remain normal even in patients who required antihypertensive before pregnancy. Gradually, BP may rise as pregnancy progresses, requiring reintroduction of hypertensive medications such as labetalol, methyldopa or nifedipine. BP control should be targeted to be less than 140/90 mmHg [119]. As these patients are at higher risk to develop pre-eclampsia, high dose calcium supplementation and aspirin should be prescribed before entering 16 weeks of gestation [120, 121]. Ultrasound screening including uterine and umbilical artery Doppler to detect early signs of placental insufficiency may be performed at regular interval, especially in high-risk patients.
Hydroxychloroquine is safe during pregnancy and discontinuation has been associated with lupus flare. It also significantly reduces the risk of foetal congenital heart block in patients with positive SS-A (anti-Ro) [116]. Other drugs for consideration in LN and compatible with pregnancy include AZA, CNIs (TAC, Cys), plasma exchange and intravenous immunoglobulins. Data on RTX in pregnancy is limited, although some clinicians have used it safely in early trimester without apparent complication [122]. LN flare during pregnancy can be treated with drugs mentioned above and with addition or increased dosage of steroid. Pulsed intravenous methylprednisolone may be given during severe flares, followed by oral prednisolone [114]. While use of steroid is associated with elevated BP and new onset diabetes, it is probably not related to cleft lip and palate as previously thought [123, 124] (Table 6).
Medication
Pregnancy
Breastfeeding
Cyclophosphamide
Increased risk of teratogenicity, especially in 1st trimester
May cause infants’ bone marrow suppression
Mycophenolate
Increased risk of congenital malformation and miscarriage
Limited data, not recommended
Azathioprine
Relatively safe. Alternative to mycophenolate
Relatively safe
Hydroxychloroquine
Relatively safe. Improve outcome in antiphospholipid syndrome
Relatively safe
Glucocorticoids
Increase risk of hypertension, preeclampsia, GDM. May have neutral effect on cleft lip and palate
Relatively safe
Calcineurin inhibitor
Increase risk of high blood pressure and diabetes. Relatively safe
Relatively safe
Rituximab
Limited data. No teratogenic effect in animal. 1st trimester use may be possible.
Limited data
Immunoglobulin
Safe in pregnancy. Headache & rash common side effect
Relatively safe
Table 6.
Summary of immunosuppressive drugs during perinatal period.
GDM: Gestational diabetes mellitus.
Differentiating between pre-eclampsia and LN flare in pregnancy may be difficult, especially after 20 weeks gestation. Features like proteinuria, high BP, thrombocytopenia and renal impairment are common in both conditions. Red cell cast in urine, abnormal level of complements and anti-dsDNA may point toward LN flare [125]. Elevated soluble fms-like tyrosine kinase 1 (sFlt1)/placental growth factor (PlGF) ratio may assist in predicting pre-eclampsia [126, 127] although not commonly available in clinical practice.
Renal biopsy may be required during pregnancy but poses increased risk of complications. In a systematic review involving data on renal biopsies performed during pregnancy, overall complication rate was higher at 7%, compared to 1% when performed post-partum. Importantly, 4 biopsies during pregnancy had major bleeding complications that required blood transfusion, with median gestational age of 25 weeks; hence, biopsy should only be considered early during the course of pregnancy when results may lead to changes in therapy. Biopsy should be considered if LN flare is suspected and to distinguish it from pre-eclampsia, with finding of glomerular endotheliosis would suggest the latter [128].
Multidisciplinary team approach and patients’ engagement are prudent during severe LN flare, as pregnancy termination may be considered with risks and benefits weighed carefully, so that patient can be treated with urgent cytotoxic drugs. Overall rate for preterm delivery and Caesarean section are higher in patients with LN. For patients with non-active disease, delivery at term should be aimed. In those likely to deliver prematurely, dexamethasone should be given to accelerate foetal lung maturation. Delivery should be aimed after 34 weeks to minimise neonatal adverse outcomes; nonetheless, this strategy relies on the overall clinical picture. Timing of delivery is determined by usual obstetric indications and risk of renal deterioration. Mode of delivery does not seem to affect maternal renal function and again should be based on the usual indications accordingly [129].
6.1.3 After pregnancy
The WHO recommends breastfeeding for all babies until 6 months of age, even in patients on immunosuppressive therapy. Although studies found trace amount of immunosuppressives excreted into breast milk, the amount absorbed by infant is negligible and do not exert any clinical effect [130]. Hence, immunosuppressives deemed safe during pregnancy such as corticosteroid, AZA and CNIs can be safely taken during breastfeeding [114]. Post-partum, regular antihypertensive drugs such as amlodipine or bisoprolol can be reinstated and RAAS blockers such as enalapril or captopril can be safely used during breastfeeding [131] (Table 6).
Postpartum risk of thromboembolic disease increases in SLE especially in active LN patients with nephrotic-range proteinuria. Preventative measure with heparin during postpartum period is controversial, but may be considered in active LN patients with risk factors such as advanced age, obesity, Caesarean section delivery, and pre-eclampsia [132]. For patients with chronic kidney disease and significant proteinuria during pregnancy, careful monitoring after delivery is required as decline in renal function may accelerate within 6–12 months postpartum, despite having stable renal function during pregnancy [133].
6.2 Renal transplantation in lupus nephritis
Approximately 10–20% of patients with LN will progress to ESRD, with young female of African ancestry having the highest risk [8, 134]. In general, outcome for renal transplant is better compared to dialysis particularly with preemptive transplantation, including in patients with LN [135]. However, many patients may not be in complete remission despite dialysis initiation, making preemptive transplantation difficult. Current guidelines suggest that clinical lupus activity and ideally, serologically should be quiescent for 6 months and on no or minimal immunosuppression prior to transplantation [47, 136]. Even if on dialysis, the waiting time for transplant should be maximally shortened to reduce potential risk of graft failure [137].
Although the benefit of transplantation is clear, earlier studies have suggested that LN patients may have worse survival outcome compared to ESRD patients of other aetiologies; however, more contemporary studies seem to abrogate this finding [138]. Clinically relevant recurrence rate of SLE post transplantation is less than 5%, but it increases the risk of graft failure [136]. The rate may even be higher if electron microscopy finding is included and protocol biopsy implemented; nevertheless, the lower rate is probably due to the similar immunosuppressive therapy used in both transplant recipient and active LN.
During pre-transplant evaluation, particular attention should be given to screening of aPL as its’ presence increases the risk of graft thrombosis. Patients with APS would require careful consideration of perioperative anticoagulation to prevent graft loss. Presence of anti-dsDNA or low complement level is not a predictor for renal transplant outcomes. SLE patients have higher risk for cardiovascular mortality hence will require careful cardiac evaluation prior to transplantation [138]. Recurrence of LN after transplantation can be treated by increasing the dose of the immunosuppressive drugs already being used post transplant. CYC may be considered in severe or aggressive disease while RTX has been used in resistant cases [139].
There is concern in LN patients of having higher risk to develop cancer with prolonged exposure to immunosuppression. Previous exposure to CYC doubles the risk for cancer post transplantation, primarily of the skin [140]. Prior use of immunosuppressive therapies before transplant also increases the risk for non-Hodgkin’s lymphoma, anogenital, breast, renal and bladder cancers [141, 142]. Furthermore, prolonged corticosteroid exposure in transplanted SLE patients should adhere to the screening and treatment recommendations on bone health [143].
7. Conclusion
Emerging insights into the heterogenous immunopathogenesis of LN have lead to novel, tailored therapeutic options, resulting in significantly better disease control and prolonged remission among patients; nonetheless, more in-depth studies are required to better understand the pathogenesis while novel therapies continue to be tested. The advent of signature biomarkers show promise in diagnosis, evaluation and management of LN and will continue to be validated for meaningful real-world application. Timely diagnosis, prompt treat-to-target treatment, MDT approach and adherence to therapy are important factors to preserve renal function, prevent disease progression and significantly improve patients’ overall outcome.
Better understanding of disease pathways and discoveries with subsequent validation of biomarkers will provide opportunity for improvement in early detection, prognostic and disease severity prediction, subgroups stratification, treatment adherence assessment, and decision for best treatment option in a timely manner. Studies targeting a single organ or specific subgroup with similar disease severity, duration and background SOC therapy will assist in better assesment of drug effectiveness and accelerate drug development in LN.
\n',keywords:"SLE, lupus, nephritis",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/76056.pdf",chapterXML:"https://mts.intechopen.com/source/xml/76056.xml",downloadPdfUrl:"/chapter/pdf-download/76056",previewPdfUrl:"/chapter/pdf-preview/76056",totalDownloads:276,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:39,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"October 3rd 2020",dateReviewed:"February 26th 2021",datePrePublished:"March 31st 2021",datePublished:"August 25th 2021",dateFinished:"March 31st 2021",readingETA:"0",abstract:"Lupus is a heterogenous multisystem autoimmune disease whereby nephritis is one of its most common cause of overall morbidity and mortality. Accurate, timely diagnosis and effective treatment in lupus nephritis (LN) remains a challenge to many clinicians including those who are directly involved in the daily care of these patients. Despite significant improvement in patients’ survival rate in recent years, in this era of precision medicine, there is pressing need to further improve our understanding and management of this disease. Our chapter would shed light on the key issues in LN including recent advances in our scientific understanding of its’ pathophysiology, major challenges and treatment strategies.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/76056",risUrl:"/chapter/ris/76056",book:{id:"9104",slug:"lupus-need-to-know"},signatures:"Fahd Adeeb and Wan Ahmad Hafiz Wan Md Adnan",authors:[{id:"201088",title:"Dr.",name:"Fahd",middleName:null,surname:"Adeeb",fullName:"Fahd Adeeb",slug:"fahd-adeeb",email:"fahd_adeeb@yahoo.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Kerry General Hospital",institutionURL:null,country:{name:"Ireland"}}},{id:"334104",title:"Dr.",name:"Wan Ahmad Hafiz",middleName:null,surname:"Wan Md Adnan",fullName:"Wan Ahmad Hafiz Wan Md Adnan",slug:"wan-ahmad-hafiz-wan-md-adnan",email:"wahafiz@um.edu.my",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"University Malaya Medical Centre",institutionURL:null,country:{name:"Malaysia"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Epidemiology",level:"1"},{id:"sec_2_2",title:"2.1 Systemic lupus erythematosus (SLE)",level:"2"},{id:"sec_3_2",title:"2.2 Lupus nephritis (LN)",level:"2"},{id:"sec_5",title:"3. Pathogenesis",level:"1"},{id:"sec_6",title:"4. Diagnosis and classification",level:"1"},{id:"sec_6_2",title:"4.1 Role of renal biopsy",level:"2"},{id:"sec_7_2",title:"4.2 Classification criteria",level:"2"},{id:"sec_7_3",title:"Table 2.",level:"3"},{id:"sec_9_2",title:"4.3 Diagnosis of lupus nephritis",level:"2"},{id:"sec_11",title:"5. Management",level:"1"},{id:"sec_11_2",title:"5.1 Current management strategies",level:"2"},{id:"sec_11_3",title:"5.1.1 Induction phase",level:"3"},{id:"sec_12_3",title:"5.1.2 Maintenance phase",level:"3"},{id:"sec_13_3",title:"5.1.3 Refractory lupus nephritis",level:"3"},{id:"sec_15_2",title:"5.2 Future novel therapeutic options",level:"2"},{id:"sec_17",title:"6. Special considerations",level:"1"},{id:"sec_17_2",title:"6.1 Pregnancy and lupus nephritis",level:"2"},{id:"sec_17_3",title:"6.1.1 Pre-pregnancy",level:"3"},{id:"sec_18_3",title:"Table 5.",level:"3"},{id:"sec_19_3",title:"6.1.3 After pregnancy",level:"3"},{id:"sec_21_2",title:"6.2 Renal transplantation in lupus nephritis",level:"2"},{id:"sec_23",title:"7. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Anders H, Saxena R, Zhao M, Parodis I, Salmon JE, Mohan C. lupus nephritis. Nat Rev Dis Primers 2020; 6: 7'},{id:"B2",body:'Mohan, C., Putterman, C. Genetics and pathogenesis of systemic lupus erythematosus and lupus nephritis. Nat Rev Nephrol 2015; 11: 329-341'},{id:"B3",body:'Gonzalez-Crespo MR, Lopez-Fernandez JI, Usera G, Poveda MJ, Gomez-Reino JJ. Outcome of silent lupus nephritis. Semin Arthritis Rheum 1996; 26: 468-76'},{id:"B4",body:'Wakasugi D, Gono T, Kawaguchi Y, Hara M, Koseki Y, Katsumata Y, et al. 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Association of time to kidney transplantation with graft failure among U.S. patients with end-stage renal disease due to lupus nephritis. Arthritis Care Res 2015; 67: 571-81'},{id:"B138",body:'Wong T, Goral S. lupus Nephritis and Kidney Transplantation: Where Are We Today? Adv Chronic Kidney Dis 2019; 26: 313-22'},{id:"B139",body:'Lionaki S, Skalioti C, Boletis JN. Kidney transplantation in patients with systemic lupus erythematosus. World J Transplant 2014; 4: 176-82'},{id:"B140",body:'Jorgenson MR, Descourouez JL, Singh T, Astor BC, Panzer SE. Malignancy in Renal Transplant Recipients Exposed to Cyclophosphamide Prior to Transplantation for the Treatment of Native Glomerular Disease. Pharmacotherapy 2018; 38: 51-7'},{id:"B141",body:'Hibberd AD, Trevillian PR, Wlodarczyk JH, Kemp DG, Stein AM, Gillies AH, et al. Effect of immunosuppression for primary renal disease on the risk of cancer in subsequent renal transplantation: a population-based retrospective cohort study. Transplantation 2013; 95: 122-7'},{id:"B142",body:'Song L, Wang Y, Zhang J, Song N, Xu X, Lu Y. The risks of cancer development in systemic lupus erythematosus (SLE) patients: a systematic review and meta-analysis. Arthritis Res Ther 2018; 20: 270'},{id:"B143",body:'Ketteler M, Block GA, Evenepoel P, Fukagawa M, Herzog CA, McCann L, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what\'s changed and why it matters. Kidney Int 2017; 92: 26-36'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Fahd Adeeb",address:"fahd_adeeb@yahoo.com",affiliation:'
Department of Rheumatology, University Hospital Kerry, Ireland
'},{corresp:null,contributorFullName:"Wan Ahmad Hafiz Wan Md Adnan",address:null,affiliation:'
Department of Nephrology, University Malaya, Malaysia
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1. Introduction
The prevalence of diabetes has increased rapidly over the past few years, mainly in low to middle-income countries, and became one of the major causes of premature death worldwide. According to the WHO statistics, 422 million people were estimated as diabetes in 2014, and 1.6 million deaths were reported [1]. The International Diabetes Federation estimated that the world’s diabetic population has increased to 592 million by 2035. The largest number of diabetes cases was reported in the Western Pacific region (132 million), while 71.4 million diabetes cases were reported in the South Asian area [2].
Diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both. It is mainly classified as insulin-dependent diabetes mellitus (Type 1 DM) and non-insulin-dependent diabetes mellitus (type 2 DM). Type 1 DM is associated with deficiency of insulin, which occurs due to the destruction of pancreatic ß-cells via an autoimmune process. In contrast, type 2 DM is linked with insulin resistance, which reduces insulin utilization by peripheral tissues and results in hyperglycemia and obesity [3]. Type 2 DM became a major health problem worldwide associated with microvascular and macrovascular health complications. Microvascular and microvascular complications include diabetic retinopathy, neuropathy, nephropathy, and cerebrovascular diseases, peripheral arterial diseases, respectively [4]. Therefore, natural therapeutic approaches [5] should be developed to maintain the blood glucose level and long-term complications in patients with type 2 DM.
As currently available treatment regimens for type 2 DM have adverse side effects, it is necessary to search for an effective drug that helps maintain the blood glucose level and complications in patients with type 2 DM. Even though most of the researchers focused on herbal medicine, none have a full beneficial effect on curing patients with type 2 DM [6]. Hence, it is worth emphasizing marine seaweeds as they have been identified as a rich source of promising bioactive compounds synthesized from their biochemical and physiological mechanisms. Besides, most marine seaweeds are survived in extremely harsh environments, which provide enormous potential to produce complex bioactive compounds to withstand extreme conditions. As a result, the composition of the bioactive compounds in marine seaweeds can vary depending on the geographic area and seasonal changes [7]. As most marine seaweeds are a potential source of bioactive compounds with various therapeutic effects, this chapter mainly emphasizes the pharmacological uses of marine algae as an anti-diabetic therapy.
2. Therapeutic targets for type 2 diabetes mellitus
As type 2 DM is a progressive disorder, the search for effective treatments is essential to maintain hyperglycemia and its associated diabetic complication. Insulin resistance and impaired beta-cell function lead to hyperglycemia due to alteration in glucose homeostasis, which in turn cause loss of postprandial glucose control. Therefore, postprandial blood glucose maintenance is essential to manage the hyperglycemic condition and associated complications in type 2 diabetes patients [8]. Postprandial hyperglycemia in type 2 DM patients can be controlled by inhibiting metabolic enzymes such as α-amylase, α-glucosidase, dipeptide peptidase-IV, gut-derived peptide hormones (incretins), and glucagon-like peptide-1 hormone. The glucose-dependent insulinotropic peptide, aldose reductase, angiotensin-converting enzyme, and protein tyrosine phosphatase 1B are involved with diabetic complications [9].
Alpha-amylase and alpha-glucosidase are exo-acting glycoside hydrolase enzymes involved in carbohydrate digestion. Alpha-amylase is involved in the digestion of long-chain carbohydrates, while alpha-glucosidase catalyzes the end step hydrolysis of starch or disaccharides into simple glucose units. Therefore, inhibitors of these enzymes delay glucose absorption, reducing the postprandial blood glucose level [10].
Dipeptide peptidase-IV is a protease enzyme involved in the degradation of incretins, a group of metabolic hormones that stimulate ß cells of Langerhans’ islet to release insulin. Incretins are released after nutrient intake, and they delayed gastric emptying and decrease glucagon secretion in addition to stimulation of insulin secretion [11]. Contrarily, the incretin effect on insulin secretion gradually decreases once the patient becomes euglycaemic [12]. Hence, inhibitors of dipeptide peptidase IV are efficient therapeutic means to reduce the degradation of incretins, which help maintain hyperglycemic conditions in type 2 DM.
Similarly, aldose reductase is a rate-limiting enzyme involved in the polyol pathway, which catalyzes glucose reduction into sorbitol in an NADPH-dependent pathway. As the aldose reductase has broad substrate specificity, it binds with glucose and converts it into sorbitol once the hexokinase is saturated and the blood glucose level is high. As a result, produced sorbitol is accumulated within the cells and creates an osmotic effect, leading to cataracts and diabetic neuropathy [13, 14]. Thus, aldose reductase inhibitors prevent secondary diabetes complications.
Similarly, the angiotensin-converting enzyme plays a vital role in the renvital angiotensin-aldosterone system, a hormone system responsible for maintaining the blood pressure and fluid balance in the body. Angiotensin-converting enzymes convert angiotensin I into angiotensin II, a potent vasoconstrictor that mainly acts on arterioles that stimulate the release of aldosterone from the renal cortex and improve sodium reabsorption from the kidney. Therefore, activation of the renin-angiotensin-aldosterone system leads to increased blood pressure, resulting in microvascular and macro-vascular complications in patients with type 2 DM. Thus, inhibitors of the angiotensin-converting enzyme reduce the long-term microvascular and macrovascular complications by lowering the arterial and venous blood pressure [15]. A study reported by Ustundag et al. [16] confirms that angiotensin-converting enzyme activity is increased in diabetic patients compared to normal individuals.
Correspondingly, protein tyrosine phosphatase IB (PTP IB) is a negative regulator of the insulin signaling pathway that dephosphorylate tyrosine residues in insulin receptor and insulin receptor substrate-1. Which in turn reduces insulin sensitivity [17]. Hence, inhibition of the PTP IB enzyme leads to lower blood glucose levels by enhancing insulin sensitivity. The stable hyperglycemic condition in type 2DM patients leads to the accumulation of advanced glycated end products in various tissues resulting in diabetic complications such as neuropathy, nephropathy, retinopathy, and other chronic diseases [18]. Therefore, the natural compounds, which inhibit the formation of advanced glycation end products, would be a promising therapeutic target to suppress the diabetic complications associated with glycated products.
3. Bioactive compounds present in marine seaweeds
Marine seaweeds are categorized into three algal classes; red (Rhodophyceae), green (Chlorophyceae), and brown algae (Phaeophyceae) based on the presence of natural pigments. Phaeophyceae contains brown color fucoxanthin pigment, whereas Rhodophyceae possess red color pigments phycoerythrin and phycocyanin, and Chlorophyceae is rich in green color pigment chlorophyll. Among the three varieties, most marine algae are referred to as “edible” that can be used for human consumption. Asians and South Africans mainly consume these edible seaweeds as a promising complementary and alternative medicine [19].
Recently, marine seaweeds have been identified as a rich source of bioactive secondary metabolites with human health benefits. In particular, polyphenols, sterols, alkaloids, flavonoids, tannins, proteins, peptides, essential fatty acids, enzymes, vitamins, and pigments are extensively synthesized by marine seaweeds. These compounds exhibit significant chemical and biological properties such as anti-diabetic, antioxidant, cytotoxic, anti-fungal, anti-bacterial, anti-coagulant, anti-inflammatory, and antiproliferative activities, etc., [19, 20]. The marine seaweeds are a rich source of sulfated polysaccharides (Figure 1), which have been reported to possess beneficial human effects. Fucoidan, alginates, and laminarans are sulfated polysaccharide found in brown seaweeds and reported to exhibit anti-diabetic, antioxidant, and anti-inflammatory activities [21]. Carrageenans and agarans are sulfated polysaccharides found in red seaweeds. Similarly, ulvan is the sulfated polysaccharide found in green seaweeds [22]. The sulfated polysaccharides are known to possess anti-viral, anti-tumor, and anti-coagulant activities [23].
Figure 1.
Chemical structures of sulfated polysaccharides present in marine seaweeds.
Marine seaweeds are rich in polyphenolic compounds, including flavonoids, bromophenols, phlorotannins, mycosprine-like amino acids, and phenolic terpenoids (Figure 2). The mycosprine-like amino acid is a small molecule with hydroxylated aromatic rings. Phlorotannins are polyphenolic metabolites found in brown seaweeds. They can be classified into six subgroups; fuhalols, phlorethols, fucophlorethols, and fucols, eckols, and carmalols based on their linkage between phloroglucinol units and hydroxyl groups. Flavonoids, bromophenol, phenolic terpenoids, phenolic acids, and mycosporine-like compounds are reported to possess antioxidant, anti-diabetic, anti-inflammatory, anti-allergic, and anticancer properties [24, 25, 26].
Figure 2.
Organic structures of phlorotannins and bromophenols.
Among the bioactive compounds present in marine seaweeds, marine algae-derived accessory pigments are important as they possess beneficial biological activities [27]. Fucoxanthin is the most abundant accessory pigment found in brown seaweeds and reported to have potent biological activities such as anticancer, antioxidant, anti-diabetic activities due to the presence of unusual allenic bond and a 5, 6-monoepoxide in its structure [21]. Phycobiliproteins, a water-soluble accessory pigment found in red seaweeds, can be divided into three main categories; phycocyanins, allophycocyanins, and phycoerythrin. Phycoerythrins are abundantly found in red seaweeds and reported to possess immuno-modulating and anticancer activities. Similarly, chlorophylls are found in green seaweeds and are said to have antioxidant activity [27].
Similarly, marine algae-derived peptides have been identified to possess a wide range of biological activities such as antioxidant, anti-diabetic, anti-microbial, antihypertensive properties, etc. Hence, most algal-derived proteins have been widely used in food and pharmaceutical industries [28]. The protein content of the marine seaweeds differs depending on the seasonal period and type of species. The brown seaweeds usually contain low protein content compared to the red and green seaweeds. Despite this, some brown algal species such as Choonospora minima, Padina gymnospora, Dictyota menstrualis, and Sargassum vulgare possess high protein content up to 10–15%. According to the reported studies, green seaweed contains an average protein content level, ranging between 10–26%. In contrast, the highest protein content was reported in red seaweeds such as Phorphyra tenure and Palmaria palmata, which was around 47% [29].
4. Anti-diabetic potentials of marine algae
Marine seaweeds have been widely studied for their anti-diabetic potential through different mechanisms due to bioactive secondary metabolites. Several in-vitro and in-vivo studies have been conducted so far to confirm the hypoglycemic effect of marine algae in addition to its ability to suppress diabetic complications. This section emphasizes the anti-diabetic potential of marine brown, red, and green seaweeds through diverse mechanisms.
4.1 Inhibitory activity of carbohydrate hydrolyzing α-amylase and α-glucosidase enzymes
Brown seaweeds
Among the brown seaweeds, “Ecklonia” and “Eisenia” genera have been reported to exert hypoglycemic effects through α-amylase and α-glucosidase inhibitory activities [30]. The observed hypoglycemic activity can be attributed to the presence of phlorotannins; eckol, dieckol, 6,6′-bieckol, phlorofucofuroeckol-A, and phloroglucinol, and 7-phloroeckol [31]. According to the reported studies, methanol extract of Ecklonia cava exercises its hypoglycemic effects through the inhibitory activity of α-glucosidase enzymes (IC50–10.7 μM), compared to the standard acarbose used. Similar results were reported with phlorotannins isolated from Ecklonia stolonifera against the α-glucosidase enzyme. Dieckol (IC50:1.61 μM) and phlorofucofuroeckol-A (IC50:1.37 μM) isolated from Ecklonia stolonifera reported to exhibit the potent inhibitory activity of α-glucosidase enzymes compared to the standard drug (IC50: 51.65 μM). Similarly, eckol (IC50: 11.16 μM) isolated from Ecklonia maxima demonstrated strong α-glucosidase inhibitory activity comparable to the isolated phloroglucinol (IC50: 1991 μM). Besides, Eisenia bicyclis from genus Eisenia reported possessing 87% of inhibitory effect on α-amylase at 1 mM concentration in addition to the inhibitory effect on α-glucosidase and advanced glycation end products. Moreover, isolated eckol (IC50: 22.78 μM), dioxinodehydroeckol (IC50: 34.60 μM) and phloroglucinol (IC50: 141.18 μM) from Eisenia bicyclis exhibited potent α-glucosidase inhibitory activity [32].
A brown seaweed Sargassum hystrix reported to exhibit inhibitory effect on α-amylase IC50: 0:58 ± 0:01 mg/ml; IC50 acarbose: 0:53 ± 0:00 mg/ml) and α-glucosidase (IC50: 0:59 ± 0:02 mg/ml; IC50 acarbose: 0:61 ± 0:01 mg/ml) enzymes compared to the standard acarbose [33]. This was further confirmed by an in-vivo study using streptozotocin-induced rats and observed that the deduction of pre-prandial (186.4 mg/ml) and postprandial (186.9 mg/ml) blood glucose levels at 300 mg/kg concentration comparable to the standard drug glibenclamide (5 mg/kg) (Pre-prandial;195.6 mg/ml; postprandial:104.8 mg/ml) without any adverse effects. Correspondingly, ethanol (150 mg/kg) and aqueous (300 mg/kg) extracts of Sargassum polycystum reported to reduce hyperglycaemic condition in diabetic rats [34]. Further studies has reported that a brown seaweed Ascophyllum nodosum effectively inhibited α-amylase (IC50: 0.1 μg/ml) and α-glucosidase enzymes ((IC50: 19 μg/ml) due to the presence of phlorotannins [35].
Green seaweeds
Green seaweeds belong to the genus “Ulva.” They have been reported to possess hypoglycemic activity, and they have been used for various food dishes in Asians due to the presence of high soluble fiber content. The aqueous extract of green seaweeds Ulva lactuca (Inhibition-α-amylase: 83.4%; α-glucosidase: 61.81%) and Ulva reticulate (Inhibition-α-amylase: 89.1%; α-glucosidase: 76.02%) were effective against α-amylase and α-glucosidase enzymes at a concentration of 100 μg/ml after 8 hours of extraction period at 37 °C in a water bath as it gets more time to release the phytochemicals and colloids to the extract [36]. Similarly, the crude extract of Ulva ohnoi exhibited α-amylase inhibition by 41.7% and complete α-glucosidase inhibition at 10 mg/mL [37].
The methanol extract of a green seaweed Chlorodesmis inhibited α-amylase enzyme by 72% at 500 μg/ml with IC50 of 408.9 μg/ml without any effect on α-glucosidase enzymes. Similarly, chloroform extract of Chaetomorpha aerea exhibited a potent inhibitory effect on α-amylase enzyme with IC50 of 147.6 μg/ml. Besides, methanol extract of green seaweeds Enteromorpha intestinalis (59%) and Cladophora rupestris (14%) exhibited a moderate and lower effect on the α-amylase inhibitory activity at a concentration of 500 μg/ml [38]. Moreover, crude extracts of green seaweeds Derbesia tenuissima and Oedogonium intermedium were reported to exhibit lower α-amylase (53.6% and 49.2%) and potent α-glucosidase (73.98% and 69.5%) inhibitory effect at a concentration of 10 mg/ml [39]. Further studies reported that the green seaweed Chlorella pyrenoidosa could suppress the hyperglycaemic condition by inhibiting α-amylase and α-glucosidase enzymes. Besides, a green seaweed Cladophora rupestris has been reported to exhibit a hypoglycemic effect through α-amylase and α-glucosidase inhibitory mechanisms [40].
Red seaweeds
Among the marine red seaweeds, the genus “Gracillaria” was reported to possess the hypoglycemic effect through the inhibitory effect on α-amylase and α-glucosidase enzymes. Gunathilaka et al, [41] reported that the ethyl acetate fraction of red seaweed Gracillaria edulis exhibited potent α-amylase (IC50: 279.48 μg/ml) and α-glucosidase (IC50: 87.92 μg/ml) inhibitory activity compared to the standard acarbose (IC50amylase: 87.43 μg/ml; IC50glucosidase: 0.38 μg/ml) due to the presence of reported anti-diabetic compound 1H-Indole-2-carboxylic acid,6-(4-ethoxy phenyl)-3-methyl-4-oxo- 4,5,6,7-tetrahydro-isopropyl ester. Further studies reported that the aqueous extract of Gracillaria edulis inhibited the α-amylase and α-glucosidase enzyme by 87.86% and 79.55% at a concentration of 100 μg/ml. Similarly, Gracilaria corticata and Acanthophora spicifera had an inhibitory effect on α-amylase (84.66%; 54.73%) and α-glucosidase (73.53%; 46.86%) enzyme at a concentration of 100 μg/ml [36].
4.2 Inhibitory activity of dipeptidyl peptidase-IV (DPP-IV)
Dipeptidyl peptidase-IV (DPP-IV) is an enzyme involved in the degradation of incretin hormones, maintaining postprandial blood glucose levels. Among three types of seaweeds, brown seaweeds have been extensively reported to possess a dipeptidyl peptidase-IV (DPP-IV) inhibitory effect compared to red and green seaweeds [42].
Brown seaweeds
The brown seaweeds Padina sulcata, Sargassum binderi, and Turbinaria conoides have been reported to exhibit a potent inhibitory effect on the DPP-4 enzyme in a dose-dependent manner. The maximum inhibitory effect of Padina sulcata, Sargassum binderi, and Turbinaria conoides were observed as 83.09%, 81.75%, and 76.20%, at a concentration of 10 mg/ml, respectively. Further, crude water extracts of the above three brown seaweeds could secrete glucagon-like peptide-1 (GLP-1) to a greater extent than prevent hyperglycaemic conditions [42]. Similarly, ethyl acetate: methanol fraction (IC50: 0.013 mg/ml) of Sargassum wightii has been reported to exhibit an inhibitory effect on DPP-4 enzymes compared to the standard drug diprotein-A (IC50: 0.007 mg/ml) [43]. The methanol extract of Turbinaria ornate exhibited a strong inhibitory effect on the DPP-4 enzyme by 55.4% at 80 μg/ml than the standard drug diprotin A (65%) might attribute to the presence of fucoids and sulfated polysaccharides in T. ornata [44].
Green seaweeds
The previous study conducted by Chin et al. [42] reported the inhibitory activity of green seaweed Halimeda macroloba on the DPP-4 enzyme. Halimeda macroloba inhibited the DPP-4 enzyme by 60.53% at a 10 mg/ml concentration compared to the positive control Berberine (75.92% at 1 mg/mL). Moreover, crude water extract of H. macroloba was able to stimulate glucagon-like peptide-1 (GLP-1) secretion.
Red seaweeds
The sulfated polygalactans isolated from red seaweeds Kappaphycus alvarezii and Gracilaria opuntia have been reported to possess the inhibitory effect on the DPP-4 enzyme. According to the results, sulfated galactans isolated from Gracilaria opuntia (IC50 0.09 mg/mL) significantly inhibited the DPP-4 enzyme than the sulfated galactans of Kappaphycus alvarezii (IC50 0.12 mg/mL) compared to the standard diprotin A (IC50 1.54 mg/mL). The observed activity might be due to the reaction between functional groups of sulfated polygalactan with DPP-4 by H-bonding and hydrophilic interactions [45]. Similarly, aqueous, alkaline, and a mixture of aqueous/alkaline fractions of a red seaweeds Palmaria palmate have exhibited a potent inhibitory effect on DPP-4 enzyme with IC50 of 2.52 ± 0.05 mg/ml, 4.60 ± 0.09 mg/ml, and 4.24 ± 0.02 mg/ml respectively [46]. Further studies reported that the red seaweed Palmaria palmate’s protein hydrolysate had a potential inhibitory effect on the DPP-4 enzyme [40]. These results confirmed the possible inhibitory effect on DPP-4 enzymes of red seaweed extracts.
4.3 Inhibitory activity of aldose reductase (AR)
Brown seaweeds
The ethyl acetate fraction of brown seaweed, Ecklonia stolonifera has been reported to possess a strong inhibitory effect on aldose reductase enzymes due to the presence of phlorotannins such as 7-phloroeckol and 2-phloroeckol in ethyl acetate fraction [47]. Similarly, phlorofucofuroeckol-A isolated from Eisenia bicyclis exhibited a potent inhibitory effect of aldose reductase enzyme (IC50: 6.22 μM). They also confirmed the inhibitory effect of fucosterol in the rat lens. Carotenoids isolated from Ecklonia stolonifera exhibited potent inhibitory activity on aldose reductase enzyme (IC50: 18.94 μM) compared to the standard positive control quercetin (IC50: 1.34 μM). The presence of porphyrin derivatives (pheophytin-A and pheophorbide-A) in the dichloromethane fraction of Saccharina japonica caused excellent inhibitory effects on aldose reductase (AR) in rat lens [48]. Moreover, fucoxanthin isolated from Undaria pinnatifida and Eisenia bicyclis reported acting as a competitive inhibitor on the aldose reductase enzyme [49].
Green seaweeds
The chloroform and ethanol fractions of green seaweed, Capsosiphon fulvescens showed a potent inhibitory action on the AR enzyme [50]. The authors further carried out isolation of compounds, and the isolated compounds (capsofulvesin A, B, and chalinasterol) demonstrated high inhibitory action on AR enzyme with IC50 values of 52.53, 101.92, and 345.27 μM, respectively.
Red seaweeds
Regarding red seaweeds, the bromophenol compounds present in red seaweeds have been identified as effective therapeutic agents. The bromophenols such as bis (2,3,6-tribromo-4,5 -dihydroxy phenyl) methane, 2,2′,3,6,6′-pentabromo- 3′,4,4′,5-tetrahydroxydibenzyl ether, and 2,2′,3,5′,6-pentabromo- 3′,4,4′,5-tetrahydroxydiphenylmethane isolated from red seaweed, Symphyocladia latiuscula are well known for their inhibitory effects on aldose reductase. This enzyme is responsible for the fructose formation in the polyol pathway [25].
4.4 Inhibitory activity of protein tyrosine phosphatase 1B (PTP 1B)
Brown seaweed
The brown seaweeds belonged to the genus “Sargassum” as reported to exhibit the potent inhibitory activity of PTP 1B enzyme due to the presence of secondary bioactive compounds. Ali et al. [51] reported that the hexane fraction (IC50: 1.83 μg/ml) of Sargassum serratifolium strongly inhibited the PTP 1B enzyme than the standard ursolic acid (IC50: 1.12 μg/ml). During the compound isolation, three plastoquinones (sargachromenol, sargahydroquinoic acid, and sargaquinoic acid) were identified, and among them, sargahydroquinoic acid exhibited a potent PTP 1B inhibitory effect (IC50:5.14 μg/ml). Similarly, the chloroform extract of Sargassum yezoense (54.4%), Sargassum fluvellum (36.1%), Sargassum horneri (46.2%), Sargassum sagmianum (21.4%), Sargassum hemiphyllum (44.1%), and Sargassum siliquastrum (14.8%) could inhibit PTP 1B enzymes at 15 μg/ml of concentration [52]. Further, the phlorotannins such as eckol, 7-phloroeckol, and phlorofucofuroeckol-A isolated from Ecklonia stolonifera, Ecklonia cava, and Eisenia bicyclis could act as non-competitive inhibitors on PTP 1B enzyme [53]. Moon et al. [32] further confirmed the inhibitory effect of phlorofucofuroeckol-A (IC50: 0.56 μM), 7-phloroeckol (IC50: 2.09 μM), and eckol (IC50: 2.64 μM) isolated from Ecklonia stolonifera and Eisenia bicyclis. Moreover, fucosterol isolated from Eisenia bicyclis and Ecklonia stolonifera also showed PTP 1B inhibitory effect [54].
Green seaweeds
Several studies have been reported to elucidate the anti-diabetic potential of green seaweeds by enhancing insulin sensitivity through the mechanism of PTP 1B inhibition. Among the marine green seaweeds, Crude chloroform and methanol extract of a green seaweed Derbesia marina has been reported to exhibit an inhibitory effect on PTP 1B enzyme by 61.7% and 80.65 respectively at a concentration of 15 μg/ml. Further, the crude chloroform and methanol extract of edible green sea lettuce “Ulva pertusa” has exhibited potent PTP 1B inhibition at 15 μg/ml by 25.8% and 48.1%, respectively. Similarly, the crude chloroform and methanol extract of Enteromorpha linza (42.1%:35.4%) and Codium adhaerens (51.5%:71.2%) increased insulin sensitivity by inhibiting PTP 1B enzyme at 15 μg/ml concentration [52]. Further, the compounds isolated from the green seaweeds belonged to the genus “Caulerpa” had a potent anti-diabetic effect by the mechanism of PTP 1B inhibition. Racemosin C, Caulerpin, Caulerpic acid isolated from Caulerpa racemosa, and Caulersin isolated from Caulerpa serrulata have reported significant PTP1B inhibitor [55].
Red seaweeds
Most of the red seaweeds belonged to the genus “Chondus” exhibited anti-diabetic activity via PTP 1B enzyme inhibition. According to the recorded studies, chloroform extract of chondus ocellanthus and chondus crispus inhibited PTP 1B enzymes by 41.5% and 27.6% at a concentration of 15 μg/ml. Similarly, red seaweeds belonged to the genus “Laurencia” had a potential inhibitory effect on PTP 1B enzyme. The methanol extract of Laurencia okamurae (33.1%) and chloroform extract of Laurencia intermedia (43.3%) could inhibit PTP 1B enzyme at 15 μg/ml of concentration. In addition to that 15 μg/ml concentration of chloroform extract of Corallina pilulifera, Gymnogongrus flabelliformis, and Gracillaria textori inhibited PTP 1B enzyme by 58.3%, 38.6%, and 24.9%, respectively [46]. Further, the compounds bromophenol and 3, 4-dibromo-5-(2-Bromo-3, 4-dihydroxy-6-(ethoxymethyl)benzyl)benzene-1,2-diol isolated from red seaweed, Rhodomela confervoides could increase insulin sensitivity via inhibition of PTP 1B enzyme [40].
4.5 Inhibitory activity of angiotensin-converting enzymes (ACE)
Brown seaweeds
Phlorotannins eckol, phlorofucofuroeckol-A, and dieckol isolated from brown seaweed, Ecklonia stolonifera could inhibit angiotensin-converting enzyme with IC50 values of 70:82 μM, 12:74 μM, and 34:25 μM, respectively. Among the isolated phlorotannins, dieckol acted as a non-competitive inhibitor of ACE [56]. Similarly, the phloroglucinol isolated from the ethyl acetate fraction of Sargassum (56.96 μg/ml) wightii significantly inhibited the ACE compared to the positive control captopril (51.79 μg/ml) [57]. An amino acid sequence isolated from edible brown seaweed, Undaria pinnatifida, could significantly inhibit angiotensin-converting enzymes [57]. The protein-derived hydrolysate of Undaria pinnatifida exhibited a potent antihypertensive effect via inhibiting ACE [39]. Further, the enzymatic hydrolysate of Ecklonia cava has been reported to show a potent inhibitory effect on ACE with IC50 values from 2.33 up to 3.56 μg/mL [58].
Green seaweeds
Among the green seaweeds, few studies have been reported regarding the inhibitory effect on the angiotensin-converting enzyme. Crude and saponified extracts of Ulva ohnoi, Derbesia tenuissima, and Oedogonium intermedium exhibited an inhibitory effect on the angiotensin-converting enzyme. The crude extract of Ulva ohnoi, Derbesia tenuissima, and Oedogonium intermedium had a less potent inhibitory effect at 10 mg/ml. In contrast, the saponified extract of Ulva ohnoi, Derbesia tenuissima, and Oedogonium intermedium inhibited 1.9%, 1.47%, and 7.37% compared to the positive control captopril (6.15% inhibition at 200 μg/ml). However, carotenoids; siphonaxanthin, neoxanthin, 9′-cis-neoxanthin, loroxanthin, violaxanthin, lutein, siphonein, α-carotene, and β-carotene present in green seaweeds are found to be poor inhibitors of ACE [37]. Further, a protein-derived hydrolysate of an edible green seaweed Enteromorpha clathrata had a potent inhibitory effect on ACE [58].
Red seaweeds
The red seaweeds have been widely studied to elucidate the inhibitory effect on angiotthe ensin-converting enzyme, as it plays a crucial role in regulating blood pressure. According to the recorded studies, the aqueous extract at 20 °C of red seaweeds Lomentaria catenata, Lithophyllum okamurae, Ahnfeltiopsis flabelliformis, and Gracilaria textorii significantly inhibited the angiotensin-converting enzyme by 98.92%, 89.23%, 73.45%, and 65.40% at a lower concentration of 200 μg/ml. Similarly, the methanol extract at 700C of red seaweeds, Ahnfeltiopsis flabelliformis, and Laurencia okamurae has been reported to exhibit a strong inhibitory effect angiotensin-converting enzyme by 97.59% and 78.01% at a concentration of 200 μg/ml. Further, the methanol extract at 70 °C of red seaweeds Grateloupia filicina, Sinkoraena lancifolia, Grateloupia elliptica, Grateloupia lanceolata, and Laurencia okamurae exhibited an inhibitory effect on ACE by 83.14%, 80.86%,68.13%, 89.04%, and 69.80% at 200 μg/ml of concentration [59]. This study revealed the presence of ACE like inhibitors in red seaweeds. Protein-derived hydrolysate in Palmaria palmate (red seaweed) showed marked antihypertensive activity. The antihypertensive activity was exerted via inhibition of angiotensin-converting enzymes [46]. Further, an enzymatic hydrolysate of a red seaweed Pyropia columbina exhibited an inhibitory effect on the angiotensin-converting enzyme with an IC50 value of 1.2 mg/ml [58].
4.6 Inhibitory activity of the formation of advanced glycation end products (AGEs)
Brown seaweeds
Among the brown seaweeds, Ecklonia cava has been extensively studied for its anti-diabetic activity. The phlorotannins isolated from Ecklonia cava such as eckol (IC50: 1:6 × 103 μM), phlorofucofuroeckol-A (IC50: 2:4 × 103 μM), fucofuroeckol A (IC50: 7:4 × 102 μM), and dieckol (IC50: 7:4 × 102 μM) could inhibit the formation of advanced glycation end products comparable to the standard drug aminoguanidine hydrochloride (IC50: 8:1 × 103 μM) [60]. Similarly, the phlorotannins isolated from methanol extract of brown seaweeds Sargassum polycystum (IC50: 35:245 μg/ml), Turbinaria Ornate (IC50: 22:7 μg/ml), and Padina pavonica IC50: 15:16 μg/ml) had the ability to suppress the formation of advanced glycation end-products [61]. Further, phlorotannins extracted from the ethyl acetate fraction of Fucus vesiculosus (IC50: 0.045 mg/ml) significantly inhibited the AGEs formation compared to the phloroglucinol (IC50: 0.068 mg/ml) [62].
Green seaweeds
So far, minimal studies have been reported to demonstrate the inhibitory effect of green seaweeds on the formation of advanced glycation end products. The chloroform, ethanol, and butanol fractions of a green seaweed Capsosiphon fulvescens have been reported to exhibit an inhibitory effect on the formation of advanced glycation end-products [50].
Red seaweeds
Regarding the red seaweeds, the ethyl acetate fraction (IC50: 586.54 μg/ml) of Gracillaria edulis has been reported to exhibit the inhibitory effect on the formation of advanced glycation end products compared to the standard drug rutin (IC50: 11.55 μg/ml) [34]. Similarly, carrageenan extract from red algae could inhibit progressive glycation end product uptake by macrophage-like RAW 264.7 cells [63].
5. Conclusions
Recently, marine seaweeds have been extensively studied for their therapeutic effects due to promising bioactive compounds. Among the non-communicable diseases, diabetes mellitus is the third leading cause of death associated with vascular complications. As it is a progressive disorder, it is necessary to search for an adequate drug for natural resources with minimum side effects. Therefore, this chapter illustrates the different anti-diabetic mechanisms of marine seaweed extracts and their bioactive compounds.
Acknowledgments
The University of Sri Jayewardenepura, Sri Lanka (ASP/01/RE/SCI/2017/50).
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"Marine seaweeds, microalgae, bioactive compound, diabetes, drug discovery, mechanisms of action",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/75771.pdf",chapterXML:"https://mts.intechopen.com/source/xml/75771.xml",downloadPdfUrl:"/chapter/pdf-download/75771",previewPdfUrl:"/chapter/pdf-preview/75771",totalDownloads:219,totalViews:0,totalCrossrefCites:1,dateSubmitted:"February 2nd 2021",dateReviewed:"February 24th 2021",datePrePublished:"April 19th 2021",datePublished:"May 11th 2022",dateFinished:"March 17th 2021",readingETA:"0",abstract:"Marine seaweeds are a promising source of bioactive secondary metabolites that can be utilized in drug development and nutraceuticals. Diabetes mellitus is a leading non-communicable disease, and it is the third leading cause of death worldwide. Among the types of diabetes, type 2 became the major health problem as it is associated with severe health complications. Since available oral hypoglycemic drugs cause several adverse effects, it is worth searching for a natural cure with fewer or no side effects that may benefit patients with type 2 diabetes. Among the marine seaweeds, brown and red seaweeds are extensively studied for the anti-diabetic activity compared to the green seaweeds. Bioactive compounds present in marine seaweeds possess anti-diabetic potential through diverse mechanisms, mainly by reducing postprandial hyperglycemia and associated complication. Most of the studies emphasized that the marine seaweeds control the hyperglycemic condition by inhibiting carbohydrate hydrolyzing α-amylase,α glucosidase enzymes, and the inhibitory effect of dipeptide peptidase-4 that are involved in the degradation of incretins. Similarly, bioactive compounds in marine seaweeds can reduce diabetes complications by inhibiting angiotensin-converting enzymes, aldose reductase, protein tyrosine phosphatase 1B enzyme. This chapter focuses on the anti-diabetic potential of marine brown, green, and red seaweeds through different mechanisms.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/75771",risUrl:"/chapter/ris/75771",signatures:"Thilina Gunathilaka, Lakshika Rangee Keertihirathna and Dinithi Peiris",book:{id:"10356",type:"book",title:"Natural Medicinal Plants",subtitle:null,fullTitle:"Natural Medicinal Plants",slug:"natural-medicinal-plants",publishedDate:"May 11th 2022",bookSignature:"Hany A. El-Shemy",coverURL:"https://cdn.intechopen.com/books/images_new/10356.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-276-5",printIsbn:"978-1-83969-275-8",pdfIsbn:"978-1-83969-277-2",isAvailableForWebshopOrdering:!0,editors:[{id:"54719",title:"Prof.",name:"Hany",middleName:null,surname:"El-Shemy",slug:"hany-el-shemy",fullName:"Hany El-Shemy"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"219479",title:"Prof.",name:"Dinithi",middleName:"C",surname:"Peiris",fullName:"Dinithi Peiris",slug:"dinithi-peiris",email:"dinithi@sci.sjp.ac.lk",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219479/images/15280_n.jpg",institution:null},{id:"343219",title:"Mrs.",name:"Thilina",middleName:null,surname:"Gunathilaka",fullName:"Thilina Gunathilaka",slug:"thilina-gunathilaka",email:"gunathilakathilina2@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"University of Sri Jayewardenepura",institutionURL:null,country:{name:"Sri Lanka"}}},{id:"356401",title:"Dr.",name:"Lakshika Rangee",middleName:null,surname:"Keerthirathna",fullName:"Lakshika Rangee Keerthirathna",slug:"lakshika-rangee-keerthirathna",email:"rangee9183@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Therapeutic targets for type 2 diabetes mellitus",level:"1"},{id:"sec_3",title:"3. Bioactive compounds present in marine seaweeds",level:"1"},{id:"sec_4",title:"4. Anti-diabetic potentials of marine algae",level:"1"},{id:"sec_4_2",title:"4.1 Inhibitory activity of carbohydrate hydrolyzing α-amylase and α-glucosidase enzymes",level:"2"},{id:"sec_5_2",title:"4.2 Inhibitory activity of dipeptidyl peptidase-IV (DPP-IV)",level:"2"},{id:"sec_6_2",title:"4.3 Inhibitory activity of aldose reductase (AR)",level:"2"},{id:"sec_7_2",title:"4.4 Inhibitory activity of protein tyrosine phosphatase 1B (PTP 1B)",level:"2"},{id:"sec_8_2",title:"4.5 Inhibitory activity of angiotensin-converting enzymes (ACE)",level:"2"},{id:"sec_9_2",title:"4.6 Inhibitory activity of the formation of advanced glycation end products (AGEs)",level:"2"},{id:"sec_11",title:"5. Conclusions",level:"1"},{id:"sec_12",title:"Acknowledgments",level:"1"},{id:"sec_15",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Zaccardi, F.; Webb, D.R.; Yates, T.; Davies, M.J. Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgrad. Med. J. 2016, 92, 63-69'},{id:"B2",body:'Panunti, B.; Jawa, A.A.; Fonseca, V.A. Mechanisms and therapeutic targets in type 2 diabetes mellitus. Drug Discov. Today Dis. Mech. 2004, 1, 151-157'},{id:"B3",body:'Heendeniya, S.N.; Keerthirathna, L.R.; Manawadu, C.K.; Dissanayake, I.H.; Ali, R.; Mashhour, A.; Alzahrani, H.; Godakumbura, P.; Boudjelal, M.; Peiris, D.C. Therapeutic Efficacy of Nyctanthes arbor-tristis Flowers to Inhibit Proliferation of Acute and Chronic Primary Human Leukemia Cells, with Adipocyte Differentiation and in Silico Analysis of Interactions between Survivin Protein and Selected Secondary Meta. Biomolecules 2020, 10, 165'},{id:"B4",body:'Vadivelu, R.; Vijayvergiya, R. 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Res. 2020, 17, 147916411989697'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Thilina Gunathilaka",address:null,affiliation:'
Department of Zoology/Genetics and Molecular Biology Unit (Center for Biotechnology), Faculty of Applied Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
Department of Zoology/Genetics and Molecular Biology Unit (Center for Biotechnology), Faculty of Applied Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
Department of Zoology/Genetics and Molecular Biology Unit (Center for Biotechnology), Faculty of Applied Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. 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