Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico
Autor(a) principal: | |
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Data de Publicação: | 2016 |
Tipo de documento: | Dissertação |
Idioma: | por |
Título da fonte: | Biblioteca Digital de Teses e Dissertações da Uninove |
Texto Completo: | http://bibliotecatede.uninove.br/handle/tede/3013 |
Resumo: | INTRODUCTION: The main cause of mortality in patients with chronic kidney disease (CKD) are Cardiovascular Diseases (CVD); associated with inflammatory mechanisms, which result in endothelial dysfunction and injury. A deficiency of 25 (OH)D3 and/or 1,25(OH)2D3 together with uremic environment may be responsible by poor outcome and activation of the Toll-like receptors (TLR). Furthermore, it is known that 1,25(OH)2D3 exerts immunomodulatory function in various cell types; however it is unclear whether supplementation with 25(OH)D3 might modulate inflammatory response in endothelial cells against uremic environment. OBJECTIVE: The aim of this study was to evaluate the effect of 25(OH)D3 on the expression of inflammatory markers and intracellular Vitamin D mechanism in endothelial cells against the uremic environment. MATERIALS AND METHODS: Endothelial cells from human umbilical cord (HUVEC) were incubated in the presence or absence of uremic serum treated or not treated with 25(OH)D3 for 24h. After incubation, we investigated the inflammatory mediators: Toll-like (TLR-4), ICAM-I (CD54), HLA-DR, Oxidative Stress (ROS) and intracellular mechanisms of Vitamin D Receptor (VDR), 1 -alphahydroxylase (CYP27) and 24-hydroxylase (CYP24) by flow cytometry. RESULTS: The uremic serum induced lower expression of TLR-4 compared with the healthy serum HUVEC. Treatment with 25(OH)D3 had no effect on the modulation of TLR-4 in these cells. For production of ROS, as expected, there was a higher expression in HUVEC stimulated with uremic serum. However, the treatment with 25(OH)D3 not decreased ROS production in these cells. We did not observe differences in the expression of VDR, CYP24 and CYP27 in any groups. We observe a positive correlation between IL-10, MCP-1 and ROS and cathelicidin, IL-10, TNFa and MCP1. There was a negative correlation between TLR-4 and ROS DISCUSSION: This study showed that the uremic serum induced a lower expression of TLR-4, higher expression of cytokines and ROS. Unfortunately, the treatment with 25(OH)D3 was not sufficient to diminish these inflammation mechanisms in HUVEC. Thus, it is necessary future studies to evaluate the impact of time response from 25(OH)D3 or 1,25(OH)2D3 in HUVEC in uremic model. |
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Dalboni, Maria Aparecidahttp://lattes.cnpq.br/9818040147487320Dalboni, Maria Aparecidahttp://lattes.cnpq.br/9818040147487320Reis, Luciene Machado doshttp://lattes.cnpq.br/6070147721873955Dellê, Humbertohttp://lattes.cnpq.br/7435662740477057http://lattes.cnpq.br/4875326730230758Rebello, Jacqueline Ferritto2022-07-27T18:56:07Z2016-12-12Rebello, Jacqueline Ferritto. Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor TOLL-LIKE (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico. 2016. 50 f. Dissertação( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo.http://bibliotecatede.uninove.br/handle/tede/3013INTRODUCTION: The main cause of mortality in patients with chronic kidney disease (CKD) are Cardiovascular Diseases (CVD); associated with inflammatory mechanisms, which result in endothelial dysfunction and injury. A deficiency of 25 (OH)D3 and/or 1,25(OH)2D3 together with uremic environment may be responsible by poor outcome and activation of the Toll-like receptors (TLR). Furthermore, it is known that 1,25(OH)2D3 exerts immunomodulatory function in various cell types; however it is unclear whether supplementation with 25(OH)D3 might modulate inflammatory response in endothelial cells against uremic environment. OBJECTIVE: The aim of this study was to evaluate the effect of 25(OH)D3 on the expression of inflammatory markers and intracellular Vitamin D mechanism in endothelial cells against the uremic environment. MATERIALS AND METHODS: Endothelial cells from human umbilical cord (HUVEC) were incubated in the presence or absence of uremic serum treated or not treated with 25(OH)D3 for 24h. After incubation, we investigated the inflammatory mediators: Toll-like (TLR-4), ICAM-I (CD54), HLA-DR, Oxidative Stress (ROS) and intracellular mechanisms of Vitamin D Receptor (VDR), 1 -alphahydroxylase (CYP27) and 24-hydroxylase (CYP24) by flow cytometry. RESULTS: The uremic serum induced lower expression of TLR-4 compared with the healthy serum HUVEC. Treatment with 25(OH)D3 had no effect on the modulation of TLR-4 in these cells. For production of ROS, as expected, there was a higher expression in HUVEC stimulated with uremic serum. However, the treatment with 25(OH)D3 not decreased ROS production in these cells. We did not observe differences in the expression of VDR, CYP24 and CYP27 in any groups. We observe a positive correlation between IL-10, MCP-1 and ROS and cathelicidin, IL-10, TNFa and MCP1. There was a negative correlation between TLR-4 and ROS DISCUSSION: This study showed that the uremic serum induced a lower expression of TLR-4, higher expression of cytokines and ROS. Unfortunately, the treatment with 25(OH)D3 was not sufficient to diminish these inflammation mechanisms in HUVEC. Thus, it is necessary future studies to evaluate the impact of time response from 25(OH)D3 or 1,25(OH)2D3 in HUVEC in uremic model.INTRODUÇÃO: A principal causa de mortalidade em pacientes com Doença Renal Crônica (DRC) são as Doenças Cardiovasculares (DCV) associadas a mecanismos inflamatórios que resultam em disfunção e lesão endotelial. A deficiência de vitamina 25(OH)D3 e 1,25(OH)2D3 (forma ativa) e o ambiente urêmico pró-inflamatório podem estar envolvidos na inflamação via ativação de receptores toll-like (TLR). Além disso, sabe-se que a 1,25(OH)2D3 exerce função imunomoduladora em vários tipos celulares, entretanto não está claro se a suplementação com 25(OH)D3 pode modular resposta inflamatória nas células endoteliais frente ao ambiente urêmico. OBJETIVO: Desta forma o objetivo do presente estudo foi avaliar o efeito da 25(OH)D3 sobre as expressões de marcadores inflamatórios e mecanismo intracelular da Vitamina D em células endoteliais frente ao ambiente urêmico. MATERIAIS E MÉTODOS: As células endoteliais de cordão umbilical humano (HUVEC) foram incubadas na presença ou ausência de soro urêmico, tratadas ou não com 25(OH)D3 por 24h. Após incubação, avaliamos os mediadores inflamatórios: toll-like (TLR-4), ICAM-l (CD54), HLA-DR e Espécies reativas de oxigênio (ERO) e os mecanismos intracelulares da Vitamina D: Receptor de Vitamina D (VDR), 1-alpha-hydroxylase (CYP27) e 24-hydroxylase (CYP24) por citometria de fluxo. RESULTADOS: Observamos que o insulto com soro urêmico induziu menor expressão de TLR-4 comparado com o soro sadio em HUVEC. O tratamento com 25(OH)D3 não teve efeito na modulação do TLR-4 nestas células. Quanto à produção de ERO, houve um aumento significativo na sua expressão no grupo de HUVEC insultadas com soro urêmico, entretanto o tratamento com 25(OH)D3 não diminuiu a produção de ERO nestas células. Não observamos diferenças significativas na expressão de VDR, CYP24 e CYP27 entre os grupos. Observamos correlação positiva entre IL-10, ERO e MCP-1 e entre catelicidina, IL-10, TNFα e MCP-1. Observou-se uma correlação negativa entre TLR-4 e ERO. DISCUSSÃO: Este estudo demonstrou que o soro urêmico diminui TLR-4, não alterou os mecanismos intracelulares da vitamina D e aumentou a produção de citocinas inflamatórias e ERO, entretanto o pré-tratamento agudo com 25(OH)D3 não demonstrou efeito sobre estes marcadores. Desta forma, estes dados reforçam que são necessários mais estudos com diferentes abordagens tempo-resposta para elucidar mecanismos que possam minimizar a inflamação e suas consequências fisiopatológicas e diversas complicações em células endoteliais frente ao ambiente urêmico.Submitted by Nadir Basilio (nadirsb@uninove.br) on 2022-07-27T18:56:07Z No. of bitstreams: 1 Jacqueline Ferritto Rebello.pdf: 1872318 bytes, checksum: 805e4b26a36150426946fb4c225730bf (MD5)Made available in DSpace on 2022-07-27T18:56:07Z (GMT). No. of bitstreams: 1 Jacqueline Ferritto Rebello.pdf: 1872318 bytes, checksum: 805e4b26a36150426946fb4c225730bf (MD5) Previous issue date: 2016-12-12application/pdfporUniversidade Nove de JulhoPrograma de Mestrado em MedicinaUNINOVEBrasilSaúdevitamina Dreceptor toll-likecitocinasuremiadoenças cardiovascularesvitamintoll-like receptorcytokinesuremiacardiovascular diseasesCIENCIAS DA SAUDEEfeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico25 (OH) D3 vitamin effect over the expression of toll-like receptor (TLR-4) and inflammatory mediators on endothelial cells (HUVEC) in uremic environmentinfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/masterThesis8765449414823306929600info:eu-repo/semantics/openAccessreponame:Biblioteca Digital de Teses e Dissertações da Uninoveinstname:Universidade Nove de Julho (UNINOVE)instacron:UNINOVEORIGINALJacqueline Ferritto Rebello.pdfJacqueline Ferritto Rebello.pdfapplication/pdf1872318http://localhost:8080/tede/bitstream/tede/3013/2/Jacqueline+Ferritto+Rebello.pdf805e4b26a36150426946fb4c225730bfMD52LICENSElicense.txtlicense.txttext/plain; charset=utf-82165http://localhost:8080/tede/bitstream/tede/3013/1/license.txtbd3efa91386c1718a7f26a329fdcb468MD51tede/30132022-07-27 15:56:07.485oai:localhost: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Biblioteca Digital de Teses e Dissertaçõeshttp://bibliotecatede.uninove.br/PRIhttp://bibliotecatede.uninove.br/oai/requestbibliotecatede@uninove.br||bibliotecatede@uninove.bropendoar:2022-07-27T18:56:07Biblioteca Digital de Teses e Dissertações da Uninove - Universidade Nove de Julho (UNINOVE)false |
dc.title.por.fl_str_mv |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
dc.title.alternative.eng.fl_str_mv |
25 (OH) D3 vitamin effect over the expression of toll-like receptor (TLR-4) and inflammatory mediators on endothelial cells (HUVEC) in uremic environment |
title |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
spellingShingle |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico Rebello, Jacqueline Ferritto vitamina D receptor toll-like citocinas uremia doenças cardiovasculares vitamin toll-like receptor cytokines uremia cardiovascular diseases CIENCIAS DA SAUDE |
title_short |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
title_full |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
title_fullStr |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
title_full_unstemmed |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
title_sort |
Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor toll-like (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico |
author |
Rebello, Jacqueline Ferritto |
author_facet |
Rebello, Jacqueline Ferritto |
author_role |
author |
dc.contributor.advisor1.fl_str_mv |
Dalboni, Maria Aparecida |
dc.contributor.advisor1Lattes.fl_str_mv |
http://lattes.cnpq.br/9818040147487320 |
dc.contributor.referee1.fl_str_mv |
Dalboni, Maria Aparecida |
dc.contributor.referee1Lattes.fl_str_mv |
http://lattes.cnpq.br/9818040147487320 |
dc.contributor.referee2.fl_str_mv |
Reis, Luciene Machado dos |
dc.contributor.referee2Lattes.fl_str_mv |
http://lattes.cnpq.br/6070147721873955 |
dc.contributor.referee3.fl_str_mv |
Dellê, Humberto |
dc.contributor.referee3Lattes.fl_str_mv |
http://lattes.cnpq.br/7435662740477057 |
dc.contributor.authorLattes.fl_str_mv |
http://lattes.cnpq.br/4875326730230758 |
dc.contributor.author.fl_str_mv |
Rebello, Jacqueline Ferritto |
contributor_str_mv |
Dalboni, Maria Aparecida Dalboni, Maria Aparecida Reis, Luciene Machado dos Dellê, Humberto |
dc.subject.por.fl_str_mv |
vitamina D receptor toll-like citocinas uremia doenças cardiovasculares |
topic |
vitamina D receptor toll-like citocinas uremia doenças cardiovasculares vitamin toll-like receptor cytokines uremia cardiovascular diseases CIENCIAS DA SAUDE |
dc.subject.eng.fl_str_mv |
vitamin toll-like receptor cytokines uremia cardiovascular diseases |
dc.subject.cnpq.fl_str_mv |
CIENCIAS DA SAUDE |
description |
INTRODUCTION: The main cause of mortality in patients with chronic kidney disease (CKD) are Cardiovascular Diseases (CVD); associated with inflammatory mechanisms, which result in endothelial dysfunction and injury. A deficiency of 25 (OH)D3 and/or 1,25(OH)2D3 together with uremic environment may be responsible by poor outcome and activation of the Toll-like receptors (TLR). Furthermore, it is known that 1,25(OH)2D3 exerts immunomodulatory function in various cell types; however it is unclear whether supplementation with 25(OH)D3 might modulate inflammatory response in endothelial cells against uremic environment. OBJECTIVE: The aim of this study was to evaluate the effect of 25(OH)D3 on the expression of inflammatory markers and intracellular Vitamin D mechanism in endothelial cells against the uremic environment. MATERIALS AND METHODS: Endothelial cells from human umbilical cord (HUVEC) were incubated in the presence or absence of uremic serum treated or not treated with 25(OH)D3 for 24h. After incubation, we investigated the inflammatory mediators: Toll-like (TLR-4), ICAM-I (CD54), HLA-DR, Oxidative Stress (ROS) and intracellular mechanisms of Vitamin D Receptor (VDR), 1 -alphahydroxylase (CYP27) and 24-hydroxylase (CYP24) by flow cytometry. RESULTS: The uremic serum induced lower expression of TLR-4 compared with the healthy serum HUVEC. Treatment with 25(OH)D3 had no effect on the modulation of TLR-4 in these cells. For production of ROS, as expected, there was a higher expression in HUVEC stimulated with uremic serum. However, the treatment with 25(OH)D3 not decreased ROS production in these cells. We did not observe differences in the expression of VDR, CYP24 and CYP27 in any groups. We observe a positive correlation between IL-10, MCP-1 and ROS and cathelicidin, IL-10, TNFa and MCP1. There was a negative correlation between TLR-4 and ROS DISCUSSION: This study showed that the uremic serum induced a lower expression of TLR-4, higher expression of cytokines and ROS. Unfortunately, the treatment with 25(OH)D3 was not sufficient to diminish these inflammation mechanisms in HUVEC. Thus, it is necessary future studies to evaluate the impact of time response from 25(OH)D3 or 1,25(OH)2D3 in HUVEC in uremic model. |
publishDate |
2016 |
dc.date.issued.fl_str_mv |
2016-12-12 |
dc.date.accessioned.fl_str_mv |
2022-07-27T18:56:07Z |
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dc.identifier.citation.fl_str_mv |
Rebello, Jacqueline Ferritto. Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor TOLL-LIKE (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico. 2016. 50 f. Dissertação( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo. |
dc.identifier.uri.fl_str_mv |
http://bibliotecatede.uninove.br/handle/tede/3013 |
identifier_str_mv |
Rebello, Jacqueline Ferritto. Efeito da vitamina 25 (OH) D3 sobre a expressão de receptor TOLL-LIKE (TLR-4) e mediadores inflamatórios sobre células endoteliais (HUVEC) no ambiente urêmico. 2016. 50 f. Dissertação( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo. |
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http://bibliotecatede.uninove.br/handle/tede/3013 |
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