Homocysteine– A Stealth Mediator of Impaired Wound Healing: A Preliminary Study
- 0 Comments
- 6909 reads
Following dermal substitute therapy, all 12 patients receiving treatment were classified as either “responders” or “non-responders” to the 8-week treatment (Table 1). Demographic parameters for study patient comparisons for wound healing included the initial wound area prior to treatment (baseline ulcer area), the wound area following 2 weeks of dermal substitute therapy (ulcer area at 2 weeks), and the corresponding percentage reduction in wound area for that patient (% reduction ulcer area) (Table 1). Homocysteine determinations were recorded following the completion of treatment and were listed as either normal or elevated according to the cardiovascular parameters previously outlined (Table 2). The number of dermal substitute patients experiencing complete wound closure within 12 weeks of the completion of dermal substitute treatment was also recorded (Table 2). Patients responding to dermal substitute were observed with early wound contraction, robust granulation tissue formation, epidermal migration, and re-epithelization of the wound. Patients not responding to dermal substitute treatment were generally observed with a decreased rate of wound contraction, poor granulation tissue formation, and poor clinical evidence of epidermal migration or re-epithelization. For the entire group of 12 patients, 6 were classified as responders and the remaining 6 were classified as non-responders (Tables 1 and 2).
There were no significant differences between the baseline wound areas of responding and non-responding patients (Table 2). However, responding patients demonstrated a significantly greater rate of wound area reduction at 2 weeks as compared to the non-responding patients. All responding patients were observed with normal serum homocysteine levels, while 83% (5/6) of the non-responding patients were observed with elevated serum homocysteine levels. In the responder group, 67% of the patients displayed complete healing of their wounds within 12 weeks of the completion of dermal substitute treatments. None of the patients in the non-responder group were observed with wound closure during this same period. Mean wound fluid NOx determinations for the patients sampled from each group were obtained for the baseline measurement prior to dermal substitute therapy (Table 2). Prior to dermal substitute applications (baseline values), the mean wound fluid NOx value in micromoles (mmol/L ± SE) for the responders group was significantly elevated at 12.98 (± 1.73) as compared to the mean wound fluid NOx value of the non-responders group at 3.50 (± 1.13).
Mean wound fluid NOx value for the responder group was not significantly different from the mean wound fluid NOx (13.9 ± 2.3 mmol/L; n = 13) for lower-extremity ulcers with normal healing responses and normal serum Hcy at the authors’ wound center.19 However, the non-responder mean wound fluid NOx value is significantly lower than the mean wound fluid NOx value associated with normal wound healing and normal serum Hcy values.
Wound fluid NOx and wound area were correlated following dermal substitute treatment for lower-extremity ulcers for a responding and non-responding diabetic lower-extremity ulcer patient in Figures 1 and 2, respectively.
1. Schwentker A, Billiar TR. Nitric oxide and wound repair. Surg Clin North Am. 2003;83(3):521–530.
2. Fukumura D, Gohongi T, Kadambi A, et al. Predominant role of endothelial nitric oxide synthase in vascular endothelial growth factor-induced angiogenesis and vascular permeability. Proc Natl Acad Sci USA. 2001;98(5):2604–2609.
3. Pollock JS, Webb W, Callaway D, Sathyanarayana, O’Brien W, Howdieshell TR. Nitric oxide synthase isoform expression in a porcine model of granulation tissue formation. Surgery. 2001;129(3):341–350.
4. Noiri E, Peresleni T, Srivastava N, et al. Nitric oxide is necessary for a switch from stationary to locomoting phenotype in epithelial cells. Am J Physiol. 1996;270(3 Pt 1):C794–802.
5. Most D, Efron DT, Shi HP, Tantry US, Barbul A. Characterization of incisional wound healing in inducible nitric oxide synthase knockout mice. Surgery. 2002;132(5):866–876.
6. Schaffer MR, Tantry U, Efron PA, Ahrendt GM, Thornton FJ, Barbul A. Diabetes-impaired healing and reduced wound nitric oxide synthesis: a possible pathophysiologic correlation. Surgery. 1997;121(5):513–519.
7. Boykin JV, Kalns JE, Shawler LG, Sommer VL, Crossland M. Diabetes-impaired wound healing predicted by urinary nitrate assay: a preliminary, retrospective study. WOUNDS. 1999;11(3):62–69.
8. Stallmeyer B, Anhold M, Wetzler C, Kahlina K, Pfeilschifter J, Frank S. Regulation of eNOS in normal and diabetes-impaired skin repair: implications for tissue regeneration. Nitric Oxide. 2002;6(2):168–177.
9. Witte MB, Thornton FJ, Tantry U, Barbul A. L-arginine supplementation enhances diabetic wound healing: involvement of the nitric oxide synthase and arginase pathways. Metabolism. 2002;51(10):1269–1273.
10. Schaffer MR, Tantry U, Ahrendt GM, Wasserkrug HL, Barbul A. Acute protein-calorie malnutrition impairs wound healing: a possible role of decreased wound nitric oxide synthesis. J Am Coll Surg. 1997;184(1):37–43.
11. Schaffer M, Weimer W, Wider S, et al. Differential expression of inflammatory mediators in radiation-impaired wound healing. J Surg Res. 2002;107(1):93–100.
12. Ulland AE, Shearer JD, Coulter C, Caldwell MD. Altered wound arginine metabolism by corticosterone and retinoic acid. J Surg Res. 1997;70(1):84–88.
13. Schaffer MR, Tantry U, Thornton FJ, Barbul A. Inhibition of nitric oxide synthesis in wounds: pharmacology and effect on accumulation of collagen in wounds in mice. Eur J Surg. 1999;165(3):262–267.
14. Schaffer MR, Tantry U, Gross SS, Wasserburg HL, Barbul A. Nitric oxide regulates wound healing. J Surg Res. 1996;63(1):237–240.
15. Witte MB, Kiyama T, Barbul A. Nitric oxide enhances experimental wound healing in diabetes. Br J Surg. 2002;89(12):1594–1601.
16. Pollock JS, Webb W, Callaway D, Sathyanarayana, O’Brien W, Howdieshell TR. Nitric oxide synthase isoform expression in a porcine model of granulation tissue formation. Surgery. 2001;129(3):341–350.
17. Welch GN, Loscalzo J. Homocysteine and atherothrombosis. N Engl J Med. 1998;338(15):1042–1050.
18. Green LC, Wagner DA, Glogowski J, Skipper PL, Wishnok JS, Tannenbaum SR. Analysis of nitrate, nitrite, and 15N-nitrate in biological fluids. Anal Biochem. 1982;126(1):131–138.
19. US patents 6,312,663B1, 6,344,181B2, and 6,436,366B2.
20. Eikelboom JW, Lonn E, Genest J Jr, Hankey G, Yusuf S. Homocyst(e)ine and cardiovascular disease: a critical review of the epidemiologic evidence. Ann Intern Med. 1999;131(5):363–375.
21. Beckman JS. The physiological and pathological chemistry of nitric oxide. In: Lancaster J, ed. Nitric Oxide. New York, NY: Academic Press; 1996:1–71.
22. Moncada S, Higgs A. The L-arginine-nitric oxide pathway. N Engl J Med. 1993;329(27):2002–2012.
23. Schaffer MR, Tantry U, van Wesep RA, Barbul A. Nitric oxide metabolism in wounds. J Surg Res. 1997;71(1):25–31.
24. Rhodes P, Leone AM, Francis PL, Struthers AD, Moncada S. The L-arginine:nitric oxide pathway is the major source of plasma nitrite in fasted humans. Biochem Biophys Res Commun. 1995;209(2):590–596.
25. Castillo L, deRojas TC, Chapman TE, Vogt J, Burke JF, Tannenbaum SR, Young VR. Splanchnic metabolism of dietary arginine in relation to nitric oxide synthesis in normal adult man. Proc Natl Acad Sci USA. 1993;90(1):193–197.
26. Baylis C, Vallance P. Measurement of nitrite and nitrate levels in plasma and urine—what does this measure tell us about the activity of the endogenous nitric oxide system? Curr Opin Nephrol Hypertens. 1998;7(1):59–67.
27. Lefer AM, Lefer DJ. The role of nitric oxide and cell adhesion molecules on the microcirculation in ischaemia-reperfusion. Cardiovasc Res. 1996;32(4):743–751.
28. Um SC, Suzuki S, Toyokuni S, et al. Involvement of nitric oxide in survival of random pattern skin flap. Plast Reconstr Surg. 1998;101(3):785–792.
29. Fukumura D, Gohongi T, Kadambi A, et al. Predominant role of endothelial nitric oxide synthase in vascular endothelial growth factor-induced angiogenesis and vascular permeability. Proc Natl Acad Sci USA. 2001;98(5):2604–2609.
30. Dhaunsi GS, Ozand PT. Nitric oxide promotes mitogen-induced DNA synthesis in human dermal fibroblasts through cGMP. Clin Exp Pharmacol Physiol. 2004;31(1-2):46–49.
31. Howdieshell TR, Webb WL, Sathyanarayana, McNeil PL. Inhibition of inducible nitric oxide synthase results in reductions in wound vascular endothelial growth factor expression, granulation tissue formation, and local perfusion. Surgery. 2003;133(5):528–537.
32. Hayden MR, Tyagi SC. Homocysteine and reactive oxygen species in metabolic syndrome, type 2 diabetes mellitus, and atheroscleropathy: the pleiotropic effects of folate supplementation. Nutr J. 2004;3:4.
33. Nygard O, Vollset SE, Refsum H, Brattstrom L, Ueland PM. Total homocysteine and cardiovascular disease. J Intern Med. 1999;246(5):425–454.
34. Petchkrua W, Burns SP, Stiens SA, James JJ, Little JW. Prevalence of vitamin B12 deficiency in spinal cord injury. Arch Phys Med Rehabil. 2003;84(11):1675–1679.
35. Brosnan JT. Homocysteine and cardiovascular disease: interactions between nutrition, genetics and lifestyle. Can J Appl Physiol. 2004;29(6):773–780.
36. Venn BJ, Green TJ, Moser R, Mann JI. Comparison of the effect of low-dose supplementation with L-5-methyltetrahydrofolate or folic acid on plasma homocysteine: a randomized placebo-controlled study. Am J Clin Nutr. 2003;77(3):658–662.
37. Deloughery TG, Evans A, Sadeghi A, et al. Common mutation in methylenetetrahydrofolate reductase. Correlation with homocysteine metabolism and late-onset vascular disease. Circulation. 1996;94(12):3074–3078.
38. Klerk M, Verhoef P, Clarke R, Blom HJ, Kok FJ, Schouten EG; MTHFR Studies Collaboration Group. MTHFR 677C-->T polymorphism and risk of coronary heart disease: a meta analysis. JAMA. 2002;288(16):2023–2031.
39. Willems FF, Boers GH, Blom HJ, Aengevaeren WR, Verheugt FW. Pharmacokinetic study on the utilisation of 5-methyltetrahydrofolate and folic acid in patients with coronary artery disease. Br J Pharmacol. 2004;141(5):825–830.
40. Yaqub BA, Siddique A, Sulimani R. Effects of methylcobalamin on diabetic neuropathy. Clin Neurol Neurosurg. 1992;94(2):105–111.
41. Zhang X, Li H, Jin H, Ebin Z, Brodsky S, Goligorsky MS. Effects of homocysteine on endothelial nitric oxide production. Am J Physiol Renal Physiol. 2000;279(4):F671–678.
42. Nihei S, Tasaki H, Yamashita K, et al. Hyperhomocysteinemia is associated with human coronary atherosclerosis through the reduction of the ratio of endothelium-bound to basal extracellular superoxide dismutase. Circ J. 2004;68(9):822–828.
43. Stuhlinger MC, Tsao PS, Her JH, Kimoto M, Balint RF, Cooke JP. Homocysteine impairs the nitric oxide synthase pathway: role of asymmetric dimethylarginine. Circulation. 2001;104(21):2569–2575.
44. Stallmeyer B, Kampfer H, Kolb N, Pfeilschifter J, Frank S. The function of nitric oxide in wound repair: inhibition of inducible nitric oxide-synthase severely impairs wound reepithelialization. J Invest Dermatol. 1999;113(6):1090–1098.
45. Majors AK, Sengupta S, Willard B, Kinter MT, Pyeritz RE, Jacobsen DW. Homocysteine binds to human plasma fibronectin and inhibits its interaction with fibrin. Arterioscler Thromb Vasc Biol. 2002;22(8):1354–1359.
46. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738–746.
47. Duan J, Murohara T, Ikeda H, et al. Hyperhomocysteinemia impairs angiogenesis in response to hindlimb ischemia. Arterioscler Thromb Vasc Biol. 2000;20(12):2579–2585.
48. Rekhter MD. Collagen synthesis in atherosclerosis: too much and not enough. Cardiovasc Res. 1999;41(2):376–384.