EXPRESSION OF CONCERN

Mediators of Inflammation would like to express concern with the article titled “I?B Kinase Inhibitor VII Modulates Sepsis-Induced Excessive Inflammation and Cardiac Dysfunction in 5/6 Nephrectomized Mice” [1] due to concerns with the data as identified by the authors. The authors contacted the journal to request the retraction of the article stating that they were unable to repeat results shown in Figure 9. They explained that the manuscript states ‘When the 5/6 nephrectomized CLP mice were treated with IKK inhibitor VII, it caused a significant reduction in the increases seen in MPO activity and in levels of plasma inflammatory cytokines’, however, when the experiments were repeated no significant difference was observed. During a reassessment of the article by the journal, potential concerns were identified in the Western blots of Figures 8 and 3, however, the resolution of the images prevented a conclusive result.

The authors apologized but did not provide a response to our request for further clarification and did not provide the original blots. As the journal has not received evidence that the findings are fundamentally flawed, it remains published, however, the conclusions should be viewed with caution.

Mediators of Inflammation
Volume 2020 (2020), Article ID 4251682, 14 pages
https://doi.org/10.1155/2020/4251682

Research Article

IκB Kinase Inhibitor VII Modulates Sepsis-Induced Excessive Inflammation and Cardiac Dysfunction in 5/6 Nephrectomized Mice

Mei Ding,1,2 Dede Lian,³ Lirong Zhang,⁴ Tiechao Jiang,1,2 and Wei Wang⁵

¹Department of Cardiovascular Medicine, China-Japan Union Hospital of Jilin University, Changchun 130033, China
²Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, 130033, China
³Department of Intensive Care Unit, China-Japan Union Hospital of Jilin University, Changchun 130033, China
⁴Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
⁵Department of Cardiovascular Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, China

Correspondence should be addressed to Tiechao Jiang; jiangtc@jlu.edu.cn and Wei Wang; wmpalk@163.com

Mei Ding and Dede Lian contributed equally to this work.

Received 17 December 2019; Revised 4 April 2020; Accepted 11 April 2020; Published 10 September 2020

Academic Editor: Daniela Novick

Copyright © 2020 Mei Ding et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. Chronic kidney disease condition requires regular dialysis; the patients have greater risk of sepsis and have high mortality rate compared to general people with sepsis. The adverse cardiac condition leads to mortality in subjects with sepsis. In the present work, we studied the consequences of chronic kidney damage by 5/6 nephrectomy on cardiac function in mice induced with sepsis and the mechanism involved. Methods. We used C57BL/6 mice and subjected them to 5/6 nephrectomy; after induction of chronic kidney damage, they were subjected to sepsis by either LPS treatment or by cecal ligation and puncture (CLP) method. The cardiac function test was done by echocardiography. Protein expression was done by western blot analysis. Results. The 5/6 nephrectomized mice showed significant increase in blood creatinine and urea levels compared to sham-operated mice; the mice also showed decreased ejection fraction and increased levels of phosphorylated IkBα and nuclear translocation of the NF-κB and inducible nitric oxide synthase (iNOS). When subjected to CLP and LPS treatment, the 5/6 nephrectomized mice augmented cardiac abnormalities and lung inflammation and increased plasma levels of TNF-α, IL-1, IL-12, and IL-18. Also, we evidenced increased levels of p-IKKα/β and Ikβα, NF-κβ, and iNOS. Treatment of IKK inhibitor VII in 5/6 nephrectomized mice after LPS administration or CLP attenuated these effects. Conclusion. Chronic kidney disease could lead to abnormal cardiac function caused by sepsis in mice; this may be due to increased expression of NF-κβ and iNOS in cardiac tissues.

1. Introduction

Sepsis is deregulated inflammatory response against infection, which in excess condition may lead to multiple organ failure and finally to death [1]. It has been evidenced that about majority of cases of sepsis lead to cardiac impairment and the mortality rate could go up to 70% in such cases [2]. Increasing deaths due to sepsis are due to the prevalence of one or more additional conditions such as diabetes and chronic kidney diseases (CKD) [3, 4]. In CKD, the patient needs regular dialysis; also, it has been found that the prevalence of cardiac disorders is the major cause of death in patients reported for CKD [5].

It has been reported that subjects with CKD subjected to dialysis have greater risk of sepsis due the uremia-mediated immune deficiency, other conditions like diabetes, and at last the procedure of sepsis itself [6–8]. In a report earlier, it was found that infected patients with sepsis when submitted to dialysis have high chances of mortality compared to a population having only sepsis [9]. In such cases, changes in cardiac function can play an important role in deaths in patients with sepsis and CKD.

Overexpression of NF-κB is correlated with development of cardiac abnormalities after development of sepsis [10]. The inactivation of NF-κB can be achieved by kBα inhibitor also called as IkBα which binds and solubilises in the cytoplasm [11]. Previously, it was found that blockage of IKK improved the sepsis-mediated multiple organ injury in animal models [12].

However, it is very much unclear whether a preexisting chronic kidney disease could augment the cardiac dysfunctioning under sepsis conditions; also, the overexpression of NF-κB is involved in driving cardiac abnormalities in the presence of chronic renal failure along with sepsis conditions. In the present work, we assessed the effects of chronic kidney disease on cardiac dysfunction under sepsis conditions.

2. Methods and Materials

2.1. Animals and Model of 5/6th Nephrectomy

We used C57BL/6 mice aging 6 weeks for the study; the animals were induced to 2-stage subtotal nephrectomy (SNx) or sham operation under xylazine/ketamine anesthesia (10/100 mg/kg). The animal experiments received approval from the institutional ethical review board of the China-Japan Union Hospital of Jilin University; the approval number was CJERB1477A. Methods were carried out in accordance with relevant guidelines and regulations. The animals were maintained at standard room temperature conditions and were provided free access to water ad libitum. The animal model of 5/6th nephrectomy (SNx) was carried as per published earlier [13].

2.2. Animal Model of Sepsis (Polymicrobial) Induced by Cecal Ligation and Puncture (CLP)

The animal model of sepsis was done by cecal ligation and puncture (CLP) as described earlier [14]. For inducing cardiac dysfunction, we used a needle (18 G) following a double puncture technique in the early phase of sepsis. Briefly, the animals were subjected to ketamine/xylazine anesthesia. The rectal temperature was maintained at 37°C. A 1.5 cm incision was made to open the abdominal portion for exposing the cecum which was ligated and punctured on both the ends. The fecal matter present was removed, and the cecum was placed in its original place, and the abdomen was sutured. The mice were injected with antibiotics (imipenem and cilastatin) 6 hours after surgery, and injection of buprenorphine (50 μg/mL) as analgesic was given after 18 hours. In sham mice, no ligation of the cecum was done but given treatments in the same way. The CLP and CKD animals after one hour were injected with IKK inhibitor VII (Sigma-Aldrich, St. Louis. USA) [12] (1 mg/kg I.V.) or vehicle (DMSO 1%).

2.3. Model of LPS-Mediated Organ Dysfunctions

An animal model of LPS-mediated organ dysfunction was developed by injecting LPS at low doses (2 mg/kg) [15] or PBS in mice with or without chronic kidney disease. The sham mice were not given a dose of LPS but received the other treatment in the same way as received by others.

2.4. Cardiac Function in Mice

The cardiac function in the experimental mice was analyzed by ECG as described earlier [16]. After 24 hours post-CLP or 18 hours post-LPS, mice were subjected to anesthesia (isoflurane 3%) and maintained at 0.5% thereafter during the whole process of test. Each time, the animals were stabilized for 5 minutes before evaluation of the cardiac function test. During the test, the heart rate was recorded by tracing of ECG. The % fractional area change (FAC), % ejection fraction (EF), and fractional shortening (FS) were evaluated by various modes of echocardiography.

For measurement of mean arterial BP, the animals were subjected to anesthesia as described earlier via the carotid artery. Before measuring, a 10-minute baseline was recorded; after injecting IKK inhibitor VII (1 mg/kg I.V.), the mean arterial BP was measured for 1 hour.

2.5. Study of Hemodynamics and Activity by Radiotelemetric in Mice

Radiotelemetric study was done for recording the BP in the free-moving conscious state mice using a radio transmitter which was implanted in the aortic arch. After 10 days of recovery, activity and the blood pressure were measured for 2 hours prior to and 20 hours after CLP. The blood pressure was recorded for 1 minute after interval of 20 minutes, and the mean values of BP and activity were calculated for each time point.

2.6. Analysis of Renal Dysfunction/Cardiac Function and Hepatic Injury

The organ dysfunction and injury were studied by collecting organ and blood samples. The renal dysfunction and hepatic injury were evaluated in mice after 18 hours of induction to LPS and 24 hours post-CLP. The mice were sacrificed using a mixture of ketamine and xylazine. Before the heart was removed, 0.5 mL of blood was collected via cardiac puncture and was analyzed for cell count; the remaining amount of blood was processed to separate plasma by centrifugation. Later, the plasma was evaluated for markers of renal function creatinine, urea, and alanine aminotransferase which is a hepatic injury marker. Plasma urea was estimated by a urea estimaton kit (Abcam, Cambridge UK), creatinine was estimated by a creatinine estimation kit (Abcam, Cambridge, UK), and the levels of alanine aminotransferase were estimated by a kit (Abcam, Cambridge UK). The entire test for urea, creatinine, and alanine aminotransferase was done as per supplied instructions. The tissue samples of the heart were frozen in liquid nitrogen.

2.7. Western Blot Analysis

Western blot analysis was done to study the phosphorylation of IKKα/β and IκBα along with expression levels of iNOS. Western blot analysis was done on the mouse cardiac tissues. For the same, the heart was isolated and homogenized using a homogenization buffer (10%) and was centrifuged at 12000 g for 20 minutes and the cytosolic fractions were obtained. The nuclei were dispersed in buffer and again centrifuged at 12000 g for 15 minutes at 4°C. The nuclear proteins were extracted, and the total protein content was calculated using a protein estimation kit. The proteins were separated on SD-PAGE and were then transferred to PVDF membranes followed by incubation with Iry antibodies p-anti IKK α/β and anti IKK α/β, anti-IκBα, and anti-iNOS. The membranes were again incubated with IIry antibodies conjugated with horseradish peroxidase for 20 minutes and were subjected to development. Densitometric analysis was done for intensity of bands. For relative protein expression, the bands were adjusted against the respective expression in the sham group of mice.

2.8. Wet-to-Dry Lung Weight Ratio

As a measure of lung water accumulation index, the wet-to-dry (W/D) ratio of the lungs was recorded. For the same, the mice were dissected under anesthesia. The left lung was weighed immediately after removal for measuring the wet ratio. The lung tissue was then dried in an oven for 5 days at a temperature of 60°C and reweighed for recording the dry weight; the W/D weight ratio was calculated.

2.9. Cultures of Primary Macrophages

The chronic kidney disease control and sham mice received an injection of 1 mL Bio-Gel (2%) (Bio-Rad, California, US) via intraperitoneal route, and after 4 days, the peritoneal lavages were recovered with EDTA 4 mL (3 mM) in phosphate-buffered saline. The cells () were incubated in RPMI media loaded with FCS (10%) and streptomycin (50 mg/mL). After incubation for 1 hour, the nonadherent cells were removed and were washed; the adhered cells were maintained in RPMI media with FCS (1%) followed by exposure to vehicle (PBS) or LPS of varied concentrations (0.1-10 ng/mL) for 5 hours at room temperature. The cytokines were analyzed in the supernatants.

2.10. Evaluation of MPO Activity and Cytokines

The MPO activity was done to mark the accumulation of neutrophils in the tissues; it was measured by extracting in lung tissues as per the procedure reported earlier [17]. Further, the MPO activity was evaluated from lung tissue extracts as described earlier [17]. Levels of cytokines were analyzed with the help of a cytometric bead array (BD Bioscience, New Jersey, US) in the culture supernatants of macrophages and plasma obtained from the CKD and CLP after treatment of IKK inhibitor VII following the supplied instructions.

2.11. Statistics

The results were presented as . One-way and two-way ANOVA was done followed by Bonferroni post hoc test for multiple comparisons. A value of 0.05 was considered significant.

3. Results

3.1. Evaluation of Organ Dysfunction in 5/6 Nephrectomized Mice

The 5/6 nephrectomized mice showed signs of kidney damage by significantly higher plasma creatinine and urea levels; along with this, the mice exhibited cardiomyopathy by showing decreased EF, FS, and FAC. The 5/6 nephrectomized mice demonstrated high mean arterial blood pressure and also increased heart weight and heart-to-body weight ratio which is a maker for cardiac hypertrophy (Table 1). In addition to this, the interventricular septum showed increased thickness in 5/6 nephrectomized mice, with no alterations in left ventricular wall suggesting concentric hypertrophy in a heart with chronic kidney disease. Blood analysis of 5/6 nephrectomized mice was done and suggested low hemoglobin levels indicating anemia and increased neutrophil-to-lymphocyte ratio (Table 1); also, the mice showed elevated levels of TNF-α, IL-1, IL-12, and IL-18 suggesting that chronic kidney damage may cause systemic inflammation.

Table 1: Combined data for all the groups prior to sepsis and 5/6 nephrectomy.

Parameter
5/6 nephrectomized mice (sham) ()
5/6 nephrectomized mice ()

Body weight (g)

Heart weight (g)

Hear weight index

Mean arterial blood pressure (MABP)

Hemoglobin (g/dL)

Neutrophils (K/μL)

Lymphocytes (K/μL)

Neutrophil to lymphocyte ratio

Interventricular septum (mm)

3.2. 5/6 Nephrectomy Elevated the Dysfunctioning of the Heart Induced by Low-Dose LPS in Mice

In sham-operated 5/6 nephrectomized mice, low-dose LPS caused no notable changes in cardiac function parameters such as FS, FAC, and EF (Figures 1(a)–1(c)). However, in 5/6 nephrectomized mice, LPS (2 mg/kg) caused a significant decrease in %FS, FAC, and EF (Figures 1(a)–1(c)), suggesting that the chronic kidney disease condition could lead to dysfunctioning of cardiac activity in mice.

(a)

(b)

(c)

(d)

(e)

(f)

Figure 1: 5/6 nephrectomy-induced chronic kidney dysfunction causes augmentation of cardiac dysfunction mediated by LPS administration or CLP. (a–c) 5/6 nephrectomized sham or 5/6 nephrectomized mice were treated with either LPS (2 mg/kg) or vehicle, i.e., PBS intraperitoneally. The cardiac function was evaluated after 18 hours. Data representing percentages of (a) EF, (b) FCA, and (c) FS. The group evaluated were 5/6 nephrectomized sham and vehicle treated (PBS), 5/6 nephrectomized sham and PBS, 5/6 nephrectomized sham and LPS (2 mg/kg), and 5/6 nephrectomized and LPS (2 mg/kg). (d–f) 5/6 nephrectomized sham or 5/6 nephrectomized mice were submitted to CLP or sham surgery. The cardiac function was evaluated after 24 hours. Data representing percentages of (d) EF, (e) FCA, and (f) FS. The groups evaluated were 5/6 nephrectomized sham, 5/6 nephrectomized and sham operated, 5/6 nephrectomized sham and CLP, and 5/6 nephrectomized and CLP. The data are presented as . compared to 5/6 nephrectomized sham group with respective treatments; # compared to respective vehicle-treated (PBS) or sham group.

3.3. 5/6 Nephrectomy Elevated the Dysfunctioning of the Heart Induced by Cecal Ligation and Puncture

An animal model of abdominal polymicrobial sepsis resembling humans was created by cecal ligation and puncture method (CLP). It was observed that CLP caused no notable change in the cardiac parameters in sham-operated mice (Figures 1(d)–1(f)). It was observed that the CLP as well as chronic kidney disease mice showed a significant downfall in percentage FS, FCA, and EF suggesting dysfunctioning of the cardiac function in mice (Figures 1(d)–1(h)). It was observed that the chronic kidney disease and CLP mice not only showed decreased cardiac function but also had decreased physical activity (Figure 2(a)). The chronic kidney disease and CLP mice showed a significant decrease in mean arterial blood pressure compared to sham-operated mice (Figure 2(b)). These findings which suggest cardiac dysfunction in CKD and CLP mice cannot be correlated to the small changes in mean arterial blood pressure, hence disqualifying its role.

(a)

(b)

Figure 2: Treatment of IKK inhibitor VII or CLP causes a notable change in activity, but a small change in MABP in 5/6 nephrectomized mice. Radiotelemetric study of (a) delta activity. (b) MABP in conscious condition of 5/6 nephrectomized sham (black mice) or 5/6 nephrectomized sham mice (white and red) subjected to CLP. After 60 minutes of CLP, 5/6 nephrectomized mice were injected with PBS (black) or IKK inhibitor VII. The results are presented as . compared to 5/6 nephrectomized, CLP, and PBS-treated mice.

3.4. 5/6 Nephrectomy in Mice Subjected to Low-Dose LPS or CLP Enhanced the Expression of p-IKKα/β and p-IkBα

In direction to find mechanism associated with sepsis-induced cardiac dysfunction in 5/6 nephrectomized mice, the mice were scanned for the signaling events in cardiac tissues in response to treatment of LPS or CLP. It was found that, as compared to sham-operated 5/6 nephrectomized mice (LPS treated or CLP), the 5/6 nephrectomized mice showed increased expression of p-IKKα/β, p-IkBα, NF-κB, and inducible nitric oxide synthase (iNOS) (Figures 3(a)–3(d) and 4(a)–4(d)). However, submitting the sham-operated 5/6 nephrectomized mice to CLP or lower dose of LPS resulted in no significant changes in the expression of p-IKKα/β, p-IkBα, and iNOS (Figures 3(a)–3(d) and Figures 4(a)–4(d)).

(a)

(b)

(c)

(d)

Figure 3: Treatment of LPS (2 mg/kg) elevates the phosphorylation of IKKα/β and IkBα, the nucleus translocation of NF-κB, and levels of iNOS. 5/6 nephrectomized sham mice or 5/6 nephrectomized mice were given either LPS (2 mg/kg) or vehicle (PBS) via intraperitoneal route. The signaling effects on cardiac tissue were evaluated after 18 hours. The optical density was assessed. (a) Optical density of phosphorylated IKKα/β against total IKKα/β levels normalized against corresponding sham band. (b) Optical density of phosphorylated IkBα against total IkBα levels normalized against corresponding sham band. (c) Levels of NF-κB in nuclear and cytosolic fractions presented as nucleus/cytosol ratio; the results were normalized against corresponding sham band. (d) Levels of iNOS normalized against actin as loading control. All the analysis was performed in triplicate. compared to 5/6 nephrectomized sham mice with described treatment; # compared to the corresponding PBS group.

(a)

(b)

(c)

(d)

Figure 4: CLP enhances the phosphorylation levels of IKKα/β and IkBα, the nucleus translocation of NF-κB, and expression of iNOS. 5/6 nephrectomized sham or 5/6 nephrectomized mice were submitted to CLP or sham surgery. The signaling effects on cardiac tissue were evaluated after 24 hours. The optical density was assessed. (a) Optical density of phosphorylated IKKα/β against total IKKα/β levels normalized against corresponding sham band. (b) Optical density of phosphorylated IkBα against total IkBα levels normalized against corresponding sham band. (c) Levels of NF-κB in nuclear and cytosolic fractions presented as nucleus/cytosol ratio; the results were normalized against corresponding sham band. (d) Levels of iNOS normalized against actin as loading control. All the analysis was performed in triplicate. compared to 5/6 nephrectomized sham mice with described treatment; # compared to the corresponding sham-operated group.

3.5. 5/6 Nephrectomy in Mice Enhanced the Severity of Renal Dysfunction and Hepatic Injury Mediated by CLP or Low Levels of LPS

In the sham-operated 5/6 nephrectomized mice which were subjected to sepsis, CLP or low dose of LPS showed no notable changes in blood levels of creatinine, urea, and alanine aminotransferase (Table 2). But in 5/6 nephrectomized mice, exposure to LPS at low doses significantly increased the blood levels of creatinine, urea, and alanine aminotransferase (Table 2). We also observed that in mice subjected to CLP caused a significant increase in blood creatinine, urea, and alanine aminotransferase suggesting the further worsening of renal as well as hepatic injury.

Table 2: Effects of LPS treatment or CLP on hepatic injury and renal function in 5/6 nephrectomized mice.

Parameter
5/6 nephrectomized mice (sham)
5/6 nephrectomized mice

PBS treated ()
LPS (2 mg/kg) treated ()
PBS treated ()
LPS (2 mg/kg) treated ()

Urea (mM/L)

a
a,b

Creatinine (μM/L)

a
a,b

ALT (U/L)

a,b

Sham operated ()
CLP ()
Sham operated ()
CLP ()

Urea (mM/L)

a,b

Creatinine (μM/L)

a

ALT (U/L)

a,b

The blood creatinine, urea, and ALT levels were analyzed at 18 hrs in mice treated with LPS (2 mg/kg) and at 24 hrs in mice subjected to CLP. The results are presented as . One-way ANOVA was done followed by Bonferroni post hoc test. a against the 5/6 nephrectomy group with mentioned treatment. b against the respective PBS or sham group.

3.6. 5/6 Nephrectomy in Mice Augmented CLP-Mediated Inflammation in the Lungs and Systemic Inflammatory Response

In sham-operated 5/6 nephrectomized mice, CLP do not produced any significant alterations in levels of blood inflammatory cytokines such as TNF-α, IL-1, IL-12, and IL-18 or lung MPO activity (Figures 5(a)–5(e)). In the case of 5/6 nephrectomized mice, CLP caused significant increase in levels of inflammatory cytokines such as TNF-α, IL-1, IL-12, and IL-18 in the blood (Figures 5(a)–5(d)) and also in lung MPO activity (Figure 5(e)) suggesting increased infiltration of neutrophils in the lungs and also increased systemic inflammatory response. On evaluation of cytokines in supernatants of macrophages, treatment of LPS caused significant increase in levels of inflammatory cytokines (Figures 6(a)–6(d)).

(a)

(b)

(c)

(d)

(e)

Figure 5: 5/6 nephrectomy-induced chronic kidney dysfunction causes systemic inflammation mediated by CLP. The inflammatory markers of lung inflammation and systemic inflammatory markers were evaluated after 24 hours in mice subjected to CLP. (a) MPO activity was assessed in lung tissues. (b) Levels of TNF-α in plasma; (c) levels of IL-1 in plasma; (d) levels of IL-12 in plasma; (e) levels of IL-18 in plasma. All the results are ; AB: absent; compared to 5/6 nephrectomized sham mice with corresponding treatment, # compared to the respective sham group, and @ compared to the 5/6 nephrectomized sham group with sham surgery.

(a)

(b)

(c)

(d)

Figure 6: Levels of cytokines in supernatants of macrophages derived from CKD, sham, and CKD chronic mice after treating with LPS: (a) levels of tumor necrosis factor- (TNF-) α (pg/mL) in the supernatant of macrophages; (b) levels of interlukin-1 in the supernatant (pg/mL); (c) levels of interlukin-12 in the supernatant (pg/mL); (d) levels of interlukin-18 in the supernatant (pg/mL). All results are presented as . ND: not detected. compared to macrophages derived from CKD sham-operated mice.

3.7. Blockage of IKK Debilitated LPS-Mediated or CLP Cardiac Dysfunction in 5/6 Nephrectomized Mice

Compared to sham-operated 5/6 nephrectomized mice, the vehicle-treated 5/6 nephrectomized mice which were subjected to CLP showed significant changes in cardiac dysfunction (Figures 7(a)–7(c)); these changes were attenuated significantly by IKK inhibitor VII (Figures 7(a)–7(d)). The 5/6 nephrectomized mice subjected to CLP which were exposed to IKK inhibitor VII showed better activity compared to those receiving vehicle (Figure 2(a)). IKK inhibitor VII elevated the mean arterial blood pressure in 5/6 nephrectomized and CLP mice (Figure 2(b)), whereas the blood pressure remained unaffected in mice subjected to anesthesia. Hence, it may be assumed that the high blood pressure in IKK inhibitor VII-treated 5/6 nephrectomized and CLP mice may be due to increased cardiac or improved cardiac function. Further, it was observed that IKK inhibitor VII caused no notable changes in blood ALT, creatinine, and urea levels (Table 3).

(a)

(b)

(c)

Figure 7: Blockade of IKK decreased the CLP-mediated cardiac dysfunction in animals subjected to 5/6 nephrectomy. 5/6 nephrectomized mice subjected to sham surgery or CLP. After 1 hour of CLP, the mice were exposed with either IKK inhibitor VII (1 mg/kg I.V.) or DMSO (2%) which was used as vehicle. The cardiac activity was evaluated after 24 hours. Data shows percentages of (a) EF, (b) FCA, and (c) FS. The groups studied were 5/6 nephrectomized mice and 5/6 nephrectomized sham mice; 5/6 nephrectomized, CLP, and vehicle treated, and 5/6 nephrectomized, CLP, and IKK inhibitor VII. All the results are presented as . compared to 5/6 nephrectomized mice, CLP, or vehicle-treated group.

Table 3: Effect of IKK inhibitor VII on renal dysfunctioning and hepatic injury mediated by sepsis in 5/6 nephrectomized mice.

Parameter
5/6 nephrectomized mice

5/6 nephrectomized mice (sham) ()
CLP+vehicle ()
CLP+IKK inhibitor VII ()

Urea (mM/L)

Creatinine (μM/L)

ALT (U/L)

The 5/6 nephrectomized mice were subjected to sham surgery or CLP. After 1-hour CLP, the mice were treated with IKK inhibitor VII or vehicle. The plasma levels of creatinine, urea, and ALT were evaluated after 24 hours post-CLP. compared to 5/6 nephrectomized vehicle treated.

3.8. Effect of IKK Inhibitor VII Treatment on IKKα/β, IκBα, NF-κB, and iNOS in LPS-Treated or CLP 5/6 Nephrectomized Mice

We observed that, compared to vehicle-treated 5/6 nephrectomized CLP mice, treatment of IKK inhibitor VII attenuated the increases in levels of p-IKKα/β, p-IκBα, nuclear translocation of NF-κB, and expression of iNOS (Figures 8(a)–8(d)). In addition to this, similar results were observed in 5/6 nephrectomized CLP mice with delayed treatment of IKK inhibitor VII.

(a)

(b)

(c)

(d)

Figure 8: Blockade of IKK provides attenuation and enhances the phosphorylation of IKKα/β and IkBα nuclear translocation of NF-κB and levels of iNOS in 5/6 nephrectomized CLP mice. The 5/6 nephrectomized mice were subjected to sham surgery, and 5/6 nephrectomized mice were subjected to CLP or sham surgery; after 1 hour post-CLP and 5/6 nephrectomy, the mice were treated with IKK inhibitor VII or vehicle (DMSO). The signaling effects in cardiac tissues were analyzed after 24 hours. Optical density of bands was assessed for the following: (a) phosphorylation of IKKα/β expressed to respective total IKKα/β normalized to respective sham band; (b) optical density of phosphorylated IkBα against total IkBα levels normalized against corresponding sham band; (c) levels of NF-κB in nuclear and cytosolic fractions presented as nucleus/cytosol ratio; the results were normalized against corresponding sham band; (d) levels of iNOS normalized against actin as loading control. Each experiment was done in triplicate; the data are presented as . compared to 5/6 nephrectomized mice, CLP mice, and vehicle-treated group.

3.9. Blockage of IKK Decreased Systemic Inflammatory Response and Lung Inflammation Induced due to LPS Treatment or CLP in 5/6 Nephrectomized Mice

When the 5/6 nephrectomized CLP mice were treated with IKK inhibitor VII, it caused a significant reduction in the increases seen in MPO activity and in levels of plasma inflammatory cytokines (Figures 9(a)–9(e)). We also observed that IKK inhibitor VII showed protective effects against inflammation in the lungs and systemic inflammatory response observed in 5/6 nephrectomized CLP mice. On studying the W/D weight ratio, it was found that the nephrectomized mice with CLP and treated with vehicle showed increased W/D ratio compared to sham-operated mice. The nephrectomized mice treated with IL had a decreased W/D ratio (Figure 9(f)).

(a)

(b)

(c)

(d)

(e)

(f)

Figure 9: Blockade of IKK provides attenuation in systemic and lung inflammatory response mediated by CLP in 5/6 nephrectomized mice. The 5/6 nephrectomized mice were subjected to CLP or sham surgery. After 1-hour CLP, 5/6 nephrectomized mice were exposed to either IKK inhibitor VII (1 mg/kg I.V.) or DMSO 9 (2%) (vehicle). The lung inflammatory and systemic markers were evaluated after 24 hours. (a) MPO activity was assessed in lung tissues, (b) levels of TNF-α in plasma, (c) levels of IL-1 in plasma, (d) levels of IL-12 in plasma, (e) levels of IL-18 in plasma, and (f) results of wet to dry (W/D) ratio of lungs. All the results are . AB: absent; compared to 5/6 nephrectomized, CLP, and vehicle-treated mice.

4. Discussion

The prevalence of cardiac abnormalities along with sepsis in patients can have high mortality rates [18]. It was reported earlier that patients with chronic kidney disease have increased risk of mortality postsepsis [19]. However, the mechanisms and pathways involved for the high risk of mortality still remain unclear. The present study was undertaken to confirm the effects and the involved mechanism of preexisting chronic kidney disease on cardiac functioning in mice with sepsis.

To create chronic kidney disease condition in mice, we operated the mice by 5/6 nephrectomy; we noticed that such mice showed significant left ventricular hypertrophy and damage in systolic function suggesting cardiorenal syndrome [20]. These findings are in agreement to earlier reports which suggested impaired cardiac function in 5/6 nephrectomy mice [21]. We believe that the cardiac dysfunction in 5/6 nephrectomized mice may be due to significantly higher blood pressure; these findings are in agreement to earlier findings which suggested that patients undergoing dialysis had significantly higher risk of left ventricular hypertrophy [22]. It is well evidenced that hypertension is correlated with adverse cardiovascular events [23]. These cardiac abnormalities linked with hypertension may lead to increased risk of cardiac mortalities in subjects with renal failure [24]. In the present study, we evidenced that the chronic kidney disease condition (5/6 nephrectomy) worsens the LPS-mediated cardiac abnormalities in sepsis. These findings are in association with the earlier reports which suggest that chronic kidney disease worsens the cardiac function having sepsis [25].

Chronic kidney disease is linked to systemic inflammation which is marked by increased levels of inflammatory cytokines such as TNF-α, IL-1, IL-12, and IL-18. All these are important inflammatory cytokines [1]. These increased levels of cytokines are a result of kidney damage which prevents excretion [26]. We evidenced that the levels of the inflammatory cytokines such as TNF-α, IL-1, IL-12, and IL-18 were increased in our chronic kidney disease model.

NF-κβ is one of the important members of proinflammatory cytokines [11]. The 5/6 nephrectomy in mice leads to phosphorylation of IKKα/β which suggested activation of IKK which further caused the activation of NF-κβ and phosphorylation of IκB-β. We also observed that chronic kidney disease caused upregulation in levels of proinflammatory cytokines and also the levels of p-IκB-α; this activation of NF-κβ in chronic kidney disease may also be due to the hypertensive state.

It is evidenced earlier that NF-κβ is activated significantly in rat cardiomyocytes in a model which mimics hypertension; this activation may contribute to cardiomyopathy via its target gene iNOS [27]. Also, it is found that activation of NF-κβ followed by overexpression of iNOS may lead to sepsis-mediated impairment of left ventricular function [28]. In the present study, levels of iNOS were increased in cardiac tissues of 5/6 nephrectomized mice (sepsis induced) accompanied with impaired cardiac function. As it was observed that none of both LPS and CLP caused any notable changes in levels of iNOS in mice with no kidney disease, it can be confirmed that the activation of NF-κβ during chronic kidney disease may be the main contributing factor for cardiac dysfunction in a chronic kidney disease model of sepsis. Also, inducing the expression of iNOS leads to activation of NF-κβ [29]. In the present work, we evidenced significant increase in plasma levels of NF-kβ, IL-1, IL-12, and IL-18 in 5/6 nephrectomized mice with CLP. As majority of cytokines are excreted from renal route, also, the inflammatory mediators have shown greater half-lives in chronic kidney damage condition compared to normal mice [30]. Hence, impaired kidney function causing high plasma life of cytokines in chronic kidney disease may increase the systemic inflammation which may further lead to cardiac abnormalities and lung inflammation in 5/6 nephrectomized mice with sepsis [31]. In the present work, increased inflammation in the lungs operated with 5/6 nephrectomy having sepsis is in agreement with these earlier studies demonstrating that preexisting defective kidney condition makes the subjects more susceptible to death [32].

Knowing the fact about the role of IKKα/β phosphorylation followed by the activation of NF-κβ in worsened cardiac function mediated by sepsis in chronic kidney disease mice, we studied the effect of IKK inhibition in mice subjected to 5/6 nephrectomy which had undergone treatment of LPS or CLP. In the present work, we found that treatment with IKK inhibitor VII decreased the levels of systemic inflammatory markers and also preserved the organs by decreasing organ damage; our findings were in agreement with earlier studies which suggested that IKK inhibitor showed an organ-protective effect and also decreased the levels of systemic inflammatory markers in mice having sepsis without chronic kidney disease [12]. Also, we reported that the treatment with IKK inhibitor VII after LPS administration or CLP corrected the sepsis-mediated cardiac abnormalities in 5/6 nephrectomized mice which was matched equally by significant attenuation of iNOS and NF-κβ in cardiac tissues.

5. Conclusion

In this study, we found that preexistence of chronic kidney disease increases the cardiac abnormalities caused by sepsis. Here, we showed that solely chronic kidney disease caused systemic inflammation and leads to activation of iNOS and NF-κβ expression in the cardiac tissues, whereas sepsis in mice with chronic kidney disease resulted in increased plasma levels of IL-1, IL-12, and IL-18 and also elevated the activation of NF-κβ and iNOS in cardiac tissues. Most interestingly, the treatment with IKK inhibitor VII inhibited the cardiac abnormalities and systemic inflammation mediated by sepsis in mice operated for 5/6 nephrectomy. Hence, we can confirm that inhibition of IKK could be the new therapeutic approach in treating inflammatory and cardiac abnormalities involved with sepsis in patients with chronic kidney disease.

Data Availability

The data used to support the findings of this study are available from the corresponding author upon request.

Ethical Approval

The animal experiments received approval from the institutional ethical review board of the China-Japan Union Hospital of Jilin University; the approval number was CJERB1477A.

Conflicts of Interest

The authors declare that they have no competing interests.

Authors’ Contributions

MD and DL prepared the manuscript; LZ, TJ, and WW along with MD and DL planned the study. MD and DL performed animal studies; and LZ, TJ, and WW worked on various experimental parameters. All the authors read the manuscript before submission. Mei Ding and Dede Lian contributed equally to this work.

Acknowledgments

The authors are thankful to the staff and management of respective departments of China-Japan Union Hospital of Jilin University.

References

R. S. Hotchkiss, G. Monneret, and D. Payen, “Immunosuppression in sepsis: a novel understanding of the disorder and a new therapeutic approach,” The Lancet Infectious Diseases, vol. 13, no. 3, pp. 260–268, 2013.

C. J. Fernandes Jr., N. Akamine, and E. Knobel, “Cardiac troponin: a new serum marker of myocardial injury in sepsis,” Intensive Care Medicine, vol. 25, pp. 1165–1168, 1999.

D. C. Angus, W. T. Linde-Zwirble, J. Lidicker, G. Clermont, J. Carcillo, and M. R. Pinsky, “Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care,” Critical Care Medicine, vol. 29, no. 7, pp. 1303–1310, 2001.

C. T. Esmon, “Why do animal models (sometimes) fail to mimic human sepsis?” Critical Care Medicine, vol. 32, pp. S219–S222, 2004.

H. Moradi, D. A. Sica, and K. Kalantar-Zadeh, “Cardiovascular burden associated with uremic toxins in patients with chronic kidney disease,” American Journal of Nephrology, vol. 38, no. 2, pp. 136–148, 2013.

A. J. Collins, R. N. Foley, C. Herzog et al., “US renal data system 2010 annual data report,” American Journal of Kidney Diseases, vol. 57, no. 1, article A8, 2011.

G. Cohen, M. Haag-Weber, and W. H. Hörl, “Immune dysfunction in uremia,” Kidney International. Supplement, vol. 62, pp. S79–S82, 1997.

L. S. Dalrymple and A. S. Go, “Epidemiology of acute infections among patients with chronic kidney disease,” Clinical Journal of the American Society of Nephrology, vol. 3, no. 5, pp. 1487–1493, 2008.

M. J. Sarnak and B. L. Jaber, “Mortality caused by sepsis in patients with end-stage renal disease compared with the general population,” Kidney International, vol. 58, no. 4, pp. 1758–1764, 2000.

A. I. Khan, S. M. Coldewey, N. S. Patel et al., “Erythropoietin attenuates cardiac dysfunction in experimental sepsis in mice via activation of the β-common receptor,” Disease Models & Mechanisms, vol. 6, no. 4, pp. 1021–1030, 2013.

U. Senftleben and M. Karin, “The IKK/NF-κB pathway,” Critical Care Medicine, vol. 30, pp. S18–S26, 2002.

S. M. Coldewey, M. Rogazzo, M. Collino, N. S. Patel, and C. Thiemermann, “Inhibition of IκB kinase reduces the multiple organ dysfunction caused by sepsis in the mouse,” Disease Models & Mechanisms, vol. 6, no. 4, pp. 1031–1042, 2013.

R. F. Gagnon and B. Gallimore, “Characterization of a mouse model of chronic uremia,” Urological Research, vol. 16, no. 2, pp. 119–126, 1988.

K. A. Wichterman, A. E. Baue, and I. H. Chaudry, “Sepsis and septic shock—a review of laboratory models and a proposal,” The Journal of Surgical Research, vol. 29, no. 2, pp. 189–201, 1980.

H. Huang, T. Liu, J. L. Rose, R. L. Stevens, and D. G. Hoyt, “Sensitivity of mice to lipopolysaccharide is increased by a high saturated fat and cholesterol diet,” Journal of Inflammation, vol. 4, no. 1, p. 22, 2007.

J. Chen, F. Chiazza, M. Collino, N. S. Patel, S. M. Coldewey, and C. Thiemermann, “Gender dimorphism of the cardiac dysfunction in murine sepsis: signalling mechanisms and age-dependency,” PLoS One, vol. 9, no. 6, article e100631, 2014.

F. C. Barone, L. M. Hillegass, W. J. Price et al., “Polymorphonuclear leukocyte infiltration into cerebral focal ischemic tissue: myeloperoxidase activity assay and histologic verification,” Journal of Neuroscience Research, vol. 29, no. 3, pp. 336–345, 1991.

J. Blanco, A. Muriel-Bombín, V. Sagredo et al., “Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study,” Critical Care, vol. 12, no. 6, p. R158, 2008.

H. I. McDonald, D. Nitsch, E. R. Millett, A. Sinclair, and S. L. Thomas, “Are preexisting markers of chronic kidney disease associated with short-term mortality following acute community-acquired pneumonia and sepsis? A cohort study among older people with diabetes using electronic health records,” Nephrology, Dialysis, Transplantation, vol. 30, no. 6, pp. 1002–1009, 2015.

P. A. McCullough, J. A. Kellum, M. Haase et al., “Pathophysiology of the cardiorenal syndromes: executive summary from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI),” Contributions to Nephrology, vol. 182, pp. 82–98, 2013.

Y. Li, G. Takemura, H. Okada et al., “Molecular signaling mediated by angiotensin II type 1A receptor blockade leading to attenuation of renal dysfunction-associated heart failure,” Journal of Cardiac Failure, vol. 13, no. 2, pp. 155–162, 2007.

R. N. Foley, P. S. Parfrey, J. D. Harnett, G. M. Kent, D. C. Murray, and P. E. Barre, “Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease,” Kidney International, vol. 49, no. 5, pp. 1379–1385, 1996.

P. Muntner, J. He, B. C. Astor, A. R. Folsom, and J. Coresh, “Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study,” Journal of the American Society of Nephrology, vol. 16, no. 2, pp. 529–538, 2005.

M. G. Shlipak, L. F. Fried, M. Cushman et al., “Cardiovascular mortality risk in chronic kidney disease: comparison of traditional and novel risk factors,” Journal of the American Medical Association, vol. 293, no. 14, pp. 1737–1745, 2005.

H. Shmuely, S. Pitlik, M. Drucker, Z. Samra, H. Konisberger, and L. Leibovici, “Prediction of mortality in patients with bacteremia: the importance of pre-existing renal insufficiency,” Renal Failure, vol. 22, no. 1, pp. 99–108, 2009.

A. Denic, R. J. Glassock, and A. D. Rule, “Structural and functional changes with the aging kidney,” Advances in Chronic Kidney Disease, vol. 23, no. 1, pp. 19–28, 2016.

A. Leychenko, E. Konorev, M. Jijiwa, and M. L. Matter, “Stretch-induced hypertrophy activates NFkB-mediated VEGF secretion in adult cardiomyocytes,” PLoS One, vol. 6, no. 12, article e29055, 2011.

C. Thiemermann and J. Vane, “Inhibition of nitric oxide synthesis reduces the hypotension induced by bacterial lipopolysaccharides in the rat in vivo,” European Journal of Pharmacology, vol. 182, no. 3, pp. 591–595, 1990.

M. A. Brown and W. K. Jones, “NF-κB action in sepsis: the innate immune system and the heart,” Frontiers in Bioscience, vol. 9, no. 1-3, pp. 1201–1217, 2004.

A. Leelahavanichkul, Y. Huang, X. Hu et al., “Chronic kidney disease worsens sepsis and sepsis-induced acute kidney injury by releasing high mobility group box protein-1,” Kidney International, vol. 80, no. 11, pp. 1198–1211, 2011.

J. E. Parrillo, C. Burch, J. H. Shelhamer, M. M. Parker, C. Natanson, and W. Schuette, “A circulating myocardial depressant substance in humans with septic shock. Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance,” The Journal of Clinical Investigation, vol. 76, no. 4, pp. 1539–1553, 1985.

D. Viasus, C. Garcia-Vidal, J. M. Cruzado et al., “Epidemiology, clinical features and outcomes of pneumonia in patients with chronic kidney disease,” Nephrology, Dialysis, Transplantation, vol. 26, no. 9, pp. 2899–2906, 2011.