2. DISCOVERY OF ADIPONECTIN AND ITS CLINICAL SIGNIFICANCE

Adiponectin and Inflammation

Yuji Matsuzawa

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From: Nutrition and Health: Adipose Tissue and Adipokines in Health and Disease Edited by: G. Fantuzzi and T. Mazzone © Humana Press Inc., Totowa, NJ

111 Abstract

Adipose tissue has been recognized as the organ not only storing excess energy but also secret- ing a variety of bioactive substances named adipocytokines. Adipocytokines include tumor necrosis factor-F and interleukin-6, which are secreted from adipose tissue and may induce inflammatory response in various tissues including vascular walls and muscles. We found a novel adipocytokine named adiponectin, which has a strong ability of anti-inflammation. Adiponectin inhibits several inflammatory responses in macrophages and endothelial cells. This chapter presents a variety of anti-inflammatory functions and also discusses the mechanism of antidiabetic, anti-atherogenic, and anti-oncogenic properties of adiponectin.

Key Words: Visceral fat; metabolic syndrome; hypoadiponectinemia; C-reactive protein; acute coronary syndrome; insulin resistance.

1. INTRODUCTION

Excess body fat, especially intra-abdominal visceral fat accumulation, is associated with a number of disease conditions, including dyslipidemia, type 2 diabetes, hyper- tension, and cardiovascular disease (1). Therefore, visceral fat accumulation—esti- mated by waist circumference—is adopted as an essential component of metabolic syndrome, which has been recently classified as a highly atherogenic state. Recent research, including ours, has shown that adipose tissue secretes various bioactive sub- stances, collectively referred to as adipocytokines, that may directly contribute to the pathogenesis of conditions associated with obesity (2). Thus, adipose tissue seems to be an endocrine organ that can affect the function of other organs, including the vascular walls, through secretion of various adipocytokines. These adipocytokines include heparin-binding epidermal growth factor-like growth factor (HB-EGF), leptin, tumor necrosis factor (TNF)-F, plasminogen activator inhibitor type 1 (PAI-1), and angio- tensinogen. The expression and plasma levels of these adipocytokines increase with visceral fat accumulation; these molecules are implicated in insulin resistance and atherosclerosis (3,4). In addition to the analysis of known genes, we identified adipose tissue’s most abundant gene transcript, which we named apM-1 (5) and named the protein encoded by apM-1 adiponectin (6). In contrast with other adipocytokines, adiponectin levels are inversely correlated to visceral adiposity and low levels have been associated with visceral obesity, type 2 diabetes, hypertension, and cardiovascular disease (7).

This article discusses the physiological roles of adiponectin in the prevention of obe- sity-related diseases, especially focusing on its anti-inflammatory function.

2. DISCOVERY OF ADIPONECTIN AND ITS CLINICAL SIGNIFICANCE

The molecule encoded by apM-1 possesses a signal peptide, collagen-like motif, and a globular domain, and has notable homology with collagen X and VIII, and complement factor C1q (5). We termed the collagen-like protein adiponectin. The mouse homolog of adiponectin has been cloned as AdipoQ or ACRP30 (8,9).

We established a method for measurement of plasma adiponectin levels using enzyme-linked immunosorbent assay (10). The average levels of adiponectin in human plasma are extremely high—up to 5 to 10 Rg/mL (10). Plasma concentrations are neg- atively correlated with body mass index (BMI), whereas leptin increases with BMI. The negative correlation of adiponectin levels and visceral adiposity is stronger than between adiponectin levels and subcutaneous adiposity (Fig. 1) (7).

The mechanism by which plasma adiponectin levels are reduced in individuals with visceral fat accumulation is not yet clarified. Coculture with visceral fat inhibits adiponectin secretion from subcutaneous adipocytes (11). This finding suggests that some inhibiting factors for adiponectin synthesis or secretion are released from visceral adipose tissue. TNF-F was reported to be a strong inhibitor of adiponectin promoter activity (12). The negative correlation between visceral adiposity and adiponectin levels might be explained at least in part by the increased secretion of this cytokine from accu- mulated visceral fat.

Plasma adiponectin concentrations are lower in people who have type 2 diabetes mellitus than in BMI-matched controls (13). Plasma adiponectin concentrations have been shown

Fig. 1. Correlation between visceral adiposity and plasma adiponectin or PAI-1 (3,7).

to correlate strongly with insulin sensitivity, which suggests that low plasma concentra- tions are related to insulin resistance (14). In a study of Pima Indians, individuals with high levels of adiponectin were less likely than those with low concentrations to develop type 2 diabetes (15). High adiponectin concentration was, therefore, a notable protec- tive factor against development of type 2 diabetes.

Studies on adiponectin knockout (KO) mice support observations in humans. The KO mice showed no specific phenotype when they were fed a normal diet, but a high- sucrose and high-fat diet induced a marked elevation of plasma glucose and insulin levels (16), although other groups have reported that the KO mouse develops insulin resistance on a regular diet (17). Insulin resistance, estimated by the insulin tolerance test during a high-sucrose with high-fat diet, also developed in adiponectin KO mice.

Supplementation of adiponectin by adenovirus transfection clearly improved insulin resistance (16). Although I will not mention the details of molecular mechanisms, adiponectin has been shown to exert its actions on muscle fatty acid oxidation and insulin sensitivity by activation of AMP-activated protein kinase (18). Plasma levels of adiponectin are also decreased in hypertensive humans, irrespective of the presence of insulin resistance (19). Endothelium-dependent vasoreactivity is impaired in people with hypoadiponectinemia, which might be at least one mechanism of hypertension in visceral obesity (20).

Most important, plasma concentrations of adiponectin are lower in people with coro- nary heart disease than in controls, even when BMI and age are matched. Kaplan-Meier analysis in Italian individuals with renal insufficiency demonstrated that those with high adiponectin concentrations were free from cardiovascular death for longer than other groups (21). A case–control study performed in Japan demonstrated that the group with plasma adiponectin lower than 4 Rg/mL has increased risk of coronary artery disease (CAD) and multiple metabolic risk factors, which indicates that hypoadiponectinemia is a key factor in metabolic syndrome (22). A prospective study by Pischon et al. (23) con- firmed that high adiponectin concentrations are associated with reduced risk of acute myocardial infarction in men. In addition to hypoadiponectinemia accompanied with vis- ceral fat accumulation, genetic hypoadiponectinemia caused by a missense mutation has been reported to be associated with the clinical phenotype of metabolic syndrome (24).

This clinical evidence shows that hypoadiponectinemia is a strong risk factor for cardiovascular disease.

3. ADIPOSE TISSUE AND INFLAMMATION

Recent studies have revealed that inflammatory responses contribute to the develop- ment of a variety of common diseases, including atherosclerosis and metabolic diseases, including diabetes mellitus. On the other hand, adipose tissue has been recognized to secrete bioactive substances that relate to inflammation. TNF-F is a typical cytokine that plays a major role in inflammatory cellular phenomena. Since Uysal et al. first reported that adipose tissue secretes this cytokine and proposed it as one of the candidates for molecules inducing insulin resistance (25), TNF-F has come to be recognized as an important adipocytokine. It has been shown that adipose TNF-F mRNA and plasma TNF-F protein are increased in most animal models and in humans with obesity and insulin resistance (25,26). Neutralizing TNF-F in obese rats with a soluble TNF-F receptor-immunoglobulin G fusion protein markedly improves insulin resistance (27).

These results indicate that higher production of TNF-F in accumulated adipose tissue may be causative for obesity-associated insulin resistance. In addition to TNF-F, inter- leukin (IL)-1G, IL-6, macrophage migration factor, nerve growth factor, and hapto- globin have been shown to be secreted from adipose tissue and linked to inflammation and the inflammatory response. More recently one typical marker of inflammation, C-reactive protein (CRP), was found to be produced in adipose tissue and CRP mRNA expression was found to be enhanced in adipose tissue in adiponectin KO mice (28).

The elevated production of these inflammation-related adipocytokines is increasingly considered to be important in the development of diseases linked to obesity, particularly type 2 diabetes and cardiovascular disease. Namely, adipose tissue is involved in exten- sive crosstalk with other organs and multiple metabolic systems through the various adipocytokines.

4. ADIPONECTIN AS A POTENT ANTI-INFLAMMATION ADIPOCYTOKINE

As already mentioned, adiponectin has multiple functions for prevention of meta- bolic diseases and cardiovascular diseases. More recently, adiponectin was shown to prevent liver fibrosis and some kinds of cancer such as endometrial cancer, breast cancer, and colon cancer, in animal models (29–32). Besides these well-characterized biological functions, recent evidence supports a strong anti-inflammatory function. We first reported that adiponectin strongly suppresses production of the potent proinflam- matory cytokine TNF-F in macrophages (33). Treatment of cultured macrophages with adiponectin significantly inhibits their phagocytic activity and their lipopolysaccharide- induced production of TNF-F. Suppression of phagocytosis by adiponectin is mediated by one of the complement C1q receptors, C1qRp, because this function was completely abrogated by the addition of an anti-C1qRp monoclonal antibody (33). These observa- tions suggest that adiponectin is an important negative regulator in immune and inflammatory systems, indicating that it may be involved in terminating inflammatory responses through its inhibitory functions.

In the process of development of atherosclerosis, macrophages play crucial roles in plaque formation. Adiponectin attenuates cholesterol ester accumulation in macrophages.

Adiponectin-treated macrophages contain fewer lipid droplet stained by oil red O (34).

Adiponectin suppresses expression of class A macrophage scavenger receptor (MSR) at both mRNA and protein levels, without affecting the expression of CD36, as demon- strated by flow cytometry (35). Adiponectin was also shown to attenuate expression of MSR and TNF-F in atherosclerotic lesions (34). Adiponectin inhibits TNF-F-induced mRNA expression of monocyte adhesion molecules without affecting the interaction between TNF-F and its receptors in human aortic endothelial cells. Adiponectin suppresses TNF-F-induced IPB-F phosphorylation and subsequent NFPB activation without affecting other TNF-F-mediated signals, including Jun N-terminal kinase, p38 kinase, and Akt kinase (36). This inhibitory effect of adiponectin is accompanied by cAMP accumulation and is blocked by either an adenylate cyclase inhibitor or a protein kinase A (PKA) inhibitor. These observations suggest that adiponectin, which is naturally present at very high amounts in the bloodstream, modulates the inflammatory response of both macrophages and endothelial cells through crosstalk between cAMP–PKA and

NFPB signaling pathways (Fig. 2). The anti-inflammatory function of adiponectin may result in the prevention of atherogenic cell phenomena, such as monocyte adhesion to endothelial cells, differentiation of monocytes to macrophages, and foam cell formation.

Recent studies demonstrate that adiponectin also induces various anti-inflammatory cytokines, such as IL-10 and IL-1 receptor antagonist (37). Acute coronary syndrome is considered to determine the prognosis of cardiovascular disease, in which vulnerability of the plaque is an important determinant of plaque rupture. In this process, matrix metalloproteinases (MMP) secreted by macrophages are thought to play an important role in plaque vulnerability. Tissue inhibitor of metalloproteinase (TIMP) is thought to act as protector of plaque rupture by inhibition of MMP activity. Adiponectin increases the expression of mRNA and protein production of TIMP in macrophages (38). Prior to the induction of TIMP formation and secretion, adiponectin induces IL-10 synthesis in macrophages, suggesting that adiponectin induces TIMP formation and secretion via induction of IL-10 synthesis in an autocrine manner in macrophages and may also inhibit MMP activity (Fig. 3) (38). These functions may result in the prevention of acute coronary syndrome.

As mentioned before, CRP is a typical marker of inflammation; increased levels of CRP are now considered to be a risk factor for atherosclerosis (39). A number of studies have shown that there is a reciprocal association of adiponectin and CRP in plasma in healthy subjects and in subjects with a variety of diseases, including type 2 diabetes, metabolic syndrome, and end-stage kidney disease (40,41). The mechanism of this reciprocal association of CRP and adiponectin remains to be clarified. Our group detected the expression of adiponectin mRNA in human adipose tissue and demon- strated a significant inverse correlation between the CRP and adiponectin mRNA (27).

In addition, CRP mRNA levels in white adipose tissue in adiponectin KO mice are Fig. 2. Anti-inflammatory functions of adiponectin (33,36).

higher than those of wild-type mice (27). The reciprocal association of adiponectin and CRP levels in both human plasma and adipose tissue might participate in the develop- ment of atherosclerosis via inflammatory responses.

5. CONCLUSIONS

Adipose tissue has long been considered to be an organ that stores excess energy and supplies stored energy when food is lacking, in order to favor survival. However, recent studies have revealed that adipose tissue secretes a variety of bioactive sub- stances—adipocytokines—controlling other organs and cells. A substantial proportion of adipocytokines are involved in inflammatory stimulation and response, as either proinflammatory adipocytokines or anti-inflammatory adipocytokines. As mentioned above, adiponectin is the most potent anti-inflammatory adipocytokine. Visceral fat accumulation causes a decrease in adiponectin plasma levels together with an increase of proinflammatory adipocytokines, such as TNF-F and PAI-1. An insufficient amount of adiponectin may be the background of enhanced inflammatory response and may result in the development of metabolic and cardiovascular diseases.

REFERENCES

1. Matsuzawa Y. Diabetes/Metab Rev 1997;13:3–13.

2. Maeda K, Okubo K, Shimomura I, et al. Gene 1997;190:227–235.

3. Shimomura I, Funahashi T, Takahashi M, et al. Nature Med 1997;2:1–5.

4. Masumoto S, Kishida K, Shimomura I, et al. Biochem Biophys Res Commun 2002;292:781–786.

5. Maeda K, Okubo K, Shimomura I, et al. Biochem Biophys Res Commun 1996;221:286–289.

6. Ouchi N, Kihara S, Arita Y, et al. Circulation 1999;100:2473–2476.

7. Matsuzawa Y. Atheroscler Thromb Vas Biol 2004;24:29–33.

Fig. 3. Adiponectin induces TIMP-1 secretion via induction of IL-10 secretion in macrophages (38).

8. Scherer EP, Williams S, Fogliano M. J Biol Chem 1995;270:26,746–26,749.

9. Hu E, Liang P, Spiegelman BM. J Biol Chem 1996;271:10,697–10,703.

10. Arita Y, Kihara S, Ouchi N, et al. Biochem Biophys Res Commun 1999;257:79–83.

11. Halleux CNM, Lee WJ, Delporte ML, et al. Biochem Biophys Res Commun 2001;288:1102–1107.

12. Maeda N, Takahashi M, Funahashi T, et al. Diabetes 2001;50:2094–2099.

13. Hotta K, Funahashi T, Arita Y, et al. Arterioscl Thromb Vas Biol 2000;20:1595–1599.

14. Hotta K, Funahashi T, Bodkin NL, et al. Diabetes 2001;50:1126–1133.

15. Lindsay RS, Funahashi T, Hanson RL, et al. Lancet 2002;360:57–58.

16. Maeda N, Shimomura I, Kishida K, et al. Nat Med 2002;8:731–737.

17. Kubota N, Terauchi Y, Yamauchi T, et al. J Biol Chem 2002;277:25,863–25,866.

18. Tomas E, Tsao TS, Saha AK, et al. Proc Natl Acad Sci USA 2002;99:16,309–16,313.

19. Iwashima Y, Katsuya T, Ishikawa K, et al. Hypertension 2004;43:1318–1323.

20. Ouchi N, Ohishi M, Kihara S, et al. Hypertension 2003;42:231–234.

21. Zoccali C, Mallamaci F, Tripepi G, et al. J Am Soc Nephrol 2002;13:134–141.

22. Kumada M, Kihara S, Sumitsuji S, et al. Arterioscler Thromb Vasc Biol 2003;23:85–89.

23. Pischon T, Girman CJ, Hotamisligil GS, et al. JAMA 2004;291:1730–1737.

24. Kondo H, Shimomura I, Matsukawa Y, et al. Diabetes 2002;51:2325–2328.

25. Ho RC, Davy KP, Hickery MS, et al. Cytokine 2005;30:14–21.

26. Moon YS, Kin DH, Song DK. Metabolism 2004;53:863–867.

27. Uysal KT, Wiesblock SM, Mario MW, et al. Nature 1997;389:610–614.

28. Ouchi N, Kihara S, Funahashi T, et al. Circulation 2003;107:671–674.

29. Kamada Y, Tamura S, Kiso S, et al. Gastroenterology 2003;125:1796–1807.

30. Petridou E, Mantzoros C, Dessypris N, et al. J Clin Endcrinol Metab 2003;88:993–997.

31. Miyoshi Y, Funahashi T, Kihara S, et al. Clin Cancer Res 2003;9:5699–5704.

32. Otake S, Takeda H, Suzuki Y, et al. Clin Cancer Res 2005;11:3642–3646.

33. Yokota T, Oritani K, Takahashi I, et al. Blood 1999;96:1727–1732.

34. Okamoto Y, Kihara S, Ouchi N, et al. Circulation 2002;26:2767–2770.

35. Ouchi N, Kihara S, Arita Y, et al. Circulation 2001;103:1057–1063.

36. Ouchi N, Kihara S, Arita Y, et al. Circulation 2000;102:1296–1301.

37. Tilg H, Wolf AM. Expert Opin Ther Targets 2005;9:245–251.

38. Kumada M, Kihara S, Ouchi N, et al. Circulation 2004;109:2046–2049.

39. Ridker PM, Burning JE, Shih J, Matias M, Hennekens CH. Circulation 1998;98:731–733.

40. Matsushita K, Yatsuya H, Tamakoshi K, et al. Arterioscler Thromb Vas Biol 2006;26:871–876.

41. Ignacy WW, Chudek J, Adamczak M, et al. Nephron Clin Prac 2005;101:c18–c24.