(Circulation. 1999;99:1878-1884.)
© 1999 American Heart Association, Inc.
Basic Science Reports |
Proinflammatory Mediators Chronically Downregulate the Formation of the Endothelium-Derived Hyperpolarizing Factor in Arteries Via a Nitric Oxide/Cyclic GMP–Dependent Mechanism
From the Institut für Kardiovaskuläre Physiologie und Institut für Anaesthesiologie, Klinikum der J.W.G.-Universität, Frankfurt/Main, Germany.
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Abstract |
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Background—Endothelium-dependent dilator responses mediated by NO and endothelium-derived hyperpolarizing factor (EDHF) are altered in arteriosclerosis and sepsis. The possibility that proinflammatory mediators that stimulate the expression of inducible NO synthase (NOS II) affect the generation of EDHF was examined in isolated arteries.
Methods and Results—Under combined blockade of NOS and cyclooxygenase, EDHF-mediated relaxation elicited by several agonists was significantly attenuated in rabbit carotid and porcine coronary arteries exposed to cytokines and lipopolysaccharide. The blunted relaxation was coincident with NOS II expression and was prevented by inhibition of NOS II as well as of global protein synthesis. The NO donor CAS 1609 and 8-bromo-cGMP mimicked the proinflammatory mediator effect. In contrast, long-term blockade of endothelial NO generation increased the relaxation in carotid but not in coronary arteries. Proinflammatory mediators reduced the synthesis of EDHF assessed as hyperpolarization of vascular smooth muscle cells elicited by the effluent from bradykinin-stimulated coronary arteries. Proinflammatory mediators induced NOS II expression in cultured endothelial cells and decreased the expression of cytochrome P450 enzymes, which are the most probable candidates for the synthesis of EDHF.
Conclusions—Proinflammatory mediators inhibit the formation of EDHF in isolated arteries. This impairment is coincident with NOS II expression in the arterial wall and seems to be mediated through the induced generation of NO, which downregulates the putative EDHF-forming enzyme. Thus, a decreased formation of EDHF may contribute to the endothelial dysfunction in arteriosclerosis and sepsis.
Key Words: endothelium-derived factors • arteries • vasodilation • arteriosclerosis • interleukins
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Introduction |
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Endothelial cells play a pivotal role in the local control of vascular tone by the release of potent short-lived vasoactive autacoids. Among the best-characterized autacoids is NO generated by the activation of NO synthase in endothelial cells (NOS III), which mediates endothelium-dependent responses in most isolated arteries and vascular beds.1 However, inhibition of NOS III only slightly attenuates endothelium-dependent relaxations in some arteries.2 These relaxations are mediated by an endothelial factor(s) distinct from NO, called endothelium-derived hyperpolarizing factor (EDHF), that hyperpolarizes the vascular smooth muscle, most likely by opening calcium-sensitive potassium channels.2 Although the chemical nature of EDHF is still unclear, the findings that inhibitors of phospholipase A2 and of cytochrome P450 diminished EDHF-mediated relaxation and hyperpolarization in the coronary microcirculation and macrocirculation and also in carotid arteries suggest that in these arteries, EDHF is a cytochrome P450 monooxygenase–derived arachidonic acid metabolite.2 3 4 5 6
Endothelial dysfunction is considered to be an
important factor in the pathogenesis of atherosclerosis
and sepsis.7 Lipopolysaccharide (LPS),
interleukin-1ß (IL-1ß), and tumor necrosis factor-
(TNF-),
the generation of which is increased during endotoxemia and
arteriosclerosis, severely blunted
endothelium-dependent relaxations in both in vitro and
in vivo studies,8 9 10 suggesting that these
proinflammatory mediators may contribute to the development of
endothelial dysfunction. Bioassay studies have
indicated that a decreased generation of
endothelium-derived NO is responsible for the impaired
endothelium-dependent relaxation in atherosclerotic and
cytokine-treated arteries.10 11 Among the
potential mechanisms proposed to account for the reduced formation of
NO are a downregulation of NOS III by proinflammatory
mediators12 and oxidized LDLs,13 a decreased
NOS III activity due to the formation of an endogenous
inhibitor such as
NG,NG'-dimethyl-L-arginine14
or due to the cytokine-induced sustained generation of NO
that affects the signal transduction cascade in
endothelial cells,10 and an excessive
inactivation of NO by oxygen-derived radicals such as superoxide
anions.15
Although cytokines and LPS can severely attenuate the generation of NO, the effect of these proinflammatory mediators on the endothelial generation of EDHF remains to be clarified. Therefore, the present study was designed to test whether proinflammatory mediators affect EDHF-mediated relaxation and hyperpolarization in isolated arteries, and if so, to elucidate the underlying mechanisms.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Materials
IL-1ß was obtained from Collaborative Research; oxyhemoglobin from Calzyme Laboratories; bradykinin from Bachem Biochemica; recombinant TNF-
from Boehringer-Ingelheim; pentobarbital
sodium from Sanofi; diclofenac from Novartis;
NG-nitro-L-arginine
(L-NNA) from Serva; minimum essential medium containing Earle's
salts and FCS from PAN Systems; penicillin, streptomycin, medium M199,
dispase, and bovine albumin fraction V from Gibco BRL;
11,12-epoxyeicosatrienoic acid (11,12-EET) from Biomol; and all other
chemicals from Sigma Chemical Co. U46619
(9,11-dideoxy-11,9-epoxymethano-prostaglandin
F2) was provided by Upjohn;
S-methylisothiourea (SMT) by Dr Garry Southan (Frederick
Cancer Research, Frederick, Md); and CAS 1609
(4-hydroxymethyl-furoxan-3-carboxamide) by Hoechst
Marion Roussel.
Preparation of Blood Vessels
Carotid arteries were obtained from New Zealand White rabbits
(anesthetized with sodium pentobarbital 60 mg/kg IV) and
coronary arteries from pig hearts, placed into ice-cold
Krebs-Henseleit solution (composition in mmol/L: NaCl 144.0, KCl
5.9, CaCl2 1.6, MgSO4 1.2,
KH2PO4 1.2,
NaHCO3 25.0, and D-glucose 11.1)
containing diclofenac 1 µmol/L, and prepared for experimentation
as described previously.4 10 The expression of NOS II was
elicited by incubating carotid artery rings in culture medium [minimum
essential medium containing 2 mmol/L glutamine, 5 mmol/L TES,
5 mmol/L HEPES (the latter 2 both at pH 7.3), 50 U/mL penicillin,
50 µg/mL streptomycin, 0.1% BSA, and 1 µg/mL polymyxin B] in the
presence of IL-1ß 100 U/mL for 7 hours and coronary artery
rings in culture medium without polymyxin B in the presence of a
combination of TNF- 1000 U/mL, interferon-
(IFN-) 500 U/mL,
and LPS 10 µg/mL for 15 hours in a cell culture incubator.
Cell Culture
Porcine Aortic Endothelial Cells
Endothelial cells were isolated as reported
previously,3 seeded onto Petri dishes coated with
fibronectin, and grown in medium M199 containing 10% FCS with
antibiotics. The expression of NOS II was elicited by incubating
confluent primary cultures of endothelial cells in
medium M199 containing antibiotics and 0.1% FCS in the presence of
TNF- 1000 U/mL, IFN- 500 U/mL, and LPS 10 µg/mL for 24 hours in
a cell culture incubator.
Rat Aortic Smooth Muscle Cells
Smooth muscle cells (SMCs) were isolated and cultured as
described previously.3 All experiments were performed on
cells between passages 12 and 16 seeded on glass coverslips.
Organ Chamber Studies
Arterial rings were set up in organ chambers
containing warm (37°C) and oxygenated (95%
O2/5% CO2) Krebs-Henseleit
solution and prepared for experimentation as described
previously.4 10 Carotid arteries were constricted with
phenylephrine 1 to 3 µmol/L and coronary
arteries with the thromboxane A2
mimetic U46619, 0.1 to 0.3 µmol/L. When tension stabilized, the
presence of a functional endothelium was demonstrated
by the relaxation to acetylcholine 1 µmol/L in carotid arteries
and to bradykinin 0.1 µmol/L in coronary arteries. After
washout, both preparations were allowed to equilibrate for 30 minutes
in the presence of either L-NNA 0.1 mmol/L or oxyhemoglobin
0.1 µmol/L. Thereafter, the rings were constricted again with
phenylephrine and U46619, respectively, before a cumulative
concentration-relaxation curve to the test compound.
Detection of EDHF Release
The release of EDHF was detected by recording changes in
membrane potential of cultured rat aortic SMCs exposed to the effluent
of a perfused endothelium-intact porcine
coronary artery segment as described
previously.3
Assay of Cytochrome P450 Monooxygenase Activity
Cytochrome P450 monooxygenase–dependent
metabolic activity was assayed as the dealkylation of
7-ethoxyresorufin in cultured endothelial cells.
Endothelial cells were incubated with 7-ethoxyresorufin
3.4 µmol/L for 15 minutes at 37°C. Thereafter, the resorufin
formed in the supernatant was measured at an excitation of 522 nm and
emission at 586 nm. Preliminary experiments demonstrated that the
cell-mediated conversion of 7-ethoxyresorufin to resorufin was linear
over a period of 
30 minutes and was abolished by the P450
inhibitor clotrimazole 3
µmol/L.6
Expression of Cytochrome P450 Monooxygenase and NOS
II Protein
Endothelial cells were lysed in double-distilled
water by 5 cycles of freeze/thaw before the addition of
homogenization buffer [Tris-HCl 50 mmol/L (pH
7.4), KCl 1.15%, EDTA 1 mmol/L, glucose 5 mmol/L,
phenylmethylsulfonyl fluoride 4.4 mg/L, and 1 mg/L each of
leupeptin, pepstatin A, trypsin inhibitor, antipain,
chymostatin, and aprotinin]. Cell homogenates were
centrifuged at 5000g for 10 minutes. The supernatant
was removed and subjected to a 1-hour centrifugation at
100 000g. The partially purified microsomal fraction was
resuspended in a buffer containing Tris-HCl 50 mmol/L (pH 7.4),
glycerin 10%, EDTA 0.1 mmol/L, and the protease
inhibitors and was used for the detection of cytochrome
P450 proteins, whereas the supernatant was used for the detection of
NOS II protein as described previously.10 Cytochrome
P450 immunoreactivity was detected by use of a polyclonal rabbit
antibody directed against cytochrome P450 2C11 (which recognizes most
members of the cytochrome P450 2C family; dilution 1:5000, provided by
Dr E. Morgan, Atlanta, Ga) and NOS II immunoreactivity by use of a
polyclonal rabbit antibody directed against NOS II (dilution 1:1000,
provided by Dr J. Pfeilschifter, Frankfurt am Main, Germany). The
autoradiographs were analyzed by scanning densitometry
(ImageMaster, Pharmacia).
Tissue Content of cGMP
Isobutylmethyl xanthine 500 µmol/L was added to the
coronary artery rings during the last 30 minutes of the 15-hour
incubation period. Thereafter, arterial rings were
homogenized in trichloroacetic acid (6%) at 4°C. After
centrifugation (10 minutes at 5000g), the
supernatant was extracted with water-saturated ethylether, and the cGMP
content in each sample was determined with a radioimmunoassay including
an acetylation step.
Statistical Analysis
Results are shown as mean±SEM of n experiments. The negative
logarithm of the concentration of U46619 causing 50% contraction
(EC50) was calculated for each
concentration-response curve. Statistical analyses were
performed with Student's paired t test (2-tailed) or an
ANOVA followed by Fisher's protected least significant difference
test. A value of P<0.05 was considered to be statistically
significant.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Proinflammatory Mediators Impair EDHF-Mediated Relaxation
In rabbit carotid arteries, the L-NNA/diclofenac–resistant EDHF-mediated relaxations to acetylcholine, substance P, and A23187 were markedly attenuated by the IL-1ß treatment (100 U/mL for 7 hours; Figure 1
). Similar findings were obtained with
acetylcholine when the generation of NO was abolished by oxyhemoglobin
0.1 µmol/L instead of L-NNA (maximal relaxations were reduced
from 45.2±3.6% to 25.2±3.5%, n=7). The treatment with
proinflammatory mediators (TNF- 1000 U/mL, IFN- 500 U/mL, and LPS
10 µg/mL for 15 hours) also strongly attenuated the EDHF-mediated
relaxation to bradykinin and, to a smaller but significant extent, that
to A23187, whereas the relaxation to 11,12-EET, an
activator of calcium-sensitive potassium
channels,5 was unaffected in porcine coronary
arteries (Figures 2 and 3).
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Both functional and biochemical studies were next performed to
demonstrate that the proinflammatory mediator treatment induced the
generation of NO in coronary arteries. Exposure of
endothelium-intact coronary arteries to
TNF-, IFN-, and LPS for 15 hours was accompanied by an
attenuation of the contractions to U46619 (EC50
changed from 0.15±0.03 to 0.56±0.04 µmol/L, and the maximal
contraction was reduced from 18.9±0.8 to 8.1±0.9 g, n=7) and by an
increase in the tissue content of cGMP (from 11.5±3.5 to 162.4±21.0
pmol/mg protein, n=5). Because both of these effects were prevented by
inhibitors of NOS (EC50 was
0.36±0.07 µmol/L and the maximal contraction was 17.6±0.9 g in
the presence of proinflammatory mediators and 10 µmol/L SMT, and
the cGMP levels were 10.1±3.0 pmol/mg protein in the presence of
proinflammatory mediators and 600 µmol/L L-NNA), they can
reasonably be attributed to an induced generation of NO. The expression
of NOS II in carotid artery rings exposed to IL-1ß for 7 hours has
been confirmed in a previous study.10
Next, the role of the proinflammatory mediator–induced generation of
NO in the attenuated EDHF-mediated relaxation was examined.
EDHF-mediated relaxations to acetylcholine were unaffected in carotid
arteries exposed to IL-1ß for only 15 minutes (Figure 4a) and also in those that had been
incubated with IL-1ß for 7 hours in combination with either
cycloheximide (Figure 4b) or
N--tosyl-L-lysine
chloromethylketone (TLCK, Figure 4c); these
treatments have been shown to prevent the induced generation of
NO.16 17 The cycloheximide treatment alone slightly
but significantly increased, whereas that of TLCK alone significantly
attenuated, the EDHF-mediated relaxation (Figure 4b and 4c).
Moreover, EDHF-mediated relaxations to acetylcholine were slightly but
significantly restored in carotid arteries exposed to IL-1ß in
combination with SMT (used at a concentration that abolished the
activity of NOS II, whereas that of NOS III was only minimally
affected)10 for 7 hours (Figure 5).
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To further assess the possibility that chronic exposure of arteries to
NO impairs the EDHF-mediated relaxation, the effects of both the basal
generation of NO by the endothelium and exogenous
activators of the NO-cGMP effector pathway were
investigated. Blockade of basal endothelial NO
generation by L-NNA for several hours increased EDHF-mediated
relaxations in carotid but not in coronary arteries (Figure 6). In contrast, long-term exposure of
carotid and coronary arteries to either CAS 1609 or
8-bromo-cGMP significantly attenuated EDHF-mediated relaxation (Figures 6 and 7).
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Proinflammatory Mediators Reduce the Synthesis of EDHF
Addition of bradykinin to the superfusate from control
coronary arteries stimulated the release of EDHF, as indicated
by a pronounced but transient hyperpolarization of
the SMCs (Figures 8 and 9). This response to bradykinin was
significantly reduced by the treatment of coronary arteries
with either a combination of TNF-, IFN-, and LPS; CAS 1609; or
8-bromo-cGMP for 15 hours (Figures 8 and 9). Direct
application of bradykinin to the SMCs resulted in only a transient
membrane depolarization (13±2 mV, n=9).
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Proinflammatory Mediators Decrease Cytochrome P450
Monooxygenase Expression in Endothelial Cells
Exposure of cultured endothelial cells to a
combination of TNF-, IFN-, and LPS for 24 hours decreased
cytochrome P450 dealkylase activity significantly, by 39.6±5.1%
(n=7). L-NNA 300 µmol/L slightly but significantly attenuated
the inhibitory effect of the proinflammatory mediator
treatment (to 29.7±4.6%), whereas the NOS inhibitor alone
had only minor effects. Both CAS 1609 (100 µmol/L, n=7) and
S-nitrosoglutathione (100 µmol/L, which was added 3
times during a 24-hour incubation period, n=2) also reduced cytochrome
P450 dealkylase activity by 23.9±3.8% and by 38.9±8.7%,
respectively. Expression of cytochrome P450 2C proteins, a major family
of cytochrome P450 monooxygenases in
endothelial cells,18 was decreased by
the proinflammatory mediator treatment (Figure 10A), and this effect was associated
with the expression of NOS II protein (Figure 10B). A decreased
cytochrome P450 2C protein level was also found in CAS 1609–treated
endothelial cells (Figure 10A).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Proinflammatory mediators have been shown to severely attenuate endothelium-dependent relaxations both in vitro and in vivo.8 9 10 This altered endothelial cell function has been shown to reflect a reduced ability of endothelial cells to generate NO10 11 and, as indicated by the present study, probably also EDHF. Indeed, the proinflammatory mediator treatment evoked in isolated carotid and coronary arteries a pronounced decrease of the component of the endothelium-dependent relaxation that is resistant to NOS and cyclooxygenase inhibitors and that has been attributed to a diffusible vascular smooth muscle hyperpolarizing factor. The impaired relaxation cannot be explained by a decreased smooth muscle response to EDHF because relaxations to 11,12-EET, an activator of calcium-sensitive potassium channels,5 were unaffected by the proinflammatory mediator treatment. Moreover, the blunted release of EDHF from endothelium-intact donor coronary arteries, as demonstrated under bioassay conditions, suggests that proinflammatory mediators most likely interfere with the synthesis and/or release of EDHF rather than its mechanism of action at the vascular smooth muscle.
The mechanism underlying the inhibitory effect of proinflammatory mediator treatment appears to be dependent on the synthesis of a peptide/protein in the arterial wall, which in turn dampens the biosynthesis of EDHF in endothelial cells. Indeed, short-term exposure of arteries to proinflammatory mediators failed to attenuate EDHF-mediated relaxations, and inhibition of de novo protein synthesis with cycloheximide fully prevented the inhibitory effect of the proinflammatory mediator treatment. In addition, because the cycloheximide treatment increased EDHF-mediated relaxations in arteries not exposed to proinflammatory mediators, the biosynthesis of EDHF is likely to be constantly subjected to an intrinsic inhibitory effect that requires de novo protein synthesis.
In parallel to the attenuation of endothelium-dependent relaxations, the proinflammatory mediator treatment caused the induction of NOS II in the arterial wall.8 10 The NOS II–derived NO appears to mediate the inhibitory effect of proinflammatory mediators on the biosynthesis of EDHF partly via a cGMP-dependent mechanism, because inhibition of either NOS II expression or activity significantly restored EDHF-mediated relaxations, and the proinflammatory mediator effect was mimicked by the chronic activation of the NO-cGMP effector pathway in endothelium-intact arteries.19 Moreover, because blunted EDHF-mediated responses were still observed in arteries examined 2 hours after the washout of the NO donor, NO may not only directly inhibit EDHF formation19 20 but also probably reduce the level of the EDHF-producing enzyme and/or induce the generation of an endogenous inhibitor. Such an inhibitory effect seems to be effective even in normal arteries, because interruption of the basal release of NO significantly increased EDHF-mediated relaxations in carotid arteries not exposed to proinflammatory mediators. The absence of such an increase in coronary arteries is probably due to the relatively small basal NO release in endothelium-intact coronary arteries,21 which may not be sufficient to affect the biosynthesis of EDHF.
Although the chemical identity of EDHF is still unclear, a number of studies support the hypothesis that EDHF is a cytochrome P450 monooxygenase–derived metabolite of arachidonic acid in the coronary microcirculation and macrocirculation as well as in rabbit carotid arteries but not in the guinea pig carotid and rat hepatic artery.2 3 4 5 6 22 23 Endothelial cells are capable of metabolizing arachidonic acid via the cytochrome P450 monooxygenase pathway to 4 major epoxyeicosatrienoic acids (5,6-EET, 8,9-EET, 11,12-EET, and 14,15-EET) that have been shown to elicit both hyperpolarization and relaxation of vascular SMCs.4 5 Thus, cytochrome P450 monooxygenases are a potential target for the inhibitory effect of the proinflammatory mediator treatment on the biosynthesis of EDHF. Consistent with such a hypothesis, chronic exposure of cultured endothelial cells to proinflammatory mediators decreased cytochrome P450 dealkylase activity that was coincident with NOS II expression and was mimicked by NO donors. Because inhibition of NOS partially but significantly prevented the proinflammatory mediator effect, the induced formation of NO, as well as other mechanisms, seems to be implicated. Such an inhibitory effect of NO could reflect a direct inhibition of the heme-containing cytochrome P450 monooxygenases24 but also a downregulation of their protein level.25
In conclusion, proinflammatory mediators cause a chronic attenuation of EDHF-mediated relaxation via a decreased formation of this hyperpolarizing factor. This attenuation is coincident with the expression of NOS II in the arterial wall and appears to be due to a downregulation of the EDHF-forming enzyme, partly by the induced formation of NO. Such a mechanism may contribute to the development of endothelial dysfunction in pathological states such as sepsis and atherosclerosis.
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Acknowledgments |
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This study was supported by grants from the Deutsche Forschungsgemeinschaft (Schi 389/2-3 and Po 521/1).
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Footnotes |
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Reprint requests to V.B. Schini-Kerth, PhD, Institut für Kardiovaskuläre Physiologie, Klinikum der J.W.G.-Universität, Theodor-Stern-Kai-7, D-60590 Frankfurt/Main, Germany.
Received September 16, 1998; revision received November 18, 1998; accepted December 7, 1998.
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G. O. Ogungbade, L. A. Akinsanmi, H. Jiang, and A. O. Oyekan Role of epoxyeicosatrienoic acids in renal functional response to inhibition of NO production in the rat Am J Physiol Renal Physiol, November 1, 2003; 285(5): F955 - F964. [Abstract] [Full Text] [PDF]
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S. Mateev, A. H. Sillau, R. Mouser, R. E. McCullough, M. M. White, D. A. Young, and L. G. Moore Chronic hypoxia opposes pregnancy-induced increase in uterine artery vasodilator response to flow Am J Physiol Heart Circ Physiol, March 1, 2003; 284(3): H820 - H829. [Abstract] [Full Text] [PDF]
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E. Kaergel, D. N. Muller, H. Honeck, J. Theuer, E. Shagdarsuren, A. Mullally, F. C. Luft, and W.-H. Schunck P450-Dependent Arachidonic Acid Metabolism and Angiotensin II-Induced Renal Damage Hypertension, September 1, 2002; 40(3): 273 - 279. [Abstract] [Full Text] [PDF]
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 C. A. Gunnett, D. D. Heistad, and F. M. Faraci Interleukin-10 Protects Nitric Oxide-Dependent Relaxation During Diabetes: Role of Superoxide Diabetes, June 1, 2002; 51(6): 1931 - 1937. [Abstract] [Full Text] [PDF]
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 R. J. Roman P-450 Metabolites of Arachidonic Acid in the Control of Cardiovascular Function Physiol Rev, January 1, 2002; 82(1): 131 - 185. [Abstract] [Full Text] [PDF]
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 P. Stenvinkel Endothelial dysfunction and inflammation--is there a link? Nephrol. Dial. Transplant., October 1, 2001; 16(10): 1968 - 1971. [Full Text] [PDF]
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 K. Stuart-Smith and J. Y. Jeremy Microvessel damage in acute respiratory distress syndrome: the answer may not be NO Br. J. Anaesth., August 1, 2001; 87(2): 272 - 279. [Abstract] [Full Text] [PDF]
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A. Huang, D. Sun, M. A. Carroll, H. Jiang, C. J. Smith, J. A. Connetta, J. R. Falck, E. G. Shesely, A. Koller, and G. Kaley EDHF mediates flow-induced dilation in skeletal muscle arterioles of female eNOS-KO mice Am J Physiol Heart Circ Physiol, June 1, 2001; 280(6): H2462 - H2469. [Abstract] [Full Text] [PDF]
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 E. T. Morgan Regulation of Cytochrome P450 by Inflammatory Mediators: Why and How? Drug Metab. Dispos., March 1, 2001; 29(3): 207 - 212. [Abstract] [Full Text]
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 N. Paolocci, P. Pagliaro, T. Isoda, F. W. Saavedra, and D. A. Kass Role of Calcium-Sensitive K+ Channels and Nitric Oxide in In Vivo Coronary Vasodilation From Enhanced Perfusion Pulsatility Circulation, January 2, 2001; 103(1): 119 - 124. [Abstract] [Full Text] [PDF]
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C. A. Gunnett, D. D. Heistad, D. J. Berg, and F. M. Faraci IL-10 deficiency increases superoxide and endothelial dysfunction during inflammation Am J Physiol Heart Circ Physiol, October 1, 2000; 279(4): H1555 - H1562. [Abstract] [Full Text] [PDF]
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P. Stenvinkel, O. Heimburger, B. Lindholm, G. A. Kaysen, and J. Bergstrom Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome) Nephrol. Dial. Transplant., July 1, 2000; 15(7): 953 - 960. [Full Text] [PDF]
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