Yeah i'm normally taking a combination of telmisartan and candesartan, currently not on any tough due to hypotension, wont add them back untill i'm back on amphetamine.
Angiotensin receptors as determinants of life span.
Cassis P, Conti S, Remuzzi G, Benigni A.
Pflugers Arch. 2009 Sep 11. [Epub ahead of print]
PMID: 19763608
Angiotensin II (Ang II), the central product of renin-angiotensin system,
has a role in the etiology of hypertension and in pathophysiology of cardiac
and renal diseases in humans. Other functions of Ang II include effects on
immune response, inflammation, cell growth and proliferation, which are
largely mediated by Ang II type 1 receptor (AT(1)). Several experimental
studies have demonstrated that Ang II acts through AT(1) as a mediator of
normal aging processes by increasing oxidant damage to mitochondria and in
consequences by affecting mitochondrial function. Recently, our group has
demonstrated that the inhibition of Ang II activity by targeted disruption
of the Agtr1a gene encoding Ang II type 1A receptor (AT(1A)) in mice
translates into marked prolongation of life span. The absence of AT(1A)
protected multiple organs from oxidative damage and the alleviation of
aging-like phenotype was associated with increased number of mitochondria
and upregulation of the prosurvival gene sirtuin 3. AT(1) receptor
antagonists have been proven safe and well-tolerated for chronic use and are
used as a key component of the modern therapy for hypertension and cardiac
failure, therefore Ang II/AT(1) pathway represents a feasible therapeutic
strategy to prolong life span in humans.
Keywords Oxidative stress - Mitochondria - Aging - Angiotensin -
Inflammation
Abbreviation:
RAS
renin-angiotensin system
- Ang II
angiotensin II
- ACE
angiotensin converting enzyme
- AT1
Ang II type 1 receptor
- AT2
Ang II type 2 receptor
- NO
nitric oxide
- eNOS
endothelial nitric oxide synthase
- ROS
reactive oxygen species
- ACEi
angiotensin-converting enzyme inhibitors
- ARBs
angiotensin II receptor blockers
- SIRT
sirtuin
- Nampt
nicotinamide phosphoribosyltransferase
- IGF-1
insulin growth factor-1
Introduction
The mean life span has been increasing steadily over the course of human
evolution, and in the last century, the human life expectancy in developed
countries has nearly doubled as indicated by an increase from around 50 to
75-80 years [12]. Before 1950, most of the gain in life expectancy was due
to marked decrease in death rates at younger ages. In the second half of the
20th century, the observed reduction in mortality at ages above 65 years
could be ascribed to the delay in the onset of several age-related disorders
and to the increased capacity to prevent organ damage, as a consequence of
improved biomedical and nutritional conditions [47]. Therefore, ensuring
disease-free survival and not merely survival per se represents an
attractive and desirable goal for society as a whole. Healthy aging and
longevity depend on the dynamic interaction between biological and
environmental factors, including medical care, healthy diet, and lifestyle.
However, emerging evidence from model organisms has indicated that several
genetic factors might play a role in longevity, putting the attention on
several molecular candidates involved in pathways contributing to protect
organs from degeneration and diseases.
In the last 20 years, one of the main goals of our research was to find out
therapeutic strategies to protect the kidney from progressive renal injury
with the final aim to reduce the need of dialysis in patients. To this aim,
our efforts have been devoted to identify factors implicated in the
progression of chronic kidney disease, whose incidence is increasing
worldwide at an alarming rate. Experimental and clinical evidence is
available that blockade of the renin angiotensin system (RAS) by angiotensin
converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers
(ARB) is effective in slowing the progression of kidney disease due to the
drugs' ability to reduce proteinuria [53]. When ACEi and ARB were given in
combination to rats genetically predisposed to progressive nephropathy,
reduction of glomerular sclerosis was even more evident, particularly in
those glomeruli that had less severe lesion to begin with. This shows that
remodeling of glomerular architecture is possible, which would imply some
form of regeneration of the capillary network [53]. Recent clinical trials
suggested that inhibition of RAS might actually prevent nephropathy in
patients with chronic renal failure of nondiabetic origin (the Ramipril
Efficacy in Nephropathy study) [57]. The effectiveness of ACEi in protecting
the kidney against the development of microalbuminuria, which is a major
risk factor for cardiovascular events and death, has been also documented in
patients with type 2 diabetes (the Bergamo Nephrologic Diabetes
Complications Trial study) [56].
Strategies able to reduce renal disease progression could translate into a
decreased incidence of cardiovascular events. A tremendous body of research,
both experimental and clinical, has unequivocally shown that pharmacologic
blockade of RAS, beyond the renal protection, reduces cardiovascular risk
more effectively than other antihypertensive treatments [54]. Inhibition of
RAS prevents end-organ damage associated with aging [14], in line with
evidence that angiotensin II (Ang II) promotes the onset and the progression
of vascular senescence, associated with vascular, functional, and structural
changes contributing to age-related vascular disease [43].
In the present review, we focus on the recent emerging data suggesting a
role of Ang II in aging. In addition we highlight the mechanisms by which
Ang II via AT1 could affect life span in mammals.
The renin-angiotensin system
Renin-angiotensin system is considered to be the major regulator of blood
pressure and fluid homeostasis. The main effector molecule of the RAS, Ang
II, is produced from the substrate angiotensinogen through sequential
enzymatic cleavages by renin and angiotensin converting enzyme (ACE). In
particular renin cleaves angiotensinogen, forming Ang I that in turn is
converted to Ang II by ACE (Fig. 1). ACE is a circulating enzyme found in
the endothelial cells of the lung, vascular endothelium, and cell membranes
of the kidney, heart, and brain. ACE also degrades bradykinin to inactive
fragments, reducing the serum levels of endogenous vasodilators [8].
Ang II causes increases in systemic and local blood pressure via its
vasoconstrictive effect, influences renal tubuli to retain sodium and water,
and stimulates aldosterone release from adrenal gland [69]. Besides being a
potent vasoconstrictor, Ang II exerts several prominent nonhemodynamic
effects including proliferative, proinflammatory, and profibrotic activities
[58].
At the cellular level, responsiveness to Ang II is conferred by the
expression of two classes of pharmacologically distinct rhodopsin-like G
protein-associated receptors, the type 1 and the type 2 receptors (AT1 and
AT2) [61, 69]. AT1 has been cloned in a number of species and two subtypes
[59], named AT1A and AT1B, have been identified in rat and mouse. AT1A is
the predominantly expressed receptor in different body districts including
kidney, liver, heart, blood vessels, adrenal glands, and cardiovascular
control centers in the brain [11], and is considered the closest murine
homolog to the single human AT1. AT1A confers most of the classical actions
of Ang II such as blood pressure increase [36], aldosterone release from the
adrenal zona glomerulosa [1], salt retention in renal proximal tubuli [42],
and stimulation of the sympathetic nervous system via receptors in the brain
[17]. The expression of the AT1B appears to be more prominent in the
anterior pituitary gland and the adrenal zona glomerulosa. AT1B regulates
blood pressure when AT1A is absent [48].
The expression of the AT2 is high in the fetus, but low in adult tissues.
AT2 is expressed in the adrenal medulla, uterus, ovary, vascular
endothelium, and distinct brain areas [65]. AT2 interacts with and modulates
actions perpetuated by the AT1, possibly antagonizing many of its effects.
The binding of Ang II to the AT2 activates vasorelaxation of conduit and
resistant arteries and improves resistance artery remodeling, promotes
cardiovascular protection against ischemia-reperfusion injury and acute
myocardial infarction, inhibits cardiac fibrosis, and protects the kidney
from ischemic injury [60]. In a mouse model of renal ablation, the lack of
AT2 aggravates renal injury and reduces survival [6].
Link between angiotensin II and oxidative stress
Angiotensin II is known to contribute to oxidative stress damage by
stimulating the generation of both nitric oxide (NO) and NAD(P)H
oxidase-derived superoxide in the cytosol of different cell types including
endothelial, vascular smooth muscle, fibroblast and tubular epithelial cells
[51, 55]. The interaction between NO and superoxide generates peroxynitrite,
a cytotoxic anion that inhibits mitochondrial electron transport, destroys
DNA and cellular proteins, leading to oxidative stress damage [52].
Furthermore, Ang II can induce endothelial nitric oxide synthase (eNOS)
uncoupling, switching from NO to superoxide production [46]. Ang II
stimulates both cytosolic and mitochondrial reactive oxygen species (ROS)
generation [64] (Fig. 2). The direct interaction between Ang II and
mitochondrial components has been suggested by the presence of Ang II in
mitochondria of brain, heart, and smooth muscle cell in rodent [22];
moreover, renin, angiotensinogen, and ACE were also detected within
intramitochondrial dense bodies [50].
One of the most prominent theories to explain aging is the "free-radical
theory" of aging which was initially proposed by Harman in 1950 s [30]. It
postulates that the loss of cell functional capacity associated to
senescence results from the accumulation of ROS-inflicted oxidative stress
damage to different molecules, leading to lipid peroxidation, protein
oxidation and oxidative modifications in nuclear and mitochondrial DNA [21].
Reactive oxygen species are generated in multiple compartments and by
multiple enzymes within the cells, including NAD(P)H oxidases on plasma
membranes, lipid metabolism within the peroxisomes, and various cytosolic
enzymes such as cyclooxygenase. The majority of intracellular ROS production
derives from mitochondrial matrix and the space between the inner and outer
mitochondrial membrane. Mitochondria utilize more than 90% of cellular
oxygen to produce energy. While most oxygen is transformed into water, 1-2%
of it forms superoxide [7]. Reactive oxygen species compromise mitochondrial
integrity and function, leading to a decreased mitochondrial ATP generation,
with a subsequent increased release of ROS by the mitochondria themselves,
initiating a vicious cycle of progressively increasing oxidative stress
[23]. The aging process is frequently associated to a reduction in
mitochondrial number and several changes in mitochondrial structure, such as
swelling, shortening of the cristae, and matrix vacuolization [10, 31, 67].
Under normal physiological conditions, the capacity of Ang II to promote
oxidative stress is tightly regulated [20, 27]. By contrast, in conditions
associated with RAS overactivation, such as aging [3, 68, 70], the
dysregulation of Ang II-dependent ROS generation may become a significant
contributor to cell oxidation and tissue damage. RAS overactivation exerts
deleterious effects on renal and cardiac functions documented by the
increase of Ang II peptide in urines [25] and increased generation of Ang II
in the heart [28] of old animals. A recent in vitro study has demonstrated
that the production of ROS induced by Ang II via AT1 led to DNA damage, and
consequently to accelerated aging of human vascular smooth muscle cells
[32]. Cell senescence following ROS production has been proposed to be
mediated by two different mechanisms of DNA damage: a telomere-independent
pathway via the induction of stress induced premature senescence (SIPS) and
a telomere-dependent mechanism via accelerated attrition of telomeres. This
hypothesis has been confirmed by data showing that the critical DNA damage
induced by AT1-mediated ROS production both increased SIPS expressions that
promoted cell cycle arrest and markedly accelerated the rate of telomere
loss that is associated with reduced cellular proliferation and premature
cell senescence [32].
All these findings demonstrate the crucial role of oxidative stress on the
aging process and strongly support the involvement of Ang II in tissue
senescence by virtue of its ability to mediate the release of oxidant
species.
Protective effect of inhibiting angiotensin II on aging
Angiotensin-converting enzyme inhibitors and ARBs are two widely used
classes of anti-hypertensive drugs that inhibit RAS at different levels.
ACEi inhibit Ang II formation by binding to the active site of the enzyme
that converts Ang I into Ang II, and ARBs prevent Ang II from binding to its
receptors.
In aging animals, the cardiovascular protective effects occurred after RAS
inhibition was associated with an increased NOS activity [26]. Moreover, in
old animals, both enalapril and losartan treatments significantly increased
NO production in heart homogenate, while reduced hydrogen peroxide formation
[15]. In spontaneously hypertensive rats, the inhibition of RAS was able to
reverse the naturally age-related and advanced myocardial hypertrophy and
fibrosis by attenuating Ang II-mediated oxidative stress, as documented by
reduced expression of NAD(P)H oxidative components p22phox, p47phox, and
gp91phox in old hearts [37]. Furthermore, oxygen radicals mediated the
accelerated cerebral endothelial dysfunction that occurs with age, and more
importantly, old mice lacking AT1 did not develop these age-related cerebral
circulation damages [45].
Other studies performed in normal adult rats have clearly shown that chronic
treatment with ACEi or ARB reduced kidney damage associated with age. Old
animals treated with enalapril and losartan presented lower glomerular and
tubulointerstitial fibrosis, reduced monocyte or macrophage infiltrates, and
decreased tubular atrophy than untreated aged animals [24].
The beneficial effect of RAS inhibition involves the preservation of renal
mitochondria from aging in rats. Enalapril and losartan treatments prevented
the age-associated decline in the renal mitochondrial capacity for energy
production and attenuated the age-associated increase in mitochondrial
oxidant production [19].
A similar protective effect of RAS inhibition was also observed in the liver
from old rats. In these animals the maintenance of an adequate mitochondrial
function during aging was due to the enhanced transcription levels of the
genes nuclear respiratory factor 1 and peroxisome proliferators activator
receptor gamma coactivator-1alpha that are involved in mitochondrial
respiration and biogenesis, respectively. These positive effects on
mitochondria maintained the integrity of the hepatocyte system, and
prevented liver fibrosis and the infiltration of inflammatory cells during
aging [18].
The development of gene-targeting technology in mice has provided new
insight into the role of RAS genes in regulating blood pressure, body fluid
homeostasis, and fetal development. Mice that are unable to generate Ang II
because of targeted mutation in the angiotensinogen (Agt -/-) or
angiotensin-converting enzyme (Ace -/-) genes had a severe phenotype
characterized by reduced survival, low blood pressure, and abnormal kidney
morphology. A similar phenotype was observed in mice lacking both Ang II
type 1 receptors (AT1A-/- AT1B-/-) [49].
The disruption of the gene encoding AT1A (Agtr1a) -- the major mouse AT1
receptor isoform -- did not cause severe postnatal mortality or the
structural abnormalities seen in the kidneys of the knockout models
described above. Taking advantage from this mouse model, we have recently
investigated the role of the AT1 in end-stage organ damage. A prospective
observational study was performed in homozygous mice deficient for the AT1A
and wild-type controls. AT1A-/- mice substantially outlived their wild-type
littermates by 26% (Fig. 3) and had normal body weight and physical activity
as reflected by their ability to perform on a rotating system that evaluates
motor coordination and vitality. Reduction in food intake of 20% and 40% in
laboratory animals extends their life span by up to 50% [29]. Reduced
caloric intake did not contribute to prolonged survival in AT1A-/- mice,
since daily food intake was virtually identical between AT1A-/- and
wild-type mice. AT1A-/- grew up normally, and the body weights increased
comparably to wild-type littermates ruling out the possibility that small
body size could be responsible of extended life span as previously described
[9].
Aging AT1A-/- mice developed fewer aortic atherosclerotic lesions and less
cardiac injury, as reflected by the reduction of myocyte size and fibrosis,
with lower deposition of interstitial collagen with respect to wild-type
mice [5]. These data point to a direct effect of Ang II via AT1A on
atherosclerotic lesion generation and on extracellular matrix deposition by
cardiac fibroblasts.
Furthermore, aging mice lacking the AT1A showed reduced production of
peroxinitrite in hearts and aortas, as compared to wild-type animals,
indicating a possible role of Ang II via AT1A into the production of ROS
[5]. Given the crucial role of mitochondria in producing peroxynitrite
during aging processes [39], ultrastructural analysis of mitochondria was
performed in proximal tubular cells of the kidney of AT1A-/- mice that
possess a large number of mitochondria and are highly dependent on
mitochondrial energy production for proper function [33]. The lack of AT1A
protected the cells from the loss of mitochondria during aging [5],
demonstrating that Ang II negatively influences mitochondrial number and
function by promoting oxidative stress, and that the absence of AT1A
strongly attenuated the functional and structural changes that occur in
kidney mitochondria following oxidative stress increase upon age [5].
Role of sirtuins in longevity associated with AT1A-/- mice
Recent evidences have suggested that mitochondrial activity could be
regulated by the expression of enzymes belonging to the Sirtuin family [16].
Sirtuins are nicotinamide adenine dinucleotide (NAD)-dependent deacetylases
proteins highly conserved from Escherichia Coli to humans and associated
with longevity, mitochondrial and cell cycle regulation, apoptosis, and DNA
damage repair [29]. In humans and mice, there are seven different sirtuins
(SIRT1-7), and three are located in the mitochondria (SIRT3, 4, and 5).
Among them, SIRT3 has an apparent direct link to extended life span in
humans, in fact mutations in an enhancer region of the Sirt3 gene that
potentially upregulate its expression were found at a high frequency in
long-lived individuals [4]. Under oxidative stress, SIRT3 overexpression
protects the cardiomyocytes against Bax-mediated apoptosis by deacetylating
the substrate Ku70, promoting the binding of Ku70 to Bax, and hence blocking
the Bax activation [66]. Of note, SIRT3 regulates adaptive thermogenesis and
decreases mitochondrial membrane potential and reactive oxygen species
production, while increasing cellular respiration [62]. For these reasons
SIRT3 acts as sensor of small reactive oxygen species that could lead to
mitochondrial damage and activates specific cellular signaling pathway to
counteract oxidative stress such as the expression of MnSOD antioxidant
protein [38]. The recent identification of the two substrates such as acetyl
coenzyme A synthetase and glutamate dehydrogenase as targets of SIRT3
revealed that this molecule controls a regulatory network involved in energy
metabolism and in mechanisms of caloric restriction and life span
determination [40, 41].
SIRT3 could exert its action only in the presence of the cosubstrate NAD+,
and the concentration of NAD+ determines cell survival. In the context of
nutrient restriction, mitochondria dictate cell survival through the
upregulation of nicotinamide phosphoribosyltransferase (Nampt) that boosts
mitochondrial NAD+ concentration [71]. Altogether these findings prompted us
to study Sirt3 and Nampt survival genes in AT1A-/- mice. Transcript levels
of both Nampt and Sirt3 were increased in kidneys from AT1A-/- mice with
respect to wild-type animals. The finding that candesartan, an AT1 receptor
antagonist, prevented Ang II-induced Nampt and Sirt3 mRNA reduction in
cultured tubular epithelial cells suggested a possible biochemical link
between Ang II and survival genes, which conceivably operates via the AT1A.
Furthermore, experiments showing that Nampt gene silencing by siRNA limited
the reduction of Sirt3 mRNA induced by Ang II would indicate a causative
role of Nampt in modulating Sirt3 gene transcription in response to Ang II
[5].
Caloric restriction prolongs the life span through an increase of sirtuins
[29, 63]. In rodents and humans the levels of Sir2 ortholog SIRT1, that
targets numerous regulatory factors affecting stress management and
metabolism, increase in response to caloric restriction and this increase
causes favorable changes in metabolism and stress tolerance [13].
The sirtuins are also involved in prolonged survival induced by resveratrol
[2], a small molecule found in red wine which activates SIRT1 and mimics the
anti-aging effect of caloric restriction. The effect of resveratrol on life
span is associated with increased mitochondrial number and is dependent on
the upregulation of Sir2 [35]. Moreover, resveratrol downregulates AT1
through SIRT1 activation in cultured vascular smooth muscle cells and mouse
aorta implying that inhibition of the AT1 contributes to resveratrol-induced
longevity [44].
In the kidney from AT1A-/- mice the levels of SIRT1 were comparable to
wild-type mice, suggesting that the increased longevity of this mouse strain
is independent from the SIRT1 pathway.
All these findings support a role of SIRT3 in the prolongation of life span,
and the manipulation of the RAS system provides a remarkable beneficial
effect on longevity by reducing oxidative stress and upregulating survival
genes (Fig. 4).
Conclusions
Chronic activation of RAS plays an important role in the promotion of
end-stage organ damage associated with aging by increasing tissue and
mitochondrial oxidative stress. Therapies targeting RAS (ACEi and ARBs)
reduce age-associated cardiovascular and renal damage and preserve the
number and the function of mitochondria. A stronger protective effect,
demonstrated by a significant prolongation of life span, was observed in
genetically modified mice, which lack the AT1A gene. In these mice, the
longevity is the consequence of reduced mitochondrial damage due to the
attenuation of oxidative stress and the upregulation of Nampt and Sirt3
survival genes.
The extension of the life span observed in AT1A-/- mice is comparable to
that of mice lacking the insulin growth factor-1 (IGF-1) receptor [34].
However the manipulation of the latter pathway in humans is not imminently
feasible. In contrast, Ang II type 1 receptor antagonists have been proven
safe, well-tolerated for chronic use and represent a key component of the
modern therapy for hypertension and cardiac failure. Thus, the inhibition of
AT1 could represent a possible therapeutic strategy for diseases of aging
and possibly for extending the life span. Further studies are necessary to
deepen the role of AT1 in humans and to understand whether the receptor
function is similar to that found in animals.