Abstract
Background and Purpose
Cholesterol is an essential lipid and its homeostasis is a major factor for many diseases, such as hyperlipidemia, atherosclerosis, diabetes, and obesity. Sodium-glucose cotransporter 2 (SGLT2) inhibitor canagliflozin (Cana) is a new kind of hypoglycemic agent, which decreases urinary glucose reabsorption and reduces hyperglycemia. Cana has been shown to regulate serum lipid, decrease serum triglyceride and increase serum high-density lipoprotein-cholesterol (HDL-C), and improve cardiovascular outcomes. But evidence of how Cana impacted the cholesterol metabolism remains elusive.
Methods
We treated Cana on mice with chow diet or western diet and then detected cholesterol metabolism in the liver and intestine. To explore the mechanism, we also treated hepG2 cells and Caco2 cells with different concentrations of Cana.
Results
In this study, we showed that Cana facilitated hepatic and intestinal cholesterol efflux. Mechanically, Cana via activating adenosine monophosphate-activated protein kinase (AMPK) increased the expression of ATP-binding cassette (ABC) transporters ABCG5 and ABCG8 in liver and intestine, increased biliary and fecal cholesterol excretion.
Conclusion
This research confirms that Cana regulates cholesterol efflux and improves blood and hepatic lipid; this may be a partial reason for improving cardiovascular disease.
Introduction
Cholesterol, as an important biologically active substance, plays a significant role in maintaining membrane structure, biosynthesis of bile acid and steroid hormones.Citation1 Cholesterol homeostasis dysregulated is also involved in the pathophysiology of various diseases, such as hyperlipidemia, cardiovascular disease,Citation2 obesityCitation3 and diabetes.Citation4
Cholesterol homeostasis mainly involves absorption of cholesterol in the intestine or biosynthesis in the liver, reverse cholesterol transport, converse into bile acid, and biliary and fecal excretion. Intestinal absorption is mainly mediated by Niemann-Pick C1-Like 1(Npc1l1).Citation5 3-hydroxy-3-methylglutaryl-CoA reductase (Hmgcr) is a rate-limiting enzyme for sterol biosynthesis. Cholesterol mainly reverses transport into the liver by high-density lipoprotein (HDL); then, a third of them are converted into bile acid through the classical pathway (mainly by Cyp7a1 and Cyp8b1) or alternative pathways (mainly by Cyp27a1 and Cyp7b1).Citation6 Cholesterol transport is mediated by many membrane transporters, including ATP-binding cassette (ABC) transporters Abca1 and Abcg1. Abca1 promotes cholesterol export to Apo A-I, and Abcg1 plays a role in cholesterol export to HDL.Citation1 In the liver and intestine, Abcg5/8 promotes secretion of cholesterol into bile or gut lumen. It has been reported that increased cholesterol excretion but not absorption can improve cardiovascular diseases.Citation7 The liver X receptor (LXR) is an important regulator of cholesterol homeostasis.Citation8 LXR regulated expression of the ABC transporters Abca1, Abag1 and Abcg5/8 is critical in enhancing cholesterol efflux.Citation9
AMPK is an important cellular energy sensor; a number of recent studies have shown that AMPK has a wide range of biological roles, involving mitochondrial oxidative respiration, energy homeostasis and autophagy.Citation10 And it has the potential to affect many human diseases, such as cancer, type 2 diabetes and atherosclerosis.Citation10,Citation11 A number of drugs, like salicylateCitation12 and Pueraria,Citation13 activating AMPK, have been reported to stimulate cholesterol efflux from macrophage and decrease cellular lipid accumulation via AMPK-Abca1 axis. Activation of AMPK increased the expression of Abca1 and its transcriptional activator LXRα in macrophages.Citation14 And metformin, a classical AMPK activating drug, increases Abcg5 and Abcg8 expression in the liver via regulating the stability of Period 2 which is a repressor of transcription on the Abcg8 promoter.Citation15 Thus, AMPK plays an important role in cholesterol homeostasis.
Canagliflozin (Cana), one of the sodium glucose cotransporters (SGLT) inhibitors, inhibits the reabsorption of glucose in the proximal glomerular tubules. Except reducing hyperglycemia, clinical trials and experience in mice have confirmed that Cana reduces body weight,Citation16,Citation17 lowers blood lipid,Citation18 and reduces the risk of cardiovascular events.Citation19–Citation21 However, there is still a lack of evidence as to how Cana impacted the cholesterol metabolism.
In this study, we showed that Cana can facilitate the cholesterol efflux into bile and feces through upregulating Abcg5 and Abcg8 expression in the liver and ileum. In vitro, we found that Cana could directly activate AMPK pathway and upregulate the expression of Abcg5 and Abcg8. Inhibition of AMPK pathway abolished the effect of Cana on the regulation of Abcg5/8. Our study provides a plausible explanation of Cana’s effect on cholesterol metabolism.
Materials and Methods
Animal Model and Treatment
C57BL/6J male mice (8 weeks old) were divided into four groups (n=8) and, respectively, fed with chow diet or western diet (42% of kcal from fat, 0.5% cholesterol, Medicinence, Cat, #TD88137A) for 12 weeks. Canagliflozin (MB1516, Meilunbio®, Dalian, China) (Supplementary Figure 1) was mixed with chow diet or western diet at 0.03% (w/w).Citation22 Fecal samples and urine were collected for three consecutive days using metabolic cages before being killed. Mice were killed through CO2 after fasted overnight. Blood, liver, duodenum, jejunum and ileum were collected and stored in −80°C. All mice were housed in the institutional animal care of West China Hospital of Sichuan University with 24°C-indoor temperature, 55±15% relative humidity, and a 12-hour light/dark cycle. Mice were bred in standard cage with ad libitum feeding. All animal experiments in this research were carried out in accordance with the relevant regulations of the Sichuan University Laboratory Animal Ethics committee and approved by the Institutional Review Board (or Ethics Committee) of the Sichuan University Laboratory Animal Ethics committee (2020061A).
Histological Staining
Mouse livers were fixed and embedded in paraffin, sectioned at 4μm, and stained with hematoxylin and eosin (H&E). Oil-Red-O staining was performed by 10μm frozen sections. The samples were examined under a light microscope (Nikon, Tokyo, Japan), at 200X or 400X magnification.
Serum Alanine Transaminase (ALT), Aspartate Aminotransferase (AST) Assays
Blood was held at 4°C for 2 hours, then centrifuged at 6000 rpm for 10 minutes, and supernatant removed. The serum was stored at −80°C. Serum ALT (100,020,000, Biosino Bio) and AST (100,020,010, Biosino Bio) levels were measured using appropriate enzymatic kits.
Cholesterol, Triglycerides, Glucose and Bile Acid Assays
Mice feces of 24 hours were collected for three consecutive days. Then dried and ground the feces, extracted with 75% ethanol at 55 degrees Celsius for 2 hours, centrifuged at 1500 rpm, 10 min and took the supernatant for detection. Liver lipids were extracted with chloroform and dissolved with 1% triton ethanol. Serum, hepatic and fecal lipids were detected by the enzymatic kits (Biosino, Beijing, China). Urine was diluted 100 times with PBS, then detected glucose with an assay kit (100,020,100, Biosino, Beijing, China). Blood glucose was measured using a glucometer (Roche, Basel, Switzerland).
Cell Culture and Treatments
All cell lines were cultured under standard conditions at 37°C, 5% CO2 in a humidified incubator. HepG2 cells (ATCC, HB8065) and Caco2 cells (ATCC, CRL-2102) were maintained in a medium (DMEM, supplemented with 10% fetal bovine serum). Cells were cultured in a 12-well, and were pretreated with 10µM Compound C (Merck, 866,405–64-3) for 1 h, then were treated with 10µM or 30µM Cana for 2 h to detect the expression of AMPK expression, or 24 h to detect the expression of ABCG5/8.
Western Blotting Analysis
The total protein was extracted by loading buffer and used BCA method to ensure protein concentration. Primary antibodies and fluorescence secondary antibodies were listed in Supplementary Table 1. The signal was visualized using LI-COR System (Lincoln, NE). Quantitative determination of band intensity was analyzed using Image Studio (Li-COR).
Total RNA Extraction and Real-Time PCR Analysis
The total RNA of the tissues was extracted with trizol reagent (135,306, Life Technologies). The cDNA synthesized from RNA by reverse transcription kit (RR037A; TaKaRa, Kyoto, Japan) and cDNA samples were quantified by CFX96 Real-time RT-PCR System (Hercules, CA) with SYBR Green PCR Master Mix (Takara, Tokyo, Japan). The Primers are listed in Supplementary Table 2.
Statistical Analysis
Data were shown as mean ± SEM. Student’s t-test or one-way ANOVA Tukey’s test was used for data analysis. In animal experiments, there are 8 mice in each group; and in the cell experiments, there are three duplicate holes in each group. P < 0.05 was considered statistically significant.
Results
Cana Improved Serum Lipid Profiles and Hepatic Lipid Metabolism
It has been reported that Cana can improve lipid metabolism.Citation19 In western diet-fed mice, Cana treatment significantly decreased western diet increased the body weight (35.41±1.244 to 30.47±0.5775g, p=0.0026) (Supplementary Figure 2A and Supplementary Table 3). Compared with control, Cana slightly increased the food intake, but did not reach statistical difference (Supplementary Figure 2B, Supplementary Table 3). As expected, Cana decreased the blood glucose under both chow diet and western diet (186.1±5.516 to 136.6±4.569 mg/dl, p<0.0001) (Supplementary Figure 2C, Supplementary Table 3). The glucose level in urine was significantly increased by 6000–8000 times in Cana treated mice (Supplementary Figure 2D, Supplementary Table 3).
We then evaluated the effect of Cana on the lipid metabolism in mice fed with chow and western diet. Serum cholesterol level was significantly decreased from 280.5±15.92 mg/dl to 217.1±20.98 mg/dl (p= 0.0275) in Cana treated mice (). Further analysis revealed that the lower serum LDL-C could account for the decreased serum cholesterol seen in Cana treated mice (). Unexpectedly, Cana increased the HDL-C under both chow diet and western diet (). The serum level of triglyceride was also lowered from in Cana treated mice after western diet (). We went on to evaluate the effect of Cana on hepatic lipid metabolism. H&E staining and Oil red O staining indicated that hepatic lipid was less in Cana treated mice (). Lipid quantification revealed that the levels of cholesterol and triglyceride were significantly lower in Cana treated mice under western diet ().
Cana Upregulated Hepatic Cholesterol Transport
To understand the cause of Cana regulated lipid metabolism, we measured the mRNA expression of genes involved in cholesterol metabolism. We first detected the gene expression in cholesterol biosynthesis. Cana had little effect on the expression of Hmgcr, and slightly decreased the expression Hmgcs in the liver of mice fed with chow diet (Supplementary Figure 3A). However, the expressions of these two genes were significantly decreased in Cana treated mice (). Once synthesized, cholesterol can be converted into bile acid, or transported into bile by its transporters.Citation6 The conversion of cholesterol into bile acid is controlled through the classical pathway (main enzyme are Cyp7a1 and Cyp8b1) and alternative pathway (main enzyme are Cyp27a1 and Cyp7b1).Citation6 The mRNA expressions of these bile acid synthetic genes were significantly increased by 1.5–2.5 times in Cana treated mice upon western diet (). On chow diet, the expressions of Cyp7a1 and Cyp27a1 were also increased (Supplementary Figure 3B). Cholesterol can be transported into plasma by Abca1 and Abcg1, or into bile by Abcg5 and Abcg8.Citation23 The mRNA expression of these transporters was upregulated about 1.5 times by Cana on both chow diet and western diet ( and Supplementary Figure 3C). Consistently, the protein levels of Abcg5 and Abcg8 were increased by 1.5–2 times in Cana treated mice (). Consequently, the biliary concentration of cholesterol and bile acid was higher in Cana treated mice (). In the liver, LXR is involved in transcriptional control of Cyp7A1, as well as induction of Abca1 and Abcg5/8 expression, and thus accelerates biliary cholesterol disposal.Citation24 The mRNA expression of LXR in liver is increased by Cana on chow diet (Supplementary Figure 3D) and western diet (). To test whether Cana could directly regulate the expression of Abcg5 and Abcg8, we treated HepG2 cells with different concentrations of Cana. We found that Cana could increase the mRNA expression of Abcg5 and Abcg8 more than 2 times (). The protein levels of Abcg5 and Abcg8 were also upregulated about 1.5 times by Cana ( and Supplementary Figure 3E and F). The mRNA expression of LXR in hepG2 cells also increased about 1.5 times by treatment with low dose of Cana and more than 2 times by high dose of Cana ().
Cana Augment the Intestinal Abcg5/8 Expression
Intestinal cholesterol absorption and transport also play a vital role in cholesterol homeostasis.Citation25 On the apical, cholesterol is transported into the enterocytes by Npc1l1.Citation5 Cana treatment had little effect on the expression of Npc1l1 (). Cholesterol in the enterocytes either transports back into the intestinal lumen by abcg5/8 or transports into basolateral by Abca1 and Abcg1.Citation26 The expression of Abcg5/8 was upregulated 2–3 times than that in the Cana treated duodenum and jejunum (), suggesting higher efflux of cholesterol back to the lumen. The expressions of Abca1 and Abcg1 were also higher 1.5–2 times in the duodenum and jejunum (). Apo A-I (apolipoprotein A-I) receives cholesterol efflux from Abca1, then participates in new HDLs synthesis.Citation27 The expression of Apo A-I was consistently increased in the duodenum and jejunum of Cana treatment western diet fed mice (). As a result of elevated efflux of cholesterol, the fecal cholesterol was consistently higher in Cana treated mice (). LXR agonist upregulates Abca1, Abag1 and Abcg5/8 expression, and accelerates biliary and fecal cholesterol disposal.Citation24,Citation28 The mRNA expression of LXR was also upregulated in intestine (). We also tested the effect of Cana in human colon adenocarcinoma cell line, Caco2 cells. In Caco2 cells, both mRNA and protein expression of Abcg5 and Abcg8 were higher about 1.5–2 times after Cana treatment (–, Supplementary Figure 4A and B). And the LXR expression was also significantly increased by about 2.5 times by Cana ().
Cana Increased Abcg5 and Abcg8 Expression via Active AMPK
To understand the mechanism of Cana regulated Abcg5 and Abcg8 expression, we explored the signaling pathway. Cana has been reported to activate AMPK in several cell lines.Citation29,Citation30 Western blot result showed that Cana could active AMPK in liver tissue () and duodenum and jejunum (Supplementary Figure 5). In hepG2 cells, Cana could directly activate AMPK and its downstream phosphorylation of ACC (). In Caco2 cells, AMPK was also activated by Cana treatment (). To confirm whether Cana regulated Abcg5 and Abcg8 was AMPK dependent, we treated hepG2 and Caco2 cells with compound C, a pharmacological inhibitor of AMPK. Inhibition of AMPK pathway abolished Cana increased expression of Abcg5 and Abcg8 in both hepG2 and Caco2 cells (–, Supplementary Figure 6A–F). Cana upregulated expressions of LXR in both hepG2 and Caco2 cells were also inhibited by Compound C (Supplementary Figure 6G and H). Taken together, Cana increased Abcg5 and Abcg8 expression via activating AMPK pathway.
Discussion and Conclusion
Cana, the first SGLT2 inhibitor, was approved as a hypoglycemic drug by the FDA in 2013.Citation18 It increases urinary sugars excretion by inhibiting glucose reabsorption in proximal glomerular tubules. Cana has been reported to regulate cholesterol metabolism. Our study reported that Cana upregulated HDL-C, and downregulated the level of cholesterol and triglyceride in serum. This result that Cana downregulated cholesterol and triglyceride was also shown in APOE-/- mice with high cholesterol feeding.Citation31 Yu et al study showed that Cana decreased cholesterol in serum but had little effect on triglyceride in C57Bl/6NTac mice fed with a high-fat diet and injected with streptozotocin.Citation32 Basu et al also analyzed the lipid profile in serum of diabetic CETP-Apolipoprotein B100 transgenic mice, and their results showed that Cana increased LDL-C and HDL-C and reduced TG in serum.Citation33 The different effect of Cana is likely a result of different backgrounds of mice and diet feeding.
Cholesterol homeostasis in the body is mainly involved in de novo synthesis, intestinal absorption, and biliary and fecal excretion. Cana has been reported that inactive Hmgcr, a key rate-limiting enzyme in de novo synthesis of cholesterol.Citation34 In our study, we also found Hmgcr and Hmgcs were decreased in Cana treatment mice. Abcg5 and Abcg8 form heterodimers acting as biliary and intestinal efflux pumps for dietary sterols and cholesterol on the apical side.Citation35 Our study showed that Cana increased Abcg5 and Abcg8 expression in the liver and ileum facilitated cholesterol biliary and fecal excretion. Npc1l1 is the most important cholesterol absorption protein in the intestinal brush border membrane.Citation5 Only increased Abcg5 and Abcg8, but not Npc1l1 can reduce atherosclerosis and improve cholesterol metabolism.Citation7,Citation36 Our study firstly reported that Cana could facilitate biliary and fecal cholesterol excretion but not change intestinal cholesterol absorption.
AMPK, an important energy sensor in cell growth, inhibits anabolic processes and promotes catabolism. Activating AMPK can inactivate Hmgcr, key enzyme of cholesterol synthesis.Citation37 Fleur Lien reported that activation of AMPK can inhibit farnesoid X receptor (FXR) transcriptional activity,Citation38 which is important in negative-feedback regulatory bile acid synthesis. Except Matthew, M. Molusky study found that AMPK through phosphorylate regulates Cry-1 and Per2 binding, which promotes ABCG5/8 expression.Citation15 LXR is also an important cholesterol regulator. In macrophages, LXR agonist upregulates Abca1 and Abag1 expression, and facilitates cholesterol conversion to HDL.Citation39 In the liver and intestine, LXR is involved in the transcriptional control of Cyp7A1, as well as induction of ABCA1, ABCG5, and ABCG8 expression, thus accelerating biliary and fecal cholesterol disposal.Citation24,Citation28 And AMPK can also activate LXR and downstream proteins, upregulate cholesterol reverse transport.Citation14 These results are coincident with our findings that Cana inhibits cholesterol synthesis, stimulates bile acid biosynthesis and facilities cholesterol efflux.
Cana has been certified to upregulate the ratio of AMP/ADP, indirectly activating AMPK at lower dose and they confirmed that in mice 100mg/kg Cana activated liver AMPK in 4h.Citation29 In adipocyte, Cana promotes mitochondrial remodeling via AMPK-Sirt1-Pgc1α pathway and stimulates energy metabolism.Citation30 In vascular endothelial cells, Cana inhibits interleukin-1β-stimulated secretion of IL-6 and monocyte chemoattractant protein-1.Citation40 However, there is no report about whether Cana activates AMPK in the intestinal segment. Therefore, we detected protein expression of AMPK and p-AMPK in duodenum, jejunum, and ileum. In the liver and intestine, Cana distinctly increased p-AMPK expression. ACC, a main major substrate of AMPK, can be phosphorylated and inhibited by AMPK.Citation41 The phosphorylation of AMPK and its downstream protein ACC was enhanced by Cana. Thus, we used Compound C, a pharmacological AMPK inhibitor, to inhibit AMPK in hepG2 cells and Caco2 cells. The expressions of Abcg5 and Abcg8 and LXR were also inhibited and Cana stimulating could not increase their expression. Therefore, AMPK activated by Cana is at least a reason for its effect on reverse cholesterol transport.
We have recognized the limitation of our study. AMPK activation can increase the expression of cholesterol efflux genes, imply antioxidant and anti-inflammatory capacities, thus been thought of as a therapeutic candidate for the treatment of cardiovascular disease.Citation11,Citation42 We found that inhibition of AMPK could abolish the effect of Cana which increased the expression of Abcg5/8. The genetic inhibition of AMPK in the liver or intestine could be used to further validate this effect. Cholesterol metabolism in macrophages is also an important part of reverse cholesterol transport.Citation43 AMPK can also enhance the anti-atherogenic properties of HDL.Citation42 Cana’s effect on macrophages can be studied further, and it may also be a reason of Cana improving cardiovascular outcomes.
In conclusion, we have shown the effect of Cana on blood lipid and hepatic cholesterol metabolism. Mechanically, we demonstrated that Cana activated LXR and increased Abcg5 and Abcg8 expression in liver and intestine via activating AMPK. Our results provide further evidence for clinical use of the drug in diabetic patients with high serum cholesterol or poor diet control.
Abbreviations
Abcg5/8, ATP-binding cassette transporters 5/8; AMPK, adenosine monophosphate-activated protein kinase; Abca1, ATP-binding cassette transporters A1; Abcg1, ATP-binding cassette transporters G1; HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-cholesterol; SGLT2, sodium glucose cotransporter 2; NPC1L1, Niemann-Pick C1-Like 1; HMGCR, 3-hydroxy-3-methylglutaryl-CoA reductase; HMGCS, 3-hydroxy-3-methylglutaryl-CoA synthase; LXR, liver X receptor; FXR, farnesoid X receptor; ALT, serum alanine transaminase; AST, aspartate aminotransferase; CD, chow diet; WD, western diet; Cana, canagliflozin; CC, compound C.
Author Contributions
Y.Z. designed and performed experiments and wrote the manuscript. Y. L., Q. L., Q.T., J. Z., Z.Z. and C. H. contributed to the discussion and review of the manuscript. H.H., G.Z., J. Z., J.Y. and Y.X. helped with experiments. J. H. and Z.Z. obtained funding, designed experiments, and wrote the manuscript. All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval for the version to be published; and agreed to be accountable for all aspects of the work.
Disclosure
The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Acknowledgments
We thank the Laboratory of Pathology, West China Hospital, for technical assistance.
Additional information
Funding
References
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