Beniamino Palmieri
Department of General Surgery and Surgical Specialties
Medical School and Surgical Clinic
University of Modena and Reggio Emilia
Modena Italy
Tommaso Iannitti
Department of Biological and Biomedical Sciences
Glasgow Caledonian University
Glasgow UK
Valeriana Sblendorio
Department of General Surgery and Surgical Specialties
Medical School and Surgical Clinic
University of Modena and Reggio Emilia
Modena Italy
Citation: B. Palmieri, T. Iannitti & V. Sblendorio : Oxidative stress: how to detect it, cope with and treat basing on evidence?. The Internet Journal of Aesthetic and Antiaging Medicine. 2009 Volume 2 Number 1
Keywords: free radicals | antioxidant | reactive oxygen species | ford | fort
Introduction
We have up-to-date reasonable evidence that ROS play, along human life, a co-factor role in several alleged diseases, and in the ageing process itself with specific morphopathological traits, through cytokyine-mediated inflammation leading to necrosis and final fibrosis. Biochemical investigations into promptly detecting the danger of an oxidative imbalance and restoring antioxidant reservoir before triggering the irreversible damage cascade are thus mandatory. They should be performed in the future as routine exams, during standard blood evaluation and repeated along the treatment plan, to monitor the efficacy of antioxidant compounds administered as primary unique therapy or complementary to some diseases –specific drugs (like antibiotics in severe infections and sepsis). The improvement of symptoms as well as prevention of inflammatory damage, degenerative diseases or cancer should be the goals of antioxidant therapy with confirmation, step by step, of the serum red-ox balance restoration and inflammation/degeneration markers disappearance. We cannot exclude, in the future, that an oxidative status check-up followed by immediate targeted treatment will achieve better social health perspectives, especially in the old age, preventing major illnesses and heavier social costs burden. Monitoring oxidative stress in humans is achieved by assaying products of oxidative damage or by investigating the potential of an organism, tissue or body fluids to withstand further oxidation. Unfortunately, there is little consensus about the selection of parameters of oxidative stress or antioxidant state in defined patients or diseases. This is not only due to the uncertainty whether or not a certain parameter is playing a causative role. Moreover, the methods of determination described in literature represent very different levels of analytical practicability, costs, and quality. Generally accepted reference ranges and interpretations of pathological situations are lacking as well as control materials. At present, the situation is changing dramatically and sophisticated methods like HPLC (High Performance Liquid Chromatography) and immunochemical determinations have become more and more common standard. Test kits for photometric determinations applicable to small laboratories or Points of Care beside measurements are increasingly available. In the screening of such simplified procedures, we found the FORT/ FORD METHOD very suitable in clinical practice, because of its reliability and ease of use. FORT (Free Oxygen Radicals Testing) is a colorimetric test based on the properties of an amine derivative employed as chromogen i.e. ChNH2 (4-Amino-N-ethyl-N-isopropylaniline hydrochloride) aiming at producing a fairly long-lived radical cation (271). When the sample is added to a ChNH2 solution, the coloured radical cation of the chromogen is formed and the absorbance at 505 nm, which is proportional to the concentration of hydroperoxyl molecules, is associated to the oxidative status of the sample. The visible spectrum of the ChNH2 radical cation, reported in figure 1, shows two peaks of absorbance ate 505 and 550 nm. The overall spectral intensity increases with time. The reactions occurring in the FORT test conditions are based on the capacity of transition metals to catalyse the breakdown of ROOH into derivative radicals, according to Fenton’s reaction. Once they are formed, ROOH maintain their chemical reactivity and oxidative capacity to produce proportional amounts of alkoxy (RO.) and peroxy (ROO.) radicals. These derivative radicals are then preferentially trapped by a suitably buffered FORT chromogen and develop, in a linear kinetic based reaction at 37°C, a coloured fairly long-lived radical cation photometrically detectable. The intensity of the colour correlates directly with the quantity of radical compounds, according to the Lambert-Beer’s law and it can be related to the oxidative status of the sample.
R-OOH + Fe2+ →R-O. +OH- +Fe3+
R-OOH + Fe3+ →R-OO. + H++Fe2+
RO. + ROO. + 2CrNH2 →RO- + ROO- + [Cr-NH2+.]
FORD (Free Oxygen Radicals Defence) is a colorimetric test based on the ability of antioxidants, present in plasma, able to reduce a preformed radical cation. The principle of the assay is that, at an acidic pH (5.2) and in the presence of a suitable oxidant solution (FeCl3), 4-Amino-N,N-diethylaniline, the FORD chromogen can form a stable and colored radical cation.
Antioxidant molecules (AOH) present in the sample which are able to transfer a hydrogen atom to the FORD chromogen radical cation, reduce it quenching the colour and producing a decoloration of the solution which is proportional to their concentration in the sample. Preliminary experiments showed that the choice of oxidant solution and the ratio between the concentration of the chromogen substance and the concentration of the oxidative compound are essential for the effectiveness of the method.
Chromogen (uncolored) + oxidant (Fe3+) H+ → Chromogen.+(purple)
Chromogen.+(purple) + AOH → Chromogen+(uncolored) + AO
The UV-visible spectrum of the FORD chromogen radical cation (Fig. 4) shows maximum of absorbance at approximately 330 nm, 510 nm and 550 nm. Hence, an end-point analysis of the colorimetric reaction at 505 nm and at 37° C was selected. The investigation clinical areas and potential antioxidant human and experimental treatment benefit can be addressed to the following pathology areas:
ROS and ageing
The ageing process is very complex: it depends on genetic disposal, but on life style and environmental conditions at the same time. Harman (1) suggested, fifty years ago, that the accumulation of oxidants could explain the alteration of physical and cognitive functions of ageing. Oxygen metabolism leads to reactive species, including free radicals, which tend to oxidize the surrounding molecules such as DNA, proteins and lipids. Oxidative stress is an adaptive process which is triggered upon oxidant accumulation and which comprises the induction of protective and survival functions. Experimental evidence shows that the ageing organism is in a state of oxidative stress, which supports the free radical theory.
ROS And Cardio- Cerebrovascular Diseases
Common vascular risk factors, including hyperlipidemia (cholesterol, low-density lipoproteins, etc.), hypertension, cigarette smoking, diabetes, overweight, physical inactivity, age, male sex and familiar predisposition, only partially explain the excessive risk of developing cerebrovascular and Coronary heart Disease (CHD) and today a lot of studies support the role of OS in their pathogenesis. Atherosclerosis is a chronic pathology involving the deposition of plasma lipoproteins and the proliferation of cellular components in the artery wall that provide a barrier to arterial blood flow. A relevant evidence has supported the theory that free-radical-mediated oxidative processes and specific related products play a key role in atherogenesis (2). At the base of this hypothesis are low-density lipoproteins (LDL), which as part of the normal circulation, occasionally leave the anti-oxidant-replete plasma, entering the sub-endothelial space of arteries: here LDL lipids are oxidized. The oxidized form of LDL (oxLDL) is able to start mechanism leading to the formation of atherosclerotic plaques as it is taken up by macrophages and induces the release of factors that recruit other cells and stimulate smooth muscle cell proliferation. oxLDL may also up-regulate expression of cellular adhesion molecules that facilitate leukocyte binding. High levels of oxLDL can also down-regulate the expression of endothelial nitric oxide synthase (eNOS), enzyme synthetizing most of vascular NO. Stroke is the main cause of disability and mortality in Western countries. Particularly the condition of ischemia and reperfusion occurring after stroke has been shown to be associated with free radical-mediated reactions probably leading to cell death (3). Even if ischemic and haemorrhagic stroke have different risk factors and pathophysiological mechanisms, there is evidence of an increased production of free radicals and other reactive species in both conditions, leading to oxidative stress
ROS, Metabolic Syndrome And Obesity
Associations between obesity and markers of oxidative stress and the lipid sensitivity leading to oxidative modification have been observed in humans (4; 5). The processes that underlie observed associations between obesity and oxidative stress are unclear, even if several theories have been proposed. For example, it has been suggested that oxidative stress in obesity may result, partly, from the accumulation of intracellular triglycerides (6). Specifically, intracellular triglycerides are supposed to elevate superoxide radical generation within the electron transport chain by inhibiting the mitochondrial adenosine nucleotide transporter. The inhibition of this transporter leads to a diminution in intra-mitochondrial adenosine diphosphate (ADP) that, in turn, reduces the proton flux through the adenosine triphosphate-synthase reaction (i.e., the adenosine triphosphate-synthase reaction requires ADP as substrate). It has been suggested that in diabetes the production of oxidative stress may be mostly due to hyperglycaemia (7; 8). The generation of free radicals correlated to chronic hyperglycaemia may result from non-enzymatic glycation (9) and glucose auto-oxidation (10). It has been hypothesized that insulin, at least hyperinsulinaemia, may directly induce intracellular generation of free radicals (11). Ceriello (12) evaluates the effects of an acute increase in glycaemia on plasma antioxidant defences. Some studies report that the use of antioxidants can neutralize some effects acutely induced by hyperglycaemia, such as vasoconstriction (13; 8), activation of coagulation and the increase in ICAM-1 (intercellular adhesion molecule 1) plasma level (11).
ROS And Neurodegenerative Disorders
OS has been implicated as a common pathogenetic mechanism in various neurodegenerative diseases. Central nervous system (CNS) is particularly exposed to free radical injury, given its high metal content, which can catalyze the formation of ROS and the relatively low content of anti-oxidant defences. Indeed, a lot of studies show markers of oxidative damage. Lipid peroxidation, protein oxidation, DNA oxidation and glycoxidation markers in brain areas affected by neurodegenerative diseases. OS damage is also intimately correlated to glutamate neurotoxicity, known as “excitotoxicity”. An excessive concentration of extracellular glutamate over-activates glutamate receptors, leading to very high intracellular calcium levels and a cascade of events resulting in neural cell death (14). Alzheimer Disease (AD) represents the most prominent cause of dementia in the elderly and is clinically characterised by memory dysfunction, loss of lexical access, spatial and temporal disorientation and impairment of judgement. Histopathologically, AD is characterised by synaptic and nerve cell loss, extracellular deposition of β-amyloid protein forming senile plaques and intracellular precipitation of tau protein. The exact biochemical mechanism of the pathogenesis of AD is still unknown, but much attention is given to the role of the massive loss of the neurotransmitter acetylcholine (necessary for cognition and memory) and to the possible involvement of OS in its development (15 ). The complex nature and genesis of oxidative damage in AD can be partly due to mitochondrial and redox-active metal anomalies. AD is essentially an acceleration of the ageing mechanism in affected brain regions that become progressively more damaged by free radicals. Parkinson Disease (PD) is clinically characterised by bradykinesia, postural inability, gait difficulty and tremor. It’s the result of neurodegeneration occurring in specific brain areas (substantia nigra and striatum) and of dopamine depletion. The processes of cell death in PD have not yet been fully elucidated, but increased OS, abnormal mitochondrial function and excitotoxicity are perhaps among the most relevant initiators or mediators of neuronal damage. ALS o Lou Gehrig’s disease is a progressive, fatal neurodegenerative disease characterized by gradual degeneration of motor neurons in the cortex, brainstem and spinal cord. Motor neurons are responsible for supplying electrical stimulation to the muscles necessary for the movement of body parts. The cause of sporadic ALS is unknown; however, in about 10% of all ALS cases, the disease is inherited and familiar (FALS). About 20% of FALS cases are associated with mutations and lowered activity of CuZnSOD. CuZnSOD catalyze the formation of hydrogen peroxide through the dismutation of superoxide radical anions playing a relevant role in regulating oxidative damage to cells. There is evidence of oxidative damage to both DNA and protein as well as lipids
ROS And Lung
The lungs function is to exchange gases between the body tissues and the outside environment. In normal conditions (i.e. when an individual is in good health and resides in a relatively clean environment) the lung, in comparison with other organs, represents a unique tissue for oxidative stress, continually exposed to relatively-high O2 tension, inevitable pollutants and the metabolic products derived from the pollutants. Inhalation of airborne irritants and pollutants, including cigarette smoke, ozone, carcinogens (e.g. diesel exhaust) and other chemicals and dust particles, will produce excess ROS and RNS in the lung. Additionally, such exposures lead to depletion of endogenous anti-oxidants (16).
Asthma
Asthma is a chronic relapsing inflammatory disease of the airways. As inflammatory cells produce and release ROS, asthmatic airways are responsible for oxidative stress. Convincing tests confirm that acute asthma in an adult is accompanied by oxidative and nitrosative stress (17). Exhaled air of patients with asthma contains high levels of some markers of OS; a lot of studies have shown that inflammatory cells from peripheral blood and bronchoalveolar lavage fluid of asthmatic subjects produce more superoxide anion radicals than those ones from controls. Further evidence for an oxidant antioxidant imbalance is provided by the finding of a decreased anti-oxidant capacity in plasma and bronchoalveolar lavage fluid of patients with asthma (18). COPD is characterised by the progressive decline of lung function and the presence of airflow obstruction as a result of chronic bronchitis or emphysema. The single most important aetiological factor in the pathogenesis of this disease is cigarette smoke. It is estimated that 90% of all patients with COPD are, or have been, smokers but only about 20% of cigarette smokers develop the condition. As oxidants play a relevant role in cigarette smoke-induced lung damage, pulmonary antioxidant status defence mechanisms have a great importance. There is evidence that plasma antioxidant capacity is decreased in smokers and in association with exacerbations of COPD, supporting evidence of a depletion of vitamin C, E and other serum antioxidants. Various therapies lead to free-radical-induced tissue damage, i.e. O2 therapy for the treatment of prematurely-born neonates and acute respiratory distress syndrome (ARDS), and chemotherapy and radiation for cancer patients. Oxidative stress is the hallmark of various chronic inflammatory lung diseases. These include, among others, ARDS, bronchopulmonary dysplasia, asthma, chronic obstructive pulmonary disease (COPD), asbestosis and bronchogenic carcinoma.
ROS And Liver Diseases
Steatohepatitis is a disease that can be progressive. It can cause fibrosis and cirrhosis and ultimately lead to liver failure and hepatocellular carcinoma in a minority of patients (19; 20; 21; 22). The pathogenesis of NASH remains unclear and the factors, which cause the progression from bland steatosis to steatohepatitis, often terme the “second hit” remain poorly understood (23; 24). Oxidative stress, an increase in oxidants and/or a decrease in antioxidant capacity, is one of the potential biochemical mechanisms involved in the pathogenesis of NASH (25). Oxidative stress is a cardinal feature of alcoholic Steatohepatitis (26).
ROS And Gastroduodenal Diseases
Helicobacter pylori is an important agent in the pathogenesis of active chronic gastritis, peptic ulcer and low-grade gastric MALT lymphoma and in gastric carcinogenesis (27). Generation of cytotoxins, urease, ammonia, T-cell mediated damage and a mainly humoral reaction are among the events which involve mucosal integrity following H. pylori infection (28). Moreover, reactive oxygen metabolites (ROMs) have been found to play a relevant role in gastroduodenal inflammatory damage (29). Particularly, the acute mucosal inflammatory infiltrate (e.g. polymorphonuclear cells, PMNs), which characterizes H. pylori-related chronic active gastritis, could be an important source of free radicals (30), as both in vivo an in vitro studies have reported a positive relation between H. pylori infection and ROMs generation (31; 29)
ROS And Virus Infections
AIDS is the terminal phase of Human Immunodeficiency Virus (HIV) infection when it runs its natural course. OS plays a relevant pathogenetic role in HIV infections. HIV-infected patients are in oxidative imbalance early in the disease: serum and tissue anti-oxidants levels are low and peroxidation products elevated. High plasma levels of MDA, reduced plasma GSH, decreased GSHPx (glutathione peroxidase) and SODs activities are normally found. HIV infection results also in considerably reduced vitamin E and C concentrations and very low plasma Zn and Se levels . Particularly, Se deficiency is related to the occurrence, virulence and disease progression of some virus infections including HIV progression to AIDS.
ROS And Mesenchymal Inflammations
Arthritis: ROS and RNS can directly or indirectly be responsible for articulation constituent damage and lead to the clinical expression of the inflammatory arthritis. Several factors are involved in the development of oxidative stress in the joints of RA patients; ROS generation from locally activated leukocytes is followed by a pressure increase in the synovial cavity (32), a capillary density reduction, vascular changes and an increased metabolic rate of synovial tissue.
ROS And Hearing Loss
ROS have been implicated in hearing loss associated with ageing and noise exposure. SODs form a first line of defence against damage mediated by the superoxide anion, the most common ROS. Absence of Cu/Zn SOD (SOD1) has been shown to potentiate hearing loss related to noise exposure and age. Conversely, over expression of SOD1 may be hypothesized to afford a protection from age- and noise-related hearing loss. This hypothesis may be tested by (33) using a transgenic mouse model carrying the human SOD1 gene.
ROS And Eye Diseases
Oxidative stress mechanisms in ocular tissues have been hypothesized to play a role in diseases such as glaucoma, cataract, uveitis, retrolental fibroplasias, age-related macular degeneration and various forms of retinopathy providing an opportunity for new approaches to their prevention and treatment. The possible sources of increased oxidative stress might include increased generation of free radicals or impaired anti-oxidant defence system. Dietary supplementation with anti-oxidants in animal models of diabetic retinopathy inhibits retinal metabolic abnormalities and retinal histopathology, suggesting that oxidative stress is associated with the development of retinopathy. The mechanism by which anti-oxidants inhibit retinopathy in diabetes warrants further investigation, but animal studies show that increasing the diversity of anti-oxidants provides significantly more protection than using any single anti-oxidant. Thus, supplementation with anti-oxidants represents an achievable adjunct therapy to help preserve vision in diabetic patients (34).
ROS And Critically Surgical Ill Patients
(35) determined the effectiveness of early, routine antioxidant supplementation using alpha-tocopherol and ascorbic acid in reducing the rate of pulmonary morbidity and organ dysfunction in critically ill surgical patients. Oxidative stress has been associated with the development of the ARDS and organ failure through direct tissue injury and activation of genes integral to the inflammatory response.
ROS And Pregnancy Disorders, Endometriosis
Oxidative processes exert a fundamental regulatory function during pregnancy. It depends on the influence of oxygen, nitric oxide, ROS and RNS metabolic pathways upon the vascular changes in the maternal organism, as well as on the regulation of uterine and cervical tone throughout gestation and delivery. Endometriosis is associated with a general inflammatory response in the peritoneal cavity and OS has been proposed as a potential factor involved in the pathophysiology of the disease. Endothelial nitric oxide synthase, the enzyme that produces NO, is also overexpressed in endometriosis and adenomyosis. The endometrium shows altered enzymes expression such as SOD and GSHPx involved in defence against OS. Also vitamin E levels are significantly lower in the peritoneal fluid of women with endometriosis in the presence of redox-active metal ions as estrogens are established oxidants. This mechanism might be due to oestrogen pro-inflammatory effect, in fact hormone therapy use results to be correlated with increased amount of C-reactive protein, a marker of inflammation (36). Then, estrogens and their metabolites have both pro-oxidant and anti-oxidant properties depending on the availability of metal ions and/or their dose and formulation.
ROS And Thyroid Diseases
Thyroid specimens from patients with Graves' disease, follicular adenoma, and papillary and follicular carcinomas contain significantly higher concentrations of xanthine oxidase (XOD) and GSH-PX, compared to those in the normal thyroid tissue.
ROS And Menopause
Lack of estrogens in menopause leads to a redox status imbalance and a change in the lipid profile. The symptoms accompanying the menopause (e.g. hot flushes) suggest that when they are manifest there is an increased metabolic activity (37) which, together with their repetitive character, could cause a redox status imbalance toward oxidative processes. ROS react with many biologic substrates, especially polyunsatured fatty acids leading to lipid peroxidation, with increased lipid peroxides in plasma and to membrane destruction. Other components of the biologic response to the presence of reactive oxygen intermediates is the decrease in anti-oxidants, including reduced sulphydryl groups
ROS And Human Infertility
The correlation between varicocele and male infertility is still obscure. Several factors seem to be involved in sperm modifications: backflow of noxious substances from the kidney or adrenal glands, testicular temperature increased, tissue hypoxia induced by venous stasis, hypothalamic or pituitary dysfunctions (38). Oxidative damage because of the testicular venous backflow may represent one of the causes of gonad injury and seems to precede the histological alteration (39).
ROS And Kidney Diseases
There is a relevant evidence suggesting that ROS are implicated in the pathogenesis of ischemic, toxic and immunologically-mediated renal injury (40; 41 )
Conclusion
There is now reasonable evidence that ROS play, along human life, a co-factor role in several alleged diseases, and in the ageing process itself with specific morphopathological traits, through cytokine-mediated inflammation leading to necrosis and final fibrosis. Biochemical investigations aimed at promptly detecting the danger of an oxidative imbalance and restoring antioxidant reservoir before triggering the irreversible damage cascade are thus mandatory. They should be performed in the future as routine exams, during standard blood evaluation, and repeated along the treatment plan to monitor the efficacy of antioxidants compounds administered as primary unique therapy or complementary to some diseases / specific drugs (like antibiotics in severe infections and sepsis). The improvement of symptoms as well as prevention of inflammatory damage, degenerative diseases or cancer should be the goals of antioxidant therapy with confirmation, step by step of the serum red-ox balance restoration and inflammation/degeneration markers disappearance. We cannot exclude, in the future, that an oxidative status check-up followed by immediate targeted treatment will achieve better social health perspectives, especially in the old age, preventing major illnesses and heavier social cost burden.
Table 1: Free radicals effects in the pathology
Table 2: Several antioxidants and their mechanism of action
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