March 2005 AMDCC Progress Report. Diabetic Uropathy. Firouz Daneshgari, M.D. The Cleveland Clinic Foundation
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1 March 2005 AMDCC Progress Report Diabetic Uropathy Firouz Daneshgari, M.D. The Cleveland Clinic Foundation
2 Diabetic Uropathy Ouline Further definition of diabetes- specific changes in the bladder Find a phentoyping assay to detect loss of bladder sensation in DBD Phenotyping assays in AMDCC animals Further definition of Humanoid Condition
3 Diabetic Bladder Dysfunction Traditional Findings Enlarged Bladder Poor Emptying/ Voiding Dysfunction Urinary incontinence High post void residual (PVR)
4 DBD in Human Bladder Overactivity in Diabetes? 76% of diabetic patients had involuntary contraction as cause of their incontinence (Starer 1990) 25% of diabetic subjects (Ueda 1997) 55% of diabetic patients; 23% had impaired detrusor contractility (Kaplan 1995) Defining the Humanoid Model
5 Proposed Natural History of Progression of Diabetic Bladder Dysfunction In Human and Animals Early Phase Late Phase Time Course/Risk factors?? Clinical: Filling problems Urodynamics: Overactive Bladder In-vitro: Hypercontractile Detrusor Voiding Problems Atonic Bladder Hypocontractile Detrusor Daneshgari 2003
6 Beaker for urine collection To recording device Force Transducer
7 Time-Dependent Alterations in Diabetic Cystopathy Duration time after diabetes induction: 3wk, 6wk, 9wk 12wk and 20wk
8 Age-matched control Diabetic-3w Diabetics-12wk Time Pressure (cmh2 O) Pressure (cmh O) 2 Pressure(cmH2 O)
9 A Time course of DBD in SD STZ-Rats Bladder Capacity Bladder Capacity (ml) Control Diabetic Post Injection Weeks
10 Time course of DBD in SD STZ-Rats Bladder Compliance Bladder Compliance (ml/cmh 2 O) Control Diabetic Post Injection Weeks
11 Time course of DBD in SD STZ-Rats Peak Pressure of Leak: Adjusted Effects of Age and DM Peak Pressure of leak (cmh2o)ls Means Week DM Control
12 EAC Comments Are the changes result of increased diuresis or hyperglycemia?
13 Time-course of STZ- induced Diabetic Bladder Dysfunction in C57Bl/6 Mouse
14 Time Course of DBD in C57Bl/6 Groups DM-untreated DM-treated Diuretic Controls Time points 3 weeks 9 weeks 12 week 20 weeks
15 Time Course of DBD in C57BL/6 Conscious Cystometrogram :22:30 15:27:30 15:32:30 15:37:30 15:42:30 Blad Press Event Mrk Data Log Mrk h:min:s Volume
16 Control DM DM-Treated Diuretic
17 Daneshgari 2005 Time Course of DBD in C57BL/6 Bladder Capacity 0.8 Control Diabetic Treated Diuresis 1 Bladder Capacity Weeks
18 Time Course of DBD in C57BL/6 Bladder Compliance 0.20 Control Diabetic Treated Diuresis 1 Compliance Weeks
19 Time Course of DBD in C57BL/6 Micturition Volume per void Measurement Group Micturation volume (ml( ml) Control 0.13± ± ± ± DM 0.22± ± ± ± Treated DM 0.14± ± ± ± Diuretic 0.30± ± ± ±
20 Time Course of DBD in C57BL/6 24-Hour urine output Measurement Group Hour urine output Control 1.05± ± ± ±0.03 DM 9.53± ± ± ±1.74 Treated DM 3.20± ± ± ±0.48 Diuretic 7.31± ± ± ±
21 Time Course of DBD in C57BL/6 Residual Urine Measurement Group Residual Urine (ml) Control 0.03± ± ± ± DM 0.35± ± ± ± Treated DM 0.04± ± ± ± Diuretic 0.09± ± ± ±
22 Time Course of DBD in C57BL/6 Peak Micturition Pressure of the Bladder 70 Control Diabetic Treated Diuresis Peak Micturation Pressure Weeks
23 Time Course of DBD in C57BL/6 Resting Pressure of the Bladder 20 Control Diabetic Treated Diuresis Resting Pressure Weeks
24 Morphometric Alterations in DBD Diabetic Control H&E
25 Morphometric Alterations in DBD
26 Morphometric Alterations in DBD
27 Morphometric Alterations in DBD Control Diabetic Diuretic Liu & Daneshgari: AJP 2005
28 Bladder Contractility Neurogenic Mediated: Cholinergic Purenergic NANC Myogenic
29 Bladder Contractility Neurogenic Mediated: Cholinergic Purenergic NANC Myogenic Electrical Field Stimulation Carbachol ATP KCL
30 A 12 EFS EFS EFS EFS 10 Tension (g) Controls B Atropine 1 µm α,β-meatp 10 µm Tetrodotoxin 1 µm Tension (g)
31 C Diabetic Tension (g) D Diuretic Tension (g)
32 ALTERATIONS IN NEUROGENICALLY MEDIATED CONTRACTILE RESPONSES OF URINARY BLADDER IN RAT WITH DIABETES Tension (g/mm 2 ) Control Diabetic Diuretic Frequency of stimulation (Hz) Liu & Daneshgari: AJP 2005
33 Cholinergic component (%) Control Diabetic Diuretic A Purinergic component (%) B Control Diabetic Diuretic Frequency of stimulation (Hz) Frequency of stimulation (Hz) C Residual NANC componen t(%) Frequency of stimulation (Hz) Control Diabetic Diuretic Liu & Daneshgari: AJP 2005
34 Diabetic Cystopathy Conclusions Time-dependent alterations in diabetic cystopathy are consistent in small animal models of DM Bladder undergoes compensatory and decompensatory changes Compensation is partially related to increased diuresis Decompensation is related to hyperglycemia and its disease specific changes in detrusor contractility
35 Diabetic Cystopathy Conclusions Identification of mechanism of detruosr decompensation in the late stage of DM is needed Mechanisms of detrusor decompensation may involve ROS pathways
36 EAC Comments: Downstream alterations? Assessment of AGEs in the diabetic bladder In Collaboration with Vincent Monnier, M.D.
37
38 Carboxymethyl Lysine (CMLi( CMLi) Adjusted Effects of Age and DM (Natural Log Scale) LCMLiLS Means LCMLiLS Means Status Week
39 Carboxyethyl Lysine (CELs( CELs,, Natural Log Scale) LCELsLS Means Week
40 EAC Comments Find a phentoyping assay to detect loss of bladder sensation in DBD
41 Preliminary Results of Quantitative Measurement of Urinary Sensory Function in Normal Bladder CPT value C-fiber Aδ-fiber Aβ-fiber BC5 BAd250 BAb2000 5Hz 250Hz 2000Hz Stimulation
42 Results of CPT values in individual cases comparing to the values in control CPT value Aβ-fiber Control Hypersensitive Hyposensitive Aδ-fiber C-fiber BC5 BAd250 BAb2000 5Hz 250Hz 2000Hz Stimulation
43 TransUrethral Afferent Current Perception Threshold (TUR-ACT) in rat/mouse Daneshgari 2004
44 Heart Rate Changes with CPT *30/5HZ Time (seconds) Heart Rate (time/min)
45 Measurement of CPT values in small animal models of diabetes Measurement of BP and HR as the ANS response Measurement of abdominal rectus muscle as a somatic pain response independent of ANS (Timothy Ness, M.D., Ph.D. UAB)
46 Assessment of CPT with Vesicomotor response
47 Inputs to differential amplifier Arterial pressure transducer EMG electrodes Bladder catheter & Temp probe Final experimental arrangement
48 C h a r t W i n d o w 3 : : : : : : 0 0 C h a r t W i n d o w 3 : : : : : : 0 0 C h a r t W i n d o w 3 : : : : : : 0 0 Final experimental output Arterial press Channel 1 (mmhg) For CMG (slow fill) Channel 3 (mmhg) Channel 4 (V) Intravesical pressure Rectified EMG EMG measures For phasic UBD
49 Diabetic Uropathy 2004 Work 4 manuscripts JDRF post-doc fellowship award STTR application Phenotyping of AMDCC animals
50 AMDCC Collaborative studies Total Body Glut4/ko-C57Bl/6 C57Bl/6- University of MI Bladder Capacity Bladder Capacity ml wk control 36-wk Glut4 k/o 42-wk Glut4 k/o Control Diabetic
51 AMDCC Collaborative studies Total Body Glut4/ko-C57Bl/6 C57Bl/6- University of MI Voiding Pressure Comparison of Micturition Peak Pressure 45 cmh2o wk control 36-wk Glut4 k/o 42-wk Glut4 k/o control Diabetic
52 KLS Mice- U of MI Bladder Capacity ml Control Diabetic Com pliance ml/cmh2o Control * Diabetic
53 KLS Mice- U of MI CMG Pressure Parameters cmh2o * * * Basal Threshold Peak Resting control Diabetic
54 METHODS A/symptomatic Patient with Type I or Type II Diabetes Informed Consent Obtained Medical & Diabetic History Obtained Complete Self-Administered Questionnaires 1. Diabetes Lower Urinary Tract Screening Questionnaire 2. Pelvic Floor Disorder Screening Questionnaire A1c Hemoglobin (HgA1c) Uroflowmetry & Determination of Post-Void Residual CPT measurement+ Autonomic Neuropathy Assessment Urodynamics
55 RESULTS Gender n = 70 Female (52%) Mean Age = 56.7 Type II Diabetic Type (82%) Male (48%) Type I (18%)
56 DM LUT Screening Questionnaire Percent Responders Voiding Frequency > 8/day Female Male Voiding Frequency >2/night Urgency Urge accidents Wear pads for urgency Leak on cough/laugh/lift 24 0 Post-void dribbling 58 0 Wear Pads for leaks UTI within year 30 0 Three or more questions positive
57 RESULTS LUT Complications % 45% 41% 10 20% 0 Symptoms of LUT Abnormal Uroflow PVR > 50 cc PVR > 100 Urinary incontinence Voiding dysfunction Maximum flow rate of <15 ml/cc
58 Diabetic Uropathy Feldman Table Animals Micturition Cycles CMG Contractility AGEs CPT C57BL/6 Glut4/ko- C57Bl/6 - - KLS - -
59 Work Role of AGEs and other ROS in decompensation of detrusor function Assessment of Afferent autonomic neuropathy in the bladder Better definition the humanoid condition Phenotyping of AMDCC animals
60 DBD Phenotyping of AMDCC animals 49 Strains in the AMDCC Identify models from each complication Do on-site or off-site phenotying of top models within the next months
61 Model/Strain Complication 24 hr MC CMG Contractility Ins2Akita Akita Bdkr2-/- Duke-Nephropathy D2B6F1Ins2 Akita Duke-Nephropathy 129-Ins2 Akita Duke-Nephropathy C57BL/6JLDLR-/- Pdx-1+/+ Rockefeller-CV C57BL/6JLDLR-/- Pdx-1+/ 1+/- Rockefeller-CV C57BL/6JLDLR-/- Rockefeller-CV C57BL/6JLDLR-/- Ob/Ob Rockefeller-CV C57BL/6J Akita Utah- Cardiac FVB Dominent Neg P13 Kinase Utah- Cardiac ACS-CIRKO CIRKO Utah- Cardiac
62 Model/Strain Complication 24 hr MC CMG Contractility C57BL/6J Vanderbilt- Nephropathy DBA/2J Vanderbilt- Nephropathy FVB/NJ Vanderbilt- Nephropathy C57BLKS db/db Michigan- Neuropathy GCLC+/-db/db High fat diet Michigan- Neuropathy GLUT1 tg db/db High fat diet Michigan- Neuropathy Elderly LDLR-/- UCLA-Macrovascular Hyplip Cross UCLA-Macrovascular SM PPAKg-/- UCLA-Macrovascular
63
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