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Increasing evidence demonstrates that advanced glycation end products (AGEs) play a pivotal role in the development and progression of diabetic vascular damage. Advanced glycation end products (AGEs) are modifications of proteins or lipids that become nonenzymatically glycated and oxidized after contact with aldose sugars. Schematic representation of the formation of some common advanced glycation end products (AGEs). The non-enzymatic reaction of reducing carbohydrates with lysine side chains and N-terminal amino groups of macromolecules (proteins, phospholipids and nucleic acids) is called the Maillard reaction or glycation. Thus, the hypothesis that it is glucose itself that is toxic in type 2 diabetes is confirmed, in line with the findings of the DCCT for type 1 diabetes: the controversy should now end and we must unravel the mechanisms of this effect in order to better approach it therapeutically.
Over the past 3 decades, four seemingly independent major mechanisms of hyperglycemia-induced damage have been discovered: polyol pathway activation, advanced glycation endproduct (AGE) formation, protein kinase C (PKC) activation, and hexosamine pathway activation. As stated above, the reactive dicarbonyl intermediates, formed from Amadori products or from sugars, react with protein amino groups to form a variety of AGEs (for details on structures see other pages on this IMARS website).
As we have described above, AGEs can be produced not only through direct action of sugars on proteins but also via distinct oxidative reactions. Glycation and the other 3 pathways linked to hyperglycemia-induced damage may be linked in a unifying hypothesis put forward by Brownlee.
AGE-peptides are filtered by the glomerulus and catabolized in part by the endolysosomal system of the proximal convoluted tubule, as shown in Figure 7.
In a nutshell, as depicted in Figure 8, AGE peptides increase in diabetes (excess of production) and in kidney failure (decreased excretion). Vascular diabetic complications may be due in part to chronic endothelial cell activation but the picture is incomplete as yet. On the other hand, as the diagram in Figure 9 summarizes, extensive literature shows a role for the glycation of lipoproteins in atherogenesis.
When renal failure was produced in streptozotocin-induced diabetic rats by surgical reduction of renal mass and aminoguanidine was administered, the treated rats had significantly superior survival than that of untreated uremic diabetic animals. In other words, they are the result of a chain of chemical reactions which follow an initial glycation reaction.
Increased serum levels of advanced glycation endproducts predict total, cardiovascular and coronary mortality in women with type 2 diabetes: a population-based 18 year follow-up study.
Immunological Evidence that Non-carboxymethyllysine Advanced Glycation End-products Are Produced from Short Chain Sugars and Dicarbonyl Compounds in vivo.
The formation of intracellular glyceraldehyde-derived advanced glycation end-products and cytotoxicity. This assay enables the convenient assesment of test articles for their effect on the formation of naturally fluorescent glyceraldehyde-derived advanced glycation endproducts (AGE), using BSA as a substrate protein. The products of this process, termed advanced glycation end products (AGEs), adversely affect the functional properties of proteins.Many AGEs have fluorescent and convalent cross-linking properties.
There are several equally defensible hypotheses on the roots of complications including but not limited to, the aldose reductase hypothesis, oxidative stress, the Maillard, or advanced glycation end product (AGE) hypothesis, modified protein kinase C activity, pseudo-hypoxia, carbonyl stress, altered lipoprotein metabolism, and altered cytokine activities. In a second phase of the glycation pathway, a complex series of rearrangements and oxidative reactions leads to the formation of multiple, very reactive species, collectively named advanced glycation end products or AGE-products, some of which are shown in greater detail in other pages on this IMARS website. Early glycation of apoB, apoAs and apo E has been described and abnormal metabolism of glycated forms of LDL and HDL have been reported. Then, following the interaction with receptors for advanced glycation end products (RAGEs), a series of events leading to vessel damage are elicited and perpetuated, which include oxidative stress, increased inflammation, and enhanced extracellular matrix accumulation.
These compounds interact with receptors, such as RAGEs (receptors for advanced glycation end products), to induce oxidative stress, increase inflammation by promoting nuclear factor-ГЄB (NFГЄB) activation, and enhance extracellular matrix accumulation.5-7 These biological effects translate into accelerated plaque formation and increased cardiac fibrosis, with consequent effects on cardiac function.
The intermediate products are known as Schiff base, Amadori, and Maillard products, after the researchers who first described them. In addition, it has recently been found that glucose can auto-oxidize to form reactive carbonyl compounds (glyoxal and methylglyoxal) which can react with proteins to form glycoxidation products (Figure 2).
These forms of RAGE are, therefore, secreted extracellularly, can be detected in circulating blood, and are called soluble receptors for advanced glycation end products (sRAGEs).5-7 This is of importance since sRAGEs can bind their ligands in the circulation, thus preventing the adverse intracellular events of the AGE-RAGE axis (see below). For example, aminoguanidine is a hydrazine compound that prevents AGE formation by interacting with derivatives of early glycation products that are not bound to proteins.

The clinical relevance of assessing advanced glycation endproducts accumulation in diabetes. Receptor for advanced glycation end products and the cardiovascular complications of diabetes and beyond: lessons from AGEing. Receptor for advanced glycation endproducts and atherosclerosis: From basic mechanisms to clinical implications. Advanced glycosylation end products and nutrition—a possible relation with diabetic atherosclerosis and how to prevent it.
Orally absorbed reactive glycation products (glycotoxins): an environmental risk factor in diabetic nephropathy. Diet-derived advanced glycation end products are major contributors to the body’s AGE pool and induce inflammation in healthy subjects. Identification of polymorphisms in the receptor for advanced glycation end products (RAGE) gene: prevalence in type 2 diabetes and ethnic groups. Coregulation of neurite outgrowth and cell survival by amphoterin and S100 proteins through receptor for advanced glycation end products (RAGE) activation.
Roles of the receptor for advanced glycation endproducts in diabetes-induced vascular injury.
Increased serum concentrations of advanced glycation end products: a marker of coronary artery disease activity in type 2 diabetic patients. Serum levels of advanced glycation end products are associated with left ventricular diastolic function in patients with type 1 diabetes. Advanced glycation end products and antioxidant status in type 2 diabetic patients with and without peripheral artery disease. Serum levels of advanced glycation end products are associated with in-stent restenosis in diabetic patients.
Increased accumulation of the glycoxidation product Nepsilon-(carboxymethyl) lysine in hearts of diabetic patients: generation and characterisation of a monoclonal anti-CML antibody.
Plasma levels of soluble receptor for advanced glycation end products and coronary artery disease in nondiabetic men.
Decreased endogenous secretory advanced glycation end product receptor in type 1 diabetic patients: its possible association with diabetic vascular complications. Plasma level of endogenous secretory RAGE is associated with components of the metabolic syndrome and atherosclerosis.
Low circulating endogenous secretory receptor for AGEs predicts cardiovascular mortality in patients with end-stage renal disease. Circulating soluble receptor for advanced glycation end products is inversely associated with glycemic control and S100A12 protein. Association between serum levels of soluble receptor for advanced glycation end products and circulating advanced glycation end products in type 2 diabetes. Skin collagen glycation, glycoxidation, and crosslinking are lower in subjects with long-term intensive versus conventional therapy of type 1 diabetes: relevance of glycated collagen products versus HbA1c as markers of diabetic complications. Metformin reverts deleterious effects of advanced glycation end-products (AGEs) on osteoblastic cells. Metformin reduces endothelial cell expression of both the receptor for advanced glycation end products and lectin-like oxidized receptor 1. Effect of metformin administration on plasma advanced glycation end product levels in women with polycystic ovary syndrome. Advanced glycation end products increase, through a protein kinase C-dependent pathway, vascular endothelial growth factor expression in retinal endothelial cells. Signalling pathways involved in retinal endothelial cell proliferation induced by advanced glycation end products: inhibitory effect of gliclazide.
Randomized trial of an inhibitor of formation of advanced glycation end products in diabetic nephropathy. Advanced glycation endproduct crosslink breaker (alagebrium) improves endothelial function in patients with isolated systolic hypertension. Benfotiamine prevents macro- and microvascular endothelial dysfunction and oxidative stress following a meal rich in advanced glycation end products in individuals with type 2 diabetes.

A neutralizing antibody against receptor for advanced glycation end products (RAGE) reduces atherosclerosis in uremic mice. Albumin Glycation Assay Kit provides rapid detection of fluorescent AGEs and inhibition assay for glycation of albumin solution by glyceraldehyde.This kit provides sufficient reagents to perform up to 96 assays.
It was conducted in subjects who had type 1 diabetes for a known duration and used well-established end-point criteria to address the glycemic hypothesis (retinopathy, nephropathy, and neuropathy). Incidentally, a similar reaction, even though more complete and produced by harsher conditions, occurs between sugars and proteins in foods, and the final result is what we see in bread or piecrusts, for instance. This diagram depicts some of the key points discussed in the text on the role of AGE products in microangiopathy as well as in macroangiopathy. This diagram outlines some of the main issues discussed in the text with regards to the role of AGE products nephropathy.
These AGE-induced changes are involved in the modification of thrombomodulin and tissue factor production. This suggests a possible role for intracellular glycation in the increased teratogeny associated with diabetes mellitus.
Following this line of reasoning, one might hypothesize that in diabetes an increase in these processes could participate in the interstitial fibrosis reaction accompanying the characteristic glomerulosclerosis of end-stage renal disease. Enhanced glycation may have direct effects and may also amplify the effects of oxidative stress on lipoproteins.
Initially, glycation involves covalent reactions between free amino groups of amino acids, such as lysine, arginine, or protein terminal amino acids and sugars (glucose, fructose, ribose, etc), to create, first, the Schiff base and then Amadori products, of which the best known are HbA1c (Figure 1) and fructosamine (fructoselysine).
Glycation results in increased synthesis of type III collagen, type V collagen, type VI collagen, laminin, and fibronectin in the ECM, most likely via upregulation of transforming growth factor-Гў pathways.
In addition, in endothelial cells, mitochondrial sources of ROS are also involved, following the AGE-RAGE interaction. At the same time, endothelial cell activation may mediate the deposition of atheroma, since oxidized low-density lipoprotein causes endothelial cell activation. Thus, glycation has been shown not only to increase the susceptibility of LDL to oxidation but also, as shown earlier, to enhance the propensity of vessel wall structural proteins to bind plasma proteins, including LDL, and thus to contribute to a more marked oxidative modification of LDL. As shown in Figure 10, aminoguanidine reacts mainly with dicarbonyl intermediates such as 3-deoxyglucosone rather than with fructosamine products on proteins. In some studies, treatment with aminoguanidine reduced endothelial proliferation and completely arrested pericyte dropout, but it did not completely attenuate the progression of vascular occlusion. Patients initially assigned to inten­sive therapy with metformin had decreased risks of combined diabetes-related end points, diabetes-related deaths, all-cause deaths, and myocardial infarction compared with the conventionally treated patients. We will briefly outline the role of AGE receptor activation in 3 key cell types: macrophages, endothelial cells, and mesangial cells.
Concurrently, these AGE-induced alterations in endothelial cell function favor thrombus formation at sites of extracellular AGE accumulation. Glycated and oxidized lipoproteins induce cholesteryl ester accumulation in human macrophages and may promote platelet and endothelial cell dysfunction.
Aggressive treatment of blood pressure produces tangible benefits irrespective of the type of anthypertensive therapy.
Glycation of laminin and type I and type IV collagens, key molecules in the basement membrane, causes inhibited adhesion to endothelial cells for both matrix glycoproteins.
In human endothelial cells, RAGE activation enhances the expression of adhesion molecules, including VCAM-1, ICAM-1, and E-selectin. As for the role of lipids, glycated low-density lipoprotein (LDL) reduces nitric oxide (NO) production and suppresses uptake and clearance of LDL through its receptor on endothelial cells.
AGE bound to RAGE on the endothelium also determines alterations to the surface antithrombotic properties of flowing blood, as shown by a reduction in thrombomodulin expression and the concomitant induction of tissue factor expression that confers procoagulant properties. As far as reducing the risk of microvascular complications is concerned, sulphonylureas and insulin produced equally good results.

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