Ketone Ester D‐β‐Hydroxybutyrate‐(R)‐1,3 Butanediol Prevents Decline in Cardiac Function in Type 2 Diabetic Mice

Background Heart failure is responsible for approximately 65% of deaths in patients with type 2 diabetes mellitus. However, existing therapeutics for type 2 diabetes mellitus have limited success on the prevention of diabetic cardiomyopathy. The aim of this study was to determine whether moderate elevation in D‐β‐hydroxybutyrate improves cardiac function in animals with type 2 diabetes mellitus. Methods and Results Type 2 diabetic (db/db) and their corresponding wild‐type mice were fed a control diet or a diet where carbohydrates were equicalorically replaced by D‐β‐hydroxybutyrate‐(R)‐1,3 butanediol monoester (ketone ester [KE]). After 4 weeks, echocardiography demonstrated that a KE diet improved systolic and diastolic function in db/db mice. A KE diet increased expression of mitochondrial succinyl‐CoA:3‐oxoacid‐CoA transferase and restored decreased expression of mitochondrial β‐hydroxybutyrate dehydrogenase, key enzymes in cardiac ketone metabolism. A KE diet significantly enhanced both basal and ADP‐mediated oxygen consumption in cardiac mitochondria from both wild‐type and db/db animals; however, it did not result in the increased mitochondrial respiratory control ratio. Additionally, db/db mice on a KE diet had increased resistance to oxidative and redox stress, with evidence of restoration of decreased expression of thioredoxin and glutathione peroxidase 4 and less permeability transition pore activity in mitochondria. Mitochondrial biogenesis, quality control, and elimination of dysfunctional mitochondria via mitophagy were significantly increased in cardiomyocytes from db/db mice on a KE diet. The increase in mitophagy was correlated with restoration of mitofusin 2 expression, which contributed to improved coupling between cytosolic E3 ubiquitin ligase translocation into mitochondria and microtubule‐associated protein 1 light chain 3–mediated autophagosome formation. Conclusions Moderate elevation in circulating D‐β‐hydroxybutyrate levels via KE supplementation enhances mitochondrial biogenesis, quality control, and oxygen consumption and increases resistance to oxidative/redox stress and mPTP opening, thus resulting in improvement of cardiac function in animals with type 2 diabetes mellitus.

[1]  K. Hosoda,et al.  Effect of tofogliflozin on cardiac and vascular endothelial function in patients with type 2 diabetes and heart diseases: A pilot study , 2019, Journal of diabetes investigation.

[2]  G. Dorn,et al.  Mitofusin 2 Is Essential for IP3-Mediated SR/Mitochondria Metabolic Feedback in Ventricular Myocytes , 2019, Front. Physiol..

[3]  P. Gargiulo,et al.  Diabetic Cardiomyopathy: Definition, Diagnosis, and Therapeutic Implications. , 2019, Heart failure clinics.

[4]  J. Sadoshima,et al.  Mitophagy Is Essential for Maintaining Cardiac Function During High Fat Diet-Induced Diabetic Cardiomyopathy , 2019, Circulation research.

[5]  V. Fuster,et al.  Empagliflozin Ameliorates Adverse Left Ventricular Remodeling in Nondiabetic Heart Failure by Enhancing Myocardial Energetics. , 2019, Journal of the American College of Cardiology.

[6]  H. Ren,et al.  Mitofusin 2 Participates in Mitophagy and Mitochondrial Fusion Against Angiotensin II-Induced Cardiomyocyte Injury , 2019, Front. Physiol..

[7]  G. Dorn,et al.  Mitochondrial Quality Control in Aging and Heart Failure: Influence of Ketone Bodies and Mitofusin-Stabilizing Peptides , 2019, Front. Physiol..

[8]  Rick B. Vega,et al.  The failing heart utilizes 3-hydroxybutyrate as a metabolic stress defense. , 2019, JCI insight.

[9]  K. Gopal,et al.  Increased ketone body oxidation provides additional energy for the failing heart without improving cardiac efficiency. , 2019, Cardiovascular research.

[10]  D. Bers,et al.  Ketone Bodies and their Polymers in Heart Failure and Type 2 Diabetes: Lessons Learned from the Ketone Ester Diet , 2019, Biophysical Journal.

[11]  D. Bers,et al.  Dual role of inorganic polyphosphate in cardiac myocytes: The importance of polyP chain length for energy metabolism and mPTP activation. , 2019, Archives of biochemistry and biophysics.

[12]  E. Abel,et al.  Heart Failure in Type 2 Diabetes Mellitus. , 2019, Circulation research.

[13]  W. Deng,et al.  Cardiac-specific Conditional Knockout of the 18-kDa Mitochondrial Translocator Protein Protects from Pressure Overload Induced Heart Failure , 2018, Scientific Reports.

[14]  G. Lopaschuk,et al.  Loss of Metabolic Flexibility in the Failing Heart , 2018, Front. Cardiovasc. Med..

[15]  Paul T. Williams,et al.  Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study , 2018, Cardiovascular Diabetology.

[16]  K. Clarke,et al.  Prior ingestion of exogenous ketone monoester attenuates the glycaemic response to an oral glucose tolerance test in healthy young individuals , 2018, The Journal of physiology.

[17]  Paul T. Williams,et al.  Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study , 2018, Diabetes Therapy.

[18]  R. Guthrie Canagliflozin and cardiovascular and renal events in type 2 diabetes , 2018, Postgraduate medicine.

[19]  U. Saikia,et al.  Alterations in Mitochondrial Oxidative Stress and Mitophagy in Subjects with Prediabetes and Type 2 Diabetes Mellitus , 2017, Front. Endocrinol..

[20]  Yoshinobu Morikawa,et al.  The diabetic heart utilizes ketone bodies as an energy source. , 2017, Metabolism: clinical and experimental.

[21]  S. Matoba,et al.  Cardiac-Specific Bdh1 Overexpression Ameliorates Oxidative Stress and Cardiac Remodeling in Pressure Overload–Induced Heart Failure , 2017, Circulation. Heart failure.

[22]  Saptarsi M. Haldar,et al.  Ketogenic Diet Reduces Midlife Mortality and Improves Memory in Aging Mice. , 2017, Cell metabolism.

[23]  K. Nicolay,et al.  Diabetic db/db mice do not develop heart failure upon pressure overload: a longitudinal in vivo PET, MRI, and MRS study on cardiac metabolic, structural, and functional adaptations , 2017, Cardiovascular research.

[24]  K. Clarke,et al.  Ketone bodies mimic the life span extending properties of caloric restriction , 2017, IUBMB life.

[25]  F. Jornayvaz,et al.  Effects of Ketogenic Diets on Cardiovascular Risk Factors: Evidence from Animal and Human Studies , 2017, Nutrients.

[26]  M. Fornage,et al.  Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association , 2017, Circulation.

[27]  K. Clarke,et al.  Metabolic remodelling in diabetic cardiomyopathy , 2017, Cardiovascular research.

[28]  J. Rawlins,et al.  Novel ketone diet enhances physical and cognitive performance , 2016, FASEB journal : official publication of the Federation of American Societies for Experimental Biology.

[29]  S. Neubauer,et al.  Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes. , 2016, Cell metabolism.

[30]  O. Ritter,et al.  Inositol 1,4,5-trisphosphate-mediated sarcoplasmic reticulum-mitochondrial crosstalk influences adenosine triphosphate production via mitochondrial Ca2+ uptake through the mitochondrial ryanodine receptor in cardiac myocytes. , 2016, Cardiovascular research.

[31]  K. Hirata,et al.  β-Hydroxybutyrate elevation as a compensatory response against oxidative stress in cardiomyocytes. , 2016, Biochemical and biophysical research communications.

[32]  J. Sadoshima,et al.  Mitochondrial autophagy in cardiomyopathy. , 2016, Current opinion in genetics & development.

[33]  T. Dick,et al.  Dissecting Redox Biology Using Fluorescent Protein Sensors. , 2016, Antioxidants & redox signaling.

[34]  B. O’Rourke,et al.  Compartment-specific Control of Reactive Oxygen Species Scavenging by Antioxidant Pathway Enzymes* , 2016, The Journal of Biological Chemistry.

[35]  M. Fischereder,et al.  Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. , 2016, The New England journal of medicine.

[36]  S. Tyagi,et al.  Moderate intensity exercise prevents diabetic cardiomyopathy associated contractile dysfunction through restoration of mitochondrial function and connexin 43 levels in db/db mice. , 2016, Journal of molecular and cellular cardiology.

[37]  Rick B. Vega,et al.  The Failing Heart Relies on Ketone Bodies as a Fuel , 2016, Circulation.

[38]  K. Margulies,et al.  Evidence for Intramyocardial Disruption of Lipid Metabolism and Increased Myocardial Ketone Utilization in Advanced Human Heart Failure , 2016, Circulation.

[39]  W. Paulus,et al.  Clinical diabetic cardiomyopathy: a two-faced disease with restrictive and dilated phenotypes. , 2015, European heart journal.

[40]  Youngil Lee,et al.  PINK1 Is Dispensable for Mitochondrial Recruitment of Parkin and Activation of Mitophagy in Cardiac Myocytes , 2015, PloS one.

[41]  L. Blatter,et al.  Distinct mPTP activation mechanisms in ischaemia-reperfusion: contributions of Ca2+, ROS, pH, and inorganic polyphosphate. , 2015, Cardiovascular research.

[42]  Å. Gustafsson,et al.  Mending a broken heart: the role of mitophagy in cardioprotection. , 2015, American journal of physiology. Heart and circulatory physiology.

[43]  Angelo Avogaro,et al.  Impact of diabetes on epidemiology, treatment, and outcomes of patients with heart failure. , 2015, JACC. Heart failure.

[44]  T. Vanitallie,et al.  A new way to produce hyperketonemia: Use of ketone ester in a case of Alzheimer's disease , 2015, Alzheimer's & Dementia.

[45]  J. Long,et al.  Phosphatase and tensin homolog-induced putative kinase 1 and Parkin in diabetic heart: Role of mitophagy , 2014, Journal of diabetes investigation.

[46]  Q. Nie,et al.  Mitofusin 2 deficiency leads to oxidative stress that contributes to insulin resistance in rat skeletal muscle cells , 2014, Molecular Biology Reports.

[47]  Lothar A. Blatter,et al.  Role of β-hydroxybutyrate, its polymer poly-β-hydroxybutyrate and inorganic polyphosphate in mammalian health and disease , 2014, Front. Physiol..

[48]  G. Lopaschuk,et al.  Mitochondrial fatty acid oxidation alterations in heart failure, ischaemic heart disease and diabetic cardiomyopathy , 2014, British journal of pharmacology.

[49]  L. Blatter,et al.  Mitochondria-mediated cardioprotection by trimetazidine in rabbit heart failure. , 2013, Journal of molecular and cellular cardiology.

[50]  G. Dorn,et al.  PINK1-Phosphorylated Mitofusin 2 Is a Parkin Receptor for Culling Damaged Mitochondria , 2013, Science.

[51]  Rick B. Vega,et al.  Perturbations in the gene regulatory pathways controlling mitochondrial energy production in the failing heart. , 2013, Biochimica et biophysica acta.

[52]  G. Lopaschuk,et al.  Targeting mitochondrial oxidative metabolism as an approach to treat heart failure. , 2013, Biochimica et biophysica acta.

[53]  Eric Verdin,et al.  Suppression of Oxidative Stress by β-Hydroxybutyrate, an Endogenous Histone Deacetylase Inhibitor , 2013, Science.

[54]  U. Baxa,et al.  A ketogenic diet increases brown adipose tissue mitochondrial proteins and UCP1 levels in mice , 2013, IUBMB life.

[55]  T. Vanitallie,et al.  Kinetics, safety and tolerability of (R)-3-hydroxybutyl (R)-3-hydroxybutyrate in healthy adult subjects. , 2012, Regulatory toxicology and pharmacology : RTP.

[56]  R. Feinman,et al.  Response of C57Bl/6 mice to a carbohydrate-free diet , 2012, Nutrition & Metabolism.

[57]  K. Clarke,et al.  Oral 28-day and developmental toxicity studies of (R)-3-hydroxybutyl (R)-3-hydroxybutyrate. , 2012, Regulatory toxicology and pharmacology : RTP.

[58]  U. Baxa,et al.  Mitochondrial biogenesis and increased uncoupling protein 1 in brown adipose tissue of mice fed a ketone ester diet , 2012, FASEB journal : official publication of the Federation of American Societies for Experimental Biology.

[59]  L. Blatter,et al.  Inorganic polyphosphate is a potent activator of the mitochondrial permeability transition pore in cardiac myocytes , 2012, The Journal of general physiology.

[60]  T. Dick,et al.  Measuring E(GSH) and H2O2 with roGFP2-based redox probes. , 2011, Free radical biology & medicine.

[61]  E. Kossoff,et al.  Dietary therapies for epilepsy: Future research , 2011, Epilepsy & Behavior.

[62]  M. Brand,et al.  High Throughput Microplate Respiratory Measurements Using Minimal Quantities Of Isolated Mitochondria , 2011, PloS one.

[63]  E. D. Abel,et al.  Obesity stresses cardiac mitochondria even when you are young. , 2011, Journal of the American College of Cardiology.

[64]  T. Dick,et al.  Fluorescent protein-based redox probes. , 2010, Antioxidants & redox signaling.

[65]  A. Camara,et al.  Mitochondrial matrix K+ flux independent of large-conductance Ca2+-activated K+ channel opening. , 2010, American journal of physiology. Cell physiology.

[66]  R. S. Sohal,et al.  Effects of age and calorie restriction on tryptophan nitration, protein content, and activity of succinyl-CoA:3-ketoacid CoA transferase in rat kidney mitochondria. , 2010, Free radical biology & medicine.

[67]  Bryan C Dickinson,et al.  Mitochondrial-targeted fluorescent probes for reactive oxygen species. , 2010, Current opinion in chemical biology.

[68]  Atsushi Tanaka,et al.  PINK1 Is Selectively Stabilized on Impaired Mitochondria to Activate Parkin , 2010, PLoS biology.

[69]  M. Gutscher,et al.  Proximity-based Protein Thiol Oxidation by H2O2-scavenging Peroxidases*♦ , 2009, The Journal of Biological Chemistry.

[70]  M. Beylot,et al.  Diabetic cardiomyopathy: effects of fenofibrate and metformin in an experimental model – the Zucker diabetic rat , 2009, Cardiovascular diabetology.

[71]  S. Boudina,et al.  Contribution of Impaired Myocardial Insulin Signaling to Mitochondrial Dysfunction and Oxidative Stress in the Heart , 2009, Circulation.

[72]  P. Neufer,et al.  Mitochondrial H2O2 emission and cellular redox state link excess fat intake to insulin resistance in both rodents and humans. , 2009, The Journal of clinical investigation.

[73]  Rogerio Margis,et al.  Glutathione peroxidase family – an evolutionary overview , 2008, The FEBS journal.

[74]  K. Wolski,et al.  Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. , 2007, The New England journal of medicine.

[75]  Stefan Neubauer,et al.  The failing heart--an engine out of fuel. , 2007, The New England journal of medicine.

[76]  K. Sunagawa,et al.  Overexpression of glutathione peroxidase attenuates myocardial remodeling and preserves diastolic function in diabetic heart. , 2006, American journal of physiology. Heart and circulatory physiology.

[77]  George F Cahill,et al.  Fuel metabolism in starvation. , 2006, Annual review of nutrition.

[78]  J. Dyck,et al.  Metabolic effects of insulin on cardiomyocytes from control and diabetic db/db mouse hearts. , 2005, American journal of physiology. Endocrinology and metabolism.

[79]  A. Yamamoto,et al.  LC3, GABARAP and GATE16 localize to autophagosomal membrane depending on form-II formation , 2004, Journal of Cell Science.

[80]  G. Nichols,et al.  Congestive heart failure in type 2 diabetes: prevalence, incidence, and risk factors. , 2001, Diabetes care.

[81]  Takeshi Noda,et al.  LC3, a mammalian homologue of yeast Apg8p, is localized in autophagosome membranes after processing , 2000, The EMBO journal.

[82]  K. Polonsky,et al.  Interactions between insulin resistance and insulin secretion in the development of glucose intolerance. , 2000, The Journal of clinical investigation.

[83]  A. Van der Laarse,et al.  Buthionine sulfoximine reduces the protective capacity of myocytes to withstand peroxide-derived free radical attack. , 1993, Journal of molecular and cellular cardiology.

[84]  C. Rackley,et al.  Measurement of Left Ventricular Wall Thickness and Mass by Echocardiography , 1972, Circulation.

[85]  B. Wyse,et al.  The influence of age and dietary conditions on diabetes in the db mouse , 1970, Diabetologia.

[86]  V. Ostojić,et al.  Diabetic ketosis during hyperglycemic crisis is associated with decreased all-cause mortality in patients with type 2 diabetes mellitus , 2016, Endocrine.

[87]  L. Wold,et al.  Metabolic dysfunction in diabetic cardiomyopathy , 2013, Heart Failure Reviews.

[88]  L. Blatter,et al.  Measuring mitochondrial function in intact cardiac myocytes. , 2012, Journal of molecular and cellular cardiology.

[89]  E. Anderson,et al.  Increased propensity for cell death in diabetic human heart is mediated by mitochondrial-dependent pathways. , 2011, American journal of physiology. Heart and circulatory physiology.

[90]  C. Folmes,et al.  Myocardial fatty acid metabolism in health and disease. , 2010, Physiological reviews.