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Background/Aim. Hyperbaric oxygen therapy (HBOT) is a method which increases oxygen solubility in plasma up to 20 times. This effect is very important in the treatment of circulatory disorders, which reduces oxygenation and leads to increased production of inflammatory mediators and free oxygen radicals. The aim of this study was to examine the impact of HBOT on the oxidative stress parameters in the patients with systemic lupus erythematosus (SLE). Methods. This prospective study included 18 females with SLE [American College of Rheumatology (ACR) criteria], average age 52.2 ? 8.82 years, treated with HBOT for 60 min/day, with average partial oxygen pressure of 2.2 atmospheres absolute (ATA), during 10 days, in combination with appropriate medication therapy for SLE. The following parameters were determined in the serum: C-reactive protein (CRP), hemoglobin, creatinine, albumin, complement 3 (C3), antinuclear antibodies (ANA), glomerular filtration rate (GFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. In the urine, parameters of oxidative stress were spectrofotometrically determined: levels of superoxide anion radical (O2 ??), hydrogen peroxide (H2O2), nitrites (NO2-) and concentration of thiobarbituric acid reactive substances (TBARS). In hemolysate, the parameters of antioxidant protection: superoxide dismutase (SOD), catalase (CAT) and reduced gluthatione (GSH), were measured. The samples for the analysis were collected three times: before HBOT (initial values), after 10 days of HBOT and 1 month after beginning the treatment in relation to the initial value. Results. We noticed a statistically significant (p
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Please cite this article: IMPACT OF THE HYPERBARIC OXYGEN THERAPY ON
THE REDOX STATUSIN PATIENTS WITH SYSTEMIC LUPUS
ERYTHEMATOSUS
UTICAJ HIPERBARIČNE OKSIGENOTERAPIJE NA REDOKS STATUS
PACIJENATA SA SISTEMSKIM ERITEMSKIM LUPUSOM
Authors: Milorad Rabrenović*, Tamara Nikolic†, Violeta Rabrenović‡ 2, Jovana
Bradic†, Saša Trešnjić*, Anica Petkovic†, Biljana Jakovljević §, Siniša Mašić§,
Dubravko Bokonjić ǁ;Vojnosanitetski pregled (2017); Online First September, 2017.
UDC:
DOI: https://doi.org/10.2298/VSP170110106R
When the final article is assigned to volumes/issues of the Journal, the Article in Press
version will be removed and the final version appear in the associated published
volumes/issues of the Journal. The date the article was made available online first will be
carried over.
IMPACT OF THE HYPERBARIC OXYGEN THERAPY ON THE REDOX
STATUSIN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS
UTICAJ HIPERBARIČNE OKSIGENOTERAPIJE NA REDOKS STATUS
PACIJENATA SA SISTEMSKIM ERITEMSKIM LUPUSOM
Milorad Rabrenović*, Tamara Nikolic, Violeta Rabrenović‡ 2, Jovana Bradic†, Saša
Trešnjić*, Anica Petkovic†, Biljana Jakovljević §, Siniša Mašić§, Dubravko Bokonjić ǁ.
Center of Hyperbaric Medicine*, Military Medical Academy, Belgrade, Serbia,
Department of Pharmacy, Faculty of Medical Science, University of Kragujevac,
Kragujevac, Serbia.
Clinic of nephrology, Military Medical Academy, Belgrade,Serbia
Institute of Hygine §, Military Medical Academy, Belgrade, Serbia
Centre for Poisoning Control ǁ, Military Medical Academy, Belgrade, Serbia
Faculty of Medicine2 , Military Medical Academy, University of Defense, Belgrade,
Serbia.
UTICAJ HIPERBARIČNE OKSIGENOTERAPIJE NA REDOKS RAVNOTEŽU
PACIJENATA SA SISTEMSKIM LUPUSOM ERITEMATOZUSOM
Milorad Rabrenović*, Tamara Nikolic, Violeta Rabrenović‡ 2, Jovana Bradic† , Saša
Trešnjić*, Anica Petkovic† ,Biljana Jakovljević §, Siniša Mašić§, Dubravko Bokonjić ǁ.
Correspondence to:
Rabrenović Milorad, Centar za hiperbaričnu medicinu,
Vojnomedicinska Akademija, Beograd , Srbija
E mail: milorad.rabrenovic@vma.mod.gov.rs
Sažetak
Uvod/Cilj:Hiperbarična oksigenoterapija (HBOT) je metoda kojom se rastvorljivost
kiseonika u plazmi povećava i do 20 puta. Taj efekat je veoma značajan u terapiji
poremećaja cirkulacije koji smanjuju oksigenaciju i dovode do povećanja produkcije
medijatora zapaljenja i slobodnih kiseoničkih radikala. Cilj ove studije bio je ispitati uticaj
HBOT na parametre oksidativnog stresa kod bolesnika sa sistemskim eritemskim lupusom
(SLE).
Metode:Prospektivnom studijom obuhvaćeno je 18 pacijentkinja sa SLE (ACR kriterijumi)
prosečne starosti 52,2 ± 8,82 godina, koje su tretirane HBOT u trajanju od 60 min/dan, pri
pritisku od 2,2 apsolutne atmosfere (ATA), ukupno 10 dana, u kombinaciji sa
odgovarajućom terapijom za SLE. U serumu su odreĎivani sledeći parametri: C-reaktivni
protein (CRP), hemoglobin, kreatinin, albumin, komplement 3 (C3), antinuklearna
antitela (ANA), stopa glomerularne filtracije(GFR korišćenjem CKD-EPI formule). U
urinu spektrofotometrijski su odredjivani parametri oksidacionog stresa: nivo superoksid
anjon radikala (O2-),vodonik peroksida (H2O2), nitrita (NO2-) i koncentracija reaktivnih
produkata tiobarbituratne kiseline (TBARS). U hemolizatu, odredjivani su parametri
antioksidativne zaštite: superoksid dismutaza (SOD), katalaza (CAT) i redukovani
glutation (GSH). Uzorci za analize su sakupljani 3 puta: pre HBOT (inicijalne vrednosti),
nakon 10 dana HBOT i nakon mesec dana terapije.
Rezultati:Uočili smo statistički značajno (p<0,05) smanjenje nivoa O2- nakon 10 dana, kao
i nakon mesec dana od HBOT (11,92 ± 6,86; 8,26 ± 13,62; 8,39± 4,94 nmol/ml). Nisu
pokazane značajne razlike u vrednostima ostalih parametara oksidativnog stresa kao što su
NO2-, TBARS i H2O2 tokom posmatranog perioda. Što se tiče parametara antioksidativne
zaštite, otkrili smo nešto veću vrednost GSH nakon tretmana (66,34±16,31; 79,43±36,77;
69,72 ± 22,32 μmol/ml eritrocita), koja se održala nakon mesec dana, ali nije bila statistički
značajna. Aktivnost SOD i CAT, pre i posle HBOT, nije se statistički značajno menjala.
Zaključak:Naši rezultati ukazuju na povoljan efekat HBOT na redoks ravnotežu kod
bolesnika sa SLE sniženjem nivoa O2-.
Ključne reči: sistemski eritemski lupus, hiperbarična oksigenoterapija, redoks status
Abstract
Introduction/Aim: Hyperbaric oxygen therapy (HOBT) is a method which increases
oxygen solubility in plasma up to 20 times. This effect is very important in the treatment of
circulatory disorders, which reduces oxygenation and leads to increased production of
inflammatory mediators and free oxygen radicals. The aim of this study was to examine the
impact of HBOT on oxidative stress parameters in patients with systemic lupus
erythematosus (SLE).
Methods: This prospective study included 18 females with SLE (ACR criteria), average
age 52.2±8.82 years, treated with HBOT for 60 minutes/day, with average partial oxygen
pressure of 2.2 atmospheres absolute (ATA), during 10 days, in combination with
appropriate medication therapy for SLE.In serum the following parameters were
determined:C-reactive protein (CRP), hemoglobin, creatinine, albumin, complement 3
(C3), antinuclear antibodies (ANA), glomerular filtration rate (GFR using the CKD-EPI
formula). In the urine parameters of oxidative stress were spectrofotometrically
determined: levels of superoxide anion radical (O2-), hydrogen peroxide (H2O2), nitrites
(NO2-) and concentration of thiobarbituric acid reactive substances (TBARS). In
hemolysate, parameters of antioxidant protection were measured: superoxide dismutase
(SOD), catalase (CAT) and reduced gluthatione (GSH). Samples for analysis were
collected three times: before HBOT (initial values), after 10 days of HBOT and after 1
month.
Results: We noticed statistically significant (p<0,05) decrease in level of O2-, both after 10
days of HBOT and after one month (11.92 ± 6.86; 8.26 ± 13.62; 8.39± 4.94
nmol/ml).Values of other parameters of oxidative stress such as NO2-, TBARS and H2O2-
showed no significant difference during the monitored period. Regarding the parameters of
antioxidant protection, we revealed slightly higher value of GSH after treatment
(66.34±16.31; 79.43±36.77; 69.72 ± 22.32 μmol/ml RBCs) which was held after a month,
but it was not statistically significant. Activity of SOD and CAT, before and after HBOT,
did not changed significantly.
Conclusion: Our results suggested potential beneficial effects of HBOT on redox status in
patients with SLE by decreasing levels of O2-.
Key words: systemic lupus erythematosus, hyperbaric oxygen treatment, redox status
Introduction
Systemic lupus erythematosus (SLE) is a very serious autoimmune inflammatory
disease, with an unpredictable course and outcome, whose etiology remains largely
unknown and the effects of conservative treatment are limited1. Human and animal studies
indicate that oxidative stress is involved in the pathogenesis of SLE. Excessive production
of reactive oxygen species (ROS)and reactive nitrogen species (RNS), including
peroxynitrite- ONOO, can damage lipids, proteins and DNA and products of oxidative
modification can be detected in biological fluids2. The abundance of those products
correlates with disease activity in SLE patients, suggesting oxidative modification acts as
biomarkers3-5. While several studies implicate nitric oxide as an important mediator
of disease in SLE6,7, there is a lack of data revealing the association between level of urine
nitrite and citrulline levels, as surrogate markers of nitrogen monooxide (NO) production,
among patients with systemic lupus erythematosus and disease activity8. Also, previous
data suggested that lipid peroxidation could be a risk factor for endothelial dysfunction in
some autoimmune diseases9.
Hyperbaric oxygen therapy (HBOT) is a treatment modality in which a person
breathes 100% O2 intermittently while exposed to increased atmospheric pressure, greater
than 1 atmosphere, usually 2 to 2.5 atmospheres absolute (ATA)10. Primary mechanisms of
action include hyperoxygenation and a decrease in bubble size, or vasoconstriction,
angiogenesis, fibroblast proliferation, oxidative leukocyte degradation, toxin inhibition and
antibiotic synergy11,12.Hyperbaric oxygen may be used as the primary therapy intervention
in some conditions, such as carbon monoxide poisoning, decompression sickness and
arterial gas embolism, arterial insufficiencies, cardiovascular diseases, osteomyelitis and as
an adjunctive therapy for wound healing13-15. HBOT has shown beneficial effects in
hypoxic diabetic ulcers that result in severe wound-healing problems and
osteoradionecrosis, and is frequently used for necrotic soft tissues and bone that fails to
heal. HBOT also induces significant angiogenesis, which in one study was measurable after
eight HBOT sessions. Previous clinical studies revealed that vasculitis skin ulcers in patient
suffering from SLE has been treated successfully with HBOT16-18. There are not many
studies that examined effects of HBO treatment on redox homeostasis and inflammation in
patients with SLE.
Given the fact that HBOT can modify oxidation-reduction reactions, the aim of our
study is to establish an influence of hyperbaric oxygenation on oxidative stress parameters
and antioxidant enzymes in patients with SLE.
Participants and Methods
This prospective study included 18 females with SLE, treated with hyperbaric
oxygenation therapy once a day for 60 minutes (total 10 days) with average partial oxygen
pressure of 2.2 ATA, in combination with appropriate therapy for SLE. The study protocol
was approved by the Institutional Ethics Committee (Faculty of Medicine of the Military
Medical Academy, University of Defence Studies, Belgrade, Serbia) and the study was
conducted in accordance with the Declaration of Helsinki. All the participants were
informed about the research protocol before giving their written consent to participate in
the study.
All patients were admitted to Military Medical Academy, Belgrade, Serbia from October
2011 to December 2014, providing that they fulfilled inclusion criteria: a diagnosis of SLE.
In order to define severity of the disease course in this study the original 1997 ACR
classification of SLE was used18,19. All participants were in similar stage of disease, in
remission (SLEDAI Score 0,30 ± 0,47), at the beginning of study. The exclusion criteria
were: pregnant women with SLE, patients with urinary infection (positive urine culture),
with renal insufficiency-creatinine clearance <60 ml/min, the presence of malignancy,
patients with any other ongoing inflammatory process, or under 18 years of age. Patients
who were on immunosuppressive therapy such as mycophenolate mofetil,
cyclophosphamide and other cytotoxic agents, were excluded. The only therapy, that the
patients have taken, was the corticosteroids-the maintenance dose of 5mg.
All patients with any contraindication for HBOT were also excluded. All
participants were non-smokers and did not take any antioxidant dietary supplement for 1
month before the study. Before beginning the HBOT, all participants passed a standard
medical and physical revision at the hospital. During the study period there were no
eliminated patients.
Hyperbaric oxygen therapy (HBOT)
HBOT was performed at The Center for Hyperbaric Medicine, Military Medical
Academy in Belgrade, Serbia. HBOT treatment consisted of 10 sessions (1 session a day/5
days a week) in a multiplace (10-person) hyperbaric chamber. In total 60 min of 100%
medical oxygen was administered to patients under increased pressure of 2.2 atmospheres
absolute (ATA) during a 70-min hyperbaric session. At this pressure, 100% oxygen was
delivered via an oronasal mask in two episodes of 30 min, each interrupted by 5 min of air
breathing. During pressure changes, great care was taken to avoid barotraumas, particularly
of the middle ear, which is the most common side-effect of a hyperbaric treatment. All
patients tolerated the treatment well without any complications.
Biochemical analysis
Samples for biochemical analysis were collected three times: before HBOT (initial
values), after 10 days of HBOT(2 hours after last HBOT session) and after 1 month. The
following parameters were determined in blood serum samples: C-reactive protein (CRP),
hemoglobin (Hb), creatinine, albumin, complement 3 (C3), antinuclear
antibodies (ANA),glomerular filtration rate(GFRusing the CKD-EPI formula).In the urine
samples, following parameters of redox status were spectrofotometrically determined:
levels of superoxide anion radical (O2-), hydrogen peroxide (H2O2), nitrites(NO2-) and
concentration of thiobarbituric acid reactive substances(TBARS). Parameters of antioxidant
protection were measured in blood samples: activity of superoxide dismutase (SOD) and
catalase (CAT) and level of reduced glutathione (GSH).
Superoxide anion radical determination (O2-)
The level of superoxide anion radical (O2-) was measured using nitro blue
tetrazolium (NBT) reaction in TRIS-buffer combined with urine samples and read at 530
nm20.
Hydrogen peroxide determination (H2O2)
The protocol for measurement of hydrogen peroxide (H2O2) is based on oxidation
of phenol red in the presence of horseradish peroxidase21. 200 μl sample with 800 μl PRS
(phenol red solution) and 10 μl POD (Horseradish Peroxidase) were combined (1:20). The
level of H2O2 was measured at 610 nm.
Nitric oxide determination (NO2-)
Nitric oxide (NO) decomposes rapidly to form stable metabolite nitrite/nitrate
products. Nitrite (NO2-) was determined as an index of nitric oxide production with Griess
reagent22. 0.1 ml 3 N PCA (Perchloride acid), 0.4 ml 20 mM ethylenediaminetetraacetic
acid (EDTA), and 0.2 ml urine were put on ice for 15 min, then centrifuged 15 min at 6,000
rpm. After pouring off the supernatant, 220 μl K2CO3 was added. Nitrites were measured at
550 nm. Distilled water was used as a blank probe.
Determination of concentration of thiobarbituric acid reactive substances (TBARS)
The degree of lipid peroxidation in urine was estimated by measuring concentration
of TBARS using 1 % TBA (thiobarbituric acid) in 0.05 NaOH, incubated with urine at 100
°C for 15 min and read at 530 nm. Distilled water was used as a blank probe. TBA extract
was obtained by combining 0.8 ml urine and 0.4 ml trichloro-acetic acid (TCA), than
samples were put on ice for 10 min, and centrifuged for 15 min at 6,000 rpm. This method
was described previously23.
Preparation of hemolysate
Blood samples were taken from an antecubital vein into vacutainer test tube
containing sodium citrate anticoagulant. Blood was centrifuged to separate plasma and red
blood cells (RBCs). Isolated RBCs were washed 3 times with 3 vol. of ice cold 0.9 mmol/l
NaCl. Blood samples were stored immediately and kept for further analyses24.
Determination of antioxidant enzymes catalase (CAT) and superoxide dismutase (SOD)
Hemolysates containing about 50 g Hb/l prepared according to McCord and
Fridovich24 were used for the determination of CAT activity which was expressed in
U/gHb x 1000. CAT activity was determined according to Beutler25. Lysates were diluted
with distilled water (1:7 v/v) and treated with chloroform-ethanol (0.6:1 v/v) to remove
hemoglobin. Then 50 μl CAT buffer, 100 μl sample, and 1 ml 10 mM H2O2 were added to
the samples.Detection was performed at 360 nm. Distilled water was used as a blank probe.
SOD activity was determined by the epinephrine method of Misra and Fridovich26and it
was expressed in U/gHb x 1000. A hundred μl lysate and 1 ml carbonate buffer were
mixed, and then 100 μl of epinephrine was added. Detection was performed at 470 nm.
Determination of reduced glutathione (GSH)
Level of reduced glutathione (GSH) was determined spectrophotometrically, and it
is based on GSH oxidation via 5,5-dithiobis-6,2-nitrobenzoic acid. GSH extract was
obtained by combining 0.1 ml 0.1 % EDTA, 400 μl haemolysate, and 750 μl precipitation
solution (containing 1.67 g metaphosphoric acid, 0.2 g EDTA, 30 g NaCl, and filled with
distilled water until 100 ml; the solution is stable for 3 weeks at +4C°). After mixing in the
vortex machine and extraction on cold ice (15 min), it was centrifuged on 4000 rpm (10
min). Distilled water was used as a blank probe. Measuring was performed at 420 nm. The
concentration is expressed as micromoles per milliliter of red blood cells (RBCs).25, 27
Statistical analyzes
In case of continuous data, variables were presented as mean value ± standard
deviation (SD). Kolmogorov-Smirnov test was used for evaluation of distribution of
biochemical data. Statistical significance between groups was tested by Friedman (repeated
measure) test (post hoc Wilcoxon test). All the analyses were estimated at p<0.05 level of
statistical significance. Complete statistical analysis of data was done with the statistical
software package, SPSS Statistics 18.
Results
A total of 18 woman, the average age 52.22 ±8.82 years, enrolled in the study. The
patients presented SLE with an average time without symptoms of healing of 20.2±5.0
months when they underwent the HBOT.
The values of the serum parameters such asC-reactive protein(CRP), hemoglobin
(Hb), creatinine, albumim, complement 3 (C3); antinuclear antibody (ANA), chronic
kidney disease estimated glomerular filtration rate(CKD eGFR), were not statistically
significantly different when compared initial values, values after 10 days and after a month
of therapy (Table 1).
Levels of Superoxide anion radical (O2-)
We noticed statistically significant decreased (p<0.05) levels of superoxide anion
radical (O2-) after 30 days HBOT compared to initial values of this parameter, and
significantly decreased values after 10 days of HBOT compared to initial values (11.92 ±
6.86, 8.26 ± 13.6, 8.39±4.94 nmol/ml) (Fig. 1).
Levels of Nitrites (NO2-)
Levels of nitrites (NO2-) before and after HBOT therapy were similar (2.72±0.16,
2.77±0.29, 2.76±0.20 nmol/ml). We found that this parameter was not significantly
affected with HBOT when comparing initial values to values after 10 days of HBOT and
after one month (Fig. 2).
Levels of Hydrogen peroxide (H2O2)
During the observed period of HBOT, there were no statistically significant changes
of H2O2levels when compared the initial values, values after 10days and after one month of
HBOT. This parameter was not changed in the group during the study (1.52 ±0.08, 1.51±
0.07, 1.54 ±0.17 nmol/ml) (Fig. 3).
Concentration of TBARS
Among the examined groups, TBARS concentration was not significantly altered
after HBOT treatment and after a month (1.01 ±0.11; 1.09± 0.11; 1.05±0.96 µmol/ml) (Fig.
4).
Activity of superoxide dismutase (SOD)
In the study group, we noticed a decreased activity of SOD after HBOT when
compared initial value to value after 10 days of therapy (27.58±8.86 to 19.47±10.63 after
HBOT). However, a month after, values were similar to those from the beginning of the
study protocol and the acitivity was 27.11±28.26. Those changes were without statistical
significance (Fig. 5).
Level of reduced glutathione (GSH)
Level of reduced glutathione (GSH) was not statistically significant increased in our
group (initially 66.34±16.31 to 79.43±36.77 after HBOT treatment). However, a month
after values were similar to those from the beginning of the study protocol and the activity
was 69.72 ± 22.32 (Fig. 6).
Activity of catalase (CAT)
We observed a decrease in the activity of catalase (CAT) after 10 days of HBOT
compared to the initial value (5.44 ± 3.55 to 4.77 ±2.93), and it continued to decrease, so
after a month it was lower than before HBOT and after 10 days of HBOT (3.82 ± 2.49).
However those differences were not statistically significant (Fig. 7).
Discussion
This study was designed in the field of physiology research of hyperbaric
oxygenation with special emphasis on potential systemic effects of disturbed redox
balance, induced by systemic disease before and after the application of oxygen. Actually,
hyperbaric oxygen therapy (HBOT) leads to an increase in the amount of dissolved oxygen
in the plasma, creating a diffusion gradient which facilitates the transition of oxygen from
the capillaries to the ischemic tissues17. Studies reported controversial results regarding the
effect of HBOT on oxidative stress and enzymes of antioxidative defense in several
pathophysiological models. The role of ROS and RNS in therapeutic responses of HBOT in
patients with SLE has still not been completely revealed and explained28-31.
Immune dysfunction, genetic, hormonal and environmental factors are included in
an etiology of SLE, however molecular mechanisms underlying this systemic autoimmune
response remain largely unknown31,32. It's believed that oxidative stress has an important
role in the pathogenesis of SLE. Excessive production of ROS (including ONOO) can
damage all biomolecules such as lipid, protein and DNA and cause a formation of different
products which can be detected in in biological fluids2-5. In case of patients with SLE, this
fact can be useful since their abundance correlates with disease activity and organ damage3.
Our study included patients with SLE in whom the disease was in remission, which was
maintained before and after HBOT was performed. Comparing laboratory parameters
(CRP, hemoglobin, creatinine, albumin, complement C3, ANA) before and after the
performed therapy, as well as after a month, we did not notice statistically significant
differences in values. We examined the effects of 10 session of HBOT on parameters of
redox balance in patients with SLE . We found statistically significant decreased levels of
O2- after HBOT, which were held after 30 days. There is a concern that HBOT might
increase oxidative stress via the production of reactive oxygen species, however oxidative
stress appears to be less of a concern at hyperbaric pressures under 2.0 ATA33. Patients in
our study were exposed to the higher pressure such as 2.2 ATA and we revealed the
beneficial effects of hyperbaric oxygen on O2- levels. On the other hand, other pro-oxidants,
such as NO2-, TBARS and H2O2 were not affected by HBOT. In order to validate our
results, we excluded all patients with renal disease or urinary infection, because oxidative
stress parameters may have not been removed from plasma because of insufficient
excretion and may continue to rediffuse in circulation30-33. So, because of this fact, we
could not be sure in unchanged levels of oxidative markers.
Literature data regarding the effects of HBOT on SLE treatment is limited, and it is
hard to compare our results to the others due to the fact that available researches were
mostly focused on the effects of HBOT on ulcers healing. One of a few studies which
examined the effects of HBOT in a SLE patient was a case report conducted by Olivieri et
al 17. They described a SLE patient with a case of refractory vasculitic ulcer responding to
hyperbaric oxygen (HBO), which was used in combination with immunosuppressive
therapy. Jou and coworkers35 reported their experience with the use of hyperbaric oxygen
for the treatment of intractable hemorrhagic cystitis in an SLE patient treated with
cyclophosphamide. They concluded that this treatment was very successful, with no
recurrent hematuria after hyperbaric oxygen therapy during 6 months35. S. Efrat et al16
reported that HBOT may serve as an effective safe treatment for patients with vasculitis
having nonhealing skin ulcers, which is in agreement with the results of previously
mentioned authors and with ours regarding safety of HBOT. Increase in tissue oxygenation
appeared to be one of the major components responsible for the high cure rates in patients
with ulcers16,17.
In order to complete our picture about influence of HBOT on redox status, we
examined activity of antioxidant enzyme system. GSH is an important endogenous
antioxidant and prime scavenger of free radicals in cells. One of the body's most powerful
natural antioxidant enzymes are superoxide dismutase and catalase. Superoxide dismutase,
essential to catalyze the dismutation of superoxide, has been shown to protect cells from
oxygen free radicals. Exposure to ROS from a variety of sources led to develop a series of
defence mechanisms to neutralize these species and so protect cells against their toxic
effects and that protection is achieved mainly by enzymatic antioxidants such as catalase.
Some of the research concludes that hyperbaric oxygen treatment below 2.0 ATA can
increase the activity of antioxidant enzymes including SOD, reduced glutathione and
catalase 36-40.
Regarding component of antioxidant defense including SOD, GSH, CAT we
observed that levels of GSH were higher (but without statistical significance) after 10 days
exposed to hyperbaric oxygen treatment and month later too.
We believe that these beneficial results in regard to levels ofO2-and GSH after
HBOT implyto possibility that the study with lager number of patients or changes of
number of treatments could have results which would be statistically significant for these
parameters. That refers on results noticed for SOD and CAT.
Activities of SOD and CAT were affected by HBOT but not statistically
significantly. We have noticed that activity of SOD decreased after 10 days, but returned
to the initial level after 30 days, and level of CAT decreased after a month compared to the
initial value and value after 10 days of HBOT. However, these changes were not
statistically significant. Considering that differences in the activity of SOD and CAT
between peroxide initial level and level after HBOT were insignificant, we have not
observed any significant influence on pro-oxidants such as hydrogen, showed insignificant
difference.
We believe that the smaller number of patients participated in our study has
influenced on our results. The assumption is that the future studies with different design
(larger number of patients, more treatments, additional analysis etc.) could clarify the fact
that we have not got correlation between decreased level of O2- (statistically significant in
our study) and increased values of antioxidant protection parameters(GSH not statistically
significant in our study).
We decided to treat SLE patients with HBOT not only because it improves the
oxygenation of ischemic tissues and exerts beneficial effects on vascular inflammatory
response by regulating the chemotaxis of leukocytes, but also because it facilitates the
healing process of infected wounds promoting the deposition of collagen, angiogenesis,
epithelialization and facilitating the oxygen-dependent killing by leukocytes16-18. Previous
studies suggested that vasculitis skin ulcers in patient suffering from SLE had been treated
successfully with HBOT17.
Given the fact that HBOT can modify oxidation-reduction reactions and because of
mentioned beneficial effects of HBOT in different tissues in patients with SLE, this
protocol of therapy can be one of the possibility.
Conclusion
Our results highlighted some of the beneficial effects of hyperbaric oxygen
treatment on redox balance among patients suffering from systemic lupus erythematosus.
However, management of systemic lupus erythematosus (SLE) is complex and more
research is required to establish the complete mechanism by which HBOT can
modify oxidation-reduction reactions in patients with SLE so it can become a additional
potential therapeutic strategy in treatment of SLE.
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Table 1-Comparison of selected laboratory parameters - the initial value, value after 10
days and after a month.
Laboratory
parameters in serum
Initial ( X± SD)
10.days (X ± SD)
30.days (X± SD)
CRP (mg/l)
5,16 ± 5,7
4,93 ± 6,06ns
3,26 ± 2,25ns
Hb (g/L)
129,3 ± 10,27
131,00 ± 12,51ns
129,44 ± 14,13ns
Creatinine (mmol/l)
72,00 ± 22,84
78,55 ± 26,09ns
74,55 ± 23,55ns
Albumin (g/l)
42,33 ± 2,95
40,66 ± 2,50ns
42,33 ± 2,95ns
C3 (g/l)
1,05 ± 0,23
1,05 ± 0,29ns
1,03 ± 0,25ns
ANA ( IU/ml)
1,11 ± 1,16
1,44 ± 1,33ns
1,00 ± 1,11ns
CKDeGFR
(mil/min/1,73m2)
89,00 ± 22,46
84,33 ± 19,53ns
87,44 ± 20,91ns
ns non significant differences in comparison to initial values
C -reactive protein(CRP), hemoglobin (Hb), complement 3 (C3); antinuclear antibody
(ANA), chronic kidney disease estimated glomerular filtration rate (CKD eGFR).
FIGURE LEGENDS
Fig. 1. Level of superoxide anion radical (O2-) in urine samples (values are presented as
mean and SD). Statistical significances are presented as significance between values after
10 days vs. initial values and after 30 days HBOT vs. initial values (*p<0.05).
Fig. 2. Levels of nitrites (NO2-) in urine samples (values are presented as mean and SD).
There was no significant difference before and after HBOT.
Fig. 3. Levels of hydrogen peroxide (H2O2) in urine samples (values are presented as mean
and SD). There were no significant differences before and after HBOT.
Fig. 4. Concentration of TBARS in our groups in urine samples (values are presented as
mean and SD). There were no significant differences before and after HBOT.
Fig. 5. Activity of superoxide dismutase (SOD) in blood samples values are presented as
mean and SD). Comparing the initial value of SOD and SOD after HBOT treatment, it was
observed decrease in the level but without significant difference. After 30 days activity of
SOD is similar to the initial values.
Fig. 6. Level of reduced glutathione (GSH) in our group in hemolysate samples (values are
presented as mean and SD). Comparing the values of GSH (initially and after HBOT
treatment) there were no statistically significant differences.
Fig. 7. Activity of catalase (CAT) in hemolysate samples(values are presented as mean and
SD). Comparing initial values, after HBOT treatment (10 days), and values after 30 days,
there was no statistically significant differences.
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Received on January 10, 2017.
Revised on July 18, 2017.
Accepted on July 24, 2017.
Online First September, 2017.
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