Exploring the impact of nanomembrane-based low volume plasma exchange on gut barrier integrity in metabolic syndrome: a prospective study

   A comprehensive understanding of the human intestine and its structural-functional unit, the “gut barrier,” implies an intricate cross-talk between epithelial cells and the underlying immune system to coordinate the surveillance of intestinal luminal contents. Disruption of this barrier leads to an increased passage of antigens and macromolecules from the external environment into the host, triggering local or systemic inflammation and immune activation, commonly referred to as “leaky gut.” In recent times, increased intestinal permeability has been recognized as a key factor or pivotal pathogenic component in chronic inflammatory diseases, including metabolic disorders. Metabolic syndrome (MetSy) encompasses a cluster of metabolic disorders associated with an elevated risk of cardiovascular diseases, despite lifestyle modifications and medications. Zonulin, among the non-invasive markers of intestinal permeability, stands out due to its sensitivity. Nanomembrane-based low-volume plasma exchange (LVPE) is an innovative approach to blood purification designed to remove toxic and inflammatory blood components. This safe and minimally invasive procedure involves a device that pumps and filters the patient’s blood through nanopores in a multi-membrane layout. Objective.

   This study aims to investigate the impact of nanomembrane-based LVPE on the intestinal barrier in individuals with MetSy, elucidating its potential therapeutic role in chronic inflammatory diseases.

   Materials and methods. In this prospective study, 48 outpatient participants (31.3 % female, 68.7 % male) with an average age of 50 years underwent four cycles of nanomembrane-based LVPE, conducted every other day. Each cycle involved the removal of 30 % of circulating plasma, replaced with a saline solution. Serum samples were collected before the first and after the fourth LVPE cycle, measuring markers including Zonulin, C-reactive protein (CRP), high-sensitive CRP, Interleukin-6 (IL6), vitamin D3, and cardiometabolic parameters. Additionally, these markers were measured in plasma samples obtained after each LVPE cycle.

   Results. After four cycles of LVPE, there was a significant decrease in the concentrations of vitamin D3 (p < 0.001), CRP (p < 0.02), glucose (p < 0.0001), total cholesterol (p < 0.0001), triglycerides (p < 0.011), and HDL-C (p < 0.006). Before the first cycle, Zonulin was significantly associated with HDL-C (β = 1.406; p = 0.002), LDL-C (β = -1.263; p = 0.012), and hsCRP (β = 0.302; p = 0.046). After the fourth cycle, significant associations were obtained for HbA1c (β = 0.342; p = 0.025) and total cholesterol (β=0.570; p=0.001).

   Conclusion. Our study advocates for the use of nanomembrane-based LVPE as a targeted method to enhance gut barrier permeability in individuals with MetSy. Through four LVPE cycles, our research validates the efficacy of this approach in correcting carbohydrate and lipid metabolism. Notably, our investigation reveals LVPE’s potential immunomodulatory effect on inflammatory pathways.

1. Fasano A. All disease begins in the (leaky) gut: role of zonulin-mediated gut permeability in the pathogenesis of some chronic inflammatory disease. F1000Res 2020;9:(F1000 Faculty Rev): 69. doi: 10.12688/f1000research.20510.1.

2. Odenwald MA, Turner JR. Intestinal permeability defects: is it time to treat? Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 2013;11(9):1075-83.

3. Fasano A. Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity and cancer. Physiological reviews. 2011;91(1):151-75.

4. Lopetuso LR, Scaldafferi F, Bruno G, Petito V, Franceschi F, Gasbarrini A. The therapeutic management of gut barrier leaking: the emerging role for mucosal barrier protectors. Eur Rev Med Pharmacol Sci 2015;19:1068-76.

5. Sturgeon C, Fasano A. Zonulin, a regulator of epithelial and endothelial barrier functions, and its involvement in chronic diseases. Tissue barriers 2016;4(4):e1251384 doi: 10.1080/21688370.2016.1251384.

6. Ajamian M, Steer D, Resella G, Gibson PR. Serum zonulin as a marker of intestinal mucosal barrier funtion: May not be what it seems. PLOS ONE 2019;14(1):e0210728. doi: 10.1317/journal.pone.021078.

7. Tsukita S, Furuse M, Itoh M. Multifunctional strands in tight junctions. Nat Rev Mol Cell Biol 2001;2:285-93.

8. Graziani C, Talocco C, De Sire R, Lopetuso LR, Gervasoni J, Persichilli S, Franceschi F, Ojetti V, Gasparrini A, Scadaferri F. Intestinal permeability in physiological and pathological conditions: major determinants and assesment modalities. Eur Rev Med Pharmacol Sci 2019;23:795-810.

9. Furuse M, Fujita K, Hiragi T et al. Claudin-1 and -2: novel integral membrane proteins localizing at tight junctions with no sequence similarity to occludin. J Cell Biol 1998;141(7):1539-50.

10. Martin-Padura I, Lostaglio S, Schneemann M et al. Junctional adhesion molecule, a novel member of the immunoglobulin superfamily that distributes at intercellular junctions and modulates monocyte transmigration. J Cell Biol 1998;142(1):117-27.

11. Ikenouchi J, Furuse M, Furuse k et al. Tricellulin constitutes a novel barrier at tricellular contacts of epithelial cells. J Cell Biol 2005;171(6):939-45.

12. Higashi T, Tokuda S, Kitajiri S et al. Analysis of the „angulin“ proteins LSR1, ILDR1 and ILDR2-tricellulin recruitment, epithelial barrier function and implication in deafness pathogenesis. J Cell Sci 2013;126(Pt 4):966-77.

13. Lee SH. Intestinal permeability regulation by tight junction: implication on inflammatory bowel diseases. Intest Res 2015;13:11-8.

14. Turner JR. Intestinal mucosal barrier function in health and diseases. Nat Rev Immunol 2009;9:799-809; PMID:19855405 doi: 10.1038/nri2653.

15. Fasano A, Shea-Donohue T. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Nature clincal practice Gastroenterology & hepatology. 2005;2(9):416-22. doi: 10.1038/ncpgasthep0259 PMID: 16265432.

16. Fasano A, Not T, Wang W, Uzzau S, Berti I, Tommasini A, Goldblum SE. Zonulin, a newly discovered modulator of intestinal permeability, its exoression in coeliac disease. Lancet 2000;358:1518-19.

17. Wang W, Uzzau I, Sapone A, Gerarduzzi T, Not T, Zielke R, Fasano A. Human zonulin a potential modulator of intestinal tight junctions. J Cell Sci 2000;113:4435-40.

18. Gutteridge JM. The antioxidant activity of haptoglobin towards haemoglobin-stimulated lipid peroxidation. Biochimica et biophysica acta. 1987; 917(2):219–23. PMID: 2879568.

19. Langlois MR, Delanghe JR. Biological and clinical significance of haptoglobin polymorphism in humans. Clin Chem. 1996; 42(10):1589–600. PMID: 8855140.

20. Arrieta MC, Bistritz I, Meddings JB. Alterations in intestinal permeability. Gut 2006;55:1512-20; PMID:16966705; doi: 10.1136/gut.2005.085373.

21. Arrieta MC, Madsen K, Doyle J, Meddings J. Reducing small intestinal permeability attenuates colitis in the IL10 gene-deficient mouse. Gut 2009;58:41-8; PMID:18829978; doi: 10.1136(gut.2008.150888.

22. Visser JT, Lammers K, Hoogendijk A, Boer MW, Brugman S, Beijer-Liefers S, Zandvoort A, Harmsen H, Welling G, Stellaard F, et al. Restoration of impaired intestinal barrier function by the hydrolysed casein diet contributes to the prevention of type I diabetes in the diabetes-prone BioBreeding rat. Diabetologia 2010;53:2621-8; PMID:20853098; doi: 10.1007/s00125-010-1903-9.

23. Cornier MA, Dabelae D, Hernandez TL, Lindstrom RC, Steig AJ, Stob NR, et al. The Metabolic Syndrome. Endocr Rev 2008;29(7):777–822. doi: 10.1210/er.2008-0024.

24. Fahed G, Aoun L, Zerdan MB, Allam S, Zerdan MB, Bouferraa Y, Assi HI. Metabolic syndrome: Updates on Pathophysiology and Management in 2021. Int J Mol Sci 2022;23(2):786, PMID: 35054972; doi: 10.3390/ijms23020786.

25. Yamakova Y, Ilieva VA, Petkov R, Yankov G. Nanomembrane-Based Therapeutuc Plasmapheresis after Non-invasive Ventilation Failure for Treatment of a Patients with Acute Respiratory Distress Syndrome and Myastenia Gravis: A Case Report. Blood Purif 2019;48:382-84.

26. Tsonchev Z, Alexandov A, Momchilova A, Pankov R, Orozova M, Georgieva R, Geogieva S, Alexandov S, Voinov V, Anaya F, et al. Therapeutic Apheresis with Nanotechnology Membrane for Human Diseases. Bulgarian Academy of Science Prof Marin Drinov Publishing House: Sofia, Bulgaria, 2020;2:1–163.

27. Alexandrov AO, Vassileva P, Momchilova A, et al. A new approach using nanomembrane-based therapeutic plasmapheresis for treatment of patients with multiple sclerosis and neuromyelitis optica. Comptes rendus de l’Académie bulgare des Sciences. 2016; 69:373–384. Link: https://bit.ly/36Bl5sF.

28. Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, et al. Recommendation on the application of therapeutic apheresis in clinical practice-based editorialcommittee for apheresis: Seventh special edition. Part 1. American society for apheresis (ASFA). J Clin Apher. 2016;31:149–338.

29. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001 May 16;285(19):2486-97. doi: 10.1001/jama.285.19.2486.

30. Schwartz J, Winters JL, Aqui N, Balogun RA, Connelly-Smith L, et al. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the writing committee of the American society for apheresis: The sixth special issue. J Clin Apher. 2013;28(3):145-284. doi: 10.1002/jca.21276 PMID:23868759.

31. Qiao Q: DECODE Study Group. Comparison of different definition of the metabolic syndrome in relation to cardiovascular mortality in European men and women. Diabetology 2006;49(12):2837-46.

32. Anagnostis P. Metabolic syndrome in the Mediterranean region: Current status. Indian Journal of Endocrinology and Metabolism 2012;16(1):72–80.

33. Yunjeong Y, Jiyeon A. Sex Differences in Risk Factors fot Metabolic Syndrome in the Korean Population. Int. J. Environ Res Public Health 2020;17:9513-27.

34. Sondos H, Raed A, Wael MAR, Sirajuudeen KNS, Hamid JM. Age and Sex Association with Metabolic Syndrome among Adukts in Sharjah, UAE. Hamdan Med J 2023;16(2):79–86.

35. Yamakova Y, Ilieva VA, Petkov R, Yankov G. Nanomembrane-Based Therapeutic Plasmapheresis after Non-Invasive Ventilation Failure for Treatment of a Patients with Acute Respiratory Distress Syndrome and Myastenia Gravis: A Case Report. Blood Purif 2019;48:382-4.

36. Slavic V. Apheresis Procedure could Prevent Sequele of HSV1 Encephalitis-Case Report. Ann Antivir Antiretrovir 2020;4:10–13.

37. Alexandrov A, Vassilieva P, Momchilova A, Tsonchev Z, et al. A new approach using nanomembrane-based therapeutic plasmapheresis for tretament of patients with multiple sclerosis and neuromyelitis optica. Compte Rendus L’academie Bulg Sci 2016;69:373-84.

38. Tonev D, Georgieva R, Vavrek E. Our Clinical Expirience in the Treatment of Myastenia Gravis Acute Exarcerbation with Novel Nanomembrane-Based Exchange Technology. J Clin Med 2022;11:4021.

39. Tonev DG, Momchilova AB. Therapeutic Plasma Exchange in Certain Immune-Mediated Neurological Disorders: Focus on a Novel Nanomembrane-Based Technology. Biomedicines 2023;11:328-53.

40. Voinov VA. Therapeutic Apheresis in Metabolic Syndrome. Immunol Endocr Metab Agents Med Chem. 2018;18(1):38–54.

41. Slavic V, Djurdjic B, Randjelovic D, Rajovic G, Delic M. Nanomembrane-based Apheresis as Safe and Effective Therapy for Cytomegalovirus and Epstein-Barr Virus Reactivation. Open Access Maced J Med Sci. 2021;9(C):258–262.

42. Khaytina TL, Balabolkin MI, Konovalov GA. Et al. Ways of lipid metabolism in patients with type 2 diabetes. Vestn MEDSI, 2008-2009;2:38–43.

43. Moreno-Navarrete JM, Sabater M, Ortega F, Ricart W, Feranandez-Real JM. Circulatinig zonulin, a marker of intestinal permeability, is increased in association with obesity-associated insulin resistence. PloS One 2012;e37160.

44. Guldiken S, Demir M, Arikan E, Turgut B, Azcan S, Gerenli M, Tugrul A. The levels of circulating markers of atherosclerosis and inflammation in subjects with different degrees of body mass index: Soluble CD40 ligand and high-sensitivity C-reactive protein. Thromb Res 2007;119(1):79–84.

45. Guillot X, Semerano L, Saidenberg-Kermanac’h N, Falgarone G, Boissier MC. Vitamin D and inflammation. Joint Bone Spine 2010;77(6):552-7.

46. Aribi M, Mennechet FJD, Touil-Boukoffa. Editorial: The role of vitamin D as an immunomodulator. Front. Immunol.2023; 14:1186635. doi: 10.3389/fimmu.2023.1186635.

47. Ohlsoon B, Orho-Melander M, Nilsson PM. Higher levels of serum zonulin may rather be associated with increased risk of obesity and hyperlipidemia, than with gastrointestinal symptoms or diseasses manifestation. Int Mol Sci 2017;18(3):582.