evaluation of the efficacy of ginger, arabic gum, and boswellia in acute...

Renal Failure, 34(1): 73–82, (2012)Copyright © Informa Healthcare USA, Inc.ISSN 0886-022X print/1525-6049 onlineDOI: 10.3109/0886022X.2011.623563

LABORATORY STUDY

Evaluation of the Efficacy of Ginger, Arabic Gum, and Boswelliain Acute and Chronic Renal Failure

Mona Fouad Mahmoud, Abdalla Ahmed Diaai and Fahmy Ahmed

Department of Pharmacology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt

Abstract

This study was conducted to evaluate the effects of Zingiber officinale Roscoe (Ginger), Arabic gum (AG), and Boswelliaon both acute and chronic renal failure (CRF) and the mechanisms underlying their effects. Acute renal failure wasinduced by 30 min ischemia followed by 24 h reperfusion, while CRF was induced by adenine feeding for 8 weeks.Prophylactic oral administration of ginger, AG, Boswellia, or vehicle (in control groups) was started 3 days beforeand along with adenine feeding in different groups or 7 days before ischemia–reperfusion. Ginger and AG showedrenoprotective effects in both models of renal failure. These protective effects may be attributed at least in part totheir anti-inflammatory properties as evident by attenuating serum C-reactive protein levels and antioxidant effects asevident by attenuating lipid peroxidation marker, malondialdehyde levels, and increasing renal superoxide dismutaseactivity. Ginger was more potent than AG in both models of renal failure. However, Boswellia showed only partialprotective effect against both acute renal failure and CRF and it had no antioxidant effects. Finally, we can say thatginger and AG could be beneficial adjuvant therapy in patients with acute renal failure and CRF to prevent diseaseprogression and delay the need for renal replacement therapy.

Keywords: ischemia–reperfusion, adenine, ginger, Arabic gum, Boswellia, CRP, oxidative stress

INTRODUCTION

It was reported that by 2010 there will be more than2 million patients worldwide on maintenance dialysis,a 400% increase in 20 years. This increase, occurringpredominantly in developing nations, is being drivenespecially by a worldwide increase in the incidence ofdiabetes and is too great to be offset by increased ratesof renal transplantation.1 The social and financial costsof renal replacement therapy are proving too great fordeveloped nations to cope with and are an impossibleburden for developing nations to meet.2

Human kidneys are under assault from environmen-tal toxins as well as from an array of diseases that placethem at risk of ultimately failing. Several natural prod-ucts have been used to protect against drug-inducedtoxicity and carcinogenic xenobiotics. Herbs and spicesare generally considered safe and proved to be effec-tive against various human ailments and their medicinaluses have been gradually increased in the developedcountries.

Address correspondence to Mona Fouad Mahmoud, Department of Pharmacology, Faculty of Pharmacy, Zagazig University, Zagazig44519, Egypt. E-mails: [email protected]; [email protected]

Received 21 May 2011; Revised 15 August 2011; Accepted 4 September 2011

Zingiber officinale Roscoe (Ginger), an indispens-able component of curry, belongs to the Zingiberaceaefamily. Ginger has been used to treat a number of dis-eases, including headache, cold, arthritis, postoperativenausea, vomiting, and motion sickness, and reducessymptoms in patients with nausea of pregnancy.3–6

Boswellia carteri is one of the 43 species in the genusBoswellia of the family Burseraceae. It is easily avail-able in the United States as dietary supplements forpatients with arthritis or other inflammation and pain-related disorders but its mechanisms of action are notwell understood, and only a few studies of its anal-gesic, antihyperalgesic, and anti-inflammatory effects onanimal models have been reported.7

Arabic gum (AG) is dried gummy exudates from thestems and branches of Acacia senegal (Leguminosae).8

AG has long been used in Arab folk medicine to reduceboth the frequency and the need for hemodialysis inpatients with chronic renal failure (CRF). Addition-ally, AG has been shown to reduce urinary nitrogen

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74 M.F. Mahmoud et al.

excretion by increasing urea disposal in the cecum andlowers serum urea concentration in rat and human.9

However, there is a dearth of information providing sci-entific support for the folkloric claims of AG on renalfunction after renal damage.

In this study, we examined and compared theeffects of ginger, AG, and Boswellia on renal functionimpairment induced by feeding adenine or ischemia–reperfusion (IR) injury. In addition, the possible under-lying mechanisms were also investigated.

MATERIALS AND METHODS

All experiments were carried out in accordance withprotocols approved by the local experimental ethicscommittee and in accordance with the guidelines of theUS National Institutes of Health on animal care. Everyeffort was made to minimize the number of animalsused and their suffering.

AnimalsAdult male albino rats weighing about 220–250 g wereobtained from the Faculty of Veterinary Medicine,Zagazig University, Egypt. The animals were housed instainless steel cages with wood shaving bedding. Theywere kept at constant temperature of 25 ± 2◦C, rela-tive humidity of approximately 50%, and illumination(12 h light/dark) throughout the experiment. They werefed standard chow diet and were given free access to tapwater.

ChemicalsAdenine was obtained from Sigma (St. Louis, MO,USA) and was prepared freshly in 10% Tween 80obtained from El Gomhouria Co., Zagazig, Egypt.Ginger, Boswellia, and AG were obtained from the localsource. Ginger and AG were dissolved in distilled water,but Boswellia was dissolved in sesame oil just beforeuse. Kits for measuring serum creatinine and ureawere supplied by Egyptian Company for Biotechnology,Egypt; for lactate dehydrogenase (LDH) obtained frombiodiagnostic kit supplied by Spinreact, Spain; for mal-ondialdehyde (MDA) supplied by Bio Diagnostic Co.,Egypt; for CRP kit supplied by DiaMed EuroGen,Belgium; and for superoxide dismutase (SOD) fromdiagnostic kit, Bio Diagnostic Co.

Induction of Chronic Renal FailureCRF was induced by oral administration of adenine ina dose of 200 mg/kg three times a week for 8 weekssuspended in 10% Tween 80.10

Induction of Acute Renal FailureRenal ischemia–reperfusion (RIR) was performedaccording to the method described by Rabb et al.11

Rats were anesthetized with an intraperitoneal injectionof thiopental sodium (50 mg/kg). To perform nephrec-tomy, a lateral incision was made in the left side and the

left kidney was mobilized to allow left renal artery to beligated, then this kidney was removed. The wound wasclosed with 3-0 silk suture for internal muscles and 4-0silk suture for external skin. To cause ischemia, a lateralincision was made in the right side and the right kidneywas mobilized and the right renal artery was clamped.This clamping was performed by tying the right renalartery over a plastic support for 30 min. Ischemia wasconfirmed visually by blanching of the kidney. After30 min the tie was cut to eliminate the clamp andthe wound was closed as described before. The ani-mals were then returned to their cages and allowed freeaccess to food and water after intramuscular injectionwith 0.5 mL penicillin. Animals were killed 24 h later.Sham-operated animals underwent the same operationbut without left kidney removal or right renal arteryclamping.

Experimental DesignOne week after acclimatization, rats were randomlydivided into 10 groups (10 rats each). Group I includescontrol rats given only 10% Tween 80 by oral gavage;Group II includes control rats given only adenine ina dose of 200 mg/kg three times a week orally for 8weeks suspended in 10% Tween 80; Group III receivedginger (500 mg/kg/day) orally 3 days before and threetimes weekly for 8 weeks concurrent with adenine;Group IV received AG (200 mg/kg) as ginger; GroupV received Boswellia (900 mg/kg) as ginger; Group VIrepresents sham-operated rats; Group VII represents IRrats; Group VIII received ginger (500 mg/kg/day) orally7 days before the induction of IR injury; Group IXreceived AG (200 mg/kg) orally 7 days before the induc-tion of RIR injury; and Group X received Boswellia (900mg/kg) orally 7 days before the induction of RIR injury.

Blood Sampling and Serum PreparationAt the end of the experiments, all animals from eachgroup were anesthetized with urethane (1.3 g/kg). Bloodsample of 3–5 mL was obtained from orbital sinus ofrat using heparinized microcapillary tubes according tothe method of Sorg and Buckner12 and samples col-lected in clean dry test tubes were then centrifugedat 2000 × g for 15 min using Heraeus Sepatech cen-trifuge (Labofuge 200, Fischer Scientific, Pittsburgh,PA, USA). The serum was collected and divided intotwo aliquots: one used for the immediate determinationof LDH and the second aliquot was kept at −20◦C forfurther biochemical analysis.

Tissue SamplingIn CRF groups, animals were killed and dissected. Onekidney from each rat was immediately removed andchilled in liquid nitrogen and kept at −20◦C for SODdetermination. The other kidney was also removedand kept in glutaraldehyde for electron microscopicexamination. While in sham-operated and in IR groups,

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Evaluation of the Efficacy of Ginger, AG, Arabic Gum and Boswellia 75

animals were killed and dissected and the remaining kid-neys were immediately removed and chilled in liquidnitrogen and kept at −20◦C for SOD determination.

Biochemical AnalysisRenal function testsSerum creatinine was determined colorimetricallyaccording to the method described by Bowers andWong,13 using a diagnostic kit supplied by the Egyp-tian Company for Biotechnology. Urea was determinedby a colorimetric method according to the principle ofShephard and Mezzachi14 using a biodiagnostic kit sup-plied by the Egyptian Company of Biotechnology. Bloodurea nitrogen (BUN) is determined by multiplying theresult of serum urea by 0.467.

Cell deathSerum LDH as indicator of necrotic cell death wasdetermined by a photometric method as describedby Vassault15 using a biodiagnostic kit supplied bySpinreact.

Lipid peroxidationSerum MDA, a product of lipid peroxidation, was deter-mined colorimetrically as described by Satoh16 using adiagnostic kit supplied by Bio Diagnostic Co.

Inflammation markersSerum C-reactive protein (CRP), an indicator of inflam-mation, was determined by an enzyme immunoassaymethod as described by Helgeson et al.17 using adiagnostic kit supplied by DiaMed EuroGen.

Antioxidant statusKidney SOD was determined by a colorimetric methodas described by Nishikimi et al.18 using a diagnostic kitsupplied by Bio Diagnostic Co.

Electron microscopic examinationOne kidney from each rat of CRF groups was cut intolongitudinal sections 2–4 mm in thickness and kept inglutaraldehyde. The kidneys were examined under elec-tron microscope to determine ultrastructural changesand a photomicrograph was taken of one kidney fromeach group.

Statistical AnalysisAll results are expressed as mean ± SEM. Statisticalanalysis was done using graph pad prism software ver-sion 5 (GraphPad Software, San Diego, CA, USA). Theintergroup variation was measured by one-way analysisof variance (ANOVA) followed by Tukey’s post hoc leastsignificant difference test. A value of p < 0.05 was usedas the limit for statistical significance.

RESULTS

Renal FunctionTable 1 shows that adenine administration induced asignificant elevation of serum creatinine, urea, and BUNcompared with normal rats (p < 0.05). It also increasedthe serum LDH levels (p < 0.05).

Ginger and AG administration along with adeninereduced serum creatinine, urea, BUN, and normalizedLDH levels (p < 0.05) when compared with adenine-treated rats. However, Boswellia reduced only serumurea and BUN levels when compared with adenine-treated rats.

Table 2 shows that RIR injury also elevated serumcreatinine, urea, and BUN compared with sham-operated rats (p < 0.05). It increased serum LDH levels(p < 0.05). Ginger, AG, and Boswellia administration7 days before RIR reduced serum creatinine, urea, andBUN (p < 0.05) when compared with IR group. Onlyginger and AG were able to reduce serum LDH levels.

Oxidative Stress and InflammationFigure 1A shows that adenine caused a signifi-cant elevation in lipid peroxidation represented byincreased MDA levels when compared with normal rats(p < 0.05). However, it did not affect renal SOD activity(Figure 1B). Adenine elevated serum CRP level whencompared with normal rats (Figure 1C). Ginger and AGadministration along with adenine reduced both serumMDA and CRP levels (Figure 1A and C) when com-pared with adenine-treated rats (p < 0.05). Boswelliaonly reduced serum CRP levels when compared withadenine-treated rats (p < 0.05).

Figure 2A and C shows that RIR caused signifi-cant elevation in lipid peroxidation (MDA levels) andserum CRP levels, respectively, when compared withsham-operated rats (p < 0.05). Renal SOD activity

Table 1. Effect of oral administration 3 days before and 8 weeks concurrent with adenine (200 mg/kg) on renal function parameters andLDH activity in adult male albino rats.

Parameters Control Adenine Ginger Boswellia AG

Serum creatinine (mg/dL) 1.01 ± 0.08 6.10∗ ± 0.03 3.20∗∗ ± 0.25 5.24 ± 0.51 4.43∗∗ ± 0.1Serum urea level (mg/dL) 35.50 ± 2.26 163.90∗ ± 4.20 57.40∗∗ ± 5.50 135.50∗∗ ± 3.50 102.80∗∗ ± 8.50Blood urea nitrogen (mg/dL) 18.04 ± 0.94 74.42∗ ± 1.96 24.15∗∗ ± 0.82 63.29∗∗ ± 1.64 40.95∗∗ ± 1.23Serum LDH activity (U/L) 494.00 ± 6.12 636.00∗ ± 18.26 462.09∗∗ ± 14.46 599.00 ± 3.51 587.22∗∗ ± 14.19

Notes: Data show the administration of Boswellia (900 mg/kg), ginger (500 mg/kg), and AG (200 mg/kg). The results are presented asmean ± SEM. N = 7 for control; 9 for adenine and AG; 11 for ginger; and 6 for Boswellia. AG, Arabic gum; LDH, lactate dehydrogenase.∗Significantly different from control at p < 0.05; ∗∗significantly different from Adenine at p < 0.05.

© 2012 Informa Healthcare USA, Inc.

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Table 2. Effect of oral administration 7 days before 30 min ischemia and 24 h reperfusion (IR) on renal function parameters and LDHactivity in adult male albino rats.

Parameters Sham-operated IR Ginger Boswellia AG

Serum creatinine (mg/dL) 0.85 ± 0.07 6.81∗ ± 0.56 2.55∗∗ ± 0.21 4.92∗∗ ± 0.30 3.02∗∗ ± 0.19Serum urea level (mg/dL) 26.00 ± 1.94 159.83∗ ± 2.84 66.33∗∗ ± 4.32 119.20∗∗ ± 6.86 74.00∗∗ ± 3.27Blood urea nitrogen (mg/dL) 10.72 ± 0.33 74.60∗ ± 1.31 30.95∗∗ ± 0.86 53.01∗∗ ± 2.30 35.85∗∗ ± 1.06Serum LDH activity (U/L) 283.80 ± 11.25 398.00∗ ± 11.95 313.83∗∗ ± 14.07 385.60 ± 10.92 290.60∗∗ ± 19.66

Notes: Data show the administration of Boswellia (900 mg/kg), ginger (500 mg/kg), and AG (200 mg/kg). The results are presented asmean ± SEM. AG, Arabic gum; LDH, lactate dehydrogenase. N = 6 for all groups except Boswellia and for Arabic gum N = 5.∗Significantly different from sham-operated rats at p < 0.05; ∗∗significantly different from IR rats at p < 0.05.

was reduced in IR group when compared with sham-operated rats (Figure 2B). All drugs reduced serumCRP levels when compared with IR group (Figure 2C).Ginger and AG reduced serum MDA levels (Figure 2A).While ginger only was able to increase renal SOD activ-ity. Boswellia had no significant effect on oxidative stresswhen compared with IR group (Figure 2A and B).

Histopathological FindingsRats in the control group showed normal kidney archi-tecture and histology with normal ultrastructure ofproximal tubules, cells with many electron-dense gran-ules, apical vacuolations, and normal-shaped nucleiwith apical microvilli and basal enfolding full of mito-chondria (Figure 3A). Adenine caused ultrastructuralheterogeneity within proximal tubules and loss ofmicrovilli. Some cells showed electron-dense cytoplasmand few mitochondria (Figure 3B). Ginger-treated ratsshowed relatively normal proximal tubules. Blood cap-illaries had corrugated basement membrane and widecapillary spaces. There were electron-dense nuclei ofblood vessels with irregular-shaped nuclei. There wasan increase in mesangial cells. The podocytes showeddark cytoplasm with dark nuclei (Figure 3C). Boswellia-treated rats showed ultrastructural damage within prox-imal tubules with very few electron-dense granules andirregular-shaped nuclei of some cells (Figure 3D). AGcaused an improvement of proximal tubules’ ultra-structural changes, wide intercellular spaces, corru-gated nuclei, thickened basement membrane, and fewelectron-dense granules (Figure 3E).

DISCUSSION

This study was performed to demonstrate the role anddifferent mechanisms of natural products such as gin-ger, AG, and Boswellia in repairing damaged kidney cellseither in acute renal failure or CRF.

We showed that the oral administration of adeninecaused renal dysfunction that is represented by anincrease of serum creatinine, urea, and BUN levels.Electron microscopic examination of renal tubulesrevealed that adenine caused loss of microvilli of prox-imal tubule and the appearance of very low electron-dense cytoplasm with few mitochondria in some cells.This indicates a decrease in cellular surface area of the

proximal tubule and destruction of sodium-potassiumadenosine triphosphatase (Na+/K+–ATPase) pump dueto low number of mitochondria. It was previouslyreported that adenine-treated kidneys were markedlyenlarged with a pale gray color with the formation offoreign body granuloma in the tubular lamina and theinterstitium of the kidney.19

The model of adenine-induced CRF was developedby Yokozawa et al.,10 in which long-term feeding of ade-nine to rats produced metabolic abnormalities resem-bling CRF in humans. In mammalian metabolism,when it is present in excess, adenine becomes a sig-nificant substrate for xanthine dehydrogenase, whichcan oxidize adenine to 2,8-dihydroxyadenine (DHA).20

DHA is highly protein bound and is actively secretedby the renal tubules,21 but it is sparingly soluble at thephysiological urinary pH. The sparingly soluble natureof DHA results in the excretion of DHA crystals inurine and frequently, the deposition of stones in kidneys.Because adenine and DHA have very low solubilities,they precipitate in the tubules of the kidney.22

The current study showed that adenine causedlipid peroxidation and inflammation, which ultimatelycaused renal cell death. This was confirmed by thesignificant increases in lipid peroxidation end product,MDA; acute phase inflammatory marker, CRP; and theelevation of serum LDH levels.

However, the activity of antioxidant enzyme SODwas not significantly changed by adenine in this study.A previous study found that the activity of SOD enzymewas significantly decreased in adenine-treated rats.23

This difference in results may be attributed to the differ-ent period of adenine treatment where in the previousstudy adenine was given for only 4 weeks, but in ourstudy adenine was given for 8 weeks. Kidneys may com-pensate for the increased oxidative stress by increasingthe synthesis of SOD again to normal levels during the8-week period.

In this study, oral administration of ginger along withadenine caused a significant improvement in renal func-tion, represented by the significant decrease in serumcreatinine, urea, and BUN. It also reduced serum LDHlevels and attenuates ultrastructural changes. Elec-tron microscopic examination showed relatively normalproximal tubules.

The mechanisms of these renoprotective effectsmay involve reduction of both oxidative stress and

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Figure 1. Effect of oral administration of Boswellia (900 mg/kg),ginger (500 mg/kg), and Arabic gum (200 mg/kg) 3 days beforeand 8 weeks concurrent with adenine (200 mg/kg) on serum MDAlevels (A), renal SOD (B), and serum CRP levels (C) in adult malealbino rats.Notes: MDA, malondialdehyde; SOD, superoxide dismutase;CRP, C-reactive protein.∗Significantly different from control at p < 0.05; ∗∗significantlydifferent from adenine group at p < 0.05.

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Figure 2. Effect of oral administration of Boswellia (900mg/kg),ginger (500 mg/kg), and Arabic gum (200 mg/kg) for 7 days beforeRIR on serum MDA levels (A), renal SOD (B), and serum CRPlevels (C) in adult male albino rats.Notes: I/R, ischemia–reperfusion; MDA, malondialdehyde; SOD,superoxide dismutase; CRP, C-reactive protein.∗Significantly different from sham-operated rats at p < 0.05;∗∗significantly different from ischemic–reperfusion (IR) group atp< 0.05.


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Figure 3. (A) Electron micrograph of normal rat kidney with nor-mal ultrastructure of proximal tubules, cells with many electron-dense granules, apical vacuolations, and normal-shaped nucleiwith apical microvilli and basal enfolding full of mitochondria(arrows); (B) electron micrograph of rat kidney treated with ade-nine with ultrastructural heterogeneity within proximal tubules,loss of microvilli, some cells show electron-dense cytoplasm, andfew mitochondria (arrows); (C) electron micrograph of rat kid-ney treated with ginger with relatively normal proximal tubules,blood capillaries, corrugated basement membrane, wide cap-illary spaces, and electron-dense nuclei of blood vessels withirregular-shaped nuclei. There is increase in mesangial cells. Thepodocytes show dark cytoplasm with dark nuclei (arrows); (D)electron micrograph of rat kidney treated with Boswellia, show-ing ultrastructural damage within proximal tubules, very fewelectron-dense granules, and irregular-shaped nuclei of somecells; and (E) electron micrograph of rat kidney treated with AG,showing an improvement of proximal tubules, wide intercellularspaces, corrugated nuclei, thickened basement membrane, andfew electron-dense granules (arrows).Note: AG, Arabic gum.

inflammation in renal cells. This is clear by sig-nificant reduction in lipid peroxidation (MDA) andserum CRP levels. It may be possible that 6-gingerol, one of the active constituents of ginger, dueto its potential antioxidant properties,24,25 improvesrenal functions by attenuating oxidative stress-mediateddecline in glomerular filtration rate (GFR) and renalhemodynamics.

Ginger was found to scavenge hydroxyl, superoxide,and other free radicals in a dose-dependent manner invitro.26 In human aortic endothelial cells, zingerone and

6-gingerol demonstrated significant antioxidant effectson low-density lipoproteins.27 Previous studies showedthat ginger ameliorated cisplatin-induced nephrotoxicityeither by preventing cisplatin-induced decline of renalantioxidant defense system or by its direct free radicalscavenging activity.28

It was also proved that ginger exhibits anti-inflammatory effects,29 which give a good rationale forsignificant decrease in serum CRP levels observed inour study. Significant decreases in serum CRP levelsare confirmed by recent studies in which [6]-gingerol isendowed with strong anti-inflammatory and antiapop-totic actions.30

The results of this study illustrated that AG attenu-ated adenine-induced renal dysfunction which is provedby significant decrease in serum creatinine, urea,and BUN levels. Electron microscopic examination ofrenal tubules also showed an improvement of tubu-lar epithelial cells. It has been previously reportedthat oral administration of AG had a protective actionagainst gentamicin-induced nephrotoxicity,31 while oth-ers reported only a modest nephroprotection by AG.32

We showed that AG offered protection against lipidperoxidation, inflammation, and renal cell damage,which is revealed by decrease in serum MDA, CRP, andLDH levels.

The anti-inflammatory effect of AG is in accordancewith Gamal El-din et al.,33 who stated that AG hasbeen reported to be used internally for the treatmentof inflammation of the intestinal mucosa, and externallyto cover inflamed surfaces.

It has also been postulated that AG enhances theamount of energy available to the colonies of bacte-ria that ferment dietary fibers and absorb nitrogen asthey grow.34 These bacterial colonies are also capableof degrading urea to ammonia, excreting it in feces,and taking some of the body nitrogen wastes withthem.8,9

The renoprotective effect of AG may be alsoattributed to the sorbent (binding) effect of AG thathelps in removing some of the creatinine and urea fromthe blood without actually changing important physio-logical variables such as GFR and creatinine clearance.It is thought that oral sorbents correct malnutrition inCRF by binding with the toxins produced by uremia.35

Collectively, the previous effects may be responsible forthe reduction of renal cell death as indicated by thedecrease of serum LDH levels shown in this study.

Huemer36 suggested that natural substances whichpossess anti-inflammatory activity may help to stabi-lize failing kidneys. Among them are curcumin (fromthe spice turmeric), Boswellia herb (source of a natural5-lipoxygenase inhibitor), and fish oils.

However, the results of this study showed thatBoswellia caused a little improvement in kidney function.This is indicated by its ability to significantly reduceurea and BUN levels. But it had no significant effect onserum creatinine levels and it also did not reduce lipid

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peroxidation. It did not protect against renal tubular celldeath as no change occurred in serum LDH levels.

Boswellia had only anti-inflammatory effect where itreduced serum CRP levels. These biochemical find-ings indicate that Boswellia has little beneficial effectin the protection against CRF. Electron microscopicexamination of the kidney showed few electron-densegranules and irregular-shaped nuclei of some cellsand no improvement in renal tubular cells. The anti-inflammatory effect of Boswellia may be due to 3-O-acetyl-11-keto-β-boswellic acid, which is the most activecomponent of Boswellia extract and has been demon-strated to be a potent inhibitor of 5-Lipoxygenase(5-LOX), which is a key enzyme in the biosynthesis ofleukotrienes (LTs) from arachidonic acid in the cellularinflammatory cascade.37

The second model used in this work is RIR injury.It is a major cause of acute renal failure and renalgraft rejection and may lead to CRF if chronic.38,39

This investigation showed that rats subjected to30-min ischemia showed a significant deterioration inrenal function when measured 24 h after reperfu-sion as compared with respective sham-operated rats.This deterioration is indicated by significant increasein serum creatinine, urea, and BUN levels. RIRinjury causes both renal and glomerular dysfunction 40

together with increased oxidative stress.41,42

This study showed that RIR was associated withincreased lipid peroxidation and reduction of renal SODactivity. In addition, it elevated serum CRP levels. Reac-tive oxygen species (ROS) such as hydrogen peroxide,superoxide, and hydroxyl radicals are generated in highconcentration in ischemic tissue after reperfusion.43

Although there is cellular defense against free radicalinjury provided by tissue SOD and free radical scav-enging systems,8 these systems are insufficient undercertain conditions to prevent the damage totally.44

Several studies have demonstrated that ROS have animportant role in the RIR injury through lipid perox-idation of cells.40 RIR injury in the kidney is associ-ated with lipid peroxidation, which is an autocatalyticmechanism leading to oxidative destruction of cellularmembranes.42 This explains why RIR was associated inour study with elevation in serum LDH levels.

Another explanation of increased LDH levels is thatproximal tubular cells with its highly selective transportmechanisms are severely disrupted due to the decline inATP. This leads to dysfunction of the Na+/K+–ATPasepump located on the basolateral surface of proximaltubular cells that allows intracellular accumulation ofNa+ ions followed by an influx of water leading tocell swelling, intracellular disruption, and eventual celldeath.41

Even when reperfusion of the kidney is established,additional RIR injury occurs. This involves the develop-ment of oxidative stress through the generation of super-oxide anions O2

•−, which has recently been measured as

an indicator of RIR injury of the transplanted kidney.45

Oxidative stress during RIR may elicit an inflamma-tory process observed in this study by the elevationof serum CRP levels. During reperfusion of ischemictissue, an intense inflammatory response is induced.46

This promotes the rapid infiltration of neutrophils,which are subsequently activated to dilute tissue damageduring RIR.

The current study showed that oral administrationof ginger for 7 days before RIR caused a significantimprovement in all renal function parameters. This isindicated by the significant decrease in serum creati-nine, urea, and BUN levels. The protective potential ofginger against RIR may be attributed to both antioxi-dant and anti-inflammatory effects.

This study showed that ginger treatment restorednormal renal level of SOD enzyme and reduced lipidperoxidation. Previous studies showed that serum MDAis significantly reduced by ginger.47

Ginger also reported to inhibit peroxidation of phos-pholipid liposomes in the presence of iron (III).48

In rats, where free radicals were generated withorganophosphate toxicity, supplementation with gin-ger provided a significant antioxidant effects, raisingtissue concentrations of SOD, catalase, and reducedglutathione.49 Ginger also reduced serum CRP levels inthis work indicating potent anti-inflammatory effect.

This investigation showed that AG caused a signif-icant improvement in kidney function by decreasingserum creatinine, urea, and BUN levels. It also has pro-tective effect against cell damage caused by RIR, whichis represented by significant decrease in serum LDHlevels.

The mechanism of this protective effect may be dueto antioxidant activities of AG which are supported byreduction in lipid peroxidation and elevation of renalSOD content. A series of articles showed a protectiveeffect of AG against experimental GM and cisplatinnephrotoxicity,32 doxorubicin cardiotoxicity50 in rats,and acetaminophen hepatotoxicity33 in mice. All thesestudies were based on the assumption that AG hasstrong antioxidant properties, and the major mechanismfor the induction of these toxicities was the generation offree radicals.

In addition, dietary supplementation with AG, byincreasing systemic levels of butyrate, may have a poten-tial beneficial effect in renal disease by suppression ofTGF-β1 activity.51

LTs are metabolites of arachidonic acid formed fromthe 5-LOX pathway and exert potent vasoactive andproinflammatory effects in conditions associated withRIR injury.52 LTs also play a physiological role inthe host defense against microbial infections. Thus,inhibitors of 5-LOX may be useful in the treatment ofconditions associated with RIR injury.53

In this work, we found that oral administrationBoswellia carteri for 7 days before RIR process caused


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a significant improvement in kidney functions indicatedby the reduction of serum creatinine, urea, and BUNlevels.

This study showed that Boswellia exerted anti-inflammatory effect by decreasing serum CRP levels inRIR. This may give an explanation for the significantreduction of serum creatinine, urea, and BUN levels.Our results are matched with Patel et al.54 who statedadministration of zileuton (a potent 5-LOX inhibitorsimilar in mechanism of action to Boswellia) significantlyattenuated renal dysfunction and injury caused by RIRof the mouse in vivo.

The reduction in serum CRP levels may beattributed to boswellic acids (BAs), which possessdiverse pharmacological properties, including antipro-liferative, proapoptotic and pro-differentiating, andanti-inflammatory effects, and are assumed as the activeprinciples of Boswellia species extracts.55

Accordingly, it is speculated that BAs may exert theiranti-inflammatory effect mainly by inhibiting the releaseof proinflammatory LT products from leukocytes andplatelets55 and by the inhibition of NF-κβ and subse-quent downregulation of TNF-α expression in activatedmonocytes.56

The protective effect of Boswellia against RIR is notattributed to the modulation of oxidative stress as it doesnot affect serum MDA or renal SOD levels. But it mayblock its subsequent inflammatory effect.

It should be noted that the renal injury and dys-function observed in rats treated with Boswellia werenot entirely abolished. In addition, the degree of inhi-bition of serum urea and creatinine was not as completeas that of serum CRP. This is not surprising, giventhat many other pathophysiological mechanisms, whichare independent of LTs and/or an enhanced inflamma-tory response, will contribute to the observed injuryduring ischemia and/or reperfusion. These mechanismsmay include (but are not limited to) the generation ofROS and reactive nitrogen species, an enhanced forma-tion of nitric oxide, modification of endogenous lipoxingeneration, or the activation of the nuclear enzymepoly(ADP-ribose) polymerase.57

In conclusion, it is clear that oxidative stress playsa crucial role in the development of adenine-inducedrenal failure and the more the potent antioxidant, themore the renoprotective effect. It is also clear that gingeris the most potent renoprotective agent against adenine-induced renal failure in this study followed by AG.However, Boswellia has the least protective effect.

This study also provided experimental evidencethat ginger attenuated RIR-induced ARF, suggesting apromising potential of ginger in protecting against ARF.Ginger was more potent than AG in both models ofrenal failure. The mechanisms of nephroprotection ofboth ginger and AG may involve antioxidant and anti-inflammatory actions. It is also observed that inflam-mation has much greater role in RIR-induced renaldysfunction than in adenine-induced renal impairment,

where Boswellia attenuates serum creatinine level inRIR but not in adenine-induced CRF. Further workon the effects of active constituents of ginger on bothadenine-induced CRF and ARF is required to deter-mine the most effective active constituent.

ACKNOWLEDGMENT

The authors thank Dr. Abier Azmy, assistant professorof histology, Faculty of Medicine, Zagazig University,for assistance in electron microscopic examination ofkidney.

Declaration of interest: The authors report no con-flicts of interest. The authors alone are responsible forthe content and writing of the paper.

REFERENCES

[1] Lysaght MJ. Maintenance dialysis population dynamics: Cur-rent trends and long-term implications. J Am Soc Nephrol.2002;13(1):37–40.

[2] Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P.Acute renal failure—Definition, outcome measures, animalmodels, fluid therapy and information technology needs: Thesecond international consensus conference of the Acute Dial-ysis Quality Initiative (ADQI) Group. Crit Care. 2004;8(4):204–212.

[3] Phillips S, Hutchinson S, Ruggier R. Zingiber officinale does notaffect gastric emptying rate. A randomized, placebo-controlled,crossover trial. Anesthesia. 1993;48(5):393–395.

[4] Arfeen Z, Owen H, Plummer JL, Ilsley AH, Sorby-Adams RA,Doecke CJ. A double-blind randomized controlled trial of gin-ger for the prevention of postoperative nausea and vomiting.Anaesth Intensive Care. 1995;23(4):449–452.

[5] Grant KL, Lutz RB. Ginger. Am J Health Syst Pharm.2005;57(10):945–947.

[6] Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea andvomiting in pregnancy: Randomized, double-masked, placebo-controlled trial. Obstet Gynecol. 2001;97(4):577–582.

[7] Fan AY, Lao L, Zhang RX, et al. Effects of an acetone extractof Boswellia carteri Birdw. (Burseraceae) gum resin on adjuvant-induced arthritis in Lewis rats. J Ethnopharmacol. 2005;101(1–3):104–109.

[8] Younes H, Garleb K, Behr S, Rémésy C, Demigné C. Fer-mentable fibers or oligosaccharides reduce urinary nitrogenexcretion by increasing urea disposal in the rat cecum. J Nutr.1995;125(4):1010–1016.

[9] Bliss DZ, Stein TP, Schleifer CR, Settle RG. Supplementa-tion with gum Arabic fiber increases fecal nitrogen excretionand lowers serum urea nitrogen concentration in chronic renalfailure patients consuming a low-protein diet. Am J Clin Nutr.1996;63(3):392–398.

[10] Yokozawa T, Zheng PD, Oura H, Koizumi F. Animal modelof adenine-induced chronic renal failure in rats. Nephron.1986;44(3):230–234.

[11] Rabb H, Mendiola CC, Saba SR, et al. Antibodies to ICAM-1protect kidneys in severe ischemic reperfusion injury. BiochemBiophys Res Commun. 1995;211(1):67–73.

[12] Sorg DA, Buckner B. A simple method of obtaining venousblood from small laboratory animals. Proc Soc Exp Biol Med.1964;115:1131–1132.

[13] Bowers LD, Wong ET. Kinetic serum creatinine assays. II. Acritical evaluation and review. Clin Chem. 1980;26(5):555–561.

Renal Failure

Ren

Fai

l Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

isso

uri C

olum

bia

on 1

1/26

/13

For

pers

onal

use

onl

y.


[14] Shephard MD, Mezzachi RD. Scientific and Technical Com-mittee: Technical Report No. 8. The collection, preservation,storage and stability of urine specimens for routine clinicalbiochemical analysis. Clin Biochem Rev.1983;4:61–67.

[15] Vassault A. Lactate dehydrogenase. UV-method with pyru-vate and NADH. In: Bergmeyer J, Grabl M, eds. Methodsof Enzymatic Analysis. Deerfield Beach, FL: Verlag-Chemie;1983:119–126.

[16] Satoh K. Serum lipid peroxide in cerebrovascular disordersdetermined by a new colorimetric method. Clin Chim Acta.1987;90(1):37–43.

[17] Helgeson NGP, Adamson DM, Pike RB, et al. C-reactive pro-tein. In: Race GJ, ed. Laboratory Medicine, Vol. 2, Chap. 29.Hagerstown: Harper & Row; 1973.

[18] Nishikimi M, Appaji N, Yagi K. The occurrence of super-oxide anion in the reaction of reduced phenazine methosul-fate and molecular oxygen. Biochem Biophys Res Commun.1972;46(2):849–854.

[19] Yokozawa T, Oura H, Nakagawa H, Okada T. Adenineinduced hyperuricemia and renal damage in rats. NipponNogeikagaku Kaishi. 1982;56:655.

[20] Stockelman MG, Lorenz JN, Smith FN, et al. Chronicrenal failure in a mouse model of human adenine phos-phoribosyltransferase deficiency. Am J Physiol. 1998;275(1):154–163.

[21] Ericson A, Groth T, Niklasson F, de Verdier CH. Plasmaconcentration and renal excretion of adenine and 2, 8-dihydroxyadenine after administration of adenine in man.Scand J Clin Lab Invest. 1980;40(1):1–8.

[22] Peck CC, Baily FJ, Moore GL. Enhanced solubility of2,8-dihydroxyadenine (DOA) in human urine. Transfusion.1977;17:383–390.

[23] Ali BH, Al-Salam S, Al Husseni I, et al. Effects of Gum Ara-bic in rats with adenine-induced chronic renal failure. Exp BiolMed. 2010;235:373–382.

[24] Afzal M, Al-Hadidi D, Menon M, Pesek J, Dhami MS. Ginger:An ethnomedical, chemical and pharmacological review. DrugMetabol Drug Interact. 2001;18(3–4):159–190.

[25] Shukla Y, Singh M. Cancer preventive properties of ginger: Abrief review. Food Chem Toxicol. 2007;45(5):683–690.

[26] Jagetia G, Baliga M, Venkatesh P. Ginger (Zingiber officinaleRosc.), a dietary supplement, protects mice against radiation-induced lethality: Mechanism of action. Cancer Biother Radio-pharm. 2004;19 (4):422–435.

[27] Fuhrman B, Rosenblat M, Hayek T, Coleman R, Avi-ram M. Ginger extract consumption reduces plasma choles-terol, inhibits LDL oxidation and attenuates development ofatherosclerosis in atherosclerotic, apolipoprotein E-deficientmice. J Nutr. 2000;130(5):1124–1131.

[28] Ajith TA, Nivitha V, Usha S. Zingiber officinale Roscoe aloneand in combination with alpha-tocopherol protect the kidneyagainst cisplatin-induced acute renal failure. Food Chem Toxicol.2007;45(6):921–927.

[29] Young HY, Luo YL, Cheng HY, Hsieh WC, Liao JC, PengWH. Analgesic and anti-inflammatory activities of [6]-gingerol.J Ethnopharmacol. 2005;96(1–2):207–210.

[30] Kim JK, Kim Y, Na KM, Surh YJ, Kim TY. [6]-Gingerolprevents UVB-induced ROS production and COX-2 expres-sion in vitro and in vivo. Free Radic Res. 2007;41(5):603–614.

[31] Gilbert DN, Wood CA, Kohlhepp SJ, et al. Polyaspartic acidprevents experimental aminoglycoside nephrotoxicity. J InfectDis. 1989;159(5):945–953.

[32] Al-Majed AA, Mostafa AM, Al-Rikabi AC, Al-ShabanahOA. Protective effects of oral Arabic gum administrationon gentamicin-induced nephrotoxicity in rats. Pharmacol Res.2002;46(5):445–451.

[33] Gamal El-din AM, Mostafa AM, Al-Shabanah OA, Al-BekairiAM, Nagi MN. Protective effect of Arabic gum against

acetaminophen-induced hepatotoxicity in mice. Pharmacol Res.2003;48(6):631–635.

[34] Ali BH, Al-Qarawi AA, Haroun EM, Mousa HM. The effectof treatment with gum Arabic on gentamicin nephrotoxicity inrats: A preliminary study. Ren Fail. 2003;25(1):15–20.

[35] Tsubakihara Y, Takabatake Y, Oka K, et al. Effects ofthe oral adsorbent AST-120 on tryptophan metabolism inuremic patients. Am J Kidney Dis. 2003;41(3 Suppl. 1):S38–S41.

[36] Huemer RP. Chronic renal disease: Orthomolecular ramifica-tions. J Orthomolecular Med. 2006;21(1):48–54.

[37] Sailer ER, Subramanian LR, Rall B, Hoernlein RF,Ammon HP, Safayhi H. Acetyl-11-keto-beta-boswellicacid (AKBA): Structure requirements for binding and 5-lipoxygenase inhibitory activity. Br J Pharmacol. 1996;117(4):615–618.

[38] Thadhani R, Pascual M, Bonventre JV. Acute renal failure. NEngl J Med. 1996;334(22):1448–1460.

[39] Gilbert RE, Kelly DJ, Atkins RC. Novel approaches to thetreatment of progressive renal disease. Curr Opin Pharmacol.2001;1(2):183–189.

[40] Paller MS. The cell biology of reperfusion injury in the kidney.J Investig Med. 1994;42(4):632–639.

[41] Sheridan AM, Bonventre JV. Cell biology and molecular mech-anisms of injury in ischemic acute renal failure. Curr OpinNephrol Hypertens. 2000;9(4):427–434.

[42] Eschwège P, Paradis V, Conti M, et al. In situ detection of lipidperoxidation by-products as markers of renal ischemia injuriesin rat kidneys. J Urol. 1999;162(2):553–557.

[43] Haugen E, Nath KA. The involvement of oxidative stress in theprogression of renal injury. Blood Purif . 1999;17(2–3):58–65.

[44] Halliwell B, Cross CE. Oxygen-derived species: Their rela-tion to human disease and environmental stress. Environ HealthPerspect. 1994;102(10):5–12.

[45] Masztalerz M, Włodarczyk Z, Czuczejko J, Słupski M,Kedziora J. Superoxide anion as a marker of ischemia-reperfusion injury of the transplanted kidney. Transplant Proc.2006;38(1):46–48.

[46] Thurman JM. Triggers of inflammation after renalischemia/reperfusion. Clin Immunol. 2007;123(1):7–13.

[47] Uz E, Karatas OF, Mete E, et al. The effect of dietary ginger(Zingiber officinals Rosc) on renal ischemia/reperfusion injuryin rat kidneys. Ren Fail. 2009;31(4):251–260.

[48] Aeschbach R, Löliger J, Scott BC, et al. Antioxidant actionsof thymol, carvacrol, 6-gingerol, zingerone and hydroxytyrosol.Food Chem Toxicol. 1994;32(1):31–36.

[49] Ahmed RS, Seth V, Pasha ST, Banerjee BD. Influenceof dietary ginger (Zingiber officinale Rosc) on oxidativestress induced by malathion in rats. Food Chem Toxicol.2000;38(5):443–450.

[50] Abd-Allah AR, Al-Majed AA, Mostafa AM, Al-Shabanah OA,Din AG, Nagi MN. Protective effect of Arabic gum against car-diotoxicity induced by doxorubicin in mice: A possible mecha-nism of protection. J Biochem Mol Toxicol. 2002;16(5):254–259.

[51] Matsumoto N, Riley S, Fraser D, et al. Butyrate modulatesTGF-beta1 generation and function: Potential renal bene-fit for Acacia (sen) SUPERGUM (gum Arabic)? Kidney Int.2006;69(2):257–265.

[52] Carter GW, Young PR, Albert DH, et al. 5-Lipoxygenaseinhibitory activity of zileuton. J Pharmacol Exp Ther. 1991;256(3):929–937.

[53] Demitsu T, Katayama H, Saito-Taki T, Yaoita H, NakanoM. Phagocytosis and bactericidal action of mouse peritonealmacrophages treated with leukotriene B4. Int J Immunophar-macol. 1989;11(7):801–808.

[54] Patel NS, Collin M, Thiemermann C. Urocortin does notreduce the renal injury and dysfunction caused by experi-mental ischemia/reperfusion. Eur J Pharmacol. 2004;496(1–3):175–180.


Ren

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l Dow

nloa

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info

rmah

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.com

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on 1

1/26

/13

For

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[55] Poeckel D, Tausch L, George S, Jauch J, Werz O. 3-O-acetyl-11-keto-boswellic acid decreases basal intracellular Ca2+ levelsand inhibits agonist-induced Ca2+ mobilization and mitogen-activated protein kinase activation in human monocytic cells.J Pharmacol Exp Ther. 2006;316:224–232.

[56] Syrovets T, Büchele B, Krauss C, Laumonnier Y, Simmet T.Acetyl-boswellic acids inhibit lipopolysaccharide-mediated

TNF-alpha induction in monocytes by direct inter-action with IkappaB kinases. J Immunol. 2005;174(1):498–506.

[57] Chatterjee PK, Zacharowski K, Cuzzocrea S, Otto M,Thiemermann C. Inhibitors of poly (ADP-ribose) synthetasereduce renal ischemia-reperfusion injury in the anesthetized ratin vivo. FASEB J. 2000;14:641–651.

Renal Failure

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evaluation of the efficacy of ginger, arabic gum, and boswellia in acute...

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