Resea ch A icle
Adipsin Is Associa ed wi h Mul iple Scle osis:
A Follow-Up S udy o Adipokines
Renuka Na a ajan,1Sanna Hagman,1Ma i Hämälainen,2Tiina Leppänen,2
P asun Das ida ,3Ee a Moilanen,2and I ina Elo aa a1,4
1Neu oimmunology Uni , Medical School, Uni e si y o Tampe e, Tampe e Uni e si y Hospi al, Bioka u 10, 33520 Tampe e, Finland
2The Immunopha macology Resea ch G oup, Uni e si y o Tampe e, School o Medicine and Tampe e Uni e si y Hospi al,
Medisiina inka u 3, 33520 Tampe e, Finland
3Depa men o Radiology, Medical Imaging Cen e, Tampe e Uni e si y Hospi al, Teiskon ie 35, 33520 Tampe e, Finland
4Depa men o Neu ology, Tampe e Uni e si y Hospi al, Teiskon ie 35, 33520 Tampe e, Finland
Co espondence should be add essed o I ina Elo aa a; i ina.elo aa[email p o ec ed]
Recei ed 26 July 2015; Re ised 30 Sep embe 2015; Accep ed 18 Oc obe 2015
Academic Edi o : Wol gang B uck
Copy igh © 2015 Renuka Na a ajan e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion
License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly
ci ed.
Backg ound and Objec i e. The ole o adipokines in egula ion o immune esponses has been ecognized, bu e y li le is known
abou hei impac on mul iple scle osis (MS). In his s udy, we analysed whe he he majo adipokines a e di e en ially exp essed
in plasma o pa ien s wi h di e en MS sub ypes and clinically isola ed synd ome (CIS) and explo ed hei associa ion wi h majo
disease cha ac e is ics. Me hods. The le els o adiponec in, adipsin, lep in, and esis in in he plasma o 80 pa ien s wi h di e en
sub ypes o MS and CIS we e ollowed up annually o e he wo yea s. The da a ob ained we e co ela ed wi h disease ac i i y, EDSS
and olumes o T1-weigh ed lesions (T1-LV), and luid a enua ion in e sion eco e y lesions (FLAIR-LV) on MRI. Resul s.InMS
g oup, a co ela ion was ound be ween he le el o adipsin and EDSS sco e a baseline (𝑟 = 0.506,𝑝 < 0.001). In RRMS, he le els
o adipsin co ela ed wi h EDSS sco es (𝑟 = 0.542,𝑝 = 0.002), T1-LV (𝑟 = 0.410,𝑝 = 0.034), and FLAIR-LV (𝑟 = 0.601,𝑝 = 0.0001)
a baseline and an inc ease in he T1-LV o e he ollow-up (𝑟 = 0.582,𝑝 = 0.003). Associa ions wi h o he adipokines we e no
de ec ed. Conclusion. Ou explo a o y s udy p o ides no el insigh s on he impac o adipokines in MS and sugges s ha adipsin
exe s p edic i e po en ial as a bioma ke o neu odegene a ion.
1. In oduc ion
Mul iple scle osis (MS) is an au oimmune demyelina ing
disease o he cen al ne ous sys em (CNS) media ed by
he ansendo helial mig a ion o ac i a ed T helpe 1 (Th1)
and Th17 lymphocy es in o he b ain issue whe e hey
igge he des uc i e in lamma o y cascade esul ing in
he accumula ion o in lamma o y in il a es, demyelina ion,
axonal loss, and gliosis [1, 2]. The damage o neu al issue
is induced by a ious e ec o mechanisms and subs ances
such as mac ophage phagocy osis, sec e ion o in lamma o y
cy okines, chemokines and an ibodies, complemen ac i a-
ion, mi ochond ial dys unc ion, elease o cy o oxic p o-
eases, and p oduc s o oxida i e s ess and exci o oxici y ha
all oge he con ibu e o he de elopmen o neu ological
wo sening [1].
Inc eased isko MSinsubjec swi hobesi ydu ing
adolescence and ea ly adul hood has been ecen ly epo ed
[3, 4]. I has been conside ed ha such isk is explained
by modula o y e ec o adipose issue on in lamma o y
esponses in obese subjec s. Indeed, adipose issue is ecog-
nizedasanendoc ineo gan ha sec e esmul iplecy okine-
like ho mones, adipokines ha a e in ol ed in egula ion
o mul iple physiological unc ions including in lamma ion
[5, 6]. Al hough dys egula ion o adipokines du ing obesi y
and in au oimmune diseases has been ecognized, only
e y li le is known abou hei ole in MS [5]. The bes -
known adipokines a e he p oin lamma o y lep in, adipsin,
Hindawi Publishing Co po a ion
Mul iple Scle osis In e na ional
Volume 2015, A icle ID 371734, 9 pages
h p://dx.doi.o g/10.1155/2015/371734
2Mul iple Scle osis In e na ional
esis in and is a in, and he an i-in lamma o y adiponec in,
omen in-1, and apelin [5, 7]. Up o now, mos s udies in MS
ha e been ocused on lep in ha was ound o be inc eased
in blood and ce eb ospinal luid (CSF) o MS pa ien s, bu
con as ing esul s ha e also been epo ed [8–11]. In hese
s udies, lep in co ela ed nega i ely wi h he numbe o
egula o y T cells [11], bu associa ions o clinical pa ame e s
we e no epo ed. The le els o is a in and esis in in se a
o MSpa ien swe e ound obeinc eased,while hele elso
adiponec in we e down egula ed [9, 12–14]. Un il now only
one s udy analysed se e al adipokines in a coho o pa ien s
including di e en sub ypes o MS [14]. Acco ding o his
s udy, ele a ed le els o is a in and dec eased le els o lep in
we e ound in pa ien s wi h elapsing- emi ing MS (RRMS),
bu associa ion wi h clinical pa ame e s was no de ec ed.
Due o he spa se knowledge on he associa ion o
adipokines wi h clinical cha ac e is ics o MS, he pu pose
o his wo-yea p ospec i e ollow-up s udy was o assess
whe he he le els o adiponec in, adipsin, lep in, and esis in
in plasma o MS pa ien s a e associa ed wi h clinical phe-
no ypes, in lamma o y disease ac i i y, neu ological disabil-
i y,and he olumeso T1-weigh edand luida enua ion
in e sion eco e y (FLAIR) lesions on magne ic esonance
imaging (MRI).
2. Pa ien s and Me hods
2.1. Subjec s. This wo-yea p ospec i e ollow-up s udy
included al oge he 80 subjec s o whom 65 had clinically
de ini e MS (CDMS) acco ding o he e ised McDonald
C i e ia [15] and 15 had clinically isola ed synd ome (CIS)
[16]. The CDMS g oup included 34 pa ien s wi h RRMS,
15 pa ien s wi h seconda y p og essi e MS (SPMS), and 16
subjec s wi h p ima y p og essi e MS (PPMS). CIS pa ien s
we e de ined as pa ien s who had had hei i s demyelina ing
neu ologic e en sugges i e o MS [16]. All pa ien s unde -
wen annual neu ological examina ions om baseline up o
woyea s.Thebloodwasd awnon hesamedayas heneu-
ological examina ion. The clinical e alua ion included he
de e mina ion o body mass index (BMI, kg/m2), p es udy
disease ac i i y (numbe o elapses wo yea s be o e he
s udy), numbe o elapses o e he wo-yea ollow-up, and
Expanded Disabili y S a us Scale (EDSS) sco e [17] a he
baseline and he end o he ollow-up as summa ized in
Table 1. Pa ien s who we e p egnan o su e ing om any
o he clinically signi ican diseases we e excluded. The s udy
was app o ed by he E hics Commi ee o Tampe e Uni e si y
Hospi al and all subjec s ga e in o med consen .
2.2. MRI Image Segmen a ion and Volume ic Analysis. All
pa ien s unde wen MRI examina ion a baseline and a
he end o ollow-up pe iod. All examina ions we e pe -
o medona1.5TeslaMRIUni (SiemensA an o,E lan-
gen, Ge many). The MRI p o ocol included a T1-weigh ed
heade ollowed by axial T1-weigh ed magne iza ion p epa ed
apid g adien echo (MP-RAGE) and T2-weigh ed u bo
spin-echo (TSE), FLAIR, magne iza ion ans e con as s
(MTC), di usion weigh ed imaging (DWI), and gadolinium
enhanced T1-weigh ed MP-RAGE sequences. T1-weigh ed
MP-RAGE, FLAIR, and T2-weigh ed TSE images we e used
o olume ic analysis. Fo MP-RAGE, he imaging pa am-
e e s we e as ollows: epe i ion ime (TR) = 1160 ms; echo
ime (TE) = 4.24 ms; in e sion ime (TI) = 600 ms; slice
hickness = 0.9 mm; in-plane esolu ion = 0.45 ∗ 0.45mm.
In FLAIR images, he ollowing pa ame e s we e used: TR =
8500 ms; TE = 100 ms; TI = 2500 ms; slice hickness =
5.0 mm; in-plane esolu ion = 0.45 ∗ 0.45mm. In TSE, he
ollowing imaging scheme was used: TR = 750 ms; TE =
115 ms; slice hickness = 3.0 mm; in-plane esolu ion = 0.90∗
0.90mm. Volume ic segmen a ion o plaques in he b ain
was pe o med using semiau oma ic so wa e Ana oma ic
ope a ing in a PC/Window 95 en i onmen [18, 19] and he
images we e analysed blind.
2.3. De e mina ion o Adipokines. Venous blood was col-
lec ed o he assessmen o plasma le els o adiponec in,
adipsin, lep in, and esis in. Blood con aining ubes we e cen-
i uged o 15 min a 1600 ×g. Plasma was sepa a ed om he
blood, aliquo ed, and s o ed a −70∘Cun iluse.Adipokines
we e de e mined by enzyme-linked immunoassay (ELISA)
using comme cial eagen s acco ding o he manu ac u e s’
ins uc ions (DuoSe ELISA, R&D Sys ems Eu ope L d.,
Abingdon, UK). The espec i e de ec ion limi s and in e as-
say coe icien s o a ia ion we e 15.6 ng/L and 2.0% o
adiponec in, 4.0 ng/mL and 3.8% o adipsin, 15.6 ng/L and
3.9% o lep in, and 15.6 ng/L and 4.0% o esis in.
2.4. S a is ical Analysis. S a is ical analyses we e pe o med
wi h SPSS e sion 18.0 (SPSS Inc., Chicago, IL, USA). A 𝑝
alue less han 0.05 was conside ed signi ican in all analyses.
Mann-Whi ney 𝑈 es wasused oanalyse hedi e en-
ces in clinical pa ame e s and MRI olumes be ween he
sub ypes. Wilcoxon signed- ank es was used o analyse he
in aindi idual changes in he olumes o MRI a each ime
poin .
Fo compa ison o he adipokines le els in di e en
sub ypes, epea ed measu es o ANOVA ollowed by Bon-
e oni co ec ion o mul iple compa isons we e used. Fo
eachou come, heanalyseswe ealsoadjus ed o ageand
gende . Pea son’s co ela ion coe icien was used o explo e
he ela ionship be ween he le els o adipokines wi h BMI o
age. The associa ions o adipsin le els wi h EDSS sco es and
he olumes o T1-weigh ed and FLAIR lesions we e s udied
by linea eg ession model by adjus ing o age, gende , and
disease sub ype. Logis ic eg ession model was used o s udy
he associa ion be ween adipokines and disease ac i i y. The
di e ences in he adipokines le els be ween gende s we e
s udied by Mann-Whi ney 𝑈 es .
3. Resul s
3.1. Clinical and MRI Follow-Up
3.1.1. Clinical Da a. The demog aphic and wo-yea clinical
ollow-up da a o he subjec s a e summa ized in Table 1. As
expec ed, hepa ien sin heSPMSandPPMSg oupshad
Mul iple Scle osis In e na ional 3
Table 1: Demog aphic and clinical cha ac e is ics o pa ien s wi h di e en MS pheno ypes.
RRMS
𝑛=34 SPMS
𝑛=15 PPMS
𝑛=16 CIS
𝑛=15
Gende F/Ma24/10 10/5 9/7 13/2
Age (yea s)b37.6 ±9.2
(20–51)
49.3 ±10.0
(32–63)
58.1 ±8.5
(40–70)
35.6 ±7.9
(24–51)
BMI (kg/m2)b24.9 ±4.0
(19.7–35.4)
26.2 ±5.0
(15.8–33.3)
24.6 ±3.4
(19.8–31.5)
25.3 ±3.2
(21.6–31.2)
Disease du a ion om i s symp oms (yea s)b8.2 ±7.2
(0.7–29.6)
19.8 ±7. 8
(6.3–34.3)
18.9 ±9.6
(2.4–43.0)
3.0 ±2.5
(0.5–8.9)
Disease du a ion om diagnosis (yea s)b4.2 ±4.1
(0.0–13.7)
12.9 ±9.0
(2.2–32.4)
13.1 ±8.4
(1.5–27.2) NA
EDSS a baselineb1.4 ±1.5
(0.0–6.0)
5.2 ±1.6
(2.5–7.5)
4.7 ±2.2
(1.0–7.0)
0.1 ±0.3
(0.0–1.0)
EDSS a end o he ollow-upb1.5 ±1.6
(0.0–6.0)
5.5 ±1.6
(2.5–8.0)
4.8 ±2.1
(1.5–7.0)
0.1 ±0.4
(0.0–1.0)
EDSS wo sening du ing ollow-upc7 (21%) 6 (40%) 4 (25%) 1 (7%)
P es udy disease ac i i yb,d1.2 ±1.4
(0–5)
0.2 ±0.6
(0–2)
0.0 ±0.0
(0-0)
0.7 ±0.6
(0–2)
Numbe o elapses o e he ollow-upb0.6 ±1.1
(0–5)
0.4 ±0.7
(0–2)
0.0 ±0.0
(0-0)
0.1 ±0.3
(0-1)
T ea men (NT/IFN/CO/MX)a12/18/3/1 15/0/0/0 16/0/0/0 15/0/0/0
RRMS: elapsing- emi ing MS, SPMS: seconda y p og essi e MS, PPMS: p ima y p og essi e MS, CIS: clinically isola ed synd ome, BMI: body mass index,
EDSS: expanded disabili y s a us scale, NT: no ea men , IFN: in e e on, CO: copaxone, MX: mi oxan one, and NA: no applicable.
aNumbe o pa ien s.
bMean ±SD ( ange).
cNumbe o pa ien s (pe cen ).
dNumbe o elapses in he 2 yea s be o e baseline.
Table 2: Volumes o T1 and FLAIR lesions a baseline and ollow-up (median (in e qua ile ange)).
T1 lesions (cm3)FLAIRlesions(cm
3)
BL 1-YR 𝑝 alueaBL 1-YR 𝑝 aluea
CIS 0.4 (0.0–0.6) 0.3 (0.2–0.8) 0.046 1.0 (0.3–2.2) 1.3 (0.5–3.1) 0.001
RRMS 1.4 (0.5–3.7)∗,#3.0 (0.8–6.0) 0.001 6.3 (2.6–17.5)∗,#14.0 (6.0–24.8) 0.00002
SPMS 5.8 (2.2–9.4)∗6.5 (3.7–18.6) 0.041 18.4 (11.6–30.1)∗29.3 (24.8–40.2) 0.004
PPMS 0.8 (0.6–2.8)∗,#2.0 (0.9–4.7) 0.004 5.3 (3.1–10.4)∗,#9.7 (6.8–15.1) 0.0004
RRMS: elapsing- emi ing MS, SPMS: seconda y p og essi e MS, PPMS: p ima y p og essi e MS, CIS: clinically isola ed synd ome, and BL: baseline.
aThe in aindi idual changes in he olumes o MRI o e he ollow-up pe iod, Wilcoxon signed- ank es .
∗Compa ed o CIS g oup, Mann-Whi ney 𝑈 es , 𝑝 < 0.01.
#Compa ed o SPMS, Mann-Whi ney 𝑈 es , 𝑝 < 0.05.
longe disease du a ion and we e olde han he pa ien s wi h
RRMS o CIS (𝑝 < 0.05). The EDSS sco es we e lowe in CIS
and RRMS han in o he MS sub ypes (𝑝 < 0.05), while no
di e ences we e ound be ween SPMS and PPMS. The e we e
no di e ences in BMI be ween any o he MS sub ypes and
CIS (𝑝 > 0.05).
A heendo he ollow-up, heEDSSsco ewasinc eased
in 27% (𝑛=17/65) o CDMS pa ien s: (21% RRMS, 40%
SPMS, and 25% PPMS). Two yea s be o e s udy en y, hal
o RRMS pa ien s we e elapse- ee, 12% had one elapse, and
he emaining 38% o subjec s had 2–5 elapses. A he end o
he ollow-up, 68% o RRMS pa ien s we e elapse- ee, 15%
o pa ien s had one elapse, and he emaining 17% o subjec s
had 2–5 elapses. The majo i y o RRMS pa ien s we e
ea ed wi h immunomodula o y d ugs (53% in e e on-be a
(IFN-𝛽), 6% gla i ame ace a e, and 3% mi oxan one). A
he end o ollow-up, 35% o pa ien s we e ea ed wi h IFN-
𝛽, 26% o pa ien s wi h copaxone, and 3% o pa ien s wi h
na alizumab.
The baseline EDSS sco e o CIS pa ien s was 0 excep o
wo subjec s ha ing sco e 1. O e he wo-yea pe iod, 7 ou
o 15 CIS pa ien s con e ed o CDMS. All con e ed pa ien s
had ele a ed IgG index and OCBs in hei CSF.
3.1.2.Volumeso T1-Weigh edandFLAIRLesions. The ol-
umes o MS plaques we e de e mined in he 75 MS and
CIS pa ien s a he baseline and a e one yea (Table 2). As
expec ed, he baseline olumes o T1-weigh ed and FLAIR
lesions we e lowes in he CIS g oup (𝑝 < 0.01). Baseline
compa ison be ween he MS sub ypes showed highe FLAIR
4Mul iple Scle osis In e na ional
Table 3: The le els o adipokines in MS sub ypes and CIS o e ollow-up pe iod (median (in e qua ile ange)).
Baseline One yea Two yea s
Adiponec in (ng/mL)
CIS
RRMS
SPMS
PPMS
4720.6 (4124.4–5407.7)
4517.3 (3380.6–6417.2)
4748.4 (3977.9–6379.9)
5618.7 (4111.5–8467.1)
5131.0 (4239.4–5880.3)
4695.7 (3452.4–7270.5)
5314.8 (4289.4–7494.9)
5855.8 (4622.6–9948.3)
5149.7 (4789.0–6812.0)
5012.7 (3222.8–7043.1)
6062.3 (4706.5–7871.2)
5278.5 (3761.6–8779.1)
Adipsin (ng ×m2/mL ×kg)a
CIS
RRMS
SPMS
PPMS
63.9 (53.9–76.8)
60.3 (52.3–71.2)∗,#
68.4 (57.4–85.0)
80.8 (69.5–93.6)
66.4 (56.9–83.5)
62.4 (55.1–71.3)∗,#
70.3 (63.3–81.7)
75.9 (67.1–94.6)
66.7 (59.7–74.4)
61.5 (56.2–69.6)∗,#
74.1 (57.7–89.6)
82.5 (66.1–95.0)
Lep in (pg ×m2/mL ×kg)b
CIS
RRMS
SPMS
PPMS
861.0 (269.8–1908.4)
662.4 (288.1–981.4)
711.1 (166.8–1649.7)
515.2 (182.6–1260.2)
694.9 (240.1–1238.7)
572.4 (286.7–1159.3)
420.0 (157.5–1496.2)
603.3 (203.5–1092.2)
754.5 (424.2–1346.5)
572.0 (321.4–1032.9)
953.2 (287.9–1822.7)
479.3 (255.6–776.1)
Resis in (pg/mL)
CIS
RRMS
SPMS
PPMS
2851.5 (2509.1–3280.5)
2505.2 (2085.0–2751.0)
2605.4 (2216.0–3388.0)
2392.5 (1794.9–3411.5)
2946.6 (2367.6–3093.8)
2402.1 (2064.9–2869.3)
2649.9 (2358.5–3146.4)
2371.2 (1663.5–3354.6)
2769.5 (2299.2–3072.8)
2315.9 (1946.9–2796.2)
2469.0 (2284.6–2975.3)
2445.4 (1711.1–3349.5)
aBMI-adjus ed adipsin le els (ng ×m2/mL ×kg).
bBMI-adjus ed lep in le els (pg ×m2/mL ×kg).
∗Compa ison o PPMS 𝑝 < 0.01.
#Compa ison o PPMS a e adjus ing o age 𝑝 < 0.05.
and T1 lesion olumes in SPMS han in PPMS o RRMS
(𝑝 < 0.05).O e he ollow-up, he olumeso heselesions
inc eased in all s udied g oups (𝑝 < 0.05).
3.2. Le els o Adipokines in MS Sub ypes du ing he Two-
Yea Follow-Up. Co ela ion analyses assessing associa ions
o adipokineswi hBMIinCDMSg oupshowedco ela ions
wi h le els o adipsin (𝑟 = 0.277,𝑝 = 0.018)andlep in(𝑟=
0.491,𝑝 < 0.0001) bu no wi h adiponec in (𝑟 = −0.132,𝑝=
0.267)o esis in(𝑟 = −0.071,𝑝 = 0.551). Due o obse ed
co ela ions wi h adipsin and lep in, hese adipokines we e
adjus ed by di iding hei concen a ions by BMI. To assess
he di e ences in he adipokines le els be ween di e en
MS sub ypes, epea ed measu es o ANOVA adjus ing o
age and gende we e used. I appea ed ha o e he wo
yea s he le els o adipokines in di e en g oups emained
s able (Table 3). The le els o BMI-adjus ed adipsin in RRMS
pa ien s we e lowe han hose in subjec s wi h PPMS
h oughou he whole ollow-up pe iod (Table 3) (𝑝 = 0.002).
A e con olling o age alone, he di e ence in he adipsin
le els be ween he g oups was s ill s a is ically signi ican (𝑝=
0.037 adjus ed), while a e adjus ing simul aneously o age
and gende only a end owa d s a is ical signi icance was
ound (𝑝 = 0.057). O he adipokines le els did no di e
be ween he sub ypes. Figu e 1 illus a es he baseline dis i-
bu ion o he adipokines le els in pa ien s wi h di e en sub-
ypes. No ably, he le els o BMI-adjus ed adipsin in ea ed
and un ea ed RRMS pa ien s we e dec eased in compa ison
o PPMS, bu no di e ences we e ound be ween hese RRMS
g oups (Supplemen a y Figu e 1 in Supplemen a y Ma e-
ial a ailable online a h p://dx.doi.o g/10.1155/2015/371734).
Likewise, he le els o adipokines we e o he simila magni-
ude in con e ed and noncon e ed pa ien s wi h CIS.
The in luence o gende on sec e ion o adipokines was
s udied by compa ing he baseline le els in men and women.
I appea ed ha in CDMS g oup he le els o lep in (869.6
(536.9–1504.9) e sus 242.3 (152.9–441.3) pg ×m2/mL ×
kg, 𝑝 < 0.001) and adiponec in (5540.9 (4197.4–8036.1)
e sus 3808.0 (3178.7–5545.4) ng/mL, 𝑝 = 0.010,median
(in e qua ile ange)) we e highe in women. In CDMS, also
he age co ela ed wi h he le els o BMI-adjus ed adipsin
(𝑟 = 0.491,𝑝 < 0.001).
3.3. Associa ion o Adipokines wi h Clinical and MRI Measu es.
Associa iono adipokinesle elswi hbaselineEDSSsco e
and he olumeso FLAIR-o T1-weigh ed lesions as well as
he change o hei olumes o e he ollow-up we e s udied
by linea eg ession model adjus ing o age, gende , and
disease sub ype. In he CDMS g oup, he analyses among
he adipokines showed a posi i e co ela ion be ween he
baseline BMI-adjus ed adipsin and EDSS sco es (𝑟 = 0.506,
𝑝 < 0.001),andsuchassocia ionswe ealsoobse eda e
adjus ing o age alone (𝑟 = 0.387,𝑝 = 0.003), o age
and gende (𝑟 = 0.376,𝑝 = 0.004), o o combina ion o
age, gende , and disease sub ype (𝑟 = 0.280,𝑝 = 0.036).
Acco ding o sub ype analysis, in RRMS g oup he co ela ion
was e en s onge (𝑟 = 0.542,𝑝 = 0.002; Figu e 2(a)). Simila
associa ions we e obse ed a e adjus ing o age (𝑟 = 0.570,
Mul iple Scle osis In e na ional 5
CIS RRMS SPMS PPMS
0
5000
10000
15000
Adiponec in (ng/mL)
(a)
CIS RRMS SPMS PPMS
0
2000
4000
6000
8000
10000
Resis in (pg/mL)
(b)
CIS RRMS SPMS PPMS
0
50
100
150 p = 0.002
Adipsin (ng ×m2/mL ×kg)
(c)
CIS RRMS SPMS PPMS
0
1000
2000
3000
4000
5000
Lep in (pg ×m2/mL ×kg)
(d)
Figu e 1: Sca e plo showing he baseline le els o Adiponec in (A), Resis in (B), BMI-adjus ed Adipsin (C) and BMI-adjus ed Lep in (D)
in MS and CIS. The ba s indica e he median and in e qua ile ange.
Table 4: Obse ed associa ions be ween he le els o adipsin and clinical and MRI pa ame e s (Pea son’s co ela ion coe icien (𝑝 alue)).
Pa ame e s Basic model Adjus ed o age Adjus ed o age and gende Adjus ed o age, gende , and sub ype
EDSS CDMS 0.506 (<0.0001) 0.387 (0.003) 0.376 (0.004) 0.280 (0.036)
RRMS 0.542 (0.002) 0.570 (0.001) 0.569 (0.002) —
T1 lesion olume RRMS 0.410 (0.034) 0.402 (0.042) 0.407 (0.043) —
FLAIR lesion olume RRMS 0.601 (0.001) 0.596 (0.001) 0.596 (0.002) —
ΔT1 lesion olume RRMS 0.582 (0.003) 0.582 (0.004) 0.583 (0.004) —
CDMS: clinically de ini e MS, RRMS: elapsing- emi ing MS, EDSS: expanded disabili y s a us scale, and FLAIR: luid a enua ion in e sion eco e y.
𝑝 = 0.001) o age and gende (𝑟 = 0.569,𝑝 = 0.002). O e he
wo yea s, he EDSS sco e inc eased in 27% o CDMS pa ien s
(𝑛=17/65) (21% RRMS, 40% SPMS, and 25% PPMS), bu he
le els o adipokines did no associa e wi h his change.
In he CDMS g oup, he le els o adipokines did no
associa ewi h he olumeso FLAIR-o T1-weigh edlesions
o he change o hei olumes o e he ollow-up (𝑝>
0.05). Howe e , acco ding o subg oup analysis, in RRMS
co ela ions we e ound be ween he baseline le els o BMI-
adjus ed adipsin and he olumes o T1-weigh ed (𝑟 = 0.410,
𝑝 = 0.034; Figu e 2(b)) and FLAIR (𝑟 = 0.601,𝑝 = 0.0001;
Figu e 2(c)) lesions o he changes o T1 lesion olumes
o e he ollow-up (𝑟 = 0.582,𝑝 = 0.003; Figu e 2(d)).
A e adjus ing o age and gende , RRMS g oup s ill showed
posi i e co ela ions in hese measu es indica ing ha age and
gende did no ha e an impac on hese co ela ions (Table 4).
We nex analysed whe he he le els o adipokines a e
associa ed wi h clinical o MRI disease ac i i y be o e s udy
en y and o e he ollow-up pe iod. Baseline clinical disease
ac i i y was de e mined by he p esence o a leas 2 elapses
du ing 2 yea s be o e s udy en y and baseline MRI ac i i y
by p esence o a leas one Gd-enhancing lesion. The disease
ac i i y on MRI o e he ollow-up was assessed based on
he p esence o a leas one Gd-enhancing lesion o new T2
lesion. A he s udy en y, he p esence o highe clinical
disease ac i i y (𝑛=13, a leas 2 elapses/2 yea s be o e
baseline) was associa ed wi h highe le els o BMI-adjus ed
adipsinincompa ison opa ien swi hs ablediseasecou se

6Mul iple Scle osis In e na ional
p = 0.002 = 0.542
100806040
0
2
4
6
8
EDSS
Adipsin (ng ×m2/mL ×kg)
(a)
p = 0.034 = 0.410
100806040
T1lesion olume (cm3)
0
2
4
6
8
10
12
Adipsin (ng ×m2/mL ×kg)
(b)
p = 0.001 = 0.601
100806040
FLAIR lesion olume (cm3)
0
10
20
30
40
Adipsin (ng ×m2/mL ×kg)
(c)
p = 0.003 = 0.582
100806040
0
2
4
6
8
10
ΔT1lesion olume (cm3)
Adipsin (ng ×m2/mL ×kg)
(d)
Figu e 2: Associa ions be ween baseline BMI-adjus ed adipsin and EDSS sco e (a), he olumes o T1 lesions (b), FLAIR lesions (c), and
changes o T1 lesion olumes o e he ollow-up (d) in RRMS pa ien s.
(𝑛=21, 0-1 elapses/2 yea s be o e baseline) (Figu e 3).
Howe e , no associa ions we e ound o e he ollow-up.
Rega ding he MRI ac i i y, hal o he pa ien s (18/34)
showed MRI ac i i y acco ding o de ined c i e ia (p esence
o Gd-enhancing lesion o new T2 lesion o e he ollow-up
pe iod), bu associa ion be ween adipokines le els and MRI
ac i i y was no ound.
4. Discussion
Cu en ly e y li le is known abou he impac o adipokines
on MS. This explo a o y s udy assessed he abili y o bes -
known adipokines o disc imina e be ween MS sub ypes
and hei po en ial o depic in lamma o y ac i i y and
neu ological de e io a ion in MS. A co ela ion be ween he
baseline le els o adipsin and EDSS sco es de ec ed in whole
MS and RRMS coho s sugges s an in ol emen o adipsin
in pa hophysiology o MS. Such in e p e a ion is u he
suppo ed by he co ela ions de ec ed be ween he baseline
adipsin and he olumes o T1-weigh ed and FLAIR lesions as
well as he change o such lesion olumes o e he ollow-up
seen in RRMS g oup.
S able Ac i e
p = 0.024
0
20
40
60
80
100
Adipsin (ng ×m2/mL ×kg)
Figu e 3: Sca e plo showing he le els o adipsin in s able
and ac i e RRMS pa ien s. The ba s indica e he median and
in e qua ile ange.
Adipsin (complemen ac o D) is a key enzyme in ol ed
in he ac i a ion o al e na i e pa hway o complemen
ac i a ion and is p ima ily sec e ed om adipocy es and
monocy es/mac ophages in human subjec s [20]. I s ole
Mul iple Scle osis In e na ional 7
in he pa hogenesis o MS has no been s udied, bu he
immunohis ochemical s udies ha e demons a ed he p es-
ence o o he complemen componen s wi hin he lesion in
no mal appea ing whi e ma e (NAWM) and co ical a eas
sugges ing in ol emen o complemen p o eins in MS [21,
22]. Complemen componen s o he classical and al e na i e
pa hway including C3, C4, C5, C9, e minals complemen
complex (TCC), complemen ecep o , and ac o s B, I, and
H [23–31] ha e been p e iously analysed in se a and CSF o
MS pa ien s [23–31]. These s udies ha e showed he posi i e
co ela ion be ween CSF le els o C3, C9, and TCC and EDSS
sco es [30, 32, 33].
The obse ed associa ion o baseline adipsin wi h neu o-
logical disabili y exp essed by EDSS sco e in whole MS and
RRMS coho s sugges s a ole o adipsin in accumula ion
o neu ological disabili y. Mo eo e , in RRMS a baseline
an associa ion be ween he adipsin and he olumes o T1-
weigh ed lesions as well as hei inc ease o e he ollow-
up sugges s p edic i e po en ial o adipsin as a bioma ke
o neu odegene a ion. Acco ding o s a is ical analyses, age
and gende did no in luence hese esul s. The absence o
e olu iono adipokinesle elso e he ollow-upismos
likely explained by ela i ely s able clinical disease cou se in
mos o ou pa ien s. Howe e , an inc ease o he olumes
o T1 and FLAIR lesions seen by MRI is consis en wi h
wo sening o MS e en du ing he ela i ely sho ollow-up in
his s udy. In pa allel, he p esence o highe adipsin in a sub-
g oup o pa ien s wi h mo e ac i e RRMS (≥2 elapses/2yea s
be o e baseline) oge he wi h a posi i e co ela ion be ween
hebaselineadipsinand he olumeso FLAIRlesionsin
whole RRMS g oup sugges s an in ol emen o adipsin also
in in lamma o y disease ac i i y. Taken oge he , acco d-
ing o hese obse a ions adipsin is a neu oin lamma ion-
p omo ing molecule ha acili a es neu ological de e io a-
ion and unde lying neu odegene a ion. I is no ewo hy ha
in lamma ion-p omo ing ac i i y o al e na i e complemen
pa hway on adap i e immune esponses has been ecen ly
epo ed also by o he in es iga o s [34, 35]. Acco ding o
hese s udies, anaphyla oxins especially p oduced du ing he
ac i a ion o al e na i e pa hway may igge in lamma ion
andchemo axis[34],al hough he oleo complemen in he
adap i e immune esponses o induce he T cell ac i a ion
and p oli e a ion has also been p oposed [35].
The p esence o dec eased adipsin in RRMS pa ien s in
compa ison o hose wi h PPMS is mos likely ela ed o
di e en pa hological mechanisms in hese MS sub ypes.
The ea ly phase o RRMS is cha ac e ized p edominan ly by
in lamma o y e en s ini ia ed by ac i a ion and di e en ia-
ion o myelin speci ic CD4+ T cells in o Th1 and Th17 cells
and hei ansmig a ion om pe iphe y o CNS e en ually
esul ing in demyelina ion and axonal loss [36]. Du ing he
ansi ion o mo e ad anced s ages like SPMS, BBB becomes
less pe meable leading o diminished en y o pe iphe al
immune cells and hei p oduc s in o CNS [37]. Recen
pa hologic s udies ha e showed ha p og essi e sub ypes a e
cha ac e ized by he widesp ead di use in lamma ion wi h
slowly expanding lesions, abundan co ical lesions, and lym-
phocy e in il a ion and mic oglia ac i a ion in he NAWM
[38]. The ele a ed le els o adipsin in ou PPMS pa ien s
mos likely e lec pe iphe al immune ac i a ion and do no
associa e wi h ongoing ocal CNS changes seen on MRI.
No ably, ecen ly he o he membe o complemen pa hway,
ha is, complemen ac o H, was ound o be ele a ed in
se a o pa ien s wi h p og essi e MS bu no in RRMS o
heal hy con ols [39]. Toge he he a ailable da a sugges ha
ele a ed le els o adipsin in pa ien s wi h p og essi e MS
e lec ongoing pe iphe al immune ac i a ion.
In e es ingly, his s udy e ealed posi i e co ela ions
be ween he BMI and he le els o lep in and adipsin. These
obse a ions suppo he hypo hesis o close in e ac ion
be ween he adipose issue and immune sys em in egula ion
o in lamma o y esponses [5]. In addi ion, he p esence o
highe le els o lep in and adiponec in in women indica es
he p esence o gende -speci ic associa ion o sec e ion o
hese adipokines. Pa allel esul s in MS and heal hy subjec s
ha e been epo ed also by o he s [8, 40, 41].
5. Conclusions
This s udy showed an associa ion o adipsin o neu ological
disabili y and ocal changes on MRI in MS hus sugges ing
ha dys egula ion o al e na e complemen pa hway may
ha e an impac on MS disease cou se. The da a sugges
ha adipsin exe s an in lamma ion-p omo ing e ec and
acili a es he de elopmen o neu odegene a i e changes.
The p edic i e po en ial o adipsin as a bioma ke o neu ode-
gene a ion needs o be e alua ed in u he s udies.
Con lic o In e es s
The au ho s decla e ha he e is no con lic o in e es s
ega ding he publica ion o his pape .
Au ho s’ Con ibu ion
Renuka Na a ajan and Sanna Hagman con ibu ed equally o
hes udyand heya eco- i s au ho s.
Acknowledgmen s
The au ho s hank bioanalys s Raija Caliskan and Ali-
isa M¨
akinen, Depa men o Neu oimmunology, Medical
school,Uni e si yo Tampe e, o hei echnicalassis ance.
They also hank Mika Helminen M.S., School o Heal h
Sciences, Uni e si y o Tampe e, o his ad ice in s a is ical
analyses. The s udy was inancially suppo ed by Compe i-
i e Resea ch Funding o Tampe e Uni e si y Hospi al and
Finnish Cul u al Founda ion.
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