Adipsin Is Associated with Multiple Sclerosis: A Follow-Up Study of Adipokines

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. Re e ences [1] M. A. F iese, B. Scha ling, and L. Fugge , “Mechanisms o neu- odegene a ion and axonal dys unc ion in mul iple scle osis,” Na u e Re iews Neu ology, ol.10,no.4,pp.225–238,2014. [2] E. Ellwa d and F. Zipp, “Molecula mechanisms linking neu- oin lamma ion and neu odegene a ion in MS,” Expe imen al Neu ology, ol.262,pa A,pp.8–17,2014. 8Mul iple Scle osis In e na ional [3] K. L. Munge , T. Chi nis, and A. Asche io, “Body size and isk o MS in wo coho s o US women,” Neu ology, ol.73,no.19, pp.1543–1550,2009. [4] A. K. Heds ¨ om, T. Olsson, and L. Al edsson, “High body mass index be o e age 20 is associa ed wi h inc eased isk o mul iple scle osis in bo h men and women,” Mul iple Scle osis, ol.18,no. 9, pp. 1334–1336, 2012. [5] M. Ve sini, P.-Y. Jeandel, E. Rosen hal, and Y. Shoen eld, “Obesi y in au oimmune diseases: no a passi e bys ande ,” Au oimmuni y Re iews, ol.13,no.9,pp.981–1000,2014. [6]M.A.Exley,L.Hand,D.O’Shea,andL.Lynch,“In e play be ween he immune sys em and adipose issue in obesi y,” Jou nal o Endoc inology, ol.223,no.2,pp.R41–R48,2014. [7] A. Aguila -Valles, W. Inoue, C. Rummel, and G. N. Luheshi, “Obesi y, adipokines and neu oin lamma ion,” Neu opha ma- cology, ol.96,pp.124–134,2015. [8] M. Ro ondi, A. P. Ba occhi, F. Cope chini e al., “Se e e disabili y in pa ien s wi h elapsing- emi ing mul iple scle osis is associa ed wi h p o ound changes in he egula ion o lep in sec e ion,” Neu oImmunoModula ion, ol.20,no.6,pp.341–347, 2013. [9] Ł. K aszula, A. Jasi´ nska, M.-O. Eusebio, P. Kuna, A. Głabi´ nski, and M. Pie uczuk, “E alua ion o he ela ionship be ween lep in, esis in, adiponec in and na u al egula o y T cells in elapsing- emi ing mul iple scle osis,” Neu ologia i Neu- ochi u gia Polska, ol.46,no.1,pp.22–28,2012. [10] A. P. Ba occhi, M. Ro ondi, M. Caggiula e al., “Lep in as a ma ke o mul iple scle osis ac i i y in pa ien s ea ed wi h in e e on-be a,” Jou nal o Neu oimmunology, ol.139,no.1-2, pp. 150–154, 2003. [11] G. Ma a ese, P. B. Ca ie i, A. La Ca a e al., “Lep in inc ease in mul iple scle osis associa es wi h educed numbe o CD4+CD25+ egula o y T cells,” P oceedings o he Na ional Academy o Sciences o he Uni ed S a es o Ame ica, ol.102,no. 14, pp. 5150–5155, 2005. [12] U. Musabak, S. Demi kaya, G. Genc¸, R. S. Ilikci, and Z. Odabasi, “Se um adiponec in, TNF-𝛼, IL-12p70, and IL-13 le els in mul iple scle osis and he e ec s o di e en he apy egimens,” Neu oImmunomodula ion, ol.18,no.1,pp.57–66,2010. [13] A. Hie aha ju, H. Kuusis o, R. Nieminen, K. Vuol eenaho, I. Elo aa a, and E. Moilanen, “Ele a ed ce eb ospinal luid adiponec in and adipsin le els in pa ien s wi h mul iple scle- osis: a Finnish co- win s udy,” Eu opean Jou nal o Neu ology, ol. 17, no. 2, pp. 332–334, 2010. [14] S. Emamgholipou , S. M. Eshaghi, A. Hossein-Nezhad, K. Mi zaei, Z. Maghbooli, and M. A. Sah aian, “Adipocy okine p o ile, cy okine le els and FOXP3 exp ession in mul iple scle osis: a possible link o suscep ibili y and clinical cou se o disease,” PLoS ONE, ol.8,no.10,A icleIDe76555,2013. [15] C. H. Polman, S. C. Reingold, B. Banwell e al., “Diagnos ic c i e ia o mul iple scle osis: 2010 e isions o he McDonald c i e ia,” Annals o Neu ology, ol.69,no.2,pp.292–302,2011. [16] C.H.Polman,S.C.Reingold,G.Edane al.,“Diagnos icc i e ia o mul iple scle osis: 2005 e isions o he ‘McDonald C i e ia’,” Annals o Neu ology, ol. 58, no. 6, pp. 840–846, 2005. [17] J. F. Ku zke, “Ra ing neu ologic impai men in mul iple scle o- sis: an expanded disabili y s a us scale (EDSS),” Neu ology, ol. 33,no.11,pp.1444–1452,1983. [18] T. Heinonen, P. Das ida , H. Eskola, H. F ey, P. Ryymin, and E. Laasonen, “Applicabili y o semi-au oma ic segmen a ion o olume ic analysis o b ain lesions,” Jou nal o Medical Enginee ing and Technology, ol. 22, no. 4, pp. 173–178, 1998. [19] T. Heinonen, P. Das ida , P. Kauppinen, J. Malmi uo, and H. Eskola, “Semi-au oma ic ool o segmen a ion and olume ic analysis o medical images,” Medical & Biological Enginee ing and Compu ing, ol.36,no.3,pp.291–296,1998. [20] R. T. Whi e, D. Damm, N. Hancock e al., “Human adipsin is iden ical o complemen ac o D and is exp essed a high le els in adipose issue,” The Jou nal o Biological Chemis y, ol.267, no.13,pp.9210–9213,1992. [21] G. Ing am, S. Lo eless, O. W. Howell e al., “Complemen ac i- a ion in mul iple scle osis plaques: an immunohis ochemical analysis,” Ac a Neu opa hologica Communica ions, ol.2,a icle 53, 2014. [22] W. Zhou, “The new ace o anaphyla oxins in immune egula- ion,” Immunobiology, ol.217,no.2,pp.225–234,2012. [23] I. Halawa, F. Lolli, and H. Link, “Te minal componen o complemen C9 in CSF and plasma o pa ien s wi h MS and asep ic meningi is,” Ac a Neu ologica Scandina ica, ol.80,no. 2, pp. 130–135, 1989. [24] H. Jans, A. Hel be g, I. Zeebe g, J. H. K is ensen, T. Fog, and N. E. Raun, “Immune complexes and he complemen ac o s C4 and C3 in ce eb ospinal luid and se um om pa ien s wi h ch onic p og essi e mul iple scle osis,” Ac a Neu ologica Scandina ica, ol.69,no.1,pp.34–38,1984. [25] P. J. H. Jongen, W. H. Doesbu g, J. L. M. Ib ahim-S appe s, W. A. J. G. Lemmens, O. R. Hommes, and K. J. B. Lame s, “Ce eb ospinal luid C3 and C4 indexes in immunological diso de s o he cen al ne ous sys em,” Ac a Neu ologica Scandina ica, ol.101,no.2,pp.116–121,2000. [26] T. E. Mollnes, B. Vand ik, T. Lea, and F. Va dal, “In a hecal complemen ac i a ion in neu ological diseases e alua ed by analysis o he e minal complemen complex,” Jou nal o he Neu ological Sciences, ol.78,no.1,pp.17–28,1987. [27] B.P.Mo gan,A.K.Campbell,andD.A.S.Comps on,“Te minal componen o complemen (C9) in ce eb ospinal luid o pa ien s wi h mul iple scle osis,” The Lance , ol.324,no.8397, pp. 251–255, 1984. [28] M. Rod iguez, D. R. Wynn, T. K. Kimlinge , and J. A. Ka zmann, “Te minal componen o complemen (C9) in he ce eb ospinal luid o pa ien s wi h mul iple scle osis and neu ologic con ols,” Neu ology, ol.40,no.5,pp.855–857,1990. [29] M. E. Sande s, C. L. Koski, D. Robbins, M. L. Shin, M. M. F ank, and K. A. Joine , “Ac i a ed e minal complemen in ce eb ospinal luid in Guillain-Ba e synd ome and mul iple scle osis,” Jou nal o Immunology, ol.136,no.12,pp.4456– 4459, 1986. [30] F. Sellebje g, I. Jaliash ili, M. Ch is iansen, and P. Ga ed, “In a hecal ac i a ion o he complemen sys em and disabili y in mul iple scle osis,” Jou nal o he Neu ological Sciences, ol. 157, no. 2, pp. 168–174, 1998. [31] G. Ing am, S. Hakobyan, C. L. Hi s e al., “Complemen egula o ac o H as a se um bioma ke o mul iple scle osis disease s a e,” B ain, ol.133,no.6,pp.1602–1611,2010. [32] G. Ing am, S. Hakobyan, C. L. Hi s e al., “Sys emic comple- men p o iling in mul iple scle osis as a bioma ke o disease s a e,” Mul iple Scle osis, ol.18,no.10,pp.1401–1411,2012. [33] S. Aeinehband, R. P. Lindblom, F. Al Nime e al., “Complemen componen C3 and bu y ylcholines e ase ac i i y a e associa ed wi h neu odegene a ion and clinical disabili y in mul iple scle osis,” PLoS ONE, ol.10,no.4,A icleIDe0122048,2015. Mul iple Scle osis In e na ional 9 [34] G. Ing am, S. Hakobyan, N. P. Robe son, and B. P. Mo gan, “Complemen in mul iple scle osis: i s ole in disease and po en- ial as a bioma ke ,” Clinical and Expe imen al Immunology, ol. 155, no. 2, pp. 128–139, 2009. [35] W.-H. Kwan, W. an de Touw, and P. S. Heege , “Complemen egula ion o T cell immuni y,” Immunologic Resea ch, ol.54, no. 1–3, pp. 247–253, 2012. [36] S.K.Yada ,J.E.Mindu ,K.I o,andS.Dhib-Jalbu ,“Ad ances in he immunopa hogenesis o mul iple scle osis,” Cu en Opinion in Neu ology, ol.28,no.3,pp.206–219,2015. [37]T.Re esz,D.Kidd,A.J.Thompson,R.O.Ba na d,andW. I. McDonald, “A compa ison o he pa hology o p ima y and seconda y p og essi e mul iple scle osis,” B ain, ol.117,no.4, pp. 759–765, 1994. [38] M.Haugen,J.L.F ede iksen,andM.Degn,“Bcell ollicle-like s uc u es in mul iple scle osis-wi h ocus on he ole o B cell ac i a ing ac o ,” Jou nalo Neu oimmunology, ol.273,no.1-2, pp.1–7,2014. [39]G.Ing am,S.Hakobyan,S.Lo eless,N.Robe son,andB.P. Mo gan, “Complemen egula o ac o H in mul iple scle osis,” Jou nal o Cellula Biochemis y, ol.112,no.10,pp.2653–2654, 2011. [40] M. E. E angelopoulos, G. Kou sis, and M. Ma kianos, “Se um lep in le els in ea men -nai e pa ien s wi h clinically isola ed synd ome o elapsing- emi ing mul iple scle osis,” Au oim- mune Diseases, ol.2014,A icleID486282,6pages,2014. [41] M. F. Saad, S. Damani, R. L. Ginge ich e al., “Sexual dimo - phism in plasma lep in concen a ion,” The Jou nal o Clinical Endoc inology & Me abolism, ol. 82, no. 2, pp. 579–584, 1997.