The effects of renal replacement therapy on plasma, asymmetric dimethylarginine, nitric oxide and C-reactive protein levels

Purpose: Asymmetric dimethylarginine (ADMA), nitric oxide (NOx), and C-reactive protein (CRP) are important risk factors for endothelial dysfunction and mortality in the end stage renal diseases population. The aim of the study was to investigate the relationship between renal replacement therapy and endothelial dysfunction. Methods: Plasma NOx, ADMA and CRP levels were examined in randomized selected 30 patients with chronic kidney diseases (CKD), 28 patients receiving continuous ambulatory peritoneal dialysis (PD) and 30 patients receiving regular hemodialysis (HD) and age-matched 20 healthy controls. The duration of dialysis was from 4, 5 to 11, and 6 years, respectively. Results: CKD patients had higher plasma ADMA (1.26±0.53?mol/L) and CRP levels (1.02±025mg/L) and lower NOx levels (28.6±5.4?mol/L) than controls (0.45±0.20; 0.65± 0.45; 32.5±37 respectively, P < 0.001).Plasma NOx and CRP levels were higher in HD patients (32.9±5.5?mol/L, P < 0.05 and 4.59±3.18mg/L, P < 0.001) and plasma ADMA and CRP levels were higher in PD patients (1.82±0.98?mol/L, P < 0.001 and 2.40±1.53mg/L, P < 0.001) than in CKD patients. PD patients had higher plasma ADMA levels (P < 0.05) and lower plasma NOx and CRP levels than HD patients (P < 0.001 and P < 0.001). Plasma ADMA levels were negatively correlated with NOx levels in all patient groups (P < 0.001). Plasma CRP levels in CKD and HD patients were positively correlated with plasma urea levels (r:0,437, P < 0,001) and duration of dialysis (r:0,370, P < 0.01), respectively. Conclusion: CRP and ADMA may be emerging as important risk factors for atherosclerosis in dialysis patients. Reduced NO elaboration secondary to accumulation of ADMA and elevated inflammation may be important pathogenic factors for endothelial dysfunction in both dialysis treatment strategies.

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MARKERS OF ENDOTHELIAL DYSFUNCTION: PATHOGENETIC ROLE AND DIAGNOSTIC SIGNIFICANCE

Russian Clinical Laboratory Diagnostics ◽

10.18821/0869-2084-2019-64-1-34-41 ◽

2019 ◽

Vol 64 (1) ◽

pp. 34-41 ◽

Cited By ~ 2

Author(s):

T. V. Stepanova ◽

A. N. Ivanov ◽

N. E. Tereshkina ◽

E. B. Popyhova ◽

D. D. Lagutina

Keyword(s):

Nitric Oxide ◽

Endothelial Dysfunction ◽

Asymmetric Dimethylarginine ◽

Vascular Endothelial ◽

C Reactive Protein ◽

Pathogenetic Role ◽

Reactive Protein ◽

Von Willebrand ◽

Endothelial Growth Factor ◽

Willebrand Factor

Endothelial dysfunction (ED) is considered one of the pathogenetic mechanisms of a whole range of diseases. Detection of specific biochemical markers in the blood is an effective way to ED diagnostics that characterize the vascular endothelium state. This review highlights the pathogenetic role of the factors synthesized by endotheliocytes whose level changes in biological fluids reflect violations of the endothelium basic physiological properties: vasomotor function, thromboresistance, angiogenesis regulation, barrier and adhesion functions. In particular, the participation of nitric oxide metabolites, asymmetric dimethylarginine, endothelin-1, metabolic products of arachidonic acid, von Willebrand factor, thrombomodulin, vascular endothelial growth factor, vasohibine-1 and adhesion molecules in the onset and development of ED are reviewed. The diagnostic significances of factors damaging endothelium, such as C-reactive protein, homocysteine and 8-hydroxy-2’-deoxyguanosine, are discussed. In addition, the literature data of recent years about the prospects of clinical implication the detection of the above-mentioned factors which indicates structural and functional endothelial cells damage are given. Particular attention is paid to the ED markers detection prognostic significance and the possibility of their practical use for the ED diagnosis. The search of literature for the current review was conducted in RSIC, CyberLeninka, Scopus, Web of Science, MedLine and PubMed databases from 2012 to 2018 using the following keywords: endothelial dysfunction, nitric oxide, asymmetric dimethylarginine, endothelin-1, prostacyclin, thromboxane A2, epoxyeicosatrienoic acids, von Willebrand factor, thrombomodulin, vascular endothelial growth factor, vasohibin-1, adhesive molecules, C-reactive protein, homocysteine, and 8-hydroxy-2-deoxyguanosine.

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Amelioration of C - Reactive Protein and Lectin Like Oxidised Low Density Lipoprotein Receptor Complex Induced Endothelial Dysfunction by Oligomeric Proanthocyanidins.

10.21203/rs.3.rs-770001/v1 ◽

2021 ◽

Author(s):

Sankar Jamuna ◽

Rathinavel Ashokkumar ◽

Niranjali Devaraj Sivasithamparam

Keyword(s):

Nitric Oxide ◽

Endothelial Cells ◽

Endothelial Dysfunction ◽

Capillary Tube ◽

Morphological Changes ◽

Protein Docking ◽

Pcr Analysis ◽

Inhibitory Mechanism ◽

C Reactive Protein ◽

Reactive Protein

Abstract C-reactive protein (CRP) is a well established biochemical marker for atherosclerosis. Inflammation induced by CRP promotes endothelial dysfunction. Modification of LDL inside the artery wall favors the elevation of this acute phase protein. The mechanism of OxLDL+CRP complex is unrevealed so far. Hence, this mechanism was considered as the important factor to trigger the monocyte to macrophages differentiation which in leads to foam cells formation. Hence this key event should be targeted and focused on how this complex (OxLDL+CRP) proceeds to endothelial dysfunction. OPC is a well known cardioprotective flavon-3-ols. The present study is challenged between the protective roles of OPC against the deleterious effect of this complex (OxLDL+CRP) on endothelial cells. Monolayer of Endothelial cells were incubated with THP-1 monocytes for 48 h supplemented with OxLDL (10mg/ml) + CRP (10 mg/ml) complex and treated with OPC (100mg/ml). Morphological changes, cell migration assay and capillary tube forming assay was carried out. Myeleoperoxidase levels were estimated to determine the adhesion of monocytes onto EC monolayer. RT-PCR analysis of L-Selectin was done. The quantification of NO levels and analysis of mRNA expressions of eNOS is to determine the nitric oxide demand caused due to OxLDL+CRP complex. LOX-1, scavenger receptor levels were analysed by mRNA expression. Proinflammatory markers such as IL-6, MCP-1 and IL-1b were studied. Accumulation of ROS levels were measured fluorimetrically using DCF-DA. Spectrophotometric analysis of Sirius red dye binding collagen levels was observed. Mitochondrial membrane potential was determined by JC-1 dye and cell cycle analysis was done by FACS analysis. Protein –Protein docking was carried out between CRP and LOX-1. This docked protein complex were again docked with OPC and atrovastatin to show the inhibitory mechanism of CRP binding with LOX-1. OPC showed a promising inhibitory mechanism against OxLDL+CRP complex. To emphasis the results OPC treated group showed decreased levels of proinflammatory markers, LOX-1 and L-Selectin levels. Endothelial nitric oxide levels were increased upon OPC treatment and reduction in the ROS levels. Endothelial cells apoptosis was prevented by OPC. Docking studies showed that in the absence of ligands (OPC) binding of CRP and LOX-1 was greater and vice versa in the presence of ligands. To conclude, OxLDL + CRP complex inhibitory effects of OPC could maintain the normal homeostasis.

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Predictor value of neurohumoral disorders in patients with chronic coronary syndrome with concomitant non-alcoholic fat disease

Reports of Vinnytsia National Medical University ◽

10.31393/reports-vnmedical-2021-25(3)-16 ◽

2021 ◽

Vol 25 (3) ◽

pp. 438-442

Author(s):

N. S. Mykhailovska ◽

L. E. Miniailenko ◽

O. O. Lisova ◽

T. O. Kulynych ◽

H. V. Grytsay ◽

...

Keyword(s):

Endothelial Dysfunction ◽

Sensitivity And Specificity ◽

Systemic Inflammation ◽

Roc Analysis ◽

Asymmetric Dimethylarginine ◽

Homa Index ◽

Liver Pathology ◽

C Reactive Protein ◽

Reactive Protein ◽

Coronary Syndrome

Annotation. Today it is important to study the clinical and prognostic role of neurohumoral disorders in patients with stable forms of chronic coronary syndrome (CCS) and concomitant liver pathology. The aim of the study: to investigate the levels of markers of insulin, adipokine balance, systemic inflammation and endothelial dysfunction and their predictor value for the presence of non-alcoholic fatty liver disease (NAFLD) in patients with CCS. The prospective monocenter double open study in parallel groups involved 120 patients with CCS: stable angina pectoris II-III functional class aged 60.0 (55.0; 64.0) years, of whom 67 (55%) men and 53 (45 %) women. The control selected group included 30 healthy individuals aged 59.0 (58.0; 66.0) years, including 14 (46%) men and 16 (54%) women. Determination of the serum concentration of biomarkers (adiponectin, resistin, insulin, asymmetric dimethylarginine (ADMA), C-reactive protein) was performed using enzyme-linked immunosorbent assay. Statistical data processing was performed using the license program package “Statistica 13.0” (StatSoftInc, USA, № JPZ8041382130ARCN10-J). The hypothesis about the normality of the distribution of the studied indicators was tested using the Shapiro-Wilk test. Quantitative traits were presented as M ± m or Me (Q25; Q75), depending on the type of distribution. Significance of differences was assessed using Student's t-test (for normal distribution) or Mann-Whitney U-test for independent samples (for distribution other than normal). In order to establish the threshold values of biomarkers for predicting the presence of NAFLD ROC analysis was used. It was found that in patients with CCS with concomitant NAFLD, compared with patients with CCS without liver pathology, there is a significant (p <0,05) increase in insulin levels, HOMA index, resistin, ADMA, RF-C-reactive protein and a decrease in adiponectin concentration. According to the results of ROC analysis, it was found that ADMA (Se = 80.0; Sp = 82.9; AUC = 0.91) had a high sensitivity, the optimal ratio of sensitivity and specificity for the diagnosis of NAFLD among all studied biomarkers. Other biomarkers (HOMA index, adiponectin, resistin, adiponectin/resistin ratio) also had an AUC greater than 0.8, but smaller sensitivity/specificity ratio. Thus, in patients with CCS associated with NAFLD, compared with patients without NAFLD, an imbalance of adipocytokines on the background of insulin resistance, systemic inflammation and endothelial dysfunction is observed. Asymmetric dimethylarginine has the highest sensitivity, the optimal ratio of sensitivity and specificity for the diagnosis of NAFLD in patients with coronary artery disease.

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Does omega-3 fatty acids supplementation affect C-Reactive protein and Nitric oxide in pediatric patients undergoing hemodialysis?

International Journal Of Applied Research and Studies ◽

10.20908/ijars.v5i5.10708 ◽

2016 ◽

Vol 5 (5) ◽

Author(s):

Areej Mohamed Ateya ◽

Dr. Nagwa Ali Sabri ◽

Dr. Ihab El Hakim ◽

Dr. Sara M Shaheen

Keyword(s):

Nitric Oxide ◽

Fatty Acids ◽

Endothelial Dysfunction ◽

Pediatric Patients ◽

Omega 3 Fatty Acids ◽

Omega 3 ◽

C Reactive Protein ◽

Once Daily ◽

Reactive Protein ◽

Traditional Risk Factors

<italic>Background:</italic>Chronic kidney disease (CKD) is a worldwide public health problem in the pediatric population. Patients with CKD die of cardiovascular causes rather than from renal disease. There are several traditional and non-traditional risk factors for cardiovascular disease (CVD) in these patients. Endothelial dysfunction is one of the non-traditional risk factors for CVD. Many studies have shown the ability of omega-3 fatty acids to improve the endothelial function and reduce the cardiovascular events in the general population. Thus, the aim of this study was to evaluate the effect of omega-3 fatty acids supplementation on markers of endothelial dysfunction in children with CKD on regular hemodialysis (HD). <italic>Methods and procedures:</italic> This double-blinded randomized placebo-controlled trial included 49 pediatric patients on maintenance HD. Group 1 (n=25) received 1 g omega-3 capsule once daily and group 2 (n=24) received 1 g matched placebo capsule once daily. Both groups were treated for four months. Blood samples were taken from patients of both groups at baseline and after 4 months of supplementation. Serum samples were examined for C-reactive protein (CRP) and nitric oxide (NO) levels as markers of endothelial dysfunction. <italic>Results:</italic> Our results showed that CRP was reduced insignificantly in omega-3 group. NO levels showed no significant differences between groups at the end of the study. <italic>Conclusion:</italic> The administration of 1 g omega-3 capsule once daily for 4 months had no beneficial effects neither on CRP nor NO but should evaluate more.

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Endothelial Dysfunction and C-Reactive Protein Are Risk Factors for Diabetes in Essential Hypertension

Diabetes ◽

10.2337/db07-1189 ◽

2007 ◽

Vol 57 (1) ◽

pp. 167-171 ◽

Cited By ~ 55

Author(s):

F. Perticone ◽

R. Maio ◽

A. Sciacqua ◽

F. Andreozzi ◽

G. Iemma ◽

...

Keyword(s):

Risk Factors ◽

Essential Hypertension ◽

Endothelial Dysfunction ◽

C Reactive Protein ◽

Reactive Protein

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Biomarkers of endothelial dysfunction in cardiovascular diseases

Medicinski pregled ◽

10.2298/mpns1702053s ◽

2017 ◽

Vol 70 (1-2) ◽

pp. 53-57

Author(s):

Sonja Smiljic ◽

Milica Mijovic ◽

Sladjana Savic

Keyword(s):

Nitric Oxide ◽

Extracellular Matrix ◽

Vascular Endothelial Growth Factor ◽

Endothelial Dysfunction ◽

Adhesion Molecules ◽

Vascular Endothelial ◽

C Reactive Protein ◽

Reactive Protein ◽

Endothelial Growth Factor

Introduction. Endothelial dysfunction is the result of numerous infectious or noninfectious acute and chronic diseases, mechanical damage, hemodynamic imbalance and effects of certain drugs. Endothelial dysfunction can be assessed by determining biomarkers (adhesion molecules, inflammatory cytokines and growth factors, and noninvasive visualization biomarkers). Intercellular adhesion molecule-1 and vascular cellular adhesion molecule. Adhesion molecules mediate the interaction of cells with the extracellular matrix, as well as with other cells. It is shown that adhesion molecules and molecules of the extracellular matrix are markers of endothelial dysfunction and they are involved in the pathogenesis of atherosclerosis. P-selectin and E-selectin. Determination of these two mediators is important not only in the evaluation of endothelial damage in acute inflammation, but in other chronic non-infectious conditions such as atherosclerosis. C-reactive protein. C-reactive protein reduces the transcription of endothelial nitric oxide synthase at the level of the endothelial cells and ?destabilize? their messenger ribonucleic acid, thus leading to a reduction of the synthesis of nitric oxide, in the basal and stimulated conditions, which is significant for the development of endothelial dysfunction as a part of the formation of subclinical atherosclerosis. Vascular endothelial growth factor, fibrinogen and thrombomodulin. Vascular endothelial growth factor is a cytokine that stimulates angiogenesis for the purpose of revascularization of ischemic tissues, and mediates in a variety of functions of endothelial cells, including proliferation, migration, invasion, survival and permeability. Noninvasive visualization biomarkers. Determination of intima-media complex thickness and calcium score index by computed tomography are considered clinically reliable methods in prevention and early diagnosis of coronary artery disease and acute myocardial infarction, changing the basic concepts of prevention. Conclusion. At this point it is not easy to say what clinical significance are listed biomarkers of endothelial dysfunction in determining the risk for cardiovascular disease.

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Peculiarities of the Course of COVID-19 in Patients with Chronic Kidney Disease Receiving Renal Replacement Therapy

Ukraïnsʹkij žurnal medicini bìologìï ta sportu ◽

10.26693/jmbs06.03.142 ◽

2021 ◽

Vol 6 (3) ◽

pp. 142-147

Author(s):

N. M. Andonieva ◽

◽

S. M. Kolupayev ◽

M. Ya. Dubovik ◽

О. A. Huts ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Peritoneal Dialysis ◽

Renal Replacement Therapy ◽

Kidney Disease ◽

Replacement Therapy ◽

Chronic Kidney Disease Stage ◽

Lung Damage ◽

Disease Stage ◽

C Reactive Protein ◽

Reactive Protein

Patients with chronic kidney disease stage 5 belong to the group of patients with the highest risk of complicated course of COVID-19. The purpose of the study was to study the prevalence and clinical and laboratory features of the COVID-19 infection among patients with end-stage of chronic kidney disease who receive renal replacement therapy. Materials and methods. The study included 172 patients with chronic kidney disease stage 5, who were receiving renal replacement therapy and who were diagnosed with COVID-19 for the period from April 2020 to April 2021. According to the type of renal replacement therapy all patients were divided into 3 groups: group 1 – 98 (56.9%) patients who received hemodialysis, group 2 – 60 (34.8%) patients who were on peritoneal dialysis, group 3 – 14 (8.1%) patients with kidney transplantation. The main clinical and laboratory parameters that characterize the course of the COVID-19 infection such as fever, diarrhea, anosmia, the percentage of oxygen saturation, the percentage of lung damage, levels of total protein, albumin, C-reactive protein, urea, creatinine, D-dimer, hemoglobin, leukocytes, platelets were evaluated. Results and discussion. The COVID-19 infection was diagnosed in 172 (38.2%) patients, the vast majority of whom – 110 (63.9%) patients were women with a mean age of 47.4±4.6 years. The analysis of clinical and laboratory parameters revealed the most severe course of the disease in patients with a kidney transplant and in patients who were on hemodialysis. In the group of renal transplant recipients there was a significant increase in the level of D-dimer, as well as a higher percentage of lung damage, compared with the average values of these indicators among patients on hemodialysis and peritoneal dialysis, but mortality in this group was 13.3% and was significantly lower than in the group of hemodialysis patients – 27.5%. It should be noted that in patients on renal replacement therapy by the method of hemodialysis, the adequacy of dialysis therapy was insufficient, which led to a more pronounced overall inflammatory response, which was characterized by the highest level of C-reactive protein (64.4±5.1 mg/l), compared with patients in the other study groups. The course of the disease in patients on hemodialysis was also complicated by anemia. In patients on renal replacement therapy by peritoneal dialysis, the COVID-19 infection was characterized by a mild course, with the lowest percentage of lung damage (22.0±2.8%) and fatalities (11.6%). Conclusion. According to our study, the incidence of COVID-19 among patients receiving renal replacement therapy is 38.2%. A more severe course of the disease was registered in the group of patients with a kidney transplant, due to the nature of comorbid pathology, as well as immunosuppressive therapy. The data obtained allow us to consider patients with a transplanted kidney as a risk group for severe COVID-19 infection

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Asymmetric Dimethylarginine, C-Reactive Protein, and Carotid Intima-Media Thickness in End-Stage Renal Disease

Journal of the American Society of Nephrology ◽

10.1681/asn.v132490 ◽

2002 ◽

Vol 13 (2) ◽

pp. 490-496

Author(s):

Carmine Zoccali ◽

Francesco Antonio Benedetto ◽

Renke Maas ◽

Francesca Mallamaci ◽

Giovanni Tripepi ◽

...

Keyword(s):

End Stage Renal Disease ◽

Asymmetric Dimethylarginine ◽

Intima Media Thickness ◽

No Synthase ◽

Endogenous Inhibitor ◽

C Reactive Protein ◽

Reactive Protein ◽

Plasma Adma ◽

Stage Renal Disease ◽

End Stage

ABSTRACT. Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide (NO) synthase that has been linked to endothelial dysfunction and atherosclerosis in the general population. ADMA is also elevated in end-stage renal disease and may contribute to the high cardiovascular risk in patients with chronic renal failure. A prospective cohort study was performed to investigate the relationship between plasma ADMA, C-reactive protein (CRP), and intima-media thickness (IMT) in 90 patients undergoing hemodialysis. In the baseline study, plasma ADMA was directly related to IMT both on univariate analysis (r = 0.32, P = 0.002) and on multiple regression analysis (β = 0.23, P = 0.01). In the follow-up study (15 mo) IMT changes were significantly related to ADMA (r = 0.51, P = 0.02) and serum CRP (r = 0.53, P = 0.01) in patients with initially normal IMT. In these patients, ADMA and CRP were strongly interrelated (r = 0.64, P = 0.002), and on multiple regression analysis the interaction between ADMA and CRP emerged as the sole independent predictor of the progression of intimal lesions. Independently of other risk factors, plasma ADMA in patients on hemodialysis is significantly related to IMT. Furthermore, in patients with initially normal IMT, ADMA and CRP are interacting factors in the progression of carotid intimal lesions. These data support the hypothesis that accumulation of this endogenous inhibitor of NO synthase is an important risk factor for cardiovascular disease in chronic renal failure and suggest a possible link between ADMA and inflammation.

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Polyphenols in preventing endothelial dysfunction

Postępy Higieny i Medycyny Doświadczalnej ◽

10.5604/01.3001.0010.3808 ◽

2017 ◽

Vol 71 (1) ◽

pp. 0-0 ◽

Cited By ~ 5

Author(s):

Sylwia Biegańska-Hensoldt ◽

Danuta Rosołowska-Huszcz

Keyword(s):

Nitric Oxide ◽

Blood Pressure ◽

Endothelial Dysfunction ◽

Oxidative Dna Damage ◽

Developed Countries ◽

The Body ◽

No Production ◽

C Reactive Protein ◽

Rat Cardiomyocytes ◽

Reactive Protein

One of the main causes of mortality in developed countries is atherosclerosis. The pathogenesis of atherosclerosis is associated with endothelial dysfunction. Consumption of food rich in natural antioxidants including polyphenols significantly improves endothelial cells functions.Polyphenols have a beneficial effect on the human body and play an important part in protecting the cardiovascular system. Polyphenols present in food have antioxidant, anti-inflammatory, antihypertensive, antithrombotic and antiproliferative properties. Catechins cause an increase in the activity of endothelial nitric oxide synthase (eNOS) and increased production of nitric oxide (NO) and decrease in blood pressure. Catechins also reduce platelet adhesion, lower the concentration of C-reactive protein and tumor necrosis factor alpha and interleukin-6. Resveratrol inhibits NADPH oxidase expression, increases the expression of eNOS and NO production as well as decreases the expression of proinflammatory cytokines, and also lowers the concentration of the soluble forms of adhesion molecules – sICAM-1 and sVCAM-1 in blood. Quercetin reduces the blood level of low density lipoprotein cholesterol, lowers blood pressure, reduces the concentration of C-reactive protein and F2-isoprostane level. Curcumin has antagonistic activity to homocysteine. Curcumin increases the expression of eNOS and reduces oxidative DNA damage in rat cardiomyocytes. Numerous attempts are taken for improving the bioavailability of polyphenols in order to increase their use in the body.

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Ameliorative effects of gallic acid on cardio-renal complexity induced by isoproterenol

International Journal of Bioassays ◽

10.21746/ijbio.2016.10.0010 ◽

2016 ◽

Vol 5 (10) ◽

pp. 4963

Author(s):

Eman Salah Abdel-Reheim

Keyword(s):

Nitric Oxide ◽

Risk Factors ◽

Myocardial Infarction ◽

Gallic Acid ◽

Kidney Function ◽

Heart Function ◽

C Reactive Protein ◽

Reactive Protein ◽

Nitrite Level ◽

Mda Content

Myocardial infarction (MI) arises out many risk factors, which work in concert and give rise to a lot of unfavorable outcome especially on the kidney. In the present study, we investigate the effect of gallic acid (GA), a natural antioxidant on cardio-renal complexity induced by isoproterenol (ISO). The myocardial infarcted rats showed deterioration in the heart function measured by lactate dehydrogenase (LDH) and creatin kinase (CK) and kidney function measured by urea, uric acid and creatinine. There were relative overweight in both the organs. Abnormal oxidation in lipids of their membrane indicated by the increased malomdialdhyde (MDA) content and nitrite level indicating the increase in their nitric oxide (NO). However, the result indicated a decrease in glutathione (GSH) content and superoxide dismutase (SOD) and peroxidase (POX) activities. These results were assured by other measurements as brain naturetic peptide (BNP) and myoglobin (Mgb) which indicated a damage happened in the myocytes, C-reactive protein (CRP) indicated the inflammatory response and homocystain, angiotensin and aldosterone levels which indicating the kidney hormones secretion. In conclusion, GA ascertained its efficacy in ameliorating the heart function biomarkers, kidney function testes and hormones and oxidation state.

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