Perspectives
AGEs and Diabetic Retinopathy
Alan W. Stitt
The pathogenesis of diabetic retinopathy is multifactorial, and
a range of hyperglycemia-linked pathways have been impli-
cated in the initiation and progression of this condition. All
cells in the retina are affected by the diabetic milieu, and in
view of such disease and tissue complexity, it is unlikely that
any single process is solely responsible for retinal pathophysi-
ology. Nevertheless, establishing causal mechanisms remains
an important research goal. This review concentrates on the
formation of advanced glycation end products (AGEs) and the
role they play in diabetic retinopathy. Perspective is provided
on advanced glycation in the retina, the impact that this pro-
cess has on retinal cell function, and how it relates to other
pathogenic pathways. Emphasis is also placed the modulatory
role of the receptor for AGEs (RAGE) and how its activation
could evoke retinal inflammatory disease. Further research is
needed to achieve a clear understanding of the cellular and
molecular processes that underpin diabetic retinopathy’s initi-
ation and progression. Such advances in basic mechanisms may
lead to effective treatments that can prevent progression of
retinopathy from the point of the diagnosis of diabetes to
sight-threatening proliferative diabetic retinopathy (PDR) and
diabetic macular edema (DME). (Invest Ophthalmol Vis Sci.
2010;51:4867– 4874) DOI:10.1167/iovs.10-5881
R etinopathy is the most common microvascular complica-
tion of diabetes, and it remains a major cause of visual
impairment worldwide.1 Epidemiology studies indicate that, at
20 years after diagnosis, most patients with type 1 diabetes will
experience retinopathy, whereas ⬃80% of insulin-dependent
patients with type 2 diabetes and ⬃50% of patients with non–
insulin-dependent type 2 diabetes will have retinopathy.2
Microvascular lesions, such as microaneurysms, blood bar-
rier dysfunction, and capillary dropout, are key features of
diabetic retinopathy.3,4 However, it should be appreciated that
the sole purpose of the retinal circulation is to support the
metabolic demands of the inner retinal neurons and glia and
that these cells are also damaged appreciably during diabetes.
Such neuronal and glial dysfunction occurs in unison with
blood flow abnormalities and often before the appearance of
overt microvascular damage.5 In diabetic patients and short-
term animal models of diabetes, reversible retinal psychophys-
ical and electrophysiological alterations are evident.6,7 Such
early-stage alterations may be signposts for the irreversible
retinal microvascular, neuronal, and glial damage observed
after longer term diabetes.8,9
From the Centre for Vision and Vascular Science, Queens Univer-
sity Belfast, Northern Ireland, United Kingdom.
Supported by the Juvenile Diabetes Research Foundation (JDRF),
Fight for Sight (UK), Action Medical Research, and the Medical Re-
search Council.
Submitted for publication May 13, 2010; revised July 9, 2010;
accepted July 9, 2010.
Disclosure: A.W. Stitt, None
Corresponding author: Alan W. Stitt, Centre for Vision and
Vascular Science, Queen’s University Belfast, Royal Victoria Hospi-
tal, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK;
a.stitt@qub.ac.uk.
Investigative Ophthalmology & Visual Science, October 2010, Vol. 51, No. 10
Copyright © Association for Research in Vision and Ophthalmology
The DCCT (Diabetes Control and Complications Trial) and
UKPDS (UK Prospective Diabetes Study) population studies in
type 1 and type 2 diabetic patients, respectively, have estab-
lished the relationship between hyperglycemia and retinopa-
thy.10,11 These seminal studies, and many others, point toward
hyperglycemia as being critical in the pathogenesis, although it
often occurs in unison with dyslipidemia and hypertension.
This epidemiology provides the foundation for ongoing re-
search, seeking to identify the cellular and molecular mecha-
nisms that underpin diabetic retinopathy. The formation of
advanced glycation end products (AGEs) and the activation of
receptors for AGEs are the focus of this article, although it
should be appreciated that hyperglycemia can simultaneously
provoke a range of other pathogenic mechanisms in retinal
cells in vitro and in vivo.12 Such pathways to diabetic retinop-
athy should not necessarily be viewed as independent phenom-
ena. Brownlee et al.13 have proposed a unifying concept
whereby hyperglycemia increases superoxide production (via
the mitochondrial electron transport chain) which in turn
initiates accelerated AGE formation and also exacerbates inter-
related pathogenic responses. This hypothesis has been rein-
forced in the field of retinopathy, in which three biochemical
abnormalities involving AGE formation, flux through the hex-
osamine pathway and diacylglycerol-mediated activation of
PKC-␤ can be attenuated with benfotiamine. This vitamin B1
thiamine derivative stimulates transketolase activity and shunts
excess triose phosphates toward the reductive pentose phos-
phate pathway, which is impaired in high-glucose diabetes.14
By converging on three harmful pathways, benfotiamine pre-
vents high-glucose–induced dysfunction in retinal microvascu-
lar cells,15 whereas treatment of diabetic animals protects
against the key lesions of retinopathy.16
BIOCHEMISTRY OF AGE FORMATION
How AGEs Are Formed
Nonenzymatic-glycation reactions between reducing sugars
and the free amino groups on proteins, lipids, and DNA are an
inevitable consequence of aldehyde reactivity. As a conse-
quence, many proteins in vivo carry some burden of chemi-
cally attached carbohydrate. An understanding of this chemis-
try was established in 1912 by the food chemist, Louis Camille
Maillard, who reported formation of brown products upon
heating mixtures of amino acids and sugars. The Maillard, or
browning, reaction begins with the formation of a Schiff base
between glucose and ␧-amino groups that slowly rearranges to
relatively stable Amadori adducts, an example of which is
hemoglobin A1c (HbA1c). Both the Schiff base and the Amadori
product can undergo further oxidation and dehydration with
concentrations ultimately dependent on both forward and re-
verse reactions. The forward reactions give rise to additional
irreversible protein-bound compounds collectively termed ad-
vanced glycation end products (AGEs). During diabetes, the
rate of formation of AGEs exceeds that predicted by first-order
kinetics. Thus, over time, even modest hyperglycemic excur-
sions can result in significant adduct accumulation on long-
lived macromolecules.17
4867
4868 Stitt
AGE adducts are highly stable at physiological pH, and their
rate of accumulation in tissues depends on factors such as
availability of metal ions, redox balances, and longevity of the
modified protein. Although AGEs may lead to pigmentation or
fluorescence, they can also inflict considerable damage on
proteins through cross-linking, changing tertiary structure,
conferring resistance to digestion, altering enzymatic activity,
or impairing receptor recognition. AGE adducts form from
many different precursors that contribute to the heterogeneity
of these chemical structures. Numerous AGE adducts have
been identified in vivo, including; N␧-(carboxymethyl) lysine
(CML), crossline, pentosidine, furoyl-furanyl imidazole (FFI), hy-
droimidazolone, argpyrimidine, glyoxal lysine dimer (GOLD), and
methylglyoxal lysine dimer (MOLD).18
AGEs Form from a Range of Precursors
Glucose is often viewed as the principal AGE precursor; how-
ever, it is considerably less reactive than ␣-oxaloaldehydes
such as glyoxal (GO), methylglyoxal (MGO), and 3-deoxyglu-
cosone (3-DG), which arise from glycolytic metabolism and
can form AGEs very rapidly.19,20 For example, GO reacts with
arginine residues to form carboxymethyl-arginine (CMA),21
whereas MGO can give rise to the AGEs N␧-(carboxyethyl)
lysine (CEL) and arginine-hydroimidazolone.19,22 The concen-
trations of these reactive carbonyls rise in high-glucose– ex-
posed cells and occur at elevated levels in diabetic serum, and
they constitute the major source of AGEs in vivo.22,23 Indeed,
in diseases of carbonyl stress, such as diabetic nephropathy,
the AGEs can reach exceptionally high levels.24
AGEs Are Also Derived from Food
AGEs and ALEs are abundant in food. Indeed a typical Western
diet contains high levels of fat and sugar and, being highly
thermally processed, can lead to high levels of harmful ad-
ducts.25 Consumption of a conventional Western diet typically
leads to a daily intake of ⬃25 to 75 mg AGE/ALEs (advanced
lipoxidation end products),25 and a proportion of these ad-
ducts pass the gut epithelium and can appear as plasma
AGEs.26 Food-derived AGEs may be linked to vascular dysfunc-
tion, especially in situations in which there is renal dysfunction
and poor clearance of plasma AGEs.27,28 The potential involve-
ment of food-derived AGEs and ALEs in diabetic retinopathy
has not been studied.
Detoxification Systems Can Limit AGE Formation
In Vivo
Cells have evolved systems that provide endogenous protec-
tion against dicarbonyls, and several detoxifying enzymes have
been identified. For example, a glutathione-dependent glyox-
alase complex (formed from glyoxalase I [GLO1] and glyox-
alase II [GLO2] components) acts as a detoxification system for
GO and MGO, which are converted to D-lactate.29 Endothelial
cells transfected to overexpress GLO1 accumulate less MGO-
derived AGEs30 and are protected against high-glucose–in-
duced responses.31 The GLO1 detoxification system has been
shown to be critical for retinal pericyte survival, but this may
be insufficient during diabetes, since these cells undergo apo-
ptosis as a direct result of MGO-derived AGE formation.32 The
importance of this enzyme system is supported by findings in
studies in which Caenorhabditis elegans was engineered to
overexpress GLO1. These worms contain fewer AGEs and
show a significantly increased lifespan when compared with
wild-type counterparts.33,34 Clearly, there is a potential for
harnessing the detoxifying property of enzymes such as GLO1,
to protect against diabetic retinopathy.
IOVS, October 2010, Vol. 51, No. 10
ALEs May Play an Important Role in
Retinal Disease
Dyslipidemia is often overlooked as a pathogenic force in
diabetic retinopathy.35 In the context of this review, lipid
peroxidation reactions can also form a class of Maillard pro-
ducts, the ALEs, which are linked to diabetes and dyslipide-
mia.36 ALEs form through the lipoperoxidative production of
reactive aldehyde species. Among the best characterized are
N ␧ -(2-propenal)lysine and dihydropyridine-type adducts
(malondialdehyde-derived), hemiacetal and pyrrole adducts
(4-hydroxy-2-nonenal, and 4-hydroxyhexenal-derived), and
N␧-(3-formyl-3,4-dehydropiperidino)lysine, or FDP-lysine; ac-
rolein-derived).37 Recent work has also shown that hemo-
globin levels of the ACR-derived ALE, FDP-lysine, are asso-
ciated with the severity of retinopathy in patients with type
1 or type 2 diabetes.38 Clearly, ALEs represent an important
source of protein modification, especially in lipid-rich,
highly oxidative environments, such as that in the retina.
The understanding of the role of ALEs in diabetic retinopa-
thy lags far behind that which is known about AGEs, and
these adducts therefore warrant further study.
PATHOGENIC ROLE OF AGES
IN DIABETIC RETINOPATHY
AGEs and Clinical Correlation
with Diabetic Retinopathy
AGEs affect cells from three main perspectives: as adducts
occurring on modified serum proteins, as endogenous adducts
formed as a consequence of glucose metabolism, or as extra-
cellular matrix–immobilized modifications on long-lived struc-
tural proteins (Fig. 1). All these AGEs can be analyzed in serum,
cells, and tissues using analytical and/or immunocytochemical
approaches. Clinically, most quantification in patient tissues
and serum has been based on ELISA of a range of AGE-antibod-
ies, but this method has often produced confounding out-
comes. With this proviso, patient-based studies have revealed
that the levels of AGEs in serum correlate with the clinical
progression of diabetic retinopathy.39 Although many reports
have measured a range of ill-defined AGE moieties, others have
used adduct-specific antibodies or chemical analysis for CML,
pentosidine, or hydroimidazolone40 – 42 and also have found
association with diabetic retinopathy. It should be acknow-
ledged that some reports have demonstrated no correlation
between AGE levels and retinopathy in diabetic patients,40,43
although the apparent disparity may be related to variations in
patient populations, the presence of nephropathy, and/or the
nonuniformity of assays for AGE quantification.
AGEs as Robust Biomarkers for Disease Risk
AGE-modified proteins are readily cleared from the blood-
stream (except during renal dysfunction), and thus quantifica-
tion of these adducts in serum may not always provide robust
biomarkers for disease. By contrast, AGE modification of extra-
cellular matrix isolated from skin biopsies often provides more
meaningful data,44 illustrated by the DCCT skin collagen ancil-
lary study group.45 They demonstrated that cross-linked AGEs
on long-lived skin proteins are significantly associated with the
progression of diabetic retinopathy. More than 200 patients
from the original DCCT were followed up for a further 10 years
under the auspices of the Epidemiology of Diabetes Interven-
tions and Complications (EDIC) Trial.46 The results revealed
that levels of diabetic retinopathy were significantly lower in
the group initially maintained under tight glycemic control
and that these benefits extended far beyond the period of
intensive insulin therapy.46 The patients under conventional
IOVS, October 2010, Vol. 51, No. 10 AGEs and Diabetic Retinopathy 4869

FIGURE 1. AGEs interact with cells N2-Carboxymethyl-lysine

from three main routes. Route 1: O C
AGE-modified serum proteins, such CH (CH )
2 4 2
–
NHCH CO
2
H N
as CML, may interact with vascular RAGE
endothelium via AGE receptors such
as RAGE, which can activate NF-␬B Increased expression of
transcription leading to enhanced ICAM, VCAM, E-selectin,
VEGF, RAGE, TNF- ROS NO
expression of adhesion molecules
and secretion of cytokines such as JAK
TNF- ␣ and VEGF. Serum-derived 1
Rac1 ERK1/2
AGEs reach pericytes via transendo- Glucose 2
thelial trafficking or as a result of Glucose-6-P

blood–retinal barrier dysfunction. Nuclear

Fructose-6-P
Methylglyoxal
transcription
These serum AGEs may also inter- factors Glyceraldehyde-3-P O
+
NAD
act directly with cell surface glyco- GAPDH O
HC
C
C
O
AP1/NF- B/ NADH
2
3
proteins with potentially damaging STAT
H

effects on membrane integrity and

function. Route 2: AGEs can form
directly from reaction of glucose
with amino groups, but this sugar is
much less reactive than carbonyls,
such as methylglyoxal. Methylg-
lyoxal can arise by spontaneous ␤
elimination of phosphate from tri- O C N
Pentosidine
ose phosphates, the concentrations crosslink CH (CH )
2 8
NH+
H N HN N
of which are increased during hy- (fluorophore) C O 3
(CH ) HC
perglycemia because of the in- 2 4
N H ? ? ?
creased flux of glucose through gly-
colysis. Route 3: Sedentary cells like endothelium encounter AGEs such as pentosidine-derived cross-links within basement membrane
proteins where they may influence cell attachment through disruption of integrin signaling. Integrins of various subunit combinations are
important for function and ongoing survival cues and disruption of signaling contributes to dysfunction and death. There are many
uncertainties about how the AGE adducts immobilized in the basement membrane could interact with RAGE (or other AGE-receptors)
expressed on the basal plasma membrane, but this effect may be a significant mode of cell dysfunction.

control for the first 10 years maintained a hyperglycemic or
metabolic memory and retained a strong association with ret-
inopathy progression. CML-modified skin collagen predicted
the progression of retinopathy (and nephropathy), even after
initiation of intensive insulin therapy.46 Furthermore, the pre-
dictive effect of hemoglobin A1c (HbA1c) vanished after ad-
justment for AGEs, suggesting that accumulation of these ad-
ducts on long-lived protein is an excellent marker for
retinopathy risk and could offer a molecular-based explanation
for the metabolic memory phenomenon.17
AGEs in the Diabetic Retina
AGEs have been extensively quantified in various ocular tissues
and are often elevated during ageing and in diabetic subjects
when compared to nondiabetic control subjects.47 This in-
cludes vitreous collagen,48 where the AGE levels correlate with
diabetic retinopathy.49 In the diabetic retina, AGEs and/or late
Amadori products have been localized to vascular cells, neu-
rons, and glia.50 –55 This would be expected to have patho-
genic implications for the individual cells and retinal function.
Although differential accumulation of AGEs exists in the retina
over the course of life, diabetes significantly enhances the
occurrence of these adducts in the vascular and neural tissue
components.54
It has been demonstrated that MGO-derived hydroimida-
zolone is increased 279% in 24-week diabetic rat retina,56 and
this finding emphasizes the fact that MGO could be the major
source of AGEs in this tissue. In terms of cell localization for
AGEs, many adducts occur at high levels in the Müller macro-
glia, and these increase as diabetes progresses.57 This fact is
significant, because Müller glia have a unique role in the archi-
tecture and physiology of the retina and show considerable
dysfunction during the hyperglycemia and hypoxia experi-
enced by diabetic retina.58,59 This dysfunction is manifested by
increased expression of glial fibrillary acidic protein (GFAP),60
NO production,61,62 and concomitant synthesis of glutamate
(as a function of disruption of the glutamate transporter63)
which may contribute to excitotoxicity in retinal neurons.64
Significantly, Winkler et al.65 have demonstrated that Müller
cells exposed to high glucose conditions in vitro produce
excess lactate, indicative of increased glycolytic flux,65 and this
effect leads to greater production of MGO. Hypoxia is also
known to enhance glycolytic metabolism through increased
HIF-1␣-dependent expression of glycolytic enzymes in the con-
version of cells to a predominantly glycolytic metabolic state in
the absence of oxygen (the Pasteur effect). Hypoxia, by in-
creasing glycolysis and MGO synthesis, could lead to significant
AGE formation in the diabetic retina.
AGEs Evoke Retinal Oxidative Stress and Retinal
Cell Death
Oxidative stress results from the disequilibrium between pro-
and antioxidants in biological systems,66 and this pathway is
intimately linked to the formation of AGEs.13,67,68 Numerous
studies have reported that oxidative stress is increased in dia-
betic patients and that it plays an important role in the patho-
genesis of diabetic complications, including retinopathy.69,70
Previous work has demonstrated that the concentration of
superoxide is elevated in the retina of diabetic rats and in
retinal cells incubated in high-glucose media.61,71,72
Of importance, it has been shown that inhibition of super-
oxide with antioxidants73,74 or overproduction of mitochon-
drial superoxide dismutase (SOD)75 can protect against capil-
lary degeneration during diabetic retinopathy in experimental
diabetes, although how this influences AGE accumulation in
the retina has not been studied. Retinal capillary degeneration
remains a hallmark of retinopathy in diabetic animal models
and patients76 and these vessels seem to be important targets
for both AGE- and superoxide-induced toxicity.77 For example,
AGEs induce toxic effects on retinal pericytes by causing oxi-
dative stress and subsequent apoptosis.78 In addition, some
4870 Stitt
studies have indicated that AGEs cause osteoblastic differenti-
ation and calcification in retinal pericytes by the activation of
alkaline phosphatases.79 Pericytes growing on AGE-modified
basement membrane show acute attenuation of endothelin-1
(ETA receptor–mediated) contraction, suggesting that AGE
cross-linking in a surrounding matrix significantly influences
pericyte physiology.80 Indeed, longer exposure times to these
substrate AGEs induce loss of integrin signaling and apoptosis.81
Retinal microvascular endothelial cells also show proangio-
genic responses to AGEs at lower concentrations by the in-
volvement of MAPK, PKC, and NF-␬B signaling pathways,82
although at higher concentrations, these adducts are toxic to
endothelial cells83 and in vivo may eventually lead to enhanced
microvascular closure.84 Under hyperglycemic conditions, ret-
inal microvascular endothelial cells accumulate MGO and
MGO-derived AGE adducts (such as hydroimidazolone and arg-
pyrimidine) which in vivo contribute to premature closure of
capillaries.85 AGEs cause upregulation of ICAM, which medi-
ates retinal capillary leukocyte adherence and inner blood–
retinal barrier breakdown.86 Independent of the complexities
of the diabetic milieu, nondiabetic mice exposed to diabetic-
like levels of injected AGE-albumin show increased retinal
expression of VEGF concomitant with blood–retinal barrier
dysfunction.87 Similar treatments may cause loss of pericytes,88
and the evidence suggests that high serum levels of AGE-
modified proteins (as particularly evident in diabetic patients
with renal dysfunction) induce lesions that are comparable to
those that occur during diabetic retinopathy.
AGE Inhibition and Prevention of Retinopathy
A pharmacologic strategy for AGE-inhibition commenced with
the small nucleophilic hydrazine compound called aminogua-
nidine (or pimagedine).89 This drug is a potent inhibitor of
AGE-mediated cross-linking and has been shown to prevent
diabetic vascular complications, including diabetic retinopa-
thy, in experimental animals.50,90 –93 Aminoguanidine has been
evaluated in a multicenter clinical trial where it failed to
achieve statistically significant lowering of serum creatinine,
and urinary albumin but showed a positive trend toward slow-
ing the progression of overt nephropathy and retinopathy.94
However, it is now known that aminoguanidine is not a spe-
cific AGE inhibitor and also acts as an effective iNOS inhibi-
tor.95
Agents with post-Amadori product scavenging properties
prevent experimental diabetic retinopathy. The so-called Ama-
dorins have an ability to scavenge reactive carbonyls and there-
fore inhibit the conversion of Amadori intermediates to AGEs
and ALEs.96 The derivative of vitamin B6, pyridoxamine (Pyri-
dorin; NephroGenex, Princeton, NJ) is an efficacious and spe-
cific post-Amadori inhibitor97 that reduces retinal AGE accu-
mulation and attenuates the upregulation of basement
membrane–associated genes and capillary acellularity in dia-
betic rat retina.57 More recently, an agent called LR-90 has been
developed as an effective multistage inhibitor of both AGE/ALE
formation with associated renoprotective and anti-inflamma-
tory potential.98 LR-90 prevents diabetic retinopathy in rats at
doses that are several-fold less than the doses of pyridoxamine.99
For many patients there will have been extensive AGE
formation at the time of type 2 diabetes diagnosis. Therefore, it
would be beneficial to attack established cross-links in tissues
and enable subsequent renal clearance of peptide fragments.
An AGE cross-link breaker attacks AGE-derived protein cross-
links and treatment with this drug reduces vascular stiffening
in experimental diabetes.90 The effects of AGE breakers on
diabetic retinopathy have yet to be evaluated.
IOVS, October 2010, Vol. 51, No. 10
INFLAMMATION, RAGE, AND DIABETIC RETINOPATHY
Inflammatory Processes in Diabetic Retinopathy
The involvement of inflammatory processes in the initiation of
neurovascular lesions during diabetic retinopathy has received
recent attention. Global mRNA expression profiling has high-
lighted altered expression of proinflammatory cytokines and
interrelated pathways, not only in the retinal vessels,100 but
also in the neuroglia.101 There is undoubtedly a complex mi-
lieu of dysregulated proinflammatory factors apparent in dia-
betic retina, but there is strong evidence of involvement of
major mediators of inflammation such as IL-1␣, IL-1␤, and IL-6
and TNF␣102–104 that may be linked to microglial activation
and infiltrating monocytes that are increased in diabetic retina,
both in humans105,106 and in animal models.107,108
RAGE as a Component of the Innate
Immune Response
The receptor for AGEs (RAGE) is the most established AGE-
binding protein and acts as a signaling receptor for at least
two distinct AGEs: CML109 and hydroimidazolone adducts.18
RAGE is now known to be a key component of the innate
immune response110 and binds to multiple ligands including
S100B, high-mobility group box (HMGB)-1, amyloid-␤, and
Mac-1 (CD11b/CD18).111,112
RAGE is constitutively expressed in a range of tissues, such
as brain, kidney, liver, heart, and the vasculature, and in various
cell types, including neurons, endothelium, smooth muscle,
epithelium, and inflammatory cells.113 RAGE and downstream
proinflammatory signaling on ligand-binding are associated
with several disease states such as diabetic complications,
Alzheimer’s disease, cancer, and viral infections.110,112,114,115
As a result of alternative mRNA splicing and proteolytic cleav-
age RAGE exists in several forms. The best known is soluble
(s)RAGE, which is composed of the extracellular domains but
lacks the transmembrane and cytosolic sequences. sRAGE may
act as a dominant negative isoform and block RAGE signaling
by function as an extracellular “decoy receptor” to inhibit
RAGE ligand-binding.116
RAGE dimerization occurs on ligand binding117 and, in
association with a binding protein diaphanous (Dia)-1,118 in-
tracellular signaling is initiated. This process can result in
phosphorylation of various protein kinases involving MAPKs,
Rac/Cdc42, and JAK/STATs and subsequently activate the
NF-␬B pathway.119,120 This signal transduction links RAGE to
several inflammation-related cell responses, such as apoptosis,
mobility, migration, and proinflammatory gene expression.116
Thus, RAGE has been the focus for several small-molecule
drugs or neutralizing antibodies that can regulate ligand bind-
ing or downstream signal transduction and thereby prevent
disease.121
RAGE Involvement in Diabetic Retinopathy
In the retina, RAGE expression has been predominantly local-
ized to glia in the inner retina, and this receptor appears to be
upregulated in diabetic conditions.122 AGE-RAGE ligands have
also been demonstrated in the retina, and they often occur at
higher levels during diabetes.51,57,87 Other RAGE ligands in-
cluding S100/calgranulins and HMGB1 are evident in the vit-
reous and preretinal membranes of eyes with proliferative
diabetic retinopathy (PDR) and proliferative vitreoretinopa-
thy (PVR).123 Hyperglycemic mice exhibit enhanced RAGE
expression in the inner retina, particularly in Müller cells,
which show elevated receptor levels at the vitreoretinal sur-
face.124 This finding opens a further new paradigm for possible
RAGE-mediated involvement in retinal neuropathic abnormali-
IOVS, October 2010, Vol. 51, No. 10
ties during diabetes, and recent studies have indicated a role
for the receptor in Müller cell dysfunction.125 It has been
reported that hyperglycemia increases RAGE, S100A8,
S100A12, and HMGB1 expression in human aortic endothelial
cells, a response that can be normalized by a superoxide
dismutase mimetic.126 We have recently shown that this re-
sponse occurs in the diabetic retina whereby hyperglycemia in
vivo and HG exposure to Müller cells in vitro induce the
expression of RAGE and its ligands, leading to cytokine signal-
ing. This signaling, in turn, leads to RAGE signaling and proin-
flammatory cytokine expression, a response that further impli-
cates involvement of this receptor in retinal inflammatory
disease.127
RAGE Blockade as a Potential Therapeutic
Strategy for Diabetic Retinopathy
sRAGE can prevent Müller cell dysfunction125 during diabetes
and retinal capillary leukostasis in AGE-infused normal mice.86
The clinical potential for reducing RAGE signaling in the dia-
betic retina is further underscored by development of new
RAGE-regulating agents. One such agent is TTP488, which is an
orally delivered small molecule, for which phase II studies have
been completed in patients with Alzheimer’s disease. Use of
these agents and other similar strategies is exciting, because
they directly address RAGE-ligand binding and show great
potential for diabetic complications. Evaluation of the role of
RAGE inhibition in diabetic retinopathy is ongoing in several
laboratories.
Some commonly used diabetes drugs, such as thiazolidine-
diones (e.g., rosiglitazone),128 or calcium channel blockers, such
as nifedipine,129 have been shown to reduce RAGE expression in
endothelial cells and could serve to limit the proinflammatory
effects of AGEs. In addition, angiotensin II receptor blockers
(ARBs) can reduce RAGE expression, and this effect should be
factored into the benefit that these agents have in preventing
diabetic retinopathy.130 In addition to the downregulation of
RAGE and associated reduction in oxidative stress, ARBs can act as
selective regulators of PPAR␥, which suggests some cross-talk
between the AGE–RAGE axis and PPAR␥ modulation.131 Thus, a
complex interplay between enhanced levels of AGEs, suppressed
antioxidant status and upregulation of the RAGE axis may to-
gether play a pivotal role in the progression of diabetic retinopa-
thy.
CONCLUSION
Long-term management of retinopathy in the ever-expanding
diabetic patient population involves precise regulation of gly-
cemic, vasotensive, and lipidemic profiles, most effectively in
combination with drugs that ameliorate an array of biochemi-
cal and metabolic abnormalities. Early-stage experimental work
suggests that AGE formation and activation of AGE-receptors
represent important, interconnected pathogenic mechanisms
in diabetic retinopathy, and inhibition of these pathways pre-
sents a valid avenue for therapeutic exploitation. As our knowl-
edge of Maillard chemistry and its biological impact improves,
alongside elucidation of AGE-receptor signaling in various ret-
inal cell-types, there may be exciting new opportunities for
therapeutic management of diabetic retinopathy at all stages of
the disease.
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