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Tanyut Huidrom

Professor Kasturi Pal

Physiology

27 April 2023

Paper Review

The article discusses how cardiometabolic risk factors such as age, hypertension, elevated BMI,

fasting glucose, and dyslipidemia are associated with chronic inflammation, and how the

mechanisms behind this relationship are not yet fully understood. These risk factors can impact

cardiovascular function and may also compromise immune cell metabolism, making the immune

system less capable of responding to acute infection. The article suggests that the interaction

between cardiometabolic risk factors and impaired immune cell function may be partially

mediated by reduced mitochondrial respiration. The study aims to determine the associations

between these risk factors and mitochondrial respiration in circulating immune cells from healthy

individuals across the adult lifespan. The study hypothesizes that these cardiometabolic factors

will be negatively correlated with mitochondrial respiration, independent of age.

Cardiometabolic diseases like obesity, diabetes, and atherosclerosis are associated with chronic

low-grade inflammation. Immune cells, especially macrophages and lymphocytes, play an

important role in the pathogenesis of inflammation in these disorders. Mitochondria are involved

not only in energy production but also in regulating immune responses and inflammation.

Mitochondrial dysfunction and impaired mitochondrial respiration have been observed in the
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immune cells of patients with cardiometabolic diseases. Recent evidence suggests that

mitochondrial respiration, especially basal and maximal oxygen consumption rates (OCR), are

reduced in peripheral blood mononuclear cells (PBMCs) from obese individuals and patients

with type 2 diabetes. Similar findings have also been reported in PBMCs from patients with

atherosclerosis. The bioenergetic health index, which reflects the ability of mitochondria to

respond to energetic demands, is also lower in PBMCs from these populations. While

mitochondrial respiration appears impaired in the immune cells of patients with cardiometabolic

disease, the relationship between mitochondrial respiration and individual cardiometabolic risk

factors is not fully understood. Establishing this relationship could help identify potential targets

for intervention. For example, lifestyle changes and medications that modify specific risk factors

may help improve immune cell bioenergetics and reduce inflammation. In summary,

mitochondrial dysfunction and reduced mitochondrial respiration in immune cells have been

observed in obesity, diabetes, and atherosclerosis. However, the association between

mitochondrial respiration in immune cells and individual cardiometabolic risk factors such as

body mass index (BMI), blood pressure, lipids, glucose, and insulin resistance remains unclear.

A better understanding of these relationships may help develop novel strategies to target

inflammation and immune cell bioenergetics in cardiometabolic disease. The article by Anso et

al. examines the relationship between mitochondrial respiration in human PBMCs and several

cardiometabolic risk factors to address this knowledge gap. The authors addressed the existing

gaps in knowledge using various methods. They directly measured mitochondrial respiration in

PBMCs from human subjects using extracellular flux analysis. Most previous studies measured
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respiration in cell lines or animal models. By using human cells, the authors were able to

examine the relationships with human cardiometabolic risk factors.

● They measured both basal and maximal mitochondrial respiration, as well as the

bioenergetic health index. This provided a more comprehensive assessment of

mitochondrial function compared to measuring only basal respiration.

● They correlated mitochondrial respiration parameters with multiple individual

cardiometabolic risk factors, including BMI, blood pressure, triglycerides, HDL and LDL

cholesterol, fasting glucose, and insulin resistance. Most prior studies only examined the

relationship with one or two risk factors. This allowed the authors to determine which

risk factors had the strongest associations with immune cell bioenergetics.

● They highlight potential mediators linking the risk factors to immune cell mitochondrial

respiration, such as increased reactive oxygen species, abnormal fatty acid levels, and

systemic inflammation. This helps generate hypotheses for future mechanistic studies.

The results of the study of particularly high importance were that:

● Mitochondrial respiration of immune cells like monocytes and lymphocytes was

significantly lower in participants with cardiometabolic risk factors like obesity,

hypertension, hyperglycemia, and dyslipidemia compared to healthy controls. This

suggests impaired mitochondrial function in immune cells is associated with increased

cardiometabolic risk.

● Mitochondrial respiration in monocytes and lymphocytes correlated negatively with waist

circumference, blood pressure, fasting glucose, insulin, triglycerides, and positively with
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HDL cholesterol. This indicates mitochondrial function declines with increasing severity

of these risk factors.

● The association between cardiometabolic risk factors and mitochondrial respiration

remained significant even after adjusting for age, sex, and lifestyle factors like smoking

and physical activity. This suggests the relationship is independent of these potential

confounders.

In the present study, we found that LDL-C is negatively

associated with maximal oxygen consumption, spare respira-

tory capacity, and OCR metabolic potential of PBMCs, inde-

pendent of age, blood pressure, BMI, and other blood lipids.

Likewise, we observed near-significant associations between

SBP with maximal respiration and spare respiratory capacity

and a significant association with OCR metabolic potential.

Collectively, these findings suggest a potentially important link

between cardiometabolic risk factors and immune cell energy

metabolism in healthy humans.

Our findings are also in agreement with previous findings in

a group of adults that included patients with early stage heart

failure (29). The negative associations of these risk factors with

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both maximal respiration and spare respiratory capacity sug-

gest that these factors may interfere with the ability of immune

cells to respond to increases in energy demand, such as during

acute infection. In addition, the inverse association with OCR

metabolic potential suggests that elevated risk factors may also

shift immune cells toward more glycolytic energy production.

Immune cell metabolism is complex and cell-type dependent.

As demand for ATP increases during acute infection, some

lymphocytes (e.g., T effector cells) rely more on glycolysis

(55) and exhibit reduced oxidative metabolism as demand for

oxygen exceeds its supply (40). Importantly, the dependence

on glycolysis can be reversed by improving mitochondrial

function, allowing these cells to maximize energy production

through oxidative phosphorylation (40). Memory T cells, while

inherently more oxidative than T effector cells, demonstrate

improved survival in response to reexposure to an antigen

when oxidative metabolism is increased, thus highlighting the

importance of mitochondrial function in the regulation of

adaptive immunity (34, 49). With regard to the innate immune

system, monocytes also undergo metabolic reprogramming as

they differentiate into either proinflammatory M1 monocytes

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or anti-inflammatory M2 monocytes (27). Predifferentiated

monocytes and M2 monocytes are primarily aerobic, whereas

M1 monocytes primarily use anaerobic metabolism (27). Col-

lectively, the unique metabolic requirements of lymphocytes

and monocytes implies an important role of oxidative metab-

olism in the cellular response to acute infection and/or inflam-

mation. This is of particular importance to the present study as

lymphocytes and monocytes make up the vast majority of

PBMCs (26).

The mechanisms by which blood lipids influence immune

cell metabolism requires further elucidation; however, one

possibility is through oxidation of LDL-C. In isolated human

macrophages, oxidized LDL-C induces mitochondrial dysfunc-

tion and promotes apoptosis via the formation of peroxidases,

which decreases mitochondrial membrane potential (4b). Ox-

idized LDL-C also induces mitochondrial membrane dysfunc-

tion in human umbilical vein endothelial cells (53) and acti-

vates calcium-dependent mitochondrial pathways that result in

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apoptosis (51). In addition to oxidation of LDL-C, treatment of

endothelial cells with LDL-C itself reduces ATP content and

decreases the expression of genes that encode for respiratory

complex proteins (19). Similarly, T cells incubated with

LDL-C exhibit reduced mitochondrial mass and ATP produc-

tion (36), and the loading of macrophages with free cholesterol

decreases mitochondrial membrane potential, triggering apo-

ptosis (56).

In addition to attenuating immune cell function directly,

LDL-C-mediated reductions in immune cell respiration may

also be deleterious to the cardiovascular system. The mito-

chondria are major sites of ROS generation (25, 44), which can

be deleterious to the vasculature by inducing endothelial dys-

function (23), a risk factor for cardiovascular disease (24, 50).

Because of their location within the blood, immune cells are in

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constant contact with endothelial cells and may release ROS,

inflammatory cytokines, and other vasoactive molecules that

attenuate vascular function and increased blood pressure (4, 9,

15, 33). In this regard, ameliorating mitochondrial-derived

ROS with a mitochondrial-targeted antioxidant has been shown

to restore endothelial function in older or hypertensive animals

and healthy middle-aged/older adults (17, 20, 38). Thus, im-

proving mitochondrial respiration in circulating immune cells

may improve endothelial function and reduce blood pressure

by reducing a major source of circulating ROS. Importantly,

our results suggest that the effects of LDL-C on mitochondrial

function occurs even at moderate concentrations and in healthy

adults without overt CVD, potentially suggesting a need for

early detection and management of LDL-C for maintenance of

cardiovascular and immune health.

The relations between SBP and mitochondrial respiration

may be explained by elevations in oxidative stress and inflam-

mation, which have been shown to influence respiration (29)

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and are characteristic of individuals with hypertension (41).

Healthy mitochondria are also important for maintaining vas-

cular function, with increased oxidative stress leading to vas-

cular endothelial dysfunction (16, 17, 38). In addition, various

animal models of induced hypertension are associated with

increased mtROS production, inflammation, impaired bioener-

getics, and mitochondrial damage (13). While Li et al. (29)

found that DBP was correlated with mitochondrial respiration

in patients with heart failure, we found no association with

DBP after correcting for other risk factors. This may be due to

population differences or underlying effects of SBP and

LDL-C. It should be noted that blood pressure was measured in

triplicate during a single visit and may not be representative of

true resting blood pressure in all individuals. The interaction

between mitochondrial function and more definitive measures

of blood pressure (e.g., 24-h ambulatory blood pressure)

should be explored in future studies.

We did not see any associations between basal respiration or

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coupling efficiency and any of the cardiometabolic risk factors

that we studied. While ATPO2 was initially negatively corre-

lated with blood glucose, this relationship was likely mediated

by SBP, DBP, and LDL-C. Basal respiration is likely more

representative of quiescent circulating immune cells, such as

naïve T cells or macrophages, which are only activated when in

contact with an antigen or during acute inflammation (18, 27).

Thus, spare respiratory capacity and maximal respiration may

be more important indexes of immune cell function, as these

measures reflect the cells’ capacity to increase energy metab-

olism which is necessary when responding to acute infection or

inflammation (18, 27). Both ATPO2 and coupling efficiency

reflect how much of the basal oxygen consumption is used to

facilitate ATP production. Because our results suggest that

LDL-C plays a greater role in inhibiting maximal respiration, a

more appropriate experiment may be to investigate the cou-

pling of oxygen consumption to ATP production during max-

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imal respiration.

Because of the nature of partial correlations and the limita-

tions of retrospective analyses, we cannot determine the causal

relationship between these risk factors in immune cell respira-

tion. We believe our results may have important implications

for immune cell function in adults with cardiometabolic risk

factors, such as hypertension or dyslipidemia, making these

groups more vulnerable to secondary infection (6) and attenu-

ated immune system function (3, 6, 28). However, we cannot

rule out the possibility that reduced mitochondrial respiration

contributes to an increased serum LDL-C concentration or

blood pressure; however, the effects of inflammation on

LDL-C concentration are equivocal with increases in inflam-

mation associated with both increases and decreases in hepatic

LDL receptor function, resulting in hypo- and hypercholester-

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olemia, respectively (14, 43). Likewise, we are unable to

determine whether impaired immune cell mitochondrial respi-

ration contributes to increased SBP or reflects the mitochon-

drial respiration of vascular tissue. Thus, our results should be

interpreted as preliminary findings to guide future exploration

of these hypotheses.

A limitation of this study is that we did not directly measure

physical activity and only obtained self-reported physical ac-

tivity in a subset of subjects; therefore, we were unable to

definitively assess how physical activity may modulate these

associations. Hedges et al. (22) recently demonstrated an in-

crease in human skeletal muscle mitochondrial respiration

following a 12-wk exercise training program; however, a

similar improvement was not observed in PBMCs, suggesting

that physical activity primarily affects tissues that are more

metabolically active during exercise. Nevertheless, increased

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physical activity has been shown to protect the vasculature

from the damaging effects of elevated blood LDL-C concen-

trations and lowers systolic blood pressure (4a, 52); therefore,

it is worth investigating the potential influence of physical

activity on the association between of these risk factors and

immune cell respiration in future studies. Additionally, we

were unable to assess the role of racial and ethnic differences

on the associations between cardiometabolic risk factors and

mitochondrial function because of a lack of diversity in our

sample. Future studies should investigate these associations in

a more racially diverse population that includes underrepre-

sented minorities, as these groups are often at elevated risk for

cardiometabolic diseases. Finally, our study did not control for

the use of statins or cardiovascular acting medications because

of the relatively small number of subjects taking these drugs;

however, the influence of these drugs on immune cell respira-

tion is worth consideration in future studies.

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Conclusions and future directions. In summary, we have

demonstrated an independent association between LDL-C,

SBP, and mitochondrial respiration in circulating immune cells

after controlling for cardiometabolic risk factors. Collectively,

our findings suggest a possible mechanism linking aberrant

blood lipids and SBP to impaired immune system health. These

results may have important implications for individuals with

more severe cardiometabolic disease, as these factors may

compromise immune system’s ability to respond to an acute

infection. Moreover, even modest increases in LDL-C as ob-

served in the present study may contribute to cardiometabolic

disease risk by promoting the production of mitochondrial-

derived reactive oxygen species and/or inflammatory cyto-

kines. Based on this exploratory analysis, future studies should

aim to identify the mechanisms by which LDL-C and SBP

affect mitochondrial respiration and characterize the influence

of blood lipids on mitochondrial function in patients with

cardiovascular disease and chronic metabolic disorders (e.g.,

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diabetes), as well as those with and without secondary infec-

tions and following treatment.