Ozone Therapy on Rats Submitted to Subtotal Nephrectomy: Role of Antioxidant System

Author Jose´ Luis Calunga1
Author Zullyt B. Zamora1
Author Aluet Borrego1
Author Sarah´ı del Rio2
Author Ernesto Barber3
Author Silvia Menendez1
Author Frank Herna´ndez1
Author Teresita Montero2
Author Dunia Taboada3
Publication 1Department of Biomedicine, Ozone Research Center, National Center for Scientific Research, PO Box 6414, Havana, Cuba
Publication 2Luis D´ıaz Soto Military Medicine Institute, Havana, Cuba
Publication 2Victoria de Giro´n Institute of Basic and Preclinical Sciences, 11600 Havana, Cuba
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Ozone Therapy on Rats Submitted to Subtotal Nephrectomy: Role of Antioxidant System

Chronic renal failure (CRF) represents a world health problem. Ozone increases the endogenous antioxidant defense system, pre- serving the cell redox state. The aim of this study is to evaluate the effect of ozone/oxygen mixture in the renal function, morphology, and biochemical parameters, in an experimental model of CRF (subtotal nephrectomy). Ozone/oxygen mixture was applied daily, by rectal insufflation (0.5 mg/kg) for 15 sessions after the nephrectomy. Renal function was evaluated, as well as different biochem- ical parameters, at the beginning and at the end of the study (10 weeks). Renal plasmatic flow (RPF), glomerular filtration rate (GFR), the urine excretion index, and the sodium and potassium excretions (as a measurement of tubular function) in the ozone group were similar to those in Sham group. Nevertheless, nephrectomized rats without ozone (positive control group) showed the lowest RPF, GFR, and urine excretion figures, as well as tubular function. Animals treated with ozone showed systolic arterial pressure (SAP) figures lower than those in the positive control group, but higher values compared to Sham group. Serum creati- nine values and protein excretion in 24 hours in the ozone group were decreased compared with nephrectomized rats, but were still higher than normal values. Histological study demonstrated that animals treated with ozone showed less number of lesions in comparison with nephrectomized rats. Thiobarbituric acid reactive substances were significantly increased in nephrectomized and ozone-treated nephrectomized rats in comparison with Sham group. In the positive control group, superoxide dismutase (SOD) and catalase (CAT) showed the lowest figures in comparison with the other groups. However, ozone/oxygen mixture induced a significant stimulation in the enzymatic activity of CAT, SOD, and glutathione peroxidase, as well as reduced glutathione in relation with Sham and positive control groups. In this animal model of CRF, ozone rectal administrations produced a delay in the advance of the disease, protecting the kidneys against vascular, hemorheological, and oxidative mechanisms. This behavior suggests ozone therapy has a protective effect on renal tissue by downregulation of the oxidative stress shown in CRF.


CRF represents a world health problem; once estab- lished, it goes irreversibly to a final stage, provoking the patient death. In contrast with the capacity of the kidneys to regain function following acute renal injury, renal in- jury of a more prolonged nature often leads to progressive and irreversible destruction of nephron mass [1]. Such re- duction of renal mass, in turn, causes structural and func- tional hypertrophy of surviving nephrons. This compen- satory hypertrophy is due to an adaptive hyperfiltration mediated by increase in glomerular capillary pressures and flows. Eventually, these adaptations prove maladap- tive, predisposing to sclerosis of the residual glomerular

Correspondence and reprint requests to Silvia Mene´ndez, De- partment of Biomedicine, Ozone Research Center, National Center for Scientific Research, PO Box 6414, Havana, Cuba; sil- via.gra@infomed.sld.cu

population [1, 2, 3, 4]. The intrarenal vasculature is the most affected structure, preventing an appropriate blood flow, favoring the glomerular sclerosis [1, 2, 3, 4, 5]. For that reason, the improvement of the rheological proper- ties of the blood could delay the progression of the CRF.

Glomerulonephritis was the most common initiating cause of CRF in the past, possibly because of its more aggressive treatment. Now, diabetes mellitus and hyper- tensive renal diseases are leading causes of CRF. The in- exorable course to renal failure often is accompanied by anemia, malnutrition, impaired metabolism of carbohy- drates, fats, and proteins, impaired platelet function, and defective utilization of energy [1].

Reactive oxygen species (ROS) play a key interme- diary role in the pathophysiologic processes of a wide variety of clinical and experimental renal diseases. It ranges from acute to chronic injuries, making the kid- ney the site in which several unrelated diseases involve ROS [6]. ROS have been demonstrated to be capable of degrading glomerular basement membrane and inducing glomerular injury, characterized by impaired glomerular filtration and sieving function [7, 8].

In order to eliminate toxic ROS, cells are equipped with various antioxidant defense  systems.  Therefore, the development of tissue injury depends  on the bal- ance between ROS generation and tissue antioxidant de- fense mechanism [9]. Among various antioxidant  sys- tems equipped within aerobic cells, three antioxidant en- zymes, superoxide dismutase (SOD), glutathione perox- idase (GSH-Px), and catalase (CAT), are major mecha- nisms to reduce local levels of ROS. Thus, these enzymes distributed in cytosol and/or mitochondria can abase pri- mary ROS, such as superoxide anion (by SOD) and hy- drogen peroxide (by GSH-Px and CAT) before they can interact to form more reactive cytotoxic metabolites (hy- droxyl radical or hypochlorous acid, among others). Stud- ies in the past demonstrated that glomerular antioxidant enzymes levels are modulated. Thus, the glomerular an- tioxidant enzymes are suggested to play an important role in the functional derangement induced by the ROS [10].

CRF is associated with depressed SOD and elevated NADPH oxidase expression, which can contribute to ox- idative stress by increasing superoxide anion [11]. An- other metabolic disturbance associated with CRF is hy- perlipidemia, closely related with decreased removal and increase of triacylglycerol production. Upregulation  of fatty acid synthase (FAS) gene expression reveals another factor involved in disturbed lipid metabolism in CRF. It seems that elevated plasma insulin and cytokine concen- tration could play an important role in the mechanism responsible for the increased FAS gene expression in CRF [12].

Taking into account some of the ozone therapeutic properties, such as antiplatelet activity [13], enhancement of cell energy [14], and the increase of the antioxidant de- fense system [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25], the

aim of this paper is to evaluate the effect of ozone therapy in the renal function, morphology, and biochemical pa- rameters that measure oxidative stress in an experimental model of CRF.



All reagents used in determinations of GSH, SOD, CAT, GSH-Px, and thiobarbituric acid reactive substances (TBARS) were purchased from Sigma Chemicals (St Louis, Mo). Other reagents of analytical grade were ob- tained from normal commercial sources.


Thirty   young   female   Wistar   rats   (180–200 g) were maintained in an air-filtered and temperature- conditioned room (20–22C) with a relative humidity of 50%–52%. Rats were fed with standard laboratory chow and water ad libitum and were kept under an artificial light/dark  cycle  of  12 hours.  The  experiments  were

performed in accordance with the ethical guidelines for investigations in laboratory animals and were approved by the Ethical Committee for Animal Experimentation of the National Center for Scientific Research, Havana, Cuba.

Treatment schedule and surgical procedure

Ozone (O3) was generated by OZOMED 01 equip- ment manufactured by the Ozone Research Center (Cuba). Ozone was obtained from medical-grade oxygen by means of a silent electric discharge, representing about 3% of the gas mixture (ozone/oxygen). The ozone concen- tration was measured by using a UV spectrophotometer at 254 nm. The ozone dose is the product of the ozone con- centration, expressed as mg/L, by the gas mixture volume (L). By knowing the body weight of the rat, the ozone dose is calculated as 0.5 mg/kg.

Surgery was performed as previously described [26]. Ventral laparotomy was performed under aseptic condi- tions after anesthesia (sodium pentobarbital, 30 mg/kg in- traperitoneal route). The right kidney was then removed, while two-thirds of the left kidney underwent acute in- farction by ligation of two first-order branches of the main renal artery. Recovery from anesthesia and from the sur- gical procedure was complete within 24 hours. Animals were allocated randomly to 3 experimental groups of 10 animals each: (1) Sham group (negative con- trol group), where rats underwent a ventral laparotomy under anesthesia as described above; however, only han- dling of the renal pedicle without the removal of renal mass was performed; (2) positive control group, where rats were subjected to 5/6 renal ablation as described above; and (3) ozone group, where rats were handled as in group 2 but also received, after the damage, 15 ses- sions of the gas mixture, composed of oxygen (O2)+ O3 (2.52.6 mL at a concentration of 50 µg/mL, representing a dose of 0.5 mg/kg weight), by rectal insufflation, once per day.

Sample preparation

A day before the subtotal nephrectomy, all animals were housed in metabolic cages for 24 hours, without food and water ad libitum. In all animals, the weight and the systolic arterial pressure (SAP) in the tail, as well as pro- tein excretion were measured. All these procedures and measurements were repeated, after the partial nephrec- tomy, once a week, for 10 weeks, the time during which, the CRF continued its evolution. The time of the study was not prolonged for more than 10 weeks, avoiding the unpredictable death due to the final stage of the CRF. In the last day of evolution, plasmatic clearance of p- aminohippurate (PAH) and inulin, in order to know the renal plasma flow (RPF) and the glomerular filtration rate (GFR), respectively, were determined using the method of unique injection (no  urine) and  the multicomparti- mental analysis of the plasmatic concentration curves in 9 blood samples [27]. Also, the urine excretion index (urine volume/water ingested) and sodium and potassium excre- tions were determined in order to know tubular work. Creatinine in serum was determined in the final blood sample obtained by intracardiac puncture (2 mL of blood were extracted). Thereafter the animals were euthanized by ether anesthesia. The kidneys were dissected and immediately frozen at 20C until analysis could be completed.

Biochemical assays

PAH and inulin were determined in deproteinated plasma samples by cadmium sulfate, using for PAH a pho- tocolorimetric technique, modified by Smith and Tinkel- stein [28]. Inulin was measured by the direct method of resorcinol without alkaline treatment [29]; correspond- ing calibration curves were used [30]. Proteins were cal- culated by the Biuret photocolorimetric technique us- ing a Shimadzu spectrophotometer [31]. Potassium and sodium urine concentrations were measured for the cal- culation of the excretions of both substances in a Corn- ing flame photometer (model 400), using the method described by Oser [32]. Creatinine in plasma was mea- sured in deproteinated filtrates by the method of sodium tungstate, using for its evaluation the method of picric acid modified by Brot [33].

Kidney homogenates were obtained using a tissue ho- mogenator Ultra-Turrax T25 polytron at 4C. The ho- mogenates were prepared by using a 100 mM KCl buffer (pH 7) containing EDTA 0.3 mM (1:10 w/v) for GSH, TBARS, GSH-Px, and SOD  determinations  (buffer  1). The homogenates  were  spun  down  with  a  centrifuge at 600g for 60 minutes at  4C. The supernatants were taken for the biochemical determinations. GSH was de- termined by a slightly modified version of Beutler method [34], using a spectrophotometer.  One  mL  of  the  kid- ney homogenate, as described before, was mixed with 1.5  mL of 5% metaphosphoric acid and centrifuged at 3000g for 10 minutes at room temperature. Fifty hun- dred microliters of this acidic supernatant was mixed with 2 mL of 0.2 M phosphate buffer and 0.25 mL of 0.04% 5,5-dithio-bis-2-nitrobenzoic acid. Absorbance of the yellow solution was measured at 412 nm within 10 minutes. A molar extinction coefficient of 13.6M cm1 that describes the formation of the thiolate anion by the reaction of sulfhydryl groups with 5,5-dithio-bis-2- nitrobenzoic acid (DTNB) at 412 nm was used to quantify GSH. Enzymatic activity of SOD was determined by a mod- ified version of Minami and Yoshikawa method [35]. One unit of SOD enzymatic activity is equal to the amount of enzyme that diminishes the initial absorbance of nitro blue tetrazolium by 50%. CAT was determined according to Evans and Diplock method [36]. Kidney homogenates for CAT enzymatic assay were carried out using 50 mM phosphate buffer (pH 7) containing  1%  Triton  X-100  (1:9 w/v)  (buffer 2). The enzyme activity is expressed as the first-order constant that describes the decomposition of H2O2  at room temperature.

Enzymatic activity of GSH-Px was measured using a modified version of Thonson et al method (see [37]). The enzyme activity is expressed as international units of en- zymatic activity/mg of protein. International units are ex- pressed as µmol of hydroperoxides transformed/min/mL of enzyme. To estimate TBARS levels, a method described by Ohkawa et al. [38] was used. The absorbance of 3 mL of the colored layer was measured spectrophotometrically at 532 nm, using 1,1,3,3-tetraethoxypropane as a standard. Protein concentrations were determined by the method of Lowry [39], using bovine serum albumin as a standard.

Histological study

Samples of rat kidneys were taken, fixed in 10% neu- tral buffered formalin, processed, and embedded in paraf- fin. A pathologist unaware of the treatment schedule examined the histological sections, stained with hema- toxylin and eosin.

Statistical analysis

First, the outliers preliminary tests for detection of error values were used. Afterward, the one-way analy- sis of variance (ANOVA) then homogeneity variance test (Bartlett-Box) were applied. In addition, Duncan’s multi- ple range test and the Student t test, for the comparison of two groups, were done. Results are presented as mean ± standard deviation (SD). Different letters indicate a statistical significance of at least P < .05.



At the end of the study (10 weeks after the partial nephrectomy), animals treated with ozone showed SAP figures lower than those in the positive control group, but higher values compared to those in Sham group (negative control group). Urine excretion index, in the ozone group, was similar to the negative control group; however, posi- tive control group showed lower values compared to those in the other groups (Table 1). Compared to protein ex- cretion and serum creatinine, figures, in the ozone group, were higher than those in the negative control group, but lower than those in the positive control group. Potas- sium and sodium excretion values in negative control and ozone groups were similar, but lower in the positive group compared to negative and ozone groups (Table 1). RPF and GFR in ozone and Sham groups showed similar fig- ures, but they are higher compared to those in positive control group (Table 1).

Histological renal injuries (RI) were 0%, 13%,  and 100% in the Sham, ozone, and positive control groups, respectively (Table 2). The histological findings for ozone and positive control groups were glomerular  collapse (GC), tubule degeneration (TD), and cortical-medullary

Table 1. Behavior of the systolic arterial pressure (SAP); urine excretion index; protein, potassium, and sodium excretions; creatinine figures; renal plasmatic flow (RPF); and glomerular filtration rate (GFR), at the end of the study, in the different groups. Data are mean ± SD. a, b, and c denote statistical significance of at least P < .05.


Table 2. Histological findings in  the  residual  renal  mass, due to the partial nephrectomy, in the different experimental groups, where GCD stands for glomerular capsule dilatation; GC glomerular collapse;  CTD  convoluted  tubules  dilatation; TD tubule degeneration; CMH cortical-medullar hemorrhages; and RI renal injury. denotes statistical significance of at least P < .05













Positive control 100 100 100 100 100 100
Ozone 100 20 100 10 10 13


hemorrhages (CMH), with 100% for the positive control group compared with 20%, 10%, and 10%, respectively, for the ozone group. Convoluted tubules dilatation (CTD) and glomerular capsule dilatation (GCD) were similar for these groups, shown in 100% of animals. The histological study of renal cortex is observed in Figure 1. GCD and CTD are reversible structural alterations that appear in the first stages of the renal damage by vascular ablation. However, GC, TD, and CMH are lesions that have a sig- nificant effect in the glomerular-tubular relation, causing an irreversible damage in the renal function.

Subtotal nephrectomy induced a significant increase in TBARS (P  =  .0253) of 144%, whereas applications of ozone/oxygen gaseous mixture after subtotal nephrec- tomy increased TBARS to 90% (P  = .0253) over the lev- els of positive control group (Table 3). SOD activity was significantly decreased to 55% (P  = .0143) in positive control group, but, in ozone group, 39% of the enzy- matic activity was recovered (P  = .0253). Ozone therapy after subtotal nephrectomy induced a total increase in SOD activity of 94% (P  = .0281). A similar behavior was observed for CAT enzymatic activity. In positive control group there was a significant decrease of 50%, whereas in ozone group a recovery of 218% was observed (P = .0143) in the enzymatic activity of CAT, indicating a total increase in CAT activity of 268% (P = .0034). GSH activity was increased to 39% (P = .0253) (Table 3).



Animals submitted to the subtraction of 5/6 of the total renal mass moved forward the installation of the CRF, demonstrated by the decrease  of  RPF  and  GFR and the increase of SAP, plasma creatinine, protein ex- cretion, decrease of potassium and sodium excretions, as well as the presence of renal damage in the histologi- cal study. This behavior is still more pronounced in the positive control group, where the renal damage reached 100%.

The results have shown, at the end of the study, that the animals treated with ozone had the highest figures of RPF and GFR, as well as lower figures of proteinuria, plasma creatinine concentration, higher urine excretion, and lower SAP in comparison with the positive control group. These results can be linked to the ozone antiplatelet activity [10], diminishing blood viscosity, that could pro- duce a decrease in the friction between the blood and the glomerular vascular walls, decreasing the flow resis- tance, increasing the RPF and GFR, achieving similar fig- ures to those shown in the Sham group. The flow rise contributes to diminishing the endothelial injuries and the glomerular collapse, avoiding the tubular hypoxia, the hemorrhages, and the release of several proinflammatory cytokines [40, 41, 42, 43].

A depression in SOD expression was reported previ- ously [11] for the same CRF model that we used, that could be correlated with the observed diminution in the activity of SOD and CAT, which can contribute to


Figure 1. Histological study of the renal cortex. (a) Sham group (200×), normal morphology; (b) positive control group (200×), glomerular collapse, cortical hemorrhages, vascular congestion, dilatation of convoluted tubules and glomerular capsule dilatation; and (c) ozone group (400×), a discrete dilatation of convoluted tubules.

Table 3. Renal concentration of different biochemical parameters, thiobarbituric acid reactive substances (TBARS), catalase (CAT), superoxide dismutase (SOD), reduced glutathione (GSH), and glutathione peroxidase (GPx), at the end of the study in the experimen- tal groups. One unit of SOD enzymatic activity is equal to the amount of enzyme that diminishes the initial absorbance of nitroblue tetrazolium by 50% and CAT activity is described as the enzymatic activity quantity that transforms 1 mol of H2O2, at room temper- ature, at 15 min/g of wet tissue. International units are expressed as µmol of transformed hydroperoxides/min/mL of GPx. a, b, and c denote statistical significance of at least P < .05


Groups Positive control Ozone
TBARS (nmol/mg protein) 0.25 ± 0.03a

0.61 ± 0.25b

1.16 ± 0.32c
CAT (K15/g of wet tissue)SOD (units/mg protein) 6.80 ± 0.39a8.72 ± 1.15a

3.40 ± 0.41b

4.74 ± 0.22b

11.12 ± 2.47c16.60 ± 0.29c
GSH (nmol/mg protein) 7.87 ± 0.90a

7.84 ± 0.47a

14.29 ± 1.20b
GPx (IU/mg protein) 6.01 ± 0.25a

7.53 ± 0.94a

10.47 ± 1.22b


oxidative stress by increasing superoxide anion and hy- drogen peroxide generation. As it was reported before [14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24], ozone therapy is an oxidative approach that by provoking brief moments of oxidative stress, may stimu- late antioxidant system to fight against the phenomenon per se. Thus, the significant increase in lipid peroxida- tion, measured in the form of TBARS, was expected af- ter the surgical procedure, followed by fifteen ozone ap- plications. In spite of the significant increase in TBARS, an increase in antioxidant status was seen in the ozone group. The increase in renal TBARS might not be re- lated with an increase in renal damage because the re- markable increase in antioxidant system surpasses this effect, inducing a general status of antioxidant protec- tion.

Renal damage in this model of CRF might correspond with generation of ROS, such as superoxide anion and hy- drogen peroxide. Renal GSH concentration and GSH-Px activity might not be directly affected by subtotal nephrec- tomy in this model. However, ozone therapy induced a significant increase in renal GSH amount and GSH-Px activity (P  = .0253), besides a remarkable stimulation of SOD and CAT activities, that surpass the increase in lipid peroxidation. This suggests that ozone therapy has a protective effect on renal tissue, by upregulation of the antioxidant system, protecting against the oxidative stress provoked by ischemia.

On the other hand, it had been demonstrated that ozone is able to regulate the calcium levels, maintaining its homeostasis, avoiding any damage to the cell structure [44]. Also, it is possible that the ozone therapy effect, with the stimulation of the antioxidant defense system [14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25], protected the tissues against the oxidative stress shown in CRF [6], being in correspondence with the positive histological re- sults obtained, where the ozone group showed the lowest percent of glomerular collapse, tubule degeneration, and cortical-medullary hemorrhages compared with positive control group. In conclusion, in this animal model of CRF, rectal ad- ministrations of ozone produced a delay in the advance of the disease, protecting the kidneys against the deleterious effects shown in the CRF. Consequently, whenever possi- ble, ozone therapy may become an important therapy to improve the quality of life of patients suffering CRF.


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