J Gastroenterol 2008; 43:780788

DOI 10.1007/s00535-008-2231-4

Atrophic gastritis: deficient complex I of the respiratory chain in

the mitochondria of corpus mucosal cells
MARJU GRUNO1,2, NADEZHDA PEET1, ANDRES TEIN2, RIINA SALUPERE3, MEELI SIROTKINA4, JULIO VALLE5,
ANTS PEETSALU2, and ENN K. SEPPET1
1

Department of Pathophysiology, Centre of Molecular and Clinical Medicine, Faculty of Medicine, University of Tartu, 19 Ravila Street,
50411 Tartu, Estonia
Department of Surgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
3
Department of Internal Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia
4
Department of Pathology, Tartu University Hospital, Tartu, Estonia
5
Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
2

Background. Mitochondrial dysfunction is one of the

most characteristic properties of the cancer cell.
However, it is not known whether oxidative energy
metabolism has already become altered in conditions of
atrophic gastritis, a precancerous state of gastric disease.
The purpose of our study was to comparatively characterize oxidative phosphorylation (OXPHOS) in the
atrophic and nonatrophic gastric corpus mucosa.
Methods. Mucosal biopsies were taken from 12 patients
with corpus dominant atrophic gastritis and from 12
patients with nonatrophic mucosa (controls). One part
of the tissue samples was permeabilized with saponin
for analysis of the function of the respiratory chain
using high-resolution respirometry, and another part
was used for histopathological examination. The serum
level of pepsinogen I (S-PGI) was determined with a
specific enzyme immunoassay (EIA). Results. Compared to the control group, the maximal capacity of
OXPHOS in the atrophy group was almost twofold
lower, the respiratory chain complex I-dependent respiration, normalized to complex II-dependent respiration, was reduced, and respiratory control by ADP in
the presence of succinate was increased in the atrophic
corpus mucosa. In the whole cohort of the patients
studied, serum S-PGI level correlated positively
with complex I-dependent respiration or complex Idependent to complex II-dependent respiration ratio.
Conclusions. Corpus dominant atrophic gastritis is
characterized by decreased respiratory capacity and
relative deficiency of the respiratory complex I of mitochondria in the mucosa, the latter defect probably limiting mitochondrial ATP production and energetic
support of the secretory function of the zymogenic
mucosal cells.

Received: February 7, 2008 / Accepted: May 29, 2008

Reprint requests to: M. Gruno

Key words: respiratory chain, atrophy, gastritis, gastric

mucosa, stomach

Introduction
Gastric corpus dominant atrophic gastritis, a consistent
finding in pernicious anemia (PA), is a definitive risk
factor for gastric cancer.1,2 The prevalence of gastric
carcinoma in PA patients is 1%3%, and 2% of patients
with gastric carcinoma have PA.3
The mechanisms mediating the progression of atrophic gastritis and its transition to carcinoma are unclear.
It has been assumed that decreased acid secretion
caused by a loss of parietal cells in the corpus mucosa
predisposes to gastric cancer by several mechanisms,
including impaired absorption of vitamin C and the constitution of the intragastric milieu allowing overgrowth
of salivary and intestinal bacteria.4 At the cellular level,
increasing evidence points to the crucial role of disturbances of energy metabolism.58 Otto Warburg was the
first to propose that development of cancer is associated with suppression of oxidative phosphorylation
(OXPHOS) and activation of glycolysis.9 More recent
studies have related the pathophysiological role of
mitochondria in cancer cell metabolism to their capability to produce reactive oxygen (ROS) and reactive
nitrogen species.1012 Excess ROS in turn causes defects
in the mitochondrial genome, thus leading to impaired
OXPHOS, which not only limits ATP generation but
also further promotes ROS production.13 Recent data
aim at mitochondria as key organelles in regulation of
expression of the hypoxia-inducible factor-1 (HIF1), which is responsible for shifting metabolism from
OXPHOS to glycolysis, a characteristic change in the
tumor cell. This shift is controlled by multiple means
including the effects of ROS (see review14) and mitochondrial succinate metabolism.15,16 Along with these

M. Gruno et al.: Energy metabolism and atrophic gastritis

781

changes, as a consequence of upregulation of antiapoptotic and downregulation of proapoptotic proteins,

mitochondria are deprived of their efficacy in impelling
apoptosis, which favors unlimited proliferation of the
cancer cells.17,18
There exist only limited data regarding altered
OXPHOS in the mucosal cells in gastric diseases.1922
The status of OXPHOS in patients with atrophic gastritis, a condition known as a precancerous state,23 has not
been investigated as yet. Because in this state morphological studies have revealed a decreased number of
swollen and vacuolized mitochondria,24 a decreased
capacity of OXPHOS might be expected. It is also conceivable that atrophy of the glandular mucosa imposes
qualitative alterations upon the systems of electron
transport and ATP synthesis, thereby inducing transition from a normal mucosa to cancer tissue. For example,
decreased activities of the respiratory chain complexes
enhance mitochondrial production of ROS, which in
turn stimulates tumour development.25 Our recent study
showed that mitochondrial defects in human gastric
mucosal cells can be reliably detected by applying
high-resolution respirometry in studies of saponinpermeabilized gastrobiopsy specimens.19
At present, it is also unclear how the bioenergetic
changes can be related to the secretory function of the
corpus mucosal cells. Based on positive correlation
between the extent of gastric acid secretion and serum
pepsinogen I (SPG-I) level,26 it is expected that the
measurements of the SPG-I provide us with useful
information for predicting the functional and morphological status of the gastric corpus mucosa.2729 In this
regard, we propose that the value of these tests might
be enhanced if the SPG-I levels would correlate with
the indices of mitochondrial function. As the experimental proof for such an assumption is still missing, it
was one aim of our study to address the relationships
between the OXPHOS and SPG-I levels in patients
with gastric disease.

from southern Estonia who underwent upper gastrointestinal endoscopy for epigastric complaints were
included. None of these subjects exhibited corpus
mucosal atrophy, and they had received nonsteroidal
anti-inflammatory drugs, H+-pump inhibitors, or antibiotics to cure their illness.

Material and methods

Blood samples and laboratory tests

Patients
Twelve patients (5 men and 7 women; mean age, 67
4 years) with PA were included in the study as a group
of patients with atrophic corpus gastritis. The criteria
for the diagnosis of PA were macrolytic anemia, appearance of parietal cell antibodies, and low serum vitamin
B12 and folic acid. The diagnosis of corpus atrophic gastritis was based on low serum pepsinogen I (S-PGI)
level and histological confirmation of gastric body
mucosal atrophy. As the control group, 12 consecutive
patients (7 men and 5 women; mean age, 66 3 years)

Endoscopy and biopsy sampling

Mucosal biopsies were taken from the anterior and
posterior walls of the medial part of the corpus and
from the antrum (2 cm above the pylorus from the
anterior and posterior walls of the stomach). One part
of each biopsy specimen was used to determine the
histology of the gastric mucosa and the presence of
Helicobacter pylori (H. pylori), for which these specimens were fixed overnight in neutral buffered formalin
and embedded in paraffin. Tissue sections were stained
for morphological and H. pylori examination by hematoxylin and eosin and modified Giemsa methods. The
presence and severity of chronic gastritis, activity of
gastritis, atrophy, and intestinal metaplasia were graded
according to the Sidney system, from 0 (no changes)
through 1 (mild) and 2 (moderate) to 3 (severe
changes).30 The amount of H. pylori in the mucosa was
estimated semiquantitatively by microscopic counting
as described earlier.31 Another part of the corpus
mucosa specimens was placed immediately in ice-cold
solution A containing (in mM) CaK2EGTA, 2.77,
K2EGTA, 7.23, MgCl2, 6.56, DTT, 0.5, K-MES, 50,
imidazole, 20, taurine, 20, Na2ATP, 5.3, phosphocreatine, 15, at pH 7.1, and used for studies of mitochondrial function.
The gastric biopsies were carried out in accordance
with the European Communities Council Directive
86/609/EEC and with the Declaration of Helsinki.32
Written informed consent was obtained from all
patients, and the Tartu University Ethics Committee
approved the study.

Basal blood samples for measurements of serum pepsinogen I (S-PGI) were drawn after an overnight fast.
Samples for S-PGI were collected into serum tubes. The
serum tubes were centrifuged at 1500 g for 10 min and
the samples were stored at 70C until analyzed. S-PGI
was determined using specific enzyme immunosorbent
assay (EIA) tests (Pepsinogen-I EIA Test Kit; Biohit,
Helsinki, Finland), and the procedure was performed
on a microwell plate in accordance with the manufacturers instructions. All technical equipment required
for the EIA techniques was provided by Biohit,
Finland.

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M. Gruno et al.: Energy metabolism and atrophic gastritis

Preparation of the permeabilized mucosal tissue

Statistical analyses

The permeabilized mucosal tissue was prepared by the

technique described previously.19,33 The mucosal tissue
biopsy samples were cut into smaller pieces in ice-cold
solution A, and the pieces were gently stretched with
thin needles to facilitate the diffusion of the medium
into the intracellular space. Next, the tissue was incubated at 4C, at mild stirring for 30 min in solution A
containing 50 g/ml saponin for permeabilization of
the cell plasma membrane. The permeabilized mucosal
tissue samples were then washed for 10 min in solution
B containing (in mM) CaK2EGTA, 2.77, K2EGTA,
7.23, MgCl2, 1.38, DTT, 0.5, K-Mes, 100, imidazole, 20,
taurine, 20, K2HPO4, 3, and 5 mg/ml bovine serum
albumin, glutamate, 10, and malate, 2, pH 7.1 at 25C;
this procedure of washing was repeated two more times
to remove all metabolites from the cells.

Data are expressed as means SE. The unpaired Students t test was used to analyze differences between the
groups. Correlation analysis was performed by Pearsons test. A P value <0.05 was considered to be statistically significant.

Analysis of the function of the respiratory chain

VO 2, nmol /min/mg ww

The permeabilized mucosal preparations were incubated in solution B in the presence of 10 mM glutamate
and 2 mM malate as the respiratory substrates at 25C,
in the chamber (volume, 1.5 ml) of the oxygraph (Oroboros, Paar KG, Austria). Oxygen consumption by the
mitochondria in the permeabilized gastric mucosal
tissue was monitored by the Clark electrode, assuming
the solubility of oxygen in the medium to be 215 nmoles
O2/ml, and analysis of the function of the respiratory
chain was performed by application of the sequential
multiple substrate-inhibitor titration protocol (see also
Fig. 1) as described.19,33

Tissue
Tissue
ADP
ADP

TMPD
TMPD
Azide
Azide
+ Asc
Asc
Cyt
Cyt cc

Rot
Rot
Succ
Succ

ATR
ATR

Ant
Ant

Results
Histological findings
We found that all 12 patients with PA had chronic
inflammation in the corpus mucosa, with the following
distribution of the severity scores: 1 of 12, score 1; 6 of
12, score 2; and 5 of 12, score 3. In 5 of 12 and 7 of 12
patients, moderate or severe atrophy, respectively,
was observed, and all these patients exhibited a similar
grade of intestinal metaplasia in the gastric corpus. In
the PA group, 2 of 12 patients had also mild active
inflammation in the corpus mucosa. As frequently
observed, the antrum mucosa was also affected, as 10 of
12 PA patients had chronic inflammation and 5 of 12
exhibited atrophy in this part of the stomach. All patients
with PA were found to be H. pylori negative, probably
because of the disappearance of H. pylori in the course
of the progression of corpus atrophy.34,35
None of the patients in the control group had atrophic gastritis in the corpus. At the same time, they
exhibited chronic inflammation in the corpus, with the
following distribution of the inflammation scores: 4 of
12, score 0; 7 of 12, score 1; and 1 of 12, score 2. One of
the 12 patients had also active chronic inflammation
(score 2). In most of the control patients (8/12), the
corpus mucosa was histologically H. pylori positive (3/8,
score 1; 1/8, score 2; 4/8, score 3), which corresponds to
earlier serological findings that more than 80% of the
inhabitants of Estonia are carriers of that bacterium.36,37
Eleven of 12 control patients had chronic inflammation
in the antrum, and 3 of the 12 had atrophic antrum
gastritis.

10 min

Fig. 1. Respirometric investigation of the respiratory chain

in a mucosal biopsy from the gastric corpus. VO2 was
measured in the presence of 10 mM malate and 2 mM
glutamate as the respiratory substrates. Additions: tissue,
permeabilized mucosal tissue, 47 mg ww; adenosine diphosphate (ADP), 2 mM; rotenone (Rot), 10 M; succinate
(Succ), 10 mM; atractyloside (ATR), 0.1 mM; antimycin A
(Ant), 10 M; N,N,N,N-tetramethyl-p-phenylenediamine
(TMPD), 0.5 mM, + ascorbate (Asc), 2 mM; cytochrome c (cyt
c), 8 M; NaN3 (azide), 1 mM

Function of OXPHOS in the atrophic gastric

corpus mucosa
Figure 1 shows a typical recording of the function of
the respiratory chain in permeabilized mucosal preparations. It is evident that the respiration of mitochondria can be effectively stimulated with ADP, a substrate
for ATP synthesis in the presence of inorganic phosphate. Rotenone suppressed this respiratory activity by
the inhibition of complex I of the respiratory chain.
Respiration was restarted by the addition of succinate
(VSucc), a substrate for complex II. The subsequent

M. Gruno et al.: Energy metabolism and atrophic gastritis

addition of atractyloside markedly inhibited succinatedependent respiration by blocking adenine nucleotide

translocase (ANT), this effect indicating preservation
of the intactness of the inner mitochondrial membrane
in a mucosa specimen. Antimycin A, a blocker of the
electron flow through complex III, inhibited the respiration almost entirely; the difference between the rates
of respiration obtained with atractyloside (VAtr) and
antimycin A was taken to indicate the rate of proton
leak. To maximally activate cytochrome oxidase (COX),
ascorbate with N,N,N,N-tetramethyl-p-phenylenediamine (TMPD) was added to the medium. To test the
possible limitations of COX activity resulting from loss
of cytochrome c, an excess amount of cytochrome c was
added to the medium.38 Then, sodium azide was added
to block COX activity, and the difference between the
respiration rates obtained with cytochrome c (in the
presence of TMPD and ascorbate) and sodium azide
was taken to represent COX activity (VCOX). Mean data
from these experiments (Table 1) show that the values
of almost all indices of respiratory rate [basal respiration rate (V0); maximal complex I-dependent ADPstimulated respiration rate (VGlut), VAtr, VCOX, and
proton leak] were about twofold lower in the atrophic
mucosa compared to the nonatrophic tissue. The only
exception was VSucc, which was not significantly
decreased. These data suggest that mucosal atrophy is
associated with both partial loss of mitochondria and
altered properties of the respiratory chain. To analyze
these changes independently of individual variation, the
ratios of respiration rates in the case of different substrates were calculated. Figure 2A shows that in the
nonatrophic corpus mucosa the VGlut/VSucc ratio was
about 1.4. Thus, in state 3 (phosphorylation of ADP),
complex I-dependent respiration was higher than

783

complex II-dependent respiration, which implies the

redox potential gained with NADH-linked substrates
was higher than that gained with FADH2-linked respiratory substrates. Compared to the nonatrophic mucosa,
the atrophic mucosa exhibited reduced VGlut/VSucc but
higher VSucc/VCOX ratios (Fig. 2A,B). Figure 2C demonstrates that in the nonatrophic mucosa the index of
respiration control during oxidation of glutamate/
malate (RCIGlut, calculated as VGlut/V0) was higher compared to the relevant parameter for succinate oxidation
(RCISucc, calculated as VSucc/VAtr). Regarding RCIGlut,
mitochondria in the atrophy and nonatrophy groups
were similar. At the same time, the RCISucc was markedly higher in the atrophy group than in the nonatrophy
group (Fig. 2C). The data presented in Table 1 show
that although state 3 respiration with succinate was
about 1.3 fold lower, proton leak with the same substrate exhibited an even larger (1.9-fold) depression in
the atrophy group compared to the nonatrophy group.
At the same time, these results indicate that atrophy of
the gastric corpus mucosa in PA patients is associated
with relative deficiency of complex I of the respiratory
chain in mitochondria. However, mitochondria use succinate more effectively in this tissue compared to their
counterparts in the nonatrophic mucosa, as they are
more tightly coupled to phosphorylation as a consequence of the smaller proton leak.
Figure 3 shows that the serum pepsinogen I (S-PGI)
levels of the patients correlated fairly well with the VGlut/
VSucc ratio. These levels were also found to correlate
with VGlut (r = 0.684, P = 0.0005, n = 22), but not with
VSucc (not shown). These findings suggest that the low
secretory activity of the gastric oxyntic mucosa can be
related to complex I deficiency developing in association with atrophy of the corpus mucosa.

Table 1. Characterization of the respiratory chain in gastric corpus mucosa

Histological appearance
Parameter

Nonatrophic (n = 12)

Atrophic (n = 12)

P value (t test)

V0
VGlut
VSucc
VATR
VCOX
Proton leak

0.291 0.020
0.820 0.060
0.636 0.067
0.408 0.041
1.271 0.106
0.173 0.038

0.135 0.011
0.366 0.018*
0.493 0.022
0.202 0.017
0.600 0.025
0.090 0.010

<0.001
<0.001
0.055
<0.001
<0.001
<0.05

Values are means SE

The rates of respiration (V) are given in nmol O2/min/mg wet weight: V0, basal respiration
without ADP or ATP; VGlut, ADP-stimulated respiration in the presence of glutamate and
malate; VSucc, ADP-stimulated respiration in the presence of rotenone and succinate; VAtr, respiration after inhibition of succinate-stimulated respiration by atractyloside; proton leak, difference between the rates of respiration before and after addition antimycin A; VCOX, respiratory
equivalent of cytochrome oxidase activity calculated as [VCOX = VTMPD+cytc VTMPD+cytc+NaN3], where
VTMPD+cytc and VTMPD+cytc+NaN3 are TMPD + cyt c-stimulated respiration rates before and after addition of NaN3; VFCCP, respiration in the presence of the uncoupler, FCCP
*P < 0.001 compared to VSucct in atrophy group

784

M. Gruno et al.: Energy metabolism and atrophic gastritis

VSucc/VCOX

VGlut/VSucc

0.5

0.6

0.3

Non-atrophic

Atrophic

Non-atrophic

Atrophic

RCIGlut
4

RCISucc

RCI

0.9

1.5

Non-atrophic

Atrophic

2.5

r =0.727, P =0.0001

VGlut/VSucc

2
1.5

Fig. 2. Changes in the ratios of the respiration rates of the respiratory chain
complexes in the atrophic corpus mucosa.
A VGlut/VSucc, ratio of ADP-stimulated
respiration rate in the presence of glutamate and malate (indicating the activity
of complex I) to ADP-stimulated respiration rate in the presence of rotenone and
succinate (indicating the activity of
complex II). B VSucc/VCOX, ratio of the
VSucc to COX (complex IV)-dependent
respiration rate. C RCI, respiratory
control index; RCIGlut, ratio of VGlut to
basal respiration (V0) without ADP or
ATP; RCISucc, ratio of VSucc to respiration
rate after inhibition of succinate-stimulated respiration by atractyloside; n = 12
in both groups. *P < 0.001 compared to
the nonatrophy group; **P < 0.001 compared to RCIGlut, ***P < 0.001 compared
to RCISucc in the nonatrophy group

This observation is compatible with intactness of the

mitochondrial outer membrane and preservation of the
cytochrome c pool in the intermembrane space, despite
the presence of the underlying disease or stirring of the
specimens in the oxygraph chamber throughout the
experiment.

1
0.5

Discussion

0
0

50

100

150

S-PGI, g/l
Fig. 3. Correlation between the relative deficiency of respiratory chain complex I and serum pepsinogen I (S-PGI) level.
Patients with nonatrophic gastritis (squares) and patients
with atrophic gastritis (triangles); VGlut/VSucc, ratio of ADPstimulated respiration rate in the presence of glutamate and
malate to ADP-stimulated respiration rate in the presence of
rotenone and succinate. n = 22

Evaluation of the status of intactness of mitochondrial

membranes in permeabilized mucosal cells
The mean value of the effect of cytochrome c (relative
increase in respiration in the presence of ascorbate and
TMPD compared to that before cytochrome c addition
(see Fig. 1) was 2.0% 0.9% (n = 12) in the corpus
mucosa of the atrophy group and 2.7% 1.1% (n = 10)
in the mucosa of the nonatrophy group, these changes
being nonsignificant and not different for the groups.

This study reveals a decreased capacity of OXPHOS in

the atrophied corpus mucosa in patients with PA, which
is in line with previous findings that atrophic gastritis is
associated with an abnormally low content of mitochondria in mucosal cells.24 The underlying cellular basis may
include disruption of normal developmental pathways
during autoimmune gastritis, resulting in depletion of
parietal and zymogenic cells, rich in mitochondria, but
rapid proliferation of short-living immature gastric epithelial stem cells with blocked differentiation to endstage cells.39
We found that mitochondria in the nonatrophic
corpus mucosa exhibit mitochondria with markedly
higher RCIGlut than RCISucc, which is characteristic of
mitochondria in mucosa with normal morphology.19,21 A
novel finding was that atrophic gastritis of the corpus
mucosa is associated with relative changes in the activities of individual respiratory chain complexes, expressed
as a decreased VGlut/VSucc ratio in comparison with the
corresponding ratio for the nonatrophic mucosa. A
reduced VGlut/VSucc ratio is considered to be a reliable

M. Gruno et al.: Energy metabolism and atrophic gastritis

index of respiratory chain deficiency at the level of

complex I,4042 registered typically in most mitochondrial diseases. It can result either from an isolated defect
in a single protein, or, more frequently, from multiple
respiratory chain deficiencies.43 Impairment of respiratory chain complexes has also been described in cancer
cells,25,44,45 and dramatic collapse of NADH-linked respiration is known to take place in an early phase of
chemically induced carcinogenesis in the rat liver.46
In our experiments, VGlut and VSucc were measured in
the presence of ADP, i.e., in the conditions of OXPHOS.
Respiratory control by ADP in the presence of glutamate + malate (RCIGlut) was similar for the nonatrophy
and atrophy groups (see Fig. 2C). Thus, the low maximal
respiration with complex I-dependent substrates in the
atrophy group in comparison with the control (see Table
1) was not caused by a defect in the coupling of respiration to ATP synthesis. At the same time, in the atrophy
group, proton leak was relatively less weakly expressed,
giving rise to higher RCISucc than noted in the nonatrophic mucosa. Thus, mitochondria in the atrophic
mucosa showed a markedly tighter coupling between
respiration and phosphorylation, which enabled them
to maintain the VSucc close to that observed in the nonatrophic mucosa.
In general, it appears that atrophy of the corpus
mucosa is associated with a metabolic shift characterized by a lower tissue content of mitochondria and
alterations in the individual properties of mitochondria
in a mode that weakens their ability to use NADHlinked substrates but favors use of the FADH2-linked
substrate, succinate, to fuel OXPHOS. At present, the
reasons for and the underlying mechanisms of this
finding are unclear. However, several potential mechanisms could be outlined on a current state-of-the-art
basis.
First, the role of mitochondrial ROS deserves attention.14 It is known that most of mitochondrial ROS is
produced at the level of complex I, where unpaired
electrons are transferred to O2 to generate superoxide,
and suppression of the complex I significantly compels
ROS production.13,47 Thus, the relative inhibition of
complex I observed in the atrophic mucosa should most
likely be accompanied with ROS production that eventually culminates not only with inflammation and cell
proliferation, the typical features of gastritis, but also
with tumorigenesis. Indeed, among a variety of the
mechanisms underlying cancer development, mitochondrial DNA (mtDNA) mutations induced by ROS represent one of the key elements; and because respiratory
complexes I and IV contain subunits encoded by
mtDNA,13,48 deterioration of complex I may be a major
outcome, irrespective of whether ROS production is the
cause or the result of altered mitochondrial function. In
these conditions, the relatively well preserved function

785

of complex II observed in our study may help to maintain mitochondrial ATP synthesis. In support of this
suggestion, a compensatory elevation in the activity of
complex II in the blood cells of patients with Lebers
hereditary optic neuropathy with a mutation of mitochondrial DNA has been reported49 (see also the next
paragraph).
Second, a defect in complex I may be regarded as a
common and specific marker of adaptation of the mitochondria in response to stressors causal for proliferation
of immature epithelial cells seen in murine autoimmune
gastritis39 and in human H. pylori-associated atrophic
gastritis (in the latter case qualified as intestinal metaplasia).50,51 In these processes, the rearrangements of the
activities of mitochondrial enzymes and the respiratory
chain may be similar to those occurring in rapidly
growing cancer and yeast cells. For example, HeLa cells
possess mitochondria with a truncated Krebs cycle and
probably a defect in complex I, as a consequence of
which they are unable to utilize NADH-linked substrates and switch largely to succinate utilization.52 An
analogous mitochondrial phenotype has been observed
in chronologically aging yeast cells, in which the shunting of the complete Krebs cycle by the glyoxylate cycle
with concomitantly increased rates of succinate formation and oxidation may underlie their higher viability.53
Our study demonstrates a novel outcome of these
changesimproved coupling between oxidation and
phosphorylation with succinate.
Moreover, there exists evidence that altered succinate metabolism in the mitochondria of the atrophic
mucosa may also regulate transition of mucosal cells
into a tumor state, via regulating the HIF-1-mediated
pathway, the activation of which induces expression of
glycolytic enzymes and glucose transporters, thereby
enabling tumor cells to escape hypoxic damage.1416
Very interestingly, Agani et al.15 have shown that the
activity of HIF-1 depends directly on the status of
the mitochondrial respiratory chain, or, more specifically, on a balance between complex I-dependent and
complex II-dependent respiration. By using a cybrid
cell model of altered complex I activity in vivo, they
found that partial complex I deficiency effectively prevented hypoxic induction of HIF-1 protein, whereas
succinate restored the hypoxic response in cybrid cells.15
Other authors have shown that excessive succinate
accumulation promotes tumorigenesis by inhibiting the
prolyl hydroxylation of HIF-1, which eventually
enables translocation of HIF-1 into the nuclei, followed by induction of a tumor-specific metabolic phenotype even in normoxic conditions.16 Notably, the
HIF-1-mediated mechanisms are tightly integrated
with the mitochondrial ROS production described
earlier, as ROS activate HIF-1, probably via its stabilization mediated by the p38 mitogen-activated protein

786

kinase.5456 At present, it is unclear whether and how the

relative complex I deficiency associated with improved
succinate utilization, as observed in our study, may be
related to transition of gastric mucosal cells from proliferation to tumorigenesis. Further studies characterizing the relationships between succinate accumulation
and utilization in association with HIF-1 inactivation
and its activation in gastric mucosal cells are required
to clarify this issue.
It is well known that serum pepsinogen levels are
important biochemical markers for monitoring peptic
secretion and the status of the gastric mucosa in healthy
subjects and in patients with gastrointestinal diseases.57
This study emphasizes further the significance of S-PGI
measurements via showing that changes in this parameter are positively correlated with the VGlut/VSucc
ratio (see Fig. 3). Secretion of pepsinogen is largely
controlled by intracellular Ca2+ cycling,57,58 which is
dependent on cellular ATP,59 as is the case with other
exocytotic processes in gastric cells.60 Suppression of
either complex I- or complex II-dependent respiration
must directly compromise mitochondrial capacity to
produce ATP coupled either to NADH or to FADH2linked substrates.61 Based on these considerations, the
results in Fig. 3 might be interpreted as being caused by
the relative deficiency of complex I. The rate of mitochondrial ATP production remains below that required
for maintaining the activity of endoplasmic reticulum
Ca2+-ATPases in gastric zymogenic cells, which compromises their secretory function. This assumption plus the
evidence that defects in mitochondrial respiratory chain
are related to the shift from normal to cancerous cell
growth (described above) also suggest that the relative
deficiency of complex I may be a marker of an early
precancerous change in the course of atrophic
gastritis.
It has been shown that the mitochondria isolated
from the musculus soleus of rats suffering from experimental peritonitis exhibit abnormally low oxygen consumption in the presence of glutamate plus malate, but
respiration can be significantly upregulated by succinate, bypassing the predominant inhibition of complex
I.62 On the other hand, blocking of complex I with rotenone protects against ischemia/reperfusion injury in the
rat intestinal mucosa in vivo by suppressing increases in
inflammatory cytokines and lipid peroxidation.63 The
foregoing investigations suggest that medical treatment
aimed at site-targeted alterations of the balance between
the utilization of NADH- and FADH2-linked substrates,
either by inhibiting complex I-mediated pathways with
rotenone or by upregulating complex II by succinate,
warrants further exploration in vivo as a putative therapeutic modality for healing gastritis.
In conclusion, the gastric corpus mucosa of patients
with corpus dominant atrophic gastritis exhibits a

M. Gruno et al.: Energy metabolism and atrophic gastritis

decreased respiratory capacity and relative deficiency

of respiratory complex I, these changes correlating
with the decreased secretion of S-PGI. In addition,
mitochondria of the atrophic mucosa showed an
increased coupling of succinate oxidation to phosphorylation. Thus, gastric mucosal atrophy in PA patients
is associated with remodeling of the systems of
OXPHOS, which may limit the secretory capacity of
mucosal cells. Analysis of mitochondrial function in
vivo in gastrobiopsy specimens may offer a novel diagnostic means to identify the defects in the function of
the mitochondrial respiratory chain as early precancerous changes in a diseased gastric mucosa as well as to
monitor the effect of medical treatment at the mitochondrial level.
Acknowledgments. This study was supported by grants No
7117 and No 5266 of the Estonian Science Foundation, and
by grant 0182549s03 of the Estonian Ministry of Education
and Research. The authors thank E. Gvozdkova for technical
assistance and Mrs. E. Jaigma for correction of the English
text of the manuscript.

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