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Table of Contents
Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 34-40

Pioglitazone induces dysplastic urothelial changes in urinary bladder of experimental diabetes

1 Department of Anatomy, Taibah College of Medicine, Taibah University, Almadina Almonawara, Buraydah, Kingdom of Saudi Arabia; Department of Histology and Medical Cell Biology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Histology and Medical Cell Biology, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Department of Basic Medical Sciences, Unaizah College of Medicine, Qassim University, Buraydah, Kingdom of Saudi Arabia

Date of Submission02-Apr-2021
Date of Decision20-May-2021
Date of Acceptance22-May-2021
Date of Web Publication06-Aug-2021

Correspondence Address:
Dr. Ahmed A. M. Abdel-Hamid
Department of Histology and Cell Biology, Faculty of Medicine, Mansoura University, Mansoura

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmau.jmau_34_21

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Objectives: Pioglitazone (PIO) is a widely prescribed oral antidiabetic drug that has concerns regarding a potential risk of developing carcinoma of the urinary bladder. The objective of the current study was to assess this potential risk. Materials and Methods: The potential risk of PIO-induced urinary bladder carcinoma was assessed in the current study by examining urinary bladder of rats for urothelial cytokeratin (CK) expression and proliferative activity by Ki67 immunostaining. Results: Histological examination revealed dysplastic urothelial changes in PIO per se and diabetes mellitus + PIO (diabetic rats receiving PIO). In addition, a significantly (P < 0.05) decreased CK7 and CK8 expression together with a significantly increased CK20 as well as Ki67 expression was detected in the urothelial cells of groups administrated PIO, contrary to those which did not. Conclusion: The manifestations of urothelial dysplasia evidenced by histological examination as well as by the aberrant expression in CK and Ki67 after PIO administration add supporting evidence at cellular and experimental level to the previous clinical suspicions.

Keywords: Cytokeratin, diabetes, Ki67 staining, pioglitazone, proliferation, urothelial dysplasia

How to cite this article:
Abdel-Hamid AA, Firgany AE. Pioglitazone induces dysplastic urothelial changes in urinary bladder of experimental diabetes. J Microsc Ultrastruct 2023;11:34-40

How to cite this URL:
Abdel-Hamid AA, Firgany AE. Pioglitazone induces dysplastic urothelial changes in urinary bladder of experimental diabetes. J Microsc Ultrastruct [serial online] 2023 [cited 2023 Mar 31];11:34-40. Available from: https://www.jmau.org/text.asp?2023/11/1/34/323335

  Highlights Top

  • Pioglitazone (PIO) significantly decreases cytokeratin (CK) 7 and CK8 expression in urothelium
  • PIO significantly increases CK20 expression in urothelium
  • PIO significantly increases proliferative activity in urothelium
  • PIO provokes dysplastic changes in urothelium observed by routine histology
  • PIO does not affect the urothelium thickness or smooth muscle/collagen ratio.

  Introduction Top

Although pioglitazone (PIO), a thiazolidinedione, is a widely used oral antidiabetic drug in patients with type 2 diabetes mellitus (DM),[1] a contradictory evidence has been emerged regarding its administration and the association with urinary bladder cancer.[2] Some reports proposed that the cumulative use of PIO is not associated with the incidence of bladder cancer;[3],[4] nonetheless, other studies have suggested an increased risk of bladder cancer with its use.[1],[5],[6] Therefore, additional researches are required to provide more precise evidence for the potential implications of PIO administration.

Ki67, a nuclear marker of cellular proliferation, has been shown to correlate with the growth of many neoplasms, including transitional cell carcinoma (TCC). It may be used as a marker of urothelial cells as its expression paralleled that of p53 in TCC.[7] In addition, cytokeratin (CK) family consists of at least 20 types of cytoplasmic intermediate filaments found in the epithelial cells.[8],[9] Its abnormal expression has been found in various forms of neoplasia.[10] CK20, a low-molecular-weight CK, is specifically limited to the superficial umbrella cells in the normal urothelium.[11],[12],[13] Aberrant CK20 expression has been documented as a useful diagnostic marker in urothelial carcinoma.[9]

CK7 and CK8 are also intermediate filaments found in the urothelial neoplasia of the urinary bladder.[14] CK7 together with CK20 has a diagnostic role in differentiating origin of carcinomas, including urothelial carcinoma of the urinary bladder.[15],[16] In addition, CK8 may play a key role in tumor cell invasion, although the exact mechanism is not yet clarified.[17]

Morphologically, the noninvasive, intraepithelial neoplasms of the urothelium may be papillary or flat.[18] One of these flat lesions is urothelial dysplasia, a premalignant condition that should be clearly identified from other flat urothelial lesions as flat hyperplasia, reactive atypia, atypia of unknown significance (AUS), and carcinoma in situ (CIS). In most cases, morphologic features alone suffice for diagnosis; yet, immunohistochemical (IHC) markers by CK and proliferative markers may be required for the precise diagnosis.[19],[20]

The objective of the current study was to investigate the effect of PIO administration on urothelium of urinary bladder focusing on the histological changes including those occurring in the expression of a panel of CK as well as in the proliferative marker, Ki67.

  Materials and Methods Top

Design of the experiment

Adult Sprague–Dawley rats weighing 190–230 g were provided by the Animal Housing Center of the Mansoura College of Pharmacy. Standard plastic cages were used to place the animals at room temperature of 23°C–25°C and under 12/12-h light/dark cycle. All the experimental maneuvers were approved by the Ethical Committee of Mansoura College of Medicine and were conducted according to their guidelines.

The animals were equally divided (20 animals per group) into four groups: I (control group), II (DM group), III (PIO group), and IV (DM + PIO group). During the whole period of experiment control and PIO per se, animals received standard laboratory animal's chow and water ad libitum. To induce DM in Group II and IV, rats were injected with streptozotocin (STZ, 15 mg/kg, intraperitoneally) after feeding on high-fat diet (containing fat which represents 30% of calories) for 2 months.[21] Blood glucose analyses were carried out to get sure that rats become diabetic; rats having fasting blood glucose ≥ 160 mg/dl 1 week after STZ injection for 2 successive measurements were considered diabetic. In addition, PIO (20 mg/kg) was administered orally for 28 days to rats Group II and Group IV.[22]

Histological and immunohistochemical evaluation

After 28 days of the start of PIO treatment, rats were sacrificed. Their urinary bladder was irrigated by a transurethral catheter with 10% formalin solution and kept distended overnight after ligation of both ureters. Rinsing of fixed bladder tissues with PBS and dehydration in graded concentration of alcohol, with subsequent paraffin embedding, were performed. Then, their sections (thickness = 4 μm) were processed for staining by hematoxylin and eosin (H and E), and various IHC assays were processed for anticipated histopathological changes. Meanwhile, Masson's trichrome staining was used to evaluate contents of smooth muscles and collagen in sections of the urinary bladder.

Morphometric assessment

Urothelial thickness

Urothelial thickness was evaluated in the H and E-stained sections of the urinary bladder (×1000). The distance (in μm) between the urothelial basement membrane to the apical border was calculated with ImageJ program v 1.43 (Bethesda, Maryland, USA). In each section, five fields were assessed with the estimation of 10 measurements in each field.

Smooth muscle/collagen ratio

The smooth muscle as well as collagen areas were quantitatively measured in sections of urinary bladder stained by Masson's trichrome. This was also accomplished by ImageJ program using color segmentation technique as a basis for evaluation. The ratio between the smooth muscle area% to that of collagen was estimated, considering the positive area for Masson's stain as the parameter of evaluation (10 fields were assessed/section in five sections for each animal).

Ki67 immunohistochemistry

Paraffin sections of the urinary bladder were IHC stained by anti-Ki67 (1/25, monoclonal, MIB-5, Dako, Glostrup, Denmark) antibodies. Antibodies were applied on paraffin-embedded sections with 20-min heat-induced epitope retrieval in Dako Target Retrieval Solution, citrate pH 6, and 30-min incubation at room temperature with the primary antibody. Combination of biotinylated rabbit anti-mouse immunoglobulins (Dako, code No. E0464) diluted 1:50, and streptavidin/HRP, diluted 1:300, was used for visualization using DAB+ (DakoCytomation) as chromogen.

Cytokeratin 7

To assess Ck7 IHC expression, we used anti-CK-7 antibody (Monoclonal, EPR17078, 1/8000 dilution, Abcam) in the current study. Antigen retrieval was performed heat-mediated procedure with employing Tris/EDTA buffer, at pH 9.0; then, further steps of the protocol IHC technique were commenced. Then, paraffin-embedded urinary bladder was labeled with CK7 ab181598, followed by goat anti-rabbit immunoglobulin G H&L (HRP), at 1/500 dilution. Counterstaining was performed with hematoxylin.

Cytokeratin 8

In the current study, anti-CK 8 antibody (Abcam, M20, Monoclonal, at concentration of 4 μg/ml) was employed to detect CK8 IHC expression with an automated system DAKO Autostainer Plus. Sections of the urinary bladder were rehydrated, and antigen was retrieved by Dako 3-in-1 AR buffer EDTA pH 9.0 in a DAKO PT Link. Slides were blocked in 3% H2O2 in methanol and then in Dako Protein block (containing casein 0.25% in PBS, each for 10 min). Afterward, they were incubated with the primary antibody (for 20 min) and the colorimetric reaction was detected by Diaminobenzidine Dako using Envision Flex amplification kit (30 min). Finally, counterstaining of slides with haematoxylin and coverslipping were commenced.

Cytokeratin 20

Anti-CK 20 antibody (Abcam, SP33 ab64090, Rabbit monoclonal, 1/100 dilution) was purchased to evaluate CK20 IHC expression. Urinary bladder sections were incubated with the primary antibody for 30 min at room temperature. Heat mediated antigen retrieval with Tris-EDTA buffer (pH 6.0, epitope retrieval solution 1) for 10 min. We used an HRP/DAB detection kit as a secondary antibody. Hematoxylin was used as a counterstain.

Statistical analysis

Statistical analysis was performed by SPSS 20 software (Chicago, IL, USA). Mean and standard deviations were used for data presentation and ANOVA test to compare between various groups regarding Ki67 and various histological parameters, whereas Mann–Whitney test was selected for CK quantification. A P < 0.05 was considered statistically significant.

  Results Top

Effect of pioglitazone on routine histology

H and E-stained sections of the control [Figure 1]a and DM [Figure 1]b groups displayed that urothelium is formed of the typical 4–7 layers, with the top one having the umbrella-shaped cells and then the intermediate layer on the underling basal one. The cells exhibited vesicular nuclei with visible nucleolus and frequent cytoplasmic spaces. Although we did not detect a frank sinister pathology in the form of invasive carcinoma as TCC, yet atypical changes of urothelium have been observed in the PIO [Figure 1]c and DM + PIO [Figure 1]d groups. These included loss of the frequent empty spaces seen in the cytoplasm together with relative nuclear augmentation compared to the cytoplasmic compartment (N/C ratio), loss of nuclear polarity, as well as nuclear irregularity, and hyperchromasia. Unexpectedly, mitotic figures were scarcely seen in the urothelium of various groups. On the other hand, the loose connective tissue of the corium remained unchanged in all groups without evidence of inflammatory changes [Figure 1].
Figure 1: Representative bladder micrographs showing atypical characters in the pioglitazone and diabetes mellitus + pioglitazone (c and d respectively) urothelia contrary to those of nondiabetic and diabetes mellitus (a and b respectively) animals. These include partial loss of the frequent empty cytoplasmic spaces, together with relatively augmented N/C ratio and loss of nuclear polarity. Interestingly, occasional binucleation of superficial cells was observed in the diabetes mellitus group. Mitotic figures were not frequently encountered in urothelium of various groups. The corium appears relatively unchanged in various study groups. (H and E, ×400, scale bar = 20 μm)

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Concerning the urothelium thickness and the smooth muscle/collagen ratio, no significant changes were detected in either PIO or DM + PIO groups compared to others [Figure 2]a and [Figure 2]b.
Figure 2: Graphs representing urothelial thickness (a, b μm) and the ratio between smooth muscle and collagen, which remained insignificantly changed in various groups. The lower panel of the figure shows the % of Ki67-stained cells (c) and their intensity score (arbitrary unit, d) which are significantly increased in animals administrated pioglitazone, contrary to those which did not. Values are expressed as mean ± standard deviations (n = 20 in each group). *: Significant versus control group, $: Significant versus diabetes mellitus group, P < 0.05 is significant

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Effect of pioglitazone on urothelial proliferation

To assess the proliferative activity of urothelium, we stained Urinary bladder (UB) sections with anti-Ki67 immunostaining. A minimal to nearly negative Ki67 immunoreactivity was observed in both the nondiabetic [Figure 3]a and DM [Figure 3]b urothelia. Nonetheless, a positive Ki67 immunostaining was detected in urothelial cells of the PIO [Figure 3]c and DM + PIO [Figure 3]d groups which involved its full thickness from top layer to basal one [Figure 3]. This was statistically confirmed by the significant increase in both Ki67% and intensity in urothelial cells of PIO as well as DM + PIO groups versus the other ones [Figure 2]c and [Figure 2]d.
Figure 3: Representative bladder micrographs in various groups immunostained with anti-Ki67. Urothelia of both the nondiabetic and diabetes mellitus (a and b, respectively) animals display a nearly negative Ki67 immunoreactivity. An intense positive Ki67 immunoreactivity is seen in urothelial cells of pioglitazone and diabetes mellitus + pioglitazone (c and d, respectively) groups including the whole epithelial thickness. (Anti-Ki67 immunostaining, ×400, scale bar = 20 μm)

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Effect of pioglitazone on cytokeratin expression

To confirm the dysplastic changes observed by routine histology as well as Ki67 immunostaining, we stained bladder sections of various groups with CK7, CK8, and CK20 immunostaining. The urothelium of both control [Figure 4]a and DM [Figure 4]b groups displayed a positive CK7 reactivity, particularly in the most superficial cells involving the umbrella-shaped ones; nonetheless, PIO [Figure 4]c and DM + PIO [Figure 4]d urothelia showed a weak-to-negative immunoreactivity. In addition, the urothelial cells of both nondiabetic [Figure 5]a and DM [Figure 5]b groups showed a diffuse CK8 reaction including all its layers, whereas that of the PIO [Figure 5]c and DM + PIO [Figure 5]d groups displayed minimal positive-to-negative reaction. On the contrary, the urothelium of both control [Figure 6]a and DM [Figure 6]b groups exhibited CK20 reaction limited to top layer including the umbrella cells. Yet, extension of the CK20 immunoreactivity toward the deeper layer was observed in urothelium of the PIO [Figure 6]c and DM + PIO [Figure 6]d groups.
Figure 4: Representative bladder micrographs showing an intense CK7 reactivity in urothelia of both the control (a) and diabetes mellitus (b) groups, particularly in the most superficial cells involving the umbrella-shaped ones. On the other hand, those of pioglitazone and diabetes mellitus + pioglitazone (c and d, respectively) groups show a negative reactivity towards anti-CK7 antibodies. (Anti-CK7 immunostaining, ×400, scale bar = 20 μm)

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Figure 5: Representative bladder micrographs displaying a diffuse and intense CK8 reactivity in urothelium of both the control and diabetes mellitus (a and b, respectively) groups including all its layers. On the other hand, that of the pioglitazone and diabetes mellitus + pioglitazone (c and d respectively) groups displays minimal to negative reaction towards anti-CK8 antibodies. (Anti-CK8 immunostaining, ×400, scale bar = 20 μm)

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Figure 6: Representative bladder micrographs showing CK20 immunoreactivity limited to top layer including the umbrella cells in urothelium of both the control (a) and diabetes mellitus (b) groups. On the other hand, extension of the CK20 immunoreactivity toward the deeper layers is seen in urothelium of the pioglitazone and diabetes mellitus + pioglitazone (c and d, respectively) groups. (Anti-CK20 immunostaining, ×400, scale bar = 20 μm)

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Statistical validation of expression of CK7, CK8, and CK20 was determined by comparing the corresponding IHC scoring in various groups. A significant decrease in the expression of CK7 [Figure 7]a and CK8 [Figure 7]b was detected in PIO and DM + PIO groups compared to control and DM groups. On the other hand, the score of CK20 expression was significantly increased in the PIO as well as DM + PIO groups versus those which did not administrate PIO whether diabetic or not [Figure 7]c.
Figure 7: Graphs representing CK7, CK8, and CK20 IHC score in various groups. A significantly decreased expression of CK7 (a) and CK8 (b) is detected in groups administered pioglitazone, contrary to those which did not. On the other hand, a significantly increased CK20 expression (c) is detected in urothelia of pioglitazone as well as diabetes mellitus + Pioglitazone compared to controls and diabetes mellitus groups. Expression of CK7, CK8, and CK20 in each group, based on the percentage of cells with strong staining. *: Significant versus control group, $: Significant versus diabetes mellitus group, P < 0.05 by Kruskal–Wallis and Wilcoxon rank-sum test

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  Discussion Top

Routine bladder histology of the control and DM groups displayed that urothelium is formed of 4–7 layers; the most superficial displayed the characteristic cells of umbrella-shaped cells and then an intermediate layer lying on basal cells. Urothelial nuclei appeared vesicular with frequent spaces in the cytoplasm. These findings coincide with what was previously reported.[19],[20] The observed clear cytoplasmic areas occur as a result of the dissolving of its glycogen.[13]

In the current study, atypical changes of urothelium were observed in the PIO and DM + PIO groups including loss of the frequent empty cytoplasmic spaces together with relative nuclear augmentation, compared to the cytoplasmic fragment, loss of nuclear polarity, as well as nuclear irregularity and hyperchromasia without significant changes in urothelial thickness. These findings are typically the morphological manifestations reported in urothelial dysplasia.[12],[23],[24] Cells of the intermediate layer classically demonstrate apical/basal nuclear polarity with the longitudinal axis lying perpendicularly on the basement membrane. Crowding of cells together with a longitudinal axis of their nuclei parallel to the basement membrane is stigmata of loss of this polarity.[13]

Urothelial dysplasia denotes an early morphologic sign of progressive changes between normal urothelium and CIS. It is of clinical significance as up to one-fifth of its cases can progress to further lesions.[25] In contrast, reactive atypia does not progress to dysplasia, CIS, or urothelial carcinoma.[19],[20] It usually follows cystitis, stones, or instrumentation and is manifested by mild nuclear changes occurring in inflamed urothelia with frequent basal mitoses but without loss of the normal nuclear polarity.[25],[26]

Our data revealed occasional binucleation of the superficial cells in the DM group; nonetheless, mitotic figures were not frequently encountered in urothelium of various groups. The occasional binucleation of the superficial cells should not be misinterpreted as dysplastic change.[13] We have previously demonstrated this binucleation in normal nondysplastic urothelium.[27] Similar to our findings, Hodges et al. mentioned that mitotic figures are not usually seen in normal urothelium apart from its basal layer.[13]

Interestingly, the corium remained unchanged in all groups of the current study without evidence of inflammatory reaction or changes in smooth muscle/collagen ratio. This was consistent with former researches which proposed that dysplasia is unlike AUS where the corium beneath urothelium is typically inflamed and acquires neovascularity.[19],[20]

A statistically significant increase in Ki67 immunoreactivity involving full urothelial thickness was detected in the PIO and DM + PIO groups, contrary to the minimal or virtually negative immunoreactivity in the control and DM groups. Ki67 is normally absent or <10% positive in the basal urothelium, indicating a low proliferative rate.[24],[28],[29] The higher percentage and intensity of Ki67 expression in dysplastic urothelial cells comparable to that detected in TCC is supporting evidence that it could progress to invasive TCC.[7]

We detected a significantly decreased IHC score of CK7 and CK8 expression in the groups administrated PIO compared to those which did not. The urothelium of the latter displayed a positive CK7 reactivity, particularly in the top layer and a rather diffused CK8 expression compared to the weak-to-negative reaction of the PIO and DM + PIO groups. CK7 and CK8 expression has been demonstrated in most bladder tumors,[14] and CK7 is detected in a major fraction of carcinomas of the bladder.[9] Yet, Wilkerson mentioned that CK7 and CK8 are detectable in normal, reactive, as well as neoplastic urothelium but nearly undetectable in urothelial dysplasia.[30] Loss of CK8 expression, a characteristic of simple epithelia, may be also seen in interstitial cystitis.[31] Moreover, a decrease in CK7 and CK8 expression can occur in some higher-grade TCCs.[17]

Together with Ki67, CK20 may be helpful in differential consideration for urothelial dysplasia from reactive atypia.[32],[33] Ki67 is well known marker for epithelial proliferation in vascular, [34] metabolic[35-40] as well as pre-neopalstic lesions.[41-43] CK20 expression is restricted to the umbrella cells in normal urothelium.[13],[29] In dysplasia, aberrant expression of CK20 is seen in the deeper layers of the urothelium.[19],[20] This was in agreement with our findings of a significantly increased score of CK20 expression with deeper extension of its immunoreactivity in urothelium of the PIO and DM + PIO compared to other groups.

Although some studies suggested that no evidence of association between the risk of bladder cancer and PIO administration,[3],[4] others have reported a possible increased risk.[1],[5],[44] This was particularly proposed in people after long-term and high-dose cumulative administration.[2],[45] Therefore, cessation of PIO and substitution with a suitable alternative might be recommended in patients with having risk factors, such as smoking, family history, or previous chemotherapy, besides those with newly diagnosed bladder cancer.[1]

  Conclusion Top

Although we did not find a frank sinister pathology as carcinoma, PIO had clearly induced dysplastic changes in urothelium of the urinary bladder manifested by histological alterations besides the aberrant expression of the CK as well as ki67. These findings provide supporting evidence at experimental level for potentially premalignant changes occurred in the urothelium after PIO administration. This warrants both further investigation and a selective and judicious prescription of PIO, particularly in those with high risk of developing bladder carcinoma.


Based on the potential evidence of dysplastic urothelial changes induced by PIO in urinary bladder of experimental diabetes, we recommend further experimental research as well as clinical trials to confirm this potential risk.

Ethical approval

Approval of procedures of this work (Proposal Code: MS.18.05.160-2018/05/30) was obtained from Mansoura College of Medicine Ethical Committee.


The authors have not made any acknowledgment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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