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1 Supplemental Methods: Pharmacokinetic experiments on mice A detailed experimental procedure was described previously [1]. Briefly, male Mate1(+/+) wild-type, Mate1(+/-) heterozygous and Mate1(-/-) homozygous mice between 14 and 18 weeks of age were used. Mice were anesthetized with sodium pentobarbital (50 mg/kg i.p.). They were given bolus doses of 5 mg/kg and 146 mg/kg of metformin and mannitol via the jugular vein, respectively, followed by a constant infusion of 1% mannitol. Blood samples were obtained from both femoral veins at 1, 5, 15 and 30 min and from the abdominal aorta at 60 min after drug administration. After the collection of urine samples for 60 min, the mice were sacrificed and the kidney and liver were removed to determine tissue concentrations of metformin. Sample concentrations of metformin were measured by a high-performance liquid chromatography (HPLC), as previously described [2]. All protocols were approved by the Animal Research Committee, Graduate School of Medicine, Kyoto University. Animal experiments were in accordance with The Guidelines for Animal Experiments of Kyoto University. Western blot analysis Polyclonal antibody was raised against a synthetic peptide corresponding to the intracellular domain of mouse Mate1 (CQQAQVHANLKVN, No. 466-478) [3]. Brush-border membrane fractions were prepared from mouse kidneys. 2 Western blot analysis was carried out in accordance with the NuPAGE manufacturer’s instructions (Invitrogen Co., Carlsbad, California, USA), as previously described [1]. Transport studies HEK293 cells (American Type Culture Collection CRL-1573) were cultured in complete medium consisting of Dulbecco’s modified Eagle’s medium (Wako Pure Chemical Ind., Osaka, Japan) supplemented with 10% fetal bovine serum (Invitrogen) in an atmosphere of 5% CO2 and 95% air at 37ºC. Cellular uptake of [14C]metformin hydrochloride (112 mCi/mmol, American Radiolabeled Chemicals Inc., St. Louis, Missouri) was measured with monolayer cultures grown on poly-D-lysine-coated 24-well plates. The composition of the incubation buffer was as follows: 145 mM NaCl, 3 mM KCl, 1 mM CaCl2, 0.5 mM MgCl2, 5 mM D-glucose, and 5 mM HEPES (pH 7.4 adjusted with NaOH). Ammonium chloride was contained in the incubation medium for the uptake experiments on mouse Mate1, but not for those on mouse Oct1 and mouse Oct2. The experimental procedures were performed as described previously [2, 4, 5]. Clinical study design Forty-eight Japanese patients (18 males, 30 females) with diabetes mellitus were enrolled in this study after providing written informed consent. All were 3 inpatients at the Department of Diabetes and Clinical Nutrition, Kyoto University Hospital. Patients were given metformin hydrochloride tablets (Melbin®, Dainippon Sumitomo Pharma Co. Ltd., Osaka, Japan) continuously for the treatment of diabetes mellitus. Blood samples (2 mL) were collected before the administration to measure baseline metformin levels. Patients received 250 mg, 375 mg or 500 mg of metformin hydrochloride in the morning, and then blood samples were obtained at 4 and 9 hours after administration. This study was conducted in accordance with the Declaration of Helsinki and its amendments and was approved by Kyoto University Graduate School and the Faculty of Medicine, Ethics Committee. Blood samples and genotyping of MATE1, MATE2-K and OCT2 Blood samples were used for the extraction of genomic DNA and for the measurement of metformin plasma concentrations. The determination of metformin plasma concentrations were described above. Genotyping was carried out to examine all non-synonymous SNPs of the MATE1 and MATE2-K genes that have been previously reported [6, 7]. We selected all non-synonymous variants in the OCT2 gene that have been identified in Asian populations (T199I, T201M and A270S) [8-10]. Genomic DNA samples were extracted from peripheral blood using the Wizard® Genomic DNA Purification kit (Promega Co., Madison, Wisconsin, USA). The targeted regions of the MATE and OCT2 genes were amplified by polymerase chain reaction (PCR). 4 The PCR primers and conditions for MATE1 and MATE2-K exons were as previously described [7]. The PCR primers for OCT2 exon 3 and 4 were as follows: exon 3: forward, 5’-GACCATAGGGTATTCAGCACAG-3’; reverse, 5’-AAGAATCTGGGTGGCATTATG-3’; exon 4: forward, 5’-TGATTCCAGCCCTCTGCTAAG-3’; and reverse, 5’-TCTCCACCCTAAAGTTTCCTCTG-3’. The PCR amplification was performed with an initial denaturation step of 3 min at 94°C, followed by 35 cycles of 94°C for 30 s, 60°C for 30 s and 72°C for 1 min, and then a final extension step of 10 min at 72°C. PCR products were purified and then sequenced using Applied Biosystems 3730xl DNA Analyzer (Bio Matrix Research Inc., Chiba, Japan). Clinical pharmacokinetic analysis The population pharmacokinetic analysis was carried out using nonlinear mixed-effects modeling program NONMEM version VI by a first-order conditional estimation method [11, 12]. The oral clearance (CL/F) of metformin was estimated, assuming that metformin pharmacokinetics after an oral administration is described by a 1-compartment model with first-order absorption. To describe the distribution of errors, a logarithmic-error model was selected for pharmacokinetic parameters and residual concentrations. Individual CL/F was obtained by the empirical Bayesian method. Creatinine clearance (Ccr) was measured using 24-hour urine sampling of each patient. 5 Estimated glomerular filtration rate (eGFR) per 1.73 m2 is represented by the 3-variable Japanese equation: eGFR (mL/min/1.73m2) = 194 × Serum creatinine-1.094 × Age-0.287 × 0.739 (if female) [13]. We calculated eGFR using eGFR per 1.73 m2 and body surface area obtained by the formula of DuBois and DuBois as follows: BSA (m2) = 0.007184 × Weight0.425 × Height0.725. Statistical analysis Values were presented as the mean ± S.D. Unpaired Student’s t-test was used to analyze the difference in metformin CL/F between MATE-reference and MATE-variant groups. All pharmacokinetic parameters were statistically assessed with the one-way analysis of variance followed by Dunnett’s test. In NONMEM analysis, the statistical significance of parameters was evaluated by the likelihood ratio test. A difference in the objective function value (a negative of twice the log likelihood difference, -2LLD) more than 6.64, with 1 degree of freedom, was considered statistically significant (P < 0.01). The data were analyzed using GraphPad Prism 4.0 (GraphPad Software Inc., San Diego, California, USA). Supplemental References: 1 2 Tsuda M, Terada T, Mizuno T, Katsura T, Shimakura J, Inui K. Targeted disruption of the multidrug and toxin extrusion 1 (Mate1) gene in mice reduces renal secretion of metformin. Mol Pharmacol 2009; 75: 1280-1286. Kimura N, Masuda S, Tanihara Y, Ueo H, Okuda M, Katsura T, et al. 6 3 4 5 6 7 8 9 10 11 12 13 Metformin is a superior substrate for renal organic cation transporter OCT2 rather than hepatic OCT1. Drug Metab Pharmacokinet 2005; 20: 379-386. Masuda S, Terada T, Yonezawa A, Tanihara Y, Kishimoto K, Katsura T, et al. Identification and functional characterization of a new human kidney-specific H+/organic cation antiporter, kidney-specific multidrug and toxin extrusion 2. J Am Soc Nephrol 2006; 17: 2127-2135. Kimura N, Okuda M, Inui K. Metformin transport by renal basolateral organic cation transporter hOCT2. Pharm Res 2005; 22: 255-259. Tanihara Y, Masuda S, Sato T, Katsura T, Oyawa O, Inui K. Substrate specificity of MATE1 and MATE2-K, human multidrug and toxin extrusions/H+-organic cation antiporters. Biochem Pharmacol 2007; 74: 359-371. Chen Y, Teranishi K, Li S, Yee SW, Hesselson S, Stryke D, et al. Genetic variants in multidrug and toxic compound extrusion-1, hMATE1, alter transport function. Pharmacogenomics J 2009; 9: 127-136. Kajiwara M, Terada T, Ogasawara K, Iwano J, Katsura T, Fukatsu A, et al. Identification of multidrug and toxin extrusion (MATE1 and MATE2-K) variants with complete loss of transport activity. J Hum Genet 2009; 54: 40-46. Leabman MK, Huang CC, Kawamoto M, Johns SJ, Stryke D, Ferrin TE, et al. Polymorphisms in a human kidney xenobiotic transporter, OCT2, exhibit altered function. Pharmacogenetics 2002; 12: 395-405. Fukushima-Uesaka H, Maekawa K, Ozawa S, Komamura K, Ueno K, Shibakawa M, et al. Fourteen novel single nucleotide polymorphisms in the SLC22A2 gene encoding human organic cation transporter (OCT2). Drug Metab Pharmacokinet 2004; 19: 239-244. Kang HJ, Song IS, Shin HJ, Kim WY, Lee CH, Shim JC, et al. Identification and functional characterization of genetic variants of human organic cation transporters in a Korean population. Drug Metab Dispos 2007; 35: 667-675. Beal SL, Boeckmann AJ, Sheiner LB. NONMEM Users Guides. University of California, San Francisco, CA: NONMEM Project Group; 1992. Fukudo M, Yano I, Masuda S, Goto M, Uesugi M, Katsura T, et al. Population pharmacokinetic and pharmacogenomic analysis of tacrolimus in pediatric living-donor liver transplant recipients. Clin Pharmacol Ther 2006; 80: 331-345. Matsuo S, Imai E, Horio M, Yasuda Y, Tomita K, Nitta K, et al. Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis 2009; 53: 982-992.