Plasma total homocyst(e)ine may not be the most appropriate index for cardiovascular disease risk

Plasma Reduced Homocysteine and Other Aminothiol Concentrations in Patients With CKD

BACKGROUND

Hyperhomocysteinemia, a risk factor for cardiovascular disease, is present in the majority of patients with chronic kidney disease (CKD). Several studies indicated that the moiety of homocysteine (Hcy) with an unbound -SH group (reduced Hcy [rHcy]) is the atherogenic molecule. This study is designed to examine the relation between different forms of Hcy and other aminothiols in hemodialysis (HD) patients, peritoneal dialysis (PD) patients, and nondialyzed patients with CKD.

METHODS

rHcy, free Hcy (fHcy), and total Hcy (tHcy), as well as different forms of cysteine, cysteinyl-glycine, and glutathione, were studied by using a high-performance liquid chromatography technique in 19 HD patients, 12 PD patients, 47 patients with CKD, and 15 control subjects.

RESULTS

In PD patients, tHcy levels were 2.8 times greater compared with controls, and in HD patients and those with CKD, 2.1 and 1.9 times greater, respectively. Mean rHcy/tHcy ratios were significantly greater in both HD (P < 0.05) and PD patients (P < 0.01), but did not differ in patients with CKD compared with controls. The decrease in rHcy levels during 1 HD treatment was smaller than that in tHcy and fHcy levels, and rHcy/tHcy ratio increased (before HD, 1.25% +/- 0.44%; after HD, 1.44% +/- 0.66%; P < 0.05).

CONCLUSION

Levels of rHcy and other aminothiols are markedly increased in patients with impaired renal function. In dialysis patients, rHcy/tHcy ratio is markedly elevated and shows greater variability than in patients with CKD and controls. We conclude that because rHcy is believed to induce endothelial dysfunction and may be part of the accelerated atherogenic process in patients with CKD, plasma rHcy level could be a more relevant marker of cardiovascular disease risk than tHcy level.

Methods for measuring sulfur amino acid metabolism

PURPOSE OF REVIEW

The importance of sulfur amino acid metabolism has become increasingly apparent in recent years. Methionine and cysteine are precursors of glutathione, which plays an important role in intracellular antioxidant/free radical defenses. Homocysteine is a non-protein-bound sulfur amino acid strongly implicated in the pathogenesis of several diseases. Both glutathione and homocysteine are affected by abnormalities in sulfur amino acid metabolism that occur in the clinical setting.

RECENT FINDINGS

The Storch-Young model, which determines methionine turnover and homocysteine remethylation by means of a tracer methionine infusion, has been improved by using plasma homocysteine (rather than methionine) enrichment in the model. A complex new tracer method involving the use of tracer serine, methionine, and leucine has been described to determine the effects of folate or pyridoxine deficiency on sulfur amino acid-methyl transfer reactions in humans. The etiology of hyperhomocysteinemia in chronic renal failure is controversial; new concepts in this area are described. There is new interest in the subspecies of homocysteine in the circulation. A new method is described for measuring the extremely low plasma concentrations of reduced homocysteine, using gas chromatography-mass spectrometry. Plasma S-adenosylhomocysteine, measured by fluorescence high-performance liquid chromatography, has been suggested as being superior to homocysteine as a predictor of the risk of vascular disease.

SUMMARY

This review highlights and critiques the above recent developments, and points out some of the complexities and pitfalls in designing and interpreting human metabolic studies involving the sulfur amino acids.

Selenium deficiency in Fisher-344 rats decreases plasma and tissue homocysteine concentrations and alters plasma homocysteine and cysteine redox status

The purpose of the present study was to determine the effect of graded amounts of dietary selenium on plasma and tissue parameters of methionine metabolism including homocysteine. Male weanling Fisher-344 rats (n = 7-8/group) were fed a selenium-deficient, torula yeast-based diet, supplemented with 0 (selenium deficient), 0.02, 0.05 or 0.1 microg (adequate) selenium (as selenite)/g diet. After 61 d, plasma total homocysteine and cysteine were decreased (P < 0.0001) and glutathione increased (P < 0.0001) by selenium deficiency. The concentrations of homocysteine in kidney and heart were decreased (P = 0.02) by selenium deficiency. The activities of liver betaine homocysteine methyltransferase, methionine synthase, S-adenosylmethionine synthase, cystathionine synthase and cystathionase were determined; selenium deficiency affected only betaine homocysteine methyltransferase, which was decreased (P < 0.0001). The ratios of plasma free reduced homocysteine (or cysteine) to free oxidized homocysteine (or cysteine) or to total homocysteine (or cysteine) were increased by selenium deficiency, suggesting that selenium status affects the normally tightly controlled redox status of these thiols. Most differences due to dietary selenium were between rats fed 0 or 0.02 microg selenium/g diet and those fed 0.05 or 0.1 microg selenium/g diet. The metabolic consequences of a marked decrease in plasma homocysteine and smaller but significant decreases in tissue homocysteine are not known.

Novel Approach for the Determination of the Redox Status of Homocysteine and Other Aminothiols in Plasma from Healthy Subjects and Patients with Ischemic Stroke

Background: Plasma “redox” status can be assessed by measurements of reduced (r)-, free (f)-, oxidized (ox)-, and protein-bound (b)-homocysteine (Hcy) plus the related aminothiols cysteine, cysteinylglycine (CysGly), and glutathione (GSH), but sample collection has been complex. The redox status has not been determined in ischemic stroke patients and may provide increased understanding of its role in pathogenesis. We wished to examine the feasibility of this measurement in samples collected in readily available acidic sodium citrate.

Methods: We measured aminothiols and their stability in stabilized protein-free filtrate using acidic sodium citrate (BioPool® StabilyteTM, pH 4.3) vs EDTA whole blood. Before analysis, plasma samples were also ultrafiltered to obtain a protein-free filtrate. The concentrations of total Hcy (tHcy), fHcy, and rHcy and their related aminothiols, cysteine, cysteinylglycine, and glutathione were simultaneously determined on acidic sodium-citrated blood using reversed-phase HPLC with fluorescence detection. Bound and oxidized aminothiols were calculated by difference using the concentrations of the total, free, and reduced fractions. Using this approach, we compared the redox status in newly diagnosed ischemic stroke patients (n = 20) and healthy age- and sex-matched subjects (n = 20).

Results: tHcy, tCys, tCysGly, and tGSH concentrations in whole blood with Stabilyte were stable for 8 h; the reduced fraction of each aminothiol was stable for 4 h. Recovery in the protein-free filtrate was 90–100% for all reduced thiols in acidified sodium-citrated blood. Patients with ischemic stroke had higher plasma tHcy, fHcy, bHcy, rHcy, and oxHcy (P &lt;0.0005) and higher plasma t-, f-, r-, and oxCys (P &lt;0.05). t-, b-, and rCysGly concentrations were lower in the stroke patients (P &lt;0.05), as were t-, b-, and oxGSH (P &lt;0.005).

Conclusions: Collection of blood in acidic sodium citrate (BioPool Stabilyte) permits the determination of the redox status of Hcy and its related aminothiols, which may add to the understanding of their relationship to the etiology of cerebrovascular disease.

Reduction of dehydroascorbic acid by homocysteine

To determine the reductive process of extracellular dehydroascorbic acid (DHA), molecules (homocysteine, homocysteine thiolactone, methionine, cysteine, and homoserine) were tested to identify those with the potential to reduce DHA to ascorbic acid (AA). Homocysteine (Hcy) was the most potent of the molecules tested. The efficacy of Hcy was compared with that of other molecules able to reduce DHA (reduced glutathione (GSH) and cysteine (Cy)). Although all three molecules were able to reduce DHA, GSH and Cy were not to reduce DHA to AA at concentrations lower than 100 micromol/l, and only less than 5% DHA was reduced to AA at concentrations of 200-300 micromol/l. In contrast, Hcy reduced DHA to AA stoichiometrically at concentrations as low as 10 micromol/l. In Jurkat and U937 cells, the increasing concentrations of extracellular Hcy suppressed intracellular dehydroascorbic acid uptake, indicating that extracellular reduction of DHA by Hcy leads to decreasing extracellular DHA available for its intracellular uptake. Simultaneous oxidation and reduction of Hcy and DHA were accelerated extracellularly in the presence of quercetin, an inhibitor of DHA uptake, suggesting that extracellular ascorbic acid concentration increased via blocking DHA uptake by quercetin and reducing extracellular DHA by Hcy. The effect of homocysteine on DHA reduction and uptake was confirmed with human umbilical vein endothelial cells. The oxidation of Hcy also prevented the decrease in DNA synthesis in human umbilical vein endothelial cells, which would occur following exposure to Hcy.

Plasma reduced homocysteine concentrations are increased in end-stage renal disease

BACKGROUND

Plasma total homocysteine (tHcy) concentrations> 15 micromol/L are associated with an increased risk of cardiovascular disease. This is especially the case in end-stage renal disease (ESRD), in which tHcy concentrations commonly range between 20 and 30 micromol/L. Adverse vascular or prothrombotic effects associated with hyperhomocysteinemia are assumed to be mediated by the free sulfhydryl (reduced) form of the molecule (rHcy), but data based on fluorescence high-pressure liquid chromatography (HPLC) indicate that rHcy concentrations are not increased in ESRD despite two- to threefold elevations in tHcy.

METHODS

We developed a sensitive method for measuring plasma rHcy concentrations in which freshly drawn blood is incubated with sodium iodoacetate, and the resulting S-carboxymethylhomocysteine is analyzed by gas chromatography mass spectrometry.

RESULTS

Unlike with the earlier methodology, we found plasma rHcy concentrations two to four times higher than normal in ESRD. These concentrations were lowered by hemodialysis and were proportional to plasma tHcy over the range of tHcy concentrations that has been associated with increased cardiovascular risk (r2 = 0.39, P < 0.0001).

CONCLUSIONS

These results support the hypothesis that homocysteine could directly mediate vascular disease through mechanisms related to the reactivity of its free sulfhydryl group. It remains to be determined how much of the variability between plasma tHcy and rHcy is due to analytical variation and how much is due to biologic factors that separately influence concentrations of the disease marker, tHcy, and its presumed mediator, rHcy.