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Hobson S, Arefin S, Rahman A, Hernandez L, Ebert T, de Loor H, Evenepoel P, Stenvinkel P, Kublickiene K. Indoxyl Sulphate Retention Is Associated with Microvascular Endothelial Dysfunction after Kidney Transplantation. Int J Mol Sci 2023; 24:ijms24043640. [PMID: 36835051 PMCID: PMC9960432 DOI: 10.3390/ijms24043640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Kidney transplantation (KTx) is the preferred form of renal replacement therapy in chronic kidney disease (CKD) patients, owing to increased quality of life and reduced mortality when compared to chronic dialysis. Risk of cardiovascular disease is reduced after KTx; however, it is still a leading cause of death in this patient population. Thus, we aimed to investigate whether functional properties of the vasculature differed two years post-KTx (postKTx) compared to baseline (time of KTx). Using the EndoPAT device in 27 CKD patients undergoing living-donor KTx, we found that vessel stiffness significantly improved while endothelial function worsened postKTx vs. baseline. Furthermore, baseline serum indoxyl sulphate (IS), but not p-cresyl sulphate, was independently negatively associated with reactive hyperemia index, a marker of endothelial function, and independently positively associated with P-selectin postKTx. Finally, to better understand the functional effects of IS in vessels, we incubated human resistance arteries with IS overnight and performed wire myography experiments ex vivo. IS-incubated arteries showed reduced bradykinin-mediated endothelium-dependent relaxation compared to controls via reduced nitric oxide (NO) contribution. Endothelium-independent relaxation in response to NO donor sodium nitroprusside was similar between IS and control groups. Together, our data suggest that IS promotes worsened endothelial dysfunction postKTx, which may contribute to the sustained CVD risk.
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Affiliation(s)
- Sam Hobson
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
| | - Samsul Arefin
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
| | - Awahan Rahman
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
| | - Leah Hernandez
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
| | - Thomas Ebert
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
- Medical Department III—Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, D-04103 Leipzig, Germany
| | - Henriette de Loor
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, BE-3000 Leuven, Belgium
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, BE-3000 Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, BE-3000 Leuven, Belgium
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
| | - Karolina Kublickiene
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska, Institutet, 141 52 Stockholm, Sweden
- Correspondence:
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Kanbay M, Ureche C, Copur S, Covic AM, Tanriover C, Sekmen M, Covic A. Kidney transplantation: is it a solution to endothelial dysfunction? Int Urol Nephrol 2022; 55:1183-1191. [PMID: 36396804 DOI: 10.1007/s11255-022-03415-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endothelial dysfunction is associated with elevated cardiovascular risk in patients with end-stage renal disease (ESRD). Kidney transplantation has demonstrated significant ability in reducing mortality and improving quality of life in recipients. Recent studies have also reported improvements in endothelial function following kidney transplantation; however, current literature is limited. METHODS We performed a systematic review of PubMed/Medline, Web of Science, Scopus, Cochrane Library, and CINAHL databases for prospective cohort studies that assessed endothelial function prior to and following kidney transplantation via various clinical markers. Follow-up duration ranged from 1 month to 1 year. A meta-analysis of pooled data was conducted using random-effect models for four key markers: brachial artery flow-mediated dilatation (FMD), high-sensitivity C-reactive protein (hsCRP), nitroglycerin-mediated dilation (NMD), and adiponectin. RESULTS We included nine studies in our final analysis with a total of 524 patients. Significant improvement of all four biomarkers was observed after transplantation. The mean difference was 2.81% (95% CI 1.92-3.71, p < 0.00001) for FMD, 17.27 mg/L (95% CI 5.82-28.72, p = 0.003) for hsCRP, 1.05%, (95% CI 0.56-1.54, p < 0.0001) for NMD, and 9.27 µg/mL (95% CI 5.96-12.57, p < 0.00001) for adiponectin. CONCLUSION There is an immediate reversal of endothelial dysfunction in ESRD patients who undergo kidney transplantation, which may explain observed improvements in cardiovascular morbidity in transplant recipients. Future longitudinal studies are needed to understand possible re-emergence of endothelial dysfunction in the long-term postoperative period.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Section of Nephrology, Koc University School of Medicine, 34010, Istanbul, Turkey.
| | - Carina Ureche
- Cardiovascular Diseases Institute, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Alexandra M Covic
- Department of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mert Sekmen
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
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Hsu BG, Lee MC, Lin HH, Ho CC, Chen YC, Ho GJ. Serum myostatin level is a positive predictor of endothelial function measured by digital thermal monitoring of vascular reactivity in kidney transplantation patients. Tzu Chi Med J 2022; 34:62-68. [PMID: 35233358 PMCID: PMC8830547 DOI: 10.4103/tcmj.tcmj_268_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/24/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives: Myostatin is a myokine predominantly expressed and secreted in skeletal muscle in response to stimulations, including oxidative stress or inflammation. We investigated a potential association between myostatin levels and endothelial function among kidney transplantation (KT) patients. Materials and Methods: Fasting blood samples were collected from 64 KT patients. The endothelial function that indicated by vascular reactivity index (VRI) was measured by digital thermal monitoring test. Serum myostatin levels were measured using a commercial enzyme-linked immunosorbent assay kit. All patients were categorized into three groups according to their VRI values: poor vascular reactivity was considered if VRI <1.0; 1.0 ≤VRI <2.0 indicated intermediate vascular reactivity, and VRI ≥2.0 was grouped as good vascular reactivity. Results: Seven KT patients (10.9%) were categorized as poor vascular reactivity, 24 KT patients (37.5%) were grouped as intermediate vascular reactivity, and 33 KT patients had good vascular reactivity. Advanced age (r = −0.372, P = 0.002) and serum alkaline phosphate (ALP) level (r = −0.341, P = 0.006) were negatively correlated with VRI. However, serum myostatin level (r = 0.430, P < 0.001) was positively correlated with VRI. In multivariable forward stepwise linear regression analysis, high serum level of myostatin (β = 0.441, adjusted R2 change = 0.171; P < 0.001), advanced age (β = −0.317, adjusted R2 change = 0.138; P = 0.003), and serum ALP level (β = −0.270, adjusted R2 change = 0.060; P = 0.011) were significantly associated with VRI in KT patients. Conclusion: Our study showed that fasting myostatin level was positively associated with VRI and endothelial function among KT patients.
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Liew H, Roberts MA, McMahon LP. Markers of the Endothelial Glycocalyx Are Improved following Kidney Transplantation. Kidney Blood Press Res 2021; 46:581-587. [PMID: 34320503 DOI: 10.1159/000517317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The endothelial glycocalyx on the vascular luminal surface contributes to endothelial health and function. Damage to this layer is indicative of vascular injury, reflected by increased levels of its shed constituents in serum and an increase in the perfused boundary region (PBR) when measured in sublingual capillaries using the GlycoCheck™ device. We aimed to examine the longitudinal effects of kidney transplantation on the glycocalyx by measuring biochemical markers of the glycocalyx and endothelial dysfunction and the PBR. METHODS We recruited healthy controls and stage 5 CKD patients scheduled to undergo a kidney transplant. Investigations were performed before transplant and then 1 and 3 months after transplantation. At each point, blood was collected for hyaluronan, syndecan-1, vascular cell adhesion molecule (VCAM-1), and von Willebrand factor (vWF), and a PBR measurement was performed. RESULTS Thirty healthy controls and 17 patients undergoing a kidney transplant were recruited (9 cadaveric and 8 live donation; 12 on dialysis and 5 pre-emptive). Before transplant, transplant recipients had greater evidence of glycocalyx damage than controls. After transplant, PBR improved from median 2.22 (range 1.29-2.73) to 1.98 (1.65-2.25) µm, p = 0.024, and syndecan-1 levels decreased from 98 (40-529) to 36 (20-328) ng/mL, p < 0.001. Similarly, VCAM-1 fell from 1,479 (751-2,428) at baseline to 823 (516-1,674) ng/mL, p < 0.001, and vWF reduced from 3,114 (1,549-5,197) to 2,007 (1,503-3,542) mIU/mL, p = 0.002. Serum levels of hyaluronan remained unchanged. CONCLUSION The combination of reduced PBR and syndecan-1 following transplant suggests that transplantation may improve glycocalyx stability at 3 months after transplant.
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Affiliation(s)
- Hui Liew
- Department of Renal Medicine, Eastern Health, Box Hill, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Matthew A Roberts
- Department of Renal Medicine, Eastern Health, Box Hill, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health, Box Hill, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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Roumeliotis S, Mallamaci F, Zoccali C. Endothelial Dysfunction in Chronic Kidney Disease, from Biology to Clinical Outcomes: A 2020 Update. J Clin Med 2020; 9:jcm9082359. [PMID: 32718053 PMCID: PMC7465707 DOI: 10.3390/jcm9082359] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
The vascular endothelium is a dynamic, functionally complex organ, modulating multiple biological processes, including vascular tone and permeability, inflammatory responses, thrombosis, and angiogenesis. Endothelial dysfunction is a threat to the integrity of the vascular system, and it is pivotal in the pathogenesis of atherosclerosis and cardiovascular disease. Reduced nitric oxide (NO) bioavailability is a hallmark of chronic kidney disease (CKD), with this disturbance being almost universal in patients who reach the most advanced phase of CKD, end-stage kidney disease (ESKD). Low NO bioavailability in CKD depends on several mechanisms affecting the expression and the activity of endothelial NO synthase (eNOS). Accumulation of endogenous inhibitors of eNOS, inflammation and oxidative stress, advanced glycosylation products (AGEs), bone mineral balance disorders encompassing hyperphosphatemia, high levels of the phosphaturic hormone fibroblast growth factor 23 (FGF23), and low levels of the active form of vitamin D (1,25 vitamin D) and the anti-ageing vasculoprotective factor Klotho all impinge upon NO bioavailability and are critical to endothelial dysfunction in CKD. Wide-ranging multivariate interventions are needed to counter endothelial dysfunction in CKD, an alteration triggering arterial disease and cardiovascular complications in this high-risk population.
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Affiliation(s)
- Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, School of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Francesca Mallamaci
- CNR-IFC (National Research Council of Italy, Centre of Clinical Physiology, Clinical Epidemiology of Renal Diseases and Hypertension Unit, Reggio Cal., c/o Ospedali Riuniti, 89124 Reggio Cal, Italy;
| | - Carmine Zoccali
- CNR-IFC (National Research Council of Italy, Centre of Clinical Physiology, Clinical Epidemiology of Renal Diseases and Hypertension Unit, Reggio Cal., c/o Ospedali Riuniti, 89124 Reggio Cal, Italy;
- Correspondence: ; Tel.: +39-340-73540-62
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Junarta J, Hojs N, Ramphul R, Lowe-Jones R, Kaski JC, Banerjee D. Progression of endothelial dysfunction, atherosclerosis, and arterial stiffness in stable kidney transplant patients: a pilot study. BMC Cardiovasc Disord 2020; 20:6. [PMID: 31914943 PMCID: PMC6947963 DOI: 10.1186/s12872-019-01309-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background Kidney transplant patients suffer from vascular abnormalities and high cardiovascular event rates, despite initial improvements post-transplantation. The nature of the progression of vascular abnormalities in the longer term is unknown. This pilot study investigated changes in vascular abnormalities over time in stable kidney transplant patients long after transplantation. Methods Brachial artery flow-mediated dilation (FMD), nitroglycerin-mediated dilation, carotid-femoral pulse wave velocity (cf-PWV), ankle-brachial pressure index, and common carotid artery intima-media thickness (CCA-IMT) were assessed in 18 kidney transplant patients and 17 controls at baseline and 3–6 months after. Results There was no difference in age (51 ± 13 vs. 46 ± 11; P = 0.19), body mass index (26 ± 5 vs. 25 ± 3; P = 0.49), serum cholesterol (4.54 ± 0.96 vs. 5.14 ± 1.13; P = 0.10), systolic blood pressure (BP) (132 ± 12 vs. 126 ± 12; P = 0.13), diastolic BP (82 ± 9 vs. 77 ± 8; P = 0.10), or diabetes status (3 vs. 0; P = 0.08) between transplant patients and controls. No difference existed in vascular markers between patients and controls at baseline. In transplant patients, FMD decreased (− 1.52 ± 2.74; P = 0.03), cf-PWV increased (0.62 ± 1.06; P = 0.03), and CCA-IMT increased (0.35 ± 0.53; P = 0.02). No changes were observed in controls. Conclusion Markers of vascular structure and function worsen in the post-transplant period on long-term follow-up, which may explain the continued high cardiovascular event rates in this population.
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Affiliation(s)
- Joey Junarta
- Renal and Transplantation Unit, St George's University Hospitals, NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Nina Hojs
- Renal and Transplantation Unit, St George's University Hospitals, NHS Foundation Trust, London, UK
| | - Robin Ramphul
- Renal and Transplantation Unit, St George's University Hospitals, NHS Foundation Trust, London, UK
| | - Racquel Lowe-Jones
- Renal and Transplantation Unit, St George's University Hospitals, NHS Foundation Trust, London, UK
| | - Juan C Kaski
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals, NHS Foundation Trust, London, UK. .,Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
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Kaczmarska M, Grzelak P, Goździk M, Stefańczyk-Jakubowicz K, Stefańczyk L, Kurnatowska I. Arterial vessel reactivity in patients in the long term after kidney transplantation - preliminary study. Arch Med Sci 2019; 15:1240-1246. [PMID: 31572469 PMCID: PMC6764299 DOI: 10.5114/aoms.2019.87240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/02/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the endothelial-dependent and -independent arterial vessels' reactivity in patients in the long term after kidney transplantation (KTx). MATERIAL AND METHODS The study included 36 (15 females; 21 males) patients after KTx with good, stable graft function and 94 healthy individuals (51 males, 43 females). The endothelial-dependent dilatory capacity of the brachial artery was estimated by an ischemic test (flow-mediated dilation - FMD), and independent by nitroglycerin-mediated vasodilation (NMD). The results were shown for age-related groups and compared with age-related healthy people. RESULTS KTx patients were mean 5.1 ±2.3 years after transplantation with the mean estimated glomerular filtration rate (eGFR) 50.3 ±17.1 ml/min/1.73 m2. The mean vessel diameter before tests was significantly larger in healthy people than in KTx patients. The FMD test showed vasodilation becoming weaker along with age in both groups, but in KTx patients this relationship was clearly enhanced. The NMD was delayed in relation to age, and in KTx patients was preserved, being only slightly weaker than in healthy people. CONCLUSIONS Both endothelium-dependent and -independent arterial wall reactions decrease with age. The endothelial-dependent vascular response is more attenuated in KTx patients than the independent one. The endothelium-independent vasodilation in KTx patients is comparable with that in healthy people.
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Affiliation(s)
- Magdalena Kaczmarska
- Department of Radiology and Diagnostic Imaging, Medical University of Lodz, Lodz, Poland
| | - Piotr Grzelak
- Department of Radiology and Diagnostic Imaging, Medical University of Lodz, Lodz, Poland
| | - Maciej Goździk
- Department of Clinical Pharmacology, 1 Chair of Internal Medicine, Medical University of Lodz, Lodz, Poland
- Department of Nephrology, Norbert Barlicki Memorial Teaching Hospital, Lodz, Poland
| | | | - Ludomir Stefańczyk
- Department of Radiology and Diagnostic Imaging, Medical University of Lodz, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, 1 Chair of Internal Medicine, Medical University of Lodz, Lodz, Poland
- Department of Nephrology, Norbert Barlicki Memorial Teaching Hospital, Lodz, Poland
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Chen TL, Lee MC, Ho CC, Hsu BG, Tsai JP. Serum Adipocyte Fatty Acid-Binding Protein Level is Negatively Associated with Vascular Reactivity Index Measured by Digital Thermal Monitoring in Kidney Transplant Patients. Metabolites 2019; 9:E159. [PMID: 31370219 PMCID: PMC6724141 DOI: 10.3390/metabo9080159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/04/2022] Open
Abstract
Adipocyte fatty acid-binding protein (A-FABP) is abundantly found in mature adipocytes and is involved in cardiovascular disease. Our aim is to investigate the association between serum A-FABP levels and endothelial function among kidney transplant (KT) patients. Fasting blood samples were obtained from 80 KT patients. Serum A-FABP levels were measured using a commercially available enzyme immunoassay kit. Endothelial function and vascular reactivity index (VRI) were measured using digital thermal monitoring test. In this study, VRI < 1.0, VRI 1.0-1.9, and VRI ≥ 2.0 were defined as poor, intermediate, and good vascular reactivity, respectively. There were 12 (15.0%), 30 (37.5%), and 38 (47.5%) KT patients categorized as having poor, intermediate, and good vascular reactivity, respectively. Increased serum levels of alkaline phosphatase (p = 0.012), γ-glutamyltranspeptidase (GGT; p = 0.032), and A-FABP (p < 0.001) were associated with decreased vascular reactivity. Multivariable forward stepwise linear regression analysis revealed that age (β = -0.283, adjusted R2 change = 0.072; p = 0.003) and serum log-A-FABP level (β = -0.514, adjusted R2 change = 0.268; p < 0.001) were significantly associated with VRI values in KT patients. We concluded that serum fasting A-FABP level is negatively associated with VRI values and plays a role in endothelial dysfunction of KT patients.
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Affiliation(s)
- Tai-Li Chen
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Ming-Che Lee
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Ching-Chung Ho
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan
| | - Bang-Gee Hsu
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan.
- Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97004, Taiwan.
| | - Jen-Pi Tsai
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 62247, Taiwan.
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Outcomes for peripheral vascular intervention and lower extremity bypass in kidney transplant recipients are superior to outcomes of patients remaining on dialysis. J Vasc Surg 2019; 69:1849-1862.e6. [DOI: 10.1016/j.jvs.2018.10.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/02/2018] [Indexed: 11/17/2022]
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Yilmaz O, Afsar B, Ortiz A, Kanbay M. The role of endothelial glycocalyx in health and disease. Clin Kidney J 2019; 12:611-619. [PMID: 31583086 PMCID: PMC6768294 DOI: 10.1093/ckj/sfz042] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Indexed: 12/20/2022] Open
Abstract
The endothelium is the largest organ in the body and recent studies have shown that the endothelial glycocalyx (eGCX) plays a major role in health and disease states. The integrity of eGCX is vital for homoeostasis and disruption of its structure and function plays a major role in several pathologic conditions. An increased understanding of the numerous pathophysiological roles of eGCX may lead to the development of potential surrogate markers for endothelial injury or novel therapeutic targets. This review provides a state-of-the-art update on the structure and function of the eGCX, emphasizing the current understanding of interorgan crosstalk between the eGCX and other organs that might also contribute to the pathogenesis of kidney diseases.
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Affiliation(s)
- Onur Yilmaz
- Department of Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
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Liew H, Roberts MA, MacGinley R, McMahon LP. Endothelial glycocalyx in health and kidney disease: Rising star or false Dawn? Nephrology (Carlton) 2017; 22:940-946. [DOI: 10.1111/nep.13161] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Hui Liew
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Matthew A Roberts
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Robert MacGinley
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School; Monash University; Box Hill Victoria Australia
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12
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Long term evolution of endothelial function during kidney transplantation. BMC Nephrol 2016; 17:160. [PMID: 27770793 PMCID: PMC5075412 DOI: 10.1186/s12882-016-0369-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 10/11/2016] [Indexed: 01/22/2023] Open
Abstract
Background Endothelial dysfunction is an important precursor to the development of atherosclerosis, and has been suggested to play a role in the increased cardiovascular risk in patients with end stage renal disease. Endothelial function improves rapidly following post kidney transplantation, but the long term change remains unclear. Hypothesizing that endothelial function would remain improved long term post kidney transplantation, we evaluated the longitudinal change of endothelial function, measured by flow-mediated dilation (FMD) of the brachial artery, from months 1 to 24 post transplantation. Given the previously reported association of fibroblast growth factor 23 (FGF-23) with endothelial dysfunction, we also examined changes in the association between FGF-23 levels and the change in FMD following kidney transplantation. Methods We performed a prospective cohort study of 149 kidney transplant recipients, measuring endothelial function by FMD at months 1, 12, and 24 post-transplant. FGF-23 levels were measured at months 1 and 24 post-transplant. Linear mixed effects models were used to assess both the unadjusted and adjusted outcomes. Results The cohort (mean age 49 ± 13 years) was 74 % male and 75 % white. The median FMD was 6.3 % (IQR: 3.4, 10.2), 5.4 % (IQR: 3.1, 8.5), and 5.6 % (IQR: 3.5, 9.1) at 1, 12, and 24 months, respectively. After adjustment for covariates, compared to month 1, no change occurred in FMD at 12 months (−0.66 %; 95 % CI: −1.81 %, 0.49 %; P = 0.262) or 24 months (−0.25 %; 95%CI: −1.76 %, 1.26 %; P = 0.746). FGF-23 decreased significantly over time (P = 0.024), but there was no significant association between FGF-23 and FMD (P = 0.799). Conclusion Endothelial function remained stable at 12 and 24 months from 1 month post-kidney transplant, indicating that the improved endothelial function seen with transplant is maintained up to 2 years post transplantation. There was also no significant association between FGF-23 and endothelial function following kidney transplantation.
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13
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Ali A, Macphee I, Kaski JC, Banerjee D. Cardiac and vascular changes with kidney transplantation. Indian J Nephrol 2016; 26:1-9. [PMID: 26937071 PMCID: PMC4753734 DOI: 10.4103/0971-4065.165003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular event rates are high in patients with chronic kidney disease (CKD), increasing with deteriorating kidney function, highest in CKD patients on dialysis, and improve with kidney transplantation (KTx). The cardiovascular events in CKD patients such as myocardial infarction and heart failure are related to abnormalities of vascular and cardiac structure and function. Many studies have investigated the structural and functional abnormalities of the heart and blood vessels in CKD, and the changes that occur with KTx, but the evidence is often sparse and occasionally contradictory. We have reviewed the available evidence and identified areas where more research is required to improve the understanding and mechanisms of these changes. There is enough evidence demonstrating improvement of left ventricular hypertrophy, except in children, and sufficient evidence of improvement of left ventricular function, with KTx. There is reasonable evidence of improvement in vascular function and stiffness. However, the evidence for improvement of vascular structure and atherosclerosis is insufficient. Further studies are necessary to establish the changes in vascular structure, and to understand the mechanisms of vascular and cardiac changes, following KTx.
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Affiliation(s)
- A Ali
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK
| | - I Macphee
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK
| | - J C Kaski
- Division of Clinical Sciences, Cardiovascular and Cell Sciences Research Institute, St George's University of London, Tooting, London SW17 0RE, UK
| | - D Banerjee
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK; Division of Clinical Sciences, Cardiovascular and Cell Sciences Research Institute, St George's University of London, Tooting, London SW17 0RE, UK
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Dundon BK, Torpey DK, Nelson AJ, Wong DTL, Duncan RF, Meredith IT, Faull RJ, Worthley SG, Worthley MI. Beneficial cardiovascular remodeling following arterio-venous fistula ligation post-renal transplantation: a longitudinal magnetic resonance imaging study. Clin Transplant 2014; 28:916-25. [DOI: 10.1111/ctr.12402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Benjamin K. Dundon
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - David K. Torpey
- Department of Renal Medicine; Royal Adelaide Hospital; Adelaide SA Australia
| | - Adam J. Nelson
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Dennis T. L. Wong
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - Rae F. Duncan
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Ian T. Meredith
- Monash Cardiovascular Research Centre; Monash HEART; Monash Health; Melbourne Vic. Australia
| | - Randall J. Faull
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
- Department of Renal Medicine; Royal Adelaide Hospital; Adelaide SA Australia
| | - Stephen G. Worthley
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
| | - Matthew I. Worthley
- Cardiovascular Research Centre at the Royal Adelaide Hospital; University of Adelaide; Adelaide SA Australia
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Sharma J, Kapoor A, Muthu R, Prasad N, Sinha A, Khanna R, Kumar S, Garg N, Tewari S, Sharma RK, Goel P. Assessment of endothelial dysfunction in Asian Indian patients with chronic kidney disease and changes following renal transplantation. Clin Transplant 2014; 28:889-96. [PMID: 24930933 DOI: 10.1111/ctr.12398] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endothelial dysfunction may explain increased cardiovascular risk in patients with chronic kidney disease (CKD). METHODS Brachial artery was imaged during reactive hyperemia (endothelium-dependent, flow-mediated dilatation, FMD) and during glyceryl trinitrate-mediated dilatation (nitroglycerine-mediated dilatation, NMD, endothelium-independent) in 108 patients with CKD and three months following renal transplantation (RT) in 60 of them. RESULTS Patients with CKD had significantly lower FMD vs. controls (9.1% vs. 18.3%, p < 0.001) while NMD was comparable (19.8% vs. 21.8%, p = ns). Impaired FMD (<4.5%) was observed in 26.8% patients with CKD and was more common in those on hemodialysis (HD; 28.4% vs. 15.4%) vs. those not on dialysis. FMD for patients with glomerular filtration rate (GFR) 15-60 vs. <15 mL/min/1.73 m(2) was 12.9% and 8.8% (p = 0.05; respectively -29% and -52% lower vs. controls), indicating reduced FMD with increasing CKD severity. There was +72% increase in FMD following RT (9.1 to 15.7%, p < 0.001) while mean NMD was unchanged. Following RT, only 3.3% had impaired FMD. CONCLUSIONS Patients with CKD have endothelial dysfunction as evidenced by reduced FMD. Decreased FMD indicating worsening endothelial function was noted with increasing severity of CKD. Within three months of RT, there was significant improvement in FMD, while NMD values did not change.
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Affiliation(s)
- Jugal Sharma
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
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Assessment of endothelial dysfunction: the role of symmetrical dimethylarginine and proinflammatory markers in chronic kidney disease and renal transplant recipients. DISEASE MARKERS 2013; 35:173-80. [PMID: 24167363 PMCID: PMC3774969 DOI: 10.1155/2013/306908] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/19/2013] [Accepted: 07/17/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The study was designed to evaluate associations between symmetric dimethylarginine (SDMA), inflammation, and superoxide anion (O2∙-) with endothelial function and to determine their potential for screening of endothelial dysfunction in patients with chronic kidney disease (CKD) and renal transplant (RT) recipients. MATERIALS AND METHODS We included 64 CKD and 52 RT patients. Patients were stratified according to brachial artery flow-mediated dilation (FMD). RESULTS Logistic regression analysis showed that high SDMA and high sensitive C-reactive protein (hs-CRP) were associated with impaired FMD in CKD and RT patients, after adjustment for glomerular filtration rate. The ability of inflammation, SDMA, and O2∙- to detect impaired FMD was investigated by receiving operative characteristic analysis. Hs-CRP (area under the curves (AUC) = 0.754, P < 0.001), IL-6 (AUC = 0.699, P = 0.002), and SDMA (AUC = 0.689, P = 0.007) had the highest ability to detect impaired FMD. SDMA in combination with inflammatory parameters and/or O2∙- had better screening performance than SDMA alone. CONCLUSIONS Our results indicate a strong predictable association between hs-CRP, SDMA, and endothelial dysfunction in CKD patients and RT recipients. The individual marker that showed the strongest discriminative ability for endothelial dysfunction is hs-CRP, but its usefulness as a discriminatory marker for efficient diagnosis of endothelial dysfunction should be examined in prospective studies.
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Baas MC, Gerdes VEA, Ten Berge IJM, Heutinck KM, Florquin S, Meijers JCM, Bemelman FJ. Treatment with everolimus is associated with a procoagulant state. Thromb Res 2013; 132:307-11. [PMID: 23906938 DOI: 10.1016/j.thromres.2013.07.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 06/05/2013] [Accepted: 07/09/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Renal transplant recipients are at increased risk of venous thromboembolic events, which is in part caused by their treatment with maintenance immunosuppressive drugs. Because we observed an increased incidence of venous thromboembolic events in renal transplant recipients treated with the mTOR inhibitor (mTORi) everolimus, we aimed to identify prothrombotic mechanisms of this immunosuppressive drug. MATERIALS AND METHODS In a single center study, nested in a multi-center randomized controlled trial, we measured parameters of coagulation, anti-coagulation and fibrinolysis in renal transplant recipients, receiving the mTORi everolimus (n=16, mTOR group) and compared them to a similar patient group, receiving a calcineurin inhibitor and/or mycophenolate sodium (n=20, non-mTOR group). All patients were at least 6 months following transplantation with a stable transplant function. RESULTS The use of an mTORi was associated with significantly higher levels of von Willebrand factor, prothrombin fragment 1+2, thrombin-activatable fibrinolysis inhibitor and plasminogen activator inhibitor-1 as compared to a non-mTORi based immunosuppressive regimen. CONCLUSIONS Treatment with an mTORi leads to increased endothelial activation, thrombin formation and impaired fibrinolysis in renal transplant recipients. This suggests an increased risk of thrombotic events in renal transplant recipients treated with mTOR inhibitors. A prospective study to establish the precise risk of thrombotic events in these patients is urgently needed.
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Affiliation(s)
- Marije C Baas
- Renal Transplant Unit, Department of Nephrology, Division of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Endothelial Dysfunction Is Associated With Graft Loss in Renal Transplant Recipients. Transplantation 2013; 95:733-9. [DOI: 10.1097/tp.0b013e31827d6312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hornum M, Clausen P, Idorn T, Hansen JM, Mathiesen ER, Feldt-Rasmussen B. Kidney transplantation improves arterial function measured by pulse wave analysis and endothelium-independent dilatation in uraemic patients despite deterioration of glucose metabolism. Nephrol Dial Transplant 2010; 26:2370-7. [DOI: 10.1093/ndt/gfq704] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Gorgulu N, Yelken B, Caliskan Y, Elitok A, Cimen AO, Yazici H, Oflaz H, Golcuk E, Ekmekci A, Turkmen A, Yildiz A, Sever MS. Endothelial dysfunction in hemodialysis patients with failed renal transplants. Clin Transplant 2009; 24:678-84. [DOI: 10.1111/j.1399-0012.2009.01160.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Keven K, Elmaci S, Sengul S, Akar N, Egin Y, Genc V, Erturk S, Erbay B. Soluble endothelial cell protein C receptor and thrombomodulin levels after renal transplantation. Int Urol Nephrol 2009; 42:1093-8. [DOI: 10.1007/s11255-009-9654-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 09/11/2009] [Indexed: 10/20/2022]
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Association between chronic hepatitis C infection and coronary flow reserve in dialysis patients with failed renal allografts. Transplant Proc 2009; 41:1519-23. [PMID: 19545669 DOI: 10.1016/j.transproceed.2009.03.069] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/10/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C infection occurs frequently among patients with end-stage renal disease and increases the risk of atherosclerotic cardiovascular diseases. Endothelial dysfunction (ED) is an early event in the pathogenesis of atherosclerosis. It has been reported among patients treated with hemodialysis (HD), peritoneal dialysis (PD), or renal transplantation. The aim of the present study was to evaluate effects of chronic hepatitis C infection on ED in patients with failed renal transplants. METHODS Twenty-six nondiabetic, anti-hepatitis C virus (HCV)-positive (15 females, mean age: 38 +/- 8 years) and 26 anti-HCV-negative patients (15 females, mean age: 36 +/- 5 years), all of whom had returned to PD or HD after renal transplant failure were studied to assess coronary flow reserve (CFR) by transthoracic Doppler echocardiography. Serum high-sensitivity C-reactive protein (hs-CRP) levels were measured as markers of chronic inflammation. CFR recordings and intima-media thickness measurements were performed using the Vivid 7 echocardiography device. RESULTS Demographic and clinical characteristics of patients were similar between the two groups. Serum hs-CRP levels were significantly higher among HCV-positive patients versus HCV-negative counterparts. HCV-positive patients showed lower CFR measurement than HCV-negative ones. Also, a negative correlation was observed between serum hs-CRP levels and CFR values. CONCLUSION CFR values are worse among anti-HCV-positive patients with failed renal transplants compared with anti-HCV-negative subjects. Graft dysfunction per se may aggravate a proinflammatory states thereby inducing ED. Furthermore, the presence of HCV is a greater trigger of ED among patients with renal failed grafts.
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Horcicka V, Zadrazil J, Karasek D, Al JAbry S, Krejci K, Strebl P, Halenka M, Elfmark M. Significance of HLA Nondependent Risk Factors of Chronic Transplant Nephropathy for the Development of Endothelial Dysfunction After Kidney Transplantation. Transplant Proc 2009; 41:1599-603. [DOI: 10.1016/j.transproceed.2008.10.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2007] [Revised: 06/15/2008] [Accepted: 10/06/2008] [Indexed: 11/26/2022]
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Influence of single-nucleotide polymorphisms on C-reactive protein levels in chronic kidney disease before and after kidney transplantation. Transplant Proc 2009; 40:3349-53. [PMID: 19100387 DOI: 10.1016/j.transproceed.2008.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 04/10/2008] [Indexed: 11/21/2022]
Abstract
INTRODUCTION We sought to evaluate 2 single-nucleotide polymorphisms (SNPs) in the C-reactive protein (CRP) gene promoter region for their effects on CRP levels in chronic kidney disease (CKD) patients before and after a successful kidney transplantation. METHODS Fifty CKD patients were evaluated before and at the first and second years after the graft. Two SNPs were studied, a bi-allelic (G-->A) at the -409 and a tri-allelic (C-->T-->A) variation at the -390 position in the CRP gene. RESULTS All patients presented the -409GG genotype. At the -390 position, the "A" allele was not found; there were 15 "CC" patients, 11 "TT" patients, and 24 "CT" patients. CRP levels were different among patients with various genotypes (P < .019). Also the presence of the allele "T" was sufficient to determine differences in CRP levels both in pretransplantation (P = .045) and at 1 year posttransplantation (P = .011), but not at the second year (P = .448). CONCLUSION SNPs at the -390 position of the CRP gene promoter region influence CRP basal levels in such a way that the "C" allele correlated with the lowest and the "T" with the highest. We did not observe this influence in our patients at the second year posttransplantation.
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Ardalan MR, Tarzamni MK, Shoja MM, Tubbs RS, Rahimi-Ardabili B, Ghabili K, Khosroshahi HT. Black Tea Improves Endothelial Function in Renal Transplant Recipients. Transplant Proc 2007; 39:1139-42. [PMID: 17524915 DOI: 10.1016/j.transproceed.2007.04.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endothelial damage and dysfunction are commonplace in renal transplant recipients. Impaired endothelial function is an important contributor to cardiovascular diseases. We hypothesized that short-term black tea consumption may improve endothelium-dependent arterial dilation in kidney recipients. METHODS Fifteen recipients were studied on an outpatient basis in a single, university-affiliated clinic. Inclusion criteria were stable and good allograft function. The main exclusion criteria were uncontrolled hypertension, smoking, alcohol consumption, coffee drinking, diabetes mellitus, and coronary artery disease, or a history of upper limb vascular manipulations. After overnight fasting, the brachial artery diameter (BAD) was measured at the end of diastole using an ultrasound machine before (basal BAD) and 1 minute after temporary ( approximately 3 minutes) external occlusion (posthyperemia BAD). Flow-mediated vasodilation (FMV) and percent of FMV (FMV%) were calculated by appropriate formula. FMV and FMV% were determined at baseline and 2 hours after consuming 0.5 L freshly brewed black tea. For control, the study was repeated for each patient the next day and FMV and FMV% were determined before and 2 hours after consuming 0.5 L of water. RESULTS The men age of patients was 37.2 +/- 9.7 years (range, 25 to 50) with a male:female ratio of 3:2. Patients were 26.8 +/- 10.6 months postrenal transplantation. Black tea consumption significantly increased posthyperemia BAD, FMV, and FMV% (P<.05). However, water consumption did not alter the basal or posthyperemia BAD, FMV, or FMV% (P>.05). CONCLUSION Based on our study, short-term consumption of black tea may improve endothelial function and endothelium-dependent arterial vasodilation in renal transplant recipients.
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Affiliation(s)
- M R Ardalan
- Department of Nephrology, Tabriz Medical University, Tabriz, Iran.
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