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Kountouras J, Boziki M, Kazakos E, Theotokis P, Kesidou E, Nella M, Bakirtzis C, Karafoulidou E, Vardaka E, Mouratidou MC, Kyrailidi F, Tzitiridou-Chatzopoulou M, Orovou E, Giartza-Taxidou E, Deretzi G, Grigoriadis N, Doulberis M. Impact of Helicobacter pylori and metabolic syndrome on mast cell activation-related pathophysiology and neurodegeneration. Neurochem Int 2024; 175:105724. [PMID: 38508416 DOI: 10.1016/j.neuint.2024.105724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/03/2024] [Accepted: 03/17/2024] [Indexed: 03/22/2024]
Abstract
Both Helicobacter pylori (H. pylori) infection and metabolic syndrome (MetS) are highly prevalent worldwide. The emergence of relevant research suggesting a pathogenic linkage between H. pylori infection and MetS-related cardio-cerebrovascular diseases and neurodegenerative disorders, particularly through mechanisms involving brain pericyte deficiency, hyperhomocysteinemia, hyperfibrinogenemia, elevated lipoprotein-a, galectin-3 overexpression, atrial fibrillation, and gut dysbiosis, has raised stimulating questions regarding their pathophysiology and its translational implications for clinicians. An additional stimulating aspect refers to H. pylori and MetS-related activation of innate immune cells, mast cells (MC), which is an important, often early, event in systemic inflammatory pathologies and related brain disorders. Synoptically, MC degranulation may play a role in the pathogenesis of H. pylori and MetS-related obesity, adipokine effects, dyslipidemia, diabetes mellitus, insulin resistance, arterial hypertension, vascular dysfunction and arterial stiffness, an early indicator of atherosclerosis associated with cardio-cerebrovascular and neurodegenerative disorders. Meningeal MC can be activated by triggers including stress and toxins resulting in vascular changes and neurodegeneration. Likewise, H.pylori and MetS-related MC activation is linked with: (a) vasculitis and thromboembolic events that increase the risk of cardio-cerebrovascular and neurodegenerative disorders, and (b) gut dysbiosis-associated neurodegeneration, whereas modulation of gut microbiota and MC activation may promote neuroprotection. This narrative review investigates the intricate relationship between H. pylori infection, MetS, MC activation, and their collective impact on pathophysiological processes linked to neurodegeneration. Through a comprehensive search of current literature, we elucidate the mechanisms through which H. pylori and MetS contribute to MC activation, subsequently triggering cascades of inflammatory responses. This highlights the role of MC as key mediators in the pathogenesis of cardio-cerebrovascular and neurodegenerative disorders, emphasizing their involvement in neuroinflammation, vascular dysfunction and, ultimately, neuronal damage. Although further research is warranted, we provide a novel perspective on the pathophysiology and management of brain disorders by exploring potential therapeutic strategies targeting H. pylori eradication, MetS management, and modulation of MC to mitigate neurodegeneration risk while promoting neuroprotection.
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Affiliation(s)
- Jannis Kountouras
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece.
| | - Marina Boziki
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Evangelos Kazakos
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; School of Healthcare Sciences, Midwifery Department, University of West Macedonia, Koila, Kozani, 50100, Macedonia, Greece
| | - Paschalis Theotokis
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Evangelia Kesidou
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Maria Nella
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Christos Bakirtzis
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Eleni Karafoulidou
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Elisabeth Vardaka
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Alexander Campus, 57400, Macedonia, Greece
| | - Maria C Mouratidou
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece
| | - Foteini Kyrailidi
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece
| | - Maria Tzitiridou-Chatzopoulou
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; School of Healthcare Sciences, Midwifery Department, University of West Macedonia, Koila, Kozani, 50100, Macedonia, Greece
| | - Eirini Orovou
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; School of Healthcare Sciences, Midwifery Department, University of West Macedonia, Koila, Kozani, 50100, Macedonia, Greece
| | - Evaggelia Giartza-Taxidou
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece
| | - Georgia Deretzi
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; Department of Neurology, Papageorgiou General Hospital, Thessaloniki, Macedonia, Greece
| | - Nikolaos Grigoriadis
- Laboratory of Experimental Neurology and Neuroimmunology and the Multiple Sclerosis Center, 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - Michael Doulberis
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital, 54642, Thessaloniki, Macedonia, Greece; Gastroklinik, Private Gastroenterological Practice, 8810, Horgen, Switzerland; Division of Gastroenterology and Hepatology, Medical University Department, Kantonsspital Aarau, 5001, Aarau, Switzerland
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Goyal JL, Gupta A, Gandhi P. Ocular manifestations in renal diseases. Indian J Ophthalmol 2023; 71:2938-2943. [PMID: 37530260 PMCID: PMC10538849 DOI: 10.4103/ijo.ijo_3234_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/22/2023] [Accepted: 03/27/2023] [Indexed: 08/03/2023] Open
Abstract
The eyes and kidneys are the targets for end-organ damage in multiple pathologies. Both these organs develop during the same embryonic stage around the fourth to sixth week of gestation, thus sharing a strong correlation between both eye and kidney diseases. Both the eyes and kidneys can be the target of the systemic disease process; however, the eyes can also be affected as a consequence of renal disease or its treatment. Risk factors such as diabetes, hypertension, and smoking are commonly shared between kidney and eye diseases. Ocular manifestations can be predictive of renal disease, and/or patients with renal disease are at higher risk for developing ocular manifestations. Various congenital anomalies of the eyes and kidneys can also present as an oculorenal syndrome. This article summarizes the ocular pathology, which can be seen in renal diseases.
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Affiliation(s)
- Jawahar Lal Goyal
- Department of Ophthalmology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Arushi Gupta
- Department of Ophthalmology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Pulkit Gandhi
- Rochester General Hospital, Centre for Kidney Disease and Hypertension, Rochester, New York, USA
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Kountouras J, Doulberis M, Papaefthymiou A, Polyzos SA, Zavos C, Kazakos E, Arapoglou S, Kyrailidi F, Mouratidou MC, Boziki M, Vardaka E. Controlling the Impact of Helicobacter pylori-Related Hyperhomocysteinemia on Neurodegeneration. Medicina (B Aires) 2023; 59:504. [PMID: 36984505 PMCID: PMC10056452 DOI: 10.3390/medicina59030504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Helicobacter pylori infection consists a high global burden affecting more than 50% of the world’s population. It is implicated, beyond substantiated local gastric pathologies, i.e., peptic ulcers and gastric cancer, in the pathophysiology of several neurodegenerative disorders, mainly by inducing hyperhomocysteinemia-related brain cortical thinning (BCT). BCT has been advocated as a possible biomarker associated with neurodegenerative central nervous system disorders such as Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and/or glaucoma, termed as “ocular Alzheimer’s disease”. According to the infection hypothesis in relation to neurodegeneration, Helicobacter pylori as non-commensal gut microbiome has been advocated as trigger and/or mediator of neurodegenerative diseases, such as the development of Alzheimer’s disease. Among others, Helicobacter pylori-related inflammatory mediators, defensins, autophagy, vitamin D, dietary factors, role of probiotics, and some pathogenetic considerations including relevant involved genes are discussed within this opinion article. In conclusion, by controlling the impact of Helicobacter pylori-related hyperhomocysteinemia on neurodegenerative disorders might offer benefits, and additional research is warranted to clarify this crucial topic currently representing a major worldwide burden.
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Liu W, Guo R, Huang D, Ji J, Gansevoort RT, Snieder H, Jansonius NM. Co-occurrence of chronic kidney disease and glaucoma: Epidemiology and etiological mechanisms. Surv Ophthalmol 2023; 68:1-16. [PMID: 36088997 DOI: 10.1016/j.survophthal.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 02/01/2023]
Abstract
As the histology, physiology, and pathophysiology of eyes and kidneys show substantial overlap, it has been suggested that eye and kidney diseases, such as glaucoma and chronic kidney disease (CKD), may be closely interlinked. We review the relationship between CKD and various subtypes of glaucoma, including primary open-angle glaucoma, primary angle- closure glaucoma, normal tension glaucoma, pseudoexfoliation syndrome, and several glaucoma endophenotypes. We also discuss the underlying pathogenic mechanisms and common risk factors for CKD and glaucoma, including atherosclerosis, the renin-angiotensin system, genes and genetic polymorphisms, vitamin D deficiency, and erythropoietin. The prevalence of glaucoma appears elevated in CKD patients, and vice versa, and the literature points to many intriguing associations; however, the associations are not always confirmed, and sometimes apparently opposite observations are reported. Glaucoma and CKD are complex diseases, and their mutual influence is only partially understood.
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Affiliation(s)
- Wei Liu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China; Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruru Guo
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Dandan Huang
- Department of Ophthalmology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jian Ji
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Ron T Gansevoort
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nomdo M Jansonius
- Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Kountouras J, Papaefthymiou A, Polyzos SA, Kazakos E, Vardaka E, Touloumtzi M, Tzitiridou-Chatzopoulou M, Liatsos C, Sgantzou IK, Knuchel J, Doulberis M. Impacto da Síndrome Metabólica Relacionada à Infecção por Helicobacter pylori Ativa na Hipertensão Arterial Sistêmica. Arq Bras Cardiol 2022; 119:502-504. [PMID: 36074383 PMCID: PMC9438526 DOI: 10.36660/abc.20210931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ng FYC, Song HJJMD, Tan BKJ, Teo CB, Wong ETY, Boey PY, Cheng CY. Bidirectional association between glaucoma and chronic kidney disease: A systematic review and meta-analysis. EClinicalMedicine 2022; 49:101498. [PMID: 35747173 PMCID: PMC9189872 DOI: 10.1016/j.eclinm.2022.101498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Glaucoma and chronic kidney disease (CKD) are prevalent and debilitating conditions, with common pathogenic pathways like oxidative stress and fluid dysregulation. We evaluated if there is a bidirectional association between them, as previous studies have yielded conflicting results. METHODS In this systematic review and meta-analysis, we searched PubMed, Embase and Cochrane Library from inception until 15 June 2021, including full-length English articles published in peer-reviewed journals reporting on glaucoma and CKD as either exposure or outcome, among participants aged ≥18 years. We pooled overall summary estimates of odds ratios using random-effect meta-analysis and conducted subgroup meta-analyses and univariate meta regression. We assessed risk of bias using the Newcastle-Ottawa Scale (NOS) and quality of evidence using the GRADE framework. Our article is PROSPERO-registered and adherent to both PRISMA and MOOSE guidelines. This review is registered with PROSPERO (CRD42021262846). FINDINGS We identified 14 articles comprising of 3 retrospective cohort studies and 12 cross-sectional studies from 2,428 records, including 1,978,254 participants. Risk of bias was low to moderate. Participants with CKD at baseline had higher pooled odds of glaucoma (odds ratio[OR]=1.18, 95% confidence interval[CI]=1.04-1.33, I2=66%, N=12) compared to participants without CKD. The association remained significant in subgroups of longitudinal studies, participants with diabetes, East Asian studies and primary open-angle glaucoma. In the reverse direction, participants with glaucoma at baseline had over three-fold higher odds of incident CKD compared to participants without glaucoma after 10-15 years of follow-up in longitudinal studies (OR=3.67, 95% CI=2.16-6.24, I2=75%, N=2). All studies adjusted for age and sex, while most studies adjusted for comorbidities such as diabetes and hypertension. Meta-regression identified ethnicity (East Asians vs Non-East Asians) as a significant effect moderator. Associations were robust to trim-and-fill adjustment for publication bias, single-study influence and cumulative meta-analyses. INTERPRETATION Our meta-analysis suggests a bidirectional relationship between glaucoma and CKD, particularly among East Asians. Further studies are required to elucidate underlying mechanisms and account for differential association by ethnicity. FUNDING Ching-Yu Cheng is supported by Clinician Scientist Award (NMRC/CSA-SI/0012/2017) of the Singapore Ministry of Health's National Medical Research Council.
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Affiliation(s)
- Faye Yu Ci Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Emmett Tsz Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - Pui Yi Boey
- Glaucoma Service, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
| | - Ching-Yu Cheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Glaucoma Service, Singapore National Eye Centre, Singapore
- Ocular Epidemiology Research Group, Singapore Eye Research Institute, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
- Corresponding author at: Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, 20 College Road, The Academia, Level 6, Singapore.
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Ro JS, Moon JY, Park TK, Lee SH. Association between chronic kidney disease and open-angle glaucoma in South Korea: a 12-year nationwide retrospective cohort study. Sci Rep 2022; 12:3423. [PMID: 35232992 DOI: 10.1038/s41598-022-07190-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 01/19/2022] [Indexed: 02/02/2023] Open
Abstract
Various non-intraocular pressure factors have been identified as possible risk factors for open-angle glaucoma (OAG). However, there is still controversy around the association between OAG and chronic kidney disease (CKD). In this study, we used a nationwide cohort to investigate the risk of OAG in the 12 years following a diagnosis of CKD. This retrospective cohort study included 1,103,302 subjects from the Korean National Health Insurance Service National Sample Cohort database. The CKD group (n = 1318) included patients who were initially diagnosed with CKD between 2003 and 2008. The subjects in the comparison group were matched at a 1:5 ratio using propensity scores. In multivariate Cox regression analysis, a diagnosis of CKD was significantly associated with an increased incidence of OAG (hazard ratio [HR] = 1.546, 95% confidence interval [CI] 1.363–1.754, p < 0.001). Further analysis revealed that the risk of OAG increased with the severity of CKD (mild to moderate CKD [CKD stage 1–3]: HR = 1.280, 95% CI 1.077–1.521, p = 0.005; advanced CKD [CKD stage 4–5]: HR = 1.861, 95% CI 1.589–2.180, p < 0.001). In subgroup analysis, female CKD patients had a greater risk of developing OAG than males, and subjects with CKD aged ≥ 40 years were more likely to develop OAG compared with those aged < 40 years. Our study demonstrates that CKD is a significant risk factor for OAG and that severe CKD is associated with an increased risk of developing OAG.
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Kountouras J, Doulberis M, Polyzos SA, Kazakos E, Vardaka E, Touloumtzi M, Manolakis A, Tzitiridou-Chatzopoulou M, Liatsos C, Sotiriades ES, Ntona S, Papaefthymiou A. Impact of Helicobacter pylori-related metabolic syndrome with hyperhomocysteinemia on extragastric pathologies. J Gastroenterol Hepatol 2022; 37:407-408. [PMID: 34894006 DOI: 10.1111/jgh.15753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/01/2021] [Indexed: 12/09/2022]
Affiliation(s)
- J Kountouras
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - M Doulberis
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece.,Division of Gastroenterology and Hepatology, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland.,First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - S A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - E Kazakos
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - E Vardaka
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece.,Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Alexander Campus, Thessaloniki, Macedonia, Greece
| | - M Touloumtzi
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece
| | - A Manolakis
- Department of Gastroenterology, University Hospital of Larisa, Larisa, Greece
| | - M Tzitiridou-Chatzopoulou
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece.,School of Healthcare Sciences, Midwifery Department, University of West Macedonia, Kozani, Macedonia, Greece
| | - C Liatsos
- Department of Gastroenterology, 401 General Military Hospital of Athens, Attiki, Greece
| | - E S Sotiriades
- Healthcare Management Program, School of Economic and Management, Open University of Cyprus, Nicosia, Cyprus
| | - S Ntona
- Alexandrovska University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - A Papaefthymiou
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece.,First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Macedonia, Greece.,Department of Gastroenterology, University Hospital of Larisa, Larisa, Greece
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9
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Kountouras J, Papaefthymiou A, Polyzos SA, Deretzi G, Vardaka E, Soteriades ES, Tzitiridou-Chatzopoulou M, Gkolfakis P, Karafyllidou K, Doulberis M. Impact of Helicobacter pylori-Related Metabolic Syndrome Parameters on Arterial Hypertension. Microorganisms 2021; 9:microorganisms9112351. [PMID: 34835476 PMCID: PMC8618184 DOI: 10.3390/microorganisms9112351] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/28/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022] Open
Abstract
Arterial hypertension is a risk factor for several pathologies, mainly including cardio-cerebrovascular diseases, which rank as leading causes of morbidity and mortality worldwide. Arterial hypertension also constitutes a fundamental component of the metabolic syndrome. Helicobacter pylori infection is one of the most common types of chronic infection globally and displays a plethora of both gastric and extragastric effects. Among other entities, Helicobacter pylori has been implicated in the pathogenesis of the metabolic syndrome. Within this review, we illustrate the current state-of-the-art evidence, which may link several components of the Helicobacter pylori-related metabolic syndrome, including non-alcoholic fatty liver disease and arterial hypertension. In particular, current knowledge of how Helicobacter pylori exerts its virulence through dietary, inflammatory and metabolic pathways will be discussed. Although there is still no causative link between these entities, the emerging evidence from both basic and clinical research supports the proposal that several components of the Helicobacter pylori infection-related metabolic syndrome present an important risk factor in the development of arterial hypertension. The triad of Helicobacter pylori infection, the metabolic syndrome, and hypertension represents a crucial worldwide health problem on a pandemic scale with high morbidity and mortality, like COVID-19, thereby requiring awareness and appropriate management on a global scale.
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Affiliation(s)
- Jannis Kountouras
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.); (M.T.-C.); (M.D.)
- Correspondence:
| | - Apostolis Papaefthymiou
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.); (M.T.-C.); (M.D.)
- Department of Gastroenterology, University Hospital of Larisa, 41110 Larisa, Greece
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Stergios A. Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Georgia Deretzi
- Multiple Sclerosis Unit, Department of Neurology, Papageorgiou General Hospital, 56403 Thessaloniki, Greece;
| | - Elisabeth Vardaka
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, 57400 Thessaloniki, Greece;
| | - Elpidoforos S. Soteriades
- Healthcare Management Program, School of Economics and Management, Open University of Cyprus, Nicosia 2252, Cyprus;
- Department of Environmental Health, Environmental and Occupational Medicine and Epidemiology (EOME), Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Maria Tzitiridou-Chatzopoulou
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.); (M.T.-C.); (M.D.)
- School of Healthcare Sciences, Midwifery Department, University of West Macedonia, Koila, 50100 Kozani, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, 1070 Brussels, Belgium;
- Department of Medical Oncology, Institut Jules Bordet, 1000 Brussels, Belgium
| | - Kyriaki Karafyllidou
- Department of Pediatrics, University Children’s Hospital of Zurich, 8032 Zurich, Switzerland;
| | - Michael Doulberis
- Second Medical Clinic, School of Medicine, Ippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.); (M.T.-C.); (M.D.)
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
- Division of Gastroenterology and Hepatology, Medical University Department, Kantonsspital Aarau, 5001 Aarau, Switzerland
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Johnson DW, Kay TD, Vesey DA, Isbel N, Campbell SB, Hawley CM. Peritoneal Homocysteine Clearance is Inefficient in Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080002000630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ObjectivesTo investigate the degree and the determinants of peritoneal homocysteine (Hcy) clearance and to compare measured Hcy clearance with the Hcy clearance predicted based on molecular weight (MW).DesignCross-sectional observational analysis.SettingTertiary care institutional dialysis center.PatientsSixty-five stable peritoneal dialysis (PD) patients.Outcome MeasuresFasting blood and 24-hour pooled dialysate effluents were collected for determination of peritoneal clearances of Hcy (CpHcy), urea (CpUr), and creatinine (CpCr). The dialysate-to-plasma creatinine ratio at 4 hours (D/P Cr 4 h) and levels of red cell folate, B12, ferritin, and C-reactive protein (CRP) were measured concurrently. Observed CpHcy was compared with predicted clearance, based on Hcy plasma protein binding and the relative molecular weights of Hcy, urea, and creatinine.ResultsPlasma concentrations of Hcy averaged 24.6 ± 1.1 μmol/L and were elevated above the upper limit of normal in 59 (91%) patients. The mean dialysate concentration of Hcy was 2.9 ± 0.3 μmol/L, equating to a daily peritoneal elimination of 34.6 ± 3.6 μmol. Observed CpHcy was closely approximated by predicted CpHcy (8.7 ± 0.6 L/week/1.73 m2vs 9.0 ± 0.3 L/week/1.73 m2respectively, p = 0.55). Patients maintained on automated PD ( n = 5) had a CpHcy similar to that of patients treated with continuous ambulatory peritoneal dialysis (8.9 ± 1.0 L/week/1.73 m2vs 8.7 ± 0.6 L/week/1.73 m2, p = 0.92). The CpHcy was significantly correlated with C-reactive protein (CRP), D/P creatinine, CpUr, CpCr, and peritoneal protein loss, but not with plasma Hcy, albumin, B12, ferritin, age, dialysis duration, peritonitis episodes, or daily dialysate effluent volume. By multivariate analysis, the only variables that remained significant independent predictors of CpHcy were CRP and D/P Cr 4 h. High and high-average transporters had a higher CpHcy than low and low-average transporters (9.7 ± 0.8 L/week/1.73 m2vs 7.0 ± 0.7 L/week/1.73 m2, p < 0.05), despite comparably elevated plasma Hcy concentrations [25.2 ± 1.5 μmol/L vs 23.4 ± 1.6 μmol/L, p = nonsignificant (NS)].ConclusionsElevated plasma concentrations of Hcy are not efficiently reduced by PD. The relatively low peritoneal clearance of Hcy is largely accounted for by a high degree of plasma protein binding and is significantly influenced by peritoneal membrane permeability.
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Affiliation(s)
- David W. Johnson
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Troy D. Kay
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - David A. Vesey
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole Isbel
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Scott B. Campbell
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Carmel M. Hawley
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia
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Affiliation(s)
- Jonas BergstrÖm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
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12
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Abstract
Elevated plasma total homocysteine (tHcy) is a risk factor for cardiovascular disease; however, in light of several recent randomized trials, the issue of causality has been cast into doubt. Patients with end-stage renal disease are particularly interesting as they consistently have elevated tHcy and their leading causes of morbidity and mortality are related to cardiovascular disease. In the present article, we review the early evidence for the homocysteine theory of atherosclerosis, homocysteine metabolism, mechanisms of toxicity, and pertinent available clinical investigations. Where appropriate, the sparse evidence of homocysteine in peritoneal dialysis is reviewed. We conclude by addressing the difficulties associated with lowering plasma tHcy in patients with end-stage renal disease and suggest some novel methods for lowering tHcy in this resistant population. Finally, to address the issue of causality, we recommend that clinicians and scientists await the results of the FAVORIT trial before abandoning homocysteine as a modifiable risk factor for cardiovascular disease, as this study has recruited patients from a population with consistently elevated plasma tHcy who are known to respond to vitamin therapy.
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Affiliation(s)
- Bradley L. Urquhart
- Departments of Medicine The University of Western Ontario, London, Ontario, Canada
- Physiology/Pharmacology, The University of Western Ontario, London, Ontario, Canada
| | - Andrew A. House
- Departments of Medicine The University of Western Ontario, London, Ontario, Canada
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Ersoy Dursun F, Gunal AI, Kirciman E, Karaca I, Dagli MN. Comparison of Chronic Hemodialysis Patients under Strict Volume Control with respect to Cardiovascular Disease. Int J Nephrol 2019; 2019:6430947. [PMID: 31354995 PMCID: PMC6636557 DOI: 10.1155/2019/6430947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/18/2019] [Accepted: 04/18/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The objective of this study was to determine the effects of strict volume control and nondipper situation on cardiovascular disease in chronic hemodialysis patients. METHODS This study is an observational and cross-sectional study including 62 patients with normotensive chronic hemodialysis using no antihypertensive drugs. A series of measurements including ambulatory blood pressure monitoring, left ventricular mass index by echocardiography, common carotid artery intima-media thickness by ultrasound, and body fluids by bioimpedance analysis were conducted for all subjects. RESULTS The patients were divided into two groups as dippers and nondippers according to their ambulatory blood pressure monitoring results. Average 48 h systolic, diastolic, and mean arterial blood pressure and nocturnal systolic, diastolic, and mean arterial blood pressure were significantly different between the dipper and nondipper groups (p<0.05). Before and after dialysis, extracellular fluid/intracellular fluid and extracellular fluid/dry body weight ratios were significantly higher in the nondipper group. Left ventricle mass index and interventricular septum thickness were significantly higher in the nondipper group (p<0.05). Left ventricle ejection fraction was significantly lower and common carotid artery intima-media thickness was higher in the nondipper group with a statistical significance (p<0.05). A two-predictor logistic model was fitted to the data to predict the comparability of dippers and nondippers. CONCLUSION According to logistic regression analysis, the odds ratio for daytime diastolic blood pressure indicates that nondippers are 0.45 times more likely to have high blood pressure than dippers in daytime. But in night time, nondippers are about 2.55 times more likely to have high blood pressure comparing to dippers. An important finding of this study is that nondipping pattern is associated with cardiac hypertrophy and lower left ventricle ejection fraction in dialysis of patients with no hypertension. The results also suggest that applying strict volume control to achieve a normal blood pressure alone is not sufficient to reduce the risk of cardiovascular morbidity and mortality if the patients do not have a dipper status of nocturnal blood pressure.
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Affiliation(s)
- Fadime Ersoy Dursun
- Firat University School of Medicine, Department of Internal Medicine, Elazig, Turkey
| | - Ali Ihsan Gunal
- Firat University School of Medicine, Department of Nephrology, Elazig, Turkey
| | - Ercan Kirciman
- Firat University School of Medicine, Department of Internal Medicine, Elazig, Turkey
| | - Ilgin Karaca
- Firat University School of Medicine, Department of Cardiology, Elazig, Turkey
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Nusinovici S, Sabanayagam C, Teo BW, Tan GSW, Wong TY. Vision Impairment in CKD Patients: Epidemiology, Mechanisms, Differential Diagnoses, and Prevention. Am J Kidney Dis 2019; 73:846-857. [PMID: 30929852 DOI: 10.1053/j.ajkd.2018.12.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/31/2018] [Indexed: 11/11/2022]
Abstract
Eyes and kidneys have numerous structural, developmental, physiologic, and pathogenic pathways in common, suggesting that many kidney and eye diseases may be interlinked. Studies suggest that the prevalence of eye diseases and vision impairment are higher among persons with end-stage kidney disease and earlier stages of chronic kidney disease (CKD) than in those without. Ocular morbidity in persons with CKD and end-stage kidney disease may be due to the following risk factors: (1) underlying conditions and risk factors for CKD such as diabetes or hypertension, (2) metabolic disorders associated with CKD, (3) uremia and anemia, and (4) CKD treatment. Among the chief eye diseases, diabetic retinopathy and age-related macular degeneration are most consistently associated with CKD. Further research for eye diseases such as glaucoma and cataract is needed to determine their relationships with CKD. Despite the high prevalence and burden of vision impairment among persons with CKD, eye screening in patients with CKD is not currently recommended as standard practice. This review suggests that patients with CKD should be encouraged to undergo a complete eye examination. Furthermore, physicians should be aware that patients undergoing dialysis may develop acute eye problems such as acute glaucoma, and appropriate referral to ophthalmologists should be considered in those with a history of glaucoma or recent ocular surgery. Interdisciplinary collaboration between nephrologists and ophthalmologists will ensure enhanced and appropriate management of patients with CKD.
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Affiliation(s)
- Simon Nusinovici
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Boon Wee Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gavin Siew Wei Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore.
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Shim SH, Sung KC, Kim JM, Lee MY, Won YS, Kim JH, Park KH. Association between Renal Function and Open-Angle Glaucoma. Ophthalmology 2016; 123:1981-8. [DOI: 10.1016/j.ophtha.2016.06.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 01/12/2023] Open
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Sederholm Lawesson S, Alfredsson J, Szummer K, Fredrikson M, Swahn E. Prevalence and prognostic impact of chronic kidney disease in STEMI from a gender perspective: data from the SWEDEHEART register, a large Swedish prospective cohort. BMJ Open 2015; 5:e008188. [PMID: 26105033 PMCID: PMC4480024 DOI: 10.1136/bmjopen-2015-008188] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Gender differences in prevalence and prognostic impact of chronic kidney disease (CKD) in ST segment elevation myocardial infarction (STEMI) have been poorly evaluated. In STEMI, female gender has been independently associated with an increased risk of mortality. CKD has been found to be an important prognostic marker in myocardial infarction. The aim of this study was to evaluate gender differences in prevalence and prognostic impact of CKD on short-term and long-term mortality. DESIGN Prospective observational cohort study. SETTING The national quality register SWEDEHEART was used. In the beginning of the study period, 94% of the Swedish coronary care units contributed data to the register, which subsequently increased to 100%. The glomerular filtration rate was estimated (eGFR) according to Modification of Diet in Renal Disease Study (MDRD) and Cockcroft-Gault (CG). PARTICIPANTS All patients with STEMI registered in SWEDEHEART from the years 2003-2009 were included (37,991 patients, 66% men). MAIN RESULTS Women had 1.6 (MDRD) to 2.2 (CG) times higher multivariable adjusted risk of CKD. Half of the women had CKD according to CG. CKD was associated with 2-2.5 times higher risk of in-hospital mortality and approximately 1.5 times higher risk of long-term mortality in both genders. Each 10 mL/min decline of eGFR was associated with an increased risk of in-hospital and long-term mortality (22-33% and 9-16%, respectively) and this did not vary significantly by gender. Both in-hospital and long-term mortality were doubled in women. After multivariable adjustment including eGFR, there was no longer any gender difference in early outcome and the long-term outcome was better in women. CONCLUSIONS Among patients with STEMI, female gender was independently associated with CKD. Reduced eGFR was a strong independent risk factor for short-term and long-term mortality without a significant gender difference in prognostic impact and seems to be an important reason why women have higher mortality than men with STEMI.
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Affiliation(s)
- Sofia Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Karolina Szummer
- Department of Cardiology, Karolinska University Hospital, Huddinge, Institution of Medicine (H7), Karolinska Institutet, Stockholm, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine Division of Occupational and Environmental Medicine and Forum Östergötland Faculty of Medicine and Health Sciences, Linköping University, Linköping,
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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17
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Stack AG, Donigiewicz U, Abdalla AA, Weiland A, Casserly LF, Cronin CJ, Nguyen HT, Hannigan A. Plasma fibrinogen associates independently with total and cardiovascular mortality among subjects with normal and reduced kidney function in the general population. QJM 2014; 107:701-13. [PMID: 24633257 DOI: 10.1093/qjmed/hcu057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The contribution of novel risk factors to mortality in chronic kidney disease remains controversial. AIM To explore the association of plasma fibrinogen with mortality among individuals with normal and reduced kidney function. METHODS We identified 9184 subjects, age 40 and over from the Third National Health and Nutrition Examination Survey (1988-94) with vital status assessed through 2006. Plasma fibrinogen was modeled as continuous variable and in quartile groups (0 to <7.7, 7.7 to <9.0, 9.0 to <10.5 and ≥ 10.5 µmol/l) with total and cardiovascular mortality across categories of glomerular filtration rate (eGFR); <60, 60-90, >90 ml/min/1.73 m(2) using Cox regression. RESULTS In multivariate analysis, the adjusted hazard ratio (HR) per 1 µmol/l (34 mg/dl) increase in fibrinogen was 1.07 [95% confidence interval (CI) 1.04-1.09] for total mortality and 1.06 (95% CI 1.03-1.09) for cardiovascular mortality. The adjusted HR for total mortality was 1.05 (1.01-1.09) for subjects with eGFR 60-90 ml/min/1.73 m(2) and 1.06 (1.02-1.10) for subjects with eGFR <60 ml/min/1.73 m(2). Subjects in the highest quartiles within each eGFR category; >90, 60-90 and <60 ml/min/1.73 m(2) experienced HRs of 1.45 (95% CI 1.03-2.03), 1.35 (95% CI 1.00-1.83) and 1.72 (95% CI 1.14-2.58), respectively, compared with subjects in the lowest quartile group. The patterns were similar for cardiovascular mortality. CONCLUSIONS Plasma fibrinogen associates with mortality among subjects with mild to moderate kidney impairment as it does in subjects with normal kidney function and should be considered a therapeutic target for cardiovascular risk reduction.
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Affiliation(s)
- A G Stack
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - U Donigiewicz
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - A A Abdalla
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - A Weiland
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - L F Casserly
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - C J Cronin
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - H T Nguyen
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
| | - A Hannigan
- From the Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Graduate Entry Medical School, University of Limerick, Limerick and Department of Medicine, School of Medicine, National University of Ireland, Galway, Ireland
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Wong CW, Wong TY, Cheng CY, Sabanayagam C. Kidney and eye diseases: common risk factors, etiological mechanisms, and pathways. Kidney Int. 2014;85:1290-1302. [PMID: 24336029 DOI: 10.1038/ki.2013.491] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/09/2013] [Accepted: 09/19/2013] [Indexed: 12/14/2022]
Abstract
Chronic kidney disease is an emerging health problem worldwide. The eye shares striking structural, developmental, and genetic pathways with the kidney, suggesting that kidney disease and ocular disease may be closely linked. A growing number of studies have found associations of chronic kidney disease with age-related macular degeneration, diabetic retinopathy, glaucoma, and cataract. In addition, retinal microvascular parameters have been shown to be predictive of chronic kidney disease. Chronic kidney disease shares common vascular risk factors including diabetes, hypertension, smoking, and obesity, and pathogenetic mechanisms including inflammation, oxidative stress, endothelial dysfunction, and microvascular dysfunction, with ocular diseases supporting the 'Common Soil Hypothesis.' In this review, we present major epidemiological evidence for these associations and explore underlying pathogenic mechanisms and common risk factors for kidney and ocular disease. Understanding the link between kidney and ocular disease can lead to the development of new treatment and screening strategies for both diseases.
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Stack AG, Murthy BV. Cigarette Use and Cardiovascular Risk in Chronic Kidney Disease: An Unappreciated Modifiable Lifestyle Risk Factor. Semin Dial 2010; 23:298-305. [DOI: 10.1111/j.1525-139x.2010.00728.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Tzanatos HA, Tseke PP, Pipili C, Retsa K, Skoutelis G, Grapsa E. Cardiovascular Risk Factors in Non-Diabetic Hemodialysis Patients: A Comparative Study. Ren Fail 2009; 31:91-7. [DOI: 10.1080/08860220802595484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Krause MW, Massing M, Kshirsagar A, Rosamond W, Simpson RJ. Combination Therapy Improves Survival After Acute Myocardial Infarction in the Elderly with Chronic Kidney Disease. Ren Fail 2009; 26:715-25. [PMID: 15600265 DOI: 10.1081/jdi-200037110] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Individuals with chronic kidney disease have a high mortality rate after acute myocardial infarction. It is not known how frequently these individuals are prescribed combination cardioprotective therapy and if survival is affected by such therapy after acute myocardial infarction. METHODS A retrospective cohort study of 1,342 Medicare recipients with acute myocardial infarction. Data were collected by medical chart abstraction as part of the Cooperative Cardiovascular Project in 60 hospitals in North Carolina during 5/30/1996-12/28/1997. We categorized cardioprotective medication use as aspirin alone, aspirin with beta-blockers, and aspirin with beta-blockers and ace-inhibitors. Chronic kidney disease was defined as a derived glomerular filtration rate (GFR) ranging from 15-89 mL/min/1.73 m2. Cox proportional hazards regression analyses were performed to determine the effect of cardioprotective medication use on survival while controlling for potential explanatory variables. RESULTS The prevalence of cardioprotective medication use differed among levels of chronic kidney disease. Those with severe kidney disease (GFR 15-29 mL/min/1.73 m2) were less frequently prescribed aspirin with beta-blockers, 27.1%, and only 8.6% were prescribed aspirin with beta-blockers and ace-inhibitors. Survival was improved with prescribed cardioprotective medication use. In severe kidney disease (GFR 15-29 mL/min/1.73 m2), the hazards risk for death was 0.21 (0.08, 0.53) for aspirin alone, 0.17 (0.06, 0.51) for aspirin with beta-blockers, and 0.35 (0.09, 1.42) for aspirin with beta-blockers and ace-inhibitors. CONCLUSIONS Individuals with chronic kidney disease benefit from combination cardioprotective therapy, but are less likely to be prescribed them after acute myocardial infarction. Further investigation is warranted to identify possible reasons for these observed treatment disparities.
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Affiliation(s)
- Michelle W Krause
- Division of Nephrology and Hypertension, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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23
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Perry A, Wang X, Goldberg R, Ross R, Jackson L. The relationship between cardiometabolic and hemostatic variables: influence of race. Metabolism 2008; 57:200-6. [PMID: 18191049 DOI: 10.1016/j.metabol.2007.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 09/20/2007] [Indexed: 11/24/2022]
Abstract
Elevated concentrations of hemostatic variables such as fibrinogen, plasma activator inhibitor 1 (PAI-1), and tissue plasminogen activator (t-PA)/PAI-1 complex have been implicated in the pathogenesis of arterial lesion progression and subsequent cardiovascular disease. In the present study, traditional cardiometabolic variables (CMV) associated with cardiovascular disease risk were examined in relation to hemostatic variables in a group of 36 White American (WA) and 30 African American (AA) overweight/obese women. There were 9 CMV significantly related to PAI-1 and/or the t-PA/PAI-1 ratio, but not fibrinogen. A significant race effect was found for 5 CMV in relation to fibrinogen and/or the t-PA/PAI-1 ratio, but not PAI-1. Significant race and high-density lipoprotein cholesterol interactions were found for fibrinogen (P = .021); and significant race and waist to hip ratio (P = .015), diastolic blood pressure (P = .013), and insulin (P = .037) interactions were found for PAI-1. No interactions were found for the t-PA/PAI-complex. Both PAI-1 and the t-PA/PAI-1 ratio are favored above fibrinogen in the diagnostic evaluation of health risk in both WA and AA women. Because of differences by race, independent consideration should be given in the clinical management of WA and AA women presenting with elevated CMV. Our findings indicated the t-PA/PAI-1 complex to be the most global indicator of health risk in both WA and AA overweight/obese women.
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Affiliation(s)
- Arlette Perry
- Laboratory of Clinical and Applied Physiology, University of Miami, Coral Gables, FL 33124, USA.
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Rosas S, Joffe M, Wolfe M, Brayman K, Rader DJ. Effects of renal replacement therapy on plasma lipoprotein(a) levels. Am J Nephrol 2008; 28:361-5. [PMID: 18057868 PMCID: PMC2786011 DOI: 10.1159/000112225] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Accepted: 10/15/2007] [Indexed: 02/05/2023]
Abstract
Patients with end-stage renal disease (ESRD) have significantly higher levels of lipoprotein(a) [Lp(a)] when compared to control populations. Elevated levels of Lp(a) may play a role in the high incidence of cardiovascular disease in ESRD. We conducted a prospective study to test the hypothesis that plasma levels of Lp(a) decline rapidly after renal transplantation proportional to the improvement in renal function, but are not affected by hemodialysis. All adults that initiated hemodialysis or received a renal transplant from our institution during a 10-month period were invited to participate in the study. Lp(a) levels were obtained immediately prior to the initiation of renal replacement therapy. In transplant recipients, repeat Lp(a) measures were done at 3 days, 5 days, 1 week, 2 weeks, 3 weeks and 4 weeks post-transplant. In hemodialysis patients, repeat Lp(a) measures were done after 3 months. We used a mixed effects model to analyze the effect of time, race and creatinine on Lp(a) after transplant. Lp(a) levels decreased rapidly after renal transplantation. Mean Lp(a) levels at 2 weeks were 35.3% lower than prior to transplantation. Each reduction of 50% in creatinine was associated with a 10.6% reduction in Lp(a) (p < 0.001). In contrast, there was no significant change in Lp(a) after initiation of hemodialysis. The rapid decrease of Lp(a) levels after renal transplantation provides support for a metabolic role of the kidney in Lp(a) catabolism and suggests that the increase in Lp(a) seen in chronic kidney disease is due to loss of functioning renal tissue.
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Affiliation(s)
- Sylvia Rosas
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
AbstractThe objectives were firstly to assess the evidence that homocysteine is a significant and independent risk factor for vascular disease with special reference to cardiovascular disease, and secondly to evaluate the evidence that a food staple fortified with folic acid will reduce this problem on a population basis.The structure of plasma homocysteine (tHcy) is described. Homocysteine, a highly reactive compound, is synthesized from the amino acid, methionine, and is metabolized by two pathways, the catabolic transsulphuration routeviacystathionine β-synthase (EC 4.2.1.22) and the remethylation path using 5-methyltetrahy-drofolate polyglutamate, the product of 5,10-methylenetetrahydrofolate reductase (MTHFR; EC 1.1.1.171),viathe cobalamin dependent enzyme, methionine synthase (MS; EC 2.1.1.13).The mechanisms whereby hyper-tHcy is produced include both increased rates of synthesis and decreased metabolism. The latter may occur owing to nutritional deficiency of the vitamin cofactors which are necessary for the normal function of the metabolic enzymes. In particular, folate is required for methylene reductase, pyridoxal phosphate for cystathionine synthase and cobalamin for methionine synthase. When these vitamins are deficient hyper-tHcy is induced and this occurs especially in the elderly. Alternatively, a variant form of methylene reductase has recently been described which occurs in nearly 10% of the normal population. This variant is associated with hyper-tHcy, especially in situations associated with a low folate nutritional status.Meta-analysis of both retrospective case-control studies, nested prospective case-control surveys and a secondary trial of mortality in postmyocardial infarct patients have shown that the association of hyper-tHcy with vascular disease is beyond doubt. This has been further supported by direct assessments of the degree of vascular disease in the carotid brachial and aortic arteries in relation to tHcy levels. Furthermore, treatment with a cocktail of the vitamin cofactors has produced lowering of tHcy levels and regression of the vascular disease in the carotid arteries of affected individuals.Suggested pathogenic mechanisms in vascular disease induced by hyper-tHcy include vascular endothelial cell dysfunction, smooth muscle proliferation and derangements of normal intravascular regulation mechanisms. A variety of clinical conditions are known to be associated with a high incidence of thromboembolic complications. Some of these are associated with hyper-tHcy.Low physiological doses of folic acid, as well as pharmocological doses, lower tHcy. However, because of the poor bioavailability of food folate (50%) and the considerable chemical instability of the naturally occurring reduced forms of folate, in most people it would require unacceptably high consumption of green vegetables to accomplish the necessary increase in intracellular folate and reduction in tHcy. Accordingly, folic acid, the nonreduced synthetic form of the vitamin, which is 100% bioavailable and chemically extremely stable, should be added to a food staple such as flour to ensure maximum protection for most of the population.
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Baber U, de Lemos JA, Khera A, McGuire DK, Omland T, Toto RD, Hedayati SS. Non-traditional risk factors predict coronary calcification in chronic kidney disease in a population-based cohort. Kidney Int 2008; 73:615-21. [PMID: 18075501 DOI: 10.1038/sj.ki.5002716] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The increased burden of cardiovascular disease in chronic kidney disease cannot be explained by traditional risk factors alone. Here, we evaluated the impact of non-traditional factors on the association of chronic kidney disease with coronary artery calcification using logistic regression among 2672 Dallas Heart Study patients of whom 220 had chronic kidney disease. The prevalence of coronary calcification significantly increased across all chronic kidney disease stages and this remained independently associated with coronary calcification after adjusting for traditional factors. The calcium x phosphorus product, homocysteine, and osteoprotegerin each diminished the magnitude of association between kidney disease and coronary calcification. After adjustment for these, the association between kidney disease and coronary calcification was no longer significant with the effects most prominent in the stages 3-5 subgroup. Our study has identified three non-traditional independent predictors of coronary calcification that diminished the association between chronic kidney disease and coronary calcification. These factors may represent novel mechanistic links warranting further investigation.
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Baber U, Toto RD, de Lemos JA. Statins and cardiovascular risk reduction in patients with chronic kidney disease and end-stage renal failure. Am Heart J 2007; 153:471-7. [PMID: 17383281 DOI: 10.1016/j.ahj.2006.10.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 10/28/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although numerous large-scale trials have firmly established the benefits of statins for primary and secondary prevention of coronary artery disease, the role of this class of agents in patients with impaired renal function remains unclear. METHODS AND RESULTS In the following review, we evaluate current evidence regarding the role of statins in patients with both chronic kidney disease (CKD) and end-stage renal disease (ESRD) on hemodialysis. Although statins do appear to reduce cardiovascular risk in patients with CKD, it remains unclear whether such benefit extends to the ESRD population. Thus far, 1 randomized placebo-controlled trial failed to demonstrate a statistically significant reduction in the primary endpoint of cardiovascular death, stroke, and nonfatal myocardial infarction among patients with ESRD on hemodialysis. This finding contrasts with observational analyses suggesting improved outcomes among patients with ESRD taking statins. CONCLUSIONS Risk factors unique to the CKD population, which may not be modifiable with statins, could contribute to the increased cardiovascular morbidity among patients with ESRD. These include alterations in mineral metabolism, elevation in serum homocysteine, and increased oxidative stress. Larger prospective studies are needed to elucidate the role of statins in patients with chronic kidney disease, including those with ESRD on dialysis. Pending further data, we currently recommend using statins in patients with CKD.
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Affiliation(s)
- Usman Baber
- Donald W. Reynolds Cardiovascular Clinical Research Center, University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA
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Abstract
The enormous burden of CAD and PVD inpatients who have CKD contributes substantially to increased morbidity and mortality. The increased risk of vascular disease observed in CKD patients is likely to be multifactorial, with contributions from traditional and nontraditional cardiovascular factors. Given the overwhelming evidence on the known benefits of cardioprotective medications, their underuse remains puzzling in a population at enormous risk. During the past 5 years, the research community and national interest groups have made significant progress in organizing a concerted approach to improve the management of patients who have CKD and vascular disease. Much work remains to be done. The development of national guidelines in the management of these patients at high risk for future cardiovascular events will be a welcome step. The evaluation of multitargeted interventions for reduction of cardiovascular risk through randomized clinical trials is desperately needed. Finally, the low use of known cardioprotective strategies in this high-risk group is a serious issue and warrants immediate attention at local and national levels.
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Affiliation(s)
- Austin G Stack
- Regional Kidney Centre, Department of Medicine, Floor D, Letterkenny General Hospital, County Donegal, Ireland, and Internal Medicine, University of Texas Health Science Center, 6431 Fanin Street, Houston, TX 77030, USA.
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Abstract
We evaluated the risk of coronary-artery disease in patients with chronic renal failure (CRF) by measuring the coronary-artery calcium scores with electron beam CT (EBCT). A total of 81 CRF patients were divided into three groups; pre-dialysis (group I, n = 35), hemodialysis (group II, n = 31) and peritoneal dialysis (group III, n = 15). The several serum biochemical markers and calcium score levels by EBCT were determined. The Ca x P products were significantly higher in groups II (p < 0.05) and III (p < 0.01) than in group I. The serum calcium levels were significantly higher in group III than in both group I (p < 0.01) and II (p < 0.05). The serum calcium level in 15 patients with a calcium score > 400 was significantly higher than the 66 patients with a score < or =400 (p < 0.01). The calcium score was significantly higher in the 15 patients with cardiovascular complications than in the 66 patients without cardiovascular complications (628.9+/-904.8 vs. 150.4+/-350.9, p < 0.01). EBCT seemed to be a good diagnostic tool for evaluating the risk of coronary-artery disease ''noninvasively'' in CRF patients who are at increased risk of cardiovascular morbidity and mortality.
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Affiliation(s)
- Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji-Hyung Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyuk-Joon Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Min-Hwa Jang
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyeog-Man Kwon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jun-Chul Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Min Lee
- Department of Diagnostic Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Dong-Kyu Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Abstract
Cardiovascular disease (CVD) is the principal cause of mortality in patients with chronic renal disease undergoing hemodialysis. In addition to the CVD risk factors, a new hypothesis has recently been aroused related to "new" factors involved in the development of atherosclerosis in the uremic patient; worthwhile mentioning are the homocysteine, inflammation, and oxidative stress, among others. The potential utility of the folic acid in the hyperhomocysteinemia control is well known, although its mechanism of action, either as antioxidant or anti-inflammatory, has not been established. Our results confirm that the patients undergoing dialysis demonstrate hyperhomocysteinemia, an increased inflammatory status, and an increase of the lipid peroxidation markers. The administration of IV folinic acid induces a reduction of homocysteine levels subordinate to the inflammatory status of the patient. Additionally, although no inflammatory effects were shown, the results provide evidence for the antioxidant effect of IV folinic acid administration by reducing the lipid peroxidation marker levels. The statistic analysis demonstrates no correlation among the 3 markers, in spite of its higher levels in these particular patients. Homocysteine does not independently predict mortality in patients taking oral folic acid. Nevertheless, the PCR (an inflammation marker) and the antibody antioxidative-LDL (a lipidic peroxidation marker) show a good prediction of mortality at the 24-month follow-up analysis. The knowledge of these "new" CV risk factors, as well as the factors that influence them, could be useful to prevent the development of atherosclerosis in patients with chronic renal disease.
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Affiliation(s)
- Beatriz Bayés
- Department of Nephrology, Hospital Universitari Germans Trias I Pujol, 08916 Badalona, Spain.
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Abstract
BACKGROUND Numerous studies have identified risk factors and markers associated with incidence of cardiovascular disease (CVD). However, few studies have examined whether established risk factors, novel blood markers, carotid ultrasonography, or ankle-brachial index can predict recurrent CVD events. METHODS AND RESULTS We analyzed the relation of established risk factors and markers of atherosclerosis with the risk of recurrent CVD in 766 participants. Over a mean of 8.7 years of follow-up, 70 women and 243 men had a recurrent CVD event (85.3% coronary heart disease and 23.7% stroke). Adjusting for age and sex, this study found that established risk factors were associated with recurrent CVD events in the anticipated direction. Being in the highest (vs lowest) quartiles of lipoprotein (a), fibrinogen, white blood cells, and creatinine at baseline were associated with 47%, 69%, 65%, and 81%, respectively, greater risk of a CVD event, and being in the highest quartile of albumin was associated with 39% lower risk. Being in the highest (vs lowest) quartile of carotid intima-media thickness (IMT) was associated with a doubling of risk, and having carotid plaque with acoustic shadowing (vs having no plaque) was associated with 83% increased risk of a CVD event. After adjustment for established risk factors, creatinine, albumin, and carotid IMT in the highest quartile (vs lowest quartile) and carotid plaque with acoustic shadowing (vs no plaque) were independently associated with recurrent CVD events. CONCLUSION Established risk factors, but only a few of novel risk factors and markers, were independent predictors of recurrent CVD events.
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Affiliation(s)
- Keattiyoat Wattanakit
- Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minn 55454-1015, USA
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Affiliation(s)
- M W Yerkey
- Department of Medicine, Divisions of Cardiology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Abstract
Elevated homocysteine (hyperhomocysteinaemia) in renal patients is a major concern for physicians. Although cause and effect between homocysteine and cardiovascular disease (CVD) has not been established in either the general population or renal patients, there is much evidence that this relationship does exist. Purported mechanisms that may explain this effect include increases in endothelial injury, smooth muscle cell proliferation, low-density lipoprotein oxidation and changes in haemostatic balance. Renal patients have a much greater incidence of hyperhomocysteinaemia and this may be explained by decreases in either the renal or extrarenal metabolism of the compound. We conclude that data from long-term placebo-controlled trials are urgently required to determine whether hyperhomocysteinaemia in renal patients is a cause of CVD events and requires therapeutic targeting.
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Affiliation(s)
- Simon K Austen
- School of Human Movement Studies, University of Queensland, St Lucia, Queensland, Australia
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Rosas S, Szapary P, Rader DJ. Management of selected lipid abnormalities: hypertriglyceridemia, isolated low HDL-cholesterol, lipoprotein(a), and lipid abnormalities in renal diseases and following solid organ transplantation. Cardiol Clin 2003; 21:377-92. [PMID: 14621452 DOI: 10.1016/s0733-8651(03)00075-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although the focus in treating lipid disorders is on reducing LDL-C levels, additional lipid-related independent risk factors, such as TG, HDL-C, and Lp(a) levels, should be used clinically to assess cardiovascular risk. Decisions to initiate drug therapy for LDL-C reduction may be influenced by levels of these other lipoprotein fractions. Data supporting intervention to modify these factors are less abundant than for LDL-C reduction, but in certain circumstances. drug therapy targeted at TGs or HDL-C may be appropriate. Patients who have nephrotic syndrome and end-stage renal disease are at particularly high risk for the development of CVD and should be treated aggressively for their lipid disorders. Finally, solid organ transplant recipients are almost always hyperlipidemic and appropriate therapy could reduce cardiovascular events.
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Affiliation(s)
- Sylvia Rosas
- University of Pennsylvania Medical Center, 654 BRBII/III Labs, 421 Curie Boulevard, Philadelphia, PA 19104-6160, USA
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Zoccali C, Mallamaci F, Tripepi G, Cutrupi S, Parlongo S, Malatino LS, Bonanno G, Rapisarda F, Fatuzzo P, Seminara G, Stancanelli B, Nicocia G, Buemi M. Fibrinogen, mortality and incident cardiovascular complications in end-stage renal failure. J Intern Med 2003; 254:132-9. [PMID: 12859694 DOI: 10.1046/j.1365-2796.2003.01180.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Fibrinogen is an established predictor of cardiovascular events in the general population but the relationship between fibrinogen, mortality and incident cardiovascular complications has been very little investigated in patients with end-stage renal disease (ESRD). DESIGN AND SUBJECTS We investigated the relationship between fibrinogen and all cause mortality and cardiovascular outcomes in a prospective cohort study in 192 patients on chronic haemodialysis treatment (follow-up: 34 +/- 16 months). RESULTS Fibrinogen was significantly higher in patients who died during the follow-up than in those who survived. Similarly, fibrinogen was higher in patients who had fatal or nonfatal cardiovascular events than in event free patients. On multivariate Cox regression analysis fibrinogen was an independent predictor of survival [hazard ratio (1 g x L(-1) increase in plasma fibrinogen): 1.19, 95% confidence interval (CI): 1.05-1.35, P = 0.006] and a highly significant (P = 0.0008), independent predictor of fatal and nonfatal cardiovascular events [hazard ratio (1 g x L(-1) increase in plasma fibrinogen): 1.25, 95% CI: 1.10-1.43] in a model including traditional risk factors and serum C-reactive protein (CRP) and plasma homocysteine. CONCLUSIONS Fibrinogen is as an independent risk factor for overall and cardiovascular mortality in patients with ESRD. Intervention studies are required to see whether reducing plasma fibrinogen may help to curb the exceedingly high cardiovascular risk of the uremic population.
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Affiliation(s)
- C Zoccali
- National Research Council, Institute of Biomedicine, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Cal, Italy.
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Parsons DS, Reaveley DA, Pavitt DV, Brown EA. Relationship of renal function to homocysteine and lipoprotein(a) levels: the frequency of the combination of both risk factors in chronic renal impairment. Am J Kidney Dis 2002; 40:916-23. [PMID: 12407635 DOI: 10.1053/ajkd.2002.36321] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Total homocysteine (tHcy) and lipoprotein(a) [Lp(a)] levels have been recognized as risk factors for vascular disease. The combination of elevated tHcy and Lp(a) levels may be particularly atherogenic, although no study has examined the prevalence of the combination of both risk factors in patients with chronic renal impairment. METHODS One hundred ninety-seven patients with renal impairment were studied. Patients had glomerular filtration rate (GFR) measured by clearance of chromium 51-labeled EDTA. Blood was obtained for the determination of tHcy, Lp(a), and apolipoprotein(a) [apo(a)] isoform levels. RESULTS Patients were divided into five groups according to GFR. Mean tHcy levels in the five groups were as follows: GFR less than 10 mL/min, 30.2 +/- 9.8 (SD) micromol/L; GFR of 10 to 20 mL/min, 26.6 +/- 10.5 micromol/L; GFR of 20 to 30 mL/min, 23.9 +/- 8.6 micromol/L; GFR of 30 to 45 mL/min, 22.2 +/- 8.6 micromol/L; and GFR of 45 to 75 mL/min, 18.2 +/- 9.1 micromol/L compared with control levels of 12.7 +/- 4.6 micromol/L. There was a progressive increase in median Lp(a) levels with declining renal function: median Lp(a) levels for those with a GFR less than 10 mL/min were 37.1 mg/dL (range, 0.6 to 156.0 mg/dL); GFR of 10 to 20 mL/min, 30.3 mg/dL (range, 2.6 to 163.7 mg/dL); GFR of 20 to 30 mL/min, 26.1 mg/dL (range, 0.0 to 164.0 mg/dL); GFR of 30 to 45 mL/min, 20.9 mg/dL (range, 0.0 to 99.8 mg/dL), and GFR of 45 to 75 mL/min, 16.8 mg/dL (range, 2.1 to 81.0 mg/dL) compared with control values of 12.5 mg/dL (range, 0.0 to 88.7 mg/dL). CONCLUSION Defining hyperhomocysteinemia as tHcy levels greater than the 90th percentile of controls and elevated Lp(a) level as greater than 30 mg/dL, the frequency of the combination increased with declining renal function. Fifty-eight percent of patients with a GFR less than 10 mL/min had both hyperhomocysteinemia and elevated Lp(a) levels, and even in patients with mild renal impairment, 20% of patients had both risk factors present.
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Affiliation(s)
- Darren S Parsons
- Department of Renal Medicine, Faculty of Medicine, Imperial College School of Science, Technology and Medicine, Charing Cross Hospital, London, UK.
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Abstract
BACKGROUND Elevated plasma concentrations of C-reactive protein (CRP) is a risk factor for cardiovascular disease (CVD) in the general population and in hemodialysis patients. The prognostic value of CRP is less well known in peritoneal dialysis (PD) patients. We examined the association between CRP and cardiovascular event (CVE) in a large population of PD patients. METHODS Two hundred and forty patients starting PD were enrolled in this prospective study. The role of CRP was analyzed with respect to other known cardiovascular risk factors. RESULTS The patients were followed for a mean duration of 41 +/- 21 months; the median value of CRP was 7 mg/L. Eighty-nine cardiovascular events (CVE; 37.1%) occurred in 84 patients and the CRP levels were higher in patients who experienced CVE (27 +/- 14 vs. 6 +/- 8 mg/L; P < 0.0001). In the Cox model, patients in the three lower quartiles of the CRP levels had a decreased risk of CVE compared with those in the highest quartile. Cox regression analysis also revealed that age, a previous history of cardiovascular disease, hyperhomocysteinemia and hypoalbuminemia were risk factors for CVE. CRP levels were higher in patients who died during the study period (25 +/- 12 vs. 5 +/- 8 mg/L; P = 0.003). In the Cox model, patients with CRP levels above the median had an increased risk of death compared with those in the lowest quartile. CONCLUSIONS Chronic inflammation, as reflected by elevated CRP levels, is frequent in patients starting PD and independently contributes to an increased incidence of CVE in this population.
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Affiliation(s)
- Didier Ducloux
- Department of Nephrology, Dialysis, and Renal Transplantation, Saint Jacques University Hospital, Besançon, France.
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Locsey L, Szegedi J, Dán A, Görögh S, Tóths E. Homocysteine and cystatin C level changes in haemodialysed patients and connection with cerebro- and cardiovascular complications. Acta Physiol Hung 2002; 88:293-9. [PMID: 12162587 DOI: 10.1556/aphysiol.88.2001.3-4.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Plasma homocysteine and Cystatin C levels of 360 chronic haemodialysed patients were measured in fasting (191 men, mean age: 55.5 years; and 169 women, mean: 62.9 years). The patients were divided into subgroups: diabetes mellitus (34 men and 38 women 7 vs 8 IDDM). obliterative arteriosclerosis (68 men and 61 women), cardiovascular complications (75 men and 84 women) and stroke (16 men and 12 women), and after renal transplantation in chronic rejection (15 men and 5 female). Homocysteine was determined by IMx analyser from Abbott by FPIA method. Immunoturbidimetric method was used for quantification of Cystatin C (PETIA). The lowest Cystatin C concentration was found in diabetic patients (4.35 +/- 0.15 mg/l in men and 3.18 +/- 1.77 mg/l in women) and the highest one occurred in anuric and bilateral nephrectomised and transplanted chronic rejected patients (6.075 mg/l in men and 6.35 mg/l in women: p<0.001). The homocysteine levels (24.98 +/- 2.94 micromol/l in men and 23.88 +/- 1.76 micromol/l in women) exceeded the upper limit of reference range (<15.0 micromol/l). There was a significant difference in favour of subgroup of cardiovascular (27.25 micromol/l in men and 26.87 micromol/l in women) and stroke patients (27.16 micromol/l in men and 30.76 micromol/l in women p<0.001). Elevated levels were found in chronic rejected patients with accelerated arteriosclerotic events (25.94 micromol/l in men and 27.43 micromol/l in women). Good positive linear correlation was found between serum homocysteine and Cystatin C levels (r=0.2393 and 0.2252). The authors demonstrated hyperhomocysteinaemia associated with high Cystatin C concentration in four subgroups of haemodialysed patients (obliterative and accelerated arteriosclerosis, cardiovascular disease, and cerebrovascular complications and stroke).
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Affiliation(s)
- L Locsey
- EuroCare 10, Dialysis Center Debrecen, Hungary
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Al Suwaidi J, Reddan DN, Williams K, Pieper KS, Harrington RA, Califf RM, Granger CB, Ohman EM, Holmes DR. Prognostic implications of abnormalities in renal function in patients with acute coronary syndromes. Circulation 2002; 106:974-80. [PMID: 12186803 DOI: 10.1161/01.cir.0000027560.41358.b3] [Citation(s) in RCA: 322] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outcomes in patients with mild to moderate renal function (RF) abnormalities presenting with acute coronary syndromes (ACS) are not well defined. METHODS AND RESULTS A convenience sample of 4 ACS trial databases including all enrolled patients was assessed to determine 30- and 180-day outcomes. The 4 trials were Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb, GUSTO-III, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), and Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A). Patients were stratified into ST-segment elevation (STE) and non-ST-segment elevation (NSE) groups and by the presence or absence of abnormal RF (creatinine clearance <70 mL/min). In the STE group, 7670 of 18 621 patients (41%) had abnormal RF. In the NSE group, 8152 of 19 304 (42%) had abnormal RF. Patients with abnormal RF were older, more often female, and more likely to have adverse baseline characteristics. They had higher mortality and higher mortality/nonfatal myocardial infarction (MI) at both 30 and 180 days, regardless of ST-segment status. Creatinine clearance was independently associated with risk of mortality (hazard ratio 0.79 in the STE group and 0.81 in the NSE group) and with risk of mortality/MI (hazard ratio 0.93) in the NSE group at 180 days. CONCLUSIONS Patients presenting with ACS frequently have abnormal RF. Abnormal RF is a marker of adverse baseline clinical characteristics and is independently associated with increased risk of death and death/MI.
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Musselman DL, Marzec U, Davidoff M, Manatunga AK, Gao F, Reemsnyder A, Duggirala S, Larsen H, Taylor RW, Hanson S, Nemeroff CB. Platelet activation and secretion in patients with major depression, thoracic aortic atherosclerosis, or renal dialysis treatment. Depress Anxiety 2002; 15:91-101. [PMID: 12001177 DOI: 10.1002/da.10020] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Relatively little is known concerning the magnitude of alterations of platelet activation and secretion markers of patients with major depression when compared to patients at increased risk for, or with current, clinically significant atherosclerosis. Markers of in vivo platelet stimulation and secretion were measured under basal conditions in normal comparison subjects (n = 12) and three patient groups: patients diagnosed with DSM-IV major depression (n = 15), dialysis-dependent patients (n = 12), and patients with severe thoracic aortic atherosclerosis (n = 10). In comparison to normal comparison subjects, depressed patients and patients with thoracic aortic atherosclerosis exhibited the greatest platelet stimulation as detected by increased anti-LIBS platelet binding. Dialysis-dependent patients exhibited the highest plasma concentrations of the renally-excreted platelet-specific secretion protein, beta-thromboglobulin. This study extends previous observations of increased platelet activation in patients with major depression and documents similar alterations in patients with transesophageal echocardiography (TEE)-documented thoracic aortic atherosclerosis. Future studies will determine whether the magnitude of platelet stimulation and secretion in patients with comorbid depression and atherosclerotic aortic disease is greater than that observed in nondepressed patients with atherosclerotic aortic disease or major depression alone. These findings provide further evidence for either increased platelet activation and/or intrinsic heightened platelet reactivity as one of the biological substrates underlying the increased risk of depressed patients for cardiovascular disease.
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Affiliation(s)
- Dominique L Musselman
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 1639 Pierce Drive, Atlanta, GA 30322, USA
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Abstract
BACKGROUND Vascular access remains the Achilles' heel of successful hemodialysis, and thrombosis is the leading cause of vascular access failure. Hyperhomocystinemia is common in hemodialysis patients and is associated with venous and arterial thrombosis in patients without end-stage renal disease. SUBJECTS AND METHODS In the study, 65 hemodialysis patients with native arteriovenous fistula were included. Two groups of patients were defined: group A including 45 patients with their vascular access either never or only once thrombosed, and group B including 20 patients with two or more thromboses of their vascular access. We determined serum concentrations of total homocysteine (immunoassay, Abbott) in our patients. RESULTS In 63 (96.9%) patients, hyperhomocystinemia was presented. There was no statistically significant difference between group A and B regarding age, gender and duration of hemodialysis treatment. Total homocysteine concentrations were higher in group A (42.1 +/- 18.6 micromol/l) than in group B (36.1 +/- 18.1 micromol/l) patients but the difference was small and not statistically significant. CONCLUSION We found no significant differences in total homocysteine concentrations between group A (thrombosis non-prone) and group B (thrombosis prone) patients. Our results suggest that thrombosis of native arteriovenous fistulas may not be caused by hyperhomocystinemia in these patients.
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Affiliation(s)
- Radovan Hojs
- Department of Nephrology, Teaching Hospital Maribor, Slovenia.
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Abstract
BACKGROUND Plasma aminothiols, including homocysteine, cysteine, and glutathione, function as an important extracellular redox system. We examined the plasma aminothiol concentration and redox status in ten chronic hemodialysis patients compared to ten age-matched healthy subjects. METHODS Plasma levels of reduced, free oxidized, and protein-bound homocysteine, cysteine, cysteinylglycine, and glutathione were determined using high-pressure liquid chromatography (HPLC). RESULTS Total plasma homocysteine, cysteine, and cysteinylglycine levels were significantly elevated in hemodialysis patients before dialysis compared to healthy subjects. Total plasma concentration of cysteine and homocysteine significantly decreased after hemodialysis. The ratio of free oxidized to free reduced homocysteine, cysteine, cysteinylglycine, and glutathione were each significantly elevated before dialysis compared to healthy subjects, and decreased significantly by the end of dialysis. The free oxidized to reduced ratio of cysteine and homocysteine were also significantly correlated with total plasma concentrations. CONCLUSIONS Plasma aminothiols are excessively oxidized in uremia, while the hemodialysis procedure is restorative of redox status. Oxidized aminothiols are candidate uremic toxins.
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Affiliation(s)
- Jonathan Himmelfarb
- Maine Medical Center and Maine Medical Center Research Institute, Portland, Maine 04102, USA.
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Lindner A, Bankson DD, Stehman-Breen C, Mahuren JD, Coburn SP. Vitamin B6 metabolism and homocysteine in end-stage renal disease and chronic renal insufficiency. Am J Kidney Dis 2002; 39:134-45. [PMID: 11774112 DOI: 10.1053/ajkd.2002.29904] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Homocysteine (tHcy) is a risk factor for atherosclerosis in patients with end-stage renal disease and chronic renal insufficiency (CRI). Vitamin B6 deficiency may result in high tHcy levels, especially after a methionine load (PML). Therefore, we evaluated vitamin B6 metabolism and tHcy (fasting and PML) levels in patients with CRI and those on hemodialysis (HD) therapy before and during high-dose sequential vitamin B6 and folic acid supplementation in male patients (27 patients, HD, 17 patients, CRI) and 19 age-matched healthy controls. Vitamin B6 doses were 100 mg/d in patients with CRI and 200 mg/d in HD patients, plus folic acid (5 mg/d), for more than 3 months in each period. We analyzed vitamin B6 metabolites by high-performance liquid chromatography in plasma and red blood cells (RBCs) and fasting tHcy in all cases and PML in subgroups of 11 HD patients and 14 patients with CRI. We found vitamin B6 deficiency and high tHcy (fasting and PML) levels in all patients. Plasma and RBC levels of pyridoxal and pyridoxal phosphate were abnormally low, whereas levels of pyridoxic acid (PA), an end product of vitamin B6 metabolism, were extremely high in both groups. Fasting and PML tHcy levels were partially resistant to vitamin B6 supplements, with different response patterns in HD patients and those with CRI. Thus, the PML defect was more responsive to folic acid in HD patients, whereas vitamin B6 partially reduced PML tHcy levels in patients with CRI. Resistance of tHcy to vitamin B6 treatment in patients with CRI and HD patients is not caused by poor absorption or low tissue stores. Rather, nonvitamin factors or potentially toxic PA levels may be implicated in abnormal vitamin B6 and/or tHcy metabolism during renal insufficiency.
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Affiliation(s)
- Armando Lindner
- Department of Medicine, Veteran's Affairs Puget Sound Health Care System, University of Washington, Seattle, WA 98108, USA.
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Abstract
BACKGROUND Patients with diabetes mellitus (DM) have 2- to 6-fold increase in the prevalence of cardiovascular disease (CVD) compared to non-DM subjects. Epidemiological data show that DM is synergic with other conventional risk factors. Total plasma homocysteine (tHcy) is an emerging CVD risk factor. We reviewed the literature to explore the relation between tHcy and CVD in patients with DM. METHODS We searched the MEDLINE database for articles on homocysteine, DM and CVD published from January 1991 to October 2000. RESULTS The mean plasma tHcy level is usually low or normal in DM patients, except when nephropathy is present. Levels in that case tend to be higher than in non-DM patients. An independent association with tHcy and CVD was shown in retrospective studies, for DM patients. Prospective studies showed an association between elevated tHcy and all cause mortality in DM patients. In general, the association between elevated levels of tHcy and the outcome was stronger than in non-DM individuals, for all types of study. DISCUSSION To date, there are no prospective work that specifically examined the relationship between levels of tHcy and the presence of CVD in the DM population. Nor are there studies to show that treating elevated tHcy results in a reduction of CVD events. Such studies are ongoing. Nevertheless, since hyperhomocysteinemia is potentially reversible with vitamin therapy, interaction of DM with high levels tHcy on the risk of CVD may have consequences with regard to management of primary and secondary prevention in DM patients who are at particularly high risk of CVD events.
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Affiliation(s)
- M C Audelin
- The Internal Medicine Division of the Centre Hospitalier de l'Université de Montréal, H2W 1R7, Montreal, Canada
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Abstract
Cardiovascular disease is a major challenge to nephrologists, whether we deal with patients with pre-end-stage renal failure, on dialysis or after successful renal transplantation. It is the most common cause for death in patients with a functional allograft, and prevents many dialysis patients from being engrafted. Coronary artery disease is a diagnostic and therapeutic challenge, as it differs in some respects from that seen in non-uremic cohorts, and lacks much of the evidence-base on which therapeutic intervention rests. This review examines the experimental and clinical literature on cardiovascular disease in uremia, focusing on coronary artery disease. We focus on the incidence, presenting syndromes, screening tools, and interventions in the context of acute and chronic coronary syndromes. Recent evidence comparing coronary angioplasty, coronary artery stenting, and bypass surgery in subjects with renal failure is also reviewed. Coronary artery disease is more prevalent in uremia, more difficult to diagnose and less rewarding to treat compared to non-uremic subjects. Many more randomized trials are needed. In the absence of information from such trials, we advocate aggressive control of conventional and novel cardiovascular risk factors, and early intervention for symptomatic coronary disease.
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Affiliation(s)
- D J Goldsmith
- Renal Unit, Guy's Hospital, London, England, United Kingdom.
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Affiliation(s)
- F A Zantvoort
- Medical Clinic III, Central Hospital, Bremen, Germany
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Borawski J, Naumnik B, Pawlak K, Mysliwiec M. Endothelial dysfunction marker von Willebrand factor antigen in haemodialysis patients: associations with pre-dialysis blood pressure and the acute phase response. Nephrol Dial Transplant 2001; 16:1442-7. [PMID: 11427638 DOI: 10.1093/ndt/16.7.1442] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Increased plasma soluble von Willebrand factor antigen (vWF : Ag) level, a marker of vascular endothelial cell dysfunction, is a strong predictor of atherosclerotic cardiovascular disease (CVD) in the general population. We studied cross-sectional associations between vWF : Ag level, prevalence of CVD, and related factors including pre-dialysis arterial blood pressure (BP) and some markers of inflammation in maintenance haemodialysis (HD) patients. Methods and results. Plasma vWF : Ag level measured by an enzyme-linked immunosorbent assay (ELISA) was higher in 110 HD patients than in 20 controls. On bivariate regression analysis, vWF : Ag level was directly associated with the presence of CVD, age, fibrinogen and the use of enoxaparin (vs unfractionated heparin) during HD procedures, and inversely with albumin and pre-dialysis BP. The patients with prevalent CVD were older, had higher vWF : Ag, white blood cell and platelet counts, fibrinogen and triglycerides, lower albumin levels, and were less frequently on combination antihypertensive therapy. Multivariable analyses identified low pre-dialysis BP, hypoalbuminaemia and hyperfibrinogenaemia (in descending order of significance) as independent predictors of high vWF : Ag level. There were no associations between vWF : Ag levels and gender, ABO blood type, smoking, body mass index, renal failure cause, duration of HD therapy, K(t)/V, normalized protein catabolic rate, dialysate buffers, dialysers, viral hepatitis, erythropoietin treatment, specific antihypertensive drugs, haemoglobin, white blood cell and platelet counts, liver enzymes, phosphorous, total cholesterol, and triglycerides. CONCLUSION Elevated plasma levels of endothelial dysfunction marker vWF : Ag in maintenance HD patients are associated with established cardiovascular mortality risk factors such as low pre-dialysis blood pressure and the activated acute phase response.
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Affiliation(s)
- J Borawski
- Department of Nephrology and Internal Medicine, Medical Academy, Bialystok, Poland
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