The Correlation between Lipid Metabolism Disorders and Prostate Cancer

Prostate cancer is the second most common cancer affecting the male population all over the world. The existence of a correlation between lipid metabolism disorders and cancer of the prostate gland has been widely known for a long time. According to hypotheses, cholesterol may contribute to prostate cancer progression as a result of its participation as a signaling molecule in prostate growth and differentiation via numerous biologic mechanisms including Akt signaling and de novo steroidogenesis. The results of some studies suggest that increased cholesterol levels may be associated with a higher risk of a more aggressive course of the disease. The aforementioned alterations in the synthesis of fatty acids are a unique feature of cancer and, therefore, constitute an attractive target for therapeutic intervention in the treatment of prostate cancer. Pharmacological or gene therapy aims to reduce the activity of enzymes involved in de novo synthesis of fatty acids, FASN, ACLY (ATP citrate lyase) or SCD-1 (Stearoyl-CoA Desaturase) in particular, that may result in cells growth arrest. Nevertheless, not all cancers are unequivocally associated with hypocholesterolaemia. It cannot be ruled out that the relationship between prostate cancer and lipid disorders is not a direct quantitative correlation between carcinogenesis and the amount of circulating cholesterol. Perhaps the correspondence is more sophisticated and connected to the distribution of cholesterol fractions or even sub-fractions of e.g. HDL cholesterol.

Nephrotoxicity as a Complication of Chemotherapy and Immunotherapy in the Treatment of Colorectal Cancer, Melanoma and Non-Small Cell Lung Cancer

Acute kidney injury is a common complication of many medical procedures, including those used in cancer treatment. Both chemotherapy and immunotherapy may result in deterioration of kidney function, which may lead to an increase in mortality among patients with cancer. Antineoplastic agents can affect any element of the nephron, leading to the appearance of clinical symptoms such as proteinuria, hypertension, electrolyte disorders, glomerulonephritis, acute and chronic interstitial nephritis and acute kidney injury. The medical literature describing renal complications occurring during chemotherapeutic and immunotherapeutic treatment in neoplasms, such as colorectal cancer, non-small cell lung cancer and melanoma, was analysed. The immune system plays an important role in controlling the development of neoplasms and fighting them. Oncological treatment algorithms include immunotherapy as monotherapy, combined with chemotherapy or chemotherapy as monotherapy. In the treatment of the above-mentioned neoplasms immunotherapeutics are used, such as checkpoint inhibitors (CPI) (i.e., ipilimumab, pembrolizumab, nivolumab, atezolizumab), vascular endothelial growth factor (VEGF) inhibitors (i.e., bevacizumab, ramucirumab) and a variety of chemotherapeutic agents (irinotecan, capecitabine, oxaliplatin, gefitinib, erlotinib, gemcitabine, cisplatin, paclitaxel, carboplatin, doclitaxel, vinorelbine, topotecan, etoposide). In our article, we focused on the number and type of renal complications as well as on the time of their manifestation when using specific treatment regimens. Our analysis also includes case reports. We discussed treatment of immunological complications and adjustments of the dose of chemotherapeutic agents depending on the creatinine clearance. Analysing the data from the literature, when two immunotherapeutic agents are used together, the number of recorded renal complications increases. Bevacizumab and ramucirumab are the cause of the largest number of renal complications among the immunotherapeutic agents described above. Cisplatin is the best-described substance with the greatest nephrotoxic potential among the chemotherapeutic agents. Crucial for renal complications are also cancer stage, previous chemotherapy and other risk factors of AKI such as age, comorbidities and medications used. Due to the described complications during oncological treatment, including kidney damage, it seems necessary to elaborate standards of cooperation between oncologists and nephrologists both during and after treatment of a patient with cancer. Therefore, it is necessary to conduct further research and develop algorithms for management of a cancer patient, especially during such an intensive progress in oncology.

Biochemical Markers in the Prediction of Contrast-induced Acute Kidney Injury

For many years clinicians have been searching for "kidney troponin"- a simple diagnostic tool to assess the risk of acute kidney injury (AKI). Recently, the rise in the variety of contrast-related procedures (contrast computed tomography (CT), percutaneous coronary intervention (PCI) and angiography) has resulted in the increased number of contrast-induced acute kidney injuries (CI-AKI). CIAKI remains an important cause of overall mortality, prolonged hospitalisation and it increases the total costs of therapy. The consequences of kidney dysfunction affect the quality of life and they may lead to disability as well. Despite extensive worldwide research, there are no sensitive and reliable methods of CI-AKI prediction. Kidney Injury Molecule 1 (KIM-1) and Neutrophil Gelatinase Lipocalin (NGAL) have been considered as kidney-specific molecules. High concentrations of these substances before the implementation of contrast-related procedures have been suggested to enable the estimation of kidney vulnerability to CI-AKI and they seem to have the predictive potential for cardiovascular events and overall mortality. According to other authors, routine determination of known inflammation factors (e.g., CRP, WBC, and neutrophil count) may be helpful in the prediction of CIAKI. However, the results of clinical trials provide contrasting results. The pathomechanism of contrast- induced nephropathy remains unclear. Due to its prevalence, the evaluation of the risk of acute kidney injury remains a serious problem to be solved. This paper reviews pathophysiology and suggested optimal markers facilitating the prediction of contrast-induced acute kidney injury.

The Impact of CKD on Uremic Toxins and Gut Microbiota

Numerous studies have indicated that the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD) is strictly associated with the accumulation of toxic metabolites in blood and other metabolic compartments. This accumulation was suggested to be related to enhanced generation of toxins from the dysbiotic microbiome accompanied by their reduced elimination by impaired kidneys. Intestinal microbiota play a key role in the accumulation of uremic toxins due to the fact that numerous uremic solutes are generated in the process of protein fermentation by colonic microbiota. Some disease states, including CKD, are associated with the presence of dysbiosis, which can be defined as an "imbalanced intestinal microbial community with quantitative and qualitative changes in the composition and metabolic activities of the gut microbiota". The results of studies have confirmed the altered composition and functions of gut microbial community in chronic kidney disease. In the course of CKD protein-bound uremic toxins, including indoxyl sulfate, p-cresyl glucuronide, p-cresyl sulfate and indole-3-acetic acid are progressively accumulated. The presence of chronic kidney disease may be accompanied by the development of intestinal inflammation and epithelial barrier impairment leading to hastened systemic translocation of bacterial-derived uremic toxins and consequent oxidative stress injury to the kidney, cardiovascular and endocrine systems. These findings offer new therapeutic possibilities for the management of uremia, inflammation and kidney disease progression and the prevention of adverse outcomes in CKD patients. It seems that dietary interventions comprising prebiotics, probiotics, and synbiotics could pose a promising strategy in the management of uremic toxins in CKD.

Are Nutraceuticals Beneficial in Chronic Kidney Disease?

Chronic kidney disease (CKD) is a worldwide health problem in which prevalence is constantly rising. The pathophysiology of CKD is complicated and has not been fully resolved. However, elevated oxidative stress is considered to play a vital role in the development of this disease. CKD is also thought to be an inflammatory disorder in which uremic toxins participate in the development of the inflammatory milieu. A healthy, balanced diet supports the maintenance of a good health status as it helps to reduce the risk of the development of chronic diseases, including chronic kidney disease, diabetes mellitus, and hypertension. Numerous studies have demonstrated that functional molecules and nutrients, including fatty acids and fiber as well as nutraceuticals such as curcumin, steviol glycosides, and resveratrol not only exert beneficial effects on pro-inflammatory and anti-inflammatory pathways but also on gut mucosa. Nutraceuticals have attracted great interest recently due to their potential favorable physiological effects on the human body and their safety. This review presents some nutraceuticals in which consumption could exert a beneficial impact on the development and progression of renal disease as well cardiovascular disease.

Diabetes-induced Alterations in HDL Subfractions Distribution

INTRODUCTION

Diabetes mellitus (DM) due to its increasing prevalence and associated morbidity and mortality has become a serious public health problem. In DM, HDL may lose its beneficial features and become proatherogenic due to its altered biological activity thus increasing cardiovascular risk. The aim of this study was to assess the influence of the presence of diabetes mellitus type 2 and its duration on the distribution of HDL subfractions. Moreover, the effect of statin treatment on HDL subfraction share was analysed in this study.

METHODS

The study group consisted of 50 patients with newly diagnosed DM and 50 persons with DM for longer than 10 years while the control group consisted of 50 healthy volunteers. HDL subfractions were analysed with the use of Lipoprint.

RESULTS

We demonstrated progressive worsening of heart functioning and impairment of its structure in the course of diabetes mellitus. Moreover, we observed that HDL-6 subfraction and intermediate HDL fraction are lowest in the group with advanced DMt2 compared to the group with newly diagnosed DM and a healthy control group. Finally, the results of our study indicated the effect of statin treatment on HDL subfractions that seems not to be advantageous.

CONCLUSION

It seems that in patients with diabetes mellitus compromised antiatherogenic properties of HDL, as a result of oxidative modification and glycation of the HDL protein as well as the transformation of the HDL proteome into a proinflammatory protein, increase cardiovascular risk.

Oxidative Stress in ESRD Patients on Dialysis and the Risk of Cardiovascular Diseases

Chronic kidney disease is highly prevalent worldwide. The decline of renal function is associated with inadequate removal of a variety of uremic toxins that exert detrimental effects on cells functioning, thus affecting the cardiovascular system. The occurrence of cardiovascular aberrations in CKD is related to the impact of traditional risk factors and non-traditional CKD-associated risk factors, including anemia; inflammation; oxidative stress; the presence of some uremic toxins; and factors related to the type, frequency of dialysis and the composition of dialysis fluid. Cardiovascular diseases are the most frequent cause for the deaths of patients with all stages of renal failure. The kidney is one of the vital sources of antioxidant enzymes, therefore, the impairment of this organ is associated with decreased levels of these enzymes as well as increased levels of pro-oxidants. Uremic toxins have been shown to play a vital role in the onset of oxidative stress. Hemodialysis itself also enhances oxidative stress. Elevated oxidative stress has been demonstrated to be strictly related to kidney and cardiac damage as it aggravates kidney dysfunction and induces cardiac hypertrophy. Antioxidant therapies may prove to be beneficial since they can decrease oxidative stress, reduce uremic cardiovascular toxicity and improve survival.

Serum NGAL, KIM-1, IL-18, L-FABP: new biomarkers in the diagnostics of acute kidney injury (AKI) following invasive cardiology procedures

PURPOSE

The aim of this study was to assess the levels of selected markers in patients who underwent planned or emergency coronary angiography and to examine if they correlated with the occurrence of AKI.

METHODS

The study included 52 patients who underwent planned or emergency coronary angiography and received contrast agent. Serum levels of markers (NGAL, L-FABP, KIM-1, IL-18) were analyzed in all patients using ELISA tests, at baseline, after 24 and 72 h from angiography.

RESULTS

9.62% of patients developed CI-AKI. No significant differences were observed between markers levels in patients who developed CI-AKI and those who did not. After 24 h, serum levels of IL-18 were higher in patients with CI-AKI, however, this difference was on the verge of significance. Increase in serum NGAL, KIM-1 and IL-18 was observed after 24 h. Serum levels of biomarkers were insignificantly higher in group with CI-AKI. Significant changes in levels in time (baseline vs. 24 h vs. 72 h) were observed only for NGAL [157.9 (92.4-221.0) vs. 201.8 (156.5-299.9) vs. 118.5 (73.4-198.7); p < 0.0001]. No significant correlations were observed between the decrease in eGFR or the increase in creatinine and biomarkers level.

CONCLUSION

Obtained results do not allow for the indication of efficient AKI biomarkers. Their further validation in large studies of CI-AKI patients is required.

The Role of Metabolic Factors in Renal Cancers

An increasing number of evidence indicates that metabolic factors may play an important role in the development and progression of certain types of cancers, including renal cell carcinoma (RCC). This tumour is the most common kidney cancer which accounts for approximately 3–5% of malignant tumours in adults. Numerous studies indicated that concomitant diseases, including diabetes mellitus (DM) and hypertension, as well as obesity, insulin resistance, and lipid disorders, may also influence the prognosis and cancer-specific overall survival. However, the results of studies concerning the impact of metabolic factors on RCC are controversial. It appears that obesity increases the risk of RCC development; however, it may be a favourable factor in terms of prognosis. Obesity is closely related to insulin resistance and the development of diabetes mellitus type 2 (DM2T) since the adipocytes in visceral tissue secrete substances responsible for insulin resistance, e.g., free fatty acids. Interactions between insulin and insulin-like growth factor (IGF) system appear to be of key importance in the development and progression of RCC; however, the exact role of insulin and IGFs in RCC pathophysiology remains elusive. Studies indicated that diabetes increased the risk of RCC, but it might not alter cancer-related survival. The risk associated with a lipid profile is most mysterious, as numerous studies provided conflicting results. Even though large studies unravelling pathomechanisms involved in cancer growth are required to finally establish the impact of metabolic factors on the development, progression, and prognosis of renal cancers, it seems that the monitoring of health conditions, such as diabetes, low body mass index (BMI), and lipid disorders is of high importance in clear-cell RCC.

Correction to: Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis

An amendment to this paper has been published and can be accessed via the original article.

Pharmacogenomics of Hypertension Treatment

Hypertension is one of the strongest modifiable cardiovascular risk factors, affecting an increasing number of people worldwide. Apart from poor medication adherence, the low efficacy of some therapies could also be related to inter-individual genetic variability. Genetic studies of families revealed that heritability accounts for 30% to 50% of inter-individual variation in blood pressure (BP). Genetic factors not only affect blood pressure (BP) elevation but also contribute to inter-individual variability in response to antihypertensive treatment. This article reviews the recent pharmacogenomics literature concerning the key classes of antihypertensive drugs currently in use (i.e., diuretics, β-blockers, ACE inhibitors, ARB, and CCB). Due to the numerous studies on this topic and the sometimes-contradictory results within them, the presented data are limited to several selected SNPs that alter drug response. Genetic polymorphisms can influence drug responses through genes engaged in the pathogenesis of hypertension that are able to modify the effects of drugs, modifications in drug–gene mechanistic interactions, polymorphisms within drug-metabolizing enzymes, genes related to drug transporters, and genes participating in complex cascades and metabolic reactions. The results of numerous studies confirm that genotype-based antihypertension therapies are the most effective and may help to avoid the occurrence of major adverse events, as well as decrease the costs of treatment. However, the genetic heritability of drug response phenotypes seems to remain hidden in multigenic and multifactorial complex traits. Therefore, further studies are required to analyze all associations and formulate final genome-based treatment recommendations.

Cholesterol Subfraction Analysis in Patients with Acute Coronary Syndrome

BACKGROUND

There is a close relationship between lipid metabolism disorders and atherosclerosis. Guidelines focus on lowering Low-Density Lipoprotein Cholesterol (LDL-C) levels. However, it should be kept in mind that LDL and High-Density Lipoprotein (HDL) consist of subfractions which can affect the progression of atherosclerosis.

OBJECTIVE

We assessed the concentration of LDL and HDL subfractions in patients with Acute Coronary Syndromes (ACS). The influence of the presence of type 2 diabetes mellitus on LDL and HDL subfractions was also analyzed.

METHODS

The study group consisted of 127 patients (62 men, 65 women) with ACS. All patients had coronary angiography and coronary angioplasty and stenting when necessary. Medical history was collected during 12 months of follow-up. HDL and LDL subfraction distribution was measured using Lipoprint (Quantimetrix).

RESULTS

No differences in LDL nor HDL subfractions were observed between ST-Segment Elevation Myocardial Infarction (STEMI), Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) and unstable angina (UA) patients. However, those with restenosis and the necessity of repeated revascularization had higher levels of intermediate-density lipoprotein C (IDL-C) (p=0.055) and LDL3 (p=0.048) as compared with the patients without, while the level of IDL A (IDLA) was lower than in the latter group (p=0.036). In diabetic patients, the percentage share of HDL10 and small-dense HDL was significantly higher while the share of HDL1 (small-dense) (p=0.028), HDL4 (intermediate density) (p=0.052) and HDL5 (intermediate density) (p=0.060) were lower than in patients without DM.

CONCLUSION

Patients with multi-vessel CAD disease had higher levels of LDL3 subfraction and IDL-C and a lower proportion of IDLA.

Selected cardiovascular risk factors in early stages of chronic kidney disease

Cardiovascular diseases, including hypertension, congestive heart failure, myocardial infarction, stroke and atherosclerosis, are common in patients with chronic kidney disease. Aside from the standard biomarkers, measured to determine cardiovascular risk, new ones have emerged: markers of oxidative stress, apoptosis, inflammation, vascular endothelium dysfunction, atherosclerosis, organ calcification and fibrosis. Unfortunately, their utility for routine clinical application remains to be elucidated. A causal relationship between new markers and cardiovascular diseases in patients with chronic kidney disease remains to be established. First of all, there is a lack of large, randomized trials. Moreover, most studies focus on patients with end-stage renal disease as well as on dialysed patients. In such patients, cardiovascular diseases are already present and advanced while early detection of cardiovascular disease risk factor in patients with early-stages of chronic kidney disease would allow more precise prognosis and, as a result, changes in treatment algorithm. In this article, we conduct a comprehensive review of literature for publications relating to cardiovascular risk factors in patients with early-stages of chronic kidney disease. Overall, there are many encouraging advances in detection of cardiovascular risk factors that are making the future more promising for patients suffering from chronic kidney disease.

The influence of cognitive-behavioral therapy on depression in dialysis patients - meta-analysis

INTRODUCTION

Depressive disorders are the most common mental health problem among patients undergoing dialysis. Furthermore, depression is an independent factor increasing the mortality and frequency of hospitalization in this group of patients, yet psychological intervention programs aimed at improving the mental health of dialysis patients have still not been developed. This meta-analysis aimed to assess the effects of cognitive-behavioral therapy on depressive symptoms in dialysis patients. The main hypothesis of this study is that cognitive-behavioral therapy is an effective psychological method of reducing the severity of depression symptoms among patients undergoing dialysis.

MATERIAL AND METHODS

A systematic search was conducted using Medline, PubMed, Web of Science, Scopus and Google Scholar. Data extraction was carried out by two independent researchers. The severity of depression symptoms in the included studies was measured by the Beck Depression Inventory. A random-effects model was used to estimate the pooled mean difference of these values between patients undergoing CBT and the controls.

RESULTS

Four of the 1841 search results met the inclusion criteria with data from 226 patients who had undergone dialysis therapy due to renal disorders and psychological intervention based on cognitive-behavioral therapy. This therapy significantly reduced the level of depression symptoms in all studies included in the meta-analysis (mean difference = -5.3, p = 0.001; 95% CI: -7.95 to -2.66).

CONCLUSIONS

The study showed that the use of psychological intervention based on cognitive- behavioral therapy was an effective method of decreasing the severity of depressive symptoms in hemodialyzed patients. For the sake of patient well-being, it seems reasonable to extend renal replacement therapy with psychological intervention such as cognitive-behavioral therapy.

Cytisine - From the Past to the Future

INTRODUCTION

Neuronal nicotinic acetylcholine receptors are ligand-gated ion channel receptors, distributed throughout central nervous system, as well as in peripheral ganglia and some non-neuronal cells. Cytisine, a qulinolizidine alkaloid, could be considered a high affinity ligand of those receptors. It is a partial agonist of β2*-containing receptors and a full agonist of α7 and β4*-containing receptors.

Current indication

At present, pharmacodynamic properties of cytisine are leveraged only in a few European countries where it is available as medicinal product (Desmoxan and Tabex) indicated in the pharmacotherapy of nicotine addiction. Cytisine mimics the influence of nicotine on α4β2* receptors, but with higher affinity and lower activity. It lowers rewarding and reinforcing effects of nicotine in smoking persons and reduces withdrawal symptoms and craving in quitting ones.

Potential indications

The results of non-clinical studies suggest that cytisine could affect ethanol consumption, has an antidepressant and neuroprotective effect and could be useful in reducing body mass and preventing weight gain. Although there is a lack of research on cytisine in the treatment of areca nuts usage, the preliminary data suggest its usefulness. The combination of cytisine and Trolox C was selected as a possible effective treatment for type 2 diabetes. Though these drugs alone are not effective, their theoretical usefulness was confirmed in animal models.

SUMMARY

Treatment with cytisine is an effective, cost-efficient, affordable and well tolerated nicotine addiction therapy. Potential new indications for cytisine include the treatment of alcoholism, areca nuts usage, Parkinson's disease, an autonomic-system failure. Further studies are necessary.

Cholesterol Disturbances and the Role of Proper Nutrition in CKD Patients

Chronic kidney disease (CKD) is a widespread disease with increasing prevalence in the modern society. Lipid disturbances are common in this group of patients. In most patients with CKD atherogenic dyslipidemia is observed. Dyslipidemia in patients with renal diseases increases the risk of cardiovascular diseases and it accelerates the progression of chronic kidney disease to its end stage. The amelioration of dyslipidemia and the lowering of oxidative stress, inflammatory processes, insulin sensitivity and remnant lipoproteins levels may lead to the reduction in cardiovascular burden. Nutritional interventions can strengthen the beneficial effect of treatment and they play an important role in the preservation of overall well-being of the patients with CKD since the aim of appropriate diet is to reduce the risk of cardiovascular events, prevent malnutrition, and hamper the progression of kidney disease. The management of dyslipidemia, regardless of the presence of chronic kidney disease, should be initiated by the introduction of therapeutic lifestyle changes. The introduction of diet change was shown to exert beneficial effect on the lipid level lowering that reaches beyond pharmacological therapy. Currently available evidence give the impression that data on dietary interventions in CKD patients is not sufficient to make any clinical practice guidelines and is of low quality.

Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis

BACKGROUND

The role of statins in patients with heart failure (HF) of different levels of left ventricular ejection fraction (LVEF) remains unclear especially in the light of the absence of prospective data from randomized controlled trials (RCTs) in non-ischemic HF, and taking into account potential statins' prosarcopenic effects. We assessed the association of statin use with clinical outcomes in patients with HF.

METHODS

We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until August 2018 for RCTs and prospective cohorts comparing clinical outcomes with statin vs non-statin use in patients with HF at different LVEF levels. We followed the guidelines of the 2009 PRISMA statement for reporting and applied independent extraction by multiple observers. Meta-analyses of hazard ratios (HRs) of effects of statins on clinical outcomes used generic inverse variance method and random model effects. Clinical outcomes were all-cause mortality, cardiovascular (CV) mortality and CV hospitalization.

RESULTS

Finally we included 17 studies (n = 88,100; 2 RCTs and 15 cohorts) comparing statin vs non-statin users (mean follow-up 36 months). Compared with non-statin use, statin use was associated with lower risk of all-cause mortality (HR 0.77, 95% confidence interval [CI], 0.72-0.83, P < 0.0001, I2 = 63%), CV mortality (HR 0.82, 95% CI: 0.76-0.88, P < 0.0001, I2 = 63%), and CV hospitalization (HR 0.78, 95% CI: 0.69-0.89, P = 0.0003, I2 = 36%). All-cause mortality was reduced on statin therapy in HF with both EF < 40% and ≥ 40% (HR: 0.77, 95% Cl: 0.68-0.86, P < 0.00001, and HR 0.75, 95% CI: 0.69-0.82, P < 0.00001, respectively). Similarly, CV mortality (HR 0.86, 95% CI: 0.79-0.93, P = 0.0003, and HR 0.83, 95% CI: 0.77-0.90, P < 0.00001, respectively), and CV hospitalizations (HR 0.80 95% CI: 0.64-0.99, P = 0.04 and HR 0.76 95% CI: 0.61-0.93, P = 0.009, respectively) were reduced in these EF subgroups. Significant effects on all clinical outcomes were also found in cohort studies' analyses; the effect was also larger and significant for lipophilic than hydrophilic statins.

CONCLUSIONS

In conclusion, statins may have a beneficial effect on CV outcomes irrespective of HF etiology and LVEF level. Lipophilic statins seem to be much more favorable for patients with heart failure.

P705Step by step diagnosis and management of statin intolerance: position paper from an international lipid expert panel

Background

Statin intolerance is a clinical syndrome whereby adverse effects associated with statin therapy (most commonly muscle symptoms) result in the discontinuation of therapy. Statin discontinuation is associated with increased risk of adverse cardiac outcomes. Many patients who initially experience adverse effects are able to tolerate statin therapy to some extent. Careful stepwise diagnosis and management of individuals who experience adverse effects is essential to enable optimal reduction of cardiovascular risk.

Purpose

In this Position Paper of the International Lipid Expert Panel (ILEP), we present a step by step approach to the diagnosis and practical management of statin intolerance resulting from muscle symptoms, and other adverse effects with demonstrated statin causality.

Methods

Relevant clinical evidence and international clinical guidelines were discussed and assimilated by ILEP members. Consensus was used to formulate recommendations for the diagnosis and management of statin intolerance.

Results

Consensus resulted in the adoption of three parts to the recommendation. 1) diagnosis of Statin Intolerance; 2) advice for management of all patients with statin intolerance; 3) specific advice for patients who have partial (rather than complete) statin intolerance. Patients with partial statin intolerance are likely to make up the vast majority (even 95%) of statin-intolerant individuals. Each part of the recommendation consists of a four-step process and has an associated acronym to aid memory (see attached recommendations). We adopted the Banach and Mikhailidis four-step approach to diagnosis and we developed novel recommendations for management.

Summary of the ILEP SI recommendations.

Conclusions

We present recommendations, which will enable clinicians to distinguish between rare, severe adverse effects; true statin intolerance, and symptoms incorrectly attributed to statin therapy. In each case we summarize guidelines, clinical evidence and expert opinion pertaining to the optimal management of cardiovascular disease in these patients.

Acknowledgement/Funding

None

1446A greater healthy behaviors score is associated with a lower risk of all-cause and cause specific mortality: insight from two prospective multi-ethnic surveys

Background

Mortality from non-communicable diseases (NCDs) is influenced bymodifiable risk factors. Simple tools which do not require laboratory tests, (blood pressure (BP) [B], exercise [E], weight [W], alimentation [A] (fruit and vegetable consumption), and tobacco [T] (BEWAT) may estimate the risk of all-cause and cause specific mortality.

Purpose

Therefore, we evaluated the link between BEWAT and mortality in a randomly selected sample of the US population.

Method

Adults aged ≥20 years, enrolled in the Third National Health and Nutrition Examination Survey (NHANES-III, 1988–1994) and continuous NHANES (2005–2010), and followed up to December 31st 2011, were included in the present analysis. Multiple Cox regressionswere applied to evaluate the associations between the total BEWAT score and each of its components with all-cause and cause specific mortality.

Results

Overall, 22,968 participants (47.1% men) were included in the present analysis (mean age: 47.4 years). Individuals in the highest BEWAT tertile (T3) had a 25% lower risk of mortality compared with T1 [hazard ratio (HR): 0.75, 95% confidence interval (CI): 0.71–0.79], further corrections slightly diluted the magnitude of link to 22% (HR: 0.78, 95% CI: 0.75–0.81) (Figure). In a fully adjusted model, individuals in T3 also had a 26% lower risk of cardiovascular disease (CVD) mortality compared with those in T1 (HR: 0.74, 95% CI: 0.64–0.83), similar trends were observed across the BEWAT tertiles for cancer mortality risk (participants in T3 had a 31 and 26% lower risk for cancer death in Models 1 and 2, respectively). For sensitivity analyses after excluding smoking from the total BEWAT score, in the fully adjusted model the association between the BEWAT score and cancer death was attenuated but remained significant (HR: 0.80, 95% CI: 0.72–0.89 for T3 vs T1). Furthermore, total BEWAT score (without the BP component) could still predict CVD mortality (T3= HR: 0.71, 95% CI: 0.61–0.82).

All-cause death and BEWAT tertiles.

Conclusion

A higher BEWAT status is beneficial regarding all-cause and cause specific mortality. Our results highlight the value of modifiable risk factors as a simple and affordable variable for evaluating the risk of mortality.

P5313The association between coffee and caffeine consumption and renal function: insight from individual-level data, Mendelian randomization, and meta-analysis

Background

The reported relationship between coffee intake and renal function is poorly understood.

Purpose

By applying on two-sample Mendelian randomization (MR) and systematic review and meta-analysis we investigated the association between caffeine and coffee intake with prevalent CKD and markers of renal function.

Methods

For the individual data analysis we analysed the NHANES data on renal function markers and caffeine intake. MR was implemented by using summary-level data from genome-wide association studies conducted on coffee intake (N=91,462) and kidney function (N=133,413). Inverse variance weighted method (IVW), weighted median-based method, MR-Egger, MR-RAPS, MR-PRESSO were applied. Random effects models and generic inverse variance methods were used for the meta-analysis.

Results

Finally, we included the data of 18,436 participants, 6.9% had prevalent CKD (based on eGFR). Caffeine intake for general population was 131.1±1.1 mg. The % of pts. with CKD, by caffeine quartile was 16.6% in Q1 (lowest), 13.9% in Q2, 12.2% in Q3 and 11.0% in Q4 (p<0.001). After adjustment, for increasing quartiles for caffeine consumption, mean urine albumin, albumin-creatinine ratio and eGFR did not change significantly (p>0.234). In fully adjusted logistic regression models, there was no significant difference in chances of CKD prevalence (p-trend=0.745) (Table). In the same line, results of MR showed no impact of coffee intake on CKD (IVW=β: −0.0191, SE: 0.069, p=0.781) (Figure), on eGFR (overall= IVW= β: −0.0005, SE: 0.005, p=0.926) both in diabetic (IVW= β: −0.006, SE: 0.009, p=0.478), and non-diabetic patients (IVW= β: −6.772, SE: 0.006, p=0.991). Results from the meta-analysis indicted that coffee consumption was not significantly associated with CKD (OR: 0.85, 95% CI 0.71–1.02, p=0.090, n=6 studies, I2=0.32). These findings were robust in sensitivity analyses.

Levels of CKD markers across caffeine Qs Characteristics Quartiles of Caffeine p-value First Second Third Fourth Number of participants (n) 4609 4611 4608 4608 Log Urine Albumin (mg/L) 2.20±0.02 2.16±0.02 2.19±0.02 2.17±0.02 0.239 Serum Creatinine (mg/dL) 0.89±0.003 0.90±0.004 0.91±0.002 0.88±0.003 0.234 Log ACR (mg/g) 2.14±0.02 2.10±0.02 2.11±0.02 2.16±0.02 0.352 eGFR (ml/min/1.73m2) 91.2±0.7 92.8±0.4 90.2±0.5 89.6±0.3 0.415

MR on the impact of coffee intake on CKD

Conclusions

By implementing on different strategies we have highlighted no significant association between coffee consumption with renal function and chance of CKD.

Acknowledgement/Funding

None

Biomarkers of Cardiovascular Risk in Haemodialysis Patients

BACKGROUND

All stages of chronic kidney disease (CKD) are associated with increased risks of atherosclerosis and cardiovascular morbidity and mortality. According to studies, levels of copeptin, growth differentiation factor-15 (GDF-15) and heart fatty-acid binding protein (h-FABP) are increased in dialysis patients.

MATERIALS

This study included 50 patients (19 women, 31 men) chronically undergoing haemodialysis. The concentration of markers such as: copeptin, GDF-15, h-FABP, troponin and serum creatine kinase MB (CKMB) was measured with the use of ELISA tests. Serum concentration of 10 high-density lipoprotein (HDL) subfractions and 7 low-density lipoprotein (LDL) subfractions was analysed with the use of Lipoprint™ system (Quantimetrix Corp.).

RESULTS

In this study, we observed higher copeptin level, lower percentage share of cholesterol HDL4 subfraction and higher percentage share of small HDL particles subfraction in HD patients with diabetes mellitus than in those without diabetes. We also found significantly lower percentage share of cholesterol HDL5 subfraction in patients with GDF-15 > 3rd quartile (Q3) compared with those with GFD-15 ≤ Q3. Finally, it was observed that the percentage share of cholesterol HDL5 subfraction was significantly lower in patients with h-FABP > Q3, and the share of intermediate HDL subfractions was significantly lower in haemodialysis (HD) patients with h-FABP > 75 percentile.

CONCLUSION

The fact that increased level of one biomarker correlated with higher values of other markers may suggest that their concentration depends on the severity of disease. The obtained results also suggest that the measurement of copeptin may support the diagnosis of cardiovascular problems in dialysis patients.

A systematic review and meta-analysis of clinical trials investigating the effects of flaxseed supplementation on plasma C-reactive protein concentrations

INTRODUCTION

Many experimental and clinical trials have suggested that flaxseed might be a potent antihypertensive, but the evidence concerning the effects of flaxseed supplements on plasma C-reactive protein (CRP) concentrations has not been fully conclusive. We assessed the impact of the effects of flaxseed supplementation on plasma CRP concentrations through a systematic review of literature and meta-analysis of available randomised controlled trials (RCTs).

MATERIAL AND METHODS

The literature search included EMBASE, ProQuest, CINAHL, and PUBMED databases up to 1^st February 2016 to identify RCTs investigating the effect of flaxseed supplements on plasma CRP concentrations. Meta-analysis was performed using a random-effects model, and effect size was expressed as weighed mean difference (WMD) and 95% confidence interval (CI).

RESULTS

Meta-analysis of 17 selected RCTs with 1256 individuals did not suggest a significant change in plasma CRP concentrations following supplementation with flaxseed-containing products (WMD: -0.25 mg/l, 95% CI: -0.53, 0.02, p = 0.074). The effect size was robust in the leave-one-out sensitivity analysis. Subgroup analysis did not suggest any significant difference in terms of changing plasma CRP concentrations among different types of flaxseed supplements used in the included studies, i.e. flaxseed oil (WMD: -0.67 mg/l, 95% CI: -2.00, 0.65, p = 0.320), lignan extract (WMD: -0.32 mg/l, 95% CI: -0.71, 0.06, p = 0.103) and ground powder (WMD: -0.18 mg/l, 95% CI: -0.42, 0.06, p = 0.142).

CONCLUSIONS

The meta-analysis of RCTs did not show a significant change in plasma CRP concentrations following supplementation with various flaxseed products. Large, well-designed studies should be still performed to validate the current results.

Association between phenotypic familial hypercholesterolaemia and telomere length in US adults: results from a multi-ethnic survey

Aims

Familial hypercholesterolaemia (FH) accelerates atherosclerotic cardiovascular disease (ASCVD) and accordingly is the most potent hereditary cause of premature coronary heart disease. The association between telomere length (TL), a biological index of ageing, and FH has not been hitherto investigated. We addressed this question using data from the US National Health and Education National Surveys (NHANES, 1999-2002).

Methods and results

We included individuals, who had TL measurements (with quantitative polymerase chain reaction method) and a phenotypic diagnosis of FH based on the Dutch Lipid Clinic Network (DLCN) criteria. Sample weights were applied for unequal probabilities of selection, non-response bias, and oversampling by complex sample analysis. The adult prevalence of FH in NHANES was 0.43% [95% confidence interval (95% CI) 0.33-0.57]. The frequencies of probable FH (mean DLCN score: 6.2) and definite FH (mean DLCN score: 8.9) were 0.42% (95% CI 0.32-0.48) and 0.03% (95% CI 0.02-0.06), respectively. Subjects with FH had a higher prevalence of non-communicable diseases (hypertension, diabetes 2 type, and obesity) and early atherosclerosis (2.9% in overall population vs. 42.2% in FH). Overall, the mean TL in the non-FH population was 1.09 (95% CI 1.06-1.12) (T/S ratio) and 1.09 (95% CI 1.03-1.12) [(T/S ratio) for total FH]. Telomere length adjusted for age, sex, race, and body mass index was shorter in FH compared with healthy subjects (FH 0.89, 95% CI 0.84-0.93 vs. healthy: 1.05, 95% CI 0.97-1.11 T/S ratio; P < 0.001). Subjects with longer TL (highest quartile) had 12% less chance of having FH compared with those with TL in the lowest quartile (Q1, 95% CI 0.78-0.93).

Conclusions

These preliminary data suggest an association between TL, an index of biological age, and the presence of FH, the most common inherited cause of premature ASCVD. Given our relatively low sample size, the findings need confirmation in larger studies.

The Role of Nutraceuticals in Statin Intolerant Patients

Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

Biomarkers, myocardial fibrosis and co-morbidities in heart failure with preserved ejection fraction: an overview

The prevalence of heart failure with preserved ejection fraction (HFpEF) is steadily increasing. Its diagnosis remains difficult and controversial and relies mostly on non-invasive echocardiographic detection of left ventricular diastolic dysfunction and elevated filling pressures. The large phenotypic heterogeneity of HFpEF from pathophysiologic al underpinnings to clinical manifestations presents a major obstacle to the development of new therapies targeted towards specific HF phenotypes. Recent studies suggest that natriuretic peptides have the potential to improve the diagnosis of early HFpEF, but they still have significant limitations, and the cut-off points for diagnosis and prognosis in HFpEF remain open to debate. The purpose of this review is to present potential targets of intervention in patients with HFpEF, starting with myocardial fibrosis and methods of its detection. In addition, co-morbidities are discussed as a means to treat HFpEF according to cut-points of biomarkers that are different from usual. Biomarkers and approaches to co-morbidities may be able to tailor therapies according to patients' pathophysiological needs. Recently, soluble source of tumorigenicity 2 (sST2), growth differentiation factor 15 (GDF-15), galectin-3, and other cardiac markers have emerged, but evidence from large cohorts is still lacking. Furthermore, the field of miRNA is a very promising area of research, and further exploration of miRNA may offer diagnostic and prognostic applications and insight into the pathology, pointing to new phenotype-specific therapeutic targets.

Impact of Vitamin D on the Cardiovascular System in Advanced Chronic Kidney Disease (CKD) and Dialysis Patients

In patients suffering from chronic kidney disease (CKD), the prevalence of cardiovascular disease is much more common than in the general population. The role of vitamin D deficiency had been underestimated until a significant association was found between vitamin D therapy and survival benefit in haemodialysis patients. Vitamin D deficiency is present even in the early stages of chronic kidney disease. The results of experimental studies have revealed the relationship between vitamin D deficiency and impairment of cardiac contractile function, higher cardiac mass and increased myocardial collagen content. Experimental models propose that intermediate end points for the relationship between vitamin D deficiency and higher risk of cardiovascular disease comprise diminished left ventricular hypertrophy (LVH), enhanced left ventricular diastolic function, and decreased frequency of heart failure. Multiple observational studies have demonstrated an association between the use of active vitamin D therapy in patients on dialysis and with CKD and improved survival. However, there are also many studies indicating important adverse effects of such treatment. Therefore, large randomized trials are required to analyze whether supplementation of vitamin D may affect outcomes and whether it is safe to be used in CKD patients.

Are Markers of Cardiac Dysfunction Useful in the Assessment of Cardiovascular Risk in Dialysis Patients?

BACKGROUND

Cardiovascular morbidity and mortality of dialysis patients are major problems in this group of patients.

METHODS

The purpose of this study was also to evaluate whether any of the studied markers are better than troponin in early detection of the occurrence of ventricular arrhythmias and prolongation of QT interval. This study included 45 patients undergoing hemodialysis. ECG Holter and echocardiographic examination were performed before and after dialysis. The concentrations of markers: copeptin, GDF-15, HFABP and troponin were measured with the use of ELISA tests.

RESULTS

We observed significantly higher QT (p=0.004), QTc (0.018), right atrium volume (p=0.006) and concentrations of copeptin (p<0.0001) and H-FABP (p<0.0001) as well as smaller left atrium volume (p<0.0001) and width of inferior vena cava (p<0.0001) after dialysis than before it. Significantly longer QT and higher copeptin levels were seen in patients with ventricular arrhythmia. A trend between the increase in copeptin concentration and H-FABP level and the presence of ventricular arrhythmias was also noted.

CONCLUSION

Generally, we failed to find any strong predictor of post-dialysis ventricular arrhythmia or the prolongation of QT, however, it seems that copeptin may have prognostic value, but this has to be analyzed in large studies.

The Use of Plant Sterols and Stanols as Lipid-Lowering Agents in Cardiovascular Disease

BACKGROUND

The prevalence of premature atherosclerosis and cardiovascular disease (CVD) is constantly increasing worldwide. It has been proved that LDL-cholesterol (LDL-C) plays causal role in the development of coronary atherosclerosis. The fact that atherosclerosis is a chronic and progressive disease which onsets during the first three decades of life bores questions what to do to maintain LDL-C at low levels throughout life and thus to delay and/or prevent the progress this disease. Currently, most of public health expenses are spared on treatment, but not on prophylaxis.

METHODS

This is a review article summarizing novel reports concerning the efficacy of sterols/stanols as lipidlowering agents, assessing their influence on cardiovascular risk and safety.

RESULTS

It has been suggested that sterols and stanols are effective in the lowering of low-density cholesterol levels and diminishing cardiovascular risk. However, the results of other studies suggest that phytosterols may not exert positive effects during atherogenesis. Firstly, patients with phytosterolaemia (genetic disease in which high plant sterol plasma concentrations are observed) develop malignant premature atherosclerosis. Moreover, several epidemiological studies demonstrated the association between upper normal plasma concentrations of plant sterols and increased risk of cardiovascular events. Finally, the supplementation with plant stanols and plant sterols may be not beneficial due to their incorporation in various tissues and potentially resulting in adverse effects.

CONCLUSION

Despite the worldwide promotion of sterols as health improving supplements, it seems that in some people responding with relatively high phytosterol serum levels after its consumption such additives may turn out to be as good as it has been believed.

Hypertension - Current Natural Strategies to Lower Blood Pressure

The prevalence of hypertension (HTN) worldwide is high and is constantly rising. HTN is considered to be a silent killer since often there are no obvious symptoms but long-term, HTN significantly increases the risk of coronary heart disease and cerebrovascular diseases. Those with diagnosed HTN or at high risk of its development, should start blood pressure (BP) lowering therapy based on natural methods including: lifestyle, regular physical activity, respiratory training, reducing body mass, lowering sodium intake with food, potassium supplementation, balanced diet enriched with herbs, reducing caffeine and alcohol intake, smoking cessation, stress avoidance and regular monitoring of the BP. This review focuses on several most common methods of natural BP lowering since it is not possible to consider all of them.

Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke

Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present treatment guidelines and gaps in evidence. There remains a need for further studies assessing the meaning of potential cardiac sources of embolism and establishment of rules for optimal medical prevention (antiplatelet therapy [APT] vs. oral anticoagulation [OAC]) and interventional procedures to reduce the incidence of ischemic strokes. Currently available data does not provide definitive evidence on the comparative benefits of OAC vs. APT in patients with cryptogenic stroke or embolic stroke of undetermined source. There is a lack of antithrombotic treatment scheme in the time between stroke and the completed diagnosis of potential sources of thromboembolism.

Clinical and prognostic usefulness of soluble urokinase plasminogen activator receptor in hemodialysis patients

PURPOSE

Considering its prognostic usefulness and the relationship with chronic kidney disease, we analyzed the clinical utility of soluble urokinase plasminogen activator receptor (suPAR) in end-stage renal disease patients undergoing hemodialysis treatment. We focused on the association between suPAR levels and clinical outcomes, especially those related to cardiovascular events and mortality as well as the effect of hemodialysis on the protein levels.

METHODS

We enrolled 64 patients. Blood samples for laboratory tests were collected before and after the midweek hemodialysis. The concentration of suPAR was assessed using suPARNostic ELISA, ViroGates.

RESULTS

Spearman rank analyses showed a positive association between suPAR and creatinine, cystatin C, galectin 3, N-terminal prohormone of brain natriuretic peptide and troponin T (p < 0.05). In ROC analysis, the suPAR concentration equal to 11.5 ng/mL was established to be the cutoff value for the prediction of mortality in the analyzed patients. Simultaneous analysis of creatinine and suPAR increased the predictive value of the latter-the area under curve increased to 0.84 (95% CI 0.70-0.94, p < 0.0001). Logistic regression analysis revealed that increase in the suPAR level was associated with the increase in odds ratio for death by 1.3 (95% CI 1.1-1.6, χ2 = 8.2, p = 0.004). In multivariable analysis, the prediction power of suPAR appeared to be stronger after including creatinine (p = 0.0005).

CONCLUSIONS

Elevated suPAR levels provide independent information on mortality risk in patients undergoing hemodialysis. The protein appears not to cross the dialysis membrane; thus, blood collection before the second hemodialysis session seems to give reliable information on the suPAR level for clinical interpretation.

Increased Exhaled H2O2 and Impaired Lung Function in Patients Undergoing Bioincompatible Hemodialysis

Background

Chronic renal failure (CRF) and hemodialysis (HD) accumulate an inflammatory milieu, contributing to increased systemic and airway oxidative stress that may lead to lung damage.

Objectives

This study was designed to assess exhaled hydrogen peroxide (H2O2), lung function and whole blood chemiluminescence in HD and CRF patients and healthy controls.

Methods

The study included 59 patients (Polyamide S™ or Hemophan® membranes-19, cuprophane-16, hemodiafiltration-14, continuous ambulatory peritoneal dialysis-10), 16 CRF and 16 healthy controls. The assessment of lung function included FVC (forced vital capacity), FEV1 (forced expiratory volume in the first second) and DLCOc (single breath CO diffusing capacity). Exhaled H2O2 was determined fluorometrically and resting and n-formyl-methionyl-leucyl-phenylalanine (fMLP) luminol-dependent whole blood chemiluminescence (LBCL) were measured simultaneously.

Results

Only cuprophane HD patients presented decreased lung function (FVC 63.8±17.4%, FEV1 55.9±20.3 and DLCOc 72.1± 9.3 % of predicted; p<0.05 vs. controls). These patients exhaled the highest H2O2 levels in comparison to CRF (p<0.01): median 0.36 μM (range R: 0.09–0.56 μM) and controls (p<0.05): 0.17 μM (0.2–17.8 μM). These levels were not decreased during the HD session: preHD 1.25 μM (0.2–16.5μM) and postHD 1.3 μM (0.2–17.8 μM). As a marker of systemic oxidative stress, fMLP-induced LBCL (total light emission) was increased in these patients (1570.6 aUxs /10phagocytes; R: 274.2–8598.9) and in the CRF group (2389.4 aUxs /10phagocytes; R: 491.5–6184; p<0.05 vs. controls). Other patient groups did not express elevated LBCL and revealed decreased exhaled H2O2 after a session.

Conclusions

An increased oxidative burden in the lungs may contribute to functional lung impairment in patients dialyzed with a cellulose membrane. Biocompatible dialysis with other modalities might reduce airway-borne oxidative stress and is not related with lung damage.

[Complications of endoscopic retrograde cholangiopancreatography]

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure of the diagnosis and treatment of biliary and pancreatic diseases. ERCP combines both endoscopic and radiologic imaging. Despite the fact that it is widely considered as relatively safe and useful procedure when performed by an experienced endoscopist, ERCP may potentially result in complications due to its invasive nature. These complications vary in severity and include post-ERCP pancreatitis, cholangitis, hemorrhage and perforations of the gastrointestinal tract. Therefore, the selection of patients and their appropriate preparation before the procedure as well as the careful consideration of indications are highly required.

Lipoprotein Subfractions, Uric Acid and Cardiovascular Risk in End-Stage Renal Disease (ESRD) Patients

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem and an independent risk factor for cardiovascular disease (CVD).

OBJECTIVE

We assessed cardiovascular risk in end-stage renal disease (ESRD) patients and evaluated the relationship between serum uric acid (SUA) and lipoprotein subfractions.

METHODS

The study group consisted of 66 patients on dialysis and a control group of 25 healthy volunteers. Concentration of high-density lipoproteins (HDL) and low-density lipoproteins (LDL) subfractions were analysed using a Lipoprint™. Lipid profiles and SUA were measured.

RESULTS

There were significant differences in the distribution of HDL1-HDL5 subfractions levels, which were significantly higher in patients with impaired renal function than in the control group (p≤0.013 for all comparisons). HDL7-HDL10 subfractions were significantly more prevalent in healthy volunteers compared with CKD patients (p≤0.001 for all comparisons). The analysis of LDL subfractions revealed significant differences only in IDL-B (p<0.05), IDL-A (p<0.05) and LDL2 (p<0.001) between patients with CKD stage 5 and controls.

CONCLUSION

Our study demonstrated that higher SUA level might be associated with lower prevalence of CVD among haemodialysis patients. An elevated SUA concentration in haemodialysis population may be a marker of better nutritional status and also represent the antioxidant properties SUA.

Association between statin use and plasma D-dimer levels

D-dimers, specific breakdown fragments of cross-linked fibrin, are generally used as circulating markers of activated coagulation. Statins influence haemostatic factors, but their effect on plasma D-dimer levels is controversial. Therefore, the aim of this meta-analysis was to evaluate the association between statin therapy and plasma D-dimer levels. We searched PubMed, Web of Science, Cochrane Library, Scopus and EMBASE (up to September 25, 2014) to identify randomised controlled trials (RCTs) investigating the impact of statin therapy on plasma D-dimer levels. Two independent reviewers extracted data on study characteristics, methods and outcomes. Meta-analysis of data from nine RCTs with 1,165 participants showed a significant effect of statin therapy in reducing plasma D-dimer levels (standardised mean difference [SMD]: –0.988 µg/ml, 95 % confidence interval [CI]: –1.590 – –0.385, p=0.001). The effect size was robust in sensitivity analysis and omission of no single study significantly changed the overall estimated effect size. In the subgroup analysis, the effect of statins on plasma D-dimer levels was significant only in the subsets of studies with treatment duration ≥ 12 weeks (SMD: –0.761 µg/ml, 95 %CI: –1.163– –0.360; p< 0.001), and for lipophilic statins (atorvastatin and simvastatin) (SMD: –1.364 µg/ml, 95 % CI: –2.202– –0.526; p=0.001). Hydrophilic statins (pravastatin and rosuvastatin) did not significantly reduce plasma D-dimer levels (SMD: –0.237 µg/ml, 95 %CI: –1.140–0.665, p=0.606). This meta-analysis of RCTs suggests a decrease of plasma D-dimer levels after three months of statin therapy, and especially after treatment with lipophilic statins. Well-designed trials are required to validate these results.

Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

Lipid-modifying effects of krill oil in humans: systematic review and meta-analysis of randomized controlled trials

Context

Some experimental and clinical trials have shown that krill oil, extracted from small red crustaceans, might be an effective lipid-modifying agent, but the evidence is not conclusive.

Objective

The effect of krill oil supplements on plasma lipid concentrations was assessed through a systematic review of the literature and a meta-analysis of available randomized controlled trials.

Data sources

PubMed and Scopus were searched up to March 25, 2016, to identify RCTs investigating the effect of krill oil supplements on plasma lipids.

Study selection

Randomized controlled trials that investigated the impact of at least 2 weeks of supplementation with krill oil on plasma/serum concentrations of at least one of the main lipid parameters (ie, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or triglycerides) and that reported sufficient information on plasma/serum lipid levels at baseline and at the end of study in both krill oil and control groups were eligible for inclusion.

Data extraction

Two reviewers independently extracted the following data: first author's name, year of publication, study location, study design, number of participants in the krill oil and control groups, dosage of krill oil, type of control allocation, treatment duration, demographic characteristics of study participants, and baseline and follow-up plasma concentrations of lipids. Effect size was expressed as the weighted mean difference (WMD) and 95% confidence interval (95%CI).

Results

Meta-analysis of data from 7 eligible trials (14 treatment arms) with 662 participants showed a significant reduction in plasma concentrations of low-density lipoprotein cholesterol (WMD, -15.52 mg/dL; 95%CI, -28.43 to -2.61; P = 0.018) and triglycerides (WMD, -14.03 mg/dL; 95%CI, -21.38 to -6.67; P < 0.001) following supplementation with krill oil. A significant elevation in plasma concentrations of high-density lipoprotein cholesterol was also observed (WMD, 6.65 mg/dL; 95%CI, 2.30 to 10.99; P = 0.003), while a reduction in plasma concentrations of total cholesterol did not reach statistical significance (WMD, -7.50 mg/dL; 95%CI, -17.94 to 2.93; P = 0.159).

Conclusion

Krill oil supplementation can reduce low-density lipoprotein cholesterol and triglycerides. Additional clinical studies with more participants are needed to assess the impact of krill oil supplementation on other indices of cardiometabolic risk and on the risk of cardiovascular outcomes.

The role and function of HDL in patients with diabetes mellitus and the related cardiovascular risk

BACKGROUND

Diabetes mellitus (DM) is a major public health problem which prevalence is constantly raising, particularly in low- and middle-income countries. Both diabetes mellitus types (DMT1 and DMT2) are associated with high risk of developing chronic complications, such as retinopathy, nephropathy, neuropathy, endothelial dysfunction, and atherosclerosis.

METHODS

This is a review of available articles concerning HDL subfractions profile in diabetes mellitus and the related cardiovascular risk. In this review, HDL dysfunction in diabetes, the impact of HDL alterations on the risk diabetes development as well as the association between disturbed HDL particle in DM and cardiovascular risk is discussed.

RESULTS

Changes in the amount of circulation lipids, including triglycerides and LDL cholesterol as well as the HDL are frequent also in the course of DMT1 and DMT2. In normal state HDL exerts various antiatherogenic properties, including reverse cholesterol transport, antioxidative and anti-inflammatory capacities. However, it has been suggested that in pathological state HDL becomes "dysfunctional" which means that relative composition of lipids and proteins in HDL, as well as enzymatic activities associated to HDL, such as paraoxonase 1 (PON1) and lipoprotein-associated phospholipase 11 (Lp-PLA2) are altered. HDL properties are compromised in patients with diabetes mellitus (DM), due to oxidative modification and glycation of the HDL protein as well as the transformation of the HDL proteome into a proinflammatory protein. Numerous studies confirm that the ability of HDL to suppress inflammatory signals is significantly reduced in this group of patients. However, the exact underlying mechanisms remains to be unravelled in vivo.

CONCLUSIONS

The understanding of pathological mechanisms underlying HDL dysfunction may enable the development of therapies targeted at specific subpopulations and focusing at the diminishing of cardiovascular risk.

Telomere attrition, kidney function, and prevalent chronic kidney disease in the United States

Background

Telomere length is an emerging novel biomarker of biologic age, cardiovascular risk and chronic medical conditions. Few studies have focused on the association between telomere length (TL) and kidney function.

Objective

We investigated the association between TL and kidney function/prevalent chronic kidney disease (CKD) in US adults.

Methods

The National Health and Nutrition Examination Survey (NHANES) participants with measured data on kidney function and TL from 1999 to 2002 were included. Estimated glomerular filtration rate (eGFR) was based on CKD Epidemiology Collaboration (CKD-EPI) equation. Urinary albumin excretion was assessed using urinary albumin-creatinine ratio (ACR). We used multivariable adjusted linear and logistic regression models, accounting for the survey design and sample weights.

Results

Of the 10568 eligible participants, 48.0% (n=5020) were men. Their mean age was 44.1 years. eGFR significantly decreased and ACR significantly increased across increasing quarters of TL (all p<0.001). The association between TL and kidney function remained robust even after adjusting for potential confounding factors, but the association between TL and ACR was only borderline significant (β-coefficient= -0.012, p=0.056).

Conclusion

The association of kidney function with a marker of cellular senescence suggests an underlying mechanism influencing the progression of nephropathy.

Novel Biomarkers in the Diagnosis of Chronic Kidney Disease and the Prediction of Its Outcome

In its early stages, symptoms of chronic kidney disease (CKD) are usually not apparent. Significant reduction of the kidney function is the first obvious sign of disease. If diagnosed early (stages 1 to 3), the progression of CKD can be altered and complications reduced. In stages 4 and 5 extensive kidney damage is observed, which usually results in end-stage renal failure. Currently, the diagnosis of CKD is made usually on the levels of blood urea and serum creatinine (sCr), however, sCr has been shown to be lacking high predictive value. Due to the development of genomics, epigenetics, transcriptomics, proteomics, and metabolomics, the introduction of novel techniques will allow for the identification of novel biomarkers in renal diseases. This review presents some new possible biomarkers in the diagnosis of CKD and in the prediction of outcome, including asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), uromodulin, kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), miRNA, ncRNA, and lincRNA biomarkers and proteomic and metabolomic biomarkers. Complicated pathomechanisms of CKD development and progression require not a single marker but their combination in order to mirror all types of alterations occurring in the course of this disease. It seems that in the not so distant future, conventional markers may be exchanged for new ones, however, confirmation of their efficacy, sensitivity and specificity as well as the reduction of analysis costs are required.

The effect of statins on cardiovascular outcomes by smoking status: A systematic review and meta-analysis of randomized controlled trials

Smoking is an important risk factor for cardiovascular disease (CVD) morbidity and mortality. The impact of statin therapy on CVD risk by smoking status has not been fully investigated. Therefore we assessed the impact of statin therapy on CVD outcomes by smoking status through a systematic review of the literature and meta-analysis of available randomized controlled trials (RCTs). The literature search included EMBASE, ProQuest, CINAHL and PUBMED databases to 30 January 2016 to identify RCTs that investigated the effect of statin therapy on cumulative incidence of major CVD endpoints (e.g. non-fatal myocardial infarction, revascularization, unstable angina, and stroke). Relative risks (RR) ratios were calculated from the number of events in different treatment groups for both smokers and non-smokers. Finally 11 trials with 89,604 individuals were included. The number of smokers and non-smokers in the statin groups of the analyzed studies was 8826 and 36,090, respectively. The RR for major CV events was 0.73 (95% confidence interval [CI]: 0.67-0.81; p<0.001) in nonsmokers and 0.72 (95%CI: 0.64-0.81; p<0.001) in smokers. Moderate to high heterogeneity was observed both in non-smokers (I²=77.1%, p<0.001) and in smokers (I²=51.6%, p=0.024) groups. Smokers seemed to benefit slightly more from statins than non-smokers according to the number needed to treat (NNT) analysis (23.5 vs 26.8) based on RRs applied to the control event rates. The number of avoided events per 1000 individuals was 42.5 (95%CI: 28.9-54.6) in smokers and 37.3 (95%CI: 27.2-46.4) in non-smokers. In conclusion, this meta-analysis suggests that the effect of statins on CVD is similar for smokers and non-smokers, but in terms of NNTs and number of avoided events, smokers seem to benefit more although non-significantly.

The Effect of Diet on the Survival of Patients with Chronic Kidney Disease

The prevalence of chronic kidney disease (CKD) is high and it is gradually increasing. Individuals with CKD should introduce appropriate measures to hamper the progression of kidney function deterioration as well as prevent the development or progression of CKD-related diseases. A kidney-friendly diet may help to protect kidneys from further damage. Patients with kidney damage should limit the intake of certain foods to reduce the accumulation of unexcreted metabolic products and also to protect against hypertension, proteinuria and other heart and bone health problems. Despite the fact that the influence of certain types of nutrients has been widely studied in relation to kidney function and overall health in CKD patients, there are few studies on the impact of a specific diet on their survival. Animal studies demonstrated prolonged survival of rats with CKD fed with protein-restricted diets. In humans, the results of studies are conflicting. Some of them indicate slowing down of the progression of kidney disease and reduction in proteinuria, but other underline significant worsening of patients’ nutritional state, which can be dangerous. A recent systemic study revealed that a healthy diet comprising many fruits and vegetables, fish, legumes, whole grains, and fibers and also the cutting down on red meat, sodium, and refined sugar intake was associated with lower mortality in people with kidney disease. The aim of this paper is to review the results of studies concerning the impact of diet on the survival of CKD patients.