Rabbit and human atherosclerotic lesions contain IgG that recognizes epitopes of oxidized LDL

Immunomodulation and vaccination for atherosclerosis

During the last few decades, the pathogenesis of atherosclerosis has been related not only to cholesterol deposition and cell proliferation in the lesions, but also to infiltration of immune cells, which are involved in both systemic and local, innate as well as adaptive, immune responses. A number of antigen candidates, such as oxidised low-density lipoprotein and heat-shock proteins, have been associated with the disease process. As some inflammatory and autoimmune diseases could be treated by immunologically based therapy, it is of particular interest whether such principles can also be applied to prevent or treat atherosclerosis. Indeed, modification of immune reactions in animal models can greatly affect the development and progression of atherosclerosis. This review provides an overview of our current understanding of how immunomodulation changes the course of atherosclerosis and how vaccination may be used for preventing the disease.

Autoantibodies against oxidized LDLs and atherosclerosis in type 2 diabetes

OBJECTIVE

The aim of our study was to examine, in type 2 diabetic patients, the relationship between autoantibodies against oxidatively modified LDL (oxLDL Ab) and two indexes of atherosclerosis, intimal-medial thickness of the common carotid artery (CCA-IMT), which reflects early atherosclerosis, and the ankle-brachial index (ABI), which reflects advanced atherosclerosis.

RESEARCH DESIGN AND METHODS

Thirty newly diagnosed type 2 diabetic patients, 30 type 2 diabetic patients with long duration of disease, and 56 control subjects were studied. To detect oxLDL Ab, the ImmunoLisa Anti-oxLDL Antibody ELISA was used. ABI was estimated at rest by strain-gauge plethysmography. Carotid B-mode imaging was performed on a high-resolution imaging system (ATL HDI 5000).

RESULTS

In patients with long duration of disease, IgG oxLDL Ab were significantly higher and ABI significantly lower compared with the other two groups. We found a correlation between IgG oxLDL Ab and CCA-IMT in all diabetic patients. A significant inverse correlation between IgG oxLDL Ab and ABI only in patients with long duration of disease was seen, demonstrating a close relationship between these autoantibodies and advanced atherosclerosis.

CONCLUSIONS

IgG OxLDL Ab may be markers of the advanced phase of the atherosclerotic process and the response of the immunological system to the oxLDL, which are present within atherosclerotic lesions.

Chronic Renal Dysfunction as an Independent Risk Factor for the Development of Cardiovascular Disease

Cardiac disease is the leading cause of death in patients having end-stage renal disease (ESRD). Patients with ESRD have a higher risk for developing coronary artery disease (CAD) than one would estimate from the presence of traditional risk factors such as hypertension, diabetes, hyperlipidemia, and cigarette smoking. Patients with milder forms of renal dysfunction who do not require dialysis also appear to have an increased risk for CAD. ESRD is associated with anemia, hyperhomocystinemia, increased calcium-phosphate product, hypoalbuminemia, increased troponin, increased markers of inflammation, increased oxidant stress, and decreased nitric oxide activity, factors that could contribute to increased CAD risk. Patients with ESRD require aggressive management of traditional risk factors for CAD, which include hypertension, hyperlipidemia, hyperhomocystinemia, and hypercoagulability. Milder forms of renal dysfunction could also be predictors of occult CAD and should be screened for in assessing cardiac risk in asymptomatic individuals.

Role of oxidatively modified low density lipoproteins and anti-oxidants in atherothrombosis

Retrospective studies have demonstrated an association between coronary artery disease (CAD) and increased plasma levels of oxidised low density lipoproteins (LDL). A very recent prospective study in heart transplant patients has demonstrated that oxidised LDL is an independent risk factor for transplant CAD, thus further supporting the hypothesis that oxidised LDL is actively involved in the development of CAD. The increase of circulating oxidised LDL is most probably caused by back-diffusion from the atherosclerotic arterial wall in the blood, independent of plaque rupture. Indeed, plasma levels of oxidised LDL were very similar in patients with stable CAD and in patients with acute coronary syndromes. These were, however, associated with increased release of malondialdehyde (MDA)-modified LDL. Oxidised LDL may be generated by radical-mediated or by lipoxygenase or phospholipase catalysed lipid oxidation, and by myeloperoxidase catalysed protein and lipid oxidation. Prostaglandin synthesis by endothelial cells under oxidative stress and platelet activation are associated with the release of aldehydes; these induce the oxidative modification of the apolipoprotein B-100 moiety of LDL in the absence of lipid peroxidation, and thus generate MDA-modified LDL. Efficient prevention of in vivo oxidation may involve efficient cholesterol lowering, improving the anti-oxidative status of LDL by increasing the anti-oxidant content and increasing the oleate content of LDL, and by shifting the LDL away from phenotype B (characterised by small dense LDL particles). Anti-oxidative and anti-inflammatory enzymes associated with HDL may inhibit the oxidation of LDL or reverse the atherothrombotic effects of LDL.

Atherosclerosis: humoral and cellular factors of inflammation

In the past decade, atherosclerosis has come to be recognized as active and inflammatory rather than simply a passive process of lipid infiltration or a reparative process after endothelial injury. In general, atherosclerosis can be considered as an intramural chronic inflammation resulting from interactions between modified lipoproteins, monocyte-derived macrophages, lymphocytes, and the normal cellular elements of the arterial wall. The process of inflammation occurs in response to functional and structural injury through a variety of known and unknown stimuli and is active over years and decades. Here, we review recent experimental and human studies of inflammatory mechanisms underlying the pathogenesis of atherosclerosis.

Autoimmune mechanisms of atherosclerosis

Accumulating evidence supports an autoimmune mechanism as one of the prime pathogenic processes involved in the development of atherosclerosis. So far, three proteins, including heat shock proteins (HSPs), oxidized low-density lipoprotein (oxLDL), and beta2 glycoprotein1 (beta2GP1) have been recognized as autoantigens. It has been demonstrated that risk factors for atherosclerosis, such as hypercholesterolemia, hypertension, infections, and oxidative stress, evoke increased expression of HSPs in cells of atherosclerotic lesions. Autoantibody levels against HSPs are significantly increased in patients with atherosclerosis and T lymphocytes specifically responding to these autoantigens have been demonstrated within atherosclerotic plaques. Subcutaneous immunization of animals with HSP65 induced atheroma formation in the arterial wall. Furthermore, circulating immunoglobulin (Ig) G and IgM oxidized low-density lipoprotein (oxLDL) antibodies are present in the plasma of animals and humans and form immune complexes with oxLDL in atherosclerotic lesions. These antibodies closely correlate with the progression and regression of atherosclerosis in murine models. Interestingly, recent reports demonstrated that pneumococcal vaccination to LDL receptor-deficient mice results in elevation of anti-oxLDL IgM Ab EO6, which is inversely correlated with the development of atherosclerosis. Finally, it has been observed that autoantigen beta2GP1 localizes in the atheroma and that autoantibodies to beta2GP1 are correlated with the incidence of atherosclerosis in patients. Hence, these autoimmune reactions to HSPs, oxLDL and beta2GP1 can contribute to the initiation and progression of atherosclerosis.

Natural antibodies and the autoimmunity of atherosclerosis

In recent years, the subject of natural antibodies has been revisited and the immunobiological roles of these humoral factors are being better defined. These antibodies are secreted by distinct sets of innate-like B cells, B-1 cells and marginal zone B cells, which arise early in development to become the sources of "natural immune memory". Due to their interactions with a variety of self-determinants, natural antibodies have previously been postulated to play roles in the maintenance of host homeostasis. A central paradigm has recently been developed from the demonstration that oxidation derived epitopes on apoptotic cells and oxidized low-density lipoproteins are recognized by the phosphorylcholine-specific germline encoded B-1 cell natural antibody, T15, which has provided important insights into possible "house-keeping" functions under both normal and pathological conditions. In this review, the potential functions of natural antibodies in the pathogenesis and progression of the chronic inflammatory condition of atherosclerosis are discussed, as well as their capacities for apoptotic cell binding and clearance. These interactions of natural antibodies and oxidation-epitopes from phospholipids appear to provide a dynamic immunobiological connection linking host responses in infection, autoimmunity and atherosclerosis.

Atherosclerosis and the immune system

The immune system is involved at all stages of the atherosclerotic disease process. Innate immunity, represented by macrophages and other cells, is directly activated by microbial components and possibly also by autologous lipids and proteins. It elicits inflammatory activity, which is a key component of the atherosclerotic lesion. Adaptive immunity is initiated by recognition of disease-related antigens, which include oxidatively modified lipoproteins, heat shock proteins and microbial macromolecules. In the artery wall, adaptive immune recognition mainly leads to Thl effector responses, which are characterized by secretion of proinflammatory cytokines and by activation of macrophages and vascular cells. Therefore, both the innate and adaptive arms of the immune system lead to inflammation in the developing atherosclerotic lesion. Interestingly, several effector pathways of cellular as well as humoral immunity tend to counteract proatherogenic, proinflammatory immunity. The notion that immunity plays an important role in the development of atherosclerosis has focused attention on a number of potential novel targets for intervention based on modulation of such immune responses.

Differences in human antioxidized LDL autoantibodies in patients with stable and unstable angina

BACKGROUND

Autoantibodies to oxidized LDL (anti-oxLDL) have been found in the serum of patients with coronary artery disease (CAD). This study was designed to compare the differences in anti-oxLDL titers and isotypes in unstable and stable angina patients and to correlate these results with known markers of active inflammation in CAD.

METHODS

Thirty patients from a tertiary referral general hospital with documented CAD were studied. Anti-oxLDL IgG titers and its isotypes, high sensitivity C-reactive protein (hsCRP) and serum amyloid A (SAA) were measured.

RESULTS

The anti-oxLDL IgG titer was lower (p=0.03) in the unstable angina group compared to the stable angina patients (0.084+/-0.102 OD versus 0.195+/-0.149 OD, respectively). The predominant IgG isotype in both groups was IgG2. IgG4 was significantly higher (0.270+/-0.146 OD, p=0.04) in the unstable angina group versus patients with stable angina (0.198+/-0.019 OD). There was a significant inverse correlation between anti-oxLDL and hsCRP and SAA in this sample population (R=0.37, p<0.05 and R=0.36, p<0.05, respectively).

CONCLUSION

Patients with unstable angina have lower levels of anti-oxLDL IgG in the acute setting of CAD. Plaque instabilization does not seem to acutely modify the isotype subsets of anti-oxLDL IgG in these patients.

Reduced cGMP signaling associated with neointimal proliferation and vascular dysfunction in late-stage atherosclerosis

Atherosclerosis is associated with alterations in nitric oxide (NO)/cGMP signaling. In early stages of the disease, inflammatory and possibly other cells produce reactive oxygen species that scavenge vasoprotective NO. In addition to the oxidative stress, expression and activity of enzymes downstream to NO formation may also be affected. Here, we show in the aortas of chronically hypercholesterolemic rabbits (a model of late-stage atherosclerosis), both subunits and specific activity of the NO receptor soluble guanylyl cyclase (sGC) were significantly reduced, whereas overall NO synthase activity was unaffected. These changes were most prominent in the neointimal layer, wherein cGMP-dependent protein kinase I (cGK) levels also were reduced. Additionally, a protein (p38(nt)) that was constitutively tyrosine-nitrated was detected, and its expression was significantly reduced in atherosclerotic aorta. Phosphorylation of the cGK substrate vasodilator-stimulated phosphoprotein (VASP) at Ser-239, an established biochemical endpoint of NO/cGMP signaling, also was reduced. Thus, late-stage atherosclerosis is associated not only with enhanced NO breakdown but also with altered NO reception and cGMP signaling. Preferential down-regulation in neointima suggests a direct connection of these changes to neointimal proliferation and vascular dysfunction and provides a rationale for future pharmacotherapy using classical and novel sGC activators.

Association between monocyte Fcgamma subclass expression and acute coronary syndrome

Background

Atherosclerosis lesions contain abundant immunoglobulins complexed with oxidized LDL (OxLDL) that are endocytosed by macrophages to form foam cells. While recent evidence supports a role for the macrophage scavenger receptor pathway in 75–90% of OxLDL uptake, in vitro evidence suggests another potential uptake pathway could involve autoantibody binding to IgG subclass-specific Fc receptors.

Objective and Methods

To address this mechanism from an in vivo standpoint, the objective of this study was to utilize flow cytometry to prospectively determine monocyte Fcγ (FcR) I, II, and III receptor expression levels in patients with acute coronary syndrome (ACS, n = 48), diabetes mellitus (DM, n = 59), or neither (C, n = 88).

Results

Increased FcR I expression was found in the ACS versus DM groups [geometric mean, (95% CI) = 2.26 (2.07, 2.47) versus 1.83 (1.69, 1.98) (p < 0.001)] and versus C [1.90 (1.78, 2.03) (p = 0.005)]. Similar relationships were found with both the FcR II receptor [ACS mean = 4.57 (4.02, 5.19) versus DM 3.61 (3.22, 4.05) (p = 0.021) and versus C 3.86 (3.51, 4.24) (p = 0.09)] and FcR III receptor [ACS mean = 1.55 (1.44, 1.68) versus DM 1.36 (1.27, 1.46) (p = 0.038) and versus C 1.37 (1.30, 1.45) (p = 0.032)]. There was no difference between DM and C groups in FcR I, II or III expression.

Conclusions

This in vivo data supports a possible second OxLDL-autoantibody macrophage uptake mechanism through an Fc receptor-mediated pathway and a potential relationship between atherosclerotic plaque macrophage FcR levels and ACS.

Oxidized low-density lipoprotein in plasma is a prognostic marker of subclinical atherosclerosis development in clinically healthy men

OBJECTIVE

To investigate the association between plasma oxidized low-density lipoprotein (OxLDL) and the progress of clinically silent atherosclerosis, as measured by ultrasound in the carotid arteries.

DESIGN

Prospective, observational study with more than 3 years of follow-up.

SETTING

One-centre study at university hospital.

MATERIAL AND METHODS

The subjects (n = 326) were obtained by stratified sampling from a population sample of men who were 58 years old at baseline. Carotid artery intima-media thickness (IMT) was measured bilaterally by high-resolution B-mode ultrasound at baseline and after follow-up. Plasma OxLDL cholesterol concentrations and conventional cardiovascular risk factors were measured at study entry. Automated measurements of IMT were performed. Plaque occurrence and size were assessed (plaque status). Plasma OxLDL at entry was measured by a specific monoclonal antibody, mAb-4E6.

RESULTS

OxLDL at entry, but not LDL cholesterol, was associated with the number and size of plaques at follow-up (P = 0.008), also after adjustment for plaque status at entry (P = 0.033). The plasma OxLDL concentration at entry was associated with change in carotid artery IMT (r = 0.17; P = 0.002) and in a stepwise multiple regression analysis this association remained after adjustment for other cardiovascular risk factors (P = 0.005).

CONCLUSIONS

These results provide new information, supporting the concept that circulating OxLDL was associated with the silent phase of atherosclerosis progression in clinically healthy men independently of conventional risk factors.

Autoimmune and inflammatory mechanisms in atherosclerosis

The present review focuses on the concept that cellular and humoral immunity to the phylogenetically highly conserved antigen heat shock protein 60 (HSP60) is the initiating mechanism in the earliest stages of atherosclerosis. Subjecting arterial endothelial cells to classical atherosclerosis risk factors leads to the expression of HSP60 that then may serve as a target for pre-existent cross-reactive antimicrobial HSP60 immunity or bona fide autoimmune reactions induced by biochemically altered autologous HSP60. Endothelial cells can also bind microbial or autologous HSP60 via Toll-like receptors, providing another possibility for targetting adaptive or innate immunological effector mechanisms.

Antiphospholipid antibodies and atherosclerosis

Antiphospholipid antibodies (APA) are present in a variety of autoimmune disorders, including systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Increasing evidence suggests that a subset of APA can also be detected in patients with atherosclerosis. In this review, we discuss the specificities of the autoantibodies that are present during both APS and atherosclerosis. A critical and unresolved question is whether these APA are specific for epitopes that result from lipid oxidation. Despite the fact that APA are present in patients with systemic autoimmunity and that they may participate in the pathogenesis of APS, recent studies have paradoxically proposed a beneficial role for some APA in atherosclerosis. We review the evidence that some APA specificities may be protective against plaque formation, and we discuss the putative mechanisms by which some APA could be useful in the prevention of atherosclerosis.

Definition of the immunogenic forms of modified human LDL recognized by human autoantibodies and by rabbit hyperimmune antibodies

Humans and laboratory animals recognize human modified LDL as immunogenic. Immune complexes (ICs) isolated from human sera contain malondialdehyde-modified LDL (MDA-LDL) and N (epsilon)(carboxymethyl)lysine-modified LDL (CML-LDL) as well as antibodies reacting with MDA-LDL, copper-oxidized LDL (OxLDL), CML-LDL, and advanced glycosylation end product (AGE)-modified LDL. OxLDL and AGE-LDL antibodies isolated from human sera recognize the same LDL modifications and do not react with modified non-LDL proteins. Rabbit antibodies have different reactivity patterns: MDA-LDL antibodies react strongly with MDA-LDL and MDA-BSA but weakly with OxLDL; OxLDL antibodies react strongly with OxLDL and weakly with MDA-LDL; CML-LDL antibodies react with CML-LDL > CML-BSA > AGE-LDL > OxLDL; AGE-LDL antibodies react strongly with AGE-LDL, react weakly with OxLDL, and do not react with CML-LDL. Thus, human and rabbit antibodies seem to recognize different epitopes. Capture assays carried out with all rabbit antibodies showed binding of apolipoprotein B-rich lipoproteins isolated from ICs, suggesting that laboratory-generated epitopes are expressed by in vivo-modified LDL, although they are not necessarily recognized by the human immune system. Thus, the definition of immunogenic forms of modified LDL eliciting human autoimmune responses requires the isolation and characterization of autoantibodies and modified LDL from human samples, whereas rabbit antibodies can be used to detect in vivo-modified human LDL.

Assessment of atherosclerotic risk factors and endothelial function in children and young adults with pediatric-onset systemic lupus erythematosus

OBJECTIVE

To characterize atherosclerotic risk factors and endothelial function in pediatric-onset systemic lupus erythematosus (SLE).

METHODS

Lipoproteins, oxidized state, and autoantibodies to oxidized low-density lipoprotein (Ox-LDL) were assessed. Endothelial function was evaluated using brachial artery reactivity.

RESULTS

Thirty-three SLE patients and 30 controls were studied. SLE subjects had significantly decreased mean high-density lipoprotein (HDL) cholesterol (41 mg/dl versus 51 mg/dl; P = 0.002) and apolipoprotein A-I (97 mg/dl versus 199 mg/dl; P = 0.0004). There was no difference between groups in markers of oxidized state (including nitric oxide metabolites, isoprostanes, and Ox-LDL) or in endothelial function. However, SLE subjects had increased median anti-Ox-LDL IgG (2,480 relative light units [RLU] versus 1,567 RLU; P = 0.0007) and IgG immune complexes with LDL (4,222 RLU versus 2,868 RLU; P = 0.002).

CONCLUSION

Pediatric SLE patients had significantly decreased levels of HDL cholesterol and apolipoprotein A-I and elevated titers of autoantibodies to Ox-LDL. Despite these atherosclerotic risk factors, SLE patients had normal measures of oxidized state and endothelial function.

Preventive effects of diets supplemented with sweetie fruits in hypercholesterolemic patients suffering from coronary artery disease

BACKGROUND

Diets rich in vegetables and fruits prevent development of atherosclerosis.

OBJECTIVE

To investigate the preventive effects of diets supplemented with a new kind of citrus fruit-pummelo-grapefruit hybrid in hypercholesterolemic patients suffering from coronary artery disease (CAD).

SUBJECTS AND METHODS

Sixty-six hypercholesterolemic volunteers after coronary bypass surgery ages 47-68 years were randomly divided into two experimental (EG1 and EG2) groups and one control (CG) group, 22 each. The diets of the patients of the experimental groups (EG1 and EG2) were supplemented with one or two peeled sweeties, respectively. A comprehensive clinical investigation of all 66 patients was done. Blood samples were collected before and after the investigation for a wide range of laboratory tests.

RESULTS

A high content of dietary fibers and antioxidant compounds in peeled sweeties was found. After 30 days of the investigation, peeled sweeties-supplemented diets have decreased plasma lipids levels in EG1 and EG2 vs. CG group: (a) total cholesterol (TC)-7.38 vs. 8.08 mmol/L, - 8.7%, and 6.78 vs. 8.08. mmol/L, -16.1%, respectively; (b) low-density lipoprotein cholesterol (LDL-C)-5.65 vs. 6.39 mmol/L, - 1.6%, and 5.04 vs. 6.39 mmol/L, -21.2%, respectively; (c) triglycerides (TG)-2.01 vs. 2.27 mmol/L, -11.5%, and 1.71 vs. 2.27 mmol/L, -24.7%, respectively. In addition, a significant increase in the plasma antioxidant capacity in EG2, and to a lesser degree in EG1 groups, was observed. No changes in the studied indices in the patients of the CG were detected.

CONCLUSION

Peeled sweeties have high contents of dietary fibers and antioxidant compounds. Diets supplemented with peeled sweeties positively influence plasma lipid metabolism and plasma antioxidant capacity in patients suffering from hypercholesterolemia. Therefore, the addition of peeled sweeties to a generally accepted antiatherosclerotic diet may be beneficial in prevention of atherosclerosis, mainly in hypercholesterolemic patients.

Evidence for anti-inflammatory activity of statins and PPARα activators in human C-reactive protein transgenic mice in vivo and in cultured human hepatocytes in vitro

Inflammatory processes, aside from cholesterol, play a central role in atherogenesis. Human C-reactive protein (huCRP) signals systemic inflammation and independently predicts future cardiovascular risk. Cholesterol-lowering statins reduce atherosclerosis and plasma huCRP levels. Evidence is sought for a direct anti-inflammatory statin effect in vivo, independent of effects on plasma cholesterol and atherogenesis. The effect of atorvastatin and simvastatin on huCRP expression was studied in nonatherosclerotic huCRP transgenic mice and compared with another class of hypolipidemic drugs, peroxisome proliferator-activated receptor-alpha (PPARα) activators, notably fenofibrate and Wy14643. Like statins, PPARα activators combine antiatherosclerotic properties with huCRP-lowering effects. Dietary treatment with statins or PPARα activators decreased basal and interleukin-1β (IL-1β)-induced plasma huCRP levels independently of cholesterol lowering. These direct anti-inflammatory in vivo effects occurred at the transcriptional level and could be confirmed in cultured human liver slices and in human hepatoma cells transiently transfected with a huCRP promoter-driven luciferase reporter. A molecular rationale for the suppression of IL-1-induced huCRP transcription is provided by showing that statins and PPARα activators up-regulate IκBα protein expression. This results in a reduced nuclear translocation of p50-nuclear factor κ B (NFκB) and thereby decreased amounts of nuclear p50-NFκB∼CCAAT/enhancer binding protein beta (C/EBPβ) complexes, which determine the huCRP transcription rate. Our results provide conclusive evidence for a direct suppressive effect of statins and PPARα activators on huCRP expression independent of cholesterol lowering and atherogenesis. (Blood. 2004;103:4188-4194)

Role of simvastatin as an immunomodulator in type 2 diabetes

OBJECTIVE

To test the hypothesis that simvastatin reduces the levels of circulating immune complexes (ICs) containing modified lipoproteins (mLDLs; mLDL-ICs), which may represent an additional mechanism for the reduced incidence of cardiovascular events in patients treated with simvastatin.

RESEARCH DESIGN AND METHODS

A total of 26 patients with type 2 diabetes and triglyceride levels <400 mg/dl who were not receiving lipid-lowering medications or CYP 3A4 inhibitors were enrolled in the study. After 2 weeks on a lipid-lowering diet and exercise, the patients were started on simvastatin 20 mg/day. The dose of simvastatin was adjusted until the levels of LDL cholesterol were < or =100 mg/dl. Blood was collected at baseline, 3 and 6 months after LDL cholesterol levels reached target, and 3 months after stopping simvastatin to measure advanced glycation end product LDL and oxidized LDL antibodies, mLDL-IC, intracellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), E-selectin, metalloproteinase-1 (MMP-1), lipid profile, liver function tests, creatinine kinase, glucose, and HbA(1c).

RESULTS

Twenty-one patients completed the study. Their HbA(1c) remained within 1% of baseline levels. There was a highly significant decrease in mLDL-IC levels after 3 and 6 months of treatment with simvastatin, with a return to near baseline levels after discontinuation.

CONCLUSIONS

Simvastatin significantly reduced the concentration of mLDL-IC, probably as a consequence of both a decrease in the formation of mLDL and to a reduction in the titers of mLDL antibodies. This effect is likely to have a beneficial impact in the inflammatory reaction associated with atherosclerosis.

Immunopathogenesis of atherosclerosis

Recent clinical studies indicate that the number of microbial infections (the "pathogen burden") critically determines the development and progression of atherosclerotic disease. Viruses or bacteria with a specific tropism for cells of the vascular wall may contribute to the initial vascular injury via direct cytopathic effects or via the induction of genuine autoimmune responses. Immunopathological processes such as molecular mimicry, epitope spreading, or bystander activation of self-reactive lymphocytes most likely fuel the chronic inflammatory process in the vascular wall. Recognition of atherogenesis as a pathogen-driven, immunopathological process makes this disease amenable to new treatment strategies such as vaccination or immunomodulation.

Associations among oxidized low-density lipoprotein antibody, C-reactive protein, interleukin-6, and circulating cell adhesion molecules in patients with unstable angina pectoris

Oxidized low-density lipoprotein (LDL) is believed to play a key role in the development of atherosclerosis. However, the significance of anti-oxidized LDL antibody in atherogenesis is unclear. The purposes of this study were to assess whether anti-oxidized LDL antibody titers are related to other inflammatory markers of possible interest in atherosclerotic development, such as soluble cell adhesion molecules, interleukin-6, and C-reactive protein (CRP), and to determine the prognostic value of anti-oxidized LDL antibody as a predictor of cardiac events in patients with unstable angina pectoris. Sixty patients (35 men and 25 women; mean age 60 years) with unstable angina were included in this study. The levels of CRP and of intercellular adhesion molecule-1 (ICAM-1) at 24 and 72 hours after admission were significantly higher than their baseline levels (p <0.05, respectively). After adjusting for age, gender, body mass index, and statin use, anti-oxidized LDL antibodies were positively correlated with CRP (r = 0.72, p <0.001) and ICAM-1 (r = 0.68, p <0.001). Elevated anti-oxidized LDL antibodies (mean >11.37 U/ml) and CRP levels (median >2.4 mg/L) on admission were correlated with a significantly lower 16-month, event-free survival rate (Kaplan-Meier event-free survival analysis, log-rank p <0.01 and p <0.05, respectively). Multivariate analysis by logistic regression revealed that elevated levels of anti-oxidized LDL antibody (mean >11.3 U/ml) on admission were an independent risk factor for an adverse cardiac event (odds ratio 2.2, 95% confidence interval 1.5 to 10.7, p = 0.001). This study demonstrates that anti-oxidized LDL antibody expression is associated with the expression of CRP and adhesion molecules, especially ICAM-1, and is a predictor of cardiac events in patients with unstable angina pectoris. The observed elevated levels of anti-oxidized LDL antibody suggest plaque instability and may be useful for identifying patients at higher risk of a cardiac event.

Vaccination and atherosclerosis

Atherosclerosis is an inflammatory disease. Both innate and adaptive immunity are involved in lesion formation and development. A number of antigen candidates, such as oxidized low-density lipoprotein and heat shock protein, have been associated with the inflammation and immune reaction that is part of the atherosclerotic process. Because experimental models of some other inflammatory/autoimmune diseases can be improved by vaccination, it is of interest to investigate if vaccination can also be applied to prevent or retard atherosclerosis. Indeed, the modification of immune responses in animal models can greatly affect the development and progression of atherosclerosis. This review provides an overview of our current understanding of effects and proposed mechanisms of immunization on preventing atherosclerosis.

Severe Hypercholesterolaemia Leads to Strong Th2 Responses to an Exogenous Antigen

Severe hypercholesterolaemia is associated with decreased levels of immunoglobulin G2a (IgG2a) antibodies [T-helper 1 (Th1) response] to modified malondialdehyde-modified low-density lipoprotein (MDA-LDL) and increased levels of Th2-dependent IgG1 antibodies in apolipoprotein E-deficient (apoE(-/-)) mice. To investigate whether this reflects a general pattern of metabolic regulation of the humoral immune response, apoE(-/-) mice were fed diets resulting in different degrees of hypercholesterolaemia and immunized with keyhole limpet haemocyanin (KLH) in aluminium hydroxide. Cholesterol levels for different treatment groups ranged from 14 to 77 mmol/l in serum and from 10 to 39 mmol/g in liver. Mice with severe hypercholesterolaemia had increased IgG1 antibodies to MDA-LDL and decreased IgG2a anti-MDA-LDL. Importantly, titres of IgG2a antibodies to KLH were also decreased, while IgE anti-KLH was increased, with a corresponding induction of interleukin-4 (IL-4) and IL-10 and a decrease in interferon-gamma (IFN-gamma) in KLH-stimulated spleen cells in vitro. Thus, hypercholesterolaemia clearly affects antibody production both to the autoantigen MDA-LDL and to the exogenous antigen KLH, favouring antibody isotypes (IgG1 and IgE) that are dependent on Th2 help to B cells. Nuclear receptors ligated by oxidized lipid derivatives modulate T-cell responses, and it is speculated that this mechanism may cause the switch to Th2 in severe hypercholesterolaemia.

Autoantibodies against oxidized low-density lipoprotein (ox-LDL) and LDL oxidation status

Oxidized low-density lipoproteins (ox-LDLs) and their autoantibodies (OLAB) are involved in the development of atherosclerosis in animal models, but their role in humans is still not clear. For this reason we studied 54 patients with β-thalassemia major (TM), as a model of chronically low circulating LDLs with a high level of oxidation; 44 patients with primary hypercholesterolemia, as model of chronically high circulating LDLs; 24 type 2 diabetic mellitus patients (T2DM) before and after 3 months of atorvastatin treatment (20 mg/day), as a model of acute changes in circulating LDLs; and 41 normolipidemic subjects as a control group. ox-LDLs were measured by the determination of baseline diene concentration in the plasma LDL lipidic fraction after 12 hours fasting and were expressed as the amount of conjugated dienes/liter (BDC/l) or BDC/LDL-cholesterol (LDL-C), which indicate respectively LDL oxidation degree and status. OLABwere determined using an enzyme immunoassay and related to LDL oxidation degree (BDC/l). In TM, BDC/l was lower, while BDC/LDL-C was significantly higher, compared to both hypercholesterolemia and normolipidemic subjects. Patients with hypercholesterolemia had higher BDC/l, but lower BDC/LDL-C and OLAB/BDC-l, than normolipidemic subjects. In T2DM patients at diet, BDC/LDL-C and OLAB/BDC-l were lower than in normolipidemic subjects. After 3 months of atorvastatin treatment, BDC/LDL-C and OLAB/BDC-l ratios increased. When all patients were evaluated together, a significant inverse correlation was evident between OLABand either LDL or BDC/l. Our findings suggest that a relationship between OLABtiter and oxidation indices (BDC/l and BDC/LDL-C) does exist and we may speculate that an increase in OLAB/BDC-l ratio might be protective against the risk of atherosclerosis.

Role of monocytes in atherogenesis

This review focuses on the role of monocytes in the early phase of atherogenesis, before foam cell formation. An emerging consensus underscores the importance of the cellular inflammatory system in atherogenesis. Initiation of the process apparently hinges on accumulating low-density lipoproteins (LDL) undergoing oxidation and glycation, providing stimuli for the release of monocyte attracting chemokines and for the upregulation of endothelial adhesive molecules. These conditions favor monocyte transmigration to the intima, where chemically modified, aggregated, or proteoglycan- or antibody-complexed LDL may be endocytotically internalized via scavenger receptors present on the emergent macrophage surface. The differentiating monocytes in concert with T lymphocytes exert a modulating effect on lipoproteins. These events propagate a series of reactions entailing generation of lipid peroxides and expression of chemokines, adhesion molecules, cytokines, and growth factors, thereby sustaining an ongoing inflammatory process leading ultimately to lesion formation. New data emerging from studies using transgenic animals, notably mice, have provided novel insights into many of the cellular interactions and signaling mechanisms involving monocytes/macrophages in the atherogenic processes. A number of these studies, focusing on mechanisms for monocyte activation and the roles of adhesive molecules, chemokines, cytokines and growth factors, are addressed in this review.

Role of complement activation in atherosclerosis

PURPOSE OF REVIEW

Atherosclerosis is characterized by a strong inflammatory component. One factor contributing to inflammation in the arterial intima is the complement system. Here we summarize recent progress in the field of complement research on atherogenesis.

RECENT FINDINGS

The complement system is activated in human atherosclerotic lesions and is actively regulated by the local synthesis of complement components and of complement regulatory proteins. Potential triggers of complement activation in the arterial intima include immunocomplexes, C-reactive protein, modified lipoproteins, apoptotic cells, and cholesterol crystals. Complement activation releases anaphylatoxins, and anaphylatoxin receptors have been identified in human atherosclerotic lesions. However, experiments on genetically engineered mice with severe hyperlipidemia have been unable to show a major role for complement in experimental atherogenesis.

SUMMARY

In humans there is extensive circumstantial evidence for a role of complement in atherosclerosis, which is somewhat contradictory to recent modest or negative findings in atherosclerosis-prone genetically engineered hyperlipidemic mice.

Up-regulation of matrix metalloproteinase-1 expression in U937 cells by low-density lipoprotein-containing immune complexes requires the activator protein-1 and the Ets motifs in the distal and the proximal promoter regions

We reported previously that low-density lipoprotein (LDL)-containing immune complexes (LDL-IC) stimulated matrix metalloproteinase-1 (MMP-1) expression in U937 histiocytes through Fc gamma receptor (FcgammaR)-mediated extracellular signal-regulated kinase pathway. The present study has explored the transcriptional mechanisms involved in the stimulation. Deletion analysis showed that LDL-IC stimulated MMP-1 promoter activity in cells transfected with the Construct 1 that contained a 4,334-bp MMP-1 promoter fragment, but had no effect in cells transfected with other constructs that had shorter MMP-1 promoter (2685-bp or less), suggesting that cis-acting elements located between -4334 and -2685 are required for the promoter stimulation. The mutation study further indicated that the activator protein-1 (AP-1) (-3471) or Ets (-3836) motifs in this distal region were essential for the LDL-IC-stimulated MMP-1 expression. Moreover, although above deletion analysis showed that LDL-IC did not stimulate MMP-1 promoter activity in cells transfected with constructs that contained the proximal AP-1 (-72) and Ets (-88) in the promoter fragments that are 2685-bp or less, the mutations of the -72 AP-1 or the -88 Ets motif in the construct 1 abolished the stimulation of MMP-1 expression by LDL-IC, suggesting that a long promoter sequence is required for the -72 AP-1 and -88 Ets motifs to be involved in the stimulation. Finally, electrophoretic mobility shift assay showed that LDL-IC stimulated the activities of transcription factors AP-1 and Ets. In conclusion, the present study shows that both the distal and proximal AP-1 and Ets motifs are required for LDL-IC-stimulated MMP-1 expression in U937 histiocytes.

LDL immune complexes stimulate LDL receptor expression in U937 histiocytes via extracellular signal-regulated kinase and AP-1

We have previously shown that LDL-containing immune complexes (LDL-ICs) induce up-regulation of LDL receptor (LDLR) expression in human macrophages. The present study further investigated the molecular mechanisms leading to LDLR up-regulation by LDL-ICs as well as the signaling pathways involved. Results showed that treatment of U937 histiocytes with LDL-ICs did not increase the precursors and the cleaved forms of sterol-regulatory element binding proteins (SREBPs) 1a and 2, suggesting that SREBPs may not be involved in LDLR up-regulation by LDL-ICs. Promoter deletion and mutation studies showed that the AP-1 binding sites were essential for LDL-IC-stimulated LDLR expression. Electrophoretic mobility shift assays further demonstrated that LDL-ICs stimulated transcription factor AP-1 activity. Studies assessing the signaling pathways involved in LDLR up-regulation by LDL-ICs showed that the up-regulation of LDLR was extracellular signal-regulated kinase (ERK) dependent. In conclusion, the present study shows that LDL-ICs up-regulate LDLR expression via the ERK signaling pathway and the AP-1 motif-dependent transcriptional activation.

A water-extract of the Korean traditional formulation Geiji-Bokryung-Hwan reduces atherosclerosis and hypercholesteremia in cholesterol-fed rabbits

Geiji-Bokryung-Hwan (GBH), a drug preparation consisting of five herbs of Cinnamomi Ramulus (Geiji), Poria Cocos (Bokryun), Mountan Cortex Radicis (Mokdanpi), Paeoniae Radix (Jakyak) and Persicae Semen (Doin), is a traditional Korean herbal medicine that is widely used in the treatment of atherosclerosis-related disorders. A water extract of GBH was found to scavenge 1,1-diphenyl-2-picrylhydrazyl (DPPH) radicals and inhibit low-density lipoprotein (LDL) oxidation more effectively than probucol, a well-known commercially available antioxidant. In order to evaluate the anti-atherogenic potential of this medication, New Zealand White (NZW) rabbits were fed a normal diet for 12 weeks, a high cholesterol diet, a high cholesterol diet containing 1% probucol or a high cholesterol diet containing 5% water-soluble extract of GBH. Both GBH and probucol reduced plasma cholesterol levels. LDLs from the GBH-treated group were more resistant to Cu(2+)-induced oxidation and contained more vitamin E than LDLs from the high cholesterol diet group. Endothelial damage, determined at week 6, was reduced by 55% in the GBH group (P<0.01). GBH treatment reduced an atherosclerotic area in the abdominal aorta by 58% (P<0.05) and cholesterol deposition in the thoracic aorta by 55% (P<0.05). The severity of atherosclerosis in the GBH group was significantly reduced after an adjustment using cholesterol exposure as an index of the cholesterol-lowering effect. On the other hand, diet-induced hyperlipidemic rabbits were given water extract of GBH in doses of 50 (Group B) and 200 mg/kg (Group C) and compared with controls (Group A). At 40 days after intervention in groups A, B and C, total and LDL cholesterol levels were significantly lowered (P<0.01). LDL/high density lipoprotein (HDL) ratio was also significantly decreased (P<0.01). This study concludes that the reduction in atherosclerosis by GBH relies not only on its cholesterol-lowering effect but also more heavily on its antioxidant potential, which prevents endothelial damage and inhibits LDL oxidative modification in hypercholesterolemic animals.

High oxidative stress in patients with stable coronary heart disease

Oxidized low density lipoprotein (oxLDL) plays a pivotal role in the development of atherosclerosis. The aim of the study was to investigate the relationship between oxLDL and other oxidative stress biomarkers with stable coronary heart disease (CHD). We compared the degree of oxidative stress in patients with CHD and sex-matched healthy control subjects in a case-control study. The study included 64 male subjects: 32 patients with stable CHD and 32 normal control subjects. Levels of circulating oxLDL were measured by a monoclonal antibody 4E6-based competition ELISA. Comparison of oxidative stress marker levels between cases and controls, adjusted for age, revealed significantly higher plasma oxLDL levels (63.32+/-25.49 vs. 37.73+/-20.58 U/l, P=0.001), lower serum levels of autoantibodies against oxLDL (341.53+/-350.46 vs. 796.45+/-1034.2 mU/ml, P=0.021), higher activities of the antioxidant enzymes superoxide dismutase in erythrocytes (951+/-70.2 vs. 771.6+/-191.2 U/g, P=0.032) and glutathione peroxidase in whole blood (GSH-Px: 10714.4+/-3705.4 vs. 5512.2+/-1498.1 U/l, P<0.001). The risk of having CHD was 20.6-fold greater (95% CI, 1.86-228.44, P=0.014) in the highest tertile of the oxLDL distribution than in the lowest, determined by logistic regression analysis on the combined study population after adjustment for age and other potential confounding factors. When the risk associated with GSH-Px levels was calculated, the odds ratio was 305.3 (95% CI, 5.07-18369.95, P=0.006) in the highest tertile compared with the lowest. Our results showed that an oxidative stress occurs in patients with CHD despite being clinically stable and under medical treatment. The combination of oxLDL levels and GSH-Px activity may be useful for the identification of patients with stable CHD.

Endothelial dysfunction and inflammation: what is the link?

Cardiovascular disease, resulting from arteriosclerotic remodeling of the vasculature, is the main cause of death in end-stage renal disease (ESRD) patients. Early during the course of arteriosclerosis, endothelial dysfunction can be detected in various vascular beds, including peripheral forearm arteries, as well as the coronary circulation. Furthermore, endothelial dysfunction seems to predict the prognosis of cardiovascular disease. Therefore, the question deserves attention whether endothelial dysfunction is simply a marker of cardiovascular disease, or an active player in the progress of the disease. A possible link between arteriosclerosis, endothelial dysfunction, and cardiovascular disease is increased oxidative stress. Inflammatory processes involved in the pathogenesis of arteriosclerosis enhance vascular O2- formation, leading to endothelial dysfunction. An activated renin angiotensin system, together with oxidized low-density lipoprotein, may play a prominent role for enhanced vascular oxidative stress. In this context, the endothelium is not only a target of oxygen radicals, but may also contribute to O2- formation. It is the aim of this article to highlight the interplay of inflammation, endothelial dysfunction, and oxidative stress.

Anti-oxidized LDL antibodies and wine consumption: a population-based epidemiological study in Dicomano, Italy

PURPOSE

In previous studies, higher levels of oxidized low-density lipoprotein (ox-LDL) have been reported to increase the risk of cardiovascular disease. Furthermore, the anti-oxidative properties of red wine have been invoked to explain the paradox of low cardiovascular mortality, in spite of high-fat intake, in the French population. However, the distribution of ox-LDL-antibodies (ox-LDL-Ab) in the unselected population and its relationship with red wine consumption are unknown. This study was carried out to identify factors associated with ox-LDL-Ab, with particular emphasis on the association with wine consumption.

METHODS

We performed a cross-sectional study of 551 unselected, community-dwelling older adults (aged 65 to 94 years) living in Dicomano (Italy). Ox-LDL-Ab titre was measured with an ELISA method.

RESULTS

In the whole study sample, ox-LDL-Ab increased with age and was unrelated to blood lipids, HbA(1c), and smoking habit. A significant inverse relationship was found between ox-LDL-Ab titre and daily wine intake, which persisted after adjusting for possible confounders or in subgroup analyses of participants who reported to drink wine or were free from significant morbidity.

CONCLUSIONS

These results suggest that wine affects ox-LDL-Ab titre in older populations, possibly because of its antioxidant properties.

Autoimmune response to advanced glycosylation end-products of human LDL

Advanced glycosylation end-products (AGEs) are believed to play a significant role in the development of vascular complications in diabetic patients. One such product, AGE-LDL, has been shown to be immunogenic. In this report, we describe the isolation and characterization of human AGE-LDL antibodies from the sera of seven patients with Type 1 diabetes by affinity chromatography using an immobilized AGE-LDL preparation that contained primarily the AGE N epsilon (carboxymethyl)lysine (CML, 14.6 mmol/mol lysine), and smaller amounts of N epsilon (carboxyethyl)lysine (CEL, 2.7 mmol/mol lysine). The isolated antibodies were predominantly IgG of subclasses 1 and 3, and considered proinflammatory because of their ability to promote Fc gamma R-mediated phagocytosis and to activate complement. We determined dissociation constants (Kd) for the purified antibodies. The average Kd values (4.76 +/- 2.52 x 10(-9) mol/l) indicated that AGE-LDL antibodies are of higher avidity than oxidized LDL antibodies measured previously (Kd = 1.53 +/- 07 x 10(-8) ml/l), but of lower avidity than rabbit polyclonal LDL antibodies (Kd = 9.34 x 10(-11)). Analysis of the apolipoprotein B-rich lipoproteins isolated with polyethylene glycol-precipitated antigen-antibody complexes from the same patients showed the presence of both CML and CEL, thus confirming that these two modifications are recognized by human autoantibodies. A comparative study of the reactivity of purified AGE-LDL antibodies with CML-LDL and CML-serum albumin showed no cross-reactivity.

Clinical, biochemical, and immunohistochemical features of necrobiotic xanthogranulomatosis

AIMS

To describe the clinical features of two patients with paraproteinaemia and necrobiotic xanthogranulomatosis together with detailed immunohistochemistry of the lesions in one.

METHODS

The clinical history and results of biochemical investigations of the patients were retrieved from the files. Immunohistochemistry was used to investigate the expression of macrophage and mast cell markers, amyloid A and P, S-100 protein, and apolipoprotein AI and B in xanthogranulomatous skin lesions from patient 2. In addition, protein A-sepharose chromatography was used to separate serum from patient 2 and apolipoprotein B and the IgG paraprotein were measured in the fractions eluted.

RESULTS

Monocytes/macrophages comprised the major cellular component of the lesion, and unusually for xanthomata, areas of collagen necrosis were also seen. Activated mast cells were present at the margins of macrophage clusters and adjacent to areas of collagen necrosis. Serum paraprotein was bound to low density lipoproteins as judged by protein A-sepharose chromatography, and was also located within macrophagic foam cells of the lesion on immunohistochemistry.

CONCLUSIONS

These observations demonstrate many features similar to atherosclerosis including collagen necrosis and mast cell activation.

Lipoprotein oxidation and plasma vitamin E in nondiabetic normotensive obese patients

OBJECTIVE

To correlate the susceptibility of low-(LDL) and very-low-density lipoprotein to oxidation in vitro and the concentrations of serum antibodies against malondialdehyde-modified LDL and plasma vitamin E with the anthropometric and laboratory characteristics of obesity.

RESEARCH METHODS AND PROCEDURES

A total of 75 nondiabetic, normotensive obese patients were assigned to one of four groups according to their body mass index (BMI): moderately obese (30 <or= BMI <or= 34.9 kg/m(2), n = 11), severely obese (35 <or= BMI <or= 39.9 kg/m(2), n = 20), morbidly obese (40 <or= BMI <or= 50 kg/m(2), n = 29), and very severely obese (BMI > 50 kg/m(2), n = 15).

RESULTS

The oxidation lag time for LDL from patients with a BMI >or=35 kg/m(2) was shorter than that for LDL from non-obese controls (n = 13), whereas very-low-density lipoprotein oxidation lag times were not significantly different. The serum antibodies against modified LDL were similar in all groups, whereas the plasma vitamin E concentrations of obese patients were decreased (p <or= 0.01). There was a negative correlation between LDL oxidation lag time and BMI (r = -0.35, p = 0.0008), and between plasma vitamin E and BMI (r = -0.53, p < 0.0001) and waist-to-hip ratio (r = -0.40, p = 0.0003).

DISCUSSION

The LDL of nondiabetic, normotensive obese patients is more readily oxidized, and plasma vitamin E concentrations are low. These are both risk factors for coronary heart disease.

Assay methods of modified lipoproteins in plasma

Modified lipoproteins, especially oxidatively modified low-density lipoprotein (Ox-LDL), are present in the plasma of patients with atherosclerosis and related diseases. The modification of LDL is believed to play an important role in the development of atherosclerosis. Thus, measurement of plasma Ox-LDL is essential not only for investigating its relevance to atherosclerotic diseases, but also for diagnosis. Chromatographic methods are effective for indirectly measuring the oxidatively modified state of LDL or directly measuring the modified LDL. Indirect determination can be done by estimating the LDL subfraction, LDL particle size, oxidized amino acids in apolipoprotein B, lipid hydroperoxide or F(2)-isoprostane in LDL. Direct determination of the modified LDL in plasma can be done with chromatographic methods such as anion-exchange chromatography and size-exclusion chromatography. Other methods for estimating the modified state of LDL include electromigration methods such as agarose gel, polyacrylamide gradient gel and capillary electrophoresis. Recently, enzyme-linked immunosorbent assay methods of malondialdehyde (MDA)-LDL and autoantibodies against Ox-LDL have been developed to assess Ox-LDL in plasma. This review article summarizes the detection and assay methods of modified lipoproteins in plasma.

Endothelial vasodilatory function is predicted by circulating apolipoprotein B and HDL in healthy humans

Endothelium-dependent vasodilation (EDV), LDL particle size, and antibodies against oxidized LDL (oxLDLab) have been shown to be related to the development of atherosclerosis and cardiovascular disease. In this study, we investigated whether LDL particle size, oxLDLab, apolipoproteins, and lipoproteins are related to endothelial vasodilatory function in a population sample of 58 apparently healthy subjects aged 20 to 69 yr. EDV and endothelium-independent vasodilation (EIDV) were studied in the forearm during local administration of methacholine chloride (2 and 4 microg/min) or sodium nitroprusside (5 and 10 microg/min). Forearm blood flow was determined with venous occlusion plethysmography. In multiple stepwise regression analyses, neither oxLDLab nor small LDL particles were significantly predictive of endothelial vasodilatory function. Instead, a high level of apolipoprotein B (apoB) was an independent predictor of both attenuated EDV and EIDV (r = -0.43, P < 0.01, and r = -0.34, P < 0.05, respectively). HDL cholesterol, on the other hand, was the only lipid variable that was significantly related to the EDV to EIDV ratio, an index of endothelial vasodilatory function (r = 0.35, P < 0.01). The inverse associations between apoB and both EDV and EIDV indicate that apoB might be an early marker of structural vascular changes in healthy subjects, whereas HDL seems to be more specifically related to endothelial vasodilatory function.

Antibody to oxidized low-density lipoprotein and cardiovascular mortality in end-stage renal disease

BACKGROUND

Immune response to oxidized low-density lipoprotein (oxLDL) may modulate the process of atherogenesis and cardiovascular disease.

METHODS

We performed a prospective, observational cohort study in 249 patients with end-stage renal disease (ESRD) to examine whether the serum titer of anti-oxLDL antibody can predict cardiovascular mortality.

RESULTS

The median anti-oxLDL antibody titer was 320 mU/mL at baseline. During the follow-up (63 +/- 23 months), 72 deaths including 34 cardiovascular deaths occurred. When the subjects were divided into two groups by the median titer, the high titer group showed a lower risk for cardiovascular mortality (P = 0.040 by Kaplan-Meier analysis and log-rank test). Multivariate Cox proportional hazards model indicated that the lower risk of cardiovascular death in the high titer group remained significant (hazard ratio of 0.46, 95%CI 0.23-0.95, P = 0.037) and independent of age, presence of vascular complications, presence of diabetes mellitus, and elevated C-reactive protein. In contrast, anti-oxLDL antibody titer was not associated with non-cardiovascular mortality.

CONCLUSIONS

These results demonstrate, to our knowledge for the first time, that serum anti-oxLDL antibody titer is an independent predictor of cardiovascular mortality in a cohort of patients with ESRD.

Proatherogenic and proinflammatory properties of immune complexes prepared with purified human oxLDL antibodies and human oxLDL

Immune complexes (IC) prepared with human low density lipoprotein (LDL) and rabbit LDL antibodies induce foam cell transformation of human macrophages and activate the release of proinflammatory mediators by human macrophages and THP-1 cells. Because the affinity of human oxidized LDL (oxLDL) antibodies is lower than that of rabbit antibodies, IC formed with human antibodies could have limited pathogenic potential. Immune complexes prepared with human oxidized LDL (oxLDL) and purified human oxLDL antibodies (predominantly of the IgG1 and IgG3 isotypes) were presented to THP-1 cells using two protocols previously described in studies of the properties of LDL-IC prepared with rabbit antibodies. OxLDL/human oxLDL antibody IC immobilized by adsorption to red blood cells (RBC) induced the release of significantly higher levels of TNF from THP-1 cells (872-313 pg/ml) than oxLDL adsorbed to RBC (461-75.6 pg/ml) and caused a higher degree of cholesterol ester accumulation in the same cells (5.4-0.77 in cells incubated with IC-coated RBC vs 1.99-1.16 in oxLDL-coated RBC). Insoluble IC prepared with oxLDL/human oxLDL antibody were even more effective in promoting intracellular accumulation of cholesterol in THP-1 cells (total cholesterol = 53.8-13.5 and cholesterol esters = 24.0-7.2 mg/l in THP-1 cells incubated with insoluble IC (200 micrograms) vs total cholesterol = 32.4-8.2 and cholesterol esters = 7.7 +/- 2.8 micrograms/l in THP-1 cells incubated with an identical concentration of oxLDL) and also induced the release of TNF. Thus we have demonstrated that IC prepared with human oxLDL and human oxLDL antibodies have the same atherogenic and proinflammatory properties as IC prepared with human LDL and rabbit LDL antibodies. This strongly supports the concept that modified LDL-IC present in circulation and/or tissues play an important pathogenic role in arteriosclerosis.

The autoantibody expression against different source of oxidized low density lipoprotein in patients with acute myocardial infarction

The aim of this study was to examine the expression of antibodies against two different sources of low density lipoprotein (LDL) that were oxidized by CuSO(4), in patients with early stage of acute myocardial infarction (AMI). When LDL purified from sera with high level of LDL was used as a modified antigen, the results indicated that the titers of antibodies against the oxidized LDL in 30 patients were increased by 135% compared to those in normal subjects; however, the titers of antibody against modified LDL purified from normal-range LDL in the same patients were only slightly increased by 52%. Comparing the levels of autoantibody expressed in the high LDL sera group, high triglyceride sera group, and AMI patients sera group (total of 41; in addition to 30 AMI patients, 11 more sera of AMI patients were collected), the amount of autoantibody against the oxLDL purified from high LDL sera in AMI patients sera group was significantly increased up to 195%. In contrast to AMI patients, the sera titers against the same antigen in two subject groups with either high LDL or high triglyceride are only 50% higher than normal subjects. Moreover, the ratio of thromboxane B(2) over 6-keto-prostaglandin F(1alpha) (6-keto-PG F(1alpha)) in the acute myocardial infarction patients was 1.79, which is much lower than the normal subjects, 4.19. Concluding from the above observations, we suggest that the expression level of anti-oxidized LDL antibody may play a role on the pathogenesis of acute myocardial infarction disease, but is independent with the levels of thromboxane A(2) and prostacyclin in the examined sera.

The evaluation of autoantibodies against oxidatively modified low-density lipoprotein (LDL), susceptibility of LDL to oxidation, serum lipids and lipid hydroperoxide levels, total antioxidant status, antioxidant enzyme activities, and endothelial dysfunction in patients with Behçet's disease

OBJECTIVES

Behçet's disease is a multisystem disorder characterized by a chronic inflammation including acute attacks and remission periods. Decreased enzyme activity of the antioxidant system and increased levels of free radicals may have important roles in the damage of tissues observed in the disease period. In addition, the atherogenic tendency of serum lipid, lipoproteins, lipid peroxidation levels and endothelial dysfunction accompany the above mentioned findings. As a consequence of these events, different degrees of low density lipoprotein (LDL) oxidation occur in vivo, and then autoantibodies against oxidized-LDL(AuAb-oxLDL) are produced.

DESIGN AND METHODS

Lipids, lipoproteins, lipid hydroperoxide, AuAb-oxLDL, total antioxidant status (TAS), serum-soluble intercellular adhesion molecule-1 (sICAM-1), plasminogen activator inhibitor 1 (PAI-1) levels in serum, the activities of antioxidant enzymes including glutathione peroxidase (GSH-Px), glutathione reductase (GR), superoxide dismutase (SOD), and catalase (CAT) in erythrocytes and plasma, were determined in 25 patients with Behçet's disease and in 25 healthy volunteers. Also, susceptibility to copper-induced in vitro oxidation of LDL by using lag time, a measure of resistance to oxidation, oxidation rate and extent of oxidation, a measure of diene production in both groups, was studied.

RESULTS

It was observed that lipid hydroperoxide and AuAb-oxLDL levels in patients with Behçet's disease were significantly higher, but erythrocyte SOD, CAT, plasma GSH-Px activities, and TAS were significantly lower than those in healthy subjects. Susceptibility of LDL to oxidation in the patients was found to be increased. Total cholesterol, LDL-C and apo B levels and acute phase reactants were significantly higher, but HDL-C and apo AI levels were significantly lower, in patients when compared to healthy subjects. The levels of AuAb-oxLDL in patients were found to correlate with TAS, total cholesterol, LDL-C, lipid hydroperoxide and erythrocyte SOD activities (r = -0.62, p < 0.01; r = 0.64, p < 0.01; r = 0.55, p < 0.01; r = 0.81, p < 0.01; r = -0.63, p < 0.01, respectively). In addition, lipid hydroperoxide levels were found to correlate with total cholesterol, LDL-C and erythrocyte SOD activities (r = 0.45, p < 0.05; r = 0.45, p < 0.05; r = -0.46, p < 0.05, respectively). PAI-1 and sICAM-1 were found to be increased in the patients and correlated with AuAb-oxLDL and lipid hydroperoxide levels (r = 0.56, p < 0.01; r = 0.67, p < 0.01 and r = 0.59, p < 0.01; r = 0.61, p < 0.01, respectively).

CONCLUSIONS

It was concluded that the observed increase of lipid, lipoproteins, lipid hydroperoxide, susceptibility of LDL to oxidation, autoantibodies against ox-LDL levels and decrease of antioxidant enzyme activities and total antioxidant status and increased secretion of endothelial derivated peptides including sICAM and PAI-1, and their interactions may indicate that there is a tendency to atherothrombotic events in patients with Behçet's disease.

Protective immunity against atherosclerosis carried by B cells of hypercholesterolemic mice

Atherosclerosis is characterized by vascular inflammation and associated with systemic and local immune responses to oxidized LDL (oxLDL) and other antigens. Since immunization with oxLDL reduces atherosclerosis, we hypothesized that the disease might be associated with development of protective immunity. Here we show that spleen-associated immune activity protects against atherosclerosis. Splenectomy dramatically aggravated atherosclerosis in hypercholesterolemic apoE knockout (apoE degrees ) mice. Transfer of spleen cells from atherosclerotic apoE degrees mice significantly reduced disease development in young apoE degrees mice. To identify the protective subset, donor spleen cells were divided into B and T cells by immunomagnetic separation before transfer. Protection was conferred by B cells, which reduced disease in splenectomized apoE degrees mice to one-fourth of that in splenectomized apoE degrees controls. Protection could also be demonstrated in intact, nonsplenectomized mice and was associated with an increase in antibody titers to oxLDL. Fewer CD4(+) T cells were found in lesions of protected mice, suggesting a role for T-B cell cooperation. These results demonstrate that B cell-associated protective immunity develops during atherosclerosis and reduces disease progression.

High titres of serum antinuclear antibodies, mostly directed against nucleolar antigens, are associated with the presence of coronary atherosclerosis

BACKGROUND

Inappropriate inflammation is a key mechanism in the development of atherosclerosis. Antibodies against components of the atherosclerotic lesion, in particular, oxidised low density lipoprotein, have been described.

OBJECTIVE

To determine whether a systemic autoimmune response, characterised by the presence of high titres of antinuclear antibodies, is associated with the presence of coronary atherosclerosis.

METHODS

Serum was prepared from 40 subjects (aged 53-76) with at least 50% stenoses of three main coronary arteries (TVD subjects), and 30 subjects (aged 48-74) with no evidence of coronary atherosclerosis (NCA subjects) determined by coronary angiography.

RESULTS

Antinuclear antibodies (ANA), characterised by immunofluorescent detection of human antibodies bound to HEp-2000 cells, were detected at a titre of at least 1/40 in 28 (70%) of the TVD subjects, but only five (17%) of the NCA patients (odds ratio 11.67 (95% confidence interval (CI) 3.91 to 17.82; p<0.001)). Most ANA positive TVD subjects had a pattern typical of antibodies directed against nucleolar antigens. The antigen has not yet been identified, but several common extractable antigens were excluded. The presence of ANA was not associated with incidence of prior myocardial infarction among the TVD group.

CONCLUSION

The presence of ANA, commonly associated with autoimmune diseases, is substantially more prevalent among subjects with severe coronary atherosclerosis than those with normal coronary arteries. This association merits further assessment as a potentially useful indicator of increased risk of coronary heart disease.

IFN-gamma pretreatment augments immune complex-induced matrix metalloproteinase-1 expression in U937 histiocytes

We reported recently that immune complexes (ICs) induced matrix metalloproteinase-1 (MMP-1) expression in U937 histiocytes. The present study was undertaken to determine the effect of pretreatment of U937 cells with interferon-gamma (IFN-gamma) on IC-induced MMP-1 expression. Our flow cytometry studies showed that IFN-gamma upregulated the surface expression of FcgammaRI, but not FcgammaRII. Results also showed that pretreatment of the cells with IFN-gamma augmented LDL-containing IC (LDL-IC)-induced MMP-1 secretion in a dose- and time-dependent manner. Furthermore, Northern blot analysis revealed that IFN-gamma pretreatment led to a marked increase in MMP-1 mRNA. Finally, we demonstrated that PD98059 was able to block LDL-IC-induced MMP-1 secretion, regardless of whether the cells were pretreated with IFN-gamma or not, suggesting that IFN-gamma pretreatment did not alter the essential role of the ERK signaling pathway in LDL-IC-induced MMP-1 expression. In conclusion, the present study has demonstrated that IFN-gamma pretreatment augments LDL-IC-induced MMP-1 expression in U937 cells, thus elucidating an immune mechanism potentially involved in plaque destabilization.