Dyslipoproteinemia in pediatric systemic lupus erythematosus

Sex Differences in Lipid Metabolism: Implications for Systemic Lupus Erythematosus and Cardiovascular Disease Risk

It is known that healthy women during childbearing years have a lower risk of cardiovascular disease (CVD) and coronary heart disease compared to age matched men. Various traditional risk factors have been shown to confer differential CVD susceptibilities by sex. Atherosclerosis is a major cause of CVD and mortality and sex differences in CVD risk could be due to reduced atherogenic low and very low-density lipoproteins (LDL and VLDL) and increased atheroprotective high density lipoproteins (HDLs) in women. In contrast, patients with systemic lupus erythematosus (SLE), a chronic inflammatory disease that predominately affects women, have an increased atherosclerotic and CVD risk. This increased CVD risk is largely associated with dyslipidaemia, the imbalance of atherogenic and atheroprotective lipoproteins, a conventional CVD risk factor. In many women with SLE, dyslipidaemia is characterised by elevated LDL and reduced HDL, eradicating the sex-specific CVD protection observed in healthy women compared to men. This review will explore this paradox, reporting what is known regarding sex differences in lipid metabolism and CVD risk in the healthy population and transgender individuals undergoing cross-sex hormone therapy, and provide evidence for how these differences may be compromised in an autoimmune inflammatory disease setting. This could lead to better understanding of mechanistic changes in lipid metabolism driving the increased CVD risk by sex and in autoimmunity and highlight potential therapeutic targets to help reduce this risk.

Cardiovascular Health in Pediatric Rheumatologic Diseases

Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association

This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.

Mortality Risks among Various Primary Renal Diseases in Children and Adolescents on Chronic Dialysis

There is little information available on the association between primary renal disease (PRD) and long-term mortality in the pediatric dialysis population. The objective of this study was to explore mortality risks in children and adolescents on chronic dialysis, specifically focused on the risk of various PRDs. The study cohort included children and adolescents with end-stage renal disease (ESRD) (aged < 20 years) who had received dialysis for at least 90 days between 2000 and 2014 and were identified from Taiwan's National Health Insurance medical claims. A total of 530 children and adolescents were included in the study. The median age of the included patients was 13.6 years and 305 (57.5%) patients were males. One hundred and seven patients died during the follow-up period and the median survival time was 6.0 years. Mortality was highest in the youngest patients. For patients with the following PRDs, mortality was significantly higher than that in patients with primary glomerulonephritis: secondary glomerulonephritis (adjusted hazard ratio (aHR): 2.50; 95% confidence interval (CI): 1.03⁻6.08), urologic disorder (aHR: 4.77; 95% CI: 1.69⁻13.46), and metabolic diseases (aHR: 5.57; 95% CI: 1.84⁻16.85). Several kinds of PRDs appear to have high mortality risks in the pediatric dialysis population. These differences in mortality risk highlight the importance of the focused clinical management of these high-risk subgroups.

Complementary role of cardiovascular imaging and laboratory indices in early detection of cardiovascular disease in systemic lupus erythematosus

Background

Cardiovascular disease (CVD) has been documented in >50% of systemic lupus erythematosus (SLE) patients, due to a complex interplay between traditional risk factors and SLE-related factors. Various processes, such as coronary artery disease, myocarditis, dilated cardiomyopathy, vasculitis, valvular heart disease, pulmonary hypertension and heart failure, account for CVD complications in SLE.

Methods

Electrocardiogram (ECG), echocardiography (echo), nuclear techniques, cardiac computed tomography (CT), cardiovascular magnetic resonance (CMR) and cardiac catheterization (CCa) can detect CVD in SLE at an early stage. ECG and echo are the cornerstones of CVD evaluation in SLE. The routine use of cardiac CT and nuclear techniques is limited by radiation exposure and use of iodinated contrast agents. Additionally, nuclear techniques are also limited by low spatial resolution that does not allow detection of sub-endocardial and sub-epicardial lesions. CCa gives definitive information about coronary artery anatomy and pulmonary artery pressure and offers the possibility of interventional therapy. However, it carries the risk of invasive instrumentation. Recently, CMR was proved of great value in the evaluation of cardiac function and the detection of myocardial inflammation, stress-rest perfusion defects and fibrosis.

Results

An algorithm for CVD evaluation in SLE includes clinical, laboratory, ECG and echo assessment as well as CMR evaluation in patients with inconclusive findings, persistent cardiac symptoms despite normal standard evaluation, new onset of life-threatening arrhythmia/heart failure and/or as a tool to select SLE patients for CCa.

Conclusions

A non-invasive approach including clinical, laboratory and imaging evaluation is key for early CVD detection in SLE.

Oxidative stress leads to reduction of plasmalogen serving as a novel biomarker for systemic lupus erythematosus

Oxidative stress is elevated in systemic lupus erythematosus (SLE) patients, and associated extensively with SLE pathogenesis. However, no common indicators of oxidative stress are yet in routine clinical use because of their instability, nonspecificity, and non-representation of all SLE symptoms. Moreover, the method for reproducible analysis of reactive oxygen species is still lacking. Lipids and their metabolites are essential components of biological systems, many of which serve as molecular targets of oxidative stress and play crucial roles in signaling, inflammation, and immune responses. Thus, determining the changed levels of lipids and their metabolites may serve the needs for SLE research. In the pilot study, shotgun lipidomics of sera from 30 SLE patients and 30 controls was performed and revealed a marked reduction of ethanolamine plasmalogen (pPE) species from 85.03±3.06 to 62.39±4.34 nmol/mL serum in controls and patients, respectively, accompanying significant increases in lysoPE (LPE) content (~46mol%) and 4-hydroxynonenal (an indictor of oxidative stress) in patients. Representative proinflammatory cytokines were also determined, revealing significant elevation of IL-6, IL-10, and TNF-α in SLE patients. Multivariate and multiple regression analyses showed for the first time that significant correlation among the SLE disease activity index, IL-10 levels, and pPE content exists, providing insights into SLE pathogenesis. The study also indicates that the changes of pPE (molecular targets of oxidative stress) and their peroxidation products may serve as novel biomarkers for diagnosis of SLE.

Lupus and Cardiovascular Disease: The Facts

Accelerated atherosclerosis leading to coronary artery disease (CAD) and other cardiac manifestations have increasing importance for the management and outcome of systemic lupus erythematosus (SLE). There is increased cardiovascular mortality in SLE. Several traditional and disease-related risk factors, as well as corticosteroids are involved in lupus-associated atherosclerosis and its clinical manifestations. Cardiovascular risk is even higher in lupus patients also having secondary antiphospholipid syndrome (APS) due to the additive effects of SLE- and APS-related risk factors. The primary and secondary prevention of atherosclerosis and CAD in these diseases includes drug treatment, such as the use of statins and aspirin, as well as lifestyle modifications. Apart from CAD, other cardiac manifestations may also be present in SLE patients. Among these conditions, pericarditis is the most common, however, myocarditis, endocarditis and valvular disease, conduction abnormalities, impairment of systolic and diastolic function, pulmonary or peripheral arterial hypertension and microcirculatory problems may also occur. Early diagnosis of SLE, active immunosuppressive treatment and close follow-up of lupus patients and prevention may help to minimize cardiovascular risk in these individuals.

Abnormal body composition, cardiovascular endurance, and muscle strength in pediatric SLE

BACKGROUND

Children with SLE are known to have higher fat mass compared to their peers but there are no published data regarding exercise capacity as measured by cardiovascular endurance and muscle strength. In our pilot study of ten children with SLE, we sought to examine body composition, cardiovascular endurance, and isometric muscle strength.

FINDINGS

Ten pediatric SLE patients were studied with a mean age of 15.5 years and 90 % female. Percent body fat above 30 %, the recommended normal level in adolescent females, were found in 89 % of female subjects and 40 % of all participants had lower than the recommended norms of muscle mass for their age/gender. Subjects with renal disease were more likely to have low muscle mass compared to those without renal disease (p = 0.03). Cardiovascular endurance was reported as estimated maximal oxygen consumption (VO2max) during cycle ergometry. All participants scored in less than fifth percentile for VO2max measurements compared to data from age and gender matched published norms. Isokinetic muscle strength testing was performed on upper and lower extremities. Only one participant (male subject) reached goal percentiles for age and gender.

CONCLUSIONS

We found significant deficit in body composition, muscle strength and cardiovascular endurance in the pediatric SLE population compared to reported published norms. Clinicians should consider these data and focus on exercise programs that can increase aerobic capacity and muscle strength in this high-risk population.

The frequency of high/moderate lipoprotein risk factor for coronary artery disease is significant in juvenile-onset systemic lupus erythematosus

To determine the prevalence of dyslipoproteinemia on a large juvenile systemic lupus erythematosus (jSLE) cohort, we selected 40 patients after rigorous exclusion criteria. Lipoprotein levels were determinated after 12 hours fast and risk levels for CAD were defined by standards of the Brazilian Guidelines for dyslipoproteinemia according to US-NCEP. All individuals were under steroid therapy and chloroquine and 43% had active disease. Thirty patients (75%) had high-risk levels for CAD (23 isolated low HDL, while in seven subjects low HDL was associated to high TG in four, high LDL in one, high TG/LDL in one and high TC/LDL in one). Remarkably, overall analysis revealed that 85% patients were included in high/medium risk levels group (29% for TC, 29% for LDL, 88% for HDL, and 18% for TG) and these disturbances occured mainly in the first four years of disease. Unexpectedly, one-third of the patients presented two or more high/medium lipoprotein risk factors. Independently, active jSLE was associated to TG (OR = 3.2; P < 0.001) and had a tendency towards reduction on HDL (OR = 8.5; P = 0.056). Considering improvements on jSLE outcome, the increased frequency of high/medium lipoprotein risk levels for CAD reinforces the need of prevention measures in order to minimize deleterious effects of this disturbance.

The prevalence of dyslipoproteinemia in Thai patients with systemic lupus erythematosus

Fasting blood samples taken from 93 pairs of outpatient systemic lupus erythematosus (SLE) women and matched controls were assessed for total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol. The demographic data, clinical manifestations, Mexican-SLE Disease Activity Index (MEX-SLEDAI), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index and medication prescribed in the SLE patients were reviewed. A significant elevation of TG levels was observed in the SLE patients compared to controls (mean ±SD 113.3 ±59.5 versus 77.7 ±45.7 mg/dL, P < 0.001). The HDL-c level was also significantly lower in SLE patients than controls (mean ±SD 49.7 ±12.7 versus 65.0 ±14.8 mg/dL, P < 0.001). The percentage of samples with low HDL-c (<35 mg/dL) was higher in the SLE group (9.7%) than controls (0%; P = 0.002). The LDL-c and TC levels were comparable in both groups. The use of antimalarial drugs was negatively associated with TC (OR 0.22, 95%CI 0.08-0.61) and LDL-c levels (OR 0.27, 95%CI 0.09-0.80). The increased prevalence of dyslipoproteinemia in SLE patients in this report has confirmed the results of previous studies and emphasized the importance of controlling this modifiable cardiovascular risk factor by the combination of lifestyle modification and medical treatments.

Why are kids with lupus at an increased risk of cardiovascular disease?

Juvenile-onset systemic lupus erythematosus (SLE) is an aggressive multisystem autoimmune disease. Despite improvements in outcomes for adult patients, children with SLE continue to have a lower life expectancy than adults with SLE, with more aggressive disease, a higher incidence of lupus nephritis and there is an emerging awareness of their increased risk of cardiovascular disease (CVD). In this review, we discuss the evidence for an increased risk of CVD in SLE, its pathogenesis, and the clinical approach to its management.

High-density lipopoprotein antioxidant capacity, subpopulation distribution and paraoxonase-1 activity in patients with systemic lupus erythematosus

Background

The causes of increased cardiovascular risk in systemic lupus erythematosus (SLE) are not understood thoroughly, although presence of traditional cardiovascular risk factors and disease-specific agents were also proposed. In this study, we investigated the quantitative changes in the lipid profile, as well as qualitative characteristics of high-density lipoprotein (HDL) and markers of inflammation and disease activity in SLE patients.

Methods

Lipoprotein levels were determined in 51 SLE patients and 49 healthy controls, matched in age and gender. HDL antioxidant capacity was determined spectrophotometrically with a cell-free method of hemin-induced low-density lipoprotein (LDL) oxidation. Polyacrylamide gel-electrophoresis was used for HDL subfraction analysis. Human paraoxonase-1 (PON1) activity, apolipoprotein A1 (ApoA1) and oxidized LDL concentrations, as well as interleukin-6, high-sensitivity C-reactive protein, serum amyloid A and monocyte chemotactic protein-1 levels were determined.

Results

HDL-cholesterol and ApoA1 concentrations decreased significantly in SLE subjects. Also, PON1 arylesterase activity (125.65 ± 26.87 vs. 148.35 ± 39.34 U/L, p = 0.001) and total HDL antioxidant capacity (165.82 ± 58.28 % vs. 217.71 ± 54.36 %, p < 0.001) were significantly reduced in patients compared to controls. Additionally, all HDL subfraction concentrations were significantly decreased in patients, while the levels of the examined inflammatory markers were significantly elevated in SLE subjects. The latter correlated positively with disease activity, and negatively with HDL concentration and total HDL antioxidant capacity, respectively. PON1 arylesterase activity and erythrocyte sedimentation rate were independent predictors of total HDL antioxidant capacity.

Conclusions

Induced by the systemic inflammation, altered composition and antioxidant activity may diminish the anti-atherogenic effect of HDL and therefore may contribute to the increased cardiovascular risk of SLE patients.

Impact of Antiphospholipid Syndrome and/or Systemic Lupus Erythematosus on the Long-term Adverse Cardiovascular Outcomes in Patients After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) are 2 rare autoimmune disorders which commonly affect women. Several previous studies showed APS to have been evolved from SLE. Secondary APS often coexists with SLE. One common feature relating these 2 diseases are the antiphospholipid antibodies, which are found in most of the patients with APS and in approximately 30% to 40% of patients with SLE, among which, about 10% develop APS. The leading cause of death in these patients is from cardiovascular disease due to accelerated atherosclerosis, which often progresses more rapidly, compared with the general population. However, the impact of APS and/or SLE on the cardiovascular outcomes in patients undergoing percutaneous coronary intervention (PCI) is controversial. Therefore, to solve this issue, we aim to compare the long-term (≥1 year) adverse cardiovascular outcomes after PCI, in patients with APS and/or SLE, and those without these disorders.Medline and EMBASE databases were searched for studies comparing the long-term adverse cardiovascular outcomes between SLE and non-SLE, APS and non-APS, or SLE + APS and non-SLE + non-APS after PCI. We calculated odd ratios (OR) and 95% confidence intervals (CIs) for these categorical variables, and the pooled analyses were performed with RevMan 5.3.Seven studies consisting of a total of 253,436 patients (568 patients in the experimental group and 252,868 patients in the control group) were included in this meta-analysis. During a follow-up period of ≥1 year, mortality and myocardial Infarction (MI) were significantly higher in the experimental group (OR 2.02, 95% CI 1.63-2.49, P < 0.00001 and OR 1.59, 95% CI 1.23-2.05, P = 0.0004, respectively). Major adverse cardiac events and repeated revascularization were also significantly higher in the SLE/APS group (OR 2.40, 95% CI 1.42-4.03, P = 0.001 and OR 2.59, 95% CI 1.26-5.31, P = 0.01, respectively).Antiphospholipid syndrome and SLE are associated with significantly higher long-term (≥1 year) adverse cardiovascular outcomes after PCI. However, because of the limited number of patients and researches done, and due to a larger percentage of heterogeneity observed among several subgroups, this analysis may not generate a powerful result.

Dyslipidemia in patients with systemic lupus erythematosus: Association with disease activity and B-type natriuretic peptide levels

The aim of the present study was to evaluate the association between the levels of lipids and B-type natriuretic peptide (BNP) in systemic lupus erythematosus (SLE) patients with heart failure (HF). A total of 46 patients with active SLE and 40 healthy, age-matched control subjects were studied. BNP was measured by an immunofluorescence assay in fresh plasma. Total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, apolipoprotein (Apo) B, ApoA-I and lipoprotein(a) were assessed. Compared with the control subjects, HDL-C and ApoA-I levels were considerably decreased and TG level increased markedly from SLE patients. The average concentration of HDL-C and ApoA-I in the SLE group with HF was significantly reduced compared to those patients without HF. The results showed that the levels of HDL-C and ApoA-I in SLE patients were negatively correlated with BNP. Disease activity was associated with the TC and TG levels. The present data indicated the presence of a cardiovascular (CV) risk in active SLE with high disease activity, which was demonstrated by the high frequency of dyslipidemia and higher BNP concentrations. Therefore, dyslipoproteinemia may underlie some of the increased risk for CV disease and HF in patients with SLE.

mTOR activation is a biomarker and a central pathway to autoimmune disorders, cancer, obesity, and aging

The mechanistic target of rapamycin (mTOR) is a ubiquitous serine/threonine kinase, which plays pivotal roles in integrating growth signals on a cellular level. To support proliferation and survival under stress, two interacting complexes that harbor mTOR, mTORC1 and mTORC2, promote the transcription of genes involved in carbohydrate metabolism and lipogenesis, enhance protein translation, and inhibit autophagy. Although rapamycin was originally developed as an inhibitor of T cell proliferation for preventing organ transplant rejection, its molecular target, mTOR, has been subsequently identified as a central regulator of metabolic cues that drive lineage specification in the immune system. Owing to oxidative stress, the activation of mTORC1 has emerged as a central pathway for the pathogenesis of systemic lupus erythematosus and other autoimmune diseases. Paradoxically, mTORC1 has also been identified as a mediator of the Warburg effect that allows cell survival under hypoxia. Rapamycin and new classes of mTOR inhibitors are being developed to block not only transplant rejection and autoimmunity but also to treat obesity and various forms of cancer. Through preventing these diseases, personalized mTOR blockade holds promise to extend life span.

Cardiovascular risk in pediatric-onset rheumatological diseases

Cardiovascular morbidity and mortality are becoming major health concerns for adults with inflammatory rheumatic diseases. The enhanced atherogenesis in this patient population is promoted by the exposure to traditional risk factors as well as nontraditional cardiovascular insults, such as corticosteroid therapy, chronic inflammation and autoantibodies. Despite definite differences between many adult-onset and pediatric-onset rheumatologic diseases, it is extremely likely that atherosclerosis will become the leading cause of morbidity and mortality in this pediatric patient population. Because cardiovascular events are rare at this young age, surrogate measures of atherosclerosis must be used. The three major noninvasive vascular measures of early atherosclerosis--namely, flow-mediated dilatation, carotid intima-media thickness and pulse wave velocity--can be performed easily on children. Few studies have explored the prevalence of cardiovascular risk factors and even fewer have used the surrogate vascular measures to document signs of early atherosclerosis in children with pediatric-onset rheumatic diseases. The objective of this review is to provide an overview on cardiovascular risk and early atherosclerosis in pediatric-onset systemic lupus erythematosus, juvenile idiopathic arthritis and juvenile dermatomyositis patients, and to review cardiovascular preventive strategies that should be considered in this population.

[Atherosclerosis in systemic lupus erythematosus]

CONTEXT

Evidence from epidemiological studies demonstrates that patients with systemic lupus erythematosus (SLE) are at increased risk for the development of cardiovascular disease. Traditional cardiovascular risk factors' play an important role in this phenomenon but do not account for the entire risk in lupus patients.

OBJECTIVES

The incidence and prevalence of cardiovascular events and infraclinical atherosclerosis are reviewed. Combinations of traditional risk factors with lupus-specific and treatment-related variables are detailed.

RESULTS

Atherosclerosis is more prevalent and occurs prematurely in lupus patients. Relative risk of myocardial infarction is between 5 to 8 times greater that of general population, and may exceed 50 in women between 35 and 44 years old. SLE was also found as an independent risk factor for subclinical atherosclerosis, and more than one third of lupus patient show evidence of carotid plaques of coronary artery calcifications. Lupus patients have more frequent traditional risk factors compared with general population of similar age and sex. Besides the traditional risk factors, SLE specific risk factors have been identified among witch advanced age at diagnosis, current disease activity, duration of the disease and renal activity. Moreover, lipid abnormalities in patients with SLE are common and likely are one of the major causes of premature atherosclerosis in these patients; the dyslipoprotein associated increased triglycerides and depressed HDL-cholesterol with proinflammatory HDL production. Autoimmunity may have a part of responsibility, but data's in favour of this hypothesis are not strong. Other mechanisms such as vascular inflammation, oxidative stress, immune complexes and complement activation may also elicit endothelial damage and promote atherosclerosis are associated with the pathogenesis of both SLE and atherosclerosis. Steroids may have a true double-edged role with a pro-atherogenic risk regarding the exacerbation of metabolic risk factors and a "beneficial" anti-inflammatory role. It is becoming increasingly apparent that antimalarials treatment in SLE has an atheroprotective and a cardioprotective effect. The other immunosuppressive drugs may reduce progression of atherosclerosis and cardiovascular events but their precise role remains to be elucidated. Despite their role in primary prevention in target general population, for now, systematic prescription of statins does not show a great benefit in the cardiovascular risk in lupus patients.

CONCLUSION

Mechanisms of atherosclerosis in SLE remain elusive. It is partially explained by the interaction of traditional cardiovascular risk factors, lupus-specific factors and therapy specially corticosteroids. Management strategies of lupus should include early all those items.

HDL in innate and adaptive immunity

During infections or acute conditions high-density lipoproteins cholesterol (HDL-C) levels decrease very rapidly and HDL particles undergo profound changes in their composition and function. These changes are associated with poor prognosis following endotoxemia or sepsis and data from genetically modified animal models support a protective role for HDL. The same is true for some parasitic infections, where the key player appears to be a specific and minor component of HDL, namely apoL-1. The ability of HDL to influence cholesterol availability in lipid rafts in immune cells results in the modulation of toll-like receptors, MHC-II complex, as well as B- and T-cell receptors, while specific molecules shuttled by HDL such as sphingosine-1-phosphate (S1P) contribute to immune cells trafficking. Animal models with defects associated with HDL metabolism and/or influencing cell cholesterol efflux present features related to immune disorders. All these functions point to HDL as a platform integrating innate and adaptive immunity. The aim of this review is to provide an overview of the connection between HDL and immunity in atherosclerosis and beyond.

Apolipoprotein B as an independent predictor of arterial stiffness in systemic lupus erythematosus patients

AIM

To determine the relationship of apolipoprotein B (Apo-B) and arterial stiffness determined by brachial-ankle pulse wave velocity (baPWV) in systemic lupus erythematosus (SLE) subjects.

METHODS

Eighty-seven Thai SLE subjects with inactive disease activity were studied. Fasting blood was collected for creatinine, glucose, lipid profiles, Apo-B and Apo-A1. Pearson correlation and stepwise-linear regression were used for the analysis.

RESULTS

The mean age of the subjects was 36.69 ± 10.85 years; 6.90% of them had stage 3 or more severe chronic kidney disease, 49.40% took anti-hypertensive drugs and 4.60% had abnormal glucose metabolism. The mean value for baPWV was 1332 ± 274.12 cm/s. Thirty-six percent of the subjects had increased arterial stiffness with mean Apo-B levels of 1.05 ± 0.31 g/L compared to 0.94 ± 0.24 in normal arterial stiffness. There were correlations of baPWV with age, systolic blood pressure (BP), diastolic BP and creatinine clearance. Apo-B tended to be associated with baPWV (P = 0.06) whereas low-density lipoprotein cholesterol did not (P = 0.2). By multiple regression analysis, systolic BP, age and Apo-B were the significant predictors of baPWV.

CONCLUSION

Apo-B was independently associated with arterial stiffness in SLE subjects.

Hydroxychloroquine reduces low-density lipoprotein cholesterol levels in systemic lupus erythematosus: a longitudinal evaluation of the lipid-lowering effect

The influence of antimalarials on lipids in systemic lupus erythematosus (SLE) has been identified in several studies but not in many prospective cohorts. The aim of this study was to longitudinally determine the effect of antimalarials on the lipoprotein profile in SLE. Patients and methods: Fasting total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL) and low-density lipoprotein cholesterol (LDL) plasma levels were determined at entry and after 3 months of hydroxychloroquine (HCQ) treatment in a longitudinal evaluation of 24 patients with SLE. Results: a significant decrease in TC (198 ± 33.7 vs. 183 ± 30.3 mg/dl, p = 0.023) and LDL levels (117 ± 31.3 vs. 101 ± 26.2 mg/dl, p = 0.023) were detected after the 3 months of HCQ therapy. The reduction of 7.6% in TC ( p = 0.055) and 13.7% in LDL levels ( p = 0.036) determined a significant decrease in the frequency of dyslipidemia (26% vs. 12.5%, p = 0.013) after HCQ therapy. Conclusion: This longitudinal study demonstrated the beneficial effect of antimalarials on lipids in SLE since this therapy induced a reduction of atherogenic lipoproteins.

Prevalence of LDL atherogenic phenotype in patients with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematosus (SLE) are 5-8 times more likely to develop coronary heart disease than the general population. The aim of this study was to find out the prevalence of the small dense low-density lipoprotein (LDL) cholesterol particle in patients with SLE.

METHODS

We recruited 50 consecutive patients with SLE who had no evidence of hypertension or renal failure. Fifty age- and gender-matched healthy controls were also recruited. We measured serum lipid levels and LDL particle diameters by gradient gel electrophoresis in both patients and controls.

RESULTS

Patients with SLE had significant dyslipidemia, characterized by elevated plasma triglycerides, LDL cholesterol, Apoprotein B, triglyceride:high-density (HDL) lipoprotein cholesterol ratio, and decreased plasma concentrations of HDL cholesterol. The LDL particle size in SLE (24.8 ± 1.23 nm) was significantly (P < 0.01) smaller than that in controls (26.1 ± 1.31 nm). The prevalence of the LDL phenotype B (the atherogenic phenotype) was 52% in SLE but only 20% in healthy controls.

CONCLUSION

We conclude that the high prevalence of small dense LDL in SLE may contribute to the high incidence of coronary heart disease seen in this disorder.

Laboratory markers of cardiovascular risk in pediatric SLE: the APPLE baseline cohort

As part of the Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE) Trial, a prospective multicenter cohort of 221 children and adolescents with systemic lupus erythematosus (SLE) (mean age 15.7 years, 83% female) underwent baseline measurement of markers of cardiovascular risk, including fasting levels of high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), lipoprotein A (Lpa), homocysteine and high-sensitivity C-reactive protein (hs-CRP). A cross-sectional analysis of the baseline laboratory values and clinical characteristics of this cohort was performed. Univariable relationships between the cardiovascular markers of interest and clinical variables were assessed, followed by multivariable linear regression modeling. Mean levels of LDL, HDL, Lpa, TG, hs-CRP and homocysteine were in the normal or borderline ranges. In multivariable analysis, increased Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), prednisone dose, and hypertension (HTN) were independently associated with higher LDL levels. Higher hs-CRP and creatinine clearance were independently related to lower HDL levels. Higher body mass index (BMI), prednisone dose, and homocysteine levels were independently associated with higher TG levels. Only Hispanic or non-White status predicted higher Lpa levels. Proteinuria, higher TG and lower creatinine clearance were independently associated with higher homocysteine levels, while use of multivitamin with folate predicted lower homocysteine levels. Higher BMI, lower HDL, and longer SLE disease duration, but not SLEDAI, were independently associated with higher hs-CRP levels. The R(2) for these models ranged from 7% to 23%. SLE disease activity as measured by the SLEDAI was associated only with higher LDL levels and not with hs-CRP. Markers of renal injury (HTN, proteinuria, and creatinine clearance) were independently associated with levels of LDL, HDL, and homocysteine, highlighting the importance of renal status in the cardiovascular health of children and adolescents with SLE. Future longitudinal analysis of the APPLE cohort is needed to further examine these relationships.

Increased risk of death in pediatric and adult patients with ESRD secondary to lupus

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can cause significant kidney disease. Our goal was to assess the relative mortality risk associated with SLE in pediatric and adult populations with end-stage renal disease (ESRD) maintained on hemodialysis (HD). We performed Kaplan-Meier survival analysis from data collected by the United States Renal Data System (USRDS) in strata of pediatric and adult patients. This file includes data on all Medicare-reimbursed renal replacement patients. Cox proportional hazard models were used to assess mortality after adjusting for race and gender. Subjects were censored at transplantation or at end of follow-up. Pediatric patients with ESRD secondary to SLE had a 2-fold increased risk of death compared with other pediatric patients with ESRD (hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.5-3.7). Adult patients with ESRD secondary to SLE were also at increased risk of death compared with other adult patients (HR: 1.7, 95% CI: 1.2-2.7). The most common causes of death in both pediatric and adult patients with SLE were cardiovascular disease and cardiac arrest. Our study demonstrates that there is a significant increase in mortality secondary to cardiovascular disease in pediatric and adult patients with ESRD secondary to SLE. Patients with ESRD secondary to SLE may need aggressive monitoring for traditional risk factors for atherosclerosis and the diagnosis of SLE alone may be an independent risk factor for death in patients with ESRD.

Review on anti-lipoprotein lipase antibodies

Lipoprotein lipase (LPL) is a member of the lipase family, and LPL is known to hydrolyze triglyceride molecules found in lipoprotein particles. Understanding the pathogenesis of atherosclerosis in autoimmune diseases, particularly systemic lupus erythematosus (SLE), is vital to reduce morbidity and mortality of this disease. It is now recognized that SLE has a particular pattern of dyslipoproteinemia characterized by low HDL levels and increased triglycerides, which is aggravated by flare. Antilipoprotein lipase (anti-LPL) antibodies have been recently described in rheumatic diseases, mainly in SLE and systemic sclerosis (SSc). Several studies have reported a close link between antibodies, inflammation and lipoprotein levels and an increased risk of cardiovascular damage in this particular group of patients. These studies have emphasized the importance of rigorous clinical control of disease activity and prevention of cardiovascular risk factors. This review summarized the studies that have discussed the presence of anti-LPL in rheumatic diseases and other conditions and analyzed the importance of this antibody in the complex atherosclerotic process in autoimmune diseases.

Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus?

Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.

Energy regulation and neuroendocrine-immune control in chronic inflammatory diseases

Energy regulation (EnR) is most important for homoeostatic regulation of physiological processes. Neuroendocrine pathways are involved in EnR. We can separate factors that provide energy-rich fuels to stores [parasympathetic nervous system (PSNS), insulin, insulin-like growth factor-1, oestrogens, androgens and osteocalcin] and those that provide energy-rich substrates to consumers [sympathetic nervous system (SNS), hypothalamic-pituitary-adrenal axis, thyroid hormones, glucagon and growth hormone]. In chronic inflammatory diseases (CIDs), balanced energy-rich fuel allocation to stores and consumers, normally aligned with circadian rhythms, is largely disturbed due to the vast fuel consumption of an activated immune system (up to 2000 kJ day(-1)). Proinflammatory cytokines such as tumour necrosis factor or interleukins 1beta and 6, circulating activated immune cells and sensory nerve fibres signal immune activation to the rest of the body. This signal is an appeal for energy-rich fuels as regulators are switched on to supply energy-rich fuels ('energy appeal reaction'). During evolution, adequate EnR evolved to cope with nonlife-threatening diseases, not with CIDs (huge negative selection pressure and reduced reproduction). Thus, EnR is inadequate in CIDs leading to many abnormalities, including sickness behaviour, anorexia, hypovitaminosis D, cachexia, cachectic obesity, insulin resistance, hyperinsulinaemia, dyslipidaemia, fat deposits near inflamed tissue, hypoandrogenaemia, mild hypercortisolaemia, activation of the SNS (hypertension), CID-related anaemia and osteopenia. Many of these conditions can contribute to the metabolic syndrome. These signs and symptoms become comprehensible in the context of an exaggerated call for energy-rich fuels by the immune system. We propose that the presented pathophysiological framework may lead to new therapeutical approaches and to a better understanding of CID sequence.

What's new in paediatric SLE?

Although more commonly presenting in adulthood, approximately 15-20% of systemic lupus erythematosus (SLE) cases occur before age 16 years. Unfortunately, SLE is usually more severe when presenting in childhood, and frequently involves vital organs such as the kidney. Over the past several decades, mortality rates have dropped, largely due to earlier diagnosis, improved management of the SLE and improved general medical care to reduce infection. Treatment strategies for nephritis in children is largely adopted from experience in adults, and the recent advances in therapeutic options for adults have brought new treatment to children. However, determining efficacy is difficult due to the absence of clinical trial data. Furthermore, determination of safety in a developing child or adolescent cannot be extrapolated from adult studies. As survival has improved, numerous secondary complications have emerged, including early atherosclerosis. As for adults with SLE, it is generally accepted that atherogenesis in SLE results from both disease- and treatment-related factors. Most surprising is that persons with childhood-onset SLE can develop myocardial ischaemia as early as 20-30 years of age. Better understanding of the pathogenesis and development of preventative strategies is needed to ensure that these young people do not succumb to atherosclerosis instead of to SLE.

Risk Factors for Development of Coronary Artery Disease in Women with Systemic Lupus Erythematosus

Objective.

To ascertain coronary artery disease (CAD) outcomes and predictive factors in a prospective study of patients with systemic lupus erythematosus (SLE) and matched healthy controls.

Methods.

SLE patients and non-SLE age-matched controls without a history of CAD were recruited into a prospective study between 1997 and 1999. CAD events were assessed at clinic visit for SLE patients and through telephone interview and chart review for controls. All events were verified with patient medical records.

Results.

Followup information was available on 237 controls and 241 SLE patients. The mean followup time was 7.2 years. Univariate analyses identified age and postmenopausal status as predictors of CAD in both the groups. Sedentary lifestyle, hypertension, the presence of metabolic syndrome, and the number of Framingham risk factors were predictive in the control group only. The 10-year risk of CAD score was predictive in both groups but was not as marked in the SLE group as in the controls. None of the lipid subfractions were predictive for CAD in the SLE group, whereas in the controls, a high triglyceride level ≥ 2.8 was predictive. Time-to-event multivariate analysis for CAD in all subjects revealed SLE itself, older age, and triglycerides ≥ 2.8 to be highly predictive for CAD.

Conclusion.

In a prospective study of patients with SLE and matched controls followed over a median of 8 years, patients with SLE developed significantly more CAD events than controls. Accounting for demographic variability, CAD risk factors, and lipid factors, SLE is an independent risk factor for the development of CAD.

Body composition, lipid and lipoprotein levels in childhood‐onset systemic lupus erythematosus

OBJECTIVES

Systemic inflammation, corticosteroid therapy, and reduced physical activity are risk factors for altered body composition in patients with systemic lupus erythematosus (SLE). The aim of this study was to assess whether body composition differs between childhood-onset SLE patients and healthy controls, and to investigate the impact of disease characteristics and lifestyle factors on body fat mass, serum lipids, and lipoproteins.

METHODS

Fat mass and lean tissue mass were measured in a cross-sectional study of 68 childhood-onset SLE patients and 68 matched healthy controls by dual-energy X-ray absorptiometry (DXA). The influence of disease, glucocorticosteroids, disease activity and severity, physical activity, and dietary intake on fat mass was evaluated by multiple linear regression analysis. Serum lipid and lipoprotein levels were measured.

RESULTS

Patients had a significantly higher fat mass [mean (SD) 35.3 (10.8) vs. 30.9 (11.1)%; p = 0.024] and lower lean mass [39.7 (9.8) vs. 44.4 (1.5) kg; p = 0.003] than controls. Corticosteroid use and the disease itself were significant independent predictors of greater fat mass, while disease activity, physical activity, and dietary intake had only a minor influence. Mean high density lipoprotein (HDL) cholesterol and apolipoprotein A1 (apo A1) levels were significantly lower (p<0.001), and the mean apo B/apo A1 ratio significantly higher (p = 0.004), in patients than in controls.

CONCLUSION

Childhood-onset SLE patients had a higher fat mass and lower lean mass than healthy controls and corticosteroid use was an independent predictor of increased fat mass. Patients had a more proatherogenic lipid profile, which will contribute to the increased risk of coronary heart disease in SLE patients.

Changes in Lipid Profile Between Flare and Remission of Patients with Systemic Lupus Erythematosus: A Prospective Study

Objective.

To determine the lipid profile of patients with systemic lupus erythematosus (SLE) according to the disease activity, and to calculate the percentage of patients that diverged from optimal values.

Methods.

Serum was collected from 52 patients with SLE at flare and at remission. SLE disease activity was measured by using the SLE Disease Activity Index (SLEDAI). Clinical and biological measures were evaluated in both situations. Total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), low-density lipoprotein cholesterol (LDLC), and triglyceride (TG) levels were analyzed after overnight fasting. We also calculated the atherogenic ratios of TC/HDLC and LDLC/HDLC.

Results.

SLE patients had significantly higher median TC/HDLC and LDLC/HDLC ratios at flare than during remission: 4.5 ± 1.5 versus 3.9 ± 1.0 (p = 0.007) and 2.7 ± 1.1 versus 2.4 ± 0.8 (p = 0.015), respectively. The differences persisted after adjustments based on kidney disease and treatment but not after adjusting by creatinine clearance < 60 ml/min/1.73 m2in remission. The variation between flare and remission of the percentage of SLE patients with high-risk levels of lipid profile to desirable values, and vice versa, was statistically significant for the LDLC/HDLC ratio (9 vs 1; p = 0.021).

Conclusion.

Our results reflect a higher risk of atherosclerosis phenomena in SLE patients during flare than during clinical remission. This might explain the propensity to develop coronary heart disease in patients with SLE.

Metabolic syndrome in patients with systemic lupus erythematosus from Southern Spain

The aim of this cross-sectional study was to establish the frequency, phenotype and characteristics of metabolic syndrome (MS), as defined by the Adult Treatment Panel III, in a cohort of patients with systemic lupus erythematosus (SLE) and its possible association with cardiovascular diseases (CVD). A total of 160 patients with SLE and 245 age, sex, educational level and ethnically matched controls were included. Association with cardiovascular risk factors, SLE features, treatment of SLE and history of CVD were assessed in patients with SLE and controls with and without MS. MS was non-significantly increased in patients with SLE (20%) compared with controls (13%; P = 0.083). It was more commonly observed in patients with SLE ≤40 years old (15.8%) than in controls of the same age group (4.2%; P < 0.001). The mean number of MS criteria was significantly higher among patients with SLE than in controls. The frequency of CVD was also 28-fold higher among patients with SLE (11.3%) than in controls (0.4%). SLE with MS presented higher levels of inflammatory markers than SLE without MS. In a multivariate analysis, educational level, serum triglycerides, HDL-cholesterol and C3 serum levels and hydroxychloroquine use were independently associated with MS.

Predictors of acquired lipodystrophy in juvenile-onset dermatomyositis and a gradient of severity

We describe the clinical features of 28 patients with juvenile dermatomyositis (JDM) and 1 patient with adult-onset dermatomyositis (DM), all of whom developed lipodystrophy (LD) that could be categorized into 1 of 3 phenotypes, generalized, partial, or focal, based on the pattern of fat loss distribution. LD onset was often delayed, beginning a median of 4.6 years after diagnosis of DM. Calcinosis, muscle atrophy, joint contractures, and facial rash were DM disease features found to be associated with LD. Panniculitis was associated with focal lipoatrophy while the anti-p155 autoantibody, a newly described myositis-associated autoantibody, was more associated with generalized LD. Specific LD features such as acanthosis nigricans, hirsutism, fat redistribution, and steatosis/nonalcoholic steatohepatitis were frequent in patients with LD, in a gradient of frequency and severity among the 3 sub-phenotypes. Metabolic studies frequently revealed insulin resistance and hypertriglyceridemia in patients with generalized and partial LD. Regional fat loss from the thighs, with relative sparing of fat loss from the medial thighs, was more frequent in generalized than in partial LD and absent from DM patients without LD. Cytokine polymorphisms, the C3 nephritic factor, insulin receptor antibodies, and lamin mutations did not appear to play a pathogenic role in the development of LD in our patients. LD is an under-recognized sequela of JDM, and certain DM patients with a severe, prolonged clinical course and a high frequency of calcinosis appear to be at greater risk for the development of this complication. High-risk JDM patients should be screened for metabolic abnormalities, which are common in generalized and partial LD and result in much of the LD-associated morbidity. Further study is warranted to investigate the pathogenesis of acquired LD in patients with DM.

Management of dyslipidemia in children and adolescents with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an independent risk factor for atherosclerosis, placing children and adolescents with SLE at great risk for developing cardiovascular sequelae, including myocardial infarction, in adulthood. Dyslipidemia and other traditional cardiac risk factors occur frequently in pediatric SLE and are often under-recognized and under-treated. Two dyslipidemia patterns are evident in pediatric SLE. Active disease is characterized by elevated triglycerides (TG) and low high density lipoprotein (HDL). With SLE treatment HDL and TG often normalize, while total cholesterol and low density lipoprotein (LDL) rise. The complex pathophysiology of dyslipidemia in SLE involves cytokines, autoantibodies, disease activity, medications, diet, and physical activity level, as well as other factors. Routine screening for dyslipidemia with fasting lipid profiles is indicated for children and adolescents with SLE. If lipoprotein levels are abnormal, first line therapy involves diet and exercise interventions for a minimum of six months. For persistent dyslipidemia, several pharmacologic therapies are available. Hydroxychloroquine, a common treatment for SLE, can improve lipid profiles and should be considered for all patients with SLE. Statins and bile acid sequestrants are typically added first for dyslipidemia, while niacin and fibrates are reserved for refractory disease and optimally prescribed in a multidisciplinary lipid clinic. Future research is needed to further illuminate the mechanisms of dyslipidemia in pediatric SLE with well designed clinical trials to determine the safest and most effective interventions to correct lipid profiles and prevent atherosclerosis.

Chloroquine increases low-density lipoprotein removal from plasma in systemic lupus patients

Low-density lipoprotein (LDL) pathway in systemic lupus erythematosus (SLE) patients taking chloroquine diphosphate (CDP) was evaluated through the kinetic behavior of a radioactive cholesterol-rich nanoemulsion (LDE) that resembles the LDL lipidic structure. LDE was labeled with (14)C-cholesteryl ester ((14)C-CE), then IV injected in inactive female SLE patients: 10 taking CDP (CDP), 10 without therapy (NO THERAPY); and 10 normal subjects (CONTROL). Groups were age-matched and followed rigorous selection criteria of conditions that interfere in the lipid profile. Blood samples were collected in pre-established intervals after infusion for radioactivity measurement. Fasting lipoproteins were determined in the beginning of kinetic studies. Fractional clearance rate (FCR) of (14)C-CE was significantly different in the three groups (P = 0.03). In fact, a greater FCR of (14)C-CE was observed in CDP compared to NO THERAPY (0.076 +/- 0.037 versus 0.046 +/- 0.021 h(-1); P < 0.05) and to CONTROL (0.0516 +/- 0.0125 h(-1); P < 0.05). Accordingly, a significant lower total and LDL cholesterol were observed in CDP (156 +/- 16 and 88 +/- 16 mg/dl) compared to NO THERAPY (174 +/- 15 and 108 +/- 17 mg/dl; P < 0.05) and to CONTROL (200 +/- 24 and 118 +/- 23 mg/dl; P < 0.05). In contrast, no difference in (FCR) of (14)C-CE of NO THERAPY and CONTROL groups was observed. This is the first in vivo demonstration that LDE removal by LDL receptor from plasma is increased in SLE patients taking CDP with a consequent beneficial decrease in LDL-c levels.

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Homocysteine and lipid profile in children with Juvenile Idiopathic Arthritis

BACKGROUND

An increased concentration of plasma homocysteine (Hcy) has toxic effects on vascular endothelium. This seems to be a risk factor of cardiovascular disease, premature stroke and venous thrombosis. The risk is higher in coincidence with other factors like chronic diseases and familiar hypercholesterolemia. The aim of our study was to evaluate plasma Hcy concentration in patients with juvenile idiopathic arthritis (JIA) and its correlation with methotrexate (MTX) therapy, serum folate and B12 vitamin, and hyperlipidemia.

METHODS

Fifty-one patients (37 females; mean age 11.3 years, range 2.3-17 years) with JIA and 52 healthy controls (42 females; mean age 12.5 years; range 3-18 years) were included in the study. Thirty-two patients were using weekly MTX (mean doses: 0.1-1 mg/kg). For statistical analysis both JIA and control groups were distributed in three subgroups according to age (3 - 7, 8 - 12 and 13 - 18 years). The laboratory investigation included measurement of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasma Hcy, serum folate, vitamin B12, triglycerides, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL). For data analysis, we considered raised Hcy values >or= 12.56 micromol/L, which corresponds to the 90th percentile observed in the control group.

RESULTS

The mean plasma Hcy concentration was 9.3 +/- 3.16 micromol/L in JIA patients and 8.9 +/- 2.42 micromol/L in healthy controls (p = 0.615). Higher concentration of Hcy was observed in the subgroup of 13 - 18 years (patients and controls, p < 0.001). We did not find correlation between MTX use and plasma Hcy concentration. With regard to vitamin B12 concentration, we detected normal values in both patients and controls while serum folate concentration was higher in patients (p < 0.001). With regard to the lipidogram, lower concentration of HDL was found in patients (p = 0.007) and higher levels of VLDL (p = 0.014) and triglycerides (p = 0.001) were observed in controls. We did not observe correlation among plasma Hcy concentration, clinical findings, ESR and CRP.

CONCLUSION

JIA patients do not present significant increased concentration of Hcy despite the use of MTX, probably due to the folate supplementation. The mild abnormalities in the lipidogram may reflect a current concern with diet and health.

Longitudinal examination of lipid profiles in pediatric systemic lupus erythematosus

OBJECTIVE

Lipid abnormalities in patients with systemic lupus erythematosus (SLE) are common and are likely to be one of the causes of premature atherosclerosis in these patients. This study was undertaken to serially examine the lipid profile in pediatric patients with SLE to determine the roles of active disease and therapy in altering lipid levels.

METHODS

Serial lipid measurements were obtained in an inception cohort of 139 pediatric patients with SLE at the time of treatment with either a constant dose or differing doses of prednisone, and annually. The levels of cholesterol, triglycerides, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) were correlated with measures of disease activity and prednisone dose.

RESULTS

At the time of SLE diagnosis in this pediatric cohort, the mean values for all lipids were abnormal. With each reduction in prednisone dose, there was a statistically significant decrease in cholesterol and triglyceride levels (P < 0.001) but not HDL or LDL levels. Nephrotic-range proteinuria was associated with altered cholesterol, triglyceride, and LDL levels, whereas changes in HDL were more commonly associated with active nephritis. In the absence of nephrotic-range proteinuria, increases in prednisone dose were associated with increased levels of all lipids, including HDL.

CONCLUSION

Active SLE leads to a proatherogenic lipid profile. Levels of cholesterol and LDL were mainly associated with the dose of prednisone, and were abnormal only during very high disease activity. Triglyceride levels were mainly associated with proteinuria, while changes in HDL were associated with active SLE and a high dose of prednisone. Our results suggest that the lipid profile in pediatric SLE is the result of a complex interaction of disease manifestations and the effects of prednisone therapy.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Simvastatin treatment ameliorates autoimmune disease associated with accelerated atherosclerosis in a murine lupus model

Patients with systemic lupus erythematosus develop accelerated atherosclerosis independent of traditional risk factors. The 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors are widely prescribed for hyperlipidemia, but they also exhibit anti-inflammatory actions that appear to be independent of their suppressive actions on plasma cholesterol levels. In this study, we analyzed the effect of the HMG-CoA reductase inhibitor simvastatin on disease manifestations in gld.apoE-/- mice that lack functional Fas ligand and apolipoprotein E and exhibit accelerated atherosclerosis and aggravated lupus-like features. Wild-type, gld, apoE-/-, and gld.apoE-/- mice were maintained on a high cholesterol Western diet and received daily simvastatin (0.125 mg/kg) or saline for 12 wk. Serum cholesterol levels were unaffected by simvastatin treatment, but atherosclerotic lesion area was reduced in both apoE-/- and gld.apoE-/- mice treated with simvastatin. Simvastatin also reduced the lymphadenopathy, renal disease, and proinflammatory cytokine production seen in gld.apoE-/-, but not gld, mice. The immunomodulatory effects in gld.apoE-/- mice were associated with enhanced STAT6 and decreased STAT4 induction in submandibular lymph node cells. Along with reductions in serum TNF-alpha and IFN-gamma levels, there was also an increase in IL-4 and IL-10 transcript levels in lymph nodes. These data indicate that HMG-CoA reductase inhibitors ameliorate atherosclerosis and lupus-like autoimmunity independent of their cholesterol-lowering effects via a shift from a Th1 to a Th2 phenotype in the gld.apoE-/- model. Thus, the anti-inflammatory activities of statins may have utility for the treatment of both autoimmunity and atherosclerosis in patients with systemic lupus erythematosus.

Association between serum total cholesterol level and renal outcome in systemic lupus erythematosus

OBJECTIVE

To determine whether an elevated serum total cholesterol level in a first-available sample obtained at a systemic lupus erythematosus (SLE) clinic is associated with worse renal outcome in patients with SLE.

METHODS

Survival analysis methods were used on prospectively gathered data on 1,060 patients with SLE who were registered in the University of Toronto Lupus Databank. The effect of total cholesterol and 15 additional variables on the outcomes of renal deterioration, end-stage renal disease (ESRD), and death was assessed using Cox proportional hazards methods.

RESULTS

In 474 (45%) of the 1,060 patients, the total cholesterol level exceeded 5.2 mmoles/liter. In the entire study group, the median total cholesterol level was 5.1 mmoles/liter (range 1.6-17.1). During a mean followup period of 8.8 years, 93 patients (9%) experienced renal deterioration, 42 patients (4%) had ESRD, and 161 deaths occurred, 48 (30%) of which were associated with renal dysfunction (renal death), and 113 (70%) of which were not associated with renal dysfunction (nonrenal death). Kaplan-Meier survival estimates for each outcome were statistically significantly different between patients with normal versus those with elevated total cholesterol levels (cutoff 5.2 mmoles/ liter), with a worse outcome observed among those with an elevated total cholesterol concentration. In multivariate analyses, total cholesterol level (hazard ratio [HR] 1.17, 95 confidence interval [95% CI] 1.01-1.36), serum creatinine level (HR 1.06, 95% CI 1.04-1.07), proteinuria (HR 2.44, 95% CI 1.25-4.76), the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (HR 1.44, 95% CI 1.16-1.80), and corticosteroid dose (HR 1.01, 95% CI 1.00-1.02) were associated with renal deterioration. Significant predictors of ESRD were baseline proteinuria (HR 6.24, 95% CI 1.96-19.88) and serum creatinine level (HR 1.15, 95% CI 1.08-1.22). The total cholesterol level was correlated with death (HR 1.20, 95% CI 1.11-1.29), retaining statistical significance for renal death (HR 1.33, 95% CI 1.20-1.47) but not for nonrenal death (HR 1.12, 95% CI 0.99-1.25).

CONCLUSION

Those results indicate that an elevated serum total cholesterol level in a first-available sample obtained at an SLE clinic is associated with adverse renal outcomes and mortality.

Dyslipoproteinemia during the active course of systemic lupus erythematosus in association with anti-double-stranded DNA (anti-dsDNA) antibodies

Dyslipoproteinemia is common in lupus patients. In this study, we investigated the pattern of dyslipoproteinemia in the course of active systemic lupus erythematosus (SLE) in possible association with anti-double-stranded DNA (anti-dsDNA) antibodies. Forty-six lupus patients under 45 years old who fulfilled the American College of Rheumatology revised criteria for the classification of SLE were selected. The exclusion criteria were renal failure, nephrotic syndrome, thyroid or liver disease, diabetes mellitus, obesity, pregnancy and taking drugs that induce dyslipidemia. Disease activity was measured by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Comparison of the lipid profiles, between active and inactive groups determined high levels of serum TG and VLDL and low levels of serum HDL in active group in comparison with inactive group (P < 0.05). The results indicated that the levels of TG and VLDL were significantly elevated in the patients with positive anti-dsDNA (P < 0.05). Although, the mean of serum HDL levels was also lower in patients with positive anti-dsDNA, the difference was not significant. This pattern of dyslipoproteinemia in active SLE may be associated with the autoimmune mechanisms especially in relation to the presence of anti-dsDNA antibodies.