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Ankawi G, Tangirala N, Jesudason S, Hladunewich MA. Pregnancy in Patients Receiving Home Dialysis. Clin J Am Soc Nephrol 2024:01277230-990000000-00350. [PMID: 38285469 DOI: 10.2215/cjn.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/24/2024] [Indexed: 01/30/2024]
Abstract
Pregnancy is an important goal for many women with CKD or kidney failure, but important barriers exist, particularly as CKD stage progresses. Women with advanced CKD often have a limited fertility window and may miss their opportunity for a pregnancy if advised to defer until after kidney transplantation. Pregnancy rates in women with advanced kidney failure or receiving dialysis remain low, and despite the improved outcomes in recent years, these pregnancies remain high risk for both mother and baby with high rates of preterm birth due to both maternal and fetal complications. However, with increased experience and advances in models of care, this paradigm may be changing. Intensive hemodialysis regimens have been shown to improve both fertility and live birth rates. Increasing dialysis intensity and individualizing dialysis prescription to residual renal function, to achieve highly efficient clearances, has resulted in improved live birth rates, longer gestations, and higher birth weights. Intensive hemodialysis regimens, particularly nocturnal and home-based dialysis, are therefore a potential option for women with kidney failure desiring pregnancy. Global initiatives for the promotion and uptake of home-based dialysis are gaining momentum and may have advantages in this unique patient population. In this article, we review the epidemiology and outcomes of pregnancy in hemodialysis and peritoneal dialysis recipients. We discuss the role home-based therapies may play in helping women achieve more successful pregnancies and outline the principles and practicalities of management of dialysis in pregnancy with a focus on delivery of home modalities. The experience and perspectives of a patient are also shared.
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Affiliation(s)
- Ghada Ankawi
- Division of Nephrology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nishanta Tangirala
- Renal Department, Lyell McEwen Hospital, Adelaide, South Australia, Australia
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital and School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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CT-IGFBP-4 as a Predictive Novel Biomarker of Ischemic Cardiovascular Events and Mortality: A Systematic Review. J Interv Cardiol 2022; 2022:1816504. [PMID: 36051380 PMCID: PMC9420648 DOI: 10.1155/2022/1816504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Methods The electronic databases PubMed, medRxiv, ScienceDirect, and Google Scholar were searched for relevant literature from inception to the 10th of December, 2021. Thus, retrieved literature was screened by title and abstract, followed by full-text screening based on the eligibility criteria. The risk of bias was accessed using the quality in prognostic studies (QUIPSs) tool. The data on cardiovascular outcomes about CT-IGFBP-4 levels were studied and the results were synthesized. Results Five studies with a total of 1,417 participants were included in our study. The studies reported a low risk of bias. The mean age of the participants was 66.14 and more than 65% were males. Elevated CT-IGFBP-4 levels were associated with poor cardiovascular outcomes and increased mortality in severely ill patients. In contrast, there were no significant findings in the case of stable patients. Sandwich ELISA using lithium-heparin plasma provided a better detection limit of 0.15 ng/ml, low cross-reactivity (<2%), and generated linear results between 12 and 500 ng/ml. Conclusion CT-IGFBP-4 is an efficient biomarker for the prediction of MACE and mortality in patients with severe ischemic cardiovascular events.
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Chen FC, Xu YC, Zhang ZC. Multi-biomarker strategy for prediction of myocardial dysfunction and mortality in sepsis. J Zhejiang Univ Sci B 2021; 21:537-548. [PMID: 32633108 DOI: 10.1631/jzus.b2000049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was to evaluate the feasibility of using the multi-biomarker strategy for the prediction of sepsis-induced myocardial dysfunction (SIMD) and mortality in septic patients. METHODS Brain natriuretic peptide (BNP), cardiac troponin I (cTnI), and heart-type fatty acid-binding protein (h-FABP) in 147 septic patients were assayed within 6 h after admission. We also determined the plasma levels of myeloperoxidase (MPO) and pregnancy-associated plasma protein-A (PAPP-A). The receiver operating characteristic (ROC) curve was used to assess the best cutoff values of various single-biomarkers for the diagnosis of SIMD and the prediction of mortality. Also, the ROC curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) indices were used to evaluate the feasibility of using multi-biomarkers to predict SIMD and mortality. RESULTS Our statistics revealed that only h-FABP independently predicted SIMD (P<0.05). The addition of MPO and cTnI to h-FABP for SIMD prediction provided an NRI of 18.7% (P=0.025) and IDI of 3.3% (P=0.033). However, the addition of MPO or cTnI to h-FABP did not significantly improve the predictive ability of h-FABP to SIMD, as evidenced by the area under the curve (AUC), NRI, and IDI (all P>0.05). A history of shock and MPO were independent predictors of mortality in septic patients (both P<0.05). The addition of PAPP-A and h-FABP to MPO resulted in a mortality prediction with NRI of 25.5% (P=0.013) and IDI of 2.9% (P=0.045). However, this study revealed that the addition of h-FABP or PAPP-A to MPO did not significantly improve the ability to predict mortality, as evidenced by the AUC, NRI, and IDI (all P>0.05). CONCLUSIONS The findings of this study indicate that a sensitive and specific strategy for early diagnosis of SIMD and mortality prediction in sepsis should incorporate three biomarkers.
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Affiliation(s)
- Fa-Chao Chen
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yin-Chuan Xu
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhao-Cai Zhang
- Intensive Care Unit, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
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Abstract
Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.
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Tuunainen E, Lund J, Danielsson J, Pietilä P, Wahlroos V, Pudge K, Leinonen I, Porela P, Ilva T, Lepäntalo M, Pulkki K, Voipio-Pulkki LM, Pettersson K, Wittfooth S. Direct Immunoassay for Free Pregnancy-Associated Plasma Protein A (PAPP-A). J Appl Lab Med 2019; 3:438-449. [DOI: 10.1373/jalm.2018.026096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/27/2018] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Pregnancy-associated plasma protein A (PAPP-A), especially in its noncomplexed form (fPAPP-A), is linked to vulnerable atherosclerotic plaques and risk of cardiac events. An assay for sensitive detection of fPAPP-A has been lacking. Our aim was to develop and validate a direct fPAPP-A assay to meet this need.
Methods
Monoclonal antibodies binding exclusively fPAPP-A were produced by immunizing mice with recombinant PAPP-A. In the optimized immunoassay, we used an fPAPP-A–specific capture antibody together with a lanthanide-chelate–labeled monoclonal antibody recognizing all PAPP-A forms. The assay was evaluated with CLSI guidelines and compared to a 2-assay subtractive fPAPP-A approach. Clinical performance was assessed with acute coronary syndrome patients.
Results
The limits of detection and quantitation were 0.4 mIU/L and 1.3 mIU/L, respectively, and the assay was linear up to 1000 mIU/L (R2 = 0.999). Both serum and heparin plasma were suitable matrices, and the complexed form of PAPP-A caused no significant interference. Correlation between the developed assay and the 2-assay approach was fair (Pearson's r = 0.819). Median concentration in healthy individuals was 1.0 mIU/L. fPAPP-A concentration was higher in patients who had myocardial infarction or died during the 1-year follow-up period than in those who did not (1.13 mIU/L vs 0.82 mIU/L, P = 0.008, model adjusted with age and sex). fPAPP-A measured with this direct assay predicted this end point as well as (follow-up 1 year) or better (30 days) than the 2-assay fPAPP-A alone or in combination with cTnI.
Conclusions
The new assay enables sensitive and reliable measurement of low cardiac-related fPAPP-A concentrations from blood samples.
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Affiliation(s)
- Emilia Tuunainen
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Juha Lund
- Heart Center, Turku University Hospital, Turku, Finland
| | - Joanna Danielsson
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Pirjo Pietilä
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Veikko Wahlroos
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Keira Pudge
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Isto Leinonen
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Pekka Porela
- Heart Center, Turku University Hospital, Turku, Finland
| | - Tuomo Ilva
- Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
| | - Mauri Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Kari Pulkki
- Laboratory Division, Turku University Hospital, Turku, Finland
| | | | - Kim Pettersson
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
| | - Saara Wittfooth
- Department of Biochemistry/Biotechnology, University of Turku, Turku, Finland
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Tuunainen E, Maaniitty T, Knuuti J, Pettersson K, Wittfooth S, Saraste A. Free PAPP-A as a biomarker: heparin-induced release is not related to coronary atherosclerotic burden. Clin Chem Lab Med 2019; 57:e155-e158. [DOI: 10.1515/cclm-2018-1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/18/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Emilia Tuunainen
- Department of Biochemistry/Biotechnology , University of Turku , Turku , Finland
| | | | - Juhani Knuuti
- Turku PET Centre , University of Turku , Turku , Finland
| | - Kim Pettersson
- Department of Biochemistry/Biotechnology , University of Turku , Turku , Finland
| | - Saara Wittfooth
- Department of Biochemistry/Biotechnology , University of Turku , Turku , Finland
| | - Antti Saraste
- Turku PET Centre and Heart Center , University of Turku and Turku University Hospital , Turku , Finland
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Abstract
Pregnancy is uncommon in women with end-stage renal disease (ESRD). Fertility rates are low in women on dialysis, and physicians still frequently counsel women with ESRD against pregnancy. Advancements in the delivery of dialysis and obstetric care have led to improved live birth rates in women on dialysis, so pregnancy for young women with ESRD is now more feasible and safer. However, these pregnancies remain high-risk for both maternal and fetal complications, necessitating experienced multidisciplinary care. In this article, we review fertility issues in women with ESRD, discuss pregnancy outcomes in women on dialysis, and provide an approach for management of pregnant women with ESRD.
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Affiliation(s)
- Jessica Tangren
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Molly Nadel
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Men J, Guo J, Zhou W, Dong N, Pang X, Gao B. Preparation of cationic functional polymer poly(Acryloxyethyltrimethyl ammonium chloride)/SiO2 and its adsorption characteristics for heparin. KOREAN J CHEM ENG 2017. [DOI: 10.1007/s11814-017-0131-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Al-Mohaissen MA, Carere RG, Mancini GBJ, Humphries KH, Whalen BA, Lee T, Scheuermeyer FX, Ignaszewski AP. A Plaque Disruption Index Identifies Patients with Non-STE-Type 1 Myocardial Infarction within 24 Hours of Troponin Positivity. PLoS One 2016; 11:e0164315. [PMID: 27711184 PMCID: PMC5053518 DOI: 10.1371/journal.pone.0164315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/22/2016] [Indexed: 12/11/2022] Open
Abstract
Background Markers of plaque destabilization and disruption may have a role in identifying non-STE- type 1 Myocardial Infarction in patients presenting with troponin elevation. We hypothesized that a plaque disruption index (PDI) derived from multiple biomarkers and measured within 24 hours from the first detectable troponin in patients with acute non-STE- type 1 MI (NSTEMI-A) will confirm the diagnosis and identify these patients with higher specificity when compared to individual markers and coronary angiography. Methods We examined 4 biomarkers of plaque destabilization and disruption: myeloperoxidase (MPO), high-sensitivity interleukin-6, myeloid-related protein 8/14 (MRP8/14) and pregnancy-associated plasma protein-A (PAPP-A) in 83 consecutive patients in 4 groups: stable non-obstructive coronary artery disease (CAD), stable obstructive CAD, NSTEMI-A (enrolled within 24 hours of troponin positivity), and NSTEMI-L (Late presentation NSTEMI, enrolled beyond the 24 hour limit). The PDI was calculated and the patients’ coronary angiograms were reviewed for evidence of plaque disruption. The diagnostic performance of the PDI and angiography were compared. Results Compared to other biomarkers, MPO had the highest specificity (83%) for NSTEMI-A diagnosis (P<0.05). The PDI computed from PAPP-A, MRP8/14 and MPO was higher in NSTEMI-A patients compared to the other three groups (p<0.001) and had the highest diagnostic specificity (87%) with 79% sensitivity and 86% accuracy, which were higher compared to those obtained with MPO, but did not reach statistical significance (P>0.05 for all comparisons). The PDI had higher specificity and accuracy for NSTEMI-A diagnosis compared to coronary angiography (P<0.05). Conclusions A PDI measured within 24 hour of troponin positivity has potential to identify subjects with acute Non-ST-elevation type 1 MI. Additional evidence using other marker combinations and investigation in a sufficiently large non-selected cohort is warranted to establish the diagnostic accuracy of the PDI and its potential role in differentiating type 1 and type 2 MI in patients presenting with troponin elevation of uncertain etiology.
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Affiliation(s)
- Maha A. Al-Mohaissen
- Department of Clinical Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
- * E-mail:
| | - Ronald G. Carere
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - G. B. John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karin H. Humphries
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Beth A. Whalen
- Centre for Heart Lung Innovation, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Frank X. Scheuermeyer
- Department of Emergency Medicine, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Andrew P. Ignaszewski
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
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10
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Fitzpatrick A, Mohammadi F, Jesudason S. Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby. Int J Womens Health 2016; 8:273-85. [PMID: 27471410 PMCID: PMC4948734 DOI: 10.2147/ijwh.s76819] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.
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Affiliation(s)
| | - Fadak Mohammadi
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital
| | - Shilpanjali Jesudason
- Women's and Babies Division, Women's and Children's Hospital; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital; Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Abstract
Pregnancy in women with end stage renal disease on renal replacement therapy is uncommon due to the physiologic changes associated with renal failure as well as the complexities and risk involved in managing these patients. As most of these women had long periods of illness with chronic kidney disease, the effects of their chronic illness together with the current societal trends to delay child bearing to a more advanced maternal age can hamper fertility. For those able to conceive, intensified hemodialysis (HD), through longer and/or more frequent dialysis sessions, offers improved maternal and neonatal outcomes. Intensified HD is most conveniently offered in the patient's home, where possible. This review expands the scope of the Implementing Hemodialysis in the Home website and associated supplement published previously in Hemodialysis International and includes information tailored to women of reproductive age. We describe the necessary counseling that women should receive before conception and before intensification of HD, and provide a detailed management strategy that includes nephrologic and obstetric care, should pregnancy occur.
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Affiliation(s)
- Michelle Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dori Schatell
- Executive Director, Medical Education Institute, Inc., Madison, Wisconsin, USA
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12
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Myocardial and Peripheral Ischemia Causes an Increase in Circulating Pregnancy-Associated Plasma Protein-A in Non-atherosclerotic, Non-heparinized Pigs. J Cardiovasc Transl Res 2015; 8:528-35. [PMID: 26443031 DOI: 10.1007/s12265-015-9656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/27/2015] [Indexed: 10/23/2022]
Abstract
The usefulness of circulating pregnancy-associated plasma protein-A (PAPP-A) as a biomarker for acute coronary syndrome (ACS) is widely debated. We used the pig as a model to assess PAPP-A dynamics in the setting of myocardial ischemia. Induction of myocardial ischemia by ligation of the left anterior descending (LAD) coronary artery caused a systemic rise in PAPP-A. However, the ischemic myocardium was excluded as the source of PAPP-A. Interestingly, induction of ischemia in peripheral tissues by ligation of the left femoral artery caused a systemic rise in PAPP-A originating from the left hind limb. This is the first study to demonstrate PAPP-A elevations in the absence of atherosclerosis or heparin during myocardial ischemia. Our findings thus add to the current discussion of the usefulness of PAPP-A as a biomarker for ACS.
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13
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Jespersen CHB, Vestergaard KR, Schou M, Teisner B, Goetze JP, Iversen K. Pregnancy-associated plasma protein-A and the vulnerable plaque. Biomark Med 2015; 8:1033-47. [PMID: 25343675 DOI: 10.2217/bmm.14.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
For more than a decade, pregnancy-associated plasma protein-A (PAPP-A) has been examined for its relation to acute coronary syndrome (ACS) and the vulnerable plaque. This review summarizes the current knowledge of plasma PAPP-A in relation to nonpregnant individuals focusing on patients with ACS, discusses its use as a possible biomarker for diagnosis and prognosis in ACS, briefly describes the challenges in different assay technologies and describes the effect of heparin administration on PAPP-A concentrations in plasma.
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14
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Konev AA, Smolyanova TI, Kharitonov AV, Serebryanaya DV, Kozlovsky SV, Kara AN, Feygina EE, Katrukha AG, Postnikov AB. Characterization of endogenously circulating IGFBP-4 fragments-Novel biomarkers for cardiac risk assessment. Clin Biochem 2015; 48:774-80. [PMID: 26025773 DOI: 10.1016/j.clinbiochem.2015.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/07/2015] [Accepted: 05/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent findings show that circulating N- and C-terminal fragments of IGF-binding protein-4 (NT-IGFBP-4 and CT-IGFBP-4) can be utilized as biomarkers for cardiac risk assessment in acute coronary syndrome (ACS) patients. The fragments are thought to be the products of pregnancy-associated plasma protein A (PAPP-A)-dependent proteolysis. Two immunoassays for the measurement of IGFBP-4 fragments have been proposed. However, properties of the endogenous IGFBP-4 fragments that could influence the performance of the immunoassays were still not investigated. METHODS NT- and CT-IGFBP-4 were extracted from pooled ACS plasma using affinity purification, and their concentrations were measured using sandwich immunoassays utilizing antibodies specific to their proteolytic neo-epitopes or internal epitopes. The extracted fragments were characterized by Western blots (WB) and mass-spectrometry. ACS plasma samples were analyzed by size exclusion chromatography (SEC). RESULTS Immunoassays utilizing the neo-epitope-specific and the internal epitope-specific antibodies measured equal concentrations of the analyte in the endogenous IGFBP-4 fragments preparations. Only the 18 kDa NT-IGFBP-4 and 14 kDa CT-IGFBP-4 were detected in the WB analysis. Using mass-spectrometry, peaks corresponding to intact non-truncated and non-modified NT-IGFBP-4 (14626 Da) and CT-IGFBP-4 (11346 Da) were observed. The absence of complexed forms of IGFBP-4 in patients' plasma was demonstrated using SEC. CONCLUSIONS Endogenous NT- and CT-IGFBP-4 from ACS patients' plasma correspond to the PAPP-A-derived IGFBP-4 fragments and do not undergo any truncation, modification, or complex formation in the patients' blood. Because of the demonstrated intact state of the circulating IGFBP-4 fragments, the neo-epitope-specific immunoassays perform reliably, allowing further clinical validation of these novel biomarkers.
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Affiliation(s)
- Alexey A Konev
- HyTest Ltd, Turku, Finland; School of Biology, Moscow State University, Moscow, Russia.
| | | | | | - Daria V Serebryanaya
- HyTest Ltd, Turku, Finland; School of Biology, Moscow State University, Moscow, Russia
| | | | - Andrey N Kara
- School of Biology, Moscow State University, Moscow, Russia
| | - Evgeniya E Feygina
- HyTest Ltd, Turku, Finland; School of Biology, Moscow State University, Moscow, Russia
| | - Alexey G Katrukha
- HyTest Ltd, Turku, Finland; School of Biology, Moscow State University, Moscow, Russia
| | - Alexander B Postnikov
- HyTest Ltd, Turku, Finland; School of Biology, Moscow State University, Moscow, Russia
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15
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The effect of heparin on pregnancy associated plasma protein-A concentration in healthy, non-pregnant individuals. Clin Biochem 2015; 48:757-61. [PMID: 25998835 DOI: 10.1016/j.clinbiochem.2015.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/05/2015] [Accepted: 05/11/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The objective of this study was to determine the differences in pregnancy associated plasma protein-A (PAPP-A) concentrations in heparin naive and heparin treated healthy men and non-pregnant women, to find a possible difference in different age groups, and to determine the response in PAPP-A concentration to repeated injections of unfractionated heparin. DESIGN AND METHODS Twenty-five healthy, non-pregnant volunteers divided into five groups (determined by gender and age) received 5000 IU unfractionated heparin intravenously. Five young men received an additional 5000 IU after 90 and 180 min. Blood samples to determine PAPP-A concentration and APTT were drawn at different time points. RESULTS Injection of heparin elicited increase in and rapid normalization of PAPP-A concentrations in all subjects. The group of 20-30-year-old never-pregnant women had lower responses than the individuals of the four other groups. The difference was not significant (p > 0.05). Repeated injections of heparin caused additional peaks in PAPP-A concentration of about the same sizes as the first peak. We observed an increase in time to normalization of PAPP-A concentration (from 75-90 min to 90-150 min) and APTT levels with repeated injections. CONCLUSIONS We observed a rapid normalization of PAPP-A. Our result has a great similarity to the half-life of unfractionated heparin. This result combined with the finding of equally sized peaks in PAPP-A concentration, and that all of this was found in healthy, non-pregnant individuals, suggests that heparin might compete for a binding-site on PAPP-A or with PAPP-A itself for a common receptor in healthy arterial vessels.
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16
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Hjortebjerg R, Lindberg S, Hoffmann S, Jensen JS, Oxvig C, Bjerre M, Frystyk J. PAPP-A and IGFBP-4 fragment levels in patients with ST-elevation myocardial infarction treated with heparin and PCI. Clin Biochem 2014; 48:322-8. [PMID: 25489725 DOI: 10.1016/j.clinbiochem.2014.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/04/2014] [Accepted: 11/27/2014] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Circulating levels of pregnancy-associated plasma protein-A (PAPP-A) predict outcome in patients with acute coronary syndrome (ACS). Unfortunately, administration of heparin to patients with ACS increases circulating PAPP-A, probably by a detachment of PAPP-A from cell surfaces, inducing a considerable bias when using PAPP-A as a biomarker. It remains unknown whether PAPP-A-derived N- and C-terminal fragments of insulin-like growth factor binding protein-4 (NT-IGFBP-4/CT-IGFBP-4) are acutely affected by the increase in PAPP-A. METHODS We prospectively included 78 patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Prior to PCI, patients were injected with 10,000IU of unfractionated heparin (UFH). Blood samples were collected immediately before PCI, but after UFH-injection, immediately after PCI and on day 1 and day 2. Plasma IGFBP-4, CT-IGFBP-4 and NT-IGFBP-4 levels were determined by specific, novel immunoassays, and PAPP-A and IGF-I by commercial immunoassays. RESULTS Plasma PAPP-A was strongly elevated upon STEMI, UFH-administration and PCI with mean concentrations (95%-confidence interval) pre-PCI, post-PCI, day 1, and day 2 of 13.0 (11.2;15.2), 14.8 (13.1;16.8), 1.03 (0.90;1.18), and 1.08 (0.92;1.28) μg/L, respectively (p<0.0001). Pre-PCI concentrations of IGFBP-4, CT-IGFBP-4 and NT-IGFBP-4 were 154 (142;166), 53 (47;60) and 136 (122;150) μg/L, and levels were unaltered post-PCI. Concentrations increased on day 1 by 63 (43;87)%, 69 (36;110)%, and 47 (21;79)%, respectively (p<0.0001), i.e. at a time point when PAPP-A levels had normalized. CONCLUSION Plasma IGFBP-4-fragment levels are not acutely altered in patients with STEMI treated with UFH and PCI. Thus, they possess potentials as prognostic markers in ACS patients.
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Affiliation(s)
- Rikke Hjortebjerg
- Medical Research Laboratory, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; The Danish Diabetes Academy, Odense, Denmark.
| | - Søren Lindberg
- Department of Cardiology P, Gentofte University Hospital, Copenhagen, Denmark
| | - Søren Hoffmann
- Department of Cardiology P, Gentofte University Hospital, Copenhagen, Denmark
| | - Jan S Jensen
- Department of Cardiology P, Gentofte University Hospital, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Oxvig
- Department of Molecular Biology and Genetics, Faculty of Science and Technology, Aarhus University, Aarhus, Denmark
| | - Mette Bjerre
- Medical Research Laboratory, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jan Frystyk
- Medical Research Laboratory, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Mair J, Jaffe AS. Biomarker tests for risk assessment in coronary artery disease: will they change clinical practice? Mol Diagn Ther 2014; 18:5-15. [PMID: 24072397 DOI: 10.1007/s40291-013-0057-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The clinical significance and economic impact of coronary artery disease has triggered major research efforts into the discovery of novel biomarkers for risk stratification in primary and secondary prevention and then the development of assays suitable for routine measurement. Nevertheless, the clinical impact of these novel biomarkers for risk stratification is still limited because they do not add substantially to traditional risk factors and they only modestly-even with a multimarker approach-improve risk stratification and patient reclassification. The most useful markers appear to be high-sensitivity C-reactive protein, natriuretic peptides, and, eventually, high-sensitivity cardiac troponins. Further research is clearly needed.
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Affiliation(s)
- Johannes Mair
- Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck, Austria,
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18
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Kalousová M, Zima T, Krane V, März W, Wanner C, Tesař V, Drechsler C. Pregnancy-associated plasma protein A associates with cardiovascular events in diabetic hemodialysis patients. Atherosclerosis 2014; 236:263-9. [PMID: 25108075 DOI: 10.1016/j.atherosclerosis.2014.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/01/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pregnancy-associated plasma protein A (PAPP-A) has prognostic impact in pregnancy and acute coronary syndrome. Patients with chronic kidney disease have an excessive cardiovascular risk. In an effort to identify novel risk factors for cardiovascular disease, we investigated the relationship of PAPP-A with specific outcomes in diabetic patients undergoing dialysis. METHODS PAPP-A was measured in 1098 diabetic hemodialysis patients, who participated in the German Diabetes and Dialysis Study and followed-up for a median of 4 years. By Cox regression analysis, we assessed the association of baseline levels of PAPP-A with all-cause mortality, combined cardiovascular events and the specific outcomes of sudden death, stroke, myocardial infarction and infectious mortality. RESULTS Patients had a mean age of 66 ± 8 years (54% male) and median PAPP-A concentration of 17 mIU/L (IQR 13.4-20.9 mIU/L). Per standard deviation increase in PAPP-A the adjusted risk of sudden cardiac death increased by 23% (HR 1.23, 95%CI 1.12-1.36). Categorical analyses showed that the patients in the 4(th) PAPP-A quartile had an adjusted 2.6 fold increased risk of sudden death and 2.8 fold increased risk of stroke as compared to the patients in the 1st quartile. Similarly, the risk of combined cardiovascular events was significantly elevated by the factor 1.5 in patients of the 4(th) quartile. Additionally, PAPP-A levels were associated with infectious deaths and all-cause mortality. CONCLUSIONS PAPP-A is associated with sudden death, stroke and infectious complications in diabetic dialysis patients. PAPP-A may be useful for risk assessment and monitoring in populations at high risk of cardiovascular events.
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Affiliation(s)
- Marta Kalousová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic.
| | - Tomáš Zima
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic.
| | - Vera Krane
- Division of Nephrology, Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.
| | - Winfried März
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria; Synlab Academy, Synlab Services GmbH, Mannheim, Germany.
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic.
| | - Christiane Drechsler
- Division of Nephrology, Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany; Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.
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19
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Zhang Z, Dai H, Yu Y, Yang J, Chen J, Wu L. Elevated pregnancy-associated plasma protein A predicts myocardial dysfunction and death in severe sepsis. Ann Clin Biochem 2013; 51:22-9. [PMID: 23880622 DOI: 10.1177/0004563213489275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPPA) is an emerging biomarker used in various medical fields but has yet to be evaluated in critical care medicine. This study evaluates the value of PAPPA as a biomarker in predicting myocardial dysfunction and 28-day mortality in patients with severe sepsis. METHODS Serum concentrations of PAPPA and traditional cardiac biomarkers including cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP) were measured on admission in 118 severely septic patients. The value of PAPPA for the diagnosis of sepsis-related myocardial dysfunction (SRMD) and for the prediction of 28-day mortality was subsequently evaluated using statistical methods. RESULTS PAPPA was elevated (≥4.5 ng/mL) in 76 (64.4%) patients; patients with elevated PAPPA were more likely to have SRMD (76.3% vs. 38.1%, P < 0.001). By comparison of the area under the curve (AUC) in receiver operating characteristics analysis, PAPPA had comparable value (AUC 0.661, P = 0.003) to conventional biomarkers (BNP: AUC 0.699, P < 0.001; cTnI: AUC 0.647, P = 0.007) in the diagnosis of SRMD and offered superior value (AUC 0.771, P < 0.001) over them (all AUC<0.7, P > 0.05) in the prediction of 28-day death. Increased PAPPA (≥5.4 ng/mL) was associated with lower 28-day survival (χ(2) = 19.78, P < 0.001) and independently predicted 28-day mortality in septic patients. CONCLUSIONS Serum PAPPA concentration frequently increases in patients with severe sepsis and appears to be associated with SRMD. PAPPA can be used as a novel biomarker for the diagnosis of SRMD and the prediction of outcomes in critically ill patients.
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Affiliation(s)
- Zhaocai Zhang
- Intensive Care Unit (ICU), Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
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20
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Karsli MF, Baser E, Seckin KD, Yeral Mİ, Togrul C, Ugur M. The impact of inherited thrombophilia on first trimester combined aneuploidy screening test parameters. J Matern Fetal Neonatal Med 2013; 27:346-9. [DOI: 10.3109/14767058.2013.818123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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21
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Nadeau-Fredette AC, Hladunewich M, Hui D, Keunen J, Chan CT. End-stage renal disease and pregnancy. Adv Chronic Kidney Dis 2013; 20:246-52. [PMID: 23928389 DOI: 10.1053/j.ackd.2013.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/17/2013] [Accepted: 01/18/2013] [Indexed: 01/16/2023]
Abstract
Pregnancy in patients with ESRD is rare and remains especially challenging. Because endocrine abnormalities and sexual dysfunction decrease fertility, conception rates have been remarkably low in this patient population. Moreover, when pregnancy does occur, hypertension, preeclampsia, anemia, intrauterine growth restriction, preterm delivery, stillbirth, and other complications can decrease the rate of a successful outcome. However, recent experiences with intensive hemodialysis managed by a multidisciplinary team are encouraging with respect to better overall outcomes for mothers and infants. In this article, we discuss the main causes of decreased fertility in dialysis-dependent women, review outcomes and complications of pregnancy among dialysis patients with a special focus on recent intensive hemodialysis data, and summarize the current best strategy to manage pregnant women on dialysis.
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22
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Zhao XY, Wang XF, Li L, Zhang JY, Du YY, Yao HM. Plaque characteristics and serum pregnancy-associated plasma protein A levels predict the no-reflow phenomenon after percutaneous coronary intervention. J Int Med Res 2013; 41:307-16. [PMID: 23569011 DOI: 10.1177/0300060513476423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To investigate the relationship between serum plasma pregnancy-associated plasma protein A (PAPP-A) and coronary plaque characteristics, and their prognostic value for coronary no-reflow after percutaneous coronary intervention (PCI). METHODS Patients with unstable angina undergoing PCI were divided into a normal reflow group and a no-reflow group after stent deployment. Coronary blood flow was measured angiographically; plaque components were detected by virtual histology intravascular ultrasound. Serum PAPP-A and high-sensitivity C-reactive protein (hsCRP) were measured before PCI. Cardiac troponin T (cTnT) was measured before and 24 h after PCI. RESULTS A total of 166 patients with unstable angina undergoing PCI were included: normal reflow group (n = 145) and no-reflow group (n = 21), after stent deployment. Baseline coronary blood flow was similar in the two groups. The no-reflow group had plaques with less-fibrotic tissue and a larger necrotic core, more thin-cap fibroatheromas and plaque ruptures, and higher serum PAPP-A, hsCRP and post-PCI cTnT levels than the normal reflow group. Serum PAPP-A was correlated negatively with plaque fibrotic area and positively with necrotic core area. CONCLUSION High serum PAPP-A and plaque lesions with a large necrotic core are associated with the no-reflow phenomenon after PCI, in patients with unstable angina.
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Affiliation(s)
- Xiao-Yan Zhao
- Department of Cardiology, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
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23
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Saenger AK, Jaffe AS. Biomarkers of vulnerable plaque: Can better ways to quantitate Pregnancy-Associated Plasma Protein A (PAPP-A) help? Clin Biochem 2012; 45:517-8. [DOI: 10.1016/j.clinbiochem.2012.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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High positive predictive value of PAPP-A for acute coronary syndrome diagnosis in heparin-naïve patients. J Thromb Thrombolysis 2012; 34:99-105. [DOI: 10.1007/s11239-012-0679-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Postnikov AB, Smolyanova TI, Kharitonov AV, Serebryanaya DV, Kozlovsky SV, Tryshina YA, Malanicev RV, Arutyunov AG, Murakami MM, Apple FS, Katrukha AG. N-terminal and C-terminal fragments of IGFBP-4 as novel biomarkers for short-term risk assessment of major adverse cardiac events in patients presenting with ischemia. Clin Biochem 2012; 45:519-24. [PMID: 22306170 DOI: 10.1016/j.clinbiochem.2011.12.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 12/08/2011] [Accepted: 12/27/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES Pregnancy Associated Plasma Protein A (PAPP-A)-derived N- and C-terminal fragments of IGF-binding protein-4 (NT- and CT-IGFBP-4) released from vulnerable atherosclerotic plaques are proposed to be used for cardiovascular risk assessment. DESIGN AND METHODS NT- and CT-IGFBP-4 were measured by novel immunoassays in EDTA-plasma of 180 patients admitted to the emergency department with symptoms of myocardial ischemia but without ST-segment elevation. Six-month incidence of major adverse cardiac events (MACE), including myocardial infarction, cardiac death, percutaneous coronary interventions, and coronary artery bypass grafting was recorded. RESULTS Sixteen patients met the endpoint. NT- and CT-IGFBP-4 were strong predictors of MACE: area under ROC curve (AUC) 0.856 and 0.809, respectively. NT-IGFBP-4 concentrations≥214μg/L and CT-IGFBP-4 concentrations≥124μg/L were associated with increased risk of future MACE: adjusted hazard ratio 13.79 and 7.93, respectively. CONCLUSIONS IGFBP-4 fragments can be utilized as biomarkers for MACE prediction in patients with suspected myocardial ischemia.
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Affiliation(s)
- A B Postnikov
- HyTest Ltd, Intelligate 6th floor, Joukahaisenkatu 6, 20520 Turku, Finland.
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Abstract
The ovulatory menstrual cycle is known to be affected on multiple levels in women with advanced renal disease. Menstrual irregularities, sexual dysfunction, and infertility worsen in parallel with the renal disease. Pregnancy in women with ESRD on dialysis is therefore uncommon. Furthermore, when pregnancy does occur, it can prove hazardous to both mother and baby owing to a multitude of potential complications including accelerated hypertension and preeclampsia, poor fetal growth, anemia, and polyhydramnios. Data are emerging, however, to suggest that pregnancy while on intensified renal replacement regimens may result in better pregnancy outcomes, and emerging trends include the decreased rate of therapeutic abortions probably reflecting a change in counseling practices over time. Nevertheless, a pregnant woman on intensive dialysis requires meticulous follow-up by a dedicated team including nephrology, obstetrics, and a full multidisciplinary staff. In this article, we will address fertility issues in young women with ESRD, review pregnancy outcomes in women on both hemodialysis and peritoneal dialysis, and provide suggestions for the management of the pregnant women on intensive hemodialysis.
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Affiliation(s)
- Michelle Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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