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Zhang X, van der Vorst EPC. High-Density Lipoprotein Modifications: Causes and Functional Consequences in Type 2 Diabetes Mellitus. Cells 2024; 13:1113. [PMID: 38994965 PMCID: PMC11240616 DOI: 10.3390/cells13131113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024] Open
Abstract
High-density lipoprotein (HDL) is a group of small, dense, and protein-rich lipoproteins that play a role in cholesterol metabolism and various cellular processes. Decreased levels of HDL and HDL dysfunction are commonly observed in individuals with type 2 diabetes mellitus (T2DM), which is also associated with an increased risk for cardiovascular disease (CVD). Due to hyperglycemia, oxidative stress, and inflammation that develop in T2DM, HDL undergoes several post-translational modifications such as glycation, oxidation, and carbamylation, as well as other alterations in its lipid and protein composition. It is increasingly recognized that the generation of HDL modifications in T2DM seems to be the main cause of HDL dysfunction and may in turn influence the development and progression of T2DM and its related cardiovascular complications. This review provides a general introduction to HDL structure and function and summarizes the main modifications of HDL that occur in T2DM. Furthermore, the potential impact of HDL modifications on the pathogenesis of T2DM and CVD, based on the altered interactions between modified HDL and various cell types that are involved in glucose homeostasis and atherosclerotic plaque generation, will be discussed. In addition, some perspectives for future research regarding the T2DM-related HDL modifications are addressed.
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Affiliation(s)
- Xiaodi Zhang
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH Aachen University, 52074 Aachen, Germany;
- Aachen-Maastricht Institute for CardioRenal Disease (AMICARE), RWTH Aachen University, 52074 Aachen, Germany
| | - Emiel P. C. van der Vorst
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH Aachen University, 52074 Aachen, Germany;
- Aachen-Maastricht Institute for CardioRenal Disease (AMICARE), RWTH Aachen University, 52074 Aachen, Germany
- Interdisciplinary Center for Clinical Research (IZKF), RWTH Aachen University, 52074 Aachen, Germany
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-University Munich (LMU), 80336 Munich, Germany
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2
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Dabravolski S, Orekhov NA, Melnichenko A, Sukhorukov VN, Popov MA, Orekhov A. Cholesteryl Ester Transfer Protein (CETP) Variations in Relation to Lipid Profiles and Cardiovascular Diseases: An Update. Curr Pharm Des 2024; 30:742-756. [PMID: 38425105 DOI: 10.2174/0113816128284695240219093612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 03/02/2024]
Abstract
Lipid metabolism plays an essential role in the pathogenesis of cardiovascular and metabolic diseases. Cholesteryl ester transfer protein (CETP) is a crucial glycoprotein involved in lipid metabolism by transferring cholesteryl esters (CE) and triglycerides (TG) between plasma lipoproteins. CETP activity results in reduced HDL-C and increased VLDL- and LDL-C concentrations, thus increasing the risk of cardiovascular and metabolic diseases. In this review, we discuss the structure of CETP and its mechanism of action. Furthermore, we focus on recent experiments on animal CETP-expressing models, deciphering the regulation and functions of CETP in various genetic backgrounds and interaction with different external factors. Finally, we discuss recent publications revealing the association of CETP single nucleotide polymorphisms (SNPs) with the risk of cardiovascular and metabolic diseases, lifestyle factors, diet and therapeutic interventions. While CETP SNPs can be used as effective diagnostic markers, diet, lifestyle, gender and ethnic specificity should also be considered for effective treatment.
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Affiliation(s)
- Siarhei Dabravolski
- Department of Biotechnology Engineering, ORT Braude College, Braude Academic College of Engineering, Karmiel, Israel
| | - Nikolay A Orekhov
- Laboratory of Angiopatology, Research Institute of General Pathology and Pathophysiology, The Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Alexandra Melnichenko
- Laboratory of Angiopatology, Research Institute of General Pathology and Pathophysiology, The Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Vasily N Sukhorukov
- Laboratory of Angiopatology, Research Institute of General Pathology and Pathophysiology, The Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Mikhail A Popov
- Laboratory of Angiopatology, Research Institute of General Pathology and Pathophysiology, The Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Alexander Orekhov
- Laboratory of Angiopatology, Research Institute of General Pathology and Pathophysiology, The Russian Academy of Medical Sciences, Moscow, Russian Federation
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den Hartigh LJ, May KS, Zhang XS, Chait A, Blaser MJ. Serum amyloid A and metabolic disease: evidence for a critical role in chronic inflammatory conditions. Front Cardiovasc Med 2023; 10:1197432. [PMID: 37396595 PMCID: PMC10311072 DOI: 10.3389/fcvm.2023.1197432] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Serum amyloid A (SAA) subtypes 1-3 are well-described acute phase reactants that are elevated in acute inflammatory conditions such as infection, tissue injury, and trauma, while SAA4 is constitutively expressed. SAA subtypes also have been implicated as playing roles in chronic metabolic diseases including obesity, diabetes, and cardiovascular disease, and possibly in autoimmune diseases such as systemic lupus erythematosis, rheumatoid arthritis, and inflammatory bowel disease. Distinctions between the expression kinetics of SAA in acute inflammatory responses and chronic disease states suggest the potential for differentiating SAA functions. Although circulating SAA levels can rise up to 1,000-fold during an acute inflammatory event, elevations are more modest (∼5-fold) in chronic metabolic conditions. The majority of acute-phase SAA derives from the liver, while in chronic inflammatory conditions SAA also derives from adipose tissue, the intestine, and elsewhere. In this review, roles for SAA subtypes in chronic metabolic disease states are contrasted to current knowledge about acute phase SAA. Investigations show distinct differences between SAA expression and function in human and animal models of metabolic disease, as well as sexual dimorphism of SAA subtype responses.
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Affiliation(s)
- Laura J. den Hartigh
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, WA, United States
- Diabetes Institute, University of Washington, Seattle, WA, United States
| | - Karolline S. May
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, WA, United States
- Diabetes Institute, University of Washington, Seattle, WA, United States
| | - Xue-Song Zhang
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, NJ, United States
| | - Alan Chait
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, WA, United States
- Diabetes Institute, University of Washington, Seattle, WA, United States
| | - Martin J. Blaser
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, NJ, United States
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Expanding the Molecular Disturbances of Lipoproteins in Cardiometabolic Diseases: Lessons from Lipidomics. Diagnostics (Basel) 2023; 13:diagnostics13040721. [PMID: 36832218 PMCID: PMC9954993 DOI: 10.3390/diagnostics13040721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/28/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
The increasing global burden of cardiometabolic diseases highlights the urgent clinical need for better personalized prediction and intervention strategies. Early diagnosis and prevention could greatly reduce the enormous socio-economic burden posed by these states. Plasma lipids including total cholesterol, triglycerides, HDL-C, and LDL-C have been at the center stage of the prediction and prevention strategies for cardiovascular disease; however, the bulk of cardiovascular disease events cannot be explained sufficiently by these lipid parameters. The shift from traditional serum lipid measurements that are poorly descriptive of the total serum lipidomic profile to comprehensive lipid profiling is an urgent need, since a wealth of metabolic information is currently underutilized in the clinical setting. The tremendous advances in the field of lipidomics in the last two decades has facilitated the research efforts to unravel the lipid dysregulation in cardiometabolic diseases, enabling the understanding of the underlying pathophysiological mechanisms and identification of predictive biomarkers beyond traditional lipids. This review presents an overview of the application of lipidomics in the study of serum lipoproteins in cardiometabolic diseases. Integrating the emerging multiomics with lipidomics holds great potential in moving toward this goal.
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Dai J, Zhang X, Zhou J, Pan W, Yu F. Clinical performance evaluation of serum amyloid A module of Mindray BC-7500CS automated hematology analyzer. Transl Pediatr 2023; 12:20-30. [PMID: 36798927 PMCID: PMC9926133 DOI: 10.21037/tp-22-661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Laboratory detection of high values of serum amyloid A (SAA) is impaired by the hook effect. In response to this problem, Mindray has launched the new generation BC-7500CS automated hematology analyzer with an SAA autodilution (SAA-D) function. The present study aimed to verify the performance of the SAA module. METHODS Venous whole-blood specimens anticoagulated with EDTA-K2 were randomly collected from outpatients and inpatient of the Children's Hospital of Nanjing Medical University (CH). Background, repeatability, precision, linear range, intermode comparison, and interference of the SAA module of the Mindray BC-7500CS were evaluated, and the performance of the SAA-D function was verified. RESULTS The Mindray BC-7500CS showed an SAA background of 0.14 mg/L, well below that claimed by the manufacturer. Repeatability of SAA with standard deviation (SD) <0.6 mg/L and coefficient of variation (CV) <6%, the quality control (QC) precision was less than 8%. The measured value of the linear range was essentially consistent with the theoretical value, and the maximum measured values could reach 1932.38 mg/L. The deviation between whole-blood mode and micro-whole-blood mode was small (r=0.999), and the SAA module displayed high anti-interference ability. In addition, the measured results of specimens with high SAA concentration diluted by SAA-D were close to those after manual dilution (r=0.993). CONCLUSIONS The SAA module of the Mindray BC-7500CS had excellent performance, and the SAA-D function was highly accurate at measuring specimens with high SAA concentration, enabling reliable SAA detection in the laboratory and clinical practice.
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Affiliation(s)
- Jincheng Dai
- Department of Clinical Laboratory, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyu Zhang
- Department of Clinical Laboratory, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhou
- Department of Clinical Laboratory, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Pan
- Department of Clinical Laboratory, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Fei Yu
- Department of Clinical Laboratory, Children's Hospital of Nanjing Medical University, Nanjing, China
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Venkat P, Gao H, Findeis EL, Chen Z, Zacharek A, Landschoot-Ward J, Powell B, Lu M, Liu Z, Zhang Z, Chopp M. Therapeutic effects of CD133 + Exosomes on liver function after stroke in type 2 diabetic mice. Front Neurosci 2023; 17:1061485. [PMID: 36968490 PMCID: PMC10033607 DOI: 10.3389/fnins.2023.1061485] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Background and purpose Non-alcoholic fatty liver disease (NAFLD) is known to adversely affect stroke recovery. However, few studies investigate how stroke elicits liver dysfunction, particularly, how stroke in type 2 diabetes mellitus (T2DM) exacerbates progression of NAFLD. In this study, we test whether exosomes harvested from human umbilical cord blood (HUCBC) derived CD133 + cells (CD133 + Exo) improves neuro-cognitive outcome as well as reduces liver dysfunction in T2DM female mice. Methods Female, adult non-DM and T2DM mice subjected to stroke presence or absence were considered. T2DM-stroke mice were randomly assigned to receive PBS or Exosome treatment group. CD133 + Exo (20 μg/200 μl PBS, i.v.) was administered once at 3 days after stroke. Evaluation of neurological (mNSS, adhesive removal test) and cognitive function [novel object recognition (NOR) test, odor test] was performed. Mice were sacrificed at 28 days after stroke and brain, liver, and serum were harvested. Results Stroke induces severe and significant short-term and long-term neurological and cognitive deficits which were worse in T2DM mice compared to non-DM mice. CD133 + Exo treatment of T2DM-stroke mice significantly improved neurological function and cognitive outcome indicated by improved discrimination index in the NOR and odor tests compared to control T2DM-stroke mice. CD133 + Exo treatment of T2DM stroke significantly increased vascular and white matter/axon remodeling in the ischemic brain compared to T2DM-stroke mice. However, there were no differences in the lesion volume between non-DM stroke, T2DM-stroke and CD133 + Exo treated T2DM-stroke mice. In T2DM mice, stroke induced earlier and higher TLR4, NLRP3, and cytokine expression (SAA, IL1β, IL6, TNFα) in the liver compared to heart and kidney, as measured by Western blot. T2DM-stroke mice exhibited worse NAFLD progression with increased liver steatosis, hepatocellular ballooning, fibrosis, serum ALT activity, and higher NAFLD Activity Score compared to T2DM mice and non-DM-stroke mice, while CD133 + Exo treatment significantly attenuated the progression of NAFLD in T2DM stroke mice. Conclusion Treatment of female T2DM-stroke mice with CD133 + Exo significantly reduces the progression of NAFLD/NASH and improves neurological and cognitive function compared to control T2DM-stroke mice.
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Affiliation(s)
- Poornima Venkat
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
- *Correspondence: Poornima Venkat,
| | - Huanjia Gao
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | | | - Zhili Chen
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Alex Zacharek
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | | | - Brianna Powell
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, United States
| | - Zhongwu Liu
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Zhenggang Zhang
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
| | - Michael Chopp
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
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Välikangas T, Suomi T, Chandler CE, Scott AJ, Tran BQ, Ernst RK, Goodlett DR, Elo LL. Benchmarking tools for detecting longitudinal differential expression in proteomics data allows establishing a robust reproducibility optimization regression approach. Nat Commun 2022; 13:7877. [PMID: 36550114 PMCID: PMC9780321 DOI: 10.1038/s41467-022-35564-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Quantitative proteomics has matured into an established tool and longitudinal proteomics experiments have begun to emerge. However, no effective, simple-to-use differential expression method for longitudinal proteomics data has been released. Typically, such data is noisy, contains missing values, and has only few time points and biological replicates. To address this need, we provide a comprehensive evaluation of several existing differential expression methods for high-throughput longitudinal omics data and introduce a Robust longitudinal Differential Expression (RolDE) approach. The methods are evaluated using over 3000 semi-simulated spike-in proteomics datasets and three large experimental datasets. In the comparisons, RolDE performs overall best; it is most tolerant to missing values, displays good reproducibility and is the top method in ranking the results in a biologically meaningful way. Furthermore, RolDE is suitable for different types of data with typically unknown patterns in longitudinal expression and can be applied by non-experienced users.
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Affiliation(s)
- Tommi Välikangas
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, FI-20520, Turku, Finland
| | - Tomi Suomi
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, FI-20520, Turku, Finland
| | | | - Alison J Scott
- University of Maryland - Baltimore, Baltimore, MD, 21201, USA
| | - Bao Q Tran
- US Army 20th Support Command CBRNE Analytical and Remediation Activity, Baltimore, MD, 21010-5424, USA
| | - Robert K Ernst
- University of Maryland - Baltimore, Baltimore, MD, 21201, USA
| | - David R Goodlett
- University of Victoria, Victoria, BC, V8P 3E6, Canada
- International Centre for Cancer Vaccine Science, Gdansk, Poland
| | - Laura L Elo
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, FI-20520, Turku, Finland.
- Institute of Biomedicine, University of Turku, FI-20520, Turku, Finland.
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Liu Q, Sun J, Xu T, Bian G, Yang F. Associations of serum amyloid A and 25-hydroxyvitamin D with diabetic nephropathy: A cross-sectional study. J Clin Lab Anal 2022; 36:e24283. [PMID: 35133014 PMCID: PMC8906018 DOI: 10.1002/jcla.24283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The present study investigated the relationships between serum amyloid A (SAA), 25-hydroxyvitamin D (25(OH)VD) and diabetic nephropathy (DN) to provide evidence for the prevention and management of DN. METHODS A total of 182 patients with type 2 diabetes mellitus (T2DM) were enrolled in this study. The levels of SAA, 25(OH)VD, and other conventional indicators were measured and analyzed. Receiver operating characteristic curve analysis was applied for the combined measurement of SAA and 25(OH)VD, and risk factors for DN were evaluated using binary logistic regression analysis. RESULTS The levels of SAA in T2DM patients were significantly higher than those in healthy subjects, and the level significantly increased with the progression of DN (p < 0.05). In contrast, the level of 25(OH)VD in T2DM patients was significantly lower than that in healthy subjects, and the level significantly decreased with the progression of DN (p < 0.05). The combined measurement of SAA and 25(OH)VD distinguished DN patients from T2DM patients better than the measurement of SAA or 25(OH)VD alone. SAA was an independent risk factor for DN, and 25(OH)VD was an independent protective factor for DN. CONCLUSION SAA and 25(OH)VD might be used as potential markers to identify patients at increased risk of developing DN.
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Affiliation(s)
- Qian Liu
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang, Lianyungang, China
| | - Jin Sun
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang, Lianyungang, China
| | - Tongdao Xu
- Department of Endocrinology, The Second People's Hospital of Lianyungang, Lianyungang, China
| | - Guangrong Bian
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang, Lianyungang, China
| | - Fumeng Yang
- Department of Laboratory Medicine, The Second People's Hospital of Lianyungang, Lianyungang, China
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Doğan K, Şeneş M, Karaca A, Kayalp D, Kan S, Gülçelik NE, Aral Y, Yücel D. HDL subgroups and their paraoxonase-1 activity in the obese, overweight and normal weight subjects. Int J Clin Pract 2021; 75:e14969. [PMID: 34626508 DOI: 10.1111/ijcp.14969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/10/2021] [Accepted: 10/07/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Obesity and overweight are significant public health problems because of higher risk for coronary artery disease (CAD). It is very important to determine new predictive markers to identify the CAD risk in obese and overweight. To aim this, we analysed HDL-C subgroups (HDL2-C and HDL3-C) and their paraoxonase-1 (PON-1) activity in obese, overweight and normal weight subjects. METHOD 71 obese, 40 overweight and 30 healthy subjects as a control group were enrolled the study. Serum lipids levels were determined with enzymatic colorimetric method. Further, PON-1 activities and HDL-C levels were determined by spectrophotometric methods. Non-HDL3-C concentrations were calculated with the subtraction of HDL3-C from total HDL-C. RESULTS The mean serum levels of total HDL-C, HDL3-C, Non-HDL3-C and ApoA1 were higher in control group than obese and overweight groups. There were a statistically significant difference between obese and control group in terms of Lp(a), hsCRP and HOMA index. Higher total PON-1, non-HDL3 PON-1 and HDL3 PON-1 activities were found in the control group compared with obese and overweight groups. Total HDL was weakly negative correlated with the HOMA index, BMI and waist circumference. There was a weak negative correlation between non-HDL3-C and waist circumference. CONCLUSION Altered HDL-subgroups pattern and decreased PON-1 activities may cause increased risk for CVD in obese and overweight individuals. Therefore determination of HDL subgroups and their PON-1 activity may improve risk prediction compared with measuring total HDL-C levels and its PON-1 activity alone. Body weight and insulin resistance appear to have a role in the decreased HDL-C levels and PON-1activity in obese. Further studies should be conducted to shed more light on impacts of these markers in CVD.
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Affiliation(s)
- Kübra Doğan
- Department of Clinical Biochemistry, Sivas Numune State Hospital, Ministry of Health, Sivas, Turkey
| | - Mehmet Şeneş
- Department of Clinical Biochemistry, Ankara Training and Research Hospital, Ministry of Health Ankara, Turkey
| | - Anara Karaca
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ministry of Health Ankara, Turkey
| | - Damla Kayalp
- Department of Clinical Biochemistry, Yozgat City Hospital, Ministry of Health, Yozgat, Turkey
| | - Seyfullah Kan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - Neşe Ersöz Gülçelik
- Department of Endocrinology and Metabolism, Gülhane Training and Research Hospital, Ministry of Health Ankara, Turkey
| | - Yalçın Aral
- Department of Endocrinology and Metabolism, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Doğan Yücel
- Department of Clinical Biochemistry, Faculty of Medicine, Lokman Hekim University, Ankara, Turkey
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High-Density Lipoprotein Subfractions: Much Ado about Nothing or Clinically Important? Biomedicines 2021; 9:biomedicines9070836. [PMID: 34356900 PMCID: PMC8301429 DOI: 10.3390/biomedicines9070836] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/24/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
High-density lipoproteins (HDL) are a heterogenous group of plasma molecules with a large variety in composition. There is a wide specter in lipid content and the number of different proteins that has been associated with HDL is approaching 100. Given this heterogeneity and the fact that the total amount of HDL is inversely related to the risk of coronary heart disease (CHD), there has been increasing interest in the function of specific HDL subgroups and in what way measuring and quantifying these subgroups could be of clinical importance in determining individual CHD risk. If certain subgroups appear to be more protective than others, it may also in the future be possible to pharmacologically increase beneficial and decrease harmful subgroups in order to reduce CHD risk. In this review we give a short historical perspective, summarize some of the recent clinical findings regarding HDL subclassifications and discuss why such classification may or may not be of clinical relevance.
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Naresh S, Bitla AR, Rao PVLNS, Sachan A, Amancharla YL. Efficacy of oral rosuvastatin intervention on HDL and its associated proteins in men with type 2 diabetes mellitus. Endocrine 2021; 71:76-86. [PMID: 32895874 DOI: 10.1007/s12020-020-02472-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/23/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE High-density lipoprotein (HDL) undergoes structural and functional modification in patients with type 2 diabetes mellitus (T2DM). There are limited data on effect of rosuvastatin on HDL-associated proteins and the antiatherogenic effects of rosuvastatin. The present study intended to study the efficacy of rosuvastatin intervention on HDL-associated proteins and its other antiatherogenic effects in men with T2DM. METHODS Men with T2DM on oral antidiabetic treatment, with LDL-C levels > 75 mg/dL and willing for rosuvastatin intervention (20 mg/day orally for a period of 12 weeks), were included. Fasting glucose, lipid profile were measured using standard methods. Oxidized low-density lipoprotein (oxLDL), oxidized HDL (oxHDL), paraoxonase-1 (PON-1), tumour necrosis factor-α (TNF-α) and lecithin:cholesterol acyltransferase (LCAT) in serum were measured by ELISA; serum myeloperoxidase (MPO) by spectrophotometric method and cholesterol efflux by fluorometric assay. Carotid intima-media thickness (cIMT) measurement to assess vascular health status was done using doppler. RESULTS Rosuvastatin produced a significant decrease (p < 0.05) in lipids (total cholesterol, triglycerides, LDL-C); oxidative stress (oxLDL, oxHDL, MPO); inflammation (TNF-α); LCAT concentration; cIMT; significant increase in antiatherogenic HDL and cholesterol efflux (p < 0.05) and no change in apoA-I levels from baseline to 12 weeks of follow-up. A decrease in MPO activity was found to be independently associated with an increase in cholesterol efflux. CONCLUSIONS Post intervention there is a quantitative and qualitative improvement in HDL, which helps in its reverse cholesterol transport (RCT) and antioxidant functions. Improvement in HDL functions and suppression of inflammation by rosuvastatin lead to regression in cIMT, which is beneficial in decreasing the progression of cardiovascular disease (CVD) in men with diabetes.
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Affiliation(s)
- Sriram Naresh
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, 517507, India
| | - Aparna R Bitla
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, 517507, India.
| | - P V L N Srinivasa Rao
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, 517507, India
| | - Alok Sachan
- Department of Endocrinology and Metabolism, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, 517507, India
| | - Yadagiri Lakshmi Amancharla
- Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, 517507, India
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12
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Gomes Kjerulf D, Wang S, Omer M, Pathak A, Subramanian S, Han CY, Tang C, den Hartigh LJ, Shao B, Chait A. Glycation of HDL blunts its anti-inflammatory and cholesterol efflux capacities in vitro, but has no effect in poorly controlled type 1 diabetes subjects. J Diabetes Complications 2020; 34:107693. [PMID: 32900591 PMCID: PMC7669727 DOI: 10.1016/j.jdiacomp.2020.107693] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND High-density lipoproteins (HDL) modified by glycation have been reported to be dysfunctional. Little is known regarding the anti-inflammatory effects on adipocytes of glycated HDL. AIMS We tested whether modification of HDL in vitro by glycolaldehyde (GAD), malondialdehyde (MDA) or glucose affected HDL's anti-inflammatory properties and ability to promote cholesterol efflux. To determine whether similar changes occur in vivo, we examined modifications of apolipoprotein A1 (APOA1) and APOA2 and anti-inflammatory and cholesterol efflux properties of HDL isolated from subjects with type 1 diabetes in poor glycemic control. RESULTS In vitro modification with both GAD and MDA blunted HDL's ability to inhibit palmitate-induced inflammation and cholesterol efflux in adipocytes. Modification of HDL by glucose had little impact on HDL function, like the response using HDL isolated from subjects with diabetes. Mass spectrophotometric analysis revealed that lysine residues in APOA1 and APOA2 of HDL modified by GAD and MDA in vitro differed from those modified by glucose, which resembled that seen with HDL from patients with type1 diabetes. CONCLUSIONS Modification of lysine residues in HDL by GAD and MDA in vitro does not mirror the HDL glycation in vivo in patients with diabetes, but resembles HDL modified in vitro by glucose.
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Affiliation(s)
- Diego Gomes Kjerulf
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Shari Wang
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Mohamed Omer
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Asha Pathak
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Savitha Subramanian
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Chang Yeop Han
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Chongren Tang
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Laura J den Hartigh
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Baohai Shao
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Alan Chait
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America.
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13
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Abstract
The prevalence of heart failure (HF), including reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF), has increased significantly worldwide. However, the prognosis and treatment of HF are still not good. Recent studies have demonstrated that high-density lipoprotein (HDL) plays an important role in cardiac repair during HF. The exact role and mechanism of HDL in the regulation of HF remain unexplained. Here, we discuss recent findings regarding HDL in the progression of HF, such as the regulation of excitation-contraction coupling, energy homeostasis, inflammation, neurohormone activation, and microvascular dysfunction. The effects of HDL on the regulation of cardiac-related cells, such as endothelial cells (ECs), cardiomyocytes (CMs), and on cardiac resident immune cell dysfunction in HF are also explained. An in-depth understanding of HDL function in the heart may provide new strategies for the prevention and treatment of HF.
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14
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Abstract
High-density lipoprotein cholesterol (HDL-c) has long been referred to as 'good cholesterol' due to its apparent inverse relationship with future CVD risk. More recent research has questioned a causal role for HDL-c in this relationship, however, as both genetic studies and numerous large-scale randomised controlled trials have found no evidence of a cardiovascular protective effect when HDL-c levels are raised. Instead, focus has switched to the functional properties of the HDL particle. Evidence suggests that both the composition and function of HDL may be significantly altered in the context of an inflammatory milieu, transforming the particle from a vasoprotective anti-atherogenic particle to a noxious pro-atherogenic equivalent. This review will summarise evidence relating HDL to CVD risk, explore recent evidence characterising changes in the composition and function of HDL that may occur in chronic inflammatory diseases, and discuss the potential for future HDL-modifying therapeutic interventions.
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Affiliation(s)
- Scott T Chiesa
- Vascular Physiology Unit, UCL Institute of Cardiovascular Science, 1 St. Martin's Le Grand, London, EC1A 4NP, UK.
| | - Marietta Charakida
- Vascular Physiology Unit, UCL Institute of Cardiovascular Science, 1 St. Martin's Le Grand, London, EC1A 4NP, UK
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
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15
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Griffiths K, Maxwell AP, McCarter RV, Nicol P, Hogg RE, Harbinson M, McKay GJ. Serum amyloid A levels are associated with polymorphic variants in the serum amyloid A 1 and 2 genes. Ir J Med Sci 2019; 188:1175-1183. [PMID: 30852808 DOI: 10.1007/s11845-019-01996-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serum amyloid A (SAA) is secreted by liver hepatocytes in response to increased inflammation whereupon it associates with high-density lipoprotein (HDL) and alters the protein and lipid composition of HDL negating some of its anti-atherogenic properties. AIMS To identify variants within the SAA gene that may be associated with SAA levels and/or cardiovascular disease (CVD). METHODS We identified exonic variants within the SAA genes by deoxyribonucleic acid (DNA) Sanger sequencing. We tested the association between SAA variants and serum SAA levels in 246 individuals with and without CVD. RESULTS Increased SAA was associated with rs2468844 (beta [β] = 1.73; confidence intervals [CI], 1.14-1.75; p = 0.01), rs1136747 (β = 1.53 (CI, 1.11-1.73); p = 0.01) and rs149926073 (β = 3.37 (CI, 1.70-4.00); p = 0.02), while rs1136745 was significantly associated with decreased SAA levels (β = 0.70 (CI, 0.53-0.94); p = 0.02). Homozygous individuals with the SAA1.3 haplotype had significantly lower levels of SAA compared with those with SAA1.1 or SAA1.5 (β = 0.43 (CI, 0.22-0.85); p = 0.02) while SAA1.3/1.5 heterozygotes had significantly higher SAA levels compared with those homozygous for SAA1.1 (β = 2.58 (CI, 1.19-5.57); p = 0.02). CONCLUSIONS We have identified novel genetic variants in the SAA genes associated with SAA levels, a biomarker of inflammation and chronic disease. The utility of SAA as a biomarker for inflammation and chronic disease may be influenced by underlying genetic variation in baseline levels.
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Affiliation(s)
- Kayleigh Griffiths
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Rachel V McCarter
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Patrick Nicol
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Mark Harbinson
- Centre for Medical Education, Queen's University Belfast, Belfast, Northern Ireland
- Department of Cardiology, Belfast Health and Social Care Trust, Royal Hospital, Belfast, Northern Ireland
| | - Gareth J McKay
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland.
- Centre for Public Health, Institute of Clinical Sciences, Block B, Royal Victoria Hospital, Queen's University Belfast, Belfast, BT12 6BA, Ireland.
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16
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Zhang Y, Zhang J, Sheng H, Li H, Wang R. Acute phase reactant serum amyloid A in inflammation and other diseases. Adv Clin Chem 2019; 90:25-80. [PMID: 31122611 DOI: 10.1016/bs.acc.2019.01.002] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute-phase reactant serum amyloid A (A-SAA) plays an important role in acute and chronic inflammation and is used in clinical laboratories as an indicator of inflammation. Although both A-SAA and C-reactive protein (CRP) are acute-phase proteins, the detection of A-SAA is more conclusive than the detection of CRP in patients with viral infections, severe acute pancreatitis, and rejection reactions to kidney transplants. A-SAA has greater clinical diagnostic value in patients who are immunosuppressed, patients with cystic fibrosis who are treated with corticoids, and preterm infants with late-onset sepsis. Nevertheless, for the assessment of the inflammation status and identification of viral infection in other pathologies, such as bacterial infections, the combinatorial use of A-SAA and other acute-phase proteins (APPs), such as CRP and procalcitonin (PCT), can provide more information and sensitivity than the use of any of these proteins alone, and the information generated is important in guiding antibiotic therapy. In addition, A-SAA-associated diseases and the diagnostic value of A-SAA are discussed. However, the relationship between different A-SAA isotypes and their human diseases are mostly derived from research laboratories with limited clinical samples. Thus, further clinical evaluations are necessary to confirm the clinical significance of each A-SAA isotype. Furthermore, the currently available A-SAA assays are based on polyclonal antibodies, which lack isotype specificity and are associated with many inflammatory diseases. Therefore, these assays are usually used in combination with other biomarkers in the clinic.
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Affiliation(s)
- Yan Zhang
- Shanghai R&D Center, DiaSys Diagnostic Systems (Shanghai) Co., Ltd., Shanghai, China
| | - Jie Zhang
- Shanghai R&D Center, DiaSys Diagnostic Systems (Shanghai) Co., Ltd., Shanghai, China
| | - Huiming Sheng
- Department of Laboratory Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haichuan Li
- C.N. Maternity & Infant Health Hospital, Shanghai, China
| | - Rongfang Wang
- Shanghai R&D Center, DiaSys Diagnostic Systems (Shanghai) Co., Ltd., Shanghai, China.
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17
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Robertson MD, Pedersen C, Hinton PJ, Mendis ASJR, Cani PD, Griffin BA. Elevated high density lipoprotein cholesterol and low grade systemic inflammation is associated with increased gut permeability in normoglycemic men. Nutr Metab Cardiovasc Dis 2018; 28:1296-1303. [PMID: 30459055 DOI: 10.1016/j.numecd.2018.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Serum lipids and lipoproteins are established biomarkers of cardiovascular disease risk that could be influenced by impaired gut barrier function via effects on the absorption of dietary and biliary cholesterol. The aim of this study was to examine the potential relationship between gut barrier function (gut permeability) and concentration of serum lipids and lipoproteins, in an ancillary analysis of serum samples taken from a previous study. METHODS AND RESULTS Serum lipids, lipoproteins and functional gut permeability, as assessed by the percentage of the urinary recovery of 51Cr-labelled EDTA absorbed within 24 h, were measured in a group of 30 healthy men. Serum lipopolysaccharide, high sensitivity C-reactive protein and interleukin-6 were also measured as markers of low-grade inflammation. The group expressed a 5-fold variation in total gut permeability (1.11-5.03%). Gut permeability was unrelated to the concentration of both serum total and low density lipoprotein (LDL)-cholesterol, but was positively associated with serum high density lipoprotein (HDL)-cholesterol (r = 0.434, P = 0.015). Serum HDL-cholesterol was also positively associated with serum endotoxaemia (r = 0.415, P = 0.023). CONCLUSION The significant association between increased gut permeability and elevated serum HDL-cholesterol is consistent with the role of HDL as an acute phase reactant, and in this situation, potentially dysfunctional lipoprotein. This finding may have negative implications for the putative role of HDL as a cardio-protective lipoprotein.
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Affiliation(s)
- M D Robertson
- Nutritional Sciences, University of Surrey, Guildford, UK.
| | - C Pedersen
- Nutritional Sciences, University of Surrey, Guildford, UK
| | - P J Hinton
- Medical Physics, Royal Surrey County Hospital, Guildford, UK
| | - A S J R Mendis
- Nutritional Sciences, University of Surrey, Guildford, UK
| | - P D Cani
- WELBIO - Walloon Excellence in Life Sciences and BIOtechnology, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - B A Griffin
- Nutritional Sciences, University of Surrey, Guildford, UK
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18
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Egom EE, Shiwani HA, Pharithi RB, Canning R, Khan B, Hiani YE, Maher V. Dynamic changes of the composition of plasma HDL particles in patients with cardiac disease: Spotlight on sphingosine-1-phosphate/serum amyloid A ratio. Clin Exp Pharmacol Physiol 2017; 45:319-325. [DOI: 10.1111/1440-1681.12888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Emmanuel E Egom
- Department of Cardiology; The Adelaide and Meath Hospital Dublin; Incorporating the National Children Hospital; Dublin Ireland
| | - Haaris A Shiwani
- Department of Clinical Medicine; Education Division; Trinity College Dublin; The University of Dublin; Dublin Ireland
| | - Rebabonye B Pharithi
- Department of Cardiology; The Adelaide and Meath Hospital Dublin; Incorporating the National Children Hospital; Dublin Ireland
| | | | - Barkat Khan
- Department of Cardiology; The Adelaide and Meath Hospital Dublin; Incorporating the National Children Hospital; Dublin Ireland
| | - Yassine El Hiani
- Department of Physiology and Biophysics; Dalhousie University; Halifax Canada
| | - Vincent Maher
- Department of Cardiology; The Adelaide and Meath Hospital Dublin; Incorporating the National Children Hospital; Dublin Ireland
- Department of Clinical Medicine; Education Division; Trinity College Dublin; The University of Dublin; Dublin Ireland
- Institute of Technology Tallaght; Dublin Ireland
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19
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Ebtehaj S, Gruppen EG, Parvizi M, Tietge UJF, Dullaart RPF. The anti-inflammatory function of HDL is impaired in type 2 diabetes: role of hyperglycemia, paraoxonase-1 and low grade inflammation. Cardiovasc Diabetol 2017; 16:132. [PMID: 29025405 PMCID: PMC5639738 DOI: 10.1186/s12933-017-0613-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/04/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Functional properties of high density lipoproteins (HDL) are increasingly recognized to play a physiological role in atheroprotection. Type 2 diabetes mellitus (T2DM) is characterized by low HDL cholesterol, but the effect of chronic hyperglycemia on the anti-inflammatory capacity of HDL, a metric of HDL function, is unclear. Therefore, the aim of the present study was to establish the impact of T2DM on the HDL anti-inflammatory capacity, taking paraoxonase-1 (PON-1) activity and low grade inflammation into account. METHODS The HDL anti-inflammatory capacity, determined as the ability to suppress tumor necrosis factor-α (TNF-α) induced vascular cell adhesion molecule-1 (VCAM-1) mRNA expression in endothelial cells in vitro (higher values indicate lower anti-inflammatory capacity), PON-1 (arylesterase) activity, hs-C-reactive protein (hs-CRP), serum amyloid A (SAA) and TNF-α were compared in 40 subjects with T2DM (no insulin or statin treatment) and 36 non-diabetic subjects. RESULTS T2DM was associated with impaired HDL anti-inflammatory capacity (3.18 vs 1.05 fold increase in VCAM-1 mRNA expression; P < 0.001), coinciding with decreased HDL cholesterol (P = 0.001), apolipoprotein A-I (P = 0.038) and PON-1 activity (P = 0.023), as well as increased hs-CRP (P = 0.043) and TNF-α (P = 0.005). In all subjects combined, age- and sex-adjusted multivariable linear regression analysis demonstrated that impaired HDL anti-inflammatory capacity was associated with hyperglycemia (β = 0.499, P < 0.001), lower PON-1 activity (β = - 0.192, P = 0.030) and higher hs-CRP (β = 0.220, P = 0.016). CONCLUSIONS The HDL anti-inflammatory capacity is substantially impaired in T2DM, at least partly attributable to the degree of hyperglycemia, decreased PON-1 activity and enhanced low grade chronic inflammation. Decreased anti-inflammatory protection capacity of HDL conceivably contributes to the increased atherosclerosis risk associated with T2DM.
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Affiliation(s)
- Sanam Ebtehaj
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Eke G Gruppen
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Mojtaba Parvizi
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
| | - Uwe J F Tietge
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands.
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ, Groningen, The Netherlands
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