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Kashyap S, Zeidler JD, Chini CCS, Chini EN. Implications of the PAPP-A-IGFBP-IGF-1 pathway in the pathogenesis and treatment of polycystic kidney disease. Cell Signal 2020; 73:109698. [PMID: 32569826 DOI: 10.1016/j.cellsig.2020.109698] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 12/19/2022]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic diseases implicated in the development of end stage renal disease (ESRD). Although FDA has recently approved a drug against ADPKD, there is still a great need for development of alternative management strategies for ADPKD. Understanding the different mechanisms that lead to cystogenesis and cyst expansion in ADPKD is imperative to develop new therapies against ADPKD. Recently, we demonstrated that caloric restriction can prevent the development of cystic disease in animal models of ADPKD and through these studies identified a new role for pregnancy associated plasma protein-A (PAPP-A), a component of the insulin-like growth factors (IGF) pathway, in the pathogenesis of this disease. The PAPP-A-IGF pathway plays an important role in regulation of cell growth, differentiation, and transformation and dysregulation of this pathway has been implicated in many diseases. Several indirect studies support the involvement of IGF-1 in the pathogenesis of ADPKD. However, it was only recently that we described a direct role for a component of this pathway in pathogenesis of ADPKD, opening a new avenue for the therapeutic approaches for this cystic disease. The present literature review will critically discuss the evidence that supports the role of components of IGF pathway in the pathogenesis of ADPKD and discuss the pharmacological implications of PAPP-A-IGF axis in this disease.
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Affiliation(s)
- Sonu Kashyap
- Signal Transduction and Molecular Nutrition Laboratory, Kogod Aging Center, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Julianna D Zeidler
- Signal Transduction and Molecular Nutrition Laboratory, Kogod Aging Center, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Claudia C S Chini
- Signal Transduction and Molecular Nutrition Laboratory, Kogod Aging Center, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Eduardo Nunes Chini
- Signal Transduction and Molecular Nutrition Laboratory, Kogod Aging Center, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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2
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Kashyap S, Hein KZ, Chini CC, Lika J, Warner GM, Bale LK, Torres VE, Harris PC, Oxvig C, Conover CA, Chini EN. Metalloproteinase PAPP-A regulation of IGF-1 contributes to polycystic kidney disease pathogenesis. JCI Insight 2020; 5:135700. [PMID: 31990681 DOI: 10.1172/jci.insight.135700] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of end-stage renal disease (ESRD). The treatment options for ADPKD are limited. We observed an upregulation in several IGF-1 pathway genes in the kidney of Pkd1RC/RC mice, a model of ADPKD. Pregnancy-associated plasma protein A (PAPP-A), a metalloproteinase that cleaves inhibitory IGF binding proteins (IGFBPs), increasing the local bioactivity of IGF-1, was highly induced in the kidney of ADPKD mice. PAPP-A levels were high in cystic fluid and kidneys of humans with ADPKD. Our studies further showed that PAPP-A transcription in ADPKD was mainly regulated through the cAMP/CREB/CBP/p300 pathway. Pappa deficiency effectively inhibited the development of cysts in the Pkd1RC/RC mice. The role of PAPP-A in cystic disease appears to be regulation of the IGF-1 pathway and cellular proliferation in the kidney. Finally, preclinical studies demonstrated that treatment with a monoclonal antibody that blocks the proteolytic activity of PAPP-A against IGFBP4 ameliorated ADPKD cystic disease in vivo in Pkd1RC/RC mice and ex vivo in embryonic kidneys. These data indicated that the PAPP-A/IGF-1 pathway plays an important role in the growth and expansion of cysts in ADPKD. Our findings introduce a therapeutic strategy for ADPKD that involves the inhibition of PAPP-A.
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Affiliation(s)
- Sonu Kashyap
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
| | - Kyaw Zaw Hein
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
| | - Claudia Cs Chini
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
| | - Jorgo Lika
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
| | - Gina M Warner
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
| | - Laurie K Bale
- Division of Endocrinology and Metabolism, Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Vicente E Torres
- Division of Nephrology and Hypertension and Robert M. and Billie Kelley Pirnie Translational PKD Center, Rochester, Minnesota, USA
| | - Peter C Harris
- Division of Nephrology and Hypertension and Robert M. and Billie Kelley Pirnie Translational PKD Center, Rochester, Minnesota, USA
| | - Claus Oxvig
- Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark
| | - Cheryl A Conover
- Division of Endocrinology and Metabolism, Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Eduardo N Chini
- Department of Anesthesiology and Robert and Arlene Kogod Center on Aging
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3
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Szumska M, Damasiewicz-Bodzek A, Czubilińska J, Długaszek M, Gawlik K, Krywult A, Synowiec K, Wielkoszyński T, Tyrpień-Golder K. Pregnancy-Associated Plasma Protein A (PAPP-A) Concentration in Population of Healthy Young People: Interactions with Tobacco Smoke and Anti-oxidative Status. Cardiovasc Toxicol 2019; 19:120-128. [PMID: 30302668 PMCID: PMC6469831 DOI: 10.1007/s12012-018-9479-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pregnancy-associated plasma protein A (PAPP-A) is a high-molecular zinc-binding metalloproteinase that was first detected in the serum of pregnant women. It can also be detected in men and non-pregnant women. Recently, a growing interest in determining the concentration of PAPP-A as a marker of oxidative stress and atherosclerotic processes has been observed. Among the factors that could potentially influence the PAPP-A formation is the exposure to tobacco smoke. Some components of tobacco smoke have an immediate effect on the body and also direct influence on the cardiovascular system. The aim of this study was to evaluate the relation between PAPP-A concentration and either passive or active exposure to tobacco smoke in the population of medicine students (n = 152). The relation between PAPP-A concentration and chosen markers of inflammatory response and anti-oxidative processes was analyzed. The samples of serum, urine, and saliva were collected and main nicotine metabolites in urine samples were determined using ELISA technique. Comparison of the PAPP-A concentrations in the study group revealed that in the group of active smokers, the concentration of the protein was significantly higher than in the group of passive smokers (p = .04) and the group of not-exposed students (p = .006). PAPP-A concentration showed significant positive correlation with the values of FRAP and main nicotine metabolites. The evident influence of both active and passive tobacco smoke exposure on PAPP-A levels in the studied population of young people who in general are not included in the group of high-risk cardiovascular incidents, shows how important early prevention of anti-health behaviors is.
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Affiliation(s)
- Magdalena Szumska
- Department of Chemistry, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Aleksandra Damasiewicz-Bodzek
- Department of Chemistry, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Justyna Czubilińska
- Students Research Group of Chair and Department of Chemistry, Zabrze, Poland
| | - Michał Długaszek
- Students Research Group of Chair and Department of Chemistry, Zabrze, Poland
| | - Kaja Gawlik
- Students Research Group of Chair and Department of Chemistry, Zabrze, Poland
| | - Anna Krywult
- Students Research Group of Chair and Department of Chemistry, Zabrze, Poland
| | - Konrad Synowiec
- Students Research Group of Chair and Department of Chemistry, Zabrze, Poland
| | - Tomasz Wielkoszyński
- Analytical-Bacteriological Laboratory, NZOZ, Pulmonology Unit, Tarnowskie Góry, Poland
| | - Krystyna Tyrpień-Golder
- Department of Chemistry, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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Nilsson E, Rudholm T, Stenvinkel P, Ärnlöv J. Pregnancy-associated plasma protein A and mortality in haemodialysis. Eur J Clin Invest 2018; 48:e12959. [PMID: 29802620 DOI: 10.1111/eci.12959] [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: 01/31/2018] [Accepted: 05/23/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Elevated pregnancy-associated plasma protein A (PAPP-A) levels are associated with increased risk of death in ischaemic heart disease as well as in haemodialysis patients. Previous research indicates that the prognostic value of PAPP-A may be stronger in patients with concomitant diabetes mellitus or signs of inflammation. We studied the association between PAPP-A and outcomes in prevalent haemodialysis patients and hypothesized that diabetes mellitus and inflammation status act as effect modifiers. MATERIALS AND METHODS Circulating PAPP-A levels were quantified using ELISA. Cox proportional hazards and quantile regression models were used for associations between PAPP-A and mortality. PAPP-A levels were log-transformed for Normality. RESULTS During 60-month follow-up, 37 (40%) of the 92 participants died. Higher PAPP-A was associated with increased risk of mortality in unadjusted analysis (HR per SD = 1.4, 95% CI = 1-1.9, P = .03) and when adjusted for confounders and cardiovascular risk factors (HR = 1.8, 95% CI = 1.18-2.73, P = .006). An interaction between PAPP-A levels and diabetes mellitus on mortality was found (HR for the multiplicative interaction term = 2.74 95% CI = 1.02-7.37, P = .05). In a quantile regression adjusted for age and sex, one SD increase in PAPP-A was associated with 22 months shorter estimated time until 25% of the patients died (95% CI -35 to -9.1 months). CONCLUSIONS Increased PAPP-A levels are associated with higher all-cause mortality in prevalent haemodialysis patients with concomitant diabetes mellitus.
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Affiliation(s)
- Erik Nilsson
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Tobias Rudholm
- Department of Medical Sciences/Cardiovascular epidemiology, Uppsala University, Uppsala, Sweden.,School of Health and Social Studies, Dalarna University, Falun, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ärnlöv
- School of Health and Social Studies, Dalarna University, Falun, Sweden.,Division of Family Medicine and Primary Care, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Huddinge, Sweden
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Kalousov¡ M, Lachmanov¡ J, Mokrejšov¡ M, Míkov¡ B, Fialov¡ L, Malbohan I, Tesař V, Zima T. Pregnancy-Associated Plasma Protein a during Hemodialysis with Polyamide and Diacetate Cellulosic Membranes. Int J Artif Organs 2018. [DOI: 10.1177/039139880402701106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pregnancy-associated plasma protein A (PAPP-A) is a new prognostic factor of acute coronary syndrome in the general population. It is elevated in hemodialysis (HD) patients and at baseline, it was shown to be related to inflammation and oxidative stress. The aim of the study was to examine the relationship of PAPP-A and oxidative stress and inflammatory markers to HD treatment. Studied parameters were determined in 10 chronic HD patients treated with low flux polyamide (1st session) and diacetate cellulosic membranes (2nd session) at the beginning, after 15 minutes and at the end of the dialysis session. TRACE method (Time Resolved Amplified Cryptate Emission) was used for PAPP-A assessment. Results were evaluated with ANOVA. PAPP-A levels did not depend on the type of HD membrane but changed significantly with the time of the HD session. They increased significantly from the beginning of HD to 15 min and then decreased to the end of the HD session – p<0.05 15 min of HD vs start, p<0.01 end vs start, p<0.0001 end vs 15 min of HD for polyamide membrane and p=0.05 15 min of HD vs start, p<0.01 end vs start, p<0.0001 end vs 15 min of HD for diacetate cellulosic membrane. Changes in other parameters and differences between membranes were only minimal. We can conclude that PAPP-A as a marker of cardiovascular damage shows significant changes during the HD session. Its initial increase might be ascribed to its release from complexes or storage. During dialysis, it might be destroyed or cleaved and removed as free fragments. Its levels both before and after the HD session are higher than in healthy subjects.
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Affiliation(s)
- M. Kalousov¡
- Institute of Medical Biochemistry
- Institute of Clinical Chemistry and Laboratory Diagnostics
| | - J. Lachmanov¡
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague - Czech Republic
| | - M. Mokrejšov¡
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague - Czech Republic
| | - B. Míkov¡
- Railway Hospital, Prague - Czech Republic
| | | | - I.M. Malbohan
- Institute of Medical Biochemistry
- Institute of Clinical Chemistry and Laboratory Diagnostics
| | - V. Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague - Czech Republic
| | - T. Zima
- Institute of Clinical Chemistry and Laboratory Diagnostics
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6
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Kalousová M, Dusilová-Sulková S, Kuběna AA, Zakiyanov O, Levová K, Bocková M, Gedeonová E, Song XC, Ermini ML, Špringer T, Homola J, Tesař V, Zima T. Pregnancy-Associated Plasma Protein A2 in Hemodialysis Patients: Significance for Prognosis. Kidney Blood Press Res 2017; 42:509-518. [PMID: 28854436 DOI: 10.1159/000479847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/19/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPP-A) is associated with adverse outcome of long-term hemodialysis patients (HD). The aim of the study was to test whether its homolog pregnancy-associated plasma protein A2 (PAPP-A2) can be detected in serum of HD patients and to define its significance. METHODS The studied group consisted of 102 long-term HD patients and 25 healthy controls. HD patients were prospectively followed up for five years (2009-2014). PAPP-A2 was measured by surface plasmon resonance biosensor, PAPP-A by time resolved amplified cryptate emission. RESULTS PAPP-A2, similarly as PAPP-A, was significantly increased in HD patients (median (interquartile range)) PAPP-A2: 6.2 (2.6-10.8) ng/mL, vs. 3.0 (0.7-5.9) ng/mL, p=0.006; PAPP-A: 18.9 (14.3-23.4) mIU/L, vs. 9.5 (8.4-10.5) mIU/L, p<0.001). In HD patients, PAPP-A2 correlated weakly but significantly with PAPP-A (τ=0.193, p=0.004). Unlike PAPP-A, PAPP-A2 was not significant for prognosis of HD patients when tested alone. There was a significant interaction between PAPP-A and PAPP-A2 on the mortality due to infection of HD patients (p=0.008). If PAPP-A was below median, mortality due to infection was significantly higher for patients with PAPP-A2 values above median than for patients with low PAPP-A2 levels (p=0.011). CONCLUSION PAPP-A2 is increased in HD patients and interacts with PAPP-A on patients´ prognosis.
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Affiliation(s)
- Marta Kalousová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | | | - Aleš A Kuběna
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Oskar Zakiyanov
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Kateřina Levová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Markéta Bocková
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Erika Gedeonová
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Xue Chadtová Song
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Maria Laura Ermini
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Tomáš Špringer
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Jiří Homola
- Institute of Photonics and Electronics of the CAS, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Tomáš Zima
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Pregnancy-associated plasma protein-A predicts survival in end-stage renal disease—confounding and modifying effects of cardiovascular disease, body composition and inflammation. Nephrol Dial Transplant 2017; 33:971-977. [DOI: 10.1093/ndt/gfx215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
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Jefferies HJ, Tertti R, Wittfooth S, Burton JO, Metsärinne K, Pettersson K, McIntyre CW. Elevated serum free pregnancy-associated plasma protein-A independently predicts mortality in haemodialysis patients but is not associated with recurrent haemodialysis-induced ischaemic myocardial injury. Nephron Clin Pract 2015; 129:171-8. [PMID: 25766334 DOI: 10.1159/000369557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 11/04/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Pregnancy-associated plasma protein-A (PAPP-A) is a putative marker of atheroma instability and ischaemic myocardial stress prior to necrosis. Total PAPP-A (tPAPP-A) levels in acute coronary syndromes predict adverse outcomes. However, free PAPP-A (fPAPP-A) predominates in the circulation. Ischaemic haemodialysis (HD)-induced cardiac injury (myocardial stunning) is common and is associated with markers of myocardial necrosis, inflammation, cardiovascular events and mortality. Coronary plaque instability in pathophysiology of HD-induced myocardial stunning has not been studied. We aimed to investigate the relationship of fPAPP-A with stunning and mortality. METHODS 130 prevalent patients from two HD centres (Finland and UK) were studied. Pre-HD free, complexed and total PAPP-A were measured by immunoassay. A subset of 62 patients underwent echocardiography to assess HD-induced myocardial stunning. The mean duration of follow-up was 407 ± 98 days. RESULTS fPAPP-A was elevated (median: 3.45 mIU/l) and correlated with dialysis vintage (r = 0.391, p < 0.001), cardiac troponin T (cTnT; r = 0.29, p = 0.001) and cardiac troponin I (cTnI; r = 0.22, p = 0.01). PAPP-A was not related to stunning. Dialysis vintage and cTnT independently predicted Ln fPAPP-A (model R = 0.463). fPAPP-A, cTnT and age independently predicted death (Nagelkerke R(2) = 0.362). CONCLUSIONS fPAPP-A, a novel predictor of HD-related mortality, demonstrates better prognostic power than tPAPP-A. Coronary plaque instability may contribute to sub-lethal myocardial injury, but may not be critical in pathogenesis of HD-induced ischaemic cardiac injury.
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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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10
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Abstract
Pregnancy-associated plasma protein A (PAPP-A) is a key regulator of insulin-like growth factor bioavailability essential for normal fetal development. In maternal blood, this protein increases with gestational age and then rapidly decreases after delivery. It is routinely used for Down syndrome screening in the first trimester of pregnancy, and its decrease compared to a normal pregnancy indicates an increased risk for both chromosomal anomalies and adverse pregnancy outcomes. It belongs to a group of biomarkers that predict later preeclampsia development, primarily early onset preeclampsia; however, it should be combined with a Doppler ultrasonography of the uterine artery (pulsatile index) and other biochemical and maternal factors to achieve a higher detection rate with an acceptable false positivity rate. Some studies have demonstrated an even more pronounced decrease of PAPP-A in the early second trimester of pregnancy in women who subsequently develop preeclampsia compared with women who do not develop preeclampsia. Conversely, during the last trimester of pregnancy, its concentration increases even more in patients with preeclampsia than in patients without. It is also detectable at very low levels in nonpregnant individuals, and a higher concentration indicates an adverse effect in patients with acute coronary syndromes or stable atherosclerotic disease and in patients with end-stage renal disease who are being treated with hemodialysis.
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11
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Li Y, Zhou C, Zhou X, Song L, Hui R. PAPP-A in cardiac and non-cardiac conditions. Clin Chim Acta 2012; 417:67-72. [PMID: 23262366 DOI: 10.1016/j.cca.2012.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 12/06/2012] [Accepted: 12/09/2012] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated plasma protein-A (PAPP-A), a newly discovered member of insulin like growth factors (IGFs) axis, has been reported to be a biomarker in both cardiac and non-cardiac conditions. PAPP-A mainly acts as a protease cleaving IGF inhibitors - IGF binding proteins (IGFBPs), thereby setting free IGFs. In cardiac conditions, PAPP-A plays an important role in progressive atherosclerosis. As a biomarker, PAPP-A is not only sensitive, specific and early for diagnosis of acute coronary syndrome, but also an independent risk factor for all-cause mortality or combined cardiovascular events. In non-cardiac conditions, PAPP-A is a new anti-aging target. PAPP-A knock out (KO) mice have a prolonged lifespan than the wild type. In addition, PAPP-A is also a biomarker associated with malignant cancer and end stage renal disease.
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Affiliation(s)
- Yuehua Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
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Míková B, Jarolímková E, Benáková H, Dohnal L, Tesař V, Zima T, Kalousová M. Pregnancy-associated plasma protein A (PAPP-A) and soluble receptor for advanced glycation end products (sRAGE) – intra- and inter-individual variability in chronic hemodialysis patients. Scand J Clin Lab Invest 2012; 72:296-303. [DOI: 10.3109/00365513.2012.663099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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13
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Kalousová M, Benáková H, Kuběna AA, Dusilová-Sulková S, Tesař V, Zima T. Pregnancy-associated plasma protein A as an independent mortality predictor in long-term hemodialysis patients. Kidney Blood Press Res 2011; 35:192-201. [PMID: 22123284 DOI: 10.1159/000332086] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 08/23/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Pregnancy-associated plasma protein A (PAPP-A) is a biomarker related to vascular damage. The aim of the study was to focus on PAPP-A and related parameters and their relationship to the prognosis of long-term hemodialysis (HD) patients. METHODS This is a prospective observational cohort study which included 261 long-term HD patients followed up for 5 years and 66 healthy subjects. PAPP-A, placental growth factor (PlGF), matrix metalloproteinase 2 and 9 (MMP-2, MMP-9), insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein-4 (IGFBP-4), and cardiac, nutritional and inflammatory parameters were measured at the beginning of the study and tested as predictors of mortality. RESULTS PAPP-A, PlGF, IGF-1, IGFBP-4 and MMP-2 were significantly increased in HD patients compared to controls (PAPP-A 27.6 ± 15.5 mIU/l in HD vs. 9.4 ± 2.5 mIU/l in controls, p < 0.001). Increased PAPP-A was a significant independent predictor of overall mortality and mortality due to infection in the multivariate Cox analysis [HR (95% CI): 1.237 (1.060-1.444), p = 0.007, and 1.416 (1.115-1.798), p = 0.004, per standard deviation, respectively]. PAPP-A was not related to cardiovascular mortality. CONCLUSION Increased PAPP-A is a significant independent predictor of overall mortality and mortality due to infection but it was not related to cardiovascular mortality in this study.
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Affiliation(s)
- Marta Kalousová
- Institute of Clinical Biochemistry and Laboratory Diagnostics, Charles University and General University Hospital, Prague, Czech Republic.
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Muravská A, Germanová A, Jáchymová M, Hájek Z, Svarcová J, Zima T, Kalousová M. Association of pregnancy-associated plasma protein A polymorphism with preeclampsia - a pilot study. Clin Biochem 2011; 44:1380-4. [PMID: 21986593 DOI: 10.1016/j.clinbiochem.2011.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 09/11/2011] [Accepted: 09/22/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of the study was to investigate genetic and biochemical background of PAPP-A (pregnancy-associated plasma protein A) in patients with risk pregnancies. DESIGN AND METHODS Five PAPP-A gene polymorphisms and PAPP-A maternal serum levels were studied together in 165 women in third trimester pregnancies complicated with threatening preterm labor (n=98), preeclampsia (n=35), intrauterine growth restriction (n=34) and ICP (intrahepatic cholestasis of pregnancy) (n=15). 114 healthy pregnant women served as controls. RESULTS Preeclamptic patients had significantly higher frequency of TT genotype of Cys327Cys polymorphism compared to controls (p<0.01). Patients with ICP had increased serum levels of PAPP-A compared to controls and correlation analysis showed significant relationship between PAPP-A and CRP (C-reactive protein) in the patients with intrauterine growth restriction (r=0.49, p=0.007). CONCLUSION Our study indicates the association of TT genotype of Cys327Cys polymorphism of the PAPP-A gene with preeclampsia. However, further study with larger groups of preeclamptic patients is needed to confirm our results.
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Affiliation(s)
- Alexandra Muravská
- Institute of Clinical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U nemocnice 2, 128 08 Prague, Czech Republic
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Hodkova M, Kalousova M, Dusilova-Sulkova S, Malbohan IM, Zima T. Intravenous Iron Gluconate Administration Increases Circulating PAPP-A in Hemodialysis Patients. Ren Fail 2009; 27:707-11. [PMID: 16350822 DOI: 10.1080/08860220500242868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Pregnancy-associated plasma protein-A (PAPP-A) is a proatherosclerotic molecule, interrelated with oxidative stress in hemodialysis (HD) patients. As intravenous (IV) iron might enhance oxidative stress in HD patients, this study investigates circulating PAPP-A during HD session and after IV iron administration. METHODS In 20 HD patients, plasma PAPP-A concentration was assessed immunochemically during 2 HD sessions (prior to HD and at 60, 130, and 240 min of HD session). Sodium ferric gluconate (62.5 mg) was given IV to all patients 65 min after the start of the second HD. RESULTS Sixty-five min after IV iron application, there was a significant increase in plasma PAPP-A (from 36.0+/-9.9 to 79.6+/-28.9 mU/L, p<0.0001). At the end of this HD session, PAPP-A decreased significantly (p<0.0001), but still remained 1.5-fold greater compared with predialysis levels (p<0.0005). CONCLUSION IV iron increases circulating PAPP-A, and in this way, it might contribute to more pronounced cardiovascular complications in HD patients.
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Affiliation(s)
- Magdalena Hodkova
- Institute of Medical Biochemistry, Ist Faculty of Medicine, Charles University, Prague, Czech Republic.
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Tertti R, Wittfooth S, Porela P, Airaksinen KE, Metsärinne K, Pettersson K. Intravenous administration of low molecular weight and unfractionated heparin elicits a rapid increase in serum pregnancy-associated plasma protein A. Clin Chem 2009; 55:1214-7. [PMID: 19325014 DOI: 10.1373/clinchem.2008.108738] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a useful diagnostic and prognostic marker in acute coronary syndromes. Because low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are commonly used in these cases, we analyzed the effects of intravenous administration of these heparins on serum PAPP-A concentrations. METHODS Serum concentrations of total and free PAPP-A were analyzed in 14 patients on chronic hemodialysis and in 10 coronary angiography patients. Ten of the dialysis patients received standard LMWH anticoagulation at the start of dialysis, and 4 were treated with a heparin-free method. Two of the patients on heparin-free hemodialysis received a reduced LMWH bolus 2 h after the start of dialysis. All angiography patients received UFH at the start of the procedure, and 1 patient received 2 extra boluses of UFH. Serum PAPP-A concentrations were analyzed before and during the dialysis session and during the coronary angiography examination. RESULTS A rapid increase in total PAPP-A (median, 25-fold) was seen in all patients within 5 min of administration for both LMWH and UFH boluses. This response was due to an increase in free PAPP-A in the serum. PAPP-A did not increase significantly in the patients who underwent heparin-free hemodialysis. Repeated heparin boluses induced a new PAPP-A release. In vitro addition of heparins to samples of whole blood did not increase PAPP-A concentrations. CONCLUSIONS Intravenous administration of heparin induces an intense and rapid increase in free PAPP-A in the serum. We recommend that this effect be considered when PAPP-A is assessed as a biomarker in acute coronary syndromes.
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Affiliation(s)
- Risto Tertti
- Department of Internal Medicine, Turku University Hospital, Turku, Finland.
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Coskun A, Duran S, Apaydin S, Bulut I, Sariyar M. Pregnancy-Associated Plasma Protein-A: Evaluation of a New Biomarker in Renal Transplant Patients. Transplant Proc 2007; 39:3072-6. [DOI: 10.1016/j.transproceed.2007.08.111] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 08/21/2007] [Indexed: 10/22/2022]
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Kalousová M, Hodková M, Dusilová-Sulková S, Uhrová J, Tesar V, Zima T. Effect of hemodiafiltration on pregnancy-associated plasma protein A (PAPP-A) and related parameters. Ren Fail 2007; 28:715-21. [PMID: 17162432 DOI: 10.1080/08860220600925412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Dialysis patients are at high risk of vascular/cardiovascular complications with multifactorial pathogenesis, and pregnancy-associated plasma protein A (PAPP-A) is one of the new markers related to cardiovascular risk. Because hemodiafiltration (HDF) is supposed to be better for cardiovascular status, the aim of this study was to describe whether it has any advantage concerning changes of PAPP-A and related molecules during the session in comparison with hemodialysis (HD). METHODS The studied group consisted of 20 chronic hemodialysis patients. In each patient, PAPP-A and related parameters-IGFBP-4 (insulin like growth factor binding protein), IGF-I (insulin like growth factor), and two MMPs (matrix metalloproteinases)-2 and 9-were determined both during a single online HDF session (high-flux polysulfone membrane HF80, postdilution) and during a single HD session (low-flux polysulfone membrane F6, F7) at time 0 (start), 15 min, 120 min, and 240 min (end) of the session. RESULTS PAPP-A, elevated at baseline in dialysis patients, changes significantly both during HDF and HD without significant differences between these two procedures (mean levels during HDF were 24.3, 53.9, 24.3, and 27.3 mIU/L). It increases more than two-fold from 0 to 15 min of the session (p < 0.001) and then decreases until the end of the session (p < 0.001). MMP-2 decreased slightly during both sessions (p < 0.001), and changes of other molecules were only minimal. CONCLUSION A single HDF session compared to HD has no advantage in the decrease of PAPP-A and other tested molecules, all of them related to cardiovascular risk. Studies aimed at a long-term effect of both procedures on these parameters would be needed to further evaluate these therapeutical strategies.
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Affiliation(s)
- Marta Kalousová
- Institute of Clinical Chemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University and General University Hospital, Karlovo nám. 32, 121 11 Prague 2, Czech Republic.
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Kalousová M, Bartosová K, Zima T, Skibová J, Teplan V, Viklický O. Pregnancy-associated plasma protein a and soluble receptor for advanced glycation end products after kidney transplantation. Kidney Blood Press Res 2007; 30:31-7. [PMID: 17237617 DOI: 10.1159/000098811] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Accepted: 12/08/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPP-A) and soluble receptor for advanced glycation end products (sRAGE) are new markers related to vascular damage. METHODS Thirty-one patients who had undergone kidney transplantation (TX) in the year 2005 under tacrolimus-based immunosuppression were included in this prospective single-center study. PAPP-A and sRAGE were determined before TX and 2 and 6 weeks and 3 months after TX. The results were correlated with the 3-month protocol kidney graft biopsy findings. RESULTS Both PAPP-A and sRAGE decreased after TX (mean values in serum: PAPP-A 20.8, 13.7, 12.1, and 10.7 mIU/l, respectively, before and 2 and 6 weeks and 3 months after TX, p < 0.001; sRAGE 4,403.4, 2,512.7, 1,909.0, and 1,817.6 pg/ml, respectively, before and 2 and 6 weeks and 3 months after TX, p < 0.001) and were correlated with the graft function (PAPP-A vs. modification of diet in renal disease formula r = -0.52, p < 0.001; sRAGE vs. modification of diet in renal disease formula r = -0.54, p < 0.001). Additionally, the PAPP-A levels correlated with interstitial inflammation (r = 0.57, p < 0.05) and vascular intimal thickening (r = 0.47, p < 0.05), while sRAGE correlated with arteriolar hyalinosis (r = 0.49, p < 0.05). CONCLUSIONS Our study demonstrates the role of the kidney in the metabolism and/or the removal of PAPP-A and sRAGE. After successful TX, these substances decrease, and, on the contrary, early chronic vascular changes in the kidney TX are associated with elevation of their serum levels.
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Affiliation(s)
- Marta Kalousová
- Institute of Clinical Chemistry and Laboratory Diagnostics, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
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Coskun A, Bicik Z, Duran S, Alcelik A, Soypacaci Z, Yavuz O, Oksuz S. Pregnancy-associated plasma protein A in dialysis patients. Clin Chem Lab Med 2007; 45:63-6. [PMID: 17243917 DOI: 10.1515/cclm.2007.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pregnancy-associated plasma protein A (PAPP-A) was recently described as a new marker of cardiovascular events and of inflammation in uremic patients. The aim of this study was to determine levels of PAPP-A in chronic dialysis patients and its possible relationships with renal osteodystrophy. METHODS A total of 99 adult chronic hemodialysis patients, 14 peritoneal dialysis patients and 41 control subjects were included in the study. Serum PAPP-A, intact parathormone (iPTH), calcium, phosphorus and alkaline phosphatase (ALP) were measured. The correlations between PAPP-A and iPTH, calcium, phosphorus and ALP were determined. RESULTS PAPP-A levels were significantly higher in peritoneal dialysis [4.5 (3.2-6.7) mU/L, median (interquartile range)], and hemodialysis patients [4.7 (3.8-6.5) mU/L] in comparison to control subjects [3.4 (3.0-5.0) mU/L] (p<0.05). In hemodialysis patients, post-dialysis PAPP-A levels [6.2 (4.7-9.4) mU/L] were significantly higher than pre-dialysis levels [4.7 (3.8-6.5) mU/L] (p<0.05). There was a weak but statistically significant positive correlation between serum PAPP-A and iPTH (r=0.216; p=0.041) and ALP (r=0.205; p=0.044) in the hemodialysis group. Correlation between the duration of dialysis therapy and PAPP-A levels was also significant (r=0.267; p=0.008) in the hemodialysis group. CONCLUSIONS PAPP-A levels are elevated in acute coronary syndromes and are closely related to inflammation and oxidative stress. We conclude that PAPP-A levels are increased in dialysis patients and may reflect a greater degree of chronic inflammation than osteodystrophy in uremic patients.
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Affiliation(s)
- Abdurrahman Coskun
- Department of Clinical Biochemistry, Duzce University, School of Medicine, Duzce, Turkey.
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Roberts MA, Hare DL, Ratnaike S, Ierino FL. Cardiovascular Biomarkers in CKD: Pathophysiology and Implications for Clinical Management of Cardiac Disease. Am J Kidney Dis 2006; 48:341-60. [PMID: 16931208 DOI: 10.1053/j.ajkd.2006.06.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 06/05/2006] [Indexed: 12/31/2022]
Abstract
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with all forms of chronic kidney disease (CKD). The underlying pathological state is caused by a complex interplay of traditional and nontraditional risk factors that results in atherosclerosis, arteriosclerosis, and altered cardiac morphological characteristics. This multifactorial disease introduces new challenges in predicting and treating patients with CVD sufficiently early in the course of CKD to positively alter patient outcome. Asymptomatic individuals with progressive CVD are a group of patients that deserve focused attention because early detection and intervention may provide the best opportunity for improved outcome. However, identifying CVD in asymptomatic patients with CKD or end-stage renal disease remains a significant hurdle in the management of these patients. Recently, a number of cardiovascular biomarkers were identified as predictors of patient outcome in individuals with CVD and, with additional research, may be used to guide the early diagnosis of and therapy for CVD in patients with CKD. This review examines the pathophysiological characteristics and potential clinical role of these novel cardiovascular biomarkers in risk stratification, risk monitoring, and selection of preventive therapies for patients with CKD.
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Affiliation(s)
- Matthew A Roberts
- Department of Nephrology, Division of Laboratory Medicine, Austin Health, University of Melbourne, Victoria, Australia
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Lauzurica R, Pastor C, Bayés B, Hernández JM, Romero R. Pretransplant Pregnancy-Associated Plasma Protein-A as a Predictor of Chronic Allograft Nephropathy and Posttransplant Cardiovascular Events. Transplantation 2005; 80:1441-6. [PMID: 16340789 DOI: 10.1097/01.tp.0000185199.67531.1a] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease and chronic allograft nephropathy (CAN) are two of the main complications observed in patients after renal transplantation. Both appear to be manifestations of the same process, in which inflammation plays a determinate role. Pregnancy-associated plasma protein A (PAPP-A) has been shown to be a marker of acute coronary syndrome and cardiovascular pathology. The objective of this study was to demonstrate whether or not serum concentration of pretransplant PAPP-A is a marker of CAN and a predictor of posttransplant cardiovascular events. METHODS In all, 178 renal transplants (65% males; 53+/-12 years of age) followed up over the course of 49.3+/-33.6 months were used in this study. During the follow-up period, 19 patients developed CAN (diagnosed by renal biopsy) and 27 patients had a cardiovascular event. Previous to transplantation, the following were determined: ultrasensitive C-reactive protein (CRP) (nephelometry); interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) (immunofluorimetric automatized method), and ultrasensitive PAPP-A (ELISA). RESULTS A positive correlation was found between PAPP-A and the inflammatory markers (PAPP-A vs. CRP, r=0.218; P=0.004; PAPP-A vs. IL-6, r=0.235; P<0.001; PAPP-A vs. TNF-alpha, r=0.372; P<0.001). The multiple regression analysis showed PAPP-A (relative risk [RR]: 6.4; 95% confidence interval [CI]:1.24-33.11; P=0.027) and CRP (RR: 6.05; 95% CI:1.21-29.74; P=0.028) to be predictors of posttransplant cardiovascular events and PAPP-A (RR: 4.27; 95% CI: 1.03-17.60; P=0.044) and TNF-alpha (RR: 5.6; 95% CI: 1.43-21.83; P=0.013) to be predictors of CAN. CONCLUSIONS PAPP-A correlated with the inflammatory markers studied (CRP, IL-6 and TNF-alpha). Pretransplant serum concentration of PAPP-A is a predictor of posttransplant cardiovascular events and CAN.
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Affiliation(s)
- Ricardo Lauzurica
- Department of Nephrology, Hospital Universitario Germans Trias i Pujol, Badalona, Spain.
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