Cardio-Renal Biomarker Soluble Urokinase-Type Plasminogen Activator Receptor Is Associated With Cardiovascular Death and Myocardial Infarction in Patients With Coronary Artery Disease Independent of Troponin, C-Reactive Protein, and Renal Function

suPAR in cardiovascular disease

Soluble urokinase plasminogen activator receptor (suPAR), the soluble counterpart of urokinase plasminogen activator receptor, is found in the circulation at various levels. suPAR and its parent molecule, cell surface uPAR, exhibit similar structure and extracellular functional roles facilitating fibrinolysis, cellular adhesion, and migration. Studies have assessed the correlation between suPAR in cardiovascular disease (CVD). It is postulated that suPAR may serve as an indicator of inflammatory activation and burden during CVD progression. Increased suPAR independently predicts poorer outcomes in acute coronary syndromes, in heart failure, as well as in coronary artery disease and atherosclerosis. To guide translation into clinical utization, suPAR has been assessed in numerous CVD settings for improved risk discrimination independently or in association with established traditional risk factors. Whilst the involvement of suPAR has been explored in other diseases such as kidney diseases and cancer, there is only emerging evidence of suPAR's mechanistic involvement in cardiovascular disease. In this review, we provide a background into suPAR and its potential role as a biomarker in CVD.

Soluble urokinase plasminogen activator receptor is associated with cardiovascular calcification in peritoneal dialysis patients

BACKGROUND

Cardiovascular disease (CVD) is an important cause of morbidity and mortality in peritoneal dialysis (PD) patients. Cardiovascular calcification (CVC) is highly prevalent in PD patients and could predict their cardiovascular mortality. Soluble urokinase plasminogen activator receptor (suPAR) is closely associated with coronary artery calcification in hemodialysis patients and is an important predictor of CVD. However, the role of suPAR in PD patients is poorly understood. We investigated the relationship between serum suPAR and CVC in PD patients.

METHODS

Abdominal aortic calcification (AAC) was assessed by lateral lumbar radiography, coronary artery calcification (CAC) by multi-slice computed tomography, and cardiac valvular calcification (ValvC) by echocardiography. CVC was defined as confirmed presence of calcification in one site (AAC, CAC, or ValvC). Patients were divided into CVC group and non-CVC group. Demographic characteristics, biochemical variables, comorbidities, PD regimen, serum suPAR, and medication were compared between the two groups. Logistic regression was conducted to determine association between serum suPAR and presence of CVC. The receiver-operator curve (ROC) was plotted to calculate the area under the curve (AUC) for suPAR to identify CVC and ValvC.

RESULTS

Of 226 PD patients, 111 (49.1%) had AAC, 155 (68.6%) had CAC, and 26 (11.5%) had ValvC. There were significant differences in age, BMI, diabetes, white blood cell, phosphorus, hs-CRP, suPAR, time on dialysis, total volume of dialysate, ultrafiltration, volume of urine, and Kt/V between CVC and non-CVC group. Serum suPAR was associated with CVC by multivariate logistic regression analysis in PD patients, especially in elderly patients. The levels of serum suPAR were closely related to the degree of AAC, CAC, and ValvC in PD patients. The incidence of CVC was higher in patients with higher levels of suPAR. The ROC curve showed that serum suPAR had a predictive value for CVC (AUC = 0.651), especially for ValvC (AUC = 0.828).

CONCLUSION

Cardiovascular calcification is prevalent in PD patients. High levels of serum suPAR are associated with cardiovascular calcification in PD patients, especially in elderly patients.

Role of Soluble Urokinase-Type Plasminogen Activator Receptor in Cardiovascular Disease

PURPOSE OF REVIEW

Chronic inflammation is a major contributor to cardiovascular disease (CVD) risk. Soluble urokinase plasminogen activator receptor (suPAR) is an immune-derived glycoprotein that is strongly associated with atherosclerotic disease. This review summarizes evidence on suPAR's role in CVD pathogenesis and its potential as a prognostic indicator and therapeutic target.

RECENT FINDINGS

Clinical, genetic, and experimental evidence supports suPAR's role as a pathogenic factor in atherosclerosis. suPAR promotes atherosclerosis through modulation of monocyte activation and function. Clinically, elevated suPAR levels are linked to increased cardiovascular risk across diverse populations. Ongoing clinical trials are evaluating therapies targeting suPAR signaling. Current evidence positions suPAR as a regulator of myeloid cell function that contributes to vascular inflammation and subsequent cardiovascular events. Additional research is needed to determine whether suPAR measurement can improve CVD risk prediction and enable personalized management. Overall, suPAR is a promising immune-derived biomarker and target for reducing inflammation and cardiovascular risk.

A comprehensive review of acute cardio-renal syndrome: need for novel biomarkers

Cardiorenal syndrome represents a wide-spectrum disorder involving the heart and kidneys as the primary affected organs. India has an increasingly high burden of acute CRS, coinciding with the rise in global statistics. Up to 2022, approximately 46.1% of all cardiorenal patients have been diagnosed with acute CRS in India. Acute CRS involves a sudden deterioration of kidney functionalities, referred to as acute kidney injury (AKI) in acute heart failure patients. The pathophysiology of CRS involves hyperactivation of the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS) following acute myocardial stress. The pathological phenotype of acute CRS is associated with perturbed inflammatory, cellular, and neurohormonal markers in circulation. These complications increase the risk of mortality in clinically diagnosed acute CRS patients, making it a worldwide healthcare burden. Hence, effective diagnosis and early prevention are crucial to prevent the progression of CRS in AHF patients. Present biomarkers, such as serum creatinine (sCr), cystatin C (CysC), glomerular filtration rate (GFR), blood urea nitrogen (BUN), serum and/or urine neutrophil gelatinase-associated lipocalin (NGAL), B-type natriuretic peptide (BNP), and NT-proBNP, are clinically used to diagnose AKI stages in CRS patients but are limitedly sensitive to the early detection of the pathology. Therefore, the need for protein biomarkers is emerging for early intervention in CRS progression. Here, we summarized the cardio-renal nexus in acute CRS, with an emphasis on the present clinicopathological biomarkers and their limitations. The objective of this review is to highlight the need for novel proteomic biomarkers that will curb the burgeoning concern and direct future research trials.

Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) Is a Biomarker Associated with Left Ventricular Hypertrophy in the Elderly, Specifically in Women

Left ventricular hypertrophy (LVH) may result in the development of heart failure, which is widespread among people of advanced age. The pathophysiology of LVH is complex and its biochemical pathways are not fully understood in this group. Elevated soluble urokinase-type plasminogen activator receptor (suPAR), a biomarker of immune activation, including fibrosis, reflects subclinical organ damage in systematic diseases. The present study assesses the clinical role of suPAR measurement in determination of LVH-associated cardiac disorders in the elderly. The studied population consisted of 238 individuals aged 76-91 years; of these, 139 (58%) were diagnosed with LVH. Serum biomarkers measurement (suPAR, troponin T, NT-proBNP and CRP) and echocardiography were performed in all subjects. The suPAR level was significantly higher in the LVH group (4.01 vs. 3.82 ng/mL, p = 0.033) and correlated with the parameters of cardiac diastolic function. Stepwise logistic regression found suPAR level (OR = 1.55, p = 0.016), BMI (OR = 1.17, p = 0.0003) and hypertension (OR = 2.42, p = 0.046) to be independently associated with LVH in women. In men, the strongest predictors of LVH were hypertension (OR = 7.52, p = 0.014) and BMI (OR = 1.42, p = 0.032). The observations indicate suPAR as a promising marker reflecting LVH, especially in women at advanced age, independent of age-associated cardiac remodeling.

Associations of serum high-sensitivity C-reactive protein and prealbumin with coronary vessels stenosis determined by coronary angiography and heart failure in patients with myocardial infarction

Background

To explore the associations of serum high-sensitivity C-reactive protein (hs-CRP) and prealbumin (PAB) with the number of diseased coronary vessels, degree of stenosis and heart failure in patients with myocardial infarction (MI).

Methods

A total of 39 MI patients treated in the Cardiology were selected as the observation group, and another 41 patients with normal results of coronary angiography during the same period were selected as the control group. The general data of patients were recorded in detail, the content of serum hs-CRP and PAB in the peripheral blood was detected, and the number of diseased coronary vessels and the degree of stenosis were detected via coronary angiography.

Results

Compared with those in control group, the blood pressure and heart rate significantly rose, the content of indexes related to the severity of MI were significantly increased, the content of hs-CRP was significantly increased, and the content of PAB was significantly decreased in observation group. Hs-CRP was positively correlated with the number of diseased coronary vessels, degree of stenosis and heart failure in patients, but PAB was negatively correlated with the above factors. The survival rate of MI patients with high content of hs-CRP was obviously lower than that of patients with low content of hsCRP.

Conclusions

Serum hs-CRP and PAB are closely associated with the number of diseased coronary vessels, degree of stenosis and heart failure in MI patients.

Soluble urokinase plasminogen activator receptor: from biomarker to active participant in atherosclerosis and cardiovascular disease

Atherosclerosis contributes to the majority of deaths related to cardiovascular disease (CVD). Recently, the nonspecific inflammatory biomarker soluble urokinase plasminogen activator receptor (suPAR) has shown prognostic value in patients with CVD; however, it remains unclear whether suPAR participates in the disease process. In this issue of the JCI, Hindy and colleagues report on their evaluation of a multi-ethnic cohort of over 5,000 participants without known CVD. High suPAR levels correlated with incident CVD and atherosclerosis. Genetic analysis revealed two variants associated with the suPAR-encoding gene (PLAUR) with higher plasma suPAR levels. Notably, a mouse model with high suPAR levels possessed aortic tissue with a proinflammatory phenotype, including monocytes with enhanced chemotaxis similar to that seen in atherogenesis. These findings suggest a causal relationship between suPAR and coronary artery calcification and have clinical implications that extend to inflammatory disorders beyond CVD.

Prognostic value of soluble urokinase-type plasminogen activator receptor in coronary artery disease: A meta-analysis

BACKGROUND

A potential inflammatory biomarker, soluble urokinase-type plasminogen activator receptor (suPAR) has been utilized to assist the prognostic assessment of coronary artery disease (CAD) patients; however, outcomes have been inconsistent. The prognostic relevance of suPAR as a predictor of CAD patient adverse outcomes was therefore examined.

METHODS

Research articles published as of 1 January 2022 were retrieved from PubMed, Embase, the Web of Science and the Cochrane Library. All-cause mortality, cardiovascular mortality and other major cardiovascular events (nonfatal myocardial infarction, heart failure or stroke) were analysed as a subset of relevant studies' results. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for each study. The broad EQUATOR guidelines were conformed. Risk of bias was assessed with ROBINS-I tool.

RESULTS

In total, this analysis included nine studies including 14,738 CAD patients. All included studies made a correction for certain potential confounders. However, risk of bias ranged from moderate to critical. When the ROBINS-I tool was used. Patients with CAD that exhibited increased suPAR levels had a substantially higher risk of all-cause mortality (HR = 2.24; 95% CI 1.97-2.55) or cardiovascular mortality (HR = 2.02; 95% CI 1.58-2.58), but not of developing other major cardiovascular events (HR = 1.63; 95% CI 0.86-3.11). Considerable heterogeneity across studies was observed in our meta-analyses, but no significant publication bias was detected.

CONCLUSION

In patients with coronary disease, suPAR may have prognostic value for both all-cause and cardiovascular mortality but not for other major cardiovascular events.

Soluble Urokinase Receptor and Mortality in Kidney Transplant Recipients

Main problem: Soluble urokinase plasminogen activator receptor (suPAR) is an immunological risk factor for kidney disease and a prognostic marker for cardiovascular events.

Methods: We measured serum suPAR levels in a total of 1,023 kidney transplant recipients either before (cohort 1, n = 474) or at year 1 after transplantation (cohort 2, n = 549). The association of suPAR levels and all-cause and cardiovascular mortality was evaluated by multivariable Cox regression analysis.

Results: The highest suPAR tertile compared to the two lower tertiles had a significantly higher risk of all-cause mortality in both cohorts separately (cohort 1: hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.20–3.08, p = 0.007; cohort 2: HR = 2.78, 95% CI 1.51–5.13, p = 0.001) and combined (n = 1,023, combined HR = 2.14, 95% CI 1.48–3.08, p < 0.001). The association remained significant in the subgroup of patients with normal kidney function (cohort 2: HR = 5.40, 95% CI 1.42–20.5, p = 0.013). The increased mortality risk in patients with high suPAR levels was attributable mainly to an increased rate of cardiovascular death (n = 1,023, HR = 4.24, 95% CI 1.81–9.96, p < 0.001).

Conclusion: A high suPAR level prior to and at 1 year after kidney transplantation was associated with an increased risk of patient death independent of kidney function, predominantly from cardiovascular cause.

Multiplex protein screening of biomarkers associated with major bleeding in patients with atrial fibrillation treated with oral anticoagulation

BACKGROUND

Oral anticoagulants (OAC) in patients with atrial fibrillation (AF) prevent thromboembolic events, but are associated with significant risk of bleeding.

OBJECTIVES

To explore associations between a wide range of biomarkers and bleeding risk in patients with AF on OAC.

METHOD

Biomarkers were analyzed in a random sample of 4200 patients, 204 cases with major bleedings, from ARISTOTLE. The replication cohort included 344 cases with major bleeding and 1024 random controls from RE-LY. Plasma samples obtained at randomization were analyzed by the Olink Proximity Extension Assay cardiovascular and inflammation panels and conventional immunoassays. The associations between biomarker levels and major bleeding over 1 to 3 years of follow-up were evaluated by random survival forest/Boruta analyses and Cox regression analyses to assess linear associations and hazard ratios for identified biomarkers.

RESULTS

Out of 268 proteins, nine biomarkers were independently associated with bleeding in both cohorts. In the replication cohort the linear hazard ratios (95% confidence intervals) per interquartile range were for these biomarkers: TNF-R1 1.748 (1.456, 2.098), GDF-15 1.653 (1.377, 1.985), EphB4 1.575 (1.320, 1.880), suPAR 1.548 (1.294, 1.851), OPN 1.476 (1.240, 1.757), OPG 1.397 (1.156, 1.688), TNF-R2 1.360 (1.144,1.616), cTnT-hs 1.232 (1.067, 1.423), and TRAIL-R2 1.202 (1.069, 1.351).

CONCLUSIONS

In patients with AF on OAC, GDF-15, cTnT-hs, and seven novel biomarkers were independently associated with major bleedings and reflect pathophysiologic processes of inflammation, apoptosis, oxidative stress, vascular calcification, coagulation, and fibrinolysis. Investigations of the utility of these markers to refine risk stratification and guide the management of patients at high risk of bleeding are warranted.

Cardiorenal Syndrome: New Pathways and Novel Biomarkers

Cardiorenal syndrome (CRS) is a multi-organ disease characterized by the complex interaction between heart and kidney during acute or chronic injury. The pathogenesis of CRS involves metabolic, hemodynamic, neurohormonal, and inflammatory mechanisms, and atherosclerotic degeneration. In the process of better understanding the bi-directional pathophysiological aspects of CRS, the need to find precise and easy-to-use markers has also evolved. Based on the new pathophysiological standpoints and an overall vision of the CRS, the literature on renal, cardiac, metabolic, oxidative, and vascular circulating biomarkers was evaluated. Though the effectiveness of different extensively applied biomarkers remains controversial, evidence for several indicators, particularly when combined, has increased in recent years. From new aspects of classic biomarkers to microRNAs, this review aimed at a 360-degree analysis of the pathways that balance the kidney and the heart physiologies. In this delicate system, different markers and their combination can shed light on the diagnosis, risk, and prognosis of CRS.

Prognostic value of soluble urokinase plasminogen activator receptor in patients presenting to the emergency department with chest pain suggestive of acute coronary syndrome

INTRODUCTION

Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic biomarker of cardiovascular disease.

OBJECTIVES

We aimed to evaluate the early prognostic value of suPAR in patients presenting to the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS).

PATIENTS AND METHODS

In a post-hoc analysis from a multicenter study including patients with a chest pain < 6 h, suPAR concentrations at ED admission were studied according to the outcome at 30-days.

RESULTS

198 patients (median age 56 years) in whom 16% had an ACS, were included. Fifteen (7.3%) patients presented a 30-day event. At ED admission, median (IQR) suPAR concentrations were higher in patients with a 30-day event in comparison to patients without event (4.54 (3.09-8.61) vs. 2.72 (2.10-3.43) ng/mL, p < 0.001). The ROC curve AUC of suPAR for the prediction of a 30-days event was 0.775 [95%CI: 0.710-0.831]. The optimal threshold was 3.3 ng/mL, with a sensitivity of 73 [45-92] % and a specificity of 72 [65-79] %. The association of a suPAR < 3.3 ng/mL AND a NT-proBNP < 160 ng/L AND a HEART score < 4 had a negative predictive value of 99 [91-100] %. A suPAR value at admission above 3.3 ng/mL was independently and significantly associated with a 30-day event in chest pain emergency patients (OR 4.87 [1.35-17.51], p = 0.015).

CONCLUSION

suPAR is a promising biomarker for early prediction of events in chest pain emergency patients.

Prognostic value of cystatin C in patients with acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

Circulating cystatin C has been considered as an independent predictor of cardiovascular and all-cause mortality in the general population. The purpose of this study was to evaluate the prognostic value of baseline circulating cystatin C levels in patients with acute coronary syndrome (ACS) through meta-analysis.

METHODS

Prospective studies about the relationship between the level of cystatin C and the prognosis of ACS patients were searched on PubMed, Web of science, Cochrane Library and Embase databases from the establishment of the databases to July 2020. The prognostic values included in this analysis covered all-cause mortality, major adverse cardiovascular events (MACE) and recurrent myocardial infarction. The effect index between cystatin C level and ACS risk was carried out by hazard ratio (HR). Stata 15.0 software was used for statistical analysis. The quality of the included literature was evaluated according to Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 10 studies were included in this meta-analysis. The results showed that high cystatin C levels significantly predicted the all-cause mortality of ACS, HR = 2.53 (95%CI: 1.72 ~ 3.72). High cystatin C level significantly predicted MACE of patients with ACS, HR = 3.24 (95%CI: 1.30 ~ 8.07). However, it had no significant predictive significance for recurrent myocardial infarction, HR = 1.71 (95%CI:0.99 ~ 2.97).

CONCLUSION

Our meta-analysis showed that high cystatin C levels were significantly associated with the death risk and MACE in ACS patients. Therefore, cystatin C can be included in the risk stratification model to guide the treatment of high-risk ACS patients.

Prognostic Value of Soluble Urokinase-Type Plasminogen Activator Receptor and High-Sensitivity C-Reactive Protein on Postoperative Mortality in Patients Undergoing Elective On-Pump Cardiac Surgery

OBJECTIVES

Elevated soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitivity C-reactive protein (hsCRP) have been associated with increased mortality in patients with cardiovascular disease. The aim of the present study was to explore the relationship between suPAR and hsCRP values and associated mortality after elective cardiac surgery. A secondary aim was to assess whether a combined risk model of European System for Cardiac Operative Risk Evaluation (EuroSCORE II), suPAR, and/or hsCRP would improve the prognostic accuracy compared with EuroSCORE II alone.

DESIGN

Retrospective observational study.

SETTING

Single-center, university hospital.

PARTICIPANTS

Adult patients admitted for elective on-pump cardiac surgery were included. Biobank blood samples were obtained from previous research projects at a tertiary heart center from 2012 to 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 931 patients were included. Kaplan-Meier and Cox proportional hazard analyses were used to explore a potential association between preoperative suPAR and hsCRP values and all-cause mortality up to one year after surgery. Thirty-day mortality was predicted from suPAR, hsCRP, and EuroSCORE II by logistic regression and compared using area under the receiver operating characteristics curve and Brier scores. After adjustment for known confounders, a doubling of suPAR and hsCRP corresponded to a hazard ratio for all-cause mortality of 2.27 (95% confidence interval 1.65-3.11; p < 0.001) and 1.26 (95% confidence interval 1.07-1.49; p = 0.005), respectively. However, adding the biomarkers to EuroSCORE II did not improve prediction/discrimination with respect to 30-day mortality.

CONCLUSIONS

Elevated preoperative levels of suPAR and hsCRP were associated with all-cause mortality in elective cardiac surgery patients. However, inclusion of biomarkers did not improve the prognostic accuracy of EuroSCORE II.

Cardio-Renal Biomarker Soluble Urokinase-Type Plasminogen Activator Receptor Is Associated With Cardiovascular Death and Myocardial Infarction in Patients With Coronary Artery Disease Independent of Troponin, C-Reactive Protein, and Renal Function

Background Risk stratification among patients with coronary artery disease (CAD) is of considerable interest due to the potential to guide secondary preventive therapies. Thus, we evaluated the predictive value of soluble urokinase-type plasminogen activator receptor (suPAR) levels for cardiovascular mortality and nonfatal myocardial infarction in patients with CAD. Methods and Results Plasma levels of suPAR were measured in a cohort of 1703 patients with documented CAD as evidenced by coronary angiography-including 626 patients with acute coronary syndrome and 1077 patients with stable angina pectoris. Cardiovascular death and/or nonfatal myocardial infarction were defined as main outcome measures. During a median follow-up of 3.5 years, suPAR levels reliably predicted cardiovascular death or myocardial infarction in CAD, evidenced by survival curves stratified for tertiles of suPAR levels. In Cox regression analyses, the hazard ratio for the prediction of cardiovascular death and/or myocardial infarction was 2.19 (P<0.001) in the overall cohort and 2.56 in the acute coronary syndrome cohort (P<0.001). Even after adjustment for common cardiovascular risk factors, renal function and the biomarkers C-reactive protein, N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin I suPAR still enabled a reliable prediction of cardiovascular death or myocardial infarction with a hazard ratio of 1.61 (P=0.022) in the overall cohort and 2.22 (P=0.005) in the acute coronary syndrome cohort. Conclusions SuPAR has a strong and independent prognostic value in secondary prevention settings, and thereby might represent a valuable biomarker for risk estimation in CAD.