Uric acid levels and vascular disease

Uric acid level changes after bariatric surgery in obese subjects with type 2 diabetes mellitus

Background

The purpose of the study was to investigate the incidence of hyperuricemia (HU) in obese subjects with type 2 diabetes mellitus (T2DM) before and after Roux-en-Y gastric bypass (RYGB), to describe the impact of this therapy in reducing uric acid levels, and its possible mechanism. This study was performed by cooperation with the First affiliated hospital of Soochow University and the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, department of general surgery.

Methods

A retrospective study was performed. From February 2015 to December 2017, we evaluated 147 obese patients with T2DM. Blood samples and other clinical data were drawn before and postoperative (1, 3, 6, 12 months after RYGB). All obese patients with T2DM underwent laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Different gender with HU were compared before and after surgery.

Results

A total of 147 patients received LRYGB (75 were female, 72 were male), and 48 patients with HU (22 were female, 26 were male). Four women and 2 men were lost to follow-up, they were excepted from this study. No patients with HU lost to follow-up. There's an intuitive downward trend about uric acid levels both in men and women, with men from 497.9 µmol/L before surgery to 371.5 µmol/L 1 year after surgery, P=0.000; women from 432.3 to 354.1 µmol/L, P=0.002. The proportion of HU changed with men from 37.1% (26/70) before surgery to 12.9% (9/70) one year after surgery, women from 31.0% (22/71) to 14.1% (10/71). The results of binary logistic regression analysis confirmed that triglycerides were clinical predictors for HU remission (P=0.004). No major late surgical complications were reported.

Conclusions

Our data showed that, bariatric surgery was effective to decrease the levels of serum uric acid (SUA) in obese patients with T2DM. Compared with traditional drug treatment, this shows a possible treatment of HU by RYGB. The remission of HU was associated with the decreased triglyceride levels in obese patients with T2DM, independent of BMI. The potential role of triglycerides in the remission of HU merits further study.

Short-term Lipid-Lowering Treatment with Atorvastatin Improves Renal Function But Not Renal Blood Flow Indices in Patients with Peripheral Arterial Disease

Some studies have suggested that lipid lowering with statins exerts favorable effects on the progression of chronic kidney disease. Therefore, the authors assessed the effects of short-term atorvastatin treatment on biochemical markers of renal function and evaluated duplex indices of renal blood flow (RBF) in patients with peripheral arterial disease. Hyperlipidemic claudicants (n=18), aged 44-85 years, were treated for 8 weeks with 20 mg/day atorvastatin. Blood tests at baseline and after 8 weeks included serum fasting lipids, creatinine, urate, and cystatin C (a sensitive indicator of renal function) levels. RBF was also assessed (n=9) by measuring pulsatile and resistance duplex indices. As expected, there was a significant improvement in total cholesterol, low-density lipoprotein cholesterol, and triglycerides. There was also a significant (p<0.0001) fall in serum creatinine from 89 (58-125) to 79 µmol/L (54-119) and an increase in calculated creatinine clearance (CrCl) from 72 (40-129) to 80 mL/minute (47-138; p<0.0001). Serum cystatin C values decreased significantly (p=0.0002) from 1.04 (0.57-1.56) to 0.90 mg/L (0.47-1.47). There were no detectable changes in the RBF duplex indices. Treatment of stable claudicants with atorvastatin for 8 weeks was associated with improved renal function (as assessed by serum creatinine, cystatin C, and calculated CrCl) without changes in RBF. Further studies are required to identify the mechanisms involved in this phenomenon.

Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence?

Patients who had a transient ischemic attack or stroke are at increased risk of experiencing recurrent cerebrovascular events. For this reason, secondary prevention of ischemic cerebrovascular disease is essential. Several modifiable, lifestyle-associated risk factors have been implicated, such as physical activity, smoking, and alcohol consumption. Established and emerging vascular risk factors are associated with an increased risk of stroke. Pharmacologic treatment, including the use of antiplatelet, antihypertensive, and lipid-lowering agents, has also been shown to reduce the risk of secondary cerebrovascular events. Surgical intervention, either open or endovascular, may be the preferred therapeutic option in well-defined subsets of patients. It is important to establish specific measures for the early detection and prevention of recurrent cerebrovascular disease. Therefore, further research and greater awareness in this field are needed.

High prevalence and risk factors for kidney dysfunction in patients with atherosclerotic cardio-cerebrovascular disease

BACKGROUND

Patients with atherosclerotic cardio-cerebrovascular disease are at high risk of kidney dysfunction because of the overlap of several risk factors. The purpose of this study is to examine the prevalence and characteristics and risk factors for kidney dysfunction in the cardio-cerebrovascular disease population.

METHODS

Renal functions of 1012 patients with the cardio-cerebrovascular disease were evaluated with the purpose of evaluating characteristics of the incidence, risk factors for kidney dysfunction in the cardio-cerebrovascular disease population.

RESULTS

In the univariate analysis, the major risk factors for kidney dysfunction in the patients with the cardio-cerebrovascular disease were age, gender, hypertension, diabetes mellitus, dyslipidemia and serum uric acid. In the patients with both hypertension and diabetes mellitus the percentages of significantly decreased eGFR were 25.6%. Results of multivariable analysis showed that diabetes mellitus (odds ratio (OR) 1.609, 95% confidence intervals (CI) 1.08-2.398, P = 0.019), hypertension (OR 1.547, 95% CI 1.049-2.281, P = 0.028) and serum uric acid (OR 1.009, 95% CI 1.007-1.010, P < 0.001) were independent risk factors for reduced kidney function.

CONCLUSIONS

In the context of the cardio-cerebrovascular disease kidney dysfunction is common and has a high prevalence. Patients with both cardio-cerebrovascular disease and kidney dysfunction at any stage should be recognized as high-risk population.

Epidemiology and risk factors for chronic kidney disease in patients with ischaemic stroke

BACKGROUND

There is growing evidence for an association between chronic renal disease (CKD) and adverse cerebrovascular events because of the overlap of several risk factors. The purpose of this study is to examine the epidemiology of CKD and the characteristics of risk factors for CKD in the population with ischaemic stroke.

METHODS

This retrospective study included 571 patients with ischaemic stroke. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) study equation. Renal function was assessed according to the Kidney Disease Outcomes Quality Initiative (K/DOQI)-CKD classification.

RESULTS

Study demonstrated that the major factors associated with CKD in the ischaemic stroke patients were age, diabetes mellitus, hypertension, systolic blood pressure, LDL cholesterol and serum uric acid. Diabetes mellitus (OR 4·146, 95% CI 1·047-16·418, P = 0·043), hypertension and diabetes mellitus (OR 3·574, 95% CI 1·248-10·234, P = 0·018), serum uric acid (OR 1·010, 95% CI 1·006-1·013, P < 0·001) and LDL cholesterol (OR 1·431, 95% CI 1·063-1·928, P = 0·018) were independent risk factors associated with CKD in the patients with ischaemic stroke.

CONCLUSIONS

The patients with ischaemic stroke may be considered as a high-risk population for CKD and be aggressively managed for CKD prevention. The high prevalence of CKD in population with ischaemic stroke prompts the need for greater public awareness about risks of CKD.

Statins and cardiovascular outcomes in elderly and younger patients with coronary artery disease: a post hoc analysis of the GREACE study

INTRODUCTION

The effect of cardiovascular disease (CVD) prevention measures aimed at elderly patients requires further evidence. We investigated the effect of statin treatment (targeted to achieve guideline goals) on CVD outcomes in different age groups to determine whether statins are more beneficial in the elderly.

MATERIAL AND METHODS

The primary endpoint of this post hoc analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study (n = 1,600 patients with established coronary heart disease (CHD), mean follow-up 3 years) was the absolute and relative CVD event (a composite of death, myocardial infarction, revascularization, unstable angina, heart failure and stroke) risk reduction in age quartiles (each n = 200). Patients on "structured care" with atorvastatin (n = 800) followed up by the university clinic and treated to lipid goal were compared with the corresponding quartiles on "usual care" (n = 800) followed up by specialists or general practitioners of the patient's choice outside the hospital.

RESULTS

In the elderly (mean age 69 ±4 and 70 ±3 years in the "structured" and "usual care", respectively) the absolute CVD event reduction between "structured" and "usual care" was 16.5% (p < 0.0001), while in the younger patients (mean age 51 ±3 years and 52 ±3 years in the "structured" and "usual care", respectively) this was 8.5% (p = 0.016); relative risk reduction (RRR) 60% (p < 0.0001) vs. 42% respectively (p = 0.001). The elderly had higher rates of chronic kidney disease and higher uric acid levels, plus an increased prevalence of diabetes, metabolic syndrome and non-alcoholic fatty liver disease. These factors might contribute to the increased CVD risk in older patients.

CONCLUSIONS

All age groups benefited from statin treatment, but the elderly on "structured care" had a greater absolute and relative CVD risk reduction than the younger patients when compared with the corresponding patients assigned to "usual care". These findings suggest that we should not deprive older patients of CVD prevention treatment and lipid target achievement.

Monocyte chemoattractant protein 1 is correlated with glycemic control and peripheral arterial disease in type 2 diabetic patients with metabolic syndrome

We evaluated the serum levels of monocyte chemoattractant protein 1 (MCP-1) and their association with peripheral arterial disease (PAD) in 199 patients with type 2 diabetes mellitus (T2DM) and metabolic syndrome ([MetS], group A) in comparison with 109 healthy controls (group B). In group A, MCP-1 levels were significantly (P < .001) higher than group B and exhibited a positive correlation with HbA1c (P < .001) and a negative correlation with ankle-brachial index (P < .001). In the same group, patients with PAD had significantly higher MCP-1 levels compared with those without PAD (P < .001). In conclusion, T2DM patients with MetS exhibit higher serum MCP-1 levels. The latter is associated with worse glycemic control and PAD. These results suggest a potential contributory role for MCP-1 in the pathogenesis of PAD in the presence of hyperglycemia and MetS in T2DM.

Increased serum levels of uric acid are associated with sudomotor dysfunction in subjects with type 2 diabetes mellitus

The aim of this paper was to assess serum uric acid (SUA) levels in patients with type 2 diabetes mellitus (T2DM) with or without sudomotor dysfunction (evaluated by the Neuropad test). We included 36 T2DM patients with sudomotor dysfunction (group A: mean age 63.1 ± 2.6 years) and 40 age-, gender-, renal function- and T2DM duration-matched patients without sudomotor dysfunction (group B: mean age 62.1 ± 3.1 years). SUA was significantly higher in group A (P < 0.001). There was a significant correlation between SUA and Neuropad time to colour change in both groups (group A: r_s = 0.819, P < 0.001; group B: r_s = 0.774, P < 0.001). There was also a significant positive correlation between SUA and CRP in both groups (group A: r_s = 0.947, P < 0.001; group B: r_s = 0.848, P < 0.001). In conclusion, SUA levels were higher in T2DM patients with sudomotor dysfunction than those without this complication. The potential role of SUA in sudomotor dysfunction merits further study.

Peripheral neuropathy is associated with increased serum levels of uric acid in type 2 diabetes mellitus

We assessed serum uric acid (SUA) levels in patients with type 2 diabetes mellitus (T2DM) with or without peripheral neuropathy (diagnosed by the Neuropathy Disability score [NDS]). We enrolled 64 patients with T2DM with peripheral neuropathy (group A: 31 men, mean age 63.0 ± 2.8 years) and 66 age-, gender-, renal function- and T2DM duration-matched patients without neuropathy (group B: 32 men, mean age 62.4 ± 3.1 years). Serum uric acid was significantly higher in group A (P < .001). There was a significant correlation between SUA and NDS in both groups (group A: r(s) = .93, P < .001; group B: r( s) = .95, P < .001). C-reactive protein (CRP) was also significantly higher in group A (P < .001) and correlated significantly with SUA in both groups (group A: r(s) = .93, P < .001; group B: r(s) = .87, P < .001). Serum uric acid is increased in patients with T2DM with neuropathy versus those without. Whether SUA is involved in the pathogenesis of T2DM peripheral neuropathy remains to be established.

Diabetes mellitus and cerebrovascular disease: which are the actual data?

Cerebrovascular disease (CeVD) represents a major cause of morbidity and mortality worldwide. Diabetes mellitus (DM) represents an independent risk factor for CeVD. The aim of the present review is to describe the epidemiology of CeVD in patients with DM and to explain how DM and diabetic autonomic neuropathy can increase the risk of CeVD. The prevention and management of CeVD in the diabetic population are also analyzed.

The use of sibutramine in the management of obesity and related disorders: an update

Aims:

To review the major trials that evaluated the efficacy and safety of the use of sibutramine for weight loss and the impact of this agent on obesity-related disorders.

Methods and results:

The most important articles on sibutramine up to January 2009 were located by a PubMed and Medline search. Sibutramine reduces food intake and body weight more than placebo and has positive effects on the lipid profile (mainly triglycerides and high density lipoprotein cholesterol), glycemic control and inflammatory markers in studies for up to one year. Preliminary studies showed that sibutramine may also improve other obesity-associated disorders such as polycystic ovary syndrome, left ventricular hypertrophy, binge eating disorder and adolescent obesity. The high discontinuation rates and some safety issues mainly due to the increase in blood pressure and pulse rate have to be considered. Additionally, it has not yet been established that treatment with sibutramine will reduce cardiovascular events and total mortality.

Conclusions:

Sibutramine, in conjunction with lifestyle measures, is a useful drug for reducing body weight and improving associated cardiometabolic risk factors and obesity-related disorders. Studies of longer duration are required to determine the precise indications of the drug, to evaluate safety issues and to assess its efficacy on cardiovascular mortality.

Cardiorenal anemia syndrome: do erythropoietin and iron therapy have a place in the treatment of heart failure?

The cardiorenal anemia syndrome in congestive heart failure (CHF) is an independent risk factor for vascular morbidity and mortality. Several factors play a role in the pathogenesis of anemia in CHF, including inflammation, impaired renal function, use of certain antihypertensive or cardioprotective agents, and gastrointestinal or urinary losses of essential hemopoietic factors. Several trials evaluated the effects of administering erythropoietin (EPO) and/or iron to patients with CHF. Even though most of them were uncontrolled studies, their results suggest that EPO treatment might be beneficial in CHF. Nevertheless, more studies are needed and certain issues should be resolved, particularly the optimal hemoglobin level, before EPO can become part of the treatment of patients with CHF.

The role of renin–angiotensin system inhibition in the treatment of hypertension in metabolic syndrome: are all the angiotensin receptor blockers equal?

The metabolic syndrome (MetS) is a strong predictor of cardiovascular morbidity and mortality, as well as new Type 2 diabetes. MetS consists of visceral obesity, elevated blood pressure, impaired glucose metabolism, atherogenic dyslipidaemia (elevated triglycerides and low levels of high-density lipoprotein cholesterol), as well as other metabolic abnormalities. The underlying pathophysiology seems to be largely, but not uniquely, attributable to insulin resistance. Existing antihypertensive drugs were designed to lower blood pressure rather than to modify the metabolic abnormalities associated with hypertension. This review considers the role of renin-angiotensin system inhibition and especially the use of angiotensin receptor blockers (ARBs) in the treatment of hypertension in MetS. There are differences among ARBs. Among them is the uricosuric effect of losartan. Furthermore, telmisartan may function as a partial agonist of the peroxisome proliferator-activated receptor-gamma (PPAR-gamma).

Serum Uric Acid as an Independent Predictor of Early Death After Acute Stroke

BACKGROUND

The prognostic significance of uric acid (UA) levels in acute stroke is unclear, so the objective of this study was to determine the association between levels of serum UA (SUA) and mortality in acute stroke.

METHODS AND RESULTS

Consecutive patients (n=435) presenting with ischemic stroke and intracerebral hemorrhage were included in the study. The length of stay in hospital and the occurrence of death were recorded. On univariate analysis, the occurrence of death was associated with older age, smoking, presence of congestive heart failure or atrial fibrillation, absence of hyperlipidemia, and intracerebral hemorrhage as the index event. Furthermore, glucose, urea, creatinine and SUA at admission were significantly higher in patients who died, whereas total and high-density-lipoprotein cholesterol were significantly lower. On multiple logistic regression analysis, the independent relationship between higher SUA levels and death was confirmed (odds ratio (OR), 1.37; 95%confidence interval (CI), 1.13-1.67; p=0.001). The only other variables independently associated with the occurrence of death were urea concentration and presence of atrial fibrillation. If urate was >7.8 mg/dl (0.47 mmol/L), then there would be a high probability of early death (87%).

CONCLUSIONS

Elevated levels of SUA are independently associated with an increased risk of early death in acute stroke.

Elevated serum uric acid levels in metabolic syndrome: an active component or an innocent bystander?

Elevated serum uric acid (SUA) levels are commonly seen in patients with the metabolic syndrome (MetS). Several mechanisms, both direct and indirect, connect the increased SUA levels with the established diagnostic criteria of MetS. It is possible that the increased cardiovascular disease risk associated with the MetS is partially attributed to elevated circulating SUA concentration. Several drugs used in the treatment of MetS may alter SUA levels. Thus, lifestyle measures together with the judicious selection of drugs for the treatment of hypertension, dyslipidemia, and insulin resistance associated with MetS may result in a reduction of SUA levels and possibly cardiovascular disease risk. This review summarizes the pathophysiologic association between SUA and MetS and focuses on the prevention of hyperuricemia and its cardiovascular consequences.

Statins: another class of antihypertensive agents?

The assessment of global cardiovascular risk is an essential step in the management of atherosclerotic disease prevention. Among the risk factors to be addressed are hypertension and hyperlipidaemia; these commonly coexist. A neutral or lipid-friendly antihypertensive agent is probably useful in the presence of lipid abnormalities. Similarly, statins have been shown to decrease cardiovascular risk in hypertensive patients. There is also experimental and clinical evidence that statins have blood pressure (BP)-lowering effects. In this review, we discuss the beneficial effects of statins on BP, and provide an overview of the underlying pathophysiology. We also consider the evidence justifying the use of statins in the management of hypertensive patients.

Statins and Peripheral Arterial Disease: Potential Mechanisms and Clinical Benefits

Peripheral arterial disease (PAD) is a manifestation of widespread atherosclerosis. Lipid modification (especially with statins) is a component of the treatment of patients with PAD since this condition is considered a coronary heart disease equivalent. This review considers the mechanism of action of statins in PAD. Statins have been shown to reduce the incidence of new coronary events in patients with PAD. However, surveys suggest that many such patients remain undertreated. Statins can also increase walking distance in patients with PAD. There is also evidence that statins can improve renal function in these patients. Several other actions of statins are considered in this review. PAD patients have an increased morbidity and mortality, largely due to myocardial infarction and stroke. Recognizing and treating these high-risk patients as early as possible should be a priority.

Serum uric acid and cardiovascular disease: recent developments, and where do they leave us?

The relationship between serum uric acid (SUA) and cardiovascular disease has been controversial. Here we review recent literature assessing whether hyperuricemia is an independent risk factor for adverse cardiovascular outcomes. Studies from the past 6 years evaluating the association of SUA with cardiovascular disease were identified through MEDLINE, EMBASE, and Cochrane library searches, bibliography cross-referencing, and review articles. Twenty-one cohort studies in healthy and high-risk patients with cardiovascular disease were identified and reviewed. In studies of high-risk patients, in which more overall events were recorded, 10 of 11 studies were supportive of an independent association. In 10 studies of healthy patients, 6 suggested an independent association of SUA with adverse cardiovascular outcomes. Increasing SUA is likely an independent risk factor for cardiovascular disease in high-risk individuals. However, the magnitude of excess risk attributable to high SUA is likely to be small in healthy individuals. Trials of SUA-lowering therapy in hyperuricemic patients evaluating the effect on cardiovascular outcomes are justified in high-risk patients.

Matrix metalloproteinases and diabetic vascular complications

Diabetes mellitus (DM) is associated with an increased incidence of cardiovascular events and microvascular complications. These complications contribute to the morbidity and mortality associated with DM. There is increasing evidence supporting a role for matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of matrix metalloproteinases - TIMPs) in the atherosclerotic process. However, the relationship between MMPs/TIMPs and diabetic angiopathy is less well defined. Hyperglycemia directly or indirectly (eg, via oxidative stress or advanced glycation products) increases MMP expression and activity. These changes are associated with histologic alterations in large vessels. On the other hand, low proteolytic activity of MMPs contributes to diabetic nephropathy. Within atherosclerotic plaques an imbalance between MMPs and TIMPs may induce matrix degradation, resulting in an increased risk of plaque rupture. Furthermore, because MMPs enhance blood coagulability, MMPs and TIMPs may play a role in acute thrombotic occlusion of vessels and consequent cardiovascular events. Some drugs can inhibit MMP activity. However, the precise mechanisms involved are still not defined. Further research is required to demonstrate the causative relationship between MMPs/TIMPs and diabetic atherosclerosis. It also remains to be established if the long-term administration of MMP inhibitors can prevent acute cardiovascular events.

A review of the lipid-related effects of fluvastatin

BACKGROUND

Statin therapy has been shown to significantly decrease vascular events and overall mortality in primary and secondary prevention trials. This review considers the pharmacology, nonlipid-lowering effects and clinical trial evidence of fluvastatin based on a survey of PubMed entries.

FINDINGS

Recent clinical data show that treatment with fluvastatin is associated with a variety of benefits in different high-risk populations along with a good safety profile. Fluvastatin exerts non-lipid lowering-associated pleiotropic effects in both clinical and experimental studies. Furthermore, an extended-release formulation of fluvastatin with a favourable pharmacokinetic profile is available.

CONCLUSION

Treatment with fluvastatin offers a convenient, safe and evidence-based approach to managing dyslipidaemias and preventing vascular events.

Prevention and treatment of the metabolic syndrome

The prevalence of the metabolic syndrome is increasing owing to lifestyle changes leading to obesity. This syndrome is a complex association of several interrelated abnormalities that increase the risk for cardiovascular disease and progression to diabetes mellitus (DM). Insulin resistance is the key factor for the clustering of risk factors characterizing the metabolic syndrome. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III defined the criteria for the diagnosis of the metabolic syndrome and established the basic principles for its management. According to these guidelines, treatment involves the improvement of the underlying insulin resistance through lifestyle modification (eg, weight reduction and increased physical activity) and possibly by drugs. The coexistent risk factors (mainly dyslipidemia and hypertension) should also be addressed. Since the main goal of lipid-lowering treatment is to achieve the NCEP low-density lipoprotein cholesterol (LDL-C) target, statins are a good option. However, fibrates (as monotherapy or in combination with statins) are useful for the treatment of the metabolic syndrome that is commonly associated with hypertriglyceridemia and decreased high-density lipoprotein cholesterol (HDL-C) levels. The blood pressure target is < 140/90 mm Hg. The effect on carbohydrate homeostasis should possibly be taken into account in selecting an antihypertensive drug. Patients with the metabolic syndrome commonly have other less well-defined metabolic abnormalities (eg, hyperuricemia and raised C-reactive protein levels) that may also be associated with an increased cardiovascular risk. It seems appropriate to manage these abnormalities. Drugs that beneficially affect carbohydrate metabolism and delay or even prevent the onset of DM (eg, thiazolidinediones or acarbose) could be useful in patients with the metabolic syndrome. Furthermore, among the more speculative benefits of treatment are improved liver function in nonalcoholic fatty liver disease and a reduction in the risk of acute gout.