Cathepsin S as an early biomarker for cardiovascular disease in chronic kidney disease patients / Catepsina S como um biomarcador precoce para doença cardiovascular em pacientes com doença renal crônica

Abstract Introduction: A high incidence of cardiovascular disease (CVD) events and premature mortality is observed in patients with chronic kidney disease (CKD). Thus, new biomarkers that may help predict the development of CVD in early stages of CKD are being investigated along with other traditional risk factors. Objective: To investigate cathepsin S as an early biomarker for CVD in patients with CKD. Methods: A total of 64 patients with CKD were included and classified into 2 groups: CKD patients with established CVD and CKD patients with non-established CVD. All patients were submitted to routine investigations including complete blood count, random blood sugar, glycated hemoglobin (HbA1c), serum electrolytes, urea, creatinine, total protein, total albumin, calcium total, phosphorous, uric acid, vitamin D, parathormone, lipid profile, liver function test, measurement of serum cathepsin S (Cat S), and 2D Echo of the heart. Results: The level of serum Cat S was increased in CKD patients with CVD (p <0.05) as well as in later stages of CKD (p <0.05). CVD was also more common in patients in early stage CKD. In early stages CKD, Cat S and CVD were positively correlated. Conclusion: These findings suggest that serum Cat S might be useful as an early biomarker for CVD in CKD patients.

Resumo Introdução: Uma alta incidência de eventos de doença cardiovascular (DCV) e mortalidade prematura é observada em pacientes com doença renal crônica (DRC). Assim, novos biomarcadores que podem ajudar a prever o desenvolvimento de DCV nos estágios iniciais da DRC estão sendo investigados juntamente com outros fatores de risco tradicionais. Objetivo: Investigar a catepsina S como um biomarcador precoce para DCV em pacientes com DRC. Métodos: Um total de 64 pacientes com DRC foram incluídos e classificados em 2 grupos: pacientes com DRC com DCV estabelecida e pacientes com DRC com DCV não estabelecida. Todos os pacientes foram submetidos a investigações de rotina incluindo hemograma completo, glicemia aleatória, hemoglobina glicada (HbA1C), eletrólitos séricos, ureia, creatinina, proteína total, albumina total, cálcio total, fósforo, ácido úrico, vitamina D, paratormônio, perfil lipídico, teste de função hepática, medição da catepsina S sérica (Cat S), e Eco 2D do coração. Resultados: O nível de Cat S sérica esteve aumentado em pacientes com DRC com DCV (p <0,05), bem como em estágios posteriores da DRC (p <0,05). A DCV também foi mais comum em pacientes com DRC em estágio inicial. Em estágios iniciais da DRC, a Cat S e a DCV foram positivamente correlacionadas. Conclusão: Estes achados sugerem que a Cat S sérica pode ser útil como um biomarcador precoce para DCV em pacientes com DRC.

Cathepsin S as an early biomarker for cardiovascular disease in chronic kidney disease patients.

INTRODUCTION: A high incidence of cardiovascular disease (CVD) events and premature mortality is observed in patients with chronic kidney disease (CKD). Thus, new biomarkers that may help predict the development of CVD in early stages of CKD are being investigated along with other traditional risk factors. OBJECTIVE: To investigate cathepsin S as an early biomarker for CVD in patients with CKD. METHODS: A total of 64 patients with CKD were included and classified into 2 groups: CKD patients with established CVD and CKD patients with non-established CVD. All patients were submitted to routine investigations including complete blood count, random blood sugar, glycated hemoglobin (HbA1c), serum electrolytes, urea, creatinine, total protein, total albumin, calcium total, phosphorous, uric acid, vitamin D, parathormone, lipid profile, liver function test, measurement of serum cathepsin S (Cat S), and 2D Echo of the heart. RESULTS: The level of serum Cat S was increased in CKD patients with CVD (p <0.05) as well as in later stages of CKD (p <0.05). CVD was also more common in patients in early stage CKD. In early stages CKD, Cat S and CVD were positively correlated. CONCLUSION: These findings suggest that serum Cat S might be useful as an early biomarker for CVD in CKD patients.

An observational study to estimate the level of essential trace elements and its implications in type 2 diabetes mellitus patients.

BACKGROUND AND OBJECTIVES: Insulin action of reducing blood glucose has been found to be enhanced by trace elements. MATERIAL AND METHODS: This was a cross sectional study including 150 patients with Type 2 Diabetes Mellitus (T2DM) and 50 controls. Serum concentrations of zinc, copper, chromium, selenium and magnesium was measured by colorimetric kit. Fasting Blood Glucose and Glycated Haemoglobin (HbA1c) were assayed using the standard kit. RESULTS: Out of 150 patients, 85.4% (n = 128) of the cases had uncontrolled blood sugar with HbA1c ≥7 and only 14.6% (n = 22) had good control of blood sugar with HbA1c <7%. Hypertension (42%) and hypothyroidism (14%) were the most commonly associated comorbidities among patients with T2DM. Following percentage of diabetic patients had complications such as peripheral neuropathy (45.3%), diabetic retinopathy (36.7%), coronary artery disease (20.7%), diabetic nephropathy (17.3%), peripheral vascular disease (8.7%), and cerebrovascular accident (6%) respectively. The mean level of zinc, copper, selenium and magnesium was significantly lower in patients with T2DM than the control cases (62.89 vs. 74.95 µg/dL, P < 0.05; 116.30 vs. 150.39 µg/dL, P < 0.001; 8.57 vs. 16.16 µg/dL, P < 0.001; 1.92 vs. 2.31 mg/dL, P < 0.05, respectively). Multivariate analysis showed that there was a significant trend between levels of zinc, copper, selenium, and magnesium and the prevalence of T2DM. CONCLUSIONS: The levels of selenium, zinc, copper, and magnesium were significantly lower in patients with T2DM when compared to healthy counterparts.

Association of hepcidin and anemia in early chronic kidney disease.

Hepcidin is being extensively studied for anemia and inflammation in chronic kidney disease (CKD) patients. Hepcidin is thought to regulate iron metabolism by iron blockade through various mechanisms. Patients with CKD have early cardiac mortality due to anemia and subclinical inflammation; hence, we studied hepcidin as a biomarker in patients with early stage of CKD in relation to anemia and inflammation. In our cross-sectional study, a total of 80 patients were enrolled of whom, there were 25, 26, and 29 patients in CKD stages 1, 2, and 3, respectively. Patients were divided into normal iron level (39), functional iron deficiency (FID) (18), and absolute iron deficiency (AID) (23) based on transferrin saturation and ferritin. We found significantly high level of hepcidin (P <0.05) and high-sensitivity C-reactive protein (hsCRP) (P <0.05) in FID as compared to AID as well as normal iron level. We also found other inflammatory markers such as albumin, transferrin, and ferritin to be significantly associated with FID. In univariate analysis, hemoglobin (Hb) varied significantly with serum total iron-binding capacity (r = 0.40, P <0.001), log hsCRP (r = -0.32, P <0.01), and log ferritin (r = -0.23, P <0.05); however, Hb was not affected significantly with log hepcidin (r = -0.07, P >0.05). The study indicates that among early CKD patients with FID, there was high level of hepcidin along with other inflammatory parameters, which may be associated with poor cardiovascular disease outcome due to increased inflammation.

Diabetic kidney disease: A systematic review on the role of epigenetics as diagnostic and prognostic marker.

Diabetic kidney disease is one of the most serious microvascular complications and among the leading causes of end stage renal disease. Persistently increasing albuminuria has been considered to be the central hallmark of nephropathy. However, albuminuria can indicate kidney damage for clinicians; it is not a specific biomarker for prediction of diabetic kidney disease prior to the onset of this devastating complication, and in fact all individuals with microalbuminuria do not progress to overt nephropathy. Controlled glycemia is unable to prevent nephropathy in all diabetic individuals indicating the role of other factors in progression of diabetic kidney disease. There are numerous cellular and molecular defects persisting prior to appearance of clinical symptoms. So, there is an urgent need to look for easy, novel, and accurate way to detect diabetic kidney disease prior to its beginning or at the infancy stage so that its progression can be slowed or arrested. It is now accepted that initiation and progression of diabetic kidney disease are a result of complex interactions between genetic and environmental factors. Environmental signals can alter the intracellular pathways by chromatin modifiers and regulate gene expression patterns leading to diabetes and its complications. In the present review, we have discussed a possible link between aberrant DNA methylation and altered gene expression in diabetic kidney disease. Drugs targeting to reverse epigenetic alteration can retard or stop the development of this devastating disease, just by breaking the chain of events occurring prior to the development of this microvascular complication in patients with diabetes.

Association of Vitamin D and secondary hyperparathyroidism with anemia in diabetic kidney disease.

INTRODUCTION: Anemia is common in Chronic Kidney Disease (CKD) and diabetes is a major leading risk factor for it. In Diabetic Kidney Disease (DKD), it worsens more, which further increases cardiovascular morbidity and mortality. Despite of adequate iron stores anemia persist, which may be due to impaired iron release from body stores that is unable to meet the demand for erythropoiesis (also called reticuloendothelial cell iron blockade). High parathyroid hormone (PTH) along with vitamin D, may be attributable for anemia. METHODS: A cross-sectional study of 150 advanced (Stage 4 & 5) pre dialyzed DKD patients (GFR <30ml/min/1.73 m2), aged 40-70 years were included over a period of 1 year. Any other concomitant illness/ drugs leading to anemia were excluded. Serum samples were collected and urea, creatinine, hemoglobin, iron profile, vitamin D, iPTH, uric acid, calcium, phosphorous and albumin levels were measured. A data base was constructed on Microsoft Excel 2007 and statistical analyses were performed using the SPSS software version 20.0 (IBM, NY, USA). RESULTS: Stage 5 DKD had more pronounced anemia compared to stage 4 DKD (P < 0.001). Hemoglobin (Hb) was inversely correlated with iPTH (r = -0.74, P < 0.001) and was associated with vitamin D deficiency (r = 0.51, P < 0.001) but not with serum ferritin. DKD patients with low eGFR (r = -0.6, P < 0.001), vitamin D (r = -0.43, P < 0.001) and serum calcium (r = -0.37, P < 0.001) had higher iPTH. Secondary hyperparathyroidism (beta=-0.005; P < 0.001) and Vitamin D (beta=0.053; P < 0.01) were strong predictor for Hb while parameters of iron profile was not statistically significant. CONCLUSION: An efficient control of PTH hypersecretion is therefore required to achieve a better management of anemia as well as mineral metabolism in DKD patients.

Vitamin D levels and other biochemical parameters of mineral bone disorders and their association with diastolic dysfunction and left ventricular mass in young nondiabetic adult patients with chronic kidney disease.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with end-stage renal disease. Chronic kidney disease (CKD)-associated cardiovascular mortality is more prevalent in those with diastolic heart failure and is an early predictor, while increased left ventricular mass (LVM) is a strong independent risk factor. Hypovitaminosis D is extensively being studied as a nontraditional risk factor for CVD. The aim of the present study is to look at the association of Vitamin D and other parameters of mineral bone disorder (MBD) with diastolic dysfunction and LVM in nondiabetic young adult patients with CKD. This was a hospital-based, cross-sectional observational study. Groups I and II comprised nondiabetic predialysis CKD patients (stage 4 and 5) and healthy controls, respectively. Groups IA and IB comprised cases with and without diastolic dysfunction, respectively. Vitamin D level was measured by enhanced chemiluminescence method and intact parathyroid hormone (iPTH) by electrochemiluminescence method. Parameters for diastolic function and LVM were assessed by Doppler echocardiography, tissue Doppler imaging, and M-mode echocardiography. Vitamin D level was significantly lower in Group I as compared to Group II. Diastolic dysfunction was present in 48.8% of the cases and was significantly associated with serum phosphorus and calcium-phosphorous product, but not with Vitamin D level. A statistically significant positive correlation between LVM and iPTH was found in our study. Hyperphosphatemia and high calcium-phosphorous product can be a better early predictor of diastolic dysfunction than Vitamin D while secondary hyperpara-thyroidism with increased LVM may be a bad prognostic marker.

Validity of Indian Diabetes Risk Score and its association with body mass index and glycosylated hemoglobin for screening of diabetes in and around areas of Lucknow.

OBJECTIVES: The present study aimed to assess the validity of Indian Diabetes Risk Score (IDRS) and its association with body mass index (BMI) and glycosylated hemoglobin (HbA1c) for screening of diabetes and obesity. METHODOLOGY: A cross-sectional study was designed, and samples were randomly enrolled from Lucknow and its adjoining areas. Totally, 405 subjects were included in the study. We used diabetes risk factors (age, waist circumference, physical activity, and family history of diabetes) for screening of diabetes and abdominal obesity (AO) and BMI for screening of general obesity. HbA1c was used for confirming the diabetes patients in this population. Statistical analysis was applied to all data using SPSS software (version 20.0). P < 0.05 was considered statistically significant. RESULTS: All 405 subjects were assessed for diabetic risk factors, BMI, and glycated hemoglobin. Of these, 56.3% subjects were aged ≥50 years. 1° and 2° AO was found in 47.9% and 40% subjects, respectively. About 27.1% subjects were found to have sedentary lifestyle, and 72.6% were found to have no family history of diabetes. According to IDRS, 272 subjects (67.2%) were found at high risk of diabetes (score ≥60). Based on BMI calculation, 198 subjects were obese, of which 79.3% were found at high risk for diabetes. A significant association was found between subjects with higher risk score and BMI (P < 0.001). Assessment of HbA1c showed that 97 (23.9%) were prediabetic and 204 (50.4%) were diabetic, of which 63.9% and 77%, respectively was at high risk for diabetes as per IDRS. A significant association was found between subjects with higher risk score and HbA1c (P < 0.001). CONCLUSION: Our study fully supports the validity of IDRS, as it can be used as a cost-effective tool for primary mass screening of diabetes. Moreover, its combination with BMI value and HbA1c can be used for strict monitoring for diabetes and obesity at primary health care centers to reduce the early development of diabetes complications and severe obesity comorbidities.

Evaluation of serum interleukin 6 and tumour necrosis factor alpha levels, and their association with various non-immunological parameters in renal transplant recipients.

INTRODUCTION: Renal transplant rejection involves both immunological and non-immunological factors. The objective of the present study was to investigate the association between immunological factors, such as serum interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-α), and non-immunological parameters, such as age, serum creatinine (SCr), creatinine clearance (CrCl) and dyslipidaemia, in renal transplant recipients (RTRs). METHODS: This study included 90 RTRs and 90 healthy controls. Biochemical parameters, including serum IL-6 and TNF-α, were estimated using standard protocols. CrCl was calculated using the Cockroft-Gault equation, and the type of rejection was confirmed on biopsy. Student's t-test and univariate and multivariate analyses were performed using the Statistical Package for the Social Sciences for Windows version 15. RESULTS: The mean levels of serum IL-6 and TNF-αwere significantly higher in RTRs than in the control group (p < 0.001). These parameters were also found to be significantly different between the transplant rejection (TR) and transplant stable (TS) groups (p < 0.001). CrCl was significantly decreased in the TR group when compared to the TS group (p < 0.001). The two cytokines, IL-6 and TNF-α, correlated significantly with all metabolic parameters, such as SCr, CrCl and dyslipidaemia. Multiple regression analysis showed that TNF-α and CrCl were the strongest predictors of IL-6. CONCLUSION: We conclude that immunological factors, as well as non-immunological factors such as CrCl, SCr and dyslipidaemia, play important roles in the pathogenesis of graft rejection and renal graft dysfunction.

Heat stroke presented with disseminated intravascular coagulation and bilateral intracerebral bleed.

Heat stroke is a life-threatening condition which is characterised by nausea, vomiting, confusion, disorientation and coma. Aggressive treatment in the form of intravenous fluids along with other symptomatic management can be life saving. Here we present an unusual case of heat stroke followed by disseminated intravascular coagulation, multiple organ dysfunction with bilateral intracerebral bleed who survived with judicious management and recovered without any neurological sequeale.

Three unusual presentations of plasmodium vivax malaria.

We present three cases of unusual and complicated malaria caused by Plasmodium vivax. Parenteral artemisinin derivatives or quinine should be used, irrespective of chloroquine sensitivity, for treatment of severe malaria.

Study on the role of humoral immunity in renal transplant rejections and its correlation with histopathological findings.

Immunoglobulins (Ig) and complement, which are components of humoral immunity, are supposed to play a role in renal transplant rejection. The present study was undertaken to study the level of complement C3, C4 and IgG, A and M in patients with chronic renal failure (CRF) and in those with renal transplant rejection (Tx Rej) as well as stable transplant recipients (Tx Stb) and normal healthy controls (NHC) in order to assess their role in transplant rejection and to correlate them with histopathological findings. The mean level of C3 and C4 in the CRF, Tx Rej and Tx Stb groups was not significantly different from the NHC group (P > 0.05). The mean level of C3 in the Tx Rej group was not different from that in the Tx Stb group. However, the C4 level was significantly reduced in the Tx Rej group when compared with the Tx Stb group (P < 0.05). There was no histopathological correlation between C3 levels and acute cellular rejection (ACR) or chronic allograft nephropathy (CAN); however, C4 levels were reduced in about 50% of the cases with CAN. The mean serum IgG level was significantly reduced in patients with CRF and transplant recipients as compared with NHC. The serum IgA level was also significantly reduced in Tx Rej cases. Correlation of serum IgA with histopathology in cases with rejection showed that in ACR, a lower mean level of IgA was seen as compared with that seen in cases with CAN. The serum IgM level was significantly higher in the Tx Rej group as compared with the Tx Stb group. There was no significant correlation between serum IgM levels and renal histopathology in patients with ACR and CAN. The C3 level showed a significant positive correlation with IgG (r = +0.50, P < 0.05) in the Tx Stb group. This study shows that cell-mediated immunity is the main cause of rejection in both ACR and CAN while humoral immunity is also involved along with cellular immunity in some cases with CAN.

Coexistence of ankylosing spondylitis and systemic lupus erythematosus.

Coexistence of ankylosing spondylitis with connective tissue diseases is uncommon. We describe here the coexistence of ankylosing spondylitis and systemic lupus erythematosus in a 35-year-old man. He presented with a 4-year history of pain in the hip joint and lower spine, and he later developed a malar rash and discoid rash. Immunological tests revealed that antinuclear antibody and double stranded DNA antibody were positive. The human leukocyte antigen B27 antigen was also found to be positive. We propose that development of systemic lupus erythematosus in this case may have been due to low grade chronic inflammation.

Celiac disease-associated antibodies in patients with psoriasis and correlation with HLA Cw6.

Etiopathology of psoriasis is not completely understood. Patients with psoriasis show elevated sensitivity to gluten. The aim of this study was to see the expression of celiac disease (CD)-associated antibodies gliadin IgA, gliadin IgG, and tissue transglutaminase IgA, and their correlation with HLA Cw6 in patients with psoriasis. The study comprised 56 patients with psoriasis and 60 healthy controls (HC). The levels of antibodies were detected by using ELISA technique and HLA Cw6 typing was carried out by microcytotoxicity method. HLA Cw6 was significantly expressed in psoriasis cases when compared with HC (P<0.05). CD-associated antibodies gliadin IgA/IgG and tissue transglutaminase IgA were significantly higher in the serum of patient with psoriasis when compared with HC (P<0.05, <0.05, and 0.01, respectively). Serum anti tissue transglutaminase IgA (anti tTG IgA) was significantly higher in females when compared with males and expressed more in elderly patients. There was a significant positive correlation among the antibodies (anti gliadin IgA with anti gliadin IgG: r=0.67, P<0.05; anti gliadin IgA with anti tTG IgA: r=0.45, P<0.05, anti gliadin IgG with anti tTG IgA: r=0.26, P<0.05, respectively), whereas insignificant with HLA Cw6. Our study concludes that latent CD or CD-associated antibodies were present in patients with psoriasis and also concludes that HLA Cw6 has no association with expression of these antibodies in patients with psoriasis.

Evaluation of serum tumor necrosis factor alpha and its correlation with histology in chronic kidney disease, stable renal transplant and rejection cases.

Tumor necrosis factor alpha (TNF alpha) is a cytokine secreted by macrophages, helper T cells, natural killer cells, B lymphocytes and non lymphoid cells e.g. endothelial cells, fibroblast and tumor cell lines. Aim of the study was to find the utility of TNF alpha in diagnosing renal transplant rejection among the renal transplant cases (n=29), and comparison with the levels in patients on maintenance hemodialysis (n=21) and healthy controls (n=20). TNF alpha in healthy controls varied from 2 to 15 pg/mL. In chronic renal failure and renal transplant rejection cases TNF alpha was above 45 pg/mL. In stable renal transplant patients it was higher than normal (16 to 30 pg/mL). In both acute and chronic transplant rejection TNF alpha increase correlated well with histology. Thus our study suggests that TNF alpha level more than 45 pg/mL can be taken as an immunological marker of renal transplant rejection.

Role of HLA B27 in diagnosis of seronegative spondyloarthropathies.

Seronegative Spondyloarthropathies (SSA) is a very common problem in our area. The main aim of present study was (1) to find the HLA B27 positivity in patients presenting with sacroileitis (2) to see the correlation of B27 positivity on haematological, radiological and extra articular manifestations. Total 110 patients of SSA were studied between July 2004 to June 2005. Routine haematological and immunological test were done by standard method. Total positivity of B27 in SSA was 43.63%, HLA B27 positivity was higher in children (68.75%). Sex wise analysis of B27 positive cases showed that 81.81% B27 positive patients were males. In HLA B27 positive cases lower spine, hip, sacroiliac, shoulder and knee joints were more involved (77.08%, 79.16%, 79.16%, 37.50% and 50.00% respectively). Urinary tract infection (UTI), diarrhoea and constipation were more common in B27 positive cases. Leukocytosis of neutrophilic type (33.33%), raised ESR (77.55%)., CRP positivity (63.63%) and anaemia (65.00%) were seen more frequently in B27 positive cases. In bilateral sacroiliitis diagnosed by X-ray, only 69.23% patient were B27 positive. Our study concludes that HLA B 27 positivity is higher in SSA seen in childhood and in young adult males. B27 positive patients have more severe disease and systemic manifestation Hence, male patients specially young adolescent or young adults with sacroileitis must be subjected for B27 typing.