advanced ckd as a risk factor for cardiovascular disease (foley rn et al, am j kidney dis...
TRANSCRIPT
ADVANCED CKD AS A RISK FACTOR FOR CARDIOVASCULAR DISEASE
(Foley RN et al, Am J Kidney Dis 1998;32:S112-S119)
EARLY CKD AS A RISK FACTOR FOR CARDIOVASCULAR DISEASE
(Manjunath G et al, J Am Coll Cardiol 2003;41:47-65)
(Manjunath G et al, Kidney Int 2003;63:1121-1129)
(Vanholder R et al, Nephrol Dial Transplant 2005;20:1048-1056)
EARLY CKD AS A RISK FACTOR FOR CARDIOVASCULAR DISEASE
0 0
VASCULAR PATHOPHYSIOLOGY IN CHRONIC KIDNEY DISEASE
Increased CV risk
Cardiac damage
Oxidative stress
Genes
CKD
Ambient
Microinflammation
Atherosclerosis
Increased CV risk
Metabolicalterations
Hemodynamicdisturbances
MONOCYTES/MACROPHAGES IN ATHEROSCLEROTIC LESIONS
NICOTINAMIDE ADENINE DINUCLEOTIDE PHOSPHATE (NADPH)OXIDASE IN MONOCYTES/MACROPHAGES
NADPH
gp91 p22
p47
p67
rac
·O2-
O2H+
NADP+
EC
IC
Cathcart MKRegulation of superoxide anion productionby NADPH oxidase in monocytes/macrophages.Contributions to atherosclerosis.Arterioscler Thromb Vasc Biol 2004;24:23-28
EXPRESSION OF NADPH OXIDASE IN HUMAN CORONARY ARTERIES
Nonatheroscleroticarteries
Atheroscleroticarteries
Advancedatherosclerotic
lesions
Hematoxylin-eosin Anti-p22phox Negative controls
(Azumi H et al, Circulation 1999;100:1494-1498)
PHAGOCYTIC NADPH OXIDASE ACTIVITY AND ATHEROSCLEROSISIN ASYMPTOMATIC SUBJECTS
(Zalba G et al, Arterioscler Thromb Vasc Biol 2005;APP April 28)
·O2-
pro
du
ctio
n (
coun
ts/s
)
Carotid IMT quartiles
0
25
20
15
10
5
30
P < 0.05
q1 q2 q3 q4
HYPOTHESIS AND GOALS
Early stages of CKD are associated with phagocytic NADPH oxidase overactivity
To assess NADPH oxidase-mediated ·O2-
production in peripheral blood monocytes and lymphocytes from patients with stage 1-2 and 3 CKD
&
To assess associations of NADPH oxidase activity with systemic oxidative parameters and atherosclerosis in the same patients
SUBJECTS AND DESIGN
Subjects who attended for routine medical examination
No known history of renal disease and atherosclerosis
Complete medical work-up after informed consent
21 healthy 42 patients with CKD subjects (22 stage 1-2, 20 stage 3)
Carotid Measurement of Biochemical arteries NADPH oxidase & hormonal ultrasonography in PMN cells determinations
DEMOGRAPHIC AND RENAL CHARACTERISTICS OF STUDIED SUBJECTS
(Fortuño A et al, submitted)
Controls Patients with CKD
stage 1-2 stage 3
Gender, m/f 14/7 19/3 16/4
Age, years 483 57±2 * 63±10 *
GFR, ml/min/1.73 m2 904 914 50±8 * †
U alb. : U creat., mg/g 3.60.4 33.82.4 * 46.6±4.7 * †
( * P < 0.05 compared with controls, † P < 0.05 compared with stage 1+2)
DETERMINATION OF NADPH OXIDASE ACTIVITY IN HUMAN PHAGOCYTIC CELLS
(Fortuño A et al, J Hypertens 2004;22:2169-2175)
Lu
cige
nin
-en
han
ced
lu
min
esce
nce
(R
LU
/s)
PMA
0
25
20
15
10
5
30
P < 0.05
Basal Control DPI Apocynin SOD
35
BASAL NADPH OXIDASE ACTIVITY IN PHAGOCYTIC CELLSFROM PATIENTS WITH CKD
(Fortuño A et al, submitted)
·O2-
pro
du
ctio
n (
RL
U/s
)
Controls Stage 1-2 Stage 30
2.5
2.0
1.5
1.0
0.5
3.0
N.S.
PMA-STIMULATED NADPH OXIDASE ACTIVITY IN PHAGOCYTIC CELLS FROM PATIENTS WITH CKD
(Fortuño A et al, submitted)
·O2-
pro
du
ctio
n (
RL
U/s
)
Controls Stage 1-2 Stage 30
10.0
8.0
6.0
4.0
2.0
12.0
P < 0.02
(NADPH oxidase overactivitywas not associated with age)
Abnormally high activity
Normal activity (Fortuño A et al, submitted)
PMA-STIMULATED NADPH OXIDASE ACTIVITY IN PHAGOCYTIC CELLS FROM PATIENTS WITH CKD
5%
48% 52%
53% 47%
95% Controls
Stage 1-2 CKD
Stage 3 CKD
P < 0.05
MECHANISMS OF PHAGOCYTIC NADPH OXIDASE OVERACTIVTY INPATIENTES WITH STAGE 1-2 CKD
The clinical context
(Fortuño A et al, J Hypertens 2004;22:2169-2175)
·O2-
pro
du
ctio
n (
RL
U/s
)
Basal PMA Basal PMA0
15.0
12.0
9.0
6.0
3.0
18.0
P < 0.05
P < 0.02 P < 0.01
Normotensive Hypertensive
HEMODYNAMIC CHARACTERISTICS OF PATIENTS WITH STAGE 1-2 CKD
(Fortuño A et al, submitted)
Controls Patients with stage
1-2 CKD
SBP, mmHg 1102 1414 *
DBP, mmHg 722 893 *
MAP, mm Hg 84±3 106±5 *
PP, mm Hg 30±2 51±4 *
Hypertensive, % 0 82
( * P < 0.05 compared with controls)
MECHANISMS OF PHAGOCYTIC NADPH OXIDASE OVERACTIVTY INPATIENTES WITH STAGE 1-2 CKD
Environmental factors
(Lassègue B, Am J Physiol Regul Integr Comp Physiol 2003;285:R277-R297)
NAD(P)Hox
HORMONESAng II, ET-1, Insulin...
CYTOKINES TNF, IFNγ…
METABOLITESGlucose, LDL, oxLDL...
GROWTH FACTORS TGF1, PDGF…
PPARsα ,γ
-
++
+
+
Controls Patients with stage
1-2 CKD
BMI, kg/m2 25.50.6 29.50.9 *
Glucose, mg/dL 912 992 *
Total Cholesterol, mg/dL 22012 23011
LDL-cholesterol, mg/dL 1 5111 1549
HDL-cholesterol, mg/dL 522 4510 *
Triglycerides, mg/dL 834 13010 *
Obesity
Diabetes % 0 36
Met. Synd.
HOMA 1.60.1 4.50.5 *
METABOLIC CHARACTERISTICS OF PATIENTS WITH STAGE 1-2 CKD
(Fortuño A et al, submitted)
( * P < 0.05 compared with controls)
(Fortuño A et al, submitted)
Plasma insulin (U/L)
50403020100
30
20
10
0·O
2- p
rod
ucti
on (
RL
U/s
)
25
15
5
r = 0.441P < 0.05
Pla
sma
insu
lin
(U/L
)
Controls Stage 1-2
0
20
15
10
5
P < 0.05
INSULIN AND PMA-STIMULATED NADPH OXIDASE ACTIVITY IN PHAGOCYTIC CELLS
EFFECT OF INSULIN ON HUMAN PHAGOCYTIC NADPH OXIDASE
(Fortuño A et al, submitted)
0
4
3
2
1
Basal Insulin
Fol
d in
crea
se c
ompa
red
wit
h b
asal
Insulin Apocynin
Insulin BIS I
P < 0.05
NADPH
gp91 p22
p47
p67
rac
·O2-
O2H+
NADP+
EC
IC
MECHANISMS OF PHAGOCYTIC NADPH OXIDASE OVERACTIVTY INPATIENTES WITH STAGE 1-2 CKD
The molecule itself
Critical subunitfor activity
p22
ph
ox :
β-a
ctin
(A
DU
)
0
15
10
5
Controls Normal Increased oxidase activity oxidase activity
(Fortuño A et al, submitted)
p22phox
-actin
MECHANISMS OF PHAGOCYTIC NADPH OXIDASE OVERACTIVTY INPATIENTES WITH STAGE 1-2 CKD
The molecule itself
Patients
P < 0.01
(San José et al, Hypertension 2004;44:163-169)
MECHANISMS OF PHAGOCYTIC NADPH OXIDASE OVERACTIVTY INPATIENTES WITH STAGE 1-2 CKD
The molecule itself *
* The -930 A/G polymorphismof the human p22phox gene
ATHEROGENIC MECHANISMS IN CHRONIC KIDNEY DISEASEThe role of oxidative stress
(Locatelly F et al, Nephrol Dial Transplant 2003;18:1272-1280; Moldinger PS et al, Semin Nephrol 2004;24:354-365)
Reduced anti-oxidant
systems
Increasedphagocytic-mediated
pro-oxidant activity
Renal disease
< NO availability LDL oxidation VSMC apoptosis
Endothelial Plaque Rupture & activation formation thrombosis
Oxidative stress
LDL OXIDATION AND CAROTID ATHEROSCLEROSIS IN PATIENTS WITH STAGE 1+2 CKD
(Fortuño A et al, submitted)
Oxi
diz
ed L
DL
(U
/L)
0
80
60
40
20
Controls Patients
P < 0.05
Car
otid
IM
T (
mm
)
0
0.80
0.60
0.40
0.20
Controls Patients
P < 0.05
ASSOCIATIONS OF PHAGOCYTIC NADPH OXIDASE ACTIVITY,OXIDIZED LDL AND CAROTID INTIMA-MEDIA THICKNESS
(Fortuño A et al, submitted)
Oxidized LDL (U/L)
1209060300
Car
otid
IM
T (
mm
)
0.90
0.85
0.80
0.75
0.70
0.65
0.60
r = 0.393 P < 0.005
Oxi
diz
ed L
DL
(U/L
)
·O2- production (RLU/s)
r = 0.349 P < 0.005
100806040200
140
120
100
80
60
40
20
VASCULAR PATHOPHYSIOLOGY IN EARLY CHRONIC KIDNEY DISEASEProposal
Increased CV risk
Oxidative stress
Genes
EarlyCKD
Ambient
Microinflammation
Atherosclerosis
Increased CV risk
Metabolicalterations
Hemodynamicdisturbances
Oxidant stress is aresult of NADPH oxidase-mediated
·O2- overproduction
by phagocytic cells
Cardiac damage
VASCULAR PATHOPHYSIOLOGY IN EARLY CHRONIC KIDNEY DISEASEConsequence
Increased CV risk
Oxidative stress
Genes
EarlyCKD
Ambient
Microinflammation
Atherosclerosis
Increased CV risk
Metabolicalterations
Hemodynamicdisturbances
It is necessaryto explore the
beneficial effectsof antioxidantmeasures with
proven efficacy
Cardiac damage
Universidad deUniversidad de NavarraNavarra
Cliniciens (CUN)Oscar BeloquiAlberto Benito
Inmaculada Colina
Biochemists (CIMA)Ana FortuñoUjué Moreno
Gorka San JoséGuillermo Zalba
Techniciens (CIMA)Ana MontoyaRaquel Ros