Fabio Gonano

Increased Circulating Intercellular Adhesion Molecule-1 Levels in Type II Diabetic Patients: The Possible Role of Metabolic Control and Oxidative Stress

Blood levels of the circulating form of the integrin intercellular adhesion molecule-1 (ICAM-1), malondialdehyde (MDA), and hemoglobin A1c (HbA1c) were studied at baseline and 3 months after improved metabolic control in 25 type II diabetic patients without signs of macroangiopathy, and were compared with those in 15 matched healthy normal controls. Circulating ICAM-1 and MDA levels were increased in diabetic patients, both at baseline and 3 months later. However, with improving metabolic control HbA1c, circulating ICAM-1, and MDA significantly decreased. A significant correlation between circulating ICAM-1, HbA1c, and MDA was found in diabetic patients at each time. Multiple regression analysis considering circulating ICAM-1 as the dependent variable and HbA1c and MDA as independent variables, showed a significant correlation between the three variable at each time. Similar correlations were found in control subjects. These data show increased levels of circulating ICAM-1 in type II diabetic patients, independent of the presence of macroangiopathy. Moreover, these results suggest that oxidative stress and metabolic control might participate in determining increased circulating ICAM-1 levels in both type II diabetic patients and normal subjects.

Fibrinogen Plasma Levels as a Marker of Thrombin Activation in Diabetes

This study attempted to verify the existence of a correlation between fibrinogen, a major cardiovascular risk factor in diabetes, and indexes of thrombin generation and action, prothrombin fragment 1 + 2 (F1 + 2), and D-dimer (D-D), in a group of diabetic subjects compared with a matched control group. Forty insulin-dependent diabetes mellitus patients and 30 matched healthy control subjects participated in this study. The subjects were tested for the following parameters: fibrinogen, prothrombin F1 + 2, D-D, fasting glycemia, and HbA1c. In addition, 5 diabetic subjects who maintained stable fibrinogen plasma levels > 300 mg/dl for at least 6 months before the study were treated with 12,500 U/day subcutaneous heparin for 7 days. Diabetic subjects showed increased levels of fibrinogen, prothrombin F1 + 2, and D-D plasma levels. Simple linear regression analysis detected a positive correlation between fibrinogen and prothrombin F1 + 2, D-D, and glycosylated HbA1c. In the five diabetic subjects treated with heparin fibrinogen, prothrombin F1 + 2 and D-D levels decreased at the end of the treatment. All these parameters returned to baseline after 7 days of washout. These data indicate that fibrinogen plasma levels are correlated to parameters of thrombin activation in plasma in diabetic patients and suggest that high fibrinogen plasma levels might be a risk marker for cardiovascular disease in diabetes because it is an expression of an existing thrombophilia.

Effects of third-generation oral contraceptives on high-sensitivity C-reactive protein and homocysteine in young women.

OBJECTIVE: To evaluate the effect of third-generation oral contraceptives on high-sensitivity C-reactive protein (CRP), homocysteine, and lipids levels in a population of young, fertile, nonobese women. METHODS: Blood markers were evaluated in 277 healthy white women (mean age 23 years and mean body-mass index 21 kg/m2). Seventy-seven oral contraceptive users were compared with 200 non–oral contraceptive users. Progressive cutoffs of high-sensitivity CRP and homocysteine levels were examined. RESULTS: Levels of high-sensitivity CRP posing a high risk of cardiovascular disease (3.0 to less than 10.0 mg/L) were found in 27.3% of oral contraceptive users and in 8.5% of non–oral contraceptive users (odds ratio 4.04; 95% confidence interval [CI] 1.99–8.18). Levels of high-sensitivity CRP at intermediate risk (1.0 to less than 3.0 mg/L) were found in 32.5% of oral contraceptive users and in 11.0% of non–oral contraceptive users (odds ratio 3.89; 95% CI 2.03–7.46). Notably, non–oral contraceptive users were 8.65 (95% CI 4.39–17.1) times as likely to demonstrate a protective level of high-sensitivity CRP (less than 0.5 mg/L) compared with oral contraceptive users. Oral contraceptive use increased serum triglycerides (P<.001) and total cholesterol P=.001); however, high-density lipoprotein, not low-density lipoprotein, contributed to this increase. A decreased ratio of low-density lipoprotein to high-density lipoprotein cholesterol was observed in oral contraceptive users compared with nonusers (P=.016). Oral contraceptive use did not affect homocysteine levels. CONCLUSION: Third-generation oral contraceptive use increases low-grade inflammatory status measured by high-sensitivity CRP concentrations. Alteration of inflammatory status in oral contraceptive users could affect the risk of venous thromboembolism, cardiovascular disease, and other oral contraceptive-associated adverse conditions in young women. LEVEL OF EVIDENCE: II

Increased prothrombin fragment 1 + 2 in type I diabetic patients.

Dr. Antonio Ceriello, Cattedra di Medicina Interna, Facoltà di Medicina, Università di Udine, P.le S. Maria della Misericordia, I-33100 Udine (Italy) The pathogenesis of vascular lesions in diabetic patients has been considered to be at least partly dependent on the alterations in the hemostatic system [1]. However, the existence and the relevance of a hypercoagulable state in diabetes mellitus have been the subject of much debate [1,2]. It has been demonstrated that the conversion of the coagulation zymogen prothrombin to thrombin is associated with the prominent production of a cleavage product namely prothrombin fragment 1+2 (Fl+2) [3]. It has been proposed recently that prothrombin Fl+2 plasma levels may be considered a very sensitive marker for hypercoagulable states in humans [4]. We evaluated prothrombin Fl+2‚(ELISA) levels in 19 insulin-dependent diabetic patients without signs of vascular complications (12 males and 7 females: age 23.4 ± 1.9 years, mean ± SE; body mass index 22.8 ± 1.4; duration of diabetes 6.4 ± 1.3 years; insulin regimen 25-55 U/day, mean 32.8 ± 2.5 U/ day; all subjects had 24-hour urinary albumin excretion rates less than 30 μg/min, and no microaneurysms were detected on full fundal photographs or íluorescein fundal angiogra-phy; they had systolic blood pressures < 120 mm Hg and diastolic blood pressures < 90 mm Hg; ischemic heart disease and peripheral vascular occlusion were excluded according to local criteria) compared to 10 matched healthy normal subjects (6 males and 4 females: age 24.2 ± 1.8 years, body mass index 23.2 ± 1.3). Prothrombin Fl+2 levels were significantly elevated in diabetic patients (0.69 ± 0.11 vs. 0.27 ± 0.03 nmol/l;p < 0.01), but no correlation was found between prothrombin Fl+2 plasma levels and both fasting glycemia (r = 0.17) and glycosylated Hb A1 c (r = 0.16). Increased FPA levels have been reported in diabetes [5]. These findings were considered more suggestive of a thrombin hyperac-tivity than of an increase of thrombin production [6]. This hypothesis was sustained by the evidence of normal [7] or depressed [6] levels of thrombinantithrombin complex in the presence of increased FPA [6] and fibrin monomers [7] in diabetes.

Evidence for a multifactorial control of serum erythropoietin concentration in liver disease

We measured serum erythropoietin (EPO) immunoenzymatically in 245 subjects (151 male, 94 female) to investigate the pathophysiology of its liberation in patients with liver disease. Twelve patients had acute hepatitis, 60 mild chronic liver disease (CLD), 50 cirrhosis (CIR), 43 hepatocellular carcinoma (HCC), 16 malignant extrahepatic disease, 32 benign extrahepatic disease (BEN); 32 subjects served as healthy controls. Higher EPO levels were found in all groups of patients as compared with controls (Bonferronis test, P < 0.01); CIR and HCC had higher values than CLD and BEN (P < 0.01). By multiple regression analysis, EPO correlated with haematocrit, cholinesterase and C-reactive protein (F = 18.63, P < 0.0001). Thus, circulating EPO increases in patients with liver disease, particularly in its more advanced forms. Besides anaemia, both impairment of liver function (possibly via decreased EPO metabolism) and inflammation seem to play contributory roles in elevating serum EPO.

Circulating standard CD44 isoform in patients with liver disease: relationship with other soluble adhesion molecules and evaluation of diagnostic usefulness.

OBJECTIVES To verify the diagnostic usefulness of soluble CD44 (sCD44) in liver diseases. METHODS We studied 142 subjects (90 male, 52 female): 14 had acute hepatitis (AH); 45, noncirrhotic chronic liver disease (CLD); 34, cirrhosis; 35 had extrahepatic diseases (EHD); and 14 were healthy controls. sCD44, soluble intercellular adhesion molecule-1 (slCAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured immunoenzymatically. RESULTS Patients with AH or cirrhosis had higher sCD44 in comparison to CLD, EHD, and controls (p < 0.01). On univariate analysis, sCD44 was associated with sVCAM-1, sICAM-1, bilirubin, cholinesterase, aspartate aminotransferase, and alkaline phosphatase (p < 0.001). By stepwise discriminant analysis, a set of variables, including sCD44 and sVCAM-1, were entered into a model that allocated correctly 79% of observations (p < 0.0001). However, when adhesion molecules were excluded, the model could still allocate correctly 72% of observations. CONCLUSION Although sCD44 concentration increases during severe acute or chronic liver disease, its measurement adds little to the clinical information provided by traditional liver biochemistry.

Increase of Serum α1-Acid Glycoprotein Despite the Decline of Liver Synthetic Function in Cirrhotics with Hepatocellular Carcinoma

alpha 1-Acid glycoprotein, an acute phase reactant synthesised by the liver, has been reported to be increased in neoplastic conditions and reduced in chronic liver disease. We measured serum alpha 1-acid glycoprotein by a nephelometric method in 186 subjects (112 males, 74 females): 55 had mild chronic liver disease (chronic hepatitis and steatofibrosis), 45 cirrhosis, 38 hepatocellular carcinoma, 15 extra-hepatic malignant disease; 33 healthy subjects were used as controls. Analysis of variance demonstrated a significant variability among groups (F = 17.08, P = 0.0000). Higher concentrations of alpha 1-acid glycoprotein were detected in malignant extra-hepatic disease than in all other groups (P < 0.01); concentrations of alpha 1-acid glycoprotein were higher in hepatocellular carcinoma than in cirrhosis (P < 0.01). Multiple regression analysis by groups (dependent variable = alpha 1-acid glycoprotein; group 1 = mild chronic liver disease + cirrhosis; group 2 = hepatocellular carcinoma) showed a significant correlation for both group 1 (r = 0.6264, F = 8.005, P = 0.0000) and group 2 (r = 0.8947, F = 13.643, P = 0.0000). The significant standardised regression coefficients were: cholinesterase, C-reactive protein, gamma-glutamyltransferase and iron (negative) for regression upon group 1; C-reactive protein, alpha 1-antiproteinase, gamma-glutamyltransferase, iron (negative) for regression upon group 2. A difference between the 2 regression equation coefficients was detected (F = 5.209, P = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of serum C-reactive protein measurement in the detection of hepatocellular carcinoma superimposed on liver cirrhosis

We investigated whether, in Italian patients, C-reactive protein (CRP) determination could be considered a useful adjunct, complementary to α1-fetoprotein, in the detection of liver cancer. CRP was determined by particle-enhanced nephelometry in 171 subjects (102 male, 69 female). Fifty-five patients had mild chronic liver disease (CLD), 45 cirrhosis (CIR), 38 hepatocellular carcinoma (HCC); 33 subjects were healthy controls. Patients with HCC and CIR had higher CRP levels (P<0.05) than those found in patients with CLD and controls. CRP higher than 5 mg/l was found in 30/38 (78.9%) patients with HCC, 28/45 (62.2%) patients with CIR, 16/55 (29.1%) patients with CLD (χ2 56.0,P<0.0001). Sensitivity, specificity and diagnostic accuracy of CRP in diagnosing HCC with respect to CLD+CIR were: 78.9%, 56.0% and 34.9%. However, when considered only in the subgroup of patients with α1-fetoprotein below or equalling 30 ng/ml, they were 50.0%, 54.3% and 4.3% respectively. In conclusion, CRP concentration is frequently elevated in patients with HCC, however, it does not seem to improve the ability of α1-fetoprotein to discriminate HCC from CIR.

Non-specific increase of serum carbohydrate antigen 19-9 in patients with liver disease associated with increased circulating levels of adhesion molecules

Sialyl-Lewisa antigen (SLe(a)), the immune determinant of carbohydrate antigen 19-9 (CA 19-9), is the ligand of E-selectin. To verify the possibility of an association between nonspecific elevation of CA 19-9 and adhesion molecules, sera from 12 patients with acute hepatitis, 55 with non-cirrhotic chronic liver disease, 33 with cirrhosis and 25 with hepatocellular carcinoma, were tested for common liver function tests. Besides, CA 19-9 and soluble forms of E-selectin, VCAM-1 and ICAM-1 were measured immunoenzymatically. One-way analysis of variance demonstrated that mean CA 19-9 concentration differed among groups (F 15.27, P < 0.0001) with the highest values found in patients with acute hepatitis. By univariate analysis, the strongest correlation of CA 19-9 was with soluble ICAM-1, which by stepwise multiple regression analysis was the only independent predictor of elevated CA 19-9 (multiple R 0.560). The association between ICAM-1 and CA 19-9 might originate in the biliary cells where they might be simultaneously overexpressed during inflammatory processes.

Serum Soluble Vascular-Cell Adhesion Molecule-1 (VCAM-1) in Patients with Acute and Chronic Liver Diseases

Our aim was to ascertain the degree of variation of serum soluble vascular cell adhesion molecule-1 (VCAM-1) concentrations according to the nature and the severity of an underlying liver disease. One-hundred forty sera collected from 123 patients (83 male, 40 female) with acute hepatitis (n = 14), mild chronic liver disease (n = 52) or cirrhosis (n = 57) of different etiologies as well as from 17 healthy blood donors (8 male, 9 female) were studied. Soluble VCAM-1 concentration was measured immunoenzymatically. One-way analysis of variance revealed a significant variability of the mean values of soluble VCAM-1 among groups (F = 80.02, p < 0.0001). All groups of patients had higher soluble VCAM-1 than controls; moreover, patients with acute hepatitis and patients with cirrhosis had higher soluble VCAM-1 levels than patients with mild chronic liver disease (Bonferronis test, p < 0.01). These results did not change after stratification of patients according to the etiology (viral or toxic) of liver disease (two-way analysis of variance: grouping factor diagnosis, F = 60.39, p < 0.0001; grouping factor etiology, F = 1.73, p NS). Cholinesterase, total bilirubin, circulating thrombocytes and blood area nitrogen were the independent predictors of the concentration of soluble VCAM-1. In conclusion, patients with liver disease have high serum soluble VCAM-1, which seems to reflect more the severity of impairment of liver function rather than the etiologic nature of the disease.