• Users Online: 89
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 2  |  Page : 188-193

Assessment of plasma level of cyclophilin A in type 2 diabetic patients suffering from vascular diseases


1 Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Cardiology, Faculty of Medicine, Benha University, Benha, Egypt
3 Departments of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt

Date of Submission04-Jul-2017
Date of Acceptance07-Aug-2017
Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Noha A Abd El Bar
Faculty of Medicine, Benha University, Benha, 13511
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_138_17

Rights and Permissions
  Abstract 


Background Peptidyl-prolyl isomerase cyclophilin A (CypA) plays important roles in inflammation. However, little is known about the mechanisms by which CypA exerts its effects. It is secreted in human by monocytes activated by high glucose level. It has a role as an inflammatory mediator in vascular tissue damage.
Aim This study aims to compare plasma levels of CypA in type 2 diabetic patients with or without coronary artery disease (CAD) with those in healthy participants to determine the potential role of CypA in promoting vascular disease in diabetic patient and to study the association of high-sensitivity C-reactive protein with CypA levels.
Patients and methods The present study was conducted on 80 participants who were divided into four groups: group 1, which included apparently healthy individuals; group 2, which included patients with type 2 diabetes mellitus (DM) without CAD; group 3, which included patients with type 2 DM with CAD; and group 4, which included patients with CAD without DM. The plasma level of CypA was measured using a CypA enzyme-linked immunosorbent assay kit.
Results The results showed an increase in the median CypA concentration in all patient groups in comparison with the controls (P<0.001). Also, there was a statistically highly significant increase in the median CypA concentration in diabetic patients with CAD group when compared with only diabetic patients group (P<0.001) and in patient with only CAD when compared with diabetic patients with or without CAD (P<0.001).
Conclusion This study demonstrated that CypA has a potential role in promoting vascular disease in diabetic patients and revealed that CypA is a good biomarker for CAD with or without DM better than high-sensitivity C-reactive protein.

Keywords: coronary artery disease, cyclophilin A, high-sensitivity C-reactive protein, type 2 diabetes mellitus


How to cite this article:
Yossef AA, Issa HA, Ahmad ES, Farag SE, Abd El Bar NA. Assessment of plasma level of cyclophilin A in type 2 diabetic patients suffering from vascular diseases. Benha Med J 2018;35:188-93

How to cite this URL:
Yossef AA, Issa HA, Ahmad ES, Farag SE, Abd El Bar NA. Assessment of plasma level of cyclophilin A in type 2 diabetic patients suffering from vascular diseases. Benha Med J [serial online] 2018 [cited 2018 Dec 13];35:188-93. Available from: http://www.bmfj.eg.net/text.asp?2018/35/2/188/239182




  Introduction Top


There are two types of diabetes mellitus (DM), type 1 and type 2, of which type 2 accounts for the majority (>85%). Both forms can lead to multisystem complications of microvascular endpoints, including retinopathy, nephropathy, and neuropathy, and macrovascular diseases including ischemic heart disease, stroke, and peripheral vascular disease [1]. The International Diabetes Federation showed the top 10 countries with the highest number of adults with diabetes in 2015, in which Egypt was at number 8 with 7.8 million diabetic patients [2]. The secretory nature of cyclophilin A (CypA) and its presence in plasma of patient with DM and coronary artery disease (CAD) underlines its potential as a marker for the disease [3]. CypA is a member of the peptidyl-prolyl isomerase family, a group of proteins that catalyze cistrans isomerization of peptidyl-prolyl bonds during protein folding and/or conformational change [4]. Plasma CypA is primarily secreted by monocytes and vascular wall cells in response to oxidative stress and inflammation, but can also be secreted by or leaked from damaged cardiomyocytes and interstitial fibroblasts [5]. CypA is a potential secretory marker of inflammation in type 2 DM. Expression of CypA reduces in circulating monocytes in patients with type 2 DM. CypA is secreted by monocyte in response to hyperglycemia [6]. As vascular inflammatory changes can hardly be evaluated using cardiac imaging methods, the role of inflammation biomarker testing in peripheral blood is increasing, with the high-sensitivity C-reactive protein (hsCRP) being the most profoundly studied biomarker in cardiovascular diseases. It remains stable in samples over long periods of time and can be tested quite simply, rapidly, and inexpensively. HsCRP testing is valuable in both primary and secondary cardiovascular diseases prophylaxis and for those who are already suffering from cardiovascular disease (CVD). This test is useful in evaluation of disease severity, treatment efficacy, and outcome prognosis [7]. Plasma CypA is associated with C reactive protein (CRP) levels. There is correlation between plasma CypA and serum CRP, a clinical marker of vascular inflammation [8]. This study aimed to compare plasma levels of CypA in type 2 DM patients with or without CAD with those in healthy participants to determine the potential role of CypA in promoting vascular disease in diabetic patient and to study the association of hsCRP with CypA levels.


  Patients and methods Top


Patients

The present study was conducted on 80 patients, 42 male and 38 female, attending the Cardiology and Internal Medicine Departments at Benha University Hospital from October 2015 to October 2016. Informed written consent was obtained from all participants in the study, and this study was approved by the Research Ethics Committee. The study participants were divided into four groups: group 1, which included 20 apparently healthy individuals with matched age and sex; group 2, which included 20 patients with type 2 DM without CAD; group 3, which included 20 patients with type 2 DM with CAD diagnosed after detection of diabetes; and group 4, which included 20 patients with CAD without DM. Patients with cardiac disease other than CAD, nephropathy, retinopathy, inflammatory disease of any cause, liver or kidney disease, other systemic and metabolic disease, malignancy, and pregnant women were excluded from the study. All individuals in the study were subjected to full history taking and clinical examination. Blood samples were drawn from all participants to assess levels of fasting serum glucose, total cholesterol, triglycerides (TG), high-density lipoprotein-cholesterol, low-density lipoprotein (LDL)-cholesterol, urea, creatinine, alanine aminotransferase, creatine kinase-MB (CK-MB). These analyses were carried out using Biosystems A15 Auto-analyzer (Barcelona Spain NycoCard, California, USA). In addition, HbA1c was evaluated using NycoCard diagnostic medical device, and troponin I concentration was measured on the Mini VIDAS instrument using VIDAS Troponin I Ultra (TNIU) kit (bioMerieux Inc., Durham, North Carolina, USA) for determination of human cardiac troponin I in human serum using the enzyme-linked fluorescence assay (ELFA) technique. The plasma level of CypA was measured by double-antibody sandwich enzyme-linked immunosorbent assay kit that was supplied by Cloud-Clone Corp. (Houston, Texas, USA). Blood for CypA were collected after overnight fasting under complete aseptic condition and were put into EDTA test tubes and centrifuged immediately at 3000 rpm for 15 min; the separated plasma was put into aliquots. Serum hsCRP was measured using solid phase enzyme-linked immunosorbent assay kit, which was supplied by BioCheck Inc. (Foster City, California, USA).

Statistical analysis

The collected data were tabulated and analyzed using SPSS version 16 (SPSS Inc., Chicago, Illinois, USA) software. Categorical data were presented as numbers and percentages, whereas quantitative data were expressed as mean±SD, median, and range. The χ2-test or Fisher’s exact test was used to analyze categorical variables. Quantitative data were tested for normality using Shapiro–Wilks test, assuming normality at P value more than 0.05; analysis of variance was used for normally distributed variables, and Mann–Whitney U-test, Kruskal Wallis test, and Spearman’s correlation coefficient (σ) were used for non-normally distributed variables. The receiver operating characteristic (ROC) curve was used to determine cutoff value of CypA with optimum sensitivity and specificity in prediction of type 2 DM with or without CAD. The accepted level of significance in this work was stated at 0.05 (P<0.05). A P value of more than 0.05 was considered nonsignificant, that of less than 0.05 was considered significant, and 0.001 or less was considered highly significant.


  Results Top


There was a statistically highly significant increase in the median of CypA concentration in patient groups in comparison with the control group. Also, there was a statistically highly significant increase in the median of CypA concentration in diabetic patients with CAD group when compared with only diabetic patients group and in patient with only CAD when compared with diabetic patients with or without CAD group ([Table 1] and [Figure 1]). There was a statistically highly significant increase in the median hsCRP concentration in diabetic patients with CAD group in comparison with the control group, DM group, and CAD group, and there was a statistically highly significant increase in the median hsCRP concentration in CAD without DM group in comparison with the control group ([Table 2] and [Figure 2]).
Table 1 Comparing the studied groups regarding cyclophilin A (ng/ml)

Click here to view
Figure 1 Box plot showing median and range of cyclophilin A (ng/ml). CAD, coronary artery disease; DM, diabetes mellitus.

Click here to view
Table 2 Comparing the studied groups regarding high-sensitivity C-reactive protein (mg/l)

Click here to view
Figure 2 Box plot showing median and range of high-sensitivity C-reactive protein (hsCRP) (mg/l). CAD, coronary artery disease; DM, diabetes mellitus.

Click here to view


In diabetic patients without CAD group there was a highly significant positive correlation between the level of CypA and fasting blood sugar (FBS), HbA1c, and hsCRP. In diabetic patients with CAD group there was a highly significant positive correlation between the level of CypA and FBS, HbA1c, hsCRP, LDL. Also, there was a significant positive correlation between the level of CypA and CK-MB, troponin I, cholesterol, and TG. In CAD group there was a highly significant positive correlation between level of CypA and FBS, HbA1c, CK-MB, troponin I, and hsCRP and significant positive correlation between level of CypA and cholesterol, TG, and LDL ([Table 3]). The ROC curve analysis demonstrated that the level of CypA is better than hsCRP in predicting DM, CAD, and for exclusion of CAD in diabetic patient ([Figure 3]). In patients with DM with CAD the best cutoff value for CypA was more than 22.4 ng/ml and at this point the sensitivity was 95% and specificity was 78.3%, with an area under the curve of 0.94. The best cutoff value for hsCRP was more than 3.42 mg/l and at this point the sensitivity was 80% and specificity was 66.7%, with an area under the curve of 0.65. For exclusion of CAD in diabetic patient the best cutoff value for CypA was less than 20.4 ng/ml and at this point the sensitivity was 90% and specificity was 60%, with area an under the curve of 0.66. The best cutoff value for hsCRP was less than 3.42 mg/l and at this point the sensitivity was 60% and specificity was 41.7%, with an area under the curve of 0.51. Finally, in diagnosis of CAD the best cutoff value for CypA was more than 25.4 ng/ml and at this point the sensitivity was 85% and specificity was 81.7%, with an area under the curve of 0.896. The best cutoff value for hsCRP was more than 3.06 mg/l and at this point the sensitivity was 65% and specificity was 70%, with an area under the curve of 0.653.
Table 3 Spearman’s correlation coefficient between cyclophilin A and the studied variables

Click here to view
Figure 3 (a) Receiver operating characteristic (ROC) curve of the cyclophilin A (ng/ml) and high-sensitivity C-reactive protein (hsCRP) (mg/l) for prediction of diabetes mellitus (DM) with coronary artery disease (CAD). (b) ROC curve of the cyclophilin A (ng/ml) and hsCRP (mg/l) for exclusion of CAD in patients with DM. (c) ROC curve of the cyclophilin A (ng/ml) and hsCRP (mg/l) for prediction of CAD without DM.

Click here to view



  Discussion Top


Plasma CypA is secreted by monocytes and vascular wall cells in response to oxidative stress and inflammation, but can also be secreted by or leaked from damaged cardiomyocytes and interstitial fibroblasts [5]. CypA expression and secretion are increased by oxidative stress and vascular injury. These findings are the first to identify CypA as a secreted redox-sensitive mediator, establish CypA as a vascular smooth muscle cells (VSMC) growth factor, and suggest an important role for CypA in the pathogenesis of vascular diseases [9]. CAD occurs due to atherosclerosis of the coronary arteries of the heart [10]. Complications involving the vulnerable atherosclerotic plaque are triggered by two major mechanisms, dyslipidemia and inflammation; although both are influenced by classic risk factors, each mechanism provides additional information regarding cardiovascular events and mortality [11]. The chronic DM is a major risk for cardiovascular disease. The incidence of CVD might be a foremost cause of morbidity and mortality in patient afflicted with DM [12]. In current study, there was a statistically highly significant increase in the median CypA concentration in all patient groups in comparison with the control group (P<0.001); also, there was a statistically highly significant increase in the median CypA concentration in diabetic patients with CAD when compared with only diabetic patients group (P<0.001) and in patient with only CAD when compared with diabetic patients with or without CAD (P<0.001). In concordance with these findings, Satoh et al. [13] reported that plasma CypA levels were significantly higher in patients with significant coronary stenosis compared with those without (P<0.001). Patients with acute coronary syndrome have high plasma concentrations of CypA, and CypA is strongly expressed in the athermanous plaques of patients with acute myocardial infarction (AMI) [13]. Yan et al. [14] also found that serum concentration of CypA in patients with acute coronary syndrome (ACS) (UA and AMI) was significantly higher than those with stable angina (SA) and controls (P<0.05). Hence, increased concentrations of CypA may be a valuable marker for predicting the severity of acute coronary syndrome [14]. There was a study, which support these results, found that plasma CypA is secreted by monocytes and vascular wall cells in response to oxidative stress and inflammation, but can also be secreted by or leaked from damaged cardiomyocytes and interstitial fibroblasts [5], and another study reported that CypA has proinflammatory effects on endothelial cells and may play an important role in the pathogenesis of atherosclerosis [15]. Ramachandran et al. [3] found the same results and reported that patients with type 2 DM have higher circulating levels of CypA than the normal population. Plasma CypA levels were increased in patients with DM and CAD suggesting a role of this protein in accelerating vascular disease in type 2 DM [3]. For the present study, correlation of CypA with the other studied variables is shown in [Table 3]. Ramachandran et al. [3] reported that age was positively associated with increased plasma CypA level, whereas, sex, serum levels of cholesterol, high-density lipoprotein, LDL, and TG were not associated with increase in CypA levels [3]. In contrast, Satoh et al. [13] found that age, diabetes, and dyslipidemia correlated with plasma CypA levels in their patients with stenotic coronary arteries. Also, Ramachandran et al. [3] found that fasting blood glucose and HbA1c were positively associated with plasma CypA levels indicating a specific relation of plasma CypA levels with hyperglycemia [3]. CRP belongs to the pentraxin protein family and is synthesized in hepatocytes and some extrahepatic tissues such as vascular smooth muscle, atherosclerotic plaques, and intracardial tissues [16]. Indeed, as vascular inflammatory changes can hardly be evaluated using cardiac imaging methods, the role of inflammation biomarkers testing in peripheral blood is increasing, with the hsCRP being the most profoundly studied biomarkers in CVD. It remains stable in samples over long periods of time and can be tested quite simply, rapidly and inexpensively [7]. The present study demonstrates highly significant positive correlation between level of CypA and hsCRP. Plasma CypA is associated with CRP levels, a clinical marker of vascular inflammation [8]. Also, Satoh et al. [13] reported that hsCRP correlate with plasma CypA levels in their patients with stenotic coronary arteries. Ramachandran et al. [3] found that in patients with increased serum CRP levels, plasma CypA was also elevated (P=0.016) and reported that there was a positive association between higher hsCRP levels and elevated plasma CypA in patients with diabetes as well as in those with diabetes and CAD [3]. In the present study, ROC curve analysis showed that CypA (c-statistic=0.94) is a better biomarker than hsCRP (c-statistic=0.65), however for exclusion of CAD in diabetic patient c-statistic for CypAwas 0.66, whereas it was 0.51 for hsCRP. Finally, in diagnosis of CAD c-statistic was 0.896 for CypA, while it was 0.653 for hsCRP. One more study that analyzed ROC curve demonstrated that the plasma levels of CypA is useful for the diagnosis of coronary organic stenosis (c-statistic=0.80) and in predicting future cardiovascular intervention (c-statistic=0.79) and also found that plasma CypA level of more than 15 ng/ml remained highly related to CAD (P<0.001), and on comparing plasma levels of CypA and hsCRP, CypA were superior to hsCRP in terms of evaluation of the severity of CAD [17]. Indeed, Satoh and Shimokawa [18] reported that plasma CypA level is a novel biomarker of CAD. Further studies are needed to establish the clinical significance of CypA in the pathogenesis of atherosclerotic CVD.


  Conclusion Top


This study demonstrated that CypA has a potential role in promoting vascular disease in diabetic patients and reveled that CypA is a good biomarker for CAD with or without DM, better than hsCRP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Forouhi NG, Wareham NJ. Epidemiology of diabetes. Medicini 2014; 42:698–702.  Back to cited text no. 1
    
2.
Cho NH, Whiting D, Forouhi N, Guariguata L, Hambleton I, Li R et al. A regional perspective of diabetes in executive summary. In: Cho NH, Whiting D, Forouhi N, Guariguata L, Hambleton I, Li R, et al., editors. IDF diabetes atlas. 7th ed. Belgium: Karakas Print Brussels; 2015. p. 17.  Back to cited text no. 2
    
3.
Ramachandran S, Venugopal A, Kutty VR, Vinitha A, Divya G, Chitrasree V et al. Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascular disease. Cardiovasc Diabetol 2014; 13:38.  Back to cited text no. 3
    
4.
Fischer G, Aumüller T. Regulation of peptide bond cis/trans isomerization by enzyme catalysis and its implication in physiological processes. Rev Physiol Biochem Pharmacol 2003; 148:105–150.  Back to cited text no. 4
    
5.
Hattori F. Extracellular cyclophilin A as a humoral factor modulating cardiovascular inflammatory responses. J Mol Cell Cardiol 2012; 53:1–2.  Back to cited text no. 5
    
6.
Ramachandran S, Venugopal A, Sathisha K, Reshmi G, Charles S, Divya G et al. Proteomic profiling of high glucose primed monocytes identifies cyclophilin A as a potential secretory marker of inflammation in type 2 diabetes. Proteomics 2012; 12:2808–2821.  Back to cited text no. 6
    
7.
Salazar J, Martinez MS, Mervin Chavez M, Toledo A, Añez R, Torres Y et al. C-reactive protein: clinical and epidemiological perspectives. Cardiol Res Pract 2014; 2014:605810.  Back to cited text no. 7
    
8.
Ridker PM, Buring JE, Cook NR, Rifai N. C-reactive protein, the metabolic syndrome, and risk of incident cardiovascular events: an 8-year follow-up of 14 719 initially healthy American women. Circulation 2003; 107:391–397.  Back to cited text no. 8
    
9.
Jin ZG, Melaragno MG, Liao DF, Yan C, Haendeler J, Suh YA et al. Cyclophilin A is a secreted growth factor induced by oxidative stress. Circ Res 2000; 87:789–796.  Back to cited text no. 9
    
10.
Katz MJ, Ness SM. Coronary artery disease (CAD). California, USA: Wild Iris Medical Education Inc.; 2015.  Back to cited text no. 10
    
11.
Fonseca FA, Izar MC. High-sensitivity C-reactive protein and cardiovascular disease across countries and ethnicities. Clinics (Sao Paulo) 2016; 71:235–242.  Back to cited text no. 11
    
12.
Balakumar P. Implications of fundamental signaling alterations in DM-associated vascular disease. Indian J Biochem Biophys 2014; 51:441–448.  Back to cited text no. 12
    
13.
Satoh K, Fukumoto Y, Sugimura K, Miura Y, Aoki T, Nochioka K et al. Plasma cyclophilin A is a novel biomarker for coronary artery disease. Circ J 2013; 77:447–455.  Back to cited text no. 13
    
14.
Yan J, Zang X, Chen R, Yuan W, Gong J, Wang C et al. The clinical implications of increased cyclophilin A levels in patients with acute coronary syndrome. Clin Chim Acta 2012; 2012:691–695.  Back to cited text no. 14
    
15.
Jin ZG, Lungu AO, Xie L, Wang M, Wong C, Berk BC. Cyclophilin A is a proinflammatory cytokine that activates endothelial cells. Arterioscler Thromb Vasc Biol 2004; 24:1186–1191.  Back to cited text no. 15
    
16.
Silva D, Pais de Lacerda A. High-sensitivity C-reactive protein as a biomarker of risk in coronary artery disease. Rev Port Cardiol 2012; 31:733–745.  Back to cited text no. 16
    
17.
Satoh K. Cyclophilin A in cardiovascular homeostasis and diseases. Tohoku J Exp Med 2015; 235:1–15.  Back to cited text no. 17
    
18.
Satoh K, Shimokawa H. High-sensitivity C-reactive protein: still need for next-generation biomarkers for remote future cardiovascular events. Eur Heart J 2014; 35:1776–1778.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed174    
    Printed0    
    Emailed0    
    PDF Downloaded20    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]