Atherosclerosis in chronic kidney disease: Striking ...

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337. Indian Journal of Nephrology. September 2013 / Vol 23 / Issue 5. K, et al. Association of catalytic iron with cardiovascular disease. Am J Cardiol 2012 ...

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K, et al. Association of catalytic iron with cardiovascular disease. Am J Cardiol 2012;109:438‑42. Becker BN, Himmelfarb J, Henrich WL, Hakim RM. Reassessing the cardiac risk profile in chronic hemodialysis patients: A hypothesis on the role of oxidant stress and other non‑traditional cardiac risk factors. J Am Soc Nephrol 1997;8:475‑86. Ambrosio G, Zweier JL, Jacobus WE, Weisfeldt ML, Flaherty JT. Improvement of postischemic myocardial function and metabolism induced by administration of deferoxamine at the time of reflow: The role of iron in the pathogenesis of reperfusion injury. Circulation 1987;76:906‑15. van der Kraaij AM, Mostert LJ, van Eijk HG, Koster JF. Iron‑load increases the susceptibility of rat hearts to oxygen reperfusion damage. Protection by the antioxidant (+)‑cyanidanol‑3 and deferoxamine. Circulation 1988;78:442‑9. Evans PJ, Halliwell B. Measurement of iron and copper in biological systems: Bleomycin and copper‑phenanthroline assays. Methods Enzymol 1994;233:82‑92. Gang S, Dabhi M, Rajapurkar MM. Ischaemia imaging in type 2 diabetic kidney transplant candidates – Is coronary angiography essential? Nephrol Dial Transplant 2007;22:2334‑8. Farb A, Boam AB. Stent thrombosis redux – The FDA perspective. N Engl J Med 2007;356:984‑7. Freeman RV, Mehta RH, Al Badr W, Cooper JV, Kline‑Rogers E, Eagle KA. Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors. J Am CollCardiol 2003;41:718‑24. Rostand SG, Kirk KA, Rutsky EA. Dialysis‑associated ischemic heart disease: Insights from coronary angiography. Kidney Int 1984;25:653‑9. Hase H, Nakamura R, Ui K, Imamura Y, Inishi Y, Jyoki N, et al. Risk factors for coronary artery disease in Japanese patients with chronic renal failure. Nihon JinzoGakkai Shi 1993;35:751‑6. Jungers P, Massy ZA, Nguyen Khoa T, Fumeron C, Labrunie M, Lacour B, et al. Incidence and risk factors of atherosclerotic

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cardiovascular accidents in predialysis chronic renal failure patients: A prospective study. Nephrol Dial Transplant 1997;12:2597‑602. Goldsmith DJ, Covic A. Coronary artery disease in uremia: Etiology, diagnosis, and therapy. Kidney Int 2001;60:2059‑78. Kronenberg F, Neyer U, Lhotta K, Trenkwalder E, Auinger M, Pribasnig A, et al. The low molecular weight apo (a) phenotype is an independent predictor for coronary artery disease in hemodialysis patients: A prospective follow‑up. J Am Soc Nephrol 1999;10:1027‑36. Ohtake T, Kobayashi S, Moriya H, Negishi K, Okamoto K, Maesato K, et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: An angiographic examination. J Am Soc Nephrol 2005;16:1141‑8. Sullivan JL. Iron and the sex difference in heart disease risk. Lancet 1981;1:1293‑4. Liao Y, Cooper RS, McGee DL. Iron status and coronary heart disease: Negative findings from the NHANES I epidemiologic follow‑up study. Am J Epidemiol 1994;139:704‑12. van der A DL, Marx JJ, Grobbee DE, Kamphuis MH, Georgiou NA, van Kats‑Renaud JH, et al. Non‑transferrin‑bound iron and risk of coronary heart disease in postmenopausal women. Circulation 2006;113:1942‑9. Juckett MB, Balla J, Balla G, Jessurun J, Jacob HS, Vercellotti GM. Ferritin protects endothelial cells from oxidized low density lipoprotein in vitro. Am J Pathol 1995;147:782‑9.

How to cite this article: Rajapurkar MM, Lele SS, Malavade TS, Kansara MR, Hegde UN, Gohel KD, et al. Serum catalytic Iron: A novel biomarker for coronary artery disease in patients on maintenance hemodialysis. Indian J Nephrol 2013;23:332-6. Source of Support: The study was funded by Muljibhai Patel Society for Research in Nephro‑Urology, Nadiad. This is a research organization recognized by the DSIR, Government of India., Conflict of Interest: None declared.


Atherosclerosis in chronic kidney disease: Striking while the Iron is labile Cardiovascular disease (CVD) due to atherosclerosis is a leading cause of morbidity and mortality in both developing and developed world. This holds true for patients with all stages of the chronic kidney disease (CKD) so much hence that it has been remarked that “only the lucky reach dialysis” since the majority of the pre‑dialysis subjects experience cardiovascular events before progressing to end stage renal disease. It is well‑known that even on dialysis cardiovascular disease is the most important cause for mortality. In fact, a recent study endorsed the long prevailing perception that CKD, like diabetes, should be considered as a coronary artery disease (CAD) equivalent.[1] Indian Journal of Nephrology

The understanding of pathogenesis of atherosclerosis has grown immensely and it is now known that inflammation in all its hues is plays a significant role in addition to conventional risk factors. Oxidative stress is ubiquitous in all cellular activities and its role has been implicated in a host of the disease conditions including atherovascular disease. However, unfortunately, exogenous anti‑oxidant therapy has so far delivered very limited therapeutic success in most conditions. This issue of the journal carries an article about serum catalytic iron as a biomarker for coronary artery disease in September 2013 / Vol 23 / Issue 5


[Downloaded free from on Wednesday, May 3, 2017, IP:] Rajapurkar, et al.: Serum catalytic iron a marker of CAD in MHD

patients on maintenance hemodialysis. The results of this study as well as another publication on a similar theme in subjects without CKD present impressive data about a distinct and substantial association of serum catalytic iron with prevalent CAD as well its ability to predict short‑term mortality in acute coronary syndromes.[2] This study unequivocally lends strength to the existing literature on the role of iron and CAD/atherosclerosis. However, the role of iron in the pathogenesis of atherosclerosis is still far from settled. Essentially, iron is an essential dietary component, necessary for a number of cellular functions. The importance of iron resides in its capacity to participate in electron exchange reactions. However, this nature also endows it with a capacity to catalyze free radical generation. The two main oxidative states are the divalent, Fe (II), and the trivalent, Fe (III). Because of the extremely low aqueous solubility of iron, biologic systems have evolved proteins that are able to bind Fe (III) and keep it thermodynamically stable, and proteins that are able to catalyze the reduction of Fe (III) to Fe (II) to make it kinetically available for biological processes. Through the Fenton reaction, under biologically relevant conditions, Fe (II) is capable of transforming molecular oxygen to the superoxide radical (O2‑), and weak oxidant hydrogen peroxide (H2O2) into hydroxyl radical (OH), the major damaging reactive species in nature.[3] Epidemiological studies initially suggested that low iron stores due to menstrual loss afforded protection from cardiovascular disease in women, safety that was ceded with menopause.[4] Other associations of body iron with carotid intima media thickness and acute coronary syndromes have also been reported. However, data on the role of iron in atherosclerosis is conflicting with numerous other reports that refute this association. Hemochromatosis, a condition of iron overload has not been associated with premature atherosclerosis. A very recent population based study on the associations of serum ferritin and percentage transferrin saturation (TS%) with all‑cause, cancer, and cardiovascular disease mortality actually found no correlation with serum ferritin and an inverse correlation of TS% with CVD.[5] Nevertheless, from a pathophysiological perspective, the role of iron as a potential atherogen is plausible given its susceptibility to oxidation and association with inflammatory stress. The authors report on the association of catalytic iron and not ferritin or TS% with a significant atherosclerotic coronary artery disease. The former is likely to be a better way of examining the association of iron with its inflammatory effect, a measure of the body iron that can participate in oxidative injury. 338

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Reactive oxygen species play a central role in endothelial damage and generation of oxidized low density lipoprotein (LDL), a key determinant of the atherosclerotic plaque.[6] Earlier studies have identified catalytic iron in human atherosclerotic plaques. Animal studies in cholesterol fed rabbits have demonstrated a decrease in plaque iron content with the use of the iron chelator, desferrioxamine.[7] More recently, using dual energy computed tomography and three‑dimensional tomography, researchers at Mayo identified iron in unstable plaques.[8] However, cross‑sectional data can at best be considered hypothesis generating as it is impossible to establish causality. Intra‑plaque hemorrhage is well‑known and iron deposits in macrophages could reflect a secondary phenomenon of plaque inflammation and healing following an initial injury. The etiopathogenesis of coronary artery disease is complex and truly multi‑factorial with different clinical and biochemical pathways culminating in the development of the atherosclerotic plaque. Even in the current study, it would have been helpful to have some information of inflammatory status of the subjects, the exact timing of blood sampling with respect to coronary angiogram, the indication of angiography in each subject, total iron received exogenously on dialysis and serial titers of catalytic iron, to establish their stability or time course. It is well‑accepted that the pathogenesis of atherosclerosis in CKD and uremia has additional variables than in the general population. In the current study, many of the well‑established associations of CAD fell out on multivariate regression arguing for the possibility of a non‑representative cohort of subjects. Furthermore, the association of serum catalytic iron did not show a “dose‑response” with the magnitude of CAD. Despite all these limitations, a role of iron in CAD remains plausible and even more so in CKD subjects who receive intravenous iron preparations which are known to have a measurable albeit small proportion of free iron. Further, intravenous iron has been shown to escalate oxidative status of subjects.[9] The association of iron with CAD/atherosclerosis is causative or it is just marker or a covariate can only be established by longitudinal studies. Then only, we will be able to establish the role of iron metabolism in the genesis of the coronary plaque and its therapeutic implications, if any. Until then, three decades after it was first postulated, the role of iron in atherosclerosis/CAD remains to be fully established. G. K. Modi, N. Naik1 Samarpan Kidney Institute and Research Center, Bhopal, Madhya Pradesh, 1Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India Indian Journal of Nephrology

[Downloaded free from on Wednesday, May 3, 2017, IP:] Rajapurkar, et al.: Serum catalytic iron a marker of CAD in MHD Address for correspondence: Dr. Gopesh K. Modi, Samarpan Kidney Institute and Research Center, Bhopal ‑ 462 039, Madhya Pradesh, India. E‑mail: [email protected]

References 1. Tonelli M, Muntner P, Lloyd A, Manns BJ, Klarenbach S, Pannu N, et al. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: A population‑level cohort study. Lancet 2012;380:807‑14. 2. Lele S, Shah S, McCullough PA, Rajapurkar M. Serum catalytic iron as a novel biomarker of vascular injury in acute coronary syndromes. EuroIntervention 2009;5:336‑42. 3. Kartikasari AE. Iron metabolism and coronary artery disease: An introduction. In: Iron modulates phagocyte-endothelial cell interactions: Implications for atherosclerosis. 2006, Proefschrift Universiteit Utrecht. available at dissertations/2006-0322-200123/. 4. Sullivan JL. Iron and the sex difference in heart disease risk. Lancet 1981;1:1293‑4. 5. Kim KS, Son HG, Hong NS, Lee DH. Associations of serum ferritin and transferrin % saturation with all‑cause, cancer, and cardiovascular disease mortality: Third national health and nutrition examination survey follow‑up study. J Prev Med Public

Health 2012;45:196‑203. Sullivan JL. Macrophage iron, hepcidin, and atherosclerotic plaque stability. Exp Biol Med (Maywood) 2007;232:1014‑20. 7. Minqin R, Rajendran R, Pan N, Tan BK, Ong WY, Watt F, et al. The iron chelator desferrioxamine inhibits atherosclerotic lesion development and decreases lesion iron concentrations in the cholesterol‑fed rabbit. Free Radic Biol Med 2005;38:1206‑11. 8. Wang J, Garg N, Duan X, Liu Y, Leng S, Yu L, et al. Quantification of iron in the presence of calcium with dual‑energy computed tomography (DECT) in an ex vivo porcine plaque model. Phys Med Biol 2011;56:7305‑16. 9. Mimić‑Oka J, Savić‑Radojević A, Pljesa‑Ercegovac M, Opacić M, Simić T, Dimković N, et al. Evaluation of oxidative stress after repeated intravenous iron supplementation. Ren Fail 2005;27:345‑51. 6.

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