Letters to the Editor
291
[8] Haugaa KH, Amlie JP, Berge KE, Leren TP, Smiseth OA, Edvardsen T. Transmural differences in myocardial contraction in long-QT syndrome: mechanical consequences of ion channel dysfunction. Circulation 2010;122:1355–63. [9] Panicker GK, Karnad DR, Natekar M, Kothari S, Narula D, Lokhandwala Y. Intra- and interreader variability in qt interval measurement by tangent and threshold methods in a central electrocardiogram laboratory. J Electrocardiol 2009;42:348–52. [10] Aguilar FG, Selvaraj S, Martinez EE, et al. Archeological echocardiography: digitization and speckle-tracking analysis of archival echocardiograms in the HyperGEN Study [abstract]. J Am Soc Echocardiogr 2012;25:B10.
Fig. 2. Electrocardiographic T-peak to T-end interval and radial contraction duration heterogeneity.As TpTe interval (ms) increases (organized by tertiles for illustrative purposes), heterogeneity of radial component contraction duration also increases (as measured by the standard deviation of time to peak radial strain).
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.232
PNPLA3 I148M variant as a risk factor for carotid atherosclerosis in chronic hepatitis C Rosa Zampino a,⁎, Anna Florio b, Nicola Coppola c, Grazia Cirillo d, Margherita Macera c, Aldo Marrone a, Luigi Elio Adinolfi a, Emanuele Miraglia del Giudice d a
Internal Medicine and Hepatology, Second University of Naples, Italy Vascular Surgery, Second University of Naples, Italy c Department of Public Medicine, Section of Infectious Diseases, Second University of Naples, Italy d Department of Pediatrics, Second University of Naples, Italy b
a r t i c l e
i n f o
Article history: Received 2 December 2013 Accepted 30 December 2013 Available online 10 January 2014 Keywords: Chronic hepatitis C PNPLA3 Atherosclerosis Steatosis
We read with much interest the article by Oliveira et al. in the Internal Journal of Cardiology entitled “Effects of hepatitis C virus on cardiovascular risk in infected patients: a comparative study.”[1]. The authors indicated that patients with chronic HCV infection who were non-obese, therapy-naive and non-diabetic had an intermediate cardiovascular risk and suggested the importance of inflammation, expressed as high levels of pro-inflammatory cytokines IL-6 and TNF, in the pathogenesis of atherosclerosis. Chronic hepatitis C (CHC) causes hepatic and extra-hepatic inflammation by many as yet somewhat obscure molecular pathways, including cytokine metabo-
⁎ Corresponding author at: Internal Medicine and Hepatology, Second University of Naples, Via Pansini, 5 Edificio 10, 80131 Naples, Italy. Tel.: + 39 081 5666225; fax: + 39 081 5666230. E-mail address: [email protected] (R. Zampino).
lism, oxidative stress and steatosis induction [2]. Moreover, different studies have shown the relationship between HCV and atherosclerosis development [3,4], particularly in the presence of liver steatosis [5], thus stressing the role of HCV as risk factor for atherosclerosis development. Recently, the patatin-like phospholipase domain-containing 3 gene (PNPLA3) polymorphism has been associated with liver steatosis in CHC [6], and excessive abdominal fat seems to increase this association [7]. The identification of as many risk factors as possible of cardiovascular disease is very important to control the spread of these pathologies, already widespread in many industrialized countries. We would like to make a contribution to this topic showing the results of a study analyzing the possible role of PNPLA3 polymorphism as a risk factor for carotid atherosclerosis in CHC. We studied 60 patients with histologically proven CHC, naive for antiviral treatment and without other risk factors for atherosclerosis (smoking, hypertension, age N65 years), in relation to the PNPLA3 polymorphism, histological liver steatosis and intima-media thickness (IMT). The patients underwent complete physical examination, full liver function tests, markers of HBV, HCV and HIV infections, liver ultrasound scan and liver biopsy. For all patients body mass index (BMI: kg/m2), waist circumference, triglycerides and cholesterol levels were evaluated. Liver histology was evaluated applying the Ishak scoring system to grade necroinflammation and fibrosis [8] and a home-made scoring system for steatosis (score 1 = 1-10% of hepatocytes with fatty deposition, score 2 = 11-30%; score 3 = 31-60%; score 4 N60%) [9].
292
Letters to the Editor
Table 1 General characteristics of chronic hepatitis C patients stratified according to the PNPLA3 variant.
Patients Males, n (%) Age, years (mean ± SD) BMI, (mean ± SD) Waist circumference, (mean ± SD) AST, × n.v. (mean ± SD) ALT, × n.v. (mean ± SD) gGT, IU/ml (mean ± SD) Glucose, mg/dl (mean ± SD) Triglycerides, mg/dl (mean ± SD) Total cholesterol, mg/dl, (mean ± SD) HCV RNA, IU × 106 (mean ± SD) HCV genotype, n (%) 1 2 3 6 Missing HAI score, (mean ± SD) Fibrosis score, (mean ± SD) Steatosis score, (mean ± SD) IMT, (mean ± SD) CCA BULB ICA
p148 I/I-I/M
p148 M/M
53 27 (52) 51 ± 11 26 ± 4 91 ± 10 64 ± 44 98 ± 81 50 ± 51 91 ± 19 110 ± 62 192 ± 43 3.5 ± 10
8 4 (50) 57 ± 8.3 29 ± 4 105 ± 11 66 ± 39 91 ± 51 58 ± 29 102 ± 23 103 ± 35 178 ± 41 2.2 ± 1.2
35 11 3 / 4 5.9 ± 3.6 2.2 ± 1.4 1.3 ± 1.2
2 3 1 1 1 8.2 ± 3.8 2.8 ± 1.4 2.8 ± 1.3
0.9 ± 0.28 0.96 ± 0.25 0.83 ± 0.3
0.9 ± 0.3 0.97 ± 0.28 0.72 ± 0.07
p
0.04
References
0.016
BMI: body mass index; AST: aspartate transaminase; ALT: alanine transaminase; HAI: histological activity index; IMT: intima-media thickness; CCA: common carotid artery; ICA: internal carotid artery; BULB: bulb of carotid artery; × n.v.: times normal value.
IMT was assessed by high-resolution B-mode ultrasonography, at both carotid arteries at the levels of the common (CCA), internal (ICA) and bulb tracts, and IMT N1 mm was regarded as a cut-off value for carotid atherosclerosis [10]. The PNPLA3 rs738409 C to G variant underlying the I148M substitution was identified by FokI restriction enzyme, since the G allele eliminates a FokI restriction site. The random samples were confirmed by direct genotyping. All the procedures used in the study were in accordance with the international guidelines, with the standards on human experimenta-
0167-5273/$ – see front matter © 2014 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.12.231
tion of the Ethics Committee of the Second University of Naples and with the Helsinki Declaration of 1975 and revised in 1983. Table 1 shows the characteristics of the enrolled patients according to the PNAPL3 variants. Statistical analysis confirmed the correlation between PNPLA3 polymorphism, liver steatosis (p = 0.016) and waist circumference (p = 0.04), but no association was found between the I148M PNPLA3 variant and IMT (CCA, p = 0.81; BULB, p = 0.69; CCI, p = 0.61), independently of HCV genotype and steatosis score. Visceral fat distribution was associated with IMT measured only in ICA (p = 0.05). Although larger studies are needed, the PNAPL3 polymorphism does not seem to be a risk factor for carotid atherosclerosis, even with increased liver steatosis and visceral obesity.
[1] Oliveira CP, Kappel CR, Siqueira ER, et al. Effects of hepatitis C virus on cardiovascular risk in infected patients: a comparative study. Int J Cardiol Apr 5 2013;164(2):221–6. [2] Zampino R, Marrone A, Restivo L, et al. Chronic HCV infection and inflammation: clinical impact on hepatic and extra-hepatic manifestations. World J Hepatol Oct 27 2013;5(10):528–40. [3] Petta S, Torres D, Fazio G, et al. Carotid atherosclerosis and chronic hepatitis C: a prospective study of risk associations. Hepatology May 2012;55(5):1317–23. [4] Ishizaka N, Ishizaka Y, Takahashi E, et al. Association between hepatitis C virus seropositivity, carotid-artery plaque, and intima-media thickening. Lancet 2002;359:133–5. [5] Adinolfi LE, Restivo L, Zampino R, et al. Chronic HCV infection is a risk of atherosclerosis. Role of HCV and HCV-related steatosis. Atherosclerosis 2012;221:496–502. [6] Valenti L, Rumi MG, Galmozzi E, et al. Patatin-like phospholipase domaincontaining 3 I148M polymorphism, steatosis, and liver damage in chronic hepatitis C. Hepatology 2011;53:791–9. [7] Zampino R, Coppola N, Cirillo G, et al. Abdominal fat interacts with PNPLA3 I148M, but not with the APOC3 variant in the pathogenesis of liver steatosis in chronic hepatitis C. J Viral Hepat 2013;20:517–23. [8] Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995;22:696–9. [9] Coppola N, Zampino R, Bellini G, et al. Association between a polymorphism in cannabinoid receptor 2 and severe necroinflammation in patients with chronic hepatitis C. Clin Gastroenterol Hepatol 2014;12:334–40. [10] Toubol PJ, Hennerici MG, Meairs S, et al. Mannheim carotid intima-media thickness consensus (2004–2006). Cerebrovasc Dis 2007;23:75–80.
291
[8] Haugaa KH, Amlie JP, Berge KE, Leren TP, Smiseth OA, Edvardsen T. Transmural differences in myocardial contraction in long-QT syndrome: mechanical consequences of ion channel dysfunction. Circulation 2010;122:1355–63. [9] Panicker GK, Karnad DR, Natekar M, Kothari S, Narula D, Lokhandwala Y. Intra- and interreader variability in qt interval measurement by tangent and threshold methods in a central electrocardiogram laboratory. J Electrocardiol 2009;42:348–52. [10] Aguilar FG, Selvaraj S, Martinez EE, et al. Archeological echocardiography: digitization and speckle-tracking analysis of archival echocardiograms in the HyperGEN Study [abstract]. J Am Soc Echocardiogr 2012;25:B10.
Fig. 2. Electrocardiographic T-peak to T-end interval and radial contraction duration heterogeneity.As TpTe interval (ms) increases (organized by tertiles for illustrative purposes), heterogeneity of radial component contraction duration also increases (as measured by the standard deviation of time to peak radial strain).
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.232
PNPLA3 I148M variant as a risk factor for carotid atherosclerosis in chronic hepatitis C Rosa Zampino a,⁎, Anna Florio b, Nicola Coppola c, Grazia Cirillo d, Margherita Macera c, Aldo Marrone a, Luigi Elio Adinolfi a, Emanuele Miraglia del Giudice d a
Internal Medicine and Hepatology, Second University of Naples, Italy Vascular Surgery, Second University of Naples, Italy c Department of Public Medicine, Section of Infectious Diseases, Second University of Naples, Italy d Department of Pediatrics, Second University of Naples, Italy b
a r t i c l e
i n f o
Article history: Received 2 December 2013 Accepted 30 December 2013 Available online 10 January 2014 Keywords: Chronic hepatitis C PNPLA3 Atherosclerosis Steatosis
We read with much interest the article by Oliveira et al. in the Internal Journal of Cardiology entitled “Effects of hepatitis C virus on cardiovascular risk in infected patients: a comparative study.”[1]. The authors indicated that patients with chronic HCV infection who were non-obese, therapy-naive and non-diabetic had an intermediate cardiovascular risk and suggested the importance of inflammation, expressed as high levels of pro-inflammatory cytokines IL-6 and TNF, in the pathogenesis of atherosclerosis. Chronic hepatitis C (CHC) causes hepatic and extra-hepatic inflammation by many as yet somewhat obscure molecular pathways, including cytokine metabo-
⁎ Corresponding author at: Internal Medicine and Hepatology, Second University of Naples, Via Pansini, 5 Edificio 10, 80131 Naples, Italy. Tel.: + 39 081 5666225; fax: + 39 081 5666230. E-mail address: [email protected] (R. Zampino).
lism, oxidative stress and steatosis induction [2]. Moreover, different studies have shown the relationship between HCV and atherosclerosis development [3,4], particularly in the presence of liver steatosis [5], thus stressing the role of HCV as risk factor for atherosclerosis development. Recently, the patatin-like phospholipase domain-containing 3 gene (PNPLA3) polymorphism has been associated with liver steatosis in CHC [6], and excessive abdominal fat seems to increase this association [7]. The identification of as many risk factors as possible of cardiovascular disease is very important to control the spread of these pathologies, already widespread in many industrialized countries. We would like to make a contribution to this topic showing the results of a study analyzing the possible role of PNPLA3 polymorphism as a risk factor for carotid atherosclerosis in CHC. We studied 60 patients with histologically proven CHC, naive for antiviral treatment and without other risk factors for atherosclerosis (smoking, hypertension, age N65 years), in relation to the PNPLA3 polymorphism, histological liver steatosis and intima-media thickness (IMT). The patients underwent complete physical examination, full liver function tests, markers of HBV, HCV and HIV infections, liver ultrasound scan and liver biopsy. For all patients body mass index (BMI: kg/m2), waist circumference, triglycerides and cholesterol levels were evaluated. Liver histology was evaluated applying the Ishak scoring system to grade necroinflammation and fibrosis [8] and a home-made scoring system for steatosis (score 1 = 1-10% of hepatocytes with fatty deposition, score 2 = 11-30%; score 3 = 31-60%; score 4 N60%) [9].
292
Letters to the Editor
Table 1 General characteristics of chronic hepatitis C patients stratified according to the PNPLA3 variant.
Patients Males, n (%) Age, years (mean ± SD) BMI, (mean ± SD) Waist circumference, (mean ± SD) AST, × n.v. (mean ± SD) ALT, × n.v. (mean ± SD) gGT, IU/ml (mean ± SD) Glucose, mg/dl (mean ± SD) Triglycerides, mg/dl (mean ± SD) Total cholesterol, mg/dl, (mean ± SD) HCV RNA, IU × 106 (mean ± SD) HCV genotype, n (%) 1 2 3 6 Missing HAI score, (mean ± SD) Fibrosis score, (mean ± SD) Steatosis score, (mean ± SD) IMT, (mean ± SD) CCA BULB ICA
p148 I/I-I/M
p148 M/M
53 27 (52) 51 ± 11 26 ± 4 91 ± 10 64 ± 44 98 ± 81 50 ± 51 91 ± 19 110 ± 62 192 ± 43 3.5 ± 10
8 4 (50) 57 ± 8.3 29 ± 4 105 ± 11 66 ± 39 91 ± 51 58 ± 29 102 ± 23 103 ± 35 178 ± 41 2.2 ± 1.2
35 11 3 / 4 5.9 ± 3.6 2.2 ± 1.4 1.3 ± 1.2
2 3 1 1 1 8.2 ± 3.8 2.8 ± 1.4 2.8 ± 1.3
0.9 ± 0.28 0.96 ± 0.25 0.83 ± 0.3
0.9 ± 0.3 0.97 ± 0.28 0.72 ± 0.07
p
0.04
References
0.016
BMI: body mass index; AST: aspartate transaminase; ALT: alanine transaminase; HAI: histological activity index; IMT: intima-media thickness; CCA: common carotid artery; ICA: internal carotid artery; BULB: bulb of carotid artery; × n.v.: times normal value.
IMT was assessed by high-resolution B-mode ultrasonography, at both carotid arteries at the levels of the common (CCA), internal (ICA) and bulb tracts, and IMT N1 mm was regarded as a cut-off value for carotid atherosclerosis [10]. The PNPLA3 rs738409 C to G variant underlying the I148M substitution was identified by FokI restriction enzyme, since the G allele eliminates a FokI restriction site. The random samples were confirmed by direct genotyping. All the procedures used in the study were in accordance with the international guidelines, with the standards on human experimenta-
0167-5273/$ – see front matter © 2014 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.12.231
tion of the Ethics Committee of the Second University of Naples and with the Helsinki Declaration of 1975 and revised in 1983. Table 1 shows the characteristics of the enrolled patients according to the PNAPL3 variants. Statistical analysis confirmed the correlation between PNPLA3 polymorphism, liver steatosis (p = 0.016) and waist circumference (p = 0.04), but no association was found between the I148M PNPLA3 variant and IMT (CCA, p = 0.81; BULB, p = 0.69; CCI, p = 0.61), independently of HCV genotype and steatosis score. Visceral fat distribution was associated with IMT measured only in ICA (p = 0.05). Although larger studies are needed, the PNAPL3 polymorphism does not seem to be a risk factor for carotid atherosclerosis, even with increased liver steatosis and visceral obesity.
[1] Oliveira CP, Kappel CR, Siqueira ER, et al. Effects of hepatitis C virus on cardiovascular risk in infected patients: a comparative study. Int J Cardiol Apr 5 2013;164(2):221–6. [2] Zampino R, Marrone A, Restivo L, et al. Chronic HCV infection and inflammation: clinical impact on hepatic and extra-hepatic manifestations. World J Hepatol Oct 27 2013;5(10):528–40. [3] Petta S, Torres D, Fazio G, et al. Carotid atherosclerosis and chronic hepatitis C: a prospective study of risk associations. Hepatology May 2012;55(5):1317–23. [4] Ishizaka N, Ishizaka Y, Takahashi E, et al. Association between hepatitis C virus seropositivity, carotid-artery plaque, and intima-media thickening. Lancet 2002;359:133–5. [5] Adinolfi LE, Restivo L, Zampino R, et al. Chronic HCV infection is a risk of atherosclerosis. Role of HCV and HCV-related steatosis. Atherosclerosis 2012;221:496–502. [6] Valenti L, Rumi MG, Galmozzi E, et al. Patatin-like phospholipase domaincontaining 3 I148M polymorphism, steatosis, and liver damage in chronic hepatitis C. Hepatology 2011;53:791–9. [7] Zampino R, Coppola N, Cirillo G, et al. Abdominal fat interacts with PNPLA3 I148M, but not with the APOC3 variant in the pathogenesis of liver steatosis in chronic hepatitis C. J Viral Hepat 2013;20:517–23. [8] Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995;22:696–9. [9] Coppola N, Zampino R, Bellini G, et al. Association between a polymorphism in cannabinoid receptor 2 and severe necroinflammation in patients with chronic hepatitis C. Clin Gastroenterol Hepatol 2014;12:334–40. [10] Toubol PJ, Hennerici MG, Meairs S, et al. Mannheim carotid intima-media thickness consensus (2004–2006). Cerebrovasc Dis 2007;23:75–80.
