- Email: [email protected]
Serum pentraxin 3 levels are negatively associated with carotid intima media thickness in non-obese rheumatoid arthritis patients
International Journal of Cardiology 221 (2016) 298–301
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Serum pentraxin 3 levels are negatively associated with carotid intima media thickness in non-obese rheumatoid arthritis patients Barbara Stadler Kahlow a,⁎, Roberta Petisco b, Thelma Larocca Skare a, Isabela Goeldner c, Renato M. Nisihara c, Iara J.T. Messias-Reason c a b c
Rheumatology Service, Evangelic University Hospital of Curitiba, Curitiba, PR, Brazil Evangelic School of Medicine, Curitiba, PR, Brazil Department of Medical Pathology, Federal University of Paraná, Curitiba, PR, Brazil
a r t i c l e
i n f o
Article history: Received 22 April 2016 Accepted 24 June 2016 Available online 6 July 2016 Keywords: Pentraxin 3 Rheumatoid arthritis Obesity Atherosclerosis
a b s t r a c t Background: Pentraxin-3 (PTX3) is a long pentraxin that is supposed to participate in the inflammatory process and in atherosclerosis. Aim: To study PTX3 serum levels in rheumatoid arthritis (RA) patients to know if its serum levels may reflect disease activity and/or subclinical atherosclerosis. Methods: PTX3 and carotid intima media thickness (IMT) were studied in 85 RA patients (83.5% females, median age of 59 years old, median disease duration of 13 years) along with its demographic, clinical, serological and lipid profile. For comparison PTX3 was measured in 85 healthy volunteers. Results: PTX3 levels in RA patients were similar to controls (p = 0.21) and did not correlate with inflammatory activity measured by ESR (p = 0.39) CRP (p = 0.18) and DAS28 (p = 0.67). Serum PTX3 levels were higher in nonobese RA patients than in obese (BMI vs PTX3 with rho = −0.27; 95%IC = −0.46 to −0.06; p = 0.009). In non-obese patients, PTX3 correlated negatively with carotid IMT (rho = −0.40; 95%IC = −0.66 to −0.06; p = 0.01) but not in the obese ones (p = 0.26). In the obese RA patients there was a negative correlation between PTX3 levels and LDL/HDL ratio (Rho = −0.29; 95%IC = −0.53–0.01; p = 0.03). Conclusions: PTX3 levels do not reflect inflammatory process in RA. However, it exerts a protective role in the process of atherogenesis in non-obese RA patients. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The interpretation of pentraxin 3 (PTX3) role in human diseases is complex and partially unknown. Opposing to C reactive protein (CRP) and serum amyloid protein A (SAP) that are produced in the liver in response to IL-6 and considered to be short pentraxins, PTX3 is induced mainly by IL-1 and TNFα in dendritic myeloid cells, peripheral blood leukocytes, endothelial cells, fibroblasts and adipocytes among others and is known as a long pentraxin [1,2]. Several studies have identified PTX3 as an important element in host resistance against fungal, viral and bacterial infection [1–3]. Also high levels of PTX3 have been linked to cardiovascular diseases [4,5] and inflammatory activity in autoimmune disorders such as vasculitis [6]. Some authors have proposed that measuring PTX3 may be a useful biomarker of human pathologies complementary to C-reactive protein [1]. However the results found have provided a contradictory picture. ⁎ Corresponding author. Rua Prof. Ulisses Vieira, 145 ap 54, CEP 80320-090 Curitiba, Paraná, Brazil. E-mail address: [email protected] (B.S. Kahlow).
http://dx.doi.org/10.1016/j.ijcard.2016.06.175 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
The idea of measuring serum PTX3 in inflammatory disease is grounded in its induction by pro-inflammatory cytokines (IL-1 and TNF alpha) [1,2] and by its presence in endothelial, dendritic and monocytes and polymorphonuclear cells reflecting local inflammation [6,7]. A study in patients with small vessels vasculitis showed that PTX3 levels associate with clinical disease activity [6]. Shimada et al. [8] also found PTX3 levels to be associated with LES disease activity, but others did not [9]. Also, Kim et al. [10] could not use serum PTX3 levels to distinct febrile LES patients with disease activity from those with infection. When analyzing PTX3 levels in this context, it is interesting to note that its production is also stimulated by IL-10 that is considered to be an anti-inflammatory cytokine, suggesting that PTX3 may also be involved in the IL-10 mediated regulation of inflammation [1,11]. In cardiovascular diseases studies, PTX3 was found to be localized within and around ischemic lesions [12]. Examination of atherosclerotic plaques reveals a strong expression of PTX3 in macrophages, endothelial cells, and subendothelial muscular cells [5,12]. Nevertheless, if PTX3 exerts a beneficial or a deleterious role in this setting is, similarly, a matter for discussion. Bosutti et al. [5], finding PTX3 mRNA elevated in white blood cells and adipose tissue of non-diabetic patients with high
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301
LDL levels, suggested that PTX3 may be involved in the mechanism of inflammation and oxidative stress triggered by LDL in the atherosclerotic process. Atherosclerotic and inflammatory lesions of the aorta were found to be significantly increased in knockout mice lacking PTX3 [13]. Rheumatic patients referred to coronary artery bypass grafting showed that serum PTX3 levels are higher in rheumatic patients than controls and associated with more cardiovascular risk [4]. Contraposing these ideas, others believe that PTX3 has a cardiovascular protective role because it modulates the inflammation and complement activation through C1q, factor H, ficolin-2 and apoptotic cells binding. PTX3 also interacts with fibroblast growth factor 2 that induces chemotaxis and proliferation of endothelial cells and in vivo neovascularization [1]. Baragetti et al. [14] studying 2400 subjects from the general population for PTX3 and carotid intima media thickness progression concluded that PTX3 plasma level is neither an independent predictor of development of subclinical atherosclerosis in diverse arterial territories, nor of cardiovascular events occurrence. Lipid profile may influence PTX3 levels. HDL induces PTX3 mRNA expression and protein release in in vitro and in vivo animal studies [15]. This finding has suggested that this may be one mechanism by which HDL may exert their protective effects on endothelial cells and vascular wall [15]. A third area where PTX3 has been studied is obesity. Recent studies have demonstrated elevated adipose tissue expression of PTX3 in obese patients [16]. Paradoxically however, systemic PTX3 levels were reported to be inversely associated with increased fat mass [15,17,18]. Taking into account the above information it is possible to say that inflammation, atherogenesis, alterations of lipid profile and body mass are areas of importance for PTX3 study. Rheumatoid arthritis (RA) is a common systemic chronic inflammatory disease. In RA, the chronic synovial inflammation has been linked to accelerated atherogenic process and cardiovascular events are responsible for reduced life spam in this population [19]. Obesity is also a problem in rheumatic patients and may be related to glucocorticoid use and immobility due to pain and articular dysfunction [20]. There are scare studies address PTX3 in RA. So, in the present study 85 patients with RA were investigate aiming to know its relationship with disease clinical profile and activity, degree of atherogenesis studied through measurement of carotid intima-media thickness (IMT), lipid profile and body mass index (BMI). 2. Methods This study was approved by local Committee of Ethics in Research and all participants signed consent. We included 85 adult patients from both genders that fulfilled at least four of 1987 American College Classification criteria for RA [21]. Patient's demographic, clinical and serological data were collected through chart review. All patients had measurement of height and weight for body mass index calculation (BMI), fasting overnight determinations of lipid profile (total cholesterol, triglycerides, HDL and LDL cholesterol through enzymatic colorimetric method), measurement of ESR (by Westergreen method), CRP (by immunoturbidimetry). Disease activity was determinated by DAS 28 (4v.) [22,23]. Measurement of carotid IMT was done in both sides using color doppler high resolution equipment ESAOTE®, model MyLAb40 with 18 mHZ linear transducers. Transversal and longitudinal cuts were done at common carotid vessel, 2 cm below the bulbus. All tests were read by a single professional who was blinded to clinical information. We considered that the patient had no thickening if the measurement of intimae-media complex was less than 0.8 mm; with thickness measurements from 0.8 mm to 1.5 mm and atheromatous plaques when greater than 1.5 mm [24]. For statistical calculations, we considered the value of carotid IMT which was the greatest among the two sides. PTX-3 plasma levels were measured by a commercial kit using sandwich enzyme immunosorbent assay (ELISA) (R&D Systems, Minneapolis, MN, USA). Sera from health controls were obtained from hospital staff and none had chronic inflammatory disease neither relatives with rheumatic diseases and paired for gender and age. Results are expressed as mean and standard deviation or median and interquartile range (IQR). For association studies of numeric data, Mann Whitney and unpaired t tests were used according to sample distribution. For correlation studies Spearman tests were applied. The frequency analyses were performed through Chi-square test and Fisher two-tailed test, using Graph Pad Prism 5.0 (GraphPad software Inc., La Jolla, CA, USA). A p b 0.05 was considered statistically significant.
299
3. Results 3.1. Description of studied sample Epidemiological, clinical and laboratorial characteristics of studied sample are in Table 1. In patients with RA, PTX3 levels ranged from 0.3–14.4 ng/mL; median values of 1.27 (0.43–2.45 ng/mL). In health control group PTX3 had values from 0.30–2.36 ng/mL, with median values 0.70 (0.50–1.55 ng/mL), without significant difference between groups (p = 0.21).
3.2. Studies of PTX3 plasma concentration according to RA variables Studying the PTX3 level association to epidemiological, clinical and serological variables we found the results seen in Table 2. The correlation studies (Spearman test) of PTX3 levels with age, disease duration, age at disease onset, DAS28, ESR, CRP, total cholesterol, HDL and LDL cholesterol, triglycerides, LDL/HDL ratio and IMT were all non-significant (p = NS). However, BMI showed a negative correlation with PTX3 levels (Rho = −0.27; 95%IC = −0.46 to −0.06; p = 0.009). When the RA patients were stratified into two groups (group 1 — with under and normal weight patients and group 2 — patients with overweight and obese), we found that in the group 1 the PTX3 levels were associated negatively with IMT as seen in Fig. 1. This was not found in group 2 (Rho = 0.15; 95% IC = −0.12 to 0.41). In group 2 (overweight and obese patients) a negative correlation of PTX3 levels and LDL/HDL ratio (Spearman Rho = − 0.29; 95%IC = − 0.53 to − 0.01; p = 0.03) was found. All other studied correlations (total cholesterol, triglycerides, Das 28, ESR and CRP) did not show significant difference (p = NS) in both groups.
Table 1 Epidemiological, clinical and laboratorial characteristics of 85 patients with rheumatoid arthritis. Gender
83.5% (71/85) females
Age (years) Disease duration (years) Age at disease onset (years) Ethnic background (auto-declared) Afrodescendants Eurodescendants Tobacco exposure (current and ex-smokers) Rheumatoid nodules Secondary Sjögren's syndrome Steinbrocker functional class Class 1 Class 2 Class 3 Class 4 Anti-CCP positive Rheumatoid factor positive Diabetes mellitus Arterial hypertension Statins users Body mass index (kg/m2) Underweight (I b 18.5) Normal weight (18.5 to 24.9) Overweight (25 to 29.9) Obesity (N30) Total cholesterol (mg/dL) HDL cholesterol (mg/dL) LDL cholesterol (mg/dL) Triglycerides (mg/dL) Erythrocyte sedimentation rate — ESR (mm) C reactive protein — CRP mg/dL DAS 28 Carotid intima media thickness (mm)
33–82; median 59 (48–65) 5–35; median 13.0 (10–18.5) 22–66; median 45 (29.5–50) 29.4% (25/85) 70.5% (60/85) 29/85 (34.1%) 8/85 (9.4%) 18/61 (29.5%) 41/85 (48.2%) 34/85 (40.5%) 8/85 (9.4%) 2/85 (2.3%) 70/85 (82.3%) 65/85 (76.4%) 12/85 (14.4%) 40/85 (47.0%) 36/85 (42.3%) 15.7–37.6; mean 27.0 ± 4.85 3/85 (3.6%) 30/85 (35.3%) 28/85 (32.9%) 24/85 (28.2%) 113–371; mean 183.4 ± 38.8 32–126; median 51.0 46–293; mean 104.9 ± 35.5 42–313 mg/dL; mean 129.5 ± 53.3 1–106; mean 42.5 ± 24.8 0.1–80.0; median 16.0 (8.5–24.0) 0.42–8.07; median 3.32 (2.67–4.23) 0.25–1.07; median 0.59 (0.51–0.85)
300
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301
Table 2 Comparison of PTX3 levels according to clinical, serological and demographic profile in 85 patients with rheumatoid arthritis. PTX3 levels with the variable range, median and IQR (ng/mL) Positive anti-CCP Positive rheumatoid factor Rheumatoid nodules Secondary Sjögren Associated diabetes mellitus Associated arterial hypertension Statin users Steinbrocker class
PTX3 levels without the variable range, median and IQR (ng/mL)
0.30–14.40 0.36–7.35 Median 1.29 (0.43–2.62) Median 1.29 (0.42–2.40) 0.30–14.40 0.30–5.20 Median 1.27(0.46–2.70) Median 0.93 (0.38–2.24) 0.4–8.6 0.30–14.40 Median 2.67 (0.44–8.60) Median 1.25 (0.42–2.25) 0.30–14.40 0.30–8.80 Median 1.52 (0.48–3.15) Median 1.20 (0.42–2.40) 0.30–8.50 0.30–14.40 Median 0.42 (0.36–2.27) Median 1.28 (0.48–2.45) 0.30–8.80 0.30–14.40 Median 1.10 (0.44–1.79) Median 1.45 (0.42–2.85) 0.30–7.35 0.30–7.30 Median 0.91 (0.42–2.48) Median 1.30 (0.46–2.45) Class 1 — 0.30–8.60; median 1.28 (0.38–2.45) Class 2 — 0.30–14.40; median 1.28 (0.47–2.62) Classes 3 and 4 — 0.35–8.80; median 0.59 (0.48–2.14)
P
0.72 0.33 0.18 0.27 0.06 0.38 0.38 0.69
4. Discussion Our results have shown that plasmatic PTX3 levels did not reflect inflammation in RA as no association could be found with DAS 28. DAS 28 is a composite instrument that takes into account not only objective signs of inflammation but also pain and general symptoms such as fatigue and stiffness [22,23] which may be influenced by subjective feelings. In addition, we could not find an association of PTX3 neither with other inflammatory index such as ESR nor with CRP. CRP, although unspecific, is considered the most clinically useful marker of inflammation in RA [25]. In the present study, it was also established that PTX3 concentration is inversely related to BMI in RA patients as other authors did in different populations [26–28]. Although there is no explanation for this finding, since adipose tissue is a potential relevant source of PTX3, some authors hypothesize that low PTX3 production in abdominal adipose tissue could be, at least in part, paradoxically, responsible for lower PTX3 plasma concentration [26]. Another idea is that obesity could lower PTX3 production in other cell categories through yet unknown signaling and mechanisms, that should be investigated in future studies [26]. Consistently with the inverse relationship of obesity and PTX3 levels, we also found a negative correlation between PTX3 levels and IMT in non-obese RA patients. So PTX3, instead of being an active participant in inflammation as initially proposed, may be the opposite: it may represent an adaptive anti-inflammatory response to pre-existing
Fig. 1. Negative correlation between PTX3 levels and carotid IMT (intima media thickness) in underweight and normal body mass index patients with rheumatoid arthritis (Spearman Rho = −0.40; 95%IC −0.66 to −0.06; p = 0.01).
inflammation or vascular damage [26,29]. However, we could not maintain the inverse relationship between IMT and PTX3 levels in obese patients and this may show that, in this population, other factors may interpose with PTX3 serum levels. We found a negative association of LDL/HDL relationship with PTX3 levels only in obese RA patients and the altered lipid profile participation in this context could have altered the correlation. Synthetic rates of cholesterol are increased in obese subjects, as are the production rates of very low density lipoproteintriglycerides (VLDL-TG). Since VLDL is a precursor of low density lipoproteins (LDL), overproduction of VLDL might be expected to increase LDL [30], and LDL cholesterol is a known player in cardiovascular risk. Although we can only speculate about the possibility of these interrelations, the present finding of negative association with PTX3 with LDL/HDL ratio reinforces the idea of the beneficial role of PTX3 in the process of atherogenesis. Our result does not agree with those of Mabrouk et al. [31] that studied 60 RA patients and found that serum PTX3 was significantly higher in RA patients with atherosclerotic carotid plaques compared to those without. However Mabrouk et al. did not take into account patients BMI. Concluding, in the present study PTX3 does not reflect inflammatory activity in RA patients but it is inversely related to patient's BMI. In nonobese RA patients, this serological marker associates negatively with carotid IMT and in it is also negatively associated with LDL/HDL ratio in obese RA patients. More studies are needed to clarify the intriguing role of PTX3 in human diseases. Conflict of interest None. Funding source None. References [1] S. Jaillon, E. Bonavita, S. Gentile, M. Rubino, I. Laface, C. Garlanda, et al., The long pentraxin PTX3 as a key component of humoral innate immunity and a candidate diagnostic for inflammatory diseases, Int. Arch. Allergy Immunol. 165 (2014) 165–178. [2] C. Garlanda, V. Maina, A. Cotena, F. Moalli, The soluble pattern recognition receptor pentraxin-3 in innate immunity, inflammation and fertility, J. Reprod. Immunol. 83 (2009) 128–133. [3] F. Moalli, S. Jaillon, A. Inforzato, M. Sironi, B. Bottazzi, A. Mantovani, et al., Pathogen recognition by the long pentraxin PTX3, J. Biomed. Biotechnol. 2011 (2011) 830421. [4] I. Hollan, B. Bottazzi, I. Cuccovillo, Ø.T. Førre, K. Mikkelsen, K. Saatvedt, Feiring Heart Biopsy Study Group, Increased levels of serum pentraxin 3, a novel cardiovascular biomarker, in patients with inflammatory rheumatic disease, Arthritis Care Res. (Hoboken) 62 (2010) 378–385. [5] A. Bosutti, G. Grassi, M. Zanetti, A. Aleksova, M. Zecchin, G. Sinagra, G. Biolo, G. Guarnieri, Relation between the plasma levels of LDL-cholesterol and the expression of the early marker of inflammation long pentraxin PTX3 and the stress response gene p66ShcA in pacemaker-implanted patients, Clin. Exp. Med. 7 (2007) 16–23. [6] F. Fazzini, G. Peri, A. Doni, G. Dell'Antonio, E. Dal Cin, E. Bozzolo, et al., PTX3 in smallvessel vasculitides: an independent indicator of disease activity produced at sites of inflammation, Arthritis Rheum. 44 (2001) 2841–2850. [7] A.P. van Rossum, H.H. Pas, F. Fazzini, M.G. Huitema, P.C. Limburg, M.F. Jonkman, et al., Abundance of the long pentraxin PTX3 at sites of leukocytoclastic lesions in patients with small-vessel vasculitis, Arthritis Rheum. 54 (2006) 986–991. [8] Y. Shimada, Y.F. Asanuma, K. Yokota, Y. Yoshida, H. Kajiyama, K. Sato, Y. Akiyama, T. Mimura, Pentraxin 3 is associated with disease activity but not atherosclerosis in patients with systemic lupus erythematosus, Mod. Rheumatol. 24 (2014) 78–85. [9] T.L. Skare, R. Nisihara, G.P. Ramos, S.R. Utiyama, I. Messias-Reason, Pentraxin-3 levels in systemic lupus erythematosus: association with cumulative damage but not with disease activity, Joint Bone Spine 82 (2015) 466–467. [10] J. Kim, J.K. Koh, E.Y. Lee, J.A. Park, H.A. Kim, E.B. Lee, C. Garlanda, A. Cotena, Y.W. Song, Serum levels of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and pentraxin 3 (PTX3) as markers of infection in febrile patients with systemic lupus erythematosus, Clin. Exp. Rheumatol. 27 (2009) 773–778. [11] A. Doni, M. Michela, B. Bottazzi, G. Peri, S. Valentino, N. Polentarutti, et al., Regulation of PTX3, a key component of humoral innate immunity in human dendritic cells: stimulation by IL-10 and inhibition by IFN-gamma, J. Leukoc. Biol. 79 (2006) 797–802. [12] C. Garlanda, B. Bottazzi, F. Moalli, L. Deban, F. Molla, R. Latini, et al., Pentraxins and atherosclerosis: the role of PTX3, Curr. Pharm. Des. 17 (2011) 38–46.
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301 [13] G.D. Norata, P. Marchesi, V.K. Pulakazhi Venu, F. Pasqualini, A. Anselmo, F. Moalli, et al., Deficiency of the long pentraxin PTX3 promotes vascular inflammation and atherosclerosis, Circulation 120 (2009) 699–708. [14] A. Baragetti, M. Knoflach, I. Cuccovillo, L. Grigore, M. Casula, K. Garlaschelli, et al., Pentraxin 3 (PTX3) plasma levels and carotid intima media thickness progression in the general population, Nutr. Metab. Cardiovasc. Dis. 24 (2014) 518–523. [15] G.D. Norata, P. Marchesi, A. Pirillo, P. Uboldi, G. Chiesa, V. Maina, et al., Long pentraxin 3, a key component of innate immunity, is modulated by high-density lipoproteins in endothelial cells, Arterioscler. Thromb. Vasc. Biol. 28 (5) (2008 May) 925–931. [16] O. Osorio-Conles, M. Guitart, M.R. Chacon, E. Maymo-Masip, J.M. Moreno-Navarrete, et al., Plasma PTX3 protein levels inversely correlate with insulin secretion and obesity, whereas visceral adipose tissue PTX3 gene expression is increased in obesity, Am. J. Physiol. Endocrinol. Metab. 301 (2011) E1254–E1261. [17] R. Barazzoni, A. Aleksova, C. Carriere, M.R. Cattin, M. Zanetti, P. Vinci, et al., Obesity and high waist circumference are associated with low circulating pentraxin-3 in acute coronary syndrome, Cardiovasc. Diabetol. 12 (2013) 167. [18] T. Ogawa, Y. Kawano, T. Imamura, K. Kawakita, M. Sagara, et al., Reciprocal contribution of pentraxin 3 and C-reactive protein to obesity and metabolic syndrome, Obesity (Silver Spring) 18 (2010) 1871–1874. [19] J.T. Giles, Cardiovascular disease in rheumatoid arthritis: current perspectives on assessing and mitigating risk in clinical practice, Best Pract. Res. Clin. Rheumatol. 29 (2015) 597–613. [20] I. Colmegna, C.A. Hitchon, M.C. Bardales, L. Puri, S.J. Bartlett, High rates of obesity and greater associated disability among people with rheumatoid arthritis in Canada, Clin. Rheumatol. 35 (2016) 457–460. [21] F.C. Arnett, S.M. Edworthy, D.A. Bloch, D.J. McShane, J.F. Fries, N.S. Cooper, et al., The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis, Arthritis Rheum. 31 (1988) 315–324.
301
[22] H. Mäkinen, H. Kautiainen, P. Hannonen, T. Sokka, Is DAS-28 an appropriate tool to assess remission in rheumatoid arthritis? Ann. Rheum. Dis. 64 (2005) 1410–1413. [23] J. Fransen, P.L.C.M. van Riel, DAS remission cut points, Clin. Exp. Rheumatol. 24 (2006) S29–S32. [24] A. Simon, J. Gariepy, G. Chironi, J.L. Miegnien, J. Levenson, Intima-media thickness: a new tool for diagnosis and treatment of cardiovascular risk, J. Hypertens. 20 (2002) 159–169. [25] W. Arend, C. Gabay, Cytokine network, in: G.S. Firestein, G.S. Panayi, F.A. Wolheim (Eds.), Rheumatoid Arthritis, second ed.Oxford University Press, London 2006, pp. 173–192. [26] A. Witasp, J.J. Carrero, K. Michaëlsson, H. Ahlström, J. Kullberg, V. Adamsson, et al., Inflammatory biomarker pentraxin 3 (PTX3) in relation to obesity, body fat depots and weight loss, Obesity 22 (2014) 1373–1379. [27] K. Yamasaki, M. Kurimura, T. Kasai, M. Sagara, T. Kodama, K. Inoue, Determination of physiological plasma pentraxin 3 (PTX3) levels in healthy populations, Clin. Chem. Lab. Med. 47 (2009) 471–477. [28] T. Miyamoto, A. Rashid Qureshi, O. Heimbürger, P. Bárány, K. Carrero, B. Sjöberg, et al., Inverse relationship between the inflammatory marker pentraxin-3, fat body mass, and abdominal obesity in end-stage renal disease, Clin. J. Am. Soc. Nephrol. 6 (2011) 2785–2791. [29] K.C. Lidani, M.H. Beltrame, P.R. Luz, T.L. Sandri, R.M. Nisihara, I.J. de Messias-Reason, Is pentraxin 3 a cardiovascular marker in patients with chronic Chagas disease? Int. J. Cardiol. 190 (2015) 233–235. [30] Y.A. Kesaniemi, S.M. Grundy, Increased low density lipoprotein production associated with obesity, Arteriosclerosis 3 (1983) 170–177. [31] M.M. Mabrouk, M.A. Ghazy, T.M. Hassan, Serum pentraxin 3 and interleukin-6 are associated with subclinical atherosclerosis in recent-onset rheumatoid arthritis, Egypt. J. Immunol. 17 (2010) 87–99.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Serum pentraxin 3 levels are negatively associated with carotid intima media thickness in non-obese rheumatoid arthritis patients Barbara Stadler Kahlow a,⁎, Roberta Petisco b, Thelma Larocca Skare a, Isabela Goeldner c, Renato M. Nisihara c, Iara J.T. Messias-Reason c a b c
Rheumatology Service, Evangelic University Hospital of Curitiba, Curitiba, PR, Brazil Evangelic School of Medicine, Curitiba, PR, Brazil Department of Medical Pathology, Federal University of Paraná, Curitiba, PR, Brazil
a r t i c l e
i n f o
Article history: Received 22 April 2016 Accepted 24 June 2016 Available online 6 July 2016 Keywords: Pentraxin 3 Rheumatoid arthritis Obesity Atherosclerosis
a b s t r a c t Background: Pentraxin-3 (PTX3) is a long pentraxin that is supposed to participate in the inflammatory process and in atherosclerosis. Aim: To study PTX3 serum levels in rheumatoid arthritis (RA) patients to know if its serum levels may reflect disease activity and/or subclinical atherosclerosis. Methods: PTX3 and carotid intima media thickness (IMT) were studied in 85 RA patients (83.5% females, median age of 59 years old, median disease duration of 13 years) along with its demographic, clinical, serological and lipid profile. For comparison PTX3 was measured in 85 healthy volunteers. Results: PTX3 levels in RA patients were similar to controls (p = 0.21) and did not correlate with inflammatory activity measured by ESR (p = 0.39) CRP (p = 0.18) and DAS28 (p = 0.67). Serum PTX3 levels were higher in nonobese RA patients than in obese (BMI vs PTX3 with rho = −0.27; 95%IC = −0.46 to −0.06; p = 0.009). In non-obese patients, PTX3 correlated negatively with carotid IMT (rho = −0.40; 95%IC = −0.66 to −0.06; p = 0.01) but not in the obese ones (p = 0.26). In the obese RA patients there was a negative correlation between PTX3 levels and LDL/HDL ratio (Rho = −0.29; 95%IC = −0.53–0.01; p = 0.03). Conclusions: PTX3 levels do not reflect inflammatory process in RA. However, it exerts a protective role in the process of atherogenesis in non-obese RA patients. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The interpretation of pentraxin 3 (PTX3) role in human diseases is complex and partially unknown. Opposing to C reactive protein (CRP) and serum amyloid protein A (SAP) that are produced in the liver in response to IL-6 and considered to be short pentraxins, PTX3 is induced mainly by IL-1 and TNFα in dendritic myeloid cells, peripheral blood leukocytes, endothelial cells, fibroblasts and adipocytes among others and is known as a long pentraxin [1,2]. Several studies have identified PTX3 as an important element in host resistance against fungal, viral and bacterial infection [1–3]. Also high levels of PTX3 have been linked to cardiovascular diseases [4,5] and inflammatory activity in autoimmune disorders such as vasculitis [6]. Some authors have proposed that measuring PTX3 may be a useful biomarker of human pathologies complementary to C-reactive protein [1]. However the results found have provided a contradictory picture. ⁎ Corresponding author. Rua Prof. Ulisses Vieira, 145 ap 54, CEP 80320-090 Curitiba, Paraná, Brazil. E-mail address: [email protected] (B.S. Kahlow).
http://dx.doi.org/10.1016/j.ijcard.2016.06.175 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
The idea of measuring serum PTX3 in inflammatory disease is grounded in its induction by pro-inflammatory cytokines (IL-1 and TNF alpha) [1,2] and by its presence in endothelial, dendritic and monocytes and polymorphonuclear cells reflecting local inflammation [6,7]. A study in patients with small vessels vasculitis showed that PTX3 levels associate with clinical disease activity [6]. Shimada et al. [8] also found PTX3 levels to be associated with LES disease activity, but others did not [9]. Also, Kim et al. [10] could not use serum PTX3 levels to distinct febrile LES patients with disease activity from those with infection. When analyzing PTX3 levels in this context, it is interesting to note that its production is also stimulated by IL-10 that is considered to be an anti-inflammatory cytokine, suggesting that PTX3 may also be involved in the IL-10 mediated regulation of inflammation [1,11]. In cardiovascular diseases studies, PTX3 was found to be localized within and around ischemic lesions [12]. Examination of atherosclerotic plaques reveals a strong expression of PTX3 in macrophages, endothelial cells, and subendothelial muscular cells [5,12]. Nevertheless, if PTX3 exerts a beneficial or a deleterious role in this setting is, similarly, a matter for discussion. Bosutti et al. [5], finding PTX3 mRNA elevated in white blood cells and adipose tissue of non-diabetic patients with high
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301
LDL levels, suggested that PTX3 may be involved in the mechanism of inflammation and oxidative stress triggered by LDL in the atherosclerotic process. Atherosclerotic and inflammatory lesions of the aorta were found to be significantly increased in knockout mice lacking PTX3 [13]. Rheumatic patients referred to coronary artery bypass grafting showed that serum PTX3 levels are higher in rheumatic patients than controls and associated with more cardiovascular risk [4]. Contraposing these ideas, others believe that PTX3 has a cardiovascular protective role because it modulates the inflammation and complement activation through C1q, factor H, ficolin-2 and apoptotic cells binding. PTX3 also interacts with fibroblast growth factor 2 that induces chemotaxis and proliferation of endothelial cells and in vivo neovascularization [1]. Baragetti et al. [14] studying 2400 subjects from the general population for PTX3 and carotid intima media thickness progression concluded that PTX3 plasma level is neither an independent predictor of development of subclinical atherosclerosis in diverse arterial territories, nor of cardiovascular events occurrence. Lipid profile may influence PTX3 levels. HDL induces PTX3 mRNA expression and protein release in in vitro and in vivo animal studies [15]. This finding has suggested that this may be one mechanism by which HDL may exert their protective effects on endothelial cells and vascular wall [15]. A third area where PTX3 has been studied is obesity. Recent studies have demonstrated elevated adipose tissue expression of PTX3 in obese patients [16]. Paradoxically however, systemic PTX3 levels were reported to be inversely associated with increased fat mass [15,17,18]. Taking into account the above information it is possible to say that inflammation, atherogenesis, alterations of lipid profile and body mass are areas of importance for PTX3 study. Rheumatoid arthritis (RA) is a common systemic chronic inflammatory disease. In RA, the chronic synovial inflammation has been linked to accelerated atherogenic process and cardiovascular events are responsible for reduced life spam in this population [19]. Obesity is also a problem in rheumatic patients and may be related to glucocorticoid use and immobility due to pain and articular dysfunction [20]. There are scare studies address PTX3 in RA. So, in the present study 85 patients with RA were investigate aiming to know its relationship with disease clinical profile and activity, degree of atherogenesis studied through measurement of carotid intima-media thickness (IMT), lipid profile and body mass index (BMI). 2. Methods This study was approved by local Committee of Ethics in Research and all participants signed consent. We included 85 adult patients from both genders that fulfilled at least four of 1987 American College Classification criteria for RA [21]. Patient's demographic, clinical and serological data were collected through chart review. All patients had measurement of height and weight for body mass index calculation (BMI), fasting overnight determinations of lipid profile (total cholesterol, triglycerides, HDL and LDL cholesterol through enzymatic colorimetric method), measurement of ESR (by Westergreen method), CRP (by immunoturbidimetry). Disease activity was determinated by DAS 28 (4v.) [22,23]. Measurement of carotid IMT was done in both sides using color doppler high resolution equipment ESAOTE®, model MyLAb40 with 18 mHZ linear transducers. Transversal and longitudinal cuts were done at common carotid vessel, 2 cm below the bulbus. All tests were read by a single professional who was blinded to clinical information. We considered that the patient had no thickening if the measurement of intimae-media complex was less than 0.8 mm; with thickness measurements from 0.8 mm to 1.5 mm and atheromatous plaques when greater than 1.5 mm [24]. For statistical calculations, we considered the value of carotid IMT which was the greatest among the two sides. PTX-3 plasma levels were measured by a commercial kit using sandwich enzyme immunosorbent assay (ELISA) (R&D Systems, Minneapolis, MN, USA). Sera from health controls were obtained from hospital staff and none had chronic inflammatory disease neither relatives with rheumatic diseases and paired for gender and age. Results are expressed as mean and standard deviation or median and interquartile range (IQR). For association studies of numeric data, Mann Whitney and unpaired t tests were used according to sample distribution. For correlation studies Spearman tests were applied. The frequency analyses were performed through Chi-square test and Fisher two-tailed test, using Graph Pad Prism 5.0 (GraphPad software Inc., La Jolla, CA, USA). A p b 0.05 was considered statistically significant.
299
3. Results 3.1. Description of studied sample Epidemiological, clinical and laboratorial characteristics of studied sample are in Table 1. In patients with RA, PTX3 levels ranged from 0.3–14.4 ng/mL; median values of 1.27 (0.43–2.45 ng/mL). In health control group PTX3 had values from 0.30–2.36 ng/mL, with median values 0.70 (0.50–1.55 ng/mL), without significant difference between groups (p = 0.21).
3.2. Studies of PTX3 plasma concentration according to RA variables Studying the PTX3 level association to epidemiological, clinical and serological variables we found the results seen in Table 2. The correlation studies (Spearman test) of PTX3 levels with age, disease duration, age at disease onset, DAS28, ESR, CRP, total cholesterol, HDL and LDL cholesterol, triglycerides, LDL/HDL ratio and IMT were all non-significant (p = NS). However, BMI showed a negative correlation with PTX3 levels (Rho = −0.27; 95%IC = −0.46 to −0.06; p = 0.009). When the RA patients were stratified into two groups (group 1 — with under and normal weight patients and group 2 — patients with overweight and obese), we found that in the group 1 the PTX3 levels were associated negatively with IMT as seen in Fig. 1. This was not found in group 2 (Rho = 0.15; 95% IC = −0.12 to 0.41). In group 2 (overweight and obese patients) a negative correlation of PTX3 levels and LDL/HDL ratio (Spearman Rho = − 0.29; 95%IC = − 0.53 to − 0.01; p = 0.03) was found. All other studied correlations (total cholesterol, triglycerides, Das 28, ESR and CRP) did not show significant difference (p = NS) in both groups.
Table 1 Epidemiological, clinical and laboratorial characteristics of 85 patients with rheumatoid arthritis. Gender
83.5% (71/85) females
Age (years) Disease duration (years) Age at disease onset (years) Ethnic background (auto-declared) Afrodescendants Eurodescendants Tobacco exposure (current and ex-smokers) Rheumatoid nodules Secondary Sjögren's syndrome Steinbrocker functional class Class 1 Class 2 Class 3 Class 4 Anti-CCP positive Rheumatoid factor positive Diabetes mellitus Arterial hypertension Statins users Body mass index (kg/m2) Underweight (I b 18.5) Normal weight (18.5 to 24.9) Overweight (25 to 29.9) Obesity (N30) Total cholesterol (mg/dL) HDL cholesterol (mg/dL) LDL cholesterol (mg/dL) Triglycerides (mg/dL) Erythrocyte sedimentation rate — ESR (mm) C reactive protein — CRP mg/dL DAS 28 Carotid intima media thickness (mm)
33–82; median 59 (48–65) 5–35; median 13.0 (10–18.5) 22–66; median 45 (29.5–50) 29.4% (25/85) 70.5% (60/85) 29/85 (34.1%) 8/85 (9.4%) 18/61 (29.5%) 41/85 (48.2%) 34/85 (40.5%) 8/85 (9.4%) 2/85 (2.3%) 70/85 (82.3%) 65/85 (76.4%) 12/85 (14.4%) 40/85 (47.0%) 36/85 (42.3%) 15.7–37.6; mean 27.0 ± 4.85 3/85 (3.6%) 30/85 (35.3%) 28/85 (32.9%) 24/85 (28.2%) 113–371; mean 183.4 ± 38.8 32–126; median 51.0 46–293; mean 104.9 ± 35.5 42–313 mg/dL; mean 129.5 ± 53.3 1–106; mean 42.5 ± 24.8 0.1–80.0; median 16.0 (8.5–24.0) 0.42–8.07; median 3.32 (2.67–4.23) 0.25–1.07; median 0.59 (0.51–0.85)
300
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301
Table 2 Comparison of PTX3 levels according to clinical, serological and demographic profile in 85 patients with rheumatoid arthritis. PTX3 levels with the variable range, median and IQR (ng/mL) Positive anti-CCP Positive rheumatoid factor Rheumatoid nodules Secondary Sjögren Associated diabetes mellitus Associated arterial hypertension Statin users Steinbrocker class
PTX3 levels without the variable range, median and IQR (ng/mL)
0.30–14.40 0.36–7.35 Median 1.29 (0.43–2.62) Median 1.29 (0.42–2.40) 0.30–14.40 0.30–5.20 Median 1.27(0.46–2.70) Median 0.93 (0.38–2.24) 0.4–8.6 0.30–14.40 Median 2.67 (0.44–8.60) Median 1.25 (0.42–2.25) 0.30–14.40 0.30–8.80 Median 1.52 (0.48–3.15) Median 1.20 (0.42–2.40) 0.30–8.50 0.30–14.40 Median 0.42 (0.36–2.27) Median 1.28 (0.48–2.45) 0.30–8.80 0.30–14.40 Median 1.10 (0.44–1.79) Median 1.45 (0.42–2.85) 0.30–7.35 0.30–7.30 Median 0.91 (0.42–2.48) Median 1.30 (0.46–2.45) Class 1 — 0.30–8.60; median 1.28 (0.38–2.45) Class 2 — 0.30–14.40; median 1.28 (0.47–2.62) Classes 3 and 4 — 0.35–8.80; median 0.59 (0.48–2.14)
P
0.72 0.33 0.18 0.27 0.06 0.38 0.38 0.69
4. Discussion Our results have shown that plasmatic PTX3 levels did not reflect inflammation in RA as no association could be found with DAS 28. DAS 28 is a composite instrument that takes into account not only objective signs of inflammation but also pain and general symptoms such as fatigue and stiffness [22,23] which may be influenced by subjective feelings. In addition, we could not find an association of PTX3 neither with other inflammatory index such as ESR nor with CRP. CRP, although unspecific, is considered the most clinically useful marker of inflammation in RA [25]. In the present study, it was also established that PTX3 concentration is inversely related to BMI in RA patients as other authors did in different populations [26–28]. Although there is no explanation for this finding, since adipose tissue is a potential relevant source of PTX3, some authors hypothesize that low PTX3 production in abdominal adipose tissue could be, at least in part, paradoxically, responsible for lower PTX3 plasma concentration [26]. Another idea is that obesity could lower PTX3 production in other cell categories through yet unknown signaling and mechanisms, that should be investigated in future studies [26]. Consistently with the inverse relationship of obesity and PTX3 levels, we also found a negative correlation between PTX3 levels and IMT in non-obese RA patients. So PTX3, instead of being an active participant in inflammation as initially proposed, may be the opposite: it may represent an adaptive anti-inflammatory response to pre-existing
Fig. 1. Negative correlation between PTX3 levels and carotid IMT (intima media thickness) in underweight and normal body mass index patients with rheumatoid arthritis (Spearman Rho = −0.40; 95%IC −0.66 to −0.06; p = 0.01).
inflammation or vascular damage [26,29]. However, we could not maintain the inverse relationship between IMT and PTX3 levels in obese patients and this may show that, in this population, other factors may interpose with PTX3 serum levels. We found a negative association of LDL/HDL relationship with PTX3 levels only in obese RA patients and the altered lipid profile participation in this context could have altered the correlation. Synthetic rates of cholesterol are increased in obese subjects, as are the production rates of very low density lipoproteintriglycerides (VLDL-TG). Since VLDL is a precursor of low density lipoproteins (LDL), overproduction of VLDL might be expected to increase LDL [30], and LDL cholesterol is a known player in cardiovascular risk. Although we can only speculate about the possibility of these interrelations, the present finding of negative association with PTX3 with LDL/HDL ratio reinforces the idea of the beneficial role of PTX3 in the process of atherogenesis. Our result does not agree with those of Mabrouk et al. [31] that studied 60 RA patients and found that serum PTX3 was significantly higher in RA patients with atherosclerotic carotid plaques compared to those without. However Mabrouk et al. did not take into account patients BMI. Concluding, in the present study PTX3 does not reflect inflammatory activity in RA patients but it is inversely related to patient's BMI. In nonobese RA patients, this serological marker associates negatively with carotid IMT and in it is also negatively associated with LDL/HDL ratio in obese RA patients. More studies are needed to clarify the intriguing role of PTX3 in human diseases. Conflict of interest None. Funding source None. References [1] S. Jaillon, E. Bonavita, S. Gentile, M. Rubino, I. Laface, C. Garlanda, et al., The long pentraxin PTX3 as a key component of humoral innate immunity and a candidate diagnostic for inflammatory diseases, Int. Arch. Allergy Immunol. 165 (2014) 165–178. [2] C. Garlanda, V. Maina, A. Cotena, F. Moalli, The soluble pattern recognition receptor pentraxin-3 in innate immunity, inflammation and fertility, J. Reprod. Immunol. 83 (2009) 128–133. [3] F. Moalli, S. Jaillon, A. Inforzato, M. Sironi, B. Bottazzi, A. Mantovani, et al., Pathogen recognition by the long pentraxin PTX3, J. Biomed. Biotechnol. 2011 (2011) 830421. [4] I. Hollan, B. Bottazzi, I. Cuccovillo, Ø.T. Førre, K. Mikkelsen, K. Saatvedt, Feiring Heart Biopsy Study Group, Increased levels of serum pentraxin 3, a novel cardiovascular biomarker, in patients with inflammatory rheumatic disease, Arthritis Care Res. (Hoboken) 62 (2010) 378–385. [5] A. Bosutti, G. Grassi, M. Zanetti, A. Aleksova, M. Zecchin, G. Sinagra, G. Biolo, G. Guarnieri, Relation between the plasma levels of LDL-cholesterol and the expression of the early marker of inflammation long pentraxin PTX3 and the stress response gene p66ShcA in pacemaker-implanted patients, Clin. Exp. Med. 7 (2007) 16–23. [6] F. Fazzini, G. Peri, A. Doni, G. Dell'Antonio, E. Dal Cin, E. Bozzolo, et al., PTX3 in smallvessel vasculitides: an independent indicator of disease activity produced at sites of inflammation, Arthritis Rheum. 44 (2001) 2841–2850. [7] A.P. van Rossum, H.H. Pas, F. Fazzini, M.G. Huitema, P.C. Limburg, M.F. Jonkman, et al., Abundance of the long pentraxin PTX3 at sites of leukocytoclastic lesions in patients with small-vessel vasculitis, Arthritis Rheum. 54 (2006) 986–991. [8] Y. Shimada, Y.F. Asanuma, K. Yokota, Y. Yoshida, H. Kajiyama, K. Sato, Y. Akiyama, T. Mimura, Pentraxin 3 is associated with disease activity but not atherosclerosis in patients with systemic lupus erythematosus, Mod. Rheumatol. 24 (2014) 78–85. [9] T.L. Skare, R. Nisihara, G.P. Ramos, S.R. Utiyama, I. Messias-Reason, Pentraxin-3 levels in systemic lupus erythematosus: association with cumulative damage but not with disease activity, Joint Bone Spine 82 (2015) 466–467. [10] J. Kim, J.K. Koh, E.Y. Lee, J.A. Park, H.A. Kim, E.B. Lee, C. Garlanda, A. Cotena, Y.W. Song, Serum levels of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and pentraxin 3 (PTX3) as markers of infection in febrile patients with systemic lupus erythematosus, Clin. Exp. Rheumatol. 27 (2009) 773–778. [11] A. Doni, M. Michela, B. Bottazzi, G. Peri, S. Valentino, N. Polentarutti, et al., Regulation of PTX3, a key component of humoral innate immunity in human dendritic cells: stimulation by IL-10 and inhibition by IFN-gamma, J. Leukoc. Biol. 79 (2006) 797–802. [12] C. Garlanda, B. Bottazzi, F. Moalli, L. Deban, F. Molla, R. Latini, et al., Pentraxins and atherosclerosis: the role of PTX3, Curr. Pharm. Des. 17 (2011) 38–46.
B.S. Kahlow et al. / International Journal of Cardiology 221 (2016) 298–301 [13] G.D. Norata, P. Marchesi, V.K. Pulakazhi Venu, F. Pasqualini, A. Anselmo, F. Moalli, et al., Deficiency of the long pentraxin PTX3 promotes vascular inflammation and atherosclerosis, Circulation 120 (2009) 699–708. [14] A. Baragetti, M. Knoflach, I. Cuccovillo, L. Grigore, M. Casula, K. Garlaschelli, et al., Pentraxin 3 (PTX3) plasma levels and carotid intima media thickness progression in the general population, Nutr. Metab. Cardiovasc. Dis. 24 (2014) 518–523. [15] G.D. Norata, P. Marchesi, A. Pirillo, P. Uboldi, G. Chiesa, V. Maina, et al., Long pentraxin 3, a key component of innate immunity, is modulated by high-density lipoproteins in endothelial cells, Arterioscler. Thromb. Vasc. Biol. 28 (5) (2008 May) 925–931. [16] O. Osorio-Conles, M. Guitart, M.R. Chacon, E. Maymo-Masip, J.M. Moreno-Navarrete, et al., Plasma PTX3 protein levels inversely correlate with insulin secretion and obesity, whereas visceral adipose tissue PTX3 gene expression is increased in obesity, Am. J. Physiol. Endocrinol. Metab. 301 (2011) E1254–E1261. [17] R. Barazzoni, A. Aleksova, C. Carriere, M.R. Cattin, M. Zanetti, P. Vinci, et al., Obesity and high waist circumference are associated with low circulating pentraxin-3 in acute coronary syndrome, Cardiovasc. Diabetol. 12 (2013) 167. [18] T. Ogawa, Y. Kawano, T. Imamura, K. Kawakita, M. Sagara, et al., Reciprocal contribution of pentraxin 3 and C-reactive protein to obesity and metabolic syndrome, Obesity (Silver Spring) 18 (2010) 1871–1874. [19] J.T. Giles, Cardiovascular disease in rheumatoid arthritis: current perspectives on assessing and mitigating risk in clinical practice, Best Pract. Res. Clin. Rheumatol. 29 (2015) 597–613. [20] I. Colmegna, C.A. Hitchon, M.C. Bardales, L. Puri, S.J. Bartlett, High rates of obesity and greater associated disability among people with rheumatoid arthritis in Canada, Clin. Rheumatol. 35 (2016) 457–460. [21] F.C. Arnett, S.M. Edworthy, D.A. Bloch, D.J. McShane, J.F. Fries, N.S. Cooper, et al., The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis, Arthritis Rheum. 31 (1988) 315–324.
301
[22] H. Mäkinen, H. Kautiainen, P. Hannonen, T. Sokka, Is DAS-28 an appropriate tool to assess remission in rheumatoid arthritis? Ann. Rheum. Dis. 64 (2005) 1410–1413. [23] J. Fransen, P.L.C.M. van Riel, DAS remission cut points, Clin. Exp. Rheumatol. 24 (2006) S29–S32. [24] A. Simon, J. Gariepy, G. Chironi, J.L. Miegnien, J. Levenson, Intima-media thickness: a new tool for diagnosis and treatment of cardiovascular risk, J. Hypertens. 20 (2002) 159–169. [25] W. Arend, C. Gabay, Cytokine network, in: G.S. Firestein, G.S. Panayi, F.A. Wolheim (Eds.), Rheumatoid Arthritis, second ed.Oxford University Press, London 2006, pp. 173–192. [26] A. Witasp, J.J. Carrero, K. Michaëlsson, H. Ahlström, J. Kullberg, V. Adamsson, et al., Inflammatory biomarker pentraxin 3 (PTX3) in relation to obesity, body fat depots and weight loss, Obesity 22 (2014) 1373–1379. [27] K. Yamasaki, M. Kurimura, T. Kasai, M. Sagara, T. Kodama, K. Inoue, Determination of physiological plasma pentraxin 3 (PTX3) levels in healthy populations, Clin. Chem. Lab. Med. 47 (2009) 471–477. [28] T. Miyamoto, A. Rashid Qureshi, O. Heimbürger, P. Bárány, K. Carrero, B. Sjöberg, et al., Inverse relationship between the inflammatory marker pentraxin-3, fat body mass, and abdominal obesity in end-stage renal disease, Clin. J. Am. Soc. Nephrol. 6 (2011) 2785–2791. [29] K.C. Lidani, M.H. Beltrame, P.R. Luz, T.L. Sandri, R.M. Nisihara, I.J. de Messias-Reason, Is pentraxin 3 a cardiovascular marker in patients with chronic Chagas disease? Int. J. Cardiol. 190 (2015) 233–235. [30] Y.A. Kesaniemi, S.M. Grundy, Increased low density lipoprotein production associated with obesity, Arteriosclerosis 3 (1983) 170–177. [31] M.M. Mabrouk, M.A. Ghazy, T.M. Hassan, Serum pentraxin 3 and interleukin-6 are associated with subclinical atherosclerosis in recent-onset rheumatoid arthritis, Egypt. J. Immunol. 17 (2010) 87–99.