Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC yxmDVYKC8Y7YJNNcYt8stGh S0066-782X2022005008203 S0066-782X2022000900436 abc.20210599 10.36660/abc.20210599 Artigo Original A Associação de TWEAK com Calcificação da Artéria Coronária em Pacientes com Doença Renal Crônica 0000-0003-1058-7194 Tatlisu Mustafa Adem 1 0000-0001-6580-7954 Atici Adem 1 Ozcan Fatma Betul 1 Çelik Mehmet 1 Kirac Eray 1 Baycan Omer Faruk 1 Caliskan Mustafa 1 Istanbul Medeniyet University Istanbul Turquia Istanbul Medeniyet University, Istanbul – Turquia Correspondência: Mustafa Adem Tatlisu Istanbul Medeniyet University Faculty of Medicine, Cardiology. Istanbul Goztepe Prof Suleyman Yalcin City Hospital Istanbul Istanbul 34722 – Turquia E-mail: ademtatlisu@gmail.com

Contribuição dos autores

Concepção e desenho da pesquisa, Obtenção de dados: Tatlisu MA, Atici A, Ozcan FB, Çelik M, Kirac E, Baycan OF; Análise e interpretação dos dados: Tatlisu MA, Atici A, Ozcan FB, Çelik M, Kirac E, Baycan OF, Caliskan M; Análise estatística: Atici A, Caliskan M; Obtenção de financiamento: Tatlisu MA, Caliskan M; Redação do manuscrito: Tatlisu MA; Revisão crítica do manuscrito quanto ao conteúdo intelectual importante: Tatlisu MA.

Potencial Conflito de Interesse

Declaro não haver conflito de interesses pertinentes.

 10 06 2022 09 2022 119 3 436 445 13 07 2021 28 11 2021 09 03 2022 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Resumo Fundamento

O receptor fraco indutor de apoptose semelhante a fator de necrose tumoral solúvel (sTWEAK) é um membro da superfamília de TNF que tem um papel crítico na proliferação e inflamação na circulação arterial.

 Objetivos

Este estudo prospectivo tem o objetivo de mostrar a relação entre os níveis de sTWEAK e calcificação da artéria coronária (CAC) em pacientes com doença renal crônica (DRC).

 Métodos

Este estudo prospectivo incluiu 139 pacientes consecutivos que passaram por angiografia coronariana por tomografia computadorizada, por qualquer motivo, para síndromes coronarianas agudas, de agosto de 2020 a fevereiro de 2021. Um total de 12 pacientes foi excluído do estudo devido aos critérios de exclusão. Os pacientes foram divididos em dois grupos com base em terem um escore CAC menor que 400 (n=84) ou um escore de 400 ou mais (n=43). A significância foi presumida em p-valor bilateral <0,05.

 Resultados

À medida que o escore CAC aumentou, os níveis de sTWEAK diminuíram de forma estatisticamente significativa e detectou-se uma relação forte entre níveis de sTWEAK e escore CAC (r: -0,779, p<0,001). A análise ROC revelou que o nível de corte ideal de sTWEAK para prever o escore CAC de 400 era 761 pg/mL com uma sensibilidade de 71% e especificidade de 73% (AUC: 0,78; IC 95%: 0,70-0,85; p <0,001).

 Conclusões

Embora os estudos em larga escala tenham demonstrado uma correlação positiva entre os níveis de TFGe e sTWEAK, alguns estudos detectaram que o aumento nos níveis de sTWEAK estão associados a mortalidade e gravidade do sistema da artéria coronária em pacientes com DRC. Nossos resultados comprovam nossa hipótese de que os níveis de sTWEAK mostram calcificação coronária em vez de outros tipos de placas ateroscleróticas.

 Doenças Cardiovasculares Insuficiência Renal Crônica Rigidez Vascular Aterosclerose Doença da Artéria Coronariana Istanbul Medeniyet University 1462/T-GAP-2019-1462 Fontes de Financiamento: O presente estudo foi parcialmente financiado por Istanbul Medeniyet University Research Grant n° 1462/T-GAP-2019-1462. Introdução

A associação entre aterosclerose e doença renal crônica (DRC) é bem estabelecida, e pacientes com DRC estão associados a um índice de mortalidade relacionada a aterosclerose 8 vezes mais alto do que o da população geral.1 , 2 A fisiopatologia da aterosclerose inclui anormalidades lipídicas, disfunção endotelial, envelhecimento e inflamação.3 O papel da inflamação e da imunidade na fisiopatologia da aterosclerose foi demonstrado nas últimas décadas.3 - 5 O receptor fraco indutor de apoptose semelhante a fator de necrose tumoral solúvel (sTWEAK) é um membro da superfamília de TNF que tem um papel crítico na proliferação e na inflamação.6 - 8 O sTWEAK foi estudado em pacientes com DRC e já se demonstrou que seu nível diminui à medida que a taxa de filtração glomerular estimada (TFGe) diminui.9 , 10 Embora o nível reduzido de sTWEAK tenha sido encontrado na aterosclerose, outro estudo detectou o aumento do nível de sTWEAK com a gravidade das artérias coronárias.11

Na DRC, o metabolismo anormal de minerais e ossos resulta no acúmulo de calcificação arterial.12 Devido aos resultados controversos, neste estudo prospectivo, temos o objetivo de demonstrar a relação entre o nível de sTWEAK e a calcificação da artéria coronária (CAC) em pacientes com DRC em tratamento conservador.

 Métodos Participantes do estudo

Este estudo prospectivo incluiu 139 pacientes consecutivos passando por angiografia coronariana por tomografia computadorizada (ACTC), por qualquer motivo, de agosto de 2020 a fevereiro de 2021. Todos os pacientes cadastrados neste estudo foram diagnosticados com DRC, e tinham uma taxa de filtração glomerular estimada (TFGe) abaixo de 60 por ≥3 meses ou uma TFGe acima de 60 com albuminuria (razão creatinina/albumina na urina ≥30 mg/g).13 A TFGe foi calculada usando-se a fórmula do estudo Modificação da dieta na doença renal (MDRD).14 Um total de 57 pacientes (41%) tinha DRC categoria 2; 45 (32%), DRC categoria 3a; 33 (24%), DRC categoria 3b; e 4 (0,2%), categoria 4. A população estudada não tinha histórico de aterosclerose (doença arterial coronariana, acidente vascular isquêmico, doença arterial periférica, e aneurisma torácico/abdominal). Os critérios de exclusão incluíam: (i) qualquer doença cardiovascular anterior, (ii) transplante de órgão anterior, (iii) presença de mais de uma doença valvar leve, (iv) presença de insuficiência cardíaca ou sistólica, (v) presença de disfunção diastólica diferente da disfunção diastólica grau 1, e hipertrofia do ventrículo esquerdo, (vi) presença de estenose da artéria coronária epicárdica, (vii) pacientes em hemodiálise, (viii) pacientes com síndromes coronarianas agudas. Um total de 12 pacientes foi excluído do estudo antes da ACTC por apresentarem doença arterial periférica (n=4), estenose aórtica grave (n=1), e por fazerem uso de medicamento para a síndrome coronariana crônica (n=7) ( Figura 1 ). Um total de 127 pacientes foi dividido em dois grupos com base em terem um escore CAC menor que 400 (n=84) ou um escore de 400 ou mais (n=43). Este estudo foi aprovado pelo Comitê de ética em estudos clínicos (Nº 2021/0005). O termo de consentimento informado foi obtido de todos os pacientes cadastrados neste estudo.

Fluxograma ilustrando a exclusão de participantes para a amostra final do estudo.

Dados clínicos e demográficos

Todos os pacientes preencheram os questionários de histórico de saúde e de medicamentos, incluindo o histórico clínico de doença arterial coronariana (DAC), doença arterial periférica (DAP), diabetes mellitus (DM), hipertensão (HTN), e uso de medicamentos. Antes da CTA, todos os pacientes passaram por ecocardiograma transtorácico, ultrassom duplex da carótida, e ultrassom Doppler arterial de membro inferior para excluir a aterosclerose subclínica. Foi realizado um ecocardiograma usando-se o sistema Vivid 7 (GE Vingmed Ultrasound AS, Horten, Noruega), e a fração de ejeção ventricular esquerda (FEVE) foi calculada usando-se o método de Simpson modificado.15

Os valores do hemograma foram obtidos de amostras de sangue venoso coletadas na internação. O hemograma completo foi realizado usando-se um Coulter LH 780 Hematology Analyzer (Beckman Coulter Ireland, Inc., Galway, Irlanda). As medições bioquímicas foram realizadas usando-se kits e calibradores da Siemens Healthcare Diagnostic Products (Marburg, Alemanha). As amostras sanguíneas para níveis de sTWEAK plasmático foram obtidas antes da CTA e foram determinados usando-se kits ELISA (Bender MedSystems, Viena, Áustria).

 Definições

O escore Agatston é um dos sistemas de pontuação usados mais frequentemente para avaliar a calcificação da artéria coronária. Em geral, o score CAC é dividido em cinco grupos da seguinte maneira; 0, sem calcificação coronária; 1 a 100, calcificação coronária leve; >100 a 399, calcificação coronária moderada; 400 a 999, calcificação coronária grave; e ≥1.000, calcificação coronária extensa.16 , 17 Dividimos a população do estudo em dois grupos de pacientes com CAC de grave a extensa (n=43) e pacientes sem CAC ou com CAC leve a moderada (n=84).

 Análises estatísticas

Todos os testes estatísticos foram realizados usando-se o Statistical Package for the Social Sciences 19.0 para Windows (SPSS Inc., Chicago, IL, EUA). O teste Kolmogorov-Smirnov foi usado para analisar a normalidade dos dados. Variáveis contínuas com distribuição normal foram descritas usando-se médias ± desvio padrão (DP) e variáveis contínuas sem distribuição normal foram descritas usando-se mediana e faixa interquartil. Dados categóricos são expressos como frequência (%). Diferenças nas variáveis categóricas entre os grupos foram avaliadas com o teste qui-quadrado. As relações entre parâmetros sem distribuição normal foram avaliadas usando-se a análise de correlação de Spearman. O teste t de Student ou o teste U de Mann Whitney foram usados para comparar amostras não pareadas conforme necessário. Análises de regressão logística univariadas e multivariadas foram usadas para identificar variáveis independentes de DAC e CAC. Após realizar a análise univariada, variáveis significativas obtidas foram selecionadas nas análises de regressão logística multivariadas com o método stepwise. Os resultados das análises de regressão univariada e multivariada foram apresentados como razão de chance com 95%. Para o parâmetro laboratorial do sTWEAK, foram obtidas curvas de característica de operação do receptor (ROC), e foram selecionados os valores ideais com a sensibilidade e a especificidade mais altas na previsão do escore de cálcio coronário (400). A significância foi presumida em p-valor bilateral <0,05.

 Resultados

Um total de 127 pacientes (média de idade 59,9± 9,4 anos; homens 39%) passando por CTA cadastrados no estudo, e as características de linha de base, bem como os parâmetros laboratoriais são apresentados na Tabela 1 . Os pacientes cadastrados no estudo foram diagnosticados com DRC em estágios 3-5, e os níveis médios de TFGe, creatinina, e nitrogênio ureico sanguíneo foram de 39,9±13,1 mL/dk/1,73 m2, 1,8±0,2 mg/dL, e 43,5±8,4 mg/dL, respectivamente. O escore CAC por Agatston médio foi de 90 (0-1605), e 43 pacientes apresentaram um escore de >400, o que representa CAC grave a extensa ( Tabela 1 ).

Características clínicas e laboratoriais de pacientes com doença renal crônica
n=127
Idade, anos 59,9 ± 9,4
Sexo (masculino, %) 49 (39%)
IMC kg/m2 29,0 ± 3,7
HTN, n(%) 87 (68%)
DM, n(%) 53 (42%)
Tabagismo, n(%) 35 (27%)
Pressão arterial sistólica, mmHg 134,2±22,7
Pressão arterial diastólica, mmHg 77,4±11,8
Glicemia em jejum, mg/dL 119,4±47,1
Hemoglobina, g/dL 13,8±1,6
PLT, células/µL 237,7±65,2
WBC, células/µL 7,5±1,8
Creatinina, mg/dL 1,8±0,2
TFGe, ml/dk/1,73 m2 39,9±13,1
BUN, mg/dL 43,5±8,4
Ácido úrico, mg/dL 7,4±1,2
Sódio, mmol/L 139,6±2,3
Potássio, mmol/L 4,3±0,4
Cálcio, mmol/L 9,4±0,4
AST, U/L 22,4±9,3
ALT, U/L 23,8±11,2
PCR, mg/dL 0,3 (0,1-9,2)
Albumina, g/dL 4,3±0,4
CT, mg/dL 207,3±45,8
LDL, mg/dL 126,7±42,5
HDL, mg/dL 48,7±12,0
Tg, (mg/dL) 161,3±77,5
sTWEAK, pg/mL 845,0±418,0
Escore CAC 90 (0-1605)
Escore CAC <400, n (%) 84 (66%)
Escore CAC ≥400, n (%) 43 (34%)

AST: aspartato aminotransferase; ALT: alanina aminotransferase; IMC: índice de massa corporal; CAC: calcificação da artéria coronária; PCR: proteína C reativa; DM: diabetes mellitus; TFGe: taxa de filtração glomerular estimada; HDL: lipoproteína de alta densidade; HTN: hipertensão; LDL: lipoproteína de baixa densidade; PLT: plaqueta; sTWEAK: receptor fraco indutor de apoptose semelhante a fator de necrose tumoral solúvel; CT: colesterol total; TG: triglicérides; WBC: leucócito. aVariáveis contínuas são apresentadas como média (DP); variáveis categóricas são apresentadas como frequência (%).

A relação entre níveis de sTWEAK e o escore CAC foi avaliada pela análise de correlação de Spearman. À medida que o escore CAC aumentou, os níveis de sTWEAK diminuíram significativamente e detectou-se uma relação forte entre níveis de sTWEAK e escore CAC, que é mostrada na Figura 2 (r: -0,615, p<0,001).

Análise de correlação do sTWEAK e escore de calcificação da artéria coronária (r:-0,615, p<0,001, boa correlação).

Os participantes foram divididos em dois grupos, pacientes com um escore CAC <400 (n=84) pacientes com um escore CAC ≥400 (n=43). Não houve diferenças estatisticamente significativas entre os grupos em relação a idade, sexo, IMC, HTN, DM, ou tabagismo, conforme mostrado na Tabela 2 . Os parâmetros laboratoriais, tais como glicemia em jejum, Hgb, WBC de plaqueta, creatinina, TFGe, ácido úrico, sódio, potássio, CT, LDL, HDL, Tg, não representaram diferenças estatisticamente significativas ( Tabela 2 ).

Características clínicas e laboratoriais dos pacientes divididos em dois grupos com base no escore de calcificação da artéria coronáriaa
SCC≥400 (n=43) SCC <400 (n=84) p
Idade, anos 61,7 ± 8,8 59,0 ± 9,6 0,126
Sexo (masculino%) 19(44%) 30(35%) 0,353
IMC kg/m2 29,8 ± 3,8 28,6± 3,6 0,098
HT, n(%) 33(78%) 54(65%) 0,121
DM, n(%) 22(52%) 31(37%) 0,108
Tabagismo, n(%) 15(36%) 20(25%) 0,198
Pressão arterial sistólica, mmHg 137,5±20,7 132,4±23,6 0,241
Pressão arterial diastólica, mmHg 80,0±11,5 76,0±11,7 0,073
Glicemia em jejum, mg/dL 122,8±62,9 117,5±24,5 0,601
Hemoglobina, g/dL 13,6±1,4 13,9±1,7 0,336
PLT, células/µL 235,5±68,1 239,0±63,9 0,797
WBC, cédulas/µL 7,4±1,8 7,5±1,9 0,687
Creatinina, mg/dL 1,8±0,2 1,9±0,1 0,887
Estágios da DRC
Estágio 2 18 36 0,914
Estágio 3a 15 27 0,756
Estágio 3b 10 18 0,814
Estágio 4 1 2 0,984
TFGe, ml/dk/1,73 m2 39,8±13,6 40,2±12,9 0,890
BUN, mg/dL 36,4±9,3 32,0±7,4 0,009
Ácido úrico, mg/dL 7,5±1,1 7,3±1,3 0,274
Sódio, mmol/L 139,5±2,2 139,6±2,3 0,825
Potássio, mmol/L 4,2±0,5 4,3±0,3 0,115
Cálcio, mmol/L 9,3±0,3 9,4±0,4 0,066
AST, U/L 22,2±8,1 22,6±11,3 0,875
ALT, U/L 23,5±11,1 24,0±10,0 0,898
PCR, mg/dL 0,3 (0,1-9,2) 0,2 (0,1-2,0) 0,009
Albumina, g/dL 4,1±0,5 4,4±0,2 0,005
CT, mg/dL 215,8±41,6 202,9±47,5 0,132
LDL, mg/dL 135,2±40,0 122,4±43,4 0,108
HDL, mg/dL 49,6±13,3 48,3±11,3 0,550
Tg, (mg/dL) 158,4±59,1 162,8±85,7 0,758
sTWEAK, pg/mL 586,2±286,6 977,5±413,8 <0,001
Escore CAC 488 (402-1605) 45 (0-312) <0,001

AST: aspartato aminotransferase; ALT: alanina aminotransferase; IMC: índice de massa corporal; CAC: calcificação da artéria coronária; PCR: proteína C reativa; DM: diabetes mellitus; TFGe: taxa de filtração glomerular estimada; HDL: lipoproteína de alta densidade; HTN: hipertensão; LDL: lipoproteína de baixa densidade; PLT: plaqueta; CT: colesterol total; Tg: triglicérides; sTWEAK: receptor fraco indutor de apoptose semelhante a fator de necrose tumoral solúvel; WBC: leucócito. aVariáveis contínuas são apresentadas como média (DP); variáveis categóricas são apresentadas como frequência (%).

O nível de sTWEAK foi significativamente menor no grupo com um escore CAC ≥400 que no grupo com um escore CAC <400 ( Tabela 2 ). A relação entre níveis de sTWEAK e o escore CAC em pacientes com escores CAD mais baixos (<400) foi avaliada pela análise de correlação de Spearman. À medida que o escore CAC aumentou, os níveis de sTWEAK diminuíram de maneira estatisticamente significativa, e detectou-se uma relação moderada entre níveis de sTWEAK e escore CAC, que é mostrada na Figura 3 (r: -0,385, p<0,001). A relação entre níveis de sTWEAK e o escore CAC em pacientes com escores CAD mais altos (≥400) foi avaliada pela análise de correlação de Spearman. À medida que o escore CAC aumentou, os níveis de sTWEAK diminuíram de maneira estatisticamente significativa, e detectou-se uma relação forte entre níveis de sTWEAK e escore CAC, que é mostrada na Figura 4 (r: -0,779, p<0,001). Avaliamos a especificidade e a sensibilidade dos níveis de sTWEAK pela análise da característica de operação do receptor (ROC) para prever a presença do escore CAC de 400. A análise ROC revelou que o nível de corte ideal de sTWEAK para prever o escore CAC de 400 era 761 pg/mL com uma sensibilidade de 71% e especificidade de 73% (AUC: 0,78; IC 95%: 0,70-0,85; p <0,001) ( Figura 5 ).

Análise de correlação do sTWEAK e escore de calcificação da artéria coronária de menos de 400 (r:-0,385, p<0,001, correlação moderada).

Análise de correlação do sTWEAK e escore de calcificação da artéria coronária de 400 ou mais (r:-0,779, p<0,001, correlação forte).

A análise ROC revelou que o valor de corte ideal de sTWEAK para prever o escore CAC de ≥ 400 era 761 pg/mL com uma sensibilidade de 71% e especificidade de 73% (AUC= 0,78; IC 95%: 0,70-0,85; p <0,001).

Os parâmetros que afetam o desenvolvimento da CAC foram avaliados por análise univariada e multivariada. Os prováveis preditores de DAC, tais como idade, sexo, HTN, DM, DRC, tabagismo, IMC, PCR, LDL, e sTWEAK foram avaliados na análise univariada. Na análise multivariada, idade, tabagismo, LDL e sTWEAK foram associados ao escore CAC de 400 (RC da idade: 1,033, p: 0,003; RC tabagismo: 4,638, p: 0,003; RC LDL: 1,016, p: 0,005; RC sTWEAK: 0,345, p<0,001) ( Tabela 3 ).

Preditores univariados e modelo multivariado para o escore de calcificação da artéria coronária de 400
Variável Univariada Multivariada
RC IC95% p RC IC95% p
Idade 1,049 1,009-1,091 0,016 1,033 1,016-1,058 0,003
Sexo 0,567 0,276-1,166 0,123
HTN 1,093 0,492-2,265 0,877
DM 0,591 0,289-1,209 0,150
DRC 1,105 0,151-8,105 0,922
Tabagismo 4,552 1,898-10,915 0,001 4,638 1,965-11,236 0,003
IMC 0,969 0,881-1,066 0,513
PCR 2,490 0,802-7,731 0,314
LDL 1,017 1,007-1,027 0,001 1,016 1,005-1,028 0,005
sTWEAK 0,314 0,172-0,507 <0,001 0,345 0,201-0,581 <0,001

IMC: índice de massa corporal; DRC: doença renal crônica; PCR: proteína C reativa; DM: diabetes mellitus; HTN: hipertensão; LDL: lipoproteína de baixa densidade; sTWEAK: receptor fraco indutor de apoptose semelhante a fator de necrose tumoral solúvel.

Discussão

Os pacientes com o escore CAC de 400 têm um risco alto de eventos cardíacos adversos (>2% por ano), e um terço desses pacientes têm imagens de perfusão miocárdica anormais.18 , 19 Neste estudo, a população do estudo foi dividida em dois grupos com base em seu escore CAC. À medida que o escore CAC aumentou, o sTWEAK diminuiu de forma estatisticamente significativa, especialmente em pacientes com um escore de 400 (r: -779, p<0,001, correlação forte) ( Figura 2-4 ). Os níveis de sTWEAK mais baixos continuaram a ser um preditor de escore alto de CAC na análise multivariada ( Tabela 2 ).

A placa aterosclerótica consiste em mediadores pró-inflamatórios, citocinas e quimiocinas.20 , 21 As citocinas podem desestabilizar a placa e aumentar o risco de eventos trombóticos.22 - 24 O sTWEAK é um dos mensageiros inflamatórios que contribui para a formação da placa aterosclerótica, e detectou-se que o nível alto de sTWEAK está associado à gravidade das artérias coronárias em pacientes com síndrome coronariana crônica.11 Vários estudos em animais corroboraram esses achados que demonstraram a relação entre o sTWEAK e as atividades pró-trombóticas.6 , 7 , 25 Além disso, identificou-se que o tratamento anti-TWEAK reduz o avanço das placas ateroscleróticas e a inflamação em modelos animais.6 , 25

A relação inversa foi demonstrada na aterosclerose nas artérias carótidas em pacientes em hemodiálise.26 A associação também foi encontrada na aterosclerose carótida em pacientes com infecção por HIV.27 Em vários estudos, a redução gradual no nível de sTWEAK foi observada com a redução da TFGe.9 , 28 , 29 Embora tenha-se levantado a hipótese de que o nível aumentado de sTWEAK pudesse refletir vasos saudáveis, detectou-se que o nível de sTWEAK aumentado em pacientes em hemodiálise é um preditor de mortalidade.30 Ainda há uma controvérsia sobre se o nível alto ou baixo de sTWEAK está associado a aterosclerose. Vários estudos demonstraram que o nível de sTWEAK era mais baixo em pacientes com DRC com aterosclerose e observaram uma diminuição contínua no nível de sTWEAK após o acompanhamento por 2 anos.10 , 28 , 31 Resultados opostos foram identificados em outro estudo, que demonstrou que um aumento no nível de sTWEAK estava associado a um escore de Gensini alto.11

Placas ateroscleróticas geralmente desenvolvem calcificações. Sabe-se que membros da família TNF, tais como o ligante do receptor ativador de NF-B (RANKL), promovem a formação de cálcio em placas ateroscleróticas.3 Pacientes com DRC têm placas coronárias calcificadas mais graves do que aqueles sem DRC.31 - 33 À medida que a TFGe diminui, especialmente para menos de 60 mL/min/1,73 m2, a capacidade da eliminação das quedas de fósforo. Ele acaba reduzindo os níveis de 1,25-dihidroxicholecalciferol, que causa hipocalcemia relativa. Essa hipocalcemia pode desencadear a liberação do hormônio paratormônio, causando o acúmulo de cálcio no sistema vascular.12 Sastre C et al.6 identificaram que o sTWEAK pode diminuir a carga da calcificação da placa, e isso pode explicar a inconsistência dos estudos em termos dos níveis de sTWEAK em pacientes com aterosclerose. O estudo encontrou uma correlação positiva com a gravidade das artérias coronárias, incluindo pacientes com DRC de leves a moderadas, e os pesquisadores avaliaram angiografias coronárias invasivas convencionais.11 Eles não utilizaram a CTA, que é uma ferramenta excelente para mostrar calcificações das artérias coronárias. Neste estudo, analisamos um grupo homogêneo de pacientes com DRC com e sem calcificações coronárias. Nossos resultados comprovam nossa hipótese de que os níveis de sTWEAK mostram calcificação coronária em vez de aterosclerose.

Limitações

Este estudo tem possíveis limitações. Primeiramente, nossa população se limitava a pacientes com DRC. Portanto, nossos resultados não podem ser generalizados para todos os pacientes com aterosclerose. Em segundo lugar, o número de pacientes do estudo era relativamente pequeno, e, portanto, estudos posteriores em grande escala são necessários para confirmar esses achados. Terceiro, o estudo foi realizado em um único hospital terciário universitário. Portanto, havia a possibilidade de viés de seleção, embora tenha-se prestado muita atenção para garantir que todos os pacientes consecutivos que estavam passando por CTA fossem incluídos para evitar tal viés de seleção. Além disso, o viés interobservador pode ser alto no escore Agatston, que foi usado para calcular a carga de calcificação.

 Conclusões

Embora os estudos em larga escala tenham demonstrado uma correlação positiva entre os níveis de TFGe e sTWEAK, alguns estudos detectaram que o aumento nos níveis de sTWEAK estão associados a mortalidade e gravidade do sistema da artéria coronária em pacientes com DRC. Nossos resultados comprovam nossa hipótese de que os níveis de sTWEAK mostram calcificação coronária em vez de outros tipos de placas ateroscleróticas.

 Referências 1. Henry RM, Kostense PJ, Bos G, Dekker JM, Nijpels G, Heine RJ, et al. Mild renal insufficiency is associated with increased cardiovascular mortality: the Hoorn Study. Kidney Int. 2002;62(4):1402–7. doi: 10.1111/j.1523-1755.2002.kid571.x. Henry RM Kostense PJ Bos G Dekker JM Nijpels G Heine RJ et al Mild renal insufficiency is associated with increased cardiovascular mortality: the Hoorn Study Kidney Int 2002 62 4 1402 1407 10.1111/j.1523-1755.2002.kid571.x 2. Valdivielso JM, Rodríguez-Puyol D, Pascual J, Barrios C, Bermúdez-López M, Sánchez-Niño MD, et al. Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol. 2019;39(10):1938-66. doi: 10.1161/ATVBAHA.119.312705. Valdivielso JM Rodríguez-Puyol D Pascual J Barrios C Bermúdez-López M Sánchez-Niño MD et al Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol 2019 39 10 1938 1966 10.1161/ATVBAHA.119.312705 3. Libby P. The Vascular Biology of Atherosclerosis. In Zipes D.P.& Libby P.& Bonow R.O.& Mann D.L.& Tomaselli G.F., editors. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11thed Philadelphia: Elsevier; 2019. V.1.1, p:867-9. Libby P The Vascular Biology of Atherosclerosis Zipes D.P Libby P Bonow R.O Mann D.L Tomaselli G.F editors Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine 11 Philadelphia Elsevier 2019 1.1 867 869 4. Silverman MG, Harkness JR, Blankstein R, Budoff MJ, Agatston AS, Carr, JA, et al. Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: Multi-ethnic study of atherosclerosis, JACC Cardiovasc. Imaging. 2014;7(5):476-86. doi: 10.1016/j.jcmg.2014.03.005. Silverman MG Harkness JR Blankstein R Budoff MJ Agatston AS Carr JA et al Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: Multi-ethnic study of atherosclerosis, JACC Cardiovasc Imaging 2014 7 5 476 486 10.1016/j.jcmg.2014.03.005 5. Ramji DP, Davies TS. Cytokines in atherosclerosis: key players in all stages of disease and promising therapeutic targets. Cytokine Growth Factor Rev. 2015;26:673-85. doi: 10.1016/j.cytogfr.2015.04.003. Ramji DP Davies TS Cytokines in atherosclerosis: key players in all stages of disease and promising therapeutic targets Cytokine Growth Factor Rev 2015 26 673 685 10.1016/j.cytogfr.2015.04.003 6. Sastre C, Fernández-Laso V, Madrigal-Matute J, Muñoz-García B, Moreno JA, Pastor-Vargas C, et al. Genetic deletion or TWEAK blocking antibody administration reduce atherosclerosis and enhance plaque stability in mice. J Cell Mol Med. 2014;4(6):721-34. doi: 10.1111/jcmm.12221. Sastre C Fernández-Laso V Madrigal-Matute J Muñoz-García B Moreno JA Pastor-Vargas C et al Genetic deletion or TWEAK blocking antibody administration reduce atherosclerosis and enhance plaque stability in mice J Cell Mol Med 2014 4 6 721 734 10.1111/jcmm.12221 7. Muñoz-García B, Moreno JA, López-Franco O, Sanz AB, Martín-Ventura JL, Blanco J, et al. Tumor necrosis factor-like weak inducer of apoptosis (TWEAK) enhances vascular and renal damage induced by hyperlipidemic diet in ApoE-knockout mice. Arterioscler. Thromb. Vasc. Biol. 2009; 29(12):2061-8. doi: 10.1161/ATVBAHA.109.194852. Muñoz-García B Moreno JA López-Franco O Sanz AB Martín-Ventura JL Blanco J et al Tumor necrosis factor-like weak inducer of apoptosis (TWEAK) enhances vascular and renal damage induced by hyperlipidemic diet in ApoE-knockout mice Arterioscler. Thromb. Vasc. Biol 2009 29 12 2061 2068 10.1161/ATVBAHA.109.194852 8. Blanco-Colio LM. TWEAK/Fn14 axis: a promising target for the treatment of cardiovascular disease. Front Immunol. 2014 Jan;5:3. doi: 10.3389/fimmu.2014.00003. Blanco-Colio LM TWEAK/Fn14 axis: a promising target for the treatment of cardiovascular disease Front Immunol 2014 01 5 3 10.3389/fimmu.2014.00003 9. Yilmaz MI, Carrero JJ, Ortiz A, Martin-Ventura JL, Sonmez A, Saglam M, et al. Soluble TWEAK plasma levels as a novel biomarker of endothelial function in patients with chronic kidney disease. Clin J Am Soc Nephrol. 2009;4(11):1716–23. doi: 10.2215/CJN.02760409. Yilmaz MI Carrero JJ Ortiz A Martin-Ventura JL Sonmez A Saglam M et al Soluble TWEAK plasma levels as a novel biomarker of endothelial function in patients with chronic kidney disease Clin J Am Soc Nephrol 2009 4 11 1716 1723 10.2215/CJN.02760409 10. Fernández-Laso V, Méndez-Barbero N, Valdivielso JM, Betriu A, Fernández E, Egido J, et al. Soluble TWEAK and atheromatosis progression in patients with chronic kidney disease. Atherosclerosis. 2017;260:130-7. doi: 10.1016/j.atherosclerosis.2017.03.043. Fernández-Laso V Méndez-Barbero N Valdivielso JM Betriu A Fernández E Egido J et al Soluble TWEAK and atheromatosis progression in patients with chronic kidney disease Atherosclerosis 2017 260 130 137 10.1016/j.atherosclerosis.2017.03.043 11. Azak A, Akdogan MF, Denizli N, Huddam B, Kocak G, Gucun M, et al. Soluble TWEAK levels are independently associated with coronary artery disease severity in patients with stage 2–3 kidney disease. Int Urol Nephrol. 2014;46(2):411–5. doi: 10.1007/s11255-013-0562-4. Azak A Akdogan MF Denizli N Huddam B Kocak G Gucun M et al Soluble TWEAK levels are independently associated with coronary artery disease severity in patients with stage 2–3 kidney disease Int Urol Nephrol 2014 46 2 411 415 10.1007/s11255-013-0562-4 12. Mccullough PA. Interface Between Renal Disease and Cardiovascular Illness. In: Zipes DP, Libby P, Bonow RO, Mann DI, Tomaselli GF., editors. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11thed. Philadelphia: Elsevier; 2019. p.1916. Mccullough PA Interface Between Renal Disease and Cardiovascular Illness Zipes DP Libby P Bonow RO Mann DI Tomaselli GF editors Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine 11 Philadelphia Elsevier 2019 1916 13. Stevens PE, Levin A. Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158(11):825-30. doi: 10.7326/0003-4819-158-11-201306040-00007. Stevens PE Levin A Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline Ann Intern Med 2013 158 11 825 830 10.7326/0003-4819-158-11-201306040-00007 14. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130(6):461–70. doi: 10.7326/0003-4819-130-6-199903160-00002. Levey AS Bosch JP Lewis JB Greene T Rogers N Roth D A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group Ann Intern Med 1999 130 6 461 470 10.7326/0003-4819-130-6-199903160-00002 15. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on standards, subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr. 1989;2(5):358–67. doi: 10.1016/s0894-7317(89)80014-8. Schiller NB Shah PM Crawford M DeMaria A Devereux R Feigenbaum H et al Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on standards, subcommittee on quantitation of two-dimensional echocardiograms J Am Soc Echocardiogr 1989 2 5 358 367 10.1016/s0894-7317(89)80014-8 16. Abbara S, Blanke P, Maroules CD, Cheezum M, Choi AD, Han BK, et al. SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee endorsed by the North American Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr. 2016;10(6):435–49. doi: 10.1016/j.jcct.2016.10.002. Abbara S Blanke P Maroules CD Cheezum M Choi AD Han BK et al SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee endorsed by the North American Society of Cardiovascular Imaging (NASCI) J Cardiovasc Comput Tomogr 2016 10 6 435 449 10.1016/j.jcct.2016.10.002 17. Hecht HS, Cronin P, Blaha MJ, Budoff MJ, Kazerooni EA, Narula J, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr. 2017;11(1):74–84. doi: 10.1016/j.jcct.2016.11.003. Hecht HS Cronin P Blaha MJ Budoff MJ Kazerooni EA Narula J et al 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology J Cardiovasc Comput Tomogr 2017 11 1 74 84 10.1016/j.jcct.2016.11.003 18. Berman DS, Wong ND, Gransar H, Peats RM, Dahlbeck, Hayes SW, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol. 2004;44(4):923–30. doi: 10.1016/j.jacc.2004.06.042. Berman DS Wong ND Gransar H Peats RM Dahlbeck Hayes SW et al Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography J Am Coll Cardiol 2004 44 4 923 930 10.1016/j.jacc.2004.06.042 19. Hacker M, Becker C. The incremental value of coronary artery calcium scores to myocardial single photon emission computer tomography in risk assessment. J Nucl Cardiol. 2011;18(4):700–11. doi: 10.1007/s12350-011-9384. Hacker M Becker C The incremental value of coronary artery calcium scores to myocardial single photon emission computer tomography in risk assessment J Nucl Cardiol 2011 18 4 700 711 10.1007/s12350-011-9384 20. Libby P, Hansson GK, Lichtman AH. Immune effector mechanisms implicated in atherosclerosis: from mice to humans. Immunity. 2013;38(6):1092–104. doi: 10.1016/j.immuni.2013.06.009. Libby P Hansson GK Lichtman AH Immune effector mechanisms implicated in atherosclerosis: from mice to humans Immunity 2013 38 6 1092 1104 10.1016/j.immuni.2013.06.009 21. Libby P. History of discovery: inflammation in atherosclerosis. Arterioscler Thromb. 2012;32(9):2045–51. doi: 10.1161/ATVBAHA.108.179705. Libby P History of discovery: inflammation in atherosclerosis Arterioscler Thromb 2012 32 9 2045 2051 10.1161/ATVBAHA.108.179705 22. Ketelhuth DFJ, Hansson GK. Adaptive response of T and B cells in atherosclerosis. Circ Res. 2016;118(4):668–78. doi: 10.1161/CIRCRESAHA.115.306427. Ketelhuth DFJ Hansson GK Adaptive response of T and B cells in atherosclerosis Circ Res 2016 118 4 668 678 10.1161/CIRCRESAHA.115.306427 23. Tsiantoulas D, Diehl CJ, Witztum JL, Binder CJ. B cells and humoral immunity in atherosclerosis. Circ Res. 2014;114(11):1743–56. doi: 10.1161/CIRCRESAHA.113.301145. Tsiantoulas D Diehl CJ Witztum JL Binder CJ B cells and humoral immunity in atherosclerosis Circ Res 2014 114 11 1743 1756 10.1161/CIRCRESAHA.113.301145 24. Nus M, Mallat Z. Immune-mediated mechanisms of atherosclerosis and implications for the clinic. Expert Rev Clin Immunol. 2016;12(11):1217–37. doi: 10.1080/1744666X.2016.1195686. Nus M Mallat Z Immune-mediated mechanisms of atherosclerosis and implications for the clinic Expert Rev Clin Immunol 2016 12 11 1217 1237 10.1080/1744666X.2016.1195686 25. Schapira K, Burkly LC, Zheng T, Wu P, Groeneweg M, Rousch M, et al. Fn14-Fc fusion protein regulates atherosclerosis in ApoE-/- mice and inhibits macrophage lipid uptake in vitro. Arterioscler Thromb Vasc Biol. 2009;29(12):2021-7. doi: 10.1161/ATVBAHA.109.195040. Schapira K Burkly LC Zheng T Wu P Groeneweg M Rousch M et al Fn14-Fc fusion protein regulates atherosclerosis in ApoE-/- mice and inhibits macrophage lipid uptake in vitro Arterioscler Thromb Vasc Biol 2009 29 12 2021 2027 10.1161/ATVBAHA.109.195040 26. Shi X, Qiu B, Shen H, Feng S, Fu J. Inverse Relationship between Plasma Tumor Necrosis Factor-Like Weak Inducer of Apoptosis and Carotid Intima-Media Thickness among Patients Undergoing Hemodialysis and Peritoneal Dialysis. Cardiorenal Med. 2020;10 (3):137-44. doi: 10.1159/000503811. Shi X Qiu B Shen H Feng S Fu J Inverse Relationship between Plasma Tumor Necrosis Factor-Like Weak Inducer of Apoptosis and Carotid Intima-Media Thickness among Patients Undergoing Hemodialysis and Peritoneal Dialysis Cardiorenal Med 2020 10 3 137 144 10.1159/000503811 27. Dirajlal-Fargo S, Sattar A, Kulkarni M, Funderburg N, McComsey GA. Soluble TWEAK may predict carotid atherosclerosis in treated HIV infection. HIV Clin Trials. 2017;18(4):156-63. doi: 10.1080/15284336.2017.1366001. Dirajlal-Fargo S Sattar A Kulkarni M Funderburg N McComsey GA Soluble TWEAK may predict carotid atherosclerosis in treated HIV infection HIV Clin Trials 2017 18 4 156 163 10.1080/15284336.2017.1366001 28. Bozic M, Méndez-Barbero N, Gutiérrez-Muñoz C, Betriu A, Egido J, Fernández E, et al. Combination of biomarkers of vascular calcification and sTWEAK to predict cardiovascular events in chronic kidney disease. Atherosclerosis. 2018;270:13-20. doi: 10.1016/j.atherosclerosis.2018.01.011. Bozic M Méndez-Barbero N Gutiérrez-Muñoz C Betriu A Egido J Fernández E et al Combination of biomarkers of vascular calcification and sTWEAK to predict cardiovascular events in chronic kidney disease Atherosclerosis 2018 270 13 20 10.1016/j.atherosclerosis.2018.01.011 29. Akdoğan MF, Azak A, Denizli N, Huddam B, Koçak G, Gucun M, et al. MCP-1 and soluble TWEAK levels are independently associated with coronary artery disease severity in patients with chronic kidney disease. Ren Fail. 2015;37(8):1297-302. doi: 10.3109/0886022X.2015.1065428. Akdoğan MF Azak A Denizli N Huddam B Koçak G Gucun M et al MCP-1 and soluble TWEAK levels are independently associated with coronary artery disease severity in patients with chronic kidney disease Ren Fail 2015 37 8 1297 1302 10.3109/0886022X.2015.1065428 30. Carrero JJ, Ortiz A, Qureshi AR, Martin-Ventura JL, Barany P, Heimburger O, et al. Additive effects of soluble TWEAK and inflammation on mortality in hemodialysis patients. Clin J Am Soc Nephrol. 2009;4(1):110–8. doi: 10.2215/CJN.02790608. Carrero JJ Ortiz A Qureshi AR Martin-Ventura JL Barany P Heimburger O et al Additive effects of soluble TWEAK and inflammation on mortality in hemodialysis patients Clin J Am Soc Nephrol 2009 4 1 110 118 10.2215/CJN.02790608 31. Fernandez-Laso V, Sastre C, Valdivielso JM, Fernandez E, Martín-Ventura JL, Egido J, et al. Soluble TWEAK levels predict the presence of carotid atherosclerotic plaques in subjects free from clinical cardiovascular diseases. Atherosclerosis. 2015;239(1):358-63. doi: 10.1016/j.atherosclerosis.2015.01.019. Fernandez-Laso V Sastre C Valdivielso JM Fernandez E Martín-Ventura JL Egido J et al Soluble TWEAK levels predict the presence of carotid atherosclerotic plaques in subjects free from clinical cardiovascular diseases Atherosclerosis 2015 239 1 358 363 10.1016/j.atherosclerosis.2015.01.019 32. Schwarz U, Buzello M, Ritz E, Stein G, Raabe G, Wiest G, et al. Morphology of coronary atherosclerotic lesions in patients with end-stage renal failure. Nephrol Dial Transplant. 2000; 15(2):218–23. doi: 10.1093/ndt/15.2.218. Schwarz U Buzello M Ritz E Stein G Raabe G Wiest G et al Morphology of coronary atherosclerotic lesions in patients with end-stage renal failure Nephrol Dial Transplant 2000 15 2 218 223 10.1093/ndt/15.2.218 33. Gross ML, Meyer HP, Ziebart H, Rieger P, Wenzel U, Amann K, et al. Calcification of coronary intima and media: immunohistochemistry, backscatter imaging, and x-ray analysis in renal and nonrenal patients. Clin J Am Soc Nephrol. 2007;2(1):121-34. doi: 10.2215/CJN.01760506. Gross ML Meyer HP Ziebart H Rieger P Wenzel U Amann K et al Calcification of coronary intima and media: immunohistochemistry, backscatter imaging, and x-ray analysis in renal and nonrenal patients Clin J Am Soc Nephrol 2007 2 1 121 134 10.2215/CJN.01760506

Vinculação Acadêmica

Não há vinculação deste estudo a programas de pós-graduação.

Aprovação ética e consentimento informado

Este estudo foi aprovado pelo Comitê de Ética do(a) Goztepe Research and Training Hospital sob o número de protocolo 2021/0005. Todos os procedimentos envolvidos nesse estudo estão de acordo com a Declaração de Helsinki de 1975, atualizada em 2013. O consentimento informado foi obtido de todos os participantes incluídos no estudo.

Fontes de Financiamento: O presente estudo foi parcialmente financiado por Istanbul Medeniyet University Research Grant n° 1462/T-GAP-2019-1462.

 Original Article The Association of TWEAK with Coronary Artery Calcification in Patients with Chronic Kidney Disease 0000-0003-1058-7194 Tatlisu Mustafa Adem 1 0000-0001-6580-7954 Atici Adem 1 Ozcan Fatma Betul 1 Çelik Mehmet 1 Kirac Eray 1 Baycan Omer Faruk 1 Caliskan Mustafa 1 Turkey Istanbul Medeniyet University, Istanbul – Turkey Mailing Address: Mustafa Adem Tatlisu Istanbul Medeniyet University Faculty of Medicine, Cardiology. Istanbul Goztepe Prof Suleyman Yalcin City Hospital Istanbul Istanbul 34722 – Turkey E-mail: ademtatlisu@gmail.com

Author contributions

Conception and design of the research and Acquisition of data Tatlisu MA, Atici A, Ozcan FB, Çelik M, Kirac E, Baycan OF; Analysis and interpretation of the data: Tatlisu MA, Atici A, Ozcan FB, Çelik M, Kirac E, Baycan OF, Caliskan M; Statistical analysis: Atici A, Caliskan M; Obtaining financing: Tatlisu MA, Caliskan M; Writing of the manuscript: Tatlisu MA; Critical revision of the manuscript for intellectual content: Tatlisu MA.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

 Abstract Background

The soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) is a member of the TNF superfamily that plays a critical role in proliferation and inflammation in the arterial circulation.

 Objectives

This prospective study aimed to show the relationship between the sTWEAK levels and coronary artery calcification (CAC) in patients with chronic kidney disease (CKD).

 Methods

This prospective study included 139 consecutive patients undergoing computed coronary angiography for any reason except for acute coronary syndromes from August 2020 to February 2021. A total of 12 patients were excluded from the study due to exclusion criteria. Patients were divided into two groups with regard to having a CAC score of less than 400 (n=84) and 400 or more (n=43). Significance was assumed at a 2-sided p<0.05.

 Results

As the CAC score increased, sTWEAK levels presented a statistically significant decrease, and a strong relationship between sTWEAK levels and the CAC score (r: -0.779, p<0.001) was observed. The ROC analysis revealed that the optimal cut-off level of sTWEAK for predicting the CAC score of 400 was 761 pg/mL with a sensitivity of 71% and a specificity of 73% (AUC: 0.78; 95% CI:0.70-0.85; p < 0.001)

 Conclusions

Even though the large-scale studies showed a positive correlation between eGFR and the sTWEAK levels, some studies found the increased sTWEAK levels to be associated with mortality and the severity of the coronary artery system in patients with CKD. Our results support our hypothesis that the sTWEAK level shows coronary calcification rather than other types of atherosclerotic plaques.

 Cardiovascular Diseases Renal Insufficiency,Chronic Vascular Stiffness Atherosclerosis Coronary Artery Disease Introductıon

The association of atherosclerosis with chronic kidney disease (CKD) is well-established, and the patients with CKD are associated with a more than 8-fold atherosclerosis-related death rate than in the general population.1 , 2 The pathophysiology of atherosclerosis includes lipid abnormalities, endothelial dysfunction, aging, and inflammation.3 The role of inflammation and immunity in the pathophysiology of atherosclerosis has been demonstrated in recent decades.3 - 5 The soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) is a member of the TNF superfamily that plays a critical role in proliferation and inflammation.6 - 8 The sTWEAK has been studied in patients with CKD, and it has been shown that its’ level declines as the estimated glomerular filtration rate (eGFR) decreases.9 , 10 Even though the decreased sTWEAK level was found in atherosclerosis, another study found the association of increased sTWEAK level with severity of coronary arteries.11

In CKD, the abnormal metabolism of minerals and bones results in the accumulation of arterial calcification.12 On account of the controversial results, this prospective study aimed to show the relationship between the sTWEAK level and coronary artery calcification (CAC) in patients with CKD under conservative treatment.

 Methods Study participants

This prospective study included 139 consecutive patients undergoing computed coronary angiography (CCA) for any reason from August 2020 to February 2021. All patients enrolled in the study were diagnosed with CKD, who had an estimated glomerular filtration rate (eGFR) below 60 for ≥ 3 months or an eGFR above 60 with albuminuria (urine albumin/creatinine ratio ≥ 30 mg/g).13 The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) formula.14 A total of 57 patients (41%) had category 2 CKD; 45 (32%), category 3a CKD; 33 (24%), category 3b CKD; and 4 (0.2%), category 4. The studied population had no history of atherosclerosis (coronary artery disease, ischemic stroke, peripheral artery disease, and thoracic/abdominal aneurysm). The exclusion criteria included: (i) any previous cardiovascular disease, (ii) previous organ transplantation, (iii) presence of more than a mild valvular disease, (iv) presence of systolic or heart failure, (v) presence of diastolic dysfunction other than grade 1 diastolic dysfunction and left ventricular hypertrophy, (vi) presence of epicardial coronary artery stenosis, (vii) patients on hemodialysis, and (viii) patients with acute coronary syndromes. A total of 12 patients were excluded from the study before the CCA, as they presented peripheral artery disease (n=4), showed severe aortic stenosis (n=1), and were taking medication for the chronic coronary syndrome (n=7) ( Figure 1 ). A total of 127 patients were divided into two groups based on having coronary artery calcium (CAC) scores of less than 400 (n=84) and 400 or more (n=43). This study was approved by the local Clinical Studies Ethics Committee (No: 2021/0005). Informed consent was obtained from all patients enrolled in this study.

The flowchart illustrating the exclusion of participants for the final study sample.

Demographic and clinical data

All patients completed the health and medication history questionnaires, including the clinical history of coronary artery disease (CAD), peripheral artery disease (PAD), Diabetes Mellitus (DM), hypertension (HTN), and medication use. Before CTA, all patients underwent

transthoracic echocardiography, carotid duplex ultrasound, and lower extremity arterial Doppler ultrasound to exclude subclinical atherosclerosis. An echocardiogram was performed using a Vivid 7 system (GE Vingmed Ultrasound AS, Horten, Norway), and left ventricular ejection fraction (LVEF) was calculated using the modified Simpson method.15

Blood values were obtained from venous blood samples upon hospital admission. The complete blood count was measured by using a Coulter LH 780 Hematology Analyzer (Beckman Coulter Ireland, Inc., Galway, Ireland). Biochemical measurements were performed by using Siemens Healthcare Diagnostic Products kits and calibrators (Marburg, Germany). The blood samples for plasma sTWEAK levels were obtained before the CTA and were determined using ELISA kits (Bender MedSystems, Vienna, Austria).

 Definitions

The Agatston score is one of the most frequently used scoring systems to assess coronary artery calcification. In general, the CAC score is divided into five groups as: 0, no coronary calcification; 1-100, mild coronary calcification; >100 to 399, moderate calcification; 400 to 999, severe calcification; and ≥1,000, extensive calcification.16 , 17 We divided the study population into two groups as patients with severe to extensive CAC (n=43) and patients without any CAC or mild to moderate CAC (n=84).

 Statistical analyses

All statistical tests were conducted using the Statistical Package for the Social Sciences 19.0 for Windows (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was used to analyze the normality of the data. Continuous variables with normal distribution were described using mean ± standard deviation (SD); and continuous variables without normal distribution were described using median and interquartile range. The categorical data are expressed as frequency (%). The Chi-square test was used to assess differences in categorical variables between groups. The relationships among parameters without normal distribution were assessed using Spearman’s correlation analysis. The Student’s t-test or Mann Whitney U test was used to compare unpaired samples as needed. Univariate and multivariate logistic regression analysis were used to identify independent variables of CAD and CAC. After performing univariate analysis, significantly obtained variables were selected into the multivariate logistic regression analyses with the stepwise method. The results of univariate and multivariate regression analyses were presented as odds ratio with 95%. For the laboratory parameter of sTWEAK receiver operating characteristic (ROC) curves were obtained, and the optimal values with the greatest total sensitivity and specificity in the prediction of coronary calcium score (≥400) were selected. Significance was assumed at a 2-sided p<0.05.

 Results

A total of 127 patients (mean age 59.9± 9.4 years; men 39%) undergoing CTA enrolled in the study, and the baseline characteristics and laboratory parameters are shown in Table 1 . The patients enrolled in the study were diagnosed with CKD stages 3-5, and the mean eGFR, creatinine, blood urea nitrogen levels were 39.9±13.1 mL/dk/1.73 m2, 1.8±0.2 mg/dL, 43.5±8.4 mg/dL, respectively. The mean Agatston CAC score was 90 (0-1605), and 43 patients had a score of >400, which represents severe to extensive CAC ( Table 1 ).

Clinical and laboratory characteristics of patients with chronic kidney disease
n=127
Age, years 59.9 ± 9.4
Gender (male, %) 49 (39%)
BMI, kg/m2 29.0 ± 3.7
HTN, n(%) 87 (68%)
DM, n(%) 53 (42%)
Smoking, n(%) 35 (27%)
Systolic blood pressure, mmHg 134.2±22.7
Diastolic blood pressure, mmHg 77.4±11.8
Fasting blood glucose, mg/dL 119.4±47.1
Hemoglobin, g/dL 13.8±1.6
PLT, cells/µL 237.7±65.2
WBC, cells/µL 7.5±1.8
Creatinine, mg/dL 1.8±0.2
eGFR, ml/dk/1.73 m2 39.9±13.1
BUN, mg/dL 43.5±8.4
Uric acid, mg/dL 7.4±1.2
Sodium, mmol/L 139.6±2.3
Potassium, mmol/L 4.3±0.4
Calcium, mmol/L 9.4±0.4
AST, U/L 22.4±9.3
ALT, U/L 23.8±11.2
CRP, mg/dL 0.3 (0.1-9.2)
Albumine, g/dL 4.3±0.4
TC, mg/dL 207.3±45.8
LDL, mg/dL 126.7±42.5
HDL, mg/dL 48.7±12.0
Tg, mg/dL 161.3±77.5
sTWEAK , pg/mL 845.0±418.0
CAC score 90 (0-1605)
CAC score <400, n(%) 84 (66%)
CAC score ≥400, n(%) 43 (34%)

AST: aspartate aminotransferase; ALT: alanine aminotransferase; BMI: body mass index; CAC: coronary artery calcification; CRP: C-reactive protein; DM: diabetes mellitus; eGFR: estimated glomerular filtration rate; HDL: high-density lipoprotein; HTN: hypertension; LDL: low-density lipoprotein; Plt: platelet; TC: total cholesterol; TG: triglyceride; sTWEAK: soluble tumor necrosis factor-like weak inducer of apoptosis; WBC: white blood cell.aContinuous variables are presented as mean (SD); categorical variables presented as frequency (%).

The relationship between sTWEAK levels and the CAC score was evaluated by Spearman correlation analysis. As the CAC score increased, sTWEAK levels decreased significantly, and there was a good relationship between sTWEAK levels and the CAC score, which is shown in Figure 2 (r: -0.615, p<0.001).

The correlation analysis of sTWEAK and the coronary artery calcification score (r:-0.615, p<0.001, good correlation).

The participants were divided into two groups as patients with a CAC score of <400 (n=84) and patients with a CAC score of ≥400 (n=43). There were no statistically significant differences between the groups concerning age, gender, BMI, HTN, DM, and smoking status, as shown in Table 2 . The laboratory parameters, such as fasting glucose, Hgb, platelet WBC, creatinine, eGFR, uric acid, sodium, potassium, TC, LDL, HDL, Tg, showed no statistically significant differences ( Table 2 ).

Clinical and laboratory characteristics of patients divided into two groups with regard to coronary artery calcification scorea
CCS≥400 (n=43) CCS<400 (n=84) p
Age, years 61.7 ± 8.8 59.0 ± 9.6 0.126
Gender (male%) 19(44%) 30(35%) 0.353
BMI, kg/m2 29.8 ± 3.8 28.6± 3.6 0.098
HT, n(%) 33(78%) 54(65%) 0.121
DM, n(%) 22(52%) 31(37%) 0.108
Smoking, n(%) 15(36%) 20(25%) 0.198
Systolic blood pressure, mmHg 137.5±20.7 132.4±23.6 0.241
Diastolic blood pressure, mmHg 80.0±11.5 76.0±11.7 0.073
Fasting blood glucose, mg/dL 122.8±62.9 117.5±24.5 0.601
Hemoglobin, g/dL 13.6±1.4 13.9±1.7 0.336
PLT, cells/µL 235.5±68.1 239.0±63.9 0.797
WBC, cells/µL 7.4±1.8 7.5±1.9 0.687
Creatinine, mg/dL 1.8±0.2 1.9±0.1 0.887
Stages of CKD
Stage 2 18 36 0.914
Stage 3a 15 27 0.756
Stage 3b 10 18 0.814
Stage 4 1 2 0.984
eGFR, ml/dk/1.73 m2 39.8±13.6 40.2±12.9 0.890
BUN, mg/dL 36.4±9.3 32.0±7.4 0.009
Uric acid, mg/dL 7.5±1.1 7.3±1.3 0.274
Sodium, mmol/L 139.5±2.2 139.6±2.3 0.825
Potassium, mmol/L 4.2±0.5 4.3±0.3 0.115
Calcium, mmol/L 9.3±0.3 9.4±0.4 0.066
AST, U/L 22.2±8.1 22.6±11.3 0.875
ALT, U/L 23.5±11.1 24.0±10.0 0.898
CRP, mg/dL 0.3 (0.1-9.2) 0.2 (0.1-2.0) 0.009
Albumine, g/dL 4.1±0.5 4.4±0.2 0.005
TC, mg/dL 215.8±41.6 202.9±47.5 0.132
LDL, mg/dL 135.2±40.0 122.4±43.4 0.108
HDL, mg/dL 49.6±13.3 48.3±11.3 0.550
Tg, mg/dL 158.4±59.1 162.8±85.7 0.758
sTWEAK, pg/mL 586.2±286.6 977.5±413.8 <0.001
CAC score 488 (402-1605) 45 (0-312) <0.001

AST: aspartate aminotransferase; ALT: alanine aminotransferase; BMI: body mass index; CAC: coronary artery calcification; CRP: C-reactive protein; DM: diabetes mellitus; eGFR: estimated glomerular filtration rate; HDL: high-density lipoprotein; HTN: hypertension; LDL: low-density lipoprotein; PLT: platelet; sTWEAK: soluble tumor necrosis factor-like weak inducer of apoptosis; TC: total cholesterol; TG: triglyceride; WBC: white blood cell. aContinuous variables are presented as mean (SD); categorical variables presented as frequency (%).

The sTWEAK level was significantly lower in the group with a CAC score of ≥400 than the group with a CAC score of <400 ( Table 2 ). The relationship between sTWEAK levels and the CAC score in patients with lower CAC scores (<400) was evaluated by Spearman correlation analysis. As the CAC score increased, sTWEAK levels decreased significantly, and there was a moderate relationship between sTWEAK levels and the CAC score, which is shown in Figure 3 (r: -0.385, p<0.001). The relationship between sTWEAK levels and the CAC score in patients with higher CAC scores (≥400) was evaluated by Spearman correlation analysis. As the CAC score increased, sTWEAK levels decreased significantly, and there was a strong relationship between sTWEAK levels and the CAC score, which is shown in Figure 4 (r: -0.779, p<0.001). We evaluated the specificity and sensitivity of the sTWEAK levels by Receiver Operating Characteristic (ROC) analysis to predict the presence of the CAC score of 400. The ROC analysis revealed that the optimal cut-off level of sTWEAK for predicting the CAC score of 400 was 761 pg/mL, with a sensitivity of 71% and specificity of 73% (AUC: 0.78; 95% CI:0.70-0.85; p < 0.001) ( Figure 5 ).

The correlation analysis of sTWEAK and the coronary artery calcification score of less than 400 (r:-0.385, p<0.001, moderate correlation).

The correlation analysis of sTWEAK and the coronary artery calcification score of 400 or more (r: -0.779, p<0.001, strong correlation).

The ROC analysis revealed that the optimal cut-off value of the sTWEAK to predict the CAC score of ≥ 400 was 761 pg/mL with a sensitivity of 71% and specificity of 73% (AUC=0.78; 95% CI:0.70-0.85; p<0.001).

The parameters affecting the development of CAC were evaluated by univariate and multivariate analysis. The probable predictors of CAD, such as age, gender, HTN, DM, CKD, smoking, BMI, CRP, LDL, and sTWEAK were evaluated in the univariate analysis. In the multivariate analysis, age, smoking, LDL, and sTWEAK were associated with the CAC score of 400 (Age OR:1.033, p: 0.003; smoking OR: 4.638, p: 0.003; LDL OR:1.016, p: 0.005; sTWEAK OR: 0.345, p<0.001) ( Table 3 ).

Univariate predictors and multivariate model for the coronary artery calcification score of ≥400
Variable Univariate Multivariate
OR 95%CI p OR 95%CI p
Age 1.049 1.009-1.091 0.016 1.033 1.016-1.058 0.003
Gender 0.567 0.276-1.166 0.123
HTN 1.093 0.492-2.265 0.877
DM 0.591 0.289-1.209 0.150
CKD 1.105 0.151-8.105 0.922
Smoking 4.552 1.898-10.915 0.001 4.638 1.965-11.236 0.003
BMI 0.969 0.881-1.066 0.513
CRP 2.490 0.802-7.731 0.314
LDL 1.017 1.007-1.027 0.001 1.016 1.005-1.028 0.005
sTWEAK 0.314 0.172-0.507 <0.001 0.345 0.201-0.581 <0.001

BMI: body mass index; CKD: chonic kidney disease; CRP: C-reactive protein; DM: diabetes mellitus; HTN: hypertension; LDL: low-density lipoprotein; sTWEAK: soluble tumor necrosis factor-like weak inducer of apoptosis.

Dıscussıon

The patients with the CAC score of 400 have a high risk for adverse cardiac events (>2% per year), and one-third of those patients have abnormal myocardial perfusion imaging.18 , 19 In our study, the study population was divided into two groups regarding their CAC scores. As the score of CAC increased, the sTWEAK decreased in a statistically significant manner, especially in patients with a score of 400 (r: -779, p<0.001, strong correlation) ( Figure 2-4 ). The lower sTWEAK levels remained an independent predictor of a high CAC score in the multivariate analysis ( Table 2 ).

The atherosclerotic plaque consists of proinflammatory mediators, cytokines, and chemokines.20 , 21 The cytokines can destabilize the plaque and increase the risk of thrombotic events.22 - 24 The sTWEAK is one of the inflammatory messengers that contributes to atherosclerotic plaque formation, and the high level of sTWEAK was found to be associated with the severity of coronary arteries in patients with the chronic coronary syndrome.11 Several animal studies supported these findings, which showed the relationship between the sTWEAK and prothrombic activities.6 , 7 , 25

Furthermore, anti-TWEAK treatment was found to reduce atherosclerotic plaque progression and inflammation in animal models.6 , 25

The inverse relationship was shown in atherosclerosis in carotid arteries in patients on hemodialysis.26 This association was also found in carotid atherosclerosis in patients with HIV infection.27 In several studies, the gradual reduction in the level of sTWEAK was observed as eGFR declined.9 , 28 , 29 Even though it was hypothesized that the increased level of sTWEAK might reflect healthy vessels, the increased sTWEAK level in patients on hemodialysis was found to be a predictor of mortality.30 It is still controversial whether the high or low sTWEAK level is associated with atherosclerosis. Several studies found that the sTWEAK level was lower in CKD patients with atherosclerosis and observed a continuous decrease in the sTWEAK level after a 2-year follow-up.10 , 28 , 31 The opposite results were found in another study, which showed that an increase in the sTWEAK level was associated with a high Gensini score.11

Atherosclerotic plaques usually develop calcifications. The member of the TNF family, such as the Receptor activator of NF-κB ligand (RANKL), is known to promote calcium formation in atherosclerotic plaques.3 The patients with CKD have more severe calcified coronary plaques than those without CKD.31 - 33 As the eGFR declines, especially at below 60 mL/min/1.73 m2, the capacity of elimination of phosphorus falls. It ends up reducing 1,25 dihydroxy-vitamin D levels, which causes relative hypocalcemia. This hypocalcemia can trigger the release of parathyroid hormone, causing the accumulation of calcium in the vascular system.12 . Sastre C et al.6 found that sTWEAK might decrease the burden of calcification of the plaque; this may explain the inconsistency of the studies in terms of the sTWEAK levels in patients with atherosclerosis. The study found a positive correlation with the severity of coronary arteries, including the mild to moderate CKD patients, and the investigators assessed the conventional invasive coronary angiograms.11 They did not use the CTA, which is excellent to show calcifications of the coronary arteries. The present study analyzed a homogenous group of CKD patients with and without coronary calcifications. Our results support that the sTWEAK level shows coronary calcification rather than atherosclerosis.

Limitations

This study has potential limitations. First, our population was limited to patients with CKD. Hence, our results cannot be generalized to all patients with atherosclerosis. Second, the number of study patients was relatively small; therefore, further larger-scale studies are needed to confirm these findings. Third, the study was carried out in a single tertiary university hospital. Hence, there was a possibility of selection bias, although great attention was paid to include all consecutive patients undergoing CTA to avoid selection bias. Furthermore, interobserver bias could be high in the Agatston score, which was used to calculate the burden of calcification.

 Conclusions

Even though the large-scale studies showed a positive correlation between eGFR and the sTWEAK levels, some studies found the increased sTWEAK levels to be associated with mortality and the severity of the coronary artery system in patients with CKD. Our results support our hypothesis that the sTWEAK level shows coronary calcification rather than other types of atherosclerotic plaques.

Study Association

This study is not associated with any thesis or dissertation work.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Goztepe Research and Training Hospital under the protocol number 2021/0005. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

Sources of Funding: This study was partially funded by Istanbul Medeniyet University Research Grant n° 1462/T-GAP-2019-1462