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Clinical Chemistry 54:5 Molecular Diagnostics and Genetics

851–857 (2008)

Association between the UGT1A1


TA-Repeat Polymorphism and Bilirubin
Concentration in Patients with
Intermittent Claudication:
Results from the CAVASIC Study
Barbara Rantner,1,2 Barbara Kollerits,1 Marietta Anderwald-Stadler,1,3 Peter Klein-Weigel,4 Ingrid Gruber,2
Anke Gehringer,1 Markus Haak,1 Mirjam Schnapka-Köpf,5 Gustav Fraedrich,2 and Florian Kronenberg1*

BACKGROUND: Bilirubin has antioxidative and cytopro- CONCLUSIONS: Our study of a well-phenotyped group of
tective properties. Low plasma concentrations of bili- patients with intermittent claudication and control in-
rubin are reportedly associated with the development dividuals revealed a clear association between low bili-
of coronary and cerebrovascular disease, and bilirubin rubin concentrations and peripheral arterial disease
concentrations are strongly correlated with the enzyme but no association between the UGT1A1 polymor-
activity of the hepatic uridine diphosphate glucurono- phism and the disease.
syltransferase (UGT1A1). The activity of UGT1A1 is © 2008 American Association for Clinical Chemistry
influenced by a TA-repeat polymorphism in the pro-
moter of the UGT1A1 gene (UDP glucuronosyltrans-
ferase 1 family, polypeptide A1). In a case-control
study, we investigated the association between the The heme degradation product bilirubin has potent
UGT1A1 polymorphism, bilirubin concentration, and antioxidative capacities that play a protective role in
intermittent claudication. various diseases, including coronary artery and vascu-
lar disease (1, 2 ). Studies on the relationship between
METHODS: We included 255 consecutive male patients bilirubin concentration and cardiovascular disease
presenting with intermittent claudication in the inves- have shown an inverse relationship between bilirubin
tigation and matched the patients by age and diabetes concentration and atherosclerosis (3–13 ). Low biliru-
mellitus with 255 control individuals. bin concentrations have also been independently and
inversely related to impaired flow-mediated vasodila-
RESULTS: Plasma bilirubin concentrations were signifi- tation and increased carotid intima-media thickness in
cantly lower in patients than in controls [mean (SD), clinically healthy subjects (14, 15 ). These in vivo obser-
12.5 (5.3) ␮mol/L vs 15.4 (7.9) ␮mol/L; P ⬍ 0.001]. We vations and experimental studies (16 ) suggest a protec-
found a clear association between the number of TA tive effect of high physiological bilirubin concentra-
repeats and plasma bilirubin concentration. Consider- tions on early steps in atherogenesis.
ing the 6/6 TA-repeat genotype as the wild type, we By linkage analysis we recently identified a region
observed a slight increase in bilirubin concentration on chromosome 2q significantly linked to bilirubin
individuals with the heterozygous 6/7 genotype and concentration (17 ), a finding that was subsequently
pronounced increases for those with the homozygous confirmed by investigators for the Framingham Heart
7/7 genotype. This association occurred in both con- Study (18 ). The identified chromosomal region har-
trols and patients; however, patients and controls were bors the gene for the uridine diphosphate glucurono-
not significantly different with respect to UGT1A1 TA- syltransferase (UGT1A1,6 UDP glucuronosyltrans-
repeat genotype frequencies. ferase 1 family, polypeptide A1), the major enzyme of

1
Division of Genetic Epidemiology, Department of Medical Genetics, Molecular Department of Medical Genetics, Molecular and Clinical Pharmacology, Inns-
and Clinical Pharmacology, Innsbruck Medical University, Innsbruck, Austria; bruck Medical University, Schöpfstr. 41, A-6020 Innsbruck, Austria. Fax (43)
2
Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, 512 9003-73560 or (43) 512 9003-73561; e-mail Florian.Kronenberg@i-med.
Austria; 3 3rd Medical Department of Metabolic Diseases and Nephrology, ac.at.
Hietzing Hospital, Vienna, Austria; 4 DRK-Klinik Mark Brandenburg, Department Received December 12, 2007; accepted February 15, 2008.
of Angiology, Berlin, Germany; 5 Central Laboratory for Medical and Chemical Previously published online at DOI: 10.1373/clinchem.2007.102046
6
Laboratory Diagnostics, Innsbruck Medical University, Innsbruck, Austria. Human Genes: UGT1A1 (aliases: GNT1, HUG-BR1, UDPGT, UGT1, UGT1A), UDP
* Address correspondence to this author at: Division of Genetic Epidemiology, glucuronosyltransferase 1 family, polypeptide A1.

851
bilirubin glucuronidation, which mainly determines inine ⬎133 ␮mol/L, malignancy, past organ transplan-
bilirubin elimination in humans. The activity of tation, and therapy with nicotinic acid or cortico-
UGT1A1 is substantially influenced by a TA-repeat steroids.
polymorphism in the UGT1A1 promoter (19 ). Indi- We recruited 255 control individuals from the
viduals homozygous for 7 TA repeats (7/7) have lower same geographic region and matched them with the
promoter activity and higher subsequent bilirubin patients with respect to age and presence of type 2 dia-
concentrations than heterozygous (6/7) or wild-type betes mellitus (T2DM). All members of the control
homozygous (6/6) individuals (19 –21 ). In an investi- group had volunteered to participate in the study after
gation of the correlation between the TA-repeat poly- the publication of an invitation in newspapers. We ap-
morphism and the incidence of cardiovascular and plied the same exclusion criteria to the control group as
coronary heart disease in the Framingham Offspring we used for the patients. Control individuals with
Study, we observed a statistically significant decreased symptomatic PAD were excluded, but those with a his-
risk for individuals with the 7/7 genotype (8 ). tory of cardiovascular disease were allowed to partici-
Previous studies of bilirubin have primarily fo- pate. Eighteen of the 255 controls either had a positive
cused on patients with coronary artery disease. To our cardiovascular history for angina pectoris according to
knowledge, the present study is the first to investigate their responses on the Rose questionnaire (22 ) or had
an association between plasma bilirubin concentration had documented cardiovascular events or procedures,
and the UGT1A1 TA-repeat polymorphism in a male such as myocardial infarction, aortocoronary bypass
cohort with symptomatic peripheral arterial disease surgery, percutaneous transluminal coronary angio-
(PAD)7 and an age- and diabetes-matched group of plasty, and/or coronary angiography or stroke.
control individuals. Neither the patients nor the controls had acute
illnesses or clinically detectable inflammatory pro-
Materials and Methods cesses at the time of enrollment. All study participants
provided written informed consent, and the ethics
STUDY PARTICIPANTS AND STUDY DESIGN committee of the participating study centers approved
The CAVASIC (Cardiovascular Disease in Intermittent the examination protocol.
Claudication) Study is a prospective case-control study To minimize interobserver bias, we had a single
initiated in 2002 to identify cardiovascular risk factors physician at each of the 2 clinical centers conduct all
in patients with intermittent claudication. Patient and of the interviews and examinations; these physicians
controls were enrolled in 2 clinical centers, the Depart- were specially trained in vascular examinations and
ment of Vascular Surgery, Medical University Inns- echocardiography.
bruck, and the 3rd Medical Department of Metabolic
Diseases and Nephrology, Hietzing Hospital, Vienna, BASELINE VASCULAR EXAMINATION
Austria. Participants are to be followed for at least 6 For the measurement of the ankle-brachial index
years. We describe our study of the association of bili- (ABI), the systolic brachial blood pressure was initially
rubin concentration and the UGT1A1 polymorphism measured once on both arms, and 2 additional blood
with the presence of symptomatic PAD at baseline. pressure measurements were made on the arm with the
Patients (n ⫽ 255) were consecutively included in higher systolic value. We used the mean of these 2 ad-
the study when they presented with or had a history of ditional measurements on the arm with the higher sys-
intermittent claudication (PAD IIa or IIb, according to tolic value for further calculations. Systolic blood pres-
the criteria of Fontaine), regardless of whether they had sures on the lower extremity were measured 3 times for
already undergone a treatment procedure (bypass sur- each artery (dorsalis pedis artery and tibialis posterior
gery or intervention). Patients were excluded from the artery, on both the left and right ankles). The mean of
study for any of the following reasons: presence of the second and third measurements for each site was
acute or critical limb ischemia (Fontaine III or IV), used to calculate the ABI for each of the 4 lower-ex-
impaired liver function with increased enzyme concen- tremity sites. The ABI was calculated as the ratio of the
trations (aspartate aminotransferase ⬎50 U/L, alanine systolic blood pressure (mean of second and third mea-
amino transferase ⬎25 U/L, ␥-glutamyltransferase surements) of each of the 4 sites to the mean systolic
⬎60 U/L), impaired kidney function with serum creat- blood pressure of the arm. We used the lowest ABI
value from the 4 sites for further data analysis to yield a
higher sensitivity of the ABI (23 ) and to be in line with
the Reduction of Atherothrombosis for Continued
7
Health (REACH) Registry (24 ).
Nonstandard abbreviations: PAD, peripheral arterial disease; UGT1A1, uridine
diphosphate glucuronosyltransferase; T2DM, type 2 diabetes mellitus; ABI, The Edinburgh questionnaire was used to iden-
ankle-brachial index. tify symptomatic intermittent claudication (25 ). Pa-

852 Clinical Chemistry 54:5 (2008)


Bilirubin and Peripheral Arterial Disease

tients who presented with symptoms of intermittent als with a 5 TA-repeat allele and 2 persons with an 8
claudication and had an ABI ⬍0.90 were considered TA-repeat allele. Because of the low frequencies of
to have PAD. Furthermore, we performed a pulse these alleles and functional studies that revealed de-
volume recording and evaluated walking distance with creasing promoter activity with increasing numbers
a standardized constant-load treadmill examination of TA repeats, we combined the 5 and 6 TA-repeat
(12% acceleration and 3.0 km/h). If any further ther- alleles and the 7 and 8 TA-repeat alleles for statistical
apy was planned, additional ultrasound scanning or analyses. Variables contributing to PAD status were
magnetic resonance imaging of the arteries of the identified by logistic regression analysis, and an ad-
lower extremity was done. Conventional angiography justed general linear regression model was used to
was performed in cases requiring further endovascular estimate the proportion of the variation in bilirubin
treatment. concentration explained by different variables. The
full model included the UGT1A1 polymorphism
OTHER PHENOTYPIC CHARACTERIZATION (coded as a recessive model for the 7 TA repeats),
Demographic data, clinical history, smoking status, al- age, LDL cholesterol, smoking status, T2DM, and glu-
cohol consumption, diet, amount of leisure, physical cose. A submodel included these variables without the
activity during work, and atherosclerosis risk profile UGT1A1 polymorphism. The difference in r2 between
were recorded via a standardized interview. Current the 2 models was considered to be the amount of the
medications were recorded at the baseline exam. variation in bilirubin concentration explained by the
All participants underwent a clinical examination UGT1A1 polymorphism.
that was focused on the heart and arteries and included Statistical analyses were performed with the Statisti-
electrocardiographic and echocardiographic evaluations. cal Package for the Social Sciences for Windows (SPSS)
Participants received a diagnosis of diabetes mel- version 15.0 and SAS version 9.1 (SAS Institute).
litus if their fasting plasma glucose concentration was
⬎6.99 mmol/L and/or they were being treated with an- Results
tidiabetes drugs. Participants were considered hyper-
tensive when the systolic blood pressure was ⱖ140 BASELINE CHARACTERISTICS
mmHg, if the diastolic blood pressure was ⱖ90 mmHg, Between July 2002 and July 2006, we included 255 un-
and/or if they were being treated with antihypertension related male patients (age range, 35–70 years) who pre-
drugs. sented with intermittent claudication graded as stage
IIa or IIb according to the Fontaine classification. Thir-
LABORATORY MEASUREMENTS ty-eight of these patients had T2DM. The patients and
Plasma and serum samples treated with EDTA and ci- the age- and T2DM-matched controls had similar
trate were obtained after an overnight fasting period of T2DM durations [mean (SD), 11.7 (7.4) years vs
10 –14 h, immediately processed, centrifuged, and 10.7 (8.4) years] and similar glycosylated hemoglobin
stored in aliquots at ⫺80 °C until laboratory measure- (HbA1c) values [7.5% (1.4%) vs 7.4% (1.1%)]. These
ments were made. Bilirubin was measured immedi- differences were not statistically significant.
ately after blood collection via a colorimetric method Table 1 summarizes the characteristics of the pa-
(diazotized sulfanilic acid reaction; Roche Diagnostics tients and control individuals. The patient group
reagent sets) in a Modular P800 analyzer. had a significantly higher frequency of smokers and
significantly higher triglyceride and creatinine con-
GENOTYPING centrations and lower HDL cholesterol and albumin
DNA was extracted from whole-blood samples by a concentrations than the control group. Hyperten-
salting-out method (Invisorb Blood Universal Kit; In- sion frequency and blood pressures were markedly
vitek). The UGT1A1 promoter polymorphism was an- higher in the patient group.
alyzed as recently described (8 ). Samples were geno-
typed within the Genotyping Unit of the Gene BILIRUBIN CONCENTRATIONS AND THE UGT1A1
Discovery Core Facility at the Innsbruck Medical Uni- POLYMORPHISM IN PATIENTS AND CONTROLS
versity, Innsbruck, Austria. Patients with PAD had significantly lower bilirubin
concentrations than the controls [mean (SD), 12.5 (5.3)
STATISTICAL ANALYSIS ␮mol/L vs 15.4 (7.9) ␮mol/L; P ⬍ 0.001] (Table 2). Be-
Variables for the patient and control groups were eval- cause the control group included 18 individuals with a
uated statistically by means of unpaired Student t-tests, history of cardiovascular disease, we performed a sen-
nonparametric Wilcoxon rank sum tests, and the Pear- sitivity analysis and excluded these 18 control individuals;
son ␹2 test. Besides the 6 and 7 TA-repeat alleles for the nevertheless, the mean bilirubin concentration for the
UGT1A1 polymorphism, we also observed 6 individu- control group remained unchanged [15 (7.7) ␮mol/L].

Clinical Chemistry 54:5 (2008) 853


Table 1. Baseline clinical and laboratory data for patients with peripheral arterial occlusive disease and for
control individuals matched by age and diabetes mellitus.a

Controls (n ⴝ 255) Patients (n ⴝ 255) P

Age, years 57.2 (9.2) 58.0 (7.0) NS


Body mass index, kg/m 26.8 (5.7) 26.8 (4.0) NS
Smoking (nonsmokers/former smokers/ 114/99/42 (44.7/38.8/16.5) 19/109/124 (7.5/43.3/49.2) ⬍0.001
current smokers), n (%)
Total cholesterol, mmol/L 5.39 (0.906) 5.34 (1.06) NS
LDL cholesterol, mmol/L 3.52 (0.855) 3.44 (0.958) NS
HDL cholesterol, mmol/L 1.54 (0.451) 1.28 (0.321) ⬍0.001
Triglycerides, mmol/Lb 1.51 (0.915) 1.94 (1.40) ⬍0.001
关0.904, 1.29, 1.75兴 关1.06, 1.51, 2.41兴
Glucose, mmol/L 5.83 (1.72) 6.00 (1.61) 0.006
Creatinine, ␮mol/L 90 (12) 88 (17) ⬍0.001
Albumin, g/L 45.5 (4) 44.6 (5) 0.014
Systolic blood pressure, mmHg 140 (17) 150 (20) ⬍0.001
Diastolic blood pressure, mmHg 82 (9) 83 (10) 0.180
Hypertension, n (%)c 153 (60.5) 214 (84.9) ⬍0.001
Ankle-brachial indexd 1.04 (0.15) 0.73 (0.24) ⬍0.001
a
Data are expressed as the mean (SD) except where noted.
b
Data are expressed as the mean (SD) 关25th, 50th, 75th percentiles兴.
c
Hypertension was defined as a systolic blood pressure ⱖ140 mmHg, a diastolic blood pressure ⱖ90 mmHg, and/or receiving antihypertension treatment.
d
The lowest ABI value from the 4 sites was used for data analysis (see Materials and Methods). Individuals with ABI values ⬎1.30 were excluded from this analysis.

There was a clear association between the TA-re- the homozygous 7/7 genotype. This association was ap-
peat polymorphism in the UGT1A1 promoter and bil- parent in both the controls (12.3 ␮mol/L, 14.9 ␮mol/L,
irubin concentration. Considering the 6/6 TA-repeat and 26.7 ␮mol/L, respectively; P ⬍ 0.001) and the pa-
genotype as the wild type, we observed a slight increase tients (10.9 ␮mol/L, 12.5 ␮mol/L, and 16.6 ␮mol/L,
in bilirubin concentration in individuals with the het- respectively; P ⬍ 0.001) (Fig. 1). The proportion of the
erozygous 6/7 genotype and a pronounced increase for total variation in bilirubin concentration explained by
the TA-repeat polymorphism was 12.3% in the pa-
tients after adjusting for covariates, compared with
Table 2. Bilirubin concentrations and the UGT1A1 27.9% in the control group (Table 3).
TA-repeat polymorphism in controls and patients A comparison of the bilirubin concentrations for
with peripheral arterial occlusive disease. the patient and control groups by genotype revealed
lower bilirubin concentrations in the patients than in
Controls Patients the controls for each genotype (Fig. 1). The difference
(n ⴝ 255) (n ⴝ 255) P
was most pronounced for individuals with the 7/7 TA-
Bilirubin, ␮mol/La 15.4 (7.9) 12.5 (5.3) ⬍0.001 repeat genotype (16.6 ␮mol/L vs 26.7 ␮mol/L; P ⬍
关9.9, 13.7, 18.1兴 关9.1, 11.5, 14.7兴 0.001). The patients and control individuals showed no
UGT1A1 TA-repeat differences with respect to genotype frequencies, how-
genotype frequency, ever, regardless of whether the 18 control individuals
n (%)
with a history of cardiovascular disease were included
6/6 94 (37.0) 91 (36.8)
in the analysis (Table 2) or not (data not shown).
6/7 127 (50.0) 119 (48.2)
7/7 33 (13.0) 37 (15.0) 0.803 MULTIPLE LOGISTIC REGRESSION ANALYSIS
a
Data are expressed as the mean (SD) 关25th, 50th, 75th percentiles兴.
Finally, we investigated whether bilirubin concentra-
tion was associated with the case-control status. After

854 Clinical Chemistry 54:5 (2008)


Bilirubin and Peripheral Arterial Disease

diseases by protecting against oxidative stress, possibly


P < 0.001
30 Controls Patients 26.7
through the action of bilirubin or in conjunction with
bilirubin metabolism (2, 26 ). Several studies have de-
Bilirubin (µmol/L)

25

20
P < 0.001 scribed an association between low bilirubin concen-
P = 0.027 16.6
14.9 trations and coronary heart disease (3–13 ). The asso-
15 12.3 12.5
10.9
10
ciation of bilirubin with atherosclerosis might be
explained by in vitro findings that have shown bili-
5
rubin to have antioxidative and cytoprotective prop-
0
erties (27, 28 ). Bilirubin scavenges peroxyl radicals
6/6 6/7 7/7
and suppresses oxidation in liposomes more efficiently
UGT1A1 TA-repeat polymorphism
than ␣-tocopherol (27, 28 ). It also has antithrombotic
properties (29 ) and modulates macrophage activation
Fig. 1. Plasma bilirubin concentrations in control in- within atherosclerotic lesions (30 ). Because the en-
dividuals and patients with PAD and stratified by 3 zyme activity of uridine diphosphate glucuronosyl-
TA-repeat genotypes (6/6, 6/7, and 7/7) of the transferase is strongly influenced by the investigated
UGT1A1 promoter polymorphism. TA-repeat polymorphism (19 –21 ), the hypothesis of
an association between this polymorphism and athero-
sclerotic outcome is attractive.
adjustment for age, we found a 1.7-␮mol/L increase in The highly significant association between biliru-
bilirubin concentration decreased the probability of bin concentration and PAD noted in our study is con-
being a patient by 11.5% (Table 4, model 1). This asso- vincing and in line with the majority of the other stud-
ciation was still significant after we adjusted for other ies on coronary heart disease (3–13 ). Furthermore, we
risk factors, such as smoking status, HDL cholesterol, found a strong association between the UGT1A1 poly-
glucose, creatinine, and hypertension (Table 4). morphism and bilirubin concentration; however, we
were surprised that we could find no association be-
Discussion tween the UGT1A1 polymorphism and PAD. In a re-
cent Framingham Heart Study investigation, a strong
To our knowledge, this study is the first to investigate association was observed between the 7/7 TA-repeat
plasma bilirubin concentration and the UGT1A1 pro- genotype and a lower risk of cardiovascular disease.
moter TA-repeat polymorphism in a cohort of patients During a 24-year follow-up, carriers of this geno-
with PAD and an age- and diabetes-matched control type had about one third the risk for cardiovascular
group. We observed significantly lower bilirubin con- disease and coronary heart disease as carriers of the 6
centrations in patients than in controls, and the allele (8 ). This finding is in contrast to the longitudinal
UGT1A1 polymorphism was strongly associated with population– based Rotterdam Study of elderly indi-
bilirubin concentration in both patients and controls. viduals, which found no association of either the TA-
Interestingly, the polymorphism was not associated repeat polymorphism or bilirubin concentration with
with PAD. coronary heart disease (31 ). Similarly, the ECTIM
Activation of heme oxygenase and the heme cata- case-control study of myocardial infarction found no
bolic pathway are both strongly influenced by genetics association of the UGT1A1 7 TA-repeat allele with cor-
and have been proposed to have beneficial effects on onary heart disease (32 ).
The differences between these studies and our
study of PAD patients in comparison with the Fra-
Table 3. Percentage of total variation in bilirubin
mingham Heart Study are obvious: the Framingham
concentration explained by the UGT1A1 TA-repeat
Heart Study is a population-based prospective cohort
polymorphism.
study of individuals free of cardiovascular disease at
baseline. Although the Rotterdam Study was a prospec-
r 2, full r 2, r 2 explained by
tive study, participants had a mean age of nearly 70
modela submodelb polymorphism years at baseline, which makes a survival bias highly
Controls 35.2% 7.3% 27.9% likely. We cannot exclude a survival bias in our study
because concomitant PAD and cardiovascular disease
Patients 18.6% 6.3% 12.3%
is the rule rather than the exception.
a
Full model is adjusted for age, LDL cholesterol, smoking status, T2DM, In this context we consider the following observa-
glucose, and UGT1A1 TA-repeat polymorphism. tion highly interesting: Although we observed an asso-
b
Submodel is the same as the full model but without adjustment for the
UGT1A1 TA-repeat polymorphism.
ciation between the TA-repeat polymorphism and
bilirubin concentration in both the controls and the

Clinical Chemistry 54:5 (2008) 855


Table 4. Logistic regression analysis for predicting PAD.

Model 1 Model 2 Model 3

Variable (increment) Odds ratio (95% CIa) P Odds ratio (95% CI) P Odds ratio (95% CI) P

Bilirubin (1.7 ␮mol/L) 0.885 (0.840–0.933) ⬍0.001 0.913 (0.864–0.964) 0.001 0.914 (0.862–0.970) 0.003
Age (1 year) 1.014 (0.992–1.037) 0.218 1.025 (1.001–1.050) 0.042 1.019 (0.990–1.049) 0.193
Smoking (current smoking) — 4.510 (2.936–6.927) ⬍0.001 4.105 (2.526–6.672) ⬍0.001
HDL cholesterol (0.026 mmol/L) — — 0.960 (0.946–0.975) ⬍0.001
Creatinine (88.4 ␮mol/L) — — 0.271 (0.078–0.939) 0.039
Glucose (0.056 mmol/L) — — 0.998 (0.991–1.006) 0.641
Hypertension (yes) — — 4.500 (2.632–7.696) ⬍0.001
a
CI indicates confidence interval.

cases, the relative and absolute differences in bilirubin that we cannot detect an association of this polymor-
concentration between individuals with the 6/6 and 7/7 phism with PAD outcome, although the association of
TA-repeat genotypes was much more pronounced in bilirubin concentration with PAD is relatively strong. It
the controls than in the patients. Control individuals is possible that thousands of patients and controls
with the 7/7 TA-repeat genotype had bilirubin concen- would be needed in a case-control study to detect such
trations that were about 120% higher than controls an association, if it exists. The clear association ob-
with the 6/6 TA-repeat genotype. This difference in served in the Framingham Heart Study might be ex-
PAD patients was only about 52%, however (Fig. 1). plained by its having a prospective study design that is
We speculate that the lower relative difference in bili- less confounded by most kinds of selection and survival
rubin concentration in PAD patients with the 7/7 ge- bias than case-control designs.
notype could be explained by a selection bias between In summary, our study of a well-phenotyped
the patients and controls within the 7/7 genotype group of PAD patients and control individuals shows a
group. If this speculation is accurate, we expect the clear association between low bilirubin concentrations
bilirubin concentrations of patients with the 7/7 geno- and peripheral arterial occlusive disease.
type to fall in the lower range of expected values for this
genotype, whereas the bilirubin concentrations in the
control group would fall more toward the center of the Grant/Funding Support: This study was supported by
expected range. Such a phenomenon might account for grants from the “Austrian Nationalbank” (Project
the observation that the TA-repeat polymorphism ex- 9331) and the Austrian Heart Fund, and by the
plained only about half of the bilirubin variance in “Genomics of Lipid-associated Disorders—GOLD” of
PAD patients compared with controls (12.6% vs the “Austrian Genome Research Programme GEN-
25.6%, Table 3). If we consider that only 12.6% of the AU” to F.K. B.R. was supported by a DOC-fFORTE
variance in bilirubin concentration is explained by the scholarship from the Austrian Academy of Sciences.
TA-repeat polymorphism, it is no longer surprising Financial Disclosures: None declared.
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