ORIGINAL ARTICLE

E n d o c r i n e R e s e a r c h

Plasma Carboxy-Terminal Provasopressin (Copeptin):

A Novel Marker of Insulin Resistance and Metabolic
Syndrome

Umer Saleem, Mahyar Khaleghi, Nils G. Morgenthaler, Andreas Bergmann,

Joachim Struck, Thomas H. Mosley Jr., and Iftikhar J. Kullo
Division of Cardiovascular Diseases (U.S., M.K., I.J.K.), Mayo Clinic, Rochester, Minnesota 55905; Research
Department of BRAHMS AG (N.G.M., A.B., J.S.), Biotechnology Centre, D-16761 Hennigsdorf/Berlin, Germany; and

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the Department of Medicine (Geriatrics) (T.H.M.), University of Mississippi Medical Center, Jackson, Mississippi 39216

Context: Stress-mediated hypothalamic-pituitary-adrenal axis activation, regulated by arginine

vasopressin (AVP), may have a role in the pathophysiology of metabolic syndrome (MetSyn).

Objective: The objective of the study was to investigate whether plasma C-terminal provasopressin
fragment (copeptin), a surrogate for circulating AVP, was associated with measures of insulin
resistance and presence of MetSyn.

Design, Setting, and Participants: This was a multicenter, community-based study, investigating
novel biomarkers for vascular disease. Participants included 1293 African-Americans (AA) (64 ⫾ 9
yr) and 1197 non-Hispanic whites (NHW) (59 ⫾ 10 yr) belonging to hypertensive sibships.

Main Outcome Measures: Plasma copeptin levels were measured by an immunoluminometric assay.
MetSyn was defined per Adult Treatment Panel III criteria. Generalized estimating equations were used
to assess whether plasma copeptin was associated with measures of insulin resistance and MetSyn.

Results: The prevalence of MetSyn was 50% in AA and 49% in NHW. In each group, after adjust-
ment for age and sex, plasma copeptin levels significantly correlated with body mass index, fasting
plasma glucose and insulin, homeostasis model assessment of insulin resistance, triglycerides, and
(inversely) high-density lipoprotein cholesterol (P ⬍ 0.05 for each variable). In multivariable logistic
regression models that adjusted for age, sex, smoking, statin use, serum creatinine, education,
physical activity, and diuretic use, plasma copeptin levels in the highest quartile were associated
with an increased odds ratio of having MetSyn compared with bottom quartile: odds ratio (95%
confidence interval) in AA, 2.07 (1.45–2.95); in NHW, 1.74 (1.21–2.5).

Conclusions: Our findings indicate a novel cross-sectional association between plasma copeptin
and measures of insulin resistance and MetSyn. (J Clin Endocrinol Metab 94: 2558 –2564, 2009)

M etabolic syndrome is a major public health burden with

nearly a quarter of the world’s adult population af-
fected (1). The syndrome is associated with a 5-fold higher risk
of developing type 2 diabetes (2) and 2- to 3-fold higher risk
of cardiovascular disease (2). The pathophysiology of meta-
bolic syndrome is not well defined, and several investigators
have sought to identify a unifying factor that could explain all
the components of the syndrome. In addition to insulin resis-
tance/hyperinsulinemia (3), investigators have found several
biomarkers to be associated with metabolic syndrome includ-
ing leptin (2), epinephrine and norepinephrine (3), brain na-
triuretic peptide (4), oxidized low-density lipoprotein choles-
terol (5), uric acid (6), C-reactive protein (2), plasminogen
activator inhibitor-1 (2), and aldosterone (2), highligh-
ting diverse pathophysiological perturbations in metabolic
syndrome.

ISSN Print 0021-972X ISSN Online 1945-7197 Abbreviations: AVP, Arginine vasopressin; BMI, body mass index; BP, blood pressure; CV,
Printed in U.S.A. coefficient of variation; HDL, high-density lipoprotein; HOMA-IR, homeostasis model as-
Copyright © 2009 by The Endocrine Society sessment of insulin resistance; HPA, hypothalamic-pituitary-adrenal; OR, odds ratio.
doi: 10.1210/jc.2008-2278 Received October 20, 2008. Accepted April 8, 2009.
First Published Online April 14, 2009

2558 jcem.endojournals.org J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564

J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564
Chronic psychosocial stress, defined as feelings of fatigue,
lack of energy, irritability, demoralization, and hostility (7), has
been linked to metabolic syndrome (7, 8). Chronic psychosocial
stress is frequently accompanied by increased plasma levels of
arginine vasopressin (AVP), which is an amplifier of the hypo-
thalamic-pituitary-adrenal (HPA) axis along with CRH (9 –11).
Several reports suggest that stress-mediated activation of the
HPA axis may have a role in the pathogenesis of insulin resistance
and metabolic syndrome (8).
We therefore hypothesized that plasma AVP would be asso-
ciated with measures of insulin resistance and metabolic syn-
drome. We tested this hypothesis in a cohort of adults belonging
to sibships ascertained on the basis of hypertension and well
characterized for presence of metabolic syndrome and its com-
ponents. We measured plasma levels of the C-terminal pro-AVP
fragment also known as copeptin, as a surrogate for circulating
AVP levels. Copeptin is secreted in equimolar amounts to AVP
and therefore directly reflects the release of AVP into the circu-
lation. Unlike AVP, it remains stable ex vivo for several days at
room temperature in serum or plasma (12).
Subjects and Methods
The study methods have been described previously (13). Briefly, the
study was part of the Proteomic Markers of Arteriosclerosis Study, which
is investigating the association of multiple markers in various etiologic
pathway of vascular disease with several phenotypes of arteriosclerosis.
The non-Hispanic white participants were recruited from the Olmsted
County, Minnesota, whereas the African-American participants were
recruited from Jackson, MS. If the eligible proband, at either center, had
at least one sibling with hypertension, all available full biological siblings
of the index hypertensive including normotensive siblings were invited to
participate in interviews, physical examinations, and phlebotomy at
their respective centers. The only exclusionary criterion at enrollment at
either center was the presence of a secondary cause of hypertension (such
as documented renal artery stenosis or advanced renal insufficiency) in
the index siblings (13). The study was approved by the Institutional
Review Boards of the University of Mississippi Medical Center (Jackson
MS) and Mayo Clinic (Rochester MN). Written informed consent was
obtained from each participant. The present study included 2490 par-
ticipants (1293 African-Americans and 1197 non-Hispanic whites). We
excluded two participants with copeptin levels greater than 100 ␮l/liter.
Height was measured by stadiometer, weight by electronic balance,
and body mass index (BMI) was calculated as weight in kilograms di-
vided by the square of height in meters. Ever smoking was defined as
having smoked more than 100 cigarettes. Resting systolic blood pressure
and diastolic blood pressure were measured by random zero sphygmo-
manometer (Hawskley and Sons, London, UK). The diagnosis of hyper-
tension was established based on blood pressure (BP) levels measured at
the study visit (ⱖ140/90 mm Hg) or a prior diagnosis of hypertension and
current treatment with antihypertensive medications. Diabetes was con-
sidered present if the subject had history of diabetes, was being treated
with insulin or oral agents, or had a fasting glucose level of 126 mg/dl or
greater. Information about the use of BP medications and statins was
obtained from the participants at the time of the study visit. We con-
structed a physical activity score by considering the responses to ques-
tions on how many hours per day of heavy activity, moderate activity,
slight activity, and sedentary activity the participant engaged in. Specif-
ically, the physical activity score was derived as follows: 3heavy ⫹ 2mod-
erate ⫹ 1light (hours).
Blood was collected by venipuncture after an overnight fast, and the
plasma/serum samples were stored at ⫺80 C until analyzed. Serum total
jcem.endojournals.org 2559
cholesterol and high-density lipoprotein (HDL) cholesterol were mea-
sured by standard enzymatic methods. Insulin was determined by a RIA
method using the human insulin specific RIA kit (Linco Research, St.
Charles, MO). The sensitivity of the assay was 0.03 ␮U/ml with an
interassay coefficient of variation (CV) of less than 10%. Homeostasis
model assessment of insulin resistance (HOMA-IR) was calculated as
insulin (microinternational units per milliliter) ⫻ [glucose (milligrams
per deciliter) ⫻ 0.055/22.5] (14). Metabolic syndrome was defined as the
presence of three or more of the following components: 1) waist circum-
ference of 35 in. or greater (ⱖ88.9 cm) in women or 40 in. or greater
(ⱖ101.6 cm) in men; 2) BP 130/85 mm Hg or greater or treatment for
hypertension; 3) fasting triglycerides 150 mg/dl or greater (ⱖ1.70 mmol/
liter); 4) HDL cholesterol 40 mg/dl or less (ⱕ1.04 mmol/liter) in men or
50 mg/dl or less (ⱕ1.30 mmol/liter) in women; and 5) fasting blood
glucose 110 mg/dl or greater (ⱖ6.11 mmol/liter) or treatment for dia-
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betes (15, 16). Copeptin was measured in a blinded fashion in a single
batch with a commercial sandwich immunoluminometric assay (LUMI-
test C-terminal pro-AVP; BRAMHS AG, Hennigsdorf/Berlin, Germany)
as described previously (12, 17). The assay yielded results within 3 h. The
analytical detection limit was 1.84 pg/ml (1.7 pmol/liter) and the inter-
assay CV was less than 20% for values greater than 2.44 pg/ml (⬎2.25
pmol/liter) (12).
Statistical methods
Because of the presence of siblingships in the sample, regression anal-
yses were performed using generalized estimating equations to correct
for intrafamilial correlations (18). Continuous data were summarized as
either mean ⫾ SD or median and quartiles, and categorical data were
expressed as percentages. Due to significant differences in age and the
proportion of women in the two ethnic groups, participant characteris-
tics were assessed after adjustment for age and sex. All analyses were
stratified by ethnicity. Serum creatinine and alcohol intake were log
transformed to reduce skewness. We calculated Spearman correlation
coefficients (adjusted for age and sex) between plasma copeptin and the
following variables: 1) conventional risk factors for cardiovascular dis-
ease (total cholesterol, HDL cholesterol, triglycerides, systolic BP, smok-
ing, and diabetes); 2) measures of adiposity and insulin resistance (BMI,
waist circumference, fasting blood sugar, insulin level, and HOMA-IR);
and 3) lifestyle variables (physical activity score, alcohol intake, and
education).
To evaluate the association of copeptin with metabolic syndrome, we
constructed multivariable logistic regression models in each ethnic group
to assess whether plasma copeptin was independently associated with
metabolic syndrome. We calculated the odds ratio for the presence of
metabolic syndrome in quartiles of copeptin with participants in the
lowest quartile of copeptin considered the referent group. Adjustments
were performed for age and sex; and age, sex, serum creatinine, smoking,
statin use, history of myocardial infarction/stroke, lifestyle variables
(physical activity score and educational status), and diuretic use. Alcohol
intake was not associated with copeptin levels in the present study; there-
fore, this was not used in the final model (see Table 2). The above analyses
were repeated in nondiabetic individuals in both ethnic groups. A two-
sided P⬍ 0.05 was used for statistical significance. Statistical analyses
were carried out using SAS version 9.1 software package (SAS Institute,
Cary, NC).
Results
There was a greater proportion of women than men in both
African-American and non-Hispanic white cohorts and African-
Americans were older. After adjustment for age and sex, African-
Americans had a higher prevalence of diabetes than their non-
Hispanic white counterparts and lower use of statins. However
the prevalence of metabolic syndrome was similar in the two
2560 Saleem et al. Copeptin and Metabolic Syndrome J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564

TABLE 1. Participant characteristics (n ⫽ 2490) TABLE 2. Age- and sex-adjusted (Spearman) correlations
between copeptin and select variables
Non-
African- Hispanic African-Americans Non-Hispanic
Americans whites P (n ⴝ 1286) whites (n ⴝ 1197)
(n ⴝ 1293) (n ⴝ 1197) value
r P r P
Age, yra 63.6 ⫾ 9.3 58.9 ⫾ 10.2 ⬍0.001
Waist 0.16 ⬍0.001 0.20 ⬍0.001
Men, n (%)a 373 (28.9) 510 (42.6) ⬍0.001
BMI 0.14 ⬍0.001 0.19 ⬍0.001
BMI, kg/m² 31.6 ⫾ 6.6 30.8 ⫾ 6.3 0.47
Plasma glucose 0.12 ⬍0.001 0.17 ⬍0.001
Waist circumference, cm 103.6 ⫾ 14.5 100.6 ⫾ 15.9 0.83
Plasma insulina 0.14 ⬍0.001 0.22 ⬍0.001
Plasma glucose, mg/dl 112.7 ⫾ 47.7 104.9 ⫾ 24.5 ⬍0.001
HOMA-IRa 0.17 ⬍0.001 0.23 ⬍0.001
Plasma insulin, IU/ml 9.3 ⫾ 8.2 8.0 ⫾ 6.0 0.005
Diabetes 0.13 ⬍0.001 0.07 0.014
HOMA-IR 3.4 ⫾ 10.4 2.3 ⫾ 2.7 0.011
HDL cholesterol ⫺0.07 0.014 ⫺0.08 0.009
Diabetes, n (%) 385 (29.8) 177 (14.8) ⬍0.001
Triglycerides 0.09 0.002 0.09 0.002
Total cholesterol, mg/dl 201.7 ⫾ 41 197.3 ⫾ 34.8 0.004

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Systolic BP 0.06 0.022 ⫺0.02 0.59
HDL cholesterol, mg/dl 57.7 ⫾ 18.3 51.9 ⫾ 15.3 ⬍0.001
Heart rate 0.07 0.015 0.07 0.025
Triglycerides, mg/dl 101.5 (77.5–142) 135 (97–192) ⬍0.001
Metabolic score 0.16 ⬍0.001 0.14 ⬍0.001
Hypertension 1034 (80) 875 (73) ⬍0.001
Physical activity score ⫺0.10 ⬍0.001 ⫺0.07 0.018
Systolic BP, mm Hg 138.6 ⫾ 20.9 131.1 ⫾ 17.1 ⬍0.001
Education ⫺0.06 0.002 ⫺0.004 0.89
Diastolic BP, mm Hg 79 ⫾ 10.8 73.8 ⫾ 9.3 ⬍0.001
Alcohol intake 0.02 0.45 ⫺0.005 0.074
Heart rate 67 ⫾ 11.6 65.4 ⫾ 10.9 ⬍0.001
Serum creatinine, mg/dl 0.9 ⫾ 0.3 0.9 ⫾ 0.2 ⬍0.001 a
n ⫽ 1070 in the African-Americans and 1142 in the non-Hispanic whites,
Physical activity score 9.8 ⫾ 3.4 13.3 ⫾ 5.2 0.67 respectively, for both HOMA-IR and insulin correlations.
Smoking, n (%) 525 (40.6) 584 (48.8) 0.17
Education, yr in school 12.1 ⫾ 3.6 13.4 ⫾ 2.3 ⬍0.001
ratios (OR) of having metabolic syndrome, OR 1.49 (P ⫽ 0.010)
Alcohol intake, oz/month 1.5 ⫾ 5.5 5.6 ⫾ 10.5 ⬍0.001
Previous history of MI or 152 (11.8) 129 (10.8) 0.24 and 2.18 (P ⬍ 0.001), respectively. This association remained
stroke significant after additional adjustment for serum creatinine, sta-
Statin use, n (%) 242 (18.7) 346 (28.9) ⬍0.001 tin use, past history of myocardial infarction/stroke, lifestyle
Aspirin, n (%) 430 (33.3) 490 (40.9) ⬍0.001 variables (history of smoking, educational status, and physical
Diuretic use, n (%) 605 (47) 452 (35) ⬍0.001
activity score), and diuretic use, with ORs of 1.49 (P ⫽ 0.017)
␤-Blockers, n (%) 221 (17) 393 (33) ⬍0.001
RAAS blockers, n (%) 517 (40) 422 (35) ⬍0.001 and 2.07 (P ⬍ 0.001) for the third and fourth copeptin quartile,
Ca-channel blockers, 371 (29) 178 (15) ⬍0.001 respectively (Table 3). In the subset of participants without di-
n (%) abetes (n ⫽ 908), having a plasma copeptin level in the fourth
Copeptin (pmol/liter) 8.0 (5.0 –12.7) 5.0 (3.3–7.9) ⬍0.001 quartile was significantly associated with the presence of meta-
Continuous variables are presented as means ⫾ SD or median and interquartile bolic syndrome (OR 1.54; P ⫽ 0.036) after adjustment for age
range, whereas categorical variables are presented as counts and percentages. and sex. This association was weakened after adjustment for
MI, Myocardial infarction; RAAS, renin-angiotensin-aldosterone system; Ca-
channel, calcium channel. additional covariates (OR 1.42; P ⫽ 0.10).
a
P values for variables age and men are unadjusted. All other variables are In non-Hispanic whites, mean copeptin levels in participants
adjusted for age and sex. without and with metabolic syndrome were 6.13 and 8.27 pmol/
liter, respectively P ⬍ 0.001. After adjustment for age and sex,
ethnic groups (Table 1). In the African-Americans (n ⫽ 1293), plasma copeptin positively correlated (P ⬍ 0.05) with BMI, waist
652 (50%) subjects met the criteria for metabolic syndrome, circumference, fasting serum glucose and insulin levels, HOMA-IR,
whereas 584 (49%) subjects met this criteria in the non-Hispanic presence of diabetes, and serum triglycerides and inversely cor-
whites (n ⫽ 1197). related with HDL cholesterol and physical activity score (Table
In African-Americans, mean copeptin levels in participants 2). After additional adjustment for BMI, plasma copeptin re-
without and with metabolic syndrome were 9.48 and 11.51 mained positively correlated (P ⬍ 0.05) with waist circumfer-
pmol/liter, respectively P ⬍ 0.001. After adjustment for age and ence, fasting plasma glucose and insulin levels, and HOMA-IR
sex, plasma copeptin positively correlated (P ⬍ 0.05) with BMI, (analyses not shown). Plasma copeptin levels increased with
waist circumference, fasting plasma glucose and insulin level, increasing number of metabolic syndrome components (P ⬍
HOMA-IR, presence of diabetes, and serum triglycerides and 0.001, Fig. 1B). In multivariable logistic regression analyses that
inversely correlated with HDL cholesterol and physical activity adjusted for age and sex, plasma copeptin levels in the third and
score (Table 2). After additional adjustment for BMI, plasma fourth quartile were significantly associated with a higher odds
copeptin remained positively correlated (P ⬍ 0.05) with waist of having metabolic syndrome: OR of 1.81 (P ⬍ 0.001) and 1.91
circumference, fasting plasma glucose and insulin level, HOMA- (P ⬍ 0.001), respectively. This association remained significant
IR, presence of diabetes, systolic BP, and serum triglycerides after additional adjustment for age, sex, serum creatinine, statin
(analyses not shown). Plasma copeptin levels increased with in- and aspirin use, past history of myocardial infarction/stroke,
creasing number of metabolic syndrome components (P ⬍ lifestyle variables (history of smoking, educational status, and
0.001; Fig. 1A). In multivariable logistic regression analyses that physical activity score), and diuretic use, with an OR of 1.79 (P ⬍
adjusted for age and sex, plasma copeptin levels in the third and 0.001) and 1.74 (P ⫽ 0.003) for the third and fourth copeptin
fourth quartile were significantly associated with higher odds quartile, respectively (Table 3). In the subset of participants with-
J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564 jcem.endojournals.org 2561

glucose and insulin, and HOMA-IR) and the

presence of metabolic syndrome. Partici-
pants with metabolic syndrome had higher
mean copeptin levels than those without
metabolic syndrome and participants in the
third or fourth quartiles for plasma copeptin
had 70 –100% higher odds of metabolic
syndrome compared with those in the bot-
tom quartile (Table 3). In addition, plasma
copeptin levels were higher in participants
who had greater clustering of metabolic syn-
drome components (Fig. 1, A and B). These
associations were independent of adiposity,

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FIG. 1. Association of plasma copeptin levels with the number of metabolic syndrome components in
African-Americans (A) and non-Hispanic whites (B), respectively.
out diabetes (n ⫽ 1021), having a plasma copeptin level in the
third or fourth quartile was significantly associated with the
presence of metabolic syndrome (OR 1.83, P ⬍ 0.001; OR 1.82,
P ⫽ 0.001, respectively) after adjustment for age and sex. This
association remained significant after adjustment for additional
covariates (OR 1.84, P ⫽ 0.001; OR 1.70, P ⫽ 0.007, for the
third and fourth copeptin quartiles, respectively).
Discussion
The present study, to the best of our knowledge, is the first to
report that plasma copeptin, a surrogate for plasma AVP release,
is associated with measures of insulin resistance (fasting plasma
highlighting AVP as a novel marker of in-
sulin resistance and metabolic syndrome.
The relatively high prevalence of metabolic
syndrome in both groups (⬃50%) in this
study is consistent with the high prevalence
of hypertension and the older age of study
participants (1, 2).
AVP is a vasoactive neurohypophysial
hormone that plays a central role in the regulation of water and
electrolyte balance, its release stimulated by a change in plasma
tonicity, hypovolemia, or low blood pressure (19). Several ex-
perimental studies have shown that under chronic psychosocial
stress states, AVP becomes a key amplifier of ACTH release from
the anterior pituitary in concert with CRH (9, 10, 20). Also, AVP
levels more closely correlate with ACTH levels than do CRH
levels in these chronic stress studies, suggesting a more dynamic
role for AVP in activity of the stress axis and a primarily per-
missive function for CRH (9, 10).
We speculate that the activation of HPA axis by AVP (copep-
tin) in chronic psychosocial stress may be one of the mediators of
its association with insulin resistance/metabolic syndrome. Mul-
tiple endocrine perturbations that favor insulin resistance ensue

TABLE 3. Association of plasma copeptin with the presence of metabolic syndrome: logistic regression analyses

OR (95% CI)
P value
First quartile Second quartile Third quartile Fourth quartile
African-Americans
Copeptin, pmol/liter ⬍5.0 5.0 – 8.0 8.0 –12.7 ⬎12.7
Unadjusted 1 1.35 (1.01–1.81) 1.36 (1.01–1.83) 2.04 (1.48 –2.81)
0.045 0.042 ⬍0.001
Age and sex adjusted 1 1.40 (1.04 –1.89) 1.49 (1.10 –2.02) 2.18 (1.56 –3.06)
0.025 ⬍0.001 ⬍0.001
Fully adjusted 1 1.42 (1.05–1.93) 1.49 (1.07–2.06) 2.07 (1.45–2.95)
0.024 0.017 ⬍0.001
Non-Hispanic whites
Copeptin, pmol/liter ⬍3.32 3.32–5.0 5.0 –7.91 ⬎7.91
Unadjusted 1 1.17 (0.84 –1.62) 1.82 (1.33–2.48) 2.0 (1.41–2.71)
0.36 ⬍0.001 ⬍0.001
Age and sex adjusted 1 1.16 (0.84 –1.62) 1.81 (1.32–2.49) 1.91 (1.36 –2.66)
0.38 ⬍0.001 ⬍0.001
Fully adjusted 1 1.12 (0.79 –1.59) 1.79 (1.27–2.51) 1.74 (1.21–2.5)
0.52 ⬍0.001 0.003
The fully adjusted model includes age, sex, serum creatinine, history of ever smoking, statin use, past history of myocardial infarction/stroke, physical activity,
educational status, and diuretic use. CI, Confidence interval.
2562 Saleem et al. Copeptin and Metabolic Syndrome
(summarized in Fig. 2) including a decrease in thyroid and GH,
reduction in testosterone and estrogen level (21), and an increase
in cortisol levels (9, 10, 20). AVP is also known to directly stim-
ulate cortisol release in both cows and humans by activating the
V1a receptors on the adrenal cortex cells (22). Cortisol impedes
the action of insulin to promote glucose uptake in cells and stim-
ulates glucagon secretion and glycogenolysis (23), which results
in higher plasma glucose levels. It also induces stress-related ex-
cessive feeding behavior (24). Furthermore, plasma cortisol de-
ficiency leads to elevated plasma AVP, suggesting that glucocor-
ticoids may be feedback inhibitors of AVP secretion (25). AVP
activates the V1b receptors on the chromaffin cells in the adrenal
medulla to increase epinephrine levels, which may subsequently
contribute to hyperglycemia by stimulating glycogenolysis in
liver (26, 27).
AVP directly induces hepatic glycogenolysis (26, 28), glucog-
enolysis (28), and gluconeogenesis in perfused rat liver via acti-
vation of V1a receptors in hepatocytes (28). AVP activates V1b
receptors on the ␣-cells of the pancreatic islets to increases the
secretion of glucagon (23, 26, 29) and potentiates insulin release
from the ␤-cells of the pancreatic islets, in the presence of glucose,
by activation of the phosphoinositide receptor pathway (23, 29,
30). In diabetic rats, AVP had a greater impact on glucagon
secretion than insulin secretion (23). Infusion of AVP in both
mice and humans results in higher plasma glucose levels (31). The
combined effect of these perturbations may lead to insulin re-
sistance as manifested by higher fasting glucose and insulin levels
and greater HOMA-IR. Diabetes is known to be associated with
higher AVP levels (32); therefore, we repeated the analyses in the
subset of participants without diabetics. Inferences remained
similar, although in African-Americans the association was of
borderline significance.
FIG. 2. Mechanisms by which AVP may lead to insulin resistance and metabolic
syndrome.
J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564
In addition to measures of insulin resistance, we found plasma
copeptin to be independently associated with several compo-
nents of metabolic syndrome including adiposity (higher waist
circumference and BMI) and dyslipidemia (lower HDL choles-
terol and higher triglyceride levels) (Table 2). In multivariable
logistic regression analyses that adjusted for age, sex, serum cre-
atinine, history of myocardial infarction and stroke, and con-
ventional cardiovascular risk factors (including diabetes and hy-
pertension), higher plasma copeptin was independently associated
with measures of adiposity including BMI and waist circumfer-
ence (P ⬍ 0.001 for both BMI and waist circumference for both
ethnic groups (analyses not shown). In a retrospective study of 52
patients with tumors involving the hypothalamic region, 52%
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patients were found to be obese after a median of 5 yr of follow-
up. Use of Desmopressin (a vasopressin analog) was associated
with the highest odds (OR 13) of weight gain and obesity after
diagnosis (33). The association of plasma copeptin with obesity
may be due to AVP’s role in increasing cortisol levels, which then
may lead to weight gain by increasing appetite, altering body fat
distribution, and increasing truncal adiposity (24).
Plasma copeptin was significantly associated with higher tri-
glyceride levels and lower HDL cholesterol levels (Table 2). In-
traperitoneal injection of AVP in goats resulted in an increase in
plasma triglyceride levels (34). The association of copeptin with
higher triglyceride levels may be secondary to increased hepatic
synthesis of triglycerides under the influence of glucocorticoids,
glucagon, and epinephrine released under stress, all of which are
up-regulated by AVP (34) (Fig. 2). Plasma copeptin levels were
found to be inversely associated with physical activity (Table 2).
Aerobic fitness has been associated with a lower HPA axis response
to psychological stress, suggesting that aerobic physical activity may
blunt the activation of the HPA axis due to stress (35).
Increased levels of other vasoactive peptides have been asso-
ciated with features of metabolic syndrome. For example, higher
levels of epinephrine and norepinephrine, reflective of increased
sympathetic nervous system activity, are associated with meta-
bolic syndrome (3). In contrast, lower levels of brain natriuretic
peptide, a vasodilator hormone, have been found to be associ-
ated with several traits of metabolic syndrome (4). Thus, an
imbalance between vasoconstrictor, antidiuretic hormones, and
vasodilator natriuretic peptides may contribute to the patho-
physiology of metabolic syndrome.
Study strengths and limitations
Strengths of the present study include the use of uniform pro-
tocols in the two ethnic groups including questionnaires, anthro-
pometric measurements, availability of conventional clinical co-
variates, and the novel copeptin assay. Hitherto, assessing the
role of AVP in various pathophysiologic states has been difficult
because of its instability in isolated plasma; binding to platelets,
which leads to interference in its measurement; rapid clearance
from plasma given short half-life of 24 min; and the need for
12–24 h of incubation in conventional assays; all of above factors
lead to difficulty in precise measurement of AVP. In contrast,
copeptin is a sandwich immunoassay with high sensitivity (an-
alytical detection limit of 1.7 pmol/liter) and good precision (in-
terlaboratory CV ⬍ 20%) (17). Copeptin levels show identical
J Clin Endocrinol Metab, July 2009, 94(7):2558 –2564
changes under disordered water states as previously shown for
AVP, with higher values in fasting states or with infusion of
hypertonic saline and a rapid decline in vivo during hypotonic
saline infusion (36). The assay can detect plasma copeptin in
97% of the healthy population regardless of osmolality, whereas
AVP is often not detectable in plasma samples with medium or
low osmolality (17). Copeptin has emerged as a validated surrogate
for AVP in numerous recently published studies (17, 36, 37).
Several limitations of our study need to be mentioned. The
study is cross-sectional and therefore precludes direct inferences
concerning causality or a temporal relationship between higher
copeptin, measures of insulin resistance, and metabolic syn-
drome, even though studies of social stress in nonhuman pri-
mates (38) and mice (39) have established that increased activity
of HPA axis precedes by several months to several years the
development of metabolic syndrome (38, 39). We did not mea-
sure psychosocial stress in the participants or plasma levels of
cortisol, the final mediator of a perturbed HPA axis. We calcu-
lated HOMA-IR as a measure of insulin resistance, and although
not the gold standard, it has been validated as a reliable and
clinically useful index of insulin sensitivity in type 2 diabetic
patients (40). Diuretic use may lead to volume depletion and a
compensatory rise in copeptin levels. Participants on diuretics
had higher plasma copeptin levels than those not on diuretics
(analyses not shown). We repeated the multivariable analyses
relating copeptin to metabolic syndrome, stratified by diuretic
use. Inferences remained similar in these stratified analyses, al-
though the use of diuretics was associated with higher mean
copeptin levels (analyses not shown). Measures of plasma tonic-
ity were not available, and we were therefore unable to adjust for
any possible influence of plasma tonicity on AVP levels. How-
ever, our study included ambulatory participants who were not
acutely ill and thus unlikely to be volume depleted or hyper-
natremic. Finally, the study was conducted in a predominantly
hypertensive cohort and the generalizability of our findings to
normotensive adults needs to be established.
Conclusions
In summary, higher copeptin levels, a surrogate for AVP re-
lease, are associated with measures of insulin resistance (higher
fasting plasma glucose and insulin, and greater HOMA-IR), ad-
iposity (BMI and waist circumference), and metabolic syndrome,
independent of potential confounders. Higher plasma copeptin
levels may lead to a perturbed HPA axis in individuals exposed
to chronic psychosocial stress. Such neuroendocrine dysregula-
tion may lead to higher cortisol, decreased energy expenditure,
increased appetite and food consumption, increased peripheral
vascular resistance, and increased insulin levels. In turn this
could lead to visceral obesity, insulin resistance, dyslipidemia,
and hypertension and the development of metabolic syndrome.
Copeptin may be a novel marker of insulin resistance, and further
work is needed to assess its utility as a predictor of incident
diabetes mellitus and metabolic syndrome. Our findings suggest
a novel pathophysiological mechanism underlying insulin resis-
tance and metabolic syndrome.
jcem.endojournals.org 2563
Acknowledgments
Address all correspondence and requests for reprints to: Iftikhar J. Kullo,
M.D., Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street
S.W., Rochester, Minnesota 55905. E-mail: kullo.iftikhar@mayo.edu.
This work was supported by Grant HL-81331 from the National
Institutes of Health.
Disclosure Summary: A.B. holds ownership in BRAHMS AG, owns
patent rights to the markers of the study, and is a member of the board
of directors of BRAHMS AG. J.S. holds patent rights to the markers and
is an employee of BRAHMS AG. N.G.M. is an employee of BRAHMS
AG, a midsized company based in Hennigsdorf, Germany, that com-
mercializes immunoassays and has developed the copeptin assay, for
which it owns patent rights. The present study was not financed by
BRAHMS AG. The remaining authors report no conflict of interest.
Downloaded from https://academic.oup.com/jcem/article/94/7/2558/2597252 by guest on 26 April 2021
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