ROMANIAN JOURNAL

OF
INTERNAL MEDICINE
Volume 46 No. 4, 2008

CONTENTS

REVIEWS

H. BĂLAN, Chronotherapy of Hypertension: When Can Be As Important As With What ........................................................ 269
ADINA STOICA, CARMEN GINGHINĂ, Cardiovascular Risk in Patients with Peripheral Vascular Diseases ...................... 275
ADRIANA GABRIELA FILIP, SIMONA CLICHICI, DOINA DAICOVICIU, DIANA OLTEANU, ADRIANA
MUREŞAN, SIMINA DREVE, Photodynamic Therapy – Indications and Limits in Malignant Tumors Treatment ...... 285
NICOLETA MITROI, MARIA MOŢA, Nutrigenomics/Nutrigenetics ...................................................................................... 295

ORIGINAL ARTICLES

RALUCA MIHĂILESCU, VICTORIA ARAMĂ, SIMONA PARASCHIV, A. STREINU-CERCEL, D. OŢELEA,

DANIELA MUNTEANU, MIHAELA IOSIPENCO, CARMEN CHIOTAN, OTILIA ELISABETA BENEA,
MARIANA MĂRDĂRESCU, MIHAELA RĂDULESCU, ADRIANA HRISTEA, RODICA UNGURIANU, S.S. ARAMĂ,
ANCA STREINU CERCEL, RUXANDRA CĂLIN, C. BĂICUŞ, Impact of Highly Active Antiretroviral Therapy on
Cytomegalovirus Viraemia in the Absence of Specific Anti-Cytomegalovirus Therapy ................................................. 305
LUCIA AGOŞTON-COLDEA, TEODORA MOCAN, C. BOBAR, Arterial Stiffness and Left Ventricular Diastolic Function
in the Patients with Hypertension ..................................................................................................................................... 313
TEODORA MOCAN, LUCIA AGOŞTON-COLDEA, L.D. RUSU, RALUCA PAIS, M. GATFOSSE, L.C. MOCAN,
M.L. RUSU, The Correlation Between Alcohol Consumption, Lipids, Apolipoproteins and Coronary Heart Disease ... 323
BRÎNDUŞA DIACONU, TEODORA MOCAN, LIDIA CIOBANU, Risk Factors in Patients with Chronic Pancreatitis in Romania 331
INIMIOARA MIHAELA COJOCARU, M. COJOCARU, R. TĂNĂSESCU, CECILIA BURCIN, ANDREEA CRISTINA
MITU, IULIANA ILIESCU, LAURA DUMITRESCU, ISABELA PAVEL, ISABELA SILOSI, Detecting Anti-
Prothrombin Antibodies in Young Women with Acute Ischemic Stroke ......................................................................... 337
ALEXANDRINA L. DUMITRESCU, L. ZETU, SILVIA TESLARU, BEATRICE C. DOGARU, C.D. DOGARU, Is It An
Association Betwen Body Appreciation, Self-Criticism, Oral Health Status and Oral Health-Related Behaviors? ......... 343

CASE REPORTS

CAMELIA IONESCU, MONICA ECOBICI, DANA OLARU, C. STĂNESCU, IOANA LUPESCU, M. VOICULESCU,
Pneumoperitoneum – Rare Complication in End Stage Renal Disease Patient on Automated Peritoneal Dialysis .......... 351
LAURA POANTĂ, D.L. DUMITRAŞCU, DANIELA FODOR, ADRIANA ALBU, Atrial Septal Aneurysm and Stroke –
A Report of Two Cases .................................................................................................................................................... 357
RALUCA TRIFĂNESCU, CĂTĂLINA POIANĂ, D. HORTOPAN, Autoimmune Thyroid Disease – A Continuous Spectrum 361
GH. BURNEI, ANCA BURNEI, D. HODOROGEA, ŞT. GAVRILIU, ILEANA GEORGESCU, C. VLAD, LUCIA HURMUZ,
DANA DAN, Renoureteral Diseases Inducing Hypertension in Children ....................................................................... 367
SABINA ZURAC, R. ANDREI, G. PETSAKOS, LUCIANA NICHITA, ALEXANDRA BASTIAN, GIANINA MICU,
ELIZA GRAMADĂ, CRISTIANA POPP, FLORICA STĂNICEANU, ŞTEFANA PETRESCU, GABRIELA
NEGROIU, DORINA GIURCĂNEANU, VIRGINIA CHIŢU, Cutaneous Metastases of Malignant Melanoma – How
Difficult Can It Be? .......................................................................................................................................................... 375

ROM. J. INTERN. MED., 2008, 46, 4, 267–378

268
 REVIEWS

Chronotherapy of Hypertension: When Can Be As Important As With What

H.ăB LANă
“CarolăDavila”ăUniversityăofăMedicineăandăPharmacyă
IIndăMedicalăClinic,ăClinicalăEmergencyăHospitalăIlfovăCounty,ăBucharest,ăRomaniaă

Theă“manometric”ăwayăofăconsideringătheăgeneralămanagementăofăhighăbloodăpressureă(HBP)ă
mustă remaină ancientă history.ă Theă hugeă therapeuticală armamentariumă (overă 75ă preparations,ă ină 9ă
differentă classes)ă existingă nowadaysă allowsă usă toă selectă theă drugsă mostă appropriateă foră theă
comorbiditiesăofăeachăcase.ăTheăBPălevelătarget,ăunanimouslyăconsideredăaăveryăimportantăelementăofă
HBPămanagement,ămustănotăbeătheăonlyăone.ăAnăimportantăandăveryăpromisingăpossibilityătoăimproveă
theă therapeuticală efficacyă ofă theă antihypertensiveă treatmentă isă chronotherapy.ă Byă usingă ambulatoryă
bloodăpressureămonitoringă(ABPM)ăităisănowăpossibleătoă“refine”,ătoăbetteră“tailor”ătheămanagementă
ofăhypertension.ăăă
Key words:ăchronotherapy,ăhypertension,ăcircadianărhythms.ă

Weă areă livingă ină aă universeă ină whichă determinantsăofămorbidityăandămortality.ăTheyămayă

rhythmicityăisăoneăofătheămainăcharacteristics.ăTheă
temporalăvariationsăofătheăcardiovascularăfunctionsă
haveă beenă remarkedă sinceă theă IIndă centuryă afteră
ChristăbyăGalenă(quotedăbyă1).ăManyăstudies,ăinătheă
pastă thirtyă years,ă haveă confirmedă theiră existence,ă
revealingă thată theă maximală BPă valuesă areă
encounteredă ină theă morningă (betweenă 6.00ă andă
10.00ă a.m.),ă aă secondă peakă beingă notedă betweenă
4.00ăandă7.00ăp.m.);ăbetweenă03.00–04.00ăa.m.ăareă
encounteredătheăminimalăvalues.ăItăisănowăgenerallyă
acceptedă thată bloodă pressureă (BP)ă representsă aă
phenomenonă withă aă temporală rhythmicală variability.ă
Theă variabilityă ofă BPă duringă aă singleă dayă isă huge:ă
overă100.000ăfluctuationsă[1].ă
Theă diagnostică andă theă therapeuticală decisionsă
ină hypertensionă areă still,ă toă aă greată extent,ă basedăă
onă theă so-calledă casual/office/clinicală BPă values:ă
theă valueă ată aă certaină casuală moment,ă usuallyă inăă
theă morning,ă afteră 10.00ă o’clock,ă determinedă ină
medicalăsettings.ă
Maybe the most appropriate comparison
of the reality and the reliability of a conclusion
based on a single measurement at a single
moment that can be completely undefinitory for
the subject condition, is with a movie chronicle,
based on a single frame.
The human body is not only organized in
space, anatomically, but it is also organized in
time, in terms of biological rhythms.ă Circadiană
rhythms,ă andă theiră alterationă couldă beă importantă
alsoăbeăveryăimportantăinădeterminingătheăresponsesă
toăantihypertensiveămedicationsă[2].ă
Theă primaryă goală ofă treatmentă ofă aă hyper-
tensiveă patientă isă toă achieveă theă maximumă
reductionă ină long-termă totală riskă ofă cardiovasculară
morbidityăandămortalityă[3–6].ă
Butătheăcasuală(clinical)ăBPăvaluesăhaveămanyă
limitations:ă systematicală overestimatesă (ină ată leastă
1/3ă ofă theă patients)ă =ă “whiteă coată hypertension”ă
(WCH);ă lackă ofă precisionă ină estimatingă theă
hypotensiveăeffectsăofătherapy;ăallătheăreadingsăareă
madeăinăartificialăconditions:ăphysical/psychicărest;ă
offersă noă dataă duringă theă sleepă period.ă Andă alsoă
manyăsourcesăofăerror:ădevice-associated;ăobserver-
associated,ă evenă theă presenceă ofă theă observeră =ă
WCH;ă associatedă withă theă readingă technique;ă
“auscultatoryă gap”ă oră theă “pseudo-hypertensionă ofă
theăelderly”ă(Oslerăphenomenon).ă
TheăbetterăcorrelationăofăHBPăprognosisăwithă
Ambulatoryă Bloodă Pressureă Monitoringă (ABPM)ă
thană withă clinic/office/casuală pressuresă cană beă
attributedă toă aă combinationă ofă twoă facts:ă first,ă theă
effectăofătheăgreaterănumberăofăreadings;ătheăsecondă
factoră isă theă moreă representativeă natureă ofă theă
ambulatoryăreadings.ă
Toăcounteractătheăeffectsă ofă“theămostă activeă
andă efficientă killeră ofă oură times”ă oneă mustă begină
withă the accuracy of the diagnosis, that can be
achieved only by ABPMă[7–14].ăTheămostărecentă
ABPMăwonătheăbattles:ă

ROM.ăJ.ăINTERN.ăMED.,ă2008,ă46,ă4,ă269–274ă
270ă
ă H.ăB lană
♦ Aprilă 2003ă –ă Medicareă &ă Medicaidă decidedă
ABPMăreimbursementăforăWCH.ă
♦ JNCă VIIă (2003):ă “Ină mostă individuals,ă BPă
decreasesăbyă10ătoă20ăpercentăduringătheănight;ă
thoseăinăwhomăsuchăreductionsăareănotăpresentă
areăatăincreasedăriskăforăcardiovascularăevents”.ă
CHOBANIANăet al.ă[3]:ă“Theănormalisationăofă
theăcircadianăBPăpatternătoăaădipperăprofileăisăaă
novelătherapeuticăgoal,ăandăaccumulatingămedicală
evidenceă suggestsă thisă cană delayă theă pro-
gressionă towardsă theă renală andă cardiovasculară
pathologyă knownă toă beă aă consequenceă ofă theă
non-dipperăBPăpattern.”ă
GeneralăsituationsăwhereăABPMăisăextremelyă
helpful:ă1)ăhypertensionăinătheăelderlyă(WCH,ăsystolică
hypertension,ă pseudo-hypertension,ă hypotension,ă
orthostatic/postprandială hypotension,ă diurnal/ă nocturnală
hypotension,ădrugăinducedăhypotension);ă2)ăautonomică
dysfunction;ă 3)ă pulselessă syndrome;ă 4)ă arrhythmias;ă
5)ă obeseă patients;ă 6)ă maskedă hypertension. N.B.
Actigraphs or a diary concerning the type of
activity, the sleeping/awakening hour, the moment
of drug administration are mandatory as are also
the AAMI (2002), BHS (1993), European Society
of Hypertension Working Group on Blood
Pressure Monitoring – International Protocol
device validation.
For all these reasons, ABPM is now
considered the golden standard in: diagnostic,
management, epidemiology, research, decisions
concerning hypertension. The next generation of
guides will be evidence based, not consensus based. ă
ArgumentsăinăfavourăofăABPM:ăoffersăsimilară
dataă toă intra-arterială readingsă (theă “golden
standard”);ă hasă aă goodă reproducibility;ă offersă aă
clearlyăsuperiorăcorrelationăwithătheăcardio-vasculară
morbidity/mortalityă andă withă theă echocardiographic,ă
eyeă fundică examination,ă renală functionă evaluation;ă
inăpopulationalăstudiesăităoffersămuchămoreăpreciseă
pressure/riskăcurves;ăhighlightsătheărealăimportanceă
ofă theă minoră increasesă ofă BP;ă allowsă toă avoidă
differentă kindă ofă “artifacts”:ă WCH;ă “pseudo-
hypertension”ă ofă theă elderlyă (OSLERă effect);ă
placeboă effect;ă maskedă hypertension;ă cană haveă aă
goodăcost/efficiencyăratioăifăweăconsiderătheăeconomyă
generatedă byă avoidingă unnecessaryă therapyă +ă hisă
side-effects,ă allows to highlight the evolution of
BP values in critical moments: the morning
surge; the BP values during sleep.ăă
Thereă areă someă specială situationsă thată haveă
imposedăABPM:ă1.ătoădetermineăepisodic,ăborderlineă
ă
2ăă
oră uncontrolledă HBPă andă orthostatică hypotension;ă
2.ătoăestablishătheăseverityăofăHBP,ăinărelationăwithă
TOD;ă3.ătoădetermineătheăefficacyăofătheăprescribedă
medication,ă regardingă theădosesă andă theă frequencyă
ofă theiră administration;ă 4.ă toă establishă theă effectsăă
ofătheăinteractionăofăseveralădrugs;ă5.ătoăcertifyătheă
diagnosisăofăHBP.ăăă
Theătimingăofăcircadiană(duringă24ăhours)ăBPă
peaksăandătroughsăisăquiteăpredictableăfromăoneădayă
toă anotheră ină mostă peopleă whoă adhereă toă aă fairlyă
regulară sleep-activityă schedule.ă Clearly,ă theseă dataă
areă compellingă thată humană biochemistryă andă
physiologyă areă notă constant;ă theyă ratheră varyă ină aă
predictableămannerăduringătheă24-hourătimeăperiod.ăă
Ită seemsă plausibleă thată timingă ofă certaină
medicală conditionsă andă life-threateningă emergenciesă
mayă parallelă theseă physiochemicală circadiană
variations.ă Thereă isă ană “evilă crossing”ă ofă manyă
unfavorableăeventsăearlyăinătheămorning:ă
Hemodynamic factors:ă BPă andă heartă rate,ă
strokeă volumeă andă cardiacă output,ă totală peripherală
resistance,ăvascularătone,ăplasmaăvolume,ăpulmonaryă
arterială pressure,ă plateletă agregability,ă bloodă
coagulability,ă bloodă viscosity,ă serumă cholesterolă areă
increased;ăcoronaryăbloodăflow,ăforearmăbloodăflow,ă
renalăflow,ăglomerularăfiltrationărate,ăurinaryăflow,ă
fibrinolysisăareădecreased.ă
Neuro-hormonal factors:ă autonomousă tone,ă
plasmaticăconcentrationsăof:ănorepinephrine,ăepine-
phrine,ă tyrosine,ă dopamine,ă prorenine,ă renine,ă
angiotensinăI,ăaldosterone,ăACTH,ăcortisol,ăendogenousă
opioidsăhaveă increased values;ăserotonine,ă natriuretică
peptideă system,ă Naă excretion,ă Kă excretionă haveă
decreased values.ă
Ină theă firstă morningă hoursă the physical and
mental activity is increased,ă soă thată theă “sheară
stress”ă ofă vasculară atheromaă isă alsoă increased,ă ofă
sufficientămagnitudeătoăcauseăinitialădisruptionăofăaă
stableăatheroscleroticăplaque.ăă
Theă termă “dippers”describesă thoseă patientsă
whoseă nocturnală pressureă isă ată leastă 10%ă toă 20%ă
loweră thană theiră daytimeă pressure.ă “Extremeă
dippers”ă haveă aă nocturnală pressureă thată isă >ă 20%ă
loweră thană theiră daytimeă pressure.ă Ină 10%ă toă 30%ă
ofă hypertensiveă patients,ă however,ă thisă characteristică
patternă mayă beă absentă oră blunted.ă Theseă patientsă
areă knownă asă “nondippers”.ă Thisă subgroupă ofă
hypertensivesăareăatătheăgreatestăriskăforăTODă(e.g.,ă
LVH,ă cerebrovasculară disease,ă microalbuminuria,ă
congestiveă heartă failure,ă vasculară dementia,ă
myocardială infarction,ă renală damage,ă glucoseă
3ă Chronotherapyăofăhypertensionă
intolerance,ă plasmatică fibrinogenă increase,ă “pro-
coagulant”ă trendă ină theă morning).ă Foră theă extremeă
dippers,ătheăriskăforăTODăisăalsoăhighă(althoughănotă
asăhighăasăwithănondippers)ă[5][7–16].ăă
The chronotherapy of hypertension takes
into account the epidemiology of the BP pattern,
plus potential administration-time determinants
of the pharmacokinetics and dynamics of
antihypertensive medications, as a means of
enhancing beneficial outcomes and/or attenuating
or averting adverse effects. Chronotherapy
provides a means of individualizing treatment of
hypertension according to the circadian BP profile
of each patient, and constitutes a new option to
optimize BP control and reduce risk.
Theă developmentă ofă newă formulationsă ofă
antihypertensiveă drugs,ă fromă short-actingă toă long-
actingă toă once-dailyă products,ă hasă raisedă theă
possibilityăofăcontrollingătheăreleaseăofătheseădrugsă
andă timingă ită foră whenă ită isă mostă effective.ă Manyă
existingă antihypertensiveă drugsă accomplishă thisă
goală foră hypertensiveă “dippers”.ă Treatmentă shouldă
alsoă beă directedă towardă convertingă hypertensiveă
non-dippersăintoănormotensiveădippers.ă
Someă ofă theă issuesă couldă beă bestă addressedă
byă administeringă antihypertensiveă drugsă basedă onă
theă principleă ofă releasingă theiră activeă agentsă ată
differentă timesă duringă theă day,ă accordingă toă
biologicalăneeds,ăwhichăisătheăbasisăforăchronotherapy.ă
TheăidealăagentăshouldăproduceăaăfallăinăBPăonlyăduringă
theăperiodăthatăităisăabnormallyăelevatedă(sleepăină“non-
dippers”)ăandăhaveălittleăorănoăeffectăduringătheădaytimeă
whenăităisănormalăorăcloseătoănormal.ă
Evidenceă foră theă cardiovasculară benefitsă ofă
antihypertensiveă treatmentă isă amongă theă strongestă
inămedicine.ăEvenăsmallăreductionsăinăBPăforăshortă
periodsă substantiallyă improveă cardiovasculară
outcomes.ă Moreă recentă evidenceă hasă emphasizedă
theă importanceă ofă optimală bloodă pressureă control,ă
particularlyă onă patientsă withă highă cardiovasculară
risk;ă theă resultsă areă stillă unsatisfactory:ă 62%ă ofă
cerebrovascularăandă49%ăofăischemicăheartădiseaseă
canăbeăattributedătoăsuboptimalăBPătreatment.ă
Aă 2002ă pollă ofă 200ă primaryă careă physiciansă
treatingăhypertensiveăpatientsăfoundăthatăwhileă90%ă
ofă themă knewă thată circadiană factorsă couldă boostă
patients’ă riskă ofă strokeă oră heartă attackă ată certaină
timesă ofă theă dayă onlyă slightlyă moreă thană halfă
consideredă theă body’să naturală rhythmsă whenă
prescribingă treatmentă foră hypertension.ă Andă whileă
80%ă knewă ofă theă increasedă early-morningă riskă ofă
heartă attackă andă stroke,ă onlyă two-thirdsă toldă theiră
271ă
patientsătoătakeătheirămedicationăinătheămorningăoră
whenătheyăwokeăupă[18].ă
Twenty-four hour blood pressure control
may be necessary to gain complete benefit from
blood pressure-lowering therapy.
Nighttimeăbloodăpressureăisăinăgeneralăaăbetteră
predictoră ofă outcomeă thană daytimeă pressureă ină
hypertensiveă patientsă andă theă night-dayă bloodă
pressureă ratioă predictsă mortality,ă evenă afteră
adjustmentă foră 24-houră bloodă pressureă [5–18].ă Ană
elevatedă BPă duringă theă sleepingă hoursă causesă LVHă
(geneăexpressionăinătheăheartăisădramaticallyădifferentă
duringă theă dayă asă comparedă toă night),ă whereasă aă
normală bloodă pressureă duringă theă sleepingă hoursă
allowsă LVHă reduction.ă LVHă isă aă cardinală
manifestationă ofă TODă ină patientsă withă hypertensionă
andă hasă aă strongă independentă adverseă prognostică
significance.ă Reversingă LVHă isă ană extremelyă
importantăgoalăofăantihypertensiveătherapy.ă
Thată meansă theă risk/benefită ratioă ofă aă
therapeutică interventionă isă notă uniformă acrossă theă
24ă houră cycleă bută occursă ină aă diurnală fashion;ă theă
functională organizationă ofă theă cardiovasculară
systemă showsă specifică timeă courses:ă aă temporală
organizationă isă presentă ină theă clinicală manifestationsă
ofă mostă cardiovasculară diseases;ă theă sensitivityă ofăă
theă cardiovasculară systemă toă bothă pathologicală
mechanismsă andă therapeutică interventionsă isă time-
dependent.ă Normalization of the circadian BP
pattern is considered to be an important clinical
goal of HBP therapyă becauseă ită mayă slowă theă
advanceă ofă renală injuryă andă avertă end-stageă renală
failure.ă
To alleviate/to abolish the morning surge is
mandatory:ătheă“evilăcrossing”ăduringătheămorningă
hoursă generatesă aă clusteringă of:ă silentă myocardială
ischemia,ă anginaăunstableă pectoris,ă acuteămyocardială
infarctionă (AMI),ă coronaryă spasm,ă pulmonaryă
thromboembolism,ăectopicăbeats,ăventricularătachy-
cardia,ă atrială flutteră andă fibrillation,ă paroxysmală
supraventricularătachycardia,ăaorticăaneurismărupture,ă
spontaneousăaorticădissection,strokes.ăAllăofăthemăareă
muchămoreăfrequentăinătheămorningăhours.ă
It’s now possible to use either time-
coordinated schedules of conventional anti-
hypertensive drugs administration (see below)
or products specially conceived for chronotherapy:
Conventional antihypertensive drugs [3][10][17–21]:
♦ Anyă short acting BETA-BLOCKERă shouldă
beăadministeredăinătheămorning;ă
♦ CALCIUM ANTAGONISTS WITH SUS-
TAINED RELEASEă haveă aă significantă residuală
272ă
ă H.ăB lană
effectă evenă afteră 24ă hours:ă AMLODIPINE,ă
ISOPTIN-RR,ă CALAN-SR,ă VERELAN-PM,ă
ISRADIPINE,ă VERAPAMIL-SR.ă Whenă youă
administeră themă ină theă morningă youă cană attenuateă
theămorningăpeak,ăbut,ăbyăvesperalăadministrationăită
isă possibleă toă induceă aă “dipper”ă profile,ă alsoă
attenuatingătheămorningăpeak;ă
♦ Long/intermediate acting ACEI:ăităisăpreferableă
toăadministerăthemăinătheăevening:ăRamiprilă(ină
theă Heartă Outcomeă Preventionă Evaluationă
(HOPE)ă trială theă vesperală administrationă wasă
foundă toă beă significantlyă associatedă withă
decreasedă cardiovasculară morbidity/mortalityă
ină patientsă ată highă riskă foră cardiovasculară
events:ă combinedă cardiovasculară endpointă
(cardiovasculară mortality,ă MI,ă stroke)ă –ă aă
decreaseă ofă 22%ă (pă <ă 0.001);ă cardiovasculară
mortalityă –ă aă decreaseă ofă 26%ă (pă <ă 0.001);ă
strokeă–ăaădecreaseăofă32%ă(pă<ă0.001).ă
Ităisăpreferableătoăuseămorningăadministrationăfor:ă
♦ Quinaprilă (ită isă possibleă toă haveă ană excessiveă
effectăwithăaăvesperalăadministration)ă
♦ Perindoprilă(forăanăeffectălongerăthană24ăhours)ă
♦ DIURETICS:ă Indapamide;ă Xipamideă haveă
bothăsimilarăBPăloweringăeffectsăinămorningăoră
eveningăadministrationă
♦ α-BLOCKERS:ă DOXAZOSINă –ă determineă
theă higestă BPă reductionă whenă isă administeredă
inătheămorning.ă
Dippers,ă non-dippersă andă excessiveă dippersă
seemă toă getă someă benefită fromă chronotherapeutică
dosing.”ă [16].ă Bută bothă silentă cerebrovasculară
damageăandăanteriorăischemicăopticăneuropathyăareă
potentială risksă ofă excessivelyă lowă overnightă bloodă
pressure.ăAlso,ăextra-lowănightătimeăbloodăpressureă
dipsă meană ană evenă steeperă earlyă morningă bloodă
pressureă surge.ă Foră theseă patientsă whoă haveă
“excessiveădipping”ăatănight,ătheirăriskăofăexcessiveă
droppingă bloodă pressureă overnightă couldă increase.ă
Chronotherapeutică antihypertensiveă drugs,ă whichă
areă designedă toă haveă theiră peakă effectă afteră theă
overnightă riskă period,ă mayă beă ană optimală
therapeuticăoptionăinăvesperalăadministration.ă
HBP CHRONOTHERAPY MUST BE MODULATED
AND VERIFIED BY ABPM
Drugătoxicity,ădrugăactivityăandădrugăkinetics,ă
chronotoxicology,ă chronopharmaco-dynamicsă andă
chronokineticsă haveă allă biologicală rhythms.ă Allă
ă
4ăă
mentionedă ină theă nextă paragraphă haveă biologicală
rhythms:ă theă gastro-intestinală tract,ă itsă pH,ă theă
digestiveă motility,ă activity/rest,ă posture,ă bloodă
flow,ă tissulară perfusion,ă theă activityă ofă theă hepatică
enzymes,ă theă hepatică bloodă flow,ă theă glomerulară
filtrationă rate,ă urinaryă pH,ă theă absorptionă (oral,ă
parenteral,ă cuteneous,ă transmucosal),ă distributionă
(plasmaă proteină binding,ă tissulară binding,ă volumeă
ofă distribution),ă metabolismă ofă drugsă (ină theă liver,ă
ină otheră tissues),ă eliminationă ofă drugsă (renal,ă
biliary,ă otheră ways).ă Thereă areă manyă sourcesă ofă
variabilityă ină chronopharmacokinetics:ă pharmaco-
logicalăvariabilityădependsăon:ătheăpatientă(elderly,ă
children,ămale/female);ătheăpathologyă(renalăfailure,ă
hepaticăfailure,ăcardiacăfailure,ăimmuno-depression,ă
malnutrition,ăobesity);ătheădrugă(routeăofăadministration,ă
conditionă ofă administration:ă singleă dose,ă repeatedă
doses,ăconstantărateăinfusion).ăă
Despiteă thisă hugeă complexityă ofă internală andă
externalăinfluences,ăchronotherapyăhasăalreadyăwonă
manyă battles:ă morningă administrationă ofă cortico-
steroids;ă asymmetricală administrationă ofă cortico-
steroidsă ină Addisonă disease;ă vesperală administrationă
ofă H2ă receptorsă blockers;ă vesperală administrationă
ofă HMG-CoAă antagonists;ă vesperală administrationă
ofă Theophyllineă retardă preparations;ă asymmetricală
administrationă ofă beta-2ă antagonistsă ină asthma;ă
temporală administrationă ofă melatonină ină sleepă
disturbancesă treatment;ă vesperală administrationă ofă
aspirinăinăpreeclampsia.ă
Chronotherapy is a must: when the pathology-
risk is well-known; when the effect of the drug
can be obtained only by a time-modulated
therapy; when the therapeutic “window” is
small; when the kinetics and/or the drug effects
are time-dependent; when the treatment must
mimic the temporal structure of a function.ă
Maină targetsă ofă hypertensionă treatmentsă
[1][3][9]:ătoăalleviate/abolishătheămorningăpeak;ătoă
induceă aă benefică circadiană profileă (“dipper”);ă toă
increaseătheăactionăperiodă(“missingăpill”);ătoăavoidă
significantăhypotension;ă effectiveă 24-hă BPă control;ă
smoothă antihypertensiveă effectă withă reducedă
variability;ă attenuationă ofă theă earlyă morningă surgeă
ină BP;ă maintenanceă ofă theă normală circadiană patternă
ofă BP;ă effectiveă therapeutică coverageă ină theă faceă ofă
suboptimală compliance;lackă ofă reflexă activationă ofă
theă sympathetică nervousă system;ă toăhaveătheălesseră
andătheămostădiscreteăpossibleăsideăeffects;ălackăofă
unfavorableă metabolică effects;ă toă beă efficientă ină
monotherapy,ă ină singleă administration;ă toă decreaseă
theă locală andă generală vasculară tonus;ă toă maintaină
5ă Chronotherapyăofăhypertensionă 273ă

unchangedă theă cardiacă outpută andă theă locală bloodă HS;ăVERELAN-PM;ăCARDIZEM-LA;ăINNOPRAN-

flow;ă toă allowă theă synergică association,ă withoută
sideă effects,ă withă otheră antihypertensiveă drugs.ăă
Questionsătoăbeăasked:ăcanătheăBPărhythmicityă
beămodifiedăinăsuchăaăwayătoămodifyătheămorbidity/ă
mortality?;ă isă ită possibleă toă personalizeă chrono-
therapy?;ă isă ită worthă individualizingă theă chrono-
therapyă ofăhypertension?;ăwhenăisă ită worthă doingă it?ă
Toă produceă itsă characteristică effectsă aă drugă mustă beă
presentă ină appropriateă concentrationsă ată itsă sitesă ofă
actionăat the right moment [Cmax,ăTmax,ăVd,ăAUC,ă
bioavailability,ăbindingătoăplasmaticăproteins,ăT1/2ă–ă
allăhaveătime-dependentăvariabilityă[9]].
New,ă innovativeă drug-releaseă technologies,ă
allowingă medicationsă thată areă maximallyă effectiveă
atădifferentăpointsăinăoură24-hourăcircadianăcycleătoă
beă usedă accordingă toă theă body'să specifică physio-
logicăneedsăhaveăbeenădevelopped.ăThisănewăeraăofă
therapeuticsăhasăbeenătermedăchronopharmacology
orăchronotherapy.ăă
Drugsă speciallyă conceivedă foră CHRONO-
THERAPY: an efficient 24 hours control, the
highest reductions appearing in the critical
hours of the morning; their action begins after
4 hours; their maximal plasmatic levels are
reached around 10.00 a.m.
N.B.ă Theseă kindă ofă preparationsă mustă beă
swallowedăwholeăandănotăchewed,ăcrushed,ăorăsplit,ă
asă thisă mayă damageă theă drugă deliveryă systemă andă
causeădoseădumping.ăăăă
Chronotherapy of hypertension: special
formulations marketed in the USA:ă COVERA-
XL;ă NIFEDIPINE-GITS;ă PROCARDIA-XL and
conventional extended release medications
dosed at bedtime versus upon awakeningă (FDAă
recommendations).
“Youămayăbeăgettingătheăideaăthatăallăyouăneedă
toădoăisăgiveăpatientsădrugsăonce-a-dayădrugsăatănightă
ratherăthanăearlyăinătheămorningăonătheăgroundsăthată
theyăwillăhaveăaăniceădrugălevelăwhenătheyăwakeăupăină
theă morningă foră theă dangerousă morningă hours,ă bută
thatăisănotănecessarilyătheăcase.Whileăthisăisăappropriateă
foră drugsă designedă specificallyă foră thisă purpose,ă justă
givingăaăconventionalădrugăatănightămayăbringăbloodă
pressureă downă tooă lowă ată nightă andă endă upă havingă
littleăeffectăforătheărestăofătheăday.ăYouăhaveătoăknowă
aboută theă propertiesă ofă theă individuală drugă whenă
givingă ită ină theă morningă oră ină theă evening,ă andă justă
simplyăgivingăallădrugsăinătheăeveningăisănotădesirable.ă
Attempts to oversimplify chronotherapy for
hypertension could have dangerous results.”
[1][4]. Chronotherapy is now possible and
constitutes a new option to optimise BP control
and reduce cardiovascular risks. Significant
administration-time differences in the kinetics
and in the beneficial and adverse effects of
antihypertensive medications are well known.
Theă firstă stepsă haveă beenă made.ă Let’să imagineă theă
followingăones.ă
Don’t forget: “When there’s a will…
there’s a way”.

ă
Abordarea strict manometrică a hipertensiunii arteriale (HTA) trebuie să
devină istorie.
Impresionantul arsenal terapeutic actual (peste 75 produse, în 9 clase diferite)
ne permite să alegem medicamentele cele mai adecvate comorbidităţii pacientului.
Nivelul optim al TA, unanim considerat un element foarte important al abordării
HTA nu trebuie să fie singurul scop. O importantă şi foarte promiţătoare
posibilitate de a ameliora eficacitatea terapeutică a medicamentelor este
cronoterapia. Prin utilizarea monitorizării ambulatorii automate este acum posibil
“a rafina”, “a croi” mai bine abordarea terapeutică.ă

Corresponding author:ăăH.ăB lan,ăAssoc.ăProfessoră

ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă EmergencyăHospitalăIlfovăCountyă
ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă 49–51,ăBlvd.Basarabiei,ăBucharest,ăRomaniaă
ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă E-mail:ăbalanhoria@yahoo.comă

REFERENCES

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5. COHUETă G.,ă STRUIJEKER-BOUDIERă H.,ă Mechanisms of target organ damage caused by hypertension; therapeutic
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implications for drug therapy.ăCurr.ăPharm.ăDes.,ă2006;ă12 (13):ă1581–92.ă
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cohort study.ăLancet,ă2007;ă370:1219–1229.ă
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cardiac and cerebrovascular complications in hypertension.ăAm.ăJ.ăHypertens.,ă2007,ăFeb.;ă20ă(2):ă154–61.ă
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relevant? BloodăPressăMonit.,ă2008,ă13 (3):ă153–155.ă
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aspects of blood pressure during sleep.ăHypertension,ă2007,ă49 (6)ă1235–41.ă
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(3A):ă33–91.ă
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(9–10):ă923–39.ă
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21. REDFERNăP.H.,ăLEMMERăB.ă(eds),ăPhysiology and pharmacology of biological rhythms.ăBerlin,ăSpringer-Verlag,ă1997;ă375–414.ă

ReceivedăJulyă12,ă2008ă

ă
 Cardiovascular Risk in Patients with Peripheral Vascular Diseases

ADINAăăSTOICA,ăăCARMENăăGINGHIN
“Prof.ăDr.ăC.C.ăIliescu”ăInstituteăforăCardiovascularăDisorders,ă
Bucharest,ăRomaniaă

Peripheralăarterialădiseaseă(PAD)ăisăcharacterizedăbyăincreasedăincidenceăandăprevalence,ăbothă
ofă whichă increasingă withă ageă (prevalenceă aboută 19%ă aboveă 70ă yearsă versusă 2.5%ă belowă 60ă years);ă
PADă isă stronglyă dependentă uponă smokingă andă diabetesă mellitusă asă cardiovasculară riskă factors.ă
Patientsă sufferingă fromă peripherală arterială diseaseă areă patientsă ată highă cardiovasculară risk,ă albeită
symptomatică patientsă (intermittentă claudication)ă oră asymptomatică patientsă (addedă riskă foră cardio-
vascularăeventsă4–5%/year);ătheseărisksăincreaseăinăpatientsăneedingărevascularizationăsurgeryă(6%),ă
mainlyădueătoăassociationăofăcoronaryăorăcerebro-vascularădisease.ăă
Aăfairăassessmentăofăpreoperativeărisksă(risksădependingăonăpatientăbackground,ătypeăofăsurgery,ă
emergencyăstatusăofăsurgicalăprocedure)ăaidsăinătheăoptimalămanagementăofăsuchăpatientăbothăatătheătimeă
ofăperformingătheăprocedureăandăinătheălong-termăpatientămanagement.ăThisăisăwhyănewăparametersăareă
requiredăforăassessingătheăriskăandăidentifyingăaăsubgroupăofăpatientsăatăhigh-riskăforăacuteăcardiovasculară
eventsăandăforăcustomizingătheădiagnosticăandătherapeuticăalgorithmsăforăsuchăpatients.ăă

Ităhasăbeenăpreviouslyăprovenăthatăperipherală Theă earlyă diagnostică ofă peripherală vasculară

vasculară diseaseă isă ană independentă predictoră foră
cardiovasculară death,ă moreă importantă ină assessingă
survivală ratesă thană theă previousă clinicală historyă ofă
coronaryăheartădiseaseă[1].ăă
Patientsă withă peripherală arterială diseaseă areă ată
highăriskăforăcardiovascularămorbidityăandămortality,ă
regardlessă ofă sex,ă albeită symptomatică patientsă
(intermittentăclaudication)ăandăasymptomaticăpatientsă
(Fig.ă 1).ă Lengă et al.ă showedă ină aă prospectiveă studyă
includingă 1592ă patientsă withă claudicationă andă
asymptomatică agedă 55–74ă years,ă followedă forăă
5ă yearsă thată asymptomatică patientsă seemă toă haveă
increasedă riskă ratesă foră cardiovasculară eventsă andă
deathăsimilarătoătheăonesăofăsymptomaticăpatientsă[2].ăă
Evenăfollowingăsuccessfulămyocardialărevascu-
larization,ă patientsă alsoă sufferingă fromă peripherală
arterială disordersă remaină ată highă mortalityă ratesă
(OR–2.77)ă asă comparedă toă theă patientsă withă
myocardială revascularizationă therapyă bută withă noă
peripheralăarterialădisorderă[3].ă
Sinceă theă characteristică symptomă –ă andă
namelyă intermittentă claudicationă –ă isă presentă ină ată
mostă 30%ă ofă patientsă (40–50%ă areă eitheră
asymptomaticăorăpresentăwithăatypicalăcomplaintsă–ă
paresthesia,ă tingling,ă numbnessă ină theă affectedă
limb)ă[4],ăandătheăeffortăcapacityăisămostăfrequentlyă
decreased,ă theă diagnosisă ofă limbă arteritisă isă mostă
oftenă eitheră omittedă oră late,ă suchă patientsă showingă
increasedăriskăforăcardiovascularăeventsăandălackingă
secondaryăpreventionămeasures.ăă
diseaseă andă theă optimală managementă ofă suchă
patientsămayădecreaseătheăcardiovascularămorbidityă
riskă sinceă althoughă peripherală revascularizationă
(surgical/interventional)ă mayă improveă symptoms,ă
theyăshowănoăimpactăonăsurvivalăratesă[4].
INCIDENCE AND PREVALENCE OF PERIPHERAL
ARTERIAL DISEASE
Theă incidenceă andă prevalenceă ofă peripherală
arterialădiseaseădependăonăage,ăriskăfactorsăinăstudyă
group,ă associationă withă otheră atherosclerotică
disorders,ă theă diagnostică methodsă foră peripherală
arterială diseaseă (questionnaire,ă clinicală examination,ă
ankle-brachială pressureă index,ă continuousă Doppleră
examination),ă soă thată theyă mayă varyă amongă
differentăstudiesă(TableăI)ă[1][2][5–10].ă
Peripheralăarterialădiseaseăisămoreăfrequentăină
eldersă (prevalenceă aboută 19%ă ină ageă groupă overăă
70ăyearsăversusă2.5%ăbelowă60ăyears)ăandăisămoreă
frequentăinămen.ăă
Epidemiologyă andă clinicală consequencesă ofă
theădiseaseăareăcloselyărelatedătoătheăatherosclerotică
riskă factorsă (smoking,ă diabetes,ă hypertension,ă
dislipidemia,ă familyă history,ă hyperhomocysteinemia,ă
post-menopauseă status),ă sinceă theă mostă frequentă
underlyingă causeă ofă theă diseaseă isă atherosclerosis.ă
Amongstăallăriskăfactors,ăsmokingăisăaăstrongăpredictoră
ofăperipheralăarterialădisease,ătheăriskăforădevelopingăă

ROM.ăJ.ăINTERN.ăMED.,ă2008,ă46,ă4,ă275–283ă
276ă
ă AdinaăStoica,ăCarmenăGinghin ă 2ă

Normal subjects

Asymptomatic
patients

Symptomatic
patients

Patients with severe

symptoms

ă
Fig.ă1.ă–ăPeripheralăarterialădiseaseăpatient’sămortalityăbyăsymptomsăă
(adaptedăbyăCriquiăM.H.ăet al.,ăN. Engl. J. Med.,ă1992;ă326:381–386).ă

Table I

Epidemiologicăcharacteristicsăofăperipheralăarterialădiseaseăpatientsă
Trials Characteristics Diagnosis Age Incidence Prevalence Notes
(years)
Framinghamă 2336ămenă+ăă Roseăquestionnaireă+ă 30–44ă 6/10000ăă ă ă
2873ăwomenă clinicalăexamăatăă ă menă/yeară
ă 2ăyearsă ă 3/10000ăwomenă/ă
ă yeară
65–74ă 61/10000ămen/yeară
54/10000ă
women/yeară
Edinburghă 1592ăpeopleă Questionnaireă+ăABIă 55–74ăă 15.5/1000/ăyeară 4.5%ă Prevalenceăofă
1ă
ă CHD2ă–ă11.1%ă
Criquiăet al.ă 613ăpeopleă Questionnaireă+ă <ă60ăă ă 2.5%ă ă
(SanăDiegoă clinicalăexamă+ăABIă ă ă
Study)ă +ăcontinuousă 60–69ă 8.3%ă
Dopplerăultrasoundă ă ă
>ă70ă 18.8%ă
PARTNERSă 6979ăpeopleă ABIă >ă70ăoră ă 29%ă 16%ăhasăATS3ăă
ă 50–ă69ăforă inăotherăvasculară
smokers/ă territoryă
diabetesă
mellitusă
NHANESă 2174ăpeopleă ABIă >ă40ă ă 4.3%ă ă
>ă70ă ă
14.4%ă
3ă Cardiovascularăriskăinăperipheralăvascularădiseasesă
Rotterdamă 7715ăpeopleă RoseăQuestionnaireă
ă +ăABIăă
Hooiăet al.ă 2327ăpeopleă RoseăQuestionnaireă
+ăABIă
Dawsonăet al.ă ă ă
Lengăet al.ă 1592ăpeopleă ă 55–74ă
ă symptomsă
Bowlinăet al.ă 10059ăpeopleă RoseăQuestionnaireă
+ăABIă
ABIă–ăankle-brahialăindex,ăCHDă–ăcoronaryăheartădisease,ăATSă–ăatherosclerosisă
ă
peripheralăarterialădiseaseăbeingă2–3ătimesăhigherăină
smokersăthanătheăriskăforădevelopingăcoronaryăheartă
diseaseă [6],ă whileă diabetesă mellitusă increasesă theă
riskă foră criticală ischemică complicationsă andă
amputationsă (RR=7–15ă accordingă toă variousă
authors)ă [1][8],ă soă thată theă riskă factoră profilesă ină
studyă subgroupsă influenceă bothă epidemiologyă dataă
(incidence,ă prevalence),ă andă theă morbidityă andă
mortalityărates.ă
ASSOCIATION WITH CORONARY AND
CEREBROVASCULAR DISEASES
Theă prognosisă foră patientsă withă peripherală
vasculară diseaseă isă alteredă byă increasedă riskă foră
ischemicăcardiovascularăeventsădueătoăsimultaneousă
coronaryăandăcerebrovascularădiseases,ămostăfrequentlyă
dueătoăatherosclerosisă[11].ăă
Theă recordedă prevalenceă ofă coronaryă andă
cerebrovasculară diseaseă ină patientsă sufferingă fromă
obliteratingă arteritisă dependsă onă theă diagnostică
criteriaă andă methodsă used.ă Aboută oneă thirdă upă toă
oneă halfă ofă theă patientsă withă obliteratingă arteritisă
presentă obviousă signsă ofă coronaryă heartă diseaseă ină
physicală examinationă andă restingă ECGă andă upă toă
twoă thirdsă ofă theseă patientsă presentă alterationsă ofă
stressă testsă [12].ă Aă largeă proportionă (60–80%)ă ofă
patientsă withă peripherală arterială diseaseă presentă
significantă coronaryă lesionsă asă provenă byă
angiography,ăinăatăleastăoneăvascularăterritoryă[13].ă
Theseă patientsă mayă alsoă associateă carotidă
arteryălesionsăwhichămayăbeăsignificantăină12ăupătoă
25%ăaccordingătoăvariousăauthorsă[14].ă
Variousă trialsă identifiedă simultaneousă
alterationsă ină severală vasculară territoriesă ină largeă
proportions.ă Theă CAPRIEă studyă (aboută 19000ă
patientsă ină theă studyă group)ă identifiedă thată 1ă ofăă
277
Table I (continued)
>ă55ăă ă 19.1%ă ă
(6.3%ăhadă
symptoms)ă
ă 9.9/1000/yeară ă ă
(1/1000/yearăhadă
symptoms)ă
40–59ă ă 3%ă ă
60–69ă 8%ă
>ă70ăă 19%ă
1.6%ă/yearăwithă ă ă
40–65ă 8.6ă%ă/yearăwithă ă ă
symptomsă
4ă patientsă withă atherosclerotică lesionsă presentedă
lesionsăinăseveralăvascularăterritoriesă[15].ăAlso,ătheă
AGATHAăstudyăincludingă8891ăsubjectsăidentifiedă
aă secondaryă affectedă vasculară territoryă ină patientsă
withă peripherală arterială diseaseă ină aboută 13%ă ofă
patientsă (simultaneousă peripherală arterială diseaseă
andă coronaryă heartă diseaseă –ă 6.7%ă andă
simultaneousăperipheralăarterialădiseaseăandăcarotidă
arteryă lesionsă –ă 6.2%),ă whileă simultaneousă
alterationsăinăallăthreeăterritoriesăwereăidentifiedăină
7.1%ăofăallăsubjectsă[16].ăă
Aă highă rateă ofă associationă withă peripherală
arterială diseaseă wasă alsoă notedă ină theă groupsă withă
coronaryăheartădiseaseăandăcerebrovascularădiseaseă
(1/3ă ofă menă andă 1/4ă ofă womenă withă knownă
coronaryă heartă diseaseă oră cerebrovasculară diseaseă
alsoă showă peripherală vasculară lesions)ă [17].ă Theă
REACHă registryă prevalenceă rateă foră peripherală
vasculară diseaseă ină coronaryă heartă diseaseă patientsă
wasă11%ă[18].ă
CARDIOVASCULAR EVENTS RISK
Moreărecentătrialsă[19–21]ăreportedăcombinedă
risksă foră AMI,ă strokeă andă deathă reachingă 4–5%ă
/year,ăwithănoăsignificantădifferencesădueătoăsexăoră
intermittentă claudicationă asă comparedă toă asympto-
maticăpatients,ăbutăincreasingăupătoă6%ă/yearăwhenă
alsoăincludingăpatientsăwithăperipheralărevasculari-
zationă therapy.ă Theă cardiovasculară riskă isă increasedă
ină patientsă withă severeă symptomsă ofă ischemiaă
(criticalăischemiaă–ă1-yearămortalityărateă–ă25%)ăandă
withăaădecreasedăankle-brachialăpressureăindexă[22].ă
Severalăauthorsăprovedăthatătheărelativeăriskăforă
cardiovasculară mortalityă andă morbidityă (coronaryă
heartă disease,ă stroke)ă isă higheră ină patientsă withă
peripheralăvascularădiseaseăthanăinăpatientsăwithănoă
278ă
ă AdinaăStoica,ăCarmenăGinghin ă
arterială disease,ă regardlessă ofă theă clinicală evidenceă
pleadingă foră coronaryă heartă disease.ă Thusă Eagleăă
et al.ă provedă onă aă groupă ofă 2296ă patientsă withă
peripheralăarterialădiseaseăvs.ă13953ăwithănoăarterială
disease,ă allă ofă themă sufferingă fromă stableă anginaă
pectorisă thată theă mortalityă rateă wasă 25%ă higheră ină
patientsă withă peripherală vasculară diseaseă [23],ă
whileă theă incidenceă ofă strokeă wasă 42%ă higheră ină
patientsăwithăperipheralăarterialădiseaseă[24].ă
Aă highă riskă foră cardiovasculară eventsă andă
mortalityă wasă alsoă identifiedă ină patientsă withoută
evidenceă ofă coronaryă heartă disease;ă Yogtă et al.ă
showedă notă onlyă aă highă riskă foră coronaryă heartă
diseaseă (RR–3.7)ă andă foră cardiovasculară eventsă
(RR–4),ă bută alsoă increasedă risksă foră overallă
mortalityă (RR–3.1ă ină 4ă years).ă Otheră authorsă alsoă
documentedăanăincreasedăriskăforăcardiovascularăandă
coronaryă heartă diseaseă mortality,ă Criquiă etă al.ă
identifyingăaărelativeăriskăforăcardiovascularămortalityă
5.9ătimesăhigherăandăaărelativeăriskăforăcoronaryăheartă
diseaseă mortalityă 6.6ă timesă higheră ină theseă patients;ă
moreover,ă theyă alsoă provedă thată theă cardiovasculară
mortalityă riskă increasesă furthermoreă ină patientsă withă
severeă symptomsă dueă toă lesionsă ină largeă vesselsă –ă
distalăaorta,ăiliacăarteriesă(RR–15)[25].ăOtherăauthorsă
alsoă correlatedă theă severityă ofă peripherală arterială
diseaseăwithăincreasedăriskăforăcardiovascularăeventsă
(AMI,ăstroke)ăandăcardiovascularădeathă[1].ă
Peripherală revascularizationă surgeryă therapiesă
includeă highă risksă foră post-surgicală cardiovasculară
eventsă andă mortality.ă Mortalityă isă 25–50%ă higheră ină
patientsă withă cardiacă disordersă subjectă toă high-riskă
surgicalăproceduresăthanăinănormal-heartedăpatients.ăă
Postoperativeă risksă partlyă dependă onă theă typeă
ofă surgicală intervention.ă Theă electiveă aorto-
bifemorală revascularizationă interventionsă associateă
ană in-surgeryă mortalityă rateă ofă 3.3%ă andă aă
cardiovasculară morbidityă rateă ofă 8.3%,ă withă acuteă
myocardială infarctionă (incidenceă betweenă 0.8ă andă
5.2%ăinăvariousăstudies)ăandăkidneyăfailureă(0–4.6%)ă
asătheăleadingăcardiovascularăcomplicationsă[26].ăă
Forăinterventionsăbelowătheăinguinalăregionăină
selectedă patients,ă mortalityă reachedă upă toă 6%ă ină
variousă studies,ă riskă significantlyă increasingă foră
amputations.ă Majoră loweră limbă amputationsă
associatedă aă highă riskă foră cardiovasculară mortalityă
ină30ădaysăofăupătoă30%ăandămorbidityăratesă(AMI,ă
strokeă andă infections)ă rangingă fromă 20ă toă 37%ă
accordingătoăvariousăauthorsă[27].ă
Revascularizationă ofă theă aortaă andă belowă theă
inguinalăfossaăisăstillăassociatedăwithăincreasedă30-dayă
andă1-yearămortalityăratesăaccordingătoăFleischer.ăHeă
4ă
moreoveră provesă thată aortică surgeryă associatesă
increasedă short-termă mortality,ă whileă interventionsă
belowăinguinalăfossaăareămostăoftenăassociatedăwithă
increasedă long-termă mortalityă [28].ă Krupskiă et al.ă
alsoăprovedăincreasedă2-yearăriskăforăfatală/ănonfatală
myocardială infarctionă ină patientsă withă infra-
inguinală by-passă versusă aorto-bifemorală by-passă
(RR–3.5),ă differencesă beingă dueă toă increasedă
prevalenceă ofă diabetes,ă coronaryă heartă diseaseă
(previousă oldă myocardială infarction,ă anginaă
pectoris)ă andă heartă failureă ină patientsă withă infra-
inguinalăperipheralăvascularădiseaseă[29][30].ă
ESTIMATING CARDIOVASCULAR RISK
Perioperativeă cardiovasculară riskă dependsă onă
theăpatientăandăonătheătypeăofăsurgicalăprocedure,ăasă
wellă asă onă theă circumstancesă leadingă toă surgicală
procedureă(emergencyă/ăelectiveăsurgery).ă
Duringă theă surgicală interventionă theă patientă
suffersă disturbancesă ofă theă cardiovasculară systemă
mainlyădueătoătheăanesthesiaăandătoătheăsurgicalăprocedureă
(depressedă myocardială contractility,ă increasedă
myocardială excitability,ă indirectlyă dueă toă respiratoryă
distress,ă bloodă pressureă variations,ă variationsă ofă theă
ventricularăfillingăpressure,ăofătheăbloodăvolumeăandă
temperature,ă effectsă ofă tonusă variationsă ofă theă
vegetativeănervousăsystem)ăorădueătoătheăcomplicationsă
whichă additionallyă over-stressă theă cardiovasculară
systemă (bloodă loss,ă cardiacă complicationsă –ă AMI,ă
arrhythmias,ă acuteă pulmonaryă edema,ă heartă failure,ă
pulmonaryăembolism,ăpulmonary/systemicăinfections,ă
respiratory/kidneyăcomplications,ăetc.).ă
Theă perioperativeă riskă isă thereforeă partlyă
influencedă byă factorsă pertainingă toă theă typeă ofă
interventionă(hemodynamicăchangesăinducedăbyătheă
aortică clamp,ă wateră andă electrolyteă balanceă
alterations,ăsurgicalătechnique),ătheădurationăofătheă
surgicalăprocedureă(complicationăriskăfollowingătheă
correctionă accordingă toă theă typeă ofă interventionă
doesănotăseemătoăcorrelateăwithătheădurationăunlessă
majoră complicationsă occur),ă theă emergencyă statusă
ofă theă procedureă (AMI/deathă riskă increasesă 2.5–ă
4ătimesăasăcomparedătoăelectiveăsurgery).ă
Theăfactorsăpertainingătoătheăpreviousădiseaseă
historyă significantlyă influenceă theă perioperativeă
prognosis,ă sinceă revascularizationă surgeryă high-
risksă areă mainlyă dueă toă theă associationă withă
coronaryă heartă disease,ă justifyingă theă interestă ină aă
thoroughă assessmentă ofă allă patientsă beforeă surgeryă
ină orderă toă identifyă allă potentially-correctableă riskă
5ă Cardiovascularăriskăinăperipheralăvascularădiseasesă
factorsăinăorderătoăimproveătheăshort-termăandălong-
termă prognosis.ă Thereă hasă beenă previousă concernă
foră identifyingă someă independentă pre-operativeă
predictorsă significantlyă correlatedă withă increasedă
riskă foră fatală oră potentiallyă fatală peri-operativeă
complicationsă notedă ină non-cardiacă surgicală
proceduresăonăpatientsăagedăoveră40ăyears.ăVariousă
authorsă identifiedă severală clinicală factorsă (basedă
fromă personală history,ă physicală examinationă andă
restingă ECG)ă predictiveă foră perioperativeă riskă
factorsă (coronaryă heartă diseaseă –ă AMIă ină previousăă
6ă monthsă oră unstableă anginaă ină theă previousăă
6ă months,ă anginaă (Canadiană classă IIIă oră IV),ă
congestiveă heartă failureă –ă protodiastolică gallop,ă
turgescentă jugulară veinsă oră historyă ofă acuteă
pulmonaryă edema,ă non-sinusă rhythm,ă moreă thanăă
5ă prematureă ventriculară complexesă peră minute,ă
severeă aortică stenosis,ă creatinineă levelsă exceedingă
2mg/dl,ăchronicăliverădiseaseăorădiabetes,ăageăoveră
70ăyears,ă theă typeă ofă surgicală interventionă –ă aortică
surgery,ă theă emergencyă status)[31–33].ă Basedă onă
theseă factorsă aă multifactorială indexă ofă cardiacă riskă
ină non-cardiacă surgicală proceduresă wasă draftedă –ă
theăoriginalăindexă–ăGoldmană[31].ăSinceătheăindexă
wasă derivedă basedă onă unselectedă patientă studies,ă
agedă overă 40ă years,ă theă indexă seemsă toă under-
estimateăbyăalmostă40%ătheăriskăinăpatientsăatăhighă
basalăriskă(i.e.ăpatientsăwithăstableăangina,ăinăwhichă
theă riskă isă 2–4%ă evenă ifă lackingă anyă otheră riskă
factor)ă oră ină patientsă undergoingă moreă complexă
surgicalăproceduresă(i.e.ăaorticăsurgery)[34].ă
Moreă recentă worksă suggestedă criteriaă foră
assessingă theă surgicală riskă simpleră thană theă
compositeă riskă score,ă factorsă whichă provedă byă
multivariateă analysisă toă leadă toă increasedă peri-
surgicalăriskăforămyocardialăinfarction,ăheartăfailureă
oră death;ă theyă wereă classifiedă asă major,ă inter-
mediateăandăminorăriskăpredictorsă[35].ăă
Theămajorăriskăpredictorsăare:ă
− Coronaryăsyndromes:ă
− acuteăorărecentăMIă(moreăthană7ădays,ăbută
lessă thană 1ă month)ă withă evidenceă ofă
increasedă ischemică riskă eitheră clinicallyă
orăatănonivasiveăproceduresă
− unstableăorăsevereăanginaă(Canadianăclassă
III–IV)ă
− Decompensatedăheartăfailureăă
− Severeăarrhythmias:ă
− high-degreeăatrio-ventricularăblocksă
− symptomatică ventriculară arrhythmiasă ină
theăpresenceăofăheartădiseaseă
− supraventriculară arrhythmiasă withă un-
controlledăheartăratesăă
279
− Severeăvalvularădisordersă(severeăaorticăstenosis)ă
Intermediateăriskăpredictors:ă
− moderateăanginaăpectorisă(CanadianăclassăI–II)ă
− previousă myocardială infarctionsă (historyă oră
pathologicăQăwaves)ă
− compensatedăorăpreviousăheartăfailureă
− diabetesămellitusă(especiallyăifăinsulin-dependent)ăă
− kidneyăfailureă(creatinineălevelsăaboveă2ămg/dl)ă
Minorăriskăpredictors:ă
− oldăageă(moreăthană70ăyears)ăă
− ECGămodificationsă(leftăventricularăhypertrophy,ă
leftăanteriorăfascicularăblock,ăST-Tăchanges)ă
− Non-sinusărhythmă(i.e.ăatrialăfibrillation)ă
− decreasedăexerciseăcapacityăă
− previousăhistoryăofăstrokeăă
− uncontrolledăhypertensionăă
Dependingăonătheăpresenceăofăriskăfactorsătheă
attitudeă isă expectedă toă beă adjusted;ă therefore,ă foră
majorăriskăpredictorsăoneămayăoptăforăcancelingăoră
ată leastă delayingă theă surgicală procedureă untilă theă
patientă isă stabilized,ă ifă theă respectiveă procedureă isă
notă ană emergency,ă whileă ifă onlyă intermediateă riskă
predictorsă areă presentă (markersă associatedă withă
increasedăriskăforăperi-surgicalăheartăcomplicationsă
oneă mayă performă aă moreă thoroughă preoperativeăă
assessmentă usingă noninvasiveă techniquesă and,ă
dependingăonătheăresults,ăusingăinvasiveăexplorationsă
(coronaryă angiography).ă Ină theă presenceă ofă minoră
riskăpredictorsătheăpatientsăareăableătoăundergoătheă
surgicală procedureă or,ă ină caseă ofă decreasedă
toleranceătoăeffortă(lessăthană4ăMETs),ătheyăshouldă
beă non-invasivelyă assessedă and,ă dependingă onă theă
resultsă ofă theă lateră investigations,ă theyă mayă alsoă
undergoă coronarographyă (Fig.ă 2)ă [35].ă Therefore,ă
followingă clinicală assessment,ă theă patientsă mayăă
a)ăavoidăsurgicalăprocedureă(majorăriskăpredictors),ă
oră b)ă undergoă surgicală proceduresă (minoră riskă
predictors)ă oră c)ă requireă noninvasiveă andă coronaryă
angiographyă ă beforeă undergoingă theă surgicală
procedureă dependingă onă theă increasedă riskă factorsă
involved,ă explorationsă whichă mayă leadă toă
performingă coronaryă revascularizationă oră intensiveă
medicală therapyă prioră toă electiveă peripherală
revascularization.ă Ită wasă moreoveră provedă thată theă
clinicalăfactorsăareămoreăsensitiveăthanătheăsurgicală
factorsăinăpredictingăperi-surgicalăcomplications.ăă
Severalălong-termăpost-surgicalărevascularizationă
studiesă (2ă toă 5ă yearsă follow-up)ă haveă beenă
performedă onă patientsă withă peripherală vasculară
disease.ă Suchă studiesă identifiedă thată theă long-ă
termă riskă assessmentă foră patientsă undergoingăă
surgicalărevascularizationămayăconsiderăallăclinicalăriskăă
280ă
ă AdinaăStoica,ăCarmenăGinghin ă 6ă

ă
Fig.ă2.ă–ăStepwiseăapproachătoăpreoperativeăcardiacăassessmentăatăperipheralăarterialădiseaseăpatients.ă(adaptedăbyăEagleăK.A.ăet al.,ă
ACC/AHAăGuidelineăUpdateăonăPerioperativeăCardiovascularăEvaluationăforăNoncardiacăSurgery,ăCirculation, 2002;ă105:1257).ă
ă
markers:ă ejectionă fraction,ă dobutamineă stressă oră stressă scintiscan,ă oră ofă multi-vasculară coronaryă
echocardiography,ă stressă scintiscană withă thalium- heartădisease.ăăă
dipiridamol,ăcoronarography.ăLong-termăheartădiseaseă Theăbestăcost-efficiencyăratioăconsideringătheă
mortalityăforăpatientsăundergoingăsurgeryăincreasesă 5-yeară event-freeă intervală wasă deemedă toă beăă
ină theă presenceă ofă majoră clinicală riskă factors,ă ofă theă stressă scintiscană withă thalium-dipiridamoleăă
decreasedăejectionăfractionă(EFălowerăthană35%),ăofă foră intermediateă clinicală riskă patients;ă patientsă ată
multipleăischemicăsegmentsăinăstressăechocardiographyă highăriskărequireăcoronarographyăassessmentăwhileă
7ă Cardiovascularăriskăinăperipheralăvascularădiseasesă 281

low-riskă patientsă doă notă requireă furtheră patientsăsufferingăfromăperipheralăvascularădisease,ă

investigationsă[36].ă
FUTURE DIRECTIONS
Theăworldwideăgeneralăinterestănotedăinătheăpastă
coupleă ofă yearsă ină preventionă strategiesă isă ină
identifyingănewăcardiovascularădisease/cardiovasculară
eventăriskăstratificationămarkers,ăinăhealthyăpopulationă
asă wellă asă ină patientsă withă provenă cardiovasculară
disordersă(hypertension,ăcoronaryăheartădisease,ăacuteă
coronaryăsyndromes),ăinăorderătoăidentifyăpopulationă
groupsă ată risk,ă whichă mayă benefită fromă optimală
treatment.ă Theă mostă promisingă resultsă amongstă theă
latestă studiedă parametersă promisingă resultsă seemă toă
ariseăfromăstudyingăcertainăinflammationămarkersă(i.e.ă
Că reactiveă protein,ă interleukinsă IL1,ă 6,18)ă andă theă
endothelială dysfunctionă (intima-mediaă index,ă flow-
mediatedăvasodilation).ăItăisăacceptedăthatăusingăsuchă
assessmentămethodsăstillărequiresăwiderăstudiesăinăorderă
toăpinpointătheirăroleăinătheăriskăstratificationăstrategiesă
foră patientsă withă coronaryă heartă diseaseă andă
stable/unstableăangina,ăwhileălittleăevidenceăisăavailableă
forăpatientsăwithăperipheralăvascularădiseaseă[37].ă
Theă increasedă prevalenceă ofă peripherală
vasculară diseaseă ină olderă patientsă (8%ă betweenăă
60ă andă 69ă yearsă andă 19%ă ină patientsă agedă overăă
70ăyears)ăandătheăincreasedăriskăforăcardiovasculară
andă coronaryă heartă diseaseă mortalityă ină theă latteră
patientsă tendă toă justifyă theă interestă ină identifyingă
newă high-riskă identificationă markersă foră cardio-
vasculară eventsă ină suchă patients.ă Moreover,ă ină
theămethodsăavailableăforădiagnosingăsimultaneousă
oră successiveă timelyă alterationsă ofă otheră vasculară
territoriesă (i.e.ă coronaryă oră cerebrală arteries)ă areă
somewhată limitedă byă patientsă symptomsă (stressă
test)ă oră byă availableă resourcesă (stressă scintiscan,ă
stressăechocardiography)ăorăevenăposeăhigherărisksă
foră complicationsă ină suchă patientsă –ă invasiveă
maneuversă (coronarography).ă Thisă isă whyă theă
identificationă ofă newă parametersă isă requiredă foră aă
simpler,ă moreă cost-effectiveă assessmentă ofă
cardiovasculară eventă risk;ă suchă parametersă areă
requiredă ină theă peri-surgicală andă long-termă riskă
assessmentăalgorithmăforăsuchăpatients.ăAnăaccurateă
assessmentăofătheăcardiovascularăriskăofăperipherală
vasculară diseaseă patientsă assistsă ină loweringă theă
cardiovasculară eventă riskă (a)ă onă theă shortă rună viaă
(a.1.)ă pre-surgicală measuresă (optimizationă ofă
medicală treatmentă andă possiblyă delayingă theă
surgicalăinterventionăuntilăcompensating/correctingă
heartădisorderăand/orăanyăotherăassociatedădisordersă
or,ăinăspecialăcircumstancesă–ămyocardialăorăcarotidă
arteryă revascularizationă –ă albeită interventională oră
chirurgical)ă andă (a.2.)ă intra-operativeă measuresă (i.e.ă
carefulă intraoperativeă monitoring,ă includingă invasiveă
monitors,ă theă choiceă ofă ană adequateă surgicală
technique,ăloweringătheăbloodălossăandăhemodynamică
alterationsădueătoăaorticăclamping),ăasăwellăasă(b)ăonă
theălongărunăviaăsecondaryăpreventionămeasures.ăTheă
optimală managementă ofă patientsă withă peripherală
vasculară disorderă mayă leadă toă loweringă theă costă ofă
short-termă andă long-termă careă sinceă theă socială costsă
areămuchăhigherăforătheseăpatients.ăă

Boala arterială periferică se caracterizează printr-o incidenţă şi prevalenţă

care cresc cu vârsta (prevalenţa de aproximativ 19% la grupul de vârstă de peste
70 de ani comparativ cu 2,5% la grupul de vârstă sub 60 de ani) şi este puternic
asociată cu fumatul şi diabetul zaharat dintre factorii de risc cardiovasculari.
Pacienţii cu arteriopatie periferică reprezintă un grup de pacienţi cu risc
cardiovascular crescut; atât pacienţii simptomatici prin claudicaţie intermitentă,
cât şi cei asimptomatici (risc de evenimente cardiovasculare de 4–5%/an), risc
care creşte la pacienţii care necesită revascularizare chirurgicală (6%), risc
crescut din cauza asocierii bolii coronariene sau cerebrovasculare.
Estimarea corectă a riscului preoperator (risc ce depinde de terenul
pacientului, tipul intervenţiei chirurgicale şi caracterul de urgenţă al intervenţiei)
ajută la un management optim al acestor pacienţi atât perioperator, cât şi pe
termen lung. De aceea este necesară găsirea unor noi parametri de evaluare a
riscului care să ajute la identificarea unui subgrup de pacienţi cu risc foarte înalt
de a suferi un eveniment cardiovascular acut şi individualizarea algoritmului de
diagnostic şi a tratamentului la aceşti pacienţi.
282ă
ă AdinaăStoica,ăCarmenăGinghin ă 8ă

Corresponding author: AdinaăStoicaă

ă “Prof.ăC.C.ăIliescu”ăInstituteăforăCardiovascularăDisordersă
ă 285ăŞos.ăFundeniă
ă E-mail:ăadistoica1@yahoo.comă

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ReceivedăJulyă8,ă2008ă

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284ă
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ă
Photodynamic Therapy – Indications and Limits in Malignant Tumors Treatment

ADRIANA GABRIELA FILIP1, SIMONA CLICHICI1, DOINA DAICOVICIU1, DIANA OLTEANU1,

ADRIANA MUREŞAN1, SIMINA DREVE2
1
Physiology Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca
2
National R&D Institute of Isotopic and Molecular Technologies, Cluj-Napoca, Romania

Photodynamic therapy (PDT) is a very promising technique used for the treatment of a variety
of solid neoplasms, based on the formation of singlet oxygen induced by a photosenstizer after
irradiation with visible light. The mechanism of interaction of the photosensitizers and light is
discussed, along with the effects produced in the target tissue. PDT has been approved in many
countries for the treatment of lung, esophageal, bladder, skin and head and neck cancers. The
antitumor effects of this treatment result from the combination of direct tumor cell photodamage,
destruction of tumor vasculature and activation of an immune response. The present status of clinical
PDT is discussed along with the newer photosensitizers being used and their clinical roles.
Despite the promising results from earlier clinical trials of PDT considerable additional work
is needed to bring this new modality of treatment into modern clinical practice.
Key words: photodynamic therapy, photosensitizers, cancers, side effects.

Despite the latest advances in oncology, the
problem of treating malignant diseases has not been
resolved yet. In most cases, the treatment is
beneficial at early stages of cancer. However, two
thirds of patients reveal advanced cancer and only
half of them undergo special treatment. Surgery,
radiotherapy, and combined treatment have limited
capabilities for advanced cancer, most of the
patients die of relapses and metastases. Moreover,
many patients (up to 25 percent) have operable
cancer, but cannot have surgical treatment. This is
because of serious associated diseases and age-
related disorders. These patients often undergo
organ-saving surgical treatment with a high rate of
local relapses. Until the last decade, there was no
adequate treatment for these patients either. The
advent of photodynamic therapy (PDT) has
considerably extended oncologic capabilities.
PDT is a relatively new therapeutic modality
for neoplastic diseases, which involves light
activation of certain photosensitizers (PS) that have
been somewhat selectively taken up by the target
tissue in the presence of molecular oxygen. PS are
compounds that absorb energy from light of specific
wavelengths and are capable of using that energy to
induce reactions in other non-absorbing molecules
[1]. PDT offers a number of advantages over
traditional therapies for malignant tumors. First, PDT
is highly selective and targeted in action. Second, it is
free of surgical risks, serious damages, and systemic
complications. Third, PDT sessions can be repeated
as many times as needed. Fourth, a single PDT
procedure enables both the treatment and fluorescent
diagnosis. Finally, most patients exhibit tumor
resolution after a single PDT session, which can be
performed under outpatient conditions [2].
HISTORY OF PDT
The studies regarding PDT have a long
history, which dates back more than a century. The
first clinical application of PDT was mentioned in
1903, when two researchers, Von Tappeiner H. and
Jasionek A., observed that basal cell tumors would
heal when exposed to eosine and light for a few
weeks [3]. In 1942 Auler and Banzer injected
hematoporphirin in tumor carrying animals and
found that after exposing them to a halogen lamp,
fluorescence and tumor necrosis appears. The
purification of hematoporphirin, the use of its
derivatives, and especially the introduction of laser
as a light source by Maiman in 1960 lead to an
improvement of the effects of this therapy [4].
The development of endoscopy offered new
opportunities for the treatment of tumors located in
less accessible areas such as the esophagus, the
lung, the bladder, Hayata et al. being the first to
utilize laser in the treatment of bronchial tumors
[4]. In the USA Photofrin is the only PS approved by

ROM. J. INTERN. MED., 2008, 46, 4, 285–293

286 Adriana Gabriela Filip et al.
the Food and Drug Administration (FDA) for clinical
use in palliation of “patients with completely
obstructing esophageal cancer and for treatment of
microinvasive endobronchial nonsmall cell lung
cancer in patients for whom surgery and radiotherapy
are not indicated” (National Cancer Institute
http://cancernet.nci.nih.gov). Because of the long
lasting skin phototoxicity of Photofrin, several new
PS have recently been introduced in clinical trials:
5 amino-levulinic acid (5–ALA, Levulan; DUSA
Pharmaceuticals Inc. Wilmington, MA), the methyl
ester of ALA (Metvix, Photocure ASA, Oslo,
Norway), Visudyne (verteporfin, benzoporphyrin
derivative monoacid ring A, BPD-MA) and meso-
tetra-hydroxylphenyl-chlorin (mTHPC, Foscan, Biolitec
Pharma Ltd., Dublin, Ireland) [2].
PRINCIPLE OF PDT
PDT involves the administration of a PS
followed by local illumination of the tumor with
light to activate the specific drug so that PS would
pass from the base state to the excited state of
singlet, with higher energy and very short life [2].
From this state the substance can follow two paths:
it either passes back to the unexcited, base form
and emits fluorescence which allows the detection
of the photosensitiser in the tissue and the
visualization of the tumor [5], or it passes in a
triplet state with low energy and longer life span
than the singlet form. In a triplet state, the molecule
transfers its own energy either to the molecular
oxygen present in the tissues and generates 1O2
(reaction type II) [4], or to the biomolecules from
the tissue and it generates hydroxyl radicals,
hydrogen peroxide, and anion superoxide (reaction
type I) [5]. Radicals can also be formed after the
reaction of 1O2 with the proteins and the unsaturated
lipids from the cells resulting hydroperoxides, which
in their turn react as secondary reactive oxygen
species (ROS). The radicals and the peroxides
having a long life can diffuse in the cell and can
determine distant oxidative lesions, even in the DNA
or proteins [6–8].
In fact, the results of the in vivo application
of PDT depend on the effects that it has on tumor
cells, on tumor vascularization as well as on the
host’s immune cells, a combination of these effects
contributing to the long-term control of the tumor
[9]. The vascular modifications depend on PS, but
in most of the cases lesions of the vascular
2
endothelium appear and thrombi form through the
activation of the platelets and through the release of
thromboxane. Also, vasoconstriction can occur due
to the inhibition of formation/release of endothelial
nitric oxide (NO) [10][11]. The inflammation is
considered an important event in the development
of the specific antitumor immunity; this type of
therapy induces the expression of some cytokines
and pro-inflammatory chemokines: interleukine
(IL1ß, IL6), tumor necrosis alpha (TNFα), of
inflammatory proteins of the macrophages (MIP-1,
MIP-2) but also of the cellular adhesion molecules:
Selectin E and intercellular adhesion molecule
(ICAM). These modifications are accompanied by
a massive infiltration of the treated tumor with
leucocytes, most of them being neutrophils, mast
cells and macrophages [9].
PHOTOSENSITIZERS
The ideal PS would be a chemically pure
drug with preferential uptake in tumor, rapid
clearance, and a strong absorption peak at light
wavelengths >630 nm [2]. There are a few
mechanisms which increase the retention of the PS
in the tumors: tumor cells proliferate rapidly, have
reduced lymphatic drainage, express more
receptors for low density lipo-proteins, have low
pH, have increased vascular permeability, have
increased porphyrin binding collagen production,
the macrophages in the tumor favor the captation of
hydrophobic PS in cells [5].
FIRST GENERATION
The first generation of PS comprises hemato-
porphyrin (HpD), hematoporphyrin derivatives, and
the purified commercial compound, Sodium Porfimer
or Photofrin [2]. Photofrin, a mixture of porphyrin
oligomers, has maximum absorption at 630 nm, a
depth of action of 0.5 cm, has not specificity for
tumor tissue, does not present systemic toxicity, and
determines prolonged photosensitivity (4 to 8 weeks)
[5]. It requires large dosages and a high fluence rate
in order to obtain the same effects as the second
generation of photosensitizing substances.
SECOND GENERATION
The most utilized compound of the second
generation is the 5-aminolevulinic acid (5-ALA)
3 Photodynamic therapy in malignant treatment
(Levulan), an intermediary product of the porphyrin
biosynthesis, which, applied locally, increases the
concentration of protoporphyrin IX (PpIX) in the
tumor cells. The 5-ALA accumulation in the target
cells is higher comparatively to the healthy tissue
because these cells have an intense metabolic activity;
they rapidly release the precursor, and because of a
weak specificity of the ferrochelatase determine
increased concentrations of the Pp IX [12]. Levulan
only acts to a depth of 1.5 mm that is why it is used in
the treatment of superficial cutaneous carcinoma,
especially in the basocellular carcinoma and in the oral
cavity dysplasias [13]. It does have advantages when
compared to Sodium Porfimer because it persists less
in the organism and the photosensitivity is reduced
(1–2 days) [2]. Because of its hydrophylicity it enters
the cells with difficulty. A few ALA alkyl esters with
increased penetration in tissues were tried. The methyl
ester ALA (Metvix) was approved by the European
Union (EU) in 2001 for the treatment of the actinic
keratoses and of the basal cells carcinoma [14].
Other porphyrins were also tested such as
meso-tetrahydroxy tetraphenyl chlorin (m–THPC)
or Foscan, which was approved by the EU in 2001
for the palliative treatment of head and neck
cancers. It is more potent than Sodium Porfimer
and ALA, it requires a small dosage for the control
of the tumors (0.1mg/kg) and a fluence rate of
10–20J/cm2 and the photosensitivity persists for
2–4 weeks. It can penetrate deeper in the tissues
because it has maximum absorption at 652mm.
THIRD GENERATION
The new, 3rd generation PS are still in study,
especially those activated by the long wavelength
light which cause short photosensitivity and have
broad tumor specificity. Although new classes of
PS have entered in clinical trials few results have
been published. These are: ethyletiopurpurin (SnET2),
mono-L-aspartyl-chlorin e6 (Npe6), benzoporphyrin
derivatives (BPD–Verteporfin), lutetium texaphyrin
(Lu-Tex), phthalocyanines, anthracenes, rostaporfin
(Photrex), purpurines, hypocrelines and hyperricin [5].
LIGHT SOURCES
The light sources used can be conventional,
incoherent, cheap (halogen lamps, tungsten lamps,
xenon lamps, fluorescent lamps), as well as
unconventional, i.e. LASER. The conventional ones
287
have the advantage of being simple, cost effective,
and can be applied both in vitro studies as well as
in preclinical studies, in vivo. The disadvantages of
this type of illumination are: significant thermal
discomfort, low light intensity, and difficulties
controlling the light dosage. Light emitting diodes
(LED) represent a new light source for PDT. They
can generate high luminous energy at the wished
wavelength, and can be assembled in different shapes
and sizes. The optimal illumination is obtained from
LASERs because they are monochrome, have high
intensity, and they can be easily coupled with fiber
optics for endoscopic utilization or interstitial
implants. The LASERs emit light with precise
wavelengths but are expensive and require high-grade
technical assistance [2].
PDT AS A CLINICAL APPLICATION FOR
CANCER
For PDT, as for any new cancer therapy, it is
important to identify the specific indications for the
treatment and to evaluate its benefits and
disadvantages relative to standard therapies. Before
discussing in detail the possibilities of usage for the
PDT in different types of carcinoma it is worth
noting a few general aspects regarding this therapy.
PDT is a treatment that usually requires only one
administration of the photosensitizing substance
followed by a single irradiation at a certain time
interval, unlike radiotherapy and chemotherapy,
which require more sessions for 6–7 weeks. The
surgical treatment, although comprised of a single
procedure, requires anesthesia and hospitalization
for a period of time. The cost/effectiveness ratio
suggests that PDT is an efficient treatment method,
rather cheap and which increases the life
expectancy when compared to other palliative
treatments in head, neck and esophagus cancers [2].
Another argument for this type of therapy is that it
is applied locally, the necrosis seldom passes
10mm and because the low penetrability of light,
the healthy tissue around the tumor is not affected.
The local side effects are minor; the functionality is
kept with good tissue regeneration because the sub-
epithelial collagen and elastin are kept intact. In the
case of recurrence the treatment can be applied on
exactly the same area that was previously irradiated
which offers a real advantage compared to radio-
therapy or surgery.
288 Adriana Gabriela Filip et al.
GENERAL INDICATIONS TO PDT
In the case of early primary cancer and early
relapses, PDT is indicated to patients with serious
associated diseases and age-related disorders. It is
performed according to a radical program when
traditional therapeutic techniques (such as surgery
and radiotherapy) are contraindicated. In the case
of advanced tumors of tubular organs (such as the
esophagus, cardiac portion of the stomach, trachea,
rectum, as well as the main, intermediate, and lobe
bronchi), PDT is performed to rechannel these
organs. It is employed as a palliative therapeutic
technique.
ESOPHAGEAL CANCER
Due to very low survival rates at 5 years
(12.5%) and also because the standard treatment,
esophagectomy has a very high mortality, new
treatments were employed, that are less invasive:
endoscopic mucosal resection, coagulation and
PDT [15]. For PDT, illumination is given using
flexible cylindrical diffusers that are placed via an
endoscope, near the tumor. The first studies with
PDT in the esophagus were done as palliative
treatment for obstructive tumors [16]. In 1995
Lightdale et al. published the result of a
prospective randomized multicenter trial that
compared Photofrin-PDT with Nd:YAG thermal
ablation for the palliation of partially obstructing
esophageal tumors. In this trial PDT proved its
efficiency leading to the relief of dysphasia for a
longer period of time compared to thermal ablation.
Moreover, there were less treatment sessions
needed and 9 out of 236 had a complete response
(CR) after PDT, there was only one patient with
esophageal perforation compared to 7% registered
using thermal ablation [17]. PDT is efficient as a
curative treatment for small, superficial tumors. A
CR of 87% after 6 months and of 25% after 5 years
was obtained in a group of 123 patients treated with
sodium Porfimer [18]. PDT has also been proposed
for the treatment of Barrett’s esophagus (BE) with
high-grade dysplasias to destroy an area of thin
tissues spread eventually over a wide area instead
of a mass of tissues [19]. Only PDT using
Photofrin® is approved by the FDA for the
treatment of precancerous lesions in BE. Overholt
4
et al. have published extensively studies regarding
their experience of using PDT in 103 patients, most
of whom had high-grade dysplasia (HGD). The
mean follow-up in this group was over 4 years. Of
the 65 patients with HGD 78% had their HGD
eliminated. On the basis of an intention-to-treat
analysis, 54% had no residual BE [20]. The overall
stricture rate for patients treated with PDT was 30%,
but for those who required more than one PDT
treatment it was 50%. Subsquamous, nondysplastic
specialized intestinal metaplasia occurred in 4.9% of
patients, but more importantly 3 patients (4.6%)
developed subsquamous adenocarcinoma.
CHOLANGIOCARCINOMA
PDT can be used in the endoscopic palliative
treatment of cholangiocarcinoma. Two small-
randomized studies have reported both palliative
effects and an increase in median survival. For
example, Ortner et al. conducted a trial of 39 patients
with nonresecable cholangiocarcinoma who were
randomized to receive either endoscopic stenting
alone or in conjunction with PDT. The median
survival of the 20 patients in the PDT group was
493 days compared to 98 days in the 19 patients
who underwent stenting alone. The trial was
terminated prematurely due to the favorable results
[21]. Preliminary studies suggest that operative
PDT might also improve survival for those patients
undergoing surgical resection [22].
Currently the National Comprehensive
Cancer practice guidelines for the treatment of
hepatobiliary cancer do not list photodynamic
therapy as one of the treatment options.
STOMACH CANCER
Most of the reports of PDT for gastric cancer
are included in large reports of PDT for various
upper gastrointestinal cancers such as esophageal,
cardia region and gastric [23]. The data currently
available for gastric cancer are very similar to those
for early esophageal cancer in that they involve
small series of patients with short follow-up, a
variety of tumor stages, different light dosimetry,
and different means of evaluating tumor response
[23][24]. If light delivery can be improved and if
gastric tumors can be detected early enough, then
PDT may play a role in their treatment.
5 Photodynamic therapy in malignant treatment
COLORECTAL CANCER
Only a handful of papers describe PDT for
colon and rectal cancer; this is surprising when one
considers the incidence of this disease [25][26].
PDT has been performed on smaller lesions,
namely adenomas. The first study included eight
patients with nine sessile villous adenomas, all but
one of which recurred after Nd:YAG thermal
ablation. After a follow-up period of 9 to 56
months, a biopsy was performed, and it was found
that seven of the nine adenomas had been
completely eradicated [27]. Use of the Nd: YAG
laser to ablate adenomas is an alternative in
nonoperative candidates. Although it successfully
removes the lesion in 84% to 93% of cases with
low morbidity and mortality rates (1% to 5% and
0%, respectively), the progression to invasive
cancer after treatment is 5.7% to 9.1% [23].
Another study involved the treatment of large
recurrent intestinal polyps in six patients with
familial adenomatous polyposis. Of the two
patients with colonic polyps, one was found to
show a CR to treatment and no complications were
reported [27].
HEAD AND NECK CANCER
Early-stage carcinomas in the head and neck
area are normally treated with surgery and/or
radiotherapy, while, for advanced disease,
chemoradiation is standard treatment. Cure rates
are good, especially for early disease, but can be
associated with high morbidity (functional damage,
swallowing, speech difficulties, xerostomia, trismus,
and even osteonecrosis).
PDT is effective for small superficial tumors
or palliative treatment of recurrent disease but has
the advantage of sparing tissue beneath the tumor,
giving excellent long-term functional and cosmetic
results [28]. Foscan is so far the most potent
licensed photosensitizer for PDT. A large-scale
multi-center study using Foscan-PDT for early
stage (T1 and early T2) oral cancers has been done.
The CR at 2 years was 75% after one PDT
treatment but if re-PDT, surgery or radiotherapy
were used a CR could be achieved in 8/13 patients
[29]. PDT with mTHPC of second and multiple
primary cancers resulted in CR rates of 67% for all
tumors and 85% for T1 tumors [2]. For superficial
tumors of the larynx and oropharynx similar results
were obtained with a single treatment [30]. Of
289
19 patients treated had a histological CR over a
follow-up period of 13–71 months. Because the
action of PDT is limited to small superficial tumors
to treat deep-seated, bulky tumors, Lou et al.
implemented interstitial PDT. The overall median
survival of the patients was 14 months while 72%
overall palliative benefit was achieved. The local
control rate at 12 months was 41% [31].
BASAL CELL CARCINOMA (BCC)
Skin cancers are ideal for the study of the
effects of PDT [2]. Dougherty was the first to treat
three BCC of face with PDT in a 72 years old
patient with PDT with a CR of over 85% [9].
Feyh et al. [30] in a study conducted on
57 patients using hematoporfirin 2 mg/kg and laser
argon light at a fluence of 100 J/cm2 evaluated the
results using skin biopsies after 2 months and saw a
complete response in 51 patients. The patients that
did not have a complete response after the first
treatment were treated again with PDT and a CR
was registered in all the patients. For the patients
with only few localized lesions is used topical ALA
or an ester of ALA called Metvix. ALA can be
applied topical a few hours before irradiation with
excellent results in the treatment of basal cell
carcinoma. Soler et al. [32] studied the long-term
effects of methyl 5-aminolaevulinate (MAL)-PDT
in 59 patients with 350 BCC. Nodular tumors were
curetted before PDT and MAL (160 mg/g) was
applied to all tumors for 24 h or 3h prior to
irradiation with a broadband halogen light source
(50–200 J/cm2). Patients were followed for 2–4 years
(mean 35 months). Overall cure rate was 79%,
cosmetic outcome was excellent or good in 98% of
the completely responding lesions. Svanberg et al.
[33] showed an improved response after PDT in
nodular BCC (from 64% up to 100%) if prior to the
treatment drugs that enhance the penetration into
the tissue are applied (dimethyl sulfoxide 20% and
EDTA 4% added to ALA 20%).
In a recent European multicenter, open,
randomized trial, MAL-PDT for nodular BCC was
compared with surgery. A total of 101 patients
were included and received either PDT twice,
7 days apart (75 J/cm2 red light) or surgical
excision. The primary end point of this trial was the
clinically assessed lesion clearance at 3 months
after treatment, besides cosmesis. The 3-month
cure rate was similar with MAL-PDT or surgery
(915 vs. 98%), the 24 month recurrence rate was
290 Adriana Gabriela Filip et al.
10% with MAL-PDT and 25 with surgery. The
cosmetic result was rated good/excellent in 85% of
the patients receiving PDT vs. 33% with surgery [34].
A recent prospective phase III trial that
compared the effects of ALA-PDT with cryo-
therapy in the treatment of superficial and nodular
BCC did not find any difference between the two,
only superior results for PDT regarding cosmetical
results and quicker healing [35]. Complete
resolution of 96% after 12 months for BCC is
possible if the treatment is repeated after 7 days
[36]. The guideline issued by the British
Association of Dermatologists in 1999 regarding
the treatment of BCC advises the use of PDT as the
primary treatment for superficial BCC in spread
forms or in those with multiple localizations.
BOWEN’S DISEASE
Bowen’s disease is the affection with the best
response to PDT. Topical PDT using 20% ALA
has been extensively assessed in Bowen’s disease
with more than 14 open and three randomized
comparison studies [36]. In a recent study by Salim
et al. ALA-PDT was compared to topical 5-fluoro-
uracil (5-FU). In this bi-center, randomized, phase
III trial, 40 patients with one to three lesions of
previously untreated, histologically proven Bowen’s
disease received either PDT (20% ALA in an o/w
emulsion 4h prior to illumination) or 5-FU (once
daily in week one and then twice daily during
weeks 2–4). Twenty-nine of 33 lesions (88%)
treated with pDT showed CR vs. 67% after 5-FU
[37]. The data in the literature are controversial,
though, as to the antitumor response to ALA-PDT.
Some researchers give results of 90–100% while
others only 50% [38].
BLADDER CANCER
The first license for Photofrin was granted in
Canada in 1993 for use following transurethral
resection for papillary tumors [14]. In clinical trials
with HpD or Porfimer sodium PDT it was observed
that PDT is more efficient in the treatment of
superficial recurrent bladder carcinoma, with very
high initial response rates (70–100% at 3 months)
and long term response rates of 30–60%, compared
to the responses after transurethral resection or
treatment with bacillus Calmette-Guerin [39]. For
whole–bladder PDT there was, however, a very
high incidence of side effects: urinary frequency,
6
pain, and persistent reduction in bladder capacity.
These complications were associated with excessive
light doses and no uniform light delivery. Because
of severe and long lasting side effects, Nseyo
et al. suggested multiple treatments at lower drug
dose [40].
Whole bladder PDT with green light and
proper dosimetry remains an attractive treatment
option for carcinoma in situ although this has not
been fully evaluated. Recently, it was shown that
ALA PDT, used solely or in association with
mitomycin C, determines a complete response in
40%–52% of the cases at 18–24 months, without
any significant side effects [41]. Kreigmair et al.
used intravesical ALA in 10 patients with
refractory superficial transitional cell carcinoma
and obtained a complete remission in 4 patients
after 10–12 weeks and a partial one in 2 patients.
Fifty percent of patients had progressive disease
that required cystectomy after a mean follow-up of
15 months. It has been shown that with repeated
PDT treatments, it is possible to limit or inhibit
progression of disease and cures a proportion of
patients [42].
PROSTATE CANCER
Since the beginning of the 90’s there were
attempts to use Foscan and ALA PDT to treat
patients with prostate cancer that do not respond to
radiotherapy. In studies using canine models it was
shown that PDT leads to necrosis of the prostatic
tissue and does not affect the collagen. This
suggests that using a proper dosage of light and PS
you can destroy the whole prostatic tissue and not
affect the perineal anatomy [43]. There are first
phase trials using mTHPC in the treatment of
recurrent forms of cancer [2]. Also Motexafin
lutetium and Tookad were used for the complete
ablation of the gland. This therapy involves the
implantation of multiple diffuser fibers into the
prostate gland through a transperineal brachy-
therapy template. Because there is a difference in
the optical properties of the different tissues in the
prostate we ought to measure in real time the
concentration of PS and light fluence. Protection of
the pelvic nerve also becomes an inevitable
challenge during total ablation because we need to
minimize the adverse effects on sexual and urinary
functions [22]. Using Pd-bacteriopheophorbide or
Tookad, also known as WST09 (NegmaLerads/-
Steba Biotech), has some advantages: rapid clearance,
7 Photodynamic therapy in malignant treatment 291

profound penetration of the light leading to
important destructions in the glandular tissue; it
affects primarily the blood vessels that feed the
tumor. This supports the approach being used in
current Phase I/II clinical trials of Tookad-PDT for
recurrent prostate cancer [22].
LUNG CANCER
Many publications have shown the therapeutic
usefulness of PDT in different stages of endo-
bronchial disease. Palliative treatment of obstructive
cancer with HpD or Porfimer sodium PDT was safe
and resulted in symptom relief in almost all patients
[44]. The effects are similar to those obtained with
Nd:YAG laser but they last longer [14]. The results of
a multicentric trial which compares the two
modalities reported, but not published, shows a more
durable response with PDT and the superiority of
PDT comparatively to Nd: YAG for relief of
dyspnea, cough and haemoptysis.
PDT has also been used as a curative
treatment in early lung cancer. Overall, 5-year
survival rates were in the range of 56%–70% with a
disease specific 5-years survival rate of 90% for
carcinoma in situ. The optimum response appeared
to be in patients with small tumors less than 1 cm
in length (97% versus 42.9% for tumors larger than
1 cm) [46]. Another indication for endobronchial
PDT is field cancerization or recurrence of tumors
after resection or irradiation.
Malignant pleural mesothelioma, often related
to asbestos exposure, responds poorly to conventional
therapies and it is very aggressive. Photofrin-PDT has
been tested as an adjuvant intraoperative modality in
several countries and proved to be safe and efficient
in stages II mesothelioma and I. To improve its
efficiency it should be tried in combination with
hyperbaric oxygenation [22].
CONCLUSIONS
In conclusion, future research will undoubt-
edly be directed toward the development of
improved photosensitizers increased tumor normal
selectivity and fewer side effects. The research is
also focusing on more efficient light delivery and
increased understanding of the optical properties of
tissues in addition to the effects of drug and light
fractionation. Only when all these issues have been
addressed will PDT fully realize its potential role
as a major form of cancer treatment.

Terapia fotodinamică (PDT) este o tehnică nouă utilizată în tratamentul

neoplaziilor solide şi se bazează pe formarea de singlet oxigen indusă de
fotosensibilizatori după iradierea cu lumină vizibilă. În articol se discută
mecanismul interacţiunii fotosensibilizant – lumina precum şi efectele produse în
tesutul ţintă. PDT a fost aprobată în multe ţări în tratamentul cancerelor din sfera
ORL, a celor de esofag, plămân, vezică urinară, piele. Efectele antitumorale ale
PDT se datorează atât actiunii citotoxice directe asupra celulelor tumorale cât şi
leziunilor vasculare care apar şi activării imunităţii gazdei. Se discută în articol
indicaţiile clinice ale PDT şi se trec în revistă principalele clase de
fotosensibilizanţi. În ciuda rezultatelor promiţătoare obţinute în primele trialuri
clinice sunt necesare în continuare studii pentru a transforma această modalitate
de tratament într-o tehnică modernă.

Corresponding author: Adriana Filip, MD

Physiology Depart., “Iuliu Hatieganu” University of Medicine and
Pharmacy, Cluj-Napoca
E-mail:adrianafilip33@yahoo.com

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Received September 1, 2008

294 Adriana Gabriela Filip et al. 10
 Nutrigenomics/Nutrigenetics

NICOLETA MITROI1, MARIA MO Aβ

1
Clinical County Emergency Hospital Craiova, Clinic of Diabetes Nutrition and Metabolic Diseases
β
University of Medicine and Pharmacy Craiova, Diabetes Department

Since Hippocrates it is known that nutrition plays a very important role in maintaining health,
people being advised to consider “food intake as a real medicine” [1][β]. Modern science shows that
important and necessary for an optimal state of health is not only the intake of some specific nutrients,
but, above all, specific quantities of each and every nutrient which are to be taken. New notions have
consequently appeared, such as dietetic recommendations and nutritional epidemiology. At the same
time, it has been emphasized that nutrition can directly contribute to diseases appearance
(nutrients/food generally interact with the genes in a “benign” way, but in some circumstances this
interaction can also have fatal consequences) [1–γ].
Human development is influenced by both environmental factors (diet, smoking, education,
physical activity etc.) and heredity; both factors should be given equal attention, if our aim is to
maintain the state of health. Experimental studies are often dedicated either only to the influence of
environmental factors or exclusively to genes’ influence and not to both simultaneously [4]. Modern
techniques and methods of study are designed to solve the problem.
Key words: nutrients, gene, epigenetic interactions, genetic variations.

Last generation techniques allow the study of related, they need nevertheless a fundamental
all genes, proteins and metabolites in a given sample, different approach in understanding gene-diet
enabling at the same time the correlation of relation. On the long term, the two scientific
information. The result of these investigations domains interact and share a common goal: to
consists in creating new terms which are improve the state of health and to prevent the
characterized by the fact that they all contain the appearance of nutritional diseases (Fig. 1).
Greek suffix “ome”/”omic” (in translation complete,
global, totally or whole): Genomicsţglobal genes’
analysis; Transcriptomicsţglobal analysis of mRNA;
Proteomicsţproteins’global analysis; Metabolomicsţ
metabolites’global analysis [5].
Nutrigenomics studies the interaction between
nutrients and genes [1][6]. Nutrients modulate the
expression and regulation of coding genes of
proteins, metabolisms, cellular differentiation and
growth [1, 6]. Nutrigenomics has a double role: on
the one hand, to explain the functional interaction
between food bioactive components and human
genome (at molecular, cellular and systemic level); Fig. 1. – Personalized nutrition (from MUTCH D.M., WAHLI
on the other hand, the role of Nutrigenomics is to W., WILLIAMSON G., Nutrigenomics and nutrigenetics: the
reveal the effects of genic variation upon diet- emerging faces of nutrition. The FASEB Journal, β005, 19:
160β–1616, modified).
disease interaction.
The study focused on the discovery of the
specific response of each individual to food items, DIET-DISEASE RELATION
aiming to develop individualized dietetic recommen-
dations [1][7]. At present, two terms are used to The understanding of diseases’ appearance has
define the two scientific aspects: Nutrigenomics and considerably progressed since human genome
Nutrigenetics. Although the two terms are intimately sequencing has been performed for some eukaryotes

ROM. J. INTERN. MED., β008, 46, 4, β95–γ04

β96 Nicoleta Mitroi, Maria Mo a
[8]. From about 1000 genes that have been by now
associated with the development of some diseases,
97% are related to diseases with monogenic
determinism [9]. Modifying the intake of some
food items or nutrients, one can prevent diseases
with monogenic determinism, for example
galactosemia and phenylketonuria. On the other
hand, the diseases which tend to become
epidemical, such as neoplasy, obesity, diabetes and
cardiovascular diseases appear most frequently as a
result of the disfunctionality of more genes, being
thus called polygenic diseases. If we consider
establishing some dietetic solutions in order to
prevent these diseases, then we must know not only
the way in which a nutrient can influence a biologic
system, but, above all, the way in which a complex
ingredients mixture – which is actually the diet –
interacts in modulating biologic functions [10].
FOOD/NUTRIENT – GENE INTERACTIONS
Food contains genic expression regulators,
such as: nutrients: fatty acids, selenium, zinc; non-
Food:
-nutrients Direct interactions
-non-nutrients
-metabolites of
food
components
-compounds
resulted from Epigenetic interactions
intestinal
metabolism
Genetic variation
SNPs
Fig. β. – The complex relationship between nutrition and genic expression.
NUTRIGENOMICS
Nutrition can no longer be considered to be just
the science of simple epidemiologic studies which
aim to discover the relationships between nutrition
and chronic diseases in genetically uncharacterized
populations. At the same time, one must also take into
consideration the integration of cellular biology,
biochemistry and genetics knowledge. Nutrigenomics
aims to identify the biological markers which can
describe more accurately the state of health (by
discovering new molecular targets).
β
nutrients: phytochemicals, isoflavones; metabolites
of food components: eicosanoides; compounds
resulted from food processing: heterocyclic amines;
compounds resulted from intestinal metabolism
under the influence of microbial flora [4].
Nutrient – gene relation is characterized by
the existence of the following interaction types:
−
direct interactions: the nutrients, possibly as a
result of the interaction with a receptor, behave as
transcription factors which can bind at the DNA
level, causing the acute expression of a gene.
− epigenetic interactions: the nutrients can
modify DNA structure, case in which the
expression alteration of that particular gene
becomes chronic.
− genetic variations: common genetic variations
(single nucleotide polymorphism-SNPs) can
modify a gene’s expression or function.
The interaction between nutrient and gene can
cause the disturbance of the following processes
(Fig. β): genic transcription; mRNA translation; mRNA
processing; mRNA determining; post translational
modifications.
Genic transcription
mRNA translation
GENE mRNA processing
mRNA determining
Post-translational
modifications
From the three possible interactions between
a nutrient and a gene (mentioned above),
Nutrigenomics evaluates the acute effects of the
nutrients upon the transcription process and
epigenetic interactions.
ACUTE EFFECTS OF THE NUTRIENTS UPON
GENES TRANSCRIPTION [11]
There are several nutrients which can modify
genes expression, acting as transcription factors:
− vitamin A interacts with retinoic acid receptor,
and the resulted complex causes transcription
γ Nutrigenomics/Nutrigenetics
activation or inhibition, in the case of attaching
to a certain level of gene promotor region [1β]
− fatty acids can interact with PPAR (peroxisome
proliferator-activated receptors), which can
modify genes expression by attaching at DNA
level [1γ]
− the interaction between vitamin D and its
receptor
− Calcium-calcineurin interaction
− Zinc – transcription factor 1 interaction (metal-
responsive transcription factor 1) [14].
All these examples refer to a nutrient which
acts like a short term trigger and causes the acute
modification of the transcription process; this effect
generally disappears once the exposure to the
specific nutrient has been stopped.
EPIGENETIC INTERACTIONS
Epigenetic mechanisms have been recently
implicated in describing the way in which nutrients
modify genes expression; these are mediated either
by DNA methylation or by histone methylation or
acetylation, or by both [15]. Such epigenetic modi-
fications can lead to genic expression perturbance
which can last the whole life and can be transmitted
to the coming generations.
DNA methylation is usually performed at the
level of cytosine base (regions 5’-CpG-γ’) [16],
influencing thus both genes transcription process
and genome stability [17]. If this modification
takes place at the level of promotor region, the
result is a perturbance in genic expression [18].
Normally, the intensification of methylation
process associates with genic expression reduction
[18] because the methylated regions 5’-CpG-γ’
possess the property to provoke protein attachment,
hindering thus the access of transcription factors
[19]. Once the methylation is completed, it will
replicate each time when the gene is copied.
DNA is surrounded by proteins (histone)
which hinder the access to genes promotor regions.
If histone methylation or acetylation take place
[β0], then some channels can be created, through
which transcription factors can penetrate, causing
promoters activation.
Diet modification concerning methyl groups
can induce stable modifications in genes methylation,
disturbing genic expression and resultant phenotype
[β1]. For example, the choline quantity (methyl
donor) that is to be found in the nutrition of
β97
pregnant mice females influences proliferation and
apoptosis rates of nervous cells in the fetus brain
[ββ]. Colin quantity reduction in food was
associated with DNA methylation perturbance [βγ].
Differences regarding visual, spatial and auditive
memory have been also observed [β4]. If colin
intake was high, the offspring had a γ0% higher
visual, spatial and auditive memory [β5], this high
colin exposure during intrauterine period causing
also the perseveration of memory capacity.
Epigenetic effects of nutritional modifications
were also observed in humans. In this sense, the
specialists discovered that persons whose paternal
grandparents were confronted in the growing up
period with the absence of some nutrients from the
diet (they did not have a diverse diet) presented a
higher life expectation and a risk of diabetes
mellitus with up to 75% lower [β6]. Pembrey [β7]
demonstrated that these nutrition effects are being
performed through epigenetic mechanisms hereditary
transmitted. In a similar way, epigenetic mechanisms
can be involved in carcinogenesis process modulation
in adults.
LONG-CHAIN POLYUNSATURATED FATTY ACIDS
(LC-PUFA) AND CARCINOGENESIS
LC-PUFA are implicated in numerous
processes such as: growing process, neurological
development, the development of muscular and
adipose mass, reproduction, innate and acquired
immunity, virus infections, bacteria and parasites,
the incidence and gravity of some diseases,
including neoplasias, atherosclerosis, stroke,
arthritis, diabetes, osteoporosis, neurodegenerative
and inflammatory diseases and skin pathology
[β8][β9]. The roles played by LC-PUFA are
associated to their capacity to act (or to be
transformed in) as ligands for various transcription
factors, including PPAR, hepatic nuclear factor 4,
the protein responsible for sterol transport, liver-X-
receptor alpha, nuclear factor κ [γ0][γ1]. It was
also demonstrated that fatty acids are involved in
lipid metabolism modifications (related to phosphor-
lipids, triglycerides and cholesterol esters) [γβ][γγ].
LC-PUFA represents also the most frequently
studied lipid fraction regarding its role in neoplasias
appearance [γ4]. It has been demonstrated that fish
oil (rich in omega-γ fatty acids) inhibits the cell
growth of a colon tumor, both in vitro and in vivo
[γ5]. Preliminary results indicate the involvement
of these nutrients in function modulation of some
β98 Nicoleta Mitroi, Maria Mo a
transcription factors, RNA transcription process,
prostaglandins synthesis, genes activity responsible
for nitric oxide synthesis [γ6][γ7].
SITOSTEROLEMIA
Sitosterolemia is a rare autosomal recessively
inherited metabolic disorder, characterized by hyper-
absorption and decreased biliary excretion of
dietary sterols, leading to hypercholesterolemia,
xanthomatosis, premature development of athero-
sclerosis, and abnormal hematological and liver
function test results. Sitosterolemia shares several
clinical characteristics with familial hypercholestero-
lemia; however, in contrast to familial hypercholestero-
lemia, it presents normal to moderately elevated
total sterol levels and very high levels of plant
sterols (10–β5 times).
The results of the Berge’study explained two
disputed aspects: the mechanism through which
plant sterols – structurally similar to cholesterol –
are normally absorbed in a negligible proportion
and the fact that patients with sitosterolemia show
an increased absorption of plant sterols [γ8]. Study
design: evaluation of mice subjected to the
treatment with a drug that interferes with lipid
metabolism; mRNA profiles for different tissues
were compared with those of normal mice. It was
discovered a gene belonging to the family “ATP
binding cassette” (ABC), which includes genes that
codify the proteins responsible for lipid transport.
Berge concluded that the proteins codified by genes
belonging to this family, respectively ABCG5 and
ABCG8, are the ones implicated in the transport
modulation of animal or vegetal sterols absorbed at
intestinal level. The human homologue of this gene
was then identified, and, after its cloning, it was
used in the screening of patients with sitostero-
lemia. All evaluated cases proved to carry mutations
of this gene, lacking thus the control mechanism
responsible for a selective and controlled cholesterol
transport. This fact leads to increased sterol
absorption, including those of vegetal origin.
NUTRIGENETICS
Nutrigenetics studies the way in which the
genetic inheritance of each individual interferes in
the response of the organism to nutrition. There are
more than 10 million SNPs (Single Nucleotide
Polymorphisms) which appear in more than 1% of
4
the population [γ9], some of them being
encountered with a frequency which varies
between 5% and 50%. Most humans are
heterozygote for ≥ 50.000 SNPs [40]. The SNP
Consortium is in charge with mapping important
polymorphic sites which dictate phenotype
differences. The largest SNP database contains
approximately 7.7 million SNPs (dbSNP). Some of
these cause either genic expression perturbance, or
structural and functional modifications of gene
codified proteins.
There are some genes (so-called “susceptible”)
which are characterized by the existence of a specific
interrelation with diet [41]. In order to identify
these genes, one must take into account several
conditions: genes chronically activated in illness
periods and which proved to be sensitive to dietary
interventions; genes with important functional
variations; genes that are important in biological
cascades; polymorphisms with high prevalence in
population; genes with associated biomarkers,
enabling thus the performing of clinic studies.
In some regions of the genes (≤ 500kb) we
can encounter combinations of some SNPs related
to one another which are identified in many
persons (haplotype blocks). These associated SNPs
combinations are transmitted over several generations
[4β]. The identification of some alleles of a haplotype
block can lead to the description of all polymorphic
sites from this region characteristic for a group of
people with the same race or ethnical background,
and this could make SNPs analysis much more
accessible for nutritionists and clinicians.
GENETIC VARIABILITY CAN INFLUENCE
DIETARY NECESSITIES
We mention here some examples of SNPs
which are known to influence food intake
necessities of a nutrient:
−
5,10 methylentetrahydrofolate reductase (MTHFR)
is an enzyme implicated in folate metabolism.
The gene which codifies for MTHFR has a
common SNPs (allele C677T) that is associated
with the reduction of enzymatic activity
translated in the reduction of homocystein
conversion in methionine. Homozygote subjects
are characterized by high plasmatic homocystein
concentrations [4γ] (considered to be cardio-
vascular risk factor) [44]. Although the
nutrient-gene interaction has been described
5 Nutrigenomics/Nutrigenetics
[45], there are still controversies regarding the
fact that diet supplementation with folate could
reduce cardiovascular risk [46]. According to
some studies, the frequency of these SNPs in
the population is 10–15% [47], and 15–γ0%,
according to others [4γ].
− there are SNPs which modify the risk of
appearance of organ dysfunction [81, 8β, 8γ, 84].
For example, in case of a low choline food intake,
some persons develop hepatic and muscular
affections, others do not. Premenopausal women
carrying very frequent SNPs (MTHFD1-
G1958A) show a 15 times higher risk of
developing choline deficiency compared to
those who do not have these SNPs [85]. It has
been also observed that the appearance risk of
neural tube defects in offspring is increased
also if mothers carry these SNPs [86] and if
they had a diet characterized by a low choline
intake [51]. It is interesting to find out if these
women (with the higher risk) are also SNP
G1958A carriers.
− PEMT gene (phosphatidylethanolamine n-methyl-
transferase) codifies a protein responsible for
choline endogeneous formation at hepatic level
[5β] and it is induced by estrogen [5γ]. Studying
organ dysfunctions which can appear in case of
choline deficit, one discovered that a SNPs
present at the level of PEMT gene promotor
region (rs1βγβ5817) is associated with susceptibility
increment only in women [51].
− SNPs of SREBP gene (sterol response element
binding protein) influence the hepatic lipo-
genesis process induced by fructose [54].
− the gene for PPAR-alpha has a SNPs which was
associated with the modifications of total
cholesterol, LDL cholesterol and apolipoprotein
B concentrations [55], perturbing the organism
response to n-6 polyunsaturated fatty acids
intake. In persons carrying the variant allele, the
high n-6 polyunsaturated fatty acids intake was
associated with a significant reduction of triacyl-
glycerol concentration [55].
Several studies evaluated the correlations
between some SNPs and particular phenotypes, aiming
to investigate the relations between the millions of sites
of recently discovered genetic variants.
INSULIN RESISTANCE AND TYPE β DIABETES
MELLITUS
Some observational studies described a
higher type β DM incidence in persons with low
β99
physical activity or high food intake [56]. Once the
results of the first study carried out in this direction
had been presented (West and Kalbfleish [57]), it
was known that a diet characterized by a high
caloric and lipid intake plays an important role in
type β DM appearance. According to present
information, both genetic and environmental
factors are significant for diabetic disease etiology.
Recent studies on mice carrying genetic variations
which interfere with lipid metabolism have proved
the relationship between lipids and diabetes [58].
The evaluation of genes implicated in fatty acids
and triglycerides synthesis played an important role
in demonstrating that neither diabetes, nor insulin
resistance are diseases with monogenic determinism;
numerous genes implicated in lipid metabolism
regulation and insulin sensitivity modulate DM
appearance risk (for example the genes for
adiponectin and resistin) [59]. The present data also
show that these genes are diet responsive,
demonstrating at the same time the existence of
correlations between genotype and diet in
developing type β DM predisposition.
CORONARY HEART DISEASE
Epidemiologic studies showed the existence
of a correlation between lipids and coronary heart
disease [60], and The National Cholesterol Education
Program added that two of the lipoprotein fractions
are the main targets in fighting this disease: LDL and
HDL. In dyslipidemia treatment, the optimization of
lifestyle represents the first therapeutic step and
includes diet and physical activity modifications,
combined with the determination to reduce
smoking and lose weight. Medicamentous
treatment is the second step of the therapy; statines
are here recommended, because they inhibit the
activity of hepatic γ-hydroxy-γ-methylglutaryl
CoA reductase (HMG-CoA reductase), causing
thus the reduction of sanguine cholesterol level
[61]. But we must also take into consideration the
fact that there are individual differences in
treatment response [100], these being associated
with genetic differences [6β]. Some susceptible
genes have been discovered by now and their SNPs
have been evaluated [6γ]. These genes codify:
cholesterol ester transfer protein (CETP); lipoprotein
lipase (LPL); hepatic triglyceride lipase (HL); LDL-
receptor; apolipoprotein E(APOE); apolipoprotein A1
(APOA1) [64]; ATP binding cassette transporter A1
(ABCA1); lecithin-cholesterol acyltransferase (LCAT).
γ00 Nicoleta Mitroi, Maria Mo a
Nutrigenetics studies reported the fact that some of
the mentioned genes and their variants (for
example APOA1 and LPL) are susceptible to
respond to diet modifications.
LIPOPROTEIN LIPASE (LPL)
Abnormalities in LPL function have been
found to be associated with a number of diseases
(atherosclerosis, obesity, Alzheimer’s disease and
dyslipidaemia associated with diabetes) [65]. There
have been described some polymorphisms characterized
by LPL dysfunction that contribute to an early
appearance of coronary heart disease, mainly
because they associate with high triglycerides
levels [66]. Merkel evaluated some of the most
common LPL polymorphisms and showed that
these cause modifications of circulating lipids in
pregnant women (who frequently present high
levels of triglycerides and total cholesterol). Thus,
although triglycerides remain unmodified, it has
been shown that some of SNPs for LPL modify
HDL level and pregnant women’s susceptibility for
coronary heart disease [67]. Another LPL poly-
morphism was also studied (T495G HindIII),
results indicating that this plays an important role
in the appearance of coronary heart disease, obesity
and diabetes [68]. The respective SNPs is
characterized by high triglycerides and low HDL
levels. Lipid profile perturbation and the diseases
correlated with T495G HindIII proved to be
influenced by several factors, such as physical
activity [69] and low caloric intake [70].
PEROXISOME PROLIFERATOR-ACTIVATED
RECEPTORS (PPARS)
PPARs mediates the cellular response to
different biologic and synthesis factors, such as
fibrates, thiazolidinediones, fatty acids and their
derivatives [71]. Three types of PPAR have been
identified: α, /δ and [7β]. PPAR- activation
promotes adipogenesis and TG storage through its
action on some genes, inclusively those responsible
for fatty acids transport, including them in TG and
through glyceroneogenesis [95]. PPAR- activation
by thiazolidinediones will result in lowering the
circulating fatty acids level by promoting their
capture in adipocytes and, finally, by increasing
insulin sensitivity. Several studies on mice have
shown that PPAR- +/– mice possessed an insulin
sensitivity superior to that expected by investigators
6
[7γ]. It has also been discovered that the absence of
specific hepatic PPAR- in an obese mouse (with
leptin deficiency) is associated with the absence of
lipid accumulation capacity in the liver, resulting in
appearance of insulin-resistance and type β diabetes
mellitus [74].
The important roles played by PPAR-
showed that the genes for these can be involved in
type β diabetes mellitus appearance [75]. It is
demonstrated that a certain mutation of the gene for
PPAR- β (replacing proline with alanine) increases
insulin sensitivity and reduces the risk of type β
diabetes mellitus appearance [77]. Thus, both The
Bogalusa Heart Study [1γ6] and The Go-DARTS
Study [1γ5] have registered the association of the
polymorphism of the gene for PPAR- β (Pro1βAla)
with insulin sensitivity increment and, respectively,
with a reduction of heart attack risk associated to
diabetes. Other trials have reported the fact that
Pro1βAla is associated with a high body mass index,
this being one of the factors which predispose to type
β diabetes mellitus appearance [78].
Through the correlations established between
genetic variability and diet, on the one hand, and
insulin resistance, type β diabetes mellitus and
cardiovascular diseases, on the other hand, these
studies have demonstrated the way in which
individual’s genotype determination can contribute
to nutrition management in order to prevent disease
appearance.
CONCLUSIONS
All examples mentioned above show that it is
possible today to understand both the way in which
genes’ SNPs are implicated in modifying nutritional
necessities, and how nutrition can influence genetic
expression. In the future we may be able to identify
thousands of SNPs and at least an equal number of
epigenetic modifications. It must be also mentioned
that these modifications in the genes can interact in
a complex way.We must notice that the integrated
analysis of genetic, proteomic, metabolomic
characteristics and of the complex interaction
between genome and food/nutrient (nutritional
phenotype) should represent the evaluation basis of
the nutritional status of a person. It becomes thus
obvious that there is a need for collective effort of
the scientific community (genetics, molecular
biology, biochemistry, nutrition, bioinformatics
etc.). For these reasons, nutrition represents in this
7 Nutrigenomics/Nutrigenetics γ01

century an exciting field of research, new the state of health or, on the contrary, to disease
information being obtained almost every day appearance. Each such piece of information helps
regarding the way in which the interaction between us to be one step closer to what we call
lifestyle and genotype contributes to the preservation of “personalized nutrition.”

Nutrigenomica studiază interacţiunea dintre nutrienţi şi gene. Genele

influenţează modul de metabolizare al nutrienţilor şi, reciproc, nutrienţii
modulează expresia şi reglarea genelor codante ale proteinelor, metabolismelor,
diferenţierii şi creşterii celulare. Astfel, rolul nutrigenomicii este dublu: pe de o
parte, scopul este de a înţelege interacţiunea funcţională dintre componentele
bioactive ale alimentelor şi genomul uman (la nivel molecular, celular şi sistemic).
Pe de altă parte, rolul nutrigenomicii este de a înţelege efectele variaţiei genice
asupra interacţiunii dietă-boală. Cercetarea s-a concentrat în acest sens pe
descoperirea răspunsului specific fiecărui individ la alimente, urmărind crearea
unor recomandări dietetice individualizate. Sunt folosiţi în prezent doi termeni
pentru a defini cele două laturi ştiinţifice: nutrigenomica şi nutrigenetica. Deşi cei
doi termeni sunt intim asociaţi, totuşi ei presupun o abordare fundamental diferită
în înţelegerea relaţiei gene-dietă. Ceea ce, pe termen lung, îşi propun drept ţintă
este însă comun şi este reprezentat de: îmbunătăţirea stării de sănătate şi
prevenirea apariţiei bolilor prin nutriţie, iar acest aspect a condus la
intrepătrunderea celor două domenii ştiinţifice.

Corresponding author: Maria Mota, Professor

University of Medicine and Pharmacy Craiova, Diabetes Department
β–4 Petru Rareş Str., Craiova
E-mail: mmota5γ@yahoo.com

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Received August β9, β008

 ORIGINAL ARTICLES

Impact of Highly Active Antiretroviral Therapy on Cytomegalovirus Viraemia in

the Absence of Specific Anti-Cytomegalovirus Therapy

RALUCAăăMIH ILESCU1,ăăVICTORIAăăARAM 1*,ăăSIMONAăăPARASCHIV1,ăăA.ăSTREINU-CERCEL1*,ăăD.ăOŢELEA1,ă

DANIELAăăMUNTEANU1,ăăMIHAELAăăIOSIPENCO1,ăăCARMENăăCHIOTAN1,ăăOTILIAăăELISABETAăăBENEA1*,ăă
MARIANAăăM RD RESCU1,ăăMIHAELAăăR DULESCU1,ăăADRIANAăăHRISTEA1*,ăăRODICAăăUNGURIANU1,ăă
S.S.ăARAM *,ăăANCAăăSTREINUăăCERCEL1*,ăăRUXANDRAăăC LIN1*,ăăC.ăB ICUŞ*ă
1
“Prof.ăDr.ăMateiăBalş”ăNationalăInstituteăofăInfectiousăDiseases,ăBucharest,ăRomaniaă
*
“CarolăDavila”ăUniversityăofăMedicineăandăPharmacy,ăBucharest,ăRomaniaă

Objectives.ă1)ătoăevaluateătheăeffectăofăHAARTăonăCMVăviraemiaăinăco-infectedăpatients,ăină
theă absenceă ofă specifică anti-CMVă therapy;ă 2)ă toă compareă 2ă moleculară biologyă techniquesă foră theă
detectionăandăquantificationăofăCMV-DNAăinătheseăpatients.ă
Methods.ăWeăpresentătheăpreliminaryădataăofăanăongoingăprospectiveăresearchăgrantăonănewlyă
diagnosedă HIVă seropositives,ă ină aă tertiaryă careă hospital,ă duringă Juneă 2006-ă Juneă 2008.ă Clinical,ă
virologicală (HIVă andă CMVă viraemia)ă andă immunologicală (CD4)ă screeningă wasă performedă everyăă
3ămonths.ăTheăCMVăviraemiaăwasăperformedăbyăRoboGeneăHumanăCytomegalovirusăQuantificationă
kită(ajăRoboscreen).ăWeăretestedăallăundetectableăCMVăviremiaăfoundăinăpatientsăwithăCD4<50/mmc,ă
byă CMVă PCRă kită (Qiagenă Diagnostics).ă Bothă PCRă reactionsă wereă performedă onă ABIă Prismă 7000ă
(AppliedăBiosystems).ăă
Results.ăUpătoădate,ăourăstudyăhasăincludedă105ăHIV-infectedăsubjects,ăwhoăwereăseropositiveă
foră anti-CMVă IgGă antibodies.ă Averageă follow-upă wasă 18ă months.ă CMVă viraemiaă wasă foundă
detectableă ină 21ă casesă ată firstă visită andă ină otheră 5ă ată theă secondă visit.ă 22ă casesă hadă CD4<50/mmc,ă
amongăwhichă14ăhadăundetectableăCMVăviraemia.ăTheăresultsăofăbothămolecularăbiologyătechniquesă
wereă widelyă theă same.ă HAARTă wasă prescribedă toă 86%ă ofă theă patients;ă allă theă patientsă havingă
detectableăCMVăviraemiaăreceivedăHAART,ăbutănotăanyăspecificăanti-CMVătherapy.ăUnderăHAART,ă
allătheădetectableăCMVăloadsăwhichăwereăretestedăinătimeăbecameăundetectableăatănextăvisits,ăafterăaă
medianăofă16.5ăweeksăfromătheăintroductionăofătherapy.ăă
Conclusions.ă CMVă viraemiaă detectionă wasă usefulă ină earlyă diagnosisă ofă asymptomatică CMVă
infection.ă Asă opposedă toă transplantă cases,ă moleculară biologyă techniquesă foră theă detectionă andă
quantificationă ofă CMV-DNAă ină HIV-patientsă haveă notă beenă standardizedăyet.ă Inăoură study,ătheă twoă
kitsăRoboGeneăHumanăCytomegalovirusă(HCMV)ăQuantificationăkită(ajăRoboscreen)ăandăCMVăPCRă
kită(QiagenăDiagnostics)ăwereăcomparable.ăHAARTămadeătheăreductionăofăCMVăviralăload,ăwithoută
anyăspecificăanti-CMVătherapy.ăAsăinătheăcaseăofăotherăopportunisticăinfections,ăundetectableănaturală
historyăofăCMVăinfectionăseemedătoăhaveăbeenăimprovedăbyăcontrollingăHIVăinfection.ăă
Key words:ăCMV-HIVăinfection,ăHAART.ă

Infectionă withă cytomegalovirusă (CMV)ă isă
widelyă spread,ă asă benignă forms.ă Bută CMVă mayă
becomeă aggressiveă ină immunodepressedă hosts,ă
augmentingă theiră rateă ofă morbidityă andă mortalityă
[1].ă CMVă infectionă usedă toă beă oneă ofă theă mostă
frequentăopportunisticăinfectionsăamongăHIVăsero-
positivesă beforeă 1997.ă Bută highlyă activeă antiretro-
virală therapyă (HAART)ă hasă hadă aă considerableă
impactăonătheăoccurrenceăandătheănaturalăhistoryăofă
opportunistică infectionsă ină HIVă patientsă [2][3].ă
Furthermore,ă ină HIV-infectedă patientsă withă activeă
CMVăreplication,ătheăimmuneăreconstitutionăfollowingăă
HAARTă seemsă toă beă sufficientă toă bringă CMVă
replicationă underă controlă withoută anti-CMVă
therapyă [4][5].ă Recentă reportsă alsoă suggestă thată
patientsă withă CD4ă cellă countă <50/mmcă areă moreă
likelyătoăhaveădetectableăCMVăviraemiaăthanăotheră
HIV-infectedăindividualsă[6].ă
MATERIAL AND METHODS
Ourăstudyăaimedăată1)ăevaluatingătheăeffectăofă
HAARTăonăCMVăviraemiaăinăco-infectedăpatients,ă
ină theă absenceă ofă specifică anti-CMVă therapy;ăă

ROM.ăJ.ăINTERN.ăMED.,ă2008,ă46,ă4,ă305–311ă
 306ă
ă RalucaăMih ilescuăet al.ă
2)ăcomparingătwoămolecularăbiologyătechniquesăforă
theă detectionă andă quantificationă ofă CMV-DNAă ină
theseăpatients.ăă
METHODSă
Weăpresentătheăpreliminaryădataăofăanăongoingă
Romaniană researchă grantă (CNCSISă 848/2006)ă onă
interactionă betweenă HIVă andă CMV,ă conductedă ină aă
tertiaryă careă hospitală –ă “Prof.ă Dr.ă Mateiă Balş”ă
NationalăInstituteăofăInfectiousăDiseases,ăinăBucharest,ă
Romania,ă overă aă periodă ofă 3ă years.ă Weă includedă
newlyădiagnosedăHIV-infectedăpatients,ăchildrenăandă
adults,ă seropositivesă foră anti-CMVă IgGă antibodies.ă
Allă theă subjectsă oră theiră tutorsă signedă ană informedă
consentăatăenrollment.ăTheăphysicianăinăchargeăfilledă
inăaădossier,ăcoveringăepidemiological,ăclinicalăandă
biologicală detailsă ofă eachă individual.ă Everyă 3ă
months,ăpatientsăwereăscheduledăforăclinicalăcheckă
upă (includingă ană ophthalmologică exam)ă andă alsoă
foră virologicală (HIVă andă CMVă viraemia)ă andă
immunologicală (CD4ă count/mmc)ă screening.ă Theă
HIVăviralăloadăwasăperformedăbyătheăcommercialăkită
Cobasă TaqMană HIV-1ă testă (Rocheă Diagnostics)ă andă
theă CMVă viraemiaă –ă byă RoboGeneă Humană
Cytomegalo-virusăQuantificationăkită(ajăRoboscreen).ă
WeăretestedăallăundetectableăCMVăviraemiaăfoundăină
patientsă withă CD4<50/mmc,ă byă CMVă PCRă kită
(Qiagenă Diagnostics).ă Bothă PCRă reactionsă wereă
performedăonăABIăPrismă7000ă(AppliedăBiosystems).ă
Allă theă patientsă havingă detectableă CMVă viraemiaă
receivedăHAART.ăă
Inăallătests,ătheălevelăofăstatisticalăsignificanceă
wasă setă ată p=0.05.ă Allă dataă wereă processedă withă
SPSSăVersionă12ă(SPSSăInc.,ăChicago,ăIL.).ă
100%
9
3 ă
21
80%
60%
40%
20%
0%
V1 V2 V3 V4 V5 V6
undetectable detectable
ă
2ă
RESULTS
Duringă Juneă 2006ă –ă Juneă 2008,ă oură studyă
includedă 105ă co-infectedă subjects,ă withă HIVă andă
CMVăinfections.ăTheăstudyăpopulationăhadătheăM:ă
Fă ratioă 1:1ă andă theă averageă ageă ofă 30ă years.ă
Averageă follow-upă wasă 18ă monthsă (6ă visits).ă
Accordingă toă standardă guidelines,ă theă majorityă
(86%)ă neededă HAARTă fromă theă enrollment,ă 90%ă
ofăthemăreceivingăităfromătheăsecondăvisit.ăă
ClinicalăstageăwasăAăină15%ăofăcases,ăBăină40%ă
andă Că ină45%.ă Thereă wereă 4ă patientsă diagnosedă withă
HIVă retinopathy.ă Moreover,ă 3ă ofă theseă patientsă hadă
detectableă CMVă virală load,ă higheră thană 7,000ă
copies/mlă(p=0.05);ăbutătheăophthalmologicădescriptionă
didă notă suspectă CMV,ă bută HIVă asă theă causeă ofă theseă
lesions.ăUnderăantiretroviralătherapy,ăallătheseăpatientsă
hadăaăfavorableăophthalmologicăoutcome.ăă
Ată baseline,ă distributionă ofă patientsă byă CD4ă
cellă countă wasă asă follows:ă 70%ă underă 200/mmcă
(20%ă evenă belowă 50/mmc),ă 24.5%ă withină 200–
500/mmcă andă onlyă 5.5%ă overă 500/mmc.ă Theă
registeredă limitsă wereă 2ă andă 4724/mmc.ă Underă
HAART,ă evolutionă ofă CD4ă Tă lymphocyteă count,ă
expressedă asă median,ă trackedă ană increasingă trend,ă
startingăfromăbelowă200/mmcăandăreachingăalmostă
normalărange,ăafteră21ămonthsăofăfollow-up.ă
HIVă plasmaă virală loadă wasă undetectable,ă
<100,000,ă100,000–1,000,000ăandă>1,000,000ăcopies/mlă
ină8,ă58,ă25ăandă11ăcases,ărespectively.ăTherefore,ăoneă
thirdă ofă theă initială HIVă virală loadă wereă higheră
>100,000ă copies/ml.ă Theiră proportionă decreasedă
gradually,ăallătheăsamplesătestedăupătoădateăforăvisitsă7ă
andă8ăbeingăunderăthisălevel.ă
Thereă wereă registeredă 21ă detectableă baselineă
CMVăviraemiaăplusă5ănewădetectableăsamplesăatăvisită
2.ă Underă HAART,ă withoută anyă specifică anti-CMVă
therapy,ă allă ofă theă detectableă CMVă loadsă testedă ină
timeăbecameăundetectableăfromăvisită4ă(Fig.ă1).ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
V7 V8 Fig.ă1.ă–ăCMVăviralăloadă(copies/ml)ăunderă
HAART.ăă
3ă Cytomegalovirusăturnedăundetectableăunderăhighlyăactiveăantiretroviralătherapyă 307

Table I
DetectableăCMVăviraemiasă(copies/ml)ăinătimeăunderăHAART,ăwithoutăanyăspecificăanti-CMVătherapyă
CMV VL CMV VL CMV VL CMV VL
CD4/mmc
V1 V2 V3 V4
Patient Age V1 HAART
SIă 38ă 172ă 3TC+ZDV+LPV/ră 475818.0ă 0ă 0ă 0ă
PGă 32ă 134ă 3TC+ddI+SQV/ră 35028.6ă 0ă 0ă 0ă
TMă 17ă 6ă 3TC+ZDV+LPV/ră 20571.6ă 0ă 0ă 0ă
DAPă 1ă 660ă 3TC+ABC+LPV/ră 19614.6ă 0ă 0ă 0ă
MGă 45ă 66ă 3TC+d4T+EFVă 18624.0ă 0ă 0ă 0ă
MCă 1ă 151ă 3TC+ABC+LPV/ră 11693.4ă <600ă 0ă 0ă
EGă 51ă 33ă 3TC+ZDV+LPV/ră 8673.0ă 0ă 0ă 0ă
CFă 34ă 45ă 3TC+ZDV+EFVă 7263.6ă 798ă 0ă 0ă
SNă 77ă 187ă 3TC+ZDV+LPV/ră 4325.4ă 2296.8ă DEADă ă
DMAă 1ă 4724ă 3TC+ABC+LPV/ră 4164.6ă 496.2ă ă ă
GDă 50ă 132ă 3TC+ZDV+EFVă 1390.2ă 0ă 0ă 0ă
BIă 19ă 19ă 3TC+ABC+EFVă 1388.4ă ă ă ă
IVă 53ă 179ă 3TC+ZDV+SQV/ră 1216.2ă 0ă 0ă 0ă
BINă 29ă 13ă 3TC+ZDV+NFVă 869.4ă 0ă 0ă 0ă
BSă 39ă 10ă 3TC+ZDV+EFVă <600ă 0ă 0ă 0ă
GGă 37ă 43ă 3TC+ZDV+SQV/ră <600ă DEADă ă ă
LGă 73ă 185ă 3TC+ZDV+SQV/ră <600ă 0ă 0ă 0ă
VVă 39ă 152ă 3TC+ABC+LPV/ră <600ă 0ă 0ă 0ă
ADă 38ă 87ă 3TC+ZDV+EFVă 484.2ă MISSINGă ă ă
GEă 17ă 11ă 3TC+ZDV+NFVă 143.4ă 0ă 0ă 0ă
BMă 22ă 273ă 3TC+ZDV+NFVă 112.8ă ă ă ă
ă ă ă ă ă V2 ă ă
AMFă 14ă 291ă 3TC+ZDV+LPV/ră 0ă 21112.2ă 0ă 0ă
PDă 15ă 173ă d4T+3TC+EFVă 0ă 1575.6ă 675.6ă ă
CPă 46ă 108ă 3TC+ZDV+EFVă 0ă <600ă 1401.6ă MISSINGă
APă 34ă 66ă d4T+3TC+EFVă 0ă <600ă 0ă 0ă
SAă 2ă 1767ă 3TC+ZDV+NVPă 0ă <600ă
VLă =ă virală loadă (copies/ml);ă 3TCă =ă lamivudine;ă ZDVă =ă zidovudine;ă LPV/ră =ă lopinavir/ă ritonavir;ă ddIă =ă didanosine;ăă
SQV/ră=ăsaquinavir/ăritonavir;ăNFVă=ănelfinavir;ăEFVă=ăefavirenz;ăABCă=ăabacavir;ăNVPă=ănevirapine.ă
undetectableălevelă(markedăinăgrey)ă
ă
Tableă Iă givesă informationă onă thoseă patientsă phalopathy,ăwhenăadmittedătoăourăhospital.ăTheăelderă
havingă detectableă CMVă viraemiaă fromă theă oneă sufferedă fromă Mediastinală andă Abdominală
beginningăorăfromătheăsecondăvisit.ăTheăCMVăvirală Lymphomaă andă Acuteă Liveră Failureă withă Hepatitisă
loadsărangedăfromăseveralăhundredsătoă475,818ăcopies/ă VirusăB,ăapartăfromăHIVăInfection.ă
ml.ăAmongătheseăindividuals,ă16ăwereăprescribedăaă Timeă toă undetectableă CMVă viraemiaă underă
HAARTă regimenă whichă includedă aă proteaseă HAARTă wasă 16.5ă weeks,ă asă median.ă Thereă wasă aă
inhibitor.ăAllăofătheătestedăsamplesă–ă17ăoutăofătheă significantă differenceă betweenă patientsă withă baselineă
26ă positiveă CMV-DNAă plasmaă samplesă –ă wereă CD4ă cellă countsă <50/mmcă andă theă othersă withă
undetectable.ă Thereă wereă 2ă subjectsă whoă missedă CD4>50/mmcă(p=0.02)(Fig.ă2).
theăscheduledăvisitsătoăourăhospital;ăoneăofăthem,ăaă Weănoticedăanăassociationăbetweenădetectableă
non-compliantă patientă fromă theă start,ă hadă evenă ană
CMVă viraemiaă andă CD4ă cellă count<50/mmcă atăă
increasingă CMVă viraemiaă level,ă asă wellă asă hisă HIVă
firstă visit,ă whichă provedă toă beă significantă (p=0.03)ăă
viraemiaălevel.ăOtherătwoăpatientsădiedănotălongăafteră
(Fig.ă3).ăWeăshouldăalsoăaddătheăcorrelationăfoundă
theă introductionă ofă HAART.ă Theă youngeră patient,ă
whoă wasă 37ă yearsă old,ă wasă immediatelyă diagnosedă betweenă detectableă CMVă viraemiaă andă clinicală
withăHIV-relatedăProgressiveăMultifocalăLeukoence- stageăCă(p=0.04).ă
308ă
ă RalucaăMih ilescuăet al.ă 4ă

50 Median time to undetectable CMV viraemia = 16.5 weeks

Median time to undetectable CMV viraemia (weeks)

40

30

20.4

20

13

10

<50 >50
Baseline CD4/mmc ă
Fig.ă2.ă–ăTimeătoăundetectableăCMVăviraemiaăunderăHAART,ădependingăonăCD4ăcellăcount.ă

35000

30000
Baseline CMV viraemia

25000

20000

15000

10000

5000

0 100 200 300 400 500 600 700

Baseline CD4/mmc ă
Fig.ă3.ă–ăCorrelationăbetweenăbaselineăCMVăviraemiaăandăCD4/mmcă(r=0.01).ă

ă
5ă Cytomegalovirusăturnedăundetectableăunderăhighlyăactiveăantiretroviralătherapyă 309

Weăcomparedă2ăPCRăkitsăforădetectingăCMVă
virală load:ă RoboGeneă Humană Cytomegalovirusă
(HCMV)ă Quantificationă kită (ajă Roboscreen)ă andă
CMVă PCRă kită Qiagenă Diagnostics.ă Bothă ofă themă
useă real-timeă PCRă technique,ă bută theyă amplifyă
differentă targetă sequencesă ofă theă CMVă genome.ă
Noticingăthatăonlyăoneăthirdăofătheă21ăpatientsăwithă
extremelyă lowă CD4ă countă (<50/mmc)ă hadă
detectableă CMVă viraemiaă byă RoboGeneă HCMVă
Quantificationă kit,ă weă retestedă theă 14ă undetectableă
CMVăplasmaăsamplesăbyămeansăofăăCMVăPCRăkit.ă
Resultsăwereăidentical.ăă
Asă aă measureă ofă qualityă control,ă weă alsoă
randomlyă retestedă 34ă samplesă ofă theă 105ă subjects.ă
Theă detectionă thresholdă ofă RoboGeneă HCMVă
Quantificationăkită(600ăcopies/ml)ăofferedăaăhigheră
sensitivityă thană Qiagenă kită (3000ă copies/ml),ă bută
theiră specificitiesă wereă similar.ă RoboGeneă HCMVă
Quantificationă kită wasă preferredă toă monitoră CMVă
viraemiaăthroughoutăătheăstudyă(Fig.ă4).ă

C positive

threshold

C negative

Amplification curves by real-time PCR

ă
Fig.ă4ăA.ă–ăAmplificationăcurvesăbyăreal-timeăPCRă(standardăandăcontrolsăCMV-DNA)ăbyămeansăofăRoboGeneăHumană
Cytomegalovirusă(HCMV)ăQuantificationăkită(ajăRoboscreen).ă
310ă
ă RalucaăMih ilescuăet al.ă 6ă

C positive

threshold

C negative

Amplification curves by real-time PCR

Fig.ă4ăB.ă–ăAmplificationăcurvesăbyăreal-timeăPCRă(standardăandăcontrolsăCMV-DNA)ăbyămeansăofăCMVăPCRăkită(Abbott).ă
ă
CONCLUSIONS
CMVă viraemiaă detectionă wasă usefulă ină earlyă
diagnosisăofăasymptomaticăCMVăinfection.ăDetectableă
levelăofăCMVăplasmaăloadăwasăsignificantlyăassociatedă
withă clinicală stageă C,ă lowă CD4ă cellă countă
(<50/mmc)ăandăpresenceăofăHIVăretinopathy.ă
ă
HAARTă effectedă theă reductionă ofă CMVă virală
load,ă withoutăanyăspecifică anti-CMVătherapy.ăTimeă
toă undetectableă CMVă viraemiaă wasă significantlyă
longeră whenă CD4ă cellă countă wasă belowă 50/mmcă
thanăwhenătheănumberăofăCD4ăTălymphocytesăwentă
aboveăthisălimit.ăAsăinătheăcaseăofăotherăopportunistică
infections,ănaturalăhistoryăofăCMVăinfectionăseemedă
toăhaveăbeenăimprovedăbyăcontrollingăHIVăinfection.ăă

ă
7ă Cytomegalovirusăturnedăundetectableăunderăhighlyăactiveăantiretroviralătherapyă 311

Asă opposedă toă transplantă cases,ă moleculară RoboGeneă Humană Cytomegalovirusă (HCMV)ă
biologyă techniquesă foră theă detectionă andă Quantificationă kită (ajă Roboscreen)ă andă CMVă PCRă
quantificationă ofă CMV-DNAă ină HIV-patientsă areă kită(QiagenăDiagnostics)ăwereăcomparable.ă
notă yetă standardized.ă Ină oură study,ă theă twoă kitsă

Obiective. 1) Evaluarea efectului HAART asupra viremiei CMV la pacienţii

coinfectaţi, în absenţa terapiei specific anti-CMV; 2) compararea a două tehnici de
biologie moleculară pentru detecţia şi cuantificarea CMV-DNA la aceşti pacienţi.
Metode. Prezentăm datele preliminare ale unui studiu asupra pacienţilor cu HIV
nou diagnosticaţi dintr-un spital de îngrijire terţiară, în perioada iunie 2006 – iulie
2008. Examenul clinic, viremiile HIV şi CMV şi numărarea CD4 au fost efectuate la
fiecare 3 luni. Viremia CMV a fost măsurată cu RoboGene Human Cytomegalovirus
Quantification kit (aj Roboscreen), iar la pacienţii cu CD4<50/mmc la care CMV nu a
fost detectabil, s-a retestat cu CMV PCR kit (Qiagen Diagnostics).
Rezultate. Până acum, în studiu au fost incluşi 105 pacienţi HIV-pozitivi,
care au fost seropozitivi pentru anticorpi anti-CMV IgG. Urmărirea medie a fost
de 18 luni. Viremia CMV a fost detectabilă la 21 de pacienţi la prima vizită şi la
alţi 5 la a doua vizită. 22 de pacienţi au avut CD4<50/mmc, dintre care 14 au avut
viremia CMV nedetectabilă. Rezultatele ambelor tehnici de biologie moleculară au
fost în mare aceleaşi. HAART a fost prescris la 86% dintre pacienţi; toţi pacienţii
cu viremie CMV detectabilă au primit HAART, dar nu şi terapie specifică anti-
CMV. Sub HAART, toate încărcăturile CMV au devenit nedetectabile după un timp
median de 16.5 săptămâni de la introducerea terapiei antiretrovirale.
Concluzii. Detectarea viremiei CMV a fost folositoare în diagnosticul
timpuriu al infecţiei asimptomatice cu CMV. Spre deosebire de cazurile de transplant,
tehnicile de biologie moleculară pentru detecţia CMV-DNA nu sunt standardizate
la pacienţii cu HIV. În studiul nostru, cele două kit-uri RoboGene Human
Cytomegalovirus (HCMV) Quantification kit (aj Roboscreen) şi CMV PCR kit (Qiagen
Diagnostics) au fost comparabile. HAART a determinat dispariţia încărcăturii virale
în lipsa unui tratament specific anti-CMV. Ca şi în cazul altor infecţii oportuniste,
infecţia cu CMV a beneficiat de pe urma controlului infecţiei HIV.

Corresponding author: VictoriaăAram ă

ă “Prof.ăDr.ăM.ăBalş”ăNationalăInstituteăforăInfectiousăDiseasesă
ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă 1,ăCalistratăGrozoviciăStr.ă
ă 021105,ăBucharest,ăRomaniaă
ă E-mail:sorinarama@gmail.comă

REFERENCES

1. GRIFFITHSăP.D., Studies of viral co-factors for HIV in vitro and in vivo.ăJ.ăGen.ăVirol.,ă1998,ă79:213-220.ă

2. DEAYTONăJ.ăet al.,ăLoss of CMV viraemia following HAART in absence of specific anti-CMV therapy.ăAIDS,ă1999,ă13:1203–1206.ă
3. SPRINGERă K.,ă WEINBERGă A.,ă CMV infection in the era of HAART: fewer reactivations and more immunity. Journală ofă
AntimicrobialăChemotherapy,ă2004,ă54:582–586.ăă
4. Human cytomegalovirus,ăInternationalăMedicalăPress,ă2007,ăpageă2.5.ă
5. DEAYTONăJ.ăet al.,ăRapid reconstitution of humoral immunity against CMV but not HIV following HAART.ăAIDS,ă2002,ă16:ă
2129–2135.ă
6. GERARDă L.ă et al., CMV viraemia and CD4 count as predictors of CMV disease in patients infected with HIV.ă Clinicală
InfectiousăDiseases,ă1997,ă24:ă836–840.ă

ReceivedăNovemberă10,ă2008ă
ă
306ă
ă RalucaăMih ilescuăet al.ă 2ă

ă
 Arterial Stiffness and Left Ventricular Diastolic Function in the Patients
with Hypertension

LUCIA AGOŞTON-COLDEA¹, TEODORA MOCAN², C. BOBAR¹

“Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
¹Department of Medical Sciences
²Department of Normal Morphology and Functions

Arterial hypertension is associated with accelerated atherosclerosis resulting in increased

arterial stiffness. It is well known that left ventricular diastolic function declines in patients with
hypertension. The study aims to determine the relationship between arterial stiffness and left
ventricular diastolic dysfunction in patients with hypertension with preserved left ventricular ejection
fraction using newly developed ultrasonic imaging.
Methods. We performed a cross-sectional study including 65 patients with hypertension. Left
ventricular systolic and diastolic function was evaluated by 2D-, M-mode by measuring transmitral
flow velocity, mitral annular motion velocity using a conventional and tissue Doppler (TDI)
ultrasonic system. Asymptomatic atherosclerosis was also determined by measuring the intimae –
media thickness and stiffness of the common carotid arteries using 2D-, M-mode and tissue Doppler
by ultrasonography.
Results. According to conventional Doppler echocardiography of transmitral and tissue
Doppler, diastolic function was classified as normal in 38 patients and abnormal in 27 patients. Of
those with diastolic dysfunction, 14 had mild (impaired relaxation) and 13 had advanced
(pseudonormal filling) dysfunction. Univariate analysis revealed that index was negatively associated
with Em (r=–0.328, p=0.005), as well as with Em/Am ratio (r= –0.446, p=0.002). Moreover, a
multivariate analysis showed that the TDI-derived Em/Am ratio was significantly associated with age
(p=0.001), relative wall thickness (p=0.006) and index β (p=0.03), while the conventional Doppler-
derived E/A ratio was significantly associated only with age (p=0.001). Arterial stiffness index was
the highest in patients with hypertension and normal function (10.2±3.4) and progressively increased
in patients with impaired relaxation (11.5±3.9), and pseudonormal filling (12.8±4.5). In a stepwise
multiple regression analysis model including: age, systolic and diastolic blood pressure, pulse
pressure, body mass index, and β index the only factor independently correlated to arterial stiffness
was left ventricular average peak systolic velocity.
Conclusions. Our data confirm the positive correlation between diastolic dysfunction and
arterial stiffness, and suggest that non-invasive assessment of the β index might be useful for studying
the effects on arterial stiffness of treatment designed to optimize cardiac performance in patients with
hypertension. Arterial stiffness is an independent predictor of diastolic dysfunction in hypertensive
patients and should be considered a potential target for intervention in diastolic heart failure. TDI-
detected left ventricular diastolic dysfunction is accompanied by increased arterial stiffness in newly
diagnosed essential hypertension.
Key words: arterial stiffness, diastolic function, essential hypertension.

Arterial hypertension is a major cardiovascular development of atherosclerosis regardless of the

risk factor associated with accelerated atherosclerosis
by arterial smooth muscle hyperplasia and hyper-
trophy as well as collagen synthesis, thereby
increasing arterial stiffness. Arterial stiffening is
found in patients with hypertension, but it is not clear
whether the arterial disease precedes or is a
consequence of sustained elevated blood pressure [1].
Increased stiffness of large arteries commonly occurs
with advancing age, thereby leading to the
presence of coexisting diseases [2]. In addition,
increased arterial stiffness is associated with
hypertension [3], elevated levels of triglycerides [4],
diabetes [5], obesity [6], and may be an early marker
for the development of cardiovascular disease.
An asymptomatic hypertensive patient with left
ventricular hypertrophy and an echocardiography
showing a normal ejection fraction and abnormal left
ventricular (LV) filling can be said to have diastolic

ROM. J. INTERN. MED., 2008, 46, 4, 313–321

314 Lucia Agoşton-Coldea et al.
dysfunction [7][8]. Diastolic dysfunction refers to an
abnormality of diastolic distensibility, filling, or
relaxation of the left ventricle, regardless of whether
the ejection fraction is normal or abnormal and whether
the patient is symptomatic or asymptomatic [7].
Arterial stiffness of hypertensive patients has
received growing attention during the last decade
because of its association with cardiovascular
diseases [9]. Interestingly, recent results demonstrate
that arterial stiffness is an independent predictor of
hypertension progression in normotensive subjects
suggesting that lower arterial elasticity is related to
the development of hypertension [10].
The measurement of pulse wave velocity is
generally accepted as the most simple, non-
invasive, and reproducible indirect method to
determine arterial stiffness [11]. However, the
progresses made in the latest year in noninvasive
ultrasonography concur to the assessment of
subclinical atherosclerosis by using tissue Doppler
ultrasonography as a direct method of simultaneous
assessment of LV diastolic function as well as
carotid distensibility [12].
The study aims to determine the relationship
between arterial stiffness and LV diastolic dysfunction
in patients with hypertension with preserved left
ventricular ejection fraction using newly developed
ultrasonic imaging.
METHODS
PATIENTS AND STUDY DESIGN
We performed a cross-sectional study with
65 patients (aged 63.6±11.7 years, women/men
ratio =29/36) with stage I–II essential hypertension,
hospitalized in the Department of Internal
Medicine, Cluj-Napoca, between January 2008 and
May 2008. Patients were informed about the study
protocol and written consent was obtained from
each patient. All patients were evaluated with the
same methodology, clinical and paraclinical
protocol: medical history, physical examination,
12-lead electrocardiography, 2D, M-mode and
Doppler echocardiography, 2D-, M-mode and
Doppler carotid echography, biochemical analysis.
Eligible criteria by enrollee comprised
1) essential arterial hypertension [13]; 2) normal
resting LV systolic function (ejection fraction
>50% and LV restrictive filling pattern) and lack of
significant valve dysfunction [14]. Essential arterial
2
hypertension was defined in patients as a systolic
blood pressure (SBP) >140 mmHg and/or diastolic
blood pressure (DBP) >90 mmHg or being treated
with blood pressure lowering drugs [13]. Office
SBP and DBP in the brachial artery were measured
using a manual sphygmomanometer. Mean values
for SBP and DBP were calculated on the basis of
two blood pressure measurements.
Exclusion criteria comprised 1) any causes of
secondary hypertension; 2) history of cardiovascular
disease, defined as myocardial infarction, coronary
heart disease, valve lesions, stroke, congestive heart
failure, and peripheral vascular disease; 2) current use
of oral hypoglycemic, antihypertensive, or lipid-
lowering drugs; 3) renal failure; and 4) ejection
fraction <50%.
The patients were divided into two groups
according to the presence or absence of left
ventricular diastolic dysfunction: group 1 – patients
without LV diastolic dysfunction and group 2 –
patients with LV diastolic dysfunction.
BLOOD SAMPLING AND BIOCHEMICAL
ANALYSIS
Venous blood samples were obtained after
12 h of fasting, and samples for lipids, glucose, and
kidney function estimated by creatinine clearance,
were drawn without stasis into evacuated glass
tubes containing 1/100 volume of 0.5 mmol of
ethylenediaminetetraacetic acid/L. Plasma obtained
by centrifugation at 1500 g for 15 minutes was
measured in fresh samples. Fasting plasma routine
tests were assessed for all patients: glycaemia, total
cholesterol (TC), HDL-cholesterol (HDL-C), LDL-
cholesterol (LDL-C), triglycerides (TG) from
plasma, analyzed by enzymatic tests performed by
a Cobras analyzer.
CLINICAL VARIABLES
We recorded the presence of several risk
factors such as: age, sex, family background of
coronary heart disease, smoking, dyslipidaemia,
diabetes mellitus, obesity – all defined in
accordance to international rules [15–17]. Family
history of coronary heart disease (CHD) was
defined by a history of premature coronary artery
disease in first-degree relatives (having occurred in
those relatives at age <55 years for men and
<65 years for women). Active smoking was defined
3 Arterial stiffness and left ventricular diastolic function in the patients with hypertension
as the smoke of at least one cigarette per day within
the previous two months.
The presence of diabetes at baseline was
defined as fasting plasma glucose >126 mg/dL
(7 mmol/L) or use of oral hypoglycaemia agents or
insulin [16]. A surrogate marker for obesity content
is the body mass index (BMI), which is determined
by weight (kilograms) divided by height squared
(square meters). In clinical terms, a BMI of 25–
29 kg/m² is called overweight; higher BMI (30 kg/m²)
are called obesity. The waist circumference was
measured on admission, midway between the last
rib and iliac crest, and the average of 2 measures
was recorded [17].
ECHOCARDIOGRAPHY
Patients were studied by conventional and
tissue Doppler echocardiography with Aloka SSD-
5500, Tokyo, Japan, ultrasound system, using a
2.5 MHz transducer. Recordings were made with a
simultaneous superimposed electrocardiography.
Conventional echocardiography 2D-, M-mode
and Doppler was used for each patient, tracings
from the parasternal long axis view were used to
measure septal thickness, left ventricular diameter
at end-diastole and end-systole, and posterior wall
thickness. Ejection fraction was derived from
Simpson’s modified single plane method using the
apical 4-chamber view [14].
Comprehensive assessment of left ventricular
diastolic function included transmitral pulsed wave
Doppler from an apical 4-chamber view. From the
transmitral flow, the peak early (E) and late atrial
(A) diastolic velocities, E-deceleration time (DT),
and isovolumetric relaxation time were successfully
recorded for all patients. Diastolic function was
classified as normal, impaired relaxation, pseudo-
normal, or restrictive according to standard
diagnostic criteria. Normal diastolic function
was defined by E/A of 0.75–1.5 and a deceleration
time of 160–230 ms. The classification of diastolic
dysfunction on echocardiography included the
following categories: 1) abnormal relaxation;
2) pseudonormal and 3) abnormal restrictive [18].
Impaired LV relaxation was defined by the
combination of E/A< 0.75 and E wave deceleration
time >230 ms, and pseudonormal pattern was
defined by the combination of 1.5>E/A<2 and an
E-DT<230 ms. No patients had a restrictive filling
pattern defined by the combination of E/A>2 and
an E-DT<160 ms.
315
Tissue Doppler echocardiography (TDI) was
used to LV longitudinal myocardial wall motion
from the apical 4-chamber view [19]. The sample
volumes of 2 mm were used with the frame rate
exceeding 100 m/s and were placed at the junction
of the LV wall with the mitral annulus of the lateral
myocardial segments. Peak systolic myocardial
velocity during ejection (Sm), early (Em) and late
(Am) diastolic velocities were measured with
pulsed wave tissue Doppler imaging. The
transducer was positioned to align the ultrasound
beam with longitudinal left ventricular motion. The
ratio of E to lateral Em was used to estimate LV
filling pressures. Normal diastolic function was
defined by E/Em of <8, and the impaired LV filling
pressure was defined by E/Em of >8 [20].
CAROTID ULTRASONOGRAPHY
Ultrasound images were acquired using a
7.5 MHz linear array transducer by Aloka SSD-5500,
Tokyo, Japan ultrasound system. Common carotid
artery intima – media thickness (IMT) end-diastole
was determined by 2D-mode ultrasound [21]. The
transducer was manipulated so that the near and far
walls of the common carotid arteries were parallel
to the transducer foot print, and the lumen diameter
was maximized in the longitudinal plane. The
reference point for measurement of the carotid IMT
was the carotid bulb. On that image, carotid IMT
was measured as the leading edges corresponding
to the transition zones between lumen – intima and
media – adventitia over a length of 1 cm proximal
to the reference point. Maximum IMT were defined
as the greatest measured from 3 contiguous sites at
1-cm intervals.
Arterial stiffness was evaluated by M-mode
ultrasonography used to calculate 2 estimates: the
arterial stiffness index β=ln(SBP/DBP)/[(Ds–Dd)/Dd],
and the elastic modulus (EM)=[(SBP-DBP)/(Ds–
Dd)]x Dd, where Ds and Dd are the end-systolic
and end-diastolic diameters of the common carotid
artery, respectively [22]. The pulse pressure was
evaluated as the difference between SBP and DBP.
STATISTICAL ANALYSIS
A commercially available statistical program,
Statistical Package of Social Sciences (SPSS 6.0,
Chicago, Ill), was used. All data are presented as the
mean ± standard deviation. For univariate analyses
316 Lucia Agoşton-Coldea et al. 4

Chi Square Test or Fisher’ Exact Test were used,
according to standard application criteria, to test
differences between qualitative data in the two groups
(presence/ absence of left ventricular diastolic
dysfunction). Continuous data were analyzed using
either Student test for independent samples or Mann-
Whitney U test, according to normality of data.
Linear regression was performed for univariate
analyses, with calculation of Pearson’s and, when
appropriate, Spearman’s correlation coefficients.
Stepwise multiple regressions were performed for
multivariate analyses. A receiver operating characteristic
(ROC) curve was used to discriminate patients with
cardiac diastolic dysfunction (E/A ratio of <0.75 and
E/Em>8) by arterial compliance. Area under the
curve with 95% confidence intervals as well as cut-
off point value was expressed. Results were
considered statistically significant for p-value < 0.05.
RESULTS
CHARACTERISTICS OF PATIENTS
The parameters of demographic and cardio-
vascular risk factors in hypertensive patients in the
2 groups are shown in Table I. The mean (SD) age
did not differ significantly between the 2 groups.
As concerns the cardiovascular risk factors –
diabetes, obesity, smoking, dyslipidaemia, familial
history of CHD – there were not significant differences
between the 2 groups.

Table I
Characteristics of patients in the 2 groups
(Continuous numerical data were expressed as mean ± SD)
Parameters Group 1 Group 2 p-value
Number of patients, n 38 27
Mean age, years 63.4±12.2 64.1±10.4 0.848
Gender (Women/Men), n 13/25 16/11 0.080
Systolic blood pressure, mmHg 156.1±18.2 161.1±24.8 0.351
Diastolic blood pressure, mmHg 96.3±10.1 100.3±9.4 0.110
Pulse pressure, mmHg 60.3 ±16.7 60.3±15.2 0.989
Body mass index, kg/m2 27.0±4.6 29.0±4.8 0.094
Family history of CHD, n (%) 10 (26.3) 13 (48.2) 0.119
Obesity, n (%) 8 (21.05) 11 (40.7) 0.149
Diabetes mellitus, n (%) 14 (36.8) 16 (59.2) 0.124
Smoking status, n (%) 23 (60.5) 12 (44.4) 0.302
Total Cholesterol level, mg/dL 205.1±41.4 208.4±36.2 0.740
LDL-Cholesterol level, mg/dL 131.2±40.4 133.3±29.9 0.819
HDL-Cholesterol level, mg/dL 38.4±11.2 36.3±11.2 0.459
Triglycerides level, mg/Dl 171.4±68.0 186.4±79.8 0.418
Fasting glycaemia, mg/dL 98.5±10.8 102.9±9.6 0.095
Continuous numerical data were expressed as mean ± SD

ECHOCARDIOGRAPHY DATA parameters and posterior wall velocity of common

Left ventricular parameters by echocardio-
graphy in the 2 groups are shown in Table II.
According to conventional Doppler echocardiography
of transmitral and tissue Doppler, diastolic function
was classified as normal in 38 (58.46%) patients and
abnormal in 27 (41.53%) patients. Of those with
diastolic dysfunction, 13 (48.2%) patients had mild
(impaired relaxation) and 14 (51.8%) patients had
advanced (pseudo-normal filling) dysfunction.
CAROTID IMT AND ARTERIAL STIFFNESS
There were no significant differences in the
carotid IMT between the 2 groups. Carotid stiffness
carotid artery were significantly lower in the group
1, whereas there was no significant change in the
carotid diameter between the 2 groups (Table III).
UNIVARIATE ANALYSES OF FACTORS
ASSOCIATED TO ARTERIAL STIFFNESS
Table IV presents linear regression results.
Significant positive correlations were obtained between
carotid stiffness β index and the following parameters:
LV filling pressure and LV wall thickness (both
posterior wall and ventricular septum measurements).
The results showed strong inverse correlations of
β index with global ejection fraction as well as E/Em
ratio, Em/Am ratio and E/A ratio parameters.
5 Arterial stiffness and left ventricular diastolic function in the patients with hypertension 317

Table II
Left ventricular parameters by conventional and TDI echocardiography of groups
Parameters Group 1 Group 2 p-value
End-diastolic ventricular septal thickness (cm) 10.9±1.5 11.2±1.8 0.467
End-diastolic LV posterior wall thickness (cm) 11.4±1.3 11.8±2.0 0.332
End-diastolic LV diameter (cm) 46.9±3.7 48.2±4.1 0.186
End-systolic LV diameter (cm) 30.9±2.1 31.4±2.5 0.385
LV ejection fraction (%) 68.4±8.7 66.9±7.6 0.473
Transmitral flow velocity
− Peak E velocity (cm/s) 64.1±12.6 63.4±12.0 0.822
− Peak A velocity (cm/s) 61.5±14.7 65.8±17.4 0.285
− E-DT (ms) 225.0±23.5 214.9±29.7 0.131
− E/A 1.04±0.3 0.96±0.4 0.361
Mitral annular motion velocity
− Peak Sm velocity lateral (cm/s) 8.3±1.3 7.9±1.5 0.255
− Peak Em velocity lateral (cm/s) 10.2±3.4 7.1±2.4 0.004
− Peak Am velocity lateral (cm/s) 7.8±3.2 9.2±3.7 0.004
− E/Em 6.3±3.2 8.9±1.7 <0.001
− Peak Sm velocity septal (cm/s) 7.3±1.3 7.1±1.2 0.568
− Peak Em velocity septal (cm/s) 9.1±2.7 7.0±1.8 0.001
− Peak Am velocity septal (cm/s) 7.0±2.2 7.2±2.7 0.743
− E/Em 7.04±3.2 9.05±1.7 0.004

Continuous numerical data were expressed as mean ± SD.

Peak E velocity, peak early diastolic velocity of transmitral flow; peak A velocity, peak atrial systolic velocity of transmitral
flow; E-DT, deceleration time from peak to baseline of the early diastolic transmitral flow velocity; E/A, the ratio of E to A;
Em, peak early diastolic mitral annular motion velocity; Am, peak atrial systolic mitral annular motion velocity; Sm, peak
systolic mitral annular motion velocity; E/Em, the ratio of E to Em.

Table III
Carotid ultrasonographic parameters of groups
Parameters Group 1 Group 2 p-value
Intima-media thickness, mm 0.7±0.2 0.8±0.3 0.111
End-diastolic carotid diameter, mm 6.6±1.2 6.7±1.2 0.741
End-systolic carotid diameter, mm 7.3±1.2 7.5±1.4 0.539
Arterial stiffness parameters
− Carotid stiffness index β 10.2±3.4 11.3±4.2 0.029
− Elastic modulus, kPa 123.1±20.4 151.5±31.5 <0.001

Table IV
Linear regression coefficients for factors associated to arterial stiffness
R p-value
Global ejection fraction –0.023 0.675
LV filling pressure 0.523 <0.001
LV wall thickness
ventricular septum 0.412 0.003
posterior wall 0.489 0.002
E/Em –0.328 0.005
Em/Am ratio –0.446 0.002
E/A ratio –0.358 0.001
Peak E velocity, peak early diastolic velocity of transmitral flow; peak A velocity, peak atrial
systolic velocity of transmitral flow; E-DT, deceleration time from peak to baseline of the early
diastolic transmitral flow velocity; E/A, the ratio of E to A; Em, peak early diastolic mitral
annular motion velocity; Am, peak atrial systolic mitral annular motion velocity; Sm, peak
systolic mitral annular motion velocity; E/Em, the ratio of E to Em.
318 Lucia Agoşton-Coldea et al. 6

MULTIVARIATE ANALYSES OF FACTORS DISCUSSIONS

ASSOCIATED TO ARTERIAL STIFFNESS
In the present study we found a strong
In a stepwise multiple regression analysis
correlation between severity of diastolic dysfunction
model including: age (r=0.616, p=0.001), systolic
and diastolic blood pressure (r=0.598, p=0.002), and arterial stiffness index assessed conventional
pulse pressure (r=0.624, p=0.01), body mass index echocardiography and tissue Doppler parameters
(p=0.619, p=0.04) and β index (r=0.635, p=0.03) regarding diastolic function and explored the
the only factor independently correlated to arterial relationship between arterial stiffness. A method for
stiffness was LV average peak systolic velocity reliably detecting the onset of LV systolic and
(r= 0.625, p < 0.001). diastolic dysfunction and asymptomatic athero-
Moreover, a multivariate analysis showed that sclerosis of arterial carotid in patients with essential
the TDI-derived Em/Am ratio was significantly hypertension before transition to irreversible damage
associated with age (p=0.001), relative wall thickness of the myocardium would be of crucial importance.
(p=0.006) and index β (p=0.03), while the conventional Cardiovascular risk factors, including hyper-
Doppler-derived E/A ratio was significantly associated tension, obesity, dyslipidaemia and diabetes
only with age (p=0.001). mellitus [23], contribute to vascular endothelial
dysfunction, determining the development of athero-
PREDICTIVE ROLE OF ARTERIAL STIFFNESS INDEX sclerosis. The atherosclerosis should be evaluated
FOR LEFT VENTRICULAR DIASTOLIC FUNCTION according to the following 2 aspects: atherosis,
which reflects structural changes in the intima and
Our results show a strong correlation between
media of vascular walls, and sclerosis, which
severity of diastolic dysfunction and arterial stiffness
reflects changes in vascular stiffness or
index. The index β was the lowest in patients with
distensibility. The carotid IMT used in the present
normal function (10.2±3.4) and progressively increased
study is an index of atherosis, and the stiffness
in patients with impaired relaxation (11.5±3.9), and
index is an index of sclerosis.
pseudonormal filling (12.8±4.5).
Decreased distensibility of the arterial wall
Receiver operating curve analyses revealed a
increases SBP and decreases DBP, leading to
good predictive power of arterial stiffness index in
diastolic dysfunction determination (p=0.001). The increased LV afterload and impairment of
obtained area under the ROC curve (95% CI) was myocardial blood flow because of decreased
0.764 (0.634–0.827), revealing a sensitivity of coronary perfusion pressure. These abnormalities
72.3% and 91.2% in the cut-off point (β=10.8), as are reflected in the decreased LV diastolic function
shown in Fig. 1. preceding LV systolic dysfunction [24][25]. The
present study – as well as the previous ones –
1
shows that arterial stiffness increases with LV
0.9 diastolic dysfunction in hypertensive patients.
0.8
The relationship between structural and
functional changes in the carotid arteries and LV
Sensitivity (true positives)

0.7 myocardial function in patients with cardiovascular

0.6 risk factors was investigated and found that LV
relaxation is significantly associated with carotid
0.5 stiffness [26][27]. In our study, in a stepwise
0.4 multiple regression analyses model including: age,
systolic and diastolic blood pressure, pulse
0.3 pressure, body mass index, and β index the only
0.2 factor independently correlated to arterial stiffness
was LV average peak systolic velocity.
0.1
With pulsed Doppler echocardiography, LV
0 diastolic function can now be evaluated non-
0 0.2 0.4 0.6 0.8 1 invasively by recording transmitral flow and mitral
1 - Specificity (false positives) annular or LV wall motion velocities [28]. Many
Fig. 1. – Receiver operating characteristic curve of carotid studies have indicated that LV diastolic dysfunction
stiffness in diastolic dysfunction presence determination. occurs before LV systolic dysfunction in patients
7 Arterial stiffness and left ventricular diastolic function in the patients with hypertension 319

with hypertension [29] even in the absence of an
apparent cardiovascular disease. Recently, previous
studies [30][31] have demonstrated a significant
univariate relation between arterial distensibility,
mitral inflow propagation velocity, and mitral E/A in
patients with newly diagnosed hypertension. Our
study showed that hypertension increases arterial
stiffness and there is an association between LV
diastolic dysfunction measured by mitral E/A.
The relationship between blood flow derived
velocities and regional myocardial wall motion
derived velocities, measured by tissue Doppler
echocardiography, and expressed as the ratio of peak
early diastolic velocities E/Em, has been shown in
several studies [32][33]. In addition, E/Em ratio,
measured both at the lateral and medial parts of the
mitral annulus, has limitations in discriminating
patients with mildly to moderately elevated LV
filling pressures such as hypertensive patients [33].
Increased fibrosis in the LV is known to be a part of
the pathological process in hypertensive patients
[34]. In the present study, we demonstrated that
hypertension increases arterial stiffness and there is
an association between left ventricular diastolic
dysfunction measured by mitral E/Em ratio.
Redfield et al. [35] proposed the criteria of
mild cardiac diastolic dysfunction by Doppler
ultrasound examination in the general population.
According to their criteria, Yambe et al. [24]
showed that the ROC curve that has a brachial-
ankle PWV over 1,600 cm/s is a marker of
abnormal cardiac diastolic function (E/A ratio of
0.75) (sensitivity=78% and specificity=58%). The
present study demonstrated that increased arterial
stiffness is correlated with the parameters reflecting
atherosclerosis, but also with those reflecting cardiac
diastolic dysfunction.
The study had some additional limits. First,
case ascertainment is an issue in the design of the
cross-sectional study and cannot establish causal
relations but can only generate the hypothesis that
could be evaluated by prospective studies. Second,
in some subsets, because of the limited number of
patients, we were unable to make a strong case for
the true interaction between diastolic dysfunction
and arterial stiffness.
CONCLUSIONS
Our data confirm the positive correlation
between diastolic dysfunction and arterial stiffness,
and suggest that non-invasive assessment of the β
index might be useful for studying the effects on
arterial stiffness of treatment designed to optimize
cardiac performance in patients with hypertension.
Arterial stiffness is an independent predictor of
diastolic dysfunction in hypertensive patients and
should be considered a potential target for
intervention in diastolic heart failure. TDI-detected
LV diastolic dysfunction is accompanied by
increased arterial stiffness in newly diagnosed
essential hypertension.
Conflict of interest: The authors declare that there is
no conflict of interest that would prejudice the impartiality of
this scientific work.

Obiectivele studiului. Hipertensiunea arterială se asociază cu accelerarea

aterosclerozei şi conduce la creşterea rigidităţii arteriale. Este bine cunoscut
faptul că funcţia diastolică a ventriculului stâng scade la pacienţii cu hipertensiune
arterială. Lucrarea de faţă are ca scop determinarea relaţiei dintre rigiditatea
arterială şi disfuncţia diastolică ventriculară stângă la pacienţii hipertensivi cu
fracţia de ejecţie a ventriculului stâng prezervată, utilizând recentele metode de
imagistică ultrasonică.
Material şi metodă. Am realizat un studiu transversal ce a inclus 65 de
pacienţi cu hipertensiune arterială esenţială. Funcţia sistolică şi diastolică a
ventriculului stâng la aceşti pacienţi a fost evaluată prin ecocardiografie Doppler
conventional şi tisular în modul 2D- şi M, prin măsurarea vitezei la nivelul fluxului
transmitral, vitezei de mişcare a inelului mitral. Ateroscleroza asimptomatică a fost
de asemenea evaluată prin măsurarea grosimii intimă-medie şi a rigidităţii arterei
carotide comune, utilizând ultrasonografia Doppler în modul 2D-, M şi tisulară.
Rezultate. În conformitate cu ecocardiografia Doppler convenţională şi
tisulară, funcţia diastolică a fost normală la 38 de pacienţi şi alterată la 27 de
320 Lucia Agoşton-Coldea et al. 8

pacienţi, (14 pacienţi cu disfuncţie de tip relaxare alterată şi 13 pacienţi cu

disfuncţie de tip pseudonormalizare). Analiza univariată a relevat faptul că indexul
de rigiditate arterială a fost asociat negativ cu unda Em (r= –0.328, p=0.005), şi
cu raportul Em/Am (r= –0.446, p=0.002). Analiza multivariată a arătat că raportul
Em/Am a fost semnificativ asociat cu vârsta (p=0.001), grosimea indice-medie
(p=0.006) şi indicele β (p=0.03), în timp ce raportul E/A a fost semnificativ asociat
doar cu vârsta (p=0.001). Indexul de rigiditate arterială a crescut progresiv fiind de
10.2±3.4 la pacienţii cu funcţia distolică normală, de 11.5±3.9 la cei cu disfuncţie
diastolică de tip relaxare alterată şi 12.8±4.5 la cei cu disfuncţie de tip
pseudonormalizare. În analiza de regresie multiplă singurul factor independent corelat
cu rigiditatea arterială a fost vârful vitezei sistolice medii a ventriculului stâng.
Concluzii. Datele noastre confirmă corelaţia pozitivă dintre disfuncţia
diastolică şi rigiditatea arterială şi sugerează că evaluarea non-invazivă a
indicelui β poate fi utilă în optimizarea performanţelor cardiace la pacienţii
hipertensivi. Rigiditatea arterială este un predictor independent al disfuncţiei
diastolice la pacienţii hipertensivi şi poate fi considerată ca o potenţială ţintă în
evaluarea insuficienţei cardiace diastolice. Disfuncţia diastolică a ventriculului
stâng determinată prin TDI este acompaniată de creşterea rigidităţii arteriale,
fiind un nou mijloc de evaluarea a pacienţilor hipertensivi.

Corresponding author: Lucia Agoşton-Coldea

2–4 Clinicilor, 400006, Cluj-Napoca, Romania
Telephone: +40264591942; Fax: 0264/599817
E-mail: luciacoldea@yahoo.com

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Received August 28, 2008

322 Lucia Agoşton-Coldea et al. 10
 The Correlation Between Alcohol Consumption, Lipids, Apolipoproteins
and Coronary Heart Disease

TEODORA MOCAN1, LUCIA AGOŞTON-COLDEA2, L.D. RUSU2, RALUCA PAIS2, M. GATFOSSE3, L.C. MOCAN4,
M.L. RUSU2
1
Department of Normal Morphology and Functions, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2
Department of Medical Sciences, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
³Department of Internal Medicine, CH Coulommiers, France
4
Department of Surgical Disciplines, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Moderate alcohol consumption is associated with a lower risk of coronary heart disease.
Whether alcohol is truly protective or whether the amount, type, or pattern of intake is the most
important is still under debate. The aim of this study was to evaluate the relationship between effect
of presence, rhythm, frequency of alcohol consumption on lipid and apolipoproteic profile, and
indirectly of cardiovascular risk.
Methods. We performed a cross-sectional transversal study on 105 patients free of coronary
heart disease (men and women) aged 58.08(10.43) years. Alcohol and dietary intakes were assessed
by using validated questionnaires. The dosages of lipids were measured by the enzymatic method and
the dosages of apolipoproteins were measured by immuno-turbidometric methods.
Results. Presence of chronic alcohol consumption independently correlated with HDL-Cholesterol
(p<0.5) and apoA-I levels (p<0.05). Ethylic dose positively associated with HDL-C (r=0.71, p=0.003) and
apoA-I levels (r=0.65, p=0.002). Mean HDL-C levels significantly increase from the <1drink/day group
(46.58±35.12) to >7drinks/day group (55.54 ±49.12) (p<0.05). apoA-I also had a higher mean level for the
>7drinks/day group (1.78 ±1.21) than the 1-6 drinks/day group (1.58±0.05) and than the <1 drink/day group
(1.53±0.09). Differences were found to be significant (p<0.05).
Conclusion. Alcohol consumption interferes with lipids and lipoproteins balance and is one of
the parameters that indirectly decrease the cardiovascular risk. A higher ethylic quantity and rhythm
of consumption correlates with a higher protection offered by HDL-Cholesterol and apo A-I.
Key words: alcohol; cardiovascular risk; lipids; high-density lipoprotein cholesterol; apolipo-
proteins.

Epidemiological evidence links moderate
alcohol consumption to a lower risk of cardio-
vascular disease [1–4]. Moderate alcohol consumption
is also specifically associated with cardio-protective
benefits, whereas increasingly excessive consumption
results in proportional worsening of outcomes. The
moderate alcohol consumption is the cardiovascular
protection predominately through improvements in
insulin sensitivity and high-density lipoprotein
cholesterol (HDL-C) [2–6]. Heavy alcohol consumption
may indeed increase atherosclerotic risk by damaging
or hampering the capacity to synthesize (HDL-C),
which is supposed to play a significant role in
preventing atherosclerosis by removing free
cholesterol from the arterial wall [7].
The mechanisms that mediate the inverse
association of moderate drinking and cardiovascular
disease remain uncertain. A meta-analysis of more
than 40 such trials confirmed that consumption of
30 g of alcohol daily raises levels of HDL-C by
0.10mmol/L and lowers levels of fibrinogen by
0.22µmol/L [8]. Moderate alcohol use also
improves insulin sensitivity [9] [10] and possibly
markers of inflammation [11] in experimental
trials. However, few studies have directly assessed
the association of alcohol consumption with
atherosclerosis [12] [13].
Numerous studies reported a significant
relationship between alcohol consumption and
changes in blood lipids and lipoproteins [7]. Thus,
alcohol intake is associated with less total LDL
particles, lower levels of small LDL, HDL, and
very-low-density lipoprotein particles, and higher
levels of large LDL and medium- and large-sized
HDL particles in older adults free of prevalent
clinical cardiovascular disease [6]. It was initially

ROM. J. INTERN. MED., 2008, 46, 4, 323–330

324 Teodora Mocan et al.
believed that alcohol raises only the HDL3 fraction
of HDL, whereas HDL2 is the fraction inversely
correlated with coronary heart disease (CHD) risk.
Moreover, alcohol may speed up the removal of
triglycerides (TG) from HDL2 from fresh HDL3
particles by enhancing the lipoprotein lipase and
hepatic triglyceride lipase activities [7].
In most large studies risk of CHD decreases
in a downward linear fashion with alcohol intake
up to three drinks a day. This reduction is generally
attributed to the beneficial effects of alcohol on
lipids and haemostatic factors [7] [14].
The present study analyses the relationship
between effect of presence, rhythm, frequency of
alcohol consumption on lipid plasma levels as well
as on apolipoprotein levels, as indirect markers of
cardiovascular risk.
MATERIAL AND METHODS
PATIENTS
We conducted a cross-sectional study among
105 patients free of the CHD, who were recruited
in the Department of Internal Medicine, Coulommiers,
France between May 2005 and December 2005.
The study protocol was approved by the ethics
committee and all subjects gave their informed
consent before participation in the study.
Those eligible for inclusion were white men
and women less than 75 years of age 4 with no
history of previous myocardial infarction or angina
pectoris before admission. All patients were
evaluated with the same structural quiz. Information
about usual alcohol consumption was self-reported
on a standard questionnaire.
Patients were also excluded for hypo-
thyroidism, nephrotic syndrome or cholestasis with
dyslipidaemia, neoplasia, inflammatory diseases
and acute infections.
BLOOD SAMPLING
Venous blood samples were obtained after
12 h of fasting, and samples for lipids, apolipo-
proteins A-I and B (apoA-I and apoB), were drawn
without stasis into evacuated glass tubes containing
1/100 volume of 0.5 mmol of disodium EDTA/L.
Plasma, obtained by centrifugation at 1500 g for
15 min, was measured in fresh samples.
2
PARAMETERS
We analysed the prevalence of several risk
factors such as: age, gender, family history for CHD,
smoking, hypertension, diabetes mellitus, dyslipi-
daemia, obesity – all defined in accordance to
international criteria [15–18]. Active smoking was
defined as smoking of at least one cigarette per day
within the previous two months. Total cholesterol
(TC), HDL-C, LDL-Cholesterol (LDL-C), and TG
were determined in fasting state using a Roche-
Hitachi 911 analyser. Non-HDL-Cholesterol (non-
HDL-C) was calculated as the difference between TC
and HDL-C (in mg/dL) [18]. Plasma concentrations
of apoA-I and apoB were measured by immuno-
turbidimetry with Roche/Hitachi Modular analyser,
using reagents and standard controls [19].
Participants reported their usual frequency of
consumption of beer, wine, and liquor and the usual
number of glasses. We categorized participants into
categories according to weekly ethanol consumption
as follows: none, former, <1 drink weekly, 1–6 drinks
weekly, >7 drinks weekly.
STATISTICAL ANALYSIS
We used Independent Sample Student Test
and ANOVA test for mean difference univariate
analyses (two groups and three groups, respectively).
Continuous data correlations were performed using
Linear Regression with calculus of Pearson
correlation coefficient. Multiple logistic regressions
were used for multivariate analyses with estimation
of odds ratios (OR) and 95% confidence intervals
(CI). The univariate statistical analysis was
performed in Epi-Info 6 version, and the multiple
logistic regressions were performed in Statistical
Package for the Social Sciences (SPSS) for
Windows 6.0. Results were considered statistically
significant for a p value< 0.05.
RESULTS
PATIENT CHARACTERISTICS
The main characteristics of the included
patients are shown in Table I. The following general
risk factors were studied: high blood pressure,
diabetes and obesity, smoking and family history of
CHD. The subjects varied in age from 35 to 75 years,
in weight from 51.4 to 97.5 kg, and in body mass
index from 18.9 to 35.0 kg/m2. Among patients
3 Alcohol consumption, lipids, apolipoproteins and coronary heart disease 325

50.48% is alcohol consumption with high prevalence drank at least 40 g/day of alcohol while, among
of the men (54.71%). Among drinkers, 71% of men women, 42% exceeded 40 g/day.

Table I
The main characteristics in patients included in the study
Parameters Non-drinker Drinker p-value
(n=52 ) (n=53)
Mean age (SD), years 57.7 (12.8) 58.5 (13.2) NS
Men, n (%) 24 (46.16) 29 (54.71) <0.05
Body Mass Index, (SD), kg/m2 29.1 (6.6) 30.6 (7.4) NS
Family History of CHD, n (%) 15 (28.84) 13 (24.52) NS
Obesity, n (%) 25 (48.07) 23 (43.39) NS
Diabetes mellitus, n (%) 16 (30.46) 12 (22.64) <0.05
Hypertension, n (%) 41 (78.84) 23 (43.39) <0.05
Smoke status, n (%) 25 (48.07) 32 (60.37) <0.05
Continuous numerical data were expressed as mean SD

IMPACT OF ALCOHOL CONSUMPTION PRESENCE
Alcohol intake tended to be positively
associated with male gender, cigarette smoking,
and inversely associated with prevalence of
diabetes and hypertension. Univariate analyses
showed that most of lipid and lipoprotein markers
are significantly correlated with alcohol
consumption (Table II). After adjusting for gender,
smoking, diabetes and hypertension 2 multivariate
analyses were performed. The first model included:
TC, LDL-C, HDL-C, TG, apoB/apoA-I ratio.
Results selected HDL-C as single independent
factor (OR (CI95%)=1.61(1.23-1.81), p<0.05) we
built a second regression model by including: apoB
and apoA-I. Out of the two markers ApoA-I
concentration was proved to be independently
correlated (OR (CI95%)=1.54(0.42–1.79), p<0.05)
with alcohol consumption (Table II).

Table II
Univariate and multivariate analyses results of alcohol consumption correlation with plasma lipid levels
Parameters Univariate Analysis Multivariate Analysis

Non-drinker Drinker p-value OR CI95% p-value

(n=52) (n=53)
Total cholesterol, mg/dL 198.64 (41.33) 181.24 (49.79) <0.05 0.23 0.16–3.2 NS
LDL-Cholesterol, mg/dL 123.66 (41.11) 113.44 (44.64) <0.05 0.65 0.51–1.24 NS
HDL-Cholesterol, mg/dL 44.28 (12.31) 53.22 (23.21) <0.05 1.61 1.23–1.81 <0.05
Non-HDL-Cholesterol, mg/dL 143.42 (41.37) 133.35 (39.25) <0.05 0.45 0.37–1.32 NS
Triglycerides, mg/dL 158.26 (72.43) 147.75 (64.31) NS 0.65 0.41–1.14 NS
Total/HDL-Cholesterol 4.34 (1.51) 4.03 (1.39) <0.05 0.62 0.51–1.25 <0.05
Apolipoproteins B, g/L 0.67 (0.15) 0.62 (0.12) <0.05 0.57 0.31–1.42 NS
Apolipoproteins A-I, g/L 1.51 (0.17) 1.67 (0.11) <0.05 1.54 0.42–1.79 <0.05
ApoB/apoA-I ratio 0.43 (0.15) 0.39 (0.09) <0.05 0.43 0.32–1.04 NS

Continuous numerical data were expressed as mean SD

Abbreviations: OR, odd ratio; CI, confidence intervals; NS, non-significant

IMPACT OF ETHYL INTAKE QUANTITY IMPACT OF ALCOHOL CONSUMPTION RHYTHM

The dose of alcohol positively correlated with Table III presents drinking pattern results.
HDL-C (r=0.71, p=0.003) (Fig. 1). ApoA-I levels also Evidences revealed a decreasing tendency of TC,
showed a significant positive relationship with alcohol LDL-C, non HDL-C, TG, TC/HDL-C, apoB and
consumption quantity (r=0.65, p=0.002) (Fig. 2). apoB/apoA-I ratio plasma levels for higher frequency
326 Teodora Mocan et al. 4

of alcohol use. However, values were not significant mean level for the >7 group (1.78±1.21) than for
(p<0.05). Mean HDL-C levels significantly increased the 1–6 group (1.58±0.05) or the <1 group (1.53±0.09).
from the <1 group (46.58±35.12) to >7 group Differences were found to be significant (p<0.05)
(55.54±49.12) (p<0.05). ApoA-I also had a higher (Fig. 3).

Table III
The fasting lipids and apolipoproteins and the drinking pattern in patients with alcohol intake
Parameters Alcohol intake frequency (no. of drinks/week) p-value

<1 (n=15) 1–6 (n=29) >7 (n=9)

Total cholesterol , mg/dL 185.52 (23.85) 184.67 (46.12) 177.42 (49.79) NS
LDL-Cholesterol, mg/dL 119.51 (34.62) 115.51 (46.64) 110.42 (35.12) NS
HDL-Cholesterol, mg/dL 49.58 (35.12) 50.11 (23.12) 55.54 (49.32) <0.05
Non-HDL-Cholesterol, mg/dL 137.31 (41.32) 135.31 (48.25) 132.62 (41.25) NS
Triglycerides, mg/dL 147.25 (61.73) 143.46 (41.52) 140.24 (31.42) NS
Total/HDL-Cholesterol 4.15 (0.32) 4.10 (0.12) 3.90 (1.29) NS
Apolipoproteins B, g/L 0.65 (0.21) 0.63 (0.14) 0.62 (0.03) NS
Apolipoproteins A-I, g/L 1.53 (0.09) 1.58 (0.05) 1.78 (1.21) <0.05
ApoB/apoA-I ratio 0.41 (0.15) 0.40 (0.03) 0.38 (0.040 NS
Continuous numerical data were expressed as mean SD

90
80
70
60
ALCOHOL(g/d)

50
40
30
20
10
0
0 0.5 1 1.5 2 2.5 3
APOLIPOPROTEIN A1(g/L)

Fig. 1. – The correlation between apoA-I and alcohol consumption.

120

100

80
ALCOHOL(g/d)

60

40

20

0
0 20 40 60 80 100 120 140 160
HDL-CHOLESTEROL(m g/dL)

Fig. 2. – The correlation between HDL-Cholesterol and alcohol consumption.

5 Alcohol consumption, lipids, apolipoproteins and coronary heart disease
140
120
PERCENT 100
80
60
40
GROUP <1 GROUP 1-6
ALCOHOL CONSUMPTION
FREQUENCY GROUP
Fig. 3. – Frequency of alcohol intake and percent differences of mean HDL-cholesterol and apolipoprotein A-I
plasma levels.
DISCUSSION
Our research analyses the modulator effect of
alcohol consumption main characteristics on lipid
and lipoprotein profile. We first tested the effect of
alcohol intake presence on plasma lipid and
apolipoproteic levels and found plasma apoA-I and
HDL-C concentrations high with alcohol intake.
Similar to other studies [7] [20] [21] [22], we
indirectly found that presence of ethyl consumption
acts as a protective factor against cardiovascular
pathology, by correlation with HDL-C or apoA-I.
Elevated plasma HDL-C concentration,
associated with a moderate alcohol intake, has been
reported in many previous studies [7] [23] and this
association has been suggested to be one of the key
factors explaining the now well-accepted cardio-
protective effects of alcohol. Furthermore, it has
been consistently shown that apoA-I levels rise
with alcohol consumption suggesting that apoA-I
levels could be better predictors of atherosclerosis
than HDL subfractions [7]. The alcohol-induced
increase in HDL-C levels has been attributed to the
following mechanisms: hepatic synthesis of apoA-I
and apoAII the precursor of HDL particle formation;
metabolic raise in TG concentration, with
consequent secretion of TG-rich lipoproteins by the
liver and increased TG lipase activity; reduced
cholesterol ester transfer protein activity with
reduced transfer of cholesteryl ester from the core of
HDL to more atherogenic particles [6] [21] [24].
Our results also show that frequency of
alcohol intake can be a protective factor against
cardiovascular events, similar to other studies [7]
327
GROUP>7
HDL
CHOLESTEROL
APO A1
[12] [25]. Interestingly, Dorn and colleagues
recently found that a greater drinking frequency
had a strong inverse cross-sectional association
with central adiposity among both women and
men, whereas a higher quantity of intake per
drinking day had a positive relation [26]. Because
central adiposity is linked to low levels of HDL-C,
high levels of inflammation-sensitive proteins, and
glucose intolerance, it is intriguing to hypothesize
that alcohol use could act early in the pathway that
leads to these linked abnormalities. Indeed, average
alcohol intake has been inversely associated with
prevalence of metabolic syndrome. However, other
direct mechanisms may contribute to the effect of
alcohol on HDL-C levels [27].
Taking into account other known CHD risk
factors, an overall estimate from prospective
studies is a 30%–40% reduction in risk of CHD for
two drinks/ day among men and one drink/day
among women, with minimal additional benefit for
higher consumption levels [2].
Quantity of ingested alcohol has also been
proven to act as a distinct modulator factor. Our
results resemble reports which have stated an
inverse association between moderate alcohol
consumption and risk of CHD. In other study light
to moderate alcohol consumption (up to 1 drink
daily for women and 1 or 2 drinks daily for men) is
associated with cardioprotective benefits, whereas
increasingly excessive consumption results in
proportional worsening of outcomes [28].
Alcohol consumption confers cardiovascular
protection predominately through improvements in
insulin sensitivity and high-density lipoprotein
cholesterol. The ethanol itself, rather than specific
328 Teodora Mocan et al. 6

components of various alcoholic beverages,
appears to be the major factor in conferring health
benefits. Low-dose daily alcohol is associated with
better health than less frequent consumption. Binge
drinking, even among otherwise light drinkers,
increases cardiovascular events and mortality. Up
to date it has been shown that moderate alcohol
drinking might have beneficial effects on several
aspects of long-term prognosis after an acute
myocardial infarction [29].
Similar reports proved that former nondrinkers
who initiated moderate alcohol consumption in
middle age experienced a 38% reduction in cardio-
vascular events over 4 years, compared with
continued nondrinkers in the Atherosclerosis Risk in
Communities study [30]. The protection arising
from alcoholic beverage consumption, however,
may be a surrogate marker of healthy behaviour.
Present study proposes one innovative approach.
It suggests that for multivariate risk scoring systems
presence, frequency as well as quantity of alcohol
consumption could be considered separate predictors.
We are, however, aware of our study cross-
sectional design limitations. This study type does
not allow authors to validate alcohol consumption
risk in a prospective follow-up for cardio-vascular
events. We consider the present study could be the
pilot study of future prospective research.
CONCLUSION
Alcohol consumption interferes with lipids
and apolipoproteic balance and is one of the
parameters that indirectly decrease cardiovascular
risk. A higher ethyl quantity and rhythm of
consumption correlates with a higher protection
offered by HDL-C and apo A-I.

Obiectivele studiului. Consumul moderat de alcool este asociat cu un risc

scăzut de boală coronariană ischemică. Dacă alcoolul este cu adevărat protector
cardiovascular sau dacă este mai important tipul, doza şi cantitatea de administrare –
sunt probleme încă în dezbatere. Scopul acestui studiu a fost evaluarea relaţiei între
efectul prezenţei, ritmului şi frecvenţei administrării alcoolului asupra profilului
lipidic şi apolipoproteic şi indirect asupra riscului cardiovascular.
Metodă. Am realizat un studiu transversal în care am inclus 105 pacienţi
fără cardiopatie ischemică (bărbaţi şi femei) cu vârstă medie 58.08(10.43) de ani.
Consumul de alcool şi dieta au fost evaluate folosind chestionare validate.
Dozarea lipidelor a fost măsurată prin metode enzimatice, iar dozajul
apolipoproteinelor a fost realizat prin metode imuno-turbidimetrice.
Rezultate. Prezenţa consumului cronic de alcool s-a corelat cu valorile de
HDL-colesterol (p<0.5) şi nivelul apoA-I (p<0.05). Doza de alcool etilic s-a
corelat pozitiv cu HDL-C (r=0.71, p=0.003) şi nivelul apoA-I (r=0.65, p=0.002).
Nivelele medii ale HDL-C au crescut semnificativ odată cu consumul de alcool de
la grupul cu consum sub 1 pahar pe zi (46.58±35.12) la peste 7 pahare pe zi (55.54±
49.12) (p<0.05). De asemenea, apoA-I a avut un nivel mai mare la cei cu un
consum peste 7 pahare pe zi (1.78 ±1.21), decât la cei cu consum între 1-6 pahare
pe zi (1.58±0.05) şi decât la cei cu un consum sub 1 pahar pe zi (1.53±0.09) cu
diferenţe semnificative (p<0.05).
Concluzii. Consumul de alcool interacţioneză cu echilibrul lipidic şi apolipo-
proteic, fiind unul din factorii care scad indirect riscul cardiovascular. Consumul
crescut de alcool şi ritmul în care se administrează se corelează cu o protecţie
cardiovasculară mai mare oferită de nivelele de HDL-Colesterol şi apo A-I.

Corresponding author: Lucia Agoşton-Coldea, MD, PhD

Department of Medical Sciences
2–4, Clinicilor, 400006 Cluj-Napoca, Romania
Tel: +40264591942;
E-mail: luciacoldea@yahoo.com
7 Alcohol consumption, lipids, apolipoproteins and coronary heart disease 329

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Received April 24, 2008

 Risk Factors in Patients with Chronic Pancreatitis in Romania

BRÎNDUŞA DIACONU1, TEODORA MOCAN2, LIDIA CIOBANU1

1
Third Medical Clinic, University of Medicine and Pharmacy, Cluj-Napoca
2
Physiology Department, University of Medicine and Pharmacy, Cluj-Napoca

Chronic pancreatitis is due mostly to alcohol consumption in industrialized countries.

However, beside alcohol consumption there are other known etiologic risk factors, some patients
combining more of them. The aim of our study was to assess the different etiologic risk factors in
patients with chronic pancreatitis in Romania.
Methods. There were 94 patients with chronic pancreatitis (CP) enrolled in this prospective
study. The diagnosis of CP was established by typical findings on ultrasonography, computed
tomography, endoscopic retrograde colangiography. The visits included a careful history of alcohol
use, smoking, drug use, a clinical examination and laboratory tests. The previous hospital records of
each patient were reviewed.
Results. Out of the 94 patients, 80 had alcoholic chronic pancreatits (ACP), 10 idiopathic
pancreatitis (ICP), 2 patients had obstructive chronic pancreatitis due to pancreas divisum, 1 patient
chronic pancreatitis due to hypertriglyceridemia and 1 patient posttraumatic chronic pancreatitis. The
most frequent risk factors were alcohol consumption and smoking, the association of these two
factors was found in 91% of patients with ACP and a large proportion of patients continued to smoke
after diagnosis was established.
Conclusion. Similar to other countries alcoholic chronic pancreatitis is the most frequent
etiology, followed by the idiopathic one. Patients with ICP must be tested for gene mutations in the
future. A small proportion of patients have other etiologies like pancreas divisum, which require
specific treatment.
Key words: chronic pancreatitis, risk factors.

Chronic pancreatitis (CP) is due mostly to
alcohol consumption in industrialized countries [1].
However, beside alcohol consumption there are
other known etiologic risk factors like smoking,
hypercalcemia, hypertriglyceridemia, autoimmunity,
genetic factors and obstructive factors [2]. The
evolution of the disease is different according to
the involved risk factors[3] and some cases benefit
from specific treatment.
The aim of our study was to determine the
etiology and the etiologic risk factors in patients
with chronic pancreatitis in Romania.
MATERIAL AND METHODS
The study was approved by the hospital’s ethics
committee and all participants provided informed
consent. Patients were recruited at a tertiary referral
center (the Third Medical Clinic, Cluj-Napoca,
Romania) since January 2003 through December
2005. A diagnosis of chronic pancreatitis was
based on typical history and on one or more of the
following criteria: pancreatic calcifications, typical
histology, suggestive imaging findings on endoscopic
retrograde cholangiopancreatography (ERCP), ultra-
sonography or computed tomography and/or
steatorrhea (fecal fat>7g/24h). The medical visits
included a careful history of alcohol consumption,
smoking, drug use, a clinical examination and
laboratory tests.
Alcohol was considered causative in patients
with a daily intake of >60g in men and >40g in
women for at least 2 years and/or in the presence of
indirect markers of alcohol consumption. The
diagnosis of idiopathic chronic pancreatitis was
established for patients with a daily alcohol intake
<20g, for whom other etiologic factors were excluded.
Hypertriglyceridemia was considered a causative
factor in a patient with recurrent attacks of acute
pancreatitis and high levels of serum triglycerides of
>800mg/dL. The patients with chronic pancreatitis
due to pancreas divisum had marked changes of the
dorsal pancreatic duct on ERCP.

ROM. J. INTERN. MED., 2008, 46, 4, 331–336

332 Brînduşa Diaconu et al. 2

STATISTICS The predominent etiology was the alcoholic

The quantitative variables were expressed as
means±SD or median (range) according to
normality of data.The statistical analysis for non-
parametric data was performed with the Chi
Square, Fisher or Mann Whitney test and for
parametric data with the Student test. A p value of
<0.05 was considered statistically significant.
RESULTS
PATIENTS GENERAL CHARACTERISTICS AND
ETIOLOGY OF CHRONIC PANCREATITIS
From 94 patients 12 were women and 84 men,
with a mean age on diagnosis of 44.6±9.9 years.
one (Fig. 1), in patients with ACP most of
patients were men, in patients with idiopathic
chronic pancreatitis the gender distribution
was almost identical (Fig. 2). The other 4 patients
had: 2 patients chronic pancreatitis due to pancreas
divisum, 1 patient with chronic pancreatitis
secondary to hypertriglyceridemia (in his history he
suffered from recurrent attacks of acute pancreatitis)
and 1 patient with posttraumatic chronic pancreatitis.
There were no differences regarding age on onset
of symptoms and age on diagnosis between
patients with ACP versus ICP, but the patients with
ICP smoked less (Table I).

100 85.1

90

80

70
Percentage

60

50

40

30
10.6
20 4.3

10

0
ACP ICP Other

Fig. 1. – Etiology of chronic pancreatitis: ACP, alcoholic chronic pancreatitis; ICP, idiopathic chronic pancreatitis.

80
70
60
50 75 M
40
Nr
No

F
30
20
4
10 5 6
0
ACP ICP

Fig. 2. – Distribution of patients with chronic alcoholic pancreatitis and idiopathic chronic pancreatitis according to gender:
No, number of patients; M, male; F, female ACP, alcoholic chronic pancreatitis; ICP, idiopathic chronic pancreatitis.

The patients with idiopathic pancreatitis had ERCP which could suggest a specific cause for the
no hypergammaglobulinemia, hypercalcemia, chronic disease. Only one person under the age of 30 was
renal failure or drug use, anatomic variants at diagnosed with ICP.
3 Risk factors in patients with chronic pancreatitis 333

Table I
General characteristics of patients with chronic alcoholic pancreatitis and idiopathic chronic pancreatitis
ACP ICP p-value
n=80 n=10
Gender(F/M) 5/75 6/4 <0.001
Age on diagnosis-mean±SD 44.4±9.5 43.0±13.5 0.698
Age of onset-mean±SD 41.8±9.7 36.3±11.4 0.193
Smoking
Quantity(packs/day)-median(range) 0.7(1) 0.3(0.3) 0.003
Period(years)-median(range) 21.0(43) 23(16) 0.615
ACP – alcohol related chronic pancreatitis; ICP – idiopathic chronic pancreatitis

RISK FACTORS IN CHRONIC PANCREATITIS consumption or smoking as risk factors and only 4
presented other known risk factors, excluding the
Most of the patients had an association of alco- genetic factors for which we did not search in this
hol consumption and smoking, few had only alcohol study (Fig. 3).

80

70

60

50
Number

40 73

30

20

10
7 7 4
0
ALCOHOL+ ALCOHOL SMOKING OTHER
SMOKING

Fig. 3. – Risk factors in chronic pancreatitis: Number – number of patients

Other: pancreas divisum in 2 patients, hypertriglyceridemia in 1 patient, previous surgery in 1 patient.

ALCOHOL CONSUMPTION DRINKING AND SMOKING HABITS AFTER

The amount of alcohol consumption before
the diagnosis was 84(154) g⁄day for 8(28) years.
There was a significant difference between the
amount of alcohol consumption between males and
females (Fig. 4), but the period of alcohol
consumption did not differ (data not shown).
SMOKING
The patients smoked 0.6(1.2) packs⁄day for
21.0(43) years. There were no differences regarding
smoking between males and females (Fig. 5).
DIAGNOSIS
Because smoking and continuing alcohol
consumption are negative prognostic factors for the
disease, we assessed these two parameters, too.
While a considerable proportion of our patients
continued drinking after diagnosis (Fig. 6), the vast
majority did not stop smoking (Fig. 7).
DISCUSSION
The predominant etiology in our patients group
is the alcoholic one, which is in accordance with all
334 Brînduşa Diaconu et al. 4

p=0.001
250

200
(range)
Median(range)
150
Median

100

50 84
49
0
F M

Fig. 4. – Alcohol consumption in patients with chronic pancreatitis: alcohol amount is reported as median
(interquartile range); numbers inside bars represent the median alcohol consumption (g/day); F, female; M, male.

P=0.300

60

50

40
Median(range
(range)

30
Median

20
20
10 15

0
F M
Fig. 5. – Smoking in patients with chronic pancreatitis: smoking is reported as median (interquartile range);
numbers inside bars represent the median of cigarettes smoked (number/day); F, female; M, male.

21%
26%

74%
79% 0
0
1 1

Fig. 6. – Drinking habits after the time of diagnosis: 0, patients Fig. 7. – Smoking habits after the time of diagnosis: 0, patients
who stopped drinking; 1, patients who continued drinking. who stopped smoking; 1, patients who continued smoking.

studies from industrialized countries. The reported studies [4], but this is due to the improper patient
alcohol amount in our study is lesser than in most acknowledgement in terms of alcohol consumption.
5 Risk factors in patients with chronic pancreatitis 335

The proportion of patients with ICP is similar to
that in other studies.
Mutations in serine protease inhibitor Kazal I
(SPINKI) and in cystic fibrosis transmembrane
regulator (CFTR) gene are known to be associated
with ICP [5][6], especially with the early-onset
type. It would be useful to check our patients for
these mutations, but the probability to find an
association is low due to the fact that most of our
patients with ICP had an age at onset of over 30.
Even if the other causes of pancreatitis are
rare, it is useful to diagnose them, since chronic
pancreatitis due to pancreas divisum can benefit
from endoscopic therapy [7]; treatment of metabolic
causes (hypertriglyceridemia, hypercalcemia, etc.)
must be done and patients with autoimmune
pancreatitis are treated with corticotherapy [8].
Alcohol and drinking were associated in 91%
of patients with ACP. The amount of alcohol
consumption in women was smaller than in men,
which is well known [4][9]. The period of alcohol
consumption in women was shorter than in men,
but not reaching statistical significance. There were
no differences regarding smoking (number of
cigarettes smoked and period of smoking) between
males and females.
Continuance of drinking after diagnosis and
smoking are unfavorable prognostic factors in
alcoholic chronic pancreatitis [10][11]. In our
patients group 21% continued drinking, which is an
important proportion, and 74% of patients
continued smoking. The latter is explained by the
high dependency caused by smoking, which is
partially genetically determined [12]. More efforts
must be done by patients, physicians and
psychologists in order to reduce the number of
patients who continue to drink or smoke.
CONCLUSIONS
Alcohol and smoking are the two most
important etiologic risk factors in patients with
chronic pancreatitis and they are associated in the
majority of cases. Other causes are rare, but efforts
must be done to diagnose them, since they may
benefit from specific treatment.

În ţările industrializate pancreatita cronică se datorează în special

consumului de alcool. Totuşi, în afara consumului de alcool există şi alţi factori de
risc, care se pot asocia la unii pacienţi. Scopul studiului nostru a fost să evaluăm
factorii de risc la pacienţii cu pancreatită cronică din România.
Metode. În studiul nostru au fost incluşi 94 de pacienţi cu pancreatită
cronică, care au fost urmăriţi prospectiv. Diagnosticul a fost stabilit pe baza
modificărilor tipice la ultrasonografie, tomografie computerizată, colangiopancreato-
grafie retrogradă endoscopică. Evaluarea pacienţilor a constat într-o anamneză
amănunţită cu privire la consumul de alcool, fumat, medicamente asociată cu
examinarea clinică şi teste de laborator. De asemenea au fost studiate şi foile de
observaţie ale pacienţilor de la examinările anterioare.
Rezultate. Din cei 94 de pacienţi, 80 au avut pancreatită cronică de etiologie
etanolică, 10 pancreatită cronică idiopatică, 2 pancreatită obstructivă secundară
pancreasului divisum, 1 pacient pancreatită cronică secundară hipertrigliceridemiei
şi 1 pacient pancreatită cronică posttraumatică. Factorii de risc cei mai frecvent
întâlniţi au fost consumul de alcool şi fumatul, care s-au asociat în 91% din
cazurile cu pancreatită cronică etanolică. Majoritatea pacienţilor au continuat să
fumeze după stabilirea diagnosticului.
Concluzii. Pancreatita cronică etanolică reprezintă etiologia cea mai
frecventă, urmată de cea idiopatică. Pacienţii cu pancreatită idiopatică ar trebui
testaţi în viitor pentru mutaţii genice. O proporţie mică de pacienţi suferă de
pancreatită din cauze rare, dar ei pot beneficia de tratament specific.

Corresponding author: Brînduşa Diaconu

IIIrd Medical Clinic
Croitorilor 19–21, 400162 Cluj-Napoca, Romania
E-mail: brindusa_diaconu@yahoo.com
336 Brînduşa Diaconu et al. 6

REFERENCES

1. OWYANG C., LEWITT M., Chronic pancreatitis. In: Textbook of Gastroenterology (T. Yamanda, Ed.), Philadelphia:
Lippincott, 1999, 2152.
2. ETEMAD B., WHITCOMB D.C., Chronic Pancreatitis: Diagnosis, Classification and New Genetic Developments.
Gastroenterology, 2001, 120, 682.
3. LAYER P., YAMAMOTO H., KALTHOFF L., CLAIN J.E., BAKKEN L.J. et al., The different courses of early- and late-onset
idiopathic and alcoholic chronic pancreatitis. Gastroenterology, 1994, 107, 1481.
4. DURBEC J., SARLES H., Multicenter survey of the etiology of pancreatic diseases. Relationship between the relative risk of
developing chronic pancreatitis and alcohol, protein and lipid consumption. Digestion, 1978, 18, 337.
5. LIDDLE RA., Pathophysiology of SPINK1 mutations in pancreatic development and disease. Endocrinol. Metab. Clin. N. Am.
2006, 35, 345.
6. COHN J.A., MITCHELL M.R., JOWELL P.S., The role of cystic fibrosis gene mutations in determining susceptibility to
chronic pancreatitis. Gastroenterol. Clin. N. Am., 2004, 33, 817.
7. VITALE G.C., VITALE M., VITALE D.S., BINFORD J.C., HILL B., Long-term follow-up of endoscopic stenting in patients
with chronic pancreatitis secondary to pancreas divisum. Surg. Endosc., 2007, 21, 2199.
8. DITE P., NOVOTNY I., TRNA J., SEVCIKOVA A., Autoimmune pancreatitis. Best. Pract. Res. Clin. Gastroenterol., 2008, 22, 131.
9. HABER P., WILSON J., APTE M., KORSTEN M., PIROLA R., Individual susceptibility to alcoholic pancreatitis: Still an
enigma. J. Lab. Clin. Med., 1995, 125, 305.
10. MIYAKE H., HARADA H., OCHI K., KUNICHIKA K., TANAKA J., KIMURA I., Prognosis and prognostic factors in
chronic pancreatitis. Dig. Dis. Sci., 1989, 34, 449.
11. LOWENFELS A.B., MAISONNEUVE P., CAVALLINI G. et al., Prognosis of chronic pancreatitis: an international
multicenter study. Am. J. Gastroenterol., 1994, 89, 1467.
12. BERETTINI W.H., LERMAN C.E., Pharmacotherapy and Pharmacogenetics of Nicotine Dependence. Am. J. Psychiatry,
2005, 162, 1441.

Received August 28, 2008

 Detecting Anti-Prothrombin Antibodies in Young Women with
Acute Ischemic Stroke

INIMIOARA MIHAELA COJOCARU1, M. COJOCARU2, R. TĂNĂSESCU1,

CECILIA BURCIN3, ANDREEA CRISTINA MITU3, IULIANA ILIESCU3,
LAURA DUMITRESCU3, ISABELA PAVEL3, ISABELA SILOSI4
1
“Carol Davila” University of Medicine and Pharmacy, Clinic of Neurology,
“Colentina” Clinical Hospital, Bucharest
2
“Titu Maiorescu” University, Faculty of Medicine, Department of Physiology, Bucharest
3
Clinic of Neurology, “Colentina” Clinical Hospital, Bucharest
4
University of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Craiova, Romania

Prothrombin (PT) is a target for antibodies with lupus anticoagulant (LA) activity. Anti-
prothrombin antibodies (aPT) were recently identified as antibodies directed toward a phospholipid-
binding protein. aPT are a new serologic marker of antiphospholipid syndrome.
The objective was to detect aPT in a group of 46 patients with acute ischemic stroke in order to
correlate their presence with clinical diagnosis, laboratory and neuroradiological findings.
We tested aPT, lupus anticoagulant (LA), anticardiolipin (aCL), and anti-β2-glycoprotein I
antibodies (anti-β2-GPI) in 46 young women with acute ischemic stroke aged 34–45 years and
43 patients with nonischemic neurologic diseases and 141 normal controls. Anti-prothrombin
antibodies were detected by calcium-containing aPT ELISA, aCL and anti-β2-GPI by ELISA. All
samples were screened using the activated partial thromboplastin time (aPTT); the dilute Russell
viper venous time (dRVV) coagulation test was perfomed. The results were statistically analyzed.
Anti-prothrombin antibodies were found in 26 (57%) of 46 stroke patients. Out of 43 patients
with nonischemic neurological disorders, 2 (4.18%) were positive for aPT. aPT were detected in one
(0.70%) of the normal controls. Ten stroke patients (21%) were positive for IgG aPT only, 9 stroke
patients (18.2%) for IgM aPT only, and 8 stroke patients (16.9%) for both IgG and IgM isotypes of
aPT. Two nonischemic neurological disorders patients (4.18%) presented IgM isotype of aPT.
Patients with ischemic stroke presented aPT much more frequently than the healthy controls (OR
182.00 [95% CI 23.382-1416.6]. p<0.0001). Patients with ischemic stroke presented aPT much
frequently than the nonischemic neurological disorders patients (OR 26.650 [95% CI 5.743-123.66],
p<0.0001). When IgG or IgM aPT were considered separately, they were more frequently found in
patients with ischemic stroke than in healthy control group (OR 38.889 [95% CI 4.817-313.95],
p<0.0001) and (OR 34.054 [95% CI 4.178-277.5], p<0.0001), respectively. Simultaneous positive
titers for both isotypes of aPT (IgG and IgM) were more frequently found in patients with ischemic
stroke than in healthy control group (OR 29.474 [95% CI 3.573-243.12], p<0.0001). Eleven stroke
patients (43%) were negative for aCL, LA and anti-β2-GPI, but positive for aPT (OR 0.03287 [95%
CI 0.001794-0.6022], p<0.001). aCL, LA and anti-β2-GPI were not found both in nonischemic
neurological disorders patients and in healthy controls.
In conclusion, aPT may play a role in the pathogenesis of ischemic stroke, their presence
being associated with thrombosis.
Key words: anti-prothrombin antibodies (aPT), ischemic stroke, young women.

Anti-prothrombin antibodies belong to the rapid elimination of prothrombin-antiprothrombin

“family” of phospholipid antibodies (aPL). Pro-
thrombin (PT) was the first cofactor for phosphor-
lipid antibody determination to be identified based
on the observation that lupus anticoagulant activity
in patient plasma specimens increased upon
addition of normal plasma. A number of groups
reported patients with lupus anticoagulant (LA) and
acquired hypoprothrombinemia attributable to the
complexes [1–3].
Prothrombin (factor II) is a vitamin K-
dependent glycoprotein with a molecular mass of
72 kDa and a plasma concentration of roughly 0.1
g/l. Coagulation factors Xa and Va and Ca2+ mediate
the conversion of prothrombin to thrombin [4].
It should be mentioned that two different targets
are observed: a) epitopes on the PT molecule itself

ROM. J. INTERN. MED., 2008, 46, 4, 337–341

338 Inimioara Mihaela Cojocaru et al.
bound to oxygenated polystyrene, and b) epitope(s)
formed by the phosphatidylserine/prothrombin (PS/PT)
complex. There are numerous potential links between
aPL and coagulation disorders, including interaction
of aPL and a cofactor, β2-glycoprotein I, which itself
is involved in coagulation mechanisms [1].
Several hypotheses explain the relationship
between the antiphospholipid antibody syndrome
(APS) and thrombosis, but the underlying mechanism
remains unclear. The mechanisms that cause the
appearance of autoantibodies are not understood
[5][6].
While the specific mechanism of antiphos-
pholipid antibody-related coagulopathy is unknown,
it is clear that aPL are associated with an immune-
mediated prothrombotic state. Compared to normal,
factors responsible for autoantibody synthesis are
more complex [7–10].
Cerebral ischemia is the most common
arterial thrombotic manifestation associated with
the presence of aPL. Antiphospholipid antibodies
are a heterogeneous group of autoantibodies with
different isotypes, with varying specificities. In
patients with neurologic disorders, diagnostic value
of aPL can be increased by patient testing for
antibodies against β2 glycoprotein I, (anti-β2-GPI),
PT, C and S proteins, anexin, etc. [11–14].
The importance of aPL as a cause of ischemic
stroke in young adults is well demonstrated in the
previous studies [6][14][15].
The possible association between anti-pro-
thrombin (aPT) antibodies and thrombosis is a
subject of debate [1–4][15–23].
The objective of this study was to detect aPT
in young patients with ischemic stroke in order to
understand the underlying pathogenesis and to
correlate their presence with clinical diagnosis,
laboratory and neuroradiological findings.
MATERIAL AND METHODS
Fourty-six sera from young women with
ischemic stroke aged 34–45 years and 43 control
sera from patients with nonischemic neurological
disorders and 141 healthy subjects were tested for
aPT, lupus anticoagulant (LA), anticardiolopin
(aCL), anti-β2-GPI.
For all eligible patients, the informed consent
was given for the use of their blood in this study.
The research received approval by the ethical
committee of the institution.
2
During routine venipuncture, 2–3 ml of blood
was drawn, and immediately centrifuged. Sera
were then frozen and kept at –20°C, until the
assays were performed.
Anti-prothrombin antibodies were detected
by calcium-containing a PT ELISA. Anticardiolipin
antibodies and anti-β2-GPI were detected by ELISA.
The presence of LA was tested according to the
recommended criteria from the International Society
on Thrombosis and Hemostasis Subcommittee on
Lupus Anticoagulant-Phospholipid-dependent antibodies.
All samples were screened using the activated partial
thromboplastin time (aPTT); the dilute Russell viper
venous time (dRVV) coagulation test was perfomed.
Cerebral ischemia was documented by an
imaging technique, such as computerized tomography
(CT scan) or magnetic resonance imaging (MRI).
Ultrasound examination of cervico-cerebral
arteries and of heart was performed.
The results were statistically analyzed.
Comparison between patients and controls and
patients groups was expressed as odds ratio with its
95% confidence interval (OR [95%CI]), where a
lower limit >1.0 was considered significant. All
p values were determined by Fisher’s exact test. A
value of p<0.05 was considered statistically
significant.
RESULTS
It was no history of oral contraceptive drugs
administration and of smoking in stroke patients.
No arterial or cardiac abnormality was
observed at ultrasound examination.
Anti-prothrombin antibodies were found in
26 (57%) of 46 stroke patients.
Out of 43 patients with nonischemic neurological
disorders, 2 (4.18%) were positive for aPT.
Anti-prothrombin antibodies were detected in
one (0.70%) of the normal controls.
Ten stroke patients (21%) were positive for
IgG aPT only, 9 stroke patients (18.2%) for IgM
aPT only, and 8 stroke patients (16.9%) for both
IgG and IgM isotypes of aPT.
Two nonischemic neurological disorders
patients (4.18%) presented IgM isotype of aPT.
Patients with ischemic stroke presented aPT
much more frequently than the healthy controls
(OR 182.00 [95% CI 23.382-1416.6], p<0.0001).
Patients with ischemic stroke presented aPT
much frequently than the nonischemic neurological
3 Anti-prothrombin antibodies in acute ischemic stroke
disorders patients (OR 26.650 [95% CI 5.743-123.66],
p<0.0001).
When IgG or IgM aPT were considered
separately, they were more frequently found in
patients with ischemic stroke than in healthy
control group (OR 38.889 [95% CI 4.817-313.95],
p<0.0001) and (OR 34.054 [95% CI 4.178-277.54],
p<0.0001), respectively.
Simultaneous positive titers for both isotypes
of aPT (IgG and IgM) were more frequently found
in patients with ischemic stroke than in the healthy
control group (OR 29.474 [95% CI 3.573-243.12],
p<0.0001).
Eleven stroke patients (43%) were negative
for aCL, LA and anti-β2-GPI, but positive for aPT
(OR 0.03287 [95% CI 0.001794-0.6022], p<0.001).
Anticardiolipin antibodies, LA and anti-β2-GPI
were not found both in nonischemic neurological
disorders patients and in healthy controls.
Thrombocytopenia was also observed in
some cases, but without statistical significance.
DISCUSSION
The association between aPT and ischemic
stroke (several controversies) was analyzed in
relation to the APS [14–19].
Prothrombin (PT) appears to be a common
antigenic target for aPL. Prothrombin is an additional
PL-binding protein that can be recognized by aPL-
positive sera, and aPT have been reported to affect
the coagulation process and to be responsible for
LA activity.
Antibodies directed to PT have been also
shown to be responsible for the LA activity. The
LA activity might not be caused by aPT alone but
by a combination of different types of antibodies
(e.g. anti-β2-GPI). Ischemic events such as focal
cerebral ischemia is the most common neurologic
disorder associated with aPL; however, myelopathy,
Guillain-Barré syndrome, migraine, and chorea also
have been frequently reported in aPL-positive patients
[18][19][22][24–27].
There is now general agreement that PT,
another PL-binding protein, is also one of the target
antigens of aPL. Anti-prothrombin antibodies
directly inhibit PT activation. Based on these
observations, the role of aPT as laboratory criteria
for the APS remains to be established [20].
A recent article showed that aPL can mediate
their effects by direct interaction with neuronal
339
tissue. In particular, the authors described the
functional interactions of aPL with neuronal cell
membranes, showing that purified IgG from a
patient with APS induced depolarization of synapto-
neurosomes [3][21].
Whether the presence of aPT further
increases the risk of thrombosis carried by lupus
anticoagulants and, possibly, aCL has still to be
defined. Their presence did not correlate with that
of aCL, anti-β2-GPI, LA and/or anti-protein S
[25][28][29].
Antibody levels and frequencies of positivity
of aPT were significantly different between the
studied groups [23].
The addition of aPT data increased the
proportion of ischemic stroke patients with at least
one type of APS marker from 65 to 78%
[24][27][28].
The finding that aPT are common in ischemic
stroke supports the hypothesis that ischemic stroke
is a form of APS.
Ischemic events have been described in aPL-
positive young patients and children.
From a clinical point of view, aPT correlate
with thrombotic events in many of the published
studies, even if comparisons between series are
difficult because of the technical heterogeneity of
the assays used. Anti-prothrombin antibodies can
identify almost all the LA-positive samples [17]
[19][20][22][25]
It was observed that 48% of the patients with
aPL-related clinical features, who were negative for
aCL, LA and anti-β2-GPI, had aPT, suggesting that
testing for these antibodies could be of added
clinical benefit in patients who are negative for the
routinely used tests [23].
Anti-prothrombin antibodies can be detected
in 50–90% of patients with aPL, depending on
which test system is used. The PS/PT complexes
are strongly associated with manifestations of APS
and the occurrence of LA.
A statistically significant association between
moderate to high titers of IgG aPT and seizures was
found [21].
For the first time aPT in Romania were
studied in this work. It is a new field of research
that contributes to understanding of mechanisms of
thrombosis in ischemic stroke.
Further studies are needed to evaluate the
potential relevance of aPT for prediction of
thrombosis in stroke.
340 Inimioara Mihaela Cojocaru et al. 4

CONCLUSIONS thrombosis, making these antibodies potential

1. This study demonstrates a significant frequency
of aPT in young women with ischemic stroke
without any identifiable risk factor.
2. Anti-prothrombin antibodies may play a role in
the pathogenesis of ischemic stroke in these
patients; their presence is associated with
markers for APS.
3. Testing for aPT could be of clinical benefit in
patients who are negative for the routinely used
tests, suggesting an appropriate therapeutical
approach and monitoring of the disease.

Protrombina (PT) este substratul anticorpilor cu rol de anticoagulant lupic.

Anticorpii antiprotrombină au fost recent identificaţi ca anticorpi împotriva
proteinei care leagă fosfolipidele. Anticorpii antiprotrombină (aPT) reprezintă un
marker serologic nou al sindromului antifosfolipidic.
Obiectivul studiului a fost detectarea aPT la un grup de 46 pacienţi cu stroke
ischemic acut pentru a stabili corelaţia acestora cu diagnosticul clinic şi datele de

(aCL), anticoagulantul lupic (LA) şi anticorpii anti-β2-glicoproteina I (anti-β2-GPI) la

laborator şi neuroradiologice. Au fost determinaţi aPL, anticorpii anticardiolipinici

46 paciente tinere cu stroke ischemic acut cu vârsta între 34–45 ani şi la 43 pacienţi cu
afecţiuni neurologice neischemice, precum şi la 141 martori sănătoşi asemănători ca
sex şi vârste.

Ca, aCL şi anti-β2-GPI, de asemenea, prin ELISA. Anticoagulantul lupic a fost

Anticorpii antiprotrombină au fost detectaţi prin ELISA pentru aPT ce leagă

determinat prin timpul parţial al tromboplastinei activate (aPTT) şi testul Russell

(dRVV). Rezultatele obţinute au fost prelucrate statistic.
Anticorpii antiprotrombină au fost prezenţi la 26 (57%) din cei 46 pacienţi
cu stroke. Din cei 43 pacienţi cu afecţiuni neurologice neischemice 2 (4,18%) au
prezentat aPT. Anticorpii antiprotrombină au fost prezenţi la unul (0,70%) dintre
martorii sănătoşi. Zece pacienţi cu stroke (21%) au prezentat aPT numai izotipul
IgG, 9 pacienţi cu stroke (18,2%) numai izotipul IgM de aPT şi 8 pacienţi cu stroke
(16,9%) ambele izotipuri IgG şi IgM aPT. Doi pacienţi cu afecţiuni neurologice
neischemice (4,18%) au prezentat izotipul IgM aPT. Pacienţii cu stroke ischemic
au prezentat aPT mult mai frecvent comparativ cu martorii sănătoşi (OR 182,00
[95% CI 23,382-1416,6], p<0,0001). Pacienţii cu stroke ischemic au prezentat aPT
mai frecvent decât pacienţii cu afecţiuni neurologice neischemice (OR 26,650
[95% CI 5,743-123,66], p<0,0001). Când izotipurile IgG sau IgM aPT au fost
studiate separat, acestea au fost mult mai frecvent observate la pacienţii cu stroke
ischemic comparativ cu grupul martorilor sănătoşi (OR 38,889 [95% CI 4,817-
313,95], p<0,0001), respectiv (OR 34,054 [95% CI 4,178-277,5], p<0,0001).
Ambele izotipuri IgG şi IgM aPT au fost mai frecvent observate la pacienţii cu
stroke ischemic comparativ cu grupul de martori sănătoşi (OR 29,474 [95% CI
3,573-243,12], p<0,0001). Unsprezece pacienţi cu stroke (43%) nu au prezentat
aCL, LA, anti-β2-GPI, dar au prezentat aPT (OR 0,03287 [95% CI 0,001794-
0,6022], p<0,001). Anticorpii anticardiolipinici, LA şi anti-β2-GPI au fost absenţi,
atât la pacienţii cu afecţiuni neurologice neischemice, cât şi la martorii sănătoşi.
În concluzie, aPT pot să prezinte un rol în patogenia stroke-ului ischemic,
prezenţa acestora asociindu-se cu tromboza.

Corresponding author: Inimioara Mihaela Cojocaru MD, PhD

“Colentina” Clinical Hospital
19–21, Şos. Ştefan cel Mare
Bucharest, Romania
E-mail: inimioaramihaela_cojocaru@yahoo.com
5 Anti-prothrombin antibodies in acute ischemic stroke 341

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Received August 6, 2008

342 Inimioara Mihaela Cojocaru et al. 6
 Is It An Association Between Body Appreciation, Self-Criticism, Oral Health
Status and Oral Health-Related Behaviors?

ALEXANDRINA L. DUMITRESCU1, L. ZETU2, SILVIA TESLARU2, BEATRICE C. DOGARU2, C.D. DOGARU2

1“
Carol Davila” University of Medicine and Pharmacy, Faculty of Dental Medicine
2
“G.T.Popa” University of Medicine and Pharmacy, Faculty of Dental Medicine

Objectives. Our aim was to investigate whether body appreciation and self-criticism are
associated with self-reported oral health status and oral-health-related behaviors were associated.
Methods. The present study sample consisted of 178 first year medical students. The
questionnaire included information about socio-demographic factors, behavioral variables, self-
reported oral health status, self-criticism and body appreciation.
Results. Significant differences were found on body appreciation and self-criticism scales
according to several variables: gender, anxiety, stress, depression, smoking status, perceived dental
health status, current extracted teeth, satisfaction by appearance of own teeth, self-reported gingival
condition. When oral health behaviours were analysed we observed that toothbrushing frequency
once a day or less was reported mainly in persons with low-levels of body appreciation (P<0.01) and
comparative self-criticism (P<0.05). Moreover, individuals who visit their dentist mainly when
treatment is needed or when in pain were compared with persons who visit their dentist mainly for
check-up or for tooth cleaning and scaling; they showed lower levels of body appreciation (P=0.005),
as well as higher levels of comparative self-criticism (P<0.05), internalized self-criticism (P<0.05)
and total self-criticism (P=0.009). Multiple linear regression analyses revealed that anxiety in
everyday life, body appreciation and comparative self-criticism scales were significantly positively
associated with oral health status (r2=0.144; F=3.436, P=0.001), while body appreciation was related
also to gingival health-related status (r2=0.087; F=1.943, P=0.057). When oral health behaviors were
evaluated, it was shown that gender and body appreciation scale were positively associated with
toothbrushing frequency (P<0.0001).
Conclusions. The results suggest that there is an increased risk for impaired dental health status and
behaviour among subjects with low levels of body appreciation and high levels of self-criticism.
Key words: body appreciation, self-criticism, oral health.

The relationship between the oral hygiene,
periodontal diseases and psychological factors has
been reported previously [1–3]. According to
previous studies, toothbrushing frequency is associated
with various psychological traits, including self-
esteem, self-efficacy, life satisfaction, optimism,
sense of coherence, anxiety, depression, locus of
control, stress and cynical hostility [4].
Body image is a complex, multidimensional
construct that includes self perceptions and
attitudes (i.e., thoughts, feelings, and behaviors)
with regard to the body. It involves many
individual albeit related components, such as (but
not limited to) appearance evaluation, appearance
orientation, body esteem, and accuracy of size
perception. Although these components can range
from positive to negative, the study of body image
has primarily been a pathology focused endeavor
with much extant research focused on assessing the
extent individuals’ adopt a negative orientation
toward their bodies. This extensive body of
literature has greatly enhanced awareness of
individual, cultural, familial, and interpersonal
predictors (e.g., low self-esteem, pressure for
thinness) and outcomes (e.g., eating disorder
symptomatology, negative affect, social anxiety
and inhibition, impaired sexual functioning) of
negative body image [5–6].
Self-criticism factor, with its themes of
negative self-evaluation and guilt, correlates with
measures that have been used in the literature as
indexes of depression [7]. Two developmental
levels of self-criticism were identified and
operationalized. The first level of self-criticism,
comparative self-criticism (CSC), is defined as a
negative view of the self in comparison with others.

ROM. J. INTERN. MED., 2008, 46, 4, 343–350

344 Alexandrina L. Dumitrescu et al.
The focus at this level is on the unfavorable
comparison of the self with others, who are seen as
superior and as hostile or critical; consequently, there
is discomfort with being evaluated or exposed to
others. The other level of self-criticism, internalized
self-criticism (ISC), is defined by a negative view of
the self in comparison with internal, personal
standards. These internal standards tend to be both
high and constantly receding, resulting in a chronic
failure to meet one’s own standards. The focus is not
on comparison with others, or on the opinions that
others have of one, but on one’s own view of the self
as deficient [8]. There is considerable evidence that
self-critical evaluative concern (i.e., perfectionism,
self-criticism, concern about mistakes, and doubts
about action) is correlated with suicidality [9–10],
depression [11-14], anxiety [15], well-being, relation-
ship satisfaction of couples [16–17], severity in
chronic pain patients [18], anorexia nervosa and
bulimia nervosa [19][20].
Aim of this study was to investigate the
relationship between narcissism, body appreciation
and self-criticism, oral health status and oral health
behavior.
METHODS
SAMPLE
The subjects of the study were 178 first year
medical students at the “Carol Davila” University
of Medicine and Pharmacy who were invited to this
survey using the two anonymous questionnaires, at
the beginning of the academic year. All students
selected for the survey answered the questionnaire.
A total score was calculated based on the response
on each statement. The subjects gave their
informed consent to participate in the study. The
mean age (S.D.) of medical students was 19.31
(1.21) years old. The percentage of female students
was high in the sample (71.8%).
INSTRUMENTS AND MEASURES
Data were collected through a Romanian self-
administered questionnaire, the Body Appreciation
and Narcissism Scales. A structured, anonymous
questionnaire was specifically developed for this
study and addressed the following: (1) socio-
demographic factors (age, gender, smoking), (2)
perceived oral health status (dental health, non-
2
treated caries, extracted teeth, satisfaction by
appearance of own teeth, dental pain, gingival
condition, gum bleeding), (3) oral health habits
(toothbrushing, flossing, mouthrinse frequency,
dental visiting) [21–23]. Subjects were classified as
smokers, past-smokers and non-smokers. The
questionnaire contained also three questions
concerning stress, anxiety and depression, namely
“do you feel anxious (depressed or stressed) in
your every day life” with the response alternatives,
(1) no, never, (2) yes, sometimes and (3) yes, often.
The 13-item Body Appreciation Scale
(BAS) ([5] was designed to assess the extent to
which women: (a) hold favorable opinions of their
bodies, (b) accept their bodies in spite of their
weight, body shape, and imperfections, (c) respect
their bodies by attending to their body’s needs and
engaging in healthy behaviors, and (d) protect their
body image by rejecting unrealistic images of the
thin-ideal prototype portrayed in the media. These
aspects reflect unconditional approval and respect
of the body, a construct of positive body image we
termed body appreciation. BAS items are rated
along a 5-point scale (i.e., 1 = never, 2 = seldom,
3 = sometimes, 4 = often, 5 = always) and are
averaged to obtain an overall body appreciation
score. Higher scores reflect greater body
appreciation. The BAS’s total score mean was 3.42
(SD = 0.60). In the present study Body Appreciation
Scale had a coefficient alpha of 0.83 and NPI-16
had an alpha value of 0.75.
The Levels of Self-Criticism (LOSC) Scale
consisted of the 22 items and was designed to
measure two dysfunctional forms of negative self-
evaluation: Comparative Self-Criticism (CSC) and
Internalized Self-Criticism (ISC) [8]. Coefficient
alpha for the CSC was 0.59 and for the ISC was
0.87. The scales were inter-correlated (r between -
–0.449 to 0.389, P<0.001). The scales were
translated into Romanian by two bilingual
psychologists using back translation methods.
STATISTICAL ANALYSIS
Descriptive statistics and statistical analyses
were performed with computerized statistical
package (SPSS 13.0, Inc., Chicago, USA) software.
The internal consistency of the BAS, NPI-16 and
LOSC was examined using Cronbachs α.
Descriptive statistics were used on all variables.
Differences between groups were identified with
Student’s t-test and ANOVA. Multiple linear
3 Body appreciation and oral health-related behaviours 345

regression analyses were performed utilizing age, RESULTS

sex, smoking, anxiety, stress, depression, body
appreciation and self-criticism as independent
variables in the study group. All reported P-values
are two-tailed; moreover, those P-values less than
0.05 were considered statistically significant.
Significant differences were found on body
appreciation and self-criticism scales according to
several variables: gender, anxiety, stress, depression
and smoking status (Table I).

Table I
Comparison of body appreciation and self-criticism scales according to several variables
Body Comparative Internalized Total
appreciation Self-Criticism Self-Criticism Self-Criticism
Gender
Male 3.44±0.54 31.77±8.98 38.87±10.67 70.65±15.75
Female 3.41±0.62 30.70±8.42 42.89±12.33 73.60±17.71
P value NS NS P<0.05 NS
Smoking status
Non-smoker 3.48±0.58 30.60±8.66 40.66±12.74 71.30±17.86
Smoker 3.32±0.65 32.62±8.95 42.99±10.86 75.62±17.26
Past-smoker 3.18±0.53 30.03±6.62 45.92±8.76 75.95±10.75
P value NS NS NS NS
Anxiety in every day life
No 3.63±0.55 27.28±8.82 36.41±12.36 63.60±18.14
Yes, sometimes 3.35±0.59 32.37±7.86 42.99±11.38 75.36±15.19
Yes, often 3.16±0.73 34.09±8.66 51.09±9.53 86.10±16.84
P value P=0.009 P=0.009 P<0.0001 P<0.0001
Stress in every day life
No 3.77±0.66 28.57±13.11 29.90±12.04 58.48±23.54
Yes, sometimes 3.52±0.52 29.74±7.21 39.54±10.99 69.22±14.12
Yes, often 3.16±0.63 33.69±8.91 47.85±10.96 81.45±16.84
P value P<0.0001 P=0.009 P<0.0001 P<0.0001
Depression in every day life
No 3.74±0.47 27.24±9.14 35.07±12.54 62.16±17.97
Yes, sometimes 3.40±0.55 31.70±8.06 42.30±10.91 74.02±15.05
Yes, often 2.84±0.66 35.95±6.46 52.15±9.38 88.10±13.00
P value P<0.0001 P<0.0001 P<0.0001 P<0.0001

Parentheses indicate the percentage (%).

NS: Not significant.

When oral health status was evaluated,
significant differences were observed on body
appreciation according to perceived dental health
status, current extracted teeth (others than the third
molars), satisfaction by appearance of own teeth, self-
reported gingival condition (P<0.05). Significant
differences were noted on comparative self-
criticism scale in relation with current extracted
teeth and on internalized self-criticism scale in
relation with satisfaction by appearance of own
teeth (P<0.05) (Table II).
When oral health behaviours were analysed
we observed that toothbrushing frequency once a
day or less was reported mainly in persons with
low-levels of body appreciation (0.63±0.22 vs.
0.48±0.22, P<0.01) and comparative self-criticism
(32.61±8.02 vs. 28.31±7.90, P<0.05). Moreover,
individuals who visit their dentist mainly when
treatment is needed or when pain were compared with
persons who visit their dentist mainly for check-up or
for tooth cleaning and scaling; they showed lower
levels of body appreciation (3.30±0.60 vs. 3.56±0.57,
P=0.005), as well as higher levels comparative self-
criticism (32.29±7.99 vs. 29.67±8.96, P<0.05),
internalized self-criticism (43.53±11.49 vs. 39.43±
12.09, P<0.05) and total self-criticism (75.82±15.78
vs. 69.11±17.72, P=0.009) (Table III).
Multiple linear regression analyses were
performed to examine the independent determinants of
oral health-related status and behaviors. Statistical
analysis showed that co-linearity was not
significant between variables. Anxiety in everyday
life, body appreciation and comparative self-criticism
scales were significantly positively associated with
346 Alexandrina L. Dumitrescu et al. 4

Table II
Comparison of body appreciation and self-criticism scales (Mean ± S.D.) according to self-reported oral-health status
Body Comparative Internalized Total
appreciation Self-Criticism Self-Criticism Self-Criticism
Perceived dental health
Poor/very poor 3.08±0.74 33.48±9.92 44.85±12.48 78.33±18.83
Normal 3.21±0.64 30.05±8.61 41.67±12.60 71.72±18.99
Good 3.45±0.59 30.35±8.38 42.78±11.94 73.13±17.08
Very good 3.61±0.51 31.54±8.45 38.71±12.47 70.26±17.00
Excellent 3.57±0.41 34.56±9.55 39.06±9.71 73.62±13.91
P value P<0.05 NS NS NS
Current non-treated caries
Yes 3.36±0.58 31.31±8.63 41.54±12.55 72.86±18.22
No 3.48±0.61 30.65±8.49 41.51±11.83 72.16±16.59
P value NS NS NS NS
Current extracted teeth (others than the third
molars)
Yes 3.24±0.59 33.42±7.88 42.63±10.06 76.06±15.00
No 3.47±0.60 30.31±8.64 41.20±12.65 71.51±17.83
P value P<0.05 P=0.05 NS NS
Satisfaction by appearance of own teeth
Yes 3.57±0.56 30.28±8.71 39.50±12.35 69.79±17.64
No 3.24±0.60 31.91±8.25 44.05±11.51 75.96±16.40
P value P<0.0001 NS P<0.05 P<0.05
Toothache last time
Do not remember 3.52±0.62 29.54±9.00 40.98±11.93 70.52±17.52
More than a year ago 3.48±0.56 31.30±8.23 43.24±15.14 74.55±20.51
During last year 3.33±0.54 31.71±7.87 40.57±11.52 72.29±15.22
During last 3 months 3.19±0.59 33.20±8.79 40.95± 9.44 74.15±15.91
Last week 3.14±0.76 34.02±7.09 46.36± 8.94 80.38±13.64
P value NS NS NS NS
Self-reported gingival condition
Poor/very poor 3.07±0.64 33.00±11.40 40.92±12.68 73.50±20.29
Normal 3.29±0.61 31.56±8.75 43.40±12.44 74.96±18.25
Good 3.33±0.62 31.36±7.53 43.15±11.61 74.51±15.91
Very good 3.54±0.58 30.80±9.05 39.53±12.96 70.34±18.27
Excellent 3.82±0.35 27.16±9.56 37.14±10.37 64.30±15.44
P value P=0.008 NS NS NS
Self-reported gum bleeding
No signs 3.41±0.61 31.12±9.33 42.08±12.61 73.15±17.83
Yes 3.42±0.60 30.88±8.38 41.26±12.05 71.57±17.74
P value NS NS NS NS

Parentheses indicate the percentage (%); NS: Not significant.

Table III
Comparison of body appreciation and self-criticism scales (Mean ± S.D.) according to self-reported oral-health habits
Body Comparative Self- Internalized Self- Total
appreciation Criticism Criticism Self-
Criticism
Daily toothbrushing frequency
Once a day or less 3.25±0.57 32.61±8.02 39.64± 9.50 72.26±15.08
Twice a day 3.42±0.62 31.39±8.75 42.76±12.80 74.15±17.93
More than twice a day 3.56±0.54 28.31±7.90 39.22±11.62 67.53±16.46
P value NS NS NS NS
Flossing frequency
Never 3.43±0.64 30.34±9.17 40.51±12.48 70.86±18.01
Once a month 3.46±0.53 29.85±9.41 41.27±14.82 71.12±22.65
Once a week 3.57±0.51 34.65±6.59 43.30±10.49 77.95±12.09
5 Body appreciation and oral health-related behaviours 347

More than once a week 3.31±0.58 32.13±7.36 43.59±11.68 75.73±15.81

Everyday 3.54±0.44 29.32±6.19 41.01±7.52 70.34±10.48
P value NS NS NS NS
Mouthrinse frequency
Never 3.36±0.68 30.62±8.83 42.24±12.64 72.87±18.81
Once a month 3.55±0.56 29.99±8.08 40.91±15.65 70.91±20.11
Once a week 3.66±0.40 30.41±9.06 38.67±9.78 69.08±12.22
More than once a week 3.49±0.54 32.29±9.15 41.37±11.12 73.66±17.05
Everyday 3.36±0.48 31.47±7.28 41.21±11.96 72.69±14.70
P value NS NS NS NS
Last dental visit
More than 2 years ago 3.39±0.57 29.88±8.38 42.06±13.35 71.95±17.23
1–2 years ago 3.35±0.48 32.90±7.82 44.38±13.29 77.28±18.66
6–12 months ago 3.53±0.49 29.85±9.61 40.58±12.49 70.44±18.98
Less than 6 months ago 3.39±0.72 31.48±8.11 40.71±10.71 72.19±15.52
P value NS NS NS NS
Reason for the dental visit
Never 3.20±0.65 29.50±8.64 41.66±18.43 71.16±25.90
When treatment is needed or
when pain 3.30±0.60 32.29±7.99 43.53±11.49 75.82±15.78
For check-up or for tooth
cleaning and scaling 3.56±0.57 29.67±8.96 39.43±12.09 69.11±17.72
P value P<0.05 NS NS P<0.05

Parentheses indicate the percentage (%).

NS: Not significant.

oral health status (r2=0.144; F=3.436, P=0.001), evaluated, it was revealed that gender and body
while body appreciation was also related to appreciation scale were positively associated with
gingival health-related status (r2=0.087; F=1.943, toothbrushing frequency (P<0.0001). The models
P=0.057). When oral health behaviors were were well fitted to the data (Table IV).

Table IV
Summary of the regression analyses predicting oral health habits (toothbrushing, flossing, mouthrinse frequency, dental visiting, and
reasons for dental visiting from body appreciation and self-criticism scales
Measure Toothbrushing Flossing Mouthrinse Dental visiting Reasons for
frequency frequency frequency dental visiting
Age –0.085 –0.0058 0.050 –0.174 –0.072
Gender 0.443*** 0.430 0.386 0.330 –0.081
Anxiety in everyday life 0.020 0.079 0.291 –0.269 –0.007
Stress in everyday life 0.215 –0.455* 0.280 –0.215 –0.083
Depression in everyday life –0.014 0.348 –0.376 0.024 0.144
Body appreciation 0.251* 0.198 0.272 –0.163 0.366
Comparative Self-Criticism –0.005 0.015 0.026 0.015 0.003
Internalized Self-Criticism –0.001 0.006 –0.015 –0.011 –0.012
R2 0.192 1.329 0.058 0.077 0.055
F 4.892 0.061 1.248 1.729 1.202
P P<0.0001 NS NS NS NS
*P<0.05; **P<0.01; ***P<0.001
behaviors are associated with self-esteem [24–28].
DISCUSSION Toothbrushing frequency and the proportions of
subjects brushing to make their teeth feel clean increased
To our knowledge, this is the first study to with increasing self-esteem; recent and distant
examine the influence of body appreciation and visits to the dentist were associated with low self-
self-criticism as determinants of self-reported oral esteem [27][28]. Kneckt et al. [24] showed that
health status and behavior. high self-esteem was related to good adherence to
In line with the present findings, previous exercise recommendations and an ability to adjust
studies have shown that oral health status and one’s own insulin dosage. Correspondingly, there
348 Alexandrina L. Dumitrescu et al. 6

was evidence that self-esteem was associated with
a high frequency of tooth brushing.
In recent years, a great amount of research
has documented the role of body image disturbance
in the development of eating disorders, anxiety,
stress, depression, negative mood and general well-
being [29][30]. Four primary approaches have been
offered to explain the development and/or maintenance
of body dissatisfaction: social comparison, socio-
cultural, negative verbal commentary, and maturational
status [31]. Our study revealed that individuals
with a more positive body image are mainly males,
past smokers, have a lower levels of anxiety, stress
and depression, perceive their dental/gingival
health as very good/excellent, have lower number
of current extracted teeth, tend to brush their teeth
more than twice a day and visit their dentist mainly
for check-up or for tooth cleaning and scaling.
Blatt [32] proposed two personality structures
which could strongly influence vulnerability to
depression. Anaclitic depression or dependency
was characterized by feelings of helplessness and
fears of abandonment, and was primarily concerned
with interpersonal relationships. Introbjective
depression or self-criticism was characterized by
feelings of worthlessness and guilt, and was related
in large part to “the sense that one has failed to live
up to expectations and will be disapproved of and
criticized” [33]. It was revealed that self-criticism
may be a maladaptive aspect of self-oriented
perfectionism. Blatt [34] asserted that self-critical
depressive individuals “have a chronic fear of
disapproval, criticism and rejection [and] strive for
excessive achievement and perfection” (p. 1009).
This striving to achieve and maintain approval and
acceptance by others is descriptively rather similar
to socially prescribed perfectionism [35]. Various
studies provide evidence of an association between
depression and periodontal health [36–41]. It has
also been shown that clinical depression may also
have a negative effect on periodontal treatment
outcome [42]. In line with previous findings we
observed significant differences on comparative
self-criticism scale in relation with current
extracted teeth and on internalized self-criticism
scale in relation with satisfaction by appearance of
own teeth. It was also revealed that toothbrushing
frequency once a day or less was reported mainly
in persons with low-levels of comparative self-
criticism. Moreover, individuals who visit their
dentist mainly when treatment is needed or when
pain were compared with persons who visit their
dentist mainly for check-up or for tooth cleaning
and scaling; they showed higher levels of
comparative, internalized and total self-criticism.
One limitation in our study was the exclusive
use of self-reported oral health status in under-
graduate students, fact that decreases the practical
applicability of the results. Also, the ethnic
distribution of the participants, mainly Caucasians,
limits the generalizability of the results in other
types of populations. Future research endeavors
could be aimed at demonstrating whether these
correlations are upheld with samples of adults and
with an objective dental examination.
The results indicate there is an increased risk
for impaired dental health among subjects with low
levels of body appreciation and high levels of self-
criticism.

Obiectiv. Scopul studiului a fost investigarea asocierii dintre modul de

apreciere a organismului şi auto-critica cu starea de sănătate orală şi a
comportamentelor sănătate orală auto-raportate.
Metodă. Studiul s-a realizat pe 178 de studenţi din anul întâi al Facultăţii de
Medicină. Chestionarul a inclus informaţii despre factorii socio-demografici, variabile
comportamentale, starea de sănătate orală şi a comportamentelor sănătate orală
auto-raportate.
Rezultate. Au fost găsite diferenţe semnificative privind modul de apreciere a
organismului şi auto-critica în funcţie de mai multe variabile: sex, anxietate, stres,
depresie, fumat, percepţia stării de sănătate orală, numărul dinţilor extraşi,
satisfacţia faţă de aspectul dinţilor proprii, condiţia gingivală auto-raportată. S-a
observat că frecvenţa o dată pe zi sau mai puţin a periajului a fost raportată în
principal la persoanele cu niveluri scăzute ale modului de apreciere a organismului
(P<0.01) şi cu auto-critica (P<0.05). Mai mult decât atât, persoanele fizice care
7 Body appreciation and oral health-related behaviours 349

îşi viziteaza medicul dentist în principal atunci când este nevoie de tratament sau
atunci când au observat durerea, comparativ cu persoanele care vizitează medicul
dentist în principal pentru control sau pentru curăţarea şi detartrarea dentară au
demonstrat atât niveluri scăzute ale modului de apreciere a organismului
(P=0.005), cât şi niveluri mai ridicate ale auto-criticii comparative (P<0.05),
auto-criticii interne (P<0.05) ca şi a volumului total al auto-criticii (P=0.009).
Analizele de regresie liniară au relevat faptul că anxietatea în viaţa de zi cu zi,
modul de apreciere a organismului şi auto-critica au fost semnificativ asociate cu
starea de sănătate orală (r2 = 0.144; F = 3.436, P=0.001), în timp ce modul de
apreciere a organismului a fost corelat cu starea de sănătate gingivală (r2=0.087;
F=1.943, P=0.057). Când comportamentele de sănătate orală au fost evaluate, s-a
observat că genul şi modul de apreciere a organismului au fost pozitiv asociate cu
frecvenţa periajului (P<0.0001).
Concluzii. Rezultatele sugerează că există un risc crescut de afectare a stării
de sănătate dentară la subiecţii cu niveluri scăzute ale modului de apreciere a
organismului şi cu un nivel ridicat de auto-critică.

Corresponding author: Alexandrina L. Dumitrescu,

Department of Periodontology,
School of Dental Medicine,
“Carol Davila” University of Medicine and Pharmacy,
E-mail: alexandrina_l_dumitrescu@yahoo.co.uk

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Received June 20, 2008

 CASE REPORTS

Pneumoperitoneum – Rare Complication in End Stage Renal Disease

Patient on Automated Peritoneal Dialysis

CAMELIA IONESCU1, MONICA ECOBICI1, DANA OLARU1,

C. STĂNESCU2, IOANA LUPESCU3, M. VOICULESCU1
1
Center of Internal Medicine-Nephrology,
2
Center of Abdominal Surgery and Liver Transplantation,
3
Department of Radiology, Fundeni Clinical Institute, Bucharest, Romania

Peritoneal dialysis (PD) is the first option for patients in end stage renal disease (ESRD).
Several complications such as peritonitis, exit-site or tunnels infections are encountered during PD.
Other complications such as pain, proteic malnutrition, hyperglycemia, hypertension, cardiac failure
are described in patients on continuous ambulatory peritoneal dialysis (CAPD) or APD (automated
peritoneal dialysis). Rare complications are incapsulated sclerosing peritonitis, hemoperitoneum or
pneumoperitoneum. We present the case of a female patient, 66 years old, on cyclic continuous
peritoneal dialysis (APD-CCPD) admitted for pneumoperitoneum developed during a dialysis change
from a CCPD schedule, due to an error in the Tenckhoff catheter and peritoneal dialysis
manipulation. The treatment consisted in extracting the air during manual peritoneal dialysis changes,
with the patient in Trendelenburg position and pressing on the abdominal wall, without any other
complications.
Key words: pneumoperitoneum, peritoneal dialysis, mechanical complication in PD.

Peritoneal dialysis remains the first choice
and a viable treatment option for end-stage renal
disease (ESRD) patients, even if it has several
limitations and complications. Pneumoperitoneum
is a rare complication of peritoneal dialysis and it
can be caused by a bowel perforation or by a faulty
technique that introduces air into the abdomen
during catheter manipulation.
The prevalence and clinical significance of
pneumoperitoneum in peritoneal dialysis patients is
not fully defined in current literature and some
reports suggest that, unlike in non-peritoneal
dialysis patients, it is rarely caused by visceral
perforation.
CASE REPORT
A 66 year-old woman with ESRD, consequent
to nephroangiosclerosis, had been on chronic
peritoneal dialysis with automated night therapy
(APD – CCPD) for approximately 6 months and has
done well. No episodes of peritonitis or other
complications were encountered during this period.
She was admitted at our clinic for abdominal
pain, nausea, diarrhea, dyspnea, symptoms appeared
during the second dialysis change from a continuous
cyclic peritoneal dialysis (CCPD) schedule, when
the machine instilled 2 liters dialysate. The
unexpected pain has localized in the half superior
abdomen, increasing with breathing and transmitted
in the left shoulder. The patient stopped the
procedure owing to pain.
Physical examination reveals: tympanitic
abdomen, tender and painful, blood pressure of
150/90 mmHg and tachycardia (110beats/min). The
Tenckhoff catheter exit site looks unremarkable.
The 24-hours dialysate volume drain was 800 ml
and she had 800 ml urine output. During the last
APD-CCPD procedure, the first drain volume was
1900 ml and the patient infused 2000 ml. The
peritoneal fluid is clear.
Blood chemical and peritoneal fluid studies
findings disclosed a minimal leukocytosis, inflammatory
syndrome and no peritonitis (69 cells per ml in the
peritoneal drain fluid). Abdominal X-ray shows an
important accumulation of air in the half superior
peritoneal cavity, which changes with position
corresponding to the diagnosis of pneumoperitoneum
(Fig. 1–2). Anamnesis and clinical exam did not
show a gastrointestinal disease, as bladder gravel
complication. So, the only choice is an error in the

ROM. J. INTERN. MED., 2008, 46, 4, 351–355

352 Camelia Ionescu et al. 2

Fig. 3. – Abdominal X-Ray: Partial remission of

pneumoperitoneum in a ESRD patient on APD-CCPD
treatment.

DISCUSSIONS

Because there are more and more patients on

peritoneal dialysis (continuous ambulatory peritoneal
dialysis (CAPD) or APD) and for long periods of
time, a better appreciation of the complications has
been developed (Table I).

Table I
Causes of peritoneal dialysis complications
Cause of complication Complication
Presence of intra- Hernias
abdominal fluid Fluid leaks
Rectal prolapse
Vaginal prolapse
Lumbar back pain
Pain on inflow of fluid into
Figs. 1–2. Abdominal X-Ray: Pneumoperitoneum in a ESRD peritoneum
patient on APD-CCPD treatment. Decrease in appetite
Catheter migration Exit-site infection
Tenckhoff catheter and peritoneal dialysis manipulation. Tunnel infection
Peritonitis
The air was accidentally introduced into the
Protein losses into Poor drainage
peritoneal cavity during peritoneal dialysis. The dialysate
patient did not associate peritonitis in this time. Membrane changes Hypoalbuminaemia
The treatment consisted in extracting the air Social factors Loss of UF
during manual peritoneal dialysis changes, with the Catheter migration Social isolation
patient in Trendelenburg position and pressing on the
abdominal wall. Some air was spontaneously Although peritonitis is always considered to
absorbed, so in one week abdominal X-ray was be the main complication of PD, there are many
normal (Fig. 3). other complications of PD (Table II) [1][2].
3 Pneumoperitoneum in renal disease 353

Table II
Complications during PD treatment

Peritonitis and Exit Site Infection

Mechanical Complications of Peritoneal Dialysis
I. Hernia formation (Ventral, Epigastric, Pericatheter, Umbilical, Inguinal (direct and indirect), Femoral, Spigelian, Richter,
Foramen of Morgagni, Cystocele, Enterocele)
II. Abdominal wall and pericatheter leak
III. Genital edema
IV. Respiratory complications
A. Hydrothorax
B. Altered mechanics of breathing
V. Back pain
Metabolic Complications of Peritoneal Dialysis
I. Glucose absorption
II. Lipid abnormalities
III. Protein loss
IV. Hyponatremia/hypernatremia
V. Hypokalemia/hyperkalemia
VI. Hypocalcemia/hypercalcemia
VII. Magnesium depletion vascular calcification
VIII. Hypophosphatemia/hyperphosphatemia
IX. Acidosis/alkalosis

Peritoneal dialysis has its limits and complications
such as:
−
Catheter related complications: pain, poor flow
characteristics and cuff erosion.
−
Metabolic complications: substantial calories
may derive from the absorption of glucose
through the peritoneal cavity, but more concern
is hyperglycemia in diabetic patients; malnutrition
is a problem during peritonitis or other intercurrent
illness that increases catabolism, and at all times in
the diabetic and elderly PD patient.
− Miscellaneous complications: pseudomembranous
colitis as a complication of the antibiotic
treatment of peritonitis, sclerosing obstructive or
encapsulating peritonitis, renal osteodystrophy
and altered vitamin D metabolism, hemoperitoneum,
pneumoperitoneum, etc. [3][4].
In peritoneal dialysis the PD catheter can be
an entry for both microorganisms and air into the
peritoneal cavity. This will usually settle with
conservative measures but it has to be done the
differential diagnosis between a faulty technique
and a visceral perforation [5]. There has been
controversy regarding the clinical significance of
pneumoperitoneum in patients undergoing peritoneal
dialysis. The incidence of pneumoperitoneum has
been estimated to be 21.2% to 33.7% in prior studies
of peritoneal dialysis patients. Of the peritoneal
dialysis patients with pneumoperitoneum, only a
small percentage (5.9% to 14.3%) had documented
visceral perforations. The controversy arises in that
anywhere from 20% to 100% of peritoneal dialysis
patients with pneumoperitoneum and peritonitis
had visceral perforation, and 32.4% to 57.1% of
chronic ambulatory peritoneal dialysis patients had
asymptomatic pneumoperitoneum of unknown
etiology. These disparate incidences made clinical
interpretation of pneumoperitoneum difficult [6].
Pneumoperitoneum has been reported in 11–
34% of patients included in CAPD, diagnosed by
abdominal X-ray and usually the symptoms are
missing. A small quantity of air in the peritoneum
is usually caused by a faulty technique and the
treatment is conservative, extracting the air during
manual dialysis, with the patient in Trendelenburg
position [6–8].
Large amounts of air are unusual in CAPD
patients and it has to be considered as suggestive for
visceral perforation until the cause of peritoneum is
elucidated. A large pneumoperitoneum can indicate the
bowel perforation, but this is not always right. Intestinal
perforation can be ruled out by rapid clinical
improvement with standard therapy, growth of
Staphilococcus epidermidis in the peritoneal effluent
culture, reduction of pneumoperitoneum after
correction of the fault, and in contrast to the Gram-
negatives and/or anaerobes usually found during
bowel perforation [9].
354 Camelia Ionescu et al. 4

Examination of the peritoneal effluent, the
medical history and the clinical picture help to avoid
delay and unnecessary laparotomy. Once bowel
perforation has been excluded, we must find the
cause of pneumoperitoneum and avoid its recurrence
[10-11]. The decision to operate should be based on
microbiological evidence and the clinical judgment
of the nephrologist and of the surgeon.
In our case the patient presented abdominal
symptoms: a tenderness, tympanitic and painful
abdomen and the abdominal X-ray showed a large
accumulation of air in the peritoneal cavity that
changed with position. The upright lateral chest
radiograph is more sensitive than the upright
postero-anterior chest radiograph in detecting small
amounts of pneumoperitoneum. When there is a
strong clinical suspicion of a visceral perforation, it
may be of benefit to include an erect lateral chest
radiography [12]. In the literature CT appeared to
be more sensitive than abdominal X-ray for the
detection of pneumoperitoneum [5][6]. The presence,
quantity, and distribution of free air are not helpful
in separating perforations from nonperforations.
For our patient the X-ray showed the air in the
peritoneum and we did not consider a CT to be
necessary [13].
Therapeutic measures have decreased the
incidence of peritonitis in ESRD patients on
peritoneal dialysis treatment, especially on APD
treatment, but infectious and technical complications
remain a serious threat to patient and technique
survival in PD treatment.

Dializa peritoneală reprezintă prima opţiune de terapie suportivă renală

pentru pacienţii cu boală cronică renală terminală. Deşi peritonita reprezintă
principala complicaţie secundară dializei peritoneale, un număr de alte complicaţii
au fost semnalate în diverse studii din literatură: complicaţii legate de cateter
(durere, infecţii ale locului de inserţie), malnutriţie proteică, hiperglicemie,
hipertensiune, insuficienţă cardiacă, etc. Complicaţii rare, citate în literatură, sunt
peritonita sclerozantă incapsulată, hemoperitoneul şi pneumoperitoneul. Prezentăm
cazul unei paciente în vârstă de 66 de ani cu boală renală cronică terminală, aflată
în program de supleere renală prin dializă peritoneală automată ciclică continuă,
care în timpul unei sedinţe de dializă dezvoltă pneumoperitoneu cauzat de o greşeală
de tehnică. Diagnosticul s-a bazat pe date clinice şi imagistice, iar tratamentul
medical conservator aplicat, constând în expulzia aerului prin cateterul peritoneal,
cu pacienta în poziţie Trendelenburg, a permis menţinerea dializei peritoneale fără
complicaţii ulterioare.

Corresponding author: Camelia Ionescu, MD, PhD

Center of Internal Medicine-Nephrology
Fundeni Clinical Institute
Bucharest, Romania

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12. WOODRING J.H., HEISER M.J., Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and
posteroanterior projections. American Journal of Roentgenology, 165: 45–47.
13. LEE F.T. JR., LEAHY-GROSS K.M., HAMMOND T.G., WAKEEN M.J., ZIMMERMAN S.W., Pneumoperitoneum in
peritoneal dialysis patients: significance of diagnosis by CT. J. Comput. Assist. Tomogr., 1994 May–Jun., 18(3):439–42.

Received August 26, 2008

356 Camelia Ionescu et al. 6
 Atrial Septal Aneurysm and Stroke – A Report of Two Cases

LAURAăăPOANT ,ăăD.L.ăDUMITRAŞCU,ăăDANIELAăăFODOR,ăăADRIANAăăALBUă
“I.ăHaţieganu”ăUniversityăofăMedicineăandăPharmacy,ăDepartmentăofăInternalăMedicine,ăCluj-Napoca,ăRomaniaă

Atrială septală aneurysmă (ASA)ă isă ană uncommonă lesionă whichă oftenă associatesă otheră cardiacă
abnormalitiesăsuchăasăpatentăforamenăovaleăorămitralăvalveăprolapse.ăMoreăthanăhalfăofătheăcasesăwithăASAă
associateăanăinteratrialăshuntăwhichăcanăexplainăcerebralăembolismăandăconsecutiveăischemicăstroke.ăă
Case summary. Weă presentă twoă cases which wereă admitted toă oură hospitală withă minoră
complaints.ăPersonalăhistoriesăexcludedăcardiacădisease,ăhighăbloodăpressure,ăsmoking,ăandăincludedă
ischemică strokeă ină bothă cases.ă Physicală examinationă revealedă noă abnormalities.ă Electrocardiogramă
showedărightăbundleăbranchăblockăinăoneăcase,ălabăfindingsăwereăinănormalălimits.ăă
Cardiacă ultrasoundă (transthoracică andă transesophageal)ă revealedă ină bothă casesă ană ASA,ă oneă
withă bidirectională equidistantă excursionă withoută visibleă interatrială shunt,ă andă oneă withă unilaterală
excursionăandăaăsmallăshunt.ăă
Conclusion. TheăASAădiagnosisăshouldăbeărememberedăasăanăalternativeăcauseăinăaăpatientăwithăaă
historyăofăstroke,ăorăwithădevelopingăstroke,ăandăwithoutăriskăfactorsăforăcerebrovascularădisease.ă
Key words:ăatrialăseptalăaneurysm,ăstroke.ă

Atrialăseptalăaneurysmă(ASA)ăisăanăuncommonă ofă patientsă [5].ă Theă reportă fromă theă Strokeă

lesionă withă aă varyingă prevalenceă ină studiesă withă
transthoracică echocardiographyă(TTE),ătransesophagiană
echocardiographyă (TEE)ă andă autopsiesă [1][2].ă Theă
prevalenceă ofă ASAă variesă withă theă examinationă
method:ă transthoracică echocardiographică studiesă
estimateă theă rateă toă beă betweenă 0.08%ă andă 1.2%,ă ină
autopsiesă theă prevalenceă reportedă wasă 1%,ă andă ină
moreă recentă studiesă usingă TEEă theă prevalenceă wasă
betweenă2%ăandă10%ă[1][3][4].ăă
Ităoftenăassociatesăotherăcardiacăabnormalitiesă
suchăasăpatentăforamenăovale,ăatrialăseptalădefects,ă
ventricularăseptalădefects,ăvalvularăprolapse,ăpatentă
ductusăarteriosus,ăEbstein’săanomaly,ăandătricuspidă
andă pulmonaryă atresia,ă asă wellă asă acquiredă heartă
diseasesăincludingăvalvularădisease,ăcardiomyopathy,ă
systemicăandă pulmonaryăhypertension,ăischemicăheartă
disease,ăarrhythmiasăandăthrombusăformationă[1][2][4].ăă
Moreă thană halfă ofă theă casesă withă ASAă
associateă ană interatrială shuntă whichă cană explaină aă
consecutiveăischemicăstroke.ăă
Atrialăseptalăaneurysmăhasăbeenăconsideredăaă
potentială cardiacă sourceă ofă embolismă ină recentă
yearsă(transientăischemicăattacksăandăcerebrovasculară
accidents),ăbutătheăroleăofăatrialăseptalăaneurysmăasă
aă riskă factoră isă notă veryă wellă definedă [2–4].ă Ină aă
multicentricăstudy,ătheăauthorsăconcludedăthatăatrială
septală aneurysmă couldă beă consideredă aă riskă factoră
forăcardiogenicăembolismăinăaăsignificantăsubgroupă
Prevention:ă Assessmentă ofă Riskă ină aă Communityă
(SPARC)ă studyă demonstratedă thată atrială septală
aneurysmă isă associatedă withă ană increasedă riskă ofă
stroke.ăThisăstudyăestablishedătheăprevalenceăofăASAă
ină theă generală populationă ată 2.2%.ă Theă trueă
prevalenceă ofă ASAă wasă underestimatedă beforeă theă
routineăuseăofăechocardiography,ăespeciallyăTEE.ăItă
seemsăthatăparadoxicalăembolismăisătheăpredominantă
mechanismăofăcardioembolismăinăASA,ăaccordingătoă
SPARCă [6].ă Ină contrast,ă aă prospectiveă long-termă
studyă suggestedă thată theă riskă ofă cerebrovasculară
eventsăisălowăinăaăpatientăpopulationăwithăincidentală
atrialăseptalăaneurysmă[7].ă
Atrialăseptalăaneurysmăwasădefinedăasăaăbulgingă
overă15ămmăbeyondătheăplaneăofătheăatrialăseptumăasă
measuredă byă transoesophageală echocardiography.ă
Atrială septală aneurysmă wasă classifiedă accordingă toă
Hanley’să diagnostică criteria,ă modifiedă byă Pearsonă toă
includeă typeă 1Că [8].ă Theă typeă ofă aneurysmă wasă
determinedă accordingă toă morphologyă andă bulgingă ină
fourăorăfiveătypesă[8][9].ăă
CASE ONE
MI,ă fiftyă yearsă old,ă female,ă wasă admittedă ină
oură hospitală withă dyspepsia.ă Heră personală historyă
excludedă ischemică heartă disease,ă highă bloodă
pressure,ăandăsmoking.ăă

ROM.ăJ.ăINTERN.ăMED.,ă2008,ă46,ă4,ă357–360ă
358ă
ă LauraăPoant ăet al.ă
Sheă hadă ană ischemică strokeă sevenă yearsă agoă
whichă wasă CTă diagnosedă ată theă time.ă Physicală
examinationă revealedă noă abnormalities.ă Bloodă
pressureăwasă120/70ămmHgăinăsupineăposition,ăonă
admissionă ină theă hospital.ă Restă electrocardiogramă
andălabăfindingsăwereăinănormalălimits.ăTheăpatientă
hadănormalăcarotidăarteriesăonăDopplerăultrasound.ăă
Fig.ă1.ă–ăApicalăfourăchambersăview,ăatrialăseptalăaneurysmă(arrow).ă
ă
CASE TWOă
DE,ă 55ă yearsă old, female,ă wasă admittedă withă
osteoarthritis.ă Heră personală historyă alsoă excludedă
ischemică heartă disease,ă highă bloodă pressure,ă andă
smoking;ăsheăalsoăhadăanăischemicăstrokeăthreeăyearsă
ago,ăCTăconfirmedăandăcompletelyărecovered.ăă
Physicalăexaminationărevealedănoăabnormalities.ă
Bloodăpressureăwasă135/78ămmHgăinăsupineăpositionă
onă admission.ă Restă electrocardiogramă showedă rightă
bundleă brunchă block.ă Laboratoryă findingsă wereă ină
normalălimitsăandăsheăhadănormalăcarotidăarteries.ăă
Cardiacă transthoracică ultrasoundă foundă ană
atrială septală aneurysm,ă confirmedă byă TEEă (ASAă
typeă1ăR,ăaccordingătoă[9]),ăwithăbaseăwidthă1.8ăcm,ă
withăunidirectionalăexcursionăandăinteratrialăleft-to-
rightă shunt,ă withoută intraă atrială thrombi,ă andă withă
normalăheartăchambersă(Fig.ă2).ăă
Theăfollowingăparametersăwereăalsoăevaluated:ă
lengthă ofă theă atrială septală aneurysm,ă maximală
ă
2ă
Cardiacă ultrasoundă foundă ană atrială septală
aneurysm,ă confirmedă byă TEEă (ASAă typeă 5ă
accordingătoă[9]),ăwithăaăbaseăwidthăofă2.2ăcm,ăwithă
bidirectională andă equidistantă excursionă throughoută
theă cardiacă cycle,ă withoută interatrială shuntă oră intraă
atrialăthrombiă(Fig.ă1).ă
ă
protrusionăofătheăatrialăseptalăaneurysmăbeyondătheă
planeă ofă theă atrială septumă andă theă directionă ofă theă
maximală protrusion,ă oscillationă ofă theă atrială septală
aneurysmă duringă aă normală respiratoryă cycle,ă
thickeningăofătheăatrialăseptalăaneurysm.ă
DISCUSSIONă
Weăchooseătoăpresentăthoseătwoăcasesăbecauseă
thisădiagnosisăisăuncommon,ăalthoughătheăincidenceă
ofăatrialăseptalăaneurysmăinătheănormalăpopulationăisă
stillă controversial.ă Manyă reasonsă explaină this:ă
differentădiagnosticăcriteria,ă methodologyăused,ăandă
ageăofăpatientsăandălackăofărecognitionă[1][3].ăă
Weăcannotăstateăforăsureăthatăthereăisăaădefiniteă
connectionă betweenă strokeă andă ASAă ină thoseă twoă
cases,ă bută theă probabilityă isă high.ă Theă embolică
mechanismă cannotă beă excludedă ină theă firstă case,ă
despiteătheăfactăthatătheăshuntăisămissing,ăasăcontrastă
TEEăisăinăfactămoreăsensitiveăthanăTEEăcolorăDopplerăă
3ă Atrialăseptalăaneurysmăandăstrokeă 359

Fig.ă2.ă–ăTransthoracicăview,ăatrialăseptalăaneurysmă(arrow).ă
ă
aloneă ină detectingă interatrială shuntă ofă smallă
dimensionsă[9].ă Soă weă cannotă ruleă oută theă paradoxă
embolismă ină oneă case;ă otheră possibleă causesă ofă
cardioembolicăeventsăare:ăthrombusăformationăinsideă
ASA,ăundiagnosedătransientăatrialăarrhythmias,ăsmallă
oră rapidlyă resolvingă thrombiă ină ASA.ă Bothă casesă
receivedămedicalătreatment.ăă
Manyă authorsă observedă thată aă numberă ofă
patientsă withă atrială septală aneurysmă presentedă
cerebrală ischemică events,ă whichă wereă otherwiseă
unexplained,ăasăinăourăbothăcasesă[1][3][5].ăAăstudyă
ofă Nighoghossiană et al.ă foundă atrială septală
aneurysmăinătheă34.5%ăofătheă79ăpatientsăwhoăhadă
anăunexplainedăstrokeă[10].ăă
Inăsubjectsălessăthană 55ăyearsăofăage,ăaăloweră
prevalenceă ofă atherosclerosisă makesă aă diagnosisă ofă
“cryptogenic”ă strokeă (strokeă withoută otheră cleară
cause)ă moreă frequentă thană ină olderă subjects.ă Atrială
ă
septalăaneurysmăhasăbeenădescribedărecentlyăasătheă
onlyă potentială sourceă ofă embolismă ină aă significantă
proportionăofăsubjectsăwhoăhadăsustainedăaătransientă
ischemicăattackă[11].ă
Mattioliă et al.ă haveă alsoă demonstratedă thată
patientsăwhoăhaveăsustainedăcryptogenicăstroke,ăandă
haveă atrială septală aneurysm,ă constituteă aă subgroupă
whichăisăatăaăhigherăriskăofărecurrentăstrokeă[1].ăă
CONCLUSIONă
Theă atrială septală aneurysmă diagnosisă shouldă
beă rememberedă asă ană alternativeă causeă ină patientsă
withăaăhistoryăofăstroke,ăorăwithădevelopingăstroke,ă
andă withoută riskă factorsă foră cerebrovasculară
disease,ăespeciallyăunderăfiftyăfiveăyearsăold.ăă

Anevrismul de sept interatrial (ASI) este o leziune mai puţin frecventă care se
asociază adesea cu alte anomalii cardiace cum ar fi foramen ovale patent sau
prolaps de valvă mitrală. Mai mult de jumătate dintre cazurile de ASI au asociat
un şunt interatrial care ar putea explica accidentele ischemice cerebrale
consecutive emboliei.
Prezentare de caz. Raportăm două cazuri internate în clinica noastră cu
simptome minore. Antecedentele personale patologice exclud bolile cardiace,

ă
360ă
ă LauraăPoant ăet al.ă 4ă

hipertensiunea arterială, fumatul, şi constau în accidente vasculare cerebrale

ischemice în ambele situaţii. Examenul obiectiv a fost în limite normale,
electrocardiograma arată bloc major de ramură dreaptă într-un caz, fiind normală
în celălalt, iar analizele de laborator au fost normale.
Ecocardiografia (transtoracică şi transesofagiană) a relevat în ambele
cazuri un ASI, unul cu excursie bidirecţională, echidistantă, fără şunt vizibil,
celălalt cu excursie unidirecţională şi un şunt mic.
Concluzie. Diagnosticul de ASI trebuie avut în vedere ca şi o posibilă cauză
de accident vascular cerebral ischemic la un pacient cu antecedente personale
patologice pozitive sau cu debut recent şi fără alţi factori de risc detectabili pentru
boala cerebrovasculară.

Corresponding author: LauraăPoant ă

ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă 2–4,ăClinicilorăStr.,ă400006,ăCluj-Napoca,ăRomania,ăă
ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă Mobileăphone:ă0040744894190ă
ăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăăă E-mailăaddress:ălaurapoanta@yahoo.comă

REFERENCESă

1. MATTIOLIă A.V.,ă AQUILINAă M.,ă OLDANIă A.,ă LONGHINIă C.,ă MATTIOLIă G., Atrial septal aneurysm as a cardioembolic
source in adult patients with stroke and normal carotid arteries.ăEur.ăHeartăJ.,ă2001;ă22:ă261–268.ăă
2. FEIGENBAUMăH.,ăEchocardiography.ă6thăed.ăPhiladelphia:ăLippincottăWilliamsă&ăWilkins;ă2005.ăp.ă93,ă187–191.ă
3. PEARSONăA.C.,ăLABOVITZăA.J.,ăTATIENIăS.,ăGOMEZăC.R.,ăSuperiority of transesophageal echocardiography in detecting
cardiac source of embolism in patients with cerebral ischemia of uncertain etiology.ăJ.ăAm.ăColl.ăCardiol.,ă1991;ă17:ă66–72.ă
4. LABOVITZă A.J.ă foră theă STEPSă Investigators.ă Transesophageal Echocardiography and unexplained cerebral ischemia: a
multicentric follow-up study.ăAm.ăHeartăJ.,ă1999;ă137:ă1082–7.ă
5. MUGGEă A.,ă DANIELă W.G.,ă ANGERMANNă C.ă et al., Atrial septal aneurysm in adult patients: a multicentric study using
transthoracic and transesophageal echocardiography. Circulation,ă1995;ă91:ă2785–92.ă
6. AGMONă Y.,ă KHANDEHERIAă B.K.,ă MEISSNERă I.ă et al., Frequency of Atrial Septal Aneurysms in Patients with Cerebral
Ischemic Events.ăCirculation,ă1999;ă99:ă1942–4.ă
7. BURGERă A.J.,ă SHERMANă H.B.,ă CHARLAMBă M.J., Low incidence of embolic strokes with atrial septal aneurysms: A
prospective, long term study.ăAm.ăHeartăJ.,ă2000;ă139:ă149–52.ă
8. HANLEYă P.C.,ă TAJIKă A.J.,ă HYNESă J.K.ă et al., Diagnosis and classification of atrial septal aneurysm by two-dimensional
echocardiography: report of 80 consecutive cases.ăJ.ăAm.ăColl.ăCardiol.,ă1985;ă6:1370–1382.ăă
9. OLIVARES-REYESăA.ăet al.,ăAtrial Septal Aneurysm: A new classification in 205 adults. J.ăAm.ăSoc.ăEchocardiogr.,ă1997;ă10:ă
644–56.ă
10. NIGHOGHOSSIANăN.,ăPERINETTIăM.,ăBARTHELETăM.,ăADELEINEăP.,ăTROUILLASăP.,ăPotential cardioembolic sources
of stroke in patients less than 60 years of age.ăEur.ăHeartăJ.,ă1996;ă17:ă590–4.ăă
11. BEACOCKă D.J.,ă WATTă V.B.,ă OAKLEYă G.D.,ă MOHAMMADă A.,ă Paradoxical embolism with a patent foramen ovale and
atrial septal aneurysm.ăEur.ăJ.ăEchocardiogr.,ă2006;ă7 (2):ă171–174.ăă

ReceivedăOctoberă13,ă2008ă

ă
 Autoimmune Thyroid Disease – A Continuous Spectrum

RALUCAăăTRIF NESCU1,2,ăăC T LINAăăPOIAN 1,2

,ăăD.ăHORTOPAN2ă
1
“CarolăDavila”ăUniversityăofăMedicineăandăPharmacy,ăBucharest,ăRomaniaă
2
“C.I.ăParhon”ăInstituteăofăEndocrinology,ăBucharest,ăRomaniaă

Aim:ătoăpresentăaăcaseăreportărevealingăaăvariantăofănaturalăhistoryăofăautoimmuneăthyroidădisease.ă
Case report.ăI.F.,ăaă39ăyearsăoldăwoman,ăhadăaăpreviousămedicalăhistoryăofăGraves’ădiseaseătreatedă
withăantithyroidădrugsă(ATD).ăAfteră1ăyearăofătreatment,ătheăremissionăwasăconfirmedăoneăandătwoăyearsă
afteră ATDă withdrawal.ă Twentyă yearsă afteră theă initială hyperthyroidism,ă spontaneousă subclinicală
hypothyroidismă wasă diagnosed.ă Theă patientă presentedă bothă antiă TSH-receptoră (TSH-R)ă antibodiesă (Ab),ă
antithyroperoxidaseă(TPO)ăandăantithyroglobulină(antiTgl)ăantibodiesăinăelevatedătitres.ăă
Conclusion.ă Becauseă ofă theă shiftă fromă hyperthyroidismă toă euthyroidismă oră toă spontaneousă
hypothyroidism,ăGraves’ădiseaseăpatientsădemandăaăstrictăfollow-upăafterăATDătherapy.ăItăseemsăthată
thereăisăanăeffectăofăTPOAbăonăthyroidădestruction.ă
Key words:ăGraves’ădisease,ăHashimoto’săthyroiditis,ăautoimmuneăthyroidădiseaseă

Autoimmuneă thyroidă diseaseă isă aă commonă Experimentală modelsă providedă importantă

disease,ă affectingă aboută 2%ă ofă femalesă andă 0.2%ă ofă
malesă [1],ă characterizedă byă lossă ofă toleranceă toă self-
thyroidă antigens.ă Ină bothă Graves’ă diseaseă andă
Hashimoto’să thyroiditis,ă thyroid-reactiveă Tă lympho-
cytesă areă formedă andă infiltrateă theă gland.ă Ină Graves’ă
disease,ă Tă helperă 2ă lymphocytesă stimulateă TSH-Ră
antibodiesă productionă byă Bă lymphocytes,ă generatingă
hyperthyroidism.ăInăHashimoto’săthyroiditis,ăTăhelperă1ă
lymphocytesăinfiltratingătheăthyroidăinduceăapoptosisă
ofă thyroidă folliculară cells,ă generatingă hypothyro-
idismă[2].ăă
Theă relationshipă betweenă Graves’ă diseaseă andă
Hashimoto’săthyroiditisăhasăbeenăextensivelyădebated.ă
Initiallyăconsideredătwoădifferentădiseases,ătheăcurrentă
opinionă isă thată theyă representă theă twoă endsă ofă aă
continuousăspectrum:ătheăautoimmuneăthyroidădiseaseă
[3].ă Someă patientsă withă Graves’ă diseaseă cană lateră
developă hypothyroidism,ă andă someă patientsă withă
Hashimoto’să thyroiditisă cană lateră developă hyper-
thyroidismăorăophthalmopathyă[4].ăFromătheăgeneticsă
pointăofăview,ăthyroidăantibodyăproductionăandăclinicală
autoimmuneăthyroidădiseasesăsharedătheăsameăgenetică
predisposition,ăinvolvingăCTLA-4ăgene,ăAITD-1ălocusă
andă thyroglobulină geneă [5].ă Fromă theă physio-
pathologicalăpointăofăview,ăTăregulatoryăcellăcouldăbeă
anotherălinkăbetweenăGraves’ădiseaseăandăHashimoto’să
thyroiditisă[3].ăAlthoughăabundantăinăinflamedăthyroidă
tissue,ă theyă areă unableă toă down-modulateă theă
autoimmuneăresponseăandătheătissueădamageă[2].ă
informationă onă theă pathogenesisă ofă autoimmuneă
thyroidădiseaseăandăclinicalăcasesăshowingăconsequentă
hyperă andă hypothyroidismă oră viceă versaă supportă aă
commonăpathogenesis.ăă
CASE REPORT
I.F,ăaă39ăyearsăoldăwoman,ăresidentăinăanăiodine-
repleteă area,ă presentedă ină oură outpatientă clinicsă foră
fatigability,ăineffectiveăsleep,ăindifference.ăă
MEDICALăăHISTORYă
Ată 19ă yearsă old,ă theă patientă experiencedă ană
episodeă ofă thyrotoxicosisă withoută signsă ofă activeă
ophthalmopathyă (T3ă >ă 500ă ng/dL,ă T4=ă 21ă µg/dL,ă
radioiodineăuptakeăată2ăh=ă60.43%,ăată24ăh=ă54.60%).ă
Antithyroidă drugă therapyă withă Carbimazolă wasă givenă
foră 1ă yeară period.ă Noă radicală therapyă withă eitheră
radioiodineă oră surgeryă wasă needed,ă becauseă
spontaneousă remissionă occurredă ată therapy’să
withdrawal.ă Stableă remissionă wasă confirmedă 1ăă
andă 2ă yearsă afteră antithyroidă drug’să withdrawalăă
(T3=ă145ăng/dL,ăT4=ă6.39ăµg/dLăandăT3=ă104ăng/dL,ă
T4=ă9.82ăµg/dL,ărespectively).ă
Thereă isă noă pastă medicală historyă oră familială
medicală historyă ofă otheră autoimmuneă diseaseă andă
noăpersonalămedicalăhistoryăofăiodineăoverload.ăăă

ROM.ăJ.ăINTERN.ăMED.,ă2008,ă46,ă4,ă361–365ă

ă
362ă
ă RalucaăTrif nescuăet al.ă
PHYSICALăăEXAMINATIONă
Physicală examă wasă normală apartă aă smallă
asymmetricală goiteră (degreeă I,ă WHOă classification),ă
withă aă rightă thyroidă lobeă largeră thană theă leftă one.ă
Signsăofăophthalmopathyăwereăabsent.ăă
BIOCHEMICALăăDATAă
Haematologicală andă biochemicală dataă wereă
normal.ăThyroidăaxisăassessmentărevealedăsubclinicală
hypothyroidism,ă withă increasedă serumă TSHă levelsă
(9.64ă mIU/L)ă andă normală thyroidă hormonesă levelsă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
ă
A.
Fig.ă1.ă–ăIntenseăhypoechoic,ăinhomogeneousăstructureăofăthyroidăgland,ăhighlyăsuggestiveăforăthyroidăautoimmuneădisease:ăă
A.ăRightălobe;ăB.ăLeftălobe.ă
ă
CTă scană revealedă minimală asymmetricală
protrusionă ofă theă eyeă globes,ă withă 17.4ă mmă
exophthalmometryă ină theă rightă eyeă andă 16.7ă mmă
exophthalmometryă ină theă leftă eye,ă withă minimală
infiltrationă ofă theă fată retrobulbară andă palpebrală
tissues.ă Extraoculară musclesă showedă normală
diameters:ă medială rectusă muscleă 0.38ă cmă ină theă
rightăeyeăandă0.39ăcmăinătheăleftăone,ălateralărectusă
muscleă 0.38ă cmă ină bothă theă rightă andă leftă eyes,ă
inferiorărectusămuscleă0.27ăcmăinătheărightăeyeăandă
0.33ă cmă ină theă leftă eye,ă superioră rectusă muscleăă
0.21ăcmăinătheărightăeyeăandă0.29ăcmăinătheăleftăeye.ă
Theă opticală nerves,ă theă lacrimală glandsă andă theă
superiorăophthalmicăveinsăwereănormală(Fig.ă2).ă
METHODS
Serumă levelsă ofă TSHă (normală range:ă 0.5–ă
4.5ămIU/L)ăwereămeasuredăbyăimmunoradiometrică
2ă
(T3ă =ă103ăng/dL,ăT4ă =ă5.84ăµg/dL);ăallătheămarkersă
ofă thyroidă autoimmunityă wereă positive:ă TPOă
antibodies=ă 996.2ă Æă 665.4ă IU/mLă (normală valuesă
<ă12ăIU/mL),ăantithyroglobulinăantibodiesă=ă244.7ăÆă
105ăIU/mLă(normalăvaluesă<ă34ăIU/mL),ăantiăTSH-
Răantibodiesă=ă9.222ăÆă6.234ăÆă3.2ăIU/Lă(positiveă
valuesă>ă1.5ăIU/L).ăă
Ultrasonographyă confirmedă Iă degreeă (WHOă
classification)ă goiter:ă rightă lobeă >ă 36/18.3/21.2ă mm,ă
intenseă hypoechoic,ă inhomogeneousă structure;ă leftă
thyroidă lobeă 36/15.9/18.1ă mm,ă withă similară
structureă (Fig.ă 1).ă Coloră flowă Doppleră examă
revealedăincreasedăbilateralăcirculation.ă
B.
assay.ăTotalăT3ă(normalărange:ă80-200ăng/dL),ătotală
T4ă(normalărange:ă4.5–13ăµg/dL)ăwereămeasuredăbyă
chemiluminescentăimmunoassays.ăăă
TPOă antibodies,ă antiă thyroglobulină antibodiesă
wereămeasuredăbyăMEIA,ăkităAbbottăAXSYMăSystem.ăă
DISCUSSION
Hyperthyroidismă ină Graves’ă diseaseă isă causedă
byăautoantibodiesătoătheăTSHăreceptor,ăwhereasăhypo-
thyroidismă ină Hashimoto’să thyroiditisă isă associatedă
withă thyroidă peroxidaseă andă thyroglobulină auto-
antibodies.ăAlthoughăinitiallyăconsideredătoăbeădifferentă
diseases,ătheă presentăviewăisăthatătheyărepresentătheă2ă
oppositeăsidesăofăaăcontinuousăspectrum.ă
Ină someă patients,ă autoimmuneă thyroiditis,ă
diffuseă oră focal,ă becomesă sufficientlyă extensiveă toă
destroyă theă thyroid,ă toă cureă theă hyperthyroidismă
withăresultantăhypothyroidismă[3].ă
3ă Autoimmuneăthyroidădiseaseă
ăăăă
A.
Fig.ă2.ă–ăComputedătomographyă(CT)ăscanărevealingăasymmetricalăprotrusionăofătheăeyeăglobesă(A)ăandăhigh-normalădiametersăofă
medialărectusămusclesă(B).ă
ă
Spontaneousă hypothyroidismă mayă followă theă
naturalăcourseăofăGraves’ădiseaseăafterătreatmentăwithă
antithyroidădrugsăinăupătoă20%ăofăpatientsă[6-8] andă
alsoăGraves’ădiseaseămayăfollowăhypothyroidismădueă
toăHashimoto’săthyroiditisă[9].ăInăaălargeăseriesăofă139ă
remittedă Gravesă hyperthyroidă patientsă treatedă withă
ATD,ă withă aă follow-upă periodă ofă 17.5ă years,ă
spontaneousăhypothyroidismăoccurredăină13ăpatients,ă
4ă toă 144ă monthsă (median,ă 48ă months)ă followingă
withdrawală ofă ATD.ă Theă prevalenceă ofă hypo-
thyroidismăwasă9.3%ăandătheăincidenceăwasă2.3%ăperă
year.ă Thereă wasă noă associationă withă typesă ofă drugsă
usedăorătheăregimensă[10].ă
Ită isă wellă knownă thată initiallyă highă TRAbsă
titeră (>ă 46.5ă UI/L)ă andă theă lowă percentageă ofă
TRAbsăfallăonăATDătherapyăareătheăbestăpredictorsă
foră hyperthyroidism’să recurrenceă afteră ATDă
withdrawală ină Graves’ă patientsă [11].ă Theă bestă
predictorsă foră hypothyroidismă developmentă wereă
elevatedă titersă ofă serumă TPOă Absă ată theă endă ofă
treatmentă withă ATD,ă comparedă withă theă titersă
foundăatătheăbeginningă[10].ă
Oură patientă showedă highă levelsă ofă TPOă andă
antiă thyroglobulină antibodies.ă Progressiveă thyroidă
failureăisăaăcommonăoccurrenceăinăGraves’ădisease,ă
andă ită isă suggestedă thată thisă resultsă fromă
concomitantăchronicăthyroiditis.ăHypothyroidismăasă
aă lateă sequelaă ină patientsă withă Graves’ă diseaseă
treatedă withă antiă thyroidă drugsă wasă previouslyă
reportedă ină 9ă oută ofă 15ă patientsă (3ă overtă hypo-
thyroidismă andă 6ă subclinicală hypothyroidism);ă
antimicrosomală antibodiesă wereă presentă ină 12ă oută
ofă15ăpatientsăstudiedă[12].ăă
Inăourăyoungăpatient,ătreatedăwithăantiăthyroidă
drugsăforăonlyăoneăyear,ăTRAbsăwereăstillăpositive.ă
ă
363
ă
B.
Ită wasă reportedă thată unlikeă adults,ă mostă childrenă
andăadolescentsăwithăGraves’ădiseaseărequireămoreă
thană 2ă yearsă ofă ATDă treatmentă beforeă TRAbsă areă
normalizedă[13].ăă
Recently,ă ită wasă reportedă aă possibleă linkă
betweenăGraves’ădiseaseăandăHashimoto’săthyroiditis:ă
theăTăregulatoryăcells.ăTransgenicămiceăexpressingă
lowă intrathyroidală TSHRă A-subunită (theă ecto-
domaină componentă ofă TSHRă whichă isă theă
autoantigenă drivingă theă immuneă responseă ină
Graves’ă disease)ă withă Tă regulatoryă cellsă depletionă
inducedă byă mouseă anti-CD25ă beforeă TSHR-Adă
immunizationă hadă massiveă lymphocyteă infiltrationă
andăshowedăhypothyroidism.ăLymphocyticăinfiltrationă
(includingă cytotoxică cellsă andă generatingă cytokines)ă
causeăthyrocytesădamageăandăhypothyroidism,ăwithă
releasingăofăthyroidăantigensăandăanăintermoleculară
spreadingă ofă theă humorală autoantibodyă responseă
fromăTSHRătoăotherăthyroid-specificăantigensă(TPOă
andă Tg);ă thisă lymphocytică infiltrationă andă hypo-
thyroidismăsuggestedăaăshiftăinăthisăanimalămodelăofă
Graves’ătowardsăHashimoto’săthyroiditisă[3].ă
Apartăfromăthisănaturalăprogressionăofăhyper-
thyroidă Graves’ă diseaseă toă Hashimoto’să thyroiditisă
andă hypothyroidism,ă antithyroidădrugă therapyă mayă
modifyă theă naturală historyă ofă Graves'ă diseaseă andă
contributeă toă theă remissionă andă subsequentă
hypothyroidismă occurringă ină aboută halfă ofă treatedă
patientsă [14].ă Thyrotrophină receptoră antibodyă
levels,ă centrală toă theă aetiologyă ofă Graves'ă hyper-
thyroidism,ă fallă duringă antithyroidă treatmentă andă
thată remissionă mayă beă relatedă toă thisă fallă ină aă
fashionă whichă isă dependentă onă theă doseă andă
durationă ofă treatment.ă Thisă immunosuppressiveă
effectăisăsupportedăbyăexperimentalădataă[15].
364ă
ă RalucaăTrif nescuăet al.ă 4ă

AnotherăexplanationăofăprogressionăofăGraves’ă
hyperthyroidismă toă hypothyroidismă couldă beă theă
presenceă ofă blockingă thyrotropină receptoră antibodiesă
ină theă successiveă cyclesă ofă oscillationă ofă stimulatingă
andă blockingă TSHă receptoră antibodyă activitiesă
[16][17].ă Ină oură patientă weă globallyă assessedă theă
presenceăofăTSHăreceptorăantibodies.ăStimulatingăandă
blockingă TSHă receptoră antibodyă activitiesă measuredă
byăcAMPăfunctionalăbioassaysăusingăculturedăhumană
thyrocytesă wereă notă available.ă Usually,ă thyroidă
stimulatingă antibodiesă wereă presentă throughoută theă
wholeă courseă ofă alterationsă ină thyroidă function,ă bută
thyrotrophină receptoră antibodiesă exhibitingă TSHă
antagonistă activityă seemedă toă appeară andă disappear.ă
Monitoringăsuchăactivityăindicatedăthatătheăemergenceă
ofă blockingă antibodyă seemsă toă heraldă theă onsetă ofă
hypothyroidismă[18].ăă
Ină 26ă patientsă withă Graves’ă diseaseă whoă
developedă hypothyroidismă afteră discontinuationă ofă
antithyroidă drugă therapy,ă eightă (31%)ă hadă TSH-
blockingăantibodies,ă16ă(61%)ăhadăthyroidăstimulatingă
antibodiesă (TSAb),ă andă 14ă (54%)ă hadă thyroidă
hormoneăbindingăinhibitorăimmunoglobulins.ăThyroidă
needleăbiopsies,ăperformedăină9ăpatients,ărevealedăthată
3ă ofă 5ă patientsă whoă hadă subclinicală hypothyroidismă
hadă chronică lymphocytică thyroiditis,ă andă allă hadă
positiveăTSAbătiters.ăTheăauthorsăconcludeăthatăTSH-
blockingăantibodiesămayăaccountăforăhypothyroidismă
inăapproximatelyăoneăthirdăofăpatientsăwithăGraves’ă
diseaseăwhoăwereăpreviouslyătreatedăwithăantithyroidă
drugs,ăandăthatăautoimmuneăthyroiditisăisăresponsibleă
forătheăhypothyroidismăinătheăremainingătwoăthirdsăofă
Graves’ădiseaseăpatientsă[7].ă
Ină otheră twoă Graves’ă patientsă showingă
hypothyroidismă afteră ATDă treatment,ă blockingă
TSHRAbsă wereă identified.ă Interestingly,ă theă
differenceă ină theă courseă ofă blockingă TSHRAb-
inducedă hypothyroidismă wasă associatedă withă theă
differenceă ină epitopeă reactivitiesă ofă TRAbă duringă
hypothyroidă phaseă thată developedă afteră ATDă
treatmentăofăGraves’ădiseaseă[19ă].
Graves’ă patientsă withă coexistingă blockingă
antibodiesăinitiallyărespondăwellătoăthiamazole,ăbută
areă relativelyă slowă toă achieveă remissionă [20].ă
Takingăintoăaccountăallătheseăfacts,ămeasurementăofă
blockingă antibodiesă mayă beă usefulă foră selectionă ofă
treatmentăoptionsăinăGraves’ădisease.ă
CONCLUSION
Becauseăofătheăshiftăfromăhyperthyroidismătoă
euthyroidismă oră toă spontaneousă hypothyroidism,ă
Graves’ădiseaseăpatientsădemandăaăstrictăfollow-upă
afteră ATDă therapy.ă Ită seemsă thată thereă isă ană effectă
ofăTPOAbăonăthyroidădestruction.ă

Scop: prezentarea unui caz clinic relevant pentru o variantă a evoluţiei

naturale a bolii tiroidiene autoimune.
Prezentare de caz. I.F., 39 ani, femeie, a prezentat în antecedente un episod
de boală Graves tratată cu antitiroidiene de sinteză. După un an de terapie,
remisiunea bolii a fost confirmată la 1 şi 2 ani după întreruperea tratamentului cu
antitiroidiene de sinteză. Douăzeci de ani după episodul iniţial de hipertiroidism,
pacienta a fost diagnosticată cu hipotiroidism subclinic spontan. Pacienta prezenta
atât anticorpi antireceptor pentru TSH, cât şi anticorpi antitiroperoxidază şi
antitiroglobulină în titruri crescute.
Concluzie. Datorită posibilei evoluţii naturale a hipertiroidismului spre
eutiroidism sau spre hipotiroidism spontan, pacienţii cu boală Graves trebuie
urmăriţi pe termen lung, chiar după oprirea terapiei cu antitiroidiene de sinteză.
Evoluţia spre hipotiroidism spontan poate fi datorată distrucţiei tiroidiene mediate
de anticorpii antitiroperoxidază.

Corresponding author: RalucaăTrifanescu,ăMD,ăPhDă

ăă “C.I.ăParhon”ăInstituteăofăEndocrinologyă
ă 34-36,ăAviatorilorăAv.,ăBucharest,ăRomaniaă
ă E-mail:ralucatrifanescu@yahoo.comă
5ă Autoimmuneăthyroidădiseaseă 365

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ReceivedăOctoberă14,ă2008ă

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ă RalucaăTrif nescuăet al.ă 6ă

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 Renoureteral Diseases Inducing Hypertension in Children

GH. BURNEI1, ANCA BURNEI2, D. HODOROGEA1, ŞT. GAVRILIU1,

ILEANA GEORGESCU1, C. VLAD1, LUCIA HURMUZ1, DANA DAN1
1
Paediatric Surgery and Orthopaedics Clinics, “M.S. Curie” Emergency Hospital for Children, Bucharest, Romania
2
Obstetrics and Gynecology Clinics, “Elias” Emergency Hospital, Bucharest

Revealing the cause of renal hypertension is a major objective in medical practice. A series of
investigations are required in order to elucidate the primary disease and then the treatment surgical
and/or medical. The transitory hypertension of adolescent is not discussed in this paper. Measuring
the blood pressure in children is often neglected and the evaluation of the hypertension is performed
after the diagnosis of the renovascular disease.
Aims. The classification of renovascular hypertension in children and the statistical evaluation
of its etiology in order to reveal the most frequent renovascular disease are a topical work of several
authors. A guide of the most frequent causes of hypertension in children edited after the studies of
several authors may lead to a complete classification and describe a complexed concept regarding
diagnosis, evaluation and treatment of the patients.
Materials and Methods. This paper displays an analytic study on 19 patients, aged between 2
and 15 years, diagnosed with hypertension and presenting signs and symptoms of hypertension. Four
of the 19 patients needed medical treatment, 12, surgical treatment, and for three patients the
treatment was mixed.
Results. The renal hypertension was determined by aberrant renal arteries in four cases, by
pyelonephritis in four cases, by renopyeloureteral duplication with congenital megaureter in two cases
and by transversal renal rupture, renal agenesis, horse shoe kidney, glomerulonephritis and Wilms
tumor, in one case each. In our study, the parenchymal diseases predominated (12 cases of 19–
63.1%) over the 7 cases with renovascular lesions – 36.9%. Among the parenchymal diseases seven
are unilateral, six renoureteral malformations and a pyelonephritis, and five are bilateral, four
pyelonephritis and a glomerulonephritis.Those seven cases of renovascular lesions include six indirect
lesions (three hydronephrosis, one Wilms tumor, one renal abscess, one renal trauma) and one case of
congenital vascular anomaly without stenosis (renal agenesis).
Conclusions. All renoureteral diseases included in Ursea-Ionescu-Târgovişte classification can
induce hypertension but renovascular hypertension does not appear in all cases. The diagnosis of the
renoureteral diseases inducing hypertension in children permits the treatment of hypertension and
renoureteral illness.
The analytic study of diagnostic and treatment methods of different diseases and authors may select
the most efficient methods and orientate towards a new therapeutical concept and/or evaluation system.
The treatment of the renoureteral diseases inducing hypertension avoids the development of
some serious complications: the retinopathy, the chronic renal failure, the cerebrovascular accidents.
Key words: renovascular hypertension, classification, etiopathogenical frequency.

Hypertension in children is defined as blood
pressure >95th percentile for age, gender and
height on repeated measurements. A recording
below the 90th percentile is considered normal.
Children with blood pressure between the 90th and
95th percentiles should remain under observation
and evaluated for other risk factors for hyper-
tension [1][2]. Renovascular hypertension is one of
the most important causes of hypertension in
children, although its incidence is not so frequent.
In adults, atherosclerosis of renal artery is the most
important etiology of renovascular hypertension,
whereas fibromuscular dysplasia is of greater
importance in children [3][4]. Severe hypertension
is a relatively rare condition in children compared
to that in adults. The causes of hypertension are
also different, i.e., secondary hypertension is
predominant in children, whereas essential hyper-
tension is much more common in adults [5].
Multiple studies have demonstrated that no clear

ROM. J. INTERN. MED., 2008, 46, 4, 367–374

368 Gh. Burnei et al. 2

sex difference occurs in childhood renovascular
hypertension. In children, the prevalence of
renovascular disease as the cause of hypertension is
inversely related to age. In other words, younger
children are more likely to have hypertension that
is due to renovascular disease. In children younger
than 5 years, the incidence of potentially surgically
correctable hypertension is close to 80%. This
incidence drops to 40–45% in children aged 6–10
years. In children aged 11–20 years, a 20%
incidence of surgically correctable hypertension is
observed [6].
Parenchymal or vascular renal hypertension
may appear in children in the following conditions:

The classification of renal hypertension (after Ursea and Ionescu – Tîrgovişte, modified)

I. Hypertension in renal parenchymal diseases

A. Bilateral lesions B. Unilateral lesions

1. Glomerulonephritis 1. Congenital parenchymal malformations
– diffuse acute – Renal agenesis
– diffuse subacute – Renal aplasia
– chronic – Congenital renal hypoplasia
2. Glomerulosclerosis in diabetes mellitus – Renal ectopy
3. Renal amyloidosis – Horse shoe kidney
4. Collagen diseases – Doubled kidney
– Polyarteritis nodosa 2. Chronic pyelonephritis
– Systemic lupus erythematosus 3. Renal tuberculosis
– Scleroderma 4. Acquired renal atrophy
5. Hypercalcemic nephropathy
6. Polycystic kidney
7. Chronic pyelonephritis
II. Hypertension through renovascular lesions

A. Congenital or acquired vascular B. Direct vascular lesions C. Indirect vascular lesions

anomalies (compressive and unilateral)
1. Renal artery agenesis or atresia 1. Bilateral vascular lesions 1. Renal and pararenal tumors
2. Multiple aberrant renal arteries a. Bilateral stenosis of large renal 2. Renal and perirenal cysts
3. Aberant inferior polar vessel arteries 3. Renal and perirenal hematoma
4. Intrarenal vessel malformations b. Bilateral stenosis of small renal 4. Renal and perirenal abscess
5. Renal artery aneurism arteries 5. Renal trauma
6. Arterio-venous renal fistula 2. Unilateral vascular lesions 6. Renal pedicle torsion
– Renal infarction 7. Obstructive uropathy (hydronephrosis)
– Small renal infarctions
– Progressive occlusion

nephritis (Table II).Those seven cases of renovascular

MATERIAL AND METHODS
Among the patients of our study (Table I) we
find four cases of aberrant renal arteries, four cases
of pyelonephritis, two cases of renopyeloureteral
duplication with congenital megaureter and one case
of transversal renal rupture, renal agenesis, horse
shoe kidney, glomerulonephritis and Wilms tumor.
In our study, the parenchymal diseases
predominated (12 cases of 19–63.1%) over the 7
cases with renovascular lesions – 36.9%. Among the
parenchymal diseases seven are unilateral, six
renoureteral malformations and a pyelonephritis, and
five are bilateral, four pyelonephritis and a glomerulo-
lesions include six indirect lesions (three hydro-
nephrosis, one Wilms tumor, one renal abscess, one
renal trauma) and one case of congenital vascular
anomaly without stenosis (renal agenesis).
DISCUSSION
Aberrant polar arteries, met in 21.1% of
cases, lead indirectly to renal hypertension through
the compression on pyeloureteral junction. These
aberrant vessels produce a “primary” hydro-
nephrosis sometimes followed by renal infections
and hypertension.
3 Renoureteral diseases inducing hypertension in children 369

Table I
The diagnoses and blood pressure values for 19 children with renal hypertension
Patient Sex Blood Renal etiology Treatment
Age pressure
(mm Hg)
1. P.I. Female 160/110 Aberrant renal arteries Mixed
14 years
2. C.G. male 200/150 Right kidney hypoplasia. Bilateral reflux Surgical
14 years
3. C.M. male 140/90 Transversal rupture of inferior pole of the Surgical
6 years right kidney
4. B.D. female 175/105 Chronic pyelonephritis Medical
10 years
5. B.D. male 210/150 Chronic nephritis Medical
11 years
6. O.L. male 150/90 Chronic pyelonephritis Medical
15 years
7. G.M. male 140/80 Right kidney agenesis Medical
12 years
8. D.R. female 110/50 Horse shoe kidney Mixed
2 years
9. G.H. male 135/80 Bilateral renopyeloureteral duplication. Surgical
6 years Bilateral vesicoureteral reflux
10. B.T. male 110/70 Bilateral renopyeloureteral Surgical
9 years duplication.Right vesicoureteral reflux
11. C.I. male 120/70 Bilateral congenital megaureter Surgical
5 years
12. D.R. male 140/80 Right megaureter with vesicoureteral Surgical
6 years reflux
13. P.M. male 120/70 Focal glomerulonephritis Mixed
4 years
14. R.G. male 175/110 Left kidney inferior polar artery Surgical
10 years
15. T.G. male 140/100 Left kidney pyelonephritis Surgical
11 years
16. B.T. male 140/100 Left kidney pyelonephritis Surgical
5 years
17. P.I. male 170/110 Superior and inferior aberrant polar Surgical
15 years arteries
18. C.G. female 240/130 Right kidney hypoplasia Surgical
14 years
19. S.M. female 110/70 Wilms tumor Surgical
2 years

Table II
The renal diseases inducing hypertension in our 19 children
PERCENTAGE
RENAL DISEASE
(%)
A. Parenchymal diseases and malformations 63.1
1. Bilateral diseases 26.3
– glomerulonephritis 5.2
– chronic pyelonephritis 21.1
2. Unilateral diseases 36,8
– renal malformations 31.6
– renal agenesis 5.3
– congenital renal hypoplasia 10.5
– horse shoe kidney 5.3
– doubled kidney 10.5
370 Gh. Burnei et al. 4

– unilateral pyelonephritis 5.2

B. Renal vascular lesions 36.9
1. Direct vascular lesions 0
2. Non-stenotic congenital vascular anomalies 5.2
– renal artery agenesis 5.2
– aberrant renal vessels 0
3. Indirect vascular lesions 31.7
– Wilms tumor 5.3
– renal trauma 5.3
– hydronephrosis 15.8
– renal abcess 5.3

In the following we present a case with right

inferior polar artery, hydronephrosis, pyelonephritis
and hypertension.

CASE 1

The patient P.I., female, aged 14, had repeated

admissions in another hospital for glomerulonephritis
with hypertension.
Subsequently, she experienced repeated E. coli
infections.
On first admission, laboratory findings
showed renal failure and infection: blood urea
0.76g‰ and urea clearance 41 ml/min.
Urinary syndrome marked out a hypotonic
urine and frequent white and red blood cells in the
renal sediment.
Uroculture detects over 100,000 germs/ml of
E. coli.
Urography shows a nephrotic pyelocaliceal
dilatation in the right kidney through compression
of an inferior polar artery.
We can also observe a large ovoid image Fig. 1. – Arteriography shows right kidney inferior polar artery
over the inferior half of the right kidney which emerged from aortic bifurcation (Professor N. Coban archive).
dissociates caliceal anatomy and renal failure of the
left kidney with chronic pyelonephritis and Hallwachs [9–12] reports the frequency of
alterations of the calyces. The shadow of the left the hypertension in aberrant polar vessels as 21.1%,
which is similar to our finding – 20%.
kidney is small revealing the atrophy and a
Chronic pyelonephritis, met in 21.1% of
vascularization deficit.
cases as a cause-effect relation with hypertension,
Retrograde pyelography discovers a double
represents a controversial subject. Clinical data
compression on the right kidney, one at the lumbar plead for the causative relation between chronic
ureter through a polar vessel and another at pyelonephritis and hypertension.
pyeloureteral junction by the tumor proeminent in Two mechanisms are involved in the
the renal pelvis. This tumor is a supplementary appearance of the pyelonephrotic hypertension:
kidney included in the right kidney and vascularized 1. The stimulation of renin secretion through
by the aberrant inferior polar artery. endoarterial lesions and secondary ischemia.
Arteriography confirms the right inferior 2. The insufficient secretion of the hypotensor renal
polar artery which splits into two after approaching factors due to the shrinking of the renal paren-
the renal pole, one branch for the inferior renal pole chyma through endarteritic lesions followed by
and the other for the supplementary kidney (Fig. 1). important infarctions of renal parenchyma.
5 Renoureteral diseases inducing hypertension in children
CASE 6
The patient O.L., aged 15, presents for left
lumbar pain and frequent need to urinate.
Urography showed altered renal concentration
on the left and normal urogram on the right (Fig. 2).
Fig. 2. – Intravenous urography. Left kidney chronic
pyelonephritis with altered renal concentration and hypotonic
renal pelvis (Professor N. Coban archive).
Urine examination detects elevated albumin
excretion. Uroculture was sterile.
Bacteriuria was missing as in the previous case.
Ambrose and Hill [13] declare that only 30%
of patients with pyelonephritis got over 105 germs/ml
in urine.
Lipman [14] pleads that pyelonephritic infection
cannot be excluded if urine is sterile.
The frequency of hypertension in chronic
pyelonephritis varies in different studies between
11.8% and 84.5% (Friedman [15]).
Congenital renal hypoplasia was met in
10.5% of the patients from our study. Antonescu
16][17] finds hypoplasia in 5% of the 219 cases of
renal hypertension, in adults.
The physiopathological mechanism of hyper-
tension in hypoplasia is the elevated renin secretion in
spite of the absence of the renovascular bud.
371
CASE 2
The patient C.G., male, aged 14, transfers
from ophthalmology with a retinopathy diagnosed.
Blood pressure at presentation was 240/
160 mmHg. Clinically, we observed discreet renal
edema and a slightly positive Giordano on the right side.
Laboratory findings and urography led to
diagnosis: Right kidney hypoplasia. Bilateral vesico-
ureteral reflux with urinary infection. Hypertension.
Elevated blood pressure levels and resistant to
therapy imposed surgical treatment. The right
nephroureterectomy practised showed a megaureter.
At the second presentation, we found left
megaureter with vesicoureteral reflux on single
kidney (Fig. 3).
Fig. 3. – Nephrectomy – long megaureter and hypoplasic
kidney from a child with 200/150 mm Hg blood pressure
(Professor I. Bâscă archive).
The vesicoureteral reflux. The severe hyper-
tension presented in the previous case may be
caused by the vesicoureteral reflux.
The mechanism of hypertension appearance
is similar to that in pyelonephritis because reflux is
a major factor inducing pyelonephritis.
King [18–20] reproduced experimentally the
vesicoureteral reflux and demonstrated that, for the first
20 months, the reflux does not alter global renal
function, nor the kidney above the vesicoureteral reflux.
372 Gh. Burnei et al.
In all the cases, the reflux destroys renal
parenchyma through stasis, high pressure and
added urinary infection.
Among the 19 cases followed, the reflux
participates in the starting, maintenance or increase
of hypertension in 5 cases – 26%.
Murnaghan [21][22] studied 350 patients with
urinary infection and found chronic pyelonephritis in
39% of cases and reflux in 18% of cases.
In acute glomerulonephritis, hypertension is
frequently moderate and temporary. In our statistics,
the frequency of acute glomerulonephritis is 5.25%.
Many hypotheses were proposed as a possible
explanation for the physiopathology of hypertension
in acute glomerulonephritis. The most probable
explanation comes from Defazio [23](1959) who
accused hypervolemia. The inflammation of glomerular
endothelium decreases the ultrafiltrate and leads to
hypervolemia.
Among our patients there were two cases of
congenital megaureter and bilateral renopyelou-
reteral duplication. Both cases presented hyper-
tension through the bilateral reflux which led to
renal infection.
The case with horse shoe kidney was associated
with vascular anomalies which explained the
hypertension.
The compression of renal artery by the Wilms
tumor and the activation of the renin-angiotensin
system leads to the development of systemic
hypertension. The arteriography can reveal an
intratumoral arterio-venous fistula in the cases of
Wilms tumor.
CASE 19
S.I., female, aged 2, presented for abdominal
pain and vomiting. The debut was 45 days before
with abdominal pain and the increase of abdominal
volume observed by her mother. At presentation,
the teguments were pale and marmorated. Facial
hypertrichosis and superficial venous circulation
were visible. We could palpate in the left flank a
big, boselated, tough and adherent tumor. The
patient experienced subfever and blood pressure
oscillated around 110/70 mmHg. Urinary syndrome
consisted of scarce albumin, frequent leukocytes
and erythrocytes, frequent urate crystals. Laboratory
findings found only an elevated erythrocyte
sedimentation rate (105/125 mm) and a slight
anaemia. Urography detected a right normal urogram.
Left urogram showed the tumor. Pulmonary
6
radiography revealed large and homogeneous
opacities in the base of the right lung and around
the left hilum.
Sequels after renal trauma. One patient
(5.2%) presented renal trauma in our study and
blood pressure was 140/90 mmHg.
CASE 3
The patient, male, aged 6, is admitted through
emergency department with traumatic shock.
We practised emergency surgery. Urine and
blood appeared on peritoneal cavity opening. We
observed a posterior peritoneum rupture in the right
mesenterico-colic recess. The superior pole of the
right kidney herniated through this rupture into the
peritoneal cavity. The inferior pole of the right
kidney presented a transversal rupture and a
perirenal hematoma. After the evacuation of the
blood clots from the recess we drained the recess
and restored the abdominal wall.
We found an urohematic collection on
transperitoneal exploration of the left kidney. A
large amount of urine was released from the
retroperitoneal space and we observed a break
between the ureter and renal pelvis. The ends were
resected and pyeloureteral anastomosis was made
on a splint.
The exploration of the abdominal cavity
showed contusions on the descendent colon, ileum
and pancreas, and a rupture on mesocolon. We
practised segmental resection on ileon and
descendent colon, then an end-to-end anastomosis.
In this case, the hypertension appeared after
the major injury of the right kidney which had
parenchymal and vascular lesions.
The primary lesion was the effraction of the
renal capsula which led to a perirenal hematoma.
The hematoma developed rapidly, with lumbar
pain, hemorrhagic syndrome, collapse and lumbar
swelling. The persistence of the hypertension was
probably determined by the formation of some
fibrous and atrophic areas.
Rose [24] (1970) found 3 cases of hypertension
by renal artery occlusion when studied through
arteriography, 176 of lumbar closed traumatisms.
Elkin [25] (1966) rarely accused prolonged
arteriolar spasm for renal hypertension.
Clegg [26](1969) emphasized that sometimes
a lumbar injury just reveals a preexistent renal
lesion (a renal cyst, hydronephrosis).
7 Renoureteral diseases inducing hypertension in children 373

CONCLUSIONS The analytic study of diagnostic and

All renoureteral diseases included in Ursea-
Ionescu-Târgovişte classification can induce hyper-
tension, but renovascular hypertension does not
appear in all cases. The diagnosis of the
renoureteral diseases inducing hypertension in
children permits the treatment of hypertension and
renoureteral illness.
treatment methods of different diseases and authors
may select the most efficient methods and orientate
towards a new therapeutical concept and/or
evaluation system.
The treatment of the renoureteral diseases
inducing hypertension avoids the development of
some serious complications: the retinopathy, the
chronic renal failure, the cerebrovascular accidents.

Stabilirea cauzei hipertensiunii arteriale (HTA) de origine renală constituie

un obiectiv fundamental în practica medicală. Pentru aceasta este necesar a
efectua o serie de investigaţii care să stabilească diagnosticul afecţiunii de fond şi
apoi tratamentul medical şi/sau chirurgical. HTA tranzitorie a adolescentului nu
face obiectul acestei lucrări. Adesea, mai ales la copii, măsurarea tensiunii
arteriale este neglijată şi evaluarea ei se face după stabilirea diagnosticului de
afecţiune renovasculară.
Scop. Clasificările HTA renovasculare la copil şi evaluarea statistică a
etiopatogeniei în vederea stabilirii celor mai frecvente afecţiuni renovasculare
constituie o preocupare actuală a multor autori. Un ghid cu cele mai frecvente
cauze care au determinat hipertensiune la copil, după studiile mai multor autori,
poate conduce la o clasificare completă şi la descrierea unui concept complex
privind diagnosticul, evaluarea şi tratamentul pacienţilor.
Material şi metodă. Lucrarea expune un studiu analitic efectuat pe
19 pacienţi, cu vârste cuprinse între 2 şi 15 ani, care au fost depistaţi cu
hipertensiune arterială şi care prezentau semne şi simptome datorate hiper-
tensiunii. Din cei 19 pacienţi, 4 au necesitat tratament medical, 12 tratament
chirurgical şi 3 tratament mixt.
Rezultate. Hipertensiunea de origine renală a fost determinată de vase
renale aberante în 4 cazuri, pielonefrită în 4 cazuri, duplicaţie renopieloureterală
şi megaureter congenital în 2 cazuri şi în câte un caz de ruptură transversală
renală, agenezie renală, rinichi în potcoavă, glomerulonefrită şi tumoră Wilms. În
lotul studiat, au predominat bolile parenchimatoase, 12 cazuri din 19 – 63,1%, faţă
de 7 cazuri cu afecţiuni vasculare renale – 36,9%. Din bolile parenchimatoase,
7 sunt afecţiuni unilaterale, 6 malformaţii renoureterale şi o pielonefrită, iar 5 sunt
afecţiuni bilaterale, 4 pielonefrite şi o glomerulonefrită. Cele 7 cazuri cu leziuni
vasculare renale cuprind 6 cazuri cu leziuni indirecte (3 hidronefroze şi câte un
caz de tumoră Wilms, abces renal, traumatism renal) şi un caz cu anomalie
vasculară congenitală nestenozantă (agenezie renală).
Concluzii. Toate afecţiunile renoureterale cuprinse în clasificarea Ursea-
Ionescu-Târgovişte au potenţial hipertensiv, dar nu toate dezvoltă HTA renovasculară.
Diagnosticul afecţiunilor renoureterale inductoare de hipertensiune arterială
la copil permite, atât tratamentul HTA, cât şi al afecţiunii renoureterale.
Studiul analitic al metodelor de diagnostic şi tratament, diferenţiat pe
afecţiuni şi comparat după diverşi autori, poate selecta cele mai eficiente metode şi
orienta spre un nou concept terapeutic şi/sau sistem de evaluare.
Tratamentul afecţiunilor renoureterale cu HTA evită apariţia unor complicaţii
grave: retinopatia, insuficienţa renală cronică, accidentele cerebrale, etc.
374 Gh. Burnei et al. 8

Corresponding author: Gheorghe Burnei, Professor

“M.S. Curie” Children’s Hospital,
20, C. Brancoveanu Blvd, Bucharest.
e-mail: mscburnei@yahoo.com

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Conference of Urology, Cluj, 29–30 Oct. 1971.
3. BAYAZIT A.K., YALCINKAYA F., CAKAR N., DUZOVA A., BIRCAN Z., BAKKALOGLU A. et al., Reno-vascular
hypertension in childhood: a nationwide survey. Pediatr. Nephrol., 2007; 22: 1327–33. Tokai J. Exp. Clin. Med., 2008, 33, 2,
pp. 78–83.
4. TEXTOR
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S.C., Renovascular Hypertension and Ischemic Nephropathy. In: Brenner B.M. ed. Brenner & Rector’s The Kidney,
8 ed. Philadelphia: Saunders, 2008, 1528–1566.
5. NIIMURA F., MATSUDA S., OKAMOTO S., SUGANUMA E., TAKAKURA H. et al., Renovascular hypertension due to
bilateral renal artery stenosis treated with stent implantation in a 12-year old girl, Tokai J. Exp. Clin. Med., 2008, 33, 78–83.
6. PIERCY K.T., HUNDLEY J.C., STAFFORD J.M. et al., Renovascular disease in children and adolescents. J. Vasc. Surg.,
2005, 41(6): 973–82.
7. FRUCHTER Z., COBAN N., Diagnosis of mesorenal sequestrum by polar blood vessel with hypertension in a child. Annual
Meeting of the European Society of Paediatric Radiology, London, 19–21 May 1966.
8. COBAN N., PITEA P., POPESCU MICLOSAN S., Incidence of arterial hypertension in children with malformations of the
urinary tract treated in Grigore Alexandrescu Hospital in the last 10 years. National Congress of Paediatrics, Bucharest,
29 Sept.–2 Oct. 1965.
9. HALLWACHS O., ZIEGLER M., VOLLMAR J., SCHMITZ W., Renovascular hypertension. Pathogenetic principles and
clinical picture. Langenbecks Arch. Chir., 1967, 319: 1206–7.
10. HALLWACHS O., Renal hypertension. Munch Med. Wochenschr., 1963, 105: 816–24.
11. LINDER F., HALLWACHS O., ROTH E., Surgical aspects of hypertension therapy, Deutsches Medizinisches Journal, 1968,
19(16): 576–82.
12. WINKEL K. ZUM, HALLWACHS O., GELINSKY P., SCHENCK P., The detection of renal blood circulation disorders with
radioisotope procedures in clinic and experiment. Strahlentherapie [Sonderb], 1967, 65: 116–22.
13. AMBROSE S.S., HILL J.H., Colony counts and chronic pyelonephritis, J. Urol., 1965, 94: 15–9.
14. LIPMAN R.L., JONES R.K., SHAPIRO A.P. Experimental pyelonephritis in desoxycorticosterone hypertensive rats. Effect of
antibiotic therapy on the acceleration of the hypertension. Invest Urol., 1970, 7(6): 521–7.
15. LAUTIN E.M., GORDON P.M., FRIEDMAN A.C., DOURMASHKIN L., FROMOWITZ F., Emphysematous pyelonephritis:
optimal diagnosis and treatment. Urol. Radiol., 1979, 1(2): 93–6.
16. BERONIADE V., NESTOR G., BOIU S., ANTONESCU C., CARNARU S., J. Urol. Nephrol. (Paris), 1971, 77(4): 417–23.
17. BERONIADE V., ANTONESCU C., Unevenness of ureter opacification in timed urography as a sign of reno-vascular
hypertension. J. Urol. Nephrol. (Paris), 1972, 78(4): 368–9.
18. KAVEGGIA L., KING L.R., GRANA L., IDRISS F.S., Pyelonephritis: a cause of vesicoureteral reflux?, J. Urol., 1966, 95(2):
158–63.
19. KING L.R., MELLENS J.Z., WHITE H., Measurement of the intravesical pressure during voiding. An analysis of pressure
recordings made by three different techniques with comment on the diagnostic significance of such studies in the evaluation of
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23. DEFAZIO V., CHRISTENSEN R.C., REGAN T.J., BAER L.J., MORITA Y., HELLEMS H.K., Circulatory changes in acute
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Received October 10, 2008

 Cutaneous Metastases of Malignant Melanoma – How Difficult Can It Be?

SABINA ZURAC1,2*, R. ANDREI1*, G. PETSAKOS2, LUCIANA NICHITA2, ALEXANDRA BASTIAN1, GIANINA MICU1,
ELIZA GRAMADĂ1, CRISTIANA POPP1, FLORICA STĂNICEANU1,2, ŞTEFANA PETRESCU3, GABRIELA NEGROIU3,
DORINA GIURCĂNEANU1,4, VIRGINIA CHIŢU1,4
1
Department of Pathology, Colentina University Hospital,
2
“Carol Davila” University of Medicine and Pharmacy,
3
Institute of Biochemistry,
4
Department of Dermatology, Colentina University Hospital, Bucharest, Romania

Malignant melanoma is one of the most aggressive skin neoplasms with histopathological-
based therapeutic approach. Unfortunately, in some cases, even the elementary issue of dealing with a
primary or metastatic lesion may be sometimes incredibly difficult to settle.
We studied 11 cases of malignant melanomas that required careful histopathological and
immunohistochemical analysis to differentiate between primary and secondary tumor. We evaluated
epidermotropism of primary MM including synchronic tumors, local recurrences and metastases.
Key words: epidermotropism, malignant melanoma.

Malignant melanoma (MM) is a very aggressive
neoplasm with complex therapeutic regimen based
entirely on histopathological evaluation.
Synchronic MMs (two or more tumors at the
same time with different anatomical localization)
are rare, but they occur more and more often,
especially in multiple dysplastic nevi settings. The
stage of such a patient is the stage of the most
invasive MM.
Meanwhile, satellite metastases, in-transit
metastases and local recurrences (except for the
recurrences on a true scar) represent forms of stage
III disease, as a component of nodal staging
(according to AJCC staging system). The prognosis
is similar to that of patients with multiple nodal
metastases.
When evaluating a MM, the pathologist must
answer several questions, such as: type of the
tumor, thickness, depth of invasion, ulceration,
presence of vascular or neural invasion, grade of
pleomorphism, mitotic index, distance from the
resection margins, associated lesions. It is obvious
that all these parameters concern a primary MM,
most pathologists overlooking the first step of
differentiating between primary or metastatic
lesion. In fact, the previous well stated dogma
stipulating that intraepidermal component signifies
primary tumor while the lack of it means metastasis
correlates well with most of the melanocytic lesions
and the distinction (primary versus metastasis) is
settled in an instant.
*
Sabina Zurac and R. Andrei should be regarded as first authors in equal contribution.
Establishing the primary or metastatic status
of a MM is the most important step of the
diagnosis. In rare cases, MM metastases may have
an intraepidermal component (epidermotropism)
limited in extension when compared with
nontumorigenic compartment of primary MMs as
present in superficial spreading MM, lentigo MM
and acral lentiginous MM. Also, total regression of
the nontumorigenic compartment of a primary
MM, even rare, may occur; however, the
characteristic appearance (replacement of parts of
tumors by fibroblastic proliferation, fibrosis and
chronic inflammation usually with lymphocytes
and melanophages) permit a proper interpretation
as regression and thus primary tumor despite the
lack of an intraepidermal component. We decided
to analyze 11 cases of MM with peculiar histo-
pathological appearance in order to establish
criteria for interpreting epidermotropism in MM.
MATERIAL AND METHODS
We studied 11 cases of MMs excised in the
Department of Dermatology and histopathologically
diagnosed in the Department of Pathology of
Colentina University Hospital, Bucharest:
− 5 primary MMs with adjacent satellite or in-
transit metastases
− 4 local recurrences of MM (with histopatholo-
gically confirmed MM previously excised from
the site of the present lesion)

ROM. J. INTERN. MED., 2008, 46, 4, 375–378

376 Sabina Zurac et al.
− one case with synchronic tumors.
− one primary MM with histopathological aspect
suggestive of a metastasis
All the cases were routinely processed (24–
72 h fixation in 10% buffered formalin followed by
dehydration by immersion in successive ethanol
solutions with increasing concentrations of 90° for
24 h, 96° for next 24 h, 100° for 24 h clarification
in toluene for 24 h and paraffin impregnation 24 h
at 56°C). 3 µm-thick sections were performed for
usual and histochemical stainings (hematoxylin-
eosin H&E, periodic acid Schiff PAS, Fontana
Masson and Perls whenever necessary) and 2 µm-
thick sections for immunohistochemical staining with
S100 protein (clone 4C4.9, Labvision, Ready to use)
and melanoma marker (clone HMB-45 Labvision,
Ready to use). IHC technique used is an indirect
three-step method with 3,3’-diaminobenzidine DAB
as chromogen.
RESULTS
All the 11 cases were positive for S100
protein and HMB45 with differences concerning
intensity of the staining and distribution of the
positive cells within the tumoral mass.
All the five primary MMs were Clark IV or V
MMs; Breslow index between 4.3 and 12.5 mm.
All but two were nodular MMs, one acral
lentiginous MM and one superficial spreading MM.
The tumors were composed of compact nests and
cords of predominant epithelioid cells in nodular and
superficial spreading type and predominant spindle-
shape cells in acral lentiginous type. Severe cyto-
nuclear atypia and numerous mitotic figures were
noted. In all the cases, the intraepidermal component
of the tumoral growth within the superficial layers of
the squamous epithelium (“pagetoid invasion”) was
mild and limited to the overlying epidermis. The
extent of pagetoid invasion revealed by S100 protein
and H&E was similar but HMB45 highlighted more
numerous intraepidermal invasive cells compared
with H&E. In all of the cases, no matter the histo-
pathological type, the intraepidermal component
extended to at least three rete ridges from the lateral
margin of the dermal tumor.
The four local recurrences of MM had an
important epidermotropic component with presence
of isolated cells and small nests between
keratinocytes with a similar appearance to primary
nodular MMs. Tumor cells did not extend in the
2
epidermis beyond the dermal part of the tumor. The
intraepidermal component, both in H&E and IHC
staining, failed to involve more than two rete ridges
apart from the dermal part of the tumor.
The synchronic lesions were both primary
tumors: first tumor – in situ MM developed in a
melanocytic nevus and second tumor – Clark V
nodular MM with tumoral growth in the epidermis
overlying the dermal proliferation, but no lateral
intraepidermal extension beyond the lateral margin
of the dermal growth. Serial sections of the in situ
MM failed to reveal an invasive component.
One tumor had a histopathological appearance
of a hypomelanotic dermal metastatic MM, well
circumscribed, without any intraepidermal component.
No histopathological evidence of a primary tumor was
present. However, in step sections, in the vicinity of
the tumor, some pigmented nevi nests were identified.
Thorough clinical and imagistic investigations failed
to relieve any other tumor. The patient is well, free of
disease, 12 months after diagnosis.
DISCUSSION
Differentiating between primary and metastatic
cutaneous MM is an easy task in most of the
situations since skin metastases of MM do not
usually present epidermotropism or inflammatory
reaction while inflammatory infiltrate and
junctional activity are common features in primary
MMs. However, in rare instances, metastases in
papillary dermis invade the overlying epidermis
and sometimes exhibit prominent inflammatory
infiltrate. Moreover, primary MMs may not have
epidermal involvement; nodular MM with deep
invasion may also not have an important inflammatory
reaction [1][2]. Also, local recurrences with
significant epidermotropism have the same histo-
pathological appearance as skin metastases with an
important epidermal invasion.
Clinical information can also be cumbersome
since 4–10% of the patients present as metastases
and careful search for a primary failed to reveal
any. In these cases the primary tumor is either
totally regressed [6] or is located in an unusual
internal organ. The prognosis of MM with distant
metastases in the skin or in internal organs is
unfavorable [1][2].
We studied malignant melanocytic lesions with
an important epidermal component. The majority of
3 Cutaneous metastases of malignant melanoma 377

cutaneous metastases of MM are dermal or component (beyond the dermal component) favors the
hypodermal tumors intimately correlated with diagnosis of primary MM. Epidermal invasion in
lymphatic invasion, angiotropism [3] (Fig. 1) and little nodular MM may be present, but no more than two
or no epidermotropism. Presence of lateral epidermal rete ridges from the dermal part of the tumor.

Table I
Main histopathological features of primary and metastatic cutaneous malignant melanoma

Histopathological features Primary MM Metastatic MM

Epidermotropism Marked. Usually extended beyond Absent or limitted to the overlying
the margins epidermis
Epidermis at periphery No modification Hyperplasia
Inflammation Usually present Usually absent
Evidence of regression Lymphocytes and melanophages. No
Fibroplasia
Adjacent melanocytic nevus 10%–35%, frequent with displasia Extremely rare
Angiotropism and lymphatic Inconspicuous Common
invasion

Epidermotropism (Fig. 2) with pagetoid invasion − metastatic MM in an intradermal melanocytic

was better evaluated on immunohistochemical stains
using S100 or, with better results, HMB-45
(Fig. 3). On this basis we were able to differentiate
between synchronic tumors (two or more MM at
the same time) and secondary MM respectively
between metachronic MM (recurrence of MM) and
metastases [1][2].
Our case of synchronous MMs consisted of
two separate tumors:
nevus with occult or totally regressed primary
tumor or
− nodular MM developed in the dermal component
of a melanocytic nevus or
− MM developed in melanocytic nevus with total
regression of the nontumorigenic component,
[1][2][6].
Identification of melanocytic nevus cells in a

−
nodular MM, Clark V, typical invasion of the
overlying epidermis and classical proliferation
of the lateral epidermis;
−
in situ MM, Clark I, with malignant proliferation
restricted to the intraepidermal location and
dermal-epidermal junction; a melanocytic
common nevus was present within the
underlying dermis.
This patient had either one MM with an
epidermotropic metastasis or synchronous lesions.
Serial sections of the in situ MM failed to reveal an
invasive component, thus excluding the possibility
of local metastases.
In the last case of our study no epidermal
tumor cells were present, but clinical and para-
clinical investigations failed to identify a hypo-
thetical primary tumor. The case was prone to
discuss as representing one of the following
pathogenic/physio-pathological variants, all of
them incredibly rare:
MM or close to it favors the primary tumor
hypothesis (Fig. 4). In some MM with radial growth
phase, the nontumorigenic compartment may
totally regress, the tumorigenic compartment
remaining the only part of the tumor. In those cases,
chronic inflammation including melanophages and
fibroplasia are present between the malignant
proliferation and epidermis. As the process
advances, the regression features (fibroplasia with
scanty melanophages) are the only remains of the
previous lesion. This phenomenon (luckily very
infrequently present) has been referred as “tumoral
melanosis”. Regression of the tumorigenic
compartment has not been well documented yet.
However, since there are seldom cases with MM
metastases without any identifiable primary, either
cutaneous, mucosal or in other locations, this
possibility exists and should be taken into
consideration when analyzing a MM with peculiar
histopathological appearance [1][2][4][5].

Melanomul malign este una din cele mai agresive tumori maligne cu o
atitudine terapeutică bazată pe examenul histopatologic. Din nefericire, în unele
378 Sabina Zurac et al. 4

cazuri, chiar leziunile elementare de diferenţiere între o tumoră primară sau

metastatică sunt foarte dificil de stabilit.
Am studiat 11 cazuri de melanom malign care au necesitat o examinare
atentă histopatologică şi imunohistochimică pentru a diferenţia între o tumoră
primară şi una secundară. Am evaluat epidermotropismul MM primar incluzând
tumorile sincrone, recidivele locale şi metastazele.

Corresponding author: Sabina ZURAC

Colentina Hospital
19–21, Ştefan cel Mare Bld.
Bucharest, Romania
Tel (+4021) 317 2354/5612, fax (+4021) 316 55 12
E-mail: sabina_zurac@yahoo.com

REFERENCES

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Received September 20, 2008