Sirtuin-1: A marker of contrast-induced nephropathy following percutaneous coronary intervention?

doi:10.21203/rs.3.rs-4686093/v1

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Research Article

Sirtuin-1: A marker of contrast-induced nephropathy following percutaneous coronary intervention?

https://doi.org/10.21203/rs.3.rs-4686093/v1

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Objectives

Contrast-induced acute kidney injury (CI-AKI) is a serious complication of clinical practice after cardiac catheterization. Sirtuin-1 is a crucial regulator of the protection of the kidney against ischemia/reperfusion injury, inflammation, and vasoconstriction. In the present study, we sought to investigate whether Sirtuin-1 may be an early diagnostic marker of CIN.

Methods

76 patients admitted for elective percutaneous coronary interventions (PCI) for stable angina were enrolled between July 2022 and November 2022, and 50 patients were eligible to study. Sirtuin-1 values were measured by the Elisa kit before, 24 and 72 hours after the PCI.

Results

There is no statistically significant difference between CI-AKI (n = 17) and non-AKI (n = 33) groups regarding Sirtuin-1 between patient samples obtained before and after PCI.

Conclusions

These findings refute the hypothesis that Sirtuin-1 may be clinically beneficial as a biomarker for CI-AKI following radiological procedures requiring intravascular administration of iodinated contrast media.

Sirtuin-1

CI-AKI

post-PCI

renalism

Renalism can be defined as the fear of AKI after procedures requiring contrast media. It is very common in cardiology practice, especially after interventional procedures. It can lead to delayed procedures and, therefore, delayed diagnosis and treatment of patients [1] Several studies in recent decades have shown that contrast-induced acute kidney injury (CI-AKI), even mild and transient, is associated with an increased risk of poor outcomes, including new or progressive CKD, cardiovascular events, and mortality. Considering the burden of CI-AKI, reliable biomarkers are necessary to facilitate clinical care and accelerate the development and availability of early diagnostic tools [2]. As interventional cardiologists are increasingly called upon to perform percutaneous coronary interventions (PCIs), there is a compelling need for robust and effective markers of CI-AKI in this patient population. The precise cause of CI-AKI is not completely understood yet. The primary causes are vasoconstriction, reduced oxygen delivery, and hypoxia induced by contrast media (CM). This leads to oxidative stress and cellular death due to elevated reactive oxygen species (ROS) production, resulting in renal tubular toxicity [2].

Sirtuin 1 (SIRT1) is a class III nicotinamide adenine dinucleotide (NAD+)-dependent histone deacetylase. It is a highly sensitive energy sensor [3]. SIRT1 is involved in eNOS deacetylation, increasing NO production from endothelial cells. When activated, SIRT1 enhances the resistance of renal tubular cells to oxidative stress [4]. Previous studies have shown that overexpression of SIRT-1 is protective against the effects of cisplatin-induced ischemia-reperfusion (I/R) injury [5]. In rats exposed to I/R injury by renal artery clamping, there was less tubular damage in young rats that expressed high levels of SIRT1 activity compared with older ones. In the same study, the SIRT1 activator SRT 1720 administration reduced tubular damage in SIRT-/+ rats [6]. Resveratrol, a well-known antioxidant, alleviated renal cell damage in mice by increasing SIRT1 expression in iohexol-induced CI-AKI [3].

In this preliminary study, we aimed to investigate the role of SIRT1 activation, which has previously been shown to protect the kidney from hypoxia, I/R injury, tubular toxicity, and vasoconstriction in many models, in CI-AKI caused by the same pathophysiological pathways. Our hypothesis was that patients with insufficient SIRT1 expression might develop CI-AKI, and SIRT1 could be used as a predictor of CI-AKI.

Study design

We conducted a case-control study using a hospital-based cohort of all patients (n = 76) admitted to Bursa Yuksek Ihtisas Training Hospital for elective PCI for stable angina between July 2022 and November 2022. Six patients were excluded from the study because they met the exclusion criteria, and ten patients were excluded because their 48-hour blood samples were not obtained. Analyses were performed on the 50 patients. The inclusion criteria were as follows: age between 18 and 75 years, indication for elective PCI, voluntary written consent for PCI, and participation in the study. Patients with N-acetylcysteine premedication, cardiogenic and septic shock, acute or chronic renal insufficiency of any cause, exposure to contrast media 48 hours before the study, and inability to give consent were excluded. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation [6]. Eligible subjects should have an eGFR of 60 mL/min/1.73 m2 or greater.

Study procedure

Baseline characteristics were recorded, including age, gender, body mass index, and the presence of diabetes mellitus, hypertension, and dyslipidemia. Diabetes mellitus was defined as taking any glucose-lowering medication or having a fasting glucose level of 126 mg/dL or higher. Hypertension was diagnosed if the diastolic blood pressure was > 90 mm Hg and the systolic blood pressure was > 140 mm Hg in two separate measurements or if the subject had been on treatment for this condition for at least one year. A serum cholesterol level > 220 mg/dL or treatment with cholesterol-lowering drugs was considered to be dyslipidemia. Concomitant cardiac medications used were carefully recorded. Serum creatinine (sCr) levels were analyzed at 0, 24, and 72 hours after contrast exposure. For the SIRT1 assay, blood samples were collected at 0, 24, and 72 hours after contrast exposure, centrifuged at 4500 rpm for 10 minutes, and the supernatant stored at -80°C.

The standard femoral artery approach was used for PCI. Each patient received 50–80 mL of a nonionic, low-osmolar contrast agent, iopromide (Ultravist 370, BAYER, Istanbul, Turkey). No specific protocols or medications were used in the study to prevent CI-AKI. Patients were advised to drink plenty of fluids, emphasizing oral intake.

CI-AKI was defined as an absolute sCr increase > 0.5 mg/dL or an increase > 25% from baseline. All patients were informed of the purpose of the study, gave their informed consent, and the local ethics committee approved the protocol.

Serum SIRT1 assay

Collected samples were randomly ordered for biochemical analysis, and personnel blinded to case patients and controls performed the biochemical assays. Serum SIRT1 was measured using a human SIRT1 ELISA kit (SunRed Biotechnology, China). The coefficient of variation of inter-assay and intra-assay reproducibility for SIRT1 concentration is between 6 and 10% in our laboratory and is in accordance with that reported by the kit manufacturer. The measurement sensitivity is 0.306 ng/mL, and the range is 0.5–40 ng/mL. Measurements were also repeated on 10% of the randomly selected samples to confirm the reliability of the SIRT1 results.

Data analysis

SPSS version 21.0 (SPSS, Chicago, IL, USA) was used for all calculations. Continuous variables were tested for normal distribution using the Kolmogorov-Smirnov statistic and are expressed as mean ± SD or median with interquartile range. Parametric (Student's t-test) or non-parametric (Mann-Whitney U tests) statistical analyses were used to compare the two groups. Categorical variables were expressed as counts and percentages, and comparisons were made using the Pearson χ2 test. We hypothesized that the development of CI-AKI would significantly decrease serum SIRT1 levels. Based on previous data, a total sample size of 47 patients would be sufficient to detect a significant (p < 0.05) decrease in serum SIRT1 levels using a two-sided t-test with a power of 80%. An a priori power analysis was performed using G*Power version 3.1.9.7 [7]. A value of p < 0.05 (two-tailed) was considered statistically significant.

The general characteristics of cases and controls are presented in Table 1. The mean age was significantly higher in the CI-AKI group compared to the non-AKI group (69 ± 10 vs. 61 ± 13, p = 0.038). Other clinical and pharmacological characteristics did not differ significantly between the two groups. In our cohort, the diabetes rate was 40%, and the hypertension rate was 64%. SIRT1 and sCr levels are presented in Table 2. Initial sCr and SIRT1 levels were not different between the two groups. As expected, sCr levels increased significantly in the group at 24 and 72 hours (1.11 ± 0.29 and 1.55 ± 0.62 mg/dL, p = 0.015 and p = 0.0001, respectively). SIRT1 trends and levels in patients are shown in Fig. 1. There was a decreasing trend in SIRT1 levels in the CI-AKI group between pre-PCI and post-PCI. However, this did not reach statistical significance. C-reactive protein concentrations tended to be higher in the group that developed CI-AKI (7.26 mg/dL vs. 18.0 mg/dL, p = 0.267, respectively). Table 3 shows the serum biochemical values of the patients.

Table 1

General characteristics of patients
	Without AKI (n = 33)	With CI-AKI (n = 17)	p
Age(years)	61±(13)	69± (10)	0.038
Female gender [n (%)]	10(30)	7(41)	0.534
Diabetes [n (%)]	13(40)	7(41)	0.904
Hypertension [n (%)]	18(55)	14(82)	0.550
RAS Blocker	10 (30,3)	8 (47,1)	0.242
Beta-blocker	13 (39,4)	7 (41,2)	0.903
Calcium Channel Blocker	5 (15,2)	6 (35,3)	0.151
Statins	4 (12,1)	4 (23,5)	0.419
Aspirin	11 (33,3)	7 (41,2)	0.585
Clopidogrel	6 (18,2)	1 (5,9)	0.398
SGLT2-i	1 (3,0)	2 (11,8)	0.264
p values were calculated with the χ2 test or the Student's t-test, as appropriate.

Table 2

SIRT-1 and serum creatinine values in patients with and without CI-AKI
	Without AKI (n = 33)		With CI-AKI (n = 17)
	Mean ± (SD)		Mean ± (SD)
SIRT-1 (0. hour)	5.15	± (2.87)	5.55	± (2.08)
SIRT-1 (24. hour)	5.27	± (3.21)	5.17	± (1.90)
SIRT-1 (72. hour)	5.52	± (3.75)	4.84	± (1.68)
sCr (0. hour)	0.89	± (0.18)	0.96	± (0.21)
sCr (24. hour)	0.89	± (0.21)	1.11	± (0.29)
sCr (72. hour)	0.91	± (0.18)	1.55	± (0.62)
SIRT-1; sirtuin-1, sCr; serum creatinine, SD; standard deviation

Table 3

Biochemical values of the patients.
	Without AKI (n = 33) Mean±(SD)	With CI-AKI (n = 17) Mean±(SD)	p
CRP (mg/dL)	7.26 ± (6.56)	18 ± (36.96)	0.267
Cholesterol (mg/dL)	196 ± (42)	199 ± (55)	0.845
HDL (mg/dL)	41 ± (10)	45 ± (16)	0.363
LDL (mg/dL)	125 ± (30)	132 ± (50)	0.647
Triglyceride (mg/dL)	160 ± (116)	127 ± (90)	0.285
TSH (uIU/mL)	1.10 ± (0.87)	1.95 ± (2.48)	0.249
Hgb (g/dL)	13.21± (1.86)	13.15 ± (2.14)	0.927
WBC (10³/mL)	11.12 ± (2.95)	11.39 ± (5.50)	0.824
Troponin I (ng/L)	22,42 ± (72,66)	4.17 ± (8.65)	0.319
CRP; C reactive protein, HDL; high-density lipoprotein, LDL; low-density lipoprotein, TSH; thyroid stimulating hormone, Hgb; hemoglobin, WBC; white blood cells. p values were calculated with the Mann-Whitney U or the Student's t-test, as appropriate.

Serum creatinine is currently considered a poor marker of acute kidney injury, albeit routinely used in clinical practice and clinical trials. Serum SIRT1 is easily measured by commercial ELISA kits, and the availability of commercial kits may significantly accelerate the development of the test for routine clinical use. Unfortunately, contrary to our hypothesis, the development of CI-AKI after PCI did not significantly alter serum SIRT1 levels in either the early or late phases of CI-AKI.

The true incidence of CI-AKI is difficult to assess because of the wide variation in reported rates, depending on the definitions of AKI, and the patient populations studied, which have varying baseline risk factors. Rates as low as less than 1% have been reported in patient populations with no risk factors and as high as more than 20% in patients with multiple risk factors. However, CI-AKI seems slightly more common after PCI [2]. In post-PCI patients, Moitinho et al. reported a CI-AKI rate of 37.5% [8]. Our cohort has a CI-AKI rate of 34%, which is in line with the literature.

I/R injury plays a major role in the development of AKI. Apoptosis of tubular epithelial cells (TECs) in I/R injury is observed in almost all AKI patients. SIRT1 may prevent I/R injury-induced damage. Gong et al. [9] found a significant increase in SIRT1 levels in human proximal cell (HK2) cells with hypoxia. In the same study in vivo phase, resveratrol, a potent activator of SIRT1, successfully reversed I/R-induced TEC apoptosis in rats. Contrast media cause local hypoxia and hypertonicity, leading to extreme oxidative stress in the renal medulla. Sirt1 is highly expressed in the renal medulla. He et al. [4] found a significant increase in SIRT1 in renal medullary interstitial cells (RMICs) of mice exposed to oxidative stress with H2O2. However, this increase was not observed in SIRT knockout mice, and increased cell apoptosis was observed in SIRT knockout mice. When these mice were exposed to the SIRT1 inducer SRT2183, cell viability increased. In our study, the group that did not develop AKI had higher levels of SIRT1. This suggests that high serum SIRT1 levels may have a protective effect against CI-AKI.

Inflammation is another important mechanism involved in developing CI-AKI [10]. SIRT1 is one of the key players in the process of limiting the inflammatory response [11]. SIRT1 exerts potent anti-inflammatory activity in various cell types by inhibiting NF-κB activation [12]. SIRT1 also regulates inflammation by deacetylating high-mobility group box 1 (HMGB1), a conserved structural chromatin protein. Deletion of SIRT1 increases HMGB1 acetylation, leading to systemic inflammation [12]. Activation of SIRT1 and SIRT3 can also reduce TNF production during acute inflammation [13]. Our study showed increased levels of CRP, an indicator of inflammation, in the CI-AKI group. However, the results were not statistically significant. Nevertheless, this finding may be considered as an increase in inflammation in the CI-AKI group.

SIRT1 regulates endothelium-dependent vasodilation and vascular tone via eNOS deacetylation [14]. Acute vasoconstriction due to contrast media is an important cause of CI-AKI [2]. This leads to hypoxia, particularly in the poorly perfused renal medulla. As mentioned above, SIRT1 protects against hypoxic damage and is mainly expressed in the inner medulla of the kidney [14].

In summary, numerous models of AKI induced by I/R injury and inflammation with high levels of SIRT1 have been shown to play a protective role against the development of AKI [3–5, 9, 14–16]. We hypothesized that SIRT1 levels would increase due to high hypertonicity and tubular toxicity after contrast exposure during PCI to protect the renal medulla from I/R injury, vasoconstriction, and inflammation. Patients with an insufficient increase in SIRT1 would develop CI-AKI. Thus, an insufficient increase in SIRT1 may be useful as a predictor of CI-AKI after PCI. In our preliminary study, serum SIRT1 tended to be lower at 24 and 72 hours after PCI, albeit this did not reach statistical significance. Although a larger sample size and more frequent measurements might have yielded favorable results, the significant change in serum creatinine levels in the CI-AKI patients provides confidence that our research methodology can detect meaningful changes in renal function. Furthermore, as all patients were selected from a single institution, we can be confident that our negative results are not due to sample variability. We conclude that the usefulness of serum SIRT1 as a diagnostic tool for CI-AKI is likely to be minimal, albeit insignificant.

AKI: Acute Kidney Injury

CI-AKI: Contrast-Induced Acute Kidney Injury

CKD: Chronic Kidney Disease

CM: Contrast Media

CRP: C-Reactive Protein

eGFR: Estimated Glomerular Filtration Rate

ELISA: Enzyme-Linked Immunosorbent Assay

HMGB1: High-Mobility Group Box 1

I/R: Ischemia/Reperfusion

NAD+: Nicotinamide Adenine Dinucleotide

PCI: Percutaneous Coronary Intervention

RMICs: Renal Medullary Interstitial Cells

ROS: Reactive Oxygen Species

sCr: Serum Creatinine

SD: Standard Deviation

SIRT1: Sirtuin-1

SPSS: Statistical Package for the Social Sciences

Acknowledgments

The hospital authorities provided SIRT-1 kits. We appreciate the help of the interventional cardiology team during the study.

Author contributions

CBG provided supervision, provided statistical analysis, and wrote the manuscript; MA collated the raw data and reviewed and substantially revised the manuscript.

Funding

No funding declarations.

Data availability

Access to all anonymized data is available to the corresponding author.

Corresponding author

Correspondence to Cuma Bülent GUL

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of Bursa Yuksek Ihtisas. All participants signed an informed consent form.

Consent for publication

All authors consent to the publication of this paper.

Competing interests

All authors have no competing interests to declare.

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No competing interests reported.

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You are reading this latest preprint version

Sirtuin-1: A marker of contrast-induced nephropathy following percutaneous coronary intervention?

Status:

Version 1

Abstract

Objectives

Methods

Results

Conclusions

Figures

INTRODUCTION

METHOD

Study design

Study procedure

Serum SIRT1 assay

Data analysis

RESULTS

DISCUSSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1