The Indonesian Biomedical Journal

33-56

Authors: Anna Meiliana, Andi Wijaya

BACKGROUND: The prevalence of obesity is increasing in both developed and developing countries along with associated diseases such as type 2 diabetes and coronary heart disease. The recent discovery of a number of gut hormones that play a role in appetite regulation and are released or suppressed in response to a meal may offer new targets for the treatments of obesity. CONTENT: In addition to the obvious role of the gut in the digestion and absorption of nutrient, the intestine and associated visceral organs, including the pancreas, liver, and visceral adipose depots, have important sensing and signaling roles in the regulation of energy homeostatis. Signals reflecting energy stores, recent nutritional state, and other parameters are integrated in the central nervous system, particularly in the hypotalamus, to coordinate energy intake and expenditure. SUMMARY: Our understanding of the role of the gut in energy balance and insights into gut-derived signals will stimulate previously unexplored therapeutics for obesity and other disorders of energy balance.

65-70

Authors: Johnson Wijaya, Marsetio Donosepoetro, Syakib Bakri

BACKGROUND: Vascular remodeling was an adaptive process of the vascular wall that occured in response to long-term changes in hemodynamic conditions that contribute to the changes of the vascular structure and the pathophysiology of vascular disease. On the other hand, Endothelial Progenitor Cells (EPC) derived from bone marrow had the capacity to migrate to the peripheral circulation and to differentiate into mature endothelial cells. Therefore, EPC could contribute in the endothelial repairing after endothelial injury. METHODS: This study was a cross sectional design. Analysis was done among 30 subjects with normoalbuminuria normotension, 55 subjects with normoalbuminuria hypertension and 30 subjects with with microalbuminuria hypertension. TGF-β1, MMP-9 and VEGFR-2 testing were performed by ELISA method. All statistical calculations were performed using the SPSS 11.5 statistical software package. We used the Independent sample T test, Mann-Whitney, One Way Annova and Kruskal Wallis to establish the difference among various biochemical measures. RESULTS: TGF-β1 concentration was increased from normoalbuminuria normotension to normoalbuminuria hypertension and to microalbuminuria hypertension (27.63178±12.97246 vs. 38.61193±17.09546 vs. 38.73939±12.63911 ng/mL). TGF-β1 concentration was higher significantly in normotension as compared to hypertension (27.63178±12.97246 vs. 38.65692±15.58950, p<0.001) and to microalbuminuria hypertension (38.73939±12.63911, p<0.001). MMP-9 concentration was increased in normotension to normoalbuminuria hypertension but was decreased in microalbuminuria hypertension (438.1967±156.4268 vs. 564.5873±291.2876 vs. 418.6900±188.3801 ng/mL). MMP-9 concentration was higher significantly in normoalbuminuria hypertension as compared to microalbuminuria hypertension (p=0.028). VEGFR-2 concentration was decreased from normotension to normoalbuminuria hypertension to microalbuminuria hypertension (9.90552±1.85185 vs. 9.39561±1.75413 vs. 9.00506±1.47173 ng/mL). VEGFR-2 concentration was higher significantly in normotension as compared to microalbuminuria hypertension (p=0.042). CONCLUSIONS: The increasing concentration level of TGF-β1 and decreasing concentration level of MMP-9 in microalbuminuria hypertension showed that the remodeling process was getting increased. The decreasing concentration level of VEGFR-2 in microalbuminuria hypertension showed that the repairing process was getting decreased.

76-80

Authors: Yani Lina, Gatot Susilo Lawrence, Andi Wijaya, Suryani As'ad

BACKGROUND: Fibroblast growth factor-21 (FGF21) is known as an important endocrine and paracrine regulator of metabolic homeostasis. Recent studies have shown that FGF21 attenuates lipolysis in human adipocytes, which is suggested as a FGF21's mechanism as anti-hyperlipidemia, anti-hyperglycemia and anti-obesity. The aim of this study was to measure the correlation between FGF21, FFA, hsCRP and HOMA-IR among Indonesian obese non diabetic males. METHOD: The study was observational with cross sectional design. The analysis was done in 137 subjects aged 30-60 years with non diabetic abdominal obesity. We measured the biochemical markers FGF21, FFA, hsCRP, fasting insulin and fasting glucose. We also measured weight, height, waist circumrefence (WC), creatinine, serum glutamin oxaloacetic transaminase (SGOT), and serum glutamic pyruvic transaminase (SGPT), systolic blood pressure (SBP) and diastolic blood pressure (DBP). Correlation between markers was measured using Pearson and Spearman's analysis. RESULT: There were significant positive correlations between FGF21-HOMA-IR (r=0.314, p=0.000); FGF21-WC (r=0.173, p=0.043); FFA=hsCRP (r=0.270, p=0.001); and WC-HOMA-IR (r=0.279, p=0.001). There was significant negative correlation between FGF21-FFA (r=-0.038, p=0.657) and FGF21-hsCRP (r=-0.061, p=0.482). CONCLUSION: In this study we found that although there was no significant correlation, FGF21 might act as an anti-lipolytic and anti-inflammation agent among Indonesian obese non-diabetic males. Our findings agree with results of previous studies that the positive correlation between FGF21-WC and FGF21-HOMA-IR moght occur as a compensatory mechanism or resistance to FGF21 in obesity.

88-96

Authors: Siti Nurul Mubarokah, I Dewa Agung Susilawati, Sumarno Sumarno, I Ketut Gedhe Muliartha, Djanggan Sargowo

BACKGROUND: Periodontitis is caused mostly by Porphyromonas gingivalis (P.gingivalis) and it is related to acute coronary syndrome. P.gingivalis readily invades blood circulation and potentially induces collagenolytic activity of inflammatory cells that results in collagen vascular degradation leading to atherosclerotic plague rupture (APR). APR is responsible for the occurence of fatal cardiovascular events such as acute myocardial infraction (AMI). AIMS: To show that P.gingivalis potentially induces fragmentation of the type IV vascular collagen due to macrophage-activated MMP-9. MATERIAL AND METHODS: The ability of P.gingivalis to induce the type IV collagen fragmentation, shown by digesting type IV collagen with the supernatant of monocyte-derived macrophage activated by exposure to P.gingivalis suspension for 18 hours, 37oC, 5%CO2. The type IV collagen fragments were analyzed by SDS-PAGE and confirmed by Western-blotting. Antibody of type IV collagen produced and confirmed by dot-blotting prior to its being used as primary antibody of Western-blotting. The existence of MMP-9 was detected by Dot-blot and Western-blot technique, while the MMP-9 activity was assessed by SDS-PAGE and zymograms. RESULTS: Our data showed that P.gingivalis induced macrophage to produce MMP-9 as one of collagenolytic components, and interaction with P.gingivalis proteases enhanced the proteolytic activity and resulted in degradation of type IV collagen with molecular weight of 88 kDa into two smaller fragments with molecular weight of 80 kDa and 60 kDa. CONCLUSION: P.gingivalis induced macrophage to activate its MMP-9 that led to fragmentation of vascular type IV collagen in the pathogenesis of atherosclerotic plaque rupture.

24-30

Authors: Anna Meiliana, Ilhamjaya Patellongi, Andi Wijaya

BACKGROUND: Many previous studies have reported that central obesity is related to inflammation and endothelial dysfunction. It has also been reported that resistin can induce proinflammatory cytokines TNF-α and IL-6, which can result in endothelial dysfunction, although the role of resistin in human remains unclear. The aim of this study was to assess the role of resistin in influencing the proinflammatory cytokines TNF-α, IL-6, and chemokin MCP-1 in nondiabetic, central obese individuals. Results of this study are hoped to be useful to make a strategy for early prevention of endothelial dysfunction especially in obese individuals. METHOD: This was a cross-sectional study on 73 non diabetic obese male subjects (waist circumferences >90 cm). Resistin, hs-TNF-α, IL-6, MCP-1, VCAM-1 were assessed by ELISA. Statistical analysis was performed using SPSS for Windows v.11.5 with significance p<0.05. The correlations among biomarkers were assessed using Spearman’s Rho test. RESULTS: The study results showed a significant correlation between resistin and TNF-α (r = 0,274, p<0,005), and a significant correlation between TNF-α and IL-6 (r = 0,430, p<0,001). It was found that high concentration of resistin caused the concentration of TNF-α , IL-6 and MCP-1 to increase, and affected the increase of VCAM-1 (p = 0,0030), A significant correlation between waist circumference and inflammation (hsCRP, r = 0,296 p<0,005 , IL-6, r = 0,374 p<0,001 and HOMA IR, r = 0,331 p<0,001) was also found. CONCLUSION: This study showed that the role of resistin in endothelial dysfunction occurred at a high concentration of resistin through induction of proinflammatory cytokines TNF-α, IL-6, and chemokin MCP-1. We suggest that inflammation in obesity starts with a positive feedback loop mechanism between resistin and TNF-α.

38-44

Authors: Ellis Susanti, Marsetio Donosepoetro, Gatot Susilo Lawrence

BACKGROUND: Patients with Diabetes Melitus are proven to be prone to atherosclerosis and coronary heart disease, especially type 2 Diabetes Melitus (T2DM) patient who have higher risk and mortality for cardiovascular risk factor. The Dyslipidemia condition is very common in T2DM as one of the risk factors. Diabetic dyslipidemia is marked by the increased triglyceride (TG), low HDL cholesterol (HDL-C), and increased small dense LDL and apolipoprotein B. Therefore the aim of this study is to assess the differential and correlation between Atherogenic Index of Plasma (AIP), ratio of small dense low density lipoprotein (sdLDL)/lecithin cholesterol acyl transferase (LCAT) and ratio of sdLDL/cholesteryl ester transfer protein (CETP) of controlled and uncontrolled T2DM. METHODS: This study was observational with cross sectional design. In total of 72 patients with T2DM consist of 36 controlled and 36 uncontrolled, participated in this study. The serum TG, HDL-C, sdLDL, LCAT and CETP were examined in their relationship with to T2DM risk. RESULTS: The results of the study indicate that the AIP (p < 0,001) increase controlled and uncontrolled T2DM and the ratio of sdLDL/CETP (p = 0,004), odds ratio of AIP was 4 (95% C.I : 1,501-10,658) and odds ratio of sdLDL/CETP ratio was 4 (95% C.I : 1,501-10,658) in uncontrolled T2DM. CONCLUSION: This study showed that the AIP and ratio of small dense LDL/CETP had a significant correlation with the uncontrolled T2DM. The AIP and ratio of small dense LDL/CETP increase was found at the uncontrolled T2DM to be 4 times greater than the controlled T2DM.

51-8

Authors: Marissa Arifin, Marsetio Donosepoetro, Sutomo Kasiman

BACKGROUND: Recent clinical studies have suggested that γ-glutamyltransferase (γ-GT) can trigger oxidative stress within the plaque. This study aimed to investigate whether serum γ-GT might be as a risk factor of coronary heart disease (CHD), and measure the associations of serum γ-GT with high sensitive C-Reactive Protein (hs-CRP), Oxidized LDL (Ox-LDL) and Glutathione Peroxidase (GPx). METHODS: This study recruited 48 patients aged 30-70 year who underwent coronary angiography at Haji Adam Malik Medical Center at Medan between February and April 2008 and who presented at least one coronary stenosis of > 50% of the luminar diameter. The sample subjects were consecutively selected. RESULTS: γ-Glutamyltransferase was positively associated (r = 0.546) with hs-CRP as a marker of chronic inflammation after careful adjustment for other established risk factors in CHD patient. But, there was no significant difference between γ-GT in male and female patients. Further, there were no correlations between γ-GT and Ox-LDL and GPx. Ratio of γ-GT/GPx was measured as well, and it was associated with hs-CRP. CONCLUSIONS: Ratio of γ-GT/GPx was associated with inflammation process in coronary heart disease patients.

64-73

Authors: Tetty Hendrawati, Syakib Bakri, Mansyur Arif

BACKGROUND: Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of nitric oxide synthase (NOS). ADMA reduces NO synthesis when its concentration elevates. ADMA is a novel risk factor for cardiovascular disease. Plasma ADMA accumulates in patients with endstage renal disease, due to reduced renal clearance. Hyperhomocysteinemia is often found in patients with chronic kidney disease (CKD). Homocysteine may cause ADMA to accumulate; however, the mechanism by which ADMA level elevates in hyperhomocysteinemia is still unclear. Objective of this study was to analyze the concentrations of homocysteine and ADMA and to assess the correlation between homocysteine and ADMA concentrations with the severity of chronic kidney disease. METHODS: This was a cross-sectional study on 75 patients with CKD, comprising men and women aged 40-70 years. Assessments were done on the concentrations of creatinine, homocysteine, ADMA, fasting blood glucose, cholesterol HDL and triglyceride. RESULTS: In later stage of CKD there was significantly higher tHcy concentration as compared with the earlier stage of CKD (p=0.0000). In CKD stage 2 to 4 there was a tendency for ADMA concentration to increase to a significant average (p=0.210), but ADMA concentration was lower at stage 5. There was increased ADMA along with increased tHcy concentration of around 20μ mol/L, and this then decreased. The inverse correlation between tHcy and ADMA concentrations started to appear in CKD stage 4, but this correlation was statistically insignificant (r2 = 0.19; p=0.499). CONCLUSIONS: This study showed there was a correlation between homocysteine and ADMA concentrations in patients with CKD stage 2 to 5, although statistically not significant. KEYWORDS:

32-9

Authors: A Guntur Hermawan

Over the past decade, sepsis has been diagnosed according to consensus guidelines established in 1991 as an infection in addition to the symptoms of systemic inflammatory response syndrome (SIRS). In addition to the previous criteria, the 2001 conference added several new diagnostic criteria for sepsis. Of particular interest was the inclusion of the biomarkers procalcitonin (PCT) and C-reactive protein (CRP), despite the overall conclusion that it was premature to use biomarkers for sepsis diagnosis. The primary recommendation of the panel was the implementation of the Predisposition, insult Infection, Response, and Organ dysfunction (PIRO). The immune system has traditionally been devided into innate and adaptive components, each of which has a different role and function in defending the host against infectious agents. Stimulation of different TLRs induces distinct patterns of gene expression, which not only leads to the activation of innate immunity but also increasing evidence supports an additional critical role for TLRs in orchestrating the development of adaptive immune responses. The superantigens are able to induce toxic shock syndrome and can sometimes cause multiple organ failure via adaptive immune system. The superantigenic activity of the bacterial exotoxins can be attributed to their ability to cross-link major histocompatibility complex class II molecules on antigen-presenting cells outside the peptide groove with T-cell receptors to form a trimolecular complex. This trimolecular interaction leads to uncontrolled release of a number of proinflammatory cytokines. Proinflammatory cytokines especially IFN-γ and TNF-α, the key cytokines causing toxic shock syndrome.

45-52

Authors: Ampi Retnowarnadi, Siti Boedina Kresno, Mansyur Arif

BACKGROUND: Breast cancer is the most frequent cancer diagnosed among women. Many factors influence the carcinogenesis of breast cancer. The aim of this study to analyze the role of obesity (waist circumference and body mass index), serum Estradiol levels, TNF-α, and Adiponectin in the occurrence of breast cancer. METHODS: This was observational study with casecontrol design. Eleven breast cancer patients as cases and twelve FAM (Fibroadenoma Mammae) patients as controls were analyzed. The serum Estrogen, TNF-α and Adiponectin were examined in their association with breast cancer risk. RESULTS: Women with breast tumor and waist circumference > 80 cm have significantly higher breast cancer risk than women with breast tumor and waist circumference < 80 cm (OR 8,75; 95% CI : 1,24 – 61,88; p= 0,029). Women with breast tumor and higher serum TNF-α levels ( > 2,30 pg/ml) have higher breast cancer risk (19,25 times) than women with breast tumor and have lower serum TNF-α levels (95% CI : 1,77 - 209,55, p = 0,015). Whereas, women with breast tumor and lower Adiponectin/TNF-α ratio (< 2,13) have higher breast cancer risk (22,5 times) than women with breast tumor and higher Adiponectin/TNF-α (95% CI: 2,60 – 194,51; p = 0,005). CONCLUSION: These results suggest that high concentration of serum TNF-α, waist circumference > 80 cm and low Adiponectin/TNF-α ratio in women with breast tumor are significantly associated with an increased risk for breast cancer.

61-7

Authors: Anwar Santoso, Sri Wardani, Ketut Surayana

BACKGROUND: Neopterin is a soluble biomarker of monocyte activation and its increased concentration might be expressed in atherosclerosis. Until recently, there has been lacking of information on the prognostic role of neopterin in acute coronary syndromes (ACS). The study was aimed at measuring the associations between elevated serum neopterin and increased risk of cardiovascular (CV) events in ACS. METHODS: This was a prospective cohort study, recruited 71 ACS patients from January 31 through August 31, 2007 in Sanglah Hospital of Udayana School of Medicine, Denpasar – Bali. Cardiovascular events, such as: CV death, recurrent myocardial infarction, stroke and recurrent myocardial ischemia were previously defined. Relative risk and survival rate were measured successively by Cox proportional model and Kaplan-Meier curve. RESULTS: Of 71 ACS patients aged 56.8 ± 9.5 years, 21 (29.5%) subjects underwent CV events. Overall mean followup was 151.6 (95% CI: 129.7 – 173.5) days. Baseline characteristic were similarly distributed between groups with the highest quartile neopterin level (≥ 14.7 nmol/L) than those with lowest quartile (≤ 6.2 nmol/L). Patients with the highest quartile had the worst survival curve than those with the lowest quartile (log-rank test; P = 0.047). On Cox proportional model, relative risk of highest quartile group was 5.84 (95% CI: 1.19 – 28.47; P = 0.029) compared to lowest quartile, after being adjusted with other predictors. CONCLUSIONS: Elevated serum neopterin is associated with increased risk of CV events in acute coronary syndromes.

73-9

Authors: Dewi Muliaty, Irawan Yusuf, A Guntur Hermawan

BACKGROUND: Biochemical markers may be used in diagnosis, prognostic and monitoring treatment and therapy for sepsis patients. In this study we used Lipopolysacharide Binding Protein (LBP), serum-Intercellular Adhesion Molecule-1 (ICAM-1), Procalcitonin (PCT) and protein C activity. LBP is related to lipopolysachharide or gram-negative bacterial endotoxin which bound to LBP and induced inflammatory response. ICAM-1 is associated with endothelial dysfunction in response to systemic inflammatory and septic condition. PCT increased in bacterial infection and in severe systemic inflammatory. Role of Protein C is protecting the intravascular system to systemic inflammation, sepsis and the concomitant intravascular coagulopathy. The aim of this study was to examine the associations between levels of serum LBP, sICAM-1, PCT, and protein C activity with the clinical outcome of SIRS or sepsis patients. METHODS: We included 19 post surgery patients with SIRS criteria from intensive care unit (ICU) and evaluated the level of LBP serum with Chemiliuminescent Enzyme Immunoassay (Diagnostic Product Co.), ICAM-1 with ELISA (R&D System), PCT with immunochromatography (BRAHMS), protein C activity with chromogenic method (Dade Behring). We performed the samples serially at the first admission of patients and after 72 hours. Data were analysed by non-parametric with Wilcoxon test and Mann-Whitney test. Correlation study between biomarkers calculated by Kendall’s tau and Spearman’s rho. RESULTS: Of 19 patients, 9 (47,4%) died and 10 (52,6%) surviving. The level of LBP serum decreased after 72 hours in surviving-sepsis patients, and increased in nonsurviving sepsis patients with significant different levels at 72 hours examination (P<0.05). The level of soluble-ICAM-1 which was high in the first admission showed in non-surviving sepsis patients, but the difference levels was not significant between surviving and non-surviving patients (P>0.05). In all patients were found high level of PCT serum since the first admission examination, decreasing levels were occurred significantly in surviving patients after 72 hours (P<0.05) where high PCT levels were found in non-surviving patients after 72 hours. The median level of plasma protein C activity was low at the first admission especially in non-surviving sepsis patients, the decreasing level was not significantly different after 72 hours (P>0.05) both in surviving and non-surviving patients. CONCLUSIONS: Increasing level of LBP and PCT in sepsis patients showed that those biomarkers useful for predict the clinical outcome in sepsis patients. Decreasing protein C activity level was not a good predictor in worsening clinical outcomes. Soluble ICAM-1 level was not a good marker for predict risk of sepsis severity. LBP and PCT tests were more useful in serially testing from the first admission of sepsis patients, those tests are more faster than bacterial culture.