Med Clin (Barc). 2015;145(5):201–202
Cystatin C, many answers but some unmet questions夽 Cistatina C, muchas respuestas y algunas cuestiones pendientes Juan Ignacio Pérez Calvo a,∗ , Juan José Puente Lanzarote b a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain b Servicio de Bioquímica Clínica, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
Blood concentrations of cystatin C (CysC) have been proven to be useful in predicting the development of hypertension in middle-age men1 and cardiovascular complications in general population.2,3 Its predictive capacity for future development of heart failure (HF) is particularly strong,4–6 and once this has been established, its prognostic value is unquestionable in both HF with decreased7–9 and preserved ejection fraction,10 adding further information to the one provided by natriuretic peptides.11–14 In the current issue of Clinical Medicine, Garcia Gallego et al.15 provide a new observation about the association between higher concentrations of CysC, the all-cause mortality and the incidence of cardiovascular events in hypertensive patients. In hypertensive subjects CysC concentrations have also been correlated with the decline of renal function16,17 subclinical cerebral microvascular disease18 and recurrent stroke risk.19 The usefulness of the CysC as a prognostic biomarker in cardiovascular disease is thus undeniable. It has been unanimously supported that its prognostic capacity depends on more accurate estimation of glomerular ﬁltration rate (GFR) as an overall expression of renal function. However, it is uncertain whether or not this is the only reason to explain their performance as a prognostic biomarker in cardiovascular disease. The estimated GFR is one of the most important parameters commonly used in clinical practice. In recent years, various assessment formulas have been validated based on various endogenous GFR markers. Among them, the so-called CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration), based on CysC and in its 2012 version, appears to be the most accurate formula, especially for use in the general population without signiﬁcant kidney disease.20 The advantage of using CysC in estimating GFR is that, in blood, CysC is not inﬂuenced by age, sex, weight or race,21 just the opposite to what happens with creatinine.22 Therefore, the estimates obtained are more accurate and easy to understand. The best correlation
DOI of original article: http://dx.doi.org/10.1016/j.medcle.2016.02.002 夽 Please cite this article as: Pérez Calvo JI, Puente Lanzarote JJ. Cistatina C, muchas respuestas y algunas cuestiones pendientes. Med Clin (Barc). 2015;145:201–202. ∗ Corresponding author. E-mail address: [email protected]
(J.I. Pérez Calvo). ˜ S.L.U. All rights reserved. 2387-0206/© 2015 Elsevier Espana,
between the concentrations of CysC and the GFR are due to multiple factors related to the protein itself and its intrarenal process. The gene encoding CysC synthesis was cloned in1987,23 it is located on chromosome 20, its size is 4.3 kb and is organized in 3 exons and 2 intronic regions.24 It belongs to the family of the housekeeping genes, so all nucleated cells produce it at a constant rate.25 In addition, the physicochemical properties of CysC, a small protein with a molecular mass of 13 kDa, made up of 120 amino acids in a single polypeptide chain26 and neutral electric charge,27 allow a free GFR, which is followed by a full catabolism in the proximal convoluted tubule, so there is no resorption that might inﬂuence its serum levels.28,29 It has also been suggested that CysC might be involved in the left ventricle remodeling in hypertensive patients since their early stages.5,30 In a multiethnic cohort of 2548 subjects from the Dallas Heart Study, aged 30–65 years,31 CysC concentration was associated independently with a speciﬁc cardiac phenotype with concentric left ventricular hypertrophy, with a more spherical ventricular chamber morphology, relationship persisting even after being adjusted to kidney function.31 Although this hypothesis is very attractive due to the involvement of the balance between proteases and antiproteases in left ventricular remodeling,32,33 the involvement of CysC in ventricular remodeling remains a matter of discussion. As shown in the paper by Gallego Garcia et al., the levels of serum CysC continues to provide valuable information for the clinician and is completing the prospect of a complex puzzle where a few pieces remain unplaced.
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J.I. Pérez Calvo, J.J. Puente Lanzarote / Med Clin (Barc). 2015;145(5):201–202
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