1. Introduction
Remnant lipoproteins, which are present at high circulating concentrations when lipoprotein metabolism is impaired, are associated with the progression of atherosclerosis and coronary artery disease (CAD) [
1,
2]. It is well known that high serum triglyceride (TG) concentrations are an important risk factor for coronary heart disease [
3,
4,
5]. However, it has been reported that the TG-rich remnant lipoprotein cholesterol concentration is closely associated with CAD risk in patients with normal TG concentrations [
6]. Therefore, remnant lipoprotein cholesterol concentration may represent a more sensitive marker of CAD risk than TG.
High serum TG concentrations are frequently present in patients with diabetes and are thought to be important contributors to the onset of cardiovascular disease (CVD) in patients with diabetes. Indeed, the Framingham Heart Study revealed that diabetes is an independent risk factor for CAD: its presence results in a 1.5-fold higher multivariate-adjusted risk of CAD in men and a 1.8-fold higher adjusted risk in women [
7]. The Hisayama Study also demonstrated that type 2 diabetes mellitus (T2DM) significantly increases the risks of both cerebral infarction and CAD during a five-year follow-up period in a general Japanese population [
8]. In addition, the serum TG concentration is a key predictor of CAD, having comparable value to low-density lipoprotein (LDL)-cholesterol (LDL-C) and glycated hemoglobin (HbA1c) in Japanese patients with T2DM [
9]. This suggests that remnant lipoproteins, which contain a large amount of TG, may also be a predictor of CAD in T2DM.
During the course of atherosclerosis, cerebrovascular disease and peripheral arterial disease are observed, as well as the development of ischemic heart disease. [
10]. In the case of atherosclerosis of the arteries of the lower extremities, this typically develops in multiple stages; the arteries distal to the knee are more commonly affected; and it is characterized by the presence of calcification of the middle layers of the arterial walls in patients with diabetes. Invasive revascularization therapy, including percutaneous balloon angioplasty with optional stent placement, is important for patients with CAD, but the phenomenon of restenosis, which is especially common in patients with diabetes, limits the long-term effectiveness of this treatment [
11].
One of the clinically available methods to measure the cholesterol concentration associated with remnant lipoproteins is a remnant-like particle (RLP)-cholesterol (RLP-C) assay, which is an immunoaffinity separation method (RLP-C assay; Otsuka, Tokyo, Japan). This assay involves the isolation of RLPs from human serum using an immunoaffinity gel containing two different immobilized monoclonal antibodies against human apolipoprotein (Apo)-AI and Apo-B-100 [
12,
13]. Many clinical studies have shown that RLP-C is a risk factor for CVD, and the serum RLP-C concentration is higher in patients with CAD, diabetes, or metabolic syndrome than in healthy individuals [
14,
15,
16]. Therefore, the RLP-C concentration represents a useful predictor of CVD and has the advantage that it can be measured without the requirement for ultracentrifugation. However, this measurement is relatively time-consuming and an autoanalyzer cannot be used.
After the clinical application of the RLP-C assay, a remnant lipoprotein cholesterol homogeneous assay (RemL-C assay; Kyowa Medex, Tokyo, Japan) has been developed that uses a special surfactant [polyoxyethylene-polyoxybutylene (POE-POB) block copolymer] and phospholipase D, which selectively solubilizes and degrades TG-rich remnant lipoproteins, very low-density lipoprotein (VLDL) remnants, and chylomicron remnants [
17,
18]. Nakada et al. [
18] reported that remnant lipoproteins measured using RemL-C are present at high concentrations in patients with CAD, suggesting that this assay may be useful for coronary risk assessment. However, the relationships between RemL-C and risk factors for CVD have not previously been evaluated. Therefore, in the present study, we aimed to characterize the relationships between RemL-C and several parameters related to CVD in patients with diabetes and to assess the utility of RemL-C measurement for patients with T2DM.
4. Discussion
To the best of our knowledge, this is the first study to investigate the relationships between RemL-C and clinical parameters related to CVD risk in patients with T2DM. In this observational study, we found that RemL-C is associated with FPG, HOMA-R, TC, TG, HDL-C, LDL-C, sdLDL-C, ACR, adiponectin, and ABI. Logistic regression analysis showed that sdLDL-C and ABI are independently associated with a high RemL-C concentration and that the relationship with ABI is male-specific. However, we found no association between a history of CVD and RemL-C.
There are two clinically available methods for the measurement of remnant lipoprotein cholesterol concentrations. The first, for RLP-C, is an immunoaffinity separation method that is convenient because it does not require ultracentrifugation [
12]. The second method, the RemL-C assay, can be performed by homogeneous method [
17]. Currently, these two measurements are selected by each investigator. Yoshida et al. previously reported a significant correlation between RemL-C and RLP-C in non-diabetic individuals [
26]. In the present study, RemL-C was found to significantly positively correlate with Apo-B, Apo-CII, Apo-CIII, and Apo-E, which are the major apolipoproteins in remnant lipoprotein particles. Therefore, RemL-C likely reflects the circulating remnant lipoprotein particle concentration, even in patients with T2DM.
DM is closely associated with CVD. Conventional cardiometabolic risk factors, such as hypertension, dyslipidemia, and obesity, which are common in T2DM, synergistically increase the risk of CVD. In addition, many previous studies have shown that T2DM is usually characterized by genetic predisposition, hyperglycemia, obesity, and insulin resistance. In particular, obesity and the associated insulin resistance are recognized as potent risk factors for CVD [
27]. There is a tendency for hypertriglyceridemia to be present in patients with T2DM, because of the high concentrations of TG-rich lipoproteins, including TG-rich remnant lipoproteins, VLDL remnants, and chylomicron remnants. These high concentrations of TG-rich lipoproteins are thought to increase CVD risk directly and by causing a decrease in HDL and an increase in sdLDL [
27]. Consistent with this, in the present study, we found that RemL-C positively correlates with sdLDL-C and negatively correlates with HDL-C. However, whereas RemL-C and RLP-C have previously been reported to be associated with CVD [
14,
15,
16,
18], the present findings show no relationship between RemL-C and a history of CVD in patients with T2DM, probably because of therapeutic interventions. Furthermore, LDL-C, a potent risk factor for CVD, showed a significant negative correlation with a history of CVD in the present cohort. However, the lack of a relationship between RemL-C and CVD history, while LDL-C did show an association, may indicate inadequate management of RemL-C. It has been reported that statin therapy significantly reduces the serum RemL-C concentration of hypercholesterolemic patients [
28]. Moreover, the Diabetes Atherosclerosis Intervention Study (DAIS) revealed that treatment with fenofibrate reduces serum RLP-C in patients with T2DM [
29]. Therefore, it is necessary to raise awareness of the fact that RemL-C represents a residual risk factor for CVD and to implement therapeutic interventions targeting remnant lipoproteins, the efficacy of which can easily be monitored using RemL-C.
Previous studies have shown that remnant lipoproteins are associated with several clinical parameters related to CVD. de Graaf et al. reported that RLP-C positively correlates with age, BMI, SBP, DBP, TC, TG, LDL-C, Apo-B, serum glucose, FPI, and HOMA-R and negatively correlates with HDL-C in patients without combined hyperlipidemia [
30]. In addition, Saeed et al. reported that RLP-C is positively associated with TC, TG, LDL-C, and sdLDL-C and negatively associated with HDL-C and Lp(a) in middle-aged adults [
31]. In the Framingham Heart offspring study, RLP-C was found to positively correlate with age, BMI, SBP, DBP, serum glucose, TC, TG, and LDL-C and negatively correlate with HDL-C in women [
32]. Although there have been no previous equivalent studies using RemL-C, in the present study, we have shown that RemL-C positively correlates with FPG, FPI, HOMA-R, HbA1c, TC, TG, LDL-C, and sdLDL-C and negatively correlates with HDL-C and adiponectin in patients with T2DM. In addition, when two groups were created on the basis of RemL-C, high RemL-C was found to correlate with FPG, HOMA-R, TC, TG, HDL-C, sdLDL-C, ACR, adiponectin, and ABI in patients with T2DM. Furthermore, sdLDL-C was found to be independently associated with high RemL-C in patients with T2DM. Because the clinical parameters associated with RemL-C are nearly identical to those associated with RLP-C and because RemL-C has been reported to be present at high concentration in patients with CAD [
18], RemL-C, as well as RLP-C, may be a useful index in patients with T2DM who are at high risk of CVD.
A relationship between subclinical arteriosclerosis and RemL-C has also been previously reported. Taguchi et al. reported that RemL-C concentration positively correlates with max-IMT and mean-IMT in healthy women [
33]. In the present study, RemL-C tended to positively correlate with max-IMT and mean-IMT (
χ2 = 3.140,
p = 0.076 and
χ2 = 2.805,
p = 0.094, respectively) in women with T2DM. Interestingly, multivariate logistic regression analysis indicated that ABI, which is a marker of PAD, is significantly and independently associated with high RemL-C in men with T2DM, suggesting that there may be a sex difference in the effect of remnant lipoproteins on the progression of arteriosclerosis. Further study is needed to clarify this.
Apo-AI, which is a major protein component of HDL-C, is thought to closely and inversely correlate with the risk of atherosclerotic disease [
34]. Karagiannidis et al. reported that higher levels of Apo-AI are independent predictors of lower CAD complexity in T2DM [
35]. In the present study, we have shown that a high Apo-AI concentration is an independent predictor of low RemL-C. These findings may indicate that RemL-C is linked to the complexity of CAD. In addition, we have shown that a high Apo-B concentration is an independent predictor of high RemL-C. Given that an association between Apo-B and CVD has previously been reported (35), a relationship between RemL-C and CVD may be revealed by future prospective studies.
In recent years, the relationship between TG-rich remnant lipoprotein and chronic kidney disease has been attracting attention. Sonoda et al. reported that the RemL-C concentration positively correlates with the ACR and inversely correlates with eGFR [
36]. In contrast, we found that RemL-C did not significantly correlate with eGFR (
χ2 = 0.20,
p = 0.887). The reason for the discrepancy is unknown, but it may be explained by differences in patient background. RemL-C concentration was found to significantly positively correlate with ACR (
χ2 = 4.311,
p = 0.038) in the present study, as well as the previous one. Relevant to this, Jun et al. demonstrated in a meta-analysis that fibrates reduce the risk of progression of albuminuria by 14% (
p = 0.028) [
37]. Moreover, Tsunoda et al. reported that fenofibrate reduces the concentration of RLP-C in patients with T2DM [
29]. Thus, it is possible that RemL-C is associated with albuminuria and that a therapeutic intervention aimed at reducing RemL-C would help to prevent the progression of diabetic nephropathy in patients with T2DM.
Diabetes is associated not only with lipid metabolic disorders but also with higher concentrations of modified lipoproteins that are not routinely measured in clinical practice. Recently, the role of nitrated lipoproteins in the development of cardiovascular dysfunction in patients with diabetes has been discussed [
38]. Nitrotyrosine (NT-Tyr) is a product of tyrosine modification by peroxynitrite, a potent prooxidant produced by the interaction of superoxide anions with nitric oxide [
38]. The NT-Tyr concentration has been shown to be significantly higher in patients with T2DM than in non-diabetic individuals, and histopathological studies carried out to date on sections of arterial wall have shown that the NT-Tyr concentration is higher in patients with poor cardiovascular status [
38]. Lipoproteins can undergo myeloperoxidase-catalyzed enzymatic nitration, and the reaction involves the apolipoproteins Apo-AI in HDL particles and Apo-B in LDL particles [
38]. Because Apo-B is also present in remnant lipoprotein particles, the relationship between nitrated remnant lipoproteins and CVD risk is being clarified, and the establishment of a method for the measurement of the nitrated remnant lipoprotein concentration may be expected in the future.
The present study had several limitations. First, it was a single-center cross-sectional study with a relatively small number of participants. Thus, further large-scale prospective studies are needed to confirm the associations between RemL-C and clinical parameters in patients with T2DM. Second, because a direct comparison between RemL-C and RLP-C was not possible because of a lack of RLP-C measurements, it is difficult to discuss the factors affecting the relationships of RemL-C and RLP-C with CVD. However, Yoshida et al. reported that there is generally a significant correlation between RemL-C and RLP-C in individuals without diabetes or hypertension and not taking medications for hyperlipidemia, diabetes, or hypertension (r = 0.853,
p < 0.0001) [
26]. Moreover, they demonstrated that the RemL-C assay is likely to reflect the intermediate-density lipoprotein concentration more closely than RLP-C [
26]. Therefore, the benefits of RemL-C measurement should be investigated further. Third, in the present study, other factors related to CVD, such as dyspnea classification and the heart failure status, were not available. It is a major limitation of the study. Further studies should address these issues in the future.