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• W1979207989 abstract "Developing specific markers for early detection of adverse events such as kidney failure, cardiovascular events, and all-cause mortality in chronic kidney disease (CKD) patients remains a major challenge. Cardiovascular events are the main cause of morbidity and mortality in CKD patients. Recent research supposes endocan as a biomarker for evaluating cardiovascular events, inflammatory diseases, and cancers. Yilmaz et al. propose serum endocan levels as a novel prediction marker of all-cause mortality and cardiovascular events in CKD patients. Developing specific markers for early detection of adverse events such as kidney failure, cardiovascular events, and all-cause mortality in chronic kidney disease (CKD) patients remains a major challenge. Cardiovascular events are the main cause of morbidity and mortality in CKD patients. Recent research supposes endocan as a biomarker for evaluating cardiovascular events, inflammatory diseases, and cancers. Yilmaz et al. propose serum endocan levels as a novel prediction marker of all-cause mortality and cardiovascular events in CKD patients. Patients with chronic kidney disease (CKD) face a high risk of adverse outcomes such as kidney failure, cardiovascular events, and all-cause mortality.1Levey A.S. Atkins R. Coresh J. et al.Chronic kidney disease as a global public health problem: approaches and initiatives – a position statement from Kidney Disease Improving Global Outcomes.Kidney Int. 2007; 72: 247-259Abstract Full Text Full Text PDF PubMed Scopus (1045) Google Scholar Accurate and generalizable risk prediction models for these adverse events in CKD patients are urgently needed.2Levey A.S. Tangri N. Stevens L.A. Classification of chronic kidney disease: a step forward.Ann Intern Med. 2011; 154: 65-67Crossref PubMed Scopus (28) Google Scholar Recently, the kidney failure risk equation for prediction of kidney failure in CKD patients was developed;3Tangri N. Stevens L.A. Griffith J. et al.A predictive model for progression of chronic kidney disease to kidney failure.JAMA. 2011; 305: 1553-1559Crossref PubMed Scopus (720) Google Scholar however, there are no prediction models evaluating the risk of cardiovascular events.4Rigatto C. Sood M.M. Tangri N. Risk prediction in chronic kidney disease: pitfalls and caveats.Curr Opin Nephrol Hypertens. 2012; 21: 612-618Crossref PubMed Scopus (29) Google Scholar Yilmaz et al.5Yilmaz M.I. Siriopol D. Saglam M. et al.Plasma endocan levels associate with inflammation, vascular abnormalities, cardiovascular events, and survival in chronic kidney disease.Kidney Int. 2014; 86 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar (this issue) applied serum endocan levels to a novel prediction model of all-cause mortality and cardiovascular events in CKD patients. They report that endocan levels increased in the presence of deteriorating glomerular filtration rate, showing an inverse correlation with serum endocan levels, and its value influenced all-cause mortality and cardiovascular events in the CKD patients independently of traditional and nontraditional risk factors. Moreover, plasma endocan was significantly associated with markers of inflammation (high-sensitivity C-reactive protein) and vascular abnormalities (flow-mediated vasodilation and carotid intima–media thickness). The authors investigated whether endocan was associated with an increased risk of death and cardiovascular events independent of traditional (hypertension, diabetes mellitus, cigarette smoking, and dyslipidemia) and nontraditional risk factors (inflammation, vascular calcification, and oxidative stress) using three adjusted models for survival and time-to-event analysis of cardiovascular outcomes. Cox proportional hazards models were adjusted initially only with endocan, and subsequently for several groups of covariates. In model 1, they adjusted for traditional cardiovascular risk factors: age, sex, smoking status, diabetes, systolic blood pressure, high-density lipoprotein, and total cholesterol. In model 2, they adjusted for renal-specific cardiovascular risk factors: estimated glomerular filtration rates, proteinuria, and high-sensitivity C-reactive protein. In model 3, they adjusted for all the variables used in the previous two models. Remarkably, in all three models, endocan was found to be independently associated with all-cause mortality and cardiovascular events. In the final model adjusting for both traditional and renal-specific cardiovascular risk factors, the authors unveiled that endocan was a strong predictor for mortality and cardiovascular events in CKD patients. Moreover, endocan was recognized as an improvement to the model prediction capability for cardiovascular events in CKD patients in this study. Although the results suggest that serum endocan levels provide new insights into the relationship among inflammation, vasculature, and long-term glycemic control in CKD patients, an association between endocan and hemoglobin A1c (HbA1c), a marker of glycemic control in diabetes, has not been shown in the present study. In this regard, the authors state that HbA1c values would not have added much discrimination on outcomes, given the small number of patients with diabetes and advanced CKD enrolled in the study. However, because glycemic control status plays an important role in cardiovascular risk in CKD patients with diabetes, and HbA1c has increased the ability to predict cardiovascular events mainly in diabetes, further studies should be performed with more patients with both diabetes and CKD. Serum endocan levels, solely or in combination with other biomarkers, have been verified as a biomarker for various diseases, including some kinds of cancers (originating from the brain, lung, liver, kidney, bladder, and so on), systemic inflammations, and cardiovascular diseases.6Sarrazin S. Adam E. Lyon M. et al.Endocan or endothelial cell specific molecule-1 (ESM-1): a potential novel endothelial cell marker and a new target for cancer therapy.Biochim Biophys Acta. 2006; 1765: 25-37Crossref PubMed Scopus (256) Google Scholar Endocan is only physiologically expressed and secreted as a soluble form in vascular endothelial cells of the lung and kidney.7Lassalle P. Molet S. Janin A. et al.ESM-1 is a novel human endothelial cell-specific molecule expressed in lung and regulated by cytokines.J Biol Chem. 1996; 271: 20458-20464Crossref PubMed Scopus (316) Google Scholar,8Bechard D. Meignin V. Scherpereel A. et al.Characterization of the secreted form of endothelial-cell-specific molecule 1 by specific monoclonal antibodies.J Vasc Res. 2000; 37: 417-425Crossref PubMed Scopus (161) Google Scholar Endocan expression in endothelial cells is upregulated in response to proangiogenic factors such as vascular endothelial growth factor (VEGF) and proinflammatory cytokines, such as tumor necrosis factor-α, interleukin-1β, and lipopolysaccharide, but downregulated by interferon-γ, which would result in regression of inflammatory responses.6Sarrazin S. Adam E. Lyon M. et al.Endocan or endothelial cell specific molecule-1 (ESM-1): a potential novel endothelial cell marker and a new target for cancer therapy.Biochim Biophys Acta. 2006; 1765: 25-37Crossref PubMed Scopus (256) Google Scholar,9Lee W. Ku S.K. Kim S.W. et al.Endocan elicits severe vascular inflammatory responses in vitro and in vivo.J Cell Physiol. 2014; 229: 620-630Crossref PubMed Scopus (102) Google Scholar,10Scherpereel A. Depontieu F. Grigoriu B. et al.Endocan, a new endothelial marker in human sepsis.Crit Care Med. 2006; 34: 532-537Crossref PubMed Scopus (200) Google Scholar The potential of endocan as a biomarker for various diseases may be due to the tight and specific regulation of its expression. ESM-1 promoter activity was observed only in cells of endothelial origin,11Tsai J.C. Zhang J. Minami T. et al.Cloning and characterization of the human lung endothelial-cell-specific molecule-1 promoter.J Vasc Res. 2002; 39: 148-159Crossref PubMed Scopus (45) Google Scholar which may be due to the existence of endothelial-specific transcription factors that have not yet been identified. It is also expressed in tumor endothelium in vivo by regulation of tumor-derived factors, one of which was later verified as a VEGF. VEGF-induced endocan expression is dependent on the balance of positive PKC/NFKB and negative PI3K/AKT/FKHRL1 signaling pathways (Figure 1).12Abid M.R. Yi X. Yano K. et al.Vascular endocan is preferentially expressed in tumor endothelium.Microvasc Res. 2006; 72: 136-145Crossref PubMed Scopus (98) Google Scholar Moreover, endocan was not induced during early embryogenesis in spite of abundant expression of VEGF,12Abid M.R. Yi X. Yano K. et al.Vascular endocan is preferentially expressed in tumor endothelium.Microvasc Res. 2006; 72: 136-145Crossref PubMed Scopus (98) Google Scholar which suggests the existence of another regulatory mechanism. Recently, it was reported that hypoxia-inducible factor-1α (HIF-1α) could regulate endocan in colon cancer.13Kim J.H. Park M.Y. Kim C.N. et al.Expression of endothelial cell-specific molecule-1 regulated by hypoxia inducible factor-1alpha in human colon carcinoma: impact of ESM-1 on prognosis and its correlation with clinicopathological features.Oncol Rep. 2012; 28: 1701-1708PubMed Google Scholar Our unpublished data showed that there are some CpG islands and putative HIF-1α response elements in the ESM-1 promoter. During cancer progression, unknown epigenetic mechanisms may induce demethylation of CpG islands, allowing HIF-1α access to HIF-1α response elements to induce endocan in cancer cells (Figure 1). Further studies are required to verify this hypothesis. In the study by Yilmaz et al.,5Yilmaz M.I. Siriopol D. Saglam M. et al.Plasma endocan levels associate with inflammation, vascular abnormalities, cardiovascular events, and survival in chronic kidney disease.Kidney Int. 2014; 86 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar there are some limitations. They have performed just a single measurement of serum endocan. A single point measurement of serum endocan is a little relevant, but serial multiple measurements could give more information on prognostic outcome of CKD. For instance, Li and Wang et al. performed multiple point measurements of serum endocan level during evaluation of acute rejection after renal transplantation.14Li S. Wang L. Wang C. et al.Detection on dynamic changes of endothelial cell specific molecule-1 in acute rejection after renal transplantation.Urology. 2012; 80: 738.e1-738.e8Abstract Full Text Full Text PDF Scopus (22) Google Scholar Multiple measurement of serum endocan level could discriminate acute rejection from renal allograft dysfunction. They additionally showed that endocan expression was located mainly in glomeruli, which may give a clue to the origin of serum endocan in CKD patients. Another instance is a report on serum endocan levels in septic patients.10Scherpereel A. Depontieu F. Grigoriu B. et al.Endocan, a new endothelial marker in human sepsis.Crit Care Med. 2006; 34: 532-537Crossref PubMed Scopus (200) Google Scholar,15Filep J.G. Endocan or endothelial cell-specific molecule-1: a novel prognostic marker of sepsis?.Crit Care Med. 2006; 34: 574-575Crossref PubMed Scopus (20) Google Scholar The severity of sepsis showed positive correlation with initial serum endocan levels. Moreover, it was significantly increased in non-survivors. However, the lack of multiple follow-up data on serum endocan levels prohibits the evaluation of sepsis treatment outcome, which requires multiple measurements. Another limitation is that Yilmaz et al.5Yilmaz M.I. Siriopol D. Saglam M. et al.Plasma endocan levels associate with inflammation, vascular abnormalities, cardiovascular events, and survival in chronic kidney disease.Kidney Int. 2014; 86 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar did not rule out accompanying cancers or other inflammatory diseases, which could be sources of serum endocan. Serum endocan is detected as a few hundred picograms in 1 ml of serum under normal physiologic conditions.10Scherpereel A. Depontieu F. Grigoriu B. et al.Endocan, a new endothelial marker in human sepsis.Crit Care Med. 2006; 34: 532-537Crossref PubMed Scopus (200) Google Scholar,16Balta S. Mikhailidis D.P. Demirkol S. et al.Endocan—a novel inflammatory indicator in newly diagnosed patients with hypertension: a pilot study.Angiology. 2014https://doi.org/10.1177/0003319713513492Crossref Scopus (128) Google Scholar,17Ozaki K. Toshikuni N. George J. et al.Serum endocan as a novel prognostic biomarker in patients with hepatocellular carcinoma.J Cancer. 2014; 5: 221-230Crossref PubMed Scopus (42) Google Scholar Serum endocan solely could not inform regarding the location or kinds of diseases, but its detection over the normal range may give a clue to search for some diseases, such as systemic inflammatory diseases, cardiovascular diseases, and various cancers. Finally, it is unclear whether the increased serum endocan level in CKD patients was the result of an increased secretion or a decreased renal clearance. The clearance mechanism of endocan has not yet been identified. As renal function declines, serum endocan level increases, which may be due to increased production or decreased clearance. The former might be due to kidney inflammation, which is preferable. In this report, serum endocan levels of patients in the third quartile (6.6ng/ml) or fourth quartile (13.3ng/ml) in the CKD classification based on estimated glomerular filtration rate were significantly higher than those of patients in the first (1.2ng/ml) and second quartiles (2.8ng/ml). This pattern was the same for high-sensitivity C-reactive protein, which was induced considerably by kidney inflammation.18Stuveling E.M. Hillege H.L. Bakker S.J. et al.C-reactive protein is associated with renal function abnormalities in a non-diabetic population.Kidney Int. 2003; 63: 654-661Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar However, the reason why serum endocan levels were significantly higher in CKD than in any other disease conditions must be evaluated. The possibility that the increased serum endocan levels in CKD patients resulted from decreased clearance could be evaluated simply by urine endocan level. Serial follow-up of serum endocan levels in CKD patients could also be informative in this regard. In conclusion, Yilmaz et al. have reported an endocan as a novel prediction marker of all-cause mortality and cardiovascular events in CKD patients. More detailed study of molecular mechanisms in endocan expression and degradation in CKD may increase the value of serum endocan levels. The authors thank Dong-Su Jang (medical illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the illustrations. This study was supported by the National Research Foundation of Korea funded by the Korean government (Ministry of Science, ICT and Future Planning) (grant NRF-2012R1A4A1028835)." @default.
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• W1979207989 title "Endocan as a potential diagnostic or prognostic biomarker for chronic kidney disease" @default.
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