SYNOPSIS
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
“LIPID PROFILE AND APOLIPOPROTEIN (A1 & B): PREDICTORS OF DYSLIPIDEMIA AND SEVERITY OF LIVER DAMAGE IN CIRRHOSIS”- A CASE CONTROL STUDY.
Name of the candidate : Dr. Suriyan.S.Nair
Guide : Dr. Hilda Priya D’Souza
Course and Subject : M.D. (Biochemistry)
Department of Biochemistry,
A J Institute of Medical Sciences,
Kuntikana, Mangalore – 575004.
2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the candidate and address (in block letters) / DR. SURIYAN.S.NAIRPOST GRADUATE RESIDENT,(MD)
DEPARTMENT OF BIOCHEMISTRY,
A J INSTITUTE OF MEDICAL SCIENCES MANGALORE.
2 / Name of the Institution / A J INSTITUTE OF MEDICAL SCIENCES MANGALORE.
3 / Course of study and Subject / MD BIOCHEMISTRY.
4 / Date of admission to course / 05/06/2013
5 / Title of the Topic: “LIPID PROFILE AND APOLIPOPROTEIN (A1 & B): PREDICTORS OF DYSLIPIDEMIA AND SEVERITY OF LIVER DAMAGE IN CIRRHOSIS”- A CASE CONTROL STUDY.
6 / BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR STUDY
Chronic liver disease affects people in their most productive years of life and has a significant impact on the economy as a result of premature death, illness, and disability. According to the World Health Organization, about 800,000 people die of cirrhosis annually.(1) Cirrhosis has become a major cause of mortality and morbidity in our country.
Alcoholic liver disease and Chronic viral hepatitis C are the most common causes of cirrhosis, followed by non alcoholic fatty liver disease, chronic hepatitis B, autoimmune hepatitis, metabolic diseases such as hemochromatosis, Wilson’s disease and cryptogenic cirrhosis(1).
Liver plays an vital role in lipid metabolism, several stages of lipid synthesis and transportation, storage of apolipoproteins and lipoproteins, catabolism of phospholipids and cholesterol(2).Therefore, it is reasonable to expect an abnormalities in lipoprotein profile which may be due to decreased synthesis or reduced clearance of lipoproteins complex by the liver in patients with severe liver dysfunction.
The treatment plan depends on the severity and the progression of liver disease, which can be assessed by using Child-Turcotte-Pugh (CTP) Score(3) and Model for End Stage Disease (MELD)score(4).
Studies have shown that patients with non-cholestatic parenchymal liver disease with hepatic dysfunction have abnormal plasma lipid, apolipoprotein and lipoprotein structure and metabolism. The blood status of apolipoproteins may be used as a prognostic and diagnostic index in chronic liver diseases and can also correlate with the stage and progress of the disease(5).
Due to high prevalence of chronic liver disease in our country, we are conducting this study in cirrhotic patients to assess the extent of dyslipidemia by measuring the Lipid profile (Total Cholesterol, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, Triglycerides) and levels of Apolipoproteins (A1 & B) levels and to correlate with the severity and progression of liver disease.
6.2 REVIEW OF LITERATURE
Cirrhosis, is the final stage of any chronic liver disease, which is a diffuse process characterized by parenchymal injury leading to extensive fibrosis and nodular regeneration. It is the end of all etiologies(1).
As a result of the complex pathophysiological processes associated with cirrhosis, it results in significant morbidity such as gastrointestinal bleeding, hepatic encephalopathy, and spontaneous bacterial peritonitis from portal hypertension, and eventual mortality in many patients. Patients with liver cirrhosis have frequent medical complications and more so when the liver disease is more advanced and decompensated(1).
Besides, hypolipidemia is frequently observed in severe chronic hepatic failure and is associated with higher mortality rate(6).
The Child-Turcotte-Pugh (CTP) score is an index used to calculate the extent of liver damage. More than 30%of the patients with CTP score of 10(Class C) has survival rate of one year. In contrast CTP score 5-6 (Class A) has 90% chance of survival rate of 5 yrs without transplant(3).
The Model for End-Stage Liver Disease (MELD) is computed score based ranging from 6 to 40, with respective 3-month survival from 90% to 7% in patients with cirrhosis(4).
Sanjay Kumar et al(7) study showed that total cholesterol (TC), Low Density Lipoprotein (LDL), Very Low Density Lipoprotein (VLDL), High Density Lipoprotein (HDL) were found to be significantly low in cirrhotics as compared to controls.
Sposti et al(8) found that there was a positive correlation between Child classification of each group (A,B,C) and the HDL-c: Apo A1 ratio and liver function. The differences in the HDL-c: Apo A1 ratio between the groups A and C, and the groups B and C were statistically significant.
Chabrier et al(9)studied the concentrations of Apo AI and Apo B in cirrhotics and found the concentrations to be significantly low and positively correlated with the severity. Hence concluded that Apo AI and Apo B determinations constitute a valuable index of liver synthesizing function. Apo A-1 is considered to be an antiatherogenic protein. ApoB can be used as a marker to estimate the total number of atherogenic lipoprotein particles.
Tietge et al(10)studied the lipid parameters in arterial and hepatic venous serum samples from patients with cirrhosis and from patients after liver transplantation and observed a significant decrease in total cholesterol and triglyceride levels and a very significant decrease in ApoA1 levels depending on the clinical stage. He also concluded that ApoA1 served as an excellent parameter for predicting liver function in both the groups.
Although, several studies have been performed in Lipoprotein profile alteration in cirrhotic, studies on apolipoproteins levels indicating the severity and progression of disease are scarce from India.
6.3 OBJECTIVE OF THE STUDY
1) To compare and correlate the Lipid profile (Total cholesterol, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, Triglycerides) and Apolipoproteins levels (Apo A1 & Apo B) between patients with cirrhosis (cases) and age and sex matched normal controls (control group).
2) To correlate the Lipid Profile and Apolipoproteins levels (Apo A1 & Apo B) as an index for extent of liver damage on the basis of Child Pugh Classification Score (A,B,C).
3) To correlate the Lipid Profile and Apolipoproteins levels (Apo A1 & Apo B) in patients for assessing the prognosis of cirrhosis using MELD scores.
7 / MATERIALS AND METHODS
7.1 SOURCE OF DATA Individuals in the age group of 20-65 years who come to AJIMS hospital, Mangalore, diagnosed as cirrhosis during the year 2013-2015 are considered as cases and are included in the study with age and sex matched controls.
INCLUSION CRITERIA
Known and established cases of Cirrhosis of liver by ultrasound abdomen and biochemical studies.
EXCLUSION CRITERIA
1. Patients who had used lipid lowering drugs within previous 30 days.
2. Patients with Diabetes Mellitus, Nephrotic syndrome, Hypertension, chronic smokers, malignancy, thyroid problem, acute pancreatitis and acute GI bleeding were excluded.
7.2 METHOD OF COLLECTION OF DATA
7.2 a: TYPE OF STUDY: Case control study.
7.2 b: SAMPLE SIZE: 80
Sample Group 1: Consists of 40 known patients of Liver cirrhosis with CPT score groups (A,B,C).
Group 2: Consists of 40 age and sex-matched normal individuals as controls.
7.2c:Duration of study:2 years(2013-2015)
7.2 d: METHOD OF SAMPLE COLLECTION:
After obtaining the informed consent, patient details are obtained. By aseptic precautions l of venous 7 ml venous blood is collected after 8-12 hours of fasting. Blood is collected in sodium
EDTA citrate(3.2%) added vacutainer (2ml) and plain vacutainer (5ml).
Blood collected in plain vacutainer is processed immediately to obtain serum and following parameters are estimated:
SERUM CHOLESTEROL: Estimated by enzymatic method (CHOD-PAP). [10]
SERUM HDL CHOLESTEROL: Estimated by enzymatic method after precipitation with polyanions. [11]
SERUM LDL CHOLESTEROL: Estimated by Friedewald formula.[12]
SERUM TRIGLYCERIDE: Estimated by enzymatic method (GPO-ESPAS). [13]
SERUM CREATININE: Measured by modified Jaffe’s method. [14]
SERUM TOTAL BILIRUBIN: By Acid Diazo method(15).
ALBUMIN: Quantative determination using BCG-Bromocresol green reagent(16).
APOLIPOPROTEIN AI: Measured by quantitative competitive enzyme immunoassay technique(17).
APOLIPOPROTEIN B: Measured by quantitative competitive enzyme immunoassay technique(18).
2 ml of blood collected in Sodium citrate(3.2%) added vacutainer is used for estimation of Prothrombin time
PROTHROMBIN TIME: By Electromechanical method(19).
INTERNATINAL NORMALIZED RATIO: INR= [patient PT/MNPT] ISI where the MNPT = mean normal prothrombin time and the ISI = international sensitivity index.
7.2 e: DATA ANALYSIS: Collected data will be analyzed by ANOVA, Karl Pearson correlation coefficient and by chi-square test.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, DESCRIBE BRIEFLY.
Yes, blood samples (7ml) are collected with aseptic precautions after obtaining informed consent from the patients.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED?
Approved by the Ethical Committee
List of references
1. Goldman’s Cecil Medicine: 24th Edition. Pages 999-1006.
2. Kroon PA, Powell EE. Liver, lipoproteins and disease. Biochemistry of lipoprotein metabolism.J Gastroenterol Hepatol.1992; 7: 214–24.
3. Pugh RN, Murray-Lyon IM, Dawson JL et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973; 60:646–8.
4. Kamath PS, Kim WR. Advanced Liver Disease Study Group. The model for end stage liver disease (MELD). Hepatology. 2007; 45:797–805.
5. Rubies-Prat J, Masdeu S, Nubiola AR, Chacon P, Holguera C & Masana L. High-density lipoprotein cholesterol and phospholipids, and apoprotein A in serum of patients with liver disease. Clinical Chemistry.1982; 28: 525-527.
6. D'Arienzo A, Manguso F, Scaglione G, Vicinanza G, Bennato R, Mazzacca G. Prognostic value of progressive decrease in serum cholesterol in predicting survival in Child-Pugh C viral cirrhosis.Scand J Gastroenterol.1998; 33(11):1213–8.
7. Sanjay Kumar Mandal, Koelina Sil, Sumanta Chatterjee, Jacky Ganguly, Koushik Chatterjee, Pankaj Sarkar, Satanik Hazra, Debasis Sardar. A study on lipid profiles in chronic liver diseases. National Journal of Medical Research.2013; 3(1):70-72.
8. Sposito AC, Vinagre CG, Pandullo FL et al. Apolipoprotein and lipid abnormalities in chronic liver failure.Braz J Med Biol Res. 1997; 30: 1287-90.
9. Chabrier G, Schlienger JL, Doffoel M et al.Apoproteins A1 and B as markers of the severity of cirrhosis.Presse Med. 1983; 12: 739-42.
10. Tietge UJ, Boker KH, Bahr MJ et al. Lipid parameters predicting liver function in patients with cirrhosis and after liver transplantation.Hepatogastroenterology. 1998; 45: 2255-60.
11. Allain CC. Enzymatic determination of total serum cholesterol. Clin. Chem. 1974; 20: 470-475.
12. Assmann G. Estimation of HDL Cholesterol. Clin Chem 1979; 20: 599.
13. Buccolo G and David M. Quantitative determination of serum triglyceides by use of enzymes. Clin Chem. 1973; 19: 476-482.
14. Allen LC. More on cephalosporin interference with creatinine determinations. Clin Chem. 1982; 28 (3): 555.
15. NakayamaK.Differences between enzymatic and diazo methods for measuring direct bilirubin.Eur J Clin Chem Clin Biochem.1995;33:513–5170.
16. Doumas BT, Watson WA and Biggs HG. Albumin standards and the measurement of serum albumin with bromcresol green. Clin Chem Acta. 1971; 31: 87-96.
17. Shao B, Oda MN, Vaisar T, Oram JF, Heinecke JW. Pathways for oxidation of high-density lipoprotein in human cardiovascular disease. Curr Opin Mol Ther. 2006 Jun; 8(3):198-205.
18. Furtado JD, Campos H, Appel L, et al. Effect of protein, unsaturated fat,
and carbohydrate intakes on plasma apolipoprotein B and VLDL and LDL
containing apolipoprotein C-III: results from the Omni Heart Trial. Am J Clin
Nutr 2008; 8:1623-30.
19. Kitchen S and Preston FE. Standardization of prothrombin time for laboratory control of oral anticoagulant therapy. Semin Thromb Hemost. 1999. 25; 17-25.
9 / Signature of candidate
10 / Remarks of the guide / Predictive value of dyslipidemia may help us as a tool to forecast the progression of cirrhosis and hence screening may prevent further complications.
11 / 11.1
Name& Designation of Guide
(in block letters)
11.2 Signature / DR. HILDA PRIYA D’SOUZA
ASSOCIATE PROFESSOR
MBBS, MD
A J INSTITUTE OF MEDICAL SCIENCES,
KUNTIKANA, MANGALORE.
11.5 Head of Department
11.6 Signature / DR ASHOK KUMAR J
PROFESSOR AND HEAD OF THE DEPARTMENT,
M.B.B.S, MD,
A J INSTITUTE OF MEDICAL SCIENCES,
KUNTIKANA, MANGALORE.
12 / 12.1 Remarks of the
Chairman and Principal
12.2 Signature