In a recent issue of this Journal, Montalcini and coworkers demonstrated that an increase in serum uric acid levels may be an independent risk factor for atherosclerosis in a series of healthy postmenopausal women [1]. The possible causative effect of modifications in uric acid metabolism in the pathogenesis of cardiovascular disease (CVD) was also reviewed by Manzato in the same issue of the journal [2], bringing to the attention of the scientific community the old concept of the possible role of uric acid as an additional player in the development of atherosclerosis and arterial thrombosis. Epidemiological studies showed that elevated serum uric acid may be a risk factor for CVD independent of other abnormalities commonly observed in patients with the metabolic syndrome, such as obesity, dyslipidaemia, hypertension, insulin resistance and glucose intolerance [3–5]. The study by Montalcini et al. [1] tested the pro-atherosclerotic effects of hyperuricaemia by using high-resolution ultrasound, a widely accepted technique able to noninvasively detect early atherosclerotic modifications of arterial wall in vivo, and specifically an increase in carotid intima-media thickness. It has been previously shown that this structural change correlates with future clinical events, therefore providing reliable information on the prognostic role of cardiovascular risk factors [6]. The mechanisms potentially involved in the pro-atherosclerotic effect of uric acid are still under investigation and, as mentioned by Manzato [2], several hypotheses have been made to explain this issue. One possible pathogenetic mechanism relates to the effect exerted by uric acid on vascular and inflammatory cells. It has been demonstrated that uric acid, in a range of concentration of 120–240 μmol/l (6–12 mg/dl), is able to upregulate Creactive protein (CRP) mRNA expression in human umbilical vein endothelial cells (HUVEC) in vitro, thus inducing CRP release into culture media [7]. In the same experiments uric acid was shown to stimulate human vascular smooth muscle cell (VSMC) proliferation and migration, and to inhibit endothelial cell proliferation and nitric oxide (NO) release. All these effects of uric acid could be blocked by incubation of vascular cells with anti-CRP antibodies [7]. Taken together these data suggest that uric acid may potentially contribute to vasoconstriction and platelet activation and to atherosclerotic plaque growth, and that these effects are mediated by locally produced CRP. Work by the same group showed that hyperuricaemia, obtained in rats by blocking uricase by oxonic acid, was also able to induce a decrease in serum NO levels together with an increase in systolic blood pressure, and that this effect was reversed after allopurinol treatment for 7 days. In additional experiments, uric acid was shown to dose dependently inhibit both basal and vascular endothelial growth factor (VEGF)-induced NO production by bovine endothelial cells in vitro, thus suggesting that exposure to uric acid may induce endothelial dysfunction and a pro-atherosclerotic phenotype in these cells [8]. Kanellis and coworkers also demonstrated that uric acid induced an increase in rat aortic VSMC monocyte chemoattractant protein-1 (MCP-1) expression in a timeand dose-dependent manner, with a peak at 24 h. Overexpression of MCP-1 mRNA and protein occurred as early as 3 h after the incubation of VSMC with uric acid and was associated with activation of the transcription factors NF-κB and activator protein-1 (AP-1), as well as with the activation of the mitogen-activated protein kinase (MAPK) extracellular signalling molecules ERK p44/42 and p38, and with an increase in cyclooxygenase-2 (COX2) mRNA expression [9]. Inhibition of ERK p44/42, p38 and COX-2 each suppressed uric acid-induced MCP-1 production [9]. These data clearly show that uric acid, in its soluble form, can elicit an inflammatory response in VSMC, thus providing further evidence of its potential role in monocyte recruitment, VSMC activation and finally in atherosclerotic plaque growth and rupture. A large body of experimental data demonstrated that inflammatory processes play a crucial role in all steps of atherosclerotic plaque formation and disruption and in its thrombotic complications, and that these processes are sustained by a variety of cells such as endothelial cells, VSMC and macrophages [10]. CRP is one of the most important inflammatory mediators. It is mainly produced by the liver in response to the proinflammatory cytokine IL-6 which, in turn, is syntheIntern Emerg Med (2007) 2:320–321 DOI 10.1007/s11739-007-0087-x
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