Soluble CD40 Ligand in Morbidly Obese Patients: Effect of Body Mass Index on Recovery to Normal Levels After Gastric Bypass Surgery

Article (PDF Available)inJAMA SURGERY 148(2):151-6 · February 2013with60 Reads
DOI: 10.1001/jamasurgery.2013.419 · Source: PubMed
Abstract
Importance In recent years, the CD40/CD40L system has been implicated in the pathophysiology of severe chronic inflammatory diseases. Recently, obesity has been described as a low chronic inflammatory disease, so this system could also be involved in the inflammatory process. Objective To study soluble CD40 ligand (sCD40L) and other factors implicated in coagulation (plasminogen activator inhibitor 1, antithrombin III, and fibrinogen) and inflammation (C-reactive protein) in patients with morbid obesity and different body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared), before and after weight loss induced by bariatric surgery. Design Plasma samples were obtained before and after a bariatric surgery intervention. Several inflammatory markers were then studied (sCD40L, plasminogen activator inhibitor 1, antithrombin III, and C-reactive protein). The values obtained were compared with a control group of nonobese persons. Participants Thirty-four morbidly obese patients undergoing gastric bypass surgery and 22 normal-weight controls matched for age and sex. Interventions A Roux-en-Y gastric bypass was performed in morbidly obese patients. Main Outcome Measures Levels of sCD40L, plasminogen activator inhibitor 1, antithrombin III, fibrinogen, and C-reactive protein 12 months after bariatric surgery. Results Obese men showed a tendency for decreased plasma sCD40L levels 1 year after surgery (mean [SEM], 246.5 [70.4] pg/mL before vs 82.2 [23.2] pg/mL after surgery; P < .05), whereas there were not any significant changes in obese women (285.9 [67.5] pg/mL before vs 287.0 [56.9] pg/mL after surgery). Levels of the other markers studied decreased significantly with weight loss in both sexes. However, all other studied markers tend to have higher concentrations in patients with higher BMIs, except for sCD40L, which tended to have lower concentrations in patients with BMIs higher than 55. The decreases with weight loss were lower with higher BMIs for all measurements, except for antithrombin III. Conclusions and Relevance Increased BMI, but not sex, influences recovery to normal levels for the markers studied, possibly indicating a worse prognosis.
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ORIGINAL ARTICLE
Soluble CD40 Ligand in Morbidly Obese Patients
Effect of Body Mass Index on Recovery to Normal Levels After Gastric Bypass
Surgery
Juan A. Baena-Fustegueras, MD; Eva Pardina, PhD; Eva Balada, MD; Roser Ferrer; Roberto Catala´n, PhD;
Joaquı´n Rivero, MD; Isidre Casals, PhD; Albert Lecube, MD; Jose M. Fort, MD; Vı´ctor Vargas, MD;
Julia Peinado-Onsurbe, PhD
Importance:In recent years, the CD40/CD40L system
has been implicated in the pathophysiology of severe
chronic inflammatory diseases. Recently, obesity has been
described as a low chronic inflammatory disease, so this
system could also be involved in the inflammatory pro-
cess.
Objective:To study soluble CD40 ligand (sCD40L) and
other factors implicated in coagulation (plasminogen ac-
tivator inhibitor 1, antithrombin III, and fibrinogen) and
inflammation (C-reactive protein) in patients with mor-
bid obesity and different body mass indexes (BMIs) (cal-
culated as weight in kilograms divided by height in me-
ters squared), before and after weight loss induced by
bariatric surgery.
Design:Plasma samples were obtained before and after
a bariatric surgery intervention. Several inflammatory
markers were then studied (sCD40L, plasminogen acti-
vator inhibitor 1, antithrombin III, and C-reactive pro-
tein). The values obtained were compared with a con-
trol group of nonobese persons.
Participants:Thirty-four morbidly obese patients un-
dergoing gastric bypass surgery and 22 normal-weight
controls matched for age and sex.
Interventions:A Roux-en-Y gastric bypass was per-
formed in morbidly obese patients.
Main Outcome Measures:Levels of sCD40L, plas-
minogen activator inhibitor 1, antithrombin III, fibrino-
gen, and C-reactive protein 12 months after bariatric sur-
gery.
Results:Obese men showed a tendency for decreased
plasma sCD40L levels 1 year after surgery (mean [SEM],
246.5[70.4] pg/mL before vs 82.2[23.2] pg/mL after sur-
gery; P.05), whereas there were not any significant
changes in obese women (285.9 [67.5] pg/mL before vs
287.0 [56.9] pg/mL after surgery). Levels of the other
markers studied decreased significantly with weight loss
in both sexes. However, all other studied markers tend
to have higher concentrations in patients with higher
BMIs, except for sCD40L, which tended to have lower
concentrations in patients with BMIs higher than 55. The
decreases with weight loss were lower with higher BMIs
for all measurements, except for antithrombin III.
Conclusions and Relevance:Increased BMI, but not
sex, influences recovery to normal levels for the mark-
ers studied, possibly indicating a worse prognosis.
JAMA Surg. 2013;148(2):1-2
IN RECENT YEARS,THE CD40/
CD40 ligand (CD40L) system has
been implicated in the patho-
physiology of severe chronic in-
flammatory diseases, including
atherosclerosis.1,2 Increasing evidence im-
plicates CD40L as a central signaling
mechanism that stimulates an array of pro-
atherothrombotic processes.3,4 The CD40
ligation leads to activation of inflamma-
tory cells, endothelium, and platelets.
These cells are integral to the develop-
ment of plaque disruption, acute coro-
nary syndromes, and recurrent cardiovas-
cular events. The CD40L is rapidly
upregulated during platelet activation and
triggers an inflammatory response in cells
that constitutively express CD40, that is,
endothelial cells and monocytes.5Both
CD40 and CD40L are overexpressed in hu-
man and experimental atherosclerotic le-
sions, particularly in advanced, rupture-
prone plaques.6Conversely, CD40L
induces tissue factor expression,7account-
ing for thrombotic events within the
plaque. Additional evidence suggesting a
link between atherosclerosis and the in-
flammatory properties of CD40/CD40L has
emerged from several prospective stud-
ies8,9 Studies in patients with acute coro-
nary syndromes revealed that elevated
soluble CD40L (sCD40L) levels indi-
cated a significantly increased risk of death
or nonfatal myocardial infarction.10 El-
Author Aff
Unit, Hospi
Arnau de V
Spain (Dr B
Systemic A
Unit (Dr Ba
Departmen
Catala´n), C
Enfermedad
Asociadas (
Instituto de
Diabetes Re
Lecube), En
Unit (Dr Fo
Enfermedad
Digestivas (
Instituto de
Vargas), Ins
DHebron,
Autònoma
Hospital Un
Terrassa, Ba
Biochemist
Biology Dep
Faculty (Dr
Peinado-On
Cientı´fics i
de Tècniqu
Universitat
Barcelona (
Author Affiliations are listed at
the end of this article.
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evated plasma concentrations of sCD40L were observed
in patients with unstable angina11 and were predictive for
high-risk atherosclerotic lesions8and the risk for future
cardiovascular events in women.12
Android obesity is associated with enhanced lipid per-
oxidation and persistent platelet activation, both of which
can be improved by successful weight loss.11 These ab-
normalities are driven by inflammatory triggers related
to the degree of abdominal adiposity. Santilli et al11 found
significantly higher plasma C-reactive protein (CRP) lev-
els associated with enhanced oxidative stress and plate-
let activation in otherwise healthy women with visceral
obesity. Others showed increased CD40L levels in pa-
tients with severe obesity12 and demonstrated that weight
loss during a 16-week period of caloric restriction was
associated with significant reductions in sCD40L levels
and oxidative stress.13
Because morbid obesity is closely associated with
chronic inflammation and thrombotic events, our goal
was to study levels of sCD40L and other biomarkers, such
as CRP, antithrombin III (ATIII), and plasminogen ac-
tivator inhibitor 1 (PAI-1), in patients with morbid obe-
sity and different body mass indexes (BMIs) (calculated
as weight in kilograms divided by height in meters
squared), before and after weight loss induced by bar-
iatric surgery.
METHODS
PATIENT SELECTION
A group of 34 morbidly obese patients (24 women and 10 men),
aged 27 to 61 years, were recruited from the Vall dHebron Hos-
pital in Barcelona, Spain. Our specific inclusion criteria were
as follows: a BMI higher than 40 or a BMI between 35 and 40
and at least 2 comorbid conditions (eg, diabetes, dyslipid-
emia, and steatosis), stable weight during the previous 3 months,
and no insulin treatment in diabetic patients. The diagnostic
criteria (ie, fasting glucose level 110 mg/dL [to convert glu-
cose to millimoles per liter, multiply by 0.0555], waist circum-
ference larger than 102 cm in men and 88 cm in women, tria-
cylglyceride levels 150 mg/dL [to convert triacylglycerides
to millimoles per liter, multiply by 0.0113], high-density lipo-
protein cholesterol level 40 mg/dL in men and 50 mg/dL in
women [to convert cholesterol to millimoles per liter, multi-
ply by 0.0259], and hypertension 130/83 mm Hg) that we
used for diabetes, hypertension, and metabolic syndrome are
those proposed by the National Cholesterol Education Pro-
gram.14 Twenty-three (68%) of the patients had metabolic syn-
drome. All participants were free of inflammatory disease (other
than obesity) and infectious diseases, and none were receiving
antiobesity or anti-inflammatory drugs at the time of the study.
Patients were excluded if they had neoplastic, renal, or active
systemic diseases; hypothyroidism; or an endocrine disease other
than diabetes. Height, weight, and waist and hip circumfer-
ences were recorded with participants wearing light clothing
and no shoes. Body mass index was calculated. Waist circum-
ference was measured at the natural indentation between the
10th rib and the iliac crest (minimum waist circumference).
Hip circumference was measured over the widest part of the
gluteal region.
The participants were divided into 4 groups depending on
their BMI: group 1, BMI lower than 45 (n=8); group 2, 45 to
49.9 (n=10); group 3, 50 to 54.9 (n= 12); and group 4, 55 to
60 (n =4). Obesity was defined as a BMI higher than 30. Twenty-
two normal-weight persons (BMI 25; matched in age and sex
with patients in the obese group), volunteer blood donors from
a hospital clinic blood bank, were used as controls; they were
euthyroid, normolipemic, and without digestive system dis-
eases. The study protocol was reviewed and accepted by the
hospital ethics committee, and all participants (controls and
obese patients) gave their written informed consent to partici-
pate.
BLOOD SAMPLES AND ASSAY
Patients’ blood samples were obtained after an overnight fast
before and 12 months after surgery. All obese patients under-
went an open Roux-en-Y gastric bypass using the Fobi-
Capella technique (ring, 7 cm; Roux-limb, 180 cm; biliopan-
creatic limb, 80 cm). The gastric reservoir was tested with a
36F Foucher probe. The foot loop was performed by side-to-
side anastomoses.
Plasma was separated immediately by centrifugation (2000g
for 30 minutes at 4C), and aliquots were frozen at 80C for
subsequent measurement of biochemical and inflammatory fac-
tors. In the control group, a blood sample was obtained after
an overnight fast using minimal tourniquet pressure. All the
plasma samples were stored at 80C until assay.
Fasting plasma glucose was measured enzymatically by the
hospital’s routine chemistry laboratory. Insulin was measured
with an autoanalyzer (IMMULITE 2500; Siemens Medical Di-
agnostics). The measurements were based on a noncompeti-
tive chemiluminescent immunometric assay with 2 binding sites
in solid phase. The homeostatic model assessment of insulin
resistance was calculated as described elsewhere by Matthews
et al.15
Plasma concentrations were determined as follows: sCD40L
was measured with an enzyme-linked immunosorbent assay
(ELISA; ELISA Quantikine sCD40L; R&D Systems); PAI-1, a
measure of impaired fibrinolysis, with ELISA (IMUBIND;
America Diagnostica); ATIII, with the chromogenic anti-Xa
method (BIOPEP SA); and CRP, with a turbidimetric assay (Ger-
non reagents; RAL). Plasma blood cell and platelet counts were
measured with an automatic analyzer (Beckman Coulter LH
750; Beckman Coulter), homeostasis and blood coagulation were
measured with an automatic autoanalyzer (Amelung CS-400;
Grifols), and calcium and iron were measured with an auto-
matic autoanalyzer (Olympus AU 5400; Olympus).
STATISTICAL ANALYSIS
Results are given as means (SEMs). Differences between mean
values in obese patients before and 12 months after surgery were
analyzed with a 2-tailed paired ttest. When obese and normal-
weight participants were compared, significance was assessed
using an unpaired 2-tailed ttest. Statistical differences be-
tween mean values for obese or 12-month postoperative pa-
tients by sex and BMI were assessed with 2-way analysis of vari-
ance. Individual comparisons were made with the Bonferroni
multiple-comparison test. All statistical analyses were com-
puted with the GraphPad Prism software program, version 5.00
for Windows (GraphPad Software).
RESULTS
Clinical characteristics before and 12 months after sur-
gery are shown in Table 1. All markers measured, ex-
cept platelets (counts and volume) and iron levels, were
significantly decreased 1 year after surgery.
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EFFECTS OF SEX AND WEIGHT LOSS
ON MARKERS OF COAGULATION AND
INFLAMMATION
The coagulation and inflammation markers measured in
control, obese, and 12-month postoperative groups are
summarized in Table 2. All measurements were signifi-
cantly lower in controls than in the obese group. Nota-
bly, the mean sCD40L level in controls was 126 times
lower than in obese patients. Considering both sexes to-
gether, weight loss seems slightly associated with a de-
cline in sCD40L levels, but this decline was not signifi-
cant because of the wide dispersion of the data. For men
considered separately, there was a clear, marginally sig-
nificant decrease in sCD40L levels (3-fold, P.05); no
significant changes were observed in women (Table 2).
The PAI-1 values were significantly higher in obese
patients than in controls. However, in all the patients with
weight loss, the postoperative values were lower than the
control values (39% lower in men and 58% lower in wom-
en). The ATIII values were significantly lower in con-
trols than in obese patients, but, curiously, these values
increased further with weight loss. Both fibrinogen and
CRP levels were higher in obese patients than in con-
trols, and as observed for PAI-1, the trend was for them
to decrease significantly with weight loss. Notably, as ob-
served for PAI-1, CRP values decreased with weight loss
to levels lower than those in controls. The decreases even
below the control values observed are the same as we have
observed for many other markers assessed in morbidly
obese patients undergoing weight loss by bariatric sur-
gery.16
EFFECTS OF BMI AND WEIGHT LOSS
ON COAGULATION AND INFLAMMATION
MARKERS
The Figure shows the changes in the different measure-
ments as a function of BMI before and after weight loss.
The upper left panel shows the mean BMIs in the 4 sub-
groups studied and the means in these groups 1 year af-
ter surgery. Three conclusions can be drawn about the
measurements shown in the Figure. First, measure-
ments in obese patients tended to be higher in those with
higher BMIs in a more or less pronounced way, except
for sCD40L and CRP levels, which tended to be lower
in those with BMIs greater than 55. Second, after sur-
gery, the recovery in the different measurements is also
a function of BMI, and for some markers, the postopera-
tive slope between BMI groups was almost parallel to the
preoperative slope (see ATIII and fibrinogen). Third, for
PAI-1 and CRP, the mean control values were signifi-
cantly lower than those in obese patients for all BMIs,
but these measurements not only recovered to normal
values after weight loss but fell below them. For fibrino-
gen and ATIII, control values were lower than those in
both obese and postoperative patients for all BMIs, and
patients who lost weight actually had higher ATIII ac-
tivity levels than obese patients, for all BMIs.
The profile of sCD40L is different from those of the
other markers measured, for 2 reasons. First, because of
dispersion of the data, the difference between obese and
postoperative patients was not significant. Second, when
weight loss was observed, a very steep increase in sCD40L
levels was noted between BMI groups (from 45 to 60),
with almost all values significantly higher than control
values. The small sample size of some of our subgroups
(eg, patients with BMIs 55) could limit our ability to
obtain conclusive results about sCD40L in this group.
COMMENT
The novelty of our study is that all measured markers in
obese patients, except for sCD40L, increase with BMI.
The results of our study show for the first time that
sCD40L levels did not differ significantly between obese
men and women for any BMI. However, we observed that
sCD40L levels in men can increase or decrease with sur-
gery in the BMI subgroups studied, but in women they
tended to increase with surgery in all BMI subgroups (ex-
cept 50-55). When we considered men overall, combin-
ing all BMI groups, we noted a significant decrease in
sCD40L levels with surgery in men.
We found sCD40L values ranging from 2.2 pg/mL in
the control group to 370 pg/mL in obese patients with
BMIs lower than 45 and between 37 and 1353 pg/mL in
those with BMIs 50 to 55. Unek et al17 reported differ-
ences in sCD40L levels between patients with and those
without metabolic syndrome (with BMIs of 32 and 25,
respectively) but not among patients with normal glu-
cose tolerance, prediabetes, or diabetes.
The values reported for sCD40L in the literature are
different from our findings. Reported serum concentra-
tions of sCD40L have ranged from 1 to 7 ng/mL in obese
Table 1. Characteristics of Obese Patients Before and After
Bariatric Surgery
Characteristic
Mean (SEM) Values
Obese Patients
Patients 12 mo
After Surgery
BMI 48.8 (0.9) 30.9 (0.9)a
Waist circumference,
cm
136.1 (2.3) 98.5 (2.9)a
Hip circumference,
cm
145.0 (2.3) 117.8 (3.0)a
HOMA-IR 7.7 (1.1) 1.9 (0.3)a
Platelet count,
×103/µL plasma
286 (12) 268 (12)b
Platelet volume, % 8.98 (0.17) 9.29 (0.20)b
Calcium, mg/dL 8.9 (0.1) 9.2 (0.1)c
Iron, µg/dL 67.1 (4.9) 86.4 (5.7)c
Abbreviations: BMI, body mass index (calculated as weight in kilograms
divided by height in meters squared); HOMA-IR, homeostasis model
assessment–insulin resistant; SEM, standard error of mean.
SI conversion factors: To convert calcium to millimoles per liter, multiply
by 0.25; iron to micromoles per liter, multiply by 0.179; and platelet count to
×109/L, multiply by 1.0.
aP.001 for difference between patient groups (2-tailed paired ttest).
bDifference not significant.
cP.05.
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patients with BMIs of 45,18 from 8.06 to 9.51 ng/mL in
obese patients with BMIs ranging from lower than 25 to
35 or higher,19 and from 1.6 to 2.8 ng/mL after 1 year of
weight loss.20 Some authors even observed no differ-
ences in serum levels between obese and normal-weight
patients (8.63 vs 8.06 ng/mL, respectively).19 The dis-
crepancies between studies may reflect differences in pa-
tient BMIs, differences in the kits used in assessments,
and/or the differences between serum and plasma lev-
els. We used EDTA-treated platelet-poor plasma. The
CD40L is present in platelet granules and is released on
platelet activation. Therefore, platelet-free plasma should
be used for measuring circulating levels of CD40L.
However, not all authors find differences between lev-
els of sCD40L in plasma and those in serum.21,22 More-
over, according to the supplier datasheet of the kit used
in our study, the expected values in plasma for a healthy
person would range from undetectable to 139 pg/mL and
those in serum from undetectable to 11 451 pg/mL. In
our study, we observed that at any BMI, the obese group
had higher sCD40L levels than controls, but we did not
observe these values to increase significantly with BMI,
in contrast to what other authors have described.17 One
possible reason for this divergence is that we studied pa-
tients with BMIs ranging from 35 to 60 and normal-
weight controls (BMI 25), whereas other studies in-
cluded participants with BMIs lower than 25, 25 to 30,
or higher than 30.17 The same distinction applies to the
study conducted by Guldiken et al,19 which included per-
sons with BMIs lower than 25, 30 to 35, or higher than
35. Guldiken et al19 observed no significant differences
in the values of sCD40L between normal-weight and obese
patients. The small sample sizes of some of our groups
(eg, patients with BMIs 55) and the wide dispersion of
data before and after weight loss could limit our ability
to obtain conclusive results concerning sCD40L levels.
We have also been unable to find any correlation be-
tween sCD40L levels in the obese group and many an-
thropometric and biochemical markers measured, in-
cluding body weight, excess weight, and waist and hip
circumferences; levels of triacylglycerols, fatty acids, glyc-
erol, cholesterol, CRP, leptin, ghrelin, and lipases; and
blood cell counts (eg, monocyte and leukocyte counts;
data not shown). This lack of correlation between sCD40L
levels and anthropometric markers in obese patients was
also observed by Guldiken et al.19
The only correlations with sCD40L levels that we found
in obese patients were plasma iron (r= 0.65) and cal-
cium (r= 0.62) levels (P.01 for both). The sCD40L
is a proinflammatory and prothrombotic ligand, and the
latter characteristic could help explain its association with
calcium. The extension of the clot formed by platelets is
key to the increased cytosolic calcium,23,24 although the
prothrombotic mechanism could be offset by the in-
crease in ATIII that we observed. The presence of EDTA
(a strong chelator of calcium) as an anticoagulant in blood
collection is considered effective in inhibiting the re-
lease of sCD40L, but only when added before platelet ac-
tivation,25 which was not done in our study. We also found
a positive correlation (r= 0.52; P.01) between PAI-1
and sCD40L levels.
We found no other correlations, neither in obese pa-
tients only nor after weight loss, although other authors
have found that platelet counts correlate well with sCD40L
levels in obese patients.22 The increase in CRP, accord-
ing to the degree of obesity, has been observed by other
authors,17,19 although in a much lower range than in our
study. Thus, to our knowledge, this work demonstrates
for the first time not only that CRP continues to in-
crease up to a BMI of 60 but also that when this marker
decreases as a result of weight loss, it decreases in pro-
portion to the initial BMI, to values below those of pa-
Table 2. Sex and Surgery Effects in Markers of Coagulation and Inflammation
Marker
Mean (SEM) Values
Controls
All Men Women PValues for 2-Way ANOVAa
Obese
12 mo
After
Surgery Obese
12 mo
After
Surgery Obese
12 mo
After
Surgery Sex Effect
Surgery
Effect
Sex-Surgery
Effect
sCD40L, pg/mL 2.2 (1.0) 276.1
(53.1)b
222.3
(45.0)b
246.5
(70.4)b
82.2
(23.2)b,c
285.9
(67.5)b
287.0
(56.9)b,c
.08 .24 .24
PAI-1, ng/mL 75.9 (10.4)154.6
(16.1)b
34.7
(5.5)b,e
174.0
(26.9)b
46.3
(14.6)f
146.9
(22.2)
31.6
(6.2)b,e
.38 .001 .73
ATIII activity, % 104.2 (4.0) 120.0
(2.0)b
129.7
(1.4)b,e
116.8 (3.9128.8
(2.2)b,c
120.8
(2.6)g
129.8
(2.0)b,e
.53 .001 .83
Fibrinogen, mg/mL 2.8 (0.3) 4.0 (0.1)b3.4 (0.1) f,h 4.4 (0.2)g3.4 (0.3)f3.9 (0.1) b3.5 (0.2)c.27 .001 .27
CRP, µg/mL 6.9 (0.9) 21.3 (1.8)b4.1 (0.6) e,g 29.3 (3.1)b5.6 (1.4)e21.3 (1.9) b4.6 (0.8)d,e .65 .001 .65
Abbreviations: ANOVA, analysis of variance; ATIII, antithrombin III; CRP, C-reactive protein; PAI-1, plasminogen activator inhibitor-1; sCD40L, soluble CD40
ligand; SEM, standard error of mean.
SI conversion factors: To convert C-reactive protein to nanomoles per liter, multiply by 0.524; fibrinogen to micromoles per liter, multiply by 0.0294.
aTwo-way ANOVA was used to study the interaction between sex and the effect of surgery (weight loss).
bP.001 (2-tailed unpaired ttest comparing control and obese groups).
cP.05 (2-tailed paired ttest comparing obese patients before and 12 mo after surgery).
dP.05 (comparison between male and female patients).
eP.001 (2-tailed paired ttest comparing obese patients before and 12 mo after surgery).
fP.01 (2-tailed paired ttest comparing obese patients before and 12 mo after surgery).
gP.01 (2-tailed unpaired ttest comparing control and obese groups).
hP.05 (2-tailed unpaired ttest comparing control and obese groups).
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tients with normal weight. Hanusch-Enserer et al20 have
studied some measurements that they consider noncon-
ventional markers of atherosclerosis (eg, PAI-1, CRP, and
sCD40L levels) in patients with BMIs higher than 40, be-
fore and 1 year after adjustable laparoscopic gastric band-
ing. Their results for PAI-1 and CRP were much lower
0
<45 50-55 55-60
70
50
BMI, k
Initial BMI Initial BMI
30
60
40
20
10
45-50
A
0<45 50-55 55-60
250
PAI-1, ng/mL
150
200
100
50
45-50
C D
E F
0<45 50-55 55-60
5
Fibrinogen, mg/mL
3
4
2
1
45-50
0<45 50-55 55-60
25
CRP, µg/mL
15
20
30
10
5
45-50
100 <45 50-55 55-60
140
ATIII Activity, %
130
120
110
45-50
0
<45 50-55 55-60
500
sCD40L, pg/mL
300
600
400
200
100
45-50
B
Total Surgery BMI
BMI
Ratio
P
%
2.06
.12
0.87
491.1
<.001
69.65
49.39
<.001
20.98
sCD40L
Ratio
P
%
0.48
.70
3.34
0.23
.63
0.54
0.79
.51
5.49
PAI-1
Ratio
P
%
0.34
.80
0.91
12.09
<.001
44.51
4.03
.01
10.79
Total Surgery BMI
ATIII
Ratio
P
%
0.09
.96
0.40
13.19
.001
17.55
0.78
.91
0.78
Fibrinogen
Ratio
P
%
0.52
.67
1.97
15.90
<.001
20.19
5.10
.004
19.43
CRP
Ratio
P
%
0.42
.74
1.00
67.87
<.001
53.72
0.74
.53
1.75
Figure. Body mass index (BMI) and plasma levels of soluble CD40 ligand (sCD40L), plasminogen activator inhibitor 1 (PAI-1), antithrombin III (ATIII), fibrinogen,
and C-reactive protein (CRP) in obese patients before gastric bypass (black bars) and the same patients 12 months after surgery (white bars). Values are
expressed as means and standard errors of the mean for different BMI ranges; dotted lines indicate mean values in the control (normal-weight) group. Statistical
significance was determined with 2-way analysis of variance for the interaction between BMI and surgery (“Total” in the tables); individual comparisons were
made with the Bonferroni multiple-comparison test. *P.05; P.01; and P.001.
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than what we observed (Table 2) both before surgery (data
shown as means [SDs]; CRP, 5.7 [0.6] mg/dL; PAI-1, 44.1
[15.3] ng/mL) and after surgery (CRP, 5.5 [0.4] mg/dL;
PAI-1, 34.9 [10.4] ng/mL). However, the type of sur-
gery performed in our study, gastric bypass, was also dif-
ferent. For sCD40L, these authors20 found values of 1.6
(1.5) and 2.2 (1.9) ng/mL before and after surgery (we
observed 0.28 [0.05] and 0.22 [0.05] ng/mL, respec-
tively). Hanusch-Enserer et al20 proposed, based on their
data, that only PAI-1 is a good marker of inflammatory
and prothrombotic response in extreme obesity.
Despite the small sample size (n = 4) of 1 BMI sub-
group in our study, we believe that we can begin to draw
some conclusions from our study results. We propose that,
given the marked increase in both PAI-1 and CRP as BMIs
increased, and its evident decrease with weight loss in
terms of BMI, those could also be good markers of both
risk of cardiovascular and inflammatory disease and/or
prothrombotic states. Soluble CD40L would be an added
value in the demonstration of improvement with weight
loss.
Accepted for Publication: June 12, 2012.
Author Affiliations: Surgery Unit, Hospital Universitari
Arnau de Vilanova, Lleida, Spain (Dr Baena-
Fustegueras); Systemic Autoimmune Diseases Unit (Dr
Balada), Biochemistry Department (Ms Ferrer and Dr
Catala´n), CIBER de Diabetes y Enfermedades Metabo´li-
cas Asociadas (CIBERDEM), Instituto de Salud Carlos III,
Diabetes Research Unit (Dr Lecube), Endocrinology Sur-
gery Unit (Dr Fort), and CIBER de Enfermedades Hep-
a´ticas y Digestivas (CIBEREHD), Instituto de Salud Car-
los III (Dr Vargas), Institut de Recerca Vall DHebron,
Universitat Autònoma De Barcelona; Hospital Universi-
tari Mu´tua Terrassa, Barcelona (Dr Rivero); Biochemis-
try and Molecular Biology Department, Biology Faculty
(Drs Pardina and Peinado-Onsurbe) and Centres Cientı´-
fics i Tecnològics, Unitat de Tècniques Separatives, Uni-
versitat de Barcelona, Barcelona (Dr Casals), Spain.
Correspondence: Julia Peinado-Onsurbe, PhD, Depart-
ment of Bioquı´mica y Biologı´a Molecular, Facultat de Bio-
logia, Universitat de Barcelona, Diagonal 645, 08028 Bar-
celona, Spain (jpeinado@ub.edu).
Author Contributions: Drs Baena-Fustegueras and Pei-
nado-Onsurbe had full access to all the data in the study
and take responsibility for the integrity of the data and
the accuracy of the data analysis. Study concept and de-
sign: Baena-Fustegueras, Pardina, Balada, Ferrer, Cata-
la´n, Rivero, Lecube, Fort, Vargas, and Peinado-
Onsurbe. Acquisition of data: Pardina, Balada, Ferrer, and
Catala´n. Analysis and interpretation of data: Baena-
Fustegueras, Pardina, Balada, Ferrer, Catala´n, Rivero, Le-
cube, Fort, Vargas, and Peinado-Onsurbe. Drafting of the
manuscript: Baena-Fustegueras, Pardina, and Peinado-
Onsurbe. Critical revision of the manuscript for important
intellectual content: Baena-Fustegueras, Pardina, Balada,
Ferrer, Catala´n, Casals, Rivero, Lecube, Fort, Vargas, and
Peinado-Onsurbe. Statistical analysis: Baena-
Fustegueras, Pardina, and Peinado-Onsurbe. Adminis-
trative, technical, or material support: Baena-
Fustegueras, Pardina, and Peinado-Onsurbe. Study
supervision: Baena-Fustegueras, Pardina, Balada, Ferrer,
Catala´n, Casals, Rivero, Lecube, Fort, Vargas, and Peinado-
Onsurbe.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research has received funding
from the Fondo de Investigacio´n Sanitaria del Instituto
de Salud Carlos III of the Spanish Ministry for Health and
Consumer Affairs (grants PI030042, PI030024, and
PI070079).
Additional Contributions: English grammar and lan-
guage has been corrected by the American Journal Ex-
perts.
REFERENCES
1. Phipps RP. Atherosclerosis: the emerging role of inflammation and the CD40-
CD40 ligand system. Proc Natl Acad SciUSA. 2000;97(13):6930-6932.
2. Danese S, Fiocchi C. Platelet activation and the CD40/CD40 ligand pathway: mecha-
nisms and implications for human disease. Crit Rev Immunol. 2005;25(2):
103-121.
3. Andre´P, Nannizzi-Alaimo L, Prasad SK, Phillips DR. Platelet-derived CD40L: the
switch-hitting player of cardiovascular disease. Circulation. 2002;106(8):896-
899.
4. Lutgens E, Daemen MJ. CD40-CD40L interactions in atherosclerosis. Trends Car-
diovasc Med. 2002;12(1):27-32.
5. Henn V, Slupsky JR, Gra¨fe M, et al. CD40 ligand on activated platelets triggers
an inflammatory reaction of endothelial cells. Nature. 1998;391(6667):591-
594.
6. Scho¨nbeck U, Mach F, Sukhova GK, et al. CD40 ligation induces tissue factor
expression in human vascular smooth muscle cells. Am J Pathol. 2000;156
(1):7-14.
7. Scho¨nbeck U, Varo N, Libby P, Buring J, Ridker PM. Soluble CD40L and cardio-
vascular risk in women. Circulation. 2001;104(19):2266-2268.
8. Blake GJ, Ostfeld RJ, Yucel EK, et al. Soluble CD40 ligand levels indicate lipid
accumulation in carotid atheroma: an in vivo study with high-resolution MRI.
Arterioscler Thromb Vasc Biol. 2003;23(1):e11-e14.
9. Heeschen C, Dimmeler S, Hamm CW, et al; CAPTURE Study Investigators.
Soluble CD40 ligand in acute coronary syndromes. N Engl J Med. 2003;348
(12):1104-1111.
10. Aukrust P, Mu¨ller F, Ueland T, et al. Enhanced levels of soluble and membrane-
bound CD40 ligand in patients with unstable angina: possible reflection of T lym-
phocyte and platelet involvement in the pathogenesis of acute coronary syndromes.
Circulation. 1999;100(6):614-620.
11. Santilli F, Basili S, Ferroni P, Davì G. CD40/CD40L system and vascular disease.
Intern Emerg Med. 2007;2(4):256-268.
12. Guldiken S, Guldiken B, Demir M, et al. Soluble CD40 ligand and prolactin levels
in migraine patients during interictal period. J Headache Pain. 2011;12(3):
355-360.
13. Desideri G, Ferri C. Effects of obesity and weight loss on soluble CD40L levels.
JAMA. 2003;289(14):1781-1782.
14. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol
in Adults. Executive Summary of the Third Report of the National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treat-
ment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;
285(19):2486-2497.
15. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC.
Homeostasis model assessment: insulin resistance and beta-cell function from
fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;
28(7):412-419.
16. Pardina E, Lecube A, Llamas R, et al. Lipoprotein lipase but not hormone-
sensitive lipase activities achieve normality after surgically induced weight loss
in morbidly obese patients. Obes Surg. 2009;19(8):1150-1158.
17. Unek IT, Bayraktar F, Solmaz D, et al. The levels of soluble CD40 ligand and C-
reactive protein in normal weight, overweight and obese people. Clin Med Res.
2010;8(2):89-95.
18. Schernthaner GH, Kopp HP, Krzyzanowska K, Kriwanek S, Koppensteiner R, Sch-
ernthaner G. Soluble CD40L in patients with morbid obesity: significant reduc-
tion after bariatric surgery. Eur J Clin Invest. 2006;36(6):395-401.
19. Guldiken S, Demir M, Arikan E, et al. The levels of circulating markers of athero-
sclerosis and inflammation in subjects with different degrees of body mass in-
dex: soluble CD40 ligand and high-sensitivity C-reactive protein. Thromb Res.
2007;119(1):79-84.
20. Hanusch-Enserer U, Zorn G, Wojta J, et al. Non-conventional markers of ath-
JAMA SURG/ VOL 148 (NO. 2), FEB 2013 WWW.JAMASURG.COM
6
©2013 American Medical Association. All rights reserved.
JOBNAME: Surgery PAGE: 7 SESS: 2 OUTPUT: Fri Jan 4 11:44:31 2013
/archives/13jobs/sur/feb2013/soa120047
erosclerosis before and after gastric banding surgery. Eur Heart J. 2009;30
(12):1516-1524.
21. Nannizzi-Alaimo L, Rubenstein MH, Alves VL, Leong GY, Phillips DR, Gold HK.
Cardiopulmonary bypass induces release of soluble CD40 ligand. Circulation. 2002;
105(24):2849-2854.
22. Nagasawa M, Zhu Y, Isoda T, et al. Analysis of serum soluble CD40 ligand (sCD40L)
in the patients undergoing allogeneic stem cell transplantation: platelet is a ma-
jor source of serum sCD40L. Eur J Haematol. 2005;74(1):54-60.
23. Michelson AD. How platelets work: platelet function and dysfunction. J Thromb
Thrombolysis. 2003;16(1-2):7-12.
24. Yang J, Wu J, Jiang H, et al. Signaling through Gifamily members in platelets:
redundancy and specificity in the regulation of adenylyl cyclase and other effectors.
J Biol Chem. 2002;277(48):46035-46042.
25. Furman MI, Krueger LA, Linden MD, Barnard MR, Frelinger AL III, Michelson
AD. Release of soluble CD40L from platelets is regulated by glycoprotein IIb/IIIa
and actin polymerization. J Am Coll Cardiol. 2004;43(12):2319-2325.
JAMA SURG/ VOL 148 (NO. 2), FEB 2013 WWW.JAMASURG.COM
7
©2013 American Medical Association. All rights reserved.
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