Efficacy, safety and tolerability of lovastatin and bezafibrate retard in patients with hypercholesterolemia.

Hyperlipidemia has turned out to be the most important risk factor for coronary heart disease and necessitates frequently lipid lowering long-term treatment. Therefore, efficacy and tolerability of hypolipemic drugs are of great interest. The objective of the present study was to compare the safety, tolerability and effect on plasma lipids of Lovastatin and Bezafibrate retard in patients with hypercholesterolemia. 99 patients with total cholesterol of > or = 250 mg/dl after a 4 week standard lipid-lowering diet were treated another 4 weeks with placebo and then randomized to 400 mg Bezafibrate retard or 20 to 80 mg Lovastatin given once a day for 12 weeks. Mean changes from baseline in total cholesterol, LDL cholesterol and triglycerides were significantly reduced, in HDL cholesterol increased in both treatment-groups (p < or = 0.01). The effects of Lovastatin on total cholesterol and LDL cholesterol were more pronounced than those of Bezafibrate retard (p < or = 0.01), while Bezafibrate had a larger effect on triglycerides (p < or = 0.05). The frequency of clinical adverse experiences was low and similar among treatment groups, the frequency of laboratory adverse experiences was higher in the Lovastatin group. One patient in the Bezafibrate group was withdrawn because of nausea, one patient in the Lovastatin group because of GGT elevation.

Risk factors for coronary artery disease: a study comparing hypercholesterolaemia and hypertriglyceridaemia in angiographically characterized patients.

Fifty-two male patients undergoing coronary angiography were allocated to four groups each consisting of 13 subjects: group I had normal coronary arteries and patients in groups II-IV exhibited coronary artery disease. In group II, plasma cholesterol was below 250 mg dl-1 and triglycerides below 160 mg dl-1; in group III, cholesterol was above 270 mg dl-1 and triglycerides under 160 mg dl-1; and in group IV, cholesterol was under 270 mg dl-1 and triglycerides above 180 mg dl-1. The hypertriglyceridaemic group IV had the highest coronary score. In addition, it had lowest lipoprotein lipase activity, lowest HDL-cholesterol and lowest high-density lipoproteins-2 (HDL-2) levels, suggesting that this type of hypertriglyceridaemia is caused--at least in part--by lipoprotein lipase deficiency with impaired removal of the triglyceride-rich lipoproteins and increased catabolism of HDL-2. Our findings point towards a type of hypertriglyceridaemia strongly associated with coronary artery disease which should therefore be treated accordingly.

Prevention of perinatal morbidity by tight metabolic control in gestational diabetes mellitus.

In a prospective controlled trial, we studied the effect of tight metabolic control on the outcomes of 102 gestational diabetes mellitus (GDM) pregnancies compared with outcomes of 102 matched nondiabetic control pregnancies. Women with GDM were treated to achieve and maintain a blood glucose concentration of less than 130 mg/dl at 1 h after breakfast. Treatment consisted of a diet low in oligosaccharides and fat and, if necessary, once daily insulin. By the end of gestation, 88 of the 102 women with GDM received insulin at a mean dose of 18 U/day. Duration of insulin therapy ranged from 3 to 32 wk with a median of 11 wk. Perinatal outcome of GDM pregnancies under this management equaled that of control pregnancies. The full spectrum of excess morbidity from GDM was prevented, and normal distribution of birth weight and normal rates of macrosomia, dystrophy, hypoglycemia, hypocalcemia, hyperbilirubinemia, fetal acidosis, and low Apgar scores were achieved. No mortality was observed. In addition to the two main study groups, we also studied a third group of 24 women with GDM whose treatment lasted less than or equal to 5 wk due to late diagnosis. This suboptimally treated group demonstrated a significant (P less than .05) increase of macrosomia and umbilical artery acidosis compared with the well-treated GDM group. The study reported herein demonstrates that excess mortality and morbidity typically observed in GDM can be prevented by early institution of tight metabolic control, which required insulin in 86% of our patients.

[Normalization of perinatal morbidity in gestational diabetes by strict metabolic adjustment]. / Normalisierung der perinatalen Morbidität bei Gestationsdiabetes durch straffe Stoffwechseleinstellung.

A prospective study compared the perinatal morbidity of 141 normal pregnancies (group I) with that of 108 pregnancies in whom gestational diabetes had been treated early (group II) and 35 with unsatisfactorily treated gestational diabetes (group III). The therapeutic goal in gestational diabetes was to have a postprandial blood-glucose level of less than 130 mg/100 ml. If this was not achievable through diet alone, insulin was injected once daily. Neonatal macrosomia, dystrophy, acidosis, hyperbilirubinaemia, hypoglycaemia and hypocalcaemia had a normal incidence in group II, but in group III macrosomia was twice as frequent as in group II (P less than 0.02), and acidosis (pH less than 7.20) twice as frequent (P less than 0.05). The results indicate that strict metabolic control in gestational pregnancy will achieve a normal rate of perinatal morbidity.

Proliferation and differentiation of human erythropoiesis in vitro: effect of different human lipoprotein species.

In order to permit erythroid proliferation in agar, a serum-free system was developed based on McCoy's 5A medium at pH 8.0, containing deionized and delipidated bovine serum albumin, iron-saturated transferrin, and crude erythropoietin (step III). Addition of the entire complement of serum lipoproteins, termed lipoprotein fraction I (density, less than 1.21 g/ml), increased the number of erythroid colony-forming units and erythroid burst-forming units to numbers indistinguishable from those observed with media containing serum. Moreover, terminal differentiation occurred to fully hemoglobinized normoblasts and even mature erythrocytes. Under these conditions, the erythropoietin dose-response curve obtained when not using serum was comparable to that with serum. Colony formation also displayed a linear relationship to seeding densities down to limiting dilutions. For differential analysis of the main density lipoprotein fractions, sequential ultracentrifugation was performed to isolate very low-density lipoproteins, low-density lipoproteins (LDL), high-density lipoproteins2 (HDL2), and HDL3, which were then added individually to serum-free cultures. Of the main lipoprotein classes, LDL exhibited the most proliferative capacity, followed by HDL2 and HDL3. Our findings indicate that when serum is substituted by well defined compounds including highly purified lipoprotein fractions, a serum-like proliferation and differentiation of human erythropoietic progenitor cells in agar can be obtained.

Stimulation of human early and late erythropoietic progenitor cells by insulin: evidence for different mechanisms.

In order to investigate cellular mechanisms involved in insulin stimulation of erythropoiesis, we have studied the response of early (BFU-e) and late (CFU-e) erythroid progenitor cells in a serum-free agar culture system. In this assay system, CFU-e proliferation occurred in media containing low-density lipoproteins, bovine serum albumin, transferrin and recombinant erythropoietin (rEPO). Insulin in physiological concentrations as low as 10(-12)M, added directly to cultures, augmented CFU-e colony formation. This stimulatory effect was also seen when monocyte- and T lymphocyte-depleted cells from normal donors were cultured. In contrast, BFU-e was not stimulated by media devoid of insulin. Occurrence of BFU-e colonies required the presence of insulin in concentrations higher than 10(-8)M. This insulin effect was not dependent on the presence of monocytes and T lymphocytes. Delayed addition studies of rEPO to insulin containing cultures revealed a slight but significant survival rate of CFU-e. A similar survival rate was found for BFU-e. From this, we conclude that insulin stimulates CFU-e by an EPO-like activity. For BFU-e, however, the decline in the number of bursts caused by EPO deprivation implies that insulin does not act directly as a burst-promoting activity but that it probably induces the release of this activity from non-adherent and T lymphocyte-depleted bone marrow cells.

Measurement of glycated protein by a rapid and specific method for absolute quantification of lysine-bound glucose.

We modified the liquid-chromatographic assay of Schleicher and Wieland (J Clin Chem Clin Biochem 1981; 19:81-7) for measuring lysine-bound glucose in serum proteins, increasing its performance and practicality. After precipitating serum proteins from 10- to 50-microL samples with ethanol (700 mL/L) and hydrolyzing these in 6 mol/L HCl, we inject 20 microL of the diluted hydrolysate directly into the chromatograph, which consists of an acid-resistant C18 precolumn combined with a high-resolution C18 main column. The eluent is 3.5 mmol/L H3PO4 solution containing 30 mL of acetonitrile per liter. These modifications increase sensitivity, provide excellent resolution and longevity of stationary phases, shorten assay times to 15 to 20 min, and are suited for automation. The assay is highly sensitive and highly specific, quantifying nanomoles of lysine-bound glucose per milligram of protein. A precision (CV) of 5.1% is achievable at physiological and supra-physiological glucose concentrations, and analytical recovery is 99%. This inexpensive method has been applied to serum albumin, bulk serum proteins, and preparations of low-density lipoproteins and immunoglobulins.

[Value of lipoprotein electrophoresis for the quantitative assessment of plasma lipoproteins]. / Stellenwert der Lipoproteinelektrophorese für die quantitative Bewertung von Plasmalipoproteinen.

The reliability of semiquantitative densitometric lipoprotein electrophoresis was compared with that of the quantitative determination of plasma lipoproteins by zonal ultracentrifugation on plasma from 73 patients. As an alternative to the measurement of lipoproteins by electrophoresis other, simple laboratory methods were used and also compared with plasma lipoprotein concentrations obtained by zonal ultracentrifugation. It was found that quantitative measurement of plasma lipoproteins by densitometric electrophoresis correlated positively to actual plasma concentration by zonal ultracentrifugation, but other simple methods of lipid determination--of plasma cholesterol; of triglycerides; of HDL and LDL cholesterol--are definitely better for obtaining plasma lipoprotein concentrations. Lipoprotein electrophoresis should not be used for the quantitative determination of plasma lipoproteins.

Human erythropoiesis in vitro and the source of burst-promoting activity in a serum-free system.

Bovine serum albumin (BSA) can markedly increase the number of size of erythropoietic bursts produced by mononuclear cells from human bone marrow and peripheral blood, and reduce the threshold amount of erythropoietin (Epo) required for initial burst formation. The purpose of this study was to determine a possible burst-promoting activity (BPA) of BSA. The experiments were performed in a miniaturized agar system, in which the addition of sheep Epo to cultures with or without BSA was delayed for five days. The results obtained have shown that, with or without BSA, Epo deprivation of up to five days (an epoprival state) did not markedly decrease the number of bursts produced by unfractionated peripheral mononuclear cells compared to the number produced in the presence of Epo from the beginning of culture. Similar results were found whether the fetal calf serum (FCS) concentration was 15% or 2%. The preservation of potential BFU-e formation during the epoprival state has therefore been attributed to the ability of T-lymphocytes and/or monocytes to supply BPA. In order to reduce the endogenous amount of BPA, a nonadherent, E-rosette-negative cell fraction was cultured in the presence of Epo, with or without BSA, in serum-free medium containing transferrin (TF). Under these conditions, an equal number of bursts was obtained in FCS and in serum-free medium containing Epo, BSA and TF, whereas no BFU-e growth was found in the presence of Epo and TF, but without BSA. If Epo was withheld for up to five days, the capacity to form erythroid colonies was still retained by the monocyte- and T-lymphocyte-depleted cell fraction in the continuous presence of BSA. However, BPA could not be detected in the BSA. This observation was further supported by experiments in serum-free medium using human recombinant Epo, in which no BFU-e colony formation could be detected in the presence of BSA. From our investigations carried out at limited cell density and in serum-free medium, it could be concluded that the crude Epo preparation was the source of BPA.

Stimulating effect of intermediate-density lipoproteins (IDL) from hyperlipemic plasma on hepatic lipase.

The main lipoprotein density classes, namely very-low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), low-density lipoproteins (LDL), high-density lipoproteins2 (HDL2) and HDL3 were investigated with respect to their influence on hepatic lipase (HTGL) activity in vitro. Lipoproteins from pooled normal plasma (NP) and from pooled hyperlipemic plasma (HP) were prepared by means of sequential ultracentrifugation. Hepatic lipase was determined radioenzymatically after preincubation with protamine sulfate. It could be demonstrated that IDL from HP were able to stimulate HTGL activity by approximately 100% above the baseline value. HDL3 from both NP and HP revealed an inhibiting effect on HTGL activity. VLDL, LDL, and HDL2 exhibited no significant effect on HTGL activity. It is speculated that HTGL could possibly represent a second pathophysiological pathway for the catabolism of IDL in hyperlipemia but this presumption is supported by only a few investigations in vivo.

Effect of human plasmalipoproteins on erythropoietic progenitor cells in serum-free cultures.

The purpose of the present study was to investigate the influence of human lipoproteins on CFU-e and BFU-e proliferation from human bone marrow in a serum-free system. In our previously described miniaturized agar system the main lipoprotein-density-classes from human plasma, namely very low density lipoproteins (VLDL), intermediate density lipoproteins (IDL), low density lipoproteins (LDL), high density lipoproteins2 (HDL2) and HDL3 and a mixture of all the five lipoproteins were added in rising concentrations (from 1/10 to normal human plasma concentration) to serum-free medium containing delipidated and deionized bovine serum albumin (BSA), iron saturated transferrin and erythropoietin. The results demonstrate that all lipoproteins markedly increased the CFU-e and BFU-e proliferation after 7 and 14 days of incubation, respectively. Moreover, the lipoproteins induced a shift towards a lower threshold concentration of erythropoietin. Serumlike conditions were obtained if LDL and the mixture of lipoproteins were added to serum-free medium. Furthermore, in the serum-free cultures a maturation to the mature erythrocyte could be found.

[Pathologic decrease in lipoprotein lipase activity in relation to the development of hyperlipemias and their significance for coronary heart disease]. / Pathologische Verminderung der Aktivität der Lipoproteinlipase in Zusammenhang mit der Entstehung von Hyperlipämien und deren Bedeutung für die koronare Herzerkrankung.

There is much evidence that altered lipid metabolism contributes to the development of coronary artery disease (CAD). It is generally accepted that there is a direct association between the extent of CAD and total plasma cholesterol, as well as an inverse association between the extent of CAD and plasma HDL-cholesterol. No general agreement exists about the atherogenetic potential of plasma triglycerides and of triglyceride-rich lipoproteins. Since lipoprotein lipase (LPL) is the key-enzyme in the catabolism of triglyceride-rich lipoproteins (chylomicrons and very low-density lipoproteins), we examine the relationship between triglyceride-rich lipoproteins and LPL in vitro and in vivo. The concentrations of the main lipoprotein density classes, namely very low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), low-density lipoproteins (LDL), high-density lipoproteins2 (HDL2) and HDL3, are measured by rate zonal ultracentrifugation. The preparation of VLDL, IDL, LDL, HDL2, and HDL3 is performed by sequential ultracentrifugation. The activity of LPL is measured radioenzymatically in a glycerol-based triolein emulsion. It can be demonstrated in vitro that VLDL, IDL, and HDL2 from normal plasma are able to increase LPL-activity in contrast to VLDL, IDL, and HDL2 from hyperlipemic plasma. This difference seems to be caused by an altered composition of apolipoproteins in hyperlipemic lipoproteins. An artificial acidosis in three healthy subjects shows in contrast to alkalotic and neutral blood-pH a significant decrease of LPL-activity. This result seems to be of some interest, since diseases associated with acidotic blood-pH, such as chronic renal disease, diabetes mellitus or chronic alcoholism, show secondary hyperlipemias caused by a deficit of LPL-activity. It can be shown in 15 male patients who produce a secondary type-V hyperlipemia during severe abuse of alcohol, that LPL-activity is decreased significantly as compared to 15 healthy controls. During sober phases, this alcohol-induced hyperlipemia and the impairment of LPL-activity disappears completely. In an other group of 8 male patients, who are not producing severe secondary hyperlipemia during approximately the identical alcohol intake, LPL-activity is also significantly decreased, but the activity of hepatic lipase is significantly increased. This increase of the activity of hepatic lipase seems to protect these patients from the development of secondary type-V hyperlipemia. In 89 male patients with angiographically assessed CAD a very strong inverse association between the activity of LPL and the extent of CAD is found.(ABSTRACT TRUNCATED AT 400 WORDS)

[Extent of coronary sclerosis in relation to lipoprotein lipase activity and plasma triglyceride levels]. / Ausmass der Koronarsklerose in Beziehung zur Aktivität der Lipoproteinlipase und zur Plasmakonzentration der Triglyceride.

Coronary artery disease (CAD) is closely connected with an increased concentration of cholesterol and a decreased concentration of high-density lipoprotein cholesterol (HDL-chol) in human plasma. No general agreement exists about the atherogenic potential of increased plasma triglycerides. Although both a negative correlation between plasma triglycerides and post heparin lipoprotein lipase (LPL) and a positive correlation between the plasma concentration of HDL-chol and LPL-activity are well documented, only a few studies have investigated the relationship between CAD and LPL. Therefore, 109 male patients with angiographically assessed CAD were investigated with respect to plasma lipids, post heparin LPL, and plasma testosterone and estradiol, which are both known to influence LPL-activity. Many well known results were confirmed. The extent of CAD, assessed by coronary angiography as coronary score (CS), was significantly positively correlated to plasma cholesterol, plasma triglycerides, plasma phospholipids, plasma low-density lipoprotein cholesterol (LDL-chol) and age. CS was significantly negatively correlated to LPL-activity and to the plasma concentration of HDL-chol. LPL itself was significantly negatively correlated to plasma cholesterol, plasma triglycerides and phospholipids, and significantly positively correlated to HDL-chol and plasma testosterone. The most surprising result of this study was the significant correlation between CS and LPL (r = -0.4624; p less than 0.001), a correlation which could explain the increased plasma triglycerides and decreased plasma HDL-chol.

[Autoimmune hemolysis caused by anti-Pr]. / Autoimmunhämolyse durch Anti-Pr.

Following an infection with mycoplasma pneumoniae, an anti-Pr-antibody developed in a hitherto healthy man, aged 41. Within a period of 5 days the antibody caused a severe autoimmune hemolytic reaction. The patient died on the fifth day after admission due to hemolysis and uremia. The autoantibody showed a reactivity with a broad thermal range from 4 degrees C to 37 degrees C. As an initial warning sign, the patient presented an expressed livedo reticularis. Massive wholeblood exchanges could not stop the fatal process.

Essential role of post-heparin lipoprotein lipase activity and of plasma testosterone in coronary artery disease.

89 consecutive men for whom coronary angiography was requested because of suspected coronary artery disease were investigated with respect to plasma lipids, lipoproteins, post-heparin lipoprotein lipase (LPL), and some hormones that influence LPL. The severity of coronary-artery disease was expressed by the coronary score (CS). Coronary-artery disease correlated with total plasma cholesterol, low-density lipoproteins, high-density lipoprotein cholesterol (HDL-chol), and HDL2. In addition, there was a strong negative correlation (r = -0.479, p less than 0.001) between CS and LPL, as well as positive correlations between CS and plasma triglycerides (p less than 0.01) and very low-density lipoproteins (VLDL, p less than 0.01). The impairment of LPL activity correlated with increased VLDL and decreased HDL-chol. The extent of coronary-artery disease is thus strongly influenced by an LPL deficit. LPL activity correlated with plasma testosterone, and there is evidence that low plasma testosterone may be partly responsible for the low LPL and HDL-chol.

[Alcohol-induced type V hyperlipidemia in relation to changes in the chemical composition of HDL2]. / Alkoholinduzierte Typ-V-Hyperlipidämie im Zusammenhang mit Veränderungen der chemischen Zusammensetzung der HDL2.

Alcohol consumption is one of the most common causes of secondary hyperlipidaemia in man, but not all alcohol addicts display hyperlipidaemia. 10 healthy male controls were compared with three groups of patients. The first group consisted of 9 heavy drinkers exhibiting type V hyperlipidaemia under the influence of alcohol. The second group consisted of 7 patients who had displayed type V hyperlipidaemia during alcohol consumption in the past; at the time of investigation, however, they had ceased to drink alcohol at least 6 months previously and were normolipidaemic. The third group consisted of 7 heavy drinkers without hyperlipidaemia. Determinations of plasma lipids and lipoproteins (by means of rate zonal ultracentrifugation), as well as the major apolipoproteins (apo) of high-density lipoproteins2 (HDL2) and HDL3 (by means of polyacrylamide disc-gel electrophoresis) was carried out in all subjects. Two distinct findings were obtained: the one caused by alcohol abuse itself and the other possibly representing a primary trait consisting of an alteration in lipoproteins. In both groups of heavy drinkers the content of apo-CI in HDL2 was lower and the content of apo-AII was higher than in the controls and the abstinent group. In groups I and II with alcohol-dependent type V hyperlipidaemia, the percentage content of total protein in HDL2, as well as the content of apo-D was higher than in controls and in heavy drinkers without hyperlipidaemia. This increased content of apo-D in HDL2 is discussed as being a possible primary marker of alcohol-inducible hyperlipidaemia.

[Lipoproteins, post-heparin lipoprotein lipase and hepatic triglyceride lipase in patients with and without severe hyperlipemia caused by alcoholism]. / Lipoproteine, Post-Heparin-Lipoproteinlipase und hepatische Triglyzeridlipase bei Patienten mit und ohne schwere Hyperlipämie infolge chronischem Alkoholismus.

Because of the high incidence for development of a secondary hyperlipemia during chronic alcohol intake, this study was performed to look for a possible reason, why some patients produce severe hyperlipemia and other ones not. 15 male patients with chronic alcoholism (group I) who produce under influence of alcohol a secondary type-V hyperlipoproteinemia (type-V HLP) were compared with 15 male controls. Additionally, 8 male patients with chronic alcoholism (group II) who were normolipemic under alcohol abuse, and 7 male patients (group II) who had also produced type-V HLP under chronic alcohol abuse, but were teetotal since at least 6 months, were investigated. In comparison with controls, patients of group I showed significantly (p less than 0.01) increased plasma concentrations of very low-density lipoproteins (VLDL) and significantly decreased plasma concentrations of low-density lipoproteins (LDL), high-density lipoproteins2 (HDL2) and HDL3 (all p less than 0.01). Furthermore, the activities of postheparin lipoprotein lipase (LPL) and hepatic lipase (HTGL) were significantly decreased (both p less than 0.01). In patients of group III, the plasma concentrations of lipoproteins did not differ significantly from controls, but the activity of LPL was also significantly impaired (p less than 0.01), whereas the activity of HTGL was distinctly (p less than 0.01) increased. No significant difference between patients of group II and controls could be demonstrated. It is concluded that severe alcohol intake strongly impairs LPL in patients with chronic alcoholism. The pronounced increase of HTGL in patients of group III seems to protect these individuals from producing severe hyperlipemia under the influence of alcohol.

[Distinct increase of plasma concentrations of high-density lipoprotein 2 and post-heparin lipolytic activity by constant moderate alcohol intake]. / Deutliche Erhöhung der Plasmakonzentration der HDL2 und der postheparin-lipolytischen Aktivität durch konstanten mässigen Alkoholkonsum.

In a 69-year-old man with familial hypercholesterolemia, markedly increased plasma concentrations of high-density HDL2 lipoprotein (HDL2) were found. The patient showed no signs of atherosclerotic macro- nor microangiopathy. As a possible reason for the increase of HDL2 a daily intake of 3/8 litre red wine was assumed. On three days (day 1, day 21, day 42) the influence of alcohol on the major lipoprotein density classes (i.e. very low-density lipoproteins [VLDL], intermediate-density lipoproteins [IDL], low-density lipoproteins [LDL], HDL2 and HDL3, all by means of rate zonal ultracentrifugation) and on postheparin lipolytic activity (PHLA) was investigated. At day 1 the patient was under the influence of the usual daily alcohol intake. From day 1 till day 21 patient drank no alcoholic beverages. From day 21 till day 42 the patient returned to his daily intake of 3/8 litre red wine. During the sober phase the plasma concentration of HDL2 decreased to approximately one quarter of the plasma concentration at day 1. Additionally, PHLA decreased markedly. During the daily alcohol consumption till day 42, the plasma concentration of HDL2 again rose approximately to the value of day 1 and PHLA distinctly increased. It is concluded that moderate alcohol consumption may increase the plasma concentration of the antiatherogenic HDL2 in some patients. This patient with familial hypercholesterolemia appears to be protected from premature atherosclerotic complications by his pronounced increase in plasma concentration of HDL2.