Erding Hu, Jay Giri, Lifeng Zhang, Sampath Gunda, Patrick F Wilkinson, Mark E. Burgert, Vijay A. Doraiswamy, Jonni S. Moore, Anne M. Curtis, Emile R. Mohler, Elizabeth Medenilla, Jay M. Edelberg, and Ming Gui
Diabetes mellitus is associated with accelerated atherosclerosis, leading to a two to three fold increase in the incidence of cardiovascular disease (1). Quantitative methods to distinguish cardiovascular disease risk remain elusive in the diabetic population. Current approaches rely on assessing endothelial function, including invasive and non-invasive methods (2), and the association of circulating plasma levels of soluble proteins such as high sensitivity C reactive protein (CRP) (3). Many of these approaches are either complicated, operator dependant or nonspecific (2). For example, the precise cellular source of soluble proteins is often unknown and can confound interpretation. Accurate, convenient and biologically informative markers and associated methods are necessary to assist in the early detection and treatment of vascular complications in diabetic patients. In this regard, cell derived MPs and progenitor cells (PCs), defined as CD34 positive cells, and pro-angiogenic cells (PACs), also CD34 positive along with having endothelial surface markers, have emerged as surrogate markers for cellular damage and repair respectively. Both have been associated independently with a range of vascular diseases including diabetes (4–7). MPs are membrane encapsulated vesicles of approximately 1µm or less in diameter, derived from surface membranes under conditions of cellular activation or apoptosis (8). These submicron vesicles are released into circulation, carrying with them an array of surface markers, used to identify their cellular source. Exposed membrane phosphatidylserine (PS) and tissue factor, along with a plethora of other surface molecules and cytoplasmic components, including nuclear material (9), enable MPs to impact on a variety of biological functions, including coagulation, thrombosis and angiogenesis (10). Direct receptor-ligand interactions (11) and fusion and delivery of intracellular contents (9,12) are mechanisms employed by MP’s to target and impact host cells. Increases in endothelial MPs (EMPs) (13), platelet MPs (PMPs)(14) and monocyte MPs (MMPs) (15) have all been implicated in vascular pathology, including myocardial infarction. Circulating EMPs, generated from the surface of the endothelium have received considerable attention as a surrogate marker for endothelial dysfunction (4,16,17). Due to disease specific changes and associated biological activity, these vesicles are considered active paracrine agents that aggravate further vascular dysfunction(18) and promote inflammation (19). To date, studies assessing MPs have relied on flow cytometry methods performed in specialized laboratories. The utility of a plate based method has not been tested in comparison to flow cytometry assay. PACs (formerly given the designation of endothelial progenitor cells) play a significant role in vascular homeostasis, and in the development and resolution of cardiovascular pathologies. For example, the number and function of PACs are altered immediately after a myocardial ischemic event, and in individuals at high risk of pathologic cardiovascular events (7). In addition, MPs are lowered and PACs are increased after treatment with HMG CoA reductase inhibitors (statins) (20,21). A study of hypercholesterolemic patients with higher CD31+/CD42− EMPs and lower PACs than normocholesterolemic subjects supports this hypothesis (22). We hypothesize that the ratio of MPs to PCs and/or PACs provides an indicator of cellular damage, including the integrity of the endothelium and a loss of endothelial repair capacity that could be relevant in type 2 diabetes. This ratio was directly associated with aortic pulse wave velocity (aPWV), providing a functional link between plasma cholesterol levels, MPs, PACs, endothelial injury and arterial stiffness. To test this hypothesis we evaluated the vascular health of two diabetic subpopulations using MPs and PCs/PACs as surrogate markers. As the risk of vascular events increases with the duration of diabetes (23), we recruited individuals recently diagnosed and those diagnosed for five years or more with diabetes to provide separation of these two populations.