Nephrol Dial Transplant (2004) 19: 1328-1329
Nephrol Dial Transplant Vol. 19 No. 5 © ERA-EDTA 2004; all rights reserved
Serum lipid profile in patients with severe leptospirosis
Sir,We read with great interest the recently published letter to the editor on acute renal failure in patients with severe leptospirosis [1]. The author describes the clinical and laboratory characteristics of 24 patients with Weil's syndrome [1]. He concludes that an increase in triglyceride levels in suspected cases of leptospirosis may be considered as a useful marker, which might be related to the severity of the acute renal failure and hepatitis seen in these patients. In this context, we would like to comment on the abnormalities of the serum lipid profile seen in patients with leptospirosis.
The serum lipid parameters of five patients, who were admitted to our clinic during the last 2 years with Weil's syndrome, were studied on admission and 1 month after their recovery and were compared with the serum lipid parameters on admission of 45 patients with acute bacterial infections (20 patients with acute pyelonephritis, 10 patients with pneumonia and 15 patients with acute cholecystitis) and with 116 control subjects (Table 1). In agreement with the results of the above-mentioned study [1], patients with acute leptospirosis exhibited a significant increase in the serum triglyceride level compared to patients with acute bacterial infections and to the control population. Additionally, patients with leptospirosis had significantly lower levels of low-density lipoprotein cholesterol (LDL-C) and lipoprotein (a) [Lp(a)] and higher levels of apolipoproteins (Apo) B and E compared to both the patients with acute bacterial infections and to the control subjects (Table 1). On the other hand, acute leptospirosis patients had significantly lower levels of total cholesterol, high-density lipoprotein cholesterol and ApoAI compared to control subjects, but no differences between patients with severe leptospirosis and those with acute bacterial infections were found (Table 1). Finally, the abnormalities of the serum lipid profile tended to return to normal 1 month after recovery from the acute disease (Table 1).
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Alterations of the serum lipid profile in the course of acute bacterial and parasitic infections have been described [2,3]. These alterations are mainly cytokine-mediated: interleukin-6 stimulates the LDL receptor gene expression, resulting in decreased levels of total and LDL cholesterol [4]; tumour necrosis factor-
(TNF-) decreases the activity of lipoprotein lipase and stimulates hepatic triglyceride synthesis, thus resulting in hypertriglyceridaemia [5]; and transforming growth factor-ß1 and TNF-, which predominate in severe inflammation, inhibit the expression of the Apo(a) gene [6], resulting in a negative acute-phase behaviour of Lp(a) [3]. Excess of these cytokines in severe leptospirosis might be responsible for the more pronounced increase in the levels of triglycerides and decrease in the levels of LDL-C and Lp(a) compared to patients with common bacterial infections, thus reflecting the severity of the underlying inflammatory reaction. Furthermore, markedly elevated levels of ApoE during the acute phase of the disease, possibly due to increased ApoE synthesis by the activated macrophages and/or the liver, might contribute to the observed hypertriglyceridaemia, since excess ApoE has been shown to accelerate the secretion rate and decrease the efficiency of lipolysis of the triglyceride-rich lipoproteins [7]. This finding is in agreement with our previous observations that ApoE behaves as a positive acute-phase protein in patients with infection [2,3]. Finally, we have observed a similar pattern of pronounced abnormalities in lipoprotein metabolism in patients with hantavirus-related haemorrhagic fever (data not shown). We conclude that not only hypertriglyceridaemia, but also markedly decreased levels of LDL-C and Lp(a) as well as increased levels of ApoE, albeit not specific, are useful markers in suspected cases of severe leptospirosis, possibly related to the severity of the underlying inflammatory process. Measurement of serum lipids, therefore, could be useful in assessing the severity of the underlying infection in acute febrile patients.
Conflict of interest statement. None declared.
Department of Internal Medicine University of Ioannina Ioannina Greece Email: egepi{at}cc.uoi.gr
References
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- Liberopoulos E, Alexandridis G, Bairaktari E, Elisaf M. Severe hypocholesterolemia with reduced serum lipoprotein (a) in a patient with visceral leishmaniasis. Ann Clin Lab Sci 2002; 32: 305–308
[Abstract/Free Full Text] - Gierens H, Nauck M, Roth M et al. Interleukin-6 stimulates LDL receptor gene expression via activation of sterol-responsive and Sp1 binding elements. Arterioscler Thromb Vasc Biol 2000; 20: 1777–1783
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