Dr. Sanoop Kumar Sherin Sabu M.D., (Int Med)
2 weeks back, a 56-year-old gentle man, who had been on review else where consulted me for optimization of his drugs and reevaluation of his health status on a Sunday Clinic on December 2023.
He was a diabetic for 10 years, with history of coronary artery disease- Tipple vessel disease, (with 60 to 70 % multiple occlusions in LAD and LCx territory diagnosed on October 2022). His recent Echo cardiography on March 2023 RWMA in the anterior and lateral wall with EF 43 %. He was on medical management since october 2022, with proper follow-up with his treating team.
Unfortunately he had developed diabetic foot and peripheral vascular disease involving the left lower limb, and amputation of left great toe was done in 2021.
Since July 2023 he developed early non oliguric CKD with S. Creatinine 1.4 to 1.7 mg/dl and Blood Urea 34 to 43 mg/dl
He had No history of hypertension.
Not alcoholic, not smoker. Nonvegetarian by diet.
His mother 84-year female, also have history of CAD, mesenteric artery thrombosis and Peripheral vascular disease.
Though this gentle man came to me for optimising his diabetic drugs, seeing this multiple vascular events, without history of smoking, Out of curiosity I made him do a simple blood test.
The results of the same turned out to be significantly positive. His Serum Homocytene level were 38 umol/L ( Normal <15 umol/L).
Like any other risk factors for vascular disease, Hyperhomocysteinemia is also a risk factor for development of endothelial injury and cardiovascular diseases.
To his regular cardiac medicine a Folic acid tablet was added for lowering of Serum Homocysteine levels.
If there is deficiency in Vitamin B6 and Vitamin B12 they should also be substituted in such patients.
A comprehensive approach to Vascular diseases will prevent the progression of current cardiovascular illness and also prevent development of new vascular events like stroke, dementia, peripheral vascular disease, CKD, ophthalmic involvement like Central retinal artery occlusion (CRAO) and central retinal vein occlusion CRVO.
A simple blood test which shined new hopes on a desperate man with multiple blood vessel disease
Related theory
Homocysteine is an intermediary in sulfur-amino acid metabolism pathways, linking the methionine cycle to the folate cycle.
Hyperhomocysteinemia causes oxidative stress, endothelial dysfunction and increased production of endothelin-1 which results in cardiovascular diseases, stroke, dementia, peripheral vascular disease and CKD
Increased homocysteine an elevated homocysteine(Hcy) level is associated with an increased risk of chronic kidney disease (CKD) too.
Causes of Hyperhomocysteinemia are
- Several primary and secondary disorders of methionine metabolism may be diagnosed based on measurement of homocysteine.
- Genetic defects in vitamin cofactors (vitamin B6, B12, and folate)
- nutritional deficiency of B12 and folate also lead to abnormal homocysteine accumulation.
- In Women’s HCYS concentrations increase after menopause, possibly due to decreased estrogen production.
Prevention
- Consumption of green vegetables, quiting smoking & alcohol, folic acid intake can help lowering elevated levels of HCYS.
- If primary and secondary disorders of methionine metabolism is suspected plasma amino acids and urine organic acids levels should be also assesd.
- Genetic defects should be screened in family members if suspected
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