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International Journal of Gynecology & Obstetrics 63 1998.

115]121

Article

Vascular cell adhesion molecule-1 VCAM-1. and


leukocyte activation in pre-eclampsia and eclampsia
E. Budak, R. Madazli, M.F. AksuU , A. Benian, A. Gezer, N. Palit, F. Yildizfer
Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Uni ersity of Istanbul, Istanbul, Turkey
Received 23 February 1998; received in revised form 1 July 1998; accepted 16 July 1998

Abstract
Objecti e: To evaluate the levels of VCAM-1 in pre-eclampsiareclampsia as a possible marker of leukocyte
activation and endothelial damage. Methods: We performed a case-control study on 25 healthy pregnant women and
35 patients diagnosed as pre-eclampsia or eclampsia which were randomly selected. Peripheral venous blood samples
were obtained and serum levels of VCAM-1 were measured by enzyme-linked immunoassay ELISA.. Results: In
pre-eclampsiareclampsia, VCAM-1 levels were higher than in normal pregnancy. Serum concentrations of VCAM-1
were significantly higher in severe pre-eclampsia and eclampsia compared to mild pre-eclampsia or healthy controls.
ROC analysis detected that VCAM-1 G 450 ngrml had a sensitivity of 0.79 and a specificity of 0.90 in detecting
severe pre-eclampsia and eclampsia. Conclusion: This is the first study to correlate VCAM-1 levels with severity of
disease in pre-eclampsia. Our findings indicate that increasing levels of soluble VCAM-1 are present in the
circulation of patients with severe pre-eclampsiareclampsia compared to mild pre-eclampsia or healthy pregnant
women. Elevated VCAM-1 levels may represent a possible mechanism by which endothelial cells attract leukocytes
and cause endothelial cell damage. Q 1998 International Federation of Gynecology and Obstetrics
Keywords: Vascular cell adhesion molecule-1; Endothelial damage; Pre-eclampsia

Corresponding author. Tel.: q90 212 5861514; fax: q90 212 586 1514; e-mail: ebudak@hotmail.com

0020-7292r98r$ - see front matter Q 1998 International Federation of Gynecology and Obstetrics
PII S0020-729298.00138-6

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1. Introduction
Increasing evidence suggests that generalized
endothelial cell damage and dysfunction are major pathophysiologic features of pre-eclampsia
w1]3x. Although, the mechanisms of endothelial
activation and dysfunction are yet unclear, there
is substantial evidence suggesting that leukocyteinstigated damage contribute to this process w4]6x.
Recently, studies have attempted to identify
markers of leukocyte activation and leukocyte
initiated endothelial damage in pre-eclampsia
w7]9x.
VCAM-1 is a cell adhesion molecule and a
member of the immunoglobulin supergene family
w10x. VCAM-1 has a single chain glycoprotein
structure and functions as a transmembrane receptor in vascular endothelial cell membranes.
Very late antigen-4 VLA-4., a a 4 b 1 integrin, is
the counter ligand of VCAM-1 and is expressed
by neutrophils, monocytes, lymphocytes, basophils, eosinophils and certain tumor cells w11,12x.
Cytokines and other pro-inflammatory substances
stimulate the production of endothelial cell adhesion molecules and their transport to the cell
membrane w13,14x. Concurrently, after induction
by chemostimulants or specific signals, leukocytes
become activated and adhere to endothelial cells,
by binding to VCAM-1 w15x. Leukocytes become
firmly attached to vascular endothelium and
rapidly migrate into tissues through gaps within
the endothelial lining to take part in inflammatory processes. When the primary insult is exerted
for a prolonged duration, as in chronic inflammation or autoimmune disorders, leukocyte activation and recruitment to the involved area may
accentuate the initial insult and ultimately may
become a primary cause of tissue injury w4x.
It is believed that VCAM-1 can be utilized as a
marker to monitor endothelial and leukocyte activation w9,16]18x. VCAM-1 levels have been demonstrated to correlate with disease state progression w19]22x. The purpose of the present study
was to measure circulating VCAM-1 levels in
normal pregnant women and pre-eclampsia, and
to determine if disease severity in pre-eclampsia
is correlated with serum VCAM-1 concentrations.

2. Materials and methods


2.1. Patient selection
The study population consisted of 25 women
with normal pregnancy and 35 women with preeclampsiareclampsia who were diagnosed and
treated in our department. The mean age and
gestational weeks of the groups studied were similar. The exclusion criteria were the presence of
active infectious disease or medical complications
including autoimmune disorders, diabetes mellitus and inflammatory conditions. The hypertensive patients were subclassified as mild preeclampsia n s 16., severe pre-eclampsia n s 16.
and eclampsia n s 3. w23x.
2.2. Blood samples and VCAM-1 measurements
Single peripheral venous blood samples were
obtained from all patients included in the study.
Blood samples from pre-eclamptic and eclamptic
women were drawn during labor or within 2 weeks
of delivery between 28 and 41 weeks as soon as
the diagnosis was established. Samples from the
normotensive group were obtained between 26
and 40 weeks gestation. The samples were stored
at y308C until the analyses were performed.
Serum levels of human soluble VCAM-1
h-sVCAM-1. were quantified by an ELISA technique according to the manufacturers instructions Boehringer Mannheim, Germany..
2.3. Statistical analysis
Data analysis was performed using the SPSS
statistical software package SPSS Inc., Chicago,
USA.. The results were evaluated utilizing the
Mann]Whitney U-test, correlation and regression
analysis. Test performance was evaluated by receiver-operating characteristic analysis using the
GraphROC program for Windows.
3. Results
There was no significant difference between
the distribution of patients in relation to gestatio-

E. Budak et al. r International Journal of Gynecology & Obstetrics 63 (1998) 115]121

nal age at which blood samples were obtained.


VCAM-1 levels did not differ in relation to gestational age in the normotensive group
r 2 s 0.0004.. The levels of VCAM-1 were significantly higher in pre-eclampsia and eclampsia,
compared to normal pregnant women P- 0.001..
When VCAM-1 levels of patients in preeclampsiareclampsia were further analyzed in
relation to disease severity mild pre-eclampsia,
severe pre-eclampsia and eclampsia. different results were obtained Fig. 1.. Interestingly, although VCAM-1 levels were elevated in mild
pre-eclampsia 366 " 78. compared to normal
pregnant women 326 " 102., the difference was
not statistically significant P) 0.05.. However,
when VCAM-1 levels of severe pre-eclampsia
513 " 125. and eclampsia patients 649 " 49.
were compared to control or mild pre-eclampsia
patients, a highly significant increase was found
P- 0.001.. There was a significant direct linear

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correlation with the increments of diastolic blood


pressure and VCAM-1 levels in the hypertensive
group P- 0.001, r 2 s 0.69. Fig. 2., but not in
the normal pregnancy group. VCAM-1 levels were
increased with diastolic blood pressure elevation,
most marked above 110 mmHg, which also corresponds to severe pre-eclampsia and eclampsia.
The ROC curves for mild pre-eclampsia, severe
pre-eclampsia plus eclampsia and all preeclamptic patients were constructed Fig. 3. to
express the relationship between sensitivity and
specificity of VCAM-1 levels for different subgroups of pre-eclampsia patients in relation to
disease severity mild pre-eclampsia: area under
the curve s 0.61, S.E.s 0.06; severe pre-eclampsia
plus eclampsia: area under the curve s 0.87,
S.E.s 0.05; all pre-eclamptic patients: area under
the curve s 0.76, S.E.s 0.06.. The diagnostic value
of VCAM-1 was statistically significant in predicting severe pre-eclampsia and eclampsia Ps

Fig. 1. Scattergram display of distribution of VCAM-1 concentrations in relation to disease severity in pre-eclampsia. Individual
VCAM-1 levels are shown for 25 healthy pregnant women, 16 mild pre-eclampsia, 16 severe pre-eclampsia and three eclampsia
patients.

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Fig. 2. VCAM-1 levels of patients in the hypertensive group in relation to diastolic blood pressure elevation.

0.001., but not mild pre-eclampsia P) 0.05..


ROC curve analysis showed that the most optimal
cut-off level for severe pre-eclampsia was 450
ngrml sensitivity s 0.79, specificity s 0.90.. For
predicting severe disease, the test efficiency was
calculated as 86%, positive likelihood ratio as
8.09 and negative likelihood ratio as 4.28.

4. Discussion

The mechanisms causing endothelial activation


and dysfunction are poorly defined in preeclampsia. The extent to which leukocyte activation and leukocyte-initiated damage are important in the pathophysiology of pre-eclampsia is
not well understood. Some studies have demonstrated that leukocyte activation is increased in

pre-eclampsia, and some markers used to monitor


leukocyte activation e.g. defensin, lactoferrin, selectin. were found to be elevated w5]8x.
Soluble isoforms of vascular adhesion molecules
are found in the circulation. It has been proposed
that levels of circulating adhesion molecules may
be useful markers for disease activity and that
they also may have physiological effects w16x. It
has also been shown that adhesion molecules play
key roles in the evolution of some disorders characterized by vasculitis and chronic inflammation.
Increased levels of VCAM-1 have been detected
in Wegeners granulomatosis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory
bowel disease and atherosclerosis w19]22x. Levels
of VCAM-1 were correlated to disease activity,
being significantly higher during active compared
with inactive disease and frequently normalizing
with clinical remission.

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Fig. 3. Receiver-operating characteristic curves of sensitivity and specificity of severe pre-eclampsia plus eclampsia s severe disease
curve 1., mild and severe pre-eclampsia plus eclampsia curve 2. and mild pre-eclampsia curve 3. in relation to the reference curve
curve 4.. The ROC curve for severe disease is clearly superior to other curves. This difference is particularly apparent in the area
of high specificity, where the curve is higher and more to the left than that of the other curves.

Lyall et al. w9x were the first to show that


soluble VCAM-1 was elevated in the serum of
pre-eclamptic patients. Later, they demonstrated
that increased cytokine levels were closely correlated with elevated levels of VCAM-1 w14x. Raynor
et al. w24x studied VCAM-1 levels of 78 healthy
pregnant women between 5 and 39 weeks gestation. They revealed that mean concentrations of
VCAM-1 were significantly higher before 20
weeks gestation 407 " 134 ngrml. than at or
after 20 weeks 346 " 111 ngrml.. Recently,
Austgulen et al. w18x studied the levels of soluble
adhesion molecules VCAM-1, ICAM-1 and ESelectin. in pre-eclamptic women, healthy pregnant women and healthy non-pregnant women.
They demonstrated that all three adhesion
molecules were significantly elevated in preeclamptic pregnancies, whereas serum levels in
normal pregnancy and non-pregnant healthy indi-

viduals did not differ, and no differences were


observed in relation to gestational age or labor.
Lyall et al. w9x had also studied the same adhesion
molecules but they detected significant elevations
only in VCAM-1 levels. Interestingly, when Haller
et al. w17x studied the effect of pre-eclamptic
patients serum on the expression of adhesion
molecules ICAM-1, VCAM-1. on cultured endothelial cells, they detected a significant increase
in ICAM-1 expression but not VCAM-1. Most
recently, Kraus et al. w25x published their results
on ICAM-1, VCAM-1, E-selectin and PECAM-1
platelet endothelial cell adhesion molecule-1.
levels in pre-eclampsia and healthy pregnant
women. Consistent with the results of Austgulen
et al. w18x, they showed that concentrations of all
four soluble adhesion molecules were significantly
elevated in pre-eclampsia. Furthermore, Kraus et
al. w25x found significantly elevated levels of

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E. Budak et al. r International Journal of Gynecology & Obstetrics 63 (1998) 115]121

VCAM-1 and ICAM-1 in the plasma of pregnant


women who subsequently developed preeclampsia 3]15 weeks before the onset of clinical
symptoms.
Our objective was to study VCAM-1 levels in
pre-eclampsiareclampsia; and specifically to evaluate VCAM-1 levels in relation to disease severity. Consistent with previous reports, we observed
significantly elevated levels of VCAM-1 in our
study population. However, when we subclassified
the hypertensive group into mild pre-eclampsia
and severe pre-eclampsia plus eclampsia severe
disease., we found that VCAM-1 levels increased
with disease severity. Although elevated levels
were detected in mild pre-eclampsia, the difference was not significant, either a reflection of a
more benign process or due to a small sample
size. However, serum concentrations of VCAM-1
were significantly higher in severe pre-eclampsia
and eclampsia compared to mild pre-eclampsia or
healthy controls. VCAM-1 levels G 450 ngrml
were calculated to be the most optimal cut-off
value in predicting severe disease in pre-eclamptic
patients. These data suggest that VCAM-1 is more
valuable in predicting severe pre-eclampsia and
eclampsia, but not mild pre-eclampsia, due to
higher values observed in these patients compared to mild pre-eclampsia patients. Previous
studies have documented high VCAM-1 levels in
pre-eclampsia patients but have not specifically
analyzed their results in relation to disease severity. If we assume that the extent of endothelial
activation and damage is more pronounced in
severe disease and the prognosis of mild preeclampsia is relatively benign compared to severe
pre-eclampsia and eclampsia, this is not a surprising finding.
VCAM-1 levels reported in different studies
seem to differ in similar patient populations. Since
different immuno-assays can yield different results on the same samples due to the use of
different antibodies and difference in the calibration standards used, we do not give too much
weight to absolute values. Additionally, what is
measured as freely available VCAM-1 in the circulation misses a significant portion of shed
VCAM-1 that is unavailable due to adhesion to
receptor-bearing cells w16x. Therefore it is most

appropriate to compare trends within studies


rather than absolute values among studies until
there is assay standardization.
5. Conclusion
This study shows that circulating levels of
VCAM-1 are increased in pre-eclampsia. Serum
concentrations correlate with disease severity;
VCAM-1 is significantly higher in severe preeclampsiareclampsia compared to mild preeclampsia or healthy pregnant women. The clinical value of measuring levels of soluble VCAM-1
has not been established. However, recently performed studies and our observation suggest that
this assay may be valuable in identifying patients
at risk for severe disease and also in the clinical
prediction of outcome. Additional prospective
studies are warranted to capture the utility of
VCAM-1 assay.
Acknowledgements
This work was supported by the Research Fund
of the University of Istanbul, Project Number
T-333r190397.
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