The association of adenosine deaminase with coronary artery disease: Effect of gender and diabetes

doi:10.4236/health.2013.52022

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Vol.5, No.2, 166-169 (2013) Health

http://dx.doi.org/10.4236/health.2013.52022

The association of adenosine deaminase with

coronary artery disease: Effect of gender and

diabetes

Fulvia Gloria-Bottini1*, Krzysztof Safranow2, Maria Banci3, Agnieszka Binczak-Kuleta4,

Patrizia Saccucci1, Andrzej Ciechanowicz4, Andrea Magrini1, Zdzislawa Kornacewicz-Jach5,

Egidio Bottini1, Dariusz Chlubek2

1Department of Biomedicine and Prevention, School of Medicine, University of Rome Tor Vergata, Rome, Italy;

*Corresponding Author: [email protected]

2Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland

3Department of Cardiology, Valmontone Hospital, Valmontone, Italy

4Department of Laboratory Diagnostics and Molecular Medicine, Pomeranian Medical University, Szczecin, Poland

5Department of Cardiology, Pomeranian Medical University, Szczecin, Poland

Received 16 June 2012; revised 20 July 2012; accepted 1 August 2012

ABSTRACT

An association between ADA1 and Coronary Ar-

tery Disease (CAD) has been observed in Polish

and in Italian populations but in Italian popula-

tion the association was present in males only.

In order to enlighten these differences we have

carried out a collaborative study in the two po-

pulations. In Italy 215 subjects admitted to the

Hospital for CAD, 275 subjects with Type 2 Dia-

betes (T2D) without CAD and 398 healthy new-

borns were studied. In Poland 173 subjects w ith

CAD and 200 healthy newborns were studied.

Written informed consent was obtained from all

subjects or from their mothers to participate to

the study that was approved by the I.R.B. ADA1

polymorphism was determined by DNA analysis.

Three way contingency table analysis was per-

formed by a log linear model. The association

between CAD and ADA1 is present in non dia-

betic male subject s only : OR = 0.195, p = 0.007 in

the Italian population and OR = 0.163, p = 0.004

in the Polish population. The data suggest a sig-

nificant role of immunological mechanisms in

the pathogenesis of CAD without diabetes. Gen-

der differences in immune diseases could ex-

plain the lack of association in females.

Keywords: ADA; CAD; Gender; Diabetes

1. INTRODUCTION

An association between Adenosine Deaminase locus 1

(ADA1) and Coronary Artery Disease (CAD) has been

described in the Polish population [1] and confirmed in

the Italian population [2]. In Italy, however, a significant

association was found in males only. In order to enligh-

ten these differences we have carried out a collaborative

study involving both populations.

ADA1 is a polymorphic enzyme present in all mam-

malian tissue that catalyzes the irreversible deamination

of adenosine to inosine [3]. It is controlled by a locus

with 2 codominant alleles ADA1*1 and ADA1*2 located

in the long arm of chromosome 20 [4]: the activity asso-

ciated to ADA1*2 is lower than that associated to

ADA1*1.

Adenosine is an important local hormone regulating

blood flow, neurotransmission, physiology of smooth

muscle and platelet aggregation. In the liver adenosine

counteracts insulin action by activating A2B receptors

[5]. ADA1 and CD26 are colocalized on T cell surface

and these cells are much more resistant to the inhibitory

effects of adenosine.

Adenosine is a cardioprotective agent [6], thus re-

duced activity in ADA1*2 allele carriers may have a

beneficial effect on cardiac function. Moreover ecto-

ADA1 interacts with Adenosine receptor A1 [7] which

plays an important role in ischaemic preconditioning [8].

Inhibition of platelet aggregation and adhesion and anti-

inflammatory properties of adenosine [9] may also play

an important role in the susceptibility to CAD [10].

2. MATERIAL AND METHODS

The following samples were considered.

ITALY

215 subjects admitted to the hospital for CAD.

275 subjects with type 2 diabetes without CAD (as

F. Gloria-Bottini et al. / Health 5 (2013) 166-169 167

controls for CAD with T2D).

398 consecutive healthy newborns (as controls for

CAD without diabetes).

POLAND

173 subjects admitted to the hospital for CAD.

200 consecutive healthy newborns (as controls for

CAD without diabetes).

Subjects with type 2 diabetes without CAD were not

available for this population.

Written informed consent was obtained from all sub-

jects or from their mothers to participate to the study that

was approved by the I.R.B.

Adenosine deaminase genotype determination was

carried out as previously described [1]. Three way con-

tingency table analysis was carried out by a log linear

model according to Sokal and Rohlf [11].

3. RESULTS

Table 1 shows the distribution of ADA1 genotypes

(phenotypes) in Coronary Artery Disease (Italy and Po-

land), in type 2 diabetes without CAD (Italy) and in

healthy newborns (Italy and Poland) in relation to gender

and Diabetes. The relationship among the variables con-

sidered i.e. ADA1 genotype, CAD, diabetes, gender and

population have been examined by log linear models.

The analysis of interaction among ADA1, diabetes and

gender (a) within CAD subjects shows a significant in-

teraction among the three variables with a pattern similar

in Italian and Polish samples. The analysis suggests that

the relationship between ADA1 and diabetes depends on

gender.

The analysis of interaction among ADA1, CAD (CAD

Table 1. The effect of diabetes and gender on the association between ADA1 and CAD.

Proportion of ADA1*2 allele carriers

CAD Italy CAD Poland T2D without CAD ItalyNewborns Italy Newborns Poland

Gender Diabetes % total n % total n% total n % total n % total n

Yes 14.3% 35 0.0% 8 17.0% 147

Females No 22.2% 63 10.7%28 13.1% 206 11.4%105

Yes 15.6% 45 11.1% 36 20.2% 128

Males No 4.2% 72 3.0% 101 18.2% 192 15.8%95

Statistical analyses: three way contingency table analysis by a log linear model.

(a) Interaction ADA1-Diabetes-Gender in CAD

x = Diabetes; y = ADA1; z = Gender

Italy Poland

G df p G df p

x y z interaction 5.086 1 0.028 3.580 1 0.065

cumulative probability χ2 = 12.610, df = 4, p = 0.014

(b) Interaction ADA1-CAD (CAD vs newborns)-Population in NON DIABETIC SUBJECTS

x = ADA1; y = CAD vs Newborns; z = Population (Italian vs Polish)

Males Females

G df p G df p

x y z interaction 0.039 1 0.650 0.891 1 0.350

x y independence 20.651 2 0.0001 2.903 2 0.260

after correction for multiple comparisons p < 0.001

x = ADA1; y = Gender; z = Population (Italian vs Polish)

G df p

x y z interaction 1.398 1 0.270

x y independence 1.717 2 0.450

(d) Interaction ADA1-Gender-Population in CAD NON DIABETICS

x = ADA1; y = Gender; z = Population (Italian vs Polish)

G df p

x y z interaction 0.233 1 0.650

x y independence 12.985 2 0.002

F. Gloria-Bottini et al. / Health 5 (2013) 166-169

168

vs newborns) and population (b) in non diabetic subjects

shows a lack of interaction in both males and females

suggesting that the relationship between ADA1 and CAD

is similar in the two populations studied. The association

between ADA1 and CAD is very strong in males (χ2 =

20.651, df = 2, p 0.0001, after correction for multi-

ple comparison p < 0.001) but is lacking in females.



Since in the Polish population we had no data on dia-

betic subjects without CAD a similar analysis comparing

CAD diabetics with non-CAD diabetics could not be

performed.

The analysis of interaction among ADA1, gender and

population in CAD diabetics (c) shows no significant

association between ADA1 and gender in both Italian and

Polish populations. On the contrary the same analysis in

CAD non diabetics (d) shows a significant association

between ADA1 and gender that shares a similar pattern in

Italian and Polish populations.

From these analyses it can be safely concluded 1) that

the association between CAD and ADA1 is present in

non diabetic subjects only and 2) that the pattern of as-

sociation in non diabetic CAD subjects depends on gen-

der and it is present and very strong among males only:

OR (ADA12-1 vs ADA11/CAD vs controls) = 0.195;

95% C.I. 0.059 - 0.693 (p = 0.007) in the Italian popula-

tion and OR = 0.163; 95% C.I. 0.047 - 0.630 (p = 0.004)

in the Polish population. For both populations combined

O.R. 0.170 95% C.I. 0.064 - 0.425 (p = 0.00002).

4. DISCUSSION

Since a number of newborns will suffer CAD later in

their life, it could be objected that these infants do not

represent a reliable control for our study. However, as-

suming that a given genotype is more susceptible with

respect to other genotypes to CAD, the difference be-

tween cases and newborns would be lower as compared

to the difference between cases and adults without CAD.

Therefore taking newborns as controls the association of

CAD with a given genotype will be underevaluated. If

the association is statistically significant “newborns” can

be considered a reliable control.

The present data collected in two independent White

European populations show that the association between

CAD and ADA1 is present in non diabetic patients only:

moreover such association is present and very marked

among males only. Considering both populations in

males the proportion of genotypes carrying the ADA1*2

allele is much lower among CAD patients than among

controls.

The difference between males and females could be

due to different early fatality rate; such difference, how-

ever, is present in non diabetic but not in diabetic sub-

jects and this seems against such hypothesis. Unfortu-

nately, we have no data on the subjects died during the

early stages of cardiac attack.

The fact that association between CAD and ADA1 is

present in non diabetic subjects only suggests the exis-

tence of different mechanisms leading to CAD. A role of

immunological factors has been suggested for athero-

sclerosis: taking into account the well known role of

ADA1 in immunological diseases, the association of

CAD with ADA1 suggests a prevalent role of immu-

nological factors in the pathogenesis of coronary artery

atherosclerosis in CAD without diabetes. In CAD with

diabetes a role of metabolic factors could be more im-

portant explaining the lack of association with ADA1

polymorphism.

Gender differences in immune diseases are well

documented and it has been suggested that in association

studies concerning immune diseases males and females

should be examined separately [12]. Thus, assuming an

immune component in the association between ADA1

and CAD the differences observed between males and

females are in line with other studies. Hormonal factors

may explain these differences. The immune mechanism,

however, does not exclude a direct role of adenosine as a

cardioprotective agent.

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